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K0345
F

Fire Alarm System Maintenance Deficiency

Lima, 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 and inspect the fire alarm system as required, affecting the entire component. During a document review on February 3, 2025, it was discovered that the annual fire alarm inspection report dated May 2, 2024, indicated that the duct detector for the kitchen could not be found and was not tested. The facility was unable to provide documentation showing that this deficiency had been addressed. This was confirmed during an exit interview with the Maintenance Director on February 4, 2025.

Plan Of Correction

Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0345 Johnson Controls Fire Protection was contacted and will provide information on the functionality of the duct detector. Annual fire alarm report will be reviewed by Maintenance designee to ensure this issue does not reoccur.

See complete original report
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