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K0353
D

Improper Maintenance of Sprinkler System

Elizabethtown, 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 the automatic sprinkler protection system in accordance with NFPA 25 standards. During an observation on December 17, 2024, at 10:47 AM, it was discovered that an electrical cable was improperly zip-tied to the sprinkler piping within the Clinics 4th floor IT Mechanical Room. This deficiency affected one of the 43 smoke compartments within the facility, indicating a lapse in maintaining the sprinkler system free from extraneous weight.

Plan Of Correction

1. The electrical cable zip-tied to the sprinkler piping within Clinic's 4th floor IT Mechanical Room was corrected on 12/19/2024. 2. Maintenance staff will be educated that the automatic sprinkler protection system will be free of extraneous weight. 3. The Director of Security and/or Maintenance Assistant Director or designee will monitor the building monthly to ensure that the automatic sprinkler protection system will be free of extraneous weight. The results of the audit will be forwarded to the Quality Assurance Committee for review and comment.

See complete original report
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