|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 22.214.171.124 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 126.96.36.199.6 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.
188.8.131.52, 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.
Name: TOWER BUILDING - Component: 03 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors on six of eleven floors.
1. Observation on January 22, 2020, between 10:20 a.m. and 2:20 p.m., revealed the following;
a. At 10:20 a.m., room 10B 3 door T10-16 not smoke tight in the frame.
b. At 10:45a.m., room 10 D 1 door T10-31 not smoke tight in the frame.
c. At 10:50 a.m., room 10 C 3 door T10-26 not smoke tight in the frame.
d. At 11:15 a.m., room 9 C 1 door T 9-11 not smoke tight in the frame.
e. At 11:32 a.m., room 8 A 2 door T8-6 not smoke tight in the frame.
f. At 11:40 a.m., room 8 C 3 door T8-17 not smoke tight in the frame.
g. At 12:00 p.m., room 8 B 2 door T8-32 not smoke tight in the frame.
h. At 1:20 p.m., room C 7 3 door T 7-17 not smoke tight in the frame.
i. At 1:25 p.m., room D 17 door T 7-23 not smoke tight in the frame.
j. At 1:45 p.m., room 6 D 1 door T 6-23 not smoke tight in the frame.
k. At 1:50 p.m., room 6 B 3 door T 6-36 not smoke tight in the frame.
l. At 2:15 p.m., room 5 B 3 door T 5-35 not smoke tight in the frame.
m. At 2:20 p.m., room 5 D 3 door T 5-27 not smoke tight in the frame.
2. Observation on January 23, 2020, at 8:10 a.m., revealed the door to room 4 D3, door T 4-25 was not smoke tight latched in the frame.
Exit interview with the facility administrator and the facilities manager on January 23, 2020, between 11:00 a.m. and 11:30 a.m., confirmed the doors lacked smoke tight integrity.
| ||Plan of Correction - To be completed: 03/20/2020|
a. through g.- Doors will be inspected and adjusted accordingly or we will be installing UL rated gap seal product to ensure proper closure of gaps.
Maintenance Supervisor/designee to monitor items are being checked on monthly preventative maintenance. Variances/compliance will be reported to QAPI steering committee.