Missing Fire Extinguisher Maintenance Documentation
Penalty
Summary
During an observation on May 13, 2025, at approximately 9:45 AM, it was found that the facility failed to document the required monthly maintenance for a portable fire extinguisher located in the kitchen service hallway. The inspection and maintenance tag, which is necessary to demonstrate compliance with NFPA 10 standards, was missing from the unit. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency could potentially affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings.
Plan Of Correction
The facility added the fire extinguisher inspection tag to document the required monthly maintenance on the portable fire extinguisher located in the kitchen service hallway. The Maintenance Director/Designee has been educated to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. The Maintenance Director/Designee will conduct routine rounds to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.