Improper Installation and Accessibility of Portable Fire Extinguishers
Penalty
Summary
Surveyors observed that the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101 and NFPA 10 standards. Specifically, 12 out of 18 sampled fire extinguishers were found to be mounted in cabinets with the top of the handle positioned more than sixty inches above the finished floor, with measurements ranging from sixty and a half inches to sixty-three inches. This was noted in multiple locations throughout the facility, including the kitchen, various corridors, near the nurses' station, the rehabilitation suite, and near the maintenance office. In one instance, a trash can was placed in front of a fire extinguisher cabinet, initially obstructing the cabinet door from opening until it was moved. The observations were made during a fire safety tour conducted with the Maintenance Director, who acknowledged the findings at the time. The issue was also reviewed with the Administrator, the Regional Maintenance Director, and the Maintenance Director during the exit conference. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about any medical history or conditions related to the deficiency. Additionally, the report notes that the facility failed to maintain smoking areas in accordance with NFPA 101 for both of its designated smoking areas. However, the detailed findings and observations in the report focus primarily on the improper installation height and accessibility of portable fire extinguishers, as well as the temporary obstruction of access to one extinguisher by a trash can.
Plan Of Correction
Corrective Actions On 6/9/2025, the following locations' fire extinguishers were replaced with a shorter extinguisher so that the top of the new extinguisher is less than 60 inches from the floor: A. Kitchen. Two extinguishers. B. East Corridor. Near the Staff Development Office. C. East Corridor. Near the kitchen entrance. D. SE Corridor. Near room 100. E. South Corridor. Near room 100. F. SW Corridor. Near the Nurses Station. G. West Corridor. Near room 126. H. West Corridor. Near the Maintenance Office. I. Rehabilitation Suite. J. North Corridor. Near the exit. K. North Corridor. Near room 213. L. North Corridor. Near room 200. Identification of Others Potentially Affected All fire extinguishers in cabinets were accounted for, so no further evaluation was needed. Systemic Changes The Maintenance Director, or designee, will perform documented monthly inspections for three months of the facility fire extinguishers placed in cabinets to ensure the top of the extinguisher is less than 60 inches from the floor. Quality Assurance Results of the monthly inspections will be presented at the monthly QA meetings for three months. If substantial compliance is not met after three months, results of the ongoing monthly inspections will be brought to QA meetings until substantial compliance is met. K 355 Immediate Corrective Action 1. The Courtyard was cleaned of cigarette butts on the ground on 5/28/2025. 2. The designated smoking area near the