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 March 17, 2025, it was revealed that there was no documentation available to confirm that an annual fire door assembly inspection had been conducted. This was further confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of documentation for the completed inspection.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0761 Maintenance, Inspection & Testing Doors. The Maintenance Director is performing an annual fire door assembly inspection. The Maintenance Director will ensure an annual fire door assembly inspection is completed per regulation.