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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed from closing, to positively latch, in one of one smoke compartment within the component.
Findings include:
1. Observation on August 6, 2024, between 12:25 PM and 1:09 PM, revealed corridors doors were hitting the frame and could not be closed, at the following locations:
a. 12:25 PM, A-Hall, Resident Room 8;
b. 1:06 PM, B-Hall, Resident Room 21;
c. 1:09 PM, B-Hall, Resident Room 5.
Interview at the exit interview with the Director of Maintenance and Administrator on August 6, 2024, at 2:15 PM, confirmed the corridor doors were obstructed from closing.
2. Observation on August 6, 2024, between 1:00 PM and 1:10 PM, revealed corridors doors failed to positively latch in the frame, at the following locations:
a. 1:00 PM, B-Hall, Resident Room 18;
b. 1:10 PM, B-Hall, Resident Room 1.
Interview at the exit interview with the Director of Maintenance and Administrator on August 6, 2024, at 2:15 PM, confirmed the corridor doors failed to positively latch.
3. Observation on August 6, 2024, between 12:30 PM and 12:35 PM, it was determined the facility failed to maintain unobstructed closing of corridor doors.
a. 12:30 PM, A-Hall, Resident Room 10 impeded by a walker;
b. 12:35 PM, A-Hall, Resident Room 1 impeded by a wheelchair.
Interview at the exit interview with the Director of Maintenance and Administrator on August 6, 2024, at 2:15 PM, confirmed the corridor doors were impeded from closing.
| | Plan of Correction - To be completed: 10/01/2024
1. Maintenance director will adjust the corridor door from hitting the frame inhibiting it from closing in the following locations:
a. A Hall resident room 8,
b. B Hall resident Room 21
c. B Hall resident room 5
2. The following doors will be adjusted to positively latch in the frame in the following locations
a. B Hall resident room 18
b. B Hall resident room 1
3. The maintenance director has removed the walker, in A Hall resident room 10 and the wheelchair in A Hall resident room 1.
The maintenance director will educate the maintenance team to ensure doorways are unobstructed and to maintain closing of corridor doors.
The maintenance director will conduct full facility wide audit, then weekly random rounds for 4 weeks then monthly for 12 months to ensure compliance.
The results of the random audits will be reviewed during the monthly QAPI meeting for compliance and or for further recommendations
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