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Tag No.: K0069
REMAINS CITED
Based on observation and staff interview it was determined this facility failed to ensure all suppression systems in the kitchen area were updated to UL-300 compliance at the six year maintenance or when hydrostatic testing was due. This had the potential to affect all those utilizing this area of the facility. This had the potential to affect all those utilizing this area of the facility. The patient census at the beginning of the survey was 294.
Findings include:
During this visit on 01/16/13, tour was conducted in the facility with
Staff A, B, C, D, and E. During tour of the kitchen area observation was made of two CO2 hood suppression systems which were fed from the same manifold system. When questioned as to whether there were any changes made to upgrade the system to UL-300 compliance, Staff A stated there had been no changes or maintenance conducted on the system since the 12/07/12 survey. Staff A further stated the facility requested an extension in order to complete this work, stating the existing system was scheduled to be taken out beginning 01/09/13.
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