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 one of one floor.
Findings include:
1. Observation on May 27, 2025, between 11:39 a.m., and 12:39 p.m., revealed the following:
a. 11:39 a.m., the 400 Hall Clean Utility Room door was not smoke-tight.
b. 11:43 a.m., the 300 Hall Clean Utility Room door was not smoke-tight.
c. 12:36 p.m., the Resident Room 202 door required adjustment to fully latch.
d. 12:39 p.m., the A Wing Medication Room door was not smoke-tight.
Exit interview with the Facility Administrator and the Facilities Manager between 1:10 p.m., and 1:15 p.m., on May 27, 2025, confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 06/30/2025
1.The 400 hall clean utility room door has been fixed and is now smoke-tight according to code.
2.The 300 hall clean utility room door has been fixed and is now smoke-tight according to code.
3.The resident door in 202 has been adjusted and the door is able to fully latch to meet code.
4.The A wing medication room door has been fixed and is now smoke-tight according to code.
5.Maintenance will be in serviced on maintaining smoke-tight doors per regulations and fully latching doors.
6.Random audits will be conducted monthly to ensure all doors remain smoke tight and results of audit will be presented and discussed at the facilities QAPI meetings monthly.
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