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: SKIILED NURSING - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors in one of five smoke compartments.
Findings include;
1. Observation on January 29, 2024, between 11:25 am and 11:27 am, revealed the following doors failed to latch in their frame when tested.
a. At 11:25 am, room 219, 2nd floor. b. At 11:27 am, room 215, 2nd floor.
Interview at the time of the exit conference with the administrator and maintenance supervisor on January 29, 2024, at 12:00 pm, confirmed the doors lacked positive latching.
| | Plan of Correction - To be completed: 02/14/2024
Adjustments to the door latch and seals were made for the door to operate properly and to comply with the Life Safety Code. Provide education to staff to make aware that all resident doors are to positive latch. Any that are not working properly be reported to facility designee to be fixed to comply with the Life Safety Code. A Full Audit will be done on the doors of the facility to check for positive latching. Monthly Audits x 3 Months will be conducted to ensure the ongoing compliance. Findings to be reported to QAPI.
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