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K0345
F

Fire Alarm System Deficiency Due to Faulty CO Detector Module

Pleasantville, New Jersey Survey Completed on 12-31-2024

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 ensure that all components of the fire alarm system were fully operational in accordance with NFPA 70 and 72. During an observation, it was noted that the main entrance fire alarm annunciator panel was in trouble mode, indicating a disconnection in Zone-4 and a trouble with the basement CO detector. A document from the facility vendor dated 12/13/24 revealed that a technician identified a faulty module for the CO detector, which was causing the panel to boot cycle and not return to normal supervisory status. The panel was left in supervisory mode until the necessary monitoring module and programmer could be obtained to correct the issue. This deficiency was acknowledged during the Life Safety Code exit conference.

Plan Of Correction

K-0345 (E) NFPA 101- Testing and Maintenance 1. [R] has restored functionality to the fire alarm system by installing a new module on 1/14/2025. The system was always functioning, and all residents areas are free from hazard. 2. All testing and maintenance paperwork has been completed and inspected on 1/14/2025. 3. The Maintenance Director provided education with Maintenance staff to confirm proper repairs on paperwork once deficiencies are found on 1/10/2025. 4. Every quarter for a year the Maintenance Director or designee review paperwork for proper paperwork and deficiency free reporting. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *Invoice of service installation of fire alarm system module attached*

See complete original report
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