Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically affecting one of seven smoke compartments. During a documentation review on December 23, 2024, it was found that the most recent semi-annual inspection and maintenance of the kitchen fire suppression system was completed on March 6, 2024, and was overdue for another inspection by the end of September 2024. Additionally, the facility lacked documentation for the required monthly visual inspections of the kitchen fire suppression system. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
1. No Residents were found to have been affected by the deficient practice. On 12-23-24, the Director of Maintenance performed the required monthly visual inspection. 2. All Residents have the potential to be affected by the deficient practice. 3. The Director of Maintenance was educated on regulation K0324 by the Administrator. The Administrator added the monthly kitchen fire suppression visual inspection to the list of tasks in TELS, a software which schedules and tracks maintenance tasks. The Administrator contacted two new vendors to schedule the biannual kitchen fire suppression system. 4. The Administrator will receive weekly emails from TELS updating the status of the monthly visual inspection for monitoring purposes.