Deficiency in Fire Suppression System Maintenance
Summary
The facility failed to ensure that the Ansul fire suppression system and the K extinguisher in the kitchen were inspected and maintained according to the relevant NFPA standards. During a Life Safety recertification survey, it was observed that the monthly inspection tag for the Ansul system was blank, indicating that inspections were not documented as required. This lack of documentation suggests that the necessary monthly inspections may not have been conducted, which is a violation of NFPA 101, NFPA 10, and NFPA 17 A standards. Additionally, the K extinguisher located adjacent to the stove was found with its pressure gauge needle in the recharge zone, rather than the full zone, indicating that it was not in proper working condition. The service tag on the extinguisher showed that it was last recharged in 2024, yet it was not adequately maintained to ensure it remained operational. These deficiencies were identified during a tour of the kitchen, and the Director of Maintenance acknowledged the findings.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K324 I. Immediate Corrective Action: 1. Ansul System Inspection Tag: - On 3/20/25, the Director of Maintenance immediately addressed the issue with the Ansul system inspection tag and signed for the current month. 2. K Extinguisher Pressure Gauge: - The K extinguisher was immediately removed from service and replaced with a fully charged extinguisher, ensuring it was in the full zone (green). - The service company was contacted to inspect and recharge the K extinguisher. The fire extinguisher has been replaced and recharged. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of all fire suppression systems and extinguishers in the facility to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's fire safety and inspection procedures. - The policy was updated and reviewed to ensure that all fire suppression system inspection tags are completed and signed monthly. - Maintenance staff were in serviced to consistently monitor and document inspections monthly. A checklist was updated for fire extinguishers, including monthly checks of pressure gauges to ensure that all extinguishers are within the full zone. This checklist will be used by staff during routine inspections. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of monthly fire suppression system inspections and extinguisher checks. 2. Monthly audits will be performed for six months of all ansul systems and fire extinguishers to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance
Penalty
Surveyors found that the facility’s only commercial cooking hood was not maintained in accordance with NFPA 101 and NFPA 96 requirements. During a kitchen tour with the Maintenance Director, the hood was observed to be not grease tight due to missing fire-resistant caulk, and the Maintenance Director acknowledged this condition at the time of the survey.
Surveyors found that the facility failed to maintain the kitchen fire suppression system in accordance with NFPA standards, with only one documented kitchen hood inspection in the prior year and no additional inspection records available despite multiple requests. During the kitchen tour, surveyors also observed that gas-fired appliances lacked restraints to prevent overextension of gas lines when moved for cleaning or service, a finding confirmed by the Maintenance Director. This deficiency had the potential to affect 22 of the 69 residents in the facility.
The facility did not provide documentation of the required semi-annual inspection for the kitchen hood suppression system, as confirmed during a review and interview with facility leadership. This deficiency affected one of two inspection reports.
The facility did not provide documentation for a semi-annual kitchen suppression system inspection and two semi-annual kitchen hood cleanings, as confirmed during interviews with the Administrator and Maintenance Director.
Three gas-fed appliances on casters under the commercial cooking hood were found with restraint tethers attached but not secured to the wall attachments, as confirmed by the DOM during inspection. This failure to properly limit appliance movement resulted in non-compliance with NFPA 101, NFPA 96, and NFPA 54 standards.
Kitchen staff were unable to identify or operate the manual activation for the kitchen hood fire suppression system, and this deficiency was confirmed by the administrator during interviews.
Commercial Cooking Hood Not Maintained Grease Tight per NFPA Standards
Penalty
Summary
Surveyors identified a deficiency involving the facility’s commercial cooking facilities. During a tour of the kitchen between 1:00 p.m. and 3:00 p.m. with the Maintenance Director, surveyors observed that the one commercial cooking hood in use was not grease tight. Specifically, the hood was missing required fire-resistant caulk, which is necessary for maintaining a grease-tight seal in accordance with NFPA 96 and NFPA 101 standards. The Maintenance Director acknowledged these findings at the time of observation. The deficiency was cited under NFPA 101 and NFPA 96 requirements for commercial cooking operations, which mandate that cooking equipment and associated hoods be protected and maintained in compliance with these fire and life safety codes.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur:Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system.Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor.How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place:The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by this deficient practice. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Commercial cooking hood system inspected; no additional deficient areas were identified. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur; Maintenance staff and Dietary staff education on proper use and reporting of issues related to cooking hood system. Verification of scheduled inspections and cleaning of cooking hood system by licensed vendor. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The maintenance director/designee will complete weekly audits of cooking hood system for 4 weeks, then monthly for 2 months to ensure compliance. The findings will be reported to the Quality Assurance Performance Improvement Committee for ongoing compliance.
