Failure to Maintain Duct Smoke Detectors
Penalty
Summary
The facility failed to maintain two duct smoke detectors in accordance with NFPA 101 standards. During a record review with the Maintenance Director and the Regional Maintenance Consultant, it was found that the facility did not provide evidence of the required annual duct detector differential pressure testing for the two duct detectors. The most recent testing available was from March 21, 2023, indicating that the annual testing had not been conducted as required. Additionally, the facility did not provide evidence of the biennial sensitivity testing for the two duct smoke detectors. These deficiencies were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the record review and were discussed with the Administrator during the exit conference. The lack of proper testing and maintenance records for the duct smoke detectors constitutes a failure to comply with the NFPA 101 and NFPA 72 standards.
Plan Of Correction
1. The annual duct detector differential pressure testing for both duct detectors was completed on 2/3/2025 and 3/31/2025. The biennial sensitivity testing for both duct smoke detectors was completed on 03/24/2025. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director regarding maintaining the duct detector differential pressure testing and biennial sensitivity testing for both duct smoke detectors per NFPA 101 by NHA on 4/17/2025. 4. Results from the annual duct detector differential pressure testing for both duct detectors and the biennial sensitivity testing for both detectors will be reported to the QA&A committee.