Failure to Provide Timely Fire Damper Inspection Documentation
Penalty
Summary
The facility failed to provide evidence of the required quadrennial (every four years) servicing and inspection of their installed fire dampers, as mandated by regulatory standards. During a record review on April 15, 2025, it was found that the last recorded servicing of the fire dampers was dated June 16, 2020, and no documentation supporting compliance with the current inspection requirement was available for review. This deficiency was confirmed with the facility Maintenance Director at the time of the record review. The lack of current inspection documentation could affect all 175 residents in the event of a fire, as noted in the findings.
Plan Of Correction
K521 - HVAC 1. The facility failed to ensure heating, ventilation, and air conditioning in compliance with 9.2. a. The facility scheduled the required quadrennial serving and inspection of the installed Fire Dampers. 2. The Maintenance Director was educated on the required quadrennial serving and inspection of the installed fire dampers and proper documentation following required fire drills. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete an audit monthly following each fire drill with proper documentation. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.