|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 220.127.116.11 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 18.104.22.168.6 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.
22.214.171.124, 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 in six instances, for six of more than 75 doors inspected in the facility.
1. Observation on September 25, 2019, revealed the following corridor door deficiencies:
a) 11:04 a.m., the door to resident room 311 would not close and latch when tested;
b) 11:51 a.m., the door to resident room 105 would not close and latch due to being obstructed by a fall mat;
c) 12:35 p.m., the door to the zone four clean linen room across from the south nurse station would not close and latch when tested;
d) 12:41 p.m., the door to resident room 214 would not close and latch when tested;
e) 12:43 p.m., the door to resident room 204 would not close and latch when tested.
Interview with the Facility Administrator and Maintenance Director on September 25, 2019, 1:30 p.m., confirmed the corridor door deficiencies.
| ||Plan of Correction - To be completed: 11/15/2019|
The doors to resident rooms 311, 105, 214, 204, and zone four clean linen room will be adjusted to ensure proper latching. The maintenance department will randomly check 5 doors on each unit weekly for one month, and 5 doors bi-weekly for one month. Doors will be adjusted as needed to ensure proper latching. Results will be reported QAPI committee. The QAPI committee will determine the need for continued monitoring.