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 fire protection sprinkler system on two of three floors.
Findings include:
1. Observation on June 15, 2022, between 12:12 pm, and 12:35 pm, revealed the following;
a. At 12:12 pm, ceiling tile missing in the soiled utility room, North corridor on the 1st floor. b. At 12:35 pm, a sprinkler in the clean side of the laundry room was obstructed by duct work, near the dryer access door.
Interview at the time of the exit conference with the administrator and facility maintenance representative on June 15, 2022, at 1:30 pm, confirmed the sprinkler deficiencies.
| | Plan of Correction - To be completed: 08/10/2022
The Maintenance Director installed the missing ceiling tile in the soiled utility room, north corridor on the 1st floor. The Maintenance Director contacted Cintas Fire Protection Company to set up a time for them to visit the facility in order to move the sprinkler to the clean side of the laundry room that was obstructed by duct work near the dryer access door in order to maintain the fire protection sprinkler system.
The Maintenance Director/ Designee will audit all ceiling tiles in the facility to ensure they are not missing. The Maintenance Director/ Designee will audit all sprinklers in the facility to ensure they are not obstructed.
The Maintenance Director/ Designee will complete random weekly facility location audits to ensure there are no missing ceiling tiles.
The Maintenance Director/ Designee will complete random facility location audits to ensure there are no obstructions to sprinkler heads.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.
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