Failure to Maintain Fire Door Inspection Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain fire doors as required, affecting both floors of the building. During an observation on December 10, 2024, it was found that the facility lacked fire door inspection data for the previous twelve-month period, with the last inspection having been performed in March 2023. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
Plan Of Correction
- The fire doors were inspected and documented. - Fire doors will be inspected per regulation. - Maintenance Director will be educated on fire door inspection by NHA/designee. - Audit of fire door inspection will be conducted by maintenance director annually. Trends will be reviewed at QAPI meeting.