Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10 standards, affecting the entire facility. During a document review on November 20, 2024, the facility was unable to provide certification for the inspector who conducted the annual inspection of the portable fire extinguishers. Additionally, an observation on the same day revealed that a portable fire extinguisher on the first floor, next to resident room 125, was obstructed by wheelchairs. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up revisit on January 8, 2025, showed that the facility still could not produce the required certification for the inspector, as confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K355: Portable Fire Extinguishers 1. Deficiency: Based on document review and interview, it was determined the facility failed to maintain and inspect portable fire extinguishers, affecting the entire facility. Findings include: Document review on November 20, 2024, at 8:00 a.m., revealed the facility could not produce the certification for the inspector conducting the annual portable fire extinguisher inspection. Observation on November 20, 2024, at 10:42 a.m., revealed that on the first floor, the portable fire extinguisher next to resident room 125 was blocked by wheelchairs. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the lack of documentation and the blocked fire extinguisher. Residents Affected: No residents were directly affected by these deficiencies. However, all residents have the potential to be affected in the event of a fire emergency if fire extinguishers are not properly maintained or accessible. 2. Corrective Action: 1. The certificate for the inspector conducting the annual portable fire extinguisher inspection was obtained and filed on 01/08/25. 2. The portable fire extinguisher located next to resident room 125 was immediately cleared of all wheelchairs and is now accessible. 3. Monitoring: The Maintenance Director will review the portable fire extinguisher inspection records to ensure that certifications are maintained properly. Monthly inspections will be conducted to ensure all fire extinguishers are accessible and not blocked by any items, with audits documented. 4. Timeline: The certificate for the fire extinguisher inspector was obtained and filed on 01/08/25. The wheelchairs were removed, and the fire extinguisher is now accessible as of 11/20/24. Ongoing monthly checks will be conducted to ensure compliance.