Improper Sprinkler Installation and Coverage
Penalty
Summary
The facility failed to ensure proper installation and coverage of the automatic sprinkler system as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a recertification survey, it was observed that the sprinkler coverage was inadequate at the bottom landing of Stairwell D near a discharge door and in the emergency laundry storage room located in the basement. Additionally, a pendent sprinkler in the Soiled Utility Room was installed closer than four inches from the wall, which does not comply with the minimum distance requirements. Further deficiencies were noted during a tour of the kitchen, where a sidewall sprinkler was improperly installed on the ceiling of the dessert refrigerator. On the 3rd Floor of the Manor building, a sidewall sprinkler was also incorrectly installed on the ceiling of the Staff Restroom, and a pendent sprinkler was positioned closer than four inches from the wall in the resident's Shower Room. These observations indicate a failure to adhere to the specified guidelines for sprinkler installation, potentially compromising the effectiveness of the fire protection system.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2010 NFPA 13, the Director of Engineering contacted the Fire Safety Sprinkler Company to: 1. Install the lacking fire sprinklers at the bottom landing of stairwell D and the emergency laundry storage room. 2. Appropriate sprinkler will be installed in the soiled utility room, 3rd floor Manor building staff restroom and the residents shower room. 3. The facility has signed a contract for installation and work has commenced. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility states that all residents have the potential to be affected by deficient practice. b. The contracted company reviewed sprinkler coverage throughout the facility and no additional areas were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. All Engineering staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as overview of requirements for sprinkler coverage as per K351. b. The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering has reviewed and revised the Environment Care Audit tool to ensure proper sprinkler coverage. b. Audits will be performed monthly by the Engineering Director/designee x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected by the Engineering Department or our contracted sprinkler company as needed. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering