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Based on observation, record review and interview, the facility failed to ensure the kitchen hood ducts were cleaned semiannually as required by NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This deficient practice could affect 1 of 1 residents who currently resided in the facility, as identified by the administrator on 10/18/2024. The census in the facility on 10/18/2024 was 1 resident. Findings:

1. The facility records were reviewed on 10/18/2024 at 12:40 p.m., and no documentation was found to indicate that semi-annual cleanings had been performed in the past 12 months.

2. An exit interview was conducted with the maintenance supervisor and administrator on 10/18/2024 at 3:30 p.m., and they confirmed the kitchen hood had not been cleaned every six months as required.

Based on record review and interview, the facility failed to perform smoke sensitivity tests on the smoke detectors. Without this testing, the facility had no assurance the smoke detectors would function as required for early detection of smoke/fire. This has the potential to affect 1 of 1 resident who currently reside in the facility as identified by the administrator on 10/18/2024. The facility census was 1. Findings:

1. During record review on 10/18/2024, no documentation was provided indicating that a sensitivity test had been performed.

2. An exit interview was conducted with the administrator and maintenance supervisor on 10/18/2024 at 3:30 p.m. and they stated that they did not know when the last sensitivity test had been performed.

*NFPA 72, Sec 14.4.4.3.1 through 14.4.4.3.6 requires that smoke detector sensitivity be checked within 1 year after installation and every alternate year thereafter.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. Findings:

1. The facility records were reviewed on 10/18/2024 at 12:40 p.m. The facility failed to provide documentation that a quarterly inspection had been performed during the second quarter of 2024.

2. The maintenance supervisor and administrator were present during the record review and they stated they were not aware the quarterly sprinkler inspection for Q2 of 2024 had not been done.