Failure to Maintain Required Kitchen Hood Cleaning and Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the required semi-annual hood cleaning service report for the kitchen hood system, as required by NFPA 96. Although an invoice for the hood service was provided by regional staff, the actual cleaning report was not available for review. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression inspection, as mandated by NFPA 17A. Both deficiencies were confirmed through interviews with regional staff at the time of observation. These lapses could potentially affect kitchen staff and 23 occupants within the nearest smoke compartment in the event of a fire within the kitchen hood system.
Plan Of Correction
K324 Cooking Facilities SS=E1. The required semiannual hood cleaning was completed on 4/9/25. The monthly hood suppression inspection was completed May 1, 2025, and signed off through TELS and signed off on the tag that is located in the dietary dept. The NHA validated that the TELS system has a monthly task to complete the monthly hood suppression inspection and that it was signed off in a timely manner by the Maintenance Director. The NHA educated the Maintenance Director on obtaining and uploading service inspections into the TELS system and completing the monthly hood suppression inspection. The NHA will validate that the monthly hood suppression inspections are completed and checked off monthly for 3 months and that service reports are uploaded into the TELS system from the Date of Compliance. The results of these audits will be forwarded to the QA Committee to ensure continued compliance. The NHA is responsible for ongoing compliance.