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Based on observation and staff interview the facility failed to install smoke alarms as required by NFPA 101 (12) Life Safety Code section 9.6.3.1 & 26.3.4.5.1. This deficient condition could delay the notification of smoke or fire to the room occupant.

Findings include:

On the facility tour between 8:30 am to 12:30 pm on 08/27/2019 observations revealed the staff sleeping areas did not contain smoke alarms.

This deficient condition was confirmed by the Director of Facilities.

Based on observation and staff interview, the facility failed to maintain the sprinkler system in accordance with the 2012 Life Safety Code (NFPA 101) and NFPA 25 section 5.2.1.1.2. The standard for testing and maintenance of sprinkler systems. This deficient condition could cause the sprinkler system not to function properly and allow for the spread of fire. This could affect an undetermined amount of patient, staff and visitors.

Findings include:

On the facility tour between 8:30 am to 12:30 pm on 08/27/2019 observations revealed the following.
1. The sprinkler heads in the kitchen were dirty.
2. A sprinkler head in the lab draw room was covered with dust or dirt.
3. Room NM 711 had tape on a sprinkler head.

This deficient condition was confirmed by the Director of Facilities.