Bringing transparency to federal inspections
Tag No.: K0223
NFPA 80 Standard for Fire Doors and Other Opening Protectives
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs.
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified.
(1) No open holes or breaks exist in the surface of the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational: that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
Based on observations and interview, it was determined the facility failed to ensure two fire rated door assemblies could automatically close to a latched position.
Findings include:
Observations during tour on 11/15/22 between 11:30 a.m. and 4:00 p.m. with Staff A (Director of Plant Operations) revealed the following two fire door locations and existing conditions:
1. The 90-minute fire rated door assembly, located between the 3rd floor Elevator Lobby and the Nursing Station, failed to automatically close to a latched position when released from the magnetic hold open device. The left hand door panel failed to have enough closing force to complete a full latched position.
2. The 90-minute fire rated door assembly, located between the 1st floor Main Lobby and the Patient Admitting Wing, failed to automatically close to a latched position when released from the full open position. The door assembly is equipped with an automatic door opening controller but failed to close to a full latched position.
Interview on 11/15/22 with Staff A confirmed the above findings, locations, and existing conditions.