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K0345
F

Fire Alarm System Maintenance Deficiency

Coopersburg, Pennsylvania Survey Completed on 03-12-2025

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 fire alarm system components in operable condition, affecting the entire facility. During a document review on March 12, 2025, it was found that the fire alarm annual report dated May 15, 2024, listed several issues. The pull station at the nurses' station could not be tested due to the unavailability of keys needed for resetting. Additionally, the smoke detector sensitivity values were not documented for the basement detectors, and the facility needed to contact Simplex to acquire these values. Furthermore, Zone 4 required investigation as the detectors did not automatically reset. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these deficiencies had not been resolved. The facility also failed to provide documentation for sensitivity testing on the basement smoke detectors.

Plan Of Correction

1. Tustin Fire Alarm will be scheduled to come to the facility and complete all testing. A. Keys are now available for reset. B. Tustin visited 3/31/25 and waiting on report for basement detectors. C. Zone 4 was checked when Tustin came out. Waiting on report. 2. 4/28/25 3. Maintenance staff educated on keeping up to date with the scheduling of the fire alarm system. 4. The Director of maintenance will keep all reports up to date.

See complete original report
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