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 and interview conducted on January 7, 2025, it was discovered that the facility did not have documentation to confirm that an annual fire door assembly inspection had been completed. This deficiency was confirmed through an interview with the Facility Administrator and Director of Maintenance, who acknowledged the absence of the necessary documentation at the time of the survey.
Plan Of Correction
The facility is unable to determine what happened to the door rating on the third floor soiled utility room door. Other doors were inspected and documented on the newly created fire door inspection sheet. No discrepancies were noted. The door will be inspected and appropriately rated or replaced with an approved door. Maintenance staff were re-educated on K 0761. The Executive Director will audit fire door assembly inspections monthly for two months. Results will be reviewed at the Quality Assurance Performance Improvement meeting.