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NFPA 25 (National Fire Protection Association) lists prescriptive data for frequency of inspection activities. Quarterly inspections should include alarm devices, hydraulic nameplate, and inspection of sprinkler heads for signs of leakage, corrosion or impediments.

Based on observation and interview, the facility failed to ensure the automatic sprinkler system, where installed, was maintained in accordance with NFPA 25, and not subjected to external loads by objects attached to the either the piping, pipe hangers or sprinkler heads. This deficient practice, observed in one of one storage closet, could cause broken seals and leaks in the sprinkler piping suspended from the roof deck. The facility census was 22.

Findings included:

1. Observation on 02/09/15 at 9:40 AM showed blue camera wire attached to the feed pipes for the automatic sprinklers in a housekeeping supply closet.

2. During an interview at the same date and time, Staff O, Plant Manager acknowledged the observation. He stated that he was out on medical leave when a new camera system was installed and was unable to be present and offer guidance. He stated that he was curious why the Joint Commission inspectors had overlooked them.

Based on observation, facility staff interview and record review, the facility staff failed to maintain one of one range hood extinguishing systems in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition requirements and UL-300. Failure to provide a range hood extinguishing system in accordance with NFPA 96 and UL-300 has the potential to affect all facility residents. This deficient practice could delay extinguishment of a fire under the range hood. Additionally this deficient practice could spread a grease fire throughout the kitchen. This deficient practice has the potential to affect all facility residents. Failure to provide appropriate range hood extinguishing equipment per NFPA code requirements could affect the range hood's ability to contain grease fires. The facility census was 22.

1. Observation on 02/09/15, during the Life Safety Code tour, showed a water based range hood suppression system installed over the gas fired stove and tilt skillet. A deep fryer was nearby, but was not in use and had been moved off the cookline and from under the hood.

Observation of the range hood suppression system label did not identify the suppression system as UL 300.

Record review of the semi-annual range hood inspection report, dated 04/23/14, did not state the suppression system met UL 300 standard.

During an interview on 02/19/15 at 10:45 AM, Staff Q, Registered Dietician stated that vegetable oil was the media they used for any frying. She stated that they had stopped using the deep fryer a couple of years ago, and used the tilt skillet for minimum frying and sauteing of vegetables.

The National Fire Protection Association 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition, Section 7-2.2 states "Automatic fire-extinguishing systems shall comply with standard UL-300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Exception; Automatic fire-extinguishing equipment provided as part of listed recirculating systems complying with standard UL-197, Standard for Safety-Commercial Electric Cooking Appliances."

During an interview on 02/09/15 at 10:40 AM, the facility Plant Operations Director said he/she did not know the range hood extinguishing system did not comply with UL-300 and NFPA 96.