Failure to Document Semiannual Fire Alarm System Inspections
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 72. During a record review, it was found that there was no documentation available to show that the required semiannual visual inspection of the fire alarm initiating devices had been completed, as specified by NFPA 72, section 14.3. This lack of documentation was confirmed during interviews with both the Maintenance Director and the Regional Director at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Penalty
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
The facility did not complete required sensitivity testing for all smoke and duct detectors as mandated by NFPA 101 and NFPA 72. Record review revealed that 11 smoke detectors and two duct detectors were not tested, and inspection reports lacked documentation of sensitivity testing results. The Regional Maintenance Director acknowledged these findings during the survey.
Surveyors found that the facility did not maintain its fire alarm system in operable condition, with issues such as failed battery load tests, a non-functioning buzzer at the FACP, improperly connected horn strobes, missing required signage at pull stations, and malfunctioning smoke and heat detectors. Facility leadership confirmed these deficiencies were not corrected at the time of review.
The facility did not maintain its fire alarm system as required, with the fire alarm panel displaying fault and trouble indicators over multiple survey visits. The deficiencies were confirmed by the maintenance supervisor and remained uncorrected due to delays in vendor payment and scheduling.
Surveyors found that documentation for required semi-annual fire alarm system testing was not available during review. The Administrator and Maintenance Director confirmed the missing records, resulting in a deficiency related to fire alarm system maintenance requirements.
Surveyors found that the facility did not have documentation of a required semi-annual visual inspection of the fire alarm system for all smoke compartments, as confirmed during interviews with facility leadership.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Complete Required Fire Alarm System Sensitivity Testing
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 101 and NFPA 72 standards. During a record review with the Regional Maintenance Director, it was found that the biennial smoke detector sensitivity testing did not include 11 out of 73 smoke detectors. Additionally, the repairs inspection report did not indicate that the smoke detectors were sensitivity tested, nor did it provide the results of such testing. The annual fire alarm report listed 23 duct detectors in the inventory, but the duct detector differential pressure testing documented 24 duct detectors tested, and the smoke detector sensitivity testing only included 22 duct detectors, leaving two duct detectors untested for sensitivity. These discrepancies were identified through a combination of record review and staff interviews. The Regional Maintenance Director acknowledged the findings during the review. The records failed to demonstrate that all required smoke and duct detectors underwent the necessary sensitivity testing as mandated by the applicable codes and standards. The deficiency affects all residents and staff in the affected smoke compartments, as the fire alarm system is a critical component of the facility's safety infrastructure. The findings were reviewed with both the Administrator and the Regional Maintenance Director at the exit conference, and photographic evidence was obtained to support the observations.
Plan Of Correction
Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews. Corrective Action for Affected Residents: The facility will correct the identified sprinkler system deficiency to ensure consistent and reliable fire protection within the affected smoke compartment. Specifically, the two (2) sprinkler heads in the Main Lobby that were identified as standard response sprinklers were scheduled for replacement. These sprinkler heads will be replaced with quick response sprinkler heads to ensure uniform sprinkler response characteristics throughout the area. Replacement will be completed by a licensed fire sprinkler contractor, and documentation will be maintained on-site. Identification of Other Residents Potentially Affected: To identify any additional areas that may be affected. Corrective Action for Affected Residents: All smoke detectors and duct detectors identified as not sensitivity tested or inconsistently documented will be addressed/tested. The facility will be coordinating with the licensed fire alarm vendor to: complete sensitivity testing on the 11 of 73 smoke detectors that were not tested during the biennial testing dated. Complete sensitivity testing on the two (2) duct detectors that were not included in prior sensitivity testing. Reconcile and correct discrepancies between: smoke detector sensitivity testing reports, duct detector differential pressure testing reports, and annual fire alarm inspection reports. Identification of Other Residents Potentially Affected: A 100% review of fire alarm testing records was conducted to ensure all devices are included and properly documented. Measures to Prevent Recurrence: Maintenance leadership will be re-educated on NFPA 72 sensitivity testing requirements and the importance of reconciling all fire alarm testing reports for consistency and completeness prior to acceptance. Monitoring / Quality Assurance: Annual testing will be verified by the Maintenance Director and reviewed by the Administrator during Life Safety reviews.
