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Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting one of two smoke zones. The facility has a capacity of 18 with a census of 5.

Findings Include:

During the survey on 05/29/2012 between 10:30 AM and 3:15 PM the following is observed:

1) A sprinkler head in the west recovery area located close to an air vent is heavily laden with lint.

2) A sprinkler head in the kitchen is heavily laden with lint.

Administrative Staff A, Maintenance Staff A and B were present and acknowledged the finding.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2 2.1.1.

NFPA Standard: Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture. 1998 NFPA 25, 2 4.1.8.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

NFPA Standard: Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5 5.5.2 and 5 5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A 5 5.5.1.) 1999 NFPA 13, 5 5.5.1.

NFPA Standard: Obstructions to Sprinkler Discharge Pattern Development.1999 NFPA 13, 5 5.5.2.

NFPA Standard: Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5 5.5.2. 1999 NFPA 13, 5 5.5.2.1.

NFPA Standard: Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5 6 through 5 11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures. 1999 NFPA 13, 5 5.5.2.2.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting one of two smoke zones. The facility has a capacity of 18 with a census of 5.

Findings Include:

During the survey on 05/29/2012 between 10:30 AM and 3:15 PM the following is observed:

1) A sprinkler head in the west recovery area located close to an air vent is heavily laden with lint.

2) A sprinkler head in the kitchen is heavily laden with lint.

Administrative Staff A, Maintenance Staff A and B were present and acknowledged the finding.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2 2.1.1.

NFPA Standard: Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture. 1998 NFPA 25, 2 4.1.8.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

NFPA Standard: Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5 5.5.2 and 5 5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A 5 5.5.1.) 1999 NFPA 13, 5 5.5.1.

NFPA Standard: Obstructions to Sprinkler Discharge Pattern Development.1999 NFPA 13, 5 5.5.2.

NFPA Standard: Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5 5.5.2. 1999 NFPA 13, 5 5.5.2.1.

NFPA Standard: Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5 6 through 5 11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures. 1999 NFPA 13, 5 5.5.2.2.