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K0345
F

Failure to Clearly Identify Fire Alarm System Disconnect

Pomona, California Survey Completed on 05-05-2025

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 the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During an observation and interview at the fire alarm electrical panel, the Maintenance Supervisor was unable to identify the fire alarm circuit disconnect. The fire alarm panel disconnect was not easily identifiable nor properly indicated, and the Maintenance Supervisor acknowledged that it should be clearly indicated on the electrical panel. A review of the facility's policies and procedures showed that maintenance personnel are responsible for maintaining the building in compliance with applicable laws and regulations, including keeping the fire alarm system in good working order. The facility's policy also states that an operable fire alarm system must be maintained at all times, with emergency power available in case of power loss. However, the inability to identify the fire alarm disconnect indicated a failure to comply with these requirements, affecting all smoke compartments and the safety of all residents, staff, and visitors.

Plan Of Correction

Immediate Corrective Action: On 5/20/25 the Maintenance Supervisor consulted with the Corp. Electrician, and he was able to identify and label all the fire alarm panel disconnect. Identify Other Residents: Corporate Electrician made rounds with the MS and checked all fire alarm electrical panels to ensure that all the fire alarm panel disconnects are identified. No other fire panels had this deficient practice. Measures into place: On 5/22/25 the Administrator serviced the MS and Maintenance assistant, ensuring that all fire alarm panels are labeled indicating the fire alarm circuit disconnect is easily identifiable. Monitoring: Administrator and DSD will randomly check the fire panels on a monthly basis for 3 months to ensure that the fire alarm panel disconnect is identifiable. Findings will be presented to the QAPI meeting quarterly for further review and/or actions if necessary. Completed date: 5/22/25

See complete original report
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