Failure to Exercise Fire Dampers at Required Intervals
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.
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.
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.
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