Obstructed Access to Fire Alarm Pull Stations
Penalty
Summary
Surveyors observed that access to fire alarm pull stations was obstructed in two separate locations within the facility. Specifically, two rolling portable nurse worktables were found blocking one pull station across from the nurse's station, and a dirty linen cart was left unattended in front of another pull station. These obstructions were identified during concurrent observations and interviews with the Maintenance Supervisor (MS), who acknowledged that staff were aware not to leave items in front of the pull stations and that such items should be stored on the opposite wall. A review of the facility's Maintenance Service Policy and Procedure indicated that the Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including compliance with federal, state, and local regulations. The failure to keep the pull stations accessible was noted as a deficiency, as it could potentially delay the activation of the fire alarm system in the event of an emergency.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. Corrective Action Taken: On 05/19/2025, the facility's policy is to comply with all applicable federal and state regulations regarding fire alarm system initiation requirements as specified in NFPA Life Safety Code sections 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, and 9.6.2.5. Maintenance Supervisor immediately removed the rolling portable nurse worktables and dirty linen cart that were blocking pull stations 1 and 2. The Maintenance Department conducted a facility-wide inspection of all pull stations to ensure clear access and visibility. New "Keep Clear" floor markings were installed in front of all pull stations on 05/20/2025 to designate required clearance zones. Identification of Other Areas with Potential to be Affected: On 05/20/2025, the Maintenance Director conducted a comprehensive facility-wide assessment of all fire alarm pull stations to identify any additional access issues or potential obstructions. This assessment included all four smoke compartments and verification of proper pull station placement per NFPA requirements. Systemic Changes and Measures Implemented: 1. In-service training was conducted for staff on 05/21/2025 regarding: • Proper placement of equipment and furniture • Importance of maintaining clear access to pull stations Monitoring and Quality Assurance: The Director of Maintenance/designee will conduct daily rounds to ensure pull stations remain accessible and unobstructed. The Maintenance Director will conduct weekly comprehensive fire safety inspections, including verification of pull station accessibility, and document findings on a checklist. The Director of Maintenance will compile monthly reports of monitoring results for review by the QAPI committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. Any identified issues will be addressed immediately with additional staff education and corrective measures as needed. Date of Completion: 06/12/2025