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: A0101 - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to properly maintain and test the automatic wet sprinkler system, affecting the entire facility.
Findings include:
1. Document review on February 25, 2025, between 9:00 a.m. and 11:30 a.m., revealed the facility could not provide documentation of the following:
a. Internal Valve Inspection (5 yr);
b. Internal Pipe Insp (5 yr);
c. Obstruction Investigation
Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the missing documentation.
2. Based on observation and interview, it was determined the facility failed to maintain sprinklers, affecting one of eight levels in the component.
Findings include:
Observation on February 25, 2025, at 11:05 a.m., revealed a sprinkler escutcheon dislodged from the ceiling in "evaluation /PACA" hallway.
Exit Interview with the Administrator on February 25, 2025, at 11:30 a.m., confirmed the dislodged escutcheon.
| | Plan of Correction - To be completed: 06/30/2025
1. This deficiency will be corrected as it relates to the individual by reaching out to the sprinkler contract company that completes PM's (Keystone) and by reaching out to building owner and requesting that building ownership complete and provide documentation of:
a) Internal Valve Inspection (5 yr);
b) Internal Pipe Insp (5 yr);
c) Obstruction Investigation
2. To ensure that the problem does not occur, the administrator will keep track of when these inspections are due and reach out to building ownership as a reminder that the Internal Valve Inspection, Internal Pipe Inspection, and Obstruction Investigation need to be completed. The administrator will reach out to our sprinkler contract company (Keystone)for replacement of any loose escutcheons during the next PM.
3. To ensure that this solution is sustained, the administrator will maintain documentation of all communications with the building ownership as it pertains to the Internal Valve Inspection, Internal Pipe Inspection, and Obstruction Investigation, which are due every five years. The administrator will ask Keystone to check escutcheons during all future PM's.
4. This corrective action will be completed by 06.30.2025
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