Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM. The lack of documentation indicates that the required annual inspections of fire door assemblies, as mandated by NFPA 80, were not properly recorded or possibly not conducted, leading to non-compliance with the Life Safety Code requirements.
Plan Of Correction
1 and 2. Maintenance Director has completed the annual fire door inspection in six of six smoke compartments. 3. Maintenance department will be educated on the standards of the facility's annual fire door inspection. 4. Maintenance or facility designee will audit facilities annual fire door inspection in life safety binder weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.