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K0353
E

Failure to Maintain Sprinkler System

Lehighton, Pennsylvania Survey Completed on 12-18-2024

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 automatic sprinkler systems, which affected one of five smoke compartments. During an observation on December 18, 2024, at 11:01 a.m., it was noted that the Main Entrance Vestibule storage closet had an unsealed penetration of a ceiling tile within the room. This deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager on the same day at 11:30 a.m.

Plan Of Correction

The ceiling tile was replaced with a new tile and sealed to resist the passage of smoke. Provided education to staff to make aware all voids and penetrations in ceiling tiles need to be properly sealed and maintained to comply with the LS Code. A Monthly Audit x 3 months of 10 areas will be conducted to confirm compliance. Any noncompliant items found will be corrected and reported/discuss with the facility designee. Findings to be reported to QAPI.

See complete original report
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