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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to ensure there were no impediments to the closing of the corridor doors on two of three floors within the facility.
Findings include:
1. Observations on May 14, 2026, between 11:45 a.m. and 2:15 p.m., revealed at the following locations there were impediments blocking or preventing the corridor doors from closing and positively latching:
a) on the third floor, Maple Cafe, double door coordinator failed.
b) on the second floor, Chestnut Cafe, double door coordinator failed.
Exit interview with the Administrator, Maintenance Director on May 14, 2026, at 2:30 p.m., confirmed the door closing impediments.
| | Plan of Correction - To be completed: 07/08/2026
K363
1) The door coordinators on the double doors to both the Maple Café on third floor and Chestnut Café on the second floor will be repaired so that they close and positively latch.
2) Other corridor doors will be checked to ensure that they close and positively latch.
3) The Maintenance Director and/or designee will perform audits weekly for four weeks and monthly for two months to ensure that fire extinguishers are accessible.
Results of the audits will be reported to QAPI meeting.
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