Failure to Maintain Required Kitchen Suppression System Inspections and Cleanings
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review, it was found that there was no documentation available to show that a semi-annual inspection of the kitchen suppression system had been completed. Additionally, records for two required semi-annual kitchen hood cleanings were also missing. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Kitchen exhaust hood/duct cleaned on 8/12/2025 by Cintas. Documentation sent to surveyor and placed in life safety binder. Maintenance Director and kitchen staff will be in-serviced on K0324 with focus on the importance of ensuring deficiencies noted on the inspection report are followed up on and corrected, and the location of the fire suppression system manual pull station. Maintenance director will also be educated on the continued cleaning schedule of the kitchen exhaust hood/duct. Education to be completed by the NHA/Designee. Monthly audits, four in total, will be completed to ensure the kitchen exhaust hood/duct is clean. Maintenance Director/Designee will report findings of the inspection report to the QAPI meeting.