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Home My WebLink Aboutcert of local fire inspection Jul 2024(@: DEPARTMENT Of PUBTIC HEATTH DIVISION OF HEALTH CARE FACILITY TICENSURE & CERTIFICATIOI{ 57 For€st Street Ma MA 01752 CERTlFICATION OF TOCAL FIRE INSPECTION lnstructions: Facilities and programs are to provide a copy ofthis form to their local Fire Oepartment when requesting a fire inspection for licensure purposes. Facilities and programs must return this form completed, or the inspection certificate issued by the head of their local Fire Department, when applying for or renewing a license. Nursing homes and rest homes must maintain on file with the facility proof of quarterly fire inspections as required under 105 CMR 150.015(D). \}..l \\,*d{:trFacility/Program Name Facility/Program Address Reason for lnspection: At 4 Itlrrrt^ Fy'a',n S] FACILITY/PROGRAM INFORMATION tr lnitial Licensure/ Licensure Renewal n Facility/Program Renovations Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D)) INSPECTION INFORMATION This is to document that the above facility/program was inspected on: and determined to be: ?.1 ?o2'( f i.e Department Officral 7 *ln compliance with local ordinances regardinB fire prevention and safety. _ Not to be in compliance with local ordinances regarding fire prevention and safety. The following violations were observed (list violations, or indicate if a list of violations is attached): tu Signat I \,arr L,(a 01l( Rev.06/25/15 Fire.3 Typed or Pri d Nam€ of Local Fire Department Officaal + (Date) g h rD $*<.st-F o\oo=c..l .r a! e: ->- FFSood: b(l EF 6)aiaaE ..,._E8.. ;:.8f,E:90lo:? ---^Oo€5;88-ZOE o. z oo. .E* =Ho tsc63 3 tr9 : \q IE 6'o Sda..= H Ir qlslcrarla. tL o. o. o. oooc,EEEEoooo-xtr! or ED cr, o,lrcccc<e e e effJfzzzz bEo1ooll-Joo.=-=J --.1 o (E'cE=>_ooFs:E E 6 E;ooo6EE E E EXd0O(Er!j< o lo coEEEEEaooEE PPUrur;; o< EXotro. uJn t = =fooFJfa IJJ E, Fo IIJF g aa 6; E CG:906,EE6.EE,F€2tE!€ AE ? i qpi Et.sgE-s.e3I € EE E€ 3!e+ aE3tssE a 3+ dd\6eF >-Es9iEEI FTE B3E SaI{iEr. .E e: H! E E'} e5: 9.;ie; d-gEa o ooEtsEi.,5-=r5'E E 6J e;E i :EE: :,:;F 'd z6 =a-!cqe Ez.E v)>sji o.' E Z-N.'j\t o. E€q) Report for: Gannon Fire Sprinkler 30 Perseverance Way Unit 6 Hyannis, MA 02601 POS Windsor Skilled Nursing Job Name: Windsor Skilled NursinS 265 N Main Street For Service Call: (SO8l827-7786 Job Number: Number of Samples: Date Receivedi Report Date: Page: 152984 4 o7 /t212o24 07 /r8/2O24 1of 4 Year Marking: Manufacturer: Series, Modelor SIN: Temp Ratins ("F/'C): Response Type: Releasing Mechanism: Water Seal Config: Dry Sprinkler: Thread Size: Orientation: 7974 Gem D 13s I s7 Standard Response Frangible Bulb Copper Gasket No Ll2" Pendent Location: Stairway A Basement Level Area: Nursing Home Harsh Environment: No Test Results Sample Number: I qalqlqsted: lp12o24 9:77:73 PM Test Method Test Value Requirement TestResult fn"rro*" rirn", i"..Pa5s Pass Pass Oecision Rule opplied: Simple Acceptonce; stotements ofcomplionce to specificdtions do not considet meosurcment lncettointy Pictures ofthis sprinkler in the condition it was received and an image(s)ofthe waterway post testing were made available via a link (active for 90 days) in the results emailand are also available upon request. An assessmentofthe water delivery is not part ofthe field service test as described by NFPA 25 and, therefore, Dyne does NOT det€rmine if any narrowing ofthe waterway is detrim€ntal. The field service test PASS/FA|L designation is solely based upon the sensitivity results (response time/reiponse time index) and whether the sprinkler waterway fully released according to NFPA 25 A.5.3.1.1 (most current, 2023 Ed.). The sprinkle/s appearance is NOT considered as part of thi5 evaluation. The