Failure to Maintain Fire-Rated Doors as per NFPA Standards
Penalty
Summary
During a Life Safety Code survey, it was found that fire-rated doors in the facility were not maintained according to the National Fire Protection Association (NFPA) requirements. Specifically, the fire-rated door assemblies were not inspected and tested annually as required by the NFPA 80: Standard for Fire Doors and Opening Protectives. This deficiency affected all resident use floors in both the front and rear buildings of the facility. The facility's policy titled 'Maintenance - Preventative' indicated that the Maintenance Director was responsible for ensuring routine preventative maintenance tasks, including fire door inspections, were performed timely. However, there was no documentation available to confirm that these inspections were conducted. Interviews with the Assistant Maintenance Director revealed that while smoke barrier doors were checked monthly during fire drills, no formal checks were performed on other fire-rated doors. The maintenance staff only addressed door-related issues when noted in the maintenance logs. The Administrator believed that the former Maintenance Director had been conducting regular checks, but no documentation was available to support this claim. The facility lacked a specific policy and procedure for the maintenance of fire doors beyond the general preventative maintenance policy.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 An inspection of the facility’s fire rated doors was completed using NFPA 80 guidelines. All inspections of the facility’s fire doors were reviewed and any issues were addressed. Education was provided to the Director of Maintenance and the maintenance staff regarding fire safety code NFPA 80 and the requirement to ensure fire rated door assemblies are maintained, inspected, and tested annually. An audit tool was created to ensure all fire doors remain up to date with annual inspections in accordance with NFPA 80 code. Audits will be conducted monthly x4 by the maintenance director. Results will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.