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 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure doors protecting corridor openings have no impediments to closing, resist the passage of smoke, and maintain positive latching, affecting two of four smoke compartments within this component.
Findings include:
1.Observations made on March 11, 2026, between 11:45 a.m. and 1:15 p.m., revealed:
a) First floor, across from resident room #12, small conference room, had removed interior door handle, and did not function.
b) First floor, Clean Linen, had paper towels and cardboard taped onto door strike, not permitting do to latch smoke tight.
c) First floor, Staff Bathroom at nurses' station, had a large hole in door, could not latch and was no longer smoke resistant.
d) Electrical room in Activities was missing latching door hardware, was pad locked, and was no longer smoke resistant.
Exit interview with the Administrator and Maintenance Director on March 11, 2026, at 1:30 p.m., confirmed the door deficiencies.
| | Plan of Correction - To be completed: 04/08/2026
Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.
1. A) Small Conference room door latch was repaired and is fully functional. B) paper towels were removed from door strike at first floor clean linen room allowing door to positively latch. c) staff bathroom door was repaired and latching hardware replaced allowing door to positively latch ensuring smoke resistance. d) Electrical room off activities lounge door hardware was installed and pad lock removed allowing door to positively latch and ensuring smoke resistance.
2. NHA / Designee conducted audits of facility doors to ensure all hardware is intact and doors can positively latch. Plan developed to address identified repairs based on priority.
3. NHA / Designee educated maintenance staff on requirements to ensure all doors positively latch and all hardware is intact.
4. NHA / Designee will audit facility doors weekly x4 then monthly x2 or until substantial compliance is obtained. To ensure all doors are intact and can latch, results will be brought to qapi for further evaluation and recommendation.
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