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Based on a review of an incident report, a report from the local fire department, facility policy and procedure, and a staff interview, it was determined that the facility failed to comply with state laws related to reportable events when the facility had a fire that occurred in the kitchen that destroyed the equipment. The State Agency nor State Fire Marshal were notified of the incident by the facility.

Cross-reference A0021 Compliance with State Laws as it relates to the facility failing to be in compliance with applicable Federal laws in relation to the saftey and health of patients.

Based on a review of an incident report, a report from local the fire department, facility policy and procedure, and a staff interview, it was determined that the facility failed to comply with state laws related to reportable events when the facility had a fire that occurred in the kitchen that destroyed the equipment. The State Agency nor State Fire Marshal were notified of the incident by the facility.

Findings:

A review of the "Incident Reporting - Risk Management Program" policy, effective 1/1/16, last revised in January 2021, revealed that an incident was an unanticipated event not consistent with the standard of care and/or operation of the facility. An incident report was a risk management tool that raised awareness of potential exposures to perils that may/did cause harm. The policy revealed that tragic or serious level incidents must be reported within the state requirements. The policy failed to include state requirements for reporting fires or tragic level incidents.

A review of the All-Hazards Emergency Management Plan approved on 8/24/21 failed to reveal a policy for reporting facility fires to the State Agency or State Fire Marshall.

A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. The fire was controlled at 10:19 a.m., and the last unit cleared the facility at 10:27 a.m. A fire detector had alerted building occupants. The report further revealed that the fire department arrived on the scene and went to the kitchen. There was a small grease fire under one of the cooking units that had been put out before the fire department arrived. The fire crew investigated and advised the facility manager to clean the piece of equipment before using it again. The ignition originated in the kitchen cooking area and involved cooking materials, food, and grease. The ignition was determined to be unintentional. A factor contributing to the ignition was a failure to clean. There were no human factors that contributed.

A review of an Incident Report Form, entry 362, dated 5/12/22 at 9:36 a.m., revealed an incident that occurred on 5/11/22 at 10:12 a.m. in the facility's kitchen. The report revealed that the kitchen flat top area ignited, causing a fire with smoke and flames. The fire was extinguished quickly by staff members. There was smoke damage to the kitchen and dining areas. Staff disposed of damaged food. The fire department was called and arrived at 10:17 a.m. Emergency Medical Services (EMS) was called for employees with smoke inhalation, and employees were transported to the hospital via EMS. A notification was made to the facility administration, facility maintenance, facility supervisor, and Chief Nursing Officer (CNO) on 5/11/22. Risk Management signed the incident report form on 5/13/22. Severity level classification was '1' (tragic).

An interview took place with the Director of Facility Operations (DFO) GG on 6/6/22 at 4:37 p.m. in the Conference Room. DFO GG said he did not believe the facility reported the fire to the State Department. The corporation was informed and did not mention that the facility had to report. The facility called public health immediately for the cooler and what needed to be disposed of, and the fire department was at the facility

Based on a review of an incident report, a report from the local fire department, a review of the Proactive Risk Assessments, a review of job descriptions and personnel files, interviews with staff, a review of the Governing Body Bylaws and meeting minutes, and a review of a policy and procedure, it was determined the facility failed to be responsible for the conduct of the hospital by failing to ensure that preventive maintenance, risk assessments, and proper cleaning of kitchen equipment were performed regularly. Due to this failure, a kitchen fire occurred damaging the facility kitchen equipment, interrupting dietary services, and injuring employees. In addition, the Governing Body failed to develop policies and procedures and educate facility leadership on the requirement to report fire incidents to the state fire marshal.

Cross-reference A0063 Care of Patients as it relates to the governing body failing to ensure the saftey and care of patients.

Based on a review of an incident report, a report from the local fire department, a review of the Proactive Risk Assessments, a review of job descriptions and personnel files, interviews with staff, a review of the Governing Body Bylaws and meeting minutes, and a review of a policy and procedure, it was determined the facility failed to be responsible for the conduct of the hospital by failing to ensure that preventive maintenance, risk assessments, and proper cleaning of kitchen equipment were performed regularly. Due to this failure, a kitchen fire occurred damaging the facility kitchen equipment, interrupting dietary services, and injuring employees. In addition, the Governing Body failed to develop policies and procedures and educate facility leadership on the requirement to report fire incidents to the state fire marshal.

