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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to be unobstructed from closing, and to positively latch, on two of three floors within the component.
Findings include:
1. Observation on March 4, 2025, between 1:10 PM and 1:35 PM, revealed corridors doors were impeded and could not be closed, at the following locations:
a. 1:10 PM, 1st floor, Resident Room 40, by a fall mat;
b. 1:18 PM, 1st floor, Resident Room 41, by a fall mat;
c. 1:20 PM, 1st floor, Resident Room 47, by a wheelchair;
d. 1:35 PM, 2nd floor, Resident Room 124, by a wheelchair.
Interview with the Director of Maintenance on March 4, 2025 at 1:35 PM, confirmed the corridor doors were obstructed from closing.
2. Observation on March 4, 2025, between 1:40 PM and 2:05 PM, revealed corridors doors failed to positively latch in the frame, at the following locations:
a. 1:40 PM, 2nd floor, Resident Room 131;
b. 1:50 PM, 2nd floor, Resident Room 145;
c. 2:05 PM, 2nd floor, Resident Room 148.
Interview with the Director of Maintenance on March 4, 2025 at 2:05 PM, confirmed the corridor doors failed to positively latch.
| | Plan of Correction - To be completed: 04/02/2025
1. The fall mats and wheel chairs were removed immediately from rooms 40, 41,47, and 124.
2. A baseline audit of the corridor doors was completed to ensure they were free from obstruction, positively latched and functioned appropriately. The Maintenance Director will add corridor doors to his routine preventative maintenance schedule to ensure corridor doors positively latch and are free from obstruction.
3. The facility staff was re-educated that corridor doors are the first defense against the spread of smoke, and must positively latch and cannot be obstructed and if a door does not function properly to report it immediately to his/her supervisor.
4. The Director of Maintenance and/or his designee will randomly audit corridor doors quarterly X 4 to ensure continued compliance. The results of the random audits will be presented to the Quality Assurance Team for review and further recommendations as appropriate.
1. The corridor doors 2nd floor room 131, 2nd floor 145 and 2nd floor 148 were adjusted to ensure they positively latch into the frame.
2. A baseline audit of corridor doors was completed to ensure positive latching and appropriate function.
The Director of Maintenance added corridor doors to his routine preventative maintenance schedule to ensure compliance.
3. Facility staff was re-educated that corridor doors are the first defense against the spread of smoke and that corridor doors must positively latch and if they do not to report the malfunction to his/her supervisor immediately.
4. The Director of Maintenance and/or his designee will randomly audit the corridor doors quarterly X 4. The results of the random audits will be presented to the Quality Assurance team for review and further recommendations as appropriate.
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