Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review on March 12, 2025, it was found that the facility could not provide documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year, as required. Only one inspection report dated January 17, 2025, was available. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Kitchen suppression system will be tested again and two inspections completed for the year in June. 2. 4/28/25 3. Maintenance staff will conduct quarterly inspections in the kitchen. 4. The Director of maintenance will keep inspection reports and conduct monthly audits x3.