Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374
Based on observation and interview, the facility failed to maintain smoke barrier doors, affecting three of nine smoke compartments.
Findings include:
1. Observation on June 11, 2024, revealed the following smoke barrier door deficiencies:
a) 9:00 a.m., the smoke barrier door between the dining room and unit 1 failed to self-close and latch when tested;
b) 9:45 a.m., the smoke barrier door between the dining room and unit 2 failed to self-close and latch when tested.
Interview with the Facility Administrator and the Maintenance Supervisor on June 11, 2024, at 10:00 a.m., confirmed the above smoke barrier door deficiencies.
| | Plan of Correction - To be completed: 07/11/2024
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law.
Facility had ordered replacement door on May 20,2024 for smoke barrier door between dining room and unit 2.
Facility has ordered the self-closing and latch replacement mechanism for smoke barrier door between the dining room and unit 1.
Nursing home administrator will conduct education with the maintenance director on requirements for Smoke Barrier Doors.
The Maintenance Director/designee will audit facility smoke barrier doors 1x per week for 3 weeks then monthly for 3 months to ensure all smoke barrier doors self-close and latch.
Audits will be taken to QAPI for review/discussion.
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