HospitalInspections.org

Observation revealed that the interior flame spread rating of insulation on the overhead door could not be verified that the flame spread rating is 75 or less as required by NFPA 101 "The Life Safety Code" 2000 edition section 39.3.3.2. This deficient practice could effect all patients, staff, and visitors.

Findings include:
Observations during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the insulation foam installed on the overhead garage door is exposed and open to the rehab area and could not be documented at meeting a class B interior finish.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

Observations revealed that 2 of 10 smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. These deficient practices could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the residents, staff and visitors.

Findings include:
Observations during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The 2nd floor west smoke barrier has a 1 inch hole and unsealed wire penetrations above the corridor ceiling, and

2) The 3rd floor west smoke barrier has a 1 inch hole in the barrier above the corridor ceiling.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Testing of hazardous area corridor doors showed that the 7 corridor door are not in accordance with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.2.2.2. If hazardous area corridor doors are not self-closing or do not latch nor stay tightly within their frames when closed, a fire could spread beyond the room of origin and would negatively impact all the residents, staff and guests.

Findings include:
Observations and testing of approximately fifty hazardous area corridor doors during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The corridor doors from rooms 341, 346 and 359 delivery did not close and latch,

2) The corridor doors to storage rooms 161, 204, and 211 are not self-closing,

3) The 1st floor Central Supply corridor door's in active leaf was wedged open and would not close upon fire alarm activation,

4) The corridor door to Medical Records 138, was held open with a hook catch and would not close upon fire alarm activation, and

5) The corridor door to the storage room near ICU did not have a latch.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

2). Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas must be protected in accordance with Section 8.4 Section 39.3.2.1.

a). The hazardous area must be enclosed with a fire barrier that has a one-hour fire resistance rating when the area is not protected with an automatic fire sprinkler system. 8.4.1.1.

Observation determined pipe and electrical conduit penetrations in the west wall of the Furnace Room were not sealed with fire-rated material.

b). Doors in barriers required to have a fire resistance rating must have a 3/4 hour fire protection rating and must be self-closing or automatic-closing.

Observation determined the 60-minute door to the Furnace Room was out of adjustment and would not self-close to the latched position. The door was also equipped with a kick-down hold open device.

Observations revealed that the main entrance door is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.8. This deficient practice could cause the occupants who are trying to exit through this door to stubble and fall in an emergency negatively effecting all the patients, visitors and staff.

Findings include:
Observations during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the main entrance flooring has broken up and is uneven.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

1). All means of egress must be in accordance with Chapter 7, Section 39.2.1.1.

a). Doors must be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, must not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. 7.2.1.5.1.

Exception: Exterior doors can be permitted to have key-operated locks from the egress side, provided that there is a readily visible, durable sign in lettrs not less than 1 inch high on a contrasting background that reads as follows: THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED.

Observation determined the main entrance door was equipped with a key-operated lock and an approved sign was not posted.

b). A functional test must be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test must be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment must be fully operational for the duration of the test. Written records of visual inspections and tests must be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.

Record review indicated the lack of written documentation of monthly and annual inspections of the battery -powered emergency lights and exit signage.

Observations revealed that two of ten exit discharges is not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility negatively impacting all residents as well as staff and quests using that exit.

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on August 17th, between 9:00 am and 11:00 am, revealed that the east exit stairway discharge and the business office exit discharge did not have the proper lighting so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Observations and testing of emergency lighting packs revealed that two of the lighting units did not work and a review of records did not show that they have been tested in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.9.1. This deficient practice could affect quick, effective evacuation of occupants which would negatively impact all patients, visitors and staff in the event of a power failure.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 1:00 pm and 1:30 pm. revealed that the emergency lighting may not have been tested monthly for 30 seconds, nor for 90 minutes annually as required by the LSC section 7.9.3.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

Observations indicated that the automatic sprinkler system has not been installed in accordance with NFPA 13 Standard for the Installation of Sprinkler System 1999 edition. This deficient practice may allow a fire to grow which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The north elevator equipment room and the phone\data room near the kitchen are not protected by the automatic sprinkler system, and

2) The sprinkler protection in the Main Entrance closet and in the 1st floor elevator equipment room are located to far below the ceilings of the rooms and do not meet their listings.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

A review of facility documentation and an interview with the staff revealed that the automatic sprinkler system may not have been tested in accordance with NFPA 25 The Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems 1999 edition section 9.2.7. Failure to maintain a fire protection system could allow it to fail during a fire which would negatively affect all the residents, staff and quests of the facility.

