Incomplete Fire Door Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the annual fire door inspection for all fire-rated doors in six of six smoke compartments. During a document review conducted on February 4, 2025, between 9:30 AM and 11:15 AM, it was revealed that the facility's records did not include all the fire-rated doors as required by NFPA 101 and NFPA 80 standards. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, where they acknowledged the absence of complete documentation for the annual fire door inspection.
Plan Of Correction
Fire doors will be inspected annually. Maintenance staff will be educated in completing an annual fire door inspection. Fire doors will be audited semi-annually and the results of the audits will be reported to QAPI.