Failure to Maintain Safe Room Temperatures for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for three residents who were in a day room where the temperature exceeded the facility's policy range. The facility's policy, last reviewed on January 30, 2024, required temperatures to be maintained between 71°F and 81°F. However, on June 26, 2025, the fourth floor day room was observed to have a temperature of 83.9°F. Three residents, all of whom were severely cognitively impaired, dependent on staff for care, and diagnosed with dementia, were present in the room during this time. Observations noted that one resident's face appeared clammy and another's face was flushed and pink after being in the overheated room. Staff interviews revealed that an audit of all PTAC units had been conducted two days prior, identifying multiple non-functioning units, including the one in the affected day room. The Maintenance Director confirmed the malfunction, and the Nursing Home Administrator acknowledged that common areas should be kept within safe temperature ranges. The deficiency was cited under federal and state regulations for failing to provide reasonable accommodation of resident needs and preferences, specifically regarding environmental temperature control.
Plan Of Correction
Plan of Correction: 1. Residents 7, 8, & 9 who were in 4th floor dayroom when temperature was identified above 81 degrees Fahrenheit was redirected to climate-controlled area on unit immediately. 2. New window air conditioner unit was installed to maintain a safe temperature of 71 degrees Fahrenheit to 81 degrees Fahrenheit within the 4th floor dayroom. Corrective actions were put into place to ensure the deficient practice does not reoccur. 3. The administrator re-educated the Maintenance Director on the Facility Policy "Homelike Environment," ensuring that the facility will maintain comfortable temperatures between 71 degrees F and 81 degrees F. 4. A scheduled preventative maintenance program was put into place requiring daily temperature checks to be completed in the 4th floor dayroom for two weeks. After that, audits will be reviewed monthly for the next three months, and then randomly thereafter, with the results of these audits brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Allegation of compliance 7/14/25 I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.