|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 126.96.36.199 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 188.8.131.52.6 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.
184.108.40.206, 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 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain the corridor doors in one instance, for one of over 100 corridor doors tested.
Observation on September 17, 2019, at 12:30 p.m., revealed the door to the clean linen room on the ground floor was propped open with an unapproved hold open device, which would not allow the door to close and latch.
Interview with the Facility Administrator and Maintenance Director on September 17, 2019, at 1:30 p.m., confirmed the corridor door was propped open.
| ||Plan of Correction - To be completed: 10/30/2019|
The door to the clean linen room on the ground floor was closed immediately.
The Clean Linen Room does not house hazardous chemicals, however, the door was propped open with an improper hold open device.
To prevent this from re-occurring the Director of Housekeeping was educated on door closure safety.
The Director of Housekeeping and Maintenance Director will educate all housekeeping, laundry and maintenance staff members on the proper procedure for door closure safety.
The Administrator will educate all Department Managers on the proper procedure for door closure safety in order to assist in prevention in other areas of the facility. Should any doors be found improperly propped open the department manager will report to the Safety Committee for review and a continuing action plan.