Lack of Documentation and Final Inspection for Newly Installed Boiler
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with regulatory requirements, specifically section 9.2. During an observation, it was found that a newly installed boiler heating unit lacked manufacturer information and proof of a State of Michigan boiler inspection. The office manager was unable to confirm whether the necessary corrections identified by the state boiler inspector during a previous visit had been completed, and only had limited information about the inspector. Further confirmation from the State of Michigan boiler inspector indicated that the required corrections on the new boiler installation had not yet been completed, and a final inspection had not been requested.
Plan Of Correction
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The boiler was inspected and did not pass. Contractor has made the required repairs and is calling to schedule another inspection as soon as possible. Once the state boiler inspection has been completed, the local building department will perform their inspection. I personally spoke with the state boiler inspector on Friday, as the contractor is not fulfilling his responsibilities of completing this project and scheduling the inspection. The inspector said he would be able to come on Monday, June 30 or July 1, but I have not heard back with a confirmed date or time. I am unable to force the contractor or inspector to get this taken care of in a timely manner, so I do not have firm dates that it will be inspected or approved. Address how the facility will identify other residents having a potential to be affected by the same deficient practice: The residents are not affected by this deficient practice. The boiler is not in use as it is not heating season and operates as designed when needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: This contractor will not be used again in the future. Maintenance Director will ensure any future contractors will complete permits and inspections prior to being paid in the future. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Maintenance director will monitor weekly and maintain communication with contractor to ensure the inspections are completed. Will be discussed at quarterly QAPI meetings.
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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