Deficiency in HVAC Maintenance and Room Conditions
Penalty
Summary
The facility failed to ensure timely repairs for one of three air conditioning units, which had been non-functional for about a month. The Director of Maintenance (DOM) acknowledged that the main board of the unit was not working and that a portable unit was being used as a temporary solution. Despite obtaining quotes and submitting them to the corporate office, the repairs had not been approved or completed at the time of the survey. The maintenance log showed a pending service request for the rooftop unit, which had been unresolved for 43 days. Additionally, a purchase requisition for the repair was approved, but no timeline for the repair was provided. The facility also failed to maintain resident rooms in a safe and sanitary manner. Observations revealed that two resident rooms had issues with cracking, peeling, and dislodged ceiling material with discoloration. One room had three areas of concern, each approximately 2 by 3 inches, while another room had cracks with dislodged and discolored painted material approximately 2 by 2 inches. Four residents were residing in the affected room at the time of the survey. The Nursing Home Administrator confirmed the approval of the purchase requisition but did not provide comments on the maintenance and repairs policy.
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. N-112, Physical Environment and Physical Maintenance 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) or designee in-serviced Concierge personal and staff regarding the identification and reporting of any areas of disrepair or noncompliance of the physical environment in resident rooms. Nursing Home Administrator (NHA) and/or designee in-serviced Maintenance Director regarding the Physical Environment Policy. Regional Director of Operations Consultant in-serviced 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 .