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 and interview, it was determined the facility failed to provide documentation verifying quick response sprinkler heads older than 20 years of age had been successfully sampled or replaced within the previous ten years, affecting the entire component.
Findings include:
1. Review of documentation on May 12, 2026, at 10:08 AM, revealed the facility failed to provide documentation verifying quick response sprinkler heads, older than 20 years of age, had been successfully sampled or replaced within the previous ten years. Sidewall sprinkler heads, within the spare sprinkler cabinet, were observed to exhibit a manufacture date of 2004.
Interview with the Facilities Supervisor on May 12, 2026, at 10:08 AM, confirmed the facility lacked documentation verifying quick response sprinkler heads, older than 20 years of age, had been successfully sampled or replaced within the previous ten years.
| | Plan of Correction - To be completed: 06/30/2026
The statement/s made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency/s herein.
To remain in compliance with all Federal and State regulations, the facility has taken and will continue to take the actions set forth in the following plan of correction.
The following plan of correction constitutes the center's allegation of compliance. The alleged deficiency cited has been / or will be corrected by the date/s indicated.
The facility is committed to taking all actions necessary to remain in substantial compliance with the Federal and State regulations.
The plan of correction addresses our intentions to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psycho-social well-being.
K 0353
Facility has contracted with Susquehanna Automatic Sprinklers, INC. (SASi) to provide the necessary material, labor, tools, and equipment to remove a random sampling of 16 quick response sprinklers, 4 from each wet system, and submit them for testing in accordance with NFPA 25.
Additionally, repairs of any deficiencies detected in the existing system during testing or charging of the system will also be addressed by SASi.
Contracted work is scheduled to begin the week of May 24, 2026.
Supervisor of B&G, or designee, will submit results of the sprinkler head tests and necessary actions required based on test results to the QAPI Committee for review and determination of need for further action as needed.
Facility alleges substantial compliance on June 30, 2026.
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