The executive director of a Pennsylvania continuing care retirement community where four residents died in a November 2017 fire said the provider was “deeply distressed” that investigators, according to a report issued last week, believe that the building’s main sprinkler valve was off during the blaze.

“This information confirms our worst fears, and we have taken steps to make sure this can never happen again,”  Barclay Friends Executive Director Linda Sterthous wrote in an open letter posted on the CCRC’s website.

The West Chester, PA, community is an affiliate of the Kendal Corp.

The cause of the five-alarm fire has been ruled “undetermined,” the Bureau of Alcohol, Tobacco, Firearms and Explosives and the Chester County Fire Marshal’s Office said, adding that “investigators were unable to determine definitively when the [main sprinkler] value was turned off.” The blaze does not appear to have been intentionally set, they said.

Collaborators in the investigation — including the ATF’s Philadelphia Field Division and National Response Team, the Chester County District Attorney’s Office, the Chester County Fire Marshal’s Office, Pennsylvania State Police, the West Chester Police Department, the Chester County Sheriff’s Office and the Chester County Department of Emergency Services — reached their conclusions after conducting more than 300 interviews, examining the scene, reviewing witnesses’ photographs and videos, and performing scientific testing at an ATF lab.

The fire started in a rear garden room, on the outdoor patio under an overhang of a building that housed residents with personal care and memory care needs, investigators said. The four older adults who died in the fire were residents of that building, known as the Woolman building.

Smoke and fire alarms, as well as fire doors, worked as intended on the night of the fire, according to investigators.

“Based on the totality of the investigation, it is the belief of the investigators that due to the excessive winds the night of November 16, 2017, the flammability of the vinyl siding on the building, and lack of exterior sprinklers (not currently required by code), the fire was able to intensify and spread rapidly to the roof and other parts of the building,” they said.

Since the fire, Sterthous said, Barclay Friends has “thoroughly examined and upgraded our fire protection systems and procedures across our campus.”

The CCRC’s skilled nursing building, called the Cotter building, was protected by a system of firewalls during the fire and sustained only water damage, according to Barclay Friends. It was closed after the fire until April 2018, however, so that equipment could be replaced, utilities could be rebuilt and repairs and renovations could be made.

“In advance of the reopening of the Cotter skilled nursing building, we installed an all-new fire alarm system, and all life safety systems were thoroughly inspected by multiple local and state authorities — including experts from Pennsylvania’s Department of Health’s Life Safety Division,” Sterthous wrote. “We continue to work with a team of expert advisers — engineers and architects — to make our systems better.  And, we have reinforced our training protocols.”

Barclay Friends demolished the Woolman assisted living building after the fire. Its planned replacement, named the Preston building, is being designed, Sterthous said, and “will have “state-of-the-art fire safety systems and construction materials.”

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