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: FULTON COUNTY MEDICAL CENTER (SNF) - Component: 10 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors in two instances, affecting two of four smoke compartments.
Findings include:
1. Observation on April 22, 2025, revealed the following corridor door deficiencies:
a) 10:58 a.m., the door to Room 23B, Overly Wing, would not close and latch in its frame;
b) 11:35 a.m., the door to Room 10B, Shimer Wing, would not close and latch in its frame.
Interview with the Facility Administrator and Plant Operations Manager on April 22, 2025 at 2:00 p.m., confirmed the corridor door deficiencies.
| | Plan of Correction - To be completed: 05/23/2025
1. Facility maintenance staff fixed latch on doors to resident rooms 23B and 10B and ensured doors closed and latched on 4/30/2025.
2. Monthly door inspection form was created and provided to Plant Operations manager on 05/06/2025.
3. Facility maintenance staff will begin documenting monthly fire door inspections of all fire doors on both corridors by 5/23/2025.
4. Completion of inspections and corresponding documentation will be audited at the Building and Safety Meeting attended by The Plant Operations Manager, Director of Environmental Services, FCMC Safety Officer, Nursing Home Administrator and Chief Operations Officer for six months.
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