|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 220.127.116.11 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 18.104.22.168.6 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.
22.214.171.124, 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: LEFFLER - Component: 02 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors would properly close and resist the passage of smoke, in three of six smoke compartments within the component.
1. Observation on September 11, 2019, between 12:15 PM and 12:55 PM revealed corridor doors were hitting either the neighboring leaf, or the frame, which prevented them from closing and positively latching, at the following locations:
a. 12:15 PM, Resident Room 325/327, the double doors were hitting each other;
b. 12:17 PM, Resident Room 324/326, the double doors were hitting each other;
c. 12:20 PM, Resident Room 322 was impeded by the privacy curtain;
d. 12:25 PM, Resident Room 320 was impeded by a waste basket;
e. 12:35 PM, Spa, by Personal Laundry was impeded by a walker;
f. 12:45 PM, Resident Room 305/307, the double doors were hitting each other;
g. 12:55 PM, Shower Room, by Resident Room 309, was hitting the frame;
Interview with the Director of Maintenance on September 11, 2019, at 12:55 PM confirmed the corridor door deficiencies.
2. Observation on September 11, 2019, at 1:05 PM, revealed the doors to the Serving Kitchen did not close and positively latch.
Interview with the Director of Maintenance on September 11, 2019, at 1:05 PM confirmed the door failed to positively latch.
| ||Plan of Correction - To be completed: 10/28/2019|
1a) Resident room 325/327 had the doors adjusted by maintenance to close properly.
1b) Resident room 324/326 had the doors adjusted by maintenance to close properly
1c) Resident room 322 had the privacy curtain returned to normal position away from the doors
1d) Resident room 320 had the trash can removed from the doorway.
1e) Spa room had the walker removed from the doorway
1f) Resident room 305/307 had the doors adjusted by maintenance to close properly.
1g) Shower room/BR door by room 309 was adjusted to close properly
2) Serving Kitchen doors were adjusted by maintenance to close properly.
Maintenance will do door checks weekly.
Maintenance Director will monitor results and take the results of the door checks to the QAPI committee for further recommendations.