Deficient Sprinkler Coverage in Key Areas
Penalty
Summary
During a life safety recertification survey, several deficiencies were identified in the facility's sprinkler system coverage, which did not comply with NFPA 101 and NFPA 13 standards. Specifically, the survey revealed that sprinkler coverage was missing in the alcove area of the soiled utility discharge linen chute room. Additionally, the walk-in box used for dry storage in the storage room on corridor D lacked sprinkler coverage. Furthermore, in one of the emergency exit stairwells, sprinkler coverage was not observed under the first accessible landing, affecting two resident floors and the basement. These deficiencies were noted during a survey conducted between 9:30 AM and 3:30 PM. At approximately 11:40 AM, the absence of sprinkler coverage in the alcove area was observed. By 12:00 PM, the lack of sprinkler coverage in the walk-in box was identified, and at 12:50 PM, the deficiency in the stairwell was noted. The Director of Maintenance acknowledged these findings during an interview and mentioned that a vendor would be contacted to address the issues.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K351 I. Immediate Corrective Action: 1. Soiled Utility Discharge Linen Chute Room (Alcove Area): - On 3/19/25, the Director of Maintenance immediately arranged for an inspection and installation of sprinkler coverage in the alcove area adjacent to the discharge chute in the soiled utility room. - Sprinkler coverage was installed and tested by a certified sprinkler contractor on 3/19/25, ensuring compliance with NFPA 101 and NFPA 13 standards. 2. Walk-In Storage Box: - On 3/19/25, the Director of Maintenance contacted a certified contractor to install the missing dry sprinkler coverage in the walk-in box used for storage in the storage room on corridor D. - Sprinkler coverage was installed and tested by the contractor on 3/19/25, ensuring full compliance with NFPA 101 and NFPA 13. 3. Stairwell Landing (Basement): - A sprinkler contractor was contacted to install sprinkler coverage under the first accessible landing in the emergency exit stairwell located in corridor 4 in the basement. - The missing sprinkler coverage was installed and tested ensuring compliance with NFPA 101 and NFPA 13. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a thorough inspection of all other stairwells, utility rooms, and storage areas on the premises to ensure there are no further gaps in sprinkler coverage. - Additional checks were made to verify compliance in all areas, and no further issues were found. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility’s sprinkler system installation policy to ensure that all areas, including utility rooms, storage spaces, and stairwells, are covered in accordance with NFPA 101 and NFPA 13. - A new protocol was implemented for regular, detailed inspections of sprinkler coverage during routine maintenance rounds to ensure no areas are missed in the future. 2. A review of all floor plans was conducted to verify that sprinkler coverage is properly indicated and confirmed for all spaces. 3. The Director of Maintenance in-serviced to understand the importance of compliance with sprinkler installation standards and the process for identifying and addressing gaps in coverage. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system coverage throughout the facility, ensuring ongoing compliance with NFPA 101 and NFPA 13. - Monthly inspections and audits of all sprinkler systems, including utility rooms, storage areas, and stairwells, will be conducted with findings documented for review. 2. The results of the audits and any corrective actions will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance