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: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on observation, interview, and document review, it was determined the facility failed to ensure kitchen staff were trained on how to manually activate the kitchen cooktop fire suppression system, affecting one of two floors. Refer to NFPA 101 2012 Edition, Section 19.3.2.5.3(5b). It was determined the facility failed to provide semi annual exhaust hood/duct cleaning report, affecting one of two stories.
Findings include:
1. Observation made on August 20, 2024, at 11:15 a.m., revealed in the kitchen, a staff member did not know where the kitchen fire suppression system manual pull station was located when asked.
2. Document review on August 19, 2024, between 8:30 a.m. and 12:30 p.m., revealed the facility failed to provide documentation of the reports: a. Kitchen exhaust hood/duct cleaning semi annual reports
Exit interview with the Administrator and Maintenance Director on August 20, 2024, at 12:30 p.m., confirmed kitchen staff personnel did not know the manual pull station location.
| | Plan of Correction - To be completed: 10/11/2024
Kitchen exhaust hood/duct cleaned on August 7, 2024 by Cintas Documentation sent to surveyor and placed in life safety binder
Maintenance Director and kitchen staff will be in-serviced on K0324 with focus on the importance of ensuring deficiencies noted on the inspection report are followed up on and corrected and location of fire suppression system manual pull station. Maintenance director will also be educated on continued cleaning schedule of the kitchen exhaust hood/duct. Education to be completed by the NHA/Designee. Monthly audits X 4 to be completed to ensure kitchen exhaust hood/duct is clean. Maintenance Director/ Designee will report findings of the inspection report to the QAPI meeting.
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