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K0354
C

Lack of Fire Watch Policy for Sprinkler System Outage

Lititz, Pennsylvania Survey Completed on 07-01-2025

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 a complete and accurate fire watch policy for situations when the sprinkler system is impaired or out of service for more than ten hours. During a document review, it was found that there was no policy in place addressing the procedures to follow in the event of a sprinkler system impairment or extended outage. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.

Plan Of Correction

The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.

See complete original report
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