Incomplete Annual Fire Door Inspections
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct a complete annual inspection and testing of all rated swinging fire doors as required by NFPA 101 and NFPA 80 standards. Record review on June 24, 2025, revealed that the inspection only included the seven sets of cross corridor rated fire doors and did not encompass all other rated doors, such as those for storage rooms, soiled utility rooms, and other tagged rated fire doors. This incomplete inspection was confirmed during an interview with the maintenance director at the time of record review.