|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 220.127.116.11 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 18.104.22.168.6 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.
22.214.171.124, 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 - Component: 01 - Tag: 0363
Based on observation and interview, it was determined the facility failed to maintain corridor doors to resist the passage of smoke, and to be free of impediment from closing, on one of two floors within the component.
1. Observation on January 7, 2020, at 12:55 PM revealed the door to West Hall Therapy had a gap, greater than 1/2 inch, between the door and the door stop, when in the closed position.
Interview with the Director of Maintenance on January 7, 2020, at 12:55 PM confirmed the door could not resist the passage of smoke.
2. Observation on January 7, 2020, between 1:03 PM and 1:20 PM, revealed doors failed to close into the frame, at the following locations:
a. 1:03 PM, the Snack Room in the Scenic View Lounge;
b. 1:20 PM, the Activity Room off the Lobby.
Interview with the Director of Maintenance on January 7, 2020, at 1:20 PM confirmed the doors failed to close.
| ||Plan of Correction - To be completed: 03/01/2020|
K-363 - The West Hall Therapy Door gap of more than ½" will be repaired by 3/15/2020 to be within the allowed gap margins. The snack room door in Scenic View Lounge will be repaired by 3/15/2020 to close into its frame. Activity Room Lobby door was repaired on 1/15/2020 to close into the frame. Environmental Services staff will audit the West Hall Therapy and the snack room door in Scenic View Lounge doors gap margins and the Activity Room Lobby door to close into its frame, quarterly and placed in the Life Safety notebook and the results reported to the QAPI Committee.