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NY State Tag
F

Fire Alarm System Testing Deficiency

Rye, New York Survey Completed on 02-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all devices associated with the fire alarm system were tested annually in accordance with NFPA 101 standards. During a life safety recertification survey, it was observed that the inspection and testing report for the fire alarm system did not include the inspection and testing of the magnetic hold open devices. Additionally, the service report for these devices was not provided at the time of the survey. The last recorded service of the fire alarm system by the vendor was on September 24, 2024, but it did not cover the magnetic hold open devices. This oversight was confirmed during an interview with the Director of Facilities, who acknowledged the omission and stated that the vendor would be contacted to address the issue.

Plan Of Correction

Plan of Correction: Approved March 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will contact the appropriate vendor to conduct testing of the magnetic hold open devices by 3/15/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 3/15/25 the Director of Facilities or designee will audit vendor reports monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities

See complete original report
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