|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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, on one of two floors within the component.
1. Observation on August 28, 2019, between 10:55 AM and 12:40 PM, revealed corridor doors failed to positively latch, at the following locations:
a. 10:55 AM, Activity Room door, off the Lounge by the Entrance, was hitting the frame and not closing and latching;
b. 11:00 AM, Office, by Resident Room 5, was hitting the frame;
c. 11:05 AM, Resident Room 18 was hitting the frame;
d. 11:07 AM, Resident Room 20 was hitting the frame;
e. 11:10 AM, Resident Room 25;
f. 11:15 AM, Resident Room 45 was hitting the frame;
g. 11:42 AM, Resident Room 104;
h. 12:00 PM, Resident Room 60 was hitting the frame;
i. 12:10 PM, Resident Room 79;
j. 12:15 PM, Resident Room 87, was hitting the frame;
k. 12:28 PM, Housekeeping/Laundry Office was hitting the frame;
l. 12:32 PM, Kitchen door, by the Kitchen Office;
m. 12:40 PM, Kitchen door to Dining Room.
Interview with the Director of Maintenance on August 28, 2019, at 12:40 PM confirmed corridor door failed to positively latch.
2. Observation on August 28, 2019, between 11:55 AM and 12:40 PM, revealed holes in the corridor doors, at the following locations:
a. 11:55 AM, Storage Room, by Resident Room 115, had holes, from old hardware;
b. 12:40 PM, Kitchen door to Dining Room, which is labeled, had an unsealed hole from old hardware.
Interview with the Director of Maintenance on August 28, 2019, at 12:40 PM confirmed the doors had unsealed holes.
3. Observation on August 28, 2019, at 12:20 PM revealed the Dining/Lounge door is a fire-rated door, with a gap greater 3/16 of an inch, and is damaged; by Resident Room 89.
Interview with the Director of Maintenance on August 28, 2019, at 12:20 PM confirmed the door exceeds the allowed gap margins.
| ||Plan of Correction - To be completed: 10/10/2019|
1. The doors will be adjusted to close and latch in frames (A,B,C,D,E,F,G,I,J,K,L,M). The storage room and kitchen doors will be repaired to be made smoke tight. New door and frame has been ordered; and the door will be adjusted to close and latch into frame (H) until the new door/frame arrive.
2. The doors with gaps or not properly latching will be adjust will be corrected by maintenance by September 30, 2019. The storage room door and the kitchen door will be repaired by September 30, 2019. The door identified in section H will be adjusted to latch appropriately by September 30, 2019 but will be replaced by October 10, 2019.
3. Maintenance Director will complete a full door audit of doors in the facility to identify any other doors that do not meet code.
4. All doors that were identified during survey will be audited for compliance with regulation once a week for four weeks, then once per month for twelve months. Audits will be reviewed in QAPI monthly.