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 in three instances, affecting two of twelve smoke compartments.
Findings include:
1. Observation on February 12, 2024, revealed the following corridor door deficiencies:
a) 8:45 a.m., the door to room 609 on the sixth floor, did not latch in its frame when tested;
b) 9:00 a.m., the door to room 607 on the sixth floor, did not latch in its frame when tested;
c) 9:40 a.m., the door to the first floor storage room, behind the front desk, was missing a door knob.
Interview with the Facility Administrator and Maintenance Director on February 12, 2024, at 10:30 a.m., confirmed the corridor door deficiencies.
| | Plan of Correction - To be completed: 03/21/2024
1. The door latches to room 607 and 609 were fixed immediately. A door knob was added to the first floor storage room.
2. NHA or designee will educate maintenance director and staff on corridor door safety.
3. To check for door latches and knobs, an audit will be conducted weekly x 3 weeks and monthly x 2 months.
4. Results of audits will be reviewed and submitted to QAPI for further monitoring.
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