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Based on record reviews and observations, the facility failed to provide supervised monitoring for integrity of all the automatic fire sprinkler system control valves which could allow for the control valves to be shut down, rendering the automatic fire sprinkler system inoperative without any supervisory notice to the facility, endangering the patients, staff, and other building occupants.

The Findings Include:

On November 1, 2013 at 10:00 AM to 5:00 PM during record reviews and tour with facility staff, it was observed during record review of the facility's underground water supply lines, that the facility was provided with a looped water supply coming from two points of connection from the water department main. These connections were through two (2) double check backflow preventers, one north and one south. The waterline looped around the facility with fire hydrants provided off the loop and the supply line feeding to the rear of the building supplying the facility's fire pump. In the lines to the rear of the building were multiple post indicating control valves. It was observed that the two (2) double check backflow preventer control valves and the multiple post indicating control valves were not equipped with supervisory switches to provide notification to the constantly attended location within the facility of an impairment to the system, but were only chained and locked in the open position. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility in accordance with NFPA 101 (2000) 9.7, 9.7.2.1, 18.3.5.1.


These findings were confirmed with the Director of Operations and Facility Plant Director during the exit conference on November 1, 2013 at 5:00 PM.