Fire Extinguisher Maintenance Deficiency
Summary
The facility failed to ensure that fire extinguishers were maintained according to the National Fire Protection Association 10 Standard for Portable Fire Extinguishers. The annual fire extinguisher inspection report provided by the facility was merely a receipt and did not include details about the maintenance or location of the fire extinguishers. Additionally, a fire extinguisher located in the evening maintenance closet had not undergone the required monthly inspections for two months in 2024. The facility also did not maintain the past twelve months of inspection records on site. During an interview, the Director of Environmental Services admitted to being unaware of the missed monthly inspections and acknowledged the importance of proper maintenance for the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Vendor responsible for providing the annual fire extinguisher was contacted for a summary analysis outlining the maintenance and location of the fire extinguishers within the facility. The analysis will be maintained onsite. The vendor was requested to inspect the fire extinguisher in the evening maintenance closet. Vendor inspected the fire extinguisher in the evening maintenance closet on 3/20/2025. Maintenance employees received education on consistently maintaining portable fire extinguishers monthly, reviewing vendor invoices for details such as location of extinguishers, and keeping at minimum of 1 years' worth of inspections records onsite and readily available for review. The Director of Environmental Services or designee will audit all extinguishers monthly to ensure that monthly inspection is performed and documented adequately. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for one year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services.
Penalty
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