Lack of Documentation for Kitchen Fire Suppression System Inspection
Penalty
Summary
The facility failed to provide documentation verifying that the commercial Kitchen Fire Suppression System had been inspected on a semi-annual basis within the previous twelve months. During a document review on February 11, 2025, it was discovered that there was no documentation available to confirm that the Kitchen Fire Suppression System had been inspected since March 6, 2024. This deficiency was confirmed during an interview with the Maintenance Manager, who acknowledged the lack of documentation for the required inspection of the Kitchen Suppression System.
Plan Of Correction
Inspection of the Kitchen Suppression System has been scheduled with the contractor. Inspection of the Kitchen Suppression System shall be added to the electronic task work order system by the Maintenance Director to alert when to schedule each regulatory required inspection based upon its frequency requirement. The Maintenance Director/designee shall monitor, maintain and update the electronic task work order system weekly for upcoming and completed regulatory required inspections. Administrator and Maintenance Director shall review upcoming required tests and inspections in the task work order system during monthly meeting, to ensure proper scheduling. The Maintenance Director shall be responsible for assuring the completed inspection documentation is properly filed in the Life Safety book. Administrator shall educate the maintenance department regarding semi-annual inspection requirement of the Kitchen Suppression System.