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K0351
E

Incomplete Sprinkler System Installation

North Wales, Pennsylvania Survey Completed on 02-10-2025

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 properly install sprinkler system components, affecting one of four levels. During an observation on February 10, 2025, at 1:10 p.m., it was noted that there was missing sprinkler protection over a combustible material at the main entrance's exterior portico ceiling. Additionally, at 1:15 p.m. on the same day, it was observed that a pendant sprinkler was installed in the Synagogue telephone room, but the area lacked a ceiling assembly, resulting in incomplete sprinkler coverage. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on February 10, 2025, at 1:45 p.m.

Plan Of Correction

A. Facility is submitting time limit waiver to obtain quotes for the portico sprinkler install or proof of sufficient fire safety rating. B. The sprinkler pendant was removed, and proper upright sprinkler head was installed in the synagogue telephone room. Sprinkler heads/pendants will be checked for proper installation. Maintenance director will in-service maintenance staff on proper sprinkler system components/installation. Random weekly audit of sprinkler heads/pendants will be completed X 3 weeks and findings will be reported to QAPI.

See complete original report
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