Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards, as observed during a Life Safety Survey tour. During the inspection, it was noted that several sprinklers in different areas of the facility were either covered by foreign material, corroded, or damaged. Specifically, in the kitchen, 8 out of 28 sprinklers were found to be in such a condition. Additionally, at the main entrance on the first floor, 2 out of 3 sprinklers were similarly affected. Further deficiencies were observed in the first-floor mechanical room across from the chapel, where there was a lack of a spare dry sprinkler for the freezer, and no means to restore service was available. These issues were acknowledged by the Maintenance Director during the survey and were also discussed with the Administrator during the exit conference. The report highlights that the facility did not adhere to the required standards for the inspection, testing, and maintenance of its water-based fire protection systems as outlined in NFPA 25. The lack of proper maintenance and availability of necessary equipment could potentially compromise the safety and effectiveness of the sprinkler system in the event of a fire.
Plan Of Correction
5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance 5/16/25 Immediate Action: A Certified Fire Protection contractor completed an inspection of the building on 4/8/2025. The proposal was signed April 30, 2025 to replace corroded and damaged sprinklers. The contract company is pending material availability which includes spare dry sprinkler for freezer. Identification of Residents with potential to be affected: All in-house residents have the potential to be affected. System Changes: The facility reviewed the preventive maintenance program to include a visual inspection of sprinkler heads is conducted monthly. Maintenance staff were retrained / educated on identifying signs of corrosion and damage to the sprinkler heads during the visual inspections. Monitoring: Director of Maintenance / designee will maintain a log of inspections and report will be present in the monthly Quality Assurance Performance Improvement committee meeting. Responsible Party: Director of Maintenance