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K0324
F

Failure to Maintain Kitchen Hood Suppression System

Hatboro, Pennsylvania Survey Completed on 12-18-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain and inspect the kitchen hood suppression system, which affected the entire facility. During a document review on December 18, 2024, it was revealed that the facility did not conduct the required semi-annual testing of the kitchen hood suppression system within six months of February 27, 2024. This was confirmed during an exit interview with the Administrator, Administrator in training, and Maintenance Director, who acknowledged the lack of documentation. Additionally, an observation and interview conducted on the same day at 12:40 p.m. revealed that the kitchen hood suppression system did not undergo the necessary monthly quick checks throughout the entire survey year. This was also confirmed during the exit interview with the facility's administrative staff.

Plan Of Correction

Kitchen Hood Fire Suppression system was inspected on December 19th, 2024, by an outside vendor. The equipment has been placed on an automatic inspection schedule with this vendor. Maintenance will monitor the automatic scheduling dates.

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