Failure to Maintain Fire Doors as per NFPA 101
Penalty
Summary
The facility failed to maintain fire doors in accordance with NFPA 101, as evidenced by the absence of documentation for the performance of fire doors testing by knowledgeable individuals within the last 12 months. This deficiency was identified during a records review process conducted between 11:30 am and 5:00 pm on February 17, 2025, with the Plant Security Manager. The lack of documentation indicates that the required annual inspection and testing of fire door assemblies, as stipulated by NFPA 80, were not performed or recorded. During a staff interview conducted within the same timeframe, the Plant Security Manager acknowledged the absence of documentation for the fire doors testing. The report highlights that individuals performing door inspections and testing must possess the necessary knowledge, training, or experience to demonstrate their ability, and written records of these inspections and tests must be maintained and available for review. The facility's failure to adhere to these requirements resulted in the noted deficiency.
Plan Of Correction
1. All fire doors were inspected and tested by a certified third-party vendor. 2. All residents have the potential to be affected by this deficient practice. 3. Facilities and IT Manager, Security and Transportation Manager, and Associate Executive Director have been in-serviced by the Administrator regarding annual inspecting and testing of fire doors in accordance with NFPA. 4. The Quality Assurance Process Improvement (QAPI) Committee will monitor annually for compliance. 1. All fire doors were inspected and tested by a certified third-party vendor. 2. All residents have the potential to be affected by this deficient practice. 3. Facilities and IT Manager, Security and Transportation Manager, and Associate Executive Director have been in-serviced by the Administrator regarding annual inspecting and testing of fire doors in accordance with NFPA. 4. The Quality Assurance Process Improvement (QAPI) Committee will monitor annually for compliance.