|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 22.214.171.124 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 126.96.36.199.6 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.
188.8.131.52, 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 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain three corridor openings, affecting one of one floor.
1. Observation on May 24, 2022, between 10:37 a.m., and 11:09 a.m., revealed the following:
a. 10:37 a.m., the Staff Lounge door was difficult to open/close.
b. 10:55 a.m., the Housekeeping Office door required adjustment to fully latch.
c. 11:09 a.m., the Chapel door required adjustment to fully latch.
Exit interview with Facility Representative One on May 24, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the corridor opening deficiencies.
| ||Plan of Correction - To be completed: 06/07/2022|
The staff Lounge door was adjusted to allow for proper opening and closing.
The housekeeping office door and chapel door were adjusted to fully latch.
There were no other doors identified as not opening or closing properly or not latching.
The maintenance Director and assistant are educated on the need to maintain corridor openings and have doors adjusted to fully latch and open and close properly.
An audit will be done on these three doors weekly to assure they are closing properly in addition to ten other random doors weekly.