Failure to Maintain Fire Alarm System, Fire Extinguishers, and Fire Safety Plan
Penalty
Summary
The facility failed to maintain its fire alarm system, portable fire extinguishers, and fire safety plan in accordance with National Fire Protection Association (NFPA) standards. During a facility tour, the main fire alarm panel was observed to display a system trouble alarm, specifically indicating a missing duct detector in the water heater room. The fire alarm panel also showed an incorrect date and time, which the Maintenance Director attributed to a recent power outage and subsequent hard reset of the system. The facility was aware of the trouble alarm but had only scheduled future repairs with the vendor. Additionally, document review revealed that the facility could not provide evidence of annual inspections for portable fire extinguishers. Review of the facility's evacuation and fire safety plan showed that it lacked protocols for the use of portable fire extinguishers, such as the P.A.S.S. method, and did not include procedures for reviewing the fire alarm annunciator panel during an alarm condition. These deficiencies affected 36 residents in one of six smoke compartments, with the facility having a census of 137 residents at the time of the survey.