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.