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Based upon observations made in the presence of the CFO and Facility Director on 01-14-2021, it was determined that the facility did not provide a fire sprinkler system in accordance with NFPA 101 19.3.5,9.7 and NFPA 13 5.13.8.1

This deficiency affected the attic dry pipe fire/sprinkler system.

Findings include:

During the facility tour and observations made during the interview it was determined that there was no fire/ sprinkler protection for the attic dry pipe system as it had been turned off. Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system In accordance with NFPA 13, 19.3.5.1,19.3.5.2,19.3.5.2,19.3.5.5,19.4.2,19.3.5.10,9.7,9.7.1.1 (1)

Based on record review made in the presence of the CFO and Facility Director on 01-14-2021, it was determined that the facility did not have in use a fire watch policy in the event of a fire sprinkler outage in accordance with NFPA 101 9.7.5 and NFPA 25 15.5.2.

This deficiency affected the attic dry pipe fire/sprinkler system.


Findings include:

1-During the record review the facility failed to use their fire watch policy for a fire sprinkler outage, the local fire department and other authorities having jurisdiction were not notified, there was no risk assessment completed in accordance with NFPA 101 9.7.5 and NFPA 25 15.5.2.