|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 126.96.36.199 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 188.8.131.52.6 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.
184.108.40.206, 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 (NORTH & SOUTH WINGS) - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors that positive latch and are resistive to the passage of smoke, affecting 1 of 4 smoke compartments.
1. Observation made on December 9, 2019, between 1:40 p.m. and 1:50 p.m., revealed the following corridor doors failed to positively latch into their door frame when tested:
a. 1:40 p.m., 200 wing room 203;
b. 1:45 p.m., 200 wing kitchen double doors;
c. 1:50 p.m., 200 wing room 201.
Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 p.m., confirmed the doors failed to latch.
2. Observation made on December 9, 2019, at 1:30 p.m., revealed the staff lounge corridor door had holes due to previously removed hardware.
Interview at the exit conference with the Administrator and Maintenance Director on December 9, 2019, at 2:30 p.m., confirmed the door would not resist the passage of smoke.
| ||Plan of Correction - To be completed: 01/21/2020|
The following doors have been adjusted to ensure a positive latch: Room 203, kitchen double doors, and room 201. The holes to the staff lunge corridor door have been filled with fire rated caulk.
Corrective Action Date: 1/21/2020
Maintenance will audit doors throughout the facility to ensure proper closing and completeness.
Maintenance will audit doors throughout facility to ensure proper closure and completeness monthly x3 months, then as deemed necessary by the QAPI Committee. All results will be reviewed by the QAPI Committee.