Fire Alarm System Maintenance Deficiencies
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on December 18, 2024, it was found that the fire alarm report from December 16, 2024, listed two deficiencies and one high priority recommendation without verification of repair. The first deficiency involved the inability to use the Xaap device for system inspection due to lack of cellular and WiFi reception in the basement where the Fire Alarm Control Panel (FACP) is located. The second deficiency was a repeat issue from the previous year's inspection, involving a functional failure of a pull station located on the first floor, C Wing by the activities room. Additionally, there was a high priority recommendation to update all smoke detectors to a newer model for improved sensitivity testing and troubleshooting. These findings were confirmed during an exit interview with the Facility Administrator, Administrator in training, and the Director of Maintenance.
Plan Of Correction
We have contacted Johnson Controls, who is our service contractor. They are scheduled to come to the facility on January 18th, 2025. We are anticipating that all needed repairs will be completed by January 20th, 2025.
Penalty
Surveyors found that the facility failed to perform and/or document the required annual Duct Detector Differential testing for the fire alarm system in accordance with NFPA 101, NFPA 70, and NFPA 72. During record review and interviews with the Director of Facilities, no documentation could be produced to show that this annual testing had been completed, and the Director acknowledged the lack of records. This deficiency was cited as potentially affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to maintain and properly test multiple fire alarm system components, including smoke detectors near the medical supply area and house laundry that could not be located, elevator fire hat and primary recall functions that could not be reset due to lack of a key, and an untested elevator control shunt trip. On revisit, the missing smoke detectors had been replaced with battery-operated units that were not connected to the building’s fire alarm notification system, and the previously identified fire alarm issues remained uncorrected.
The facility did not maintain required inspection and testing documentation for its fire alarm system. During surveyor review, no records could be produced to show that semi-annual visual inspections or the two-year smoke detector sensitivity testing had been completed, and the maintenance supervisor confirmed that this documentation was unavailable at the time of the survey. This deficiency affected the entire facility.
Surveyors found that the facility failed to maintain required fire alarm system documentation and testing records. During record review with the Maintenance Director, there was no vendor-signed log book at the fire panel documenting work performed at each visit, no documentation of biennial smoke detector sensitivity testing, and no fire alarm system design plans located at the fire panel, as required by NFPA 101 and NFPA 72.
Surveyors identified that the facility did not maintain its fire alarm system in accordance with NFPA 72 when the fire alarm control panel was observed displaying a trouble signal. During the observation, the Maintenance Director confirmed that the trouble condition was related to a faulty heat detector. This unresolved trouble indication showed that the fire alarm system was not being properly maintained to ensure it functioned as designed for the entire building.
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.
Failure to Perform and Document Annual Duct Detector Differential Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s fire alarm system testing and maintenance, specifically the required annual Duct Detector Differential testing. During record review conducted between 11:30 AM and 3:00 PM, surveyors requested documentation demonstrating that this annual testing had been completed in accordance with NFPA 101 (2012 and 2021 editions), NFPA 70, and NFPA 72. The facility was unable to produce records showing that the Duct Detector Differential testing had been performed as required. In an interview conducted during the same time frame, the Director of Facilities acknowledged that the facility failed to provide documentation of the annual Duct Detector Differential testing. The deficiency was cited under NFPA 101 2012 (19.2.9.1, 7.9) and NFPA 101 2021 (19.2.9.1, 7.9), indicating noncompliance with the standards that require fire alarm detection systems, including duct detectors, to be tested and maintained annually. The report notes that this deficiency could affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction, and resolving variances that may occur. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance and Soley because it is required Fire Alarm System - Testing and Maintenance K0345 1. On The facility a certified fire alarm vendor to perform annual duct detector differential testing. All required testing has now been completed and documented. 