Lack of Documentation for Kitchen Suppression System and Ductwork Cleaning
Penalty
Summary
The facility failed to maintain proper documentation of the Kitchen Suppression System's monthly 'quick checks' and semiannual cleaning of the kitchen exhaust ductwork. During a document review on February 4, 2025, it was found that the facility did not have records of the monthly checks being performed on the Kitchen Suppression System. This was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged the absence of such documentation. Additionally, the facility was unable to provide evidence of the kitchen exhaust ductwork being cleaned semiannually within the past year. The only available documentation was from October 10, 2024, indicating a lapse in maintaining the required cleaning schedule. This deficiency was also confirmed during the exit conference with the facility's administration and maintenance personnel.
Plan Of Correction
Quick checks will be completed monthly on the kitchen suppression system. Going forward, the kitchen exhaust ductwork will be cleaned semiannually. Quick checks will be completed monthly and the kitchen exhaust ductwork will be cleaned semi-annually going forward. Maintenance staff will be educated on completing monthly quick checks on the kitchen suppression system and having exhaust ductwork cleaned semiannually. Audits will be completed semi-annually regarding the kitchen suppression system and exhaust ductwork. Audit results will be reported to QAPI.