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K0353
E

Incomplete Sprinkler Head Assemblies Not Corrected

Topton, Pennsylvania Survey Completed on 12-09-2024

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 the hardware components of its automatic sprinkler protection system, affecting two of the four floors within the component. During an observation on October 7, 2024, it was noted that several sprinkler heads were missing an escutcheon in various locations, including the 3rd floor Pantry, the 1st floor RNAC Office within Nursing Administration by electrical panels, Resident Room 104, and two areas within the 1st floor Memory Care Unit. An interview with the Maintenance Lead confirmed that the sprinkler head assemblies were incomplete. A follow-up observation and interview on December 6, 2024, revealed that the issue had not been corrected, as confirmed by the Manager of Plant Operations.

Plan Of Correction

1. Escutcheons were installed on 12/12/24. 2. All sprinkler heads were checked to ensure escutcheons were in place 12/12/24. 3. Checks will be made by maintenance monthly to ensure that sprinkler escutcheons are in place. 4. Results of these checks will be made by the maintenance director to the monthly meeting of the Safety Committee and QAPI Committee.

See complete original report
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