Failure to Conduct Annual Fire Door Inspection
Penalty
Summary
The facility failed to conduct the required annual fire door inspection as mandated by NFPA 101 and NFPA 80 standards. During a document review on December 3, 2024, it was discovered that there was no documentation available to confirm that an annual fire door inspection had been performed. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation.
Plan Of Correction
0761 Annual Fire Door Inspection completed and doors adjusted/repaired as needed. Maintenance staff educated that Annual Fire Door Inspection must be completed annually. NHA will audit that Maintenance staff will routinely inspect 3 Fire Doors weekly x 90 days to assure they are closing and latching properly.