Failure to Maintain Safe Hot Water Temperatures
Summary
The facility failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns on multiple parts of the resident's body. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This created an immediate jeopardy situation that affected all facility residents. The incident was reported to the state agency, revealing that a nurse aide had placed the resident in a whirlpool tub without checking the water temperature, leading to severe burns. The registered nurse on duty failed to assess or treat the resident's burns in a timely manner, despite being asked multiple times by certified nurse assistants. The maintenance supervisor had been monitoring the water temperatures but did not report the excessive temperatures or attempt to make any changes to meet regulatory compliance. The facility's hot water temperature logs showed consistent readings above the regulatory limit of 110 degrees Fahrenheit from January 2023 through December 2023. Despite this, there was no documentation of corrective actions or adjustments to the hot water system. Interviews with staff revealed a lack of awareness and reporting of the high temperatures, and the facility's preventative maintenance and casualty prevention plan were not followed, as the safety surveillance reports were not provided to the Quality and Performance Improvement Committee as required.
Removal Plan
- Suspend the nurse aide, take all tubs out of service and check for malfunction.
- Suspend the registered nurse in addition to the nurse aide and shut down the bathtubs.
- Place the identified whirlpool (tub) out of service and investigate what may have caused the increased hot water temperature in the tub.
- Replace the malfunctioning hot water tank thermostat.
- Institute a more frequent monitoring of hot water temperatures and prevent resident use of hot water above 110 degrees.
- Stop all showers and tub baths until hot water can be restored to no higher than 110 degrees.
- Direct maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.
- Institute temperature checks of hot water outlets on the resident units.
- Report temperatures found to be greater than 110 degrees immediately to the administrator and prevent residents from using the water.
- Initiate repairs on the hot water system to isolate the hot water distributed to the resident care areas and ensure residents have no access to hot water until the final repairs are made.
- Provide reeducation to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.
Penalty
Resources
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The facility failed to maintain a safe, clean, and well‑maintained environment as required by its own policy, with surveyors observing loose kitchen handrails, damaged doors and wood paneling, exposed concrete and stained flooring in resident rooms and bathrooms, bubbling and chipped paint, rusted door frames, water‑stained ceiling tiles, scuffed walls and baseboards, damaged tiles, and deteriorated outdoor structures such as a raised garden bed. Additional issues included a broken cabinet and taped wall corner guard in shower rooms, an unsecured wall clock, a missing floor tile, dried paint splatter, rusted heating/cooling units with chipped paint, and a pool table with a missing corner guard. A resident reported a heating/air unit in her room with a missing bottom panel exposing dust and debris. Staff interviews revealed that some items had been broken for years, concerns about the safety of the handrails had not resulted in repairs, housekeeping did not consistently log issues for maintenance, and there was no formal system to track and ensure completion of maintenance work orders, as acknowledged by the DON, the Maintenance Director, and the Administrator.
The facility failed to maintain its roof and ceilings, leading to extensive leaks, stained and deteriorating ceiling tiles, rusted light fixtures, and moisture-damaged walls across multiple halls, nurses’ stations, medication rooms, and spa areas. One cognitively intact resident had to be moved from a preferred room after prolonged roof leaks caused a large stained area near a light fixture and disrupted use of the room, while another resident with chronic pain, depression, and moderate cognitive impairment slipped and fell on water that had leaked from the roof onto his room floor. Staff, including CNAs, an LPN, and the former DON, reported that the roof had been leaking for many months to over a year, that residents and their belongings were repeatedly exposed to water, that residents were frequently relocated due to leaks, and that water sometimes dripped on residents in shower rooms.
Surveyors found that a soiled utility room on the second floor had a broken door left partially open, overflowing trash on the floor and in the sink, a biohazard box in the sink, and visibly dirty floors, potentially affecting 72 residents on that unit. A housekeeping aide stated that housekeeping is responsible for cleaning soiled utility rooms but said he did not clean them because he believed floor technicians should do so, while the housekeeping director confirmed housekeeping must clean and organize the room daily and floor technicians are only responsible for floor care. The maintenance director reported repeatedly repairing the door after prior citations and stated that staff had been breaking the door to gain access, even though the room contains a linen chute that should remain locked for safety, and the housekeeping director’s job description assigns responsibility for cleaning schedules, supervision, and hazard recognition and removal.
A resident with Parkinson’s disease, altered mental status, and severe cognitive impairment was housed in a room that was not maintained in good repair, where surveyors observed a chair rail with approximately four feet of splintered wood along the wall next to the resident’s low-position bed. The resident’s care plan did not indicate any refusal of housekeeping or maintenance services, and the Director of Plant Maintenance acknowledged that the chair rail was in disrepair and required replacement, contrary to facility policy stating that safety of residents, visitors, and employees is a top priority.
