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: NEW HEALTH CENTER - Component: 04 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors on two of five floors.
Findings include:
Observation on July 8, 2024, between 1:00 p.m. and 1:22 p.m. revealed the following corridor doors were not smoke tight when latched in the corresponding frame.
a. At 1:00 p.m., on the fourth floor, room 413.
b. At 1:22 p.m., on the third floor, room 302.
Interview at the time of the exit confrence on July 8, 2024, at 2:30 p.m. with the administrator and facility representatives confirmed the doors lacked smoke tight integrity.
| | Plan of Correction - To be completed: 08/01/2024
The doors on the fourth floor, room 413, and the third floor, room 302 will be adjusted to become smoke tight in the corresponding frame.
Doors will be checked monthly to ensure a smoke tight fit when latched.
Results will be logged and initialed.
Monitored by Director of Maintenance or designee.
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