Fire Alarm System Maintenance Deficiencies
Penalty
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.