Failure to Maintain Fire Hoses in Accordance with NFPA Standards
Penalty
Summary
During a life safety code recertification survey conducted on two consecutive days in 2025, it was observed that the facility failed to maintain its fire extinguishing system in accordance with NFPA 101 and NFPA 25 standards. Specifically, the fire hoses located in Stairwells A and B on the 1st Floor, as well as throughout the facility, were found to be stamped with a date of 9/2017. This indicates that the hoses had not been tested or replaced within the required five-year period prior to the survey. The deficiency was identified through a combination of observation, document review, and staff interviews. The lack of documentation confirming the testing or replacement of the fire hoses within the stipulated timeframe was noted. At the time of the survey, the Director of Maintenance acknowledged the oversight and stated that the fire hoses would be tested or replaced, although this action is not part of the deficiency itself.
Plan Of Correction
Plan of Correction: Approved April 27, 2025 I. Immediate Corrective Action 1) The Director of Engineering engaged our Service Company to replace the identified standpipe fire hoses with new hoses in all locations more than five years old. 2) The Director of Engineering engaged our Service Company to inspect the building’s standpipe system to determine those testing years and complete NFPA required testing if necessary. II. Identification of other areas potentially affected. 1) All Residents have the potential to be affected by this practice. 2) The Director of Engineering will have the Service company inspect facility-wide standpipe and fire hose systems for similar issues. III. Systemic Changes 1) The policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2) The existing rounds inspection form has added the monthly standpipe audit tool. 3) This has been added to the facility preventive Engineering program. 4) Staff involved in the review, Engineering and/or repair of the sprinkler system were educated by the Director of Engineering that any issues with standpipe system identified during rounds will be corrected immediately and interim safety measures put in place as needed until repairs are complete. IV. Quality Assurance Monitoring 1) The Director of Engineering created an audit tool to monitor compliance with required inspections of sprinkler systems. This audit includes inspection of fire hose racks. Any identified issues will be corrected as soon as possible. 2) The Director of Engineering will audit the whole facility monthly for the first 3 months and then quarterly for 9 months. Audit results will be submitted to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. 3) The frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. V. Responsible Person: Director of Engineering