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 7.2.1.9 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 19.3.6.3.6 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.
19.3.6.3, 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.
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain four corridor openings, affecting three of five floors.
Findings include:
1. Observation on February 29, 2024, between 9:28 a.m., and 10:12 a.m., revealed the following corridor doors were not smoke-tight:
a. 9:28 a.m., fourth floor, Lounge.
b. 9:50 a.m., first floor, Resident Room 112.
c. 9:52 a.m., first floor, Resident Room 106.
d. 10:12 a.m., ground floor, OT.
Exit interview on February 29, 2024, between 10:55 a.m., and 11:10 a.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 03/21/2024
1. The corridor doors for the fourth floor lounge, first floor resident room 112, first floor resident room 106 and ground floor OT have been repaired to ensure they are smoke tight.
2. Utilizing the corridor inspection log, random audits will be conducted by the Maintenance Director 2 times per week for 4 weeks to ensure compliance. Any trends will be reported to QAPI for review and recommendations.
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