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 (WEST BUILDING) - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure that corridor doors positively latched into the door frame and remained closed in the frame, affecting two of over forty doors within the component.
1. Observations made on September 22, 2025, between 10:30 a.m. and 10:40 a.m., revealed corridor doors that failed to latch in the following locations:
a. 10:30 a.m., on the first floor, Service Hallway Kitchen door 1.
b. 10:40 a.m., on the first floor, Service Hallway Kitchen door 2.
Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the doors failed to latch in the above-named locations.
2. Observations made on September 22, 2025, between 10:30 a.m. and 12:45 p.m., revealed corridor doors that failed to latch in the following locations:
a. Resident room 111 failed to latch.
Exit Interview with the Administrator and Maintenance Director on September 22, 2025, at 1:15 p.m., confirmed the doors failed to latch in the above-named locations.
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Based on an onsite Revisit conducted on February 4, 2026, at 10:00 a.m., the following was determined:
Item 1A and 1B, not completed.
Exit interview with the Administrator on February 4, 2026, at 11:15 a.m., confirmed the door failed to close and latch.
All other deficiencies listed under this tag were corrected.
| | Plan of Correction - To be completed: 02/23/2026
1. Door vendor fixed temporarily in house. Permanent fix from vendor on 3/4/2026.
2. On 2/10/2026 the Maintenance Director/Designee audited corridor doors to verify corridor doors latch to their frame.
3. Dietary staff reeducated on keeping door closed and proper operation of door closure to ensure sealing of compartment.
4. On 2/10/2026 the Administrator educated the Maintenance department Director on ensuring corridor doors latch to their frame.
5. The Administrator/Designee began conducting audits on 2/11/2026 of corridor doors weekly for 4 weeks to ensure corridor doors latch to their frame. The results of the audits will be reviewed at the QAPI meeting held monthly.
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