Disconnected Smoke Detector in Elevator Room
Penalty
Summary
During an observation on June 6, 2025, it was found that the smoke detector in the north elevator room was disconnected from its ceiling mount and was hanging by its wires. This issue was identified during a facility inspection and was confirmed through interviews with both the Maintenance Director and the Corporate Operations Director at the time of observation. The deficiency reflects a failure to ensure the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72 standards. This condition could potentially affect 48 of the 124 residents in the facility in the event of a fire. Records of system acceptance, maintenance, and testing were required to be readily available, but the direct observation of the disconnected smoke detector indicated non-compliance with these requirements.
Plan Of Correction
K 345 Element # 1 The smoke detector in the north elevator room was reconnected to the ceiling mount. Element # 2 Current residents have the potential to be affected by the deficient practice. All smoke detectors in the facility were evaluated to ensure proper mounting to the ceiling. Element # 3 The Maintenance Department was re-educated on proper mounting of smoke detectors. Element # 4 The Administrator and/or designee will conduct random audits of the smoke detectors x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with properly mounted smoke detectors. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025