Fire Alarm System Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, which was found to be deficient and non-operational during a document review and observation conducted on April 2, 2025. The fire alarm system had been out of operation since March 21, 2025, affecting the entire facility. This deficiency was confirmed during an exit interview with the administrator and maintenance director on the same day.
Plan Of Correction
1. There was a malfunction of the fire panel on 3/21/2025. Facility was on fire watch as per policy when the fire panel is malfunctioning. Vendor was contacted to correct the problem. Fire alarm system was restored to full function on 4/3/2025. 2. Maintenance department will maintain a fully functioning fire alarm system. 3. NHA/designee will conduct audits of fire alarm system weekly for eight weeks and monthly for one month.