Failure to Implement Fire Watch During Alarm System Outage
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was out of service for more than four hours, as required by the 2012 NFPA 101 standards. During a complaint investigation survey, it was discovered that the fire alarm system in the West Unit was offline due to ongoing renovations, which had been occurring for approximately two weeks. Signage at the nursing stations indicated that the fire alarm was out of service and instructed to call 911 in case of fire. However, the facility did not notify the Department of Health about the impairment, nor did they implement a fire watch to protect the occupants during this period. The Director of Maintenance acknowledged that the fire alarm system was intentionally placed offline to prevent false alarms due to dust from the renovation work. Despite this, the facility did not take the necessary steps to ensure safety by notifying the appropriate authorities or conducting a fire watch. The Assistant Administrator later stated that the facility would implement a fire watch on an hourly basis in the future, but at the time of the survey, these measures were not in place, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility will notify the department of health and will conduct a fire watch when/if the fire alarm is impaired for more than 4 hours at any given time. 03/01/2025 2. The facility’s Fire Safety and Alarm Impairment Policy has been revised to ensure full compliance with NFPA 101: 9.6.1.6 and NYCRR regulations. Updates include: - Mandatory notification to the Department of Health for any fire alarm impairment over 4 hours. - Immediate implementation of a fire watch whenever the fire alarm system is offline, regardless of the duration. - Documentation of fire watch rounds, including times and assigned staff, to be maintained for regulatory review. - All involved staff members have been in-serviced. 03/01/25 3. The Maintenance Director will conduct weekly audits for the next 90 days to verify compliance with fire alarm impairment protocols and fire watch implementation. Any non-compliance will be immediately addressed. 03/01/25 4. Maintenance Director will be responsible for making Environmental rounds quarterly and reporting findings to Assistant Administrator to review at QA to ensure compliance for one year. 03/01/25 5. Responsible party: Director of Maintenance and Assistant Administrator. 03/01/25
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.