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K0346
C

Incomplete Fire Watch Policy During Fire Alarm System Outage

Redding, California Survey Completed on 06-09-2025

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 maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than four hours of the fire alarm system being out of service, as required. Staff confirmed that the policy lacked a defined time frame for initiating a fire watch. This deficiency affected all 90 residents across ten smoke compartments.

Plan Of Correction

The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the fire alarm system, and shall update the fire watch policy. When the fire alarm system is "out of service," the facility's fire watch policy shall include language stating, "fire watch will be implemented after no more than four hours of the fire alarm system being out of service." The updated Fire Watch Policy will be reviewed, updated, and adopted June 26, 2025, during the QA Committee meeting. Further issues regarding the fire alarm system fire watch policy shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, DON, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.

See complete original report
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