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Based on observation and interview the facility failed to maintain at least an eighteen inch clearance around all ceiling mounted sprinkler heads. This deficient practice affects all patients and staff within that smoke compartment.

Findings included:

During an initial tour of the Walnut Lawn campus conducted on 03/01/11 at 1:55 PM the ceiling mounted sprinkler head in the Pharmacy was observed to be obstructed by a refrigerator and did not have the required eighteen inch clearance.

Staff P Safety Officer confirmed at that time the clearance between the top of the refrigerator and the sprinkler head was approximately ten inches.

The National Fire Protection Association 25 Water-Based Fire Protection Systems 2002 edition, section 5.2.1.2 states: " Unacceptable obstructions to spray patterns shall be corrected. "

Based on observation and interview the facility failed to maintain all corridors free of obstructions. This deficient practice affects all patients within that smoke compartment.

Findings included:

Observations during an initial tour of the south campus conducted on the morning of 03/02/11 showed the following:

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:22 AM in the exit corridor between patient rooms 814 and 815.

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:26 AM in the exit corridor adjacent to patient room 829.

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:28 AM in the exit corridor adjacent to patient room 839.

Staff P Safety Officer confirmed at that time the 3 vital signs monitors were being recharged while in the exit corridors.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 7.1.10.1 states: " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. "

Based on observation and interview the facility failed to maintain at least an eighteen inch clearance around all ceiling mounted sprinkler heads. This deficient practice affects all patients and staff within that smoke compartment.

Findings included:

During an initial tour of the Walnut Lawn campus conducted on 03/01/11 at 1:55 PM the ceiling mounted sprinkler head in the Pharmacy was observed to be obstructed by a refrigerator and did not have the required eighteen inch clearance.

Staff P Safety Officer confirmed at that time the clearance between the top of the refrigerator and the sprinkler head was approximately ten inches.

The National Fire Protection Association 25 Water-Based Fire Protection Systems 2002 edition, section 5.2.1.2 states: " Unacceptable obstructions to spray patterns shall be corrected. "

Based on observation and interview the facility failed to maintain all corridors free of obstructions. This deficient practice affects all patients within that smoke compartment.

Findings included:

Observations during an initial tour of the south campus conducted on the morning of 03/02/11 showed the following:

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:22 AM in the exit corridor between patient rooms 814 and 815.

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:26 AM in the exit corridor adjacent to patient room 829.

A vital signs monitor, plugged into an electrical wall outlet, was observed at 9:28 AM in the exit corridor adjacent to patient room 839.

Staff P Safety Officer confirmed at that time the 3 vital signs monitors were being recharged while in the exit corridors.

The National Fire Protection Association 101 Life Safety Code, 2000 edition, section 7.1.10.1 states: " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. "