Maintenance, Inspection & Testing - Doors 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. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)
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Observations: Name: REPLACEMENT FACILITY - Component: 03 - Tag: 0761
Based on document review and interview, the facility failed to maintain, inspect, and test fire doors, in accordance with regulations, affecting the entire facility.
Findings include:
Document review on May 28, 2025, at 9:45 a.m., revealed the facility's annual door inspection (conducted May 15, 2025) identified one rated door that was in non-compliancy. The neighborhood #1 fire door next to the SPA had damaged hinges. The facility lacked documentation that the doors were repaired, or the deficiencies corrected, at the time of the survey.
Interview with the maintenance supervisor on May 28, 2025, at 9:45 a.m., confirmed the corrective documentation for the fire door was unavailable.
| | Plan of Correction - To be completed: 06/25/2025
Maintenance Director Identified fire door deficiency on 3/3/2025 during an audit. Immediately contacted vendor for replacement. Vendor provided quote on replacement 3/8/2025, and quote was approved on 3/13/2025, check for 50% deposit was given to vendor on 3/18/2025. Fire door inspection by contractor completed on 5/15/2025 noted door to be out of compliance during annual inspection. Replacement door has been ordered from the manufacturer by the vendor with an anticipated delivery and installation in August due to manufacturing lead time. Facility will audit fire doors once a week for 10 weeks to ensure fire doors are in compliance.
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