Failure to Conduct Annual Fire Door Inspection
Penalty
Summary
The facility failed to perform the required annual fire door assembly inspection, which affects the entire facility. During a documentation review on February 6, 2025, at 9:30 a.m., it was discovered that there was no documentation available for the annual fire door assembly inspection. This was confirmed in an interview with the Facility Administrator and Maintenance Director at the same time, who acknowledged the absence of the necessary documentation.
Plan Of Correction
Annual fire door assembly was completed on February 21st, 2025. The administrator or designee will reeducate the Maintenance Director on Annual Fire Door Inspection - K761. The annual inspection of this audit will be conducted by the Maintenance Director or designee and reported to Quality Assurance and Performance Improvement committee meetings.