Improper Smoke Detector Placement Near Ventilation Ducts
Summary
The facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. During the recertification survey, it was observed that smoke detectors were installed within 3 feet of ventilation ducts in the nurse office across multiple buildings, specifically Buildings #10, #14, #21, and #22. This placement does not comply with the required standards for smoke detector installation relative to ventilation system supply and return ductwork. The observations were made on March 27, 2025, between 11:00 AM and 1:30 PM. The surveyors noted that the smoke detectors' proximity to the ventilation ducts could potentially affect their functionality and effectiveness in detecting smoke. This deficiency was consistent across several buildings within the facility, indicating a systemic issue with the installation of smoke detectors. During an interview conducted at 1:30 PM on the same day, the Facilities Manager acknowledged the incorrect placement of the smoke detectors and stated that they would be relocated. However, the report does not provide details on any corrective actions taken or planned by the facility to address this deficiency. The focus remains on the improper installation of the smoke detectors and the facility's acknowledgment of the issue.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Element 1: The smoke detector will be removed and relocated to be in compliance with the National Fire Protection Association 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1 by (MONTH) 13, 2025. Element 2: All residents have the potential to be impacted by this practice. All smoke detectors will be checked to ensure compliance with National Fire Protection Association as it relates to location of detector and distance from ventilation ducts. Any alarms identified as needing to be moved to meet these requirements will be moved by (MONTH) 13, 2025. Element 3: Smoke detectors will be added to the monthly facility preventive maintenance rounds to ensure that all smoke detectors are in a location that meets National Fire Protection Association regulations. Any new installation of smoke detectors will be checked by the facility Fire Alarm Protection vendor to ensure they meet National Fire Protection Association guidelines. Element 4: Installation of new or replacement of existing smoke detectors will be added to the monthly Facility Quality Assurance Committee meeting to ensure that the new equipment was approved by the Fire Alarm Detection system vendor. This will be a standing item for this meeting. Facility Manager responsible for ongoing compliance.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.