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 220.127.116.11.2, 18.104.22.168.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 22.214.171.124.3, 126.96.36.199.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 188.8.131.52.4, 184.108.40.206.4.
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.
220.127.116.11.1 through 18.104.22.168.4, 22.214.171.124.1 through 126.96.36.199.5, 9.2.3, TIA 12-2
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on documentation review and interview, it was determined the facility failed to maintain the cooking equipment in two instances, affecting the entire facility.
1. Documentation review and interview on May 6, 2019, at 8:30 a.m., revealed the following:
a) The facility failed to have the two required semi-annual kitchen suppression inspections performed since the previous Life Safety Survey on April 16, 2018;
b) The hood cleaning report dated December 26, 2018, revealed portions of the ductwork were inaccessible and were not able to be cleaned.
Interview with the Administrator, Assistant Administrator and Maintenance Director on May 6, 2019, at 2:00 p.m., confirmed the cooking equipment deficiencies.
| ||Plan of Correction - To be completed: 06/13/2019|
Facility completed Spring 2019 Kitchen Suppression inspection on May 8th, 2019.
Duct work cleaning has been scheduled to be done through Kool Kleen on May 21st 2019.
Audits of the Kitchen Suppression test, duct work cleanings, and whole kitchen safety readiness are to be done once a week for four weeks by Maintenance Director/designee.
Nursing Home Administrator/designee will re-educate maintenance staff of K0324, cooking facilities and the results of kitchen audits will be reviewed in facility quality assurance and assessment committee.