HospitalInspections.org

Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:

¢ Residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2).
¢ Cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
¢ Cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.32.5.4, 19.3.2.5.4.

Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TA12-2


Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 12 of 12 residents.

Findings:

During the facility tour on 12/29/21, between the hours of 8:00a-4:30p observation revealed the orientation of the filters are wrong, the vains should be vertical and improper coverage of the the equipment under the hood.

Interview with the maintenance director revealed the facility the filters were wrong and the appliances in the kitchen were not covered properly by the hood suppression system.

All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements as applicable.
5.1.9, 5.2.9, 5.3.6.23.2 (NFPA 99)

Based on visual observation, the facility failed to assure the gas and vacuum piped system is installed in accordance with NFPA 99. All master, area, and local alarm systems used for medical gas and vacuum systems are required to be installed per NFPA 99. The deficient practice has the potential to affect 12 of 12 residents.

Findings:
During the facility tour and record review on 12/23/21, between the hours of 8:00a-4:30p, observation and record review revealed no medical gas alarm panel monitoring ICU and the ER did not have a medical gas alarm panel for each Med gas zone valve box in the ER.

Interview with the Maintenance Supervisor revealed the facility was not aware the med gas system was not installed correctly.