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K0353
F

Failure to Maintain Sprinkler System Components

Stillwater, Pennsylvania Survey Completed on 12-23-2024

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 its automatic sprinkler system components, which affected the entire facility. During a document review on December 23, 2024, it was found that the sprinkler inspection report from November 8, 2024, identified specific deficiencies. The sprinklers in the 'old part' of the building were dated 1974 and required UL-Testing. Additionally, the Fire Department Connection (FDC) needed to be hydrotested. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.

Plan Of Correction

1. On 1/6/2025 the Maintenance Director contacted The Tustin Group to schedule UL testing for the sprinklers in the "old part" of the building. 2. On 1/6/2025 the Maintenance Director contacted The Tustin Group to have the FDC hydrotested. Testing is scheduled for 2/2/2025. 3. On 12/24/2024 the Maintenance Director checked all sprinkler inspection reports for cited deficiencies. There were no other deficiencies. 4. On 12/30/2024 the NHA educated the maintenance team on correcting deficiencies cited following a sprinkler inspection. 5. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that the deficiencies cited following an inspection are corrected timely. Results of the audits will be reviewed at the QAPI meeting held monthly.

See complete original report
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