Failure to Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system, which is a requirement under NFPA 101 for cooking facilities. During an observation on November 20, 2024, it was noted that the kitchen hood suppression system on the first floor lacked the necessary monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director. A follow-up observation during an onsite revisit on January 8, 2025, revealed that the issue persisted, as the kitchen hood suppression system still lacked monthly inspections. This was again confirmed in an exit interview with the Administrator and the Regional Maintenance Director.
Plan Of Correction
Plan of Correction for TAG K324: Kitchen Hood Suppression System 1. Deficiency: Based on observation and interview, it was determined that the facility failed to maintain and inspect the kitchen hood suppression system, affecting one of three levels in the facility. Observation on November 20, 2024, at 10:33 a.m., revealed that on the first floor, the kitchen hood suppression system lacked monthly inspections. Exit interview with the Administrator and the Maintenance Director on November 20, 2024, at 11:00 a.m., confirmed the missing monthly inspections. No current residents were directly affected by this deficiency; however, all residents have the potential to be affected if the kitchen hood suppression system is not properly maintained and inspected in case of a fire emergency. 2. Corrective Action: The facility will conduct a thorough inspection of the kitchen hood suppression system immediately. Monthly inspections will be implemented going forward, and a log will be maintained to track the inspections. 3. Monitoring: The Maintenance Director will ensure that the kitchen hood suppression system is inspected monthly. Monthly audits will be conducted for 3 months to ensure compliance with the kitchen hood suppression system inspection requirement. 4. Timeline: The inspection will be completed by 01/28/25. Monthly inspections will continue, with audits conducted for 3 months to ensure ongoing compliance.