2. All residents and staff were considered at risk due to lack of documented testing. A facility-wide review of all fire alarm components was conducted on. 3. The facility established a service agreement to ensure all fire alarm testing (including duct detectors) is completed annually per NFPA 72 and NFPA 101 requirements. A compliance calendar has been implemented with alerts for required inspections and testing. The Director of Facilities/designee has been re-educated on required testing intervals and documentation. 4. The Director of Facilities or designee will audit for 3 months all documentation for the annual testing and inspection of the duct detector pressure differential test. The Director of Facilities will present the findings of site inspections for 3 months at Quality Assurance Performance Improvement (QAPI) meetings to confirm inspections have taken place. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. The Administrator is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction. The Administrator is responsible for confirming the status of this Plan of Correction is reviewed and discussed at QAPI meetings and action initiated if required
Failure to Maintain and Properly Test Fire Alarm System Components
Penalty
Summary
The deficiency involves the facility’s failure to maintain fire alarm system components in operable condition and in accordance with NFPA 70 and NFPA 72 requirements. During document review, surveyors noted that a fire alarm inspection report dated October 21, 2025, listed several devices that were not tested and were not included in the Deficiency/Fail results section. There was no verification available at the time of survey to show that these devices had been tested or repaired. The unverified items included a smoke detector on the 1st floor by the medical supply area that could not be found, a smoke detector by the house laundry that could not be found, a fire hat function that could not be reset because Maintenance did not have the key to reset the elevator, a primary recall function that could not be tested for the same reason, and an elevator control shunt trip that was not tested. On a subsequent onsite revisit survey, surveyors observed that the missing smoke detectors identified near the medical supply area and the house laundry had been replaced with battery-operated smoke detectors that were not connected to the facility’s fire alarm notification system. The revisit findings confirmed that these items, along with the other previously identified fire alarm system issues, remained uncorrected. The Administrator and Maintenance Director confirmed during exit interviews that the fire alarm deficiencies identified in the original and revisit surveys had not been resolved.
Plan Of Correction
Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke detectors by medical supply room and laundry room have been replaced and hard wired 5/18/26. Facility retrieved and in possession of fire hat and elevator recall key. Shunt trip, Elevator control, tested 4/13/26.Plan Review Department will be contacted for installation of new fire alarm component. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained. 3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2 5.Results will be reviewed at the quarterly QAPI meeting. Preparation and /or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action 1. Smoke detectors by medical supply room and laundry room have been replaced and hard wired 5/18/26. Facility retrieved and in possession of fire hat and elevator recall key. Shunt trip, Elevator control, tested 4/13/26.Plan Review Department will be contacted for installation of new fire alarm component. 2. Maintenance director or designee to re-educate maintenance staff on the importance of maintaining smoke detectors and ensuring elevator testing is maintained. 3.Maintenance director or designee to audit laundry rooms and medical supply rooms for smoke detectors weekly X4 monthly X2 4.Maintenance director or designee to audit elevator inspections weekly X4 monthly X2 5.Results will be reviewed at the quarterly QAPI meeting.
Missing Required Fire Alarm System Inspection and Testing Documentation
Penalty
Summary
The facility failed to ensure that its fire alarm system was inspected and tested at the required intervals in accordance with NFPA 70 and NFPA 72. During document review, surveyors found that the facility could not provide documentation showing that semi-annual visual inspections of the fire alarm system had been completed. In addition, the facility was unable to produce records confirming that the required two-year smoke detector sensitivity testing had been performed. An interview with the maintenance supervisor confirmed that the documentation for these required inspections and tests was not available at the time of the survey, and this deficiency affected the entire facility. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of required fire alarm system inspection and testing documentation.
