Deficiencies in Kitchen Suppression System Documentation and Awareness
Penalty
Summary
The facility failed to maintain proper documentation and awareness of the kitchen suppression systems in two of its kitchens, leading to deficiencies in compliance with NFPA 101 standards. In the Melrose kitchen, there was a lack of documentation confirming that the semi-annual kitchen suppression testing and maintenance had been completed, with the last recorded test occurring over a year prior. This was confirmed during an interview with the maintenance supervisor, who acknowledged that the necessary documentation was not available on-site during the survey. Similarly, in the Elmwood kitchen, the facility also failed to provide documentation of the semi-annual kitchen suppression testing and maintenance, with the last test documented over a year ago. Additionally, the kitchen staff members were unaware of the location of the manual pull activation for the kitchen hood suppression system, indicating a lack of training or communication regarding emergency procedures. These deficiencies were confirmed through observation and interviews conducted with the maintenance supervisor during the survey.
Plan Of Correction
The maintenance director provided supporting documentation to the inspector on 02/10/2025. Documentation was added to the survey readiness binder. The life safety checklist will be reviewed in the quarterly QAPI meeting. All dietary staff were reeducated on the Ansul system on 02/06/2025. Ansul system education will be included in the new hire building orientation for dietary department employees. Verbal drills will be conducted by the dietary manager or designee weekly for 1 month.