Deficiencies in Sprinkler System Maintenance and Inspection
Penalty
Summary
The facility failed to maintain its automatic sprinkler and standpipe systems in accordance with NFPA 25 standards, as observed during a life safety recertification survey. The survey revealed that the 5-year internal pipe inspection report was missing and not provided at the time of the survey. During an interview, the Facility Project Manager acknowledged that the inspection had been completed but could not locate the report. This lack of documentation indicates a failure in maintaining proper records of required inspections. Additionally, during a tour of the kitchen, it was noted that three sprinklers in the pot washing area and a sprinkler where hanging pots are stored showed signs of corrosion. This condition was confirmed by the Director of Plant Operations, who stated that the sprinklers would be replaced. Furthermore, an examination of the telephone closet revealed that a light bulb fixture obstructed the spray pattern of a sprinkler, which was also acknowledged by the Director of Plant Operations. These findings highlight deficiencies in the maintenance and inspection of the facility's fire protection systems.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The facilities Certified Sprinkler Inspection and Testing Company completed the five (5) year sprinkler obstruction and internal valve inspection on 06/07/2022. The Certified Sprinkler Company will replace the identified 3 sprinkler pendants in the Kitchen. The maintenance staff will permanently relocate the identified light fixture in the Telephone closet to remove the obstruction to the sprinkler pendant. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance will review all sprinkler inspection and testing reports were completed and available for inspection by the Authority having jurisdiction at all times. The maintenance will survey the entire building for signs of corrosion of sprinkler pendants and obstructions to sprinklers. Any deficiencies identified will be corrected. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All Maintenance staff will receive additional education and all participants will understand the life safety issues identified during the facility’s survey and the importance of ensuring compliance with the requirements of maintenance and proper installation of sprinklers 2012 NFPA 101: 9.7.5 and 2011 NFPA 25 5.2.1.1.2. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The established Preventive Maintenance & Scheduling system will be followed reflecting the inspection and testing of the automatic sprinkler system as required by all codes, rules, and regulations. All inspection results will be recorded in the building Records & Logs and available for inspection by the Authority having jurisdiction at all times. The Director of Maintenance or Designee will inspect sprinklers monthly and record the results in the facilities Records & Logs. The Director of Maintenance will also complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly sprinkler inspection audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the sprinkler inspections to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted.