Failure to Timely Repair and Maintain Essential A/C Equipment
Penalty
Summary
The facility failed to ensure timely repair and maintenance of essential equipment, specifically one of its rooftop air conditioning (A/C) units, identified as unit #11. According to staff interviews and record review, the A/C unit had a bent fan blade and had not been functioning properly since October 2024. Despite the ongoing issue, the problem was not addressed or escalated appropriately, and the Nursing Home Administrator (NHA) was unaware of the malfunction until it was brought up during the survey. Staff members, including a maintenance assistant and a maintenance director from another facility, confirmed the prolonged nature of the problem. Observations during the survey included a staff member fanning herself in the affected hallway, indicating discomfort due to inadequate cooling. Additionally, the facility did not have a written policy regarding the maintenance and repair of A/C units, as required by regulation. The lack of a maintenance policy and the failure to address the malfunctioning A/C unit in a timely manner contributed to the deficiency. The survey also noted that the facility could not confirm payment or completion of repairs for previously identified A/C issues, and that the problem with unit #11 had not been included in prior repair requests. The deficiency was cited as a Class I violation, and the facility was found to be out of compliance with relevant state and federal regulations.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The AC unit (#11) in the south hallway/activities room area repaired by 7/12/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the roof top AC units in the facility was completed. Roof top AC units identified with concerns will be repaired and/or replaced by 7/12/2025. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, Staff educated by the Administrator and/or designee on essential equipment, safe operating condition and identified concerns to be reported via TELS. 2. Newly hired staff will be educated on essential equipment, safe operating condition and identified concerns to be reported via TELS. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator and/or designee will conduct a random audit of the roof top AC units to ensure essential equipment is in safe operating condition weekly for 4 weeks, then monthly x 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance is sustained.