Failure to Maintain and Inspect Kitchen Hood Suppression System
Penalty
Summary
The facility failed to maintain and inspect the kitchen hood suppression system as required. During a document review, it was found that the facility could not provide documentation of the semi-annual testing of the kitchen hood suppression system within the required six-month interval. This deficiency was confirmed during an exit interview with the Administrator, Regional, and local Maintenance Director. The lack of documentation affected one of two inspection reports reviewed.
Plan Of Correction
The kitchen hood suppression system remains operational and compliant. Inspection documentation was reviewed and updated. Preventive maintenance scheduling has been reinforced, and documentation will be maintained on site. The maintenance director and dietary director will be re-educated on the importance of maintaining documentation of the semi-annual kitchen hood suppression system testing that should occur every 6 months. The maintenance director or designated designee will perform bi-yearly audits to ensure the semi-annual kitchen hood suppression system testing is being completed and that documentation is maintained. Date of completion: 2/16/2025