sprinkle/s appearance shall be evaluated during the annualfloor level inspection according to NFPA 25 5.2.1.1 (rnost cu.rent, 2023 Ed.) and any sprinklers that fails the floor level inspection should be replaced before samplin&/testing accordinS to NFPA 25 A.5.3.1 1 (most current,2023 Ed.). I nesoonse Time lndex {RTl), (m-s)X I water Seal Release {7 Psll LBTR-3ito4 LBTR.34O4 LBTR-3,104 44.6 193 FullReleare 0 - 88.4 < 350 FullRelease Accordingto the NFPA 25 5.3.1.3 (most current, 2023 Ed.), "Where one sprinkler within a representative cample fails to meet the test requirement, all rprinklers within the area represented by that sample shall be replaced." lf all sprinklers within a representative sample meet the test requirements and the sprinklers represented by that sample remain in servi.e, they shall be listed for use in your sYstem/application and must be resampled and retested in 5 or 10 years {depending on sprinkler type and environment) in accordance with NFPA 25 5.3.1 {most current, 2023 Ed ) Mwt Bella l(elty, Quality Techniclan It is 0€ l€sponslbllity of fE pmpert o*n6r o. dsignatGd r€Plts€r aws $' 6n$te the *T!]:,i11oTtt* i" _"r*r "r,o-to -.*i o"na6ntie" 6. i.p"rr."nt",inaud{n0 idontMng and ropl&illg sny.l€called p.oduds. TtE 6rG.rit -li iirt *mph t63tod ;6krg a t{mitcd number of laboratorscal€ m6thod3 snd do not suarant'€ ffi;ffi;ii ;i;;-r;di. n" '"oo,r-"r'"rr -t ut t"ptoaucod 6xc6ri in tull witlo'rt t,€ wrlnoh c'os€nt of Dyno T6.hmloglcs. LLC. aDvneXt P[0ItcIl0t Ltls&i::".':'::' LABORATORY TEST RESULTS Sample lnformation f 2357 Vontura fi Suil6 1 08 Woodbury, MN 55125 .o -LABORAT Y TEST RESULTS Report for: Gannon Fire Sprinkler 30 PeBeverance Way Unit 6 Hyannis, MA 02501 POS Windsor Skilled Nursing Sample lnformation Year Marking: Manufadurer: Series, Model or SIN: Temp Rating ('Fl"C): Response Type: Releasing Mechanism Water Seal Config: Dry Sprinkler: Thread Size: Orientation: Job Name: windsor Skilled NursinS 265 N Main Street For Service Call: (5081A27-77aG Job Number: Number of Samples Date Received: Report Date: Page: 7529U 4 07 /72/2024 o? /7812024 2of 4 Location: Stairway B Basement Level Area: Nursin8 Home Harsh Environment: No Test Results Sample Number: 2 Date Tested : 1 / 77 1 2024 9 t73t49 lM Test Method Value Il"lllrra,'Test Result Pass Pass Pass T o.8&4 -| . rro | ,r,,^",".r" In"tpont" fim", S"". T Response Time lndex (RTl), lm-s)X water Seal Release (7 PSI) I L8TR.34(M LSTR-3404 LSTR-3404 The field service test PASS/FAIL designation ir solely based upon the sensitivity results (response time/response time index) and whether the sprinkler waterway fully released according to NFPA 25 A.5.3.1.1 (most curren! 2023 Ed,). The sprinkle/s appearance is NOT considered as part of this evaluation. The sprinkle/s appearance shall be evaluated duringtheannualfloor levelinspedion accordingto NFPA25 5.2.1.1(mostcurrent, 2023 Ed.) and any sprinklers that fails the floor level inspection should be replaced before sampling/testinB according to NFPA 25 A.5.3.1.1 (most current, 2023 Ed.). According to the NFPA 25 5.3.1.3 (most current, 2023 Ed.), "Where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers within the area represented by that sample shall be replaced." lf all sprinklers within a representative sample meet the test requirements and the sprinkters represented bythat sample remain in service, they shall be Iisted for use in your system/application and must be resampled and retested in 5 or 10 years (depending on sprinkler type and environment) in accordance wilh NFPA 25 5.3.1 (most cunent, 2023 Ed ) B&4 & ACCREDITED aDvne Bt ?fi0ItcIl0t tlrs Bella Kelly, quality Technician h is th6 lesporBibility of th€ prDp€rly owi€r or dssignat6d epr€sEntative b €nsurs h€ sample.inlomaton is -.r"a ",,a to -,."i a"rO;nci6s or impaitmods' lncludlng idsiltlying and r€placrng any lecallod products Th€ resuft refate mV to tre samplc t65tod usirE a limited number of laborator}}scale mtthods and do not guarante€ tr'" ll"tJ" *rr'iii.t" pi"p.iay. This rspo.fthall not bo roploduc€d oxcspt in tull without ihe wrilten cons6nt of Oyn€ T€chnologi$. LLc. 1974 Gem o L3s / S7 Standard Response FranSible Bulb Copper Gasket No u2" Pendent I --T_srrl,* II tullRelease Decision Rule dpplied: Simple Acceptonce; stotements dcomplidnce to specilicotions do not consider meosurement uncertointy. Pictures of this sprinkler in the condition it was received and an imate(s) of the waterway post testinS were made available via a link (active for 90 days) in the results email and are also available upon request. An assessmentofthe water delivery is not partofthefield service test as described by NFPA 25 and, therefore, oyne does NOT determine if any narrowing of the waterway is detrimental. 2357 Vsntura Dr Suite 108 Woodbury, MN 55125 LABORATORY TEST RESULTS Report for: Gannon Fire Sprinkler 30 Perseverance Way Unit 6 Hyannis, MA 02601 PO* Windsor Skilled Nursing Sample lnformation Year Marking: Manufacturer: Series, Modelor SIN: Temp Ratinc ('Fl'C): Job Name: Windsor Skilled Nursing 265 N Main Street For service Call: l508l827-7786 Job Number: Number of Samples Date Received: Report Date: Page: l Response Type: Standard Response Releasing Mechanism: Fusible Link Water Seal Config: Copper Gasket Dry Sprinkler: No Thread Size: L/2" L Orientation: Pendent Test Results Sample Number: 3 Date Tested: 71f1J2024 9:2O:7O Pln Test Method Location: B Wing Staff Bathroom Main Floor Area: Nursing Home Harsh Environment: No Test Value Requirement TestResult 7974 Gem c 76s / 74 Response Time, Sec. Response Time lndex (RTl), (m-s)X Water Seal Release (7 PSI) LBTR-3404 LBTR.3404 LSTR-3i104 41.5 102 Full Release 0-143 < 350 FullRelease Pass Pass Pa5s Decision Rule opplied: Simple Acceptonce; stotefiehts ofcomplionce to specilicotions do not consider heosurefient uncertointy. Pictures ofthis sprinkler in the condition it was received and an image(s) of the waterway post testinB were made available via a link (active for 90 days) in the results ema il and are a lso ava ila ble upo n request. An assessme nt of the water de livery is not part of the field sewice test as described by NFPA 25 and, therefore, Dyne does NOT determine if any narrowing ofthe waterway is detrimental. The field service test PASS/FAIL designation is solely based upon the sensitivity results (response time/response time index) and whether the sprinkler waterway fully released according to NFPA 25 A.5.3.1.1 (most cunen! 2023 Ed.). The sprinklet's appearance is NOT considered as pan of this evaluation. The sprinkle/s appearance shall be evaluated during the annualfloor level inspection accordin8 to NFPA 25 5.2.1.1 (most current, 2023 Ed.) and any sprinklers that fails the floor level inspection 5hould be replaced before samplin&/testing accordinS to NFPA 25 A.5.3.1.1 (most current,2023 Ed.). According to the NFPA 25 5.3.1.3 (most current, 2023 Ed.), "Where one sprinkler within a representative sample fails to meet the ten requirement, allsprinklers within the area represented by that sample shall be replaced." lfallsprinklers within a representative sampl€ meet the test requirements and the sprinklers represented bythat sample remain in service, they shall be listed for use in your syrtem/application and must be resampled and r€tested in 5 or 10 years (dependint on rprinkler typ€ and environment) in accordance with NFPA 25 5.3.1 (most current, 2023 Ed.) Bella (elly. Quality Technacian &ACCRCDIIED aDvneIt is tlo r€3porlslbility of fle