Improper HVAC Maintenance
Penalty
Summary
The facility failed to properly maintain its HVAC systems, affecting one of three floors. On January 30, 2025, at 9:55 a.m., an observation revealed that a portable air conditioning unit was ducted into the ceiling in the ground floor South Elevator Mechanical Room. Additionally, at 9:40 a.m. on the same day, another portable air conditioning unit was found ducted into the ceiling in the North Kitchen Dietary Office on the ground floor. These findings were confirmed during an exit interview with the Administrator and the Maintenance Director on January 30, 2025, at 11:30 a.m.
Plan Of Correction
Step 1 The portable air conditioning unit was removed from the ground floor South Elevator Mechanical Room. Step 2 A facility-wide audit was completed to ensure that no other portable air conditioning units were venting directly into the ceiling. Step 3 The maintenance team was educated on the requirement to ensure that portable air conditioner units are not vented directly into the ceiling. Step 4 The maintenance director/ designee will complete a random audit monthly x 4 to ensure that no portable AC units are vented directly into the ceiling. Findings will be reviewed during QAPI. Step 1 The portable air conditioning unit was removed from the dietary office. Step 2 A facility-wide audit was completed to ensure that no other portable air conditioning units were venting directly into the ceiling. Step 3 The maintenance team was educated on the requirement to ensure that portable air conditioner units are not vented directly into the ceiling. Step 4 The maintenance director/ designee will complete a random audit monthly x 4 to ensure that no portable AC units are vented directly into the ceiling. Findings will be reviewed during QAPI.