Deficiency in Kitchen Exhaust Hood Grease Baffles
Penalty
Summary
The facility failed to ensure that two out of five exhaust hood grease baffles were fully operational, which is necessary to protect against grease and fire from entering above the exhaust hood system in accordance with NFPA 96. During an observation, it was noted that the interior channels of the #1 and #5 baffles were missing, providing no protection in those areas. The #1 grease baffle was specifically observed over the main 4-burner natural gas cooking appliance. This deficiency was confirmed through interviews conducted shortly after the observation, and it was noted that this practice had the potential to affect all residents.
Plan Of Correction
K-0324 (F) Cooking Facilities 1. Replacement of the 2 of the 5 kitchen hood grease baffles identified as missing; the interior channels of the #1 and #5 baffle were ordered and installed on 1/9/2025. 2. All other areas have been inspected and comply. All resident areas are free from hazard and all systems are operating as designed. 3. The Maintenance Director provided education with the Maintenance staff to confirm proper gap penetration in kitchen equipment on 1/10/2025. 4. Every quarter for a year, the Maintenance Director or designee will review random areas for excess penetrations. This information will then be entered on a log and will be presented to the QAPI meeting quarterly for one year. *photo of replacement of kitchen baffles attached*