F0558

D

Failure to Maintain Clean and Intact AC Unit and Filters in Resident Room

Tempe, Arizona Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the facility’s failure to maintain a resident’s room air conditioning (AC) unit and filters in a clean and intact condition. The resident involved had been admitted with multiple serious diagnoses, including COVID-19, sepsis due to E. coli, liver abscess, Klebsiella pneumoniae, and Type II diabetes, and had a care plan for bacteremia due to Klebsiella with IV antibiotics and a goal to remain free from complications related to infection. During an interview in the resident’s room, the resident reported that the AC unit was working but dirty and stated it had been that way since admission. Observation at that time showed a visible layer of dust on the top surface of the AC unit and visible dust accumulation on two AC filters.

Two subsequent observations on later dates showed that the top of the AC unit remained dirty and dusty and the filters remained full of dust. Review of the facility’s HVAC inspection log in the Direct Supply TELS preventive maintenance system showed the last HVAC inspection had been completed several months earlier. The Maintenance Manager stated that AC units and filters were cleaned monthly and as needed. However, during another observation of the same AC unit, one filter was found with an approximately 30-centimeter hole. The Maintenance Manager stated the filter had been cleaned the previous day but confirmed the damaged filter had not been replaced, acknowledged the top of the unit was dirty, and stated that the hole would prevent proper filtration and allow unfiltered air to circulate in the room, which could increase the risk of residents becoming ill. Facility policy required maintenance staff to maintain equipment per manufacturer instructions and document routine inspections and maintenance in the TELS system.