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Based on observations and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 13 (2010 edition), 8.7. This deficient practice could affect an undetermined number of inpatients, outpatients, staff, and visitors.

Findings include:

1. On 4/3/17 at 4:21 pm, observation revealed that electrical room 1076 was only 1 hour rated and did not have a sprinkler.

2. On 4/4/17 at 8:37 am, observation revealed that electrical room 1109 was only 1 hour rated and did not have a sprinkler.

The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff F.

Based on record review and interview the facility failed to conduct fire drills in accordance with, the requirements of NFPA 101 - 2012 edition, Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect an undetermined number of inpatients, outpatients, staff, and visitors.

Findings include:

On 4/3/17 at 3:29 pm, review of the facility fire drills for the last 12 months revealed that 4 of the last 5, 3rd shift drills were conducted between 11:15 pm and 11:50 pm and not varied throughout the shift. Additionally, the 1st and 3rd quarter drills did not include record of the transmission of the alarm single to the monitoring company.

This finding was confirmed by Staff F at the time of discovery.