Deficiency in Fire Suppression System Maintenance
Penalty
Summary
The facility failed to ensure that the Ansul fire suppression system and the K extinguisher in the kitchen were inspected and maintained according to the relevant NFPA standards. During a Life Safety recertification survey, it was observed that the monthly inspection tag for the Ansul system was blank, indicating that inspections were not documented as required. This lack of documentation suggests that the necessary monthly inspections may not have been conducted, which is a violation of NFPA 101, NFPA 10, and NFPA 17 A standards. Additionally, the K extinguisher located adjacent to the stove was found with its pressure gauge needle in the recharge zone, rather than the full zone, indicating that it was not in proper working condition. The service tag on the extinguisher showed that it was last recharged in 2024, yet it was not adequately maintained to ensure it remained operational. These deficiencies were identified during a tour of the kitchen, and the Director of Maintenance acknowledged the findings.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K324 I. Immediate Corrective Action: 1. Ansul System Inspection Tag: - On 3/20/25, the Director of Maintenance immediately addressed the issue with the Ansul system inspection tag and signed for the current month. 2. K Extinguisher Pressure Gauge: - The K extinguisher was immediately removed from service and replaced with a fully charged extinguisher, ensuring it was in the full zone (green). - The service company was contacted to inspect and recharge the K extinguisher. The fire extinguisher has been replaced and recharged. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of all fire suppression systems and extinguishers in the facility to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's fire safety and inspection procedures. - The policy was updated and reviewed to ensure that all fire suppression system inspection tags are completed and signed monthly. - Maintenance staff were in serviced to consistently monitor and document inspections monthly. A checklist was updated for fire extinguishers, including monthly checks of pressure gauges to ensure that all extinguishers are within the full zone. This checklist will be used by staff during routine inspections. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of monthly fire suppression system inspections and extinguisher checks. 2. Monthly audits will be performed for six months of all ansul systems and fire extinguishers to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance