Deficiency in Kitchen Fire Suppression Documentation
Penalty
Summary
The facility failed to maintain proper documentation for the kitchen hoods' fire suppression system, as required by NFPA 101 standards. During a review on January 8, 2025, it was discovered that the facility did not have records for one of the two mandatory semi-annual Kitchen Fire Suppression Testing/Maintenance sessions conducted within the past 12 months. This deficiency was identified in one of the four smoke compartments. The absence of documentation was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The kitchen fire suppression system was tested by Firefighters on January 9, 2025. There were no identified issues with the test. The maintenance director has scheduled our kitchen fire suppression system test for July 2025 to ensure we are in compliance with semi-annual testing. A recurring work order will be created electronically to serve as a reminder to the maintenance team that this test will be completed within the scheduled time frame. The maintenance director will educate all maintenance team members on the appropriate fire safety and testing of the fire suppression system by the compliance date. The maintenance director will present fire suppression testing records at the quality assurance meetings twice annually to ensure compliance. Any issues identified with fire suppression testing compliance will be addressed by the QAPI committee to ensure compliance is maintained.