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: CLASS B ASF - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components in operable condition, affecting the entire facility.
Findings include:
Document review on August 20, 2025, at 10:15 a.m., revealed the last internal valve and internal pipe inspection was dated June 2020 and not completed within the five years therafter.
Exit Interview with the Administrator on August 20, 2025, at 10:20 a.m., confirmed the inspection was not completed at the time of survey.
| | Plan of Correction - To be completed: 10/02/2025
The Facility Administrator is responsible for this plan of correction. The facility administrator has scheduled the 5-year internal sprinkler inspection, to be performed by a certified sprinkler contractor, on October 2, 2025. The facility does not have any patient procedures scheduled before 10/2/2025. Upon completion of the inspection, the contractor will provide a report. The report will be presented to the Governing Body for review/approval. Any deficiencies will be addressed immediately by the governing body. Additionally, all staff will be educated on the requirement for a 5-year internal sprinkler inspection, via in-service. This in-service will be completed by 9/24/2025. The in-service sign-in sheet will be submitted to the governing body for review. The facility administrator is responsible for ensuring all future inspections are scheduled and completed within the required time frame. Any deficiencies will be immediately addressed by the governing body.
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