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Based on observations, the facility has failed to maintain the 2-hour fire separation between I occupancy and B occupancy on the 5th floor This deficient practice could affect the safety of patients, staff and visitors in the event of a fire, as fire and smoke could pass from one occupancy to the other.

Findings include:
Observations during the facility tour on November 29, 2010 between 2:30 pm and 4:30 pm and on November 30, 2010 between 8:30 am and 3:00 pm, revealed that
The doors in the 2 hour fire separation wall between the Group I occupancy and Group I occupancy of the CSR on the 5th floor do not meet the requirements in the following areas:
1) Door 5513 and door 5500 are 90 minute fire rated doors, but do not latch into the floor.
2) Door 5400 is a 1 hour fire rated door and not the required 90 minute fire rated door.

This deficient practice was confirmed by Maintenance Manager (KO) at the time of discovery,

Based on observations, and interview, the corridor was not separated from use areas as required by Sec. 19.3.6.2.1. This deficient practice could affect all patients, staff and visitors in the event of a fire.

Findings include:

Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed a 2 foot by 4 foot hole in the corridor wall on the 4th floor going into OR Rooms 1,2,3.
This deficient practice was confirmed by Maintenance Manager (KO) at the time of discovery,

Findings:
Observations during the facility tour on November 29, 2010 between 2:30 pm and 4:30 pm and on November 30, 2010 between 8:30 am and 3:00 pm, revealed that:
1) An unsealed hole in the mechanical room wall on 5th floor
2) Soiled linen room #6127 does not have the proper separation to resist the passage of smoke.
3) Soiled linen room #3556 door does not self-close.
4) Soiled linen room #2539 has penetrations in the corridor wall that do not resist the passage of smoke.
5) Main oxygen room #1145 is not properly separated because of penetrations in the corridor side wall.

Based on observations some of the stairway doors are not properly labeled. as required by Sec. 8.2.5.2. This deficient practice could affect all patients, staff and visitors in the event of a fire.
Findings include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that the 5th floor north east stairway door does not have a fire rating label.
The Director of Maintenance (JR) and Maintenance Engineer (SO) verified this finding during the facility tour.

Based on observations during the facility tour not all exits are not in accordance with the Minnesota State Fire Code 2007 edition. This deficiency could effect all patient, staff and visitors using these exits.
Findings Include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that the following locked exit and exit access doors do not comply with the requirement for a remote release device at the nurse's station within the unit as required by the Minnesota State Fire Code, 2007 Edition, Section 1008.1.11;
1) The Children's Hospital on the 8th floor

2) The 5th floor stairway doors including stairways H, D, and E, and

3) Stairway J did not have a stair break to prevent occupants from going beyond the level of exit discharge.

Observations revealed that the facility's automatic fire sprinkler system is not properly installed. This deficiency could effect all patients , staff and visitors.
Findings Include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that:
1) Room on level 10120 is not fire sprinkler protected in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition. A duct that is 55 inches wide does not a fire sprinkler beneath it as required.

2) The elevator equipment room for elevators 6, 7, 8, and 9 is not fire sprinkler protected.

3) The freight elevator room in the northwest area of the basement is not fire sprinkler protected.

4) The 11th floor dumb waiter equipment room was not fire sprinkler protected.

5) The stairway from the 1st floor to the basement has an intermediate landing with a direct exit to the outside is not fire sprinkler protected.

6) Stairwell J, on the 3rd floor, does not have fire sprinkler protection under the lower ceiling.

7) The 4th floor corridor by OR's 4 & 5, and the corridor by OR's 1,2,3, have a mix fire sprinkler heads of the standard and quick response (QR) types.

Based on observation and interview, the facility main oxygen room did not have the proper signage in accordance with 19.3.2.4, NFPA, 8.6.4.2.
Findings Include:
Observations during the facility tour on November 29, 201,0 between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that:


1) The main oxygen storage room #1145 does not have oxygen storage and no smoking signage.

Observations revealed that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect the patients, staff and visitors of the facility.
Findings include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that;
1) On-call room #6154 had a power strip connected to a multiple adapter.
2) Office #2118B has an extension cord connected to a charger.
3) A temporary power strip was attached to the building in the basement security office and in the 7th floor ICU nurse's station that are not in accordance with the National Electrical Code (NFPA 70).

Based on observations, the facility has failed to maintain the 2-hour fire separation between I occupancy and B occupancy on the 5th floor This deficient practice could affect the safety of patients, staff and visitors in the event of a fire, as fire and smoke could pass from one occupancy to the other.

