Initial Comments:
Name - MAIN BUILDING Component - 01
Facility ID# 02050101
Component 01
Main Building
Based on a Relicensure Survey completed on May 4, 2021, it was determined that Barnes-Kasson County Hospital was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.
This is a three story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.
Plan of Correction:
NFPA 101 STANDARD
Stairways and Smokeproof Enclosures
Name - MAIN BUILDING Component - 01
Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
Observations:
Based on observation and interview, it was determined the facility failed to maintain one exit stair tower enclosure, affecting three of three floors.
Findings include:
1. Observation on May 4, 2021, at 10:00 a.m., revealed storage items were located within the first floor portion of the stair tower enclosure, located closest to the lower parking lot.
Exit interview with the facilities manager on May 4, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the stair tower enclosure deficiency.
Plan of Correction:The facility will remove the stored items from the first floor portion of the stair tower enclosure.
A facility wide assessment will be conducted to make sure that all stairways are maintained free from stored items. Barnes Kasson will make any corrections identified during this facility wide assessment.
The facility manager will be responsible for continued compliance with this plan of correction.
NFPA 101 STANDARD
Hazardous Areas - Enclosure
Name - MAIN BUILDING Component - 01
Hazardous Areas - Enclosure
2012 EXISTING
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Based on observation and interview, it was determined the facility failed to maintain two hazardous area enclosures, affecting two of three floors.
Findings include:
1. Observation on May 4, 2021, between 10:23 a.m. and 11:04 a.m., revealed the following:
a. 10:23 a.m., the patient shower is presently used as a storage room, and lacked a self-closing device.
b. 11:04 a.m., the morgue/storage room entrance door required adjustment to fully latch.
Exit interview with the facilities manager on May 4, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the hazardous area enclosure deficiencies.
Plan of Correction:The facility will install a self-closing device on the storage room door.
The facility will adjust/repair the morgue/storage room entrance door so that the door fully latches.
A facility wide assessment will be conducted to make sure that all hazardous area enclosures are maintained per NFPA 101 standard for hazardous area enclosures. Barnes Kasson will make any corrections identified during this facility wide assessment.
The facility manager will be responsible for continued compliance with this plan of correction.
NFPA 101 STANDARD
Corridor - Doors
Name - MAIN BUILDING Component - 01
Corridor - Doors
2012 EXISTING
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between bottom of door and floor covering is not exceeding 1 inch. Roller latches are prohibited by CMS regulations on corridor doors and rooms containing flammable or combustible materials. Powered doors complying with 7.2.1.9 are permissible. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.
Observations:
Based on observation and interview, it was determined the facility failed to maintain five corridor openings, affecting three of three floors.
Findings include:
1. Observation on May 4, 2021, between 10:03 a.m. and 11:02 a.m., revealed the following:
a. 10:03 a.m., the distance between the O.R. entrance doors exceeded one-eighth-inch.
b. 10:04 a.m., the Nursing Office door was warped and lacked smoke-tight integrity.
c. 10:05 a.m., the Room 20 door was not smoke-tight.
d. 10:22 a.m., holes were located within the Water Closet door.
e. 11:00 a.m., the Dietary entrance door required adjustment to fully latch.
Exit interview with the facilities manager on May 4, 2021, between 11:15 a.m. and 11:30 a.m., confirmed the corridor opening deficiencies.
Plan of Correction:The facility will make the following repairs/adjustments:
a. The O.R. entrance doors will be adjusted to correct the distance between doors to be less than one-eighth inch.
b. The Nursing Office door will be repaired or replaced so that it has smoke-tight integrity.
c. Room 20 door will be adjusted so that it is smoke-tight.
d. The holes on the water closet door will be filled/repaired.
e. The Dietary entrance door will be adjusted so that it fully latches.
A facility wide assessment will be conducted to make sure that all corridor doors are maintained in compliance with NFPA 101 standard for corridor doors. Barnes Kasson will make any corrections identified during this facility wide assessment.
The facility manager will be responsible for continued compliance with this plan of correction.
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