Deficiency in Maintaining Commercial Cooking Facility
Penalty
Summary
The facility failed to maintain their commercial cooking facility in accordance with NFPA 101 standards. During a fire safety tour, it was observed that two gas-powered cooking appliances, a steamer and an oven, located on the dairy side of the kitchen, were on castors without any means to prevent strain on the gas connection. This deficiency was identified for 2 out of 3 sampled gas-powered cooking appliances. The observation was made on March 19, 2025, at 12:33 PM, during a tour with the Maintenance Director. The Maintenance Director acknowledged the findings during an interview conducted concurrently with the observations. The findings were subsequently reviewed with both the Administrator and the Maintenance Director at the exit conference held on the same day at 3:15 PM. Photographic evidence was obtained to support the findings.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction. Corrective action completion date: 4/19/25 K324 COOKING FACILITIES 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: In the allegation of the two gas powered appliances on the dairy side of the kitchen, a steamer and an oven, on castors without the means to prevent strain on the gas connection. Maintenance has added restraints to the steamer and the oven to keep them from moving and putting strain on the gas connection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance Director or designee will put proper restraints on the gas powered steamer and oven on the dairy to keep them from putting strain on the gas connection. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Maintenance or a qualified Designee, will monitor for substantial compliance. Findings of the audits will be reported at the Monthly QAPI meeting by the Director of Maintenance or a qualified Designee to ensure effectiveness and compliance of the plan of correction.