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 three corridor openings, affecting one of one floors.
Findings include:
1. Observation on May 13, 2025, between 11:17 a.m. and 11:29 a.m., revealed the following:
a. 11:17 a.m., Resident Room 21, door required adjustment to fully latch into frame.
b. 11:21 a.m., Resident Room 27, door failed to latch into frame when tested.
c. 11:29 a.m., Resident Room 17, door required adjustment to fully latch into frame.
Exit interview with the facility administrator and facilities manager on May 13, 2025, at 12:00 p.m., confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 05/23/2025
1.The resident rooms, 21, 27, and 17 were immediately repaired to ensure the door would fully latch to the frame.
2.To identify other areas with the likelihood to be affected, the Maintenance Director conducted a facility wide audit of all resident rooms to ensure all doors properly latch to door frame.
3.The prevent future occurrence, the NHA educated the Maintenance Director on importance of maintaining door latches so that they are secured to door frame properly.
4.The monitor ongoing compliance, the Maintenance Director will complete an audit weekly x4 then monthly x2 of resident doors to ensure they latch securely. The results of this audit will be reviewed at QAPI to evaluate need for ongoing repair of door latches.
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