Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324
Based on documentation review, observation, and interview, it was determined the facility failed to maintain the kitchen hoods in one instance, affecting one of nine smoke compartments.
Findings include:
1. Document review and observation on February 26, 2024 at 8:55 a.m., revealed the most recent semi-annual kitchen hood cleaning was completed on July 10, 2023, and the next cleaning was due by the end of January, 2024.
Interview with the Facility Administrator and the Director of Plant Operations on February 26, 2024, at 12:30 p.m., confirmed the facility lacked documentation for a second semi-annual hood cleaning.
| | Plan of Correction - To be completed: 03/20/2024
1. The facility notified the hood vendor who produced documentation that hood cleaning was completed on February 28, 2024
2. The dates of the semiannual cleaning are loaded in TELS system as a visual trigger to ensure that documentation is obtained semiannually.
3. An audit will be conducted semiannually by the safety committee to ensure that semiannual hood cleaning are completed timely
4. Audits will be taken to QAPI for review of findings and further interventions if warranted.
5. Date of compliance 3/20/2024
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