Incomplete Kitchen Hood Fire Suppression System Maintenance Records
Penalty
Summary
The facility failed to maintain complete records for the kitchen's hood fire suppression system, as required by NFPA 101 and NFPA 96 standards. During a document review and interview, it was found that one of the two required semi-annual inspection records for the kitchen's hood fire suppression system was missing. The last available record was dated 11/13/24, and staff interviewed were unable to provide the missing documentation or confirm when the previous service had been conducted. This deficiency affected the nutritional services area and one of six smoke compartments in the facility. The absence of the required maintenance record was confirmed by a staff member, who stated that the missing record pertained to a period before their employment and that they did not have access to it. No information was provided regarding any specific residents or their conditions in relation to this deficiency.
Plan Of Correction
The EVS Director or designee will perform monthly inspections of hazardous area enclosures. Any deficiencies will be corrected immediately and documented. Findings from inspections will be reviewed in QAPI meetings to ensure continued compliance. Date of Compliance 4/18/25 K 324 - Cooking Facilities How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potentially to be affected. The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; The EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. The EVS Director was trained by the Administrator on the importance of safety documentation and maintaining and verifying inspection records. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; The EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) committee by the EVS Director for continued oversight. Date of Compliance 4/18/25