|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 188.8.131.52 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 184.108.40.206.6 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.
220.127.116.11, 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 openings in five locations, affecting two of six smoke compartments.
1. Observation on April 30, 2019, between 9:12 a.m. and 10:05 a.m., revealed the following:
a. 9:12 a.m., third floor, resident room 325 required adjustment to fully latch within the corresponding door frame assembly.
b. 9:13 a.m., third floor, resident room 324 lacked smoke-tight integrity.
c. 9:21 a.m., third floor, resident room 306 required adjustment to fully latch within the corresponding door frame assembly.
d. 9:59 a.m., second floor, resident room 228 required adjustment to fully latch within the corresponding door frame assembly.
e. 10:05 a.m., the second floor, resident room 209 door was held open by unapproved means (door chock).
Exit interview with the facility administrator and the facilities manager on April 30, 2019, between 11:15 a.m. and 11:30 a.m., confirmed the corridor opening deficiencies.
| ||Plan of Correction - To be completed: 05/22/2019|
1. Resident rooms 325, 324, 306 and 228 have had their door latches adjusted to fully latch. Room 209 had the door chock removed.
2. There were no other rooms affected.
3. The maintenance director/designee will audit the rooms 325, 324, 306, 228 and 209 to insure the doors positively latch and are not propped open with a door chock weekly for 4 weeks, then monthly for 2 months.
4. The results of the audit will be presented to the QA committee for review and recommendation.