Failure to Maintain and Inspect Fire and Smoke Door Assemblies
Penalty
Summary
The facility failed to provide regular inspections, testing, and maintenance of fire and smoke door assemblies as required by NFPA 80 and NFPA 105. During a record review with the Administrator and Maintenance Director, the facility was unable to produce documentation of annual inspections for smoke doors or evidence of training for a competent, certified individual responsible for fire and smoke doors. This lack of documentation and training was confirmed during interviews with facility leadership. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information was provided regarding specific residents or patient conditions related to this deficiency. The report focuses solely on the absence of required inspection records and training for fire and smoke door assemblies.