Kitchen Hood Suppression System Deficiency
Penalty
Summary
The facility failed to ensure that all five kitchen hood suppression systems had spray nozzle caps in place to protect the nozzles from grease clogs, as required by NFPA 101:2012 edition, Section 19.3.2.5.3*(10) and NFPA 17 and 96. This deficiency was observed during an inspection on December 4, 2024, at 9:08 AM, where it was noted that the nozzle blow-off caps were missing, leaving the nozzles vulnerable to grease buildup. This oversight had the potential to affect all 83 residents in the facility. The findings were confirmed and acknowledged by a representative during an interview, and the issue was discussed at the Life Safety Code exit conference on December 5, 2024.
Plan Of Correction
Completion Date: 12-25-2024 Element One: Our vendor was immediately called in for service. Upon arrival, they confirmed that there are in fact all 5 nozzle caps in place to protect from grease clogs. It is placed under the metal inside the nozzles (unlike the Ansul systems that have the orange visible caps.) Element Two: This deficient practice had the potential to affect all residents. Element Three: The U.S. FOIA (b) (6) was educated on the requirements regarding spray nozzle caps being in place to protect the nozzles from grease clogs. All 5 spray nozzle caps have been confirmed to be in place. Element Four: The Maintenance director / designee will audit the kitchen suppression system spray nozzle caps monthly x3 ensuring its in place and properly functioning. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024