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 doors in seven instances, affecting three of nine smoke compartments.
Findings include:
1. Observation on May 20, 2025, revealed the following corridor door deficiencies:
a) 9:00 a.m., the door to room 221 failed to latch when tested;
b) 9:15 a.m., the door to room 222 failed to latch when tested;
c) 9:25 a.m., the door to room 226 failed to latch due to a tray blocking the door;
d) 9:35 a.m., the door to room 225 failed to latch due to a wheelchair blocking the door;
e) 9:45 a.m., the door to room 111 failed to latch due to a table blocking the door;
f) 10:00 a.m., the door to room 103 failed to latch when tested;
g) 10:10 a.m., the door to room 120 failed to latch due to a bed blocking the door.
Interview with the Facility Administrator and Maintenance Director on May 20, 2025, at 10:30 a.m., confirmed the corridor door deficiencies.
| | Plan of Correction - To be completed: 06/17/2025
1. Doors 221,222,103 had the transitions strip changed to allow door closure and latch with ease. Doors 226,225,111 and 120 had items removed and latched with ease.
2. No other doors were identified as not latching.
3. Education was provided by the NHA/designee to ensure that nothing blocks egress of the patient doors and that if a door is not latching properly, it should be reported in TELS for repair.
4. Audits will be conducted on 5 random doors by the Maintenance Director or designee weekly x 4 for 4 weeks.
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