Failure to Maintain and Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide required testing and maintenance for its fire alarm system on a semi-annual basis. Documentation review revealed that there was no evidence of semi-annual visual inspections or testing of the fire alarm system within the previous twelve months. Additionally, the facility lacked documentation for the semi-annual inspection and testing of both wet and dry system valve supervisory switches and pressure switch waterflow alarms. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director. Further review of service call reports indicated that certain supervisory and tamper flow switches on the wet system failed to register as a priority fire alarm. There was no documentation provided to show that this issue had been resolved. The absence of records verifying the correction of these alarm deficiencies was also confirmed by facility leadership during the exit conference.
Plan Of Correction
The facility will provide testing and maintenance to the fire alarm system on a semi-annual basis as required. A copy of the January 2025 inspection report was acquired and placed in the facility life safety book. Documentation of repairs will also be placed in the life safety book. At least semi-annually, the Maintenance Director or NHA will audit the life safety book to confirm that all reports have been filed in the book. Results of the audits will be reported to the QAPI Committee. Date of correction is 7/30/2025.