Noncompliant Cooking Equipment Installation
Penalty
Summary
During an observation on May 7, 2025, surveyors identified that a shelf was protruding over the stove top burners in the facility's cooking area. This configuration was found to be noncompliant with NFPA 96, specifically section 10.2.7.3, as the shelf could obstruct the effectiveness of the hood suppression system in the event of a fire. The deficiency was confirmed through an interview with the Maintenance Director at the time of the observation. Approximately six occupants could be affected by this deficiency in the event of a fire emergency, as noted in the findings. No additional details about the medical history or condition of the occupants were provided in the report.
Plan Of Correction
LSC Annual Survey 5.7.25 K 324 Cooking Facilities Element 1 The fire suppression system over the range with the shelf was inspected by Fire Control, who adjusted the angle and type of the nozzles as well as adding. Fire Control then validated that this system was adequate for proper suppression. Element 2 A facility-wide audit does not reveal any other Ansul systems of suppression similar to the one mentioned, nor does it reveal any other obstructed sprinkler heads as part of the standard facility suppression system. Element 3 The maintenance director was educated on the regulations of tag K 324 in accordance with the NFPA 101 guidance. The regulatory maintenance schedule within TELS was reviewed and deemed appropriate, in addition to all other routine scheduled inspections and maintenance of the fire suppression systems. Element 4 The maintenance director will audit the Ansul system monthly in addition to all other routine TELS tasks to ensure nozzles are in proper place and working order. The results of all ongoing audits will be reviewed by the QAPI committee. The NHA is responsible for ongoing compliance.