Findings:

A review of the Governing Body Bylaws, approved 2018, Article 2, General Provisions, CEO Duties and Powers, revealed that the Board of Directors appointed the CEO. The CEO was responsible for the overall management of the facility. In addition, the Governing Board had delegated to the CEO broad authority and responsibility that included ensuring regular communication between hospital leadership and the Governing Board regarding quality and safety issues.

A review of the facility's policy titled "Cleaning Instructions: Cleaning Ranges," policy #CS-30, approved 11/10/18, revealed the cook on each shift would be responsible for keeping the range as clean as possible during the preparation of the meal. The range would be cleaned after each use. Spills and food particles would be wiped off as they occurred.
A review of the Proactive Risk Assessments by the Director of Facility Operations (DFO) GG dated 1/7/22 and updated on 3/29/22 revealed assessments was completed for the dining rooms, fire safety, and emergency management. There was no Proactive Risk Assessment for the kitchen.

A review of the Governing Body Meeting minutes dated 4/12/22 failed to reveal discussion or reports from the CEO concerning the maintenance of kitchen equipment or ensuring dietary personnel was properly certified.

A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

A review of an Incident Report Form, entry 362, dated 5/12/22 at 9:36 a.m., revealed an incident on 5/11/22 at 10:12 a.m. in the facility's kitchen. The incident report revealed that the kitchen's flat top area ignited, causing a fire with smoke and flames.

A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

A review of a service order summary dated 5/18/22 revealed the flat top caught on fire underneath and caused damage to most of the burner valves.

A review of the Director of Facility Operations job description revealed that the position was responsible for the overall maintenance of the facility's buildings, grounds, fixtures, and equipment. Areas of responsibility may have included two or more of the following areas/departments: safety, security, maintenance, facilities, materials management, and housekeeping. Skill requirements included a bachelor's degree in business or a technical field with a master's degree preferred. In addition, the Director must possess two years of college-level construction trade education and a minimum of five years of construction/maintenance experience or a minimum of ten years of construction/maintenance supervisory experience. In addition, the Director position required the ability to manage multiple vendors.

A review of the personnel file for the DFO GG revealed that DFO GG failed to possess a bachelor's degree, two years of college-level construction trade education, and a minimum of five years of construction or maintenance experience or a minimum of ten years of construction or maintenance supervisory experience, as listed on the job description requirements. DFO GG had an associate degree in Criminal Justice and no education or experience in facility maintenance. In addition, the personnel file for DFO GG failed to reveal experience or certification in dietary management. There were no dietary competency checkoffs for DFO GG before the fire.

An interview was conducted with the Dietary Manager (DM) HH on 6/6/22 at 2:13 p.m. in the conference room. DM HH had worked at the facility for six months. DM HH stated she spoke to the DFO GG about servicing the equipment a month prior, and the equipment had not been serviced for as long as she had been employed. Service would usually be done quarterly. DM HH further said that the staff had not had competencies completed. DM HH stated that DFO GG had no dietary background. DM HH stated the service technician said it appeared the pilot light on the stove would automatically trigger the griddle and heat the flat top grill.

An interview was conducted with DFO GG on 6/6/22 at 4:37 p.m. in the conference room. DFO GG stated that none of the kitchen equipment was on a preventive maintenance schedule before the fire. DFO GG explained that staff was unaware of openings in the back of the stove for cleaning, and a fire started underneath the flat top griddle. The only place the staff knew to clean was the grease trap and grease tray. DFO GG said that both were cleaned after each use. DFO GG stated that he had experience as a line cook for four to five years but no other qualifications for the kitchen.

An interview was conducted with the facility's cook (CK) JJ on 6/7/22 at 10:44 a.m. in the conference room. The CK JJ had been at the facility for 25 years and said the old stove in the kitchen had not been serviced in a while and was not cleaned behind the drip trays. The drip trough was cleaned, but no other maintenance was completed.

An interview was conducted with Registered Dietician (RD) RR on 6/8/2022 at 10:15 a.m. in the conference room. RD RR stated that DFO GG became food handler certified after the fire, and the dietary manager (DM) HH was the only kitchen staff with ServSafe certification before the fire. RD RR said DM HH answered directly to DFO GG.

An interview was conducted with Human Resources Director (HR) MM on 6/8/2022 at 11:27 a.m. in the conference room. HR MM stated that at one-point dietary was split between DFO GG and the Director of Admissions (DA) SS. The Chief Executive Officer (CEO) made the final decision to put DFO GG in charge of dietary.

