HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521
Based on documentation review and interview, it was determined the facility failed to maintain smoke dampers in one instance, affecting the entire facility.
Findings include:
1. Review of documentation on March 19, 2025, at 9:25 a.m., revealed there was no evidence that smoke dampers throughout the building had been inspected or tested in the last 48 months. Visual observation of the dampers revealed no inspection labels.
Interview with the Facility Administrator and Maintenance Director on March 19, 2025, at 9:25 a.m., confirmed the lack of documentation at the time of the survey.
*** During the revisit on May 13, 2025, between 8:30 a.m., and 10:30 a.m., item #1 was observed not ro have been completed.
Interview with the Facility Administrator and Maintenance Director on May 13, 2025, at 10:30 a.m., confirmed the lack of documentation at the time of the survey.
| | Plan of Correction - To be completed: 06/16/2025
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
The facility had smoke dampers inspected throughout the facility. The inspection occurred on 05/02/2025.
The facility will input the requirement of inspection and testing of smoke dampers into the facilities newly established preventative maintenance monitoring program to ensure timely notification of the need for inspection and testing as required by regulation.
The Facility NHA and Maintenance staff will be educated on 0521, as well as the newly established preventative Maintenance monitoring program. Any concerns will be addressed through the Quality Assurance Performance improvement program.
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