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The facility failed to ensure complete two-hour fire rated wall assemblies for two (2) of seven (7) occupancy separations surveyed.

Observation determined:

1) The two-hour fire rated occupancy separation wall that separated the sixth floor of the clinic from the atrium had unsealed spaces around multiple through-wall penetrations.

2) The two-hour fire rated occupancy separation wall that separated the fifth floor of the clinic from the atrium had unsealed spaces around multiple through-wall penetrations.

The facility failed to ensure the existing type of building construction met the required building construction type required in Chapter 19.

Observation determined an open pipe penetrated the two-hour fire rated floor/ceiling assembly between and the third and fourth floor from Room 4H051.

Essentia Health failed to ensured all vertical openings between floors were enclosed with construction having a fire resistance of at least two hours.

According to the Director of Engineering and Plant Operations, previously identified deficiencies continue for five of five vertical shafts in the hospital that were not constructed to provide a two-hour rated fire resistive construction. The vertical shafts were in areas passing through the floor/ceiling assemblies, attached to exterior walls, and in mechanical rooms.

The facility failed to ensure two (2) of nine (9) smoke barriers within the facility were smoke resisting and had a fire resistance rating of at least one-half hour.

Observation determined:

1) Unsealed spaces around low voltage wires penetrating the second floor smoke barrier above the cross corridor doors in the Endoscopy Unit.

2) Unsealed spaces around a PVC pipe penetrating the second floor smoke barrier above the cross corridor doors in the Endoscopy Unit.

3) Unsealed spaces around a conduit penetrating the east side of the fourth floor smoke barrier above the cross corridor doors of the south corridor.
4) An unsealed hole in the west side of the fourth floor smoke barrier above the cross corridor doors of the north corridor.

The facility failed to ensure self-closing doors in smoke barriers were operable.

Observation determined the automatic-closing door on the lower level, one (1) of six (6) floors with smoke barriers, failed to close completely.

The facility failed to ensure at least two acceptable exits were provided for each floor or fire section of the building.

Observation determined:

1) The ceiling height of the third floor west corridor was 7'-2" in height, not the required 7'-6".

2) The space between the handrails of the northeast stairs was 35", not the required 37" for six (6) of seven (7) floors.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined:

1) The exit sign in the second floor Women's Locker Room was not illuminated.

2) No directional exit sign was provided to identify the northeast stairway from the southwest direction on the third floor of the clinic.

The facility failed to ensure automatic fire sprinkler systems were installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) Two (2) sprinklers in the Pharmacy were located approximately four (4) feet apart.

2) A shower curtain with no mesh was hung in OB Triage Room #2. The shower curtain obstructed the sprinkler coverage when pulled across the space. The curtain was removed immediately by maintenance staff.

1) Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.

Observation determined the facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. The visibility of two (2) of four (4) exit signs were obstructed by hanging signs in the corridor for Radiology and Lab/Radiology.
2) A functional test be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test shall be conducted for a 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure annual 90-minute testing of emergency battery-powered lights was completed. Observation determined the battery-powered emergency light by the stairs on the first floor failed to illuminate when tested. No documentation was available for the 90-minute test on the battery-powered lights.

3) Fire alarm connections to the light and power service must be on a dedicated branch circuit. The circuit and connections must be mechanically protected. Circuit disconnection means must have a red marking, be accessible only to authorized personnel, and be identified as Fire Alarm Circuit Control. The facility has not ensured the fire alarm system was continuously maintained in a reliable operating condition.

Observation determined the facility failed to provide a locking device on the fire alarm electrical circuit breaker.

4) When an automatic sprinkler system is installed in a facility, it is to be installed and maintained in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems
1999 Edition and is to be maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

The facility failed to install and maintain the automatic sprinkler system in accordance with these standards.

Observation determined:

a) The sprinklers in the second floor Combustible Storage Room were installed a distance greater than 12 inches from the roof.

b) Information was not available to document the flow switch for the mall's automatic fire sprinkler system was interconnected to the clinic fire alarm system.

c) Sprinkler coverage by a sprinkler in the Radiology Room was obstructed by a rail attached to the ceiling adjacent to the sprinkler.

5) Fire alarm systems must be continuously maintained in a reliable operating condition and inspected, tested and maintained at frequencies in compliance with the minimum requirements of Tables 7-2 and 7-3, NFPA 72 National Fire Alarm Code 1999 Edition.

Observation and records review determined:

A manual pull station by the stairs on the first floor failed the fire alarm test on 10/23/12 by the contracted fire alarm company testing company. There was no documentation available to indicate this device was repaired or replaced.

6) Hazardous areas must be separated from all other areas by a smoke resisting enclosure in sprinklered buildings.

The facility failed to ensure enclosure of hazardous areas provided a smoke resisting separation.

Observation determined the second floor Combustible Storage Room had no door on the first floor and no door on the second floor to prevent the passage of smoke via the stairs to the first floor.

7) The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70 National Electrical Code.

Observation determined an electrical junction box lacked a cover plate in the second floor Server Room.

The minimum width of the working space in front of electric equipment must be the width of the equipment or 30 inches, whichever is greater. The work space must permit at least a 90 degree opening of equipment doors or hinged panels. The required working space must not be used for storage. NFPA 70, National Electrical Code 110.26

The facility failed to ensure adequate working space in front of the electrical panels in the Kitchen.

Observation determined combustible storage was located immediately in front of and adjacent to the electrical panels.

The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70.

Observation determined an electrical junction box lacked a cover plate in Electrical Closet 6H050 on the sixth floor.

The facility failed to ensure complete two-hour fire rated wall assemblies for two (2) of seven (7) occupancy separations surveyed.

