|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 188.8.131.52 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 184.108.40.206.6 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.
220.127.116.11, 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 & THERAPY BUILDING - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors free from impediments to closing and maintaining positive latching, affecting three of nine smoke compartments within this component.
1. Observation made on August 21, 2019, between 10:50 am and 1:30 pm, revealed the following corridor doors failed to latch into their frames:
a. 10:50 am, 4th floor, south wing, storage room next to resident library;
b. 1:30 pm, 3rd floor, north wing, resident room 331.
Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the doors failed to latch.
2. Observation made on August 21, 2019, at 2:00 p.m., revealed the 2nd floor south wing, room 227 corridor door was tied open with string onto a rack behind the door.
Interview at the exit conference with the Director of Nursing and the Maintenance Director on August 22, 2019, at 1:00 pm, confirmed the door was impeded from closing.
| ||Plan of Correction - To be completed: 10/21/2019|
1. A. At the 4th floor South Wing storage room next to the library, the latch was adjusted to fully latch into the frame. As a systematic change an annual task will be generated automatically monthly from the MP2 maintenance data base work order system to check all doors on the 4th floor for proper operation which will include fully latching into the frame. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.
B. At the 3rd Floor South Wing Room 331, the latch was adjusted to fully latch into the frame. In addition to the Semi Annual Door Check Task , which is generated automatically from the MP2 maintenance data base work order system for that for all doors on that floor, The Engineering Managers will spot check doors each week while performing neighborhood rounds and document findings on the Rounding the Rounding Log Sheet. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.
2. At the 2nd Floor South Room 227 the string used to hold the door open was removed. As a systematic change to prevent staff and residents from tying doors open with strings, a task instruction will be added to the Room Inspection Preventative Maintenance Task to check for and remove any device that can be used to hold the door open and prevent it from being closed. The Room Inspection Task is performed every 20 weeks and is automatically generated by the MP2 maintenance data base work order system. As a measure for quality assurance, the Engineering Services Managers review all ongoing completed work order tasks.
The Engineering Director or designee will monitor this plan.