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

19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless other wise permitted by 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.5.4

9.2.3 Commercial Cooking Equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (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.


Based on interview and record review of commercial cooking equipment (appliances), facility failed to ensure an annual inspection and servicing of cooking equipment was conducted. Not having commercial cooking equipment serviced annually, could result in a fire from possible failure of the equipment. This failed practice presents a risk of potential harm to all patients, staff and visitors of the facility. The findings are:

A. On 03/13/18 at 1:15 pm, during record review of commercial cooking equipment and fire extinguishing system (located within the ventilation hood above commercial appliances). No documentation was provided to indicate equipment had been serviced as required within the last twelve (12), months.

B. On 03/13/18 at 1:25 pm, during interview, Support Services Manager stated "I did not know about this requirement".

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

9.6.3.2 Occupant notification shall be in accordance with 9.6.3.3 through 9.6.3.10.2, unless otherwise provided in
9.6.3.2.1 through 9.6.3.2.4.

9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exists under normal conditions of occupancy.

19.3.4.3.1 Occupant notification shall be accomplished automatically in accordance with 9.6.3. unless otherwise modified by the following:

(1)*In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
(2) Where visual devices have been installed in patient sleeping areas in place of an audible alarm, they shall be permitted where approved by the authority having jurisdiction.



NFPA (National Fire Protection Association) 72 National Fire Alarm & Signaling Code, 2010 Edition

18.4.3* Public Mode Audible Requirements.

18.4.3.1* To ensure that audible public mode signals are clearly heard, unless otherwise permitted by 18.4.3.2 through
18.4.3.5, they shall have a sound level at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the area required to be served by the system using the A-weighted scale (dBA).

18.4.5 Sleeping Area Requirements.

18.4.5.1* Where audible appliances are installed to provide signals for sleeping areas, they shall have a sound level of at
least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least
60 seconds or a sound level of at least 75 dBA, whichever is greater, measured at the pillow level in the area required to be served by the system using the A-weighted scale (dBA).


18.4.5.3* Effective January 1, 2014, where audible appliances are provided to produce signals for sleeping areas, they shall produce a low frequency alarm signal that complies with the following:

(1) The alarm signal shall be a square wave or provide equivalent awakening ability.
(2) The wave shall have a fundamental frequency of 520 Hz ± 10 percent.


Based on observation and interview, facility failed to ensure audible notification devices throughout the facility were set at appropriate sound levels throughout the facility, as required by NFPA 72 (National Fire Alarm & Signaling Code, 2010 Edition). The current audible notification devices/appliances are set at levels higher than allowed by Code. Not having audible notification devices broadcasting at a safe level determined by Code Requirements, presents a risk of potential harm to all patients, staff, and visitors within the facility. Patients may also be be startled by the extra loud settings on the notification appliances/devices located in the patient sleeping areas. The findings are:

A. On 03/14/18 at 9:50 am, during observation of a test of the fire alarm system, devices/appliances located in the North East corridor, adjacent to the Kitchen/Main Dining Room, and Therapy Areas. Multiple audible notification device/appliances in this area appear to have been set at sound levels higher than required by Code.

B. On 03/14/18 at 9:54 am during observation of a test of the Fire alarm system, it was noted that audible notification appliances in the North Corridor and the North West Corridor of the Chemical Dependency Unit (CDU) Corridor were also set a levels higher than required by Code. This surveyor experienced some dizziness from the loudness of the appliances in this area. Staff in these areas were also observed to be covering their ears, and voicing concerns of the loudness of the notification appliances.

C. On 03/14/18, at 10:00 am, during interview, the Facility Safety Officer stated, " The alarms are very loud, even in our work areas".

NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing and Maintenance for Water Based Fire Protection Systems (2011 Edition)

13.3.2 Inspection
13.3.2.1 All valve shall be inspected weekly.
13.3.2.1.2 Valves secured with locks or supervising 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, facility failed to ensure all sprinkler valves were sealed, locked or electronically supervised. Not having all sprinkler valves inspected weekly or installing seals, locks or electronic supervision, could result in a valve being removed from it's proper working position, which could result in the failure of the sprinkler system extinguishing a fire. This failed practice presents a potential risk of injury by fire to all patients, staff and visitors within the facility. The findings are:

A. On 03/13/18 at. 11:35 am, during record review of fire sprinkler system, no documentation was provided to indicate monthly control valve inspections were being conducted.

B. On 13/13/18 at 11:40 am, during interview, Support Services Director, stated he was unaware this was a requirement.

Based on record review and interview, the facility failed to ensure fire drills were conducted at least quarterly on all three 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 a risk of potential harm by fire to all patients, staff and visitors within the facility. The findings are:

A. On 03/13/18, at 11:40 am, record review of the fire drill log indicated the facility had three (3) nursing shifts.

First Shift (6:00 am - 2:30 pm)
Second Shift (2:00 pm - 10:30 pm)
Third Shift (10:00 pm - 6:30 am)

B. Record review indicated, the First Shift conducted one drill on 05/31/17.

C. Record review indicated, the Second Shift did not conduct drills between October, 2017 thru January, 2018.

D. Record review indicated, the Third Shift did not conduct drills between February 2017, thru June of 2017.

E. On 03/13/18 at 11:50 am, during interview, the Support Services Director stated he did not conduct drills during these months.

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

9.1.3 Emergency Generators and Standby Power Systems.
Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

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

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on record review and interview the facility failed to ensure the on-site emergency generator is provided with proper annual fuel quality testing, as required by NFPA 110 (Standard for Emergency and Standby Power systems, 2010 Edition) . Failure to provide the required annual testing to ensure the stored fuel will provide for the proper operation of the emergency generator in the event of a power failure, presents a risk to patients, staff and visitors within the facility. The findings are;

A. On 03/13/18 at 11:05 am, during a record review of generator service documentation , no documentation of an annual fuel quality test could be located.

B. On 3/13/18 at 11:10 am, during an interview, the Support Services Manager advised, "We have not conducted an annual fuel quality test".