Failure to Maintain Fire Alarm System Documentation
Penalty
Summary
The facility failed to maintain their fire alarm system in accordance with NFPA 101 standards. During a record review conducted on April 15, 2025, between 10:00 AM and 2:00 PM, it was discovered that the facility did not have documentation for several critical inspections and tests. Specifically, there was no documentation for the semiannual fire alarm inspection, the biennial smoke detector sensitivity test, and the annual duct detector pressure differential test. These findings were confirmed during an interview with the Director of Continuum and the Maintenance Supervisor, who acknowledged the lack of documentation. The absence of these records indicates that the facility did not adhere to the required testing and maintenance schedule for their fire alarm system as outlined by NFPA 101 and NFPA 72. The findings were reviewed with the Director of Continuum and Maintenance Supervisor at the exit meeting on the same day, highlighting the facility's failure to comply with the necessary fire safety standards. This deficiency was classified as a Class III violation, indicating a significant lapse in maintaining essential safety protocols.