Deficiency in Cooking Facility Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, specifically regarding the required inspections of the ansul system. During an observation on March 31, 2025, it was noted that the facility did not conduct one of the two required ansul system inspections within the preceding twelve-month period. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager, indicating a lapse in the facility's adherence to fire protection protocols for its cooking equipment.
Plan Of Correction
Facility cannot retroactively correct deficiency. Education provided to Maintenance Director on annual inspections for Ansul system. Maintenance Director scheduled inspection for 4/25/2025 of the automated fire suppression Ansul system. Vendor educated as to importance of timely inspections as scheduled each 6-month interval. NHA/designee will review inspection binder including Ansul system biannually to ensure all inspections are completed. Results to the QA committee to ensure compliance.