Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the kitchen fire suppression system. During an observation and document review on January 14, 2025, it was found that the facility did not have documentation for the required semi-annual testing and maintenance of the kitchen fire suppression system, which was due between January and June 2024. This deficiency was confirmed during an interview with the Director of Nursing and the Maintenance Director on the same day, affecting one of the nine smoke compartments in the facility.
Plan Of Correction
1. The facility will obtain documentation for the semi-annual testing/maintenance of the kitchen fire suppression system. 2. Maintenance director or designee will verify that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. 3. Nursing home administrator or designee will re-educate the maintenance director of completing semi-annual testing/maintenance of the kitchen fire suppression timely. 4. Maintenance director or designee will audit that semi-annual testing/maintenance of the kitchen fire suppression is completed and audited semi-annually. Findings of these audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed. Date of Compliance will be 2/18/2025.