HospitalInspections.org

Based on observation and staff interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.6.3.6. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 7:30 am and 3:30 pm December 1, 2015 it was observed that the door for the first floor houskeeping storage did not latch when left to close on its own.

The deficient practice were confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility had a cross corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.7.7 This deficient practice could affect the safety of patients, staff and visitors if, when closed, multiple persons attempt passage at the same time.

Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015 it was observed that the cross corridor doors on the lower level in the 2010 addition were without visions panels as required.

The deficient practice were confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility has failed to provide the required "EXIT" signs required on exit doors leading to an exit access in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.1.2 and 18.2.10.1 These deficient practices could negatively affect all patients, staff and visitors using the space by causing confusion in the event of a power failure.

Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that the doors leading out of the hockey training area did not have the proper exit signage above the doors.



This deficient practice was confirmed by the Director of Maintenance. [RA]

Based on observations and staff interview it was revealed that one of the smoke barriers were not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the patients, staff and visitors.

Findings include:

During the facility tour on November 30, 2015, between 12:30 pm and 4:00 pm observations revealed that there were penetrations in the smoke barrier wall above the cross corridor doors near the accounting managers office.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from a hazardous area, located in the 1997 portion of the facility, in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the patients, staff, and visitors as smoke and fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observation revealed on the first floor near the radiology dept. a wall separating the mechanical room had unprotected penetrations.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from multiple hazardous areas located in the 1955 portion of the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the patients, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015, observation revealed on the lower level the wall separating the hazard storage room and the corridor, and the wall separating the HVAC room and the corridor had unprotected penetrations.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting patients, staff, and visitors of the facility.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed the smoke detector, located on the 1st floor near near the offfice of the Director of Radiology, was installed within 36 inches of the HVAC diffuser.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting residents, staff, and visitors of the facility.


Findings include:


On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed the smoke detectors located on the 2nd floor near room 1and on the 3rd floor near room 304 were installed within 36 inches of HVAC diffusers.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting residents, staff, and visitors of the facility.


Findings include:


On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that a smoke detector located in the lower lever male locker room and several dectectors located throughout the surgery center on the first floor, were installed within 36 inches of HVAC diffusers.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and interview with staff, the facility has failed to properly maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), Section 19.7.6, and 4.6.12, NFPA 13 Installation of Sprinkler Systems (99), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed a corroded sprinkler head located on the first floor next to the MRI restroom.


This deficient practice was verified by the Director of Engineering (RA).

Based on observations and staff interview it was determined that the room where compressed oxygen cylinders are stored is not in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition section 4-3.1.1.2 and 19.3.2.4 of the Life Safety Code.This deficient practice could allow a fire to extend beyond this room and could negatively impact patients, staff and visitors of the facility.

Findings include:
Observations during the facility tour on November 30, 2015 between the hours of 12:30 pm and 4:00 pm, revealed a penetration in a wall of the medical gas storage room.

This deficient practice was verified by the Director of Engineering (RA).

Based on observations and staff interview, structural components of the building are in violation of the Minnesota State Fire Code (07). This deficient condition could result in a weakening of the members during a fire event which could affect the structural integrity of the building. This deficiency could affect all patients, visitors, and staff.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 it was observed, in the first floor mechanical room by radiology and the lower level light bulb room, that the structural beams have areas with the fire resistive spray coating scraped off.

This deficient practice was verified by the Director of Engineering (RA).

Based on observation and interview with the staff, the facility was not limiting storage near electrical devices in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of residents, staff and visitors of the facility.


Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that there was an excessive amount of combustible items being stored within 36 inches of the 480 volt electrical transformer and other electrical panels that are located in the lower level Central Supply room.


This deficient condition was verified by the Director of Engineering [RA]

Based on observation and staff interview, the facility had a corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.6.3.6. This deficient practice could affect the safety of patients, staff and visitors, if smoke from a fire were allowed to enter the exit access corridors making it untenable.

Findings include:

On facility tour between 7:30 am and 3:30 pm December 1, 2015 it was observed that the door for the first floor houskeeping storage did not latch when left to close on its own.