The facility did not maintain a safe, orderly, and homelike environment in several resident rooms. One resident’s bathroom door had a hole, confirmed by a housekeeper. Another resident’s room had a urinal and a pair of scissors left on the floor, verified by an LPN. A third resident’s room had a long, deep gash in the lower part of the bathroom door and a trash bin with a large missing chunk on its rim, as confirmed by the DOM. These observations showed that housekeeping and maintenance services were not consistently ensuring a sanitary, comfortable environment as required by facility policy.
Surveyors found that air temperatures in multiple resident rooms and common areas on two pods were below the facility’s stated acceptable range, despite temperature logs uniformly recording 75°F with no variation and no work orders reflecting low-temperature concerns. The Director of Maintenance confirmed the low readings and the facility’s policy requiring temperatures between 71°F and 81°F in common areas. In addition, a resident was observed in a wheelchair near the nurses’ station that was visibly dirty and covered with debris, even though the wheelchair was listed on a twice-weekly cleaning schedule. The Therapy Program Director and a Unit Manager/LPN confirmed the wheelchair should have been cleaned as scheduled and acknowledged there was no specific facility policy for wheelchair cleaning, although nurses and unit managers were expected to oversee CNA completion of the cleaning schedule.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and well‑maintained environment as required by its “Home-like Environment” policy, which states residents have a right to a safe, clean, and homelike setting. Surveyors observed multiple unresolved maintenance and housekeeping issues throughout the building and grounds. These included loose and insecure handrails leading into the kitchen, a damaged kitchen entry door with scratches and a missing piece, damaged and chipped wood paneling at the nurses’ station, and multiple areas of damaged flooring in resident rooms where heating/cooling units had been removed, exposing concrete and stained flooring around toilets and sinks. Additional observations included bubbling and chipping wall paint, rusted door frames, discolored and water‑stained ceiling tiles, and scuffed walls and baseboards in hallways and the dining room. Further observations showed environmental issues in resident-use and common areas, including a water hose lying in flowerbeds at the facility entrance, a Styrofoam cup on the ground outside a resident’s window, scratched glass doors to the smoking area, damaged floor tiles at the exit to the smoking area, a cabinet in a resident shower room with a missing handle, and a wall corner guard held in place with multiple strips of tape. Another shower room had a wall clock not mounted properly, resting on cloth hooks. Additional findings included a missing floor tile in a resident room exposing concrete, dried paint splatter at entries to several resident rooms, rust and chipped paint on a heating/cooling unit and adjacent exit door, a pool table in the dining room with a missing corner guard and exposed edges, and a raised garden bed with structural deterioration and a failing, rotted base partially detached and laying on the ground. Interviews confirmed that these conditions had been ongoing and not consistently addressed through the facility’s maintenance processes. A resident reported that the heating/air unit in her room was missing the bottom part, exposing dust and debris on the floor, and stated she would clean it herself if able. A CNA reported the broken cabinet in the shower room had been in that condition for many years and that repairs were not consistently completed after being reported via logbooks. The Housekeeping Manager acknowledged awareness of scuff marks on walls and baseboards but had not entered them into the maintenance logbook. The Dietary Manager stated she had concerns about the safety of the kitchen handrails, which she believed could pose a fall risk, and that maintenance had not repaired them. The Maintenance Director stated there were no outstanding work orders in the logbook, acknowledged that monthly painting had not been done for March, and noted the damaged raised garden bed had not been repaired or removed. The DON and Administrator both acknowledged there was no formal system to track and ensure completion of maintenance work orders, and the Administrator was aware of the unsecured kitchen handrails but was not aware if repairs had ever been completed.
Widespread Roof Leaks, Water Damage, and Resident Fall Due to Unsafe Environment
Penalty
Summary
The facility failed to maintain the roof and interior ceilings in a safe, functional, and sanitary condition, resulting in widespread leaks and water damage throughout resident care areas. Observations on multiple halls revealed discolored, brown, and black ceiling tiles, sagging tiles, bubbling and chipping wall surfaces, rusted light fixtures, and makeshift systems such as plastic tarps funneling water into buckets at the nurses’ station. The East wing medication room and spa areas showed signs of heavy moisture damage, and numerous ceiling tiles in various halls were dried out and stained, indicating ongoing and repeated water intrusion. One cognitively intact resident had lived in a room with a large orange ceiling stain near a light fixture, measuring approximately 17 by 22 inches, with raised areas suggesting buildup or deterioration. This resident reported that the ceiling had been leaking for over a year, causing the light fixture to stop working and requiring him to move his bed and eventually be transferred to another room. Facility records confirmed that he was moved from that room due to roof leaks, and resident council minutes documented resident concerns about leaks in rooms. Another resident, with chronic pain, depression, and moderate cognitive impairment, experienced a fall in his room after slipping on water that had leaked from the roof onto the floor. An incident report and staff interviews described the resident being found on the floor near his bed with water present on the floor, and the resident himself reported that the roof had been leaking into his room for quite some time. Multiple staff members, including CNAs and the former DON, reported that the roof had been leaking for months to over a year, that residents and their belongings were getting wet, that residents were frequently moved from leaking rooms, and that leaks extended into shower rooms where residents were being dripped on during showers.
