|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 18.104.22.168 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 22.214.171.124.6 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.
126.96.36.199, 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: MAIN BUILDING 01 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain one corridor opening, affecting one of three floors.
1. Observation on November 17, 2021, at 9:59 a.m., revealed the third floor, Zone 3-3 Clean utility Room door was not smoke-tight.
Exit interview with the Facilities Manager on November 17, 2021, between 11:00 a.m. and 11:56 a.m., confirmed the corridor opening deficiency.
| ||Plan of Correction - To be completed: 01/15/2022|
1. Maintenance has applied Pemco Silicone Seal S77, a High Temperature gasket seal to maintain required smoke parameters for the third floor, Zone 3-3 Clean utility Room door.
2. All Doors have been audited for compliance with NFPA 101 STANDARD
Corridor – Doors.
3. Maintenance Door inspections will continue with documentation as part of the preventative maintenance program. Findings shall be reported to QA committee for review and recommendations.
4. Corrective Action Date January 15, 2022