Missing Annual Fire Alarm Test Records
Penalty
Summary
The facility failed to maintain records of the annual fire alarm system test completed within the last twelve months. During an interview and record review, facility administration and maintenance staff were unable to provide written documentation of the most recent annual fire alarm test when requested by surveyors. The Regional Maintenance Director confirmed that the annual fire alarm test record for the past twelve months was missing. This deficiency was identified through interviews and review of facility records, with no documentation available to demonstrate compliance with required fire alarm system testing and maintenance standards. 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
Fire Alarm System - Testing and Maintenance Correct Deficient Practice: On 3/07/25 MS called Delta Fire Equipment to schedule the facility's Annual Fire Alarm Test on 3/10/25. Identify Others: All residents, employees, and visitors are at risk due to this deficient practice. Systemic Changes: On 03/10/2025, the Administrator provided in-service education to Maintenance Supervisor regarding facility policy and procedures titled, "Maintenance Services" & "Fire Safety Inspections," indicating the maintenance department is responsible for maintaining the fire alarm system in good working order and the need for Annual Fire Alarm System Test inspections to be completed and forwarded to the administrator within 48 hours. MS or designee will complete the Mesa Glen Annual Fire Alarm Test Log on a yearly basis to ensure all parts of the Fire Alarm system are in working order. Any negative findings will be reported to the administrator and corrected immediately. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained.