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K0353
E

Sprinkler System Maintenance Deficiency

Everett, 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 the automatic sprinkler system, resulting in deficiencies in two of the seven smoke compartments. During an observation on January 21, 2025, it was noted that a plastic sprinkler line was improperly supported by the main sprinkler line near the smoke doors leading to the 200 hallway. Additionally, duct work was found to be supported by the sprinkler line near the smoke doors leading to the 500 hallway. These deficiencies were confirmed through an interview with the Facility Administrator and the Maintenance Director on the same day.

Plan Of Correction

1. The sprinkler line noted to be found in the proximity of the 200 hall smoke doors will be properly supported with proper hanger. The noted duct work on the sprinkler piping will be properly supported. 2. Additional sprinkler lines will be reviewed for improperly supporting duct work or others piping. 3. The Executive Director/ Designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler- maintenance and testing specific to maintaining sprinkler piping to be free from supporting other piping and duct work and will continue to monitor in accordance with the standard. 4. Any finding will be reported to the monthly QAPI Committee for further review.

See complete original report
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