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Based on observation and staff interview, the facility failed to ensure the kitchen deep fryer was properly separated from the open flames of the kitchen range as required by NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice had the potential to affect approximately 8 of 8 residents, who currently reside in the facility, as identified by the administrator on 4/24/2025. The facility had a census of 8 residents. Findings:

1. A tour of the facility was conducted on 4/24/2025 from 12:10 p.m. to 1:55 p.m., and the following observation was made:

The deep fryer was located directly against the right side of the kitchen range. An eight inch high steel or tempered glass shield was not provided to separate the deep fryer from the surface flames of the kitchen range.

2. The Director of Maintenance was present during the tour of the facility and acknowledged the deep fryer was not separated from the kitchen range surface flames.

NFPA 96, 1998 Edition, 9-1.2.3 states:
All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.
Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.

Based on record review and staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. This had the potential to affect 8 of 8 residents, who currently resided in the facility, as identified by the administrator on 4/24/2025. The facility had a census of 8 residents. Findings:

1. Review of the facility fire drill reports was conducted on 4/24/2025 at 11:20 p.m. There was no documentation the facility had conducted a fire drill for the following shift:

*Second shift for the first quarter of 2025.

2. The Director of maintenance was interviewed during the record review and he stated he could not find the missing the fire drill.

Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at unexpected times under varying conditions, at least once a quarter for each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7