HospitalInspections.org

Bringing transparency to federal inspections

425 NORTH ELM STREET

SAUK CENTRE, MN 56378

Subdivision of Building Spaces - Smoke Barrie

Tag No.: K0374

Based on observation and staff interview, the facility failed to maintain smoke barrier doors per NFPA 101 (2012 edition), Life Safety Code, sections 19.3.7.8 and 8.5.4.1. These deficient findings could have a patterned impact on the residents within the facility.

Findings include:

1. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that the smoke barrier doors going into the Shipping and Receiving area in the basement did not close when released from the magnetic hold-open device.

2. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that the fire barrier door in the basement between the hospital and the clinic did not close and latch when released from the magnetic hold-open device.

3. On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by observation that a fire door in the laundry area was being blocked in the open position with a plastic bottle. Violation was corrected at the time of discovery.

An interview with the Maintenance Director verified these deficient findings at the time of discovery.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on a review of available documentation and staff interview, the facility failed to maintain the emergency generator per NFPA 99 (2012 edition), Health Care Facilities Code, section 6.4.4.1.1.3, and NFPA 110 (2010 edition), Standard for Emergency and Standby Power Systems, sections 8.4.9, 8.4.9.1, 8.4.9.2, and 8.4.9.7. This deficient finding could have a widespread impact on the residents within the facility.

Findings include:

On 05/15/2024 between 9:00 AM and 12:00 PM, it was revealed by a review of available documentation that at the time of the survey the facility could not provide documentation showing a four (4) hour load bank test has been completed within the last 36 months.

An interview with the Maintenance Director verified this deficient finding at the time of discovery.