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K0711
F

Deficient Fire Safety Training and Evacuation Plan Implementation

Fort Gratiot, Michigan Survey Completed on 07-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, and did not provide periodic staff training consistent with their expected roles as outlined in the Fire Safety Plan. During an observation and interview, two out of three dietary staff members were unable to correctly describe the procedures for activating the installed range hood suppression system, and one dietary staff member could not identify which extinguisher should be used on a grease fire. These deficiencies were confirmed by both the Maintenance Director and the Dietary Manager during the observation. The lack of proper staff instruction and knowledge could affect all 128 residents in the event of a fire involving the deep fat fryer or kitchen range equipment.

Plan Of Correction

Element I: The dietary staff was given education regarding the procedure for activating the suppression system and which fire extinguisher to use for a grease fire. Element II: All residents and staff have the potential to be affected by the deficient practice. Element III: The fire prevention plan policy was reviewed by the IDT and deemed appropriate. All dietary staff will be educated on the fire prevention plan with emphasis on the suppression system and the appropriate fire extinguisher to use for a grease fire. The dietary supervisor/designee will ensure new hires are educated on the first day of training in the kitchen. In addition, the fire prevention plan has been added to the staff meeting agenda. Element IV: The dietary supervisor/designee will conduct random audits to ensure the staff can appropriately verbalize the use for fire extinguishers and suppression system. These audits will be weekly for 4 weeks then monthly for 2 months until compliance has been maintained. The results will be brought to the QAPI meetings. Element V: The dietary supervisor/administrator are responsible for continued compliance.

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