Non-compliance with NFPA 96 Standards in Kitchen Equipment Installation
Summary
During a life safety survey conducted on January 6, 2025, it was observed that the facility's kitchen on the first floor had a deep fryer positioned within 16 inches of a cooking surface, which is not in compliance with NFPA 96 standards. The standard requires a minimum of 16 inches of space between a deep-fat fryer and adjacent cooking equipment with surface flames, unless a steel or tempered glass baffle plate of at least 8 inches in height is installed between them. In this case, there was no physical barrier present between the fryer and the hot surface. This deficiency was confirmed through observation and a staff interview with the Facilities Director, who acknowledged the issue and mentioned plans to install a metal baffle.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 I. Immediate Corrective Action The maintenance staff permanently installed an 8” tall steel plate onto the deep-fat fryer separating it from the adjacent cooking equipment. II. Identification of Other Residents Once the 8” tall steel plate was installed onto the deep-fat fryer, the only deep-fat fryer in the facility was permanently separated from the adjacent cooking equipment. The facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide in-service education to all maintenance staff and the Director of Food Service related to the requirements of 2010 NFPA 9612.1.2.5, specifically the significance of the separation of deep-fat fryers adjacent to other cooking equipment. Lesson plan and attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor for the proper separation of the deep-fat fryer and the adjacent cooking equipment. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service
Penalty
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