Failure to Maintain Annual Inspection and Maintenance of Kitchen Cooking Equipment
Penalty
Summary
The facility failed to maintain proper inspection, maintenance, and testing of its kitchen cooking equipment as required by NFPA 96 and NFPA 101 standards. During a record review and interview with the Administrator and Maintenance Director, it was found that the facility did not have annual inspection, maintenance, and testing records for the kitchen equipment, which included six burners, two ovens, and one griddle. Instead, the equipment was only inspected when it was already broken, and there was no established program for annual inspection of the kitchen cooking equipment. This deficiency affected 24 out of 93 residents in one of the smoke compartments. The absence of required documentation and a preventive maintenance program for the kitchen equipment was directly observed and confirmed during the survey process. The Administrator acknowledged that no program was in place for annual inspection of the kitchen cooking equipment.
Plan Of Correction
K324 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Stove and oven maintenance was inspected and verified by Maintenance Director under the supervision of regional director for environmental services. Condition of all equipment, connections, and burners passed inspection. • 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 patients have the ability to be affected by this deficient practice. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Maintenance director has been put on a quarterly inspection of stove and oven components, required to fill out the log documenting all inspections and any findings to be brought to QA for review. • How the facility plans to monitor its performance to make sure that solutions are sustained: Environmental services director will be responsible for bringing the log to each quarterly QA meeting until reaching 3 consecutive quarters with no findings. • Include dates when corrective action will be completed: Inspection completed 7/2/25