Failure to Conduct Required Smoke Damper Testing in HVAC System
Summary
The facility failed to maintain its HVAC system in accordance with regulatory requirements, specifically by not conducting the required four-year inspection and testing of the fire/smoke dampers. During a document review and interview with staff, it was found that the last smoke damper testing was conducted on 9/28/20, and no subsequent testing had been performed as required. The facility was unable to provide current inspection and testing records for the smoke dampers. Staff indicated that damper testing for the Skilled Nursing Building was assumed to follow the same schedule as the Main Hospital Building, leading to the oversight. This deficiency affected all 43 residents and both smoke compartments in the facility, as the required periodic inspection and testing of fire/smoke dampers had not been completed.
Plan Of Correction
The last smoke damper inspection was completed on September 28, 2020, exceeding the four-year testing requirement. On April 15, 2025, the facility contacted the licensed HVAC inspection company to inspect and test all fire/smoke dampers within Building 02. The inspection and testing are scheduled on May 5th, 2025, by the vendor. The Maintenance Department Staff were educated on the regulatory differences between hospital and SNF buildings to prevent recurrence. A digital calendar reminder and compliance tracker were implemented to ensure timely testing in 2029. The maintenance lead will be responsible for contacting and scheduling the timely inspections with the vendor.
Penalty
Surveyors determined that the facility did not maintain required documentation showing that fire dampers had been inspected and tested in accordance with NFPA 101, NFPA 90A, and NFPA 80 standards. During record review, no inspection or testing records were produced despite multiple requests, even though fire dampers were observed throughout the building. The Maintenance Director confirmed that the documentation was not available, and this deficiency had the potential to affect all 69 residents.
Surveyors identified that the facility did not maintain required inspections or corrective actions for fourteen fire and smoke dampers in the HVAC system, with issues such as non-functioning motors, missing dampers, and inadequate fire wall protection remaining unaddressed at the time of survey.
The facility did not maintain its HVAC system as required, as two failed fire dampers were identified in an inspection report and there was no evidence of corrective action taken at the time of the survey. This was confirmed by facility leadership.
A portable air conditioning unit in a large common area near the Nurses' Station was observed to be vented directly into the ceiling's interstitial space instead of to the outside, contrary to NFPA 101 and manufacturer requirements. This was confirmed by facility leadership during the survey.
Surveyors determined that the facility did not provide documentation showing fire dampers were exercised within the required four-year interval, as confirmed by the Maintenance Director during interview.
A newly installed boiler heating unit was found to lack manufacturer information and proof of state inspection. The facility could not provide documentation that required corrections identified by a state boiler inspector had been completed, and a final inspection had not been requested.
Lack of Required Inspection and Testing Documentation for Fire Dampers
Penalty
Summary
Surveyors found that the facility failed to maintain its fire dampers in accordance with NFPA 101 (2012 Edition) sections 19.5.2 and 9.2.1, NFPA 90A (2012 Edition) sections 5.4.5.2 through 5.4.6.2 and 5.4.8.1, and NFPA 80 (2010 Edition) sections 19.4.1 through 19.4.11. During record review on the survey date beginning at 8:45 A.M., there was no documentation available to verify that the facility’s fire dampers had been inspected and tested as required by code. Documentation of fire damper inspection and testing was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of survey exit. During the physical tour, surveyors observed that fire dampers were present throughout the building, and the Maintenance Director confirmed that the requested documentation could not be produced. This deficiency had the potential to affect all 69 residents in the facility. No specific resident medical histories or conditions at the time of the deficiency were described in the report, only that 69 residents could potentially be affected.
Plan Of Correction
1. Based on observation, record review and interview, no residents experienced negative outcomes related to the missing fire damper inspection. 2. The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to ensure fire dampers were inspected and tested. 3. Fire damper inspection will be completed by contracted vendor on or before 04/30/2026. 4. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements of maintaining the facility's smoke/fire dampers, ensuring required scheduled inspections/testing.
Failure to Address Fire Damper Deficiencies in HVAC System
Penalty
Summary
The facility failed to maintain required inspections and corrective actions for its Heating, Ventilating, and Air Conditioning (HVAC) equipment, specifically affecting fourteen fire and smoke dampers. During a document review, it was found that a previous fire damper inspection report listed multiple deficiencies, including dampers with no power to the motor, motors that did not actuate and required replacement, missing dampers, dampers located outside of fire walls, dampers that did not fall and required replacement, and missing duct access doors. Additionally, some walls did not extend to the deck or had missing sheetrock, further compromising the integrity of the fire protection system. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Directors, who acknowledged that the issues identified in the inspection report had not been addressed or corrected at the time of the survey. The lack of corrective action for these deficiencies resulted in the facility not meeting the required standards for HVAC system maintenance and fire safety as outlined by NFPA 101.
