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, it was determined the facility failed to maintain smoke barrier doors, affecting two of five smoke compartments.
Findings include:
1. Observation on June 30, 2022, between 10:25 a.m. and 10:45 a.m., revealed the following:
a. 10:25 a.m. - The smoke barrier doors near the administrative area do not seal when closed.
b. 10:45 a.m.- The smoke barrier doors located near resident room #15 had an inoperable door coordinator.
Exit interview with the Facility Administrator and Facility Representative #1 on June 30, 2022, at 11:40 a.m., confirmed the lack of a door seal and inoperable door coordinator.
| | Plan of Correction - To be completed: 08/01/2022
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
A
1. The smoke barrier doors near the administrative area will be adjusted to seal the gap identified upon closure of the doors. Upon completion of this adjustment, the maintenance department will inspect the smoke barrier doors within Cole place for any gaps or seal issues.
2. The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.
B.
1. The inoperable door coordinator on the smoke barrier doors near resident room 15 will be replaced. Upon completion of this repair, the maintenance department will inspect the applicable doors within Cole Place for functioning door coordinators and schedule any necessary corrective action.
2. The corrective action and inspection will be completed by August 1, 2022. The Facilities Manager is responsible to ensure that these inspections are completed and documented in the building maintenance program. This repair and inspection will be documented and reported to the Facility Administrator.
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