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National Fire Protection Association (NFPA) 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

4.1 General
4.1.2 All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment.
4.1.3 The following equipment shall be kept in working condition:
(1) Cooking equipment
(2) Hoods
(3) Ducts (if applicable)
(4) Fans
(5) Fire-extinguishing equipment
(6) Special effluent or energy control equipment
4.1.3.1 Maintenance and repairs shall be performed on all components at intervals necessary to maintain good working condition.
4.1.4 All airflows shall be maintained.

Fire-Extinguishing Equipment
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, 2009 Edition, Standard for Wet Chemical Extinguishing Systems

7.2 Owner's Inspection.
7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.
7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

7.2.3 If any deficiencies are found, appropriate corrective action shall be taken immediately.
7.2.3.1 Where the corrective action involves maintenance, it shall be conducted by a service technician as outlined in 7.3.1.

7.2.4 Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded.
7.2.6 The records shall be retained for the period between the semiannual maintenance inspections.


Based on observation and interview, the facility failed to ensure the fire-extinguishing system, which protected the range hood within the kitchen, was inspected at least monthly as required per NFPA 17A, 7.2 requirements. Not maintaining the extinguishing system is likely to result in less than optimal system performance in the event of fire, which potentially presented a risk of harm to all residents in the dining room.

The findings are:

A. On 05/19/25 at 2:45 pm, during the kitchen walk-through, observation of the manual activation pull station monthly inspection tag revealed staff did not date or initial the tag per NFPA 17A, 7.2.5.

B. On 05/19/25 at 2:50 pm, during an interview, the Director of Facilities stated he was not aware of the monthly requirement.

National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition

33.2.3.5* Extinguishment Requirements.
33.2.3.5.1 Reserved.
33.2.3.5.2 Reserved.

33.2.3.5.3 Where an automatic sprinkler system is installed, for either total or partial building coverage, all of the following requirements shall be met:
(1) The system shall be in accordance with Section 9.7 and shall
initiate the fire alarm system in accordance with 33.2.3.4.1, as modified by 33.2.3.5.3.1 through 33.2.3.5.3.6.
(2) The adequacy of the water supply shall be documented to the authority having jurisdiction.
33.2.3.5.3.1* In prompt evacuation capability facilities, all of the following shall apply:
(1) An automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted.
(2) Automatic sprinklers shall not be required in closets not exceeding 24 ft2 (2.2 m2) and in bathrooms not exceeding 55 ft2 (5.1 m2), provided that such spaces are finished with lath and plaster or materials providing a 15-minute thermal barrier.
33.2.3.5.3.2 In slow and impractical evacuation capability facilities, all of the following shall apply:
(1) An automatic sprinkler system in accordance with NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, with a 30-minute water supply, shall be permitted.
(2) All habitable areas and closets shall be sprinklered.
(3) Automatic sprinklers shall not be required in bathrooms not exceeding 55 ft2 (5.1 m2), provided that such spaces are finished with lath and plaster or materials providing a

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.1 General.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.


Based on record review and interview, the facility failed to ensure fire sprinkler system was serviced quarterly as required, by NFPA 25. Not servicing fire sprinkler system as required could result in the failure of the sprinkler system to function properly in the event of a fire. This deficient practice presented a risk of injury by fire to all twenty (20) patients, as identified by the Census report provided by the Director of Quality & Compliance on 05/19/25

The findings are:

A. On 05/19/25 at 12:40 pm, during record review of facility fire sprinkler servicing documentation, the facility did not provide evidence to indicate the fire sprinkler system was serviced as required. The records did not contain quarterly inspection documentation of servicing for May 2024 and April 2025.

B. On 05/19/25 at 12:45 pm, during interview, Director of Facilities stated that he was not able to recover the documents from the contractor that did the inspections.



NFPA 101 Life Safety Code, 2012 Edition

18.3.5.1* Buildings containing health care occupancies shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 18.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected,tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

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 NFPA standards 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 and interview, the facility failed to ensure all fire sprinkler supervised control valves were visually inspected on a monthly basis. Not inspecting sprinkler control valves on a monthly basis as required by NFPA 25, could result in the failure of the sprinkler system functioning properly in the event of a fire. This deficient practice presents a risk of injury by fire to all twenty (20) patients in the facility as identified by the Census report provided by the Director of Quality & Compliance on 05/19/25.

The findings are:

A. On 05/19/25 during sprinkler system record review, no evidence was provided to indicate the sprinkler system control valves were visually inspected on a monthly basis.

B. On 05/19/25 at 11:15 am, during interview, Director of Facilities stated that he was not aware of the requirement.

National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 Edition

8.3 Maintenance and Operational Testing
8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM (American Standards for Testing Materials).

Based on record review and interview, the facility failed to ensure a fuel quality test for the diesel fueled powered emergency generator was conducted on an annual basis. Not conducting annual fuel quality tests could result in the failure of the emergency generator due to contaminants and/or inefficient combustion, which could leave the facility without electrical power. This deficient practice presents a potential risk of injury to all twenty (20) patients in the facility as identified by the Census report provided by the Director of Quality on 05/19/25.

The findings are:

A. Record review of the facility's emergency generator maintenance records revealed the annual fuel quality lab test dated 10/16/24 failed.

B. On 05/19/25, at 12:40 pm, during interview, the Director of Facilities stated that after failed test results, the fuel was filtered through the system and a fuel sample was sent to the lab for retesting on April 2025.