Deficiencies in Kitchen Hood Maintenance and Equipment Installation
Penalty
Summary
The facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system in four instances, affecting one of eight smoke compartments. During an observation on December 30, 2024, a gas-fired oven on wheels in the main kitchen was found not to have an approved method to ensure it was returned to an approved design location after being moved for maintenance and cleaning. This was required by section 12.1.2.3 and 12.1.2.3.1 of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The Facility Administrator and Maintenance Director confirmed that the gas-fired cooking appliance was not tethered to prevent it from being moved from the ventilation hood and gas connection. Additionally, the facility failed to maintain the kitchen hoods in three instances, affecting one of eight smoke compartments. Document review and observation revealed that the facility did not perform one of the two required semi-annual hood cleanings and one of the two required semi-annual fire suppression system inspections. Furthermore, the facility failed to document the required monthly fire suppression system visual inspections. These deficiencies were confirmed during an interview with the Facility Administrator and the Maintenance Director.
Plan Of Correction
NHA/Designee will educate the Maintenance Director/Maintenance staff on the NFPA 101 cooking facilities standard for ventilation control and fire protection. Maintenance staff will ensure the gas fired oven on wheels is tethered securely to the wall. NHA will audit the completion of the tethered oven to the wall. The hood cleaning is scheduled for February 2, 2025. The Maintenance Director/Designee will conduct monthly fire suppression system visual inspections. The NHA/Designee will audit the monthly inspections x3 monthly. The semi-annual fire suppression system inspections were performed on April 16, 2024, and October 8, 2024. The inspection reports are on file at the facility.