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:
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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