HVAC System Deficiency Due to Lack of Maintenance
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system in accordance with NFPA 101 standards. During a record review and facility tour conducted on April 15, 2025, by the Director of Continuum and the Maintenance Supervisor, it was found that there was no documentation available for the inspection of fire/smoke dampers. This lack of documentation indicates a failure to adhere to required safety protocols for HVAC systems. Additionally, the inspection revealed that exhaust fans in the soiled utility rooms located in both the north and south wings were not in working condition. These findings were acknowledged by the Director of Continuum and the Maintenance Supervisor during the review and were discussed with them at the exit meeting on the same day. The absence of operational exhaust fans in these areas suggests a lapse in maintaining proper ventilation, which is crucial for ensuring a safe and healthy environment within the facility.
Plan Of Correction
1. The fire/ Smoke damper inspections were conducted on 3/14/2024 and 4/21/2025. There are 8 fusible links and 2 mechanical dampers. 2. The exhaust fans for North and South soiled utility rooms were serviced on 4/16/25. Both function properly and will be maintained ongoing. Reports and proof service will be sent to Life Safety Inspector and available upon request. 1. The fire/ Smoke damper inspections were conducted on 3/14/2024 and 4/21/2025. There are 8 fusible links and 2 mechanical dampers. 2. The exhaust fans for North and South soiled utility rooms were serviced on 4/16/25. Both function properly and will be maintained ongoing. Reports and proof service will be sent to Life Safety Inspector and available upon request.