Inadequate Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that all areas of the building were adequately protected by the automatic sprinkler system, as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, it was observed that in the 2nd floor air handling room on the A unit, there was only one sprinkler head located on the door side of the room, with no sprinkler head under the wide ductwork suspended from the ceiling. Additionally, in the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station, and the 1st floor utility closet by the activities room, light fixtures were positioned directly under the upright sprinkler heads, potentially affecting the spray pattern of the sprinkler heads. These deficiencies were noted during the survey conducted on the 1st and 2nd floors of the facility.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The facility Director of Maintenance contacted the Fire Sprinkle Company upon Discovery to install the required missing fire sprinklers in the 2nd floor air handling room on the A unit, there was under the wide ductwork that is suspended from the ceiling. 2. In the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station and the 1st floor utility closet by the activities room, the light fixture which was located directly under the upright sprinkler heads has been relocated to provide proper clearance to not affect the spray pattern of the sprinkler heads and was provided with Appropriate coverage. II. Identification of Other Residents The Facility respectfully states that no residents were involved in this deficiency, however all residents were directly affected. The Director of Maintenance reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1. The Administrator, in conjunction with the Director of Maintenance, reviewed and revised the facility construction/renovation policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies for any Renovation Plan. 2. Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. IV. QA Monitoring 1. The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in logbook for reference and validation. 2. The Director of Maintenance will review the findings and report to QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Title Responsible Director of Maintenance