Failure to Maintain Safe and Comfortable Spa Temperatures
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment in two of its three unit spas, specifically the Evergreen and Laurel Lane spas. Observations conducted in these areas revealed that the ambient temperatures were significantly above the required range, with readings of 85.8°F in the Laurel spa and 85°F in the Evergreen spa. Additionally, there was audible fan noise in both spas, and the spa showers were noted to be dry at the time of observation. These findings were corroborated by a resident who reported that the temperature in her bathroom and the spa area was uncomfortably hot. Interviews with staff and residents confirmed the elevated temperatures and discomfort in these areas. The issue was brought to the attention of the Nursing Home Administrator, but no further information or explanation was provided at the time. The failure to maintain appropriate temperature levels and a comfortable environment in these spa areas constitutes noncompliance with federal and state regulations regarding resident rights to a safe, clean, and homelike environment.
Plan Of Correction
1. Facility is unable to retroactively correct temperatures in Laurel Lane and Evergreen Spa. Facility had been taking random temperatures throughout the facility although none taken in resident bathrooms. Routine maintenance had not been conducted on exhaust belts. Maintenance Director is responsible for this routine. Vents had been cleaned. 2. Facility purchased 5 fans on 6/27/25 and placed in the facility, including Laurel Lane and Evergreen Spas. Residents and staff were encouraged to keep bathroom doors open when not in use. Maintenance Department changed out heat lamps and replaced them with regular light bulbs in resident bathrooms. Facility had a company out to check on air conditioning units as well as ventilation system. Exhaust belts were replaced. Portable A/C units purchased for Laurel Lane and Evergreen Spas were installed. 3. NHA/Designee will educate the Maintenance Department on the importance of maintaining comfortable and safe temperature levels in the facilities, including routine maintenance on the ventilation system including exhaust belts. Maintenance Director/designee will report quarterly task compliance to NHA to ensure tasks are being completed. 4. Maintenance Director/Designee will audit random facility temperatures of resident rooms and bathrooms and facility spa rooms 3 times a week for two months, then monthly for two months, to ensure temperatures are between 71 and 81. NHA will audit maintenance records quarterly to ensure ventilation system including exhaust belts is being maintained. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.