Findings include:
Observations during the facility tour on November 29, 2010 between 2:30 pm and 4:30 pm and on November 30, 2010 between 8:30 am and 3:00 pm, revealed that
The doors in the 2 hour fire separation wall between the Group I occupancy and Group I occupancy of the CSR on the 5th floor do not meet the requirements in the following areas:
1) Door 5513 and door 5500 are 90 minute fire rated doors, but do not latch into the floor.
2) Door 5400 is a 1 hour fire rated door and not the required 90 minute fire rated door.

This deficient practice was confirmed by Maintenance Manager (KO) at the time of discovery,

Based on observations, and interview, the corridor was not separated from use areas as required by Sec. 19.3.6.2.1. This deficient practice could affect all patients, staff and visitors in the event of a fire.

Findings include:

Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed a 2 foot by 4 foot hole in the corridor wall on the 4th floor going into OR Rooms 1,2,3.
This deficient practice was confirmed by Maintenance Manager (KO) at the time of discovery,

Findings:
Observations during the facility tour on November 29, 2010 between 2:30 pm and 4:30 pm and on November 30, 2010 between 8:30 am and 3:00 pm, revealed that:
1) An unsealed hole in the mechanical room wall on 5th floor
2) Soiled linen room #6127 does not have the proper separation to resist the passage of smoke.
3) Soiled linen room #3556 door does not self-close.
4) Soiled linen room #2539 has penetrations in the corridor wall that do not resist the passage of smoke.
5) Main oxygen room #1145 is not properly separated because of penetrations in the corridor side wall.

Based on observations some of the stairway doors are not properly labeled. as required by Sec. 8.2.5.2. This deficient practice could affect all patients, staff and visitors in the event of a fire.
Findings include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that the 5th floor north east stairway door does not have a fire rating label.
The Director of Maintenance (JR) and Maintenance Engineer (SO) verified this finding during the facility tour.

Based on observations during the facility tour not all exits are not in accordance with the Minnesota State Fire Code 2007 edition. This deficiency could effect all patient, staff and visitors using these exits.
Findings Include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that the following locked exit and exit access doors do not comply with the requirement for a remote release device at the nurse's station within the unit as required by the Minnesota State Fire Code, 2007 Edition, Section 1008.1.11;
1) The Children's Hospital on the 8th floor

2) The 5th floor stairway doors including stairways H, D, and E, and

3) Stairway J did not have a stair break to prevent occupants from going beyond the level of exit discharge.

Observations revealed that the facility's automatic fire sprinkler system is not properly installed. This deficiency could effect all patients , staff and visitors.
Findings Include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that:
1) Room on level 10120 is not fire sprinkler protected in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition. A duct that is 55 inches wide does not a fire sprinkler beneath it as required.

2) The elevator equipment room for elevators 6, 7, 8, and 9 is not fire sprinkler protected.

3) The freight elevator room in the northwest area of the basement is not fire sprinkler protected.

4) The 11th floor dumb waiter equipment room was not fire sprinkler protected.

5) The stairway from the 1st floor to the basement has an intermediate landing with a direct exit to the outside is not fire sprinkler protected.

6) Stairwell J, on the 3rd floor, does not have fire sprinkler protection under the lower ceiling.

7) The 4th floor corridor by OR's 4 & 5, and the corridor by OR's 1,2,3, have a mix fire sprinkler heads of the standard and quick response (QR) types.

Based on observation and interview, the facility main oxygen room did not have the proper signage in accordance with 19.3.2.4, NFPA, 8.6.4.2.
Findings Include:
Observations during the facility tour on November 29, 201,0 between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that:


1) The main oxygen storage room #1145 does not have oxygen storage and no smoking signage.

Observations revealed that some electrical installations are not in accordance with NFPA 70 "The National Electrical Code 1999 edition. This deficiency could negatively effect the patients, staff and visitors of the facility.
Findings include:
Observations during the facility tour on November 29, 2010, between 2:30 pm and 4:30 pm and on November 30, 2010, between 8:30 am and 3:00 pm, revealed that;
1) On-call room #6154 had a power strip connected to a multiple adapter.
2) Office #2118B has an extension cord connected to a charger.
3) A temporary power strip was attached to the building in the basement security office and in the 7th floor ICU nurse's station that are not in accordance with the National Electrical Code (NFPA 70).