Deficiency in Sprinkler System Installation Under Canopy
Summary
During a recertification survey, it was observed that the automatic sprinkler system was not installed in accordance with the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.15.1. Specifically, automatic sprinkler protection was absent at an exit discharge under a cloth canopy attached to Building #3. The canopy, which is greater than 20 feet in length, was found at the exit discharge nearest to the basement of Building #1. There was no documented evidence that the canopy fabric is fire-retardant. The facility's administrator stated that the canopy was installed in 2020 and they are in the process of contacting the vendor to obtain documentation regarding the fire-retardant nature of the canopy fabric.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. Canopy attached to Building #3 to be replaced with approved fire-retardant material. 2. Other building areas where a canopy is in use and subject to this standard will be inspected to ensure appropriate fire-retardant product is in use where exterior sprinklers do not exist. 3. Documentation will be maintained demonstrating fire-retardant materials are in use when installed. 4. Once the correction is made, no further monitoring is indicated. Completion status will be reported to the Quality Assurance/Performance Improvement committee. Director of Plant Operations
Penalty
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