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K0353
E

Failure to Maintain Sprinkler System Documentation

Philadelphia, Pennsylvania Survey Completed on 01-22-2025

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 its sprinkler system as required, affecting two out of four inspections. During a document review on January 22, 2025, it was discovered that the facility could not provide documentation for the First and Third Quarter sprinkler inspections conducted in the previous 12 months. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.

Plan Of Correction

Sprinkler inspections are up to date and documentation is available. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0353- Sprinkler System Maintenance and Testing. The Maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.

See complete original report
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