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K0355
D

Failure to Perform and Document Monthly Fire Extinguisher Inspections

Pomona, California Survey Completed on 05-05-2025

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 ensure that the portable fire extinguisher (PFE) located in the main electrical panel room was inspected and maintained monthly as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation and interview, it was found that the PFE inspection tag was missing monthly inspection dates and the initials of the person performing the inspection for the period between 2/25 and 4/25. There was no documentation indicating that the PFE had been inspected during this time frame. The facility's policy and procedure titled 'Maintenance Service' required maintenance personnel to maintain the building in compliance with applicable laws and regulations, including regular inspection of safety equipment.

Plan Of Correction

Corrective Action: On 5/5/25 the Maintenance Supervisor immediately dated and initialed the monthly PFE tag. Identify Other Residents: No other portable fire extinguisher had this deficient practice. Measures into place: On 5/6/25 the Administrator serviced the MS and Maintenance Assistant ensuring that all PFE tags are monthly inspected with a date and initials of person doing the inspection. Monitoring: Administrator and Director of Staff Development will monitor monthly PFE tags to ensure that all are being inspected with dates and initials of the person doing inspection x 3 months. Findings will be presented to QAPI meeting quarterly for further review and/or actions if necessary. Completed date: 5/22/25

See complete original report
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