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WESTERN WISCONSIN HEALTH
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012 edition) Sections 19.3.5.1, 9.7.1.1, & 9.7.5; NFPA 13 (2010 edition) Section 6.2.7.3; and NFPA 25 (2011 edition) Sections 4.3, 5.1.1.2, 5.2.1.1, 13.4.3.2, 13.4.3.2.2.4, & 13.4.3.2.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.
Findings include:
1. On 04/16/2024 at 9:45 am, observation in the med/surg wing in patient room 130 revealed a concealed sprinkler head with a missing cover plate, thereby not completing the sprinkler assembly listing.
2. On 04/16/2024 at 11:03 am, record review of sprinkler system inspections and testing revealed that the facility did not have documentation of a three-year full flow test for the preaction systems.
These deficient conditions were confirmed at the time of discovery by a concurrent interview with Staff D.