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.