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K0353
E

Deficiency in Sprinkler System Maintenance

Exeter, Pennsylvania Survey Completed on 12-10-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the automatic sprinkler system, as evidenced by an observation on December 10, 2024. During the inspection, it was noted that the automatic sprinkler head assemblies located within the Laundry area were "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager on the same day.

Plan Of Correction

- The sprinkler head assemblies located in the laundry area were immediately cleaned and free of lint. - The sprinkler head assemblies throughout the facility were checked to ensure clean and free of debris. - Maintenance Director will be educated by NHA to ensure sprinkler head assemblies are clean and free of debris. - The sprinkler head assemblies will be randomly audited by the maintenance director to ensure the sprinkler head assemblies are clean and free of debris. Trends will be reviewed at QAPI meeting monthly.

See complete original report
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