K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 21, 2018
Corrected date: July 9, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code Survey, it was determined that for one of one basement, the facility did not properly maintain the sprinkler system. Specifically, sprinkler heads were not properly spaced and a non-sprinklered room had an improperly sealed opening in a required fire barrier. The findings include: Observations conducted on 5/9/18 between 1:13 p.m. and 1:31 p.m. revealed the following: a. The Main Electric room located in the basement lacked sprinkler protection. When interviewed, the Facilities Director stated that he was under the impression that a room could be un-sprinklered as long as it was completely separated by a two-hour fire wall. Further observations at that time revealed that there was a 4-inch conduit penetrating the corridor wall which had an approximate 1-inch annular space around the conduit, which was not properly sealed with a fire stopping system. There was also an approximately 3-inch conduit that was sealed from the inside of the electric room, but not on the corridor side. The annular space around the conduit was between 1 inch and 3 inches wide. b. There was approximately 14 feet of space between the wall of the basement Health Information Management storage room and the first pendant sprinkler head. There was no documentation to show the sprinkler provided extended coverage. In an interview on 5/14/18 at 2:32 p.m., the Maintenance Manager stated that he had reached out to the vendor who did not know if the sprinkler head was an extended coverage head or a standard pendant head. Further observations at that time revealed that the bottom of the deflector plate was stamped with: A SSP and 22s2. The facility was unable to determine the brand of sprinkler head, and the vendor did not provide any product data on the pendant head in question. The 2010 edition of NFPA 13: Standard for the installation of Sprinkler Systems states: 1) The distance from sprinklers to walls shall not exceed one-half of the allowable maximum distance between sprinklers. 2) Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.5.1, 9.7.1; 2010 NFPA 13: 8.1.1, 8.5.3.2.1, 8.15.10.3)

Plan of Correction: ApprovedJune 15, 2018

1. The 4-inch and 3-inch conduit were repaired with fire stop material on May22, (YEAR). Solution one will be installing another sprinkler head in the Health Information Management storage room. 2. All residents have the potential to be affected by this practice. In-service will be conducted by the Maintenance Manager on smoke barrier walls and insuring that there are no openings and an audit of sprinkler heads was completed. 3. Maintenance will conduct quarterly audits on smoke barrier walls and sprinkler heads for one year then annually thereafter. 4. Maintenance Manager will report findings to the QA committee on a quarterly basis. 5. Maintenance Manager is responsible. Date completed (MONTH) 9, (YEAR)