An additional interview was conducted with the HR MM on 6/8/22 at 12:20 p.m. in the conference room. HR MM stated there were no competencies on file for DFO GG. Dietary Competencies were checked off for DFO GG on 5/24/22 by the dietician (SS).

Based on a review of an incident report, a fire department report, a Proactive Risk Assessment, interviews with facility staff, and a review of a policy and procedure, it was determined that the facility failed to protect patient's right to a safe environment when a fire broke out in the kitchen due to failing to clean and maintain kitchen equipment. In addition to risks associated with fires, due to damages to the kitchen, food was brought in from outside catering companies, fast food, and grocery stores without verifying that the food was handled appropriately to prevent food-borne illness to patients.

Cross-reference A0144 Patient Rights: Care in a Safe Setting as it relates to the facility's failure to ensure patients received care in a safe setting.

Based on a review of an incident report, a local fire department report, a Proactive Risk Assessment, interviews with facility staff, and a review of a policy and procedure, it was determined that the facility failed to protect patient's right to a safe environment when a fire broke out in the kitchen due to failing to clean and maintain kitchen equipment. In addition to risks associated with fires, due to damages to the kitchen, food was brought in from outside catering companies, fast food, and grocery stores without verifying that the food was handled appropriately to prevent food-borne illness to patients.

Findings:

A review of the facility's policy titled "Patient Rights," revised 7/21, revealed that patients would be fully informed about patient rights at the time of admission. In addition, a review of the Patient Rights and Responsibilities given to patients at admission revealed that patients had the right to treatment in a safe environment.
A review of the Proactive Risk Assessments by the Director of Facility Operations (DFO) GG dated 1/7/22 and updated on 3/29/22 revealed assessments was completed for the dining rooms, fire safety, and emergency management. There was no Proactive Risk Assessment for the kitchen.

A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

A review of an Incident Report Form, entry 362, dated 5/12/22 at 9:36 a.m., revealed an incident on 5/11/22 at 10:12 a.m. in the facility's kitchen. The incident report revealed that the kitchen's flat top area ignited, causing a fire with smoke and flames.

A review of a service order summary dated 5/18/22 revealed the flat top caught on fire underneath and caused damage to most of the burner valves.

An interview was conducted with Dietary Manager (DM) HH on 6/6/22 at 2:13 p.m. in the conference room. DM HH had worked at the facility for six months. DM HH stated she was not in the kitchen when the fire broke out. DM HH said when Code Red was called, she saw the staff running toward the kitchen. When DM HH got to the doors of the cafeteria, DM HH saw one of the Behavioral Health Assistants (BHA) beating on the glass of the kitchen door from inside the kitchen. The BHA was screaming that the wrong code had been called and there was a fire. DM HH said she could see "so much" black smoke. In addition, she saw dietary aide (DA) EE with the fire extinguisher. DM HH said she was telling staff to get out of the kitchen because of the gas stove. Director of Facility Operations (DFO) GG was able to turn off the gas supply to the kitchen. DM HH said everyone exited the kitchen, and DA EE cleared the fire. DM HH said the CEO came into the kitchen, and the CEO said the fire probably happened because the stove was dirty. The CEO asked for the cleaning lists. The kitchen was shut down, and there was a cooler outside. Food was being catered into the facility. DM HH further said she had to call the health department about the food. The health department checked to make sure all the equipment was functioning. A service technician came to look at the equipment.

An interview was conducted with DFO GG on 6/6/22 at 4:37 p.m. in the conference room. DFO GG stated that none of the kitchen equipment was on a preventive maintenance schedule before the fire. DFO GG explained that staff was unaware of openings in the back of the stove for cleaning, and a fire started underneath the flat top griddle. The only place the staff knew to clean was the grease trap and grease tray. DFO GG said that both were cleaned after each use. The grease trays would come out for cleaning, and the kitchen staff thought the stove was sealed off behind the tray. A contractor inspected the fryer and oven and determined the stove needed to be replaced. DFO GG further said that on the day of the fire, a meeting with the Chief Executive Officer had just finished when a Code Gray was called. Code Gray was when assistance was required. DFO GG proceeded to the dining room and saw smoke and the strobe lights going off. Smoke detectors activated the fire alarms and automatically called the fire department. DFO GG said that when he got to the kitchen, the fire was in the process of being extinguished. The back door was open, and staff members were moving out of the kitchen. DFO GG further said that the kitchen doors were set up on asylum locks, which required a key on both sides to enter or exit to prevent issues with theft in the kitchen. The locks had since been changed to storeroom locks, which required a key to enter, but anybody could leave at any time. DFO GG said that since he had been at the facility, no patients had been permitted into the kitchen area. At the time of the survey, there were still double-keyed locks in the dining room. Staff with keys were always with patients in the dining room.

