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K0355
C

Failure to Document Fire Extinguisher Inspections

Gettysburg, Pennsylvania Survey Completed on 02-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with the requirements for the inspection and maintenance of portable fire extinguishers as outlined in NFPA 10. During a document review on February 4, 2025, it was discovered that the facility did not have documentation to verify that monthly visual inspections of the fire extinguishers had been conducted. Additionally, there was no documentation available to confirm that the annual inspection of the fire extinguishers had been performed. These deficiencies were confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the lack of documentation for both monthly and annual inspections.

Plan Of Correction

Visual inspections of fire extinguishers will be completed monthly. An annual fire extinguisher inspection will be completed. Maintenance staff will be educated on completing visual inspections monthly on fire extinguishers and having an annual inspection completed on fire extinguishers. A monthly audit will be completed to ensure visual inspections of fire extinguishers are occurring and an annual fire extinguisher inspection was completed. Audit results will be reported at the next QAPI meeting.

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