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 - Component: 01 - Tag: 0355
Based on document review and interview, it was determined the facility failed to maintain documentation verifying portable fire extinguishers had been subjected to monthly inspections during the previous twelve months, affecting one of three smoke compartments within the component.
Findings include:
1. Review of documentation on May 11, 2023, at 11:05 AM, revealed the facility lacked documentation verifying the portable fire extinguisher located within the Beauty Salon had been inspected since March 19, 2023.
Interview with the Director of Facilities on May 11, 2023, at 11:05 AM, confirmed the facility lacked documentation verifying the portable fire extinguisher had been inspected since March 19, 2023.
| | Plan of Correction - To be completed: 06/12/2023
The statement/s made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency/s herein. To remain in compliance with all Federal and State regulations, the facility has taken, and will continue to take the actions set forth in the following plan of correction.
The following plan of correction constitutes the center's allegation of compliance. The alleged deficiency cited has been / or will be corrected by the date/s indicated.
The facility is committed to taking all actions necessary to remain in substantial compliance with the Federal and State regulations.
The plan of correction addresses our intentions to promote care/safety for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psycho-social well-being.
No residents were affected by this deficiency.
The Director of Buildings and Grounds (B&G) verified all remaining portable fire extinguishers were subjected to monthly inspections during the previous months.
Monthly inspections of the portable fire extinguishers are routinely performed by the community's Security Staff and will continue to be inspected monthly.
The Director of B&G and/or designee will in-service the B&G staff, as well as the security staff, on NFPA 101 Portable Fire Extinguishers related to the monthly inspection requirements and the documentation required to support verification of said inspections. The Director of B&G and/or designee will perform one documented random weekly audit for one month, then 2 documented random audits per month for two months for monthly inspection verification/compliance.
Following the documented random audits over the next three months, the Director of B&G and/or designee will perform one quarterly random audit for inspection verification/compliance, each quarter, through the remainder of the fiscal year.
The results of the audits will be submitted to the QAPI committee monthly, for three months, for review and determination of need for further action as needed.
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