Failure to Maintain Kitchen Fire Extinguishing System
Penalty
Summary
The facility failed to ensure that the kitchen's automatic extinguishing system was maintained according to the 2009 NFPA 17A standards. During a document review, it was discovered that the last inspection and maintenance report for the Ansul extinguishing system in the kitchen was dated January 24, 2024, which exceeded the required six-month interval for maintenance. The report from Fire Command Co. indicated that they were unable to perform the inspection due to a lack of protection for the cheese melter and noted that the system needed to be legalized following a change in equipment by the customer. Upon interviewing the Facilities Director, it was revealed that the Ansul equipment had been replaced and a new vendor was contracted for maintenance and inspections. However, it was unclear if the local fire department had inspected and certified the new equipment, and no recent vendor inspection report was available. At the exit conference, the Administrator mentioned that the vendor had recently visited the facility, but the report was not yet available.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) Upon discovering the missed 6-month maintenance interval for the Ansul automatic extinguishing system, the facility immediately contacted a licensed and certified vendor to perform a full inspection and servicing of the system. 2) The facility will ensure the new kitchen equipment (including the Cheese Melter) is properly integrated into the Ansul system. Following the inspection, a report and work quote from the Fire Command Co. vendor was obtained and approved. Identification of Others: 1) The facility will conduct a comprehensive review of all cooking equipment in the kitchen, including checking for proper installation, fire extinguishing system coverage, and compliance with NFPA 96 and NFPA 17A. 2) The Director of Maintenance will ensure that a list of all equipment and associated fire suppression systems is updated. Additionally, the facility will maintain regular communication with the vendor and the local fire department to ensure that all future inspections are performed in a timely manner and that the equipment is certified according to the latest standards. Systemic Changes: 1) The Director of Maintenance will implement a new automated maintenance tracking system audit tool to ensure that all fire suppression and extinguishing systems are inspected at the required intervals. 2) The Director of Maintenance and all relevant maintenance staff will undergo training on the NFPA 96 and NFPA 17A standards, specifically focusing on the requirements for maintaining automatic extinguishing systems in kitchens. Quality Assurance (QA): 1) The facility will implement monthly audits of all fire safety equipment in the kitchen, including automatic extinguishing systems, fire suppression systems, and related equipment. These audits will verify that all equipment is functional and maintained according to NFPA standards, and that service reports are up to date. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.