Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in compliance with NFPA 70 and NFPA 72 standards, as evidenced by the lack of documentation for corrections of deficiencies found during the annual fire alarm system inspection and the absence of records for the semi-annual visual inspection. These deficiencies were identified during a document review on February 3, 2025, and confirmed through an interview with the Facility Administrator and Maintenance Director on February 4, 2025. Additionally, an observation on February 4, 2025, revealed a covered smoke detector in the closet of the auditorium stage, further indicating lapses in the facility's fire safety measures. The survey determined that these deficiencies affected the entire facility, which is a one-story, Type II (000), unprotected noncombustible building that is fully sprinklered. The lack of proper documentation and maintenance of the fire alarm system signifies non-compliance with the Life Safety Code requirements for an existing health care occupancy, as mandated by 42 CFR 483.90(a). The facility's inability to provide necessary documentation during the survey highlights significant gaps in their fire safety protocols.
Plan Of Correction
345 main 1 1. A new vendor was contracted to ensure a regulatory inspection deficiencies were corrected. A new vendor was contracted to ensure a regulatory semi-annual visual inspection of the fire alarm system is completed. The smoke detector was uncovered at the time of the survey. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued bi-annual inspections and corrections are completed. Ongoing audits are conducted to ensure smoke detectors are uncovered. 345 main 2 1. A new vendor was contracted to ensure a regulatory inspection deficiencies were corrected. A new vendor was contracted to ensure a regulatory semi-annual visual inspection of the fire alarm system is completed. The smoke detector was uncovered at the time of the survey. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued bi-annual inspections and corrections are completed. Ongoing audits are conducted to ensure smoke detectors are uncovered. 345 LTSR 1. A new vendor was contracted to ensure a regulatory inspection deficiencies were corrected. A new vendor was contracted to ensure a regulatory semi-annual visual inspection of the fire alarm system is completed. 2. The Director of Maintenance or designee will monitor alongside the vendor to ensure continued bi-annual inspections and corrections are completed.