HVAC System Deficiency in Soiled Utility Rooms
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the exhaust fans in the soiled utility holding rooms located in both the east wing of Pineapple Trail and the west wing of Lakeshore were not operational. These findings were made in the presence of the Director of Property Management. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the deficiencies. The findings were reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The report cites specific sections of NFPA 101 and NFPA 99 that were not adhered to, indicating a failure to comply with the required standards for HVAC maintenance.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K521 HVAC Immediate Corrective Action: On 4/29/2025, HVAC technician assessed the exhaust fans immediately. A HVAC vendor was contracted to replace the two exhaust fans in soiled utility rooms. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. HVAC system throughout the units were inspected to ensure compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. No other HVAC system was identified out of compliance. Measures: Director of Property management and Maintenance assistance were re-educated on maintaining HVAC system by ensuring exhaust fans are inspected weekly, documented on preventative maintenance sheet and report any non-functioning HVAC system to supervisor immediately. Exhaust fans in biohazard rooms are required to be functioning to ensure ventilation to manage airborne particles and prevent contamination. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure in compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. Director of Maintenance will report the findings to the Quality Assurance Performance improvement Committee Monthly X 3 months or until the committee determines substantial compliance.