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 & SUNROOM ADDITION - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors were maintained to resist the passage of smoke and positively latch, affecting one of approximately thirty doors in the component.
Findings Include:
Observation on February 24, 2025, at 12:10 p.m., revealed on the forth floor, resident room door 404 did not latch into its frame.
Exit Interview with the Administrator, Assistant Administrator, and Maintenance Director on February 24, 2025, at 1:30 p.m., confirmed the door did not latch.
| | Plan of Correction - To be completed: 04/17/2025
Resident room door 404 has been repaired to properly latch into its frame.
The Maintenance Director and/or Designee will conduct random audits weekly x 1 month and monthly x 1 month to ensure that all resident room doors positively latch.
The results of these audits will be reviewed with the IDT during the monthly QAPI meetings to ensure ongoing compliance.
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