Sprinkler System Maintenance and Signage Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During a tour of the building, a sprinkler pendant in the shower room adjacent to the MDS Office was observed to be green, corroded, and had a green-tinted fusible link. The Maintenance Consultant attributed the corrosion to moisture and steam from the showers. Additionally, the inspection revealed that the sprinkler backflow piping and Fire Department Connection (FDC) were missing the required signage to indicate the system or portion of the system they control. The Maintenance Consultant stated that the missing signage had not been previously cited and believed it was unnecessary due to the building being the only structure connected to these pipes. These deficiencies affected all five residents and both smoke compartments in the facility. The lack of proper maintenance and required signage on the sprinkler system components was directly observed and confirmed through staff interviews during the survey.
Plan Of Correction
NFPA 101 Life Safety Code Standards K353 Sprinkler Maintenance and Training The sprinkler pendant in the shower room was replaced and a sign with the facility address was placed on the sprinkler backflow piping. (See attached photos) To monitor the fire sprinkler pendants in the building and to verify that the signage is on the backflow piping, the Director of Maintenance will perform a monthly audit for 3 months. The Administrator will review the monthly audits and bring the findings to the Quality Assurance Team on a quarterly basis to evaluate the effectiveness of the program. This corrective action was completed June 20th, 2025. K 353