Improper Positioning of Kitchen Hood Filter System
Penalty
Summary
During an observation of the facility's main kitchen, it was found that the kitchen hood filter system located above the commercial stove and appliances had a filter that was partially out of position. The filter was observed resting on top of another filter, which resulted in the system not maintaining a tight seal as designed. This improper positioning of the filter compromised the system's ability to prevent grease-laden vapors from entering the plenum space above. The finding was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K0324 Cooking Facilities Element 1 The filter in the main kitchen hood system was serviced and adjusted to maintain a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Element 2 Kitchen hood system was checked to ensure that all filters are placed and fitted appropriately to maintain a tight system. No other concerns were identified. Element 3 The Maintenance Department was educated by the Nursing Home Administrator on checking the hood system for proper filter placement, ensuring a tight system is in place. Element 4 Kitchen hood system will be checked for proper filter placement weekly for 4 weeks, then monthly for 3 months to ensure a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.