Improper Maintenance of Sprinkler System
Penalty
Summary
The facility failed to ensure the proper maintenance of its sprinkler system, as observed during the Life Safety Code Survey. Specifically, there were mixed types of sprinkler heads installed in various locations, which is against the code requirements. In the main kitchen's walk-in freezer, both standard response and quick response sprinkler heads were found. Similarly, the East stairwell had a quick response sprinkler head on the bottom landing, while the other landings had standard response heads. Additionally, the area inside the first floor loading dock had a mix of five standard response and one quick response sprinkler head. These discrepancies were not documented in the quarterly sprinkler inspection reports, which showed no deficiencies or recommendations. Furthermore, the facility lacked sprinkler coverage at the top of the West basement stairwell. The Maintenance Supervisor was unaware of the code requirements regarding mixed sprinkler heads and the need for sprinkler coverage at the top of the stairwell. The supervisor relied on the vendor to ensure compliance with the code. The 2010 edition of NFPA 13 requires that all sprinklers within a compartment be of the same type and that sprinklers be installed at specific locations in stairwells, which the facility failed to comply with.
Plan Of Correction
Plan of Correction: Approved April 24, 2025 Corrective action for the affected residents: Item 1 – As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - Facility will employ our sprinkler vendor within 60 days to replace all Quick Response sprinkler heads, unifying the facility to Standard Response sprinkler heads. Item 2 – As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - Facility will employ our sprinkler vendor to add the additional Standard Response head to the West stairwell, top of shaft, at the first-floor level, within 60 days. Identification of potentially affected residents: All residents are at risk of being affected by the deficiency. Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - Facility will employ our sprinkler vendor to complete a full building audit looking for mixed heads throughout the building, as well as ensuring the correct heads are in the location they occupy within 60 days. Item 2 – As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - Facility will employ our sprinkler vendor to complete a full building audit to verify that there are no other areas out of compliance for the same reason. Measures to prevent reoccurrence: Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - The Director of Facilities, with the help of the sprinkler vendor, will educate Facilities Staff on the requirements for where, and what style of sprinkler head is required and to monitor such during our annual TELS sprinkler head inspections task. Item 2 – As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - The Director of Facilities, with the help of the sprinkler vendor, will educate Facilities Staff on the requirements for where, and what style of sprinkler head is required and to monitor such during our annual TELS sprinkler head inspections task. Continued compliance: Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - The Maintenance Dept. will audit quarterly and report the results to the QA Committee. Item 2 – As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - The Maintenance Dept. will audit quarterly and report the results to the QA Committee. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. Person Responsible: Director of Maintenance.