Failure to Document Fire and Smoke Damper Inspections per NFPA Standards
Penalty
Summary
The facility failed to maintain proper documentation for the four-year fire and smoke damper inspection, testing, and maintenance as required by NFPA 80. During a record review with the Administrator and Maintenance Director, it was found that the vendor documentation only indicated that the fire and smoke dampers were functioning, but did not specify the number of dampers, their locations, or the type of system installed. This lack of detailed documentation meant the facility could not demonstrate compliance with the required standards for maintaining the integrity of the fire alarm system to ensure proper alarm and safe relocation of residents, staff, or other building occupants in the event of a fire. These findings were confirmed by both the Administrator and the Maintenance Director during the exit conference.