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K0353
F

Deficiencies in Fire Safety Documentation and Sprinkler System Maintenance

Flourtown, Pennsylvania Survey Completed on 05-01-2025

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 provide a fire watch policy and maintain proper documentation for the sprinkler system's maintenance and testing. During a document review on May 1, 2025, at 8:15 a.m., it was revealed that the facility could not provide a fire watch policy. This was confirmed during an exit interview with the Maintenance Director at 10:30 a.m. on the same day. Additionally, the facility was unable to provide documentation for quarterly sprinkler inspections for the 1st quarter of 2025 and the 4th quarter of 2024, as well as the 5-year internal valve and pipe inspection. These deficiencies were confirmed during the exit interview with the Maintenance Director.

Plan Of Correction

The facility will maintain and inspect the sprinkler system, affecting the entire facility. Outside contracted service called and scheduled for quarterly sprinkler inspection and 5 year internal valve and pipe inspection. The Director of Maintenance or designee will audit inspect sprinkler systems 2x weekly for 2 monthly. All findings will be brought to QAPI for review.

See complete original report
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