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Based upon observations and staff interviews on 11/4/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to maintain the smoke resistant separation of fully sprinklered hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The storage room # N102 greater than 50 square feet had two unsealed penetrations in the ceiling.

The above was discussed and acknowledged by the Plant Ops Director who said he believed the sprinkler contractor had recently removed two sprinkler heads in the room and had not sealed the holes after completing the work.

Based upon record review and staff interviews on 11/3/2015 during record review between approximately 1500 and 1630 hours the facility has failed to maintain a written plan for the protection of all residents, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following:
1. Use of alarms
2. Transmission of alarms to fire department
3. Response to alarms
4. Isolation of the fire
5. Evacuation of the immediate area
6. Evacuation of smoke compartment (Partial Evacuation)
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

The findings include, but are not limited to:
The Facility-wide evacuation plans do not address the evacuation of a smoke compartment (locations and definitions of smoke compartment separations).

The above was discussed and acknowledged by the Plant Ops Director who said the plan had been previously approved where it instructs to evacuate to an adjacent "zone".

Based upon observations and staff interviews on 11/3/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to mark all doors leading to the laboratory with signage indicating the fire hazards of materials inside the lab in accordance with NFPA 99, 10-8.2.1. This could result in the failure or delay of the Fire Department to respond correctly to a fire occurring in the lab, placing staff and visitors in danger.



The findings include, but are not limited to:

There are no markings on the lab entrance doors identifying the fire hazards within the lab.

The above was discussed and acknowledged by the Laboratory Safety Manager who said he was unaware of the requirement to mark the doors with Hazard identification.

Based upon observations and staff interviews on 11/3/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to maintain laboratory fire response procedures in accordance with NFPA 99, 10.2.1.3.1, 19.3.2.1. This could result in the failure or delay to respond correctly to a fire occurring in the lab, placing staff and visitors in danger.



The findings include, but are not limited to:

There is no written fire response procedure in place for a fire occurring specifically in the laboratory, as the lab is using the Hospital wide fire procedures.

The above was discussed and acknowledged by the Laboratory Safety Manager who said he was unaware of the requirement for a lab-specific fire plan.

Based upon observations and staff interviews on 11/3/15 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to restrict the use of extension cords to providing power to permitted electrical equipment on a temporary basis. This could result in a fire from overheating of the extension cord due to the prolonged power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was an extension cord in use a TV in the OR Break room.
There was an extension cord in use with a portable heater and other miscellaneous electronics at the Medical Records Reception desk (removed on site).
There was an extension cord in use with a fan at the Medical Records north end cubicle (removed on site).

The above was discussed and acknowledged by the Plant Ops Director who said that his staff conduct periodic audits for extension cords, but that he was unaware of the extension cords in use.

Based upon observations and staff interviews on 11/4/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to maintain the smoke resistant separation of fully sprinklered hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
The storage room # N102 greater than 50 square feet had two unsealed penetrations in the ceiling.

The above was discussed and acknowledged by the Plant Ops Director who said he believed the sprinkler contractor had recently removed two sprinkler heads in the room and had not sealed the holes after completing the work.

Based upon record review and staff interviews on 11/3/2015 during record review between approximately 1500 and 1630 hours the facility has failed to maintain a written plan for the protection of all residents, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following:
1. Use of alarms
2. Transmission of alarms to fire department
3. Response to alarms
4. Isolation of the fire
5. Evacuation of the immediate area
6. Evacuation of smoke compartment (Partial Evacuation)
7. Preparation of floors and building for evacuation
8. Extinguishment of fire

The findings include, but are not limited to:
The Facility-wide evacuation plans do not address the evacuation of a smoke compartment (locations and definitions of smoke compartment separations).

The above was discussed and acknowledged by the Plant Ops Director who said the plan had been previously approved where it instructs to evacuate to an adjacent "zone".

Based upon observations and staff interviews on 11/3/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to mark all doors leading to the laboratory with signage indicating the fire hazards of materials inside the lab in accordance with NFPA 99, 10-8.2.1. This could result in the failure or delay of the Fire Department to respond correctly to a fire occurring in the lab, placing staff and visitors in danger.



The findings include, but are not limited to:

There are no markings on the lab entrance doors identifying the fire hazards within the lab.

The above was discussed and acknowledged by the Laboratory Safety Manager who said he was unaware of the requirement to mark the doors with Hazard identification.

Based upon observations and staff interviews on 11/3/2015 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to maintain laboratory fire response procedures in accordance with NFPA 99, 10.2.1.3.1, 19.3.2.1. This could result in the failure or delay to respond correctly to a fire occurring in the lab, placing staff and visitors in danger.



The findings include, but are not limited to:

There is no written fire response procedure in place for a fire occurring specifically in the laboratory, as the lab is using the Hospital wide fire procedures.

The above was discussed and acknowledged by the Laboratory Safety Manager who said he was unaware of the requirement for a lab-specific fire plan.

Based upon observations and staff interviews on 11/3/15 during the physical tour of the facility between approximately 0915 and 1500 hours the facility has failed to restrict the use of extension cords to providing power to permitted electrical equipment on a temporary basis. This could result in a fire from overheating of the extension cord due to the prolonged power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
There was an extension cord in use a TV in the OR Break room.
There was an extension cord in use with a portable heater and other miscellaneous electronics at the Medical Records Reception desk (removed on site).
There was an extension cord in use with a fan at the Medical Records north end cubicle (removed on site).

The above was discussed and acknowledged by the Plant Ops Director who said that his staff conduct periodic audits for extension cords, but that he was unaware of the extension cords in use.