|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 188.8.131.52 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 184.108.40.206.6 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.
220.127.116.11, 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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain the required smoke resistance of corridor doors, in four of eleven smoke compartments within the component.
1. Observation on May 29, 2019, between 11:00 AM and 12:20 PM, revealed corridor doors failed to positively latch, at the following locations:
a. 11:00 AM, Mechanical Room 20;
b. 11:55 AM, Resident Room 216;
c. 12:05 PM, Resident Room 131;
d. 12:20 PM, Kitchen, by the roll-down service window.
Interview with the Manager of Property Services on May 29, 2019, at 12:20 PM confirmed the corridor doors failed to positively latch.
| ||Plan of Correction - To be completed: 07/28/2019|
Time Limited Waiver Requested - Noted Below.
Manager Property Services/designee has ordered and will replace the coordinator on the Mechanical Room door 20 when it arrives to ensure positive latching.
Manager Property Services/designee has ordered and will replace the latching hardware on Resident Room door 216 when it arrives to ensure positive latching.
Manager Property Services/designee has ordered and will replace Resident Room door 131 when it arrives to ensure positive latching. *Time Limited Waiver Requested
Dining Services Director/designee changed the location of the trash can in the Kitchen by the roll-down service window and will educate the Dining Services team on maintaining corridors doors to be free of impediment and positive latching.
Manager Property Services/designee will conduct random audits of corridor doors to ensure doors positively latch weekly for 4 weeks, then monthly routinely. In addition this will also be included as part of our monthly Environmental Safety Rounds. Audit results and corrective action(s) will be reported to the Quality Assurance and Performance Improvement Safety Committee for review and/or further recommendations as needed. Resolution to be determined by committee.