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Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the Women Center, there is an open penetration above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 18.1.1.4, 18.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the Women Center, there is an open penetration above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. .

FINDINGS INCLUDE:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed the following:

Corridor door (l021) Dirty Linen Collection Room was being held open by a kick down device.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 18, Section 18.3.2.1 and 18.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. .

FINDINGS INCLUDE:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed that the corridor door to (l021) Dirty Linen Collection Room # l02, was being held open by a kick down device.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based upon a review of available records and staff interview, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect all patients.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the Night Shift during 1st Quarter of 2015.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

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, Section 1-5.6. This deficient condition 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 all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed that there was no automatic smoke detector with sounder base present in the doctors sleeping room #2015.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.7.6, 4.6.12, as well as 1998 NFPA 25, 9.7.5.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire sprinkler inspection reports provided by facility staff. The review indicated the Annual Fire Sprinkler Inspections were conducted on August 8, 2014 and September 18, 2015. The September inspection exceeds the time frame to be considered annual.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 39.3.5, as well as 1998 NFPA 25, 9.7.5.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire sprinkler inspection reports provided by facility staff. The review indicated the Annual Fire Sprinkler Inspections were conducted on August 8, 2014 and September 18, 2015. The September inspection exceeds the time frame to be considered annual.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a stairwell free from impediments to full instant use in the case of fire or other emergency, in accordance with NFPA 101 (2000), Chapter 7, Sections 7.1.10.1 and 7.1.10.2.1, and, the 2007 edition of Minnesota State Fire Code (MSFC) Chapter 10, Section 1028.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed, boxes of air filters and ceiling tile were being stored within the emergency exit from the 3rd floor OB/Nursery Area.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6.4.2.



FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the weekly generator inspection reports provided by facility staff, it was determined that the weekly inspection documentation is not adequate to show that all the required items are being inspected.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

ased on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6.4.2.



FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the weekly generator inspection reports provided by facility staff, it was determined that the weekly inspection documentation is not adequate to show that all the required items are being inspected.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed, two extension cords plugged into lamps in the Waiting Room.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1


On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire sprinkler system.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.
.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the Women Center, there is an open penetration above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 18.1.1.4, 18.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the Women Center, there is an open penetration above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 19, Section 19.3.2.1 and 19.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. .

FINDINGS INCLUDE:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed the following:

Corridor door (l021) Dirty Linen Collection Room was being held open by a kick down device.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a hazardous area door in accordance with NFPA 101 (00), Chapter 18, Section 18.3.2.1 and 18.3.6.3.2, and Chapter 8, Section 8.2.3.2.3.2. .

FINDINGS INCLUDE:

On facility tour between 0900 AM and 4:30 PM on 09/22/2015, observation revealed that the corridor door to (l021) Dirty Linen Collection Room # l02, was being held open by a kick down device.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based upon a review of available records and staff interview, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect all patients.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the Night Shift during 1st Quarter of 2015.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

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, Section 1-5.6. This deficient condition 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 all patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed that there was no automatic smoke detector with sounder base present in the doctors sleeping room #2015.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.7.6, 4.6.12, as well as 1998 NFPA 25, 9.7.5.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire sprinkler inspection reports provided by facility staff. The review indicated the Annual Fire Sprinkler Inspections were conducted on August 8, 2014 and September 18, 2015. The September inspection exceeds the time frame to be considered annual.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 39.3.5, as well as 1998 NFPA 25, 9.7.5.


FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the fire sprinkler inspection reports provided by facility staff. The review indicated the Annual Fire Sprinkler Inspections were conducted on August 8, 2014 and September 18, 2015. The September inspection exceeds the time frame to be considered annual.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain a stairwell free from impediments to full instant use in the case of fire or other emergency, in accordance with NFPA 101 (2000), Chapter 7, Sections 7.1.10.1 and 7.1.10.2.1, and, the 2007 edition of Minnesota State Fire Code (MSFC) Chapter 10, Section 1028.

FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed, boxes of air filters and ceiling tile were being stored within the emergency exit from the 3rd floor OB/Nursery Area.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Based on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6.4.2.



FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the weekly generator inspection reports provided by facility staff, it was determined that the weekly inspection documentation is not adequate to show that all the required items are being inspected.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

ased on documentation review and staff interview, the facility failed to inspect the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 Chapter 6.4.2.



FINDINGS INCLUDE:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, documentation review of the weekly generator inspection reports provided by facility staff, it was determined that the weekly inspection documentation is not adequate to show that all the required items are being inspected.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to maintain electrical supply in accordance with the requirements of 2000 NFPA 101 - 9.1.2, 1999 NFPA 70, and 2007 Minnesota State Fire Code 605.4 and 605.5 .

Findings include:

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation revealed, two extension cords plugged into lamps in the Waiting Room.

This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.

Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1


On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire sprinkler system.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.
.

Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch is provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8

On facility tour between 9:00 AM and 4:30 PM on 09/22/2015, observation and documentation reviewed revealed that there was not a single plan for the out of service plan for the fire alarm system.


This deficient practice was confirmed by the Director of Maintenance (TB) at the time of discovery.
.