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Based on observation and interview, it was determined the facility failed to maintain the building construction type throughout the facility.

Findings include:

1. Observation on July 10, 2017, at 8:15 a.m., revealed the building is a three-story, Type III (200), unprotected ordinary building, that is fully sprinklered. This construction type is not permitted to be greater than one story in height.

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the building construction type and height deficiency.

Based on observation and interview, it was determined the facility failed to maintain exit access in two instances, affecting two of seven stairways.

Findings Include:

1. Observation on July 10, 2017, revealed the following stairtowers were not in compliance with NFPA 101 section 7.7.3:

a) 9:30 a.m., stairway N1, on the first floor;
b) 9:50 a.m., stairway N2, on the first floor.

The exit discharge is located on the first floor, and the stairs continue uninterrupted to the basement:

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the building egress deficiency.

Based on observation and interview, it was determined the facility failed to properly install automatic sprinkler protection in four instances, on one of four floors.

Findings include:

1. Observation on July 11, 2017, revealed the following automatic sprinkler system installation deficiencies:

a) 10:28 a.m., First Floor IT Room 102 in the Northumberland Wing, had a mix of standard and quick response sprinklers;
b) 1:15 p.m., elevator pit 2 in the Shady Wing, lacked automatic sprinkler protection.
c) 1:20 p.m., elevator pit 6 in the Wilkins Wing, lacked automatic sprinkler protection.
d) 1:30 p.m., elevator pit 4-5 in the Northumberland Wing, lacked automatic sprinkler protection.

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the automatic sprinkler system installation deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of seventeen smoke compartments.

Findings include:

1. Observation on July 10, 2017, revealed the following automatic sprinkler system deficiencies:

a) 9:40 a.m., the sprinkler gauges in the Northumberland Wing, Air Handler Room were more than five years old and the facility could not provide supporting documentation to prove that they had been replaced or recalibrated within the last five years;
b) 2:05 p.m., there were three missing sprinkler escutcheons in Clean Linen Room D102, in the Denniston Wing.

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring in two instances, on two of four floors. Installation shall be in accordance with NFPA 70, National Electric Code. 6.3.2.1, NFPA 99.

Findings Include:

1. Observation on July 11, 2017, revealed the following exposed electric wires:

a) 9:30 a.m., there were three uncovered electrical junction boxes above the ceiling in Room 306, on the Third Floor of the Shady Wing.
b) 12:40 p.m., there was an unterminated electrical wire in the Pool Chemical Room on the Second Floor of the Shady Wing.

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the exposed electric wires.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in five instances, on one of four floors.

Findings Include:

1. Observation on July 11, 2017, revealed the following:

a) 9:58 a.m., a lamp was plugged into an extension cord in Room 321, on the Third Floor, of the Shady Wing;
b) 10:31 a.m., a power strip was plugged into another power strip in the Playroom, on the Third Floor of the Wilkins Wing;
c) 10:32 a.m., a plug multiplier was plugged into a timer, that was plugged into a power strip behind the fish tank, in the Playroom, on the Third Floor of the Wilkins Wing;
d) 10:40 a.m., an extension cord was plugged into a power strip, in Sensory Room W360, on the Third Floor of the Wilkins Wing;
e) 10:50 a.m., a four receptacle outlet was plugged into another outlet for power in the Data Closet across from Room W307A, on the Third Floor of the Wilkins Wing.

Interview with the Chief Operating Officer, Director of Nursing, and VP of Plant Operations on July 11, 2017, at 2:30 p.m., confirmed the misuse of electrical wiring.