Failure to Maintain Safe and Sanitary Soiled Utility Room Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary functional environment in the second-floor soiled utility room, potentially affecting all 72 residents on that unit. During a tour of the second floor, the surveyor observed that the soiled utility room door was broken, could not be closed, and was standing partially open. Inside the room, there was overflowing garbage on the floor, garbage in the sink, a biohazard box placed in the sink, and floors with visible black debris and dirt. The room also contained access to the second-floor linen chute, which the Maintenance Director stated should be locked at all times for safety. When interviewed, a housekeeping aide stated that housekeeping is responsible for cleaning the soiled utility rooms but reported that he personally did not clean them because he believed floor technicians should be responsible for ensuring the soiled utility rooms are clean. He also acknowledged that it is unsafe and unsanitary for the soiled utility room to go without being cleaned. The Housekeeping Director confirmed that the housekeeping department is responsible for daily cleaning of the soiled utility room, including removing trash, sweeping, and organizing, while floor technicians are responsible for waxing and keeping floors free of dirt and debris. The Maintenance Director reported that he had repaired the second-floor soiled utility door several times after citations from the state agency for the door not being locked, and that staff continued to break down the door when they could not access the room. The facility’s job description for the Director of Housekeeping documented responsibility for ensuring cleaning schedules are followed, supervising housekeeping personnel, and recognizing, removing, and reporting potential hazards, as well as ensuring housekeeping personnel follow established safety regulations.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident room in good repair when one resident’s room was observed to be in general disrepair, specifically with a chair rail that had splintered wood approximately four feet long along the wall next to the resident’s bed. The resident, admitted with diagnoses including Parkinson’s disease without dyskinesia and altered mental status, had a quarterly MDS showing a BIMS score of three out of 15, indicating severe cognitive impairment. Review of the resident’s care plan showed no indication that the resident refused housekeeping or maintenance services. During observations on consecutive days, surveyors noted the splintered chair rail adjacent to the bed, which was in a low position and horizontal to the wall with the damaged rail, and the Director of Plant Maintenance confirmed that the chair rail was in disrepair and needed replacement, contrary to the facility’s Resident Rights policy stating that safety of residents, visitors, and employees is a top priority of care. This deficiency was cited under the requirement to ensure the nursing home area is safe, easy to use, clean, and comfortable for residents, staff, and the public, and was investigated under Complaint Number 2655564.
Failure to Maintain Safe and Homelike Resident Room Environments
Penalty
Summary
The facility failed to ensure a safe and homelike environment as required by its policy that housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment. For one resident, observation of the resident’s room showed a hole in the bathroom door, which was confirmed by a housekeeper. For another resident, observation of the room revealed a urinal and a pair of scissors lying on the floor, which was verified by an LPN. For a third resident, observation of the room showed a long, deep gash in the lower part of the bathroom door and a large missing chunk on the rim of the trash bin, which was confirmed by the Director of Maintenance. These conditions were identified during observations and staff interviews and affected three residents out of six reviewed for the physical environment, in a facility with a census of 48 residents.
Failure to Maintain Required Temperatures and Sanitary Wheelchairs
Penalty
Summary
The deficiency involves the facility’s failure to maintain required ambient air temperatures and to ensure accurate monitoring and reporting of those temperatures. During an observation period, multiple resident rooms and common areas on D and E pods were found to have temperatures below the facility’s stated acceptable range of 71°F to 81°F, with readings between 67.6°F and 70.3°F obtained using the facility’s laser thermometer. The Director of Maintenance confirmed these readings and acknowledged that the facility’s policy called for temperatures in common resident areas to be kept between 71°F and 81°F, with any resident preference outside that range requiring an assessment. Review of temperature logs for several days showed all sampled temperatures documented uniformly as 75°F with no variation, and there were no open work orders or prior reports for the rooms where low temperatures were observed. The Maintenance Assistant reported he had been recording temperatures with the same thermometer for two months and denied recent concerns about temperatures being out of range. The deficiency also includes failure to maintain wheelchairs in a clean and sanitary condition. During observation on D pod, a resident was seen seated in a wheelchair near the nurses’ station that was covered in debris of different colors and was noticeably dirty. The Therapy Program Director confirmed the condition of the wheelchair and stated it had been scheduled to be cleaned on a specific night shift but it did not appear that this had been completed. The Unit Manager/LPN reported that nurses and unit managers were responsible for overseeing the wheelchair cleaning schedule carried out by CNAs and that staff were to be disciplined if cleaning was not done, but also verified that the facility did not have a policy specific to wheelchair cleaning. A wheelchair cleaning schedule for D pod showed that this resident’s wheelchair was to be cleaned twice weekly, on Mondays and Fridays.
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