HospitalInspections.org

K-363 Corridor Doors

Based on the surveyor review of fire door testing and maintenance and during staff interview, it was discovered that the fire barrier doors rating plates were covered. The fire rating plates contain information relating to the standards that the door meets, which dictates the inspection, testing and maintenance requirements as required by NFPA 101 2012 edition, section 8.3.3.2.2 and therefore, not tested to meet the requirements of NFPA 80.
Based on surveyor review of records and staff interview at approximately 2:30 PM on 3/10/2020, the facility failed to produce documentation stating the plates are not required, and could be removed, and therefore failed to meet the requirements associated with the fire barrier door. This finding was identified during exit interview with the administrator and maintenance supervisor.

This finding should not present harm to staff members situated in office spaces within the exit corridor because the doors are maintained in an operable condition and will contain smoke and fire during an emergency.