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The facility failed to test and maintain the wet chemical extinguishing system in the Kitchen in accordance with NFPA 17A, Standard for Wet Chemical Extinguishing Systems.

On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual.

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, 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.

If any deficiencies are found, appropriate corrective action shall be taken immediately. Where the corrective action involves maintenance, it shall be conducted by a trained service technician. Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions. At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections. 7.2.1 through 7.2.6

Review of documentation and interview with staff determined the monthly inspection of the wet chemical extinguishing system in the Kitchen had not been completed during May, June, July, August, and September 2023.

Failure to conduct monthly inspections of the wet chemical extinguishing system increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) The Night Shift fire drill conducted at 6:36 AM on 12/23/2022 did not include the use of the fire alarm.

2) The Night Shift fire drill conducted at 6:29 AM on 03/23/2023 did not include the use of the fire alarm.

3) The Night Shift fire drill conducted at 6:18 AM on 09/25/2023 did not include the use of the fire alarm.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected three (3) of twelve (12) drills in the past year.