An interview was conducted with the facility's cook (CK) JJ on 6/7/22 at 10:44 a.m. in the conference room. CK JJ had worked at the facility for 25 years. CK JJ stated everybody in the kitchen was responsible for cleaning as they went. The CK JJ further said staff members were supposed to always be in the dining room with patients, but most of the time, the staff members would let the patients into the dining room and stand at the door. The CK JJ said all the locks in dietary had been changed, and no one had keys except those who worked in dietary. The BHAs had keys to the dining room doors but had to knock to get into the kitchen where the food serving area was located. The CK JJ further said the old stove in the kitchen had not been serviced in a while and was not cleaned behind the drip trays.

An interview was conducted with the Registered Dietician (RD) RR on 6/8/2022 at 10:15 a.m. in the conference room. RD RR stated the facility brought in meals from different restaurants, fast food, prepared grocery store food, prepackaged chips, fruit trays, etc. The food would be put into to-go boxes. The dietician monitored to ensure nutritional needs were met for different patients. RD RR said there was no menu during the time of the fire. RD RR said the administration would sit in the board room every few days to plan meals. The Director of Operations (DOO) BB would coordinate with the restaurants in town. Breakfast was usually breakfast burritos, chicken biscuits, hashbrowns, and fruit. Lunch would be sandwiches, chips, fruit, and vegetables with dip, and dinner was always a warm meal.

An interview was conducted with the Human Resources Director (HR) MM on 6/8/2022 at 11:27 a.m. in the conference room. HR MM stated that the only kitchen personnel ServSafe certified before the fire were DM HH and dietary aide (DA) KK. HR MM further said there was no evidence of competencies on kitchen staff in the personnel files.

An additional interview was conducted with DFO GG on 6/8/2022 at 12:58 p.m. in the conference room. DFO GG stated that according to Servsafe guidelines, food needed to be checked with a metal stem thermometer inserted into the thickest part of the food to ensure that it was above 135 degrees or below 40 degrees Fahrenheit. DFO GG said he did not personally check the temperatures of any of the catered food. DFO GG further said that anything catered was served less than 20 minutes after delivery, and the caterers were no further than ten to15 minutes from the facility. DFO GG stated that for something to become unsafe for consumption, the food had to be in the danger zone for four hours. DFO GG further explained that the DM HH was supposed to monitor and verify correct foods were being prepared and served. DM HH was out for a time after the fire, and the administrative team worked on diet sheets from each unit with special diets. DFO GG said the administrative team consulted with the dietician and prepared special foods for the patients on special diets. The dietician would tell the team what to put on trays. Food was delivered to the units in to-go containers. There were no menus prepared for catered food. DFO GG further said the facility was not able to ensure the catered food was cooked at the correct standard, but any caterers to be Servsafe certified, which included infection control.

Based on a review of an incident report, a local fire department report, interviews with staff, and a review of a policy and procedure, it was it was determined that the facility failed to maintain equipment to ensure an acceptable level of safety and quality in dietary. The facility also failed to follow its own standards by employing a manger for dietary services and dietary staff who was not qualified to provide the dietary services.

Cross-reference A0620 as it relates to the facility ' s failure to ensure a qualified director of Dietary Services.

Cross-reference A0622 as it relates to the facility ' s failure to ensure the dietary staff received and maintained proper training and qualifications to provide dietary services.

Cross-reference A0629 as it relates to the facility not maintaining therapeutic diets as ordered. The facility purchased outside food and did not ensure the food quality was safe to serve to patients.

Based on a review of an incident report, a local fire department report, interviews with staff, and a review of the facility ' s employment documentation, it was determined that the facility failed to ensure the Director of Dietary services was qualified to maintain the dietary needs for the facility.

Findings:
A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

An interview was conducted with the Dietary Manager (DM) HH on 6/6/22 at 2:13 p.m. in the conference room. DM HH had worked at the facility for six months. DM HH stated she spoke to the DFO GG about servicing the equipment a month prior, and the equipment had not been serviced for as long as she had been employed. Service would usually be done quarterly. DM HH further said that the staff had not had competencies completed. DM HH stated that DFO GG had no dietary background. DM HH stated the service technician said it appeared the pilot light on the stove would automatically trigger the griddle and heat the flat top grill.

