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Based on observation, testing and staff interview the facility failed to comply with NFPA LSC 101 (2000) 19.3.6.3.3, 19-3.6.3.5 which addresses the installation and maintenance of assemblies and devices used to protect openings in walls, floors, and ceilings against the spread of fire and smoke within, into, or out of buildings shall comply with this section and NFPA 80. Corridor doors which do not meet code requirements include examples below of doors that failed to be provided with a means suitable for keeping the door closed. This deficient practice could affect all of the occupants, staff and visitors, if the corridor doors are not maintained as functional as required by code.

Findings include:

On July 30, 2012 between 9:30 a.m. and 5 p.m. accompanied by the maintenance director when touring various corridor doors did not close and latch in the door frame. Doors did not meet the code requirement of providing a means suitable to keep the door closed. The doors have trash cans and other devices used to defeat the automatic door closer's, from function as required by code. Some examples include, but are not limited to: the nourishment rooms, in dual 1 and 2 of building E. An interview was conducted at these times with the maintenance director who acknowledged and witnessed that the corridor doors did not meet the code requirement of providing a means suitable to keep the door closed.

These findings were verified by the maintenance director at the times of observation and the administrator at the exit conference on July 30, 2012.

Based on observation tour and staff interview the facility failed to comply with NFPA LSC 101 (2000) 19.1., NFPA 1 (2000) 7-1 and NFPA 13 (1999) 8.5 installation of fire sprinkler systems. NFPA 1 (2000) 7.3.3.9 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings, applied after shipment from the place of manufacture 25: 2-4.1.8. Not maintaining code required automatic fire sprinkler systems to code requirements may affect all visitors, staff and occupants.

Findings include:

On July 30, 2012 between 9:30 a.m. and 5 p.m. during the survey tour accompanied by the maintenance director revealed that numerous fire sprinkler head decorative covers were found painted in violation of the code requirements. Examples include but, are not limited to Dual Two building E, rooms 711, 713, 715, and 719. An interview with the maintenance director at this time indicated he was unaware that fire sprinkler head decorative covers were painted in violation of the code requirements

These findings were verified by the maintenance director at the time of observation and the administrator at the exit conference on July 30, 2012.

Based on observation and staff interview the facility failed to ensure that the required exhaust fans are maintained functional in accordance with NFPA LSC 101 (2000)-19.5.2.1 and 9.2. This deficient practice of not maintaining electrical exhaust fans in accordance with code requirements can endanger all occupants, staff and visitors.

Findings include:

On July 31, 2012 between 9:30 a.m. and 5 p.m. when tested for function it was revealed that the exhaust fans located in room 228 building B, SAU, staff bathrooms building D, and E did not function as required by code. An interview with the maintenance director at the time(s) of observation revealed he was unaware of the exhaust fan(s) not functioning. This did not meet the requirement of NFPA LSC.

This finding was verified by the maintenance director at the time(s) of observation and the administrator at the exit conference on July 31, 2012.

Based on observation and staff interview the facility failed to comply with the NFPA LSC 101 (2000) 9.2.3; 19.3.2.5 and NFPA 96 9, 6.1.1 Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided. If the cooking hood suppression system is not maintained as per code requirements, in the event of a fire, occupants, staff, and visitors will be affected.

Findings include:

On July 30, 2012 at 1 p.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the pre-engineered grease collection pan had been removed. An interview was conducted at this time with the maintenance director who acknowledged that the grease collection pan had been removed.

These findings were verified by the maintenance director at the times of observation and the administrator at the exit conference on July 30, 2012.

Based on observation, written document review, and staff interview the facility failed to comply with NFPA LSC 101 (2000) - 19.5.2.1 and 9.2., and NFPA 90 A - 3.4.7 Maintenance. Which requires that at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. This deficient practice of not maintaining dampers in accordance with code requirements can endanger all occupants, staff and visitors.

Findings include:

On July 30, 2012 at 4:30 p.m. based on request of written documentation provided to substantiate the required damper testing, the facility failed to produce or provide documentation to satisfy the requirement of four year testing. Paperwork is incomplete and doesn't indicate types of dampers, locations and or total number of dampers that were physically checked according to code requirements. At this same time based on interview with the maintenance director who acknowledged that written documentation to substantiate compliance was not available on the date of survey. The facility did not produce any additional documentation at the exit conference to substantiate compliance.

These findings were verified by the maintenance director at the time of observation and the administrator at the exit conference on July 30, 2012.

