Deficiencies in Cooking Facility Maintenance
Penalty
Summary
The facility failed to maintain its cooking facilities in compliance with NFPA 101 standards, as evidenced by two specific deficiencies affecting one of the twelve smoke compartments. During an observation and document review conducted on February 6, 2025, it was found that the facility lacked documentation for a semiannual kitchen fire suppression system inspection, which was due in August 2024. Additionally, there was no documentation for a semiannual hood cleaning and inspection, which was due in January 2025. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Kitchen semiannual fire suppression was completed on February 5th, 2025. Semiannual kitchen hood cleaning was completed on February 17, 2025. The administrator or designee will reeducate the Maintenance Director on cooking facilities - K324. Both inspections will be audited by the Maintenance Director or designee for timely completion on a semiannual basis. Findings will be reported to Quality Assurance and Performance Improvement committee meetings.