Failure to Maintain Operable Fire Alarm System Components
Penalty
Summary
The facility failed to maintain fire alarm system components in operable condition, as evidenced by a review of documentation and interviews. The fire alarm report identified several deficiencies, including failed load tests for Altronix BPS batteries in the first floor utility closet and electrical room, a non-functioning piezoelectric buzzer at the fire alarm control panel (FACP), and horn strobes on the fifth floor not being properly tied into the FACP soft key NAC disablements. Additionally, multiple pull stations throughout the building were missing the required 'in case of fire, call 911' signage, with approximately 23 signs absent. Further deficiencies included a smoke detector at the top of the center stairs that failed and was reported as a supervisory issue, and a heat detector in the hall by the boiler that failed and was incorrectly labeled on the FACP. During the exit interview, the administrator and maintenance directors confirmed that these fire alarm deficiencies had not yet been corrected, affecting the entire facility.
Plan Of Correction
EES was scheduled to be on site the week of January 12, 2026, to review and correct all identified fire alarm maintenance items, including panel notifications, documentation, and system reporting. A full inspection report will be retained in the Life Safety binder. The maintenance director will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility fire alarm system components remain in operable conditions.
Failure to Maintain Fire Alarm System in Accordance with NFPA Standards
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During an observation and interview, the fire alarm panel was found to display a "FAULT RSTRD" message, with both supervisory and system trouble indicator lights illuminated, indicating a malfunction of the system. The maintenance supervisor confirmed these deficiencies at the time of the survey. Subsequent document reviews and interviews during onsite revisit surveys revealed that the deficiencies with the fire alarm panel remained uncorrected over multiple visits. The facility had not completed the necessary inspection or repairs, as a vendor required payment in advance and funding had not been secured. Throughout this period, the facility continued to experience a malfunctioning fire alarm system.
Plan Of Correction
1. Absolute Fire Protection will be contacted to correct the system malfunction and restore the fire alarm panel to "normal" status by 1/30/2026. 2. The Environmental Services Director/designee will perform an audit to ensure that the fire alarm panel reads "normal" status; the audit will be conducted daily for four weeks, weekly for four weeks, and bi-weekly for five weeks. 3. The results of this audit will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.
Missing Documentation for Fire Alarm System Testing
Penalty
Summary
The facility failed to maintain proper documentation for the fire alarm system's semi-annual testing as required by NFPA 70 and NFPA 72. During a document review, surveyors were unable to locate records demonstrating that the semi-annual fire alarm testing had been completed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the required documentation. No information regarding residents or their medical conditions was included in the report, and the deficiency pertains solely to the facility's failure to provide evidence of required fire alarm system testing.
Plan Of Correction
The visual inspection of the fire alarm was completed. Maintenance director/designee will monitor fire alarm visual inspections are completed timely with proper documentation by using the TELS PM program. Weekly visual inspection of fire alarms will be conducted for 4 weeks, and then monthly for 2 months. Results are documented and placed in the Life Safety binder. Findings will be reported to the QI committee quarterly.
Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with NFPA 70 and NFPA 72 requirements, as evidenced by the absence of documentation for a semi-annual visual inspection of the fire alarm system. During a document review and interviews, it was determined that the facility could not provide records of the required inspection for all seven smoke compartments. This lack of documentation was confirmed during interviews with the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director at the time of the survey exit conference. 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
The facility failed to maintain the fire alarm system, for seven of seven smoke compartments. No residents were affected by this deficient practice. All residents have the potential to be affected. On 8/12/2025, the Maintenance Director was educated by the Administrator on the requirement that a semi-annual visual inspection of the fire alarm system is required. A semi-annual visual inspection of the fire alarm system was completed. Fire alarm system was audited to ensure compliance with the requirement. The Maintenance Director/Designee will conduct compliance audits semi-annually on an ongoing basis to ensure that a semi-annual visual inspection of the fire alarm system is completed. Results of audits will be reviewed at Quarterly Quality Assurance and Performance Improvement Committee Meeting over the duration of the audit process. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting.
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