Failure to Maintain Kitchen Equipment Inspection and Maintenance Records
Penalty
Summary
Surveyors found that the facility failed to maintain required inspection and maintenance records for its kitchen cooking equipment. During a tour and record review, it was observed that the facility could not provide annual inspection records for the kitchen equipment, and the Maintenance Director confirmed that there was no annual inspection plan in place. The Maintenance Director stated that equipment was only checked by a vendor when it broke down, rather than being inspected regularly as required. Additionally, the facility was unable to provide one of two required semiannual maintenance records for the kitchen suppression system and one of two required semiannual kitchen hood-exhaust cleaning records. Although one record for each was provided, the other records were not located, and the facility did not submit the missing documentation by the deadline given by surveyors. These deficiencies affected 17 of 77 residents in one of three smoke compartments.
Plan Of Correction
Corrective Actions Facility will make sure that all cooking equipment is maintained as required. Facility contacted the company to come for the semi-annual kitchen suppression system service and semi-annual kitchen hood cleaning system. Facility will contact a qualified company to inspect the kitchen equipment annually. Maintenance director will make sure that he is organized and keeping all maintenance records for kitchen equipment regularly and ready for an inspection. Identify other residents. Other residents may have the potential to be affected by this deficient practice, so maintenance supervisor along with dietary supervisor will make sure that all kitchen equipment is serviced, and preventive maintenance is done regularly. Administrator and maintenance director will walk through in the building to ensure that this deficient practice is not affecting any other areas. Systemic Changes As a result of systemic change, the maintenance director, dietary manager, and administrator will meet monthly to ensure that there is no kitchen equipment inspection due at that time. Facility will keep a special binder to keep all the maintenance records for the kitchen equipment. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction completed on 04/18/2025.