Non-Compliance with Heating Requirements in Resident Rooms
Penalty
Summary
York Nursing and Rehabilitation Center was found to be non-compliant with the requirement to maintain essential equipment in safe operating condition, specifically regarding air temperatures in resident rooms. The facility's policy mandates maintaining ambient temperatures between 71-81°F. However, during a survey, it was discovered that the central heater in the first south hallway was malfunctioning, affecting the heating in Rooms 119 and 239. In Room 119, the temperature was recorded at 69°F due to inadequate insulation around a window air conditioning unit, which allowed cold air to enter. The maintenance technician addressed this by removing the unit and improving window insulation, raising the temperature to 72°F. In Room 239, the overall temperature was 72°F, but the area near the window, where a resident was residing, was colder at 68°F. The resident reported feeling cold by the window, and it was noted that despite insulation, the large window allowed a draft. The resident had recently been moved to this room for more space. Both the Maintenance Director and the Administrator confirmed that the rooms were out of compliance with heating temperature requirements during the survey tour.
Plan Of Correction
Step 1 The AC window unit in room 119 was removed, and the window was insulated. The maintenance team checked the PTAC unit and confirmed that it was operational but turned off. The PTAC unit was turned on and was working adequately. The air temperature was rechecked and was within normal limits. The resident in bed 239C was moved to another room with adequate heat. The maintenance team re-insulated the window and sealed all drafts. A quote was obtained to replace the PTAC unit and the facility will install a new PTAC unit as soon as possible. The air temperatures for beds A, B, and D were rechecked and were within normal limits. Step 2 The facility completed an audit of the entire building. All window AC units were removed and windows insulated as needed. The facility audited all PTAC units and other HVAC equipment to ensure proper operation. Air temp audit completed in residents' rooms, hallways, dining, and lounge areas. No other areas were identified with air temperature issues. Step 3 Facility maintenance staff educated on air temperature policy and the requirement to check room temps daily and report any abnormal temps immediately to NHA. Step 4 The facility maintenance team will check air temps daily. NHA or designee will audit temp logs weekly x4 and monthly x2. Results will be reviewed during the monthly QAPI meeting.