Smoke Detector Failed to Initiate Fire Alarm During Testing
Penalty
Summary
During a facility tour and staff interview, surveyors observed that a smoke detector located outside resident room 209 failed to initiate the fire alarm system when tested with artificial smoke. The test was conducted twice, and on both occasions, the alarm did not activate. Staff present during the testing were unable to provide an explanation for the malfunction at the time of the observation. It was noted that the air conditioning vent was approximately 36 inches from the smoke detector, and staff speculated that airflow from the vent might be interfering with the detector's ability to sense smoke. This deficiency affected 14 out of 90 residents in one of ten smoke compartments, as the non-functioning smoke detector could delay notification to emergency forces in the event of a fire.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the smoke detectors and fire alarm system. The facility contacted Sa-Fire to inspect the current locations of the smoke detectors. Facility plans to move / re-locate the 4 ceiling mount smoke detectors away from the proximity of the air registers that may have affected the smoke detectors, causing the testing issues. Sa-Fire will be placing the system on test to complete the work, and the annual fire alarm inspection is scheduled to be completed July 25, 2025. The detectors will be re-tested at that point. Further issues regarding the fire alarm system and/or the smoke detectors will be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.