Failure to Maintain Annual Fire Door Assembly Test Documentation
Penalty
Summary
The facility failed to maintain documentation of an annual fire door assembly test as required by NFPA 80 2010 Edition Section 5.2. During interviews and record reviews, surveyors requested written documentation of the most recent annual fire door assemblies test, but the facility was unable to provide records indicating that such a test had been completed within the past twelve months. Facility staff, including the RMD, confirmed that the annual fire door assemblies test was missing from their records. This deficiency was identified through interviews and review of facility maintenance records, with no evidence provided that the required inspection and testing had occurred in the specified timeframe.
Plan Of Correction
K 761 Maintenance, Inspection & Testing - Doors Correct Deficient Practice: On 3/10/25 MS called Delta Fire Equipment, Inc. and scheduled the facility's Annual Automatic Closing Assemblies for the fire doors. The Annual Automatic Closing Assemblies for the fire doors is scheduled on 3/10/25. Systemic Changes: On 03/10/2025, Administrator provided in-service education to MS regarding NFPA 80, Fire Doors and Other Opening Protectives 5.2 Inspections. "5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ." MS verbalized understanding. MS and Administrator will create a yearly Life and Safety Checklist with all services needed for the facility to stay in compliance. MS will ensure that all services are performed on a timely basis. At the beginning of every month, MS will review the checklist and schedule the needed services. For three months or until compliance is sustained, MS will report all Life and Safety services scheduled and performed in the building to the Safety Committee. If any services were missed, the MS will immediately notify the Administrator and correct the deficient practice. Monitoring: Findings and trends from the Life and Safety Checklist will be brought to the Monthly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/25