Failure to Maintain Safe Temperature Levels
Summary
Wyndmoor Hills Rehabilitation and Nursing was found to be non-compliant with federal and state regulations regarding maintaining a safe and comfortable environment for residents. The facility failed to ensure that air temperatures were maintained within the required range of 71 to 81 degrees Fahrenheit on two nursing units, specifically the Second and Third Floors. Observations revealed that temperatures in various rooms and hallways ranged from 59 to 70 degrees Fahrenheit, which posed a risk of hypothermia to 16 residents. Interviews with residents and staff confirmed the discomfort and cold conditions within the facility. Residents were observed wearing additional clothing such as sweatshirts, coats, and hats to keep warm. Staff members, including nurse aides and the maintenance director, acknowledged the cold temperatures and reported issues with the heating system. The maintenance director noted that the facility had experienced problems with water pipes, which affected the heating system's functionality. Further investigation revealed that a commercial contractor had identified an issue with the air handler, which required shutting off the system to prevent further damage. Despite being aware of the malfunction, the facility instructed the contractor to turn the air handler back on. The lack of adequate warm blankets and the failure to maintain appropriate air temperatures led to an Immediate Jeopardy situation, as residents were at risk of developing hypothermia due to the cold environment.
Plan Of Correction
1. Residents that resided in affected rooms were immediately offered a room move. Superb Plumbing was on site on 2/7/2025 to address concerns related to the heating unit. Additional blankets were purchased and provided to residents. Warming liquid hydration stations were placed in resident common areas by culinary staff on 2/7/2025. All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present due to the central heating system being temporarily inoperable, including vital signs, skin assessments, and any other pertinent assessments. 2. All rooms in the facility have been temped and are back in compliance. Residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present. 3. Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs and symptoms of hypothermia are present. 4. An Ad Hoc QAPI Meeting was held on 2/7/2025 to discuss the events surrounding the facility's failure to ensure that the temperatures in the facility were maintained between 71 and 81 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that temperatures are appropriately maintained in the facility. The facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance. The facility will continue to audit all rooms until there are no rooms being affected. The facility will do a temperature audit once a week for one month, twice a month for one month, and once a month for one month. 5. The findings of these quality monitoring efforts will be reported to the Quality Assurance/Performance Improvement Committee monthly for six months.
Removal Plan
- The facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that facility air temperatures were maintained between 71- and 81-degrees Fahrenheit.
- Residents that resided in affected rooms were offered a room move and declined. They were informed that if they were uncomfortable and would like to move rooms at any time to inform facility staff.
- [Plumbing Company] on site to address concerns related to the heating unit. Additional blankets were purchased and provided to residents.
- Warming liquid hydration stations were placed in resident common areas by culinary staff.
- All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present to the central heating system being temporarily inoperable to include vital signs, skin assessment and any other pertinent assessments.
- All other rooms in the facility will have temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present to include vital signs, skin assessments along with any other relevant assessment related to hypothermia.
- Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs of symptoms of hypothermia are present.
- Facility temperature will be checked every shift by the manager on duty and facility administration to ensure that they are within appropriate range along with resident interview to ensure that they are comfortable with the current temperatures.
- If the facility rooms affected does not meet and maintain the appropriate temperatures facility will initiate the emergency plan to include closure of the affected rooms and mandate movement of resident to functioning rooms.
- An Ad Hoc QAPI Meeting was held to discuss the events surrounding the facility's failure to ensure temperatures in the facility were maintained between 71- and 81- degrees Fahrenheit, to identify the root cause, and to initiate improvement to the facility's processes and procedures regarding ensuring temperature levels are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance.
- The PA Healthcare Coalition was notified via phone with a voice message left.
- An interview was conducted with Heating and Air Contractor, Employee E11, reported that the heating issue had been resolved. Temperatures in the hallways and rooms were increasing.
- Observations revealed the Second-floor nursing unit-maintained temperatures between 71- and 81- degrees Fahrenheit. The third nursing unit continued to have rooms with 7 rooms were below 71 degrees Fahrenheit. Facility brought portable space heater (safe) to maintain air temperature levels between 71- and 81-degrees Fahrenheit.
- The facility provided education to all staff on assessing residents for signs and symptoms of hypothermia. Staff were instructed to ensure residents remained warm by providing blankets, conducting vital sign checks every shift, and offering warm beverages as needed.
- The vital signs auditing was reviewed and residents were not exhibiting signs and symptoms of hypothermia.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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