Incomplete Fire Damper Testing Documentation in HVAC System
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) systems were in compliance with National Fire Protection Association (NFPA) standards. During a review of facility records, it was found that documentation for the required 4-year testing of fire dampers, as specified by NFPA 80, was incomplete. A vendor report dated March 14, 2025, showed that only 15 out of 30 fire dampers had been inspected or tested. An additional vendor report from August 9, 2022, indicated that only 8 fire dampers were inspected and all passed. These findings were confirmed through an interview with the Maintenance Assistant during the record review.
Plan Of Correction
K521 #1 The missing report was obtained and placed in the Life Safety Manual to ensure all 30 items were tested. #2 All residents have the potential to be affected by this deficiency. Any deficiencies identified will be corrected by Summit Fire Protection on 5/22/25. #3 The Maintenance Director was educated on providing all paperwork as proof that the heating, ventilation and air conditioning is in compliance with NFPA and paperwork will be kept in the Life Safety Manual. #4 Any further heating, ventilation and air conditioning shall continue to stay in compliance with NFPA and paperwork will be provided and put in Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and Administrator to insure sustained compliance.