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 corridor openings in two locations, affecting one of one floor.
Findings include:
1. Observation on July 15, 2025, between 10:59 am, and 11:12 am, revealed the following:
a. At 10:59 am, Green Hall, Resident Room 108 door failed to positive latch into frame.
b. At 11:12 am, Peach Hall, Resident Room 132 door failed to positive latch into frame.
Exit interview with the Facility Administrator and the Facilities Manager on July 15, 2025, at 11:30 am, confirmed the doors failed to latch when tested.
| | Plan of Correction - To be completed: 08/04/2025
a. Resident Room 108 door, located in Green Hall, and Resident Room 132 door, located in Peach Hall; that failed to positively latch into their door frames were immediately repaired. No residents were affected.
b. An audit of the facilities remaining resident room doors was completed by the Director of Maintenance to assure that all doors were positively latching into their respective door frames with no concerns.
c. Director of Maintenance and maintenance staff were educated by the Licensed Nursing Home Administrator on maintaining positive latching of all resident room doors.
d. The Maintenance Director/Designee will conduct one weekly audit of all resident room doors for two weeks, then monthly for two months.
Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
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