proFrty owner or d63hnat€d r€prE6nttlive b 6n&tE the samPlo.inbrYhation b corr€d ani to con;l d€fid;hciB or impaltmonts,lndudlng ldontlrng snd rEpi&lng any rocslled products Th€ ;su& deto mty lD lh6 stnpl€ tr3bd usirE a limitrd numbd ot lsborebrttsEcsle m€thods end do not guaran!6e ;; "Fb, ;ll "i;.t" e^tdy. ThLe lEpo.t-shall r|ot bo Isproduc€d €xcopt in tull wlthdr ths writbn corl3€nt of Dyrb Tedmlogi€s, LLC. ,ttl tMtcrl0l trls 2357 venura tr Suile 1Og Woodbury, MN 55'125 7529A4 4 o7 /72/2024 07lt8/2024 3of 4 l I E&,ey LABORATORY TEST RESULTS Report for: Gannon Fire Sprinkler 30 Perseverance Way Unit 6 Hyannis, MA 02601 POf Windsor Skilled Nursing Year Marking: Manufadurer: Series, Model or SIN: Temp Ratins ('Fl'C): Response Type: Releasing Mechanism Water Seal config: Dry Sprinkler: Thread Size: Orientation: Job Name: windsor Skilled NuIsinE 265 N Main Street For Service Call: l508l827-7?86 Job Number: Number of Samples Date Receiv€d: Report Date: Page: Test Results Sample Number: 4 Date Testqd: 7 /ll lxt24 922.08 PM Test Method Location: A Wing Staff Bathroom Main Level Area: Nursing Home HaRh Environment: No Test Value Requirement TestResult Pass Pass Pass 1975 Gem c t6s / 74 Standard Response Fusible Link Copper Gasket No L/2" Pendent Response Time, sec. Response Time lnde)( (RTl), (m-s)% Water Seal Release (7 PSI) I 3r? 1", | ,r,,*",".r" 0-143 < 350 Full Release Oecision Rule opplied: Simple Acceptdnce; stdtements of compliohce to specilicotions do not considet meosurement uncertointy Pictures of this sprinkler in the condition it was received and an imate(s) of the waterway post testinS were made available via a link (active for 90 days)in the results emailand are also available upon request. An assessment ofthe waterdelivery is not partofthe field service test as described by NFPA 25 and, therefore, Dyne does NOT d€termin€ if any narrowing of the waterway is detrimental. The fleld service test PASS/FAIL desitnation is solely based upon the sensitivity results (response time/response time index) and whether the sprinkler waterway fully released according to NFPA 25 A.5.3.1.1 (most current, 2023 Ed.). The sprinkle/i appearance is NOT considered as part of this evaluation. The sprinkle/s appearance shall b€ evaluated during the annual floor level inspedion according to NFPA 25 5.2.1.1 (most cunent, 2023 Ed.) and any sprinklers that fails the floor level inspection should be replaced before samplin&/testing accordint to NFPA 25 A.5.3.1.1 (most current, 2023 Ed.). According to the NFPA 25 5.3.1.3 (most cunent, 2023 Ed.), "Where one sprinkler within a representative sample fails to meet the test requirement, allsprinklers within the area represented by that sample shall be replaced." lfallsprinklers within a reprerentative sample meetthetest requirements and the sprihklers represented by that sample .emain in rervice, they shall be listed for use in your system/application and must be resampled and .etested in 5 or 10 years (depending on sprinkler type and €nvironment) in accordance with NFPA 25 5.3.1 (most current, 2023 Ed.) Sella Kelly, Quality Technician aDvne&ACCREDIIED It is th6 r6spon3ibility ofthe proporty owner or d6ignat6d r€prEs6ntalive to ensure lhe samplg informelion is corcct and to corGct d6nci6oci6s oa lmpaimenb, lncludlng identivng 8nd roplecing any r6call€d producls. Tho rcsdts ltlato only to th€ sampla toslad usin€ a limiod number ol labor8tor}"scale mothods and do nol guarante€ lh6 s!,Eiem \rill ope€t6 propody. This r€pod shsll nol be r€Eoduc€d excspt in tull withotl fio writlon consent of Dyie T€.hnologies, LLC. tt ?iorlcIt0r uls 2357 Vontuia Dr Suate 108 lY@dbury, MN 55125 Sample lnformation 152984 4 07172/2024 07/78/2024 4ol 4 t 1 s& Wf LBTR.34O4 LBTR.34O4 LBTR,34O4