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F0921
D

Failure to Repair Exterior Wall Gap and Lack of Maintenance Reporting System

North Aurora, Illinois Survey Completed on 12-04-2025

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

A gap was observed between the exterior wall and the air conditioner unit in a resident's room, allowing cold air to flow directly into the room and making the space chilly. The gap was large enough that the parking lot was visible through it. The resident, who was cognitively intact and had multiple diagnoses including schizophrenia, alcohol-induced psychosis, anxiety disorder, and nicotine dependence, reported that the gap had been present for about a month. The resident's roommate was also observed fully dressed and lying under blankets, indicating discomfort due to the cold. Staff members, including the housekeeper assigned to the room and the housekeeping supervisor, were unaware of the gap until it was pointed out during the survey. The maintenance director also stated he was unaware of the issue prior to being informed by staff. There was no record of a maintenance request form being completed for the gap, and the last maintenance request received by the maintenance director was dated nearly two months prior. The facility did not have a policy regarding the reporting of maintenance issues or requesting repairs, and staff had stopped using the maintenance request form for unknown reasons. The administrator confirmed that there was no formal policy in place and that staff were expected to request repairs using the form, but could not explain why this process was not being followed.

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