Deficiencies in Cooking Hood Maintenance and Fire Suppression Inspections
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 and NFPA 96 standards regarding the maintenance of its commercial cooking hood and fire suppression system. During a record review, it was discovered that the facility did not provide evidence of one of the two required semi-annual inspections of the fire suppression system for the year 2024, with the only available inspection dated January 9, 2024. Additionally, the facility failed to conduct the 8-point monthly kitchen quick check inspection regularly, as the only record available was from March 2025. These lapses were acknowledged by the Maintenance Director and the Regional Maintenance Consultant during the review. Furthermore, during a facility tour, it was observed that the commercial cooking hood was not grease-tight, as the seams of the hood were not properly sealed. This deficiency was also acknowledged by the Maintenance Director and the Regional Maintenance Consultant. These findings were discussed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference, and photographic evidence was obtained to document the issues.
Plan Of Correction
1. Education was provided to the Maintenance Director on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the monthly 8-point kitchen quick check by NHA on 4/1/2025. The commercial cooking hoods seams were resealed to be made grease tight on 04/01/2025 by the Maintenance Director. 2. No other areas or residents were affected by deficient practice. 3. Education was provided to the Maintenance Director by the NHA on 4/1/2025 on ensuring the two semi-annual inspections of the fire suppression system are completed, completing the 8-point monthly kitchen quick check and ensuring the commercial cooking hood seams are sealed and grease tight. The Maintenance Director will conduct quality assurance checks on the commercial cooking hood to ensure seams are sealed and grease tight weekly for 12 weeks. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.