Failure to Install Clean Agent Fire Extinguisher in Telecom Room
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.
Penalty
A portable fire extinguisher next to a resident room was found to be blocked during an observation, and this was confirmed by facility leadership during the exit interview.
The facility did not provide documentation confirming that basement portable fire extinguishers were inspected monthly as required, with no records available for several months. This was confirmed by the Administrator during the survey.
The facility did not provide documentation for annual fire extinguisher maintenance and technician certification, and a fire extinguisher in the main kitchen was found blocked. These deficiencies were confirmed by facility leadership during the survey.
The facility did not ensure portable fire extinguishers were properly inspected and maintained according to NFPA 10, with one extinguisher lacking inspection records and another found overpressurized. These issues were confirmed by the Maintenance Director and could impact 15 occupants.
Surveyors found that 12 out of 18 portable fire extinguishers were installed with the top of the handle positioned above the sixty-inch maximum height allowed by NFPA 101 and NFPA 10, with some as high as sixty-three inches. In one case, a trash can obstructed access to a fire extinguisher cabinet. The Maintenance Director acknowledged these findings during the inspection.
A portable fire extinguisher in the kitchen service hallway was found without the required monthly maintenance and inspection tag, indicating a failure to document compliance with NFPA 10 standards. This was confirmed by the Maintenance Director and Administrator during surveyor interviews.
Blocked Portable Fire Extinguisher Identified
Penalty
Summary
A deficiency was identified when, during an observation, a portable fire extinguisher located next to room 425 was found to be blocked. This issue was noted on one of the six levels within the facility. The finding was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. No additional details regarding residents, staff, or specific patient conditions were provided in the report.
Plan Of Correction
The facility immediately freed the fire extinguisher next to room 425 from blockage. The maintenance director will re-educate all staff on maintaining clear access to all fire extinguishers. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly audits for 2 months to ensure the facility is maintaining clear access to all fire extinguishers. Date of completion: 2/16/2026
Failure to Document Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to provide documentation verifying that portable fire extinguishers located in the basement had been inspected on a monthly basis as required. During a document review, it was found that there was no documentation of monthly inspections for these extinguishers since January 3, 2025. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of inspection records for the specified period. No information regarding residents or their medical conditions was included in the report, and the deficiency pertains solely to the lack of required fire extinguisher inspection documentation.
Plan Of Correction
1) The facility is unable to retroactively conduct monthly fire extinguisher inspections. The basement fire extinguisher was added to the master list of fire extinguishers and inspected. 2) The maintenance director conducted a monthly audit to ensure all fire extinguishers were inspected and are on the master list. 3) The maintenance director was re-educated on ensuring that monthly fire extinguisher inspections are completed. 4) The NHA or designee will conduct an audit quarterly × 1 year to ensure that monthly fire extinguisher inspections are completed and on the master list. Results will be submitted to QAPI for review and analysis to determine need of ongoing monitoring.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required. During document review, the facility was unable to provide the annual maintenance report and the certificate for the technician who performed the annual fire extinguisher maintenance and testing. Additionally, an on-site observation revealed that a fire extinguisher located inside the main kitchen, on the kitchen side wall of the dietary office, was blocked. These findings were confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. No information regarding residents or their medical conditions was included in the report.
Plan Of Correction
Fire extinguisher inspection was completed on 3/7/2025. Facility will ensure documentation of inspection and technician's certificate are available for survey team during all inspections. Cart removed from in front of blocked fire extinguisher. Staff will be educated to ensure fire extinguishers are not blocked. Supervisors will audit weekly for 4 weeks to ensure fire extinguisher is not blocked.
Failure to Maintain and Inspect Portable Fire Extinguishers per NFPA 10
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were selected, installed, inspected, and maintained in accordance with NFPA 10 standards. During an observation on June 25, 2025, a fire extinguisher located in the patio area was found to have no record of inspection. Additionally, another fire extinguisher located behind the 200 wing nurses station was observed to be overpressurized. These deficiencies were confirmed by the Maintenance Director at the time of discovery. The deficient practices could affect 15 occupants in the event of a fire, as noted in the findings.
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
Missing Fire Extinguisher Maintenance Documentation
Penalty
Summary
During an observation on May 13, 2025, at approximately 9:45 AM, it was found that the facility failed to document the required monthly maintenance for a portable fire extinguisher located in the kitchen service hallway. The inspection and maintenance tag, which is necessary to demonstrate compliance with NFPA 10 standards, was missing from the unit. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency could potentially affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings.
Plan Of Correction
The facility added the fire extinguisher inspection tag to document the required monthly maintenance on the portable fire extinguisher located in the kitchen service hallway. The Maintenance Director/Designee has been educated to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. The Maintenance Director/Designee will conduct routine rounds to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
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