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 7.2.1.9 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 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.
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor openings in five locations, affecting two of four floors.
Findings include:
1. Observation on January 31, 2024, between 10:50 a.m., and 11:38 a.m., revealed the following:
a. 10:50 a.m., the basement-level, Dietary Storage Room door was held open by unapproved means (tape); b. 10:52 a.m., a small penetration of the basement-level, Dietary Office door. c. 10:54 a.m., the Dry Storage Room door was held open by unapproved means (propped open). d. 10:58 a.m., the basement-level, Dish Room door required adjustment to fully latch. e. 11:38 a.m., the second floor, Room 204 door was not smoke-tight.
Exit interview on January 31, 2024, between 12:15 p.m., and 12:30 p.m., with the Facilities Manager, and the Facility Administrator, confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 03/15/2024
A. All door props were immediately removed, new hardware will be installed to properly seal penetrations, all doors will be adjusted for proper closure and smoke tightness. B. All maintenance staff will be educated on the importance of doors closing properly, penetrations, props, and smoke tightness in accordance with NFPA 101 Corridor Doors C. Weekly audits for 4 weeks, and monthly audits for 3 months will be conducted by the Facilities Director to ensure compliance.
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