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 maintain corridor doors on one of two floors.
Findings include:
1. Observation on December 26, 2023, at 11:55 am, revealed the door to room 326 failed to latch in the frame.
Interview at the time of the exit conference with the Regional Director of Plant Operations and facility maintenance representative on December 26, 2023, at 1:30 pm, confirmed the door lacked positive latching.
| | Plan of Correction - To be completed: 01/19/2024
Step 1 Door of room 326 was corrected by maintenance staff at the time of survey.
Step 2 To identify other areas with the potential to be effected, the maintenance director or designee will complete a baseline observation audit to ensure that all resident room doors latch into frame and corrected if necessary
Step 3 To prevent this from reoccurring, the maintenance director was provided education regarding the importance of ensure that all resident room doors latch into frame
Step 4 To monitor and maintain ongoing compliance, the maintenance director or designee will complete random observation audits 5 day per week for 4 weeks then monthly for 2 months to ensure that all resident room doors latch in to frame without issues.
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