Failure to Maintain HVAC Equipment Inspection
Penalty
Summary
The facility failed to maintain the inspection of its Heating, Ventilating, and Air Conditioning (HVAC) equipment at the required intervals, affecting the entire facility. During a document review on April 15, 2025, it was discovered that a fire damper inspection report dated May 9, 2022, identified 73 dampers as deficient due to inaccessibility or damage. At the time of the survey, there was no evidence available to confirm that these deficiencies had been repaired. This finding was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) The facility vendor is in the process of identifying, repairing, and determining if the dampers are all necessary and if necessary to make modifications, will contact the Plan Review Department for approval of modifications to the fire suppression system. 2) The Maintenance Director and/or designee reviewed and confirmed the fire dampers are operable. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring fire dampers are inspected and operable. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee ensure fire dampers remain operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.