Pennsylvania Department of Health
 LUTHERAN HOME AT TOPTON, THE
Building Inspection Results

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LUTHERAN HOME AT TOPTON, THE
Inspection Results For:

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LUTHERAN HOME AT TOPTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on September 30, 2025, at the Lutheran Home at Topton, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73. 
 Plan of Correction:


Initial comments:Name: BUILDING 1 - Component: 01 - Tag: 0000
Facility ID #643102Component 011976 BuildingBased on a Medicare/Medicaid Recertification Survey conducted on September 30 &; October 1, 2025, it was determined that the Lutheran Home at Topton was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a two-story, Type III (200), unprotected ordinary structure, without a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0100 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component. Findings include: 1. Review of documentation September 30, 2025, between 9:45 AM and 11:45 AM, revealed the facility lacked portable, accurate and legible life safety drawings of the facility with an active FSES. Floor plans lacked compartment labeling, resident room capacities, fire wall boundaries, smoke wall boundaries, hazardous areas, length and width of zones and travel distances. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of portable, accurate life safety drawings of the facility, as required, for a facility with an active FSES.
 Plan of Correction - To be completed: 02/10/2026

The maintenance director shall organize the existing life safety drawings into a set of portable, accurate life safety drawings of the 1976 facility by 2/10/2026

Monthly, the maintenance director will audit the Life Safety Book to ensure the life safety drawings are present and complete

The maintenance director will present the results of the audit at the monthly QUAPI meeting
NFPA 101 STANDARD Building Construction Type and Height:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Building Construction Type and Height
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5

Construction Type
1 I (442), I (332), II (222) Any number of stories
non-sprinklered and sprinklered

2 II (111) One story non-sprinklered
Maximum 3 stories sprinklered

3 II (000) Not allowed non-sprinklered
4 III (211) Maximum 2 stories sprinklered
5 IV (2HH)
6 V (111)

7 III (200) Not allowed non-sprinklered
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.
Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0161 Based on observation and interview, it was determined the facility failed to maintain building construction requirements, affecting the entire component. Findings include: 1. Observation on September 30, 2025, at 11:30 AM, revealed this is a two-story, Type III (200), unprotected ordinary structure, which is fully sprinklered. The building exceeds the maximum allowable story height for this type of construction. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the construction type is not permitted in health care.
 Plan of Correction - To be completed: 02/10/2026

The Lutheran Home of Topton wishes to have DSI conduct an FSES survey.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to conduct inspections on the fire alarm system, for the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 9:45 AM and 11:45 AM, revealed the facility failed to perform a semi-annual visual inspection. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the facility failed to perform a semi-annual inspection.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director created a checklist of all the components of the fire alarm system of building 76. On December 13, 2025, and December 20, 2025, he performed a visual inspection of all the components on the checklist. He recorded the presence of each component with his initials and date. He placed the record of the inspection in the Life Safety Book . He marked the hard copy of the annual inspection schedule that the semi-annual visual inspection of the fire alarm components in building 76 was complete.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to provide quarterly, semi-annual, 3-year and 5-year sprinkler maintenance documentation and lack of hydraulic nameplates, affecting the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 10:09 AM and 10:14 AM, revealed the facility lacked documentation, for the following: a. 10:09 AM, wet system, Semi-Annual Valve Supervisory Switches and Pressure Switch Waterflow Alarm; b. 10:10 AM, 4th quarter Wet/Dry Sprinkler Report; c. 10:12 AM, dry system, Annual Trip Test and 3-year Full Flow Trip Test; d. 10:14 AM, 5-year Internal Pipe and Valve Inspection. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of documentation for the sprinkler systems. 2. Observation on October 1, 2025, at 10:25 AM, revealed the lack of hydraulic nameplates on installed sprinkler systems. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of hydraulic nameplates for the sprinkler systems.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the Wet System Semi-Annual Valve Supervisory Switches and Pressure Switch Waterflow alarm inspection they conducted on 1-2-2025 at building 76. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.



