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MAHNOMEN HEALTH CENTER
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and staff interview the facility to maintain a hazardous storage room in accordance with the 2012 Life Safety Code (NFPA 101) section 19.3.2.1.3. This deficient condition could allow smoke or fire to enter the corridor making it untenable and affect the quick and efficient exiting for all patients and an undetermined amount of staff and visitors.
Findings include:
On the Facility tour between 2:00 pm and 4:00 pm on 04/11/2018 observations revealed the soiled utility room did not have a self closing door.
This deficient condition was confirmed by the Facility Maintenance Director.
Fire Alarm System - Installation
Tag No.: K0341
Based on observations and staff interview the facility failed to install the smoke detection in accordance with NFPA 101 Life Safety Code (2012) section 19.3.4.1, 9.6.1.3 and NFPA 72 National Fire Alarm Code (2010) section 17.7.4.1. This deficient practice could affect the ability of the alarm system to sound in a timely manner during a fire event which could affect all patients and an undetermined amount of patients, staff and visitors.
Findings include:
On the facility tour between 2:00 pm and 4:00 pm on 04/11/2018 observations revealed three smoke detectors were within 36 inches of an HVAC diffuser in the following locations.
1. In the hood room
2. In the X-ray office
3. In the CT room
This deficient condition was confirmed by the Facility Maintenance Director.
Soiled Linen and Trash Containers
Tag No.: K0754
Based on observation and staff interview the facility failed to properly store soiled linen containers in a protected hazardous room as stated in the Life Safety Code NFPA 101 2012 edition section 19.7.5.7. This deficient practice could affect the safety of an undetermined amount of staff and visitors if smoke or fire from one of these containers made the corridors non-useable.
Findings include:
On the facility tour between 2:00 pm to 4:00 pm on 04/11/2018 observations revealed three soiled linen containers over 32 gallons each were stored in the corridor outside of the soiled utility room.
This deficient condition was confirmed by the Facility Maintenance Director.