|Corridor - Doors |
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 220.127.116.11 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. 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 18.104.22.168.6 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.
22.214.171.124, 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.
Name: MAIN BUILDING - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, on two of three floors within the component.
1. Observation on January 30, 2019, between 1:45 PM and 2:30 PM, revealed the following corridor door failed to positively latch:
a. 1:45 PM, Quiet Room;
b. 1:47 PM, Resident Room 202;
c. 2:30 PM, Resident Room 129.
Interview with the Director of Maintenance on January 30, 2019, at 2:30 PM confirmed the corridor doors failed to positively latch.
| ||Plan of Correction - To be completed: 02/11/2019|
Latch adjustment made to Quiet Room, Resident Room 202, and Resident Room 129 on 2/11/2019.
All deficiencies will be reported and monitored by Director Environmental Services/Designee. All audits will be reported to QA committee on a quarterly basis to ensure compliance.
Date of Completion: February 11, 2019.