Failure to Maintain Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to maintain the kitchen hood fire suppression system as required by NFPA 17A (2009). During a record review with the Maintenance Director, it was discovered that the suppression wet chemical tanks were overdue for hydrostatic testing, with the last test conducted in 2011. According to regulations, wet chemical extinguishing systems must undergo hydrostatic pressure testing at intervals not exceeding 12 years. The Maintenance Director acknowledged the oversight and stated that he was unaware of the overdue status of the chemical tanks. These findings were confirmed by the Maintenance Director during the record review and by the Administrator during the exit conference.
Plan Of Correction
1. Kitchen/hood fire suppression system hydrostatic testing was completed on 3/10/2025. 2. Current facility residents have the potential to be affected by this deficient practice. No further follow up indicated for the kitchen/hood fire suppression system indicated based on test results. 3. On 3/24/25, the facility Administrator/designee provided education for maintenance employees regarding NFPA 101 kitchen/hood fire suppression system testing/maintenance. 4. On 3/25/25, an alert was added to the facility TELS system to remind maintenance staff of the next required test. Maintenance Director/designee to complete fire suppression system testing/maintenance as required. Findings to be reviewed during the monthly QAPI Committee Meeting. Modifications implemented if indicated.