The deficient practice were confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility had a cross corridor door that did not meet the requirements of NFPA 101 LSC (00) Section 18.3.7.7 This deficient practice could affect the safety of patients, staff and visitors if, when closed, multiple persons attempt passage at the same time.

Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015 it was observed that the cross corridor doors on the lower level in the 2010 addition were without visions panels as required.

The deficient practice were confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility has failed to provide the required "EXIT" signs required on exit doors leading to an exit access in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.1.2 and 18.2.10.1 These deficient practices could negatively affect all patients, staff and visitors using the space by causing confusion in the event of a power failure.

Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that the doors leading out of the hockey training area did not have the proper exit signage above the doors.



This deficient practice was confirmed by the Director of Maintenance. [RA]

Based on observations and staff interview it was revealed that one of the smoke barriers were not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 8.3.6. This deficient practice could allow the products of combustion to travel throughout the building by passing through the smoke barrier, which will negatively impact all of the patients, staff and visitors.

Findings include:

During the facility tour on November 30, 2015, between 12:30 pm and 4:00 pm observations revealed that there were penetrations in the smoke barrier wall above the cross corridor doors near the accounting managers office.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from a hazardous area, located in the 1997 portion of the facility, in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the patients, staff, and visitors as smoke and fire in this room could enter the corridor making it untenable.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observation revealed on the first floor near the radiology dept. a wall separating the mechanical room had unprotected penetrations.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from multiple hazardous areas located in the 1955 portion of the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the patients, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015, observation revealed on the lower level the wall separating the hazard storage room and the corridor, and the wall separating the HVAC room and the corridor had unprotected penetrations.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting patients, staff, and visitors of the facility.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed the smoke detector, located on the 1st floor near near the offfice of the Director of Radiology, was installed within 36 inches of the HVAC diffuser.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting residents, staff, and visitors of the facility.


Findings include:


On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed the smoke detectors located on the 2nd floor near room 1and on the 3rd floor near room 304 were installed within 36 inches of HVAC diffusers.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting residents, staff, and visitors of the facility.


Findings include:


On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that a smoke detector located in the lower lever male locker room and several dectectors located throughout the surgery center on the first floor, were installed within 36 inches of HVAC diffusers.


This deficient practice was verified by the Director of Engineering (RA).

Based on observation and interview with staff, the facility has failed to properly maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00), Section 19.7.6, and 4.6.12, NFPA 13 Installation of Sprinkler Systems (99), and NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, (98). This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 observations revealed a corroded sprinkler head located on the first floor next to the MRI restroom.


This deficient practice was verified by the Director of Engineering (RA).

Based on observations and staff interview it was determined that the room where compressed oxygen cylinders are stored is not in accordance with NFPA 99 Standard for Health Care Facilities 1999 edition section 4-3.1.1.2 and 19.3.2.4 of the Life Safety Code.This deficient practice could allow a fire to extend beyond this room and could negatively impact patients, staff and visitors of the facility.

Findings include:
Observations during the facility tour on November 30, 2015 between the hours of 12:30 pm and 4:00 pm, revealed a penetration in a wall of the medical gas storage room.

This deficient practice was verified by the Director of Engineering (RA).

Based on observations and staff interview, structural components of the building are in violation of the Minnesota State Fire Code (07). This deficient condition could result in a weakening of the members during a fire event which could affect the structural integrity of the building. This deficiency could affect all patients, visitors, and staff.

Findings include:

On facility tour between 12:30 pm and 4:00 pm on November 30, 2015 it was observed, in the first floor mechanical room by radiology and the lower level light bulb room, that the structural beams have areas with the fire resistive spray coating scraped off.

This deficient practice was verified by the Director of Engineering (RA).

Based on observation and interview with the staff, the facility was not limiting storage near electrical devices in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect the safety of residents, staff and visitors of the facility.


Findings include:

On facility tour between 7:30 am and 3:30 pm on December 1, 2015, observations revealed that there was an excessive amount of combustible items being stored within 36 inches of the 480 volt electrical transformer and other electrical panels that are located in the lower level Central Supply room.


This deficient condition was verified by the Director of Engineering [RA]