Deficiencies in Sprinkler System Installation and Maintenance
Summary
The facility failed to ensure that all components of the building's extinguishing system were installed in accordance with NFPA 101 standards. During the Life Safety Code Recertification survey, several deficiencies were observed. In the A/C No. 10 room, a sidewall sprinkler was improperly installed facing downwards, parallel to the wall instead of having the deflector parallel to the ceiling. Additionally, a concealed sprinkler in the 1st Floor corridor by the Conference Room was missing its cap. The Loading Dock area lacked sprinkler coverage from the door to the 5 steps. Furthermore, in the small conference room on the 1st Floor, a sprinkler head was missing an escutcheon and a 2 ft by 2 ft ceiling tile. Missing escutcheons and broken ceiling tiles were observed throughout the facility, indicating a widespread issue with the maintenance of the sprinkler system.
Plan Of Correction
Plan of Correction: Approved April 26, 2025 I. Immediate Corrective Action 1) The Director of Engineering contacted the fire sprinkler company upon discovery to correct the following: a) Reinstall in the correct position a sidewall sprinkler in the A/C No. 10 room b) On 04/25/2025 the 1st Floor corridor by the Conference Room, a concealed sprinkler that had the missing cap was replaced c) Fire sprinkler company contacted to install the loading dock area sprinkler coverage from the door to the 5 steps d) On 4/25/2025, in the small conference room, on the 1st Floor, the observed sprinkler head that was missing an escutcheon and ceiling tile was installed. 2) The facility engineer in conjunction with the sprinkler company reviewed all sprinklers for proper escutcheon plates and replaced any that were found to be missing. 3) The facility engineer replaced all damaged ceiling tiles to ensure proper fitting. II. Identification of Other Residents 1) The facility respectfully states that no residents were involved in this deficiency, however all residents were indirectly affected. 2) The Director of Engineering reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1) The Administrator, in conjunction with the Director of Engineering, reviewed and revised the facility sprinkler inspection policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies. 2) Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. 3) All Maintenance staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as an overview of requirements for sprinkler coverage as per K351. 4) The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required with all associated hardware. 5) A copy of the attendance will be maintained for reference and validation. 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 a logbook for reference and validation. 2) The Director of Maintenance will review the findings and report to the QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Responsible Person: Director of Engineering/Administrator/designee
Penalty
Surveyors found that floor-to-ceiling built-in millwork cabinetry with doors in the first floor dining room was installed and in use without interior sprinkler coverage or other required fire protection measures, and this cabinetry was not shown on the approved DOH renovation and sprinkler plans, preventing verification of proper sprinkler coverage; on revisit, the same lack of fire protection within the closed-door storage cabinetry remained uncorrected, as confirmed by the Administrator and Maintenance Director.
A deficiency was cited due to the facility not being fully protected by an approved automatic sprinkler system as required by the 2012 standards for existing nursing homes and hospitals.
Surveyors found that shower curtains in multiple resident rooms were within 18 inches of sprinkler heads, violating NFPA 13 requirements, and also noted missing ceiling tiles in two utility areas. These issues were confirmed by the Facilities Director.
A hot water pipe was observed being supported and hanging from a sprinkler pipe in the 300 wing mechanical room, contrary to NFPA 13 requirements for sprinkler system installation. This was confirmed by the Maintenance Director during the survey.
The facility failed to install an automatic sprinkler system in the Main electrical (switchgear) Room in the basement, affecting one of three levels. This deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations, indicating incomplete sprinkler protection as per NFPA standards.
The facility failed to maintain sprinkler system requirements as the hydraulic elevator pit lacked a sidewall sprinkler installed within two feet of the floor. This deficiency was confirmed by the maintenance director.
Incomplete Sprinkler Coverage for Built-In Dining Room Cabinetry
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 101 sprinkler system installation requirements. During observation on the first floor, surveyors noted that floor-to-ceiling built-in millwork cabinetry with doors had been installed and was in use inside the dining room without any interior sprinkler coverage. Review of the approved Department of Health (DOH) renovation plan H-22-0980 and Sprinkler Plan H-24-1079 showed that this built-in millwork was not depicted on the submitted plans, preventing DOH Plan Review from accurately verifying sprinkler coverage conditions in this fully sprinklered facility. The cabinetry was in use during the survey without DOH life safety occupancy approval, and no alternative fire protection measures (such as heat detection tied to the fire alarm, automatic sprinklers within the cabinetry, non-combustible/limited-combustible construction, or fire-retardant-treated wood) were provided as required. During an onsite revisit survey, the same condition was again observed, and Item 1 (the lack of fire protection within the floor-to-ceiling built-in, closed-door storage cabinetry in the first floor dining room) was found not to have been corrected. In both the initial and revisit surveys, the Administrator and Maintenance Director confirmed the absence of required fire protection within the cabinetry.
