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Based on observation and interview, the facility did not provide a sleeping suite in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.2.5.7.2.3 (C), 19.3.4.1, and 9.6.2.9, as well as NFPA 72, 2010 edition, Section 17.7.3.1, 17.5.3.1, 17.7.1.6, and 17.7.3.2.3.3. This deficient practice could affect 9 patients, as well as an undetermined number of staff and visitors.

Findings include:

On 08/29/2022 at 10:50 AM, observation in Unit A and Unit B revealed a suite that was greater than 7,500 square feet which was fully sprinklered and included sleeping rooms with direct supervision from the connected, constantly attended nurse station. The 2-story, Central Day Room 1149 within Unit A did not have total coverage (complete) automatic smoke detection. No smoke detectors were observed at the upper clerestory, flat ceiling level of the room.

This deficient practice was confirmed by Staff B at the time of discovery.

Based on observation and interview, the facility did not provide an automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.5.7, and 9.7, as well as NFPA 13, 2010 edition, Section 6.2.7. This deficient practice could affect 9 patients and undetermined number of staff and visitors.

Findings include:

On 08/30/2022 at 8:59 AM, observation in the 2-story, Day Room 1150 of Unit A revealed the sprinkler head cover plate, an escutcheon plate, was not in place, thereby not completing the sprinkler assembly listing.

This deficient practice was confirmed by Staff C at the time of discovery.

Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101, 2012 edition, Sections 19.3.5.1, 19.3.7.6, 19.3.6.2.4, 19.3.6.2.6, 8.4.2, 8.4.4, and 8.5.2, and 8.5.6; as well as NFPA 25, 2011 edition, Sections 4.5, 4.7, and 5.1.1.2. This deficient practices could affect an undetermined number of staff and visitors.

On 08/29/2022 at 3:21 PM, observation in the Lobby of the Pharmacy revealed a 3 inch by 2 inch penetration in a ceiling tile of the room. This missing tile does not duplicate the smoke tight conditions that were used in the sprinkler UL certification test.

This deficient practice was confirmed by Staff C at the time of discovery.

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1, 9.1.1, and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.8 and 110.27. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings Include:

On 08/30/2022 at 9:24 AM, observation in Med Room with Door 1166 revealed an electrical conduit with exposed wiring protruding from the wall at 5 feet above the finished floor.

This deficient practice was confirmed by Staff C at the time of discovery.