Manual Fire Alarm Pull Stations Missing Protective Snap Bars
Penalty
Summary
Surveyors observed that two manual fire alarm pull stations in the facility were missing their protective plastic "snap" bars, which are designed to indicate the pull station is ready for use and has not been tampered with. One pull station missing the snap bar was located next to Resident Room 3, and another was found next to Nurse Station South. During interviews conducted at the time of observation, the Maintenance Supervisor stated that he believed patients were responsible for removing the snap bars. The absence of these snap bars means the pull stations were not maintained in proper working order and as designed, which could result in the pull stations being mistakenly activated and causing a false alarm. This deficiency affected two of three smoke compartments in the facility.
Plan Of Correction
K 342 Fire Alarm System - Initiation Correct Deficient Practice: On 03/7/25, Maintenance Supervisor (MS) called Delta Fire Equipment to get a replacement snap bar for the manual pull station. Snap bars were to be delivered and replaced on 03/10/25. Identify Others: On 03/10/2025, MS checked all manual pull stations to ensure all other manual pull stations are in proper working order and have the protective plastic "snap" bars. No other deficient practice was found. Systemic Changes: On 03/10/2025, the Administrator provided in-service education to Maintenance Supervisor regarding facility policy and procedures titled, "Maintenance Services" & "Fire Safety Inspections," indicating the maintenance department is responsible for maintaining the fire alarm system in good working order and the need for monthly fire safety inspections to be completed and forwarded to the administrator within 48 hours. MS or designee will complete the Mesa Glen Alarm Test Log on a monthly basis to ensure all manual pull stations are in proper working order and have the protective plastic "snap" bars in place. Any negative findings will be reported to the administrator and corrected immediately. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/2025.