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 01 - Component: 01 - Tag: 0353
Based on observation, document review, and interview, the facility failed to maintain the fire sprinkler system for one of one system.
Findings include:
Document review on December 27, 2023, at 9:30 a.m., revealed no documentation available for the replacement and cailbration of fire sprinkler system gauges, per NFPA 25 requirements.
Interview with the maintenance technician and the administrator on December 27, 2023, at 9:30 a.m., confirmed the deficiency existed at the time of the survey.
| | Plan of Correction - To be completed: 02/15/2024
-Fire sprinkler gauges calibrated or replaced as listed below.
- Gage # 1 Main sprinkler inlet / replaced 2020 next scheduled replacement 2025
- Gage # 2 1st floor Sprinkler riser suppling 1st floor sprinkler system and ground floor system / Replaced 2020 / next scheduled replacement 2025
- Gage # 3 2nd floor riser suppling 2nd floor sprinkler system installed 2022 replacement 2027
-All gauges are inspected quarterly.
-Nursing home administrator will educate maintenance team on NFPA 25 requirements.
-Log will be maintained with Life Safety documentation.
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