Sprinkler System Installation Deficiencies
Penalty
Summary
The facility failed to ensure that all sprinklers were installed in accordance with the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, it was observed that on two of the four resident floors and in the basement, the sprinkler system was not compliant. Specifically, on the fourth floor, an alcove off the corridor was missing a sprinkler head. On the second floor, a sprinkler head above the smoke barrier doors near a room was installed less than the required 4 inches from the adjacent wall. Similarly, in the basement laundry chute room, a sprinkler head was also less than 4 inches from the adjacent wall. These deficiencies were noted during the survey conducted between 9:30 am and 1:00 pm, and the Director of Maintenance acknowledged the need for correction.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrections: a. Director of Environmental Services checked all sprinklers in the facility across all four floors and basement. No negative findings. b. Administrator called Fire Safety Sprinkler Corp regarding the need to replace sprinkler heads on the second and fourth floor as well as the basement that are in question. c. Fire Safety Sprinkler Corp replaced 2 upright sprinkler heads next to the wall with vertical sidewall sprinkler heads near room [ROOM NUMBER] and in basement laundry chute room. d. Fire Safety Sprinkler Corp installed a new sprinkler head in the 4th floor alcove off corridor. II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed policy for Sprinkler System and found it to be compliant. b. Administrator in-serviced all maintenance staff on sprinkler coverage and need for sprinklers to be at least 4 inches from the wall. IV. Monitoring: a. Director of Environmental Services developed a sprinkler inspection audit to ensure all areas are sufficiently covered by sprinklers. b. Audits will be done weekly for quarterly for one year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency.