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 lacked quarterly inspections of pressurized water tank documentation, and maintain the sprinkler heads to be free of obstructions, affecting four of four smoke compartments within the component.
Findings include:
1. Review of documentation on July 14, 2026, between 8:45 AM and 10:45 AM, revealed the facility lacked documentation, for quarterly, exterior suppression tank inspections.
Interview at the time of the exit conference with the Administrator and Director of Maintenance on July 14, 2026, at 1:45 PM, confirmed the facility lacked documentation of fire suppression quarterly inspections.
2. Observation on July 14, 2026, between 11:45 AM and 11:50 AM, revealed sprinkler heads were subject to a load, at the following locations:
a. 11:45 AM, Main Kitchen, numerous sprinkler heads;
b. 11:48 AM, Main Kitchen, walk in refrigerator, 1 sprinkler head;
c. 11:50 AM, Main Dining Room, exterior porch,1 sprinkler head, bird's nest.
Interview at the time of the exit conference with the Administrator and Director of Maintenance on July 14, 2026, at 1:45 PM, confirmed sprinkler heads were loaded.
| | Plan of Correction - To be completed: 08/14/2026
NHA educated the Director of Maintenance that the exterior suppression water tank is to be visually inspected quarterly. The Director of Maintenance completed an exterior suppression water tank inspection on 7/31/26. The exterior tank inspections will be completed quarterly and the results reported at the QAPI meeting. The numerous sprinkler heads in the Main Kitchen and walk in refrigerator and Main Dining exterior porch were cleaned to be free of obstructions. The Director of Maintenance educated the Maintenance staff that fire suppression inspection of sprinkler heads will be completed monthly on the interior and exterior sprinkler heads to ensure sprinkler heads are free of obstruction and not subject to load. Results of the monthly sprinkler head inspections will be reported at the monthly QAPI meeting for compliance.
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