Failure to Maintain and Inspect Fire Alarm System
Penalty
Summary
The facility failed to maintain and inspect its fire alarm system as required, impacting the entire building. During document review, the facility was unable to provide records of smoke detector sensitivity testing within the past two years, annual inspection and testing, semi-annual visual inspections, semi-annual valve supervisory switch checks, and semi-annual testing of vane and pressure switch waterflow alarm devices. Additionally, observation revealed that the fire alarm panel displayed 95 device troubles at the time of the survey. These findings were confirmed in an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged the lack of required documentation and the presence of multiple device troubles on the alarm panel.
Plan Of Correction
Fire alarm system was inspected on January 6th & 7th, 2025, and documentation received from contractor. Facility will ensure documentation is available for survey team. Facility will ensure that any troubles identified on fire panel are promptly addressed and contractor is notified if necessary.