Findings include:
A review of facility documentation and an interview with staff on August 17, 2010 at approximately 1:05 pm, revealed that no documentation was available for the servicing of the automatic sprinkler system.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

A review of facility documentation revealed that the portable fire extinguishers have not been serviced in accordance with NFPA 10 Standard for Portable Fire Extinguishers 1998 sedition 9.7.4.1. This deficient practice could effect all patients, staff, and visitors.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the portable fire extinguishers have not been maintained in accordance with NFPA 10 as the last annual inspection and monthly quick check was conducted in July 2007 by Northern Fire Protection.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

Observations and a review of facility documentation on portable fire extinguishers revealed that they have not bee services in accordance with NFPA 10 Standard for Portable Fire Extinguishers 1998 edition section 9.7.4.1. This deficient practice could negatively impact all patients, staff and visitors if a fire occurs and they can not control the fire.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 1:00 pm and 1:30 pm, revealed that the portable fire extinguishers have not been maintained in accordance with NFPA 10 as the last annual inspection and monthly quick check was conducted in December 2008 by Northern Fire Protection.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

3). Portable fire extinguishers must be provided in every business occupancy in accordance with 9.7.4.1 Section 39.3.5.

a). Fire extinguishers must be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require. NFPA 10 Section 6.2.1.

Record review determined the fire extinguishers were not inspection monthly.

b). Fire extinguishers shall not be obstructed or obscured from view. NFPA 10 Section 1.5.6

Fire extinguishers mounted in cabinets or wall recesses shall be place so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. NFPA 10 Section 1.5.12.

Observation determined that several fire extinguisher cabinets throughout the facility had a solid metal door and the cabinets were not tabled.

Observations revealed that the facility has items that obstruct the full and instant use of the corridors in an emergency which is required by NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.2.1. This deficient practice can slow or even prevent exiting from the obstructed corridor, effecting the any resident, staff and guests of those areas.

Findings include:
Observations during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm, revealed storage in the 2nd floor south dayroom that is not separated from the corridor, with some storage obstructing the stairway door and some storage in the short corridor near the new elevator lobby on 2nd floor.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Observations revealed that a compressed gas cylinder was free standing and not secured to prevent falling as required by NFPA 99 Standard for Health Care Facilities 1999 edition section 4-3.1.1.2(a) 3. This deficient practice could allow a cylinder to fall and have a rapid release of gas which could negatively impact any patient, staff or visitor in the room where the cylinder is stored.

Findings include:
Observations during the facility tour on August 17, 2010 between 1:45 pm and 2:15 pm, revealed that an e-sized compressed oxygen cylinder was free standing in an exam room and not properly secured or in a stand.

Staff member Paul verified these findings during the tour of the facility and at the exit conference.

Observation of ten staff on-call rooms revealed that two do not meet the requirements of the Minnesota State Fire Code 2007 edition section 907.3.3.1 and 1027.1. This could affect the staff occupying the room by slowing their response to a fire and preventing their escape..

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on the 17, 2010, between 9:00 am and 11:00 am, revealed that the staff on-call rooms 206 and 209 did not have smoke detectors within the rooms.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Observation revealed that the interior flame spread rating of insulation on the overhead door could not be verified that the flame spread rating is 75 or less as required by NFPA 101 "The Life Safety Code" 2000 edition section 39.3.3.2. This deficient practice could effect all patients, staff, and visitors.

Findings include:
Observations during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the insulation foam installed on the overhead garage door is exposed and open to the rehab area and could not be documented at meeting a class B interior finish.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

Observations revealed that 2 of 10 smoke barriers are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. These deficient practices could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the residents, staff and visitors.

