Failure to Maintain Safe Room Temperatures and Inadequate Staff Response
Summary
The facility failed to maintain safe and comfortable temperatures in 59 of 76 occupied resident rooms and common areas, affecting all 119 residents. Multiple temperature logs and direct observations revealed that room and hallway temperatures frequently fell below 71°F, with some readings as low as 49°F to 70°F. The low temperatures were attributed to tripped electrical breakers caused by the use of multiple portable heaters, and the facility's heating system was unable to maintain adequate warmth throughout the building. Staff interviews confirmed that the issue was ongoing, with residents being offered extra blankets and some rooms being closed for the winter, but these measures were insufficient to maintain required temperatures. Staff did not consistently follow the facility's own abatement plan or policy for loss of heating. Temperature checks of resident rooms were not performed hourly as directed, and there was a lack of timely communication with the Maintenance Director regarding cold rooms and malfunctioning portable heaters. Some staff were unaware of the procedures for monitoring and reporting room temperatures, and there were discrepancies in the frequency and documentation of temperature checks. Additionally, equipment used to measure temperatures was sometimes inaccurate, further complicating efforts to monitor conditions. Residents were observed to be bundled in multiple blankets, and frost was noted on windows in several rooms. In the memory care unit, one of the portable heaters was turned off because it was blowing cold air, and staff reported difficulty keeping residents warm. The facility's failure to maintain adequate heating and to ensure staff followed established protocols resulted in an environment that did not meet regulatory requirements for resident safety and comfort.
Removal Plan
- Every resident will have their temperature taken every two hours to assess for hypothermia. If the resident temperature drops, or the resident shows signs of hypothermia, appropriate medical treatment will be provided, beginning with moving the resident to a warmer environment.
- Every occupied room temperature will be taken every hour to assure they maintain their temperature.
- If the temperature drops or there are problems with the portable heaters, maintenance will be notified immediately.
- If a resident is cold in their room, another room will be offered. If no other warmer rooms are available, residents will be moved to an area in the dining room for warmth.
- Education will be provided to nursing staff of the temperature process and schedule.
- Education will be provided to staff on the signs of hypothermia.
- A portable whole building heating unit was obtained from Nebraska Machinery. The heater will be operational.
- If the room temperature falls by more than 1 degree or there are problems with the portable heaters, maintenance will be notified immediately.
- Staff were re-educated on taking room temperatures every hour, residents temperatures every 2 hours, and when to call maintenance. Education will be provided every shift by DON or designee, until all staff have been educated and are able to verbalize understanding of the temperature process.
- DON or designee will verify that temperature procedures are being followed, and all heating units are functioning properly every two hours.
- The doors to the memory care unit will be opened to allow heat to flow through. A staff member will be stationed at each memory care unit entrance continuously to ensure no resident leaves the unit unattended.
- Velcro door signs will be added to each unit doorway as a visual reminder for residents. We will re-evaluate temperatures to determine if this needs to continue.
- Three additional large heating units have been obtained and are en route to the building.
- Heating company called to check heating system to ensure current system is working properly.
- Maintenance are working to patch large portable units into wall ventilation system so that we are not dependent on hallway heater. If maintenance unable to connect heating units to ventilation system, we will blow heat directly into the building through a door opening or window opening. Hourly monitoring to continue until comfortable temperatures are maintained.
- Staff will be educated on the carbon monoxide detectors on each unit and what to do if they alarm.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one room, the wall behind a bed had multiple strips of missing paint and numerous holes, and the ceiling near the curtain track had exposed sheetrock. Another room had a damaged windowsill with exposed rebar. In common areas, a dining room vent was covered with a black substance, and a large light fixture above the nurse’s station lacked a cover and had long, thick cobwebs. The Maintenance Supervisor reported difficulty repairing concrete walls, noted that a resident had recently moved into one of the damaged rooms, and stated that housekeeping should have cleaned the cobwebs and vent.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment for several residents and in common areas. A resident was observed sitting in a wheelchair with the seat and cushion covered in dried food, sticky residue, and grime, confirmed by a respiratory therapist. In one room, a pipe cover was on the floor under the sink, and in another room, window blinds were damaged with slats missing and one slat on the floor, while thick cobwebs covered the window area behind the blinds, as confirmed by an LPN and the Administrator. Two elevators near the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, which maintenance staff attributed to repeated impact from carts.
Staff failed to maintain a safe, clean, and homelike environment in multiple areas, including two resident rooms and several shower rooms. One room had torn door frame molding with sharp, jagged edges, and another had a broken electrical outlet with jagged edges. Shower rooms had broken and missing floor tiles, rusted and broken wall heaters (including one with exposed wiring and another partially detached from the floor), dark black residue in grout and around drains, and large amounts of hair on a shower stall floor. A CNA reported the shower rooms did not appear to have been cleaned, and the Maintenance Director stated he was unaware of the needed repairs and the poor condition of the shower rooms.