Facility failed to provide a 4th quarter Wet/Dry Sprinkler report

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the 4th quarter Wet/Dry Sprinkler test they conducted on 10-24-25 at building 76. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book in a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.



Facility failed to provide proof of a 5-year Internal Pipe and Valve Inspection.

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the 5-year Internal Pipe and Valve Inspection they conducted on 12-20-2022 at building 76. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the Maintenance Director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book in a timely manner.

The Maintenance Director will present the results of the audit at the monthly QUAPI meeting.





Facility "lacked hydraulic nameplates on the installed sprinkler systems"

The maintenance director contacted our vendor, Precision Fire Protection and asked them to survey building 76 and prepare new hydraulic nameplates for the sprinkler system.

Precision Fire Protection cannot complete the survey in 90 days.

The maintenance director will request a limited time waiver.

Our vendor will be able to complete the survey and create the nameplates by 10/2026.

The maintenance director will attach the nameplates to the sprinkler system.

Monthly, the maintenance director will audit the sprinkler system in building 76 to ensure the hydraulic nameplates remain in place.

The maintenance director will present the results of the sprinkler system audit at the monthly QUAPI meeting.
NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.
Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0371 Based on observation and interview, it was determined the facility failed to provide smoke compartments, not greater than 22,500 square feet, affecting two of two floors within the component. Findings include: 1. Observation on October 1, 2025, between 12:00 PM and 1:15 PM, revealed Zone 3, on the 1st floor, and Zones 7 and 8, on the ground floor, were extended zones. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the extended zones.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director will provide documentation based on the Life Safety drawings that new smoke walls were constructed in 2017 in building 76. The smoke zone 3 on the first floor and zones 7 and 8 on the ground floor no longer exceed the maximum allowable 22,500 square feet.

Monthly, the maintenance director will audit the Life Safety Book to ensure the life safety drawings are present and complete

The maintenance director will present the results of the audit at the monthly QUAPI meeting.
NFPA 101 STANDARD HVAC:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
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




Observations:
Name: BUILDING 1 - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility lacked documentation, verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 9:45 AM and 11:45 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of documentation for the fire dampers.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director contacted our vendor, Advanced Air, to inspect all the smoke dampers in building 76. They will inspect, clean, exercise and replace the fusible link of every smoke damper in building 76 on January 4, 2026.

The maintenance director will mark it as complete on the Life Safety Annual Inspection Schedule. He will also note on the Annual Inspection Schedule that the next inspection will be due in 2032-2035. He will place a copy of the report in the Life Safety Book

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book in a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.
Initial comments:Name: D BLDG - Component: 02 - Tag: 0000
Facility ID #643102Component 021996 BuildingBased on a Medicare/Medicaid Recertification Survey conducted on September 30 &; October 1, 2025, it was determined that the Lutheran Home at Topton was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.  Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a three-story, Type II (111), protected noncombustible structure, with a basement, which is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD General Requirements - Other:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Observations:
Name: D BLDG - Component: 02 - Tag: 0100 28 Pa. Code 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained and operated to safely and efficiently render the services offered. Based on document review and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component. Findings include: 1. Review of documentation and interview on September 30, 2025, between 9:30 AM and 11:15 AM, revealed the facility lacked portable, accurate life safety drawings of the facility. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of portable, accurate life safety drawings of the facility.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director shall organize the existing life safety drawings into a set of portable, accurate life safety drawings of the 1996 facility by 2/10/2026

Monthly, the maintenance director will audit the Life Safety Book to ensure the life safety drawings are present and complete

