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Based on observation and staff interview, it was determined that the facility failed to ensure that the sprinkler system was in compliance with NFPA 13. This could place the staff of the kitchen and the residents of C wing at risk in the event of a fire within one of the spaces.

Findings were:

During the tour of the facility on 06/02/2010 with staff M the following sprinkler deficiencies were noted:
1. At 10:15 a.m. observations revealed that the sprinkler heads located around the kitchen hood system had grease built up on the heads;
2. At 11:30 a.m. observation revealed that in the renovated bathrooms on C wing the sprinkler heads located within the room would not cover the areas at the new shower stalls; and
3. At 10:20 a.m. observation revealed that the electrical room near the kitchen had unsealed wall penetrations and would not provide at least a smoke resistive enclosure for the sprinkler system.

During an interview with staff M on 06/02/2010 at 11:35 a.m., he/she stated that he/she would have the sprinkler company replace the affected heads around the kitchen hood system, that the sprinklers located in the restrooms had not been relocated when the rest rooms where renovated but was not noted as a problem when these areas were inspected., and that the holes located in the electrical room can be filled to create a smoke resistive enclosure.

Based on observation and staff interview, it was determined that the facility failed to ensure that the kitchen hood system was in compliance with NFPA-96 requirements. This could place all residents and staff of the dining and kitchen areas at risk in the event of a fire occurring in the hood system.

Findings were:

During the tour of the facility on 06/02/2010 at 10 a.m. with staff M, the following deficiencies were noted with the kitchen hood system:
1. The ceiling tiles located within 18 inches of the kitchen hood were not of noncombustible construction; and
2. The roof top termination was an upblast type fan that did not discharge at least 40 inches above the roof.

During an interview with staff M on 06/02/2010 at 10:10 a.m. he/she stated that he/she was not aware of the problems with the tiles or the height of the discharge on the roof.

Based on observation and staff interview, it was determined that the facility failed to ensure that the sprinkler system was in compliance with NFPA 13. This could place the staff of the kitchen and the residents of C wing at risk in the event of a fire within one of the spaces.

Findings were:

During the tour of the facility on 06/02/2010 with staff M the following sprinkler deficiencies were noted:
1. At 10:15 a.m. observations revealed that the sprinkler heads located around the kitchen hood system had grease built up on the heads;
2. At 11:30 a.m. observation revealed that in the renovated bathrooms on C wing the sprinkler heads located within the room would not cover the areas at the new shower stalls; and
3. At 10:20 a.m. observation revealed that the electrical room near the kitchen had unsealed wall penetrations and would not provide at least a smoke resistive enclosure for the sprinkler system.

During an interview with staff M on 06/02/2010 at 11:35 a.m., he/she stated that he/she would have the sprinkler company replace the affected heads around the kitchen hood system, that the sprinklers located in the restrooms had not been relocated when the rest rooms where renovated but was not noted as a problem when these areas were inspected., and that the holes located in the electrical room can be filled to create a smoke resistive enclosure.

Based on observation and staff interview, it was determined that the facility failed to ensure that the kitchen hood system was in compliance with NFPA-96 requirements. This could place all residents and staff of the dining and kitchen areas at risk in the event of a fire occurring in the hood system.

Findings were:

During the tour of the facility on 06/02/2010 at 10 a.m. with staff M, the following deficiencies were noted with the kitchen hood system:
1. The ceiling tiles located within 18 inches of the kitchen hood were not of noncombustible construction; and
2. The roof top termination was an upblast type fan that did not discharge at least 40 inches above the roof.

During an interview with staff M on 06/02/2010 at 10:10 a.m. he/she stated that he/she was not aware of the problems with the tiles or the height of the discharge on the roof.