Plan Of Correction
Maintenance department was educated on the need for the fire alarm system to be inspected and tested at regular intervals that includes semi annual visual inspections and a two year smoke detector test. The semi annual inspection will be scheduled to be completed according to NFPA- 0100 70 and 72. The smoke detector sensitivity will be scheduled to be completed according to NFPA-0100 70 and 72. Random audits will be completed by the Administrator and/or designee monthly for 6 months to assure that semi annual inspections are completed and the smoke detector test was completed. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Maintain Required Fire Alarm Documentation and Testing Records
Penalty
Summary
Surveyors identified deficiencies related to the facility’s fire alarm system testing and maintenance during record review with the Maintenance Director between 9:15 AM and 1:30 PM. The facility did not have a log book located at the fire alarm panel that was signed by the fire alarm vendor and documented the work completed at each visit, as required by NFPA 101 and NFPA 72. The Maintenance Director acknowledged that the facility failed to provide this log book at the fire panel. Additionally, the facility was unable to provide documentation that biennial smoke detector sensitivity testing had been performed, and the Maintenance Director confirmed that this documentation was not available. Surveyors also found that the fire alarm system design plans were not located at the fire panel as required. The Maintenance Director acknowledged that the facility failed to provide the fire alarm system design plans at the fire panel. These findings were cited under NFPA 101 2021 sections 9.6.5 and 9.6.7 and NFPA 72.
Plan Of Correction
The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on [R] The biennial sensitivity testing on the smoke detectors was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on The biennial sensitivity testing on the smoke detectors was completed on The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation,
Failure to Maintain Fire Alarm System in Proper Working Order
Penalty
Summary
Surveyors found that the facility failed to maintain its fire alarm system in accordance with NFPA 72 requirements. During an observation at 3:30 PM, the fire alarm control panel was noted to be displaying a trouble signal. Upon concurrent interview, the Maintenance Director acknowledged the trouble condition and stated it was due to a faulty heat detector. This unresolved trouble signal on the fire alarm control panel constituted a failure to ensure the fire alarm system was maintained and functioning as designed for the entire facility. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0345 and assure continued compliance, the following plan has been put in place. K0345 - Fire Alarm System Maintenance Immediate Correction: A fire alarm provider diagnosed and repaired the trouble signal, restoring the system to a "System Normal" state. Residents in the affected zone were monitored for safety during the repair. Identification of Others: A 100% audit of the Fire Alarm Control Panel (FACP) was conducted to ensure no other trouble or supervisory signals were present facility-wide. Systemic Changes: Maintenance and administrative staff were re-educated on responding to trouble signals within 24 hours and documenting all actions in the maintenance log. Monitoring (QA): The Maintenance Supervisor will conduct daily visual inspections of the FACP. The Safety Committee will review all service reports monthly, reporting findings to the QAPI Committee.
Failure to Perform and Document Semi-Annual Fire Alarm System Inspections
Penalty
Summary
Surveyors found that the facility failed to maintain its fire alarm system components in accordance with NFPA 101 and NFPA 72 requirements. During record review, surveyors noted that fire alarm system inspection reports were incomplete and specifically that there were no records demonstrating that required semi-annual visual inspections of the fire detection components had been performed. This deficiency had the potential to affect all four residents in the facility. At the time of the review, the Director of Maintenance confirmed the absence of documentation for the six-month inspections and stated that he was unaware of the requirement to complete semi-annual inspections of the fire detection components.
Plan Of Correction
This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exits or that one was cited correctly. This Plan of Correction is submitted to meet the requirements established by state and federal law. It is the policy that Transitional Care Unit follows Life Safety State/Federal regulations. It is policy that we hold a semi-annual fire visual inspection. The Transitional Care Unit held an inspection in February of 2026 and has another one scheduled with SecurCom for August of 2026. The Life Safety Surveyors spoke directly to SecurCom on the day of survey to ensure things were scheduled appropriately going forward. Securcom, Transitional Care Unit, and Life Safety Surveyors are on the same page and have scheduled according to regulation. Bill Bergman (President of Securcom, Inc) contacted Dustin Buell to discuss the requirements of the semi-annual inspection. On 5/1/25 a Purchase Order was issued to Securcom, Inc for them to complete the semi-annual inspection. On 5/1/26 a semi-annual fire alarm system Preventative maintenance work order was developed in our maintenance management software. This will automatically kick out every August 1st of every year as a reminder to have the semi-annual inspection completed. This administrator has put it in as a quarterly QAPI follow up to ensure compliance maintains
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