Improper Sprinkler Installation in Loading Dock Corridor
Penalty
Summary
During a Life Safety Recertification Survey conducted on two consecutive days, it was observed that the facility did not comply with the 2010 NFPA 13 standards for sprinkler installation. Specifically, in the corridor leading to the secondary access of the Loading Dock, pendent-style sprinkler heads were installed approximately 56 inches below the ceiling, which exceeds the maximum allowable distance of 12 inches. This installation was at the same level as the lighting fixture. The Director of Maintenance acknowledged that the ceiling had been removed and stated it would be replaced, indicating a temporary alteration that led to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K 351 Sprinkler System - Installation 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The ceiling, in the corridor of the secondary access to the loading dock, was reinstalled where the sprinkler heads were found to be greater than 12 in. from the ceiling. The ceiling in the corridor of the secondary access to the Loading Dock was reinstalled to its original position. The pendent-style sprinkler heads were adjusted to ensure the installation is in accordance with 2010 NFPA 13. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Maintenance or Designee will conduct a thorough inspection of all sprinkler heads to confirm that installation is not greater than 12 in. from the ceiling. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Fire Safety Team and the Maintenance team were in-serviced on NFPA Standard for the installation of Sprinkler Systems and highlighted their role in ensuring that pendant style sprinkler heads are not greater than 12 in. from the ceiling in accordance with NFPA 13. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming that Sprinkler Heads are not greater than 12 in from the ceiling. The Maintenance Staff will address any sprinkler heads that are not compliant with the standard. Regular maintenance checks will be conducted to ensure that all sprinkler heads are installed and maintained in accordance with 2010 NFPA 13. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance/Designee will review 10% of all sprinkler heads to confirm that they are installed no greater than 12 in from the ceiling for a period of 3 months or until improvement is sustained that all sprinkler heads are no more than 12 in from the ceiling. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance