Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain and test its fire alarm system in accordance with NFPA 101 (2012 edition). During a record review with the Maintenance Director, it was found that the facility could not provide current documentation for the duct detectors' differential pressure testing. In an interview, the Maintenance Director acknowledged the absence of the fire alarm system inspection documentation and mentioned that he would contact the vendor to complete the inspection. These findings were confirmed by the Maintenance Director during the record review and by the Administrator during the exit conference.
Plan Of Correction
1. On 3/3/25, an approved vendor was contacted to complete the duct detector differential pressure testing. This testing was completed on 3/25/25. 2. Current facility residents have the potential to be affected by this deficient practice. No other fire alarm system inspection concerns identified. 3. On 3/24/25, the facility Administrator/designee provided education for maintenance employees regarding NFPA 101 fire alarm system inspection, specifically duct differential pressure testing/maintenance. 4. On 3/25/25, an alert has been added to the facility TELS system to remind maintenance staff of the next required test. Maintenance Director/designee to complete fire alarm system specifically duct differential pressure testing/maintenance as required. Findings to be reviewed during the monthly QAPI Committee Meeting. Modifications implemented if indicated.