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Based on observation, the facility failed to maintain the required fire resistance ratings of ceiling/floor assemblies in one or more areas of the building, in accordance with NFPA 101 (2000) Chapter 19, Section 19.3.1 and Chapter 8, Section 8.2.5. In a fire emergency, this deficient practice could adversely affect 22 of 348 occupants within the affected smoke compartment.

FINDINGS INCLUDE:

On 12/14/10 between 8:00 AM and 4:30 PM, observation revealed penetrations through the ceiling/floor assemblies in the following locations:
A). Building 03, Pharmacy Storage Room E1929;
B). Building 03, Mechanical/Electrical Room E1933.

These findings were verified with the Security Supervisor [JP] at the times of discovery.

A fire alarm system required for life safety shall be installed, tested and maintained in accordance with NFPA 70 (1999) National Electrical Code and NFPA 72 (1999) National Fire Alarm Code. The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99), in accordance with NFPA 101 (00), Chapter 9, Section 9.6.

Based on observation, the facility's fire alarm system was not installed in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.4 and Chapter 9, Section 9.6.1.4 and NFPA 70 (1999) and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 30 of 348 patients, staff and visitors.

FINDINGS INCLUDE:


1. On facility tour on 12-13-10, between 11:00 AM and 4:00 PM, observation revealed that in rooms C5213 & C5406, the smoke detectors are located with-in 3 feet of the HVAC system return diffusers.


2. On facility tour on 12-14-10, between 8:00 AM and 4:00PM, observation revealed that in rooms C1371, C1462, C2097, E2926 (detector #L12D23) and E2960A(detector #L1D20), the smoke detectors are located with-in 3 feet of the HVAC system return air diffusers.


These findings were confirmed by the Director of Plant Operation (RH) and Security Supervisor [JP] at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 12/13/10 at 12:00 PM, it was confirmed that the Elevator Machine Room located in Building 03 was not equipped with automatic fire sprinkler protection in accordance with NFPA 101 (00) Chapter 19, Section 19.3.5. This finding was confirmed with the Security Supervisor [JP] at the time of discovery.

In a fire emergency, this deficient practice could adversely affect 348 of 348 patients, visitors and staff.



25822

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On facility tour between 11:00 AM and 4:00 PM on 12/13/2010, observation revealed the following:

1. 10th floor elevator machine room, located in Building 1, was not equipped with automatic fire sprinkler protection

2. 9th floor, Building 1, the middle supply closet across from stairwell B was not equipped with automatic fire
sprinkler protection

3. The elevator machine room, located in Building 03, was not equipped with automatic fire sprinkler protection.

On facility tour between 8:00 AM and 4:00 PM on 12/14/2010, observation revealed the following in Building 01:

1. 2nd floor - kitchen cooler #17 has a bent fire sprinkler head frame.

These findings were confirmed by the Director of Plant Operation (RH) and Security Supervisor (JP) at the time of discovery.

Based on observation, the facility was storing compressed gas cylinders in a manner which was not in conformance with NFPA 101 Life Safety Code (2000 edition), Chapter 19, Section 19.3.2.4 and NFPA 99 Standard for Health Care Facilities (1999 edition) Chapter 4, Section 4-3.1.1.1 and Minnesota State Fire Code (2007) Section 3004. This deficient practice could adversely affect staff or visitors in the vicinity of the Medical Gas Storage Room, if one or more cylinders were to fall-over and rupture.

FINDINGS INCLUDE:

On 12/14/10, between 8:00 AM and 4:30 PM, observation revealed multiple H-size compressed gas cylinders located in Building 03, Bottle Gas Rooms E1950 and E1949, that were stored upright but not properly secured with chains or within a storage stand designed to prevent falling. This free-standing storage arrangement is not in conformance with NFPA 99 (1999), Chapter 4, Section 4-3.1.1., and Chapter 8, Section 8-3.1.1.

This finding was confirmed with the Security Supervisor [JP] at the time of discovery.

Based on observation, the facility failed to maintain the required fire resistance ratings of ceiling/floor assemblies in one or more areas of the building, in accordance with NFPA 101 (2000) Chapter 19, Section 19.3.1 and Chapter 8, Section 8.2.5. In a fire emergency, this deficient practice could adversely affect 22 of 348 occupants within the affected smoke compartment.

FINDINGS INCLUDE:

On 12/14/10 between 8:00 AM and 4:30 PM, observation revealed penetrations through the ceiling/floor assemblies in the following locations:
A). Building 03, Pharmacy Storage Room E1929;
B). Building 03, Mechanical/Electrical Room E1933.

These findings were verified with the Security Supervisor [JP] at the times of discovery.

A fire alarm system required for life safety shall be installed, tested and maintained in accordance with NFPA 70 (1999) National Electrical Code and NFPA 72 (1999) National Fire Alarm Code. The system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70 (99) and NFPA 72 (99), in accordance with NFPA 101 (00), Chapter 9, Section 9.6.

Based on observation, the facility's fire alarm system was not installed in conformance with NFPA 101 (2000), Chapter 19, Section 19.3.4 and Chapter 9, Section 9.6.1.4 and NFPA 70 (1999) and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 30 of 348 patients, staff and visitors.

FINDINGS INCLUDE:


1. On facility tour on 12-13-10, between 11:00 AM and 4:00 PM, observation revealed that in rooms C5213 & C5406, the smoke detectors are located with-in 3 feet of the HVAC system return diffusers.


2. On facility tour on 12-14-10, between 8:00 AM and 4:00PM, observation revealed that in rooms C1371, C1462, C2097, E2926 (detector #L12D23) and E2960A(detector #L1D20), the smoke detectors are located with-in 3 feet of the HVAC system return air diffusers.


These findings were confirmed by the Director of Plant Operation (RH) and Security Supervisor [JP] at the times of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 12/13/10 at 12:00 PM, it was confirmed that the Elevator Machine Room located in Building 03 was not equipped with automatic fire sprinkler protection in accordance with NFPA 101 (00) Chapter 19, Section 19.3.5. This finding was confirmed with the Security Supervisor [JP] at the time of discovery.

In a fire emergency, this deficient practice could adversely affect 348 of 348 patients, visitors and staff.



25822

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On facility tour between 11:00 AM and 4:00 PM on 12/13/2010, observation revealed the following:

1. 10th floor elevator machine room, located in Building 1, was not equipped with automatic fire sprinkler protection

2. 9th floor, Building 1, the middle supply closet across from stairwell B was not equipped with automatic fire
sprinkler protection

3. The elevator machine room, located in Building 03, was not equipped with automatic fire sprinkler protection.

On facility tour between 8:00 AM and 4:00 PM on 12/14/2010, observation revealed the following in Building 01:

1. 2nd floor - kitchen cooler #17 has a bent fire sprinkler head frame.

These findings were confirmed by the Director of Plant Operation (RH) and Security Supervisor (JP) at the time of discovery.

Based on observation, the facility was storing compressed gas cylinders in a manner which was not in conformance with NFPA 101 Life Safety Code (2000 edition), Chapter 19, Section 19.3.2.4 and NFPA 99 Standard for Health Care Facilities (1999 edition) Chapter 4, Section 4-3.1.1.1 and Minnesota State Fire Code (2007) Section 3004. This deficient practice could adversely affect staff or visitors in the vicinity of the Medical Gas Storage Room, if one or more cylinders were to fall-over and rupture.

FINDINGS INCLUDE:

On 12/14/10, between 8:00 AM and 4:30 PM, observation revealed multiple H-size compressed gas cylinders located in Building 03, Bottle Gas Rooms E1950 and E1949, that were stored upright but not properly secured with chains or within a storage stand designed to prevent falling. This free-standing storage arrangement is not in conformance with NFPA 99 (1999), Chapter 4, Section 4-3.1.1., and Chapter 8, Section 8-3.1.1.

This finding was confirmed with the Security Supervisor [JP] at the time of discovery.