Plan Of Correction
NotSpecified The facility reached out to LLS and Reed Electric to correct all identified fire damper deficiencies. Repairs and reinspection are due to be completed the week of January 12th, 2026. Documentation will be retained for life safety review. The maintenance director or designated designee will perform weekly audits for 4 weeks and then monthly for 2 months to ensure fire damper compliance. Date of completion: 2/16/2026
Failure to Address Failed Fire Dampers in HVAC System
Penalty
Summary
The facility failed to maintain its Heating, Ventilating, and Air Conditioning (HVAC) equipment as required. During a document review, it was found that the April 2025 Fire Damper Inspection Report identified two failed dampers. At the time of the survey, there was no evidence available to show that corrective action had been taken to address these failed dampers. This deficiency was confirmed during the exit interview with the Administrator and Maintenance Director. No information about residents or their medical conditions was included in the report.
Plan Of Correction
Vendor scheduled for damper repair. The Maintenance Director will be reeducated by the NHA/Designee on K0521 with focus on the importance of ensuring fire damper inspections are being completed and checking to ensure building is in compliance. Monthly audits to be completed x 4 to ensure valid fire damper inspection in place. Maintenance director/Designee will report findings of inspection at QAPI meeting.
Improper Venting of Portable Air Conditioning Unit
Penalty
Summary
A deficiency was identified when, during an observation, a portable air conditioning unit was found in a large common area near the Nurses' Station on one of four floors. The unit was vented directly into the interstitial space of the ceiling rather than being vented to the outside, as required. This was confirmed during an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director. The facility did not maintain the air conditioning system in accordance with NFPA 101 and the manufacturer's specifications.
Plan Of Correction
The facility failed to maintain air conditioning systems on one of four floors. No residents were affected. All residents have the potential to be affected. The portable air conditioning unit, located in a large common area near the Nurses' Station, was removed so it is not vented directly into the interstitial space of the ceiling. The expected date for HVAC repair is September 30th, 2025, with the portable air conditioners removed before October 31st, 2025. An audit was completed by the Maintenance Director to ensure that no portable air conditioning units were vented directly into the interstitial space of the ceiling, with no concerns found and compliance confirmed. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit of the portable air conditioner for four weeks, then monthly for two months. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
Failure to Exercise Fire Dampers at Required Intervals
Penalty
Summary
The facility failed to ensure that fire dampers were exercised at the required four-year intervals, as mandated by NFPA 101 HVAC standards. During a document review, surveyors found that the facility could not provide documentation showing that the fire dampers had been exercised within the previous 48 months. An interview with the Maintenance Director confirmed that the necessary documentation was not available, affecting the entire facility.
Plan Of Correction
Fire damper exercise documentation not provided at the time of survey has been obtained. The fire dampers have been exercised. The fire dampers will be exercised again in June 2026 to remain within the 48-month testing regulation. Inspection will be entered in the electronic preventative maintenance program as a task to be completed as required. Monitored by the Director of Maintenance or designee.
Lack of Documentation and Final Inspection for Newly Installed Boiler
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with regulatory requirements, specifically section 9.2. During an observation, it was found that a newly installed boiler heating unit lacked manufacturer information and proof of a State of Michigan boiler inspection. The office manager was unable to confirm whether the necessary corrections identified by the state boiler inspector during a previous visit had been completed, and only had limited information about the inspector. Further confirmation from the State of Michigan boiler inspector indicated that the required corrections on the new boiler installation had not yet been completed, and a final inspection had not been requested.
Plan Of Correction
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The boiler was inspected and did not pass. Contractor has made the required repairs and is calling to schedule another inspection as soon as possible. Once the state boiler inspection has been completed, the local building department will perform their inspection. I personally spoke with the state boiler inspector on Friday, as the contractor is not fulfilling his responsibilities of completing this project and scheduling the inspection. The inspector said he would be able to come on Monday, June 30 or July 1, but I have not heard back with a confirmed date or time. I am unable to force the contractor or inspector to get this taken care of in a timely manner, so I do not have firm dates that it will be inspected or approved. Address how the facility will identify other residents having a potential to be affected by the same deficient practice: The residents are not affected by this deficient practice. The boiler is not in use as it is not heating season and operates as designed when needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: This contractor will not be used again in the future. Maintenance Director will ensure any future contractors will complete permits and inspections prior to being paid in the future. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Maintenance director will monitor weekly and maintain communication with contractor to ensure the inspections are completed. Will be discussed at quarterly QAPI meetings.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.