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K0345
F

Deficient Fire Alarm System Testing, Maintenance, and Documentation

Stephenson, Michigan Survey Completed on 06-25-2025

Penalty

No penalty information released
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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 ensure that the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards. During record review, it was found that the most recent annual fire alarm inspection and sensitivity reports indicated that most smoke detectors were out of sensitivity or unserviceable and needed replacement. When questioned, the Maintenance Director (MD) confirmed that these issues had not been corrected. Documentation provided showed that some components such as duct detectors, key switches, and panel parts were replaced, but there was confusion regarding whether the fire alarm control panel (FACP) itself had been replaced. Further review revealed a discrepancy between the inspection report, which listed an Edwards EST Panel, and the observed installed panel, which was a Kidde FX Series. No evidence was provided to clarify if the deficiencies noted in the inspection and sensitivity reports had been addressed or to explain the discrepancies regarding the FACP. Additionally, it was observed that the breaker for the Fire Alarm Control Panel did not have a device to prevent unauthorized disconnection, such as a circuit breaker lock, as required by NFPA 72. This finding was confirmed by the MD at the time of discovery. No further information was provided to indicate that this issue had been resolved.

See complete original report
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