Missed Annual Inspection of Portable Fire Extinguisher
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by a missed annual inspection. During a facility tour, surveyors observed that the exterior portable fire extinguisher located adjacent to the generator had an inspection tag dated over a year prior. The Maintenance Director confirmed that the annual inspection had not yet been completed at the time of the survey. This deficiency affected one of two smoke compartments and impacted 23 of 45 residents.
Plan Of Correction
K 355 Immediate Correction: The fire extinguisher was replaced with one that had completed the annual inspection timely. This finding had the potential to affect all residents. No harm was identified. Sustainment: The Facilities Staff was educated by the Facilities Manager on the importance of ensuring all fire extinguishers have their required inspection and maintenance. See attached education signature sheet. Monitoring: The specified fire extinguisher location will be included in ongoing EOC rounds to ensure it doesn't get missed again in the future due to its remote location. Data will be collected and reported out to the EOC Committee and the SCU Quality Assurance committee as part of the facility QAPI program. Person Responsible: Facilities Manager