Failure to Maintain Fire Alarm System in Accordance with NFPA Standards
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 70 and NFPA 72 requirements. During an observation and interview, the fire alarm panel was found to display a "FAULT RSTRD" message, with both supervisory and system trouble indicator lights illuminated, indicating a malfunction of the system. The maintenance supervisor confirmed these deficiencies at the time of the survey. Subsequent document reviews and interviews during onsite revisit surveys revealed that the deficiencies with the fire alarm panel remained uncorrected over multiple visits. The facility had not completed the necessary inspection or repairs, as a vendor required payment in advance and funding had not been secured. Throughout this period, the facility continued to experience a malfunctioning fire alarm system.
Plan Of Correction
1. Absolute Fire Protection will be contacted to correct the system malfunction and restore the fire alarm panel to "normal" status by 1/30/2026. 2. The Environmental Services Director/designee will perform an audit to ensure that the fire alarm panel reads "normal" status; the audit will be conducted daily for four weeks, weekly for four weeks, and bi-weekly for five weeks. 3. The results of this audit will be reviewed at the facility's next two quarterly Quality Assurance Performance Improvement meetings to ensure compliance.