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425 NORTH ELM STREET

SAUK CENTRE, MN 56378

No Description Available

Tag No.: K0011

Observations revealed that 1 of several fire barriers located throughout the facility that did not meet the rated requirements for two hour fire separation and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:00 AM and 12:30 PM on 08/28/2013, observation revealed that there multiple opening in the 2-hour fire separation around piping, conduit, and other structural members located in the wall that is separating the Hospital (I-Occupancy) from the ambulance garage (S-Occupancy).


These deficient practices were confirmed by the Maintenance staff member (DJ).

No Description Available

Tag No.: K0029

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 18.3.2.1. The following deficient practices could affect residents, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM and 12:30 PM on 08/28/2013, observations revealed that the door leading to the infectious waste storage room was not equipped with the required self closing device.


These deficient practices were confirmed by the Maintenance staff member (DJ).

No Description Available

Tag No.: K0029

Based on observations, the facility has failed to provide proper protection for several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect residents, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM and 12:30 PM on 08/28/2013, observations revealed the following deficient conditions affecting several hazardous areas throughout the facility,

1. The housekeeping storage room located on the 2nd floor by the elevator was not equipped with the required self closing device

2. there were multiple penetrations found in the housekeeping storage room located on the 2nd floor by the elevator in the wall that is separating the storage room from the corridor.


These deficient practices were confirmed by the Maintenance staff member (DJ).

No Description Available

Tag No.: K0072

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 9:00 AM and 12:30 PM on 08/28/2013, it was observed that there were multiple carts and soiled linen hoppers that were being stored in the 2nd floor north corridor that are restricting and obstructing the egress access for that corridor and the exit stairway.


These deficient practices were confirmed by the Maintenance staff member (DJ).

No Description Available

Tag No.: K0076

Observations revealed that the oxygen storage room was not maintained in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition) section 4-3.1.1.2. This deficient practice could create an oxygen enriched atmosphere that could contribute to rapid fire growth. This could negatively patients, staff, and visitors in the event of an emergency.

Findings include:

On facility tour between 9:00 AM and 12:30 PM on 08/28/2013, it was observed that the number of compressed air cylinders and oxygen cylinders that are located in the oxygen storage room that is located next to the medical records storage room when calculated had an aggregate amount of compressed gases that is greater than 3000 cubic feet. It was also observed that the room that these cylinders were being stored in was not vented to the outside by a dedicated mechanical ventilation system or natural venting means that is in accordance with oxygen storage rooms that have more than 3000 cubic feet of compressed gases.


These deficient practices were confirmed by the Maintenance staff member (DJ).