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K0353
E

Deficiencies in Sprinkler System Maintenance

Stroudsburg, Pennsylvania Survey Completed on 02-04-2025

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 its automatic sprinkler system, as evidenced by several deficiencies observed during a survey. On the second floor, ceiling tiles were missing in the Mechanical Room, and similar issues were noted in the first floor IT Server Room. Additionally, the attic-level dry sprinkler system was found to be non-functional at the time of the survey. The facility also lacked an automatic sprinkler system inspection report for the fourth quarter of 2024, and was overdue for the required five-year internal valve, internal piping, and sprinkler gauge recalibration or replacement. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.

Plan Of Correction

K-0353 Sprinkler Systems 1. Ceiling tiles were lacking within the second floor Mechanical Room and ceiling tiles within the first floor IT Server Room were repaired. Attic-level dry sprinkler system was repaired and placed in service. Quarterly Sprinkler inspection was completed 2/2025. Five-year, internal valve, internal piping, and sprinkler gauge recalibration/replacement was also completed. 2. Audit will be competed for areas of missing ceiling tiles weekly x 4 then monthly x2. Sprinkler reports will be monitored for missing inspection pieces. Findings will be reviewed in QAPI.

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