HospitalInspections.org

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect six (6) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure eight (8) rooms were properly protected due to the storage in the rooms.

The findings include:

Observation, on 03/12/13 between 10:30 AM and 3:05 PM with the Director of Plant Operations, revealed:
1) The medical records office did not have proper separation extending above the drop ceiling.
2) The coal miner's clinic did not have a rated window installed for proper separation.
3) The central supply area did not have proper separation extending above the drop ceiling.
4) The MRI equipment room did not have proper separation extending above the drop ceiling.
5) The gift shop did not have a door closer installed due to the storage in the room.
6) The human resources office did not have a door closer installed for proper separation.

Interview, on 03/12/13 between 10:30 AM and 3:05 PM with the Director of Plant Operations, revealed he was not aware the areas listed above were not separated properly from the rest of the facility.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Laboratories in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the laboratory was separate from the facility with smoke resisting partitions.

The findings include:

Observations, on 03/12/13 at 2:25 PM with the Director of Plant Operations, revealed the smoke wall around the laboratory was penetrated in several locations and the lab manager office did not have a door closer on either door leaving the lab open to the corridor. Further observation revealed storage rooms that were on the other side of the smoke partition above the ceiling that did not have door closers for separation installed.

Interview, on 03/12/13 at 2:25 PM with the Director of Plant Operations, revealed he was unaware the smoke partition extending to the next floor was penetrated in several areas and did not have proper separation.


Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on record review, and interview it was determined the facility failed to maintain the sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect two (2) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the dry sprinkler system had a full flow trip test since its installation in 2007 and an obstruction investigation.

The findings Include:

Record review, on 03/12/13 at 1:40 PM with the Director of Plant Operations, revealed the facility failed to provide documentation that the dry sprinkler system had a full flow trip test in the last three (3) years. The inspection company checked back to 2007 and could not find any record of the service. Further observation revealed the sprinkler company report had recommended the obstruction investigation on all four (4) quarterly sprinkler reports for 2012.

Interview, on 03/12/13 at 1:40 PM with the Director of Plant Operations, revealed they were unaware the work had not been completed on the full flow trip test. Further interview revealed he was under the impression the note on the report was a suggestion and did not know it was required by the NFPA to perform an obstruction investigation on the dry sprinkler system every five (5) years.

Reference: NFPA 25 (1998 Edition).

9-4.4.2.2.1* Every 3 years and whenever the system is altered,
the dry pipe valve shall be trip tested with the control valve
fully open and the quick-opening device, if provided, in service.

9-4.4.2.2.2* During those years when full flow testing in accordance
with 9-4.4.2.2.1 is not required, each dry pipe valve shall
be trip tested with the control valve partially open.

10-2* Obstruction Investigation and Prevention.

10-2.1* To ensure that piping remains clear of all obstructive
foreign matter, an obstruction investigation shall be conducted
for system or yard main piping wherever any of the following
conditions exist:
(a) Defective intake for fire pumps taking suction from
open bodies of water
(b) The discharge of obstructive material during routine
water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in
check valves
(d) Foreign material in water during drain tests or plugging
of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during
building alterations
(g) Failure to flush yard piping or surrounding public mains
following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)
(j) A system that is returned to service after an extended
shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains
sodium silicate or highly corrosive fluxes in copper
systems
(l) A system has been supplied with raw water via the fire
department connection.

10-2.2* Obstruction Prevention. Systems shall be examined
internally for obstructions where conditions exist that could
cause obstructed piping. If the condition has not been corrected
or the condition is one that could result in obstruction

Based on record review, and interview, the facility failed to maintain the installed fire extinguishers in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure nineteen (19) fire extinguishers in the facility had their six (6) year maintenance.

Findings include:

Record review, on 03/12/13 at 9:50 AM with the Director of Plant Operations, revealed a fire extinguisher in the Business Office, by H.R., by bathroom, saw shop, E.R. room 5, x-ray, x-ray female dressing, old ob, by room 201, sleep lab 1, outside medical records, transcription, lobby by stairs, rehab, 2nd floor nurses' station, nurses' station, class k in kitchen, kitchen, outside boiler room #5, and the delivery bay had not had a six year maintenance service done.

Interview, on 03/12/13 at 9:50 AM with the Director of Plant Operations, revealed the facility was not aware the portable fire extinguishers had not been serviced properly, by their extinguisher service company. The Director of Plant Operations stated the vendor usually leaves a quote for a service if it is due. The facility did not have a quote to complete the required maintenance.

Reference: NFPA 10 (1998 ed.)
Actual NFPA Standard: NFPA 10, 4-4.3*. Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
Exception: Non-rechargeable fire extinguishers shall not be hydrostatically tested but shall be removed from service at a maximum interval of 12 years from the date of manufacture. Non-rechargeable halon agent fire extinguishers shall be disposed of in accordance with 4-3.3.3.
Actual NFPA Standard: NFPA 10, 4-4.4*. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
Actual NFPA Standard: NFPA 10, 4-4.4.1*. Fire extinguishers that pass the applicable 6-year requirement of 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 in. by 3 1/2 in. (5.1 cm 8.9 cm).
The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self-destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance
Actual NFPA Standard: NFPA 10, 4-4.4.2*. Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a "Verification of Service" collar.

