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K0353
E

Failure to Document Quarterly Sprinkler Inspection

Philadelphia, Pennsylvania Survey Completed on 12-23-2024

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 and inspect the sprinkler system as required, affecting one of four quarters. During a document review on December 23, 2024, at 8:30 a.m., it was revealed that the facility could not provide documentation of a quarterly sprinkler inspection for the third quarter. This deficiency was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director on the same day at 11:00 a.m.

Plan Of Correction

Documentation for the quarterly sprinkler inspection has been completed and placed in the life safety book. Maintenance Dir/designee will re-educate maintenance staff on maintaining quarterly inspection documentation on sprinkler system. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.

See complete original report
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