Failure to Complete Required Kitchen Fire Suppression System Inspections
Penalty
Summary
The facility failed to ensure that the kitchen fire suppression system underwent the required semi-annual inspections. During a documentation review, surveyors found that the facility could not provide records showing that two of the mandated semi-annual inspections had been completed for the kitchen fire suppression system. This was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security, who acknowledged that the inspection reports were not available at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Semi-annual inspections were completed. Facility will ensure documentation of testing is available for survey team during all inspections.