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, and interview, it was determined the facility failed to maintain the kitchen hood suppression system and equipment, in three instances, affecting one of seven smoke compartments.
Findings include:
1. Observation on February 8, 2024, at 10:05 a.m., revealed the fire suppression pull station in the kitchen was mounted at a height greater than the required 42 to 48 inches above the floor.
Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the pull station was mounted higher than 48 inches.
2. Observation on February 8, 2023, revealed the following kitchen cooking equipment was not protected in accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1:
a) 10:11 a.m., revealed the wheeled gas-fired tilt-top skillet on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning; b) 10:13 a.m., the gas-fired tilt-top skillet was not tethered in a way so it could not become detached from the gas line connection when moved for cleaning.
Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed kitchen cooking equipment deficiencies.
| | Plan of Correction - To be completed: 04/01/2024
The facility's kitchen hood fire suppression pull station will be lowered to meet the code requirements of 42"-48" above finish floor. This work will be completed by outside contractor, Summit, in March 2024. On 2/08/24, the wheeled gas-fired tilt-top skillet was immediately placed in its approved designed location under the kitchen hood. The equipment location will be properly marked on the floor via visual markings. The tilt-top skillet was tethered by an outside contractor, Hobart, on 2/15/24 to eliminate the possibility of detaching from the gas supply line when moved for cleaning. All kitchen staff will be inserviced in March department meeting by Maintenance Director or Designee on the proper placement and location of the tilt skillet after cleaning. The Maintenance Director or Designee will ensure proper placement of the tilt skillet via audit weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.
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