Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521
Based on observation and interview, it was determined the facility failed to comply with HVAC requirements in one instance, affecting six of seven smoke compartments.
Findings include:
1. Observation on April 16, 2026, at 8:45 a.m., revealed portable air conditioning units in the facility were ducted directly into the space above the ceiling, using the interstitial space as a plenum and there was no documentation for Interim Life Safety Measures, as the units were a temporary means to maintain indoor air temperatures.
Interview with the Facility Administrator and Maintenance Staff on April 16, 2026, at 10:30 a.m., confirmed the HVAC deficiencies.
| | Plan of Correction - To be completed: 06/15/2026
The facility acknowledges the presence of portable air conditioning units that were observed venting into the interstitial ceiling space.
These units were implemented as a temporary measure to maintain safe indoor air temperatures due to ongoing deficiencies in the building's primary HVAC system. Removal of these units at this time would place residents at risk for unsafe temperature extremes, which the facility has determined would pose a greater immediate risk to resident health and safety.
The facility has:
- Assessed all portable units currently in use
- Ensured units are functioning as designed by the manufacturer
- Confirmed that units are being used strictly as a temporary intervention
The facility has implemented the following Interim Life Safety Measures (ILSM) to mitigate risk while the temporary units remain in use:
- Increased environmental and safety rounds to monitor affected areas
- Ongoing monitoring of ambient temperatures in resident care areas to ensure safe conditions
- Routine emptying and maintenance of condensation tanks to prevent water accumulation or leakage
- Staff education on safe operation and monitoring of temporary units
- Maintenance oversight to ensure units remain in good working condition
Due to the structural design of the building, the facility does not have return ductwork or direct exhaust pathways available on resident floors. Additionally, external venting is not feasible without significant structural alteration (penetration through brick, concrete, glass, and existing infrastructure), which is not possible as an interim solution.
The portable units are being utilized in accordance with their intended design and purpose as temporary environmental control devices.
Maintenance Director or designee will conduct daily visual checks of all portable units. Environmental logs will track temperature ranges in affected areas. Leadership will review conditions during routine rounds to ensure continued resident safety. Any concerns identified will be addressed immediately
The facility is actively in the process of replacing the HVAC system to restore full compliance with Life Safety Code requirements.
Upon completion and full operation of the new HVAC system:
- All portable units will be removed from service
- The facility will return to a fully compliant ventilation system
Anticipated completion date: 8/1/26
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