Improper Installation of Fire Alarm Initiating Devices
Penalty
Summary
The facility failed to properly install fire alarm initiating devices, specifically affecting one of the three levels in the building. During an observation on January 23, 2025, at 10:45 a.m., it was noted that the manual pull station for the double exit doors in the Kitchen on the first floor was not mounted within 5 feet of the exit doors as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
1. The manual pull station in the kitchen is scheduled to be moved to be within 5 ft of exit door. 2. NHA/Designee will educate the maintenance director on the requirements of having pull stations within 5 feet of exit doors. 3. NHA/Designee will conduct an audit of exit doors to ensure there is a pull station within 5 feet. 4. Audit report will be submitted to QA.