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K0353
F

Sprinkler System Maintenance Deficiencies

Philadelphia, Pennsylvania Survey Completed on 01-21-2025

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 automatic sprinkler system, affecting the entire facility. During observations and document review on January 21, 2025, several deficiencies were identified. The facility did not conduct a 3-year full flow trip test of the dry automatic sprinkler system, and the 4th quarter 2024 sprinkler inspection was missing. Additionally, data wires were improperly strapped to the ceiling sprinkler pipe in the basement next to the upper garage elevator. Furthermore, a sprinkler in the 3rd floor Activities closet was missing its escutcheon. These deficiencies were confirmed during an exit interview with the Executive Director of Construction and Ancillary Services.

Plan Of Correction

ED of construction to Inservice supervisor of Plants Operations on policy and procedure ensuring sprinkler system maintained. All items A-D have been completed; 4th quarter report received after surveyor departed. Supervisor of Plants Operations or delegate to complete 3x per week x 4 weeks all items A-D to ensure compliance. Supervisor of Plant Operations or delegate to complete audits 3x per week x 4 weeks to compliance with policy and procedure. Audit findings will be submitted to QAPI committee monthly for review and recommendations as needed.

See complete original report
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