Inadequate Maintenance of Sprinkler System
Penalty
Summary
The facility's automatic sprinkler system was found to be inadequately maintained during a Life Safety Code survey. Observations revealed that sprinkler piping and hangers were subjected to external loads, with ceiling tiles and a light fixture improperly attached to the sprinkler piping using metal wires. Additionally, electrical wires were taped to a sprinkler pipe. These issues were observed in multiple locations on the First Floor, including above the Unit 6 corridor ceiling near the Beauty Shop and between resident rooms. The Maintenance Director confirmed that there had been no recent work in these areas and that the facility lacked documentation of inspections for the sprinkler piping above the ceiling tiles. Furthermore, the facility failed to provide documentation verifying that the automatic wet and dry sprinkler systems had been inspected, tested, and maintained on a quarterly basis. The Maintenance Director admitted that quarterly inspections and testing were not conducted for the Third and Fourth Quarters of 2023 and the First Quarter of 2024. A review of inspection reports and electronic documentation from the contractor's Property Owner Portal confirmed the absence of records for these periods, indicating a lapse in compliance with required safety standards.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility is requesting temporary waiver for F353 in order to make the necessary physical corrections to come into compliance with life safety code for the load on the sprinkler head. a. The Assessment of the sprinkler head load throughout building will be conducted by maintenance by removing all ceiling tiles. This will be done by 1/31/2024. The sprinkler load will be assessed by maintenance weekly until all load items have been removed. b. Building materials needed to be reviewed including removing wires from sprinkler load. This will include removing load from sprinkler pipe and placing on ceiling. Load will be reassessed weekly by maintenance until full removal of load from all sprinkler pipes. The material phase will be completed by [DATE]th. c. Safety plan will include area where maintenance is removing the load on the sprinkler and reinstalling in the ceiling. This will include safety precautions for all residents in work area. Residents will be removed from area while work is being performed. Unit 1/2 will be completed by [DATE]th. Unit 5 will be completed by (MONTH) 14th and unit 6 will be completed by (MONTH) 31st. d. All areas will be reviewed by maintenance staff for goal of 100% removal of wiring on sprinkler pipes and removing all load from sprinkler pipe. This will be completed on (MONTH) 31st. 2. The facility will need until (MONTH) 1, 2025 as the time needed to reinstall ceiling grid and remove it from the sprinkler head is extensive. The time needed is based on in-house labor hours. The facility will institute a safety plan for the project while the ceiling is removed and reinstalled. 3. All wires attached to sprinkler pipe will be removed including first floor corridor unit 6. All ceiling tiles attached to sprinkler head were removed by Maintenance. Light fixture hung from Sprinkler head on First Floor above the Unit 6 corridor ceiling tile between Resident rooms [ROOM NUMBERS] were removed by Maintenance staff. The facility had sprinkler system testing completed by outside vendor. 4. All residents are at risk for deficient practice of obstruction of sprinkler head and testing not being completed per regulations. 5. A full audit of all sprinkler system will be completed to ensure nothing is hanging from the sprinkler system. Administrator and Maintenance reviewed all documentation not completed in past 12 months. 6. Administrator reviewed policy and procedure on sprinkler system including obstruction including external loads and testing required. Changes were made to policy. 7. Administrator trained Maintenance Director/Tech on sprinkler external loads and mandatory testing that needs to be completed. RN educator educated all staff on sprinkler head obstruction on 1/17/2025. 8. 5 weekly audits will be completed by Maintenance on sprinklers to ensure no obstruction or external loads are provided to sprinkler pipes. Any deficient practice will be done and brought to QAPI for further review. Monthly audit of all required testing will be completed monthly by Maintenance Director and brought to QAPI for further review. Any deficient practices will be corrected. Person Responsible: Maintenance Director