Failure to Maintain and Document Annual Kitchen Equipment Inspections
Penalty
Summary
Surveyors found that the facility failed to maintain their kitchen cooking equipment in accordance with NFPA 96 standards. During a tour, observation revealed the presence of a six-burner gas range with two ovens and a griddle. When asked, the facility was unable to provide annual inspection records for the kitchen equipment, and no previous records were available for review. The Maintenance Assistant confirmed during an interview that the required inspections and servicing of the cooking equipment were not performed. This deficiency affected 25 of 43 residents in one of three smoke compartments, as the lack of inspection records indicated non-compliance with required fire safety standards for commercial cooking operations.
Plan Of Correction
K324 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: An immediate inspection of all commercial kitchen equipment was completed by maintenance staff on 5/20/25. 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 potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: A log will be created to check the kitchen equipment monthly, thoroughly inspect and clean as needed. 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 Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: A log will be created to check the kitchen equipment monthly, thoroughly inspect and clean as needed. 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 Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/2025