|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: BUILDING 1 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed, and to meet allowed gap margins, on one of two floors within the component.
1. Observation on June 10, 2019, at 1:15 PM revealed the corridor door to the DON Office failed to positively latch, due to an over-the-door clothes hanger.
Interview with the Director of Maintenance on June 10, 2019, at 1:15 PM confirmed the door was obstructed from closing.
2. Observation on June 10, 2019, at 12:45 PM revealed the corridor door from the Meadow View Dining Room to the Kitchen Corridor had gaps greater than 3/16 inch, across the top and strike side, and was a rated door.
Interview with the Director of Maintenance on June 10, 2019, at 12:45 PM confirmed the dining room door was rated, and exceeded the allowed gap margins.
| ||Plan of Correction - To be completed: 06/21/2019|
1.A. The over the door clothes hanger was removed.
B. The Director of Nursing was educated on discontinuing the use of over the door hangers.
C. Office doors will be audited monthly to insure no obstruction and positive latch.
2.A. The Meadow View Kitchen door was repaired by an outside contractor to meet the 1/8th inch requirement utilizing approved materials on 6/20/19.
B. Rated door swing audits will be increased from an annual to a quarterly basis.
Q.A. One random monthly door audit and all rated door swing audits will be reported quarterly by the Director of Maintenance to the QAPI committee for review and further intervention if required.