|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 184.108.40.206 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 220.127.116.11.6 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.
18.104.22.168, 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 corridor openings in two locations, affecting one of one floor.
1. Observation on May 23, 2022, between 11:22 a.m., and 11:23 a.m., revealed the following:
a. 11:22 a.m., the Dietary entrance door panic hardware was damaged.
b. 11:23 a.m., the Dish Room door required adjustment to fully latch.
Exit interview with the Facility Administrator on May 23, 2022, between 12:00 p.m., and 12:30 p.m., confirmed the corridor opening deficiencies.
| ||Plan of Correction - To be completed: 06/24/2022|
All panic hardware equipped doors throughout the facility were inspected for proper closure and latching; all other doors equipped with panic hardware are functioning properly.
The damaged dietary entrance door panic hardware will be replaced.
The dish room door panic hardware will be adjusted and/or replaced as necessary so that the door closes and latches.
Proper functioning of panic hardware equipped doors has been added as a quality indicator for the Quality Improvement (QI) program.
The Maintenance Director or assigned staff will inspect, document, and repair proper functioning of panic hardware equipped doors throughout weekly with a goal of 100% compliance.
Maintenance Director will review and report the results at the monthly QI program meeting. Monitoring and reporting will continue until a goal of 100% compliance attained and maintained for three consecutive months.