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K0353
E

Sprinkler System Deficiency Due to Missing Escutcheons

Carlisle, 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 sprinkler head assemblies according to manufacturer specifications, affecting one of nine smoke compartments. During an observation on December 10, 2024, between 10:33 AM and 10:55 AM, it was noted that sprinkler heads in specific locations were missing an escutcheon. These locations included the Laundry area by the dryers and the Kitchen Dish Room. An interview with the Director of Environmental Services confirmed that the sprinkler head assembly did not meet the required specifications.

Plan Of Correction

The escutcheons in the laundry dryer room and the kitchen dish room were replaced. The facilities maintenance department audited the entire facility for any other missing escutcheons. Checking for missing sprinkler escutcheons has been added to the safety committee's safety checklist and performed monthly. Findings will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation.

See complete original report
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