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K0355
F

Failure to Maintain and Inspect Portable Fire Extinguishers

Philadelphia, Pennsylvania Survey Completed on 01-23-2025

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 maintain and inspect portable fire extinguishers as required by NFPA 101 and NFPA 10 standards. During a document review, it was found that the facility could not provide certification for the technician responsible for the annual maintenance and inspection of the fire extinguishers. Additionally, observations revealed that several fire extinguishers were obstructed by storage items in various locations, including the first floor dining room, across from the 500 wing Nurses' Station, and in the basement housekeeping storage area. Furthermore, the indicator lights for recessed mounted fire extinguishers were not functioning in multiple areas throughout the facility. The facility also neglected to conduct monthly inspections of portable fire extinguishers in several locations, with some not inspected since October or November 2024, and one in the Elevator Machine Room not inspected since July 2024. Additionally, a fire extinguisher in the Basement Elevator Machine Room was found not mounted to the wall. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.

Plan Of Correction

1. The certificate of the technician conducting the annual inspection has been obtained from the vendor. Blocked fire extinguisher in the main dining room, across from the 500-unit nurses' station and housekeeping storage in the basement has been exposed and the area cleared. Indicator lights for recessed portable fire extinguishers are maintained lit. Fire extinguisher monthly checks have been scheduled for maintenance. The basement elevator machine room fire extinguisher is mounted on the wall. 2. NHA/Designee to in-service maintenance staff on the requirement of maintenance and inspection of fire extinguishers monthly, ensuring they remain free from obstruction, and the indicator display is properly functioning. 3. The Maintenance director/Designee has completed an inspection of fire extinguishers in the building to ensure they are stored, functioning, and the display indicator is properly visible. 4. The maintenance director/designee will conduct a random audit (10 total) of the fire extinguishers monthly x 3 to ensure they are properly maintained, inspected, and the indicator display is properly functioning. 5. Results of audits will be reported to QA.

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