Fire Extinguisher Maintenance Deficiency
Summary
During a Life Safety Code survey, it was observed that portable fire extinguishers in the facility were not maintained as required, specifically lacking monthly inspections. This deficiency affected all three resident use floors in the front building and both resident use floors in the rear building. The facility's policy, created in December 2020, assigns the Maintenance Director the responsibility for ensuring that maintenance staff are trained and perform routine preventative maintenance tasks, including monthly fire extinguisher checks. However, several fire extinguishers across different floors had tags indicating missed inspections for various periods between June 2024 and December 2024. The Assistant Maintenance Director, who took over after the former Maintenance Director left, acknowledged the oversight and stated that they had instructed the maintenance staff to conduct monthly checks using a paper tablet. Despite this, they were unable to locate any documentation of these checks since August. Additionally, there was a discrepancy in the number of fire extinguishers recorded, with the facility having 51 extinguishers plus one spare, while the contractor's report listed 52. The Assistant Maintenance Director was aware of a missing tag in the smoking area and had contacted a vendor to replace it.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 A monthly inspection was performed on all 52 fire extinguishers in the facility to ensure the facility is up to date in accordance with NFPA 10. A review was completed on the requirements for the facility’s fire extinguishers to ensure annual inspections had occurred as well. The monthly extinguisher checks will be recorded on the tag attached to the extinguisher and on the monthly log. The Maintenance Director and the maintenance staff were educated on the requirement and facility policy “maintenance-preventative” to ensure the fire extinguishers are inspected monthly and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. An audit tool was created to ensure required inspection intervals are adhered to by the Maintenance Director. Audits will be conducted monthly for 4 months. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Penalty
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