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Based on record review and staff interview, the facility failed to ensure that they maintained their automatic sprinkler and standpipe systems per the requirements of:

NFPA 101 Life Safety Code (LSC) 2012 edition, 4.6.1.1, 4.6.12.1, 4.6.12.4, 4.6.12.5, 9.7.1.1, 9.7.5, 9.7.7, 9.7.8
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition, 3.3.19, 4.1.1.1.1, 4.1.1.2, 5.1.1.2, 5.1.3, 14.1, 14.2 through 14.2.2.2, Table 5.1.1.2

This deficiency is an isolated event and has the potential to affect a very small number of patients, staff and visitors located throughout the facility.

Findings include:

Record review during facility tour on 5/02/2018 at approximately 0905 hrs to 1010 hrs revealed no documentation for a 5 year internal inspection of piping (obstruction).


The Interim Director of Plant Operations was present when the deficiency was identified (during record review). Exit interview with the Interim Director of Plant Operations and Chief Operating Officer on 5/02/2018 at approximately 1345 hrs verified knowledge of having no documentation for a 5 year internal inspection of piping (obstruction).