|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 22.214.171.124 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 126.96.36.199.6 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.
188.8.131.52, 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 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch in their frames, affecting one of two levels.
1. Observation on April 22, 2019, between 12:25 pm, and 12:30 pm, revealed the following corridor doors failed to close and positively latch when tested:
a. 12:25 pm, 2nd floor resident room 225;
b. 12:30 pm, 2nd floor resident room 218.
Interview at the exit conference with the Assistant Director of Nursing and the Maintenance Director on April 22, 2019, at 2:45 pm, confirmed the doors failed to close and latch when tested.
| ||Plan of Correction - To be completed: 06/03/2019|
The second floor resident room 225 and second floor resident room 218 corridor doors were adjusted to close and positively latch.
The maintenance director or designee will inspect second floor resident room doors to close and positively latch.
The maintenance director or designee will randomly audit resident room doors for closing and positively latching.
The audit results will be reviewed monthly x3 by the facility QAPI Committee.