Plan Of Correction
Completion Date: 05/18/2026 Status: APPROVED Date: 05/21/2026 Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Plan Review contacted 5/8/26 to acquire appropriate approval for built-in millwork, and for the appropriate means of protection. Cabinet doors removed to ensure compliance. Heat detectors installed 5/18/26 2. Maintenance director or designee to re-educate maintenance staff on the importance of ensuring sprinkler heads or protection by heat detection which activates the fire alarm system are in accordance with NFPA13 standards 3. Maintenance director or designee to audit built in millwork to ensure Protection by heat detection which activates the fire alarm system Weekly X4 monthlyX2 4.Results will be reviewed at the quarterly QAPI meeting.
Deficiency in Sprinkler System Installation
Penalty
Summary
A deficiency was identified regarding the installation of the sprinkler system. The report notes that nursing homes and hospitals, where required by construction type, must be protected throughout by an approved automatic sprinkler system. The facility did not meet this requirement, as the necessary sprinkler system installation was not in place as specified by the 2012 standards for existing buildings.
Plan Of Correction
Element 1: No residents were identified in this concern. The light fixture in the lobby was moved to accommodate the required distance from the sprinkler head. Completed by 7/24/2025
Sprinkler System Obstructions and Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain compliance with NFPA 13 standards for automatic sprinkler system installation and maintenance. During an inspection, surveyors observed that multiple resident room shower curtains were positioned within 18 inches of the sprinkler head spray pattern, which is not permitted under NFPA 13, section 8.5.5.2. Additionally, ceiling tiles were found to be missing in the Pewabic House Pantry and the Franklin House Clean Utility rooms. These deficiencies were confirmed by the Facilities Director at the time of discovery. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K351: Sprinkler System Installation The facility will ensure the sprinkler system is installed as required. This will be accomplished with the following: The facility will inventory all shower curtains in the facility and replace the shower curtains that are within 18" of the sprinkler head spray pattern. The facility will visually inspect each shower curtain in the facility to identify any that are not compliant, and these will be replaced. The facility will work with the Materials Management department to ensure that the appropriate shower curtains are stocked in the supply room so that when a curtain needs to be replaced, it is replaced with a compliant curtain. The facility will ensure all ceiling tiles are in place in two locations: Pewabic house pantry and Franklin clean utility room. This will be accomplished by replacing all missing ceiling tiles in these locations. The facility will conduct a weekly audit to look for missing ceiling tiles throughout the entire facility. If a missing ceiling tile is identified, the NHA will submit a work order to the Facilities department to have the ceiling tile replaced or reinstalled that day. All staff will be provided education that all ceiling tiles need to be in place at all times unless being actively worked on. All staff will sign off on this education. If staff notice a ceiling tile is missing, a work order needs to be submitted to the Facilities department to have the tile replaced or reinstalled that day.
Improper Use of Sprinkler Pipe for Mechanical Support
Penalty
Summary
A deficiency was identified when, during an observation in the 300 wing mechanical room, a hot water pipe was found being supported and hanging from a sprinkler pipe. This setup was not in accordance with NFPA 13, the Standard for the Installation of Sprinkler Systems, which requires that sprinkler systems be installed as specified and not used to support other building systems. The Maintenance Director confirmed this finding at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Hot water pipe was supported and hanging from sprinkler pipe. Hot water pipe will be removed from sprinkler pipe and supported from ceiling. Element 2: All residents/visitors/staff of the 300 wing have the potential to be impacted by this deficient practice in the event of need for sprinkler use. Element 3: On 06/03/2025 the hanger was removed from the sprinkler pipe and the hot water pipe was secured directly to the ceiling. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Incomplete Sprinkler System Installation in Electrical Room
Penalty
Summary
The facility failed to install required sprinkler system components, specifically in the Main electrical (switchgear) Room located in the basement. This deficiency was identified during an observation on April 15, 2025, at 11:25 a.m. The absence of an automatic sprinkler system in this area was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. This oversight affects one of the three levels of the facility, indicating incomplete automatic sprinkler protection as per the requirements outlined in NFPA 101 and NFPA 13 standards.
Plan Of Correction
1) The facility contractor is submitting plans to the Plan Review Department for approval of modifications to the fire suppression system for approval. 2) The Maintenance Director and/or designee will inspect the Main Electrical Room once a suitable fire suppression system is installed. 3) To prevent the potential for reoccurrence, the Administrator will educate the Maintenance Director and/or designee on the importance of a suitable fire suppression system is installed. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will check the fire suppression system is in place as required monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Sprinkler System Deficiency in Elevator Pit
Penalty
Summary
The facility failed to maintain sprinkler system requirements as evidenced by the absence of a sidewall sprinkler in the hydraulic elevator pit. During an observation conducted on April 8, 2025, at 12:00 p.m., it was noted that the elevator pit did not have a sidewall sprinkler installed within two feet of the floor, which is a requirement for proper sprinkler system installation. This deficiency was confirmed through an interview with the maintenance director at the same time, who acknowledged the lack of a sidewall sprinkler in the elevator pit.
Plan Of Correction
Maintenance Director to contact Mike at the department of labor elevator division and Tony from Schindler Elevator to determine/obtain documentation of the requirement needed for the elevator sprinkler.
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