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F0921
F

Failure to Properly Test and Verify Door Alarm Functionality

Monroeville, Pennsylvania Survey Completed on 02-27-2026

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 deficiency involves the facility’s failure to ensure that door alarm systems were regularly tested for full functionality, as required by facility procedures and state regulations. Facility documents showed that the Maintenance Manager’s job description included maintaining competency in fire prevention and safety and facility maintenance requirements, and written alarm testing instructions specified a detailed multi-step process to verify delayed egress operation, alarm activation, automatic door opening, alarm reset, signage, nurse station panel activation, and annual keypad battery replacement. However, during a surveyor interview and observation, the Maintenance Director demonstrated that he did not follow these written procedures. During an observed test of a door alarm, the Maintenance Director was unable to deactivate the alarm and required nursing staff to respond to the alarming door to silence the alarm and reactivate the locking mechanism. When questioned on how he ensured door alarms were functional, he stated that he only attempted to open the door to confirm it was locked, and acknowledged that this action did not verify the alarm’s functionality. In a separate interview, the Nursing Home Administrator confirmed that the facility failed to make certain that door alarm systems were regularly tested for functionality, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(1)(3).

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