Failure to Maintain Smoke Detectors
Penalty
Summary
The facility failed to ensure proper testing and maintenance of battery-operated smoke detectors in resident rooms, as required by the NFPA 101 Life Safety Code: 2012 Edition. This deficiency was identified during an interview and documentation review, which revealed that the facility's preventative maintenance logs lacked detailed information about the smoke detectors, such as make, model, installation date, and battery type. The logs only contained a checkmark for each room every month, without any further details. Additionally, the manufacturer's user manual indicated that the smoke detectors should be tested at least once a week, a requirement that was not reflected in the facility's documentation. This oversight affected all 114 documented battery-operated smoke detectors in the facility, potentially impacting all residents. The findings were communicated to the U.S. FOIA (b)(6) during the Life Safety Code exit conference.
Plan Of Correction
Plan of Correction K0347 Level F Completion Date: 1/15/2025 Corrective Action: 10 year maintenance free battery operated smoke detectors were tested in all resident rooms on 12/12/24 and operational as designed. ID Other Residents: Any resident within the facility Systemic Change: In-service Monitoring Smoke Detectors to the Maintenance Department by the Maintenance Director completed on 12/20/24. Smoke Detectors will be tested monthly and a log maintained by the Maintenance Department. Monitoring: Audit - Smoke Detectors will be completed on the following schedule: (10) quarterly x 3 quarter by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.