Cooking Facilities 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 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. 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. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
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Observations: Name: FORMERLY RENAISSANCE GARDENS AT MARIS GROVE - Component: 01 - Tag: 0324
Based on documentation review and interview, it was determined the facility failed to perform three of twelve monthly kitchen fire suppression system inspections, affecting one of eleven smoke compartments.
Findings include:
Document review on February 27, 2024, at 11:15 a.m., revealed the monthly inspections for the kitchen fire suppression system were not documented in November, December, or January.
Interview with the Facility Administrator and Maintenance Director on February 27, 2024, at 2:00 p.m., confirmed the missing documentation.
| | Plan of Correction - To be completed: 04/02/2024
1. The Monthly inspection reports for the kitchen suppression system are current. 2. The Maintenance Director/designee will audit current monthly maintenance inspection tasks for compliance. 3. The Maintenance Supervisor/designee will educate the maintenance staff on K0324 and the Monthly Kitchen Suppression inspection of the system. 4. The Maintenance Supervisor /designee will audit the documentation for the Kitchen Suppression system inspection reports monthly, X2 months, and report findings to the QAPI Committee for review.
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