Fire Alarm System Documentation Deficiency
Summary
The facility failed to maintain compliance with fire safety regulations as evidenced by the absence of documentation for the most recent sensitivity test results of the fire alarm system. During a document review and interview conducted on January 16, 2025, it was revealed that the facility did not have the necessary documentation available. The maintenance manager confirmed that the sensitivity testing documentation was unavailable at the time of the survey.
Plan Of Correction
The sensitivity testing has been scheduled to be completed. The maintenance director and/or designee will ensure that the sensitivity testing is completed and documentation of the test results are obtained.
Penalty
Surveyors found that the facility did not maintain required records of smoke detector sensitivity testing, as no documentation was available to show that testing had been performed within the required timeframe. This deficiency affected all residents and all smoke compartments, with the Maintenance Director unable to provide the necessary records when requested.
The facility failed to maintain smoke detection requirements in one smoke compartment. A broken and non-functional smoke detector was observed in room 406 on the fourth floor. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain battery-operated smoke detectors, as they could not provide documentation for monthly testing and semi-annual battery replacement. The maintenance supervisor confirmed these deficiencies during the survey.
A smoke detector in the kitchen wash room on the first floor was found obstructed with a plastic cover and tape, failing to meet NFPA 101 standards. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not properly test and maintain battery-operated smoke detectors in resident rooms, as required by NFPA 101. Documentation lacked details such as make, model, and battery type, and only included monthly checkmarks. The manufacturer's manual required weekly testing, which was not documented. This affected all 114 smoke detectors, potentially impacting all residents.
Failure to Maintain Smoke Detector Sensitivity Testing Records
Penalty
Summary
The facility failed to maintain required records of smoke detector sensitivity testing as mandated by NFPA 101 and NFPA 72 standards. During a record review and interview with the Maintenance Director, surveyors requested documentation showing that smoke detector sensitivity testing had been performed within the last two years. The facility was unable to provide any records of such testing, and the Maintenance Director stated that he believed the vendor had performed the test but would need to contact them for the records. No documentation was provided to the surveyors by the deadline given. This deficiency affected all 120 residents in all four smoke compartments of the facility. The lack of records means there was no evidence that the smoke detectors had been tested for sensitivity as required, which is necessary to ensure their proper functioning in the event of a fire. The surveyors noted that no previous records were available, and the required documentation was not submitted even after an opportunity was given to provide it.
Plan Of Correction
K347-Smoke Detection 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility contracted with a certified vendor who performed smoke detector sensitivity testing on all applicable smoke detectors. The vendor's report confirmed all devices were within operational parameters. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Maintenance Director educated by the Administrator on the requirements and documentation for smoke detector sensitivity testing requirements per NFPA 72: 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review testing schedules monthly to ensure smoke detector sensitivity testing is completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. K 347
Smoke Detection Deficiency in Room 406
Penalty
Summary
The facility failed to maintain smoke detection requirements in one of its smoke compartments. During an observation on January 29, 2025, at 9:20 a.m., it was found that the smoke detector in room 406 on the fourth floor was broken and non-functional. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director later that day at 1:00 p.m.
Plan Of Correction
The smoke detector in room 406 on the 4th floor was fixed on February 7th, 2025. The smoke detectors will be inspected 1 floor per week for 6 weeks, then monthly to ensure that the smoke detectors are not broken. Results will be reported to the quality assurance and performance committee.
Failure to Maintain Battery-Operated Smoke Detectors
Penalty
Summary
The facility failed to maintain smoke detectors for all battery-operated smoke detectors within the facility. During a document review and interview conducted on January 23, 2025, it was revealed that the facility could not provide documentation for the required monthly testing and semi-annual battery replacement of these smoke detectors. The maintenance supervisor confirmed these deficiencies at the time of the survey.
Plan Of Correction
Monthly testing and battery replacements were completed for the facility battery-operated smoke detectors on January 30, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025, regarding the monthly testing and semi-annual battery replacement of the facility battery-operated smoke detectors. An audit will be conducted monthly for 4 months by the Maintenance Director to ensure that the monthly testing and semi-annual battery replacement for the facility battery-operated smoke detectors are completed. The audit will be monitored by the Administrator. Results of the audit will be presented at the quarterly QAPI meeting and recommendations will be implemented.
Smoke Detector Obstruction in Kitchen Wash Room
Penalty
Summary
The facility failed to maintain smoke detectors as required by NFPA 101 standards. During an observation on December 23, 2024, at 11:20 a.m., it was found that a smoke detector in the kitchen wash room on the first floor was obstructed with a plastic cover and tape. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:15 p.m.
Plan Of Correction
1. On 12/23/2024 the Maintenance Director removed the plastic cover and tape from the obstructed smoke detector in the kitchen washroom. 2. On 12/23/2024 the maintenance team inspected all smoke detectors in the building to verify there were no obstructions. 3. On 12/30/2024 the NHA educated the Maintenance team on properly maintaining the smoke detection system in accordance with NFPA 101 requirements. 4. The Maintenance Director/designee will conduct weekly audits for 4 weeks to verify that smoke detectors are not obstructed. Results of the audits will be reviewed at the QAPI meeting held monthly.
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.
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