Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to properly install and maintain equipment protected by the kitchen hood fire suppression system, affecting one of eight smoke compartments. During an observation, it was noted that a wheeled gas-fired deep fryer in the kitchen was not equipped with an approved method to ensure it returned to its designated location after being moved for maintenance and cleaning. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director. Additionally, a document review revealed that the facility did not provide documentation for the completion of kitchen fire suppression testing and maintenance for the first six months of 2024. This lack of documentation was also confirmed during the interview with the Facility Administrator and Maintenance Director. These findings indicate a failure in maintaining the necessary fire safety protocols as required by NFPA 101 standards.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0324 Cooking Facilities. Observation #1 – wheeled gas-fired deep fryer was appropriately secured to ensure that the appliance is returned to the designated location after any maintenance or cleaning. Observation #2 is unable to be corrected. The Kitchen Fire Suppression Testing/Maintenance has been completed and is current. The Maintenance Director will continue to ensure that Kitchen Fire Suppression system is tested and maintenance completed per regulation. The Maintenance Director/designee will perform random audits of the securement of the deep fryer weekly x 2 weeks then monthly x 2 months.