Kitchen Hood Extinguishment System Inspection Deficiency
Summary
A deficiency was identified during a Life Safety Code survey concerning the maintenance of the kitchen hood extinguishment system in the Main Kitchen located on the First Floor. The system was not inspected and tested at least every six months as required. Documentation revealed that the system was inspected on 3/29/23, 8/7/23, 4/16/24, and 10/31/24. However, there was a gap between inspections from 8/7/23 to 4/16/24, which exceeded the six-month requirement. The Maintenance Director confirmed the lack of documentation for inspections between 3/29/23 and 4/16/24 and acknowledged that the system had not been continually inspected every six months. This finding is in violation of the New York State Department of Health regulations and the National Fire Protection Association standards.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 1. Administrator and Maintenance Director review all inspections for Kitchen for previous 12 months. Most recent hood inspection completed on 10/31/2024. 2. All residents are at risk for deficient practice of timely hood inspections. 3. Administrator reviewed policy and procedure on kitchen hood inspection. No changes were made to the Kitchen(NAME) Inspection policy. 4. Administrator educated Maintenance Dir/Maintenance Tech on Kitchen(NAME) inspection policy. 5. Maintenance inspection log will be brought to QAPI monthly to ensure all inspections are completed per schedule. Any deficient practices will be corrected. Person Responsible: Maintenance Director
Penalty
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