Inadequate Heating in Facility Affects Resident Comfort
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the inadequate heating on the East unit. Observations revealed that multiple residents were using multiple blankets and space heaters to keep warm, and some were wearing thick robes and sweatshirts. Interviews with residents indicated that the cold temperatures affected their daily activities, such as attending physical therapy and dining in the main area. Residents reported that the cold was more severe at night, and some resorted to using makeshift solutions like placing boxes in front of windows to block drafts. The facility's policy on cold weather emergencies required immediate temperature checks and adequate blanket supplies if temperatures fell below 70 degrees Fahrenheit. However, there was no documented evidence that room temperatures were monitored to ensure comfort. The Director of Maintenance acknowledged issues with drafts from windows and an older heating system needing repairs. Despite complaints, the Administrator was unaware of the sub-70-degree temperatures and relied on space heaters and room changes as solutions. Staff, including a registered nurse, confirmed that residents complained about the cold, and makeshift measures were taken to provide warmth.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode. 4. Some windows needed to be resealed. 5. Some rooms were missing insulation above the windows. 6. Some of the vents on the room units were in the open position. 7. Some units fan blower motors need to be replaced. 8. East Shower room, one West shower room didn't have heating units. 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogrammed, a lock box was replaced with access restricted to maintenance. 2. Visitor Bathroom heater was replaced, staff bathroom repaired. 3. Computer control board on the boiler was replaced. 4. Windows were resealed. 5. Insulation above the windows was replaced. 6. All vents were checked and closed. 7. All blower motors were checked and those that were broken were replaced. 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room. 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F584 tag.