Failure to Install Clean Agent Fire Extinguisher in Telecom Room
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the installation and maintenance of portable fire extinguishers. During a fire safety tour conducted on April 30, 2025, it was observed that the Telecommunication Equipment Room, located next to the Culinary Director's Office, did not have a clean agent fire extinguisher installed. This observation was made in the presence of the Plant Operations Technician, who acknowledged the deficiency. The absence of a clean agent fire extinguisher in the Telecommunication Equipment Room was discussed with the Administrator and the Director of Plant Operations during the exit conference on the same day. The deficiency was noted as a failure to adhere to the requirements outlined in NFPA 10 and NFPA 101, which specify the selection, installation, inspection, and maintenance of portable fire extinguishers in such areas.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K355. The telecommunication Equipment Room, located next to the Culinary Director's Office, had a clean agent fire extinguisher ordered on 05/16/2025 by the maintenance director/designee. Fire extinguishers will be audited weekly x4 weeks and monthly x6 months for compliance with K355 by the maintenance director/designee. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K353. 1. Above the ceiling of the Reflections Nurses Station, the wire was removed on 05/16/2025 by the maintenance director/designee. 2. Dynafire was notified to replace the Reflections Television Cable Room had 1 of 1 loaded fire sprinkler heads on 05/16/2025 by the maintenance director/designee. 3. Kitchen 2 of 3 loaded dry sprinkler heads in the walk-in coolers were cleaned on 05/15/2025 by the maintenance director/designee. 4. Dynafire was notified to replace the Beauty Supply Room loaded sprinkler head on 05/16/2025 by the maintenance director/designee. 5. The Phone Room, in the Laundry corridor will have the ceiling repaired by 05/24/2025 by the maintenance director/designee. 6. The Fire Riser Room, in the Laundry corridor, was inspected by Dynafire before 05/24/2025 and the red tag was removed by Dynafire. The sprinkler wrench was ordered from Dynafire on 05/15/2025. The hydraulic sign will have a repair estimate by 05/24/25 to make the sign legible. 7. The Seaway Wing, near Room 206, had the insulation removed from on top of the sprinkler pipe by the maintenance director/designee. 8. The Physical Therapy Riser Room spare sprinkler head box had a list of all of the required items posted on the wall next to the box at the time of survey. The list is posted as it does not fit inside the box. 9. The Independent Wing Riser Room hydraulic sign was inspected by Dynafire, and the center has contacted the original manufacturer Brown, on 05/13/25. The original data is unable to be retrieved. Dynafire is unable to update the data as of 05/13/25. The center will have the repair estimates to replace the signage by 05/24/25 for the independence and Laundry corridor signs. This was completed by the maintenance director/designee. Sprinkler heads, ceilings surrounding sprinkler heads, fire riser rooms, and sprinkler piping and hydraulic signs will be audited weekly x4 weeks and monthly x6 months for compliance with K353 by the maintenance director/designee. The results of these audits and any necessary repairs will be brought to QAPI for review.