|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 184.108.40.206 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 220.127.116.11.6 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.
18.104.22.168, 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 corridor doors with smoke tight resistance and positive self-latching into their frames, affecting two of four smoke compartments.
1. Observation on January 28, 2020, between 1:01 p.m. and 1:02 p.m., revealed the following corridor doors and bathroom doors were interlocked, prohibiting the corridor doors from latching into their frames, 2nd floor:
a. at 1:01 p.m., resident room 232;
b. at 1:02 p.m., resident room 227.
Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the corridor doors were obstructed from closing.
2. Observation made on January 28, 2020, between 1:15 p.m. and 1:48 p.m., revealed the following resident room corridor doors were deficient:
a. at 1:15 p.m., resident room 10 door had swelled, allowing resistance to closing, 1st floor;
b. at 1:48 p.m, resident room 211 would not latch into its frame when tested, 2nd floor.
Interview at the exit conference with the Facility Administrator and the Director of Maintenance on January 28, 2020, at 3:30 p.m., confirmed the corridors door required adjustment.
| ||Plan of Correction - To be completed: 03/10/2020|
Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.
Resident room 232, 227 doors were cleared from interlocking and latched into their frames
Room 10, 211 doors have been repaired so that it closes and latches properly
Staff will be educated by the
Maintenance Director will do audit 2 x a week for four weeks for 4 weeks, then 2 times a month for 2 months and as needed thereafter to ensure doors latch to their frames.
Results will be reported to QA for review and recommendations.