HospitalInspections.org

K324 Cooking Facilities
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 25 of 25 residents.

Findings:

During the facility tour, between the hours of 12:00pm to 5:00pm on March 9, 2022, the suppression system was yellow tagged due to an incorrect nozzle.

Interview with Maintenance Supervisor revealed the facility was aware the suppression system was yellow tagged and the nozzle was on order.

K353 Sprinkler System - Maintenance and Testing
Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 25 of 25 residents.

Findings:

During the facility tour, between the hours of 12:00pm to 5:00pm on March 9, 2022 the inspection revealed that the sprinkler system had not been inspected since 12/29/2020.

Interview with Maintenance Supervisor revealed the facility was not aware that the annual and/or quarterly inspections had not been conducted on the automatic sprinkler system and this was also acknowledged by the Administrator during the exit meeting.