Sprinkler System Deficiency in Stairwell
Penalty
Summary
The facility failed to ensure that sprinkler heads were installed in all required areas of the building, specifically on the basement side of a door interrupting the East stair on the first floor landing. This deficiency was identified during a life safety survey conducted on March 13, 2025, at approximately 10:15 am. The absence of a sprinkler head in this location was observed and acknowledged by the Maintenance Director, Administrator, and Environmental Services Director. The requirement for sprinkler systems is outlined in the 2012 NFPA 101 and 2010 NFPA 13 standards, which mandate that sprinklers be provided on each side of separations in noncombustible stair shafts.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action A sprinkler head was installed on the basement side of the door ( ). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all areas of the building was completed to ensure that where noncombustible stair shafts are divided by walls or doors, sprinklers are provided on each side of the separation. (3/27/25) No other issues were found. All Maintenance staff will be in serviced on the importance of ensuring that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on the installation of Sprinkler Systems in residential occupancies up to and including four stories in height. All Maintenance staff will be in serviced on the policy which states that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation in accordance with 2010 NFPA 13 8.15.3.2.2 (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that Sprinkler Systems in residential occupancies where noncombustible stair shafts are divided by walls or doors, that sprinklers are provided on each side of the separation. There will be a visual check of all noncombustible stair shafts that are divided by walls or doors and ensure that sprinklers are provided on each side of the separation weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25- Date of Correction.