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Based on visual observation and record review the facility failed to assure that semi-annual routine cleanings were conducted on the commercial hood/suppression system. The removal of grease laden vapors from the air is essential to decrease the risk of fire and maintain the air flow within the hood system. The deficient practice had the potential to affect 11 of 11 residents.

Findings:

During the facility tour and record review on 9/27/22, between the hours of 8:30a-2:00p observation revealed grease build-up on the kitchen hood system. The hood was last cleaned in 2021.

Interview with maintenance revealed the facility was not aware cleaning was not conducted on the hood system.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 11 of 11 residents.

Findings:

During the facility tour and record review on 9/27/22, between the hours of 8:30a to 2:00p observation revealed the generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

Interview with maintenance revealed the facility was not aware that a remote manual stop for emergency generators was required.