Failure to Timely Repair and Maintain Essential A/C Equipment
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.
Penalty
A deficiency occurred when a resident's room remained excessively hot, with temperatures near 90°F, due to an unrepaired rooftop A/C unit. The resident, who was nonverbal and medically complex, experienced physical discomfort for about a month while staff and maintenance were aware of the issue but did not routinely monitor or document room temperatures. Leadership lacked a formal process for temperature checks or maintenance reporting, and no policies were provided to ensure compliance.
The facility failed to repair a non-functional air conditioning unit for over a month, relying on a portable unit instead. Despite obtaining quotes and approval for repairs, no timeline was provided. Additionally, two resident rooms had issues with cracking and dislodged ceiling material, affecting the safety and sanitation of the environment.
Failure to Maintain Safe Room Temperatures Due to Unrepaired A/C Unit
Penalty
Summary
A deficiency was identified when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom due to an unrepaired rooftop air-conditioning (A/C) unit. Observations revealed that the resident's room had temperatures between 89.8 and 90.0 degrees Fahrenheit, with noticeable humidity and lack of cool airflow. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting the room had been warm for about a month. Multiple staff members, including CNAs and LPNs, confirmed awareness of the persistent high temperatures in the room, and it was noted that the issue had not been formally reported or addressed in the facility's electronic communication log. The resident involved had significant medical conditions, including severe intellectual disabilities, acute and chronic respiratory failure, contractures, cognitive communication deficits, and generalized muscle weakness, necessitating assistance with personal care. The resident was unable to communicate preferences or discomfort regarding room temperature. Despite the resident's vulnerability, the maintenance staff had not routinely checked or documented room temperatures, and the Maintenance Director only measured the temperature after being prompted during the survey. The Maintenance Assistant and Director both expressed expectations for room temperatures to be significantly lower than what was observed, and acknowledged that the conditions were unsuitable for a resident. Interviews with facility leadership, including the DON and NHA, revealed a lack of awareness and formal process for monitoring and documenting room temperatures. The NHA stated that temperature checks were only performed in response to A/C outages and that staff were expected to report issues through an electronic system, though no such reports were found. The facility did not provide policies or procedures for temperature monitoring or staff communication regarding maintenance concerns. The deficiency was cited due to the failure to ensure the physical environment was maintained in a manner that assured resident safety and well-being, as required by regulation.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 08/30/2025, an outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results, along with any concerns related to compliance, will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
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 .
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