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 - Component: 01 - Tag: 0353
Based on observation and interview, it was determined the facility failed to maintain hardware components of the automatic sprinkler protection system, affecting the entire component.
Findings include:
1. Observation on April 29, 2025, at 9:55 AM, revealed the sprinkler head protecting Resident Room 9, by the window, lacked an escutcheon.
Interview with the Building Systems Manager on April 29, 2025, at 9:55 AM, confirmed the sprinkler head lacked an escutcheon.
| | Plan of Correction - To be completed: 05/29/2025
An escutcheon was installed on the sprinkler head in Room 9 by the window and a full house inspection will be done to determine if any other escutcheons are missing from sprinkler heads.
Monthly rounds will take place by the Director of Facilities/designee to ensure sprinkler heads have escutcheons. Results of the rounds will be reported to the Quality Assurance Performance Improvement Committee by the Director of Facilities/designee for review and further recommendation.
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