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K0351
D

Sprinkler System Installation Deficiency

Washington, Pennsylvania Survey Completed on 03-19-2025

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 automatic sprinkler system installation requirements as evidenced by the presence of mixed standard response and quick response sprinkler heads in the basement hallway. This deficiency was identified during an observation conducted on March 19, 2025, between 10:35 a.m. and 10:55 a.m. The issue was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day at 12:30 p.m.

Plan Of Correction

1. Sprinkler heads were converted so that all sprinkler heads were standardized to the quick response sprinkler head. 2. No other variant sprinkler heads were identified within the facility. 3. The Director of Plant operations or designee will audit sprinkler heads to ensure that they are all the quick response sprinkler heads monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.

See complete original report
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