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Based on observation, the facility failed to assure the fire rated doors at the exits closed to a positive latch (NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, 2-1.2, 2-4.1.4, 2-4.4.3).

The findings include:

Observation on November 8, 2010, at 10:20 a.m., with the Plant Facility Manager and Assistant Administrator in attendance, revealed the fire rated exit door into the stair on the second floor adjacent to room 235 did not close to a positive latch. Observation on November 9, 2010, at 2:00 p.m., with the Plant Facility Manager, revealed the fire rated doors at the horizontal exits into the medical building on the second and first floor, did not close to a latch on one side of the pair of fire rated doors.

Based on record review and interview, the facility failed to assure the sprinkler system is maintained in accordance with the NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, 9-2.8.2, 9-4.1, 9-4.2, 10-2.2.

The findings include:

Record review and interview with the Plant Facility Leader on November 9, 2010, at 4:00 p.m., revealed the sprinkler system inspection, testing and maintenance records for an internal obstruction investigation, gauge maintenance, and internal valve condition within the previous five years could not be provided.

Based on observation, the facility failed to assure cooking equipment producing grease laden vapors is protected by fire extinguishing equipment. (NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, 7-1.2, 9-1.2.2)

The findings include:

Observation on November 8, 2010, at 3:10 p.m., in the kitchen with the Dietary Manger, Plant Facility Leader, and Assistant Administrator in attendance, revealed a flat grill cooking equipment under the kitchen hood but not provided with coverage from the fire extinguishing equipment. Interview with the Dietary Manager at the time of this observation revealed the flat grill had been installed within the previous month.

Based on observation, the facility failed to assure the fire rated doors at the exits closed to a positive latch (NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, 2-1.2, 2-4.1.4, 2-4.4.3).

The findings include:

Observation on November 8, 2010, at 10:20 a.m., with the Plant Facility Manager and Assistant Administrator in attendance, revealed the fire rated exit door into the stair on the second floor adjacent to room 235 did not close to a positive latch. Observation on November 9, 2010, at 2:00 p.m., with the Plant Facility Manager, revealed the fire rated doors at the horizontal exits into the medical building on the second and first floor, did not close to a latch on one side of the pair of fire rated doors.

Based on record review and interview, the facility failed to assure the sprinkler system is maintained in accordance with the NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, 9-2.8.2, 9-4.1, 9-4.2, 10-2.2.

The findings include:

Record review and interview with the Plant Facility Leader on November 9, 2010, at 4:00 p.m., revealed the sprinkler system inspection, testing and maintenance records for an internal obstruction investigation, gauge maintenance, and internal valve condition within the previous five years could not be provided.

Based on observation, the facility failed to assure cooking equipment producing grease laden vapors is protected by fire extinguishing equipment. (NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, 7-1.2, 9-1.2.2)

The findings include:

Observation on November 8, 2010, at 3:10 p.m., in the kitchen with the Dietary Manger, Plant Facility Leader, and Assistant Administrator in attendance, revealed a flat grill cooking equipment under the kitchen hood but not provided with coverage from the fire extinguishing equipment. Interview with the Dietary Manager at the time of this observation revealed the flat grill had been installed within the previous month.