Fire Alarm System Deficiency
Summary
The facility failed to maintain the fire alarm system for the entire building, as evidenced by the annual fire alarm system testing documentation from January 13, 2025. The documentation revealed that the fire alarm system did not automatically transmit the alarm to notify emergency forces in the event of a fire. This deficiency was observed during a survey on March 17, 2025, at 9:30 a.m., and it was confirmed during an exit conference with the Facility Administrator and Facilities Director at 11:30 a.m. on the same day that the issue still persisted.
Plan Of Correction
1. The fire alarm system will transmit the alarm automatically to notify emergency forces in the event of a fire. 2. The facility has an agreement in place for the work to be completed. 3. The fire alarm system will be audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facility's Q.A.P.I. meeting for review and recommendation.
Penalty
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