Facility Fails to Repair A/C Unit and Maintain Resident Rooms
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for approximately one month. The Director of Maintenance (DOM) identified the malfunction on 01/28/2025, and a proposal for repairs was submitted, but as of 03/07/2025, the repairs had not been completed despite approval of the purchase requisition on 02/12/2025. The facility relied on a portable unit in the interim, but no further information was provided regarding the timeline for the repair of the air conditioning unit. Additionally, the facility did not maintain resident rooms in a safe and sanitary manner, as evidenced by observations of cracking, peeling, and dislodged ceiling material with discoloration in two resident rooms. Room 104, which was unoccupied, had three areas of dislodged paint, each approximately 2 feet by 3 feet. Room 105, which housed four residents, had similar issues with cracks and discolored paint material approximately 2 feet by 2 feet. The Nursing Home Administrator (NHA) confirmed the air conditioning unit had not been fixed but did not comment on the condition of the resident rooms.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-0908 Essential Equipment, Safe Operating Condition Element #1. The facility's air conditioning unit was repaired on, Ceiling in resident are scheduled for repair on. Element #2. The facility's remaining air conditioning units were inspected for proper functioning on and no concerns were identified. Resident room ceilings were inspected for cracked and/or peeling paint on No areas of noncompliance were identified. Element #3. Nursing Home Administrator (NHA) and/or Designee in-serviced Concierge personnel and facility staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced the Nursing Home Administrator (NHA) regarding management of product or equipment requisitions. Element #4. Nursing Home Administrator (NHA) will randomly audit resident room ceilings and air conditioning units five (5) times weekly times eight (8) weeks to ensure that ceilings do not have cracked/peeling paint and that air conditioning units are properly functioning. Completed audits will be brought to the stand up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation. Element #5: Facility's Allegation of Compliance Date is.