Incomplete Fire Watch Policy for Sprinkler System Outage
Penalty
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 ten hours of the sprinkler system being out of service. Staff confirmed that the required time frame was not included in the policy. This deficiency affected all 90 residents across ten smoke compartments, as the policy omission could impact the facility's response during a sprinkler system impairment.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System. When the Sprinkler System is out of service, the facility shall update the Fire Watch policy to include language indicating "fire watch will be implemented after no more than ten hours of the sprinkler system being out of service." The updated Fire Watch policy will be reviewed, updated, and approved June 26, 2025 during the QA Committee meeting. Further issues regarding the Fire Watch policy or the sprinkler system shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.