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 BLDG - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to positively latch, in two of four smoke zones within the component.
Findings include:
1. Observation on May 7, 2025, between 11:45 AM and 11:53 AM, revealed corridor doors failed to positively latch, at the following locations:
a. 11:45 AM, Brossman Wing, Linen Closet by Room 24, inactive leaf flush bolt failed to engage when the active leaf was latched into the inactive leaf;
b. 11:53 AM, Franzen Wing, Spa Door.
Interview at the time of the exit conference with the Administrator and the Maintenance Director on May 7, 2025, at 12:15 PM, confirmed the corridor doors failed to positively latch.
| | Plan of Correction - To be completed: 06/06/2025
Linen Closet by Room 24: The inactive leaf flush bolt will be repaired by contracted door service. The Franzen Spa door will be repaired by contracted door service.
The Director of Facility Services will educate Maintenance, CNAs and Laundry staff on maintaining positive latching.
Maintenance staff will complete random audits of facility corridor doors to ensure they properly latch weekly for 4 weeks, monthly for 2 months and quarterly thereafter. Results of the audits will be reported to the QAPI Committee.
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