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K0351
E

Incomplete Sprinkler Coverage in Facility

Lafayette Hill, Pennsylvania Survey Completed on 12-17-2024

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 complete automatic sprinkler protection, which is a requirement under NFPA 101 for nursing homes and hospitals. During an observation on December 17, 2024, at 12:15 p.m., it was noted that the South JCI room on the second floor lacked sprinkler protection. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 1:00 p.m.

Plan Of Correction

The facility will maintain automatic sprinkler protection in all levels of care. The second floor JCI room sprinkler protection has been installed. Audits will be conducted once a week for 4 weeks, bi-weekly for a month to ensure compliance. The Facilities Director or designee will bring such audits to the QA meeting monthly for 3 months in order for the QA team to verify compliance.

See complete original report
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