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.