Failure to Inspect Rated Doors Annually
Penalty
Summary
The facility failed to conduct the required annual inspection of all rated/labeled doors as mandated by NFPA 80, Standard for Fire Doors and Other Opening Protectives. During a document review and observation on October 8, 2024, it was revealed that the rated doors in all areas had not been inspected in the last 12 months. This deficiency was confirmed through an interview with the Director of Maintenance on the same day. Further observation on December 9, 2024, confirmed that the issue had not been corrected, as the rated doors still had not been inspected. The Director of Maintenance confirmed during interviews at 10:30 AM and 11:30 AM on December 9, 2024, that the deficiency remained unaddressed.
Plan Of Correction
1. The facility is unable to retroactively document inspection of rated/labeled doors. 2. Maintenance staff will be educated on the annual fire door inspection procedures. Rated doors will be inspected annually per regulations. 3. NHA and Maintenance Director will conduct annual audits to ensure inspections and corresponding documentation is completed per annual regulatory requirement. Audit results will be documented in the Life Safety Book. 4. Audit results and corresponding documentation will be presented to QAPI committee for review and analysis of need for ongoing monitoring.