Surveyors determined that the facility did not comply with NFPA 101 and NFPA 72 requirements for fire alarm system maintenance when record review showed incomplete fire alarm inspection reports and no documentation of required semi-annual visual inspections of fire detection components. The Director of Maintenance confirmed that these six-month inspections had not been documented and reported being unaware of the requirement, creating a deficiency that had the potential to affect all four residents.
Surveyors found that the facility failed to maintain and document its fire alarm system in accordance with NFPA 101 and NFPA 72, potentially affecting all residents. The only annual fire alarm record provided was a single page without a device list, and there was no documentation of required semi-annual visual inspections or sensitivity testing of devices. During the tour, surveyors observed multiple fire alarm breakers in various electrical panels that were not marked in red, not secured from unauthorized access, and in one case left in the off position, with panel labeling insufficient to identify the presence of a fire alarm breaker. These findings were confirmed with the Maintenance Director.
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