Smoke Detector Failed to Initiate Fire Alarm During Testing
Summary
During a facility tour and staff interview, surveyors observed that a smoke detector located outside resident room 209 failed to initiate the fire alarm system when tested with artificial smoke. The test was conducted twice, and on both occasions, the alarm did not activate. Staff present during the testing were unable to provide an explanation for the malfunction at the time of the observation. It was noted that the air conditioning vent was approximately 36 inches from the smoke detector, and staff speculated that airflow from the vent might be interfering with the detector's ability to sense smoke. This deficiency affected 14 out of 90 residents in one of ten smoke compartments, as the non-functioning smoke detector could delay notification to emergency forces in the event of a fire.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the smoke detectors and fire alarm system. The facility contacted Sa-Fire to inspect the current locations of the smoke detectors. Facility plans to move / re-locate the 4 ceiling mount smoke detectors away from the proximity of the air registers that may have affected the smoke detectors, causing the testing issues. Sa-Fire will be placing the system on test to complete the work, and the annual fire alarm inspection is scheduled to be completed July 25, 2025. The detectors will be re-tested at that point. Further issues regarding the fire alarm system and/or the smoke detectors will be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Penalty
A fire alarm pull station was observed to be blocked in the Delaware dining room near the courtyard doors, making it inaccessible and in violation of NFPA 101 requirements for manual fire alarm system initiation. This was confirmed by the Facilities Director during the inspection.
Surveyors found that access to two fire alarm pull stations was blocked by portable nurse worktables and a dirty linen cart, with the Maintenance Supervisor confirming staff awareness of proper storage procedures. The facility's policy requires maintenance of safe and accessible equipment, but these obstructions were not removed as required.
Two manual fire alarm pull stations were found without their required protective snap bars, one near a resident room and another near a nurse station. The Maintenance Supervisor indicated that patients may have removed the snap bars. This deficiency impacted two smoke compartments and left the pull stations not properly maintained as designed.
The facility failed to maintain the initiation of the required fire alarm system on one level. A fire alarm pull station in the Activities Department was blocked by storage items, making it inaccessible. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A fire alarm pull box in the facility's kitchen was obstructed by a steel table used as an extension of the dishwashing machine table, blocking access to the alarm. This deficiency was confirmed during an interview with the AIT and reported at the Life Safety Code exit conference.
The facility failed to ensure fire alarm manual pull stations were accessible, as required by NFPA 72:2010. Observations revealed that a pull station in the dining room was blocked by a table, and another in the physical therapy room was obstructed by wheelchairs and a bed. This deficiency could potentially affect all 83 residents.
Blocked Fire Alarm Pull Station in Dining Room
Penalty
Summary
A deficiency was identified when a fire alarm pull station was found to be blocked in the Delaware dining room near the courtyard doors. This arrangement violates the requirements for manual initiation of the fire alarm system as specified by NFPA 101, 9.6.2.7, which mandates that manual alarm boxes must be visible and continuously accessible. The observation was made during a facility inspection and was confirmed by the Facilities Director at the time of the survey. 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
K342: Fire Alarm System Initiation The facility will ensure manual initiation of the fire alarm system is arranged as required. This will be accomplished with the following:
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
Manual Fire Alarm Pull Stations Missing Protective Snap Bars
Penalty
Summary
Surveyors observed that two manual fire alarm pull stations in the facility were missing their protective plastic "snap" bars, which are designed to indicate the pull station is ready for use and has not been tampered with. One pull station missing the snap bar was located next to Resident Room 3, and another was found next to Nurse Station South. During interviews conducted at the time of observation, the Maintenance Supervisor stated that he believed patients were responsible for removing the snap bars. The absence of these snap bars means the pull stations were not maintained in proper working order and as designed, which could result in the pull stations being mistakenly activated and causing a false alarm. This deficiency affected two of three smoke compartments in the facility.
