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K0325
D

Non-compliant Installation of ABHR Dispensers

Saint Petersburg, Florida Survey Completed on 03-31-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to install alcohol-based hand rub (ABHR) dispensers in accordance with NFPA 101 standards in one of its three smoke compartments. During a facility tour conducted with the Maintenance Director and the Regional Maintenance Consultant, it was observed that an ABHR dispenser in the employee lounge was installed within one inch of an ignition source, specifically a light switch or receptacle. Additionally, another ABHR dispenser located in the corridor across from the water heater room was also installed within one inch of an ignition source, a receptacle. These findings were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the tour. The observations were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. The report indicates that these installations do not comply with the safety requirements outlined in NFPA 101, which stipulate that dispensers should not be installed within one inch of an ignition source.

Plan Of Correction

1. The ABHR dispenser located in the employee lounge was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. The ABHR dispenser located in the corridor across from the water heater room was moved by Maintenance Director on 4/1/2025 and is no longer installed within 1 of an ignition source. 2. An audit was completed by Maintenance Director on 4/17/2025 to ensure all ABHR dispensers are not within 1 of an ignition source. No additional findings noted. 3. Education was provided to the Maintenance Director by NHA on ensuring ABHR dispensers are installed in accordance with NFPA 101 on 4/1/2025. Quality assurance checks will be completed quarterly ongoing at an integrated facility preventive maintenance program. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly to ensure continued compliance.

See complete original report
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