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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors were unobstructed from closing and could positively latch, in three of three smoke components within the component.
Findings include:
1. Observation on September 12, 2024, between 11:40 AM and 1:17 PM, revealed corridors doors were obstructed from closing, at the following locations:
a. 11:40 AM, Resident Room 803, obstructed by air mattress electrical cord; b. 12:00 PM, 700 Wing Dining, dragging; c. 12:40 PM, Resident Room 301, dragging; d. 12:48 PM, Resident Room 507 was impeded by a waste basket; e. 12:50 PM, Resident Room 509, hitting the frame; f. 1:05 PM, Resident Room 911, dragging; g. 1:17 PM, Resident Room 905, dragging.
Interview with the Director of Maintenance on September 12, 2024, at 1:17 PM, confirmed the corridor doors were obstructed from closing.
2. Observation on July 23, 2024, between 12:05 PM and 12:10 PM, revealed corridors doors failed to positively latch in the frame, at the following locations:
a. 12:05 PM, Resident Room 706; b. 12:10 PM, Resident Room 607.
Interview with the Director of Maintenance on September 12, 2024, at 12:10 PM, confirmed the corridor doors failed to positively latch.
| | Plan of Correction - To be completed: 10/31/2024
K0363
1. All stated obstructions blocking corridor doors were moved. Maintenance Director/Designee will adjust each stated corridor door that was dragging, hitting the frame, or not positively latching to ensure compliance.
2. Maintenance Director/Designee will conduct a facility audit of corridor doors to ensure they are not dragging, hitting the frame, or not positively latching. Any identified non-compliant doors will be adjusted and repaired.
3. Maintenance Director/Designee will conduct random audits monthly to ensure corridor doors close and positively latch properly for 12 months. Results to QAPI
3. Date of compliance 10/31/24
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