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K0345
F

Failure to Maintain Fire Alarm System in Proper Operating Condition

Holland, Pennsylvania Survey Completed on 07-16-2025

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 in proper operating condition, as evidenced by the fire alarm panel being in trouble mode during both the initial survey and a subsequent onsite revisit. On May 28, 2025, observation revealed that the fire alarm panel, located in the front lobby office area, was in trouble mode at the time of the survey. This condition was confirmed during the exit interview with the Administrator and Maintenance Director. During a follow-up onsite revisit on July 16, 2025, the fire alarm panel remained in trouble mode, and this was again confirmed by the Administrator and Maintenance Director during the exit interview. No information regarding residents or their medical conditions was provided in the report.

Plan Of Correction

The facility fire panel has been repaired so that it is not in trouble mode. The facility will call our fire protection company to repair if the panel should go into trouble mode. The Maintenance Director and/or designee will perform audits weekly, for four weeks and monthly for two months to ensure that the fire panels are not in trouble. Results of the audits will be reported to QAPI.

See complete original report
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