Failure to Test and Maintain Fire Alarm System per NFPA Standards
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to the requirements of NFPA 70 and NFPA 72. During a record review, it was found that documentation was missing to show that the fire alarm inspection was conducted as required, with a vendor report indicating that 28 devices remained untested. Additionally, there was no documentation provided to confirm that the semiannual visual inspection of the fire alarm initiating devices had been completed, as required by NFPA 72. These deficiencies were confirmed through an interview with the Maintenance Assistant during the record review. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K345#1 All current reports were placed in the Fire Safety Manual. The documentation for the semiannual visual inspection of the fire alarm system was completed on 3/13/25, and reports were obtained and placed in the Fire Safety Manual. Any items that need to be addressed will be corrected by Summit Fire Protection on 5/22/25. #2 A review of all reports was completed to ensure accuracy and completeness. #3 Maintenance Director was educated on following up on making sure all Fire Alarm System tests have been completed and complete paperwork is in the Life Safety Manual. #4 Any further Fire Alarm System tests will be followed up on to make sure all are completed and all paperwork is received and placed in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and the Administrator to ensure sustained compliance.