Failure to Maintain Safe, Comfortable Environment and Timely HVAC Repairs
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for all residents by not promptly addressing significant issues with its cooling system and by neglecting necessary repairs and cleaning in resident rooms and common areas. The air conditioning (AC) system was reported as malfunctioning for an extended period, with temperatures in resident areas reaching as high as 90 degrees Fahrenheit and the kitchen reaching 110 degrees Fahrenheit. Despite complaints from residents, staff, and the Ombudsman, the facility did not initiate a work order for HVAC repairs until a week after the problem was first identified. During this period, the facility did not provide adequate interim cooling measures, such as portable AC units or sufficient fans, and failed to document or monitor indoor temperatures. Staff interviews revealed that residents were not consistently provided with extra fluids or ice, and some residents reported not receiving fans that had previously been supplied during hot weather. In addition to the HVAC issues, multiple resident rooms, a common gathering area, and the main dining hall were observed to be in disrepair and in need of cleaning. Observations included large water stains, peeling paint, cracked ceilings, brownish-yellow discoloration, exposed drywall, missing baseboards, and significant dust and debris accumulation. Residents and staff confirmed that these conditions had been present for months, and complaints had been made to administration without resolution. The Director of Maintenance acknowledged a backlog of repairs and stated he lacked autonomy to address the issues, while the Administrator and DON confirmed awareness of the facility's deteriorating condition but could not provide a specific timeline for repairs. Documentation and interviews further revealed that the facility lacked policies and procedures for responding to mechanical failures of the HVAC system or for monitoring temperatures during such events. The Director of Maintenance did not keep written logs of facility temperatures, and the Administrator was unable to provide evidence supporting claims that temperatures remained within a safe range. The absence of a structured response and documentation process contributed to prolonged exposure of residents and staff to unsafe and uncomfortable conditions.