An interview was conducted with DFO GG on 6/6/22 at 4:37 p.m. in the conference room. DFO GG stated that he had experience as a line cook for four to five years but no other qualifications for the kitchen.

An interview was conducted with Registered Dietician (RD) RR on 6/8/2022 at 10:15 a.m. in the conference room. RD RR stated that DFO GG became food handler certified after the fire, and the dietary manager (DM) HH was the only kitchen staff with ServSafe certification before the fire. RD RR said DM HH answered directly to DFO GG.

An interview was conducted with Human Resources Director (HR) MM on 6/8/2022 at 11:27 a.m. in the conference room. HR MM stated that at one-point dietary was split between DFO GG and the Director of Admissions (DA) SS. The Chief Executive Officer (CEO) made the final decision to put DFO GG in charge of dietary.

An additional interview was conducted with the HR MM on 6/8/22 at 12:20 p.m. in the conference room. HR MM stated there were no competencies on file for DFO GG. Dietary Competencies were checked off for DFO GG on 5/24/22 by the dietician (SS).

A review of the Director of Facility Operations job description revealed that the position was responsible for the overall maintenance of the facility's buildings, grounds, fixtures, and equipment. Areas of responsibility may have included two or more of the following areas/departments: safety, security, maintenance, facilities, materials management, and housekeeping. Skill requirements included a bachelor's degree in business or a technical field with a master's degree preferred. In addition, the Director must possess two years of college-level construction trade education and a minimum of five years of construction/maintenance experience or a minimum of ten years of construction/maintenance supervisory experience. In addition, the Director position required the ability to manage multiple vendors.

A review of the personnel file for the DFO GG revealed that DFO GG failed to possess a bachelor's degree, two years of college-level construction trade education, and a minimum of five years of construction or maintenance experience or a minimum of ten years of construction or maintenance supervisory experience, as listed on the job description requirements. DFO GG had an associate degree in Criminal Justice and no education or experience in facility maintenance. In addition, the personnel file for DFO GG failed to reveal experience or certification in dietary management. There were no dietary competency checkoffs for DFO GG before the fire.

Based on a review of an incident report, a local fire department report, interviews with staff, and a review of the facility's employment documentation, it was determined that the facility failed to ensure the Dietary staff was qualified and competent to maintain the dietary needs for the facility.

Findings:

A review of the facility's policy titled "Cleaning Instructions: Cleaning Ranges," policy #CS-30, approved 11/10/18, revealed the cook on each shift would be responsible for keeping the range as clean as possible during the preparation of the meal. The range would be cleaned after each use. Spills and food particles would be wiped off as they occurred.

A review of the Director of Facility Operations job description revealed that the position was responsible for the overall maintenance of the facility's buildings, grounds, fixtures, and equipment. Areas of responsibility may have included two or more of the following areas/departments: safety, security, maintenance, facilities, materials management, and housekeeping. Skill requirements included a bachelor's degree in business or a technical field with a master's degree preferred. In addition, the Director must possess two years of college-level construction trade education and a minimum of five years of construction/maintenance experience or a minimum of ten years of construction/maintenance supervisory experience. In addition, the Director position required the ability to manage multiple vendors.

A review of the personnel file for the DFO GG revealed that DFO GG failed to possess a bachelor's degree, two years of college-level construction trade education, and a minimum of five years of construction or maintenance experience or a minimum of ten years of construction or maintenance supervisory experience, as listed on the job description requirements. DFO GG had an associate degree in Criminal Justice and no education or experience in facility maintenance. In addition, the personnel file for DFO GG failed to reveal experience or certification in dietary management. There were no dietary competency checkoffs for DFO GG before the fire.

A review of the Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

An interview was conducted with the Dietary Manager (DM) HH on 6/6/22 at 2:13 p.m. in the conference room. DM HH had worked at the facility for six months. DM HH stated she spoke to the DFO GG about servicing the equipment a month prior, and the equipment had not been serviced for as long as she had been employed. Service would usually be done quarterly. DM HH further said that the staff had not had competencies completed. DM HH stated that DFO GG had no dietary background. DM HH stated the service technician said it appeared the pilot light on the stove would automatically trigger the griddle and heat the flat top grill.

