Failure to Maintain Required Fire Extinguishers in TER
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the maintenance of portable fire extinguishers. During a life safety tour conducted at 2:40 p.m. on April 1, 2025, it was observed that the Telecommunication Equipment Room (TER) in the Rehabilitation Room lacked the required clean agent fire extinguishers. This deficiency was identified during an inspection with the Maintenance Director present. The Maintenance Director acknowledged the absence of the necessary fire extinguishers during a staff interview conducted at the same time. This issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The deficiency was noted under NFPA 101 (2021 Edition) and NFPA 10 (2018 Edition) standards, indicating a failure to adhere to the required fire safety protocols.
Plan Of Correction
Sprinkler System Maintenance and Testing Identify patients that were at risk and what did: When the surveyor identified the issue we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. How will you identify other patients that are at risk? No other residents were identified at risk. When the surveyor identified the issue, we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. Measure put in place: The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. The Director also checked the rest of the extinguishers to ensure they were ready for use. How will you monitor? The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. Any variances will be brought to the QAPI Committee.