Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 72 standards. During a record review with the Administrator and Maintenance Director, it was found that not all fire alarm devices had been tested, inspected, and maintained as required. Specifically, 5 out of 12 duct detector devices were missed during testing and were reported as not accessible by the fire alarm vendor. Additionally, the facility could not provide documentation showing that biennial sensitivity testing of smoke detectors had been conducted, with no records available to indicate when the last such testing occurred. During a facility tour, a smoke detector was observed to be within 36 inches of an HVAC supply vent in the main service hallway, which does not comply with placement requirements. These deficiencies were acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information about specific residents or their conditions was provided in relation to these deficiencies.