|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: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors free from impediments to closing and ensure positive latching with smoke tight resistance, affecting two of seven smoke compartments within this component.
1. Observation made on May 20, 2019, at 1:00 pm, revealed room 207 corridor door was blocked open by chair.
Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the door was impeded from closing.
2. Observation made on May 20, 2019, at 1:00 pm, revealed the 1st floor NLC wing linen closet corridor door by room 229, failed to close completely and positively latch into the frame.
Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed that door failed to positively latch.
3. Observation made on May 20, 2019, between 1:25 pm and 1:40 pm, revealed the following corridor doors would not resist the passage of smoke between the top of the door and frame:
a. 1:25 pm, room 202 corridor door;
b. 1:40 pm, room 151 corridor door.
Interview at the exit conference with the Administrator, Environmental Services Director and the Maintenance Director on May 20, 2019, at 2:45 pm, confirmed the above stated doors would not resist the passage of smoke.
| ||Plan of Correction - To be completed: 07/16/2019|
Checking for any barriers to impeded resident doors from closing will be added to facility's 'Non-Clinical Rounds' which are completely weekly by management team or designee. Results of 'Non-Clinical Rounds" will be reported through QA Steering Committee.
Door hinge was repaired during time of inspection to ensure NLC wing linen closet closed completely and positively latched into the frame. All utility closets will be audited quarterly for six months. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.
Room 202 and 151 corridor doors were repaired during time of inspection. Audit will be conducted quarterly for six months to ensure all corridor doors resist the passage of smoke between the top of the door and frame. Results of audits will be reported through Safety Committee who will then determine the frequency of audit if necessary.