Failure to Maintain Kitchen Fire Suppression System
Summary
The facility failed to ensure that the main kitchen fire suppression system was maintained in accordance with the National Fire Protection Association 96 Standard. Specifically, the facility did not complete a semi-annual inspection of the fire suppression system for the first half of 2024. During an interview, the Maintenance Director acknowledged the requirement for semi-annual inspections and admitted that they mistakenly believed two inspections had been completed in 2024. However, it was discovered that the vendor had not scheduled an inspection for the first half of the year. Additionally, deficiencies identified during the semi-annual inspection on July 5, 2024, were not corrected in a timely manner. The inspection report noted the need to replace seven tin type scissor links with steel scissor links and to replace two nozzles. The Maintenance Director admitted that they had not reviewed the comment section of the inspection report prior to the federal survey and acknowledged that these deficiencies had not been addressed. The importance of ensuring all fire suppression system components are functional was emphasized by the Maintenance Director.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 On 1/20/2025 the Fire Suppression System was inspected, and all repairs were made at the same time. Going forward, the Director of Environmental Services will have calendar reminders on when semi-annual inspections are due and ensure they are completed timely. The vendor committed to comply with strict semi-annual inspections. All Maintenance staff has been educated on the importance of hood inspections, including the aspect of why repairs need to be done immediately following the inspection. The Director of Facilities also reviewed hood inspection schedules. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Penalty
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