Failure to Conduct Semi-Annual Kitchen Suppression System Testing
Penalty
Summary
The facility failed to comply with the requirement for semi-annual testing of the kitchen cooking facilities' suppression system. During a document review and observation conducted on December 11, 2024, it was found that the kitchen suppression system had only been inspected once on March 20, 2024, instead of the required semi-annual schedule. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged that the facility did not conduct the necessary inspection of the kitchen extinguishing system.
Plan Of Correction
Maintenance Director or Designee will schedule a kitchen suppression inspection with the designated company. Senior Maintenance Director will add the semi-annual testing of kitchen cooking facilities suppression system on the TELS maintenance system in order to monitor completion and compliance. Maintenance Director and Dietary Director will be re-educated on the regulation and timeframe of inspection of the suppression system. Maintenance Director or Designee will audit 2x year the inspection reports for compliance. Maintenance Director or Designee will present findings at the QAPI meetings for review and/or recommendations.