Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation, the fire alarm remote panel located in the vestibule to Physical Therapy (new) was found to be displaying incorrect date and time information, specifically showing '0506 on 06/03/2059.' This issue was confirmed by the facility Maintenance Director at the time of observation. This deficiency could potentially affect all 175 residents in the facility in the event of a fire situation, as the fire alarm system may not function as required due to improper maintenance or testing.
Plan Of Correction
K345- Fire Alarm System- Maintenance and Testing 1. The facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72. a. The Fire alarm remote panel date and time in the vestibule to Physical Therapy is correct. 2. The Maintenance director and staff will be educated on the importance of rounding and ensuring the time and date on the fire alarm remote panels have the correct date and time. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete a random audit 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.