Fire/Smoke Door Maintenance Deficiency
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility did not maintain and inspect fire/smoke doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, on the first floor, fire doors #8 and #4 failed to close properly when tested. This deficiency was noted in the presence of the Director of Building Services, indicating a failure to ensure that these critical safety features were functioning as required. Additionally, a review of the facility's documentation revealed that the Monthly Smoke, Fire Door Operation Check, and Smoke Barrier Penetration Inspection, as well as the Monthly Fire Door Barrier Check, did not include verification of the 11 items specified by NFPA 80:5.2.4.2. This omission was acknowledged by the Director of Building Services, who stated that the facility would update their inspection checklist to include these items. However, at the time of the survey, the deficiency remained unaddressed.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. All fire doors were immediately inspected and adjusted by Director of Maintenance. Door 4 and 8 are now in compliance. No other issues were found. II. The monthly fire door barrier checklist has been updated to reflect the 11 items specified and required by NFPA 80:5.2.4.2. III. Anyone has the potential to be affected. IV. The maintenance of Director was educated on 2012 NFPA 101: Maintenance, Inspection and testing- doors on 2/12/25 by Corporate Director of Maintenance. V. An audit tool created to ensure fire doors all close properly and that the 11 specified items from NFPA 80:5.2.4.2 are included in all inspections. Audits to be conducted by the director of maintenance monthly for 12 months. All findings reported to QAPI. VI. Responsible party: Director of Maintenance/ Designee.