HospitalInspections.org

Reference: National Fire Protection Association (NFPA) 25

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review, observation and interview, the facility failed to ensure the automatic sprinkler system locked and or supervised valves were inspected monthly per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). Not inspecting valves on the required frequency could result in a valve that is not in its normal position, accessible, sealed, locked or supervised, leaking, and not properly identified. This failed practice could result in the automatic sprinkler system inoperable or unreliable which, in the event of fire, presents the risk of potential harm to all ten (10) residents at the facility as identified by the daily census report provided the Chief Executive Officer on 07/09/19. The findings are:


A. On 07/09/19 at 11:25 AM during record review, showed no evidence the sprinkler system valves were being inspected monthly and no inspection log was posted in the mechanical room.

B. On 07/09/19 at 11:30 AM, during interview, the Director of Plant Operations stated that he has been inspecting the valves but was not aware of the requirement to document the findings of the inspection.