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K0353
D

Failure to Maintain Sprinkler System

York, Pennsylvania Survey Completed on 03-06-2025

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 protection system properly, as it was observed to be burdened with extraneous weight. This deficiency affected one of the 27 smoke compartments within the facility. The report indicates that the sprinkler system was not maintained in accordance with NFPA 25, which is the standard for the inspection, testing, and maintenance of water-based fire protection systems. The failure to adhere to these standards was determined through observation and interview, highlighting a lapse in the facility's maintenance protocols for its fire protection systems.

Plan Of Correction

1. The flexible ductwork within the 1st floor Old Receptionist Room was removed from the sprinkler pipe in the same area. 2. The maintenance department will be in-serviced by NHA/Designee on the importance of having the sprinkler pipe clear of any flexible ductwork. 3. Quarterly audits will be performed by the maintenance director/designee to ensure there is no flexible ductwork hanging from the sprinkler pipe. 4. Results of the audit will be reviewed/reported to the QA committee to determine trends and compliance. QA committee will determine need for continuance of audits.

See complete original report
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