Fire Alarm System Circuit Disconnect Not Properly Marked
Penalty
Summary
The facility failed to ensure that the circuit disconnecting means for the fire alarm system control unit was properly identified with a red marking, as required by NFPA 101, NFPA 70, and NFPA 72. During an observation and interview at the electrical panel, the disconnecting means labeled as "F.A." was found not to have the required red marking. The Maintenance Supervisor confirmed that the fire alarm breaker should have been marked with red, but it was not. A review of the facility's policy and procedure for the Preventative Maintenance Program indicated that a program should be in place to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the lack of proper identification of the fire alarm system's circuit disconnecting means was observed, which did not comply with the stated requirements and facility policy.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice: Upon notification of the deficient practice on 05/28/2025, the Maintenance Supervisor (MS) placed a red marking on the fire alarm breaker. (Exhibit #1) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur: On 5/28/25, the Administrator (ADM) provided re-education to Maintenance Supervisor (MS) regarding policies and procedures entitled "Preventative Maintenance Program," to ensure that the fire alarm breaker needs to have red marking. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified: An observational audit of the Fire Alarm System will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness. Date of compliance: June 20, 2025