Uninspected and Unmounted Fire Extinguisher in Medical Records Room
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were properly inspected and mounted, as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation on April 28, 2025, at 8:55 a.m., it was noted that a fire extinguisher was not mounted in the medical records room. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
1: The fire extinguisher was mounted in medical records with signage. 2: The Director of Facilities/ Designee will perform random monthly audits times 4 then quarterly audits to ensure all fire extinguishers are properly mounted. 3: The Facilities Director/Designee will report audit findings in the quarterly QA meeting and or the Facilities Governing Body meetings.