Failure to Maintain Fire-Rated Doors
Summary
During a recertification survey, it was found that the facility failed to maintain fire-rated doors in accordance with the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition. The deficiency was identified in multiple buildings, specifically Buildings #2, #5, #6, #16, #19, #21, and #24. The issue was related to the lack of application of lubricant to the steel doors, as documented in the Coiling Steel Door Inspection and Drop Test Report dated 01/08/2025. This report indicated that lubrication was required, but there was no documented evidence that this maintenance task was completed. The deficiency was further substantiated through interviews conducted during the survey. Facilities Manager #1 confirmed during an interview on 03/26/2025 that there was no documentation available to verify that the lubrication had been applied to the doors. This lack of documentation suggests that the necessary maintenance was not performed, which could interfere with the proper operation of the fire-rated doors. The failure to maintain the fire-rated doors as required by the NFPA standards and the absence of documentation indicating that the necessary lubrication was applied represent a significant oversight in the facility's maintenance procedures. This deficiency was noted across several buildings within the facility, indicating a systemic issue in adhering to the required fire safety standards.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Element 1: Lubricant was applied to the steel door per Inspection report. Element 2: All doors in the facility were reviewed for compliance with NFPA. No issues identified. Re: Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Element 3: Facilities manager will provide education to the facility staff on following through on all inspection recommendations and documentation of work completed. Element 4: All inspection reports will be reviewed by Facility Manager to ensure any identified work needed is scheduled and completed. The report will be rolled up to the monthly quality assurance committee to review work recommended and date completed. This will be a standing agenda item for the monthly quality meeting. Facility manager responsible for ongoing compliance.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.