Sprinkler System Maintenance and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that its sprinkler systems were maintained and tested in accordance with NFPA 13 and NFPA 25 standards. During a Life Safety Code recertification survey, it was observed that sprinkler heads were improperly positioned in close proximity to light fixtures, which could obstruct the discharge and distribution of water. Specifically, a light fixture was installed approximately 2 inches from a sprinkler head in the residents' donation clothes storage room, and another was 1 inch from a sprinkler head in the dietary office closet, both on the second floor. Additionally, the survey revealed maintenance issues with the sprinkler heads themselves. The sprinkler head inside the walk-in refrigerator in the kitchen was found to have heavy dust accumulation, and another sprinkler head in the walk-in refrigerator by the mechanical room in the basement showed signs of corrosion. These conditions indicate a lack of proper maintenance and inspection, which are required to ensure the effective operation of the sprinkler system. Furthermore, a review of the facility's sprinkler system inspection records showed deficiencies in documentation. The records did not include evidence of a check valve inspection, which is required every five years. A vendor invoice from October 2023 mentioned an internal inspection of piping but did not specify if the check valve inspection was performed. Additionally, a report from October 2024 failed to record the supply and residual water pressure values during a drain test. The Director of Building Services acknowledged these documentation gaps and stated that they would contact the inspection company for clarification, but no further documentation was provided by the end of the survey.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 I. All sprinklers were audited to ensure proper location and free of dust to ensure proper distribution of water from the sprinkler head; no other issues were found. The light fixtures identified during the survey for being too close to the sprinkler heads have been relocated, allowing for proper distribution of water. Sprinkler company was called on (MONTH) 24th to schedule onsite tech to relocate the sprinkler head in the donation storage room, the dietary office. Sprinkler heads for the walk-in refrigerator have been ordered and will be replaced by 3/7/25. II. Sprinkler company was called on (MONTH) 24th to review and update the most recent 5-year sprinkler system inspection to ensure completed information, including the check valves and all boxes are checked off properly. Documents were received on 2/28/25. Sprinkler company has also supplied paperwork showing that the supply and residual water pressure was completed. III. Anyone has the potential to be affected. IV. The maintenance department has been educated on LSC K-353 NFPA 101 Sprinkler System Maintenance and Testing by the Director of Maintenance. V. Facility has developed an audit tool to ensure sprinkler inspections are properly documented and complete. Facility has developed an audit tool to ensure sprinkler heads are clear of fixtures that would impede the proper distribution of water, dusted, and corrosion-free. Audits will be completed by the Director of Maintenance after each inspection. Audits will be conducted on sprinkler heads monthly for 3 months. All findings to be reported to QAPI. VI. Responsible party: Director of Maintenance/Designee.