Sprinkler System Obstructions and Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain compliance with NFPA 13 standards for automatic sprinkler system installation and maintenance. During an inspection, surveyors observed that multiple resident room shower curtains were positioned within 18 inches of the sprinkler head spray pattern, which is not permitted under NFPA 13, section 8.5.5.2. Additionally, ceiling tiles were found to be missing in the Pewabic House Pantry and the Franklin House Clean Utility rooms. These deficiencies were confirmed by the Facilities Director at the time of discovery. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K351: Sprinkler System Installation The facility will ensure the sprinkler system is installed as required. This will be accomplished with the following: The facility will inventory all shower curtains in the facility and replace the shower curtains that are within 18" of the sprinkler head spray pattern. The facility will visually inspect each shower curtain in the facility to identify any that are not compliant, and these will be replaced. The facility will work with the Materials Management department to ensure that the appropriate shower curtains are stocked in the supply room so that when a curtain needs to be replaced, it is replaced with a compliant curtain. The facility will ensure all ceiling tiles are in place in two locations: Pewabic house pantry and Franklin clean utility room. This will be accomplished by replacing all missing ceiling tiles in these locations. The facility will conduct a weekly audit to look for missing ceiling tiles throughout the entire facility. If a missing ceiling tile is identified, the NHA will submit a work order to the Facilities department to have the ceiling tile replaced or reinstalled that day. All staff will be provided education that all ceiling tiles need to be in place at all times unless being actively worked on. All staff will sign off on this education. If staff notice a ceiling tile is missing, a work order needs to be submitted to the Facilities department to have the tile replaced or reinstalled that day.