Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
The facility failed to maintain its automatic sprinkler system free of extraneous weight, as required by NFPA 25 and related standards. During an observation on August 12, 2025, surveyors found that multiple wires and flex conduit were being supported by the sprinkler piping system above the ceiling near Resident Room 200 on the 2nd floor Engle. Additionally, on the 3rd floor Greenwood, above the ceiling by the elevator back of house, multiple wires were tied to a sprinkler bracket. These findings were confirmed during an interview with the Administrator, Vice President of Facilities, Life Safety Manager, and Facilities Manager.
Plan Of Correction
1) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored; On 8/13/25, the Life Safety Manager contacted COR Construction (outside vendor) to schedule a walkthrough of required work to remove all extraneous weight on the automatic sprinkler system at the following locations: (a) 2nd floor Engle, above ceiling, by Resident Room 200, and (b) 3rd floor Greenwood, above ceiling, by elevator back of house. COR Construction will begin this work the week of September 1, 2025, with monitoring check-ins completed by the Life Safety Manager. 2) What quality assurance program will be put into place, and the dates when corrective action will be completed? COR Construction will inspect all sprinkler lines annually to ensure no extraneous weight affects the automatic sprinkler system in the Greenwood and Engle neighborhoods. Deficiencies will be identified and remedied at time of inspection. Results of the inspection and any identified deficiencies will be reported through the QAPI program. 3) Date of compliance: 9/30/25 THIS PAGE IS NOW PART OF THIS SURVEY