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 ensure corridor doors were maintained, to resist the passage of smoke and positively latch, when tested, affecting three of four levels within the component.
Findings include:
1. Observations on October 8, 2024, between 9:10 am and 10:33 am, revealed there were 7 door locations failed to positively latch, when tested, at the following locations:
a. 9:10 am, 3rd floor, Room 302, entry door b. 9:57 am, 1st floor, Pantry door, near Custodian Closet; c. 10:10 am, basement floor, Employee Break Room, entry door; d. 10:16 am, basement floor, Kitchen double-doors #12; e. 10:22 am, basement floor, Kitchen double-doors #13; f. 10:24 am, basement floor, Central Supply Room, double-doors; g. 10:33 am, basement floor, Mechanical (Boiler) Room entry door.
Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the doors failed to latch, when tested.
2. Observation on October 8, 2024, at 10:22 am, revealed Central Supply Room, basement level, the entry door was obstructed from opening, due to file cabinet and box storage obstruction.
Exit interview with the Administrator and Maintenance Director on October 8, 2024, at 10:30 am, confirmed the obstruction.
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Based on an onsite Revisit conducted on December 9, 2024, between 8:30 a.m. and 3:20 p.m., revealed the following:
Item 1 - Not Completed. The facility failed to ensure corridor doors were maintained, to resist the passage of smoke and positively latch, when tested in the following locations:
a. 9:10 a.m., on the third floor, Room 302, entry door b. 9:57 a.m., on the first floor, Pantry door, near Custodian Closet; c. 10:10 a.m., basement floor, Employee Break Room, entry door; d. 10:16 a.m., basement floor, Kitchen double-doors #12; e. 10:22 a.m., basement floor, Kitchen double-doors #13; f. 10:24 a.m., basement floor, Central Supply Room, double-doors; g. 10:33 a.m., basement floor, Mechanical (Boiler) Room entry door.
Exit Interview with the Administrator and Maintenance Director on December 9, 2024, at 3:20 p.m., confirmed the doors failed to latch, when tested.
All other deficiencies listed under this tag were corrected.
| | Plan of Correction - To be completed: 12/27/2024
Maintenance staff has readjusted the following doors to ensure a positive latch: Rm 302 entry door, 1st floor pantry door, employee breakroom entry door, basement floor central supply room, and the basement floor mechanical room entry door. Facility staff have removed items obstructing the basement level central supply room door. Facility was unable to readjust the two double doors (#12 and #13) in the basement floor. Facility will secure several quotes for repairs/replacement of these doors and will request a TLW for correction of these two sets of doors. Maintenance staff will conduct an audit of corridor doors to ensure they are maintained and positively latched. Maintenance staff will be re-educated to maintaining corridor doors and keeping them unobstructed. Maintenance/designee will conduct random audits of corridor doors to ensure they are maintained, have a positive latch and are unobstructed. Audit will be conducted monthly x 3 months. All results will be reported to the QAPI Committee.
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