Failure to Maintain and Test Fire Doors Annually
Penalty
Summary
The facility failed to maintain and test their fire doors in accordance with NFPA 101, as evidenced by the lack of documentation for the annual inspection of fire door assemblies. During a record review conducted on April 15, 2025, with the Director of Continuum and the Maintenance Supervisor, it was found that the last recorded inspection was dated December 18, 2023. This indicates that the required annual inspection had not been performed within the stipulated timeframe. The Director of Continuum and the Maintenance Supervisor acknowledged the findings during an interview conducted concurrently with the record review. The absence of documentation for the fire door annual inspection was confirmed and discussed with them at the exit meeting on the same day. The report highlights the facility's non-compliance with the NFPA 101 and NFPA 80 standards, which require that fire door assemblies be inspected and tested annually to ensure they are in proper working condition.