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K0521
E

Failure to Address Failed Fire Dampers in HVAC System

Pottstown, Pennsylvania Survey Completed on 08-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

See complete original report
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