Failure to Inspect Fire-Rated Attic Access Doors
Penalty
Summary
The facility failed to inspect and maintain its fire doors in accordance with NFPA 101 standards, specifically for seven sampled fire-rated attic access doors. During a fire safety tour, it was observed that these doors were present, but the Plant Operations Technician was unsure if they were included in the annual fire door inspection. A review of the facility's records revealed that the annual fire door inspection conducted on April 10, 2025, did not include these attic access doors. Interviews with the Plant Operations Technician and the Director of Plant Operations confirmed the oversight, and they acknowledged the findings. The issue was discussed with the Administrator and the Director of Plant Operations during the exit conference. The report highlights that the facility did not comply with the required standards for fire door maintenance and inspection, as outlined in NFPA 101 and NFPA 80.
Plan Of Correction
No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K761. The attic fire doors were inspected by the maintenance director/designee on 05/20/2025. No concerns were identified. The result of the inspection was brought to QAPI on 05/21/2025. Attic fire doors will be inspected annually per K761 by the maintenance director/designee and the results of the inspection will be brought to QAPI for review. No residents were affected by this alleged deficient practice as of 05/16/2025 and none can be identified as of 05/16/2025. The maintenance director and assistants were educated by the Executive Director on 05/16/2025 on K1150. The annual security vulnerability assessment was completed on 05/15/25 by the Executive Director. The assessment was brought to QAPI on 05/21/25 for review. The security vulnerability assessment will be reviewed annually per K1150 by the Executive Director and QAPI Committee.