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K0324
C

Lack of Documentation for Kitchen Suppression System Inspections

Pottstown, Pennsylvania Survey Completed on 12-09-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documentation of the semi-annual inspections of the kitchen suppression system, which is a requirement under NFPA 101 for cooking facilities. During a document review and interview conducted on October 8, 2024, it was revealed that the facility did not have records verifying that the kitchen suppression system had undergone the required semi-annual inspection in the past year. This deficiency was confirmed by the Director of Maintenance during an interview on the same day. A follow-up observation on December 9, 2024, confirmed that the issue had not been corrected, as the facility still lacked the necessary documentation, which was again confirmed by the Director of Maintenance.

Plan Of Correction

1. Vendor will be contacted to provide documentation of the semi-annual inspection of the kitchen suppression system. 2. Audit will be conducted semi-annually to ensure inspections occur as required. 3. Results of audits will be reported to the governing body through QAPI.

See complete original report
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