Failure to Maintain Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which affected one of the three levels. During a document review on December 23, 2024, it was found that the facility could not provide documentation of a semi-annual kitchen exhaust hood/duct cleaning since December 17, 2023. This was confirmed during an exit interview with the Assistant Administrator and the Maintenance Director. Additionally, an observation on the same day revealed that the kitchen hood suppression system in the Basement Kitchen lacked monthly inspections. This was also confirmed during the exit interview with the Assistant Administrator and the Maintenance Director.
Plan Of Correction
Documentation for the semi-annual kitchen exhaust hood/duct has been completed and placed in the life safety book. Maintenance Dir/designee will re-educate maintenance staff on maintaining the monthly inspection documentation on kitchen hood/exhaust. NHA/designee will complete monthly audits to ensure compliance. Maintenance Director will report the findings of the audits to the QAPI Committee X 3 months.