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 with smoke tight resistance in six instances, affecting eight of eleven smoke compartments.
Findings include:
1. Observation on May 11, 2026, revealed the following smoke barrier door deficiencies:
a) 9:10 a.m., the smoke doors at the entry to the Main Hallway had a gap greater than 3/4 inch at the bottom when closed;
b) 9:20 a.m., the smoke doors leading to the Therapy Room in the Main Hallway had a gap greater than 3/4 inch at the bottom when closed;
c) 9:35 a.m., the smoke doors to TCU 1 had a gap greater than 3/4 inch at the bottom when closed;
d) 9:50 a.m., the smoke doors to TCU 2 had a gap greater than 3/4 inch at the bottom when closed;
e) 10:00 a.m., the smoke doors to second floor TCU 2 had a gap greater than 3/4 inch at the bottom when closed;
f) 10:15 a.m., the smoke doors to the Rooms 200-201 hallway had a gap greater than 3/4 inch at the bottom when closed.
Interview with the Facility Administrator and Maintenance Director on May 11, 2026, at 11:00 a.m., confirmed the smoke barrier door deficiencies.
| | Plan of Correction - To be completed: 07/01/2026
The facility will correct the identified smoke barrier door deficiencies by installing door sweeps on the cited smoke barrier doors to ensure the gaps at the bottom of the doors are 3/4 inch or less when closed. This includes the smoke barrier doors at the Main Hallway entry, Therapy Room hallway, TCU 1, TCU 2, second floor TCU 2, and Rooms 200-201 hallway. The Maintenance Director or designee will inspect the cited doors after installation to verify the door gaps are compliant. The Maintenance Director or designee will also inspect other smoke barrier doors throughout the facility to identify any additional doors with excessive gaps, and any additional concerns will be corrected as needed. The Maintenance Director or designee will inspect smoke barrier doors weekly for four weeks to ensure the doors remain in working condition and maintain compliant gaps. Findings will be reviewed by the Administrator or designee, and any needed corrective action will be completed. Corrective action will be completed by Friday, 5/29/2026. The Maintenance Director and Administrator are responsible for implementation and monitoring.
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