Attic Sprinkler System Not Installed per NFPA 13
Penalty
Summary
The facility failed to provide a sprinkler system installed in accordance with NFPA 13, as required by federal regulations. During a record review, it was found that the dry sprinkler system throughout the attic space had been capped off, resulting in the attic space lacking complete sprinkler protection. This deficiency was confirmed by the Maintenance Director at the time of the review. The report does not mention any specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
1. The facility failed to maintain the dry sprinkler system in proper working condition throughout the entire building. 2. A non-functioning dry sprinkler system poses a serious risk to the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics was engaged to install a second air compressor and replace 12 feet of main sprinkler piping. - The system was water-tested, during which two leaks were identified (above a resident room and in the boiler room); both were repaired. - A trip test will be conducted by Superiorland Electronics to verify full functionality of the system. - The Maintenance Director has received training on the importance of routine inspection and upkeep of the dry sprinkler system. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is now responsible for ensuring the sprinkler system remains fully operational and will report on system status and any maintenance issues during regular Quality Assurance (QA) Committee meetings.