|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 126.96.36.199 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 188.8.131.52.6 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.
184.108.40.206, 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 maintain three corridor openings, affecting three of nine smoke compartments.
1. Observation on February 22, 2019, between 9:11 a.m. and 10:22 a.m., revealed the following:
a. 9:11 a.m. The third floor, Pantry, lacked positive latching.
b. 10:12 a.m. The second floor, resident room 221, lacked smoke-tight integrity.
c. 10:22 a.m. The first floor, Dietary doors, required adjustment in order to fully close and latch.
Exit interview with the facility administrator and the facilities manager on February 22, 2019 between 12:15 p.m. and 12:30 p.m., confirmed the corridor opening deficiencies.
| ||Plan of Correction - To be completed: 04/01/2019|
Positive latching has been ordered for third flood pantry door.
Resident room 221 door has been ordered.
Dietary doors have been ordered.
Environmental Services director or designee to install the above listed items once arrived at facility to maintain protection in corridor areas.