Failure to Maintain Kitchen Hood Inspections and Gas Appliance Restraints
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen fire suppression system and related equipment in accordance with NFPA 101, NFPA 96, NFPA 17A, NFPA 10, and NFPA 54 requirements. During record review, surveyors determined that only one kitchen hood inspection had been documented in the previous 12 months, with the sole inspection dated 04/23/25. Additional documentation of required inspections was requested multiple times during the survey, including at the entrance conference and later in the morning, but no further records were provided by the time of exit. During the physical tour of the facility’s kitchen, surveyors observed that the gas-fired kitchen appliances were not equipped with restraints to prevent overextension of the gas lines if the appliances were moved for service or cleaning. The Maintenance Director confirmed the absence of these restraints at the time of observation. This deficient practice had the potential to affect 22 of the 69 residents residing in the facility.
Plan Of Correction
1. Based on record review, observation and staff interview, no residents experienced negative outcomes related to failure to maintain kitchen fire suppression system and equipment safeguards. 2. The Medical Director was notified by LNHA on 03/26/2026 of the deficiency including incomplete hood inspection frequency and lack of appliance restraints. 3. Hood inspection will be completed by Grexen (contracted company) on or before 04/30/2026. Appliance restraints will be installed by Maintenance Director/designee on or before 04/30/2026. Hood inspections will be added to an every six (6) month automatically recurring schedule by Administrator/designee. 4. Compliance will be reviewed in QAPI every quarter and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the kitchen hood and kitchen equipment.
Failure to Maintain and Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system as required. During a document review, it was found that the facility could not provide documentation of the semi-annual testing of the kitchen hood suppression system within the required six-month interval. This deficiency was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. The lack of documentation affected one of two inspection reports reviewed.
Plan Of Correction
The kitchen hood suppression system remains operational and compliant. Inspection documentation was reviewed and updated. Preventive maintenance scheduling has been reinforced, and documentation will be maintained on site. The maintenance director and dietary director will be re-educated on the importance of maintaining documentation of the semi-annual kitchen hood suppression system testing that should occur every 6 months. The maintenance director or designated designee will perform bi-yearly audits to ensure the semi-annual kitchen hood suppression system testing is being completed and that documentation is maintained. Date of completion: 2/16/2025
Failure to Maintain Required Kitchen Suppression System Inspections and Cleanings
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review, it was found that there was no documentation available to show that a semi-annual inspection of the kitchen suppression system had been completed. Additionally, records for two required semi-annual kitchen hood cleanings were also missing. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Kitchen exhaust hood/duct cleaned on 8/12/2025 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 the location of the fire suppression system manual pull station. Maintenance director will also be educated on the continued cleaning schedule of the kitchen exhaust hood/duct. Education to be completed by the NHA/Designee. Monthly audits, four in total, will be completed to ensure the kitchen exhaust hood/duct is clean. Maintenance Director/Designee will report findings of the inspection report to the QAPI meeting.
Commercial Cooking Equipment Not Properly Secured
Penalty
Summary
During a facility tour conducted with the Director of Maintenance (DOM) and the Administrator, it was observed that three gas-fed appliances mounted on casters under the commercial cooking hood were not properly secured. Although each appliance had a restraint tether attached, none of the tethers were connected to the installed wall attachments located behind the appliances. The DOM confirmed these findings during the inspection by visually checking behind the appliances and acknowledging that the tethers were not attached to the wall as required. This lack of proper restraint for the gas-fed appliances constitutes a failure to maintain commercial cooking equipment in accordance with NFPA 101, NFPA 96, and NFPA 54 standards. The deficiency was identified in both buildings referenced in the report, with all three appliances in each building found in the same non-compliant condition. No information regarding residents or their medical conditions was provided in relation to this deficiency.
Plan Of Correction
1) No residents were identified. 2) No residents were identified. 3) Restraint tethers immediately attached and secured to wall attachments located behind appliances on 08/04/2025 at 1:55 PM by Director of Plant Operations or designee. An in-service education was conducted by the Administrator, Director of Plant Operations, or designee on 08/21/2025 with dining staff addressing the commercial cooking equipment in accordance with NFPA 101 (2012 Edition). 4) The Director of Plant Operations, or designee will audit commercial cooking equipment in accordance with NFPA 101 (2012 Edition) to observe restraint tethers attached and secured to wall attachments located behind appliances. Audits will be conducted once a week for four weeks, once a month for two months, or until substantial compliance is achieved. The results of the audit will be forwarded to the Quality Assurance Committee for review monthly for at least three months with a goal of 100% compliance. Upon completion and 100% compliance for at least three months is achieved, frequency of further review and ongoing need for review will be determined by the QAPI committee.
Kitchen Staff Unaware of Hood Fire Suppression System Operation
Penalty
Summary
The facility failed to maintain proper knowledge and operation of the kitchen hood fire suppression system, as evidenced by document review and staff interviews. During the review, kitchen staff members were unable to identify the location or explain the operation of the manual activation for the hood fire suppression system. This deficiency was confirmed by the administrator during the interview process. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Plan Of Correction
Education will be provided to dietary employees for ansul system. Dietary manager or designee will audit knowledge of location and operation of ansul system weekly x 3 weeks then monthly until substantial compliance achieved. The results of these audits will be reviewed quarterly by the Quality Assurance and Quality Improvement committee for further analysis and recommendation.
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