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: BUILDING 02 - Component: 02 - Tag: 0363
Based on observation and interview it was determined the facility failed maintain corridor doors in two of for smoke compartments.
Findings include:
1. Observation on February 29, 2024, between 11:05 am, and 11:15 am, revealed the following corridor doors were not smoke tight when latched in the frame;
a. At 11:05 am, room 112.
b. At 11:10 am, room 103.
c. At 11:15 am, room 114.
Interview at the time of the exit conference with the administrator and maintenance supervisor on February 29, 2024, at 12:30 pm, confirmed the doors lacked smoke tight integrity.
| | Plan of Correction - To be completed: 03/28/2024
1. Maintenace dept will correct doors on rooms 112, 103 and 114 to ensure they are smoke tight when latched in frame.
2. Maintenace dept will do a whole house audit of doors to ensure they are smoke tight when latched in frame.
3. IDT team will educate maintenance employees on doors needing to be smoke tight when latched in frame.
4. Maintenance/Designee will do a random audit of doors weekly x 4 to ensure they are smoke tight when latched. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.
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