Lack of Documentation for Fire Alarm System Inspection
Penalty
Summary
The facility failed to provide documentation verifying that a functional inspection of the fire alarm system had occurred within the previous twelve months. During a review of records, surveyors were unable to locate any documentation confirming that the required inspection and testing of the fire alarm system had been completed as mandated by NFPA 70 and NFPA 72 standards. This was confirmed in an interview with the Administrator, who acknowledged the absence of such documentation. The deficiency affected the entire fire alarm system component within the facility. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1) The facility cannot retroactively conduct the fire alarm system inspections for 2024. 2) The facility placed the fire alarm system inspections on a calendar schedule with a contracted vendor. The annual inspection will take place on 8/21/2025. 3) The facility re-educated the maintenance director on ensuring vendor completion of scheduled inspections. 4) The NHA or designate will complete a sprinkler fire alarm system inspections audit quarterly for 1 year, then semi-annually for 1 year. The results will be submitted to the QAPI committee for review and analysis of the need for ongoing monitoring.