Observation determined:

1) The two-hour fire rated occupancy separation wall that separated the sixth floor of the clinic from the atrium had unsealed spaces around multiple through-wall penetrations.

2) The two-hour fire rated occupancy separation wall that separated the fifth floor of the clinic from the atrium had unsealed spaces around multiple through-wall penetrations.

The facility failed to ensure the existing type of building construction met the required building construction type required in Chapter 19.

Observation determined an open pipe penetrated the two-hour fire rated floor/ceiling assembly between and the third and fourth floor from Room 4H051.

Essentia Health failed to ensured all vertical openings between floors were enclosed with construction having a fire resistance of at least two hours.

According to the Director of Engineering and Plant Operations, previously identified deficiencies continue for five of five vertical shafts in the hospital that were not constructed to provide a two-hour rated fire resistive construction. The vertical shafts were in areas passing through the floor/ceiling assemblies, attached to exterior walls, and in mechanical rooms.

The facility failed to ensure two (2) of nine (9) smoke barriers within the facility were smoke resisting and had a fire resistance rating of at least one-half hour.

Observation determined:

1) Unsealed spaces around low voltage wires penetrating the second floor smoke barrier above the cross corridor doors in the Endoscopy Unit.

2) Unsealed spaces around a PVC pipe penetrating the second floor smoke barrier above the cross corridor doors in the Endoscopy Unit.

3) Unsealed spaces around a conduit penetrating the east side of the fourth floor smoke barrier above the cross corridor doors of the south corridor.
4) An unsealed hole in the west side of the fourth floor smoke barrier above the cross corridor doors of the north corridor.

The facility failed to ensure self-closing doors in smoke barriers were operable.

Observation determined the automatic-closing door on the lower level, one (1) of six (6) floors with smoke barriers, failed to close completely.

The facility failed to ensure at least two acceptable exits were provided for each floor or fire section of the building.

Observation determined:

1) The ceiling height of the third floor west corridor was 7'-2" in height, not the required 7'-6".

2) The space between the handrails of the northeast stairs was 35", not the required 37" for six (6) of seven (7) floors.

The facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. 7.10.1.2

Observation determined:

1) The exit sign in the second floor Women's Locker Room was not illuminated.

2) No directional exit sign was provided to identify the northeast stairway from the southwest direction on the third floor of the clinic.

The facility failed to ensure automatic fire sprinkler systems were installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) Two (2) sprinklers in the Pharmacy were located approximately four (4) feet apart.

2) A shower curtain with no mesh was hung in OB Triage Room #2. The shower curtain obstructed the sprinkler coverage when pulled across the space. The curtain was removed immediately by maintenance staff.

1) Means of egress must have exit and directional signs with continuous illumination visible from any direction of exit access. 7.10, 39.2.10.

Observation determined the facility failed to ensure exits were marked by approved signage that was readily visible from any direction of exit access and that obviously and clearly identified the exit. The visibility of two (2) of four (4) exit signs were obstructed by hanging signs in the corridor for Radiology and Lab/Radiology.
2) A functional test be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test shall be conducted for a 90-minute duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure annual 90-minute testing of emergency battery-powered lights was completed. Observation determined the battery-powered emergency light by the stairs on the first floor failed to illuminate when tested. No documentation was available for the 90-minute test on the battery-powered lights.

3) Fire alarm connections to the light and power service must be on a dedicated branch circuit. The circuit and connections must be mechanically protected. Circuit disconnection means must have a red marking, be accessible only to authorized personnel, and be identified as Fire Alarm Circuit Control. The facility has not ensured the fire alarm system was continuously maintained in a reliable operating condition.

Observation determined the facility failed to provide a locking device on the fire alarm electrical circuit breaker.

4) When an automatic sprinkler system is installed in a facility, it is to be installed and maintained in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems
1999 Edition and is to be maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.

The facility failed to install and maintain the automatic sprinkler system in accordance with these standards.

Observation determined:

a) The sprinklers in the second floor Combustible Storage Room were installed a distance greater than 12 inches from the roof.

b) Information was not available to document the flow switch for the mall's automatic fire sprinkler system was interconnected to the clinic fire alarm system.

c) Sprinkler coverage by a sprinkler in the Radiology Room was obstructed by a rail attached to the ceiling adjacent to the sprinkler.

5) Fire alarm systems must be continuously maintained in a reliable operating condition and inspected, tested and maintained at frequencies in compliance with the minimum requirements of Tables 7-2 and 7-3, NFPA 72 National Fire Alarm Code 1999 Edition.

Observation and records review determined:

A manual pull station by the stairs on the first floor failed the fire alarm test on 10/23/12 by the contracted fire alarm company testing company. There was no documentation available to indicate this device was repaired or replaced.

6) Hazardous areas must be separated from all other areas by a smoke resisting enclosure in sprinklered buildings.

The facility failed to ensure enclosure of hazardous areas provided a smoke resisting separation.

Observation determined the second floor Combustible Storage Room had no door on the first floor and no door on the second floor to prevent the passage of smoke via the stairs to the first floor.

7) The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70 National Electrical Code.

Observation determined an electrical junction box lacked a cover plate in the second floor Server Room.

The minimum width of the working space in front of electric equipment must be the width of the equipment or 30 inches, whichever is greater. The work space must permit at least a 90 degree opening of equipment doors or hinged panels. The required working space must not be used for storage. NFPA 70, National Electrical Code 110.26

The facility failed to ensure adequate working space in front of the electrical panels in the Kitchen.

Observation determined combustible storage was located immediately in front of and adjacent to the electrical panels.

The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70.

Observation determined an electrical junction box lacked a cover plate in Electrical Closet 6H050 on the sixth floor.