|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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors, affecting one of eighteen smoke compartments.
1. Observation on January 22, 2020, at 10:10 a.m., revealed the 3rd floor corridor door #318 could not close and latch.
Exit interview with the facility assistant administrator and facility representative #1, on January 23, 2020, at 11:00 a.m., confirmed the corridor door.
| ||Plan of Correction - To be completed: 02/24/2020|
Room 318 door was immediately adjusted to insure proper closure. Resident room doors were inspected and adjusted.
Random audits of resident room door closure will be conducted on 5 doors on each nursing unit weekly for 8 weeks.
Corridor doors are inspected semi-annually for proper closure. Any doors found to be not closing properly are adjusted or replaced.
Completion date is February 24, 2020.