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MILLE LACS HEALTH SYSTEM
HVAC
Tag No.: K0521
Based on a review of available documentation and staff interview, the facility failed to inspect fire dampers per NFPA 101 (2012 edition), Life Safety Code, section 8.5.5.4.2, and NFPA 105 (2010 edition), Standard for Smoke Door Assemblies and Other Opening Protectives, section 6.5.2. This deficient finding could have a widespread impact on the residents within the facility.
Findings include:
On 08/13/2024 between 09:30 AM and 12:30 PM, it was revealed by a review of available documentation that the facility could not provide documentation that the completed inspections were performed on the fire dampers at the time of the survey.
An interview with the Faciliities Manager verified this deficient finding at the time of discovery.