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: CLASS C ASF - Component: 01 - Tag: 0353
Based on observation and interview, the facility failed to maintain the sprinkler system, affecting the entire facility. Findings include: Observation on April 3, 2025, at 12:20 p.m., revealed a sprinkler escutcheon was missing in the ESD 211 closet. Exit interview with the facilities regulatory coordinator, the maintenance supervisor, and the administrator on April 3, 2025, at 1:45 p.m., confirmed the missing escutcheon.
| | Plan of Correction - To be completed: 04/22/2025
Observation #353 - The sprinkler escutcheon has been installed in the ESD 211 closet. It is unknown why this escutcheon was not in place. To prevent a reoccurrence, staff will be retrained on sprinkler inspections while performing rounds in the building by 4/25/25. Sprinkler escutcheons are to be tight to the ceiling with no visible gaps.
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