Failure to Perform Monthly Inspections of Fire Suppression System
Penalty
Summary
The facility failed to perform monthly inspections of the range-hood fire suppression system's wet chemical cylinder as required by NFPA 17 A: 2009 Edition and NFPA 96: 2011 Edition. During an observation, it was noted that the semi-annual inspection was conducted on December 2, 2024, and the inspection tag was new. However, the facility lacked documentation for the monthly inspections for the previous six months, specifically for June through November 2024. This oversight was confirmed during an interview with a staff member at the time of the observation. The deficiency was identified during a survey conducted on December 12, 2024, and was discussed with facility representatives at the Life Safety Code exit conference on December 13, 2024. The absence of monthly inspection documentation for the range-hood fire suppression system had the potential to affect all residents, as it is a critical component of the facility's fire safety measures. No further documentation was provided to demonstrate compliance with the required monthly inspections.
Plan Of Correction
1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The Maintenance director reached the vendor which confirmed that the inspection was completed, however they do not keep previous tags. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was in serviced to conduct monthly audits of kitchen hood suppression inspections and automatic sprinkler separations. Maintenance/designee will complete audit inspections and sign off tags of suppression systems the first week of every month. Monthly audit logs will be submitted to the Administrator for review and kept in the Maintenance office. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the monthly audit on a Quarterly basis x 12 months to ensure compliance.