Deficiencies in Sprinkler System Installation and Maintenance
Penalty
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