Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to maintain proper documentation of annual fire door inspections as required by NFPA 101 and NFPA 80 standards. During a document review conducted on January 27, 2025, it was discovered that the facility could not provide evidence of a fire door inspection having been conducted within the past 12 months. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation. Notably, this issue was identified as a repeat deficiency from the previous annual survey conducted on March 13, 2024.
Plan Of Correction
1. The annual fire door inspection was completed immediately. 2. A log was created to ensure proper documentation of the annual fire door inspection. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of annual fire door inspections will be conducted to ensure proper documentation and compliance. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.