Failure to Document Fire Suppression System Checks and Hood Cleaning
Penalty
Summary
The facility failed to provide documentation of the required owner's quick checks for the fixed chemical fire suppression system installed in the kitchen. During a review of facility records, surveyors were unable to locate evidence that these quick checks had been performed as required. This was confirmed in an interview with the Administrator and Maintenance Director, who acknowledged the absence of documentation for the quick checks on the kitchen's fire suppression system. Additionally, the facility could not provide documentation verifying that the kitchen exhaust ductwork had been cleaned on a semi-annual basis. The last available documentation showed that the most recent cleaning cycle was completed several months prior, with no records of subsequent cleanings. This lack of documentation was also confirmed by the Administrator and Maintenance Director during the exit conference.
Plan Of Correction
1. Kitchen suppression system inspections and hood cleaning certificates will be placed in the facility's life safety book. The owner's quick checks of the fixed chemical fire suppression system will continue to be displayed in the kitchen. The semi-annual hood cleaning has been scheduled for July 2025, and documentation will be maintained when completed. 2. The Maintenance Director will audit, at least semi-annually, the facility's life safety book to verify the existence of the required kitchen suppression inspections and hood cleaning certificates, and report to the QAPI Committee with results of these audits. Date of correction is 7/30/2025.