Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 standards, as evidenced by a review of records and interviews. On February 11, 2025, it was found that the annual fire alarm report from November 4, 2023, indicated that 8 out of 12 duct detectors could not be located for testing. Additionally, the report noted that the batteries required replacement. Furthermore, the smoke detector sensitivity inspection report was outdated, with the last inspection dated February 19, 2021, and the duct detector air stream test was last conducted on September 6, 2023. The facility's administrator acknowledged these findings and mentioned that their vendor would need to provide updated testing. The failure to maintain the fire alarm system as per NFPA 101 standards could potentially delay alarm activation during hazardous conditions, although this risk is not explicitly stated in the report. The deficiency highlights lapses in the facility's adherence to required testing and maintenance schedules for critical safety equipment.
Plan Of Correction
K345 Fire Alarm System - Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI. K345 Fire Alarm System Testing and Maintenance 1. The fire alarm inspection was conducted and is currently up to date. 2. Completed audit was conducted and any abnormal findings were corrected. 3. A. Vendor has the facility on schedule to do inspection based on regulatory requirements. B. Maintenance director educated on K345. 4. Maintenance Director will do monthly audits of Fire alarm testing and Maintenance to monthly QAPI.