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K-Tags In Review: K-Tag 353: Sprinkler System - Maintenance and Testing

July 09, 2021
Compliance, Healthcare Consulting By Emile LeDoux, Senior Consultant

When was the last time your community experienced a Life Safety Inspection?

Whether your community is preparing for an annual inspection or verifying that a recent renovation meets the Life Safety Standards, it is important to ensure your community is in compliance with each of the K-Tags. LW Consulting, Inc’s new service line, Life Safety Assessments, includes reviewing each area of the Life Safety Standards and Fire Safety Codes.

Our new K-Tags In Review Series will discuss some of the most cited K-Tags. In this blog, we will discuss K-Tag 353: Sprinkler System – Maintenance and Testing.


KTags in Review


Communities are responsible for ensuring that their automatic sprinkler system is designed, maintained, inspected, and tested to meet regulatory expectations. Records must be maintained and easily available to the inspectors. The sprinkler system should be maintained as a routine part of the community’s Preventive Maintenance Program.

While conducting inspections, the facilities/maintenance department should verify that sprinkler heads are properly maintained. In this scenario, maintained means that the sprinkler heads are clean and without rust or paint which may cause them to be ineffective. Missing or damaged sprinkler heads should be replaced immediately. Each community should keep an inventory of each kind of sprinkler head in use. Additionally, inspectors should verify that there are no obstructions to the sprinkler heads which would cause them to be ineffective.

The Department of Health (DOH) may request results of previous inspections, dates the sprinkler system was inspected, who provided the sprinkler system test, and from where the community receives its’ water supply. The entire community will be inspected including back service areas and closets to ensure they are appropriately covered.

Sample Deficiency Notes From Life Safety Inspections

  • Missing sprinkler escutcheon in basement kitchen walk-in cooler.
  • Sprinkler Inspection Report noted the following deficiency: “Fire pump failed doesn’t report to panel. Communication Failure on pump controller as other troubles.” This condition remained uncorrected at time of survey.
  • Sprinkler with build-up of dust and debris.
  • Storage items were located within 18 inches of a sprinkler head assembly within the Maintenance Shop.
  • Sprinkler installed below the minimum headroom clearance of 6’5”. With obstruct inside locker room and bathroom.
  • Storage within 18” of sprinkler inside small closet.
  • Broken sprinkler escutcheon in service hallway.


For more information on how our Life Safety Assessments can help your community, contact Emile LeDoux at 717-213-3120 or email

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