Failure to Timely Repair Malfunctioning A/C Unit
Penalty
Summary
The facility failed to ensure timely repair of essential equipment, specifically one of the rooftop air conditioning (A/C) units, identified as unit #11, out of a total of 19 units. According to staff interviews and observations, the A/C unit #11 had a bent fan blade and had not been functioning properly since October 2024. The maintenance assistant was aware of the ongoing issue, but the Nursing Home Administrator (NHA) stated she was unaware of the problem until it was brought to her attention during the survey. During the survey, staff were observed attempting to find cooler areas in the building, indicating discomfort due to the malfunctioning A/C. The facility did not have a policy in place for the maintenance and repair of A/C units. Maintenance staff confirmed that the issue with A/C unit #11 had persisted for several months without resolution. The NHA could not confirm whether payment had been made to the A/C company for previous repair requests, and only a new quote for repairs was available at the time of the survey. The lack of timely repair and absence of a maintenance policy contributed to the deficiency cited by surveyors.
Plan Of Correction
F908: 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.