Failure to Provide Duct Detector Testing Results
Summary
The facility failed to provide test results for the annual duct detector sensitivity testing, which is a requirement under NFPA 101 and NFPA 72. During a record review, it was found that the facility did not have evidence that the annual duct detector differential testing was conducted. This deficiency was confirmed during an interview with the Director of Maintenance, who was unable to locate the necessary documentation. The absence of these test results could lead to the duct detectors failing to perform as designed, potentially resulting in no notification of a fire in the ventilation system, which could cause injury to residents or staff. These findings were acknowledged by the Administrator during the exit conference.
Penalty
Surveyors determined that the facility did not comply with NFPA 101 and NFPA 72 requirements for fire alarm system maintenance when record review showed incomplete fire alarm inspection reports and no documentation of required semi-annual visual inspections of fire detection components. The Director of Maintenance confirmed that these six-month inspections had not been documented and reported being unaware of the requirement, creating a deficiency that had the potential to affect all four residents.
Surveyors found that the facility failed to maintain and document its fire alarm system in accordance with NFPA 101 and NFPA 72, potentially affecting all residents. The only annual fire alarm record provided was a single page without a device list, and there was no documentation of required semi-annual visual inspections or sensitivity testing of devices. During the tour, surveyors observed multiple fire alarm breakers in various electrical panels that were not marked in red, not secured from unauthorized access, and in one case left in the off position, with panel labeling insufficient to identify the presence of a fire alarm breaker. These findings were confirmed with the Maintenance Director.
Failure to Perform and Document Semi-Annual Fire Alarm System Inspections
Penalty
Summary
Surveyors found that the facility failed to maintain its fire alarm system components in accordance with NFPA 101 and NFPA 72 requirements. During record review, surveyors noted that fire alarm system inspection reports were incomplete and specifically that there were no records demonstrating that required semi-annual visual inspections of the fire detection components had been performed. This deficiency had the potential to affect all four residents in the facility. At the time of the review, the Director of Maintenance confirmed the absence of documentation for the six-month inspections and stated that he was unaware of the requirement to complete semi-annual inspections of the fire detection components.
Plan Of Correction
This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exits or that one was cited correctly. This Plan of Correction is submitted to meet the requirements established by state and federal law. It is the policy that Transitional Care Unit follows Life Safety State/Federal regulations. It is policy that we hold a semi-annual fire visual inspection. The Transitional Care Unit held an inspection in February of 2026 and has another one scheduled with SecurCom for August of 2026. The Life Safety Surveyors spoke directly to SecurCom on the day of survey to ensure things were scheduled appropriately going forward. Securcom, Transitional Care Unit, and Life Safety Surveyors are on the same page and have scheduled according to regulation. Bill Bergman (President of Securcom, Inc) contacted Dustin Buell to discuss the requirements of the semi-annual inspection. On 5/1/25 a Purchase Order was issued to Securcom, Inc for them to complete the semi-annual inspection. On 5/1/26 a semi-annual fire alarm system Preventative maintenance work order was developed in our maintenance management software. This will automatically kick out every August 1st of every year as a reminder to have the semi-annual inspection completed. This administrator has put it in as a quarterly QAPI follow up to ensure compliance maintains
Failure to Maintain and Document Fire Alarm System per NFPA Requirements
Penalty
Summary
Surveyors identified that the facility failed to maintain and document its fire alarm system in accordance with NFPA 101 and NFPA 72 requirements, potentially affecting all 69 residents in the building. During record review, the only annual fire alarm documentation provided consisted of a single page without a device list. No documentation was available to verify that the required semi-annual visual inspections of the fire alarm system had been completed, and there was also no documentation confirming that fire alarm devices in the facility had undergone the required sensitivity testing. Documentation was requested multiple times throughout the survey period, including at the entrance conference and later in the morning, but none was produced by the time of exit. During the physical tour of the facility, surveyors observed multiple issues with fire alarm breakers in electrical panels. In electrical panel PP-5, the fire alarm breaker was found in the off position and was neither marked in red nor secured from unauthorized access. Another fire alarm breaker located in the generator main A panel was also not marked in red or secured, and the panel itself had no label indicating that a fire alarm breaker was inside. Additionally, in the electrical panel labeled generator sub-A at the front of the building, the fire alarm breaker was not marked in red or secured from unauthorized access. These observations were confirmed in an interview with the Maintenance Director.
Plan Of Correction
1. Based on observation, record review, and staff interview, no residents experienced negative outcomes related to fire alarm system testing and maintenance deficiencies. The facility failed to provide complete annual fire alarm documentation listing (only one page with no device list provided during survey), failed to provide documentation of required semi-annual visual inspections, and failed to provide documentation of required device sensitivity testing. Additionally, observations identified fire alarm breakers that were in the off position, not marked in red, not secured from unauthorized access, and not properly labeled within electrical panels. 2. The Medical Director was notified by LNHA on 03/26/2026 of the deficiency, including incomplete fire alarm system documentation, lack of required inspections and testing, and electrical breaker deficiencies identified during survey. 3. Fire alarm system inspection, testing, and documentation will be completed by a contracted fire protection vendor on or before 04/30/2026. This will include: (a) completion of a full annual inspection with a complete device list, (b) completion and documentation of semi-annual visual inspections, and (c) completion and documentation of sensitivity testing of all required devices. All missing documentation will be obtained and maintained onsite. Electrical deficiencies will be corrected by Maintenance Director/designee or licensed electrician on or before 04/30/2026, including: (a) ensuring all fire alarm breakers are in the correct position, (b) marking all fire alarm breakers in red, (c) securing breakers from unauthorized access, and (d) labeling all panels to clearly identify fire alarm circuits including those located within generator panels. All required inspections, testing, and maintenance will be placed on an an automatically recurring schedule per NFPA 72 requirements by Administrator/designee on or before 04/30/2026. 4. Documentation of all fire alarm system inspections, testing, and maintenance will be maintained onsite and readily available. The Maintenance Director/designee will audit compliance monthly. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance. 5. LNHA educated Maintenance Director on 03/26/2026 regarding maintenance of the facility's fire alarm equipment/system, including listing out all devices.
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