Failure to Maintain HVAC System Resulting in Inoperable Cooling
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system as required by federal regulations and the National Fire Protection Association (NFPA) Life Safety Code. During a facility tour and staff interviews, surveyors observed that the chiller system, which includes four air handlers serving each wing, was completely inoperable. As a result, the facility was using six portable air conditioning units distributed throughout the corridors and dining room. Staff confirmed that the main cooling system had been nonfunctional for over a year, and the facility was in the process of obtaining a new system while relying on portable units in the interim. This deficiency affected all 95 residents across all four compartments of the facility, resulting in the inability to maintain required temperatures.
Plan Of Correction
HVAC How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Facility completed contract to have chiller replaced on 04/05/2024. Chiller install date is May of 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-service was conducted by the facility Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring the facility maintains functional HVAC system to maintain facility temperatures. d) Maintenance Director and/or designee will conduct weekly facility inspections focusing on functioning HVAC system and maintaining facility temperature. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Administrator. Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI committee for further evaluation and/or recommendations.