Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler and standpipe systems in accordance with NFPA 101 and NFPA 25 standards. During a life safety recertification survey, it was observed that the quarterly sprinkler report for the third quarter of 2024 was missing. Additionally, several sprinklers in the laundry room, dishwashing room, and family lounge area exhibited signs of corrosion and were missing escutcheon plates. Water pressure gauges on the sprinkler system were outdated, and documentation of their re-calibration or replacement was not provided. An unknown substance was also found on the sprinklers in the Beauty Salon. Interviews with the Director of Maintenance revealed that the facility had not yet addressed these issues, although the Director stated that a vendor would be contacted to assess the sprinklers. These deficiencies were noted in the basement and on one of the two resident floors, indicating a widespread issue with the maintenance of the facility's fire protection systems.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K353 I. Immediate Corrective Action: 1. Quarterly Sprinkler Report for 2024: - On 3/19/25, the Director of Maintenance contacted the sprinkler service vendor to request the missing third-quarter report for 2024. - The report was obtained on 3/20/25 and placed in the facility’s records to ensure compliance with NFPA 101 and NFPA 25. 2. Sprinkler Corrosion and Missing Escutcheon Plates: - On 3/19/25, the Director of Maintenance immediately contacted a certified sprinkler contractor to assess and address the corrosion and missing escutcheon plates on sprinklers in the laundry room, dishwashing room, family lounge area, and Beauty Salon. - The vendor inspected and replaced corroded sprinklers and installed missing escutcheon plates on 3/20/25. 3. Water Pressure Gauges: - On 3/19/25, the Director of Maintenance arranged for the recalibration or replacement of outdated water pressure gauges. - The water pressure gauges have been replaced by a certified vendor. 4. Substance on Sprinklers (Beauty Salon): - On 3/19/25, the Director of Maintenance immediately arranged for the cleaning and inspection of the sprinklers in the Beauty Salon, where an unknown substance was found. - The sprinklers were replaced on 3/20/25. II. Identification of Others: - The Director of Maintenance conducted a full inspection of all sprinkler systems in the facility, including those in other common areas, to ensure no additional sprinklers were corroded or missing escutcheon plates. - All residents have the potential to be affected. - No additional issues were found, but ongoing checks will be implemented to prevent future occurrences. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility’s sprinkler maintenance policy to ensure all quarterly sprinkler inspections are properly documented and provided in a timely manner. - Maintenance staff will now inspect all sprinklers monthly for six months to ensure no corrosion or damage is present. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system maintenance, including quarterly inspections and repairs. 2. The results of monthly audits will be reported to QAPI quarterly, with any corrective actions taken promptly. V. Person Responsible: - Director of Maintenance