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Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 16 of 16 patients.

Findings:

During the facility tour, between the hours of 10:00 and 11:00 it was observed that there was no sprnkler head in the janitor closet located on the 2nd floor between patient rooms 217 and 219. It was apparently missed during construction of the building.

Interview with Facility Management Supervisor revealed the facility was not aware the automatic sprinkler system was not complete because of the missing sprinkler head in janitor closet.