Failure to Conduct Monthly Kitchen Fire Suppression Inspections
Penalty
Summary
The facility failed to conduct the required monthly inspections of the kitchen fire suppression system, as evidenced by the absence of documentation for twelve consecutive months. This deficiency was identified during a document review and observation conducted on February 10, 2025, at 10:55 a.m. The lack of documentation was confirmed in an interview with the Facility Administrator and Maintenance Director later that day at 12:30 p.m. This oversight affected one of the five smoke compartments within the facility.
Plan Of Correction
1. The Maintenance Director/Designee will conduct the monthly inspection of the kitchen fire suppression system to be in compliance with NFPA. 2. The Nursing Home Administrator/designee will educate the maintenance staff on monthly inspection of the kitchen fire suppression system. 3. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure the monthly inspection of the fire suppression system is being completed. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.