Improper Venting of Portable Air Conditioning Unit
Summary
A deficiency was identified when, during an observation, a portable air conditioning unit was found in a large common area near the Nurses' Station on one of four floors. The unit was vented directly into the interstitial space of the ceiling rather than being vented to the outside, as required. This was confirmed during an interview with the Administrator, Regional Director, Regional Maintenance Director, and the Environmental Services Director. The facility did not maintain the air conditioning system in accordance with NFPA 101 and the manufacturer's specifications.
Plan Of Correction
The facility failed to maintain air conditioning systems on one of four floors. No residents were affected. All residents have the potential to be affected. The portable air conditioning unit, located in a large common area near the Nurses' Station, was removed so it is not vented directly into the interstitial space of the ceiling. The expected date for HVAC repair is September 30th, 2025, with the portable air conditioners removed before October 31st, 2025. An audit was completed by the Maintenance Director to ensure that no portable air conditioning units were vented directly into the interstitial space of the ceiling, with no concerns found and compliance confirmed. The Director of Maintenance and maintenance staff were educated by the Administrator on the requirement. The Maintenance Director/Designee will conduct one weekly audit of the portable air conditioner for four weeks, then monthly for two months. Results of audits will be reviewed at the Quarterly Quality Assurance and Improvement Committee Meeting over the duration of the audit process. Based on the results of the audits, a decision will be made regarding the need for continued submission and reporting.
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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