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Observations revealed that there were 2 of several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. The 2-hour fire rated building separation wall Separating the Clinic from the Hospital had penetration around the conduit above the west entry corridor door, and

2. The 2 hour fire separation wall separating the garage from the corridor was found to have multiple penetrations passing through it that were not sealed with an approved through penetration fire rated intumescent fire caulking.


These deficient practices were confirmed by the Facility Manager (SO).

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.2. This deficient practice could affect the safety of patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that the corridor door to the old nursery was equipped with a roller latch that would not hold the door fully closed if a force of 5 pounds is applied to the latch edge of the door.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. the doors to the soiled utility room were not equipped with a door closing device,

2. the west door of the soiled utility room leading to the corridor is not equipped with a positive latching device.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. There is a 3 foot by 10 foot section of ceiling tile missing from the inside of the IT storage/server room,

2. the door to the IT storage/server room was not equipped with a door closing device,

3. the door to the Housekeeping equipment storage room was not equipped with a door closing device, and

4. there were penetrations in the Housekeeping equipment storage room around the piping located above the door leading to the corridor.



This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that in the IT storage/server room that an electrical grounding cable was attached directly to the fire sprinkler piping. This deficient condition could cause electrolysis to occur in the sprinkler piping and could delay sprinkler system activation.


This deficient practice was verified by the Facilities Manager (SO).

Observations revealed that the oxygen shutoff valves were not maintained accessible in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition) section 4-3.1.2.3(i). This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively patients, staff, and visitors in the event of an emergency.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that the oxygen shutoff valves that are located in the OR suite had cart, gurneys and equipment blocking the visibility and accessibility to the shutoff valves in the event of an emergency.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility had combustibles to close to the main electrical distribution panel. This deficient practice is in violation of the Minnesota State Fire Code (07) 605.3 and 605.5. A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment; and the use of extension cords shall not be a substitute for permanent wiring. These deficient conditions could negatively affect patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, the following deficient conditions were found affecting the facility's use and maintenance of electrical equipment:

1. in the OR room there are multiple extension cords being used in place of permanent wiring to power surgical/medical equipment due to the lack of power outlets,

2. there is a surge protector that is plugged into another surge protector and not plugged directly into a power outlet located in the Communication room, and

3. in the OR suite the electrical panel was blocked by carts, gurneys, and other surgical equipment.



This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility had combustibles to close to the main electrical distribution panel. This deficient practice is in violation of the Minnesota State Fire Code (07) 605.3 and 605.5. A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment; and the use of extension cords shall not be a substitute for permanent wiring. These deficient conditions could negatively affect patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, the following deficient conditions were found affecting the facility's use and maintenance of electrical equipment:

1. in the storage room across form patient room 110 has an extension cord being used in place of permanent wiring to power a battery charger in a metal locker due to the lack of power outlets, and

2. there is a surge protector that is plugged into another surge protector and not plugged directly into a power outlet located in the storage room across from patient room 110.


This deficient practice was verified by the Facilities Manager (SO).

Observations revealed that there were 2 of several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. The 2-hour fire rated building separation wall Separating the Clinic from the Hospital had penetration around the conduit above the west entry corridor door, and

2. The 2 hour fire separation wall separating the garage from the corridor was found to have multiple penetrations passing through it that were not sealed with an approved through penetration fire rated intumescent fire caulking.


These deficient practices were confirmed by the Facility Manager (SO).

Based on observation and interview, the facility had a corridor door that did not meet the requirements of NFPA Life Safety Code 101 (2000 edition) section 19.3.6.3.2. This deficient practice could affect the safety of patients, staff and visitors, if smoke were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that the corridor door to the old nursery was equipped with a roller latch that would not hold the door fully closed if a force of 5 pounds is applied to the latch edge of the door.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. the doors to the soiled utility room were not equipped with a door closing device,

2. the west door of the soiled utility room leading to the corridor is not equipped with a positive latching device.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility has failed to provide proper protection from several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, observation revealed, that the following deficient conditions were identified:

1. There is a 3 foot by 10 foot section of ceiling tile missing from the inside of the IT storage/server room,

2. the door to the IT storage/server room was not equipped with a door closing device,

3. the door to the Housekeeping equipment storage room was not equipped with a door closing device, and

4. there were penetrations in the Housekeeping equipment storage room around the piping located above the door leading to the corridor.



This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow fire development that would reduce the egress conditions affecting all patients, staff and visitors of the facility.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that in the IT storage/server room that an electrical grounding cable was attached directly to the fire sprinkler piping. This deficient condition could cause electrolysis to occur in the sprinkler piping and could delay sprinkler system activation.


This deficient practice was verified by the Facilities Manager (SO).

Observations revealed that the oxygen shutoff valves were not maintained accessible in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition) section 4-3.1.2.3(i). This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively patients, staff, and visitors in the event of an emergency.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, it was observed that the oxygen shutoff valves that are located in the OR suite had cart, gurneys and equipment blocking the visibility and accessibility to the shutoff valves in the event of an emergency.


This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility had combustibles to close to the main electrical distribution panel. This deficient practice is in violation of the Minnesota State Fire Code (07) 605.3 and 605.5. A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment; and the use of extension cords shall not be a substitute for permanent wiring. These deficient conditions could negatively affect patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, the following deficient conditions were found affecting the facility's use and maintenance of electrical equipment:

1. in the OR room there are multiple extension cords being used in place of permanent wiring to power surgical/medical equipment due to the lack of power outlets,

2. there is a surge protector that is plugged into another surge protector and not plugged directly into a power outlet located in the Communication room, and

3. in the OR suite the electrical panel was blocked by carts, gurneys, and other surgical equipment.



This deficient practice was verified by the Facilities Manager (SO).

Based on observations, the facility had combustibles to close to the main electrical distribution panel. This deficient practice is in violation of the Minnesota State Fire Code (07) 605.3 and 605.5. A working space of not less than 30 inches in width, 36 inches in depth and 78 inches in height shall be provided in front of electrical service equipment; and the use of extension cords shall not be a substitute for permanent wiring. These deficient conditions could negatively affect patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 2:30 PM on 09/04/2013, the following deficient conditions were found affecting the facility's use and maintenance of electrical equipment:

1. in the storage room across form patient room 110 has an extension cord being used in place of permanent wiring to power a battery charger in a metal locker due to the lack of power outlets, and

2. there is a surge protector that is plugged into another surge protector and not plugged directly into a power outlet located in the storage room across from patient room 110.


This deficient practice was verified by the Facilities Manager (SO).