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Based on visual observation and record review the facility failed to assure that semi-annual inspections and routine cleanings were conducted by a licensed contractor 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 23 of 23 residents.

Findings:

During the record review, between the hours of 9:00am and 2:00pm, it was observed, the hood system received semi-annual inspection on 4/13/17, however system is yellow tagged due to needing the hydrostatic test performed.

Interview with Facilities Director revealed the facility was not aware the the hood system was yellow tagged during semi-annual inspection.

Based on visual observation, the facility failed to assure that the generator was supplied with a remote manual shut off station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

Findings:

During facility tour between 9:00am and 2:00pm, it was observed that the emergency generator was not supplied with a remote manual shut off as required by NFPA 110 5.6.5.6

Interview with facility director revealed the facility was not aware of this requirement