Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355
Based on observation and interview, it was determined the facility failed to maintain fire extinguishing equipment in two instances, in one of six smoke compartments.
Findings include:
Observation on February 28, 2024, revealed the following:
a) 11:15 a.m., the pressure gauge on the Class K fire extinguisher in the main kitchen, indicated the extinguisher was undercharged;
b) 11:40 a.m., there was no portable fire extinguisher located in the elevator equipment room on the first floor.
Interview with the Facility Administrator and Maintenance Director on February 28, 2024, at 1:30 p.m., confirmed the portable fire extinguisher deficiencies.
| | Plan of Correction - To be completed: 03/11/2024
The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated.
1. The fire extinguisher in the kitchen was replaced. The elevator room on the first floor now has a new fire extinguisher.
2. The facility has determined all fire extinguishers have the potential to be affected.
3. Maintenance Director has been educated on the need for a fire extinguisher to be in the elevator room and monitoring of the gauges on the fire extinguishers throughout the building.
4. Maintenance Director or designee with monitor fire extinguishers throughout the facility monthly. An audit will be conducted weekly for four weeks and monthly for three months.
This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.
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