Failure to Provide Fire Extinguisher in Generator Enclosure
Summary
The facility failed to properly equip the generator enclosure with the required fire safety equipment, specifically a portable fire extinguisher. During a tour and interview with the Director of Maintenance, it was observed that the diesel fuel storage area, located in an external concrete enclosure with the generator, did not have a fire extinguisher installed within the minimum required travel distance. The closest fire extinguisher was found to be inside the facility, across a courtyard, rather than within 30 or 50 feet of the diesel fuel storage enclosure as required by NFPA 10 standards for Class B hazards. This deficiency was identified during an inspection and affected all 114 residents and four smoke compartments in the facility. The absence of a fire extinguisher in the specified location was directly observed, and the Director of Maintenance confirmed the lack of appropriate fire safety equipment in the generator enclosure area.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. A fire extinguisher was put in place within the diesel fuel storage area. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and Environmental Service Director. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and/or Maintenance Director regarding "The protocols for addressing a grease fire and the appropriate procedures to address such an occurrence." The DSD and/or Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction.
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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