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F0923
E

Failure to Address Air Conditioning Malfunction and Resulting Unsafe Conditions

Decorah, Iowa Survey Completed on 09-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly monitor and intervene when the air conditioning unit in the Chronic Confusion or Dementing Illness (CCDI) unit became non-operational, resulting in excessively warm and humid conditions. Multiple staff members, including RNs, LPNs, and CNAs, observed that the unit became hot, with significant humidity causing condensation and wet, slippery floors. Staff attempted to manage the moisture by dry mopping the floors, but did not notify management or the maintenance department about the high temperatures and humidity during the evening and night shifts. The lack of timely communication delayed appropriate intervention. Staff interviews confirmed that the issue persisted across several shifts, with reports of extremely hot conditions, condensation on floors in hallways and dining areas, and water observed in resident rooms. The Director of Human Resources/Interim Administrator was eventually notified by housekeeping staff, who reported the ongoing problem. Maintenance was contacted the following morning, at which point fans and dehumidifiers were brought in, and additional equipment was purchased to address the malfunction. The deficiency was further substantiated by climatological data indicating high outdoor temperatures during the incident.

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