Fire Alarm System Testing Deficiency
Summary
The facility failed to ensure that all devices associated with the fire alarm system were tested annually, as required by the 2012 NFPA 101 and 2010 NFPA 72 standards. Specifically, the annual vendor service report for the fire alarm system for the year 2024 did not include testing of hold open devices and magnetic release mechanisms. This omission was identified during a documentation review, where it was noted that the maintenance logs lacked evidence of these components being tested. The fire alarm system was last serviced on March 25, 2024. During an interview conducted at the time of the finding, the Director of Maintenance acknowledged the oversight and stated that the vendor would be contacted to address the issue. The absence of testing for these specific devices was a clear deviation from the required standards, as outlined in the NFPA codes and New York Codes, Rules, and Regulations (NYCRR). The deficiency was based on observations, staff interviews, and record reviews conducted during the survey.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, staff, and visitors have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee conducted a facility-wide audit and notated where all hold-open and magnetic release mechanisms are located. On 2/12/2025, the Director of Environmental Services or designee called the vendor to perform an annual test on all door holders and magnetic release mechanisms now and on an annual basis. Testing was completed on 2/14/2025. The Director of Environmental Services or designee will update a contract with the vendor to include the annual inspection of all hold-open and magnetic release mechanisms. The contract was received and signed on 2/13/2025. On 2/14/2025, the Director of Environmental Services or designee will educate the Maintenance staff on which elements the contractor should check when performing the annual inspection. The Director of Environmental Services or designee will report the findings of the annual testing of the door holders and magnetic release mechanisms in QAPI. Responsible party: Director of Environmental Services or designee.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.