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 184.108.40.206.2, 220.127.116.11.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.104.22.168.3, 22.214.171.124.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 126.96.36.199.4, 188.8.131.52.4.
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.
184.108.40.206.1 through 220.127.116.11.4, 18.104.22.168.1 through 22.214.171.124.5, 9.2.3, TIA 12-2
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation and interview, it was determined the facility failed to maintain cooking facilities, affecting one of one floor.
1. Observation on September 17, 2019, at 11:00 a.m., revealed the facility lacked one of two kitchen suppression system inspection.
Exit interview with the facility administrator and the facilities manager on September 17, 2019, between 11:30 a.m., and 11:45 a.m., confirmed the cooking facilities deficiency.
| ||Plan of Correction - To be completed: 10/15/2019|
1. The St. Luke's Sacred Heart (SLSH) Facilities Manager had scheduled a kitchen suppression inspection and this was completed on September 17, 2019.
2. The results of the kitchen suppression inspection were reviewed by SLSH Facilities Manager and the Nursing Home Administrator. The results indicated that there were no issues or recommendations.
3. The SLSH Facilities Manager has scheduled kitchen suppression inspections every 6 months, and the next inspection will be completed on March 2020.
4. The results of the kitchen suppression inspection will be reviewed by the Facility Manager and the Transitional Care Facility Quality Assurance team to assure compliance and to make additional recommendations.