Non-compliance with NFPA Standards in HVAC System
Summary
The facility was found to have a deficiency related to the heating and ventilation system during a Life Safety Code portion of the recertification survey. Specifically, on the second floor of the extension building, an unducted air return was being used as a ceiling plenum in the office suite located on the lobby level. This setup was not in compliance with the 2012 NFPA 101 and 2012 NFPA 90A standards, which require that air-conditioning, heating, and ventilating systems be installed according to specific safety standards to prevent the spread of smoke and fire. During the survey, it was observed that there were multiple penetrations above the ceiling between the lobby, which serves as a means of egress, and the adjacent offices. This arrangement posed a risk as it could allow smoke to enter the lobby area, potentially impeding egress in the event of a fire in the adjacent spaces. The deficiency was identified through both observation and staff interviews, highlighting a lapse in maintaining the integrity of the fire and smoke stopping measures required by the relevant NFPA standards. At the time of the survey, the Director of Maintenance acknowledged the deficiency and indicated that it would be corrected. However, the report does not provide details on any corrective actions taken or planned to address the issue. The focus of the deficiency was on the non-compliance with the NFPA standards, which are critical for ensuring the safety and proper functioning of the facility's heating and ventilation systems.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrections: 1. The facility conducted a review of the lobby and office area plenum for compliance with NFPA 90A 4.3.11.2.1 through 4.3.11.2.7. The integrity of the fire and smoke stopping for penetrations shall be maintained. 2. The facility maintenance department has sealed with appropriate material all openings that were found throughout the above ceiling to adjoining rooms to prevent the transfer of smoke. II. Identification of Other Residents: 1. The Facility respectfully states that all residents were potentially affected but no residents were involved in this deficiency. 2. There were no additional issues identified from this environment review, as all egress doors functioned appropriately. III. Systemic Changes: 1. The Director of Maintenance has reviewed and implemented a Preventive Maintenance Program whereby the above ceilings are checked in accordance with 2012 NFPA 90A: 4.3.11.2.1 through 4.3.11.2.7 and documented on the inspection log with any corrective actions required or completed. 2. If repairs cannot be completed in house, then the items shall be logged on master work log and appropriate service company called with completion noted on master work log. 3. Staff performing the required inspections shall be in-serviced on the requirements set forth above. IV. QA-Monitoring 1. The Director of Maintenance will audit the completed inspection and testing log for completeness and completed repairs. 2. The audit will be completed weekly by the Maintenance staff/designee as assigned and reviewed by the Director of Maintenance. 3. Any quality issues identified will be communicated to the Administrator and repaired for compliance as identified. 4. Audit findings from the monthly tool will be presented to the Quarterly QA Committee by the Director of Maintenance for evaluation and follow-up as indicated. The review will continue for 6 months and then semiannual if there are no deficiencies found. Responsible Person: V. Title Responsible: Director of Maintenance
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
