Failure to Maintain HVAC Systems
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain its HVAC systems in compliance with NFPA 101 standards, specifically regarding the testing and exercising of fire/smoke dampers. During a document review on May 1, 2025, it was found that the facility could not provide documentation that these dampers had been tested or exercised within the past four years. This deficiency was confirmed during an exit interview with the Maintenance Director on the same day.
Plan Of Correction
Facility will provide documentation that the fire/smoke dampers had been tested/exercised within the past 4 years. Outside company called for service to complete testing and update EP book. NHA will audit EP book monthly x2 for documentation. Results will be reviewed in QPAI.