|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 184.108.40.206 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 220.127.116.11.6 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.
18.104.22.168, 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.
Name: MAIN BUILDING - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to close, and to be free of obstructions, on two of three floors within the component.
1. Observation on February 13, 2020, at 12:20 PM revealed first floor Resident Room 164 door was dragging on the threshold, and would not close.
Interview with the Director of Maintenance on February 13, 2020, at 12:20 PM confirmed the door failed to close.
2. Observation on February 13, 2020, at 1:30 PM revealed the 2nd floor Dining Room door, by Resident Room 252, would not close.
Interview with the Director of Maintenance on February 13, 2020, at 1:30 PM confirmed the doors would not close.
3. Observation on February 13, 2020, at 1:45 PM revealed the 2nd floor to Resident Room 205 door was impeded by a wheelchair.
Interview with the Director of Maintenance on February 13, 2020, at 1:45 PM confirmed the door was obstructed from closing.
| ||Plan of Correction - To be completed: 04/13/2020|
1. Resident room door in 164 was adjusted to close and latch.
2. The dining room door on the second floor was adjusted to close and latch
3.The chair/wheelchair was removed from the area in room 205 permitting the door to close and latch
All doors are monitored on a monthly basis. Repairs and corrections are performed in an expedient manner.
Maintenance performs this monitoring on a monthly basis and the results of this are reported to the Safety Committee and Quality Improvement Committee monthly.