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Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located in 2 of 3 smoke compartments. Findings:

1. A tour of the facility was conducted on 05/22/2024, and the following observations were made:

a. The door to the conference room had four holes above and below the door knob were old hardware had been removed.

b. The set of double doors to the old operating room had a gap between the doors that would allow smoke to pass through.

2. The maintenance supervisor was present during the tour of the facility and acknowledged the gap and the holes in the doors. He stated he would make the repairs as soon as possible.

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings:

1. The facility records were reviewed on 05/22/2024 and no documentation was found to show the facility had conducted routine corridor door inspections.

2. The facility administrator and maintenance supervisor were interviewed during the record review and they stated they had never performed corridor door inspections.


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)