Failure to Maintain and Test Fire Alarm System and Batteries
Penalty
Summary
The facility failed to maintain its Fire Alarm System (FAS) in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During a tour and document review, surveyors observed a trouble signal on the Fire Alarm Control Panel (FACP) at Nurse Station A, which was initially attributed by staff to a smoke detector being accidentally hit by equipment in a resident room. Upon resetting the FACP, the panel began displaying a cycle of trouble signals for various devices throughout the facility, with a new trouble signal appearing approximately every two seconds. A monitoring report confirmed this ongoing cycle of trouble signals, and the FAS vendor indicated that a technician would be needed to diagnose the issue. Testing of the water flow device, two smoke detectors, and a tamper switch showed that notification devices activated and signals were received by the monitoring company. Additionally, the facility failed to conduct required annual testing of the FACP batteries, specifically the discharge and charger tests. The dates of the last tests were unknown, and no records of these tests were provided when requested by surveyors. Staff confirmed the lack of testing and indicated they would follow up with their vendor, but no documentation was submitted by the deadline. These deficiencies affected all residents and smoke compartments in the facility.
Plan Of Correction
K 345 - Fire Alarm System Testing and Maintenance How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The facility immediately contacted its fire alarm system vendor to diagnose and address the ongoing trouble signals. The vendor completed necessary repairs on 4/4/25, and all alarms are now fully operational. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected. On 4/4/25, the facility performed a comprehensive assessment of all fire alarm system components to identify any additional deficiencies. No other deficiencies were noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: The EVS Director will perform a monthly check for 3 months then semi-annually to ensure semi-annual and annual fire alarm testing is completed on time. The EVS Director was trained by the Administrator on 4/9/25 on the importance of fire alarm testing and functionality. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The EVS Director will perform a monthly check for 3 months then semi-annually to ensure semi-annual and annual fire alarm testing is completed on time. Results will be reviewed in the QAPI meetings for ongoing compliance oversight. Date of Compliance 4/18/25