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.