Based on observation, testing and staff interview the facility failed to comply with NFPA LSC 101 (2000) 19.3.6.3.3, 19-3.6.3.5 which addresses the installation and maintenance of assemblies and devices used to protect openings in walls, floors, and ceilings against the spread of fire and smoke within, into, or out of buildings shall comply with this section and NFPA 80. Corridor doors which do not meet code requirements include examples below of doors that failed to be provided with a means suitable for keeping the door closed. This deficient practice could affect all of the occupants, staff and visitors, if the corridor doors are not maintained as functional as required by code.

Findings include:

On July 30, 2012 between 9:30 a.m. and 5 p.m. accompanied by the maintenance director when touring various corridor doors did not close and latch in the door frame. Doors did not meet the code requirement of providing a means suitable to keep the door closed. The doors have trash cans and other devices used to defeat the automatic door closer's, from function as required by code. Some examples include, but are not limited to: the nourishment rooms, in dual 1 and 2 of building E. An interview was conducted at these times with the maintenance director who acknowledged and witnessed that the corridor doors did not meet the code requirement of providing a means suitable to keep the door closed.

These findings were verified by the maintenance director at the times of observation and the administrator at the exit conference on July 30, 2012.

Based on observation tour and staff interview the facility failed to comply with NFPA LSC 101 (2000) 19.1., NFPA 1 (2000) 7-1 and NFPA 13 (1999) 8.5 installation of fire sprinkler systems. NFPA 1 (2000) 7.3.3.9 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings, applied after shipment from the place of manufacture 25: 2-4.1.8. Not maintaining code required automatic fire sprinkler systems to code requirements may affect all visitors, staff and occupants.

Findings include:

On July 30, 2012 between 9:30 a.m. and 5 p.m. during the survey tour accompanied by the maintenance director revealed that numerous fire sprinkler head decorative covers were found painted in violation of the code requirements. Examples include but, are not limited to Dual Two building E, rooms 711, 713, 715, and 719. An interview with the maintenance director at this time indicated he was unaware that fire sprinkler head decorative covers were painted in violation of the code requirements

These findings were verified by the maintenance director at the time of observation and the administrator at the exit conference on July 30, 2012.

Based on observation and staff interview the facility failed to ensure that the required exhaust fans are maintained functional in accordance with NFPA LSC 101 (2000)-19.5.2.1 and 9.2. This deficient practice of not maintaining electrical exhaust fans in accordance with code requirements can endanger all occupants, staff and visitors.

Findings include:

On July 31, 2012 between 9:30 a.m. and 5 p.m. when tested for function it was revealed that the exhaust fans located in room 228 building B, SAU, staff bathrooms building D, and E did not function as required by code. An interview with the maintenance director at the time(s) of observation revealed he was unaware of the exhaust fan(s) not functioning. This did not meet the requirement of NFPA LSC.

This finding was verified by the maintenance director at the time(s) of observation and the administrator at the exit conference on July 31, 2012.

Based on observation and staff interview the facility failed to comply with the NFPA LSC 101 (2000) 9.2.3; 19.3.2.5 and NFPA 96 9, 6.1.1 Listed grease filters, listed baffles, or other listed grease removal devices for use with commercial cooking equipment shall be provided. If the cooking hood suppression system is not maintained as per code requirements, in the event of a fire, occupants, staff, and visitors will be affected.

Findings include:

On July 30, 2012 at 1 p.m. accompanied by the maintenance director when inspecting the kitchen food preparation areas it was revealed that the pre-engineered grease collection pan had been removed. An interview was conducted at this time with the maintenance director who acknowledged that the grease collection pan had been removed.

These findings were verified by the maintenance director at the times of observation and the administrator at the exit conference on July 30, 2012.

Based on observation, written document review, and staff interview the facility failed to comply with NFPA LSC 101 (2000) - 19.5.2.1 and 9.2., and NFPA 90 A - 3.4.7 Maintenance. Which requires that at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. This deficient practice of not maintaining dampers in accordance with code requirements can endanger all occupants, staff and visitors.

Findings include:

On July 30, 2012 at 4:30 p.m. based on request of written documentation provided to substantiate the required damper testing, the facility failed to produce or provide documentation to satisfy the requirement of four year testing. Paperwork is incomplete and doesn't indicate types of dampers, locations and or total number of dampers that were physically checked according to code requirements. At this same time based on interview with the maintenance director who acknowledged that written documentation to substantiate compliance was not available on the date of survey. The facility did not produce any additional documentation at the exit conference to substantiate compliance.

These findings were verified by the maintenance director at the time of observation and the administrator at the exit conference on July 30, 2012.