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Based on observation and interview, it was determined that the facility failed to maintain the sprinkler heads in multiple area in the facility. Failing to maintain sprinkler heads could cause harm to residents and staff by allowing a fire to spread before the temperature is reached to set of the sprinkler head.

NFPA 101 Life Safety Code, 2012 edition, Chapter 19, Section 19.3.5.1 "Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage."

Findings Include:

On April 17, 2018, the surveyor accompanied by the Director of A&R, observed sprinkler heads with dust/lint on the sprinkler heads in the following locations:

1. In the Lobby to the downstairs, four (4) of ten (10) sprinkler heads with dust/lint.
2. Administration hallway, six (6) of six (6) sprinkler heads with dust/lint.
3. Administration suite, sixteen (16) of thirty six (36) sprinkler heads with dust/lint.

The Chief Executive Officer and the Director of A&R acknowledged during the exit conference on April 17, 2018, the sprinkler heads with dust/lint on the sprinkler heads in the downstairs lobby, administration hallway and administration suite.

Based on observation and interview, it was determined the facility failed to fill penetrations in two (2) of the smoke barriers in the facility. Failing seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

On April 17, 2018, the surveyor, accompanied by the Director of A&R and Maintenance Engineer observed unsealed penetrations in the smoke barriers in the following locations:

1. Above the main lobby doors, six (6) penetrations in the smoke barrier.
2. Above the elevator lobby doors, two (2) penetrations in the smoke barrier.

The Chief Executive Officer and the Director of A&R acknowledged during the exit conference on April 17, 2018,
unsealed penetrations in the smoke barriers above the main lobby doors, and above the elevator lobby doors.

Based on observation and interview, it was determined the facility failed to provide protective guards on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

Findings include:

On April 17, 2018, the surveyor, accompanied by the Director of A&R observed the following light bulbs exposed with no protective guards on the light bulbs:

1. Unprotected light bulbs in the Electrical/IT room located in Jupiter Wing.
2. Unprotected light bulbs in the Communication/Electrical room, located by the Palo Verde Wing.
3. Unprotected light bulbs in the Storage room located in the Tunning Fork lobby by the Palo Verde Wing.

The Chief Executive Officer and the Director of A&R acknowledged during the exit conference on April 17, 2018, light bulbs exposed with no protective guards on the light bulbs in the Electrical/IT room located in Jupiter Wing, in the Communication/Electrical room, located by the Palo Verde Wing and in the Storage room located in the Tunning Fork lobby by the Palo Verde Wing.