Fire Alarm System Documentation Deficiency
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 compliance with fire safety regulations as evidenced by the absence of documentation for the most recent sensitivity test results of the fire alarm system. During a document review and interview conducted on January 16, 2025, it was revealed that the facility did not have the necessary documentation available. The maintenance manager confirmed that the sensitivity testing documentation was unavailable at the time of the survey.
Plan Of Correction
The sensitivity testing has been scheduled to be completed. The maintenance director and/or designee will ensure that the sensitivity testing is completed and documentation of the test results are obtained.