Failure to Maintain Safe Room Temperatures and Homelike Environment
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not maintaining resident room temperatures within the required range of 71 to 81 degrees Fahrenheit. For an unknown period, 38 out of 58 resident rooms on the first and second floors did not have working heaters or thermostats, resulting in room temperatures dropping as low as 57.7 degrees Fahrenheit. Multiple residents reported feeling extremely cold for several days, with some describing their rooms as being like a refrigerator or a meat locker. Staff and visitors also noted the cold conditions, and work orders regarding non-functioning heaters and cold rooms had been submitted over several months, indicating ongoing issues with the facility's heating system. Residents affected by the deficiency included individuals with complex medical conditions such as chronic kidney disease, dependence on renal dialysis, chronic respiratory failure, pulmonary fibrosis, and cognitive impairments. These residents reported being cold, wearing extra clothing indoors, and experiencing discomfort. Despite repeated complaints to staff, there was no evidence that residents were moved to warmer areas, provided with additional warming measures, or adequately monitored for signs and symptoms of hypothermia during the period of low temperatures. Observations confirmed that staff did not offer hot beverages, extra blankets, or other interventions to mitigate the cold environment. Facility records and interviews revealed that the heating system had longstanding issues, with many HVAC units having bad compressors, control boards, refrigerant leaks, or other mechanical failures. Maintenance and clinical staff were aware of the problems, and the facility's own policies required monitoring and interventions that were not implemented. Documentation showed that room temperatures were not consistently monitored, and there was no evidence of resident assessments for cold-related illnesses during the deficiency period. The failure to maintain appropriate room temperatures and to follow established protocols placed residents at risk for cold-related health complications.
Removal Plan
- Resident #1 was interviewed by Social Service Coordinator about the comfort of her room temperatures. This was documented on an interview sheet.
- The Maintenance Technician installed a portable [vented] heater in resident's #1 room.
- A licensed nurse completed vital signs and evaluated resident #1 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- Resident #2 was interviewed by Social Service Coordinator about the comfort of his room temperatures. This was documented on an interview sheet.
- The Maintenance Technician installed a portable [vented] heater in resident's #2 room.
- A licensed nurse completed vital signs and evaluated resident #2 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- A licensed nurse completed a vital sign temperature and evaluated all current residents for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- The community received nineteen (19) portable [vented] heaters to install for residents that had concerns with room temperatures and/or to be installed in rooms in which the thermostat was not functioning.
- A licensed nurse reviewed the 24-hour Summary Report from the electronic medical record to determine if there was symptoms of hypothermia documented. No documentation was identified for symptoms of hypothermia.
- Social Services Coordinator completed 46 out of 58 resident interviews about the comfort of their room temperatures. Residents identified to have a grievance were provided with portable [vented] heaters, room change options, and/or extra blankets. The resident interviews were documented on an interview sheet.
- The Maintenance Technician audited every resident room to determine if the thermostat was functioning. Thirteen (13) rooms were determined to have thermostats that were not functioning correctly.
- The rooms identified were 58, 66, 72, 74, 75, 78, 81, 97, 8, 4, 7, 28, and 69. The Maintenance Technician installed portable [vented] heaters with the temperature display in the occupied resident rooms.
- Unoccupied rooms identified will not be used until a portable [vented] heater with a temperature display is installed or the room thermostat is replaced.
- The Regional Maintenance Technician ordered fifteen (15) additional portable [vented] heaters that display the room temperature.
- Social Services Director reviewed the Grievance Log to identify any grievances related to room temperatures.
- Clinical, Maintenance, and/or designee are auditing room temperatures of resident rooms every two (2) hours for the next five (5) days. If no occupied rooms are temping below 68 degrees the room temperature audits will continue three (3) times a day for two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks. If the outside weather is at or projected to be below 40 degrees a baseline room temperature of each resident room will be obtained. If any occupied resident room temperature is below 68 degrees the House Temperature and Extreme Heat and Cold Policy will be followed. This audit includes documenting the room thermostat temperature, obtaining a room temperature with an infrared thermometer, and if applicable the portable [vented] heater room temperature. This audit is documented on an audit sheet.
- Based on the most recent audit results there are two unoccupied rooms below 68 degrees. These rooms will remain unoccupied until repairs are completed and room temperatures are above 68 degrees.
- The Administrator and/or designee will audit the room temperature log daily for five (5) days, three (3) times a day for two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks to validate compliance.
- The Maintenance Technician and/or designee will re-train designated associate(s) who are auditing room temperatures, on how to operate the infrared thermometer and that the designated associate needs to notify the licensed nurse immediately if the room temperature is below 68 degrees. If the resident room temperature is between 68 and 71 degrees an interview will be conducted by a licensed nurse or designee with the resident and/or representative to determine if this is their desired room temperature. If the resident and/or representative respond no; offer a room change, extra blanket, move to the common area, or warm beverage until heater can be evaluated by Maintenance. This retraining shall occur prior to the associate conducting a room temperature audit. The associates not available will receive the re-training prior to being assigned to audit room temperatures. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content.
- The Director of Clinical Services (DCS) and/or designee re-educated licensed nurses and certified nursing assistance on the Homelike Environment Policy, emergency evacuation and transfer agreement process, and House Temperature and Extreme Heat and Cold Policy including symptoms of hypothermia, notification to Healthcare Provider and resident representative if the resident is having symptoms of hypothermia, the measures to take if an occupied resident's room temperature is below 68 degrees, and notification to the Administrator and/or designee if low room temperature can't be resolved.
- The associates not available will receive be re-educated prior to working their next scheduled shift. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content.
- If a resident's room temperature is below 68 degrees the following items will be initiated until the resident is located to another room with a room temperature above 68 degrees, appropriate repairs are completed to the resident's room heater, and/or a portable [vented] heater is installed in that resident's room. A licensed nurse or certified nursing assistant will obtain the residents temperature every hour, and a licensed nurse will evaluate the resident every hour for symptoms of hypothermia and document this in the medical record. If symptoms of hypothermia are identified this change of condition will be documented in the medical record, and the Healthcare Provider and Resident Representative will be notified. If the room temperature is not corrected the Administrator or designee will be notified to provide further direction related to initiating an emergency transfer plan to another location.
- New admissions rooms will be checked by Maintenance and/or designee to validate that the heater and thermostat are working and that the room temperature is in the correct range. If a repair needs to be made this will be documented on a work order. Work orders will be entered into the electronic system by the Administrator, Maintenance associates, or concierges. Paperwork orders will be available at each nurse's station and concierge's desk.
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.
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