Fire Safety and Kitchen Maintenance Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to fire safety and kitchen maintenance. During an exit interview with the Administrator and the Maintenance Director, it was confirmed that there was a lack of a second acceptable means of egress from each floor, which is a requirement for safety compliance. Additionally, the facility failed to maintain the kitchen hood exhaust suppression system as required by the National Fire Protection Association (NFPA) standards. Specifically, the facility could not provide documentation of a semi-annual kitchen exhaust hood/duct cleaning prior to August 2, 2024. This lack of documentation was confirmed during the exit interview, indicating a failure to adhere to necessary fire safety protocols.
Plan Of Correction
Step 1 The facility has partnered with AVDC for the cleaning of the Main Kitchen Hood Exhaust Systems every 6 months. Documentation of a semi-annual kitchen exhaust hood/duct cleaning will be added to the life safety binder. Step 2 The maintenance director and Food and Nutrition Services Director were educated on the requirement to ensure a semi-annual kitchen hood/duct cleaning is completed and maintain proof of documentation. Step 3 NHA/designee will audit documentation and ensure this requirement is met semiannually.