Failure to Maintain Fire-Rated Doors as per NFPA Standards
Summary
During a Life Safety Code survey, it was found that fire-rated doors in the facility were not maintained according to the National Fire Protection Association (NFPA) requirements. Specifically, the fire-rated door assemblies were not inspected and tested annually as required. This deficiency affected all resident use floors and the basement. The facility's policy, effective from November 5, 2024, stated that all fire door assemblies should be inspected and tested annually, with a written record kept for review. However, upon reviewing the facility's maintenance inspection records, there was no documentation that met the NFPA 80 requirements. Interviews conducted during the survey revealed a lack of proper record-keeping and communication regarding the inspections. The Director of Plant Operations, who had just started working at the facility, was unable to locate any documentation of the required door inspections. A Maintenance Technician mentioned that doors were checked weekly and that the Administrator had the records. However, the Administrator confirmed that while they kept logs for testing delayed egress doors, they did not maintain records for NFPA 80 door inspections. This lack of documentation and adherence to the NFPA standards led to the citation.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Areas: All fire rated doors were inspected and tested. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice. The corrective action which took place was all fire rated doors were inspected and tested. Steps to prevent further recurrence: All fire rated doors were inspected/tested and will be inspected annually. Maintenance staff will be educated to ensure the facility's fire rated door assemblies are inspected and tested annually per National Fire Protection Association requirements. How will corrective action be monitored: Results of the fire rated doors inspection and testing is to be reported to the quality assurance committee by Plant Operations Director. Plant Operations Director will be responsible for compliance.
Penalty
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