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Based on observation the facility failed to ensure that there were no impediments to the closing of doors opening onto corridors.

Findings include:

On 9/27/12, during a tour of the facility, several self-closing doors were held open with wedges, weights, and other devices.
a. Door wedge holding the door to Nuclear Medicine open,
b. Door wedge holding the door to the Emergency Department break room,
c. Ten-pound weight holding open the door to the Physicians' Lounge,
d. Crimped, metal plate holding open the door to the Ultrasound Room.

Based on observation and staff interview, the facility failed to ensure that staff responded to a fire drill in a manner which demonstrated that these procedures were part of their established routine.

Findings include:

On 9/27/12 at 2:54 PM, a fire alarm pull station in the kitchen was activated. "Code Red" was announced three times over the public address system. The receptionist left her desk to read the location of the "fire" on the Fire Alarm Control Panel which displayed the word "Supervisory". The Dietary Manager indicated that her staff called the reception desk three times to give the location of the "fire", but no one answered the phone. Minutes passed. A group of six workers were off duty and were exiting the building. They were overheard asking each other, "Is this a real fire, or a drill?" The Administrator and the Director of Maintenance expressed concern for the comment made by their employees and they both indicated that staff are instructed to respond to all drills as though they were real fires.

At 2:56 PM, the location of the fire was announced, "Code Red, Dining Room". Some staff reported to the Staff Dining Room, and some staff reported to the LTC Dining Room. "Code Green" (the conclusion of the drill), was announced over the public address system at 2:59 PM.

NFPA 13 (1996), 4-5.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 4-5.5.2 and 4-5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

Based on observation, the facility failed to ensure that one sprinkler head was installed in a location with minimal obstructions to discharge.

Findings include:

On 9/27/12 at 2:30 PM, one sprinkler head had been installed close to the exhaust hood over the dishwasher machine in the kitchen. The vertical distance from the bottom of the sprinkler deflector and the top of the exhaust hood was ten inches. There were no other sprinkler heads in the dishwasher area.

Based on observation the facility failed to ensure that there were no impediments to the closing of doors opening onto corridors.

Findings include:

On 9/27/12, during a tour of the facility, several self-closing doors were held open with wedges, weights, and other devices.
a. Door wedge holding the door to Nuclear Medicine open,
b. Door wedge holding the door to the Emergency Department break room,
c. Ten-pound weight holding open the door to the Physicians' Lounge,
d. Crimped, metal plate holding open the door to the Ultrasound Room.

Based on observation and staff interview, the facility failed to ensure that staff responded to a fire drill in a manner which demonstrated that these procedures were part of their established routine.

Findings include:

On 9/27/12 at 2:54 PM, a fire alarm pull station in the kitchen was activated. "Code Red" was announced three times over the public address system. The receptionist left her desk to read the location of the "fire" on the Fire Alarm Control Panel which displayed the word "Supervisory". The Dietary Manager indicated that her staff called the reception desk three times to give the location of the "fire", but no one answered the phone. Minutes passed. A group of six workers were off duty and were exiting the building. They were overheard asking each other, "Is this a real fire, or a drill?" The Administrator and the Director of Maintenance expressed concern for the comment made by their employees and they both indicated that staff are instructed to respond to all drills as though they were real fires.

At 2:56 PM, the location of the fire was announced, "Code Red, Dining Room". Some staff reported to the Staff Dining Room, and some staff reported to the LTC Dining Room. "Code Green" (the conclusion of the drill), was announced over the public address system at 2:59 PM.

NFPA 13 (1996), 4-5.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 4-5.5.2 and 4-5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

Based on observation, the facility failed to ensure that one sprinkler head was installed in a location with minimal obstructions to discharge.

Findings include:

On 9/27/12 at 2:30 PM, one sprinkler head had been installed close to the exhaust hood over the dishwasher machine in the kitchen. The vertical distance from the bottom of the sprinkler deflector and the top of the exhaust hood was ten inches. There were no other sprinkler heads in the dishwasher area.