Findings include:
Observations during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The 2nd floor west smoke barrier has a 1 inch hole and unsealed wire penetrations above the corridor ceiling, and

2) The 3rd floor west smoke barrier has a 1 inch hole in the barrier above the corridor ceiling.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Testing of hazardous area corridor doors showed that the 7 corridor door are not in accordance with NFPA 101 "The Life Safety Code" 2000 Edition Section 19.2.2.2. If hazardous area corridor doors are not self-closing or do not latch nor stay tightly within their frames when closed, a fire could spread beyond the room of origin and would negatively impact all the residents, staff and guests.

Findings include:
Observations and testing of approximately fifty hazardous area corridor doors during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The corridor doors from rooms 341, 346 and 359 delivery did not close and latch,

2) The corridor doors to storage rooms 161, 204, and 211 are not self-closing,

3) The 1st floor Central Supply corridor door's in active leaf was wedged open and would not close upon fire alarm activation,

4) The corridor door to Medical Records 138, was held open with a hook catch and would not close upon fire alarm activation, and

5) The corridor door to the storage room near ICU did not have a latch.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

2). Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas must be protected in accordance with Section 8.4 Section 39.3.2.1.

a). The hazardous area must be enclosed with a fire barrier that has a one-hour fire resistance rating when the area is not protected with an automatic fire sprinkler system. 8.4.1.1.

Observation determined pipe and electrical conduit penetrations in the west wall of the Furnace Room were not sealed with fire-rated material.

b). Doors in barriers required to have a fire resistance rating must have a 3/4 hour fire protection rating and must be self-closing or automatic-closing.

Observation determined the 60-minute door to the Furnace Room was out of adjustment and would not self-close to the latched position. The door was also equipped with a kick-down hold open device.

Observations revealed that the main entrance door is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.8. This deficient practice could cause the occupants who are trying to exit through this door to stubble and fall in an emergency negatively effecting all the patients, visitors and staff.

Findings include:
Observations during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the main entrance flooring has broken up and is uneven.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

1). All means of egress must be in accordance with Chapter 7, Section 39.2.1.1.

a). Doors must be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, must not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. 7.2.1.5.1.

Exception: Exterior doors can be permitted to have key-operated locks from the egress side, provided that there is a readily visible, durable sign in lettrs not less than 1 inch high on a contrasting background that reads as follows: THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED.

Observation determined the main entrance door was equipped with a key-operated lock and an approved sign was not posted.

b). A functional test must be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test must be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment must be fully operational for the duration of the test. Written records of visual inspections and tests must be kept by the owner for inspection by the authority having jurisdiction. 7.9.3.

Record review indicated the lack of written documentation of monthly and annual inspections of the battery -powered emergency lights and exit signage.

Observations revealed that two of ten exit discharges is not illuminated in accordance with NFPA 101 "The Life Safety Code" (LSC) 2000 edition, section 19.2.8. Lack of proper lighting for exit discharges could cause the slowing of evacuation of the facility negatively impacting all residents as well as staff and quests using that exit.

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on August 17th, between 9:00 am and 11:00 am, revealed that the east exit stairway discharge and the business office exit discharge did not have the proper lighting so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Observations and testing of emergency lighting packs revealed that two of the lighting units did not work and a review of records did not show that they have been tested in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 39.2.9.1. This deficient practice could affect quick, effective evacuation of occupants which would negatively impact all patients, visitors and staff in the event of a power failure.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 1:00 pm and 1:30 pm. revealed that the emergency lighting may not have been tested monthly for 30 seconds, nor for 90 minutes annually as required by the LSC section 7.9.3.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

Observations indicated that the automatic sprinkler system has not been installed in accordance with NFPA 13 Standard for the Installation of Sprinkler System 1999 edition. This deficient practice may allow a fire to grow which will negatively impact all the residents, visitors and staff.

