Failure to Maintain Smoke Detector Sensitivity Testing Records
Penalty
Summary
The facility failed to maintain required records of smoke detector sensitivity testing as mandated by NFPA 101 and NFPA 72 standards. During a record review and interview with the Maintenance Director, surveyors requested documentation showing that smoke detector sensitivity testing had been performed within the last two years. The facility was unable to provide any records of such testing, and the Maintenance Director stated that he believed the vendor had performed the test but would need to contact them for the records. No documentation was provided to the surveyors by the deadline given. This deficiency affected all 120 residents in all four smoke compartments of the facility. The lack of records means there was no evidence that the smoke detectors had been tested for sensitivity as required, which is necessary to ensure their proper functioning in the event of a fire. The surveyors noted that no previous records were available, and the required documentation was not submitted even after an opportunity was given to provide it.
Plan Of Correction
K347-Smoke Detection 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility contracted with a certified vendor who performed smoke detector sensitivity testing on all applicable smoke detectors. The vendor's report confirmed all devices were within operational parameters. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Maintenance Director educated by the Administrator on the requirements and documentation for smoke detector sensitivity testing requirements per NFPA 72: 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review testing schedules monthly to ensure smoke detector sensitivity testing is completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. K 347