HospitalInspections.org

Based on observation, records review, and interview, the facility failed to conduct a five year internal inspection of the supervised sprinkler system by a licensed sprinker agent. The deficient practice affected 2 of 2 smoke compartments, staff, and all residents.

The findings include:
Records review of the facility sprinkler inspections for the year prior to the survey on August 14, 2019 revealed the facility did not have records of five (5) year testing of internal piping of sprinkler system.


Actual NFPA Standard: NFPA 25 (2011) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System
NFPA 25:5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Interview with the Maintance Diector on August 14,2019 revealed the facility was unaware of the requirement for five (5) year inspections for the sprinkler system internal piping.