The maintenance director will present the results of the audit at the monthly QUAPI meeting.
NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
Observations:
Name: D BLDG - Component: 02 - Tag: 0345 Based on document review and interview, it was determined the facility failed to conduct inspections on the fire alarm system, for the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 9:45 AM and 11:45 AM, revealed the facility failed to perform a semi-annual visual inspection. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the facility failed to perform a semi-annual inspection.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director created a checklist of all the components of the fire alarm system of Building 96. On December 13, 2025 and December 20, 2025, he performed a visual inspection of all the components on the checklist. He recorded the presence of each component with his initials and date. He placed the record of the inspection in the Life Safety Book . He marked the hard copy of the annual inspection schedule that the semi-annual visual inspection of the fire alarm components in building 76 was complete.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: D BLDG - Component: 02 - Tag: 0353 Based on document review, observation and interview, it was determined the facility failed to provide quarterly, semi-annual, 3-year and 5-year sprinkler maintenance documentation and lack of hydraulic nameplates, affecting the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 10:09 AM and 10:14 AM, revealed the facility lacked documentation, for the following: a. 10:09 AM. wet system, Semi-Annual Valve Supervisory Switches and Pressure Switch Waterflow Alarm; b. 10:10 AM, 4th quarter Wet/Dry Sprinkler Report; c. 10:12 AM, dry system, Annual Trip Test and 3-year Full Flow Trip Test; d. 10:14 AM, 5-year Internal Pipe and Valve Inspection. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of documentation for the sprinkler systems. 2. Observation on October 1, 2025, at 10:25 AM, revealed the lack of hydraulic nameplates on installed sprinkler systems. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of hydraulic nameplates for the sprinkler systems.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the Wet System Semi-Annual Valve Supervisory Switches and Pressure Switch Waterflow alarm inspection they conducted on 1-2-2025at building 96. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.

Facility failed to provide a 4th quarter Wet/Dry Sprinkler report

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the 4th quarter Wet/Dry Sprinkler test they conducted on 10-24-2025 at building 96. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.



Facility failed to provide proof of a 5-year Internal Pipe and Valve Inspection.

The maintenance director contacted our vendor, Precision Sprinkler, and obtained a copy of the record of the 5-year Internal Pipe and Valve Inspection they conducted on 12-20-2022 at building 96. The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He placed a copy of the report in the Life Safety Book.

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book in a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.



Facility "lacked hydraulic nameplates on the installed sprinkler systems"

The maintenance director contacted our vendor, Kistler O'Brien Fire Protection Systems and asked them to survey building 96 and prepare new hydraulic nameplates for the sprinkler system.

The maintenance director will request a limited time waiver until 10/26 since Precision Sprinkler cannot complete the survey and manufacture the nameplates in 90 days

Our vendor will be able to complete the survey and create the nameplates by 10/2026.

The maintenance director will attach the nameplates to the sprinkler system.

Monthly, the maintenance director will audit the sprinkler system in building 76 to ensure the hydraulic nameplates remain in place.

The maintenance director will present the results of the sprinkler system audit at the monthly QUAPI meeting.
NFPA 101 STANDARD HVAC:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
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




Observations:
Name: D BLDG - Component: 02 - Tag: 0521 Based on document review and interview, it was determined the facility lacked documentation, verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component. Findings include: 1. Review of documentation on September 30, 2025, between 9:45 AM and 11:45 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance. Interview at the time of the exit conference with the Administrator and Manager of Plant Operations on October 1, 2025, at 1:15 PM, confirmed the lack of documentation for the fire dampers.
 Plan of Correction - To be completed: 01/30/2026

The maintenance director contacted our vendor, Advanced Air, to inspect all the smoke dampers in building 96 on . They will inspect, clean, exercise and replace the fusible link of every smoke damper in building 96 on January 4, 2026. .

The maintenance director marked it as complete on the Life Safety Annual Inspection Schedule. He will also note on the Annual inspection Schedule that the next inspection will be due in 2032-2035. He will place a copy of the report in the Life Safety Book

Monthly, the maintenance director will audit the annual inspection schedule in the Life Safety Book to ensure all required testing is scheduled, completed and all reports are received and placed in the Life Safety Book in a timely manner.

The maintenance director will present the results of the audit at the monthly QUAPI meeting.



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