Failure to Document Bi-Annual Fire Alarm Sensitivity Test
Penalty
Summary
The facility failed to provide documentation of the required bi-annual Sensitivity Test for the installed fire alarm system, as mandated by NFPA 70 and NFPA 72. During a record review on 03/25/2025, surveyors found that no documentation of this test was available, and this was confirmed through an interview with Facility Maintenance at the time of the review. The absence of this documentation indicates that the fire alarm system was not tested and maintained in accordance with the approved program requirements. 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 - Fire alarm System The Facility failed to have the bi-annual Sensitivity Test for the installed fire system completed, putting the whole facility and all occupants at risk. The maintenance director scheduled the Smoke Detector Sensitivity Test with DeLau Fire services, this was completed on 4-14-25 with all smoker detectors passing inspection; no repair or follow-up needed. He also scheduled our next bi-annual Sensitivity Test to ensure sustained compliance. The Maintenance Director was educated on the requirements and importance of having the Sensitivity Test completed and other scheduled maintenance. The Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. The Administrator is responsible for maintaining compliance.