The facility failed to provide a safe, clean, and homelike environment on both units, as evidenced by dead bugs in 2nd floor hallway light fixtures, persistent dust and debris in multiple resident rooms, and cobwebs obscuring the 2nd floor dining room windows. The 2nd floor shower room was described by an LNA as cold and not homey, contained a long-broken shower chair, was cluttered with shower chairs, a commode, and a mechanical lift, and had peeling floor paint/sealant, with clean blankets stored in bags on the floor. On the 1st floor, dining tables had missing laminate, floors were audibly sticky, and a dusty AC vent blew directly over a dining table. The 1st floor shower room was cluttered with extra chairs and other DME, had clean blankets stored on the floor, and a bathtub with a cracked area; an LNA reported that the presence of all the DME in the bathroom during care contributes to a non-homelike atmosphere. These conditions were confirmed by facility leadership during an environmental tour.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by the facility’s Homelike Environment policy revised in February 2021. Observations showed multiple areas of disrepair and uncleanliness in resident rooms and common areas. In one resident room, the wall behind the bed had four strips of missing paint with four holes in each strip, along with multiple additional small holes. The ceiling near the curtain railing in the same room had two areas of missing sheetrock paper measuring approximately 1 x 2 inches and 1 x 3 inches. In another resident room, part of the bottom right corner of the windowsill, approximately 1.5 x 2.5 inches, was missing, exposing the lower part of the rebar. Additional observations in common areas included a dining room vent covered with a black substance and a large light fixture above the nurse’s station that lacked a cover and had two long, thick cobwebs hanging from the light fixture frame. During an interview, the Maintenance Supervisor stated that the walls are concrete and difficult to repair around the window when beds break pieces off, and that the resident in one of the affected rooms had just moved in and he had not yet had time to fix the wall behind the bed. He also stated that housekeeping should have cleaned the cobwebs on the light at the nurse’s station and the vent in the dining room.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a clean, safe, comfortable, and homelike environment in multiple areas. One resident was observed in the main dining room seated in a wheelchair whose seat and cushion were completely covered in dried food, a sticky substance, and dark grime; this condition was confirmed by a respiratory therapist. In another resident’s room, a white pipe cover was observed lying on the floor under the room sink, and this was confirmed by an LPN. Additional environmental deficiencies were observed in a different resident’s room and in common areas. One resident’s window blinds had three leaves missing and one leaf lying on the floor under the air conditioning unit, as confirmed by an LPN. During a tour with the Administrator, the entire width of this resident’s window was noted to be draped with thick cobwebs behind the blind, which the Administrator confirmed. Two elevators located next to the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, a condition confirmed by the maintenance employee, who stated that carts banging into the bumpers caused the damage. The Administrator confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment in these instances.
Environmental Hazards and Poor Sanitation in Resident Rooms and Shower Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident care areas, including two resident rooms and several shower rooms. In one resident room, the door frame protective molding was torn with sharp, jagged edges, and in another room, an electrical wall outlet was broken with jagged edges. These conditions were directly observed by surveyors on multiple dates. The Maintenance Director later stated he had been unaware of the needed repairs to the room door frame molding and the broken electrical outlet. Additional environmental deficiencies were observed in several shower rooms. In the Grand Teton Hall shower room, the tile floor at the entry door had broken tile and missing grout. In the Palisades Hall shower room, the wall heater had broken and rusted areas on the front and sides, with the heater base broken, jagged, and partially disconnected from the floor; the tile floor had dark black residue in the grout and around the floor drain, and several broken floor tiles with open divots and dark black residue in the exposed areas. In the Mesa Hall shower room, the wall heater cover was removed and lying on the floor, leaving exposed wiring on the bottom side of the heater. A CNA stated the shower rooms did not look like they had been cleaned and should have been. Later observation of the Palisades Hall shower stall revealed a large amount of dark strands of hair in the drain and on the shower stall floor. The Maintenance Director also stated he was unaware that the heaters needed repair and that the shower rooms did not appear to have been cleaned.
Failure to Maintain Clean, Safe, and Homelike Environment on Both Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on both resident units. On the 2nd floor, surveyors observed multiple hallway ceiling lights containing dead bugs, dusty surfaces in resident rooms 211 and 214, and a resident room floor with large pieces of food smeared across it. On a subsequent day, the same rooms still had dusty surfaces, one room floor continued to have dust and debris, and the previously noted food remained on the floor. Cobwebs were present on the outside of the 2nd floor dining room windows, obscuring residents’ view. The Unit Manager confirmed the dusty room surfaces, and the Maintenance Director confirmed the presence of bugs in the hallway lights, noting that while the lights are cleaned on a schedule, there tend to be more bugs at that time of year. Additional environmental concerns were identified in both shower rooms and the 1st floor dining room. On the 2nd floor, an LNA described the shower room as cold-looking and not homey, and acknowledged a broken shower chair that had been in that condition for some time without knowing if maintenance was aware. The 2nd floor shower room was cluttered with shower chairs, a commode, and a mechanical lift, with large areas of peeling paint or sealant on the floor, and clean blankets stored in bags on the floor of the linen closet. On the 1st floor, dining room tables had missing laminate around the sides, the floors were audibly sticky, and a dusty air conditioner vent was blowing directly above a dining table where residents eat. The 1st floor shower room was also cluttered with extra chairs and other DME, had clean blankets in bags stored on the floor, and contained a bathtub with a cracked area. An LNA on the 1st floor reported that the bathroom normally contains all the DME when caring for residents, making it lack a homelike atmosphere. During an environmental tour, the Maintenance Director, Regional DON, LNHA, and Regional Director of Quality and Compliance confirmed these environmental concerns.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
