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Based on observation and staff interview, the facility failed to install an approved automatic sprinkler system in accordance with the NFPA 13, Standard for Installation of Sprinkler Systems. LSC 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1). This deficient practice could affect all patients in the Main Building.

Findings include:

On a facility tour between the hours of 10:00 AM and 04:00 PM on July 23, 2018, observation revealed that a sprinkler head in Room 804 was not installed with more than 12 inches of space between the sprinkler head and the ceiling.


This deficient practice was verified by a facilities engineer at the time of discovery.

Based on observation and staff interview, the facility did not use power cords and extension cords in a manner that exercises general precautions. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA99), 400.8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5. This deficient practice could affect all residents within affected smoke compartment.

Findings include:

1. On a facility tour between the hours of 10:00 AM and 04:00 PM on July 23, 2018, it was revealed that there were two power taps plugged into each other in Room 643.

2. On a facility tour between the hours of 10:00 AM and 04:00 PM on July 23, 2018, it was revealed that a microwave was found plugged into a power tap in room 843.

3. On a facility tour between the hours of 09:00 AM and 03:00 PM on July 24, 2018, it was revealed that extension cords were found plugged into power taps in Room 27-4.

4. On a facility tour between the hours of 09:00 AM and 03:00 PM on July 24, 2018, it was revealed that a refrigerator, microwave, and toaster were found plugged into a power tap in Room LL30E.


This deficient practice was verified by a facility engineer at the time of discovery.