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: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain the automatic fire sprinkler system in six instances, affecting six of seven smoke compartments.
Findings include:
1. Observation on June 10, 2026, revealed the following automatic sprinkler system deficiencies:
a) 9:30 a.m., a sprinkler escutcheon outside of Room 124 had a gap in the ceiling greater than 1/8 inch which would allow the passage of heat and smoke and may affect operation of the automatic sprinkler system;
b) 9:35 a.m., a sprinkler escutcheon outside of Room 130 had a gap in the ceiling greater than 1/8 inch;
c) 10:30 a.m., all four-sprinkler escutcheons in the Beauty Salon created a gap in the ceiling greater than 1/8 inch.
Interview with the Facility Administrator and Maintenance Supervisor on June 10, 2026, at 11:30 a.m., confirmed the automatic sprinkler system deficiency.
| | Plan of Correction - To be completed: 06/27/2026
Corrective Action:
The immediate sprinkler escutcheon outside of Room 124 that had a gap in the ceiling greater than 1/8 inch which would allow the passage of heat and smoke and may affect operation of the automatic sprinkler system was fixed before 6/27/2026.
The sprinkler escutcheon outside of Room 130 that had a gap in the ceiling greater than 1/8 inch was corrected before 6/27/2026.
All four-sprinkler escutcheons in the Beauty Salon that created a gap in the ceiling greater than 1/8 inch were corrected before 6/27/2026.
Identification of Others:
Maintenance Director observed all facility sprinkler escutcheons in the facility for a gap greater than 1/8 inch and found all other sprinklers in compliance.
Systemic Changes:
The facility has added Sprinkler Escutcheons to the technology maintenance program, TELS, for bi-annual monitoring to ensure sprinkler escutcheons do not have a gap in the ceiling greater than 1/8 inch which would allow the passage of heat and smoke and may affect operation of the automatic sprinkler system.
The Administrator provided education to Maintenance Director on 6/22/2026, to check all sprinklers after any vendor has provided work to equipment in the ceilings to ensure
Monitoring:
The Maintenance Director/designee will complete monthly inspections of all sprinkler escutcheons to ensure they meet the compliance requirements. Monitoring will be reviewed at Quality Assurance Performance Improvement meetings until the QAPI committee has deemed a lesser frequency of monitoring is appropriate.
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