Expired Smoke Detectors Remain in Service
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 70 and NFPA 72. During an observation and record review, it was found that battery-operated smoke detectors installed in resident rooms on the 500 and 600 wings had exceeded their 10-year lifespan, with manufacture dates of May 17, 2001, yet remained in service. This was confirmed during a physical inspection of the devices and verified by the Maintenance Director at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Resident room smoke detectors on 500/600 went beyond their 10-year life span. Unrequired room smoke detectors will be removed, as hallway smoke detectors connected to fire system are sufficient under the requirement. Element 2: There are hallway smoke detectors in these units that are connected to the building fire system. Without them, all residents, visitors, and staff of the 500/600 units would be impacted. Element 3: The battery-operated smoke detectors that are in individual resident rooms will be removed by 06/30/2025, as individual room smoke detectors are not required. Element 4: The Physical Plant Manager will be responsible for sustained compliance.