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 10, 2025, at 9:15 a.m., it was revealed that the facility lacked documentation for an annual fire door assembly inspection. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director on the same day at 12:30 p.m., where it was acknowledged that there was no documentation available at the time of the survey to show that the inspection had been completed.
Plan Of Correction
1. The Maintenance Director/designee will conduct the annual fire door assembly inspection. 2. The Nursing Home Administrator/designee will educate the maintenance staff on the annual fire door assembly inspection. 3. The maintenance staff/designee will audit the Life Safety Audit Documentation form to ensure the facility is in compliance with the annual fire door assembly inspection. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.