Deficiency in Kitchen Fire Suppression and Maintenance Documentation
Penalty
Summary
The facility failed to maintain proper documentation and maintenance of its cooking facilities, specifically affecting one of the twelve smoke compartments. During an observation and document review, it was found that the facility did not have records for the semi-annual kitchen fire suppression testing and maintenance for the second half of 2024. Additionally, there was no documentation for both semi-annual kitchen exhaust hood and duct cleanings for the year 2024. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
Unable to correct past deficient practice. The Administrator will educate the Maintenance Director on requirements of K0324. Maintenance Director will secure a vendor to complete testing and maintenance of kitchen fire suppression system, exhaust and hood/duct. Vendor will complete kitchen fire suppression system, exhaust hood/duct cleaning. Maintenance Director will secure ongoing agreement with vendor to complete semiannual testing and maintenance of kitchen fire suppression system, exhaust and hood/duct cleanings, to assure that the centers cooking facilities/equipment are protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Copies of service/inspection records will be maintained in the Life Safety Survey Preparedness Manual. Reports will be shared in the following safety committee for any additional review and or recommendations, ongoing.