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 corridor openings in three locations, affecting one of two floors.
Findings include:
1. Observation on November 21, 2024, between 10:24 a.m., and 11:20 a.m., revealed the following:
a. 10:24 a.m., the Therapy doors lacked positive latching hardware.
b. 10:29 a.m., the 3W Resident Room door was not smoke-tight.
c. 10:55 a.m., the Dining Room doors lacked positive latching hardware and one of the two doors was not smoke-tight.
Exit interview on November 21, 2024, between 11:50 a.m., and 12:00 p.m., with the Facility Administrator and the Facilities Manager, confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 12/10/2024
1. Latching hardware added to therapy and dining room doors. Doors to resident room W 3 and dining room doors fixed to be smoke tight.
2. Indoor facility doors to be checked to confirm they are smoke tight and contain proper latching hardware
3. NHA/designee to re-educate maintenance director and assistant on proper latching hardware for doors and doors being smoke tight.
4. NHA/designee to audit random doors weekly x 4 and monthly x 2 to confirm doors have latching hardware and are smoke tight weekly x 4 and monthly x 2. Results will be brought to monthly QAPI meeting and changes will be made as needed.
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