Incomplete Kitchen Hood Fire Suppression System Maintenance Records
Summary
The facility failed to maintain complete records for the kitchen's hood fire suppression system, as required by NFPA 101 and NFPA 96 standards. During a document review and interview, it was found that one of the two required semi-annual inspection records for the kitchen's hood fire suppression system was missing. The last available record was dated 11/13/24, and staff interviewed were unable to provide the missing documentation or confirm when the previous service had been conducted. This deficiency affected the nutritional services area and one of six smoke compartments in the facility. The absence of the required maintenance record was confirmed by a staff member, who stated that the missing record pertained to a period before their employment and that they did not have access to it. No information was provided regarding any specific residents or their conditions in relation to this deficiency.
Plan Of Correction
The EVS Director or designee will perform monthly inspections of hazardous area enclosures. Any deficiencies will be corrected immediately and documented. Findings from inspections will be reviewed in QAPI meetings to ensure continued compliance. Date of Compliance 4/18/25 K 324 - Cooking Facilities How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; All residents have the potentially to be affected. The facility has immediately scheduled a semi-annual inspection of the kitchen's hood fire suppression system to ensure compliance with NFPA 96. The inspection is scheduled to be completed by the end of April. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; The EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. The EVS Director was trained by the Administrator on the importance of safety documentation and maintaining and verifying inspection records. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system; The EVS Director will conduct a quarterly audit to ensure all fire suppression system maintenance occurs at the required intervals. Findings will be reported to the Quality Assurance and Performance Improvement (QAPI) committee by the EVS Director for continued oversight. Date of Compliance 4/18/25
Penalty
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.
Surveyors found that a movable natural gas stove in the kitchen lacked required chock devices to ensure proper alignment with fire suppression nozzles and did not have a chain or restraint to prevent overextension of the gas line. These deficiencies were confirmed by maintenance staff and were not in compliance with NFPA standards, potentially affecting all residents.
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 Safe Cooking Equipment Positioning and Restraints
Penalty
Summary
During a facility tour, surveyors observed a natural gas six-burner/griddle stove on wheels in the kitchen that was not equipped with chock devices to ensure proper alignment with the fire suppression system nozzles when the appliance was moved for cleaning or service. The absence of these chock devices meant that the required protection by the suppression system could not be guaranteed if the stove was not returned to its designated position after being moved. Additionally, the movable stove was not provided with a chain or restraint to prevent overextension of the gas line, as required by relevant NFPA standards. This lack of a restraining device could allow the gas line to be stretched or damaged during movement, which is not in compliance with the manufacturer's installation instructions and applicable codes. These deficiencies were confirmed through interviews with the Regional Maintenance Director and the Maintenance Director at the time of observation. The findings indicated that the facility failed to maintain its cooking facilities in accordance with multiple sections of NFPA 101, NFPA 54, NFPA 96, and NFPA 17A, potentially affecting all 39 residents in the facility.
Plan Of Correction
Tag: K 0324 The natural gas 6 burner griddle stove has been equipped with both chock devices and restraint to prevent over extension of gas line as of 6/20/25. There are no other natural gas moveable stoves in the facility. The administrator provided education to maintenance director on 6/16/25 regarding requirements NFPA 101 cooking facilities. The maintenance director or designee will audit the natural gas 6 burner griddle stove to ensure proper equipment and restraint weekly for the next 4 weeks. Results of the audit will be submitted to the QAPI committee for review and recommendations.
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