Combustible Materials on Heating Units
Penalty
Summary
The facility failed to maintain heating units free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation conducted on January 22, 2025, between 12:30 p.m. and 1:15 p.m., it was noted that combustible materials were placed on top of heating units in resident rooms 240 and 108. This deficiency affected two of the three levels of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Combustible materials removed from HVACs in 108 and 240. Maintenance Director conducted facility rounds and there were no other HVACs covered with combustible materials. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0522-HVAs- Any Heating Device. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.