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K0345
F

Fire Alarm System Maintenance Deficiency

Philadelphia, Pennsylvania Survey Completed on 01-23-2025

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, which affected the entire facility. During a document review on January 23, 2025, it was discovered that the fire alarm inspection report from July 29, 2024, indicated the system had four failed batteries. The facility was unable to provide documentation that these batteries had been replaced. Additionally, an observation on the same day revealed that a fire alarm strobe on the first floor in the Chapel Lobby was obstructed by a grandfather clock. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.

Plan Of Correction

1. Failed batteries from the report dated 7-29-2024 have been ordered and replaced. The clock in the chapel lobby is moved so the fire alarm strobe is not blocked. 2. NHA/Designee will educate the maintenance director in follow up regarding the requirement for failed reports and to assure furniture does not block the fire alarm strobe. 3. NHA/Designee will audit the fire alarm reports monthly x 3 to ensure all components are functioning. 4. NHA/Designee will audit fire alarm strobes weekly x 4, monthly x 2 to ensure they are not blocked. 5. Results of audits to be reported at monthly QA.

See complete original report
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