Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain the fire alarm system as required, affecting the entire facility. During a documentation review on January 28, 2025, it was discovered that the facility did not have documentation for an annual fire alarm inspection. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of the necessary inspection documentation at the time of the survey.
Plan Of Correction
The facility will ensure the fire alarm system is maintained at all times. The facility will complete its annual fire alarm inspection as required. Documentation will be stored and maintained by the facility. The administrator will audit monthly to ensure fire alarm inspections are completed as required. The maintenance director will be educated on federal tag F0345.