Failure to Document Fire Suppression System Checks
Penalty
Summary
The facility failed to conduct and document the owner's checks of the fixed chemical fire suppression system in one of the six smoke compartments within the component. During a document review and interview conducted on April 16, 2025, it was revealed that the facility could not provide documentation of the owner's quick check for the fixed chemical fire suppression system installed in the kitchen. This deficiency was confirmed during an exit conference with the Assistant Director of Nursing and the Maintenance Director, who acknowledged the lack of documentation for the required quick checks on the kitchen's fire suppression system.
Plan Of Correction
1 and 2. Maintenance Director completed the monthly check of the chemical fire suppression system. 3. Maintenance department will be educated on the standards to ensure we are checking the chemical fire suppression system monthly. 4. Maintenance or facility designee will audit facilities chemical fire suppression system to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.