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K0341
E

Lack of Smoke Detector Protection in Open Dining Room

Gettysburg, Pennsylvania Survey Completed on 06-25-2025

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

Surveyors observed that the 1st floor Dining Room had its doors (1C10 and 1C11) removed, resulting in the room being open to the corridor. Despite this change, there was no smoke detector protection installed in the area. This deficiency was confirmed during an interview with the Director of Facilities, who acknowledged the absence of smoke detection in the room. The lack of smoke detector protection in a room open to the corridor constitutes a failure to provide required fire alarm protection in one of ten smoke compartments within the facility.

Plan Of Correction

Two battery-operated, ten-year smoke detectors will be installed in the Personal Care Dining Room to alert team members of a possible fire event. A procedure will be developed to explain the steps to follow in the event that detectors sound during a fire event. Current team members associated with Personal Care will be educated initially upon installation and then annually on the procedures. New hired team members will be educated and trained during their orientation. A recurring work order will be created to test these detectors monthly for proper operation and audible levels to the end of the Personal Care corridors. Completed documentation will be presented to QAPI for evaluation.

See complete original report
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