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NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Corridor walls form a barrier to limit the transfer of smoke. Such walls are permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for the corridor walls. NFPA 101 (00) Chapter 18, Sections 18.3.6.1, 18.3.6.2, 18.3.6.5.

This STANDARD is not met as evidenced by:
Based upon observation, the facility had a visitor's lounge which was open to the corridor system, and this space was not equipped with automatic smoke detection.

FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, observation revealed a Visitor's Lounge on the second floor which was open to the corridor system, and was not equipped with an electrically supervised automatic smoke detector in accordance with NFPA 101 (00) Chapter 18, Section 18.3.6.1 and the 2007 edition of Minnesota State Fire Code [MSFC] Section 907.2.6.1.

This deficient practice was confirmed with the chief building engineer.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

This STANDARD is not met as evidenced by:
Based on a review of available documentation, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) was maintained in accordance with NFPA 101 (2000) Chapter 19, Section 19.5.2.1 and Chapter 9, Section 9.1 and NFPA 90A [1999]. In a fire emergency, a noncompliant HVAC system could adversely affect 25 of 25 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, while reviewing the facility's HVAC system with the chief building engineer, the existence of fire/smoke dampers within Building 01 of the facility was confirmed, and no documentation could be provided verifying the fire/smoke dampers were inspected/tested within the previous 6 years, in accordance with NFPA 90A [1999] Chapter 3, Section 3-4.7 and CMS S&C - 10-04-LSC.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Cooking facilities shall be protected in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.2.6 and Chapter 9, Section 9.2.3 and NFPA 96 (1998).

This STANDARD is not met as evidenced by:
Based upon observation and a staff interview, it could not be confirmed the automatic hood extinguishment system was electrically interconnected to the building fire alarm system to provide proper annunciation to building occupants, in accordance with NFPA 96 (1998) Chapter 7, Section 7-6. In a fire emergency within the main dietary department, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.


FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, during an inspection of the facility's main dietary area, it was observed the commercial range and exhaust hood were protected by an automatic fire extinguishing system, however, electrical interconnection of the automatic fire extinguishing system to the building fire alarm system could not be confirmed, in accordance with NFPA 96 (98) Chapter 7, Section 7-6.2.

This finding was confirmed with the chief building engineer.

NFPA 101 [2000] LIFE SAFETY CODE SURVEY STANDARD - Corridor walls form a barrier to limit the transfer of smoke. Such walls are permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for the corridor walls. NFPA 101 (00) Chapter 18, Sections 18.3.6.1, 18.3.6.2, 18.3.6.5.

This STANDARD is not met as evidenced by:
Based upon observation, the facility had a visitor's lounge which was open to the corridor system, and this space was not equipped with automatic smoke detection.

FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, observation revealed a Visitor's Lounge on the second floor which was open to the corridor system, and was not equipped with an electrically supervised automatic smoke detector in accordance with NFPA 101 (00) Chapter 18, Section 18.3.6.1 and the 2007 edition of Minnesota State Fire Code [MSFC] Section 907.2.6.1.

This deficient practice was confirmed with the chief building engineer.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

This STANDARD is not met as evidenced by:
Based on a review of available documentation, it could not be verified that the facility's general ventilating and air conditioning system (HVAC) was maintained in accordance with NFPA 101 (2000) Chapter 19, Section 19.5.2.1 and Chapter 9, Section 9.1 and NFPA 90A [1999]. In a fire emergency, a noncompliant HVAC system could adversely affect 25 of 25 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, while reviewing the facility's HVAC system with the chief building engineer, the existence of fire/smoke dampers within Building 01 of the facility was confirmed, and no documentation could be provided verifying the fire/smoke dampers were inspected/tested within the previous 6 years, in accordance with NFPA 90A [1999] Chapter 3, Section 3-4.7 and CMS S&C - 10-04-LSC.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY REGULATION - Cooking facilities shall be protected in accordance with NFPA 101 (2000), Chapter 19, Section 19.3.2.6 and Chapter 9, Section 9.2.3 and NFPA 96 (1998).

This STANDARD is not met as evidenced by:
Based upon observation and a staff interview, it could not be confirmed the automatic hood extinguishment system was electrically interconnected to the building fire alarm system to provide proper annunciation to building occupants, in accordance with NFPA 96 (1998) Chapter 7, Section 7-6. In a fire emergency within the main dietary department, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.


FINDINGS INCLUDE:

On 7/6/12 between 8:30 AM and 2:30 PM, during an inspection of the facility's main dietary area, it was observed the commercial range and exhaust hood were protected by an automatic fire extinguishing system, however, electrical interconnection of the automatic fire extinguishing system to the building fire alarm system could not be confirmed, in accordance with NFPA 96 (98) Chapter 7, Section 7-6.2.

This finding was confirmed with the chief building engineer.