Failure to Maintain HVAC System in Compliance with NFPA Standards
Summary
The facility failed to maintain its heating, ventilation, and air conditioning (HVAC) system in accordance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, 90 A, and NFPA 80. During a Life Safety recertification survey, it was discovered that the facility's fire/smoke dampers were inspected, tested, and cleaned by a vendor between April 4 and 6, 2025. However, several dampers failed, including damper 2 FD-008 on December 4, 2024, and damper 2 FD 124 in a specific room on December 6, 2024. A follow-up report indicating the repairs for these failures was missing and not provided at the time of the survey. In an interview with the Director of Plant Operations, it was stated that the vendor would be contacted to address the issue. On the following day, a statement was provided indicating that damper 2 FD-008 was corrected on June 16, 2023, but it did not specify how the deficiency was corrected. The Director of Plant Operations later mentioned that the date was a typo. The lack of proper documentation and follow-up on the damper repairs led to the deficiency being cited during the survey.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Actions for Residents Identified: - All residents, visitors, and staff have the potential to be affected by the deficient practice. - Fire damper vendor was contacted 5/1/2025 and will be on site to inspect fire dampers. Resident at Risk: - All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Education to Director of Plant Operations to ensure that if there are issues with inspection that needs to be repaired, it is to be completed in a timely manner to remain in compliance. - Audit will be created to ensure that all reports received are dated correctly and no damper failure reported. - If damper failure is noted, the Vendor will be contacted to repair the dampers. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will ensure all reports are dated appropriately when receiving report from fire damper vendor and that any damper failure is addressed. Weekly x4, monthly x3 or until 100% compliance. - If non-compliance is found, this will be reported to the Administrator and Director of Plant Operations. Vendors will be contacted to fix any issues present. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee
Penalty
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