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 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 one floors.
Findings include:
1. Observation on December 17, 2024, between 9:45 a.m., and 10:36 a.m., revealed the following:
a. At 9:45 a.m., 100 Hall, Resident Room 112, door failed to latch into frame when tested. b. At 10:02 a.m., 100 Hall, Shower Room, door was not smoke tight when closed into frame. c. At 10:36 a.m., 300 Hall, Dining Room, door failed to latch into frame when tested.
Exit interview with the Facility Acting Administrator, Facilities Manager, and the Environmental Director, on December 17, 2024, at 11:00 a.m., confirmed the corridor opening deficiencies.
| | Plan of Correction - To be completed: 01/15/2025
1. All identified door latches corrected to assure positive latching by maintenance director or designee on 12/27/24. All other facility doors will be inspected by maintenance director or designee to assure positive latching occurs by 1/10/25.
2. Maintenance director or designee will inspect 10 doors weekly to assure positive latching is functioning properly.
3. Results of inspections will be reported monthly to the safety and QAPI committees for further review and recommendations.
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