Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain the fire alarm system in accordance with NFPA 70 and NFPA 72 requirements, as evidenced by the absence of documentation for a semi-annual visual inspection of the fire alarm system. During a document review and interviews, it was determined that the facility could not provide records of the required inspection for all seven smoke compartments. This lack of documentation was confirmed during interviews with the Administrator, Regional Director, Regional Maintenance Director, and Environmental Services Director at the time of the survey exit conference. 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
The facility failed to maintain the fire alarm system, for seven of seven smoke compartments. No residents were affected by this deficient practice. All residents have the potential to be affected. On 8/12/2025, the Maintenance Director was educated by the Administrator on the requirement that a semi-annual visual inspection of the fire alarm system is required. A semi-annual visual inspection of the fire alarm system was completed. Fire alarm system was audited to ensure compliance with the requirement. The Maintenance Director/Designee will conduct compliance audits semi-annually on an ongoing basis to ensure that a semi-annual visual inspection of the fire alarm system is completed. Results of audits will be reviewed at Quarterly Quality Assurance and Performance Improvement Committee Meeting over the duration of the audit process. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting.