|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 18.104.22.168 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 22.214.171.124.6 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.
126.96.36.199, 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 corridor doors to be unobstructed, and to positively latch, in two of three smoke compartments within the component.
1. Observation on September 12, 2019, between 1:05 PM and 1:09 PM revealed the following corridor doors would not close and latch, due to the bathroom door being in the open position. When the bathroom door was opened, the corridor door would hit the bathroom door and prohibit it from closing:
a. 1:05 PM, Resident Room 129;
b. 1:07 PM, Resident Room 126;
c. 1:09 PM, Resident Room 124.
Interview with the Director of Maintenance on September 12, 2019, at 1:09 PM confirmed the corridor doors could not be closed due to obstruction from another door.
2. Observation on September 12, 2019, at 1:30 PM revealed the corridor door, to Resident Room 112, would not close and latch.
Interview with the Director of Maintenance on September 12, 2019, at 1:30 PM confirmed the corridor door did nto positively latch.
| ||Plan of Correction - To be completed: 11/04/2019|
1. Mechanical closures will be added to bathroom doors to prohibit obstruction with corridor doors. Resident room 112 door was adjusted to positively latch.
2. Environmental Services Director/designee will audit bathroom doors bathroom doors quarterly to ensure there is no obstruction with the corridor doors. Results of audits will be reviewed at QAPI to ensure quality assurance and compliance.