Overdue Hydrostatic Testing of Kitchen Fire Suppression Cylinders
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Record review on May 7, 2025, revealed that the wet chemical fire suppression system in the kitchen was past due for hydrostatic testing of the agent cylinders. Documentation from the facility's vendor indicated that the cylinders were marked as unsatisfactory during the last two semi-annual inspections. The cylinders, which were installed in 2012, require hydrostatic testing every 12 years, but this had not been completed. These findings were confirmed during an interview with the maintenance director at the time of the record review.
Plan Of Correction
K324 - Cooking Facilities Element 1: The Campus obtained a 12-year hydrostatic testing and recharge of agent cylinders on the wet chemical fire suppression system, on 5/22/2025. Element 2: A one-time audit was completed to ensure records of the system inspection were obtained and compliant. Element 3: Education was provided to the Director of Plant Operations on May 29, 2025, by the Executive Director to ensure timely and compliant inspections of the wet chemical fire suppression systems. Element 4: DPO/Designee will audit monthly x4 to ensure record of completion is present and compliant on the semi-annual inspection documents. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.