Based on record review and interview, it was determined that the facility failed to maintain the installation of the kitchen hood suppression system in accordance with NFPA standards. The deficiency had the potential to affect one (1) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the kitchen hood suppression system had been hydrostatically tested since 1999.

Findings include:

Record review, on 03/12/13 at 10:00 AM with the Director of Plant Operations, revealed the extinguishing agent for the kitchen hood suppression system had not been hydrostatically tested since 1999.

Interview, on 03/12/13 at 10:00 AM with the Director of Plant Operations, revealed he was unaware the kitchen hood had not been maintained properly.

Record review, on 03/12/13 at 10:05 AM with the Director of Plant Operations, revealed the manual pull for the kitchen suppression system is sticking making it hard to manually activate the hood suppression system. This was recommended to be repaired on the December 26, 2012 inspection paperwork.

Interview, on 03/12/13 at 10:05 AM with the Director of Plant Operations, revealed he must have missed this on the report and that he was unaware of any problems with manual pull for the kitchen hood system.

Reference: NFPA 10 (1998 ed.)
5-2 Frequency. At intervals not exceeding those specified
in Table 5-2, fire extinguishers shall be hydrostatically
retested. The hydrostatic retest shall be conducted within
the calendar year of the specified test interval. In no case
shall an extinguisher be recharged if it is beyond its specified
retest date. (For nonrechargeable fire extinguishers, see the
exception to 4-4.3.

Table 5-2 Hydrostatic Test Interval for Extinguishers

Extinguisher Type Test Interval(Years)

Stored-pressure water, loaded stream, and/or antifreeze 5
Wetting agent 5
AFFF (aqueous film-forming foam) 5
FFFP (film-forming fluoroprotein foam) 5
Dry chemical with stainless steel shells 5
Carbon dioxide 5
Wet chemical 5
Dry chemical, stored-pressure, with mild steel shells, 12
brazed brass shells, or aluminum shells
Dry chemical, cartridge- or cylinder-operated, with 12
mild steel shells
Halogenated agents 12
Dry powder, stored-pressure, cartridge- or cylinder operated, 12
with mild steel shells

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect six (6) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure eight (8) rooms were properly protected due to the storage in the rooms.

The findings include:

Observation, on 03/12/13 between 10:30 AM and 3:05 PM with the Director of Plant Operations, revealed:
1) The medical records office did not have proper separation extending above the drop ceiling.
2) The coal miner's clinic did not have a rated window installed for proper separation.
3) The central supply area did not have proper separation extending above the drop ceiling.
4) The MRI equipment room did not have proper separation extending above the drop ceiling.
5) The gift shop did not have a door closer installed due to the storage in the room.
6) The human resources office did not have a door closer installed for proper separation.

Interview, on 03/12/13 between 10:30 AM and 3:05 PM with the Director of Plant Operations, revealed he was not aware the areas listed above were not separated properly from the rest of the facility.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Laboratories in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the laboratory was separate from the facility with smoke resisting partitions.

The findings include:

Observations, on 03/12/13 at 2:25 PM with the Director of Plant Operations, revealed the smoke wall around the laboratory was penetrated in several locations and the lab manager office did not have a door closer on either door leaving the lab open to the corridor. Further observation revealed storage rooms that were on the other side of the smoke partition above the ceiling that did not have door closers for separation installed.

Interview, on 03/12/13 at 2:25 PM with the Director of Plant Operations, revealed he was unaware the smoke partition extending to the next floor was penetrated in several areas and did not have proper separation.


Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on record review, and interview it was determined the facility failed to maintain the sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect two (2) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the dry sprinkler system had a full flow trip test since its installation in 2007 and an obstruction investigation.

The findings Include:

Record review, on 03/12/13 at 1:40 PM with the Director of Plant Operations, revealed the facility failed to provide documentation that the dry sprinkler system had a full flow trip test in the last three (3) years. The inspection company checked back to 2007 and could not find any record of the service. Further observation revealed the sprinkler company report had recommended the obstruction investigation on all four (4) quarterly sprinkler reports for 2012.

Interview, on 03/12/13 at 1:40 PM with the Director of Plant Operations, revealed they were unaware the work had not been completed on the full flow trip test. Further interview revealed he was under the impression the note on the report was a suggestion and did not know it was required by the NFPA to perform an obstruction investigation on the dry sprinkler system every five (5) years.

Reference: NFPA 25 (1998 Edition).

9-4.4.2.2.1* Every 3 years and whenever the system is altered,
the dry pipe valve shall be trip tested with the control valve
fully open and the quick-opening device, if provided, in service.

9-4.4.2.2.2* During those years when full flow testing in accordance
with 9-4.4.2.2.1 is not required, each dry pipe valve shall
be trip tested with the control valve partially open.

10-2* Obstruction Investigation and Prevention.

