Deficiency in Kitchen Fire Safety Equipment Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in accordance with NFPA 101:2012 Edition, Sections 9.2.3, NFPA 17:2009 Edition, Section 4.3.1.5, 7.2.2, and NFPA 96. During an observation, it was noted that the kitchen range-hood fire suppression system had eight discharge spray nozzles, four of which were not equipped with a cap or cover device to protect against grease vapors or moisture. Additionally, the Class-K fire extinguisher's monthly inspection tag was not signed for monthly inspections. These deficiencies were confirmed by a staff member during an interview and were discussed at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. - Nozzle Caps/Covers: Missing caps/covers were installed on all four affected discharge nozzles on 1/7/25 by NJ Ex Order 26.4(b). - Class K Extinguisher Inspection: The Class K fire extinguisher was inspected on 1/7/25 by [R]. The inspection tag was signed and dated to document the inspection. - System Inspection: The entire kitchen fire suppression system was inspected by [R] on 1/7/25 to ensure proper operation and compliance with NFPA 101. 2. The maintenance director modified the facility maintenance schedule to include a requirement for quarterly inspections of the entire kitchen fire suppression system, including checking for missing nozzle caps/covers and inspecting the associated Class K fire extinguisher. 3. The maintenance director, or designee, will audit the kitchen fire suppression system quarterly to check for missing nozzle caps/covers and to confirm inspection of the Class K fire extinguisher. The results of the quarterly audit of the kitchen fire suppression system will be submitted to the administrator and to the QA committee quarterly for one year.