Failure to Maintain Fire Hoses as per NFPA Standards
Penalty
Summary
During a life safety code recertification survey conducted on two consecutive days in 2025, it was observed that the facility failed to maintain the fire hoses in accordance with NFPA 101 and NFPA 25 standards. Specifically, the fire hoses located in Stairwell B on the basement level and the 1st Floor were found to be stamped with a date of 4/2015, indicating they had not been tested or replaced within the required five-year period prior to the survey. This deficiency was identified through observation, document review, and staff interviews, where it was confirmed that there was no documentation of the hoses being tested or replaced as required. At the time of the finding, the Director of Maintenance acknowledged the issue and stated that the hoses would be replaced or capped.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/5/25, the facility contacted the sprinkler vendor to install all new standpipe hoses throughout the building. The vendor will conduct a visit on 3/15/2025 to prepare a proposal. 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 residents have the potential to be affected by this practice. The maintenance will survey the entire building for standpipe hoses. All standpipe hoses will be replaced. 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 identified during the facility’s survey and the importance of ensuring compliance with the requirements of inspection and testing requirements of Standpipe hoses 2011 NFPA 25 5.2* Inspection and 2011 NFPA 25: A Preventive Maintenance & Scheduling system will be developed to reflect the inspection and testing of the standpipe system as required by all codes, rules, and regulations. All inspection results will be recorded in the building Records & Logs and available for inspection by the Authority having jurisdiction at all times. 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 the standpipe system 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 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.