Failure to Maintain Fire Alarm System Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain its fire alarm system components as required, affecting the entire facility. During a document review on January 16, 2025, it was discovered that the facility could not provide documentation for the semi-annual visual fire alarm inspection. The last recorded inspection was dated May 30, 2024. An interview with the maintenance manager on the same day confirmed the absence of the necessary documentation.
Plan Of Correction
The semi-annual visual fire alarm inspection has been scheduled. The maintenance director and/or designee will ensure that all visual fire alarm inspections are completed semi-annually. The administrator and/or designee will monitor for compliance.