Failure to Conduct Annual Fire Door Inspections
Penalty
Summary
The facility failed to ensure that fire door assemblies were inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. This deficiency was identified during a documentation review and interviews conducted on December 20, 2024. The review revealed that the facility did not conduct annual inspections of fire door assemblies as required. Instead, the facility provided monthly fire door inspections, which did not include all fire doors and assemblies and did not meet the minimum requirements set by the standard. This oversight had the potential to affect all residents in the facility. The observation was confirmed during an interview with the U.S. FOIA representative, and the facility's representative was informed of the deficiency at the Life Safety Code exit conference.
Plan Of Correction
1. All residents have the potential to be affected by this deficient Life Safety Code. Facility maintenance department completed an annual fire door assembly inspection on 1/10/25. 2. The Maintenance Director modified the facility maintenance schedule to include a fire door assembly inspection and testing to be completed annually. 3. The Maintenance Director will audit the fire door assembly inspection and testing to confirm completion and submit the report to the administrator and to the QAA committee annually.