Deficiency in Fire Protection System Policy
Summary
The facility failed to prepare and maintain a policy for actions to be taken if the sprinkler system is out of service, leading to a deficiency. On December 16, 2024, a surveyor found a sprinkler head in a closet on the first floor, which was under construction, fitted with a protective cover. This cover rendered the sprinkler head inoperable in the event of an emergency. It was unclear how long the sprinkler head had been covered, and there was no record of a fire watch being conducted in this area while the sprinkler head was impaired. Further review on December 17, 2024, revealed that the facility's sprinkler documents and emergency preparedness policy lacked a policy for the protection of occupants if the automatic sprinkler system was out of service for more than 10 hours. During the exit conference, the facility's Administrator acknowledged the absence of such a policy and stated that they would develop one. This lack of policy and oversight in ensuring the operability of the fire protection system led to the cited deficiency.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: The protective cover was removed immediately upon identification to restore full operability of the sprinkler head. A facility-wide inspection was conducted to ensure no other sprinkler heads were obstructed or otherwise impaired. All sprinkler heads were confirmed to be in proper working condition. A policy was developed and implemented to address the following: Procedures for protecting occupants when the sprinkler system or a portion of it is out of service for more than 10 hours, including interim life safety measures. Routine inspection of sprinkler systems during construction or maintenance projects. Prohibition of any action that impairs the functionality of sprinkler systems without proper documentation, risk assessment, and notification. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy and requirements to maintain the sprinkler system. Training will include: Recognizing and reporting conditions that impair sprinkler system operations. Steps to implement life safety measures when sprinklers are out of service. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: Maintenance Director
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
