Failure to Perform Fire Safety Checks and Cleanings
Penalty
Summary
The facility failed to perform the required owner's quick checks on the Kitchen's fixed chemical fire suppression system. This deficiency was identified during a document review and interview conducted on March 13, 2025, between 8:45 AM and 10:45 AM. The absence of these checks was confirmed during an exit conference with the Administrator and Maintenance Director on the same day at 1:45 PM. The lack of these checks indicates a failure to adhere to the necessary safety protocols for fire suppression systems in the facility's kitchen. Additionally, the facility did not conduct the semi-annual cleaning of the Kitchen exhaust ductwork for a full year. Documentation reviewed during the survey showed that the last cleaning cycle was completed on April 8, 2024. This oversight was also confirmed during the exit conference with the Administrator and Maintenance Director on March 13, 2025. The failure to perform these cleanings as required affects one of the eight smoke zones within the component, indicating a lapse in maintaining the necessary fire safety standards.
Plan Of Correction
The maintenance Director performed a quick check on the Kitchen's fixed chemical suppression system on March 28, 2025, and documentation placed in the Life Safety Book. The kitchen exhaust and ductwork cleaning was completed on April 8, 2024, and September 20, 2024. The next cleaning of the ductwork is scheduled for May 5, 2025, due to a scheduling conflict. The Maintenance Director was re-educated on the need to perform quick checks on the Kitchen's fixed chemical suppression system monthly. The Maintenance Director and Food Service Director were re-educated on the need to schedule kitchen exhaust duct cleaning every 6 months. The NHA or designee will audit that quick checks are being completed, and reports are received and filed in the Life Safety Book. Audits will be conducted quarterly. The Maintenance Director or designee will ensure that the Kitchen exhaust duct cleaning is performed on a semi-annual basis. Inspection reports will be filed in the Life Safety Book. The NHA or designee will audit that inspections are timely on a quarterly basis.