Deficient Sprinkler System Installation
Penalty
Summary
The facility failed to ensure comprehensive protection by an approved, supervised automatic sprinkler system as required by the 2012 NFPA 101 standards. During the Life Safety portion of the recertification survey, observations were made of missing escutcheons, concealed caps, and ill-fitting or missing ceiling tiles around sprinklers in various areas, including the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, and Janitor's Closets on the 2nd and 4th Floors. Additionally, in a resident room, the sprinkler system was not adequately installed, compromising the safety standards set forth by the NFPA. Further inspection on another day revealed that the sprinklers in the corridor in front of resident rooms 518 through 521 on the 5th Floor were spaced 30 feet apart, exceeding the maximum coverage area per sprinkler. The Director of Maintenance acknowledged the deficiencies, noting that additional sprinklers would be installed and that the ceiling tiles had been recently upgraded, which might have affected the sprinkler pipes' visibility. The Director also confirmed that the missing ceiling tiles, escutcheons, and concealed caps would be addressed.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, the facility engaged our Sprinkler company to install the identified missing escutcheons and concealed caps in the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, Janitor's Closets on 2nd and 4th Floors, and in resident room [ROOM NUMBER]. Visit scheduled for 3/17/2025. On 3/3/25, the facility engaged our Sprinkler company to adjust the sprinkler pendants in the corridor in front of resident rooms 518 through 521 to provide complete coverage in the corridor. The visit is scheduled for 3/17/2025. The maintenance staff replaced the identified missing ceiling tiles and the ceiling tiles that were not smoked tight on 2/27/25. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be corrected. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with installations of sprinklers in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. An audit tool has been developed to monitor the installation of the sprinkler system, escutcheons, and missing tiles. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all ceiling tiles and sprinklers to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, the Director of Maintenance or Designee will review monthly audits and report findings to the Administrator. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Dir. Of Maintenance