Fire Alarm System Altered Without Required Plan Approval or Inspection
Summary
The facility failed to obtain required plan approval and conduct an occupancy survey before making changes to its fire alarm system. Specifically, carbon monoxide detectors were installed on the existing fire alarm system without prior plan review or approval from the Department of Health. No documentation was provided to show that the necessary approvals were sought or granted before these modifications were made. Additionally, the facility placed the altered fire alarm system into service without completing an occupancy inspection or providing a record of completion for the changes. Interviews with the Director of Nursing and Director of Maintenance confirmed that the fire alarm system was altered and put into use without the required approval from the Pennsylvania Department of Health.
Plan Of Correction
K 0341 1. The facility cannot retroactively correct. 2. All new plans related to the fire alarm system will undergo both a formal plan review and an occupancy survey prior to implementation. 3. The Environmental Services Director has been re-educated on the requirements of regulation K0341. 4. The Nursing Home Administrator (NHA) or their designee will review all proposed changes to the fire alarm system to ensure full compliance with applicable codes and regulations.
Penalty
The 1st floor Dining Room had its doors removed, leaving the room open to the corridor without any smoke detector protection. This was confirmed by the Director of Facilities, resulting in a failure to provide required fire alarm protection in that smoke compartment.
Surveyors observed that a smoke detector head was not properly mounted to the ceiling at the North Smoke Doors exit into the administration hall, and another smoke detector head in the North Mechanical closet was covered with a plastic bag. These issues were confirmed by the Facility Maintenance Director during the survey.
A smoke detector was found installed within three feet of direct airflow from an air return or supply near an exit door, contrary to NFPA 70 and NFPA 72 requirements. This installation issue was confirmed by Facility Maintenance and could impact 30 occupants during a fire emergency.
The facility did not properly install fire alarm initiating devices, affecting one level of the building. The manual pull station for the double exit doors in the Kitchen on the first floor was not mounted within 5 feet of the exit doors, as observed and confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to maintain smoke and heat detectors according to NFPA standards, as observed in the elevator equipment room where the devices were hanging from wires and not securely attached. This issue had the potential to affect 120 residents, and the responsible individual was unaware of the deficiency.
Lack of Smoke Detector Protection in Open Dining Room
Penalty
Summary
Surveyors observed that the 1st floor Dining Room had its doors (1C10 and 1C11) removed, resulting in the room being open to the corridor. Despite this change, there was no smoke detector protection installed in the area. This deficiency was confirmed during an interview with the Director of Facilities, who acknowledged the absence of smoke detection in the room. The lack of smoke detector protection in a room open to the corridor constitutes a failure to provide required fire alarm protection in one of ten smoke compartments within the facility.
Plan Of Correction
Two battery-operated, ten-year smoke detectors will be installed in the Personal Care Dining Room to alert team members of a possible fire event. A procedure will be developed to explain the steps to follow in the event that detectors sound during a fire event. Current team members associated with Personal Care will be educated initially upon installation and then annually on the procedures. New hired team members will be educated and trained during their orientation. A recurring work order will be created to test these detectors monthly for proper operation and audible levels to the end of the Personal Care corridors. Completed documentation will be presented to QAPI for evaluation.
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.
Improper Smoke Detector Placement Near Airflow Source
Penalty
Summary
A deficiency was identified when a smoke detector was observed to be installed within three feet of direct airflow from an air return or supply on the ceiling near Exit Door H. This installation does not comply with the requirements of NFPA 70 and NFPA 72, which govern the proper placement and installation of fire alarm system components. The issue was confirmed during an interview with Facility Maintenance at the time of observation. The deficient practice could affect 30 occupants in the event of a fire emergency.
Plan Of Correction
Maintenance Director moved the smoke detector to an area more than 3 feet away from the air/return supply on the ceiling. All other areas were reviewed with no concerns noted. Maintenance Director was educated on K341 tag to ensure proper placement of smoke detectors from direct airflow to an air return/supply. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance of K345.
Improper Installation of Fire Alarm Initiating Devices
Penalty
Summary
The facility failed to properly install fire alarm initiating devices, specifically affecting one of the three levels in the building. During an observation on January 23, 2025, at 10:45 a.m., it was noted that the manual pull station for the double exit doors in the Kitchen on the first floor was not mounted within 5 feet of the exit doors as required. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 11:45 a.m. on the same day.
Plan Of Correction
1. The manual pull station in the kitchen is scheduled to be moved to be within 5 ft of exit door. 2. NHA/Designee will educate the maintenance director on the requirements of having pull stations within 5 feet of exit doors. 3. NHA/Designee will conduct an audit of exit doors to ensure there is a pull station within 5 feet. 4. Audit report will be submitted to QA.
Deficient Installation of Fire Detection Devices
Penalty
Summary
The facility failed to maintain smoke detectors and heat detectors in accordance with NFPA 101, NFPA 70, and NFPA 72 standards. During an observation, it was found that the smoke detector and heat detector in the elevator equipment room were not securely attached to their device bases and were hanging from the wires. This deficiency was identified during an observation on December 3rd, 2024, at 11:45 AM. The issue had the potential to affect 120 residents. During an interview at the time of the observation, the responsible individual was not aware of the deficient installation.
Plan Of Correction
The smoke detector and heat detector devices were secured to the device base in the elevator equipment room. All residents have the potential to be affected. The Maintenance Director audited all smoke and heat detector devices in the building to assure they were secured to the device base. No additional issues were identified. The Maintenance Director will make monthly rounds to ensure all smoke and heat detector devices are properly secured to the device base. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
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