Failure to Inspect and Test Fire Door Assemblies Annually
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA 101 and NFPA 80 standards. During a document review conducted on March 12, 2025, it was discovered that the facility could not provide documentation proving that the rated fire door assemblies had been inspected and tested within the previous 12 months. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Conducted rated fire door testing and inspection of fire doors. 2. 4/28/25 3. Maintenance staff educated on completing rated fire door testing. 4. Director of maintenance will audit fire doors quarterly.