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 maintain corridor doors with positive latching and smoke tight resistance, affecting 3 of six levels.
Findings Include:
1. Observation made on July 1, 2024, between 1:58 p.m. and 2:35 p.m., revealed the following corridor door deficiencies:
a. the Dietary Supervisor's office door was propped open with a vegetable can. The door was equipped with a self-closing device, basement;
b. the Dry Storage room double doors inactive leaf had a dead bolt installed, prohibiting the doors self-latching into their frames when the bolt is engaged, basement;
c. one leaf of the kitchen corridor double doors next to the Dietary Supervisor's office, across from the exterior exit, dragged the floor and would not positively latch into the frame, basement;
d. room 153 corridor door would not latch into the frame, 1st floor east;
e. electrical closet double doors across from room 159 would not latch into the frame, 1st floor;
f. soiled linen room door across from room 168 was not smoke tight in its frame, 1st floor;
g. room 268 corridor door rubs the frame, providing resistance to closing, 2nd floor east;
h. the clean linen closet outside room 256 had a hole at the bottom of the doors, there was no latching hardware, and the door was not smoke tight in its frame, 2nd floor;
i. the double doors between the east and west wings would not latch into their frame, 2nd floor.
Exit Interview with the Facility Administrator, Assistant Administrator, Regional and Facility Maintenance Directors on July 1, 2024, at 3:30 p.m., confirmed the above corridor door deficiencies.
| | Plan of Correction - To be completed: 08/30/2024
Deadbolt removed from Dry Storage Area double doors, inactive leaf, allowing the door to properly latch into frame.
Kitchen Corridor double doors next to Dietary Supervisor's Office was adjusted to positively latch into door frame.
Room 153, 1st floor-East door was adjusted to properly latch into frame.
Door to Electrical Closet across from room 159, first floor-East was adjusted to properly latch into frame.
Door to Soiled Linen Room across from room 168, first floor-East was adjusted to properly latch into frame.
Corridor double doors adjacent to room 286, 2nd floor-East was adjusted to properly latch into frame.
Proper door hardware was installed to door of Clean Linen Closet outside of room 256, 2nd floor-East and was adjusted to properly latch into frame. Hole at the bottom of door was filled using fire-rated caulk WL3195.
Double doors 2nd floor between East and West wings were adjusted to properly fit into frame.
An audit was completed of all facility doors to ensure that doors properly latch into frame. Where doors were found not to properly latch into frame, those doors were adjusted to ensure proper latch into frame.
Maintenance staff were educated regarding the requirement that all doors properly latch into frame.
Random audits will be completed weekly x 4 and then monthly x 2 to ensure that all doors properly latch into frame.
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