Improper Storage of ABHR Exceeding Allowable Limits
Summary
The facility failed to ensure proper storage of Alcohol Based Hand Rub (ABHR) dispensers, exceeding the allowable limit of five gallons in a single smoke compartment. This deficiency was observed in one of the three buildings, specifically in the Atrium Building #1, Resident room #308. During the survey, it was noted that there were 61 cases, each containing six one-liter containers of ABHR, amounting to approximately 96 gallons. The label on each dispenser indicated that the active ingredient was 80% ethyl alcohol, and it included warnings about flammability and the need to keep the product away from fire or flame. The survey conducted on December 17, 2024, revealed that the facility did not comply with the requirements for storing ABHR, as outlined in the NFPA 101 and related regulations. The dispensers were not stored in a proper location, which is a violation of the safety standards. This issue was brought to the attention of the facility's representatives during the Life Safety survey exit on December 18, 2024.
Plan Of Correction
1. No residents experienced negative outcomes as a result of the deficient practice of excess storage of alcohol-based hand rub sanitizer within a single smoke compartment. On 12/18/2024, the excess supply was immediately discarded appropriately. 2. All residents have the potential to be affected by this deficient practice. Additional supply closets were audited and no issues were found. 3. On 12/18/2024, Maintenance and Housekeeping staff were educated by the regional Plant Operations Director on proper storage of Alcohol-based hand rub sanitizer. 4. Maintenance Director/Designee will audit single smoke compartments for alcohol-based hand rub sanitizer storage monthly for x3 months. Any concerning findings will be corrected immediately. The results of these audits will be reported to the monthly Quality Assurance Performance Improvement committee.
Penalty
An ABHR dispenser was found installed directly above a light switch, an ignition source, in a resident room. The Director of Maintenance confirmed the noncompliant placement, which did not meet NFPA 101 requirements for ABHR dispenser installation.
The facility did not meet alcohol-based hand rub dispenser requirements in a smoke compartment. An observation revealed that the basement electric control room had over 10 gallons of hand rub stored outside a cabinet and near an ignition source, with about 40 containers of 40 ounces each. The maintenance director confirmed this deficiency.
The facility failed to comply with NFPA 101 standards for the installation of alcohol-based hand rub (ABHR) dispensers. During a facility tour, it was found that dispensers in the employee lounge and corridor were installed within one inch of ignition sources, such as light switches and receptacles. These findings were acknowledged by the Maintenance Director and reviewed with the facility's administration.
A facility was found to have an alcohol-based hand rub (ABHR) dispenser improperly mounted above an ignition source in a resident room, violating NFPA 101 safety standards. This deficiency was confirmed by the maintenance supervisor during a survey.
A hand sanitizer dispenser was improperly installed directly over an electrical outlet in the main floor corridor near the resident lounge/dining room, violating NFPA 101 standards. The maintenance director confirmed this deficiency.
The facility was found to have improperly installed an Alcohol Based Hand Rub Dispenser (ABHR) directly above a light switch and electrical outlet in the basement kitchen, violating NFPA 101 safety standards. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Improper Placement of ABHR Dispenser Above Ignition Source
Penalty
Summary
A deficiency was identified when an alcohol-based hand rub (ABHR) dispenser was observed to be installed directly above a light switch, which is considered an ignition source, in Resident Room 336. This placement does not comply with NFPA 101 requirements, which prohibit ABHR dispensers from being installed within one inch of an ignition source. The Director of Maintenance confirmed the location of the dispenser during the surveyor's observation. The deficiency affected one of three smoke compartments within the facility component. No additional information regarding the medical history or condition of the resident in Room 336 was provided in the report.
Plan Of Correction
1. The wall-mounted hand sanitizer dispenser cited was moved on 6/25/25 to a non-outlet, non-switch wall. 2. All dispenser locations were verified to be appropriately mounted on a non-outlet, non-switch wall. 3. All current and new dispensers' locations will be audited once weekly for one month, and bi-weekly for two months. This will be added to the Quarterly PM. 4. All results will be reported to QAPI on a quarterly basis until satisfied that the cited deficient practice has been rectified. 5. The completion date is 8/24/25.
