Portable Fire Extinguishers Mounted Above Required Height
Penalty
Summary
Surveyors observed that portable fire extinguishers (PFEs) in the facility were not installed at the required height in accordance with NFPA 10, 2010 Edition Section 6.1.3. Specifically, during an inspection with the Maintenance Supervisor, the PFE mounted on the wall by Resident Room 54 was measured at 65 inches from the top of the extinguisher to the floor, and the PFE by Nurse Station 2 was measured at 67 inches. Both were acknowledged by the Maintenance Supervisor as being mounted too high. A review of the facility's policy and procedure titled "Extinguishing a Fire" indicated that fire extinguishers should be mounted so that the top is no more than five feet (60 inches) from the floor. The observed installation did not comply with this policy or the referenced NFPA standard, affecting one of eight smoke compartments in the facility.
Plan Of Correction
What does the facility plan to monitor its performance to make sure solutions are sustained and to ensure deficient practice will not recur: The Administrator will conduct a monthly random observation of the PFE to ensure all PFE are no more than five feet from the floor. This audit started on May 16, 2025, and will continue for 3 months. The Administrator or Designee will present the results of the audits to the Quality Assurance Performance Improvement Committee for review and recommendations monthly for 3 months or until substantial compliance is achieved. The Administrator will be responsible for monitoring and sustaining compliance. Completion Date: 05/16/25