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Based on an observation, staff interview, and record review conducted during the survey on 01/09/12 it was determined the fire sprinkler system, including tamper switches, failed to be completely maintained. The record review indicated the last fire sprinkler system inspection and test was conducted on 09/30/11. This failure and lack of tamper switches could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

The findings include:

During the tour of the facility with the director of maintenance at 10:35 a.m. on 1/9/12, it was noted the three outside stem and yoke (OSY) valves were not equipped with tamper switches. These valves are located near the front entrance driveway.


NFPA 101 (2000 edition) 9.7.2.1

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Based on a review of the facility records,observation and interview with the staff, it was determined that the facility failed to ensure that the Heating, Ventilating and Air Conditioning System (HVAC) was maintained in reliable operating condition.

The findings include:

Inspection of the main kitchen on 01/09/12 at 2:25 p.m. revealed that there was a notable negative pressure relationship between the kitchen and the dining room. opening only on door to the kitchen yielded enough pressure to defeat the hydraulic door closure and keep the door open with significant cubic feet of dining room air entering the kitchen. It was noted that the kitchen supply air was not operable and the exhaust and make up hood air was on. The kitchen air supply was shut down because it caused condensation on the A/C grilles. This condition was noted by the director of maintenance and kitchen manager.

NFPA 101, (2000) 9.2; 18.5.2, 19.5.2
NFPA 90A

The facility has requested a three month extension to correct this deficiency and the facility was e-mailed the wavier forms as requested.

Correction Date: 02/10/12