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NFPA 96, 2011 Edition

11.7 Cooking Equipment Maintenance.

11.7.1 Inspection and servicing of the cooking equipment shall be made at least annually by properly trained and qualified persons.

11.7.2 Cooking equipment that collects grease below the surface, behind the equipment, or in cooking equipment flue gas exhaust, such as griddles or charbroilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified, and certified person acceptable to the authority having jurisdiction.


Based on record review and interview, the facility failed to ensure inspection and servicing of cooking equipment was being conducted at least every 12 months as required by NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). Not having the commercial cooking equipment inspected and serviced at least annually is likely to result in a fire due to the failure of the cooking equipment or due to grease buildup. In the event of fire in the kitchen, this failed practice presents the likelihood of harm to all patients, staff and visitors of the facility. The findings are:


A. Review of the 2017 and 2018 kitchen maintenance records revealed no evidence the cooking equipment was being inspected and serviced annually.

B. On 02/06/18 at 10:45 am, during interview, the Plant Services Manager stated he wasn't sure if the cooking equipment was being inspected and serviced annually. He stated he hadn't seen any records of such inspections or servicing.

Reference NFPA 25, 2011 Edition

4.1.7 Valve Location. The location of shutoff valves shall be identified.

13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPAstandards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification


Based on record review, interview and observation, the facility failed to ensure supervised control valves within the sprinkler system were being inspected monthly as required by NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). Not inspecting supervised control valves monthly is likely to result in a valve that is not in it's normal position, accessible, sealed, locked or supervised, leaking, and not properly identified. This failed practice could render sections of the automatic sprinkler system inoperable or unreliable, which, in the event of fire, this failed practice presents the likelihood of harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the 2017 and 2018 sprinkler system maintenance records failed to reveal any evidence that the supervised sprinkler system control valves were being inspected at least once a month.

B. On 02/06/18 at 11:20 am, during observation, two supervised control valves were observed at the sprinkler riser. Neither control valve had any evidence (i.e. inspection tags, etc.) demonstrating they were being inspected at least once a month.

C. On 02/06/18 at 11:25 am, during interview, the Plant Services Manager stated that he was unaware of this requirement.

Reference NFPA 10, 2010 Edition

7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging. (See 7.1.2.)

7.2 Inspection.

7.2.1 Frequency.

7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.

7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the
following items:

(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable
range or position
(4) Fullness determined by weighing or hefting for selfexpelling-
type extinguishers, cartridge-operated extinguishers,
and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for
wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using pushto-
test pressure indicators

7.2.4 Inspection Record Keeping.

7.2.4.1 Personnel making manual inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded.

7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method.

7.2.4.5 Records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed.

7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.



Based on observation and interview, the facility failed to ensure all portable fire-extinguishers are being inspected and maintained in accordance with NFPA 10 (Standard for Portable Fire Extinguishers). Not maintaining fire extinguishers is likely to result in less than optimal performance in the event of fire, which, in the event of fire, this failed practice presents the likelihood of harm to all patients, staff and visitors of the facility. The findings are:

A. On 02/06/18 at 12:30 pm, observation of the Type K fire-extinguisher located in the kitchen revealed its hose was curled in the upright position instead of secured properly in its holder.

B. On 02/06/18 at 12:35 pm, during interview, the Plant Services Manager stated he had to curl the hose because the fire extinguisher was leaking. Observation of the fire extinguishers monthly inspection tag revealed he had inspected this fire extinguisher on 02/02/18. When he was asked if the extinguisher was leaking during his monthly inspection, he stated it was. When he was asked if he passed the fire extinguisher he stated he did. When asked if he had noted corrective action for the extinguisher he stated he hadn't done so. There was no evidence demonstrating this fire extinguisher was identified as needing repair.

C On 02/06/18 at 1:30 pm, observation of the fire extinguisher located in the north hall, west end near the smoke barrier doors, revealed this fire extinguisher was last inspected monthly on 01/03/18, while all others located throughout the hospital were inspected on 02/02/18.

D. On 02/06/18 at 1:35 pm, during interview, the Plant Services Manager stated he missed the monthly inspection for this fire extinguisher.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all nursing shifts to ensure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This deficient practice could likely result in staff not being adequately prepared to exercise their duties in accordance to the facility's fire preparedness plan in the event of fire, which presents the likelihood of harm to all patients, staff and visitors of the facility. The findings are:

A. Record review of the fire drill log indicated the facility had two (2) nursing shifts:

First Shift (6:00 am - 6:00 pm)
Second Shift (6:00 pm - 6:00 am)


B. Record review of the fire drill log revealed the following:

- There was no record fire drills were conducted between June 2017 and October 2017 for the first nursing shift, which exceeds the 90-day requirement.

- There was no record fire drills were conducted between July 2017 and November 2017 for the second nursing shift, which exceeds the 90-day requirement.

C. On 02/06/18 at 11:30 am, during interview, the Plant Services Manager stated he has been working at the facility for five months and was under the understanding that the missing fire drills were during a transitional period with the staff that were responsible for conducting the fire drills.

Reference NFPA 110, 2010 Edition

8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

(Appendix included for guidance only, not regulatory)
A.8.4.1 Weekly inspection does not require running of the EPS. Running unloaded generators as part of this weekly inspection can result in long-term problems such as wet stacking.


Based on record review and interview, the facility failed to ensure their emergency generator, used to protect residents during the times of primary power failure, was being inspected weekly in accordance with NFPA 110 (Standard for Emergency and Standby Power System). Not performing weekly inspections could result in an undetected problem with the generator. In the event of primary power failure, this failed practice is likely to leave the facility without a source of emergency power and emergency illumination, which presents the likelihood of harm to all patients, staff and visitors of the facility. The findings are:


A. Record review of the 2017 and 2018 generator's maintenance logs revealed no record the emergency generator was being inspected at least once a week.

B. On 02/06/18 at 11:05 am, during interview, the Plant Services Manager stated he was not inspecting the the generator weekly.