Deficiencies in Kitchen Suppression System Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in its kitchen, as evidenced by deficiencies in the kitchen suppression system. During an observation, document review, and interview, it was found that kitchen staff were uncertain about the location and operation of the hood fire suppression system's manual activation. Additionally, the facility could not provide documentation that the kitchen suppression system had been inspected twice in the previous year, as required. These deficiencies were confirmed during an interview with the maintenance supervisor.
Plan Of Correction
A. Kitchen staff uncertain of hood fire suppression Dietary Director immediately educated dietary staff on the location and proper operation of hood fire suppression system. Dietary Director/Designee to complete education to kitchen/dietary staff by 21MAR2025 to ensure certainty of location and operation of the hood fire suppression systems manual activation. Dietary Manager/Designee to complete annual educations ensuring dietary staff are aware of kitchen equipment and safety. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Hood Suppression Inspection 2x in prior year. Maintenance to schedule and complete hood suppression inspection and document per maintenance schedule. Maintenance to obtain and maintain documentation and have it readily available by 21MAR2025. NHA/Designee to educate staff by 21MAR2025 on importance of completing hood suppression 2x per year and obtaining proper documentation. NHA/Designee to audit hood suppression inspection documentation monthly every 6 months. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.