Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its sprinkler system adequately, as evidenced by several deficiencies observed and confirmed through interviews. On January 7, 2025, it was revealed that the facility did not have a supply of spare sprinklers following a sprinkler head failure on December 24, 2024. The maintenance staff had to use a pipe plug to repair the system temporarily, and there was no evidence that a spare sprinkler was obtained after the vendor replaced the sprinkler system on January 3, 2025. This lack of preparedness and failure to maintain necessary supplies was confirmed by the maintenance director. Further deficiencies were observed in the North Terrace corridor, where a replaced sprinkler head was located too close to a section of flexible duct, reducing its coverage area. Additionally, the facility failed to provide documentation for the replacement or representative sample testing of fast response sprinklers, which were dated from 1999 and present throughout the attic area. These issues were also confirmed by the maintenance director, indicating a lack of proper maintenance and documentation for the sprinkler system.
Plan Of Correction
Certasite (the facility vendor for the fire sprinkler system) was contacted regarding the issues following a sprinkler head failure. They will be providing a back up supply of sprinkler heads to keep on site for utilization in case of additional sprinkler head issues. Receipt of parts and repairs will also be provided for documented proof of completion. Upon repair of the ceiling flexible duct pieces will be relocated greater than 18 inches from each sprinkler head. The system will be repaired, tested, and signed off by the vendor upon completion of all needed repairs. Certasite will be asked to provide documentation after assessment of each sprinkler head to show safety and functionality of the fast response system.