An interview was conducted with DFO GG on 6/6/22 at 4:37 p.m. in the conference room. DFO GG stated that none of the kitchen equipment was on a preventive maintenance schedule before the fire. The staff was unaware of openings in the back of the stove for cleaning, and a fire started underneath the flat top griddle. The only place the staff knew to clean was the grease trap and grease tray. Both were cleaned after each use. The grease trays would come out for cleaning, and the kitchen staff thought the stove was sealed off behind the tray. DFO GG stated that he had experience as a line cook for four to five years but no other qualifications for the kitchen.

An interview was conducted with the facility's cook (CK) JJ on 6/7/22 at 10:44 a.m. in the conference room. CK JJ said the old stove in the kitchen had not been serviced in a while and was not cleaned behind the drip trays. The drip trough would be cleaned, but no other maintenance was completed.

An interview was conducted with Registered Dietician (RD) RR on 6/8/2022 at 10:15 a.m. in the conference room. RD RR stated that DFO GG became food handler certified after the fire, and the dietary manager (DM) HH was the only kitchen staff with ServSafe certification before the fire. RD RR said DM HH answered directly to DFO GG.

An interview was conducted with Human Resources Director (HR) MM on 6/8/2022 at 11:27 a.m. in the conference room. HR MM stated that at one-point dietary was split between DFO GG and the Director of Admissions (DA) SS. The Chief Executive Officer (CEO) made the final decision to put DFO GG in charge of dietary.

An additional interview was conducted with the HR MM on 6/8/22 at 12:20 p.m. in the conference room. HR MM stated there were no competencies on file for DFO GG. Dietary Competencies were checked off for DFO GG on 5/24/22 by the dietician (SS).

Based on a review of an incident report, a local fire department report, interviews with staff, and a review of a policy and procedure, it was determined that the facility failed to maintain equipment to ensure an acceptable level of safety and quality. In addition, the facility failed to provide policies that addressed preventive maintenance requirements for kitchen equipment.

Findings:

Cross-reference A0724 Facilities, Supplies, Equipment Maintenance as it relates to the facility's failure to ensure that equipment was maintained to ensure an acceptable level of safety and quality.

Based on a review of an incident report, a local fire department report, interviews with staff, and a review of a policy and procedure, it was determined that the facility failed to maintain equipment to ensure an acceptable level of safety and quality. In addition, the facility failed to provide policies that addressed preventive maintenance requirements for kitchen equipment.

Findings:

A review of the facility's policy titled "Cleaning Instructions: Cleaning Ranges," policy #CS-30, approved 11/10/18, revealed the cook on each shift would be responsible for keeping the range as clean as possible during the preparation of the meal. The range would be cleaned after each use. Spills and food particles would be wiped off as they occurred.

A review of an Incident Report Form, entry 362, dated 5/12/22 at 9:36 a.m., revealed an incident on 5/11/22 at 10:12 a.m. in the facility's kitchen. The incident report revealed that the kitchen's flat top area ignited, causing a fire with smoke and flames.

A review of the local Fire Department report revealed an alarm on 5/11/22 at 10:14 a.m. The fire department arrived at the facility at 10:18 a.m. A fire was ignited in the kitchen cooking area and involved cooking materials, food, and grease. A factor contributing to the ignition was a failure to clean.

An interview was conducted with the Dietary Manager (DM) HH on 6/6/22 at 2:13 p.m. in the conference room. DM HH had worked at the facility for six months. DM HH stated she spoke to the Director of Facility Operations (DFO) GG about servicing the equipment a month prior, and the equipment had not been serviced for as long as she had been employed. Service would usually be done quarterly. DM HH further said that the staff had not had competencies completed. DM HH said that DFO GG had no dietary background. DM HH said the service technician said it appeared the pilot light on the stove would automatically trigger the griddle and heat the flat top grill.

An interview was conducted with the DFO GG on 6/6/22 at 4:37 p.m. in the conference room. DFO GG stated that none of the kitchen equipment was on a preventive maintenance schedule before the fire. The staff was unaware of openings in the back of the stove for cleaning, and a fire started underneath the flat top griddle. The only place the staff knew to clean was the grease trap and grease tray. Both were cleaned after each use. The grease trays would come out for cleaning, and the kitchen staff thought the stove was sealed off behind the tray. At the time of the survey, DFO GG had contacted a preventive maintenance contractor to inspect equipment on a schedule. A contractor inspected the fryer and oven and determined the stove needed to be replaced.

An interview was conducted with the facility's cook (CK) JJ on 6/7/22 at 10:44 a.m. in the conference room. CK JJ said the old stove in the kitchen had not been serviced in a while and was not cleaned behind the drip trays. The drip trough would be cleaned, but no other maintenance was completed.