Failure to Maintain Kitchen Exhaust Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen exhaust hood suppression system, which affects the entire facility. During a document review on May 1, 2025, it was found that the facility could not provide documentation for the semi-annual maintenance and testing of the kitchen exhaust hood suppression system, which was due within six months after May 29, 2024. Additionally, the facility lacked documentation for the semi-annual cleaning of the kitchen exhaust hood, which was due within six months prior to March 20, 2025. An observation on the same day revealed that the kitchen hood exhaust suppression system lacked monthly inspections. These deficiencies were confirmed during an exit interview with the Maintenance Director on May 1, 2025, at 10:30 a.m., who acknowledged the absence of the required documentation and inspections.
Plan Of Correction
The facility will maintain and inspect the kitchen exhaust hood suppression system, affecting the entire facility. Contracted service called for updated visit and servicing the semi-annual kitchen exhaust hood suppression system maintenance and testing within 6 months after and will be coming out the week of 5/29/24. They will also complete a cleaning. Director of Maintenance will audit monthly x2, to ensure systems are checked and in place. Results will be brought to QAPI for review. Life Safety book will be updated.