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 maintain corridor openings in three locations, affecting one of two floors, within this component.
Findings include:
1. Observation on May 20, 2024, between 11:05 a.m., and 11:22 a.m., revealed the following:
a. At 11:05 a.m., 2nd floor, East Wing, Resident room 212, door failed to latch into frame and was not smoke tight when tested.
b. At 11:18 a.m., 2nd floor, West Wing, Resident room 301, door failed to latch into frame and was not smoke tight when tested.
c. At 11:22 a.m., 2nd floor, East Wing, Resident room 311, door failed to latch into frame and was not smoke tight when tested.
Exit interview with the Facility Administrator and Maintenance Director on May 20, 2024, at 12:15 p.m., confirmed the corridor door deficiencies.
| | Plan of Correction - To be completed: 06/07/2024
Step 1
Immediate Corrective Action was to modify flooring under door to ensure it properly latched for 2nd flr east wing resident room 212; 2nd flr west wing resident room 301; and 2nd floor east wing resident room 311.
Step 2
To identify other doors that have potential to be affected, each resident room door was checked for closure and if any were found to latch improperly or fail to latch, they would also be modified to ensure latching. No other doors were found out of compliance.
Step 3
To prevent this from reoccurring, the NHA/designee will educate the Environmental Services and Interdisciplinary Teams on proper door latching requirement and ensure they understand the requirement to enter a work order for any required remedy where a door is found to not latch properly during standard room inspections.
Step 4
To monitor and maintain compliance, the Maintenace Manger or designee will audit 10 resident room doors weekly for 4 weeks, then 100% of resident doors monthly for 2 months to ensure proper latching is maintained. Results of the audits will be forwarded to QAPI committee for further review and recommendations.
|
|