10-2.1* To ensure that piping remains clear of all obstructive
foreign matter, an obstruction investigation shall be conducted
for system or yard main piping wherever any of the following
conditions exist:
(a) Defective intake for fire pumps taking suction from
open bodies of water
(b) The discharge of obstructive material during routine
water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in
check valves
(d) Foreign material in water during drain tests or plugging
of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during
building alterations
(g) Failure to flush yard piping or surrounding public mains
following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)
(j) A system that is returned to service after an extended
shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains
sodium silicate or highly corrosive fluxes in copper
systems
(l) A system has been supplied with raw water via the fire
department connection.

10-2.2* Obstruction Prevention. Systems shall be examined
internally for obstructions where conditions exist that could
cause obstructed piping. If the condition has not been corrected
or the condition is one that could result in obstruction

Based on record review, and interview, the facility failed to maintain the installed fire extinguishers in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure nineteen (19) fire extinguishers in the facility had their six (6) year maintenance.

Findings include:

Record review, on 03/12/13 at 9:50 AM with the Director of Plant Operations, revealed a fire extinguisher in the Business Office, by H.R., by bathroom, saw shop, E.R. room 5, x-ray, x-ray female dressing, old ob, by room 201, sleep lab 1, outside medical records, transcription, lobby by stairs, rehab, 2nd floor nurses' station, nurses' station, class k in kitchen, kitchen, outside boiler room #5, and the delivery bay had not had a six year maintenance service done.

Interview, on 03/12/13 at 9:50 AM with the Director of Plant Operations, revealed the facility was not aware the portable fire extinguishers had not been serviced properly, by their extinguisher service company. The Director of Plant Operations stated the vendor usually leaves a quote for a service if it is due. The facility did not have a quote to complete the required maintenance.

Reference: NFPA 10 (1998 ed.)
Actual NFPA Standard: NFPA 10, 4-4.3*. Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using a listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.
Exception: Non-rechargeable fire extinguishers shall not be hydrostatically tested but shall be removed from service at a maximum interval of 12 years from the date of manufacture. Non-rechargeable halon agent fire extinguishers shall be disposed of in accordance with 4-3.3.3.
Actual NFPA Standard: NFPA 10, 4-4.4*. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.
Actual NFPA Standard: NFPA 10, 4-4.4.1*. Fire extinguishers that pass the applicable 6-year requirement of 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 in. by 3 1/2 in. (5.1 cm 8.9 cm).
The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self-destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance
Actual NFPA Standard: NFPA 10, 4-4.4.2*. Each extinguisher that has undergone maintenance that includes internal examination or that has been recharged (see 4-5.5) shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch.
Exception No. 1: Fire extinguishers undergoing maintenance before January 1, 1999.
Exception No. 2: Cartridge/cylinder-operated fire extinguishers do not require a "Verification of Service" collar.

Based on record review and interview, it was determined that the facility failed to maintain the installation of the kitchen hood suppression system in accordance with NFPA standards. The deficiency had the potential to affect one (1) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility is certified for Ninety (90) beds with a census of Twenty-Eight (28) on the day of the survey. The facility failed to ensure the kitchen hood suppression system had been hydrostatically tested since 1999.

Findings include:

Record review, on 03/12/13 at 10:00 AM with the Director of Plant Operations, revealed the extinguishing agent for the kitchen hood suppression system had not been hydrostatically tested since 1999.

Interview, on 03/12/13 at 10:00 AM with the Director of Plant Operations, revealed he was unaware the kitchen hood had not been maintained properly.

Record review, on 03/12/13 at 10:05 AM with the Director of Plant Operations, revealed the manual pull for the kitchen suppression system is sticking making it hard to manually activate the hood suppression system. This was recommended to be repaired on the December 26, 2012 inspection paperwork.

Interview, on 03/12/13 at 10:05 AM with the Director of Plant Operations, revealed he must have missed this on the report and that he was unaware of any problems with manual pull for the kitchen hood system.

Reference: NFPA 10 (1998 ed.)
5-2 Frequency. At intervals not exceeding those specified
in Table 5-2, fire extinguishers shall be hydrostatically
retested. The hydrostatic retest shall be conducted within
the calendar year of the specified test interval. In no case
shall an extinguisher be recharged if it is beyond its specified
retest date. (For nonrechargeable fire extinguishers, see the
exception to 4-4.3.

Table 5-2 Hydrostatic Test Interval for Extinguishers

Extinguisher Type Test Interval(Years)

Stored-pressure water, loaded stream, and/or antifreeze 5
Wetting agent 5
AFFF (aqueous film-forming foam) 5
FFFP (film-forming fluoroprotein foam) 5
Dry chemical with stainless steel shells 5
Carbon dioxide 5
Wet chemical 5
Dry chemical, stored-pressure, with mild steel shells, 12
brazed brass shells, or aluminum shells
Dry chemical, cartridge- or cylinder-operated, with 12
mild steel shells
Halogenated agents 12
Dry powder, stored-pressure, cartridge- or cylinder operated, 12
with mild steel shells

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.