Improper Installation and Obstruction of Fire Alarm System Components
Penalty
Summary
The facility failed to ensure that the fire alarm system was installed and maintained in accordance with NFPA 70 and NFPA 72 standards. During an observation, it was found that the smoke detector head at the North Smoke Doors exit into the administration hall was not properly mounted to the ceiling. Additionally, another smoke detector head located in the North Mechanical closet was discovered with a plastic bag taped over it. These deficiencies were confirmed through interviews with the Facility Maintenance Director at the time of the observations. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K3411. The Maintenance Director and/or designee will repair the smoke detector heads at the North smoke doors and North mechanical closet. The Administrator will review regulation K341 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct a weekly community audit of smoke detectors to ensure appropriate function. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.