|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 184.108.40.206 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 220.127.116.11.6 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.
18.104.22.168, 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 doors with positive latching within their frames, free from impediments to closing, affecting two of four smoke compartments within this facility.
1. Observation made on April 16, 2019, between 2:00 pm and 2:25 pm, revealed the following corridor doors failed to close completely and positively latch into the frames:
a. 2:00 pm, A wing room 114;
b. 2:25 pm, B wing room 209.
Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the doors failed to positively latch.
2. Observation made on April 16, 2019, at 2:10 pm, revealed the A wing mini lounge corridor door had an unauthorized kick down hold open device installed.
Interview with the Administrator and the Director of Environmental Services at the exit conference on April 16, 2019, at 3:00 pm, confirmed the door was impeded from closing.
| ||Plan of Correction - To be completed: 06/12/2019|
A wing room 114 and B wing room 209 doors have been fixed and now completely close and positively latch into frames.
A wing mini lounge corridor door's unauthorized kick down hold open device has been removed.
Maintenance director with audit all doors semi annually to ensure all doors completely close and positively latch.