Failure to Maintain Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a document review on January 21, 2025, it was discovered that the facility could not provide documentation of a semi-annual visual fire alarm inspection within six months of December 12, 2024. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator and the Maintenance Director.
Plan Of Correction
The documentation of the semiannual visual fire alarm inspection was missed. Annual was performed and semi-annual is scheduled. The Maintenance Director was in-serviced on ensuring that the semi-annual visual fire alarm inspection takes place every 6 months. The Maintenance Director has scheduled in TELs, our work order system, the testing of the semi-annual visual fire alarm inspection. The Maintenance Director will review this plan of correction at the monthly Quality Assurance Performance Improvement meeting to ensure compliance is maintained.