Non-Compliance with Sprinkler System Requirements in Attic Space
Penalty
Summary
The facility failed to ensure that its building construction type and number of stories complied with the requirements outlined in Table 19.1.6.1, as required unless otherwise permitted by specific exceptions. During a record review and interview, it was found that the dry sprinkler system in the attic space did not pass inspection because the system was capped and only six sprinkler heads were operational. The annual dry sprinkler inspection report confirmed this deficiency, and the Maintenance Director verified that the attic sprinkler system was not functioning properly. This failure is in violation of the requirement that all LTC facilities be fully sprinklered and maintain their systems as mandated by 73 CFR 47075.
Plan Of Correction
1. The facility did not maintain the dry sprinkler system in proper working condition throughout the building. 2. A malfunctioning dry sprinkler system poses a risk to the safety of all residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been completed as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The sprinkler system was flooded and tested, revealing two leaks (located above a resident room and in the boiler room); both have been repaired. - Superiorland Electronics will conduct a trip test to confirm the system is functioning properly. - The Maintenance Director has been educated on the critical importance of maintaining the dry sprinkler system in working order. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ongoing monitoring of the dry sprinkler system to ensure it remains operational at all times and will report system status and maintenance updates to the Quality Assurance (QA) Committee.