Non-compliance with Exhaust System Installation
Penalty
Summary
The facility failed to ensure compliance with NFPA 101 and NFPA 96 standards regarding the installation of exhaust and grease filters. During a life safety survey, it was observed that the cafe area in the Weinberg building had a deep fryer in use on the counter without an exhaust system installed above it. Additionally, an electric burner was noted in a separate area of the cafe. This deficiency was identified through both observation and staff interview, where the Director of Plant Operations acknowledged the absence of the required exhaust system and stated that the deep fryer would be removed.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff permanently removed all cooking equipment from the Café that would require an approved exhaust system and grease filter installation in accordance with NFPA 96. The Administrator banned the cooking of food that could create grease laden vapors. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout for same deficiencies. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance and café staff will receive additional education and all participants will understand the life safety issues identified, with cooking food that produces grease laden vapors without the requirements of an approved exhaust system and grease filters in accordance with 2010 NFPA 96 12.1.2.4. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check Café for unapproved cooking equipment and cooking of food that produces grease laden vapors monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted.