|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 184.108.40.206 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 220.127.116.11.6 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.
18.104.22.168, 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 maintain the positive latching of corridor doors, affecting two of ten smoke compartments within the component.
1. Observation on May 25, 2022, at 12:15 PM, revealed the door to the Telcom Room, next to Resident Room 116, failed to positively latch within the door frame.
Interview with the Administrator on May 25, 2022, at 12:15 PM, confirmed the door did not latch within the frame.
2. Observation on May 25, 2022, at 12:51 PM, revealed the single door to the Kitchen, across from the Laundry, failed to positively latch within the door frame.
Interview with the Administrator on May 25, 2022, at 12:51 PM, confirmed the door did not latch within the frame.
| ||Plan of Correction - To be completed: 07/20/2022|
The doors will be adjusted to close and latch into frame. Maintenance completed on 6-1-22.
A door audit will be completed monthly by maintenance personnel to ensure doors positively latch throughout the center.
Results of the audit will be shared monthly at the quality assurance performance improvement committee.