§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
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Observations:
Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, sanitary environment for three out of four residents (Residents R1, R2, and R3).
Findings include:
Observation on August 5, 2026, at approximately 10:00 a.m., in the Hearth Room common area finds an air conditioning window unit containing spots of a black, organic appearing substance within the air vent and on the plastic fins.
Observation on August 5, 2026, at 10:40 a.m., in the room of Resident R1, reveals an air conditioning window unit with a moderate amount of spots of a black, organic appearing substance within the air vent and on the plastic fins.
Observation on August 5, 2026, at 10:45 a.m., in the room of Resident R2, reveals an air conditioning window unit with a moderate to large accumulation of black, organic appearing substance within the air vent and on the plastic fins.
Observation on August 5, 2026, at 10:50 a.m., in the room of Resident R3, reveals an air conditioning window unit with a large amount of black, organic appearing substance within the air vent. The plastic fins of the air conditioning window unit are encrusted with a black, organic appearing substance, with a white and green fuzzy growth.
Interview with the facility Maintenance Manager on August 5, 2026, at 10:59 a.m., reveals that air conditioning window units are used in resident rooms in the Mountain Vista and Mansion View units, which are "serviced once a month or every two months." Further interview with the Maintenance Manager reveals that there is no policy regarding care of air conditioning window units, and no log or record is kept for maintenance or care performed on the air conditioning window units.
Further interview with facility Maintenance Manager on August 5, 2026, at 12:11 p.m., confirms "might be mildew" in the air vent of the air conditioning window unit in the Hearth Room.
Further interview with facility Maintenance Manager on August 5, 2026, at 12:13 p.m., confirms "buildup" within the air vents of the air conditioning window unit of Resident R2.
Further interview with facility Maintenance Manager on August 5, 2026, at 12:15 p.m., confirms large amount of black, white, and green growth within the air vents and on the plastic fins of the air conditioning window unit in Resident R3's room. stating, "looks like that one got missed."
Interview with facility Housekeeping Supervisor on August 5, 2026, at 12:27 p.m., reveals that "every time housekeeping cleans a room, they are to clean the air conditioners and place a work order if they need help from maintenance." Further interview with the facility Housekeeping Supervisor in Resident R3's room, confirms that "they should've put work order in for this," regarding the air conditioning window unit. Further interview confirms that there is no written policy or procedure in place regarding the care or cleaning of the air conditioning window units.
Review of facility work orders provided by the Nursing Home Administrator on August 5, 2026, at 1:17 p.m., does not reveal a work order placed for air conditioning window units in the Hearth Room, or the rooms of Resident R1, R2, or R3.
Interview with the Nursing Home Administrator on August 5, 2026, at 1:30 p.m., confirmed the above information.
The facility failed to maintain a safe and sanitary environment for residents, in regard to the care and maintenance of window air conditioning units.
28 Pa. Code 201.18(b)(1) Management
| | Plan of Correction - To be completed: 08/25/2026
This POC does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. It is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
The Harth Room window air conditioner and the resident air conditioner units for R1, R2, and R3 have been inspected and properly cleaned by maintenance.
All other resident room air conditioner units and common area PTAC units shall be inspected for cleanliness and cleaned and/or replaced by maintenance.
Administrator shall educate Housekeeping and Maintenance staff on the importance of proper maintenance of window and resident room air conditioner units to meet the standard of 483.90(i) providing a safe, functional, sanitary and comfortable environment for residents, staff and the public.
The preventative maintenance schedule for resident room air conditioner units and common area PTAC's has been updated to ensure proper maintenance inspection and internal cleaning is being performed on a quarterly basis in accordance with the TELS preventative maintenance program.
Housekeeping cleaning checklist has been revised to include inspecting and cleaning accessible areas of the resident room air conditioner units and filter cleaning, and filling out work orders for maintenance follow up for any additional servicing if needed.
The Maintenance Director or designee shall inspect for cleanliness at least ten resident room AC units per week for eight (8) weeks, to ensure proper cleanliness is maintained.
Inspection results shall be reported by the Maintenance Director or designee during monthly QAPI meetings over the next two months for review and recommendations.
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