Fire Extinguisher Obstructions and Installation Issues
Penalty
Summary
The facility failed to comply with NFPA 101 standards for portable fire extinguishers, as evidenced by observations made during a fire safety tour. Specifically, three out of twelve sampled portable fire extinguishers were not installed or maintained correctly. At 12:00 PM, a class ABC fire extinguisher in the Telecommunication Equipment Room was obstructed by equipment, and at 12:02 PM, the same room lacked a clean agent fire extinguisher. Additionally, at 12:55 PM and 1:22 PM, fire extinguishers near Rooms 203 and 209 were obstructed by carts, respectively. These deficiencies were confirmed through an interview with the Maintenance Director, who acknowledged the findings during the tour. The issues were further discussed with the Administrator and the Maintenance Director at an exit conference. Photographic evidence was obtained to support these observations, and the facility's non-compliance with NFPA 10 and NFPA 101 standards was documented.
Plan Of Correction
K355 NFPA 101 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K355 PORTABLE FIRE EXTINGUISHERS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of ABC fire extinguisher in the Telecommunication Equipment Room being obstructed by equipment. Maintenance has moved items around to ensure that the ABC fire extinguisher is unobstructed. 2) In the allegation of the Telecommunications room not having a clean agent fire extinguisher. Maintenance will place a clean agent fire extinguisher in the Telecommunication room. 3) In the allegation of the fire extinguisher near room 203 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 4) In the allegation of the fire extinguisher near room 209 being obstructed by a cart. The cart was moved. An in-service will be done for the staff not to place carts in front of fire extinguishers. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance will ensure that in the Telecommunication room that the ABC fire extinguisher is not obstructed. Maintenance will put a clean agent fire extinguisher in the Telecommunication room. Maintenance will in-service staff not to place carts in front of fire extinguishers. Maintenance will ensure that carts are not placed in front of fire extinguishers during rounds. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.