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.
|
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure there were no impediments closing corridor doors, affecting two of six smoke compartments within the facility.
Findings include:
1. Observations on July 1, 2026, between 9a.m., and 1:15 p.m., revealed:
a) First floor, both kitchen doors were heavily damaged, preventing the doors from closing and positively latching.
b) Second floor janitorial closet was not latched when tested due to a magnet used to block the door latch strike plate.
Exit conference with the Administrator and Maintenance Director on July 1, 2026, at 1:30 p.m., confirmed the door latching issues.
| | Plan of Correction - To be completed: 08/11/2026
The corridor doors identified during Life Safety code survey were immediately adjusted to ensure proper operation. The doors were tested to verify they close completely and latch to frame, and maintain the required resistance to processing smoke. The hardware identified for replacement is in the process of installation.
The Maintenance Director/designee conducted a facility wide inspection of all corridor doors to verify they close properly, positively latch, and are free of excessive gaps or damage. Any additional deficiencies identified during inspection were corrected immediately.
The Maintenance director/designee will include routine inspection of all corridor doors monthly. The maintenance director was educated on Life Safety Code requirements related to corridor doors, including positive latching, self closing function, and maintaining smoke-resistant construction. Any deficiencies identified during routine inspection will be corrected promptly and documented
The Maintenance Director/designee will perform and document monthly audits of corridor door compliance x 3 months to verify continued compliance.
Results will be reviewed during QAPI x 3 months
|
|
