Lack of Awareness of Kitchen Fire Suppression System
Penalty
Summary
The facility failed to ensure that the kitchen hood fire suppression system was maintained in accordance with the National Fire Protection Association (NFPA) 96 Standard. During the survey, it was found that 2 out of 3 kitchen staff members interviewed were not aware of how to activate the kitchen hood fire suppression system in the main kitchen. Specifically, one cook mentioned they would use a fire extinguisher and pull the fire alarm but were unsure about the location of the emergency button for the suppression system. Similarly, the Dietary Supervisor was unaware of the kitchen fire suppression system and would also resort to using a fire extinguisher and pulling the fire alarm. The Director of Facility Services stated that kitchen staff were trained annually on the fire suppression system and the use of K-type fire extinguishers, indicating that all dietary staff should have been familiar with the system.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 (Cooking Facilities – Staff Training on the Kitchen Fire Suppression system) The Facility Services Director will train all the Kitchen staff on how to properly use the Kitchen Fire Suppression system and where the pull switch is located to operate it. The Facility Services Director or a properly trained designee will train all dietary staff, nursing supervisors, maintenance staff, and custodial staff on how to properly use the Kitchen Fire Suppression system and where the pull switch is to operate it. This will also include all newly hired employees within the identified departments. The Facility Services Director or properly trained designee will conduct periodic audits to ensure staff knowledge of the kitchen fire suppression system and report results to QAPI. The audits will be monitored and reported to the QAPI committee on a quarterly basis for one year and annually thereafter. The deficiency will be corrected no later than 3/25/25. The Facility Services Director will be responsible for this plan of correction.