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 (BAIR PAVILION) - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure that corridor doors were maintained to resist the passage of smoke, affecting one of five floors.
Findings include:
Observation on March 11, 2024, at 11:35 a.m., revealed, in the resident room 200 on the second floor, corridor door failed to close and latch when tested.
Exit Interview with the Administrator and Maintenance Director on March 11, 2024, at 12:45 p.m., confirmed the corridor door failed to latch.
| | Plan of Correction - To be completed: 04/22/2024
Bair building room 200 door repaired and latching properly
Bair 1 and Bair 2 room doors audited to ensure doors are latching properly
Director of maintenance will in-service maintenance staff about K0363
Maintenance director or designee will complete doors audit to ensure all doors are latching properly weekly x4, then monthly x 2
Report of audit will be presented by director of maintenance at monthly QAPI until substantial compliance is achieved.
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