08/06/2026
Survey Tip of the Week: Sprinkler System and Components
K-tag 353, Sprinkler system testing and maintenance is currently the second most frequently cited K-tag in Ohio for 2026, making it an important area for facilities to proactively review. Recent survey citations have included:
- Missing required spare sprinkler heads and the appropriate sprinkler wrench.
- Incomplete or unavailable documentation of required sprinkler inspections, testing, backflow preventer testing, and pressure gauge calibration.
- Missing escutcheon plates on sprinkler heads in resident rooms, bathrooms, and common areas.
- Sprinkler heads that were corroded, dirty, obstructed, or beyond required testing intervals without evidence of the required sample testing.
- Pressure gauges that were damaged, overdue for calibration, or not maintained as required.
- Leaking backflow preventer valves.
- Exposed wiring on electronically supervised control valves (OS&Y valves).
- Deficiencies identified during annual inspections that were not corrected, including clogged inspector's test lines, malfunctioning quick-opening devices (accelerators), equipment left in the shut-off position, and deteriorated piping with significant debris buildup.
The Ohio Department of Health (ODH) has developed a Preventative Maintenance Manual for Long-Term Care Facilities that includes a comprehensive checklist of required preventative maintenance activities, along with the applicable NFPA standards and regulatory requirements. Facilities should use this resource to verify that all required inspections, testing, and maintenance are completed on schedule and appropriately documented.
CMS has also released a new Life Safety Code Advanced: Sprinkler System training through the Quality, Safety & Education Portal (QSEP). While designed for surveyors, the training is also beneficial for facility managers and maintenance staff. It reviews NFPA sprinkler system requirements, key system components, installation standards, inspection, testing and maintenance procedures, and common deficiencies that surveyors evaluate during Life Safety Code surveys.
