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Based on observations made during tour of the facility, and interview with the staff, it was determined the facility failed to maintain the commercial cooking equipment in reliable operating, safe condition.

The findings include:

Inspection of the commercial cooking equipment under the the exhaust hood, in the kitchen revealed the equipment attachments, gas plumbing, wires, and splash guards were grease laden.

Interview with the Kitchen Manager revealed that there is no schedule for cleaning and degreasing of the equipment, with the exception of the cooking surfaces themselves. When questioned who would be the responsible party for this, the kitchen manager replied that it was he.

Based on a review of the facility records, and interview with the staff during the Fire Life safety survey, it was determined the facility failed to ensure all Essential Electrical Equipment was tested as frequently as required. Essential Electrical Equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause the safety features of the equipment to fail.


The findings include:


1. There was no documentation during the 2/9/11 survey to show the Main & Feeder Circuit Breakers were exercised annually as required since 12/14/09.

The facility Director stated the electrician who is responsible for the testing was out on extended medical leave, and just returned the day of the survey, and had not had the opportunity to complete this work order.

2. There was no documentation during the 2/9/11 survey to show that Line Isolation Monitors were tested monthly and logged as required.

Operating Room 2 is the only suite with the Line Isolation Monitor and the facility Director stated that this testing was not being performed.

Based on observations made during tour of the facility, and interview with the staff, it was determined the facility failed to maintain the commercial cooking equipment in reliable operating, safe condition.

The findings include:

Inspection of the commercial cooking equipment under the the exhaust hood, in the kitchen revealed the equipment attachments, gas plumbing, wires, and splash guards were grease laden.

Interview with the Kitchen Manager revealed that there is no schedule for cleaning and degreasing of the equipment, with the exception of the cooking surfaces themselves. When questioned who would be the responsible party for this, the kitchen manager replied that it was he.

Based on a review of the facility records, and interview with the staff during the Fire Life safety survey, it was determined the facility failed to ensure all Essential Electrical Equipment was tested as frequently as required. Essential Electrical Equipment not tested as frequently as required renders the equipment unreliable, and undetected faulty equipment could cause the safety features of the equipment to fail.


The findings include:


1. There was no documentation during the 2/9/11 survey to show the Main & Feeder Circuit Breakers were exercised annually as required since 12/14/09.

The facility Director stated the electrician who is responsible for the testing was out on extended medical leave, and just returned the day of the survey, and had not had the opportunity to complete this work order.

2. There was no documentation during the 2/9/11 survey to show that Line Isolation Monitors were tested monthly and logged as required.

Operating Room 2 is the only suite with the Line Isolation Monitor and the facility Director stated that this testing was not being performed.