Deficiency in Kitchen Fire Safety Maintenance
Penalty
Summary
The facility failed to maintain cooking facilities in compliance with NFPA 101 standards, specifically affecting one of eight smoke compartments. During a review of documentation and observation on January 15, 2025, it was found that the facility lacked necessary documentation for semiannual kitchen fire suppression testing and maintenance for the second half of 2024. Additionally, there was no record of semiannual kitchen exhaust hood and duct cleanings for the same period. An interview with the Facility Administrator and Assistant Maintenance Director confirmed these deficiencies in the kitchen fire suppression system and hood maintenance.
Plan Of Correction
Semiannual kitchen fire suppression testing was located and added to the life safety binder. The cleaning of the kitchen exhaust hood/duct was scheduled for completion on 1/27/2025. Review of the life safety binder will be completed monthly by the maintenance director/designee to ensure all needed paperwork is easily accessible. The facility obtained contracted services to ensure kitchen exhaust hood/duct cleaning is completed as required. Semiannual cleaning will be monitored by the facility maintenance director/designee to ensure completion and brought to the facility's Quality Assurance Committee meeting for confirmation and review. Date of compliance: 2/28/2025.