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VANDERBILT UNIVERSITY MEDICAL CENTER
Cooking Facilities
Tag No.: K0324
Based on observation, document review, and interview, the facility failed to maintain the cooking equipment.
The findings include:
1. Observation on 05/12/2025 at 10:54 AM, revealed two (natural gas) deep fat fryers under the kitchen hood that were equipped with castors and did not have an approved method to return the equipment to the approved location after moving for cleaning or maintenance. NFPA 101, 19.3.2.5.1 (2012 Edition) NFPA 101, 9.2.3 (2012 Edition) NFPA 96, 12.1.2.3.1 (2011 Edition)
2. Interview with the Executive Chef on 05/12/2025 at 11:03 AM, revealed there have been approximately 4 or 5 previous fires due to build up of grease in the exhaust of the deep fat fryers. The Executive Chef stated that the deep cleaning and maintenance of that equipment is performed by facilities management, and that these events were reported to the facilities staff responsible for the kitchen. NFPA 101, 19.3.2.5.1 (2012 Edition) NFPA 101, 9.2.3 (2012 Edition) NFPA 96, 11.7.2 (2011 Edition) NFPA 96, 4.1.3.1 (2011 Edition)
3. Interview with the Director of Nutrition on 05/12/2025 at 11:05 AM, revealed staff failed to activate the fixed hood suppression system before using the portable class K extinguisher, and initially attempted to extinguish the fire with salt. NFPA 101, 19.3.2.5.1 (2012 Edition) NFPA 101, 9.2.3 (2012 Edition) NFPA 96, 10.5.7 (2011 Edition)
4. Document review on 05/12/2025 between 11:08 AM and 3:00 PM, revealed the facility could not provide records of inspection, cleaning (other than cleaning of the cooking oil and cooking surfaces), or maintenance of the cooking equipment. NFPA 101, 19.3.2.5.1 (2012 Edition) NFPA 101, 9.2.3 (2012 Edition) NFPA 96, 11.7.1 (2011 Edition)
The Accreditation & Regulatory Specialist was present when these findings were identified and acknowledged them during the telephone exit conference on 05/15/2025.
Utilities - Gas and Electric
Tag No.: K0511
Based on observation, the facility failed to maintain gas cooking equipment equipped with castors.
The finding includes:
Observation on 05/12/2025 at 10:54 AM, revealed two deep fat fryers equipped with castors that were not equipped with a restraint device. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.1 (2012 Edition) NFPA 54, 10.12.6 (2012 Edition)
The Accreditation & Regulatory Specialist was present when these findings were identified and acknowledged them during the telephone exit conference on 05/15/2025.