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K0353
E

Sprinkler System Maintenance Deficiencies

Berwick, Pennsylvania Survey Completed on 03-31-2025

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 in five locations on one floor. Observations made on March 31, 2025, revealed several deficiencies: an unsealed penetration of a ceiling tile in the soiled utility area of Willow Hall, two missing ceiling tiles in the storage room of Spruce Hall, and missing escutcheons in Resident Room 233, the 200 Hall lounge, and the dietary walk-in freezer. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.

Plan Of Correction

1. The facility failed to maintain the automatic sprinkler system in the following areas: a. unsealed penetration of a ceiling tile in the soiled utility hall of Willow unit. b. missing ceiling tiles within storage room of Spruce Hall. c. missing escutcheon within room 233, of Spruce Hall. d. missing escutcheon within 200 hall lounge area. e. missing escutcheon within Dietary Walk-in freezer. 2. Areas listed in the preceding statement have all been resolved. 3. The Maintenance manager/Designee will audit the affected areas and other potential areas to ensure the automatic sprinkler system is monitored appropriately. 4. Corrective Action Date: April 17, 2025.

See complete original report
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