Missing Documentation for Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual tests and inspections of the fire door assemblies as required by NFPA 80, Section 5.2. This deficiency was identified during a record review conducted on January 7, 2025, at 3:30 PM, where it was discovered that the documentation was missing from the facility's Life Safety Code Survey Binder. The surveyor requested this documentation at multiple points, including the entrance conference, during the record review, and at the exit conference, but it was not provided. During an interview at the same time, a staff member confirmed the finding and stated that the facility was unable to locate the missing documentation during the survey. This deficient practice had the potential to affect all 131 residents in the facility.
Plan Of Correction
Element 1 This deficiency was corrected by performing tests and inspections of the fire door assemblies. Element 2 All residents had the potential to be affected by this deficiency. Element 3 A Fire Door Assembly audit is being conducted by the Maintenance Director to ensure that the facility remains in compliance with K761. This audit is being completed by making rounds within the facility. Element 4 The Fire Door Assembly audit is being monitored by the Administrator or designee once a month for six months and then performed annually on a continuous basis. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.