Deficiency in Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that all areas of the building were protected by an automatic sprinkler system, as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, a storage structure attached to the back of the building was observed to be constructed with combustible materials, including wooden roof supports. This structure, measuring approximately 20 feet by 8 feet, was located within 10 feet of an egress door at the rear of the building and contained a large amount of cardboard boxes, which are considered combustible materials. The deficiency was identified during an observation at approximately 10:30 am on March 6, 2025. The lack of sprinkler protection in this area was confirmed through staff interviews, indicating a failure to comply with the required fire safety standards. The presence of combustible materials in a structure without adequate sprinkler coverage poses a potential fire hazard, which was not directly addressed in the report. The facility's administrator acknowledged the issue during the exit conference on the same day.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I. Immediate Corrective Actions 1. The facility maintenance department made a plan to demolish the storage shed near the egress. 2. The storage identified without a sprinkler will be completely removed. II. Identification of Other Residents 1. All residents have the potential to be affected by the deficient practice. 2. The maintenance department reviewed sprinkler coverage throughout the Facility and no additional areas were identified. III. Systemic Changes: 1. All Maintenance staff were informed and educated on (MONTH) 18th regarding sprinkler heads and their locations, as well as overview of requirements for sprinkler coverage as per K351. 2. The education concentrated on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. IV. QA Monitoring 1. The Maintenance staff has developed an audit tool to validate preventive maintenance and track compliance with all the sprinkler heads/locations. 2. Audits will be done weekly x4 initially by Maintenance/designee to inspect the sprinkler heads/locations, then monthly thereafter for compliance with our preventive maintenance plan. 3. Any sprinkler heads/locations identified with quality issues by these audits will be corrected by the Maintenance staff or Fire Safety Company staff as needed. 4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated. II. Responsible person: Director of Environmental Services Date of completion: 5/1/25