Failure to Maintain Required Range Hood Suppression System Inspections
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, there was no evidence provided of the required semi-annual service dates for the installed range hood suppression system from 2023 to the present, with the last recorded service date being 2/15/2023. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression system inspections for 2024 to the present. These deficiencies were confirmed during record review with the Maintenance Director and no supporting compliance documentation was presented to the surveyor by the time of exit. All 175 residents in the facility could be affected by these lapses in fire protection system maintenance, as identified during the survey process.
Plan Of Correction
K324 - Cooking Facilities 1. The facility failed to ensure cooking facilities are protected in accordance with NFPA 96. a. The facility conducted monthly hood suppression system inspections for the range hood with proper documentation. b. The facility conducted semi-annual service for the installed range hood suppression system with proper documentation. 2. The Maintenance Director and Food Service Director were educated on the importance of monthly and semi-annual testing and the proper documentation to maintain compliance. 3. To ensure continued compliance of the Hood Suppression System is maintained, the Maintenance Director/Designee will report monthly and semi-annually. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.