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K0353
F

Sprinkler System Maintenance Deficiency

Lima, Pennsylvania Survey Completed on 02-04-2025

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 and inspect its sprinkler system as required, affecting the entire component. During a document review on February 3, 2025, it was found that the facility could not provide documentation that a dry sprinkler full flow test had been conducted within the past three years. Additionally, an observation on February 4, 2025, revealed a missing sprinkler escutcheon above the ice machine on the fifth floor. These deficiencies were confirmed during an exit interview with the Maintenance Director on February 4, 2025.

Plan Of Correction

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0353 - 1 Sprinkler Company will be contracted to perform inspection. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. K 0353 - 2 Escutcheon was replaced. Area will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated.

See complete original report
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