Combustible Materials Found on Heating Units
Penalty
Summary
The facility failed to ensure that heating units were free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation on January 29, 2025, at 10:00 a.m., it was noted that combustible materials were placed on top of heating units in resident rooms 414 and 412. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 11:10 a.m. on the same day.
Plan Of Correction
Combustible materials were removed immediately from tops of heating units in resident rooms 412 and 414. Maintenance and nursing staff on fourth floor will be educated on the importance of heating units to be clear of combustible materials. Maintenance director or designee will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure compliance. Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.