Fire Alarm System Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on January 23, 2025, it was found that a fire alarm report dated December 27, 2024, listed eight deficiencies, and there was no verification of repair available at the time of the survey. An exit interview with the Director of Maintenance and Assistant Director confirmed that the facility's LTC location was not separately zoned or monitored, and the building fire alarm deficiencies remained uncorrected. Additionally, an observation on January 23, 2025, revealed that the fire alarm annunciator panel inside the electrical room on the third floor indicated several trouble conditions. This was confirmed during the exit interview with the Director of Maintenance and Assistant Director.
Plan Of Correction
The fire alarm system is a combined system with the Hospital and the (3) components of the St. Joseph's Manor campus. At the time of the inspection, we had identified the troubles listed on the fire alarm report that we had received two weeks earlier and had already scheduled the contractor to resolve the issues. The contractor had been scheduled for the following Monday and has since been here and cleared the troubles. We will be monitoring the fire panel daily to insure that any troubles are reported and resolved in a more timely fashion. The Director of Maintenance will be responsible for insuring the troubles are monitored and the contractors are trained on the alternative fire notification procedures while they have devices off-line.