Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
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Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353
Based on document review, observation, and interview, it was determined the facility failed to perform semi-annual inspections, maintenance and repairs, performed repairs and maintenance without proper qualifications and certifications required for healthcare facilities, lacked hydraulic calculation tags, and maintain the automatic sprinkler system to be free from obstructions, which serves the entire component.
Findings include:
1. Review of documentation and interview on February 24, 2026, between 9:00 AM and 11:00 AM, revealed the facility failed to perform tri-annual dry system full flow test.
Interview at the time of the exit conference with the Administrator and Maintenance Director on February 24, 2026, at 1:00 PM, confirmed the facility failed to perform the dry system full flow test.
2. Review of documentation and interview on February 24, 2026, between 9:20 AM and 9:26 AM, revealed the facility failed to perform repairs required by in the 9/2/2025 annual inspection report, by Precision Fire Protection Inc, for the following:
a. 9:20 AM, 19 gauges due for replacement;
b. 9:21 AM, Kitchen, dry system waterflow alarm did not report;
c. 9:22 AM, Kitchen, dry system, pipes and fittings leaking;
d. 9:23 AM, main drain, wet system, basement, know broken;
e. 9:24 AM, fast response heads, due for sample testing, 20 or more;
f. 9:25 AM, dry heads due for sample testing:
g. 9:26 AM, dry system, water flow alarm did not report.
Interview at the time of the exit conference with the Administrator and Maintenance Director on February 24, 2026, at 1:00 PM, confirmed the facility failed to perform the required maintenance and repairs.
3. Observation and interview on February 24, 2026, at 11:15 AM, revealed the facility lacked hydraulic tags, at the following systems:
a. Wet #1, basement;
b. Wet #2, west;
c. Wet #3. east;
d Dry #1, Kitchen;
e. Dry #2, west;
f. Dry #3, east.
Interview at the time of the exit conference with the Administrator and Maintenance Director on February 24, 2026, at 1:00 PM, confirmed the facility lacked hydraulic tags at the sprinkle wet and dry systems.
4. Observation on February 24, 2026, between 12:25 PM and 12:40 PM, revealed sprinkler heads were covered with debris, at the following locations:
a. 12:25 PM, Laundry Room, Dryer Chase Room, 1 sprinkler head;
b. 12:40 PM, Kitchen, main area, multiple sprinkler heads.
Interview at the time of the exit conference with the Administrator and Maintenance Director on February 24, 2026, at 1:00 PM, confirmed debris on the sprinkler heads
| | Plan of Correction - To be completed: 04/22/2026
1) Tri annual dry system full flow test- 3-year test cannot be fixed retroactively.
The facility cannot perform retroactively perform repairs that were required in the 9/2/2025 annual inspection report by Precision Fire Protection.
The facility cannot retroactively place hydraulic tags on any systems.
Sprinkler heads in laundry chase dryer area. Along with multiple sprinkler heads in the kitchen main area have been cleaned.
2) Tri annual dry system full flow test- 3-year test is scheduled with Precision Fire protection.
Precision Fire Protection is working on a date to complete repairs.
Hydraulic design valve tags have been installed at each location required.
3) Maintenance department has been educated on hydraulic tag design locations. Maintenance director has been educated on reviewing inspection reports and identifying the deficiencies reported and contacting vendors to schedule repairs. The maintenance director has been educated on the three-year full flow test to be completed by sprinkler vendor.
Maintenance department educated about sprinkler head inspections and cleaning requirements.
4) The life safety book will be audited quarterly by the Maintenance Director and Administrator to confirm all reports have been received and filed in the life safety book.
the maintenance director will audit the sprinkler hydraulic calculations tag and plate annually to confirm they are present and still legible. Reports to QAPI committee.
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