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K0355
E

Failure to Document Monthly Fire Extinguisher Inspections

Harrisburg, Pennsylvania Survey Completed on 03-13-2025

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 provide documentation verifying that monthly inspections of portable fire extinguishers were conducted, as required by NFPA 10, Standard for Portable Fire Extinguishers. This deficiency was identified during a document review on March 13, 2025, which revealed that inspections were not performed for six months: January 2025, February 2025, July 2024, October 2024, November 2024, and December 2024. During an exit conference on the same day, the Administrator and Maintenance Director confirmed the failure to conduct these monthly inspections, affecting the entire component of the facility.

Plan Of Correction

All portable fire extinguishers have been inspected by the Maintenance Director or designee. Our extinguisher vendor will be contacted to perform an annual inspection, and the Maintenance Director will maintain monthly documentation of quick checks. The Maintenance Director has been re-educated on the requirement to perform a monthly inspection of all portable fire extinguishers. The NHA or designee will audit the portable fire extinguishers for sign-off of inspection monthly on a quarterly basis.

See complete original report
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