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 AND THERAPY ADDITION - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain the unobstructed closing of corridor doors, affecting one of 11 floors within the component.
Findings include:
1. Observation on April 21, 2025, at 10:00 AM, revealed the 6th floor door to Resident Room E601 was obstructed from closing by a clothes hanger hung from the doorknob hardware.
Interview with the Director of Maintenance on April 21, 2025, at 10:00 AM, confirmed the corridor door was obstructed from closing.
| | Plan of Correction - To be completed: 06/18/2025
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
K0363 NFPA – Corridor-Doors 1. The clothes hanger was removed from resident room corridor door in E602, door handle at time of observation. 2. All house audit of corridor all doors to ensure that corridor doors are closing. 3. The NHA or Designee will provide re-education to the facility staff, including laundry and kitchen staff that nothing can block any corridor door. 4. The maintenance director or designee will complete random audits of corridor doors on all floors to ensure that nothing is blocking any corridor doors from closing, audit to be completed monthly. 5. The findings of the audits will be reported to the facility quality assurance performance improvement committee to determine the need for additional actions or monitoring. 6. Date of Compliance: 6/18/25
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