Failure to Maintain Adequate Temperature Levels
Penalty
Summary
Willowbrooke Court Skilled Care Center at Normandy Farms Estates was found to be non-compliant with the requirement to maintain a safe, clean, comfortable, and homelike environment for its residents. The deficiency was identified during an abbreviated survey conducted in response to a complaint. The facility failed to ensure comfortable air temperature levels for residents on the Cherry and Magnolia nursing units due to an issue with the Heating, Ventilation, and Air Conditioning (HVAC) system. The problem began on November 19, 2024, when the Nursing Home Administrator (NHA) noticed flashing thermostats in her office and in resident rooms on the affected units, which shared the same heating system. The NHA contacted the Director of Plant Services, who attempted to address the issue but ultimately required assistance from an outside contractor. The contractor visited the facility on November 20, 2024, but needed to order parts to repair the system. In the interim, the facility increased the heat in the hallways and purchased additional heating units to supplement the temperatures in resident rooms. Despite these efforts, temperature logs indicated that the heating temperatures in resident rooms ranged from 61.1 to 70.5 degrees Fahrenheit, with only one room briefly reaching above 71 degrees. A resident reported that it was cold in her room before the facility provided additional heaters. The facility's failure to maintain adequate temperature levels in resident rooms on the Cherry and Magnolia units resulted in a deficiency under the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, specifically related to the requirement for a safe, clean, comfortable, and homelike environment.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. NHA noticed thermostat blinking in her office. After checking the thermostat in an adjacent room, NHA notified maintenance of the situation (19th). After reviewing the control panel, the maintenance director called the vendor to assist in determining the issue, cause, and repair. The vendor arrived the same day (19th). The heat in the hallways was increased to supplement the rooms. Residents were spoken to regarding the issue and requested to keep their doors open to allow heat transference from the hallway. Residents were offered the opportunity to remain in common areas. We monitored temperatures throughout the night in the resident rooms and offered extra blankets. Temperatures were noted to be below 71 degrees. No resident requested extra blankets. On the 20th, we were notified of the extended timeline for repair. At that time, we began obtaining individual heating units for each resident room. Residents and Families were notified. After installation of in-room heating units, temperatures in rooms were maintained above 71 degrees. Other neighborhood thermostats were inspected. It was found that no other neighborhoods were affected by this heating unit malfunction. Other neighborhood's heating units were functioning properly. The maintenance director/designee will routinely monitor thermostats via an audit. The community will continue with regular preventative maintenance schedules with the HVAC units utilizing our contracted vendor and maintenance team. Individual heating units are currently stored on campus in the event of need. Audits will be daily for 1 week, weekly for 4 weeks, then monthly for 3 months. Findings will be reported to the QAPI steering committee for further recommendation.