Plan Of Correction
K 342 Fire Alarm System - Initiation Correct Deficient Practice: On 03/7/25, Maintenance Supervisor (MS) called Delta Fire Equipment to get a replacement snap bar for the manual pull station. Snap bars were to be delivered and replaced on 03/10/25. Identify Others: On 03/10/2025, MS checked all manual pull stations to ensure all other manual pull stations are in proper working order and have the protective plastic "snap" bars. No other deficient practice was found. Systemic Changes: On 03/10/2025, the Administrator provided in-service education to Maintenance Supervisor regarding facility policy and procedures titled, "Maintenance Services" & "Fire Safety Inspections," indicating the maintenance department is responsible for maintaining the fire alarm system in good working order and the need for monthly fire safety inspections to be completed and forwarded to the administrator within 48 hours. MS or designee will complete the Mesa Glen Alarm Test Log on a monthly basis to ensure all manual pull stations are in proper working order and have the protective plastic "snap" bars in place. Any negative findings will be reported to the administrator and corrected immediately. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/2025.
Fire Alarm Pull Station Obstructed by Storage Items
Penalty
Summary
The facility failed to maintain the initiation of the required fire alarm system, specifically affecting one of the four levels in the facility. During an observation on January 27, 2025, at 2:00 p.m., it was noted that the fire alarm pull station inside the Activities Department was not readily accessible. This inaccessibility was due to the pull station being blocked by miscellaneous storage items. During an exit interview with the Administrator and Maintenance Director on the same day at 2:30 p.m., it was acknowledged that the fire alarm pull station was obstructed by these items.
Plan Of Correction
1. Items blocking the pull station inside the Activities Department were immediately removed. 2. Pull stations throughout the facility audited to ensure they remain readily accessible. 3. Education provided to ensure proper compliance with this regulation. 4. An audit of the pull station in the Activities Department will be conducted to ensure it remains readily accessible. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Fire Alarm Box Obstruction in Kitchen
Penalty
Summary
The facility failed to ensure that each manual fire alarm box was accessible, unobstructed, and visible, as required by NFPA 101: 2012 Edition and NFPA 72: 2010 Edition. During an observation, it was noted that one of the two fire alarm pull boxes in the facility's kitchen was blocked by a freestanding steel table. This table was being used as an extension of the dishwashing machine table and had dishes and cups on it, obstructing access to the fire alarm box. This deficiency was confirmed through an interview with the Administrator in Training (AIT) at the time of the observation. The issue was brought to the attention of the facility's administration during the Life Safety Code exit conference.
Plan Of Correction
K342 1. The facility conducted a comprehensive inspection of all fire alarm pull stations to identify and ensure that all the fire alarm pull stations are accessible, unobstructed, and visible per NFPA standards. The identified area in the kitchen was repaired on 12/23/24 by Allied Fire and Safety. The maintenance director and administrator inspected the area to ensure it meets NFPA standards. 2. All maintenance personnel were educated on the importance of maintaining an accessible, unobstructed, and visible clear path in front of any fire alarm pull stations and the impact on resident safety. All residents have the potential of being affected by this. The facility will keep detailed records of fire alarm pull stations, including dates and any issues discovered. 3. The facility conducts monthly drills to ensure staff and residents are familiar with emergency procedures, which includes fire alarm pull stations. All staff at the facility are educated annually in life safety regulations, which includes maintaining an accessible, unobstructed, and visible clear path for the fire alarm pull station. 4. The facility will conduct monthly life safety audits on all fire alarm pull stations for the next 3 months to ensure the facility is in accordance with NFPA standards. The results of these audits will be communicated with the QAPI team for the next 2 quarters. Based on the results, the QAPI team will decide to conclude or continue with these audits. The QAPI team meets on a quarterly basis.
Fire Alarm Manual Pull Stations Obstructed
Penalty
Summary
The facility failed to ensure that fire alarm manual pull stations were always accessible, as required by NFPA 72:2010 Edition, section 17.14.5. During an observation on December 4, 2024, it was noted that the manual fire alarm pull station in the small dining room by the exit door was obstructed by a dining table. Additionally, the manual fire alarm pull station in the physical therapy room by the exit door was blocked by four wheelchairs and a physical therapy bed. These obstructions were confirmed by a staff member at the time of the survey. This deficiency had the potential to affect all 83 residents in the facility.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 K342 - (F) Fire Alarm System - Initiation Element One: The dining table blocking the fire alarm pull station at the exit door in the small dining room was immediately removed. The four wheelchairs and the Physical therapy bed blocking the fire alarm pull station in the Physical therapy room by the exit door were immediately removed. Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding the fire alarm manual pull stations are always accessible without obstruction. All staff were trained and educated on the above topic as well as to report findings asap. Element Four: The Maintenance director / designee will audit the above mentioned fire alarm pull stations monthly x3 ensuring they remain accessible without obstruction. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
