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K0761
C

Lack of Documentation for Annual Fire Door Inspection

Harrisburg, Pennsylvania Survey Completed on 03-13-2025

Penalty

No penalty information released
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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 provide documentation of the annual fire door inspection for eight smoke compartments. During a document review on March 13, 2025, it was discovered that the facility did not have records of the required annual inspection for fire-rated doors. This deficiency was confirmed during an exit conference with the Administrator and Maintenance Director, who acknowledged the absence of the necessary documentation.

Plan Of Correction

The fire rated doors in the eight smoke compartments have been inspected by the Maintenance Director. All fire rated doors inspections will be documented and repairs done as needed. Documentation of the inspections will be placed in the Life Safety Book. The Maintenance Director has been re-educated on the need to perform annual inspections on all fire-rated doors. The NHA or designee will audit the door inspections of fire doors to make sure the annual inspection was completed.

See complete original report
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