Non-compliance with ABHR Storage Requirements
Penalty
Summary
The facility failed to comply with alcohol-based hand rub dispenser requirements in one of its smoke compartments. During an observation on April 8, 2025, it was found that the basement electric control room contained over 10 gallons of alcohol-based hand rub stored outside of a storage cabinet. This storage was located within feet of an ignition source, which is against the stipulated guidelines. The observation revealed approximately 40 containers, each holding 40 ounces of the hand rub. The maintenance director confirmed the presence of this deficiency during an interview conducted at the same time.
Plan Of Correction
Regional Maintenance Director educated administrator on the regulation pertaining to storage of alcohol based hand rub. Administrator will educate housekeeping director and housekeeping staff of the regulation. Education will be completed by 4/30/2025. Excess hand rub was removed from electric control room on 4/8/2025. There now is less than 10 gallons stored in the control room in storage cabinet.
Non-compliant Installation of ABHR Dispensers
Penalty
Summary
The facility failed to install alcohol-based hand rub (ABHR) dispensers in accordance with NFPA 101 standards in one of its three smoke compartments. During a facility tour conducted with the Maintenance Director and the Regional Maintenance Consultant, it was observed that an ABHR dispenser in the employee lounge was installed within one inch of an ignition source, specifically a light switch or receptacle. Additionally, another ABHR dispenser located in the corridor across from the water heater room was also installed within one inch of an ignition source, a receptacle. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the tour. The observations were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. The report indicates that these installations do not comply with the safety requirements outlined in NFPA 101, which stipulate that dispensers should not be installed within one inch of an ignition source.
Plan Of Correction
1. The ABHR dispenser located in the employee lounge was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. The ABHR dispenser located in the corridor across from the water heater room was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. 2. An audit was completed by Maintenance Director on 4/17/2025 to ensure all ABHR dispensers are not within 1 of an ignition source. No additional findings noted. 3. Education was provided to the Maintenance Director by NHA on ensuring ABHR dispensers are installed in accordance with NFPA 101 on 4/1/2025. Quality assurance checks will be completed quarterly ongoing at an integrated facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.
Improper Placement of ABHR Dispenser
Penalty
Summary
The facility failed to comply with the alcohol-based hand rub dispenser requirements as outlined by NFPA 101. During an observation on March 11, 2025, at 10:40 a.m., it was noted that a resident room, specifically room 440, had an alcohol-based hand rub dispenser mounted above an ignition source. This placement is in violation of the safety standards that prohibit dispensers from being installed within 1 inch of an ignition source. The deficiency was confirmed through an interview with the maintenance supervisor at the time of the survey.
Plan Of Correction
Work order #192927 added to our computerized work order system to address and relocate any/all alcohol-based hand rubbing stations which may be located above any electrical devices throughout the Skilled Nursing Unit. All sanitizing stations have been relocated and will be monitored weekly for 4 weeks and reported at our quarterly QAPI meeting.
Non-compliant Installation of Hand Sanitizer Dispenser
Penalty
Summary
The facility failed to maintain compliance with the NFPA 101 standards for alcohol-based hand rub dispensers. During an observation, it was noted that a hand sanitizer dispenser was installed directly over an electrical outlet in the main floor corridor near the resident lounge/dining room. This installation does not meet the requirement that dispensers should not be installed within 1 inch of an ignition source. The maintenance director confirmed this deficiency during an interview conducted at the time of the observation.
Plan Of Correction
Maintenance Director will be educated that hand sanitizer dispensers cannot be mounted on walls directly over electrical outlets. Maintenance Director will move the hand sanitizer dispenser so it is not directly over an electrical outlet. Maintenance Director will audit the other hand sanitizer dispensers in the facility to assure they are not mounted on walls directly over electrical outlets.
Improper Installation of ABHR Above Electrical Outlet
Penalty
Summary
The facility failed to comply with the requirements for the installation of Alcohol Based Hand Rub Dispensers (ABHR), as observed during a survey. Specifically, an ABHR was installed directly above a light switch and a duplex electrical outlet in the basement kitchen. This placement does not meet the safety standards outlined in NFPA 101, which require that dispensers are not installed within 1 inch of an ignition source. The deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
ABHR dispenser was removed from the basement kitchen above light switch and duplex electrical outlet. All ABHR dispensers were checked for appropriate placement in accordance with guidelines. Maintenance Director will in-service all maintenance staff on proper installation and placement of ABHR dispenser. Random weekly audit of ABHR dispensers for placement will be completed for 3 weeks and findings reported to QAPI.
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