Failure to Document Annual Fire Door Inspections
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.
Penalty
A corridor door with a self-closing mechanism leading to the clean utility room by the nurse's station failed to close or self-latch when tested, as confirmed by the Facility Manager. This failure to maintain the fire door in accordance with NFPA 101 and NFPA 80 standards resulted in a deficiency.
Surveyors found that the facility did not provide documentation confirming that fire doors had been inspected within the required 12-month period. The Director of Maintenance confirmed that records of these inspections were not available.
The facility did not perform a full annual inspection and testing of all rated swinging fire doors, as only the cross corridor fire doors were included while other rated doors, such as those for storage and utility rooms, were omitted. This was confirmed by the maintenance director during record review.
The facility failed to inspect and maintain its fire-rated attic access doors according to NFPA 101 standards. During a fire safety tour, it was found that these doors were not included in the annual inspection, and the Plant Operations Technician was unsure of their inspection status. The Director of Plant Operations confirmed the oversight, acknowledging the findings during an exit conference.
The facility did not maintain and test their fire doors as required by NFPA 101, with the last inspection recorded in December 2023. During a review, the Director of Continuum and Maintenance Supervisor acknowledged the absence of documentation for the annual inspection, indicating non-compliance with fire safety standards.
The facility did not maintain fire doors according to NFPA standards, as fire-rated labels were covered with paint or illegible in the basement and on one resident floor. The Director of Maintenance acknowledged the issue during the survey.
Failure to Maintain Self-Closing Fire Door Mechanism
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, the corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station did not close or self-latch when tested. This observation was made during a facility tour with the Facility Manager, who confirmed the findings at the time of inspection. The deficiency was identified based on direct observation and interview, with no mention of any specific residents or patient involvement. The report notes that all fire door assemblies are required to be labeled, maintained in a legible condition, and equipped with functioning self-closing or automatic-closing devices. The failure to ensure the door's proper operation constituted noncompliance with the cited NFPA standards.
Plan Of Correction
The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation verifying that fire doors had been inspected within the previous 12 months, as required by NFPA 101 and NFPA 80 standards. During an observation and document review, surveyors requested records of annual fire door inspections, but the facility was unable to produce documentation confirming that these inspections had occurred. An interview with the Director of Maintenance confirmed the absence of such documentation for the required period. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
The Fire Door inspection documentation was verified to exist and to have occurred in the last 12 months for the date of 11/12/24. The Fire Door inspections will be conducted annually. Annual inspections will be scheduled through the work order system and maintain NFPA compliance. A notification will be generated through this work order system (TELS). Inspections will be monitored through the work order system for completion and documentation reported to QAPI as completed. An audit of the Life Safety Book will be completed annually to ensure compliance. The completion date is 8/24/25.
Incomplete Annual Fire Door Inspections
Penalty
Summary
The facility failed to conduct a complete annual inspection and testing of all rated swinging fire doors as required by NFPA 101 and NFPA 80 standards. Record review on June 24, 2025, revealed that the inspection only included the seven sets of cross corridor rated fire doors and did not encompass all other rated doors, such as those for storage rooms, soiled utility rooms, and other tagged rated fire doors. This incomplete inspection was confirmed during an interview with the maintenance director at the time of record review.
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.
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.
Fire Door Labeling Deficiency
Penalty
Summary
The facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. During a Life Safety survey, it was observed that the fire-rated labels on several fire doors were either covered with paint or illegible. This issue was identified in the basement and on one of the two resident floors. Specifically, the fire-rated label on the center stairwell door in the basement was covered with paint, as were the labels on the fire door to the soiled utility room, the storage room in corridor D, the stairwell door in Corridor 3, and the door to the clean linen room on the B even side. The Director of Maintenance acknowledged the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K761 I. Immediate Corrective Action: 1. Fire Door Labels Covered with Paint/Illegible: - On 3/19/25, the Director of Maintenance conducted an immediate inspection of all fire doors with illegible or covered fire-rated labels. - The paint was removed from the labels on the center stairwell door, soiled utility room door, storage room door in corridor D, stairwell door in corridor 3, and the clean linen room door on the B even side by 3/20/25. All of the above referenced fire rated labels are now legible. II. Identification of Others: - All residents have the potential to be affected. - A thorough inspection of all fire doors within the facility was conducted to ensure no other fire-rated labels were covered or illegible. - No other issues were found, but the Director of Maintenance has implemented a regular inspection schedule for fire doors to prevent the recurrence of this issue. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's policy on fire door maintenance to ensure that all fire-rated labels are always clearly visible and legible. 2. The Director of Maintenance in-serviced all maintenance staff on the importance of maintaining clear and legible fire-rated labels and ensuring fire doors remain in compliance with NFPA 101 and NFPA 80. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track the status of fire door label visibility. - Monthly audits will be conducted for six months with findings reviewed to ensure that all fire door labels are visible and legible. 2. The results of monthly audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
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