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K0345
F

Fire Alarm System Maintenance Deficiency

Wyndmoor, Pennsylvania Survey Completed on 01-27-2025

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 documentation, observation, and interviews. During a documentation review, it was found that the annual inspection of the fire alarm panel dated November 8, 2024, revealed discrepancies, including a failed operation of the indicating bell in the basement by the fire panel and a failed annunciation of the initiating smoke detector in room 234. Additionally, an observation on January 27, 2025, showed that the fire alarm panel was in trouble mode at the time of the survey. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged that the issues remained uncorrected.

Plan Of Correction

1. Discrepancies identified during the fire alarm panel's annual inspection were immediately scheduled for repair. 2. The fire alarm panel audited to ensure it is in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of fire alarm panel inspections will be conducted to ensure all repairs are scheduled and completed. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

See complete original report
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