Fire Alarm System Deficiencies
Summary
The facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72 National Fire Alarm Code 2010 edition, resulting in multiple deficiencies. During the recertification survey, it was observed that a trouble signal was activated on the fire alarm panel in both Building #1 and Building #2, indicating a malfunction that had not been corrected. Interviews with the Director of Building Services and the Facilities Manager revealed that they were unaware of the trouble signal and had not taken steps to address it. Additionally, a review of the Fire Alarm Inspection Report from May 2024 showed that 27 out of 139 smoke detectors had failed the sensitivity inspection, with no documented evidence of re-testing. Further observations revealed that smoke detectors were improperly installed within 3 feet of ventilation ducts in several areas of both buildings, including resident rooms, corridors, and common areas. This installation did not comply with the NFPA 72 code requirements. The Facilities Manager acknowledged the improper placement of smoke detectors and indicated that they would contact their vendor to address the issue. However, at the time of the survey, these deficiencies remained uncorrected, demonstrating a lack of compliance with fire safety regulations.
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.