Failure to Conduct Annual Air Flow Testing for Duct Detectors
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with the National Fire Protection Association (NFPA) 101 standards. During a record review with the Maintenance Director, it was found that there was no evidence of the annual air flow testing for the duct detectors being conducted. This deficiency was identified during an interview and record review on February 24, 2025, at 8:45 AM. The Maintenance Director acknowledged and concurred with the findings, indicating a lapse in the required testing and maintenance procedures. The report highlights that the facility did not comply with the NFPA 101 and NFPA 72 codes, which require regular testing and maintenance of fire alarm systems. The absence of documentation for the duct detectors' annual air flow testing suggests a failure to adhere to these safety standards, which are critical for ensuring the proper functioning of the fire alarm system. This oversight was confirmed through both the record review and the interview with the Maintenance Director.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Duct Detectors annual air flow testing was scheduled and completed on 3/25/25. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. The Maintenance Director reviewed all the other required Fire Alarm System testing and found no other testing deficiencies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Administrator provided re-education to the Maintenance Director and Maintenance staff on the Fire Alarm System on 3/14/25 to include: Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or Designee will review All Fire Alarm System testing weekly for 4 weeks and then monthly for 2 months to ensure compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) The compliance date is 3/28/25.