Failure to Maintain Operable Fire Alarm System Components
Penalty
Summary
The facility failed to maintain fire alarm system components in operable condition, as evidenced by a review of documentation and interviews. The fire alarm report identified several deficiencies, including failed load tests for Altronix BPS batteries in the first floor utility closet and electrical room, a non-functioning piezoelectric buzzer at the fire alarm control panel (FACP), and horn strobes on the fifth floor not being properly tied into the FACP soft key NAC disablements. Additionally, multiple pull stations throughout the building were missing the required 'in case of fire, call 911' signage, with approximately 23 signs absent. Further deficiencies included a smoke detector at the top of the center stairs that failed and was reported as a supervisory issue, and a heat detector in the hall by the boiler that failed and was incorrectly labeled on the FACP. During the exit interview, the administrator and maintenance directors confirmed that these fire alarm deficiencies had not yet been corrected, affecting the entire facility.
Plan Of Correction
EES was scheduled to be on site the week of January 12, 2026, to review and correct all identified fire alarm maintenance items, including panel notifications, documentation, and system reporting. A full inspection report will be retained in the Life Safety binder. The maintenance director will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility fire alarm system components remain in operable conditions.