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on August 17, 2010, between 9:00 am and 11:00 am, revealed that:

1) The north elevator equipment room and the phone\data room near the kitchen are not protected by the automatic sprinkler system, and

2) The sprinkler protection in the Main Entrance closet and in the 1st floor elevator equipment room are located to far below the ceilings of the rooms and do not meet their listings.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

A review of facility documentation and an interview with the staff revealed that the automatic sprinkler system may not have been tested in accordance with NFPA 25 The Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems 1999 edition section 9.2.7. Failure to maintain a fire protection system could allow it to fail during a fire which would negatively affect all the residents, staff and quests of the facility.

Findings include:
A review of facility documentation and an interview with staff on August 17, 2010 at approximately 1:05 pm, revealed that no documentation was available for the servicing of the automatic sprinkler system.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

A review of facility documentation revealed that the portable fire extinguishers have not been serviced in accordance with NFPA 10 Standard for Portable Fire Extinguishers 1998 sedition 9.7.4.1. This deficient practice could effect all patients, staff, and visitors.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 11:45 am and 12:15 pm, revealed that the portable fire extinguishers have not been maintained in accordance with NFPA 10 as the last annual inspection and monthly quick check was conducted in July 2007 by Northern Fire Protection.

Staff member BC verified these findings during the tour of the facility and at the exit conference.

Observations and a review of facility documentation on portable fire extinguishers revealed that they have not bee services in accordance with NFPA 10 Standard for Portable Fire Extinguishers 1998 edition section 9.7.4.1. This deficient practice could negatively impact all patients, staff and visitors if a fire occurs and they can not control the fire.

Findings include:
Observations and a review of extinguisher tags during the facility tour on August 17, 2010 between 1:00 pm and 1:30 pm, revealed that the portable fire extinguishers have not been maintained in accordance with NFPA 10 as the last annual inspection and monthly quick check was conducted in December 2008 by Northern Fire Protection.

Staff member AB verified these findings during the tour of the facility and at the exit conference.

3). Portable fire extinguishers must be provided in every business occupancy in accordance with 9.7.4.1 Section 39.3.5.

a). Fire extinguishers must be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require. NFPA 10 Section 6.2.1.

Record review determined the fire extinguishers were not inspection monthly.

b). Fire extinguishers shall not be obstructed or obscured from view. NFPA 10 Section 1.5.6

Fire extinguishers mounted in cabinets or wall recesses shall be place so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. NFPA 10 Section 1.5.12.

Observation determined that several fire extinguisher cabinets throughout the facility had a solid metal door and the cabinets were not tabled.

Observations revealed that the facility has items that obstruct the full and instant use of the corridors in an emergency which is required by NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 7.1.10.2.1. This deficient practice can slow or even prevent exiting from the obstructed corridor, effecting the any resident, staff and guests of those areas.

Findings include:
Observations during the facility tour on August 16, 2010 between 10:00 am and 1:30 pm, revealed storage in the 2nd floor south dayroom that is not separated from the corridor, with some storage obstructing the stairway door and some storage in the short corridor near the new elevator lobby on 2nd floor.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.

Observations revealed that a compressed gas cylinder was free standing and not secured to prevent falling as required by NFPA 99 Standard for Health Care Facilities 1999 edition section 4-3.1.1.2(a) 3. This deficient practice could allow a cylinder to fall and have a rapid release of gas which could negatively impact any patient, staff or visitor in the room where the cylinder is stored.

Findings include:
Observations during the facility tour on August 17, 2010 between 1:45 pm and 2:15 pm, revealed that an e-sized compressed oxygen cylinder was free standing in an exam room and not properly secured or in a stand.

Staff member Paul verified these findings during the tour of the facility and at the exit conference.

Observation of ten staff on-call rooms revealed that two do not meet the requirements of the Minnesota State Fire Code 2007 edition section 907.3.3.1 and 1027.1. This could affect the staff occupying the room by slowing their response to a fire and preventing their escape..

Findings include:
Observations during the facility tour on August 16, 2010, between 10:00 am and 1:30 pm and on the 17, 2010, between 9:00 am and 11:00 am, revealed that the staff on-call rooms 206 and 209 did not have smoke detectors within the rooms.

The Director of Plant Operations (JO) verified these findings during the tour of the facility and at the exit conference.