Deficient Sprinkler Coverage in Stairwell and Electrical Room
Summary
The facility failed to ensure proper sprinkler coverage in accordance with NFPA 101 and NFPA 13 standards. During a life safety tour, it was observed that sprinkler coverage was missing under the first accessible landing in stairwell B. Additionally, the electrical switch gear room located in the enclosed garage lacked sprinkler coverage. The room, which is supposed to be dedicated to electrical equipment only, contained two ladders and two chairs, indicating the presence of combustible storage, which is not permitted under the specified conditions for not requiring sprinklers.
Plan Of Correction
Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Facilities immediately removed noted ladders and chairs from electrical switch gear room. - Director of Facilities or designee will conduct in-service education with Facilities Staff on the prohibition of combustible storage in the electrical equipment room by 3/20/25. - The Director of Facilities or designee will obtain quotes and will select an appropriate vendor to install an automatic sprinkler in the first accessible landing of Stairwell B by 3/31/25. - Once an appropriate vendor is identified, the Director of Facilities or designee will schedule sprinkler installation and permit process for Stairwell B, work expected to be completed by 4/21/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of facilities will conduct audit of electrical equipment room weekly x4 and then monthly x5. Updates will be provided during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities
Penalty
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