Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom, as required by federal regulations. The air conditioning (A/C) system serving the resident's room was not functioning properly, resulting in room temperatures measured between 89.8 and 90.0 degrees Fahrenheit. Observations confirmed excessive warmth and palpable humidity in the room, with no noticeable cool air flow from the ceiling vent. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting that the room had been warm for about a month. Multiple staff members, including LPNs, CNAs, and housekeeping, were aware of the elevated temperatures in the room and reported that the issue had persisted for several weeks. Despite this, there was no evidence that maintenance staff or facility leadership had taken timely action to monitor or address the temperature problem. The maintenance director and assistant were unaware of any recent complaints or issues with the A/C unit, and temperature checks in resident rooms were not routinely performed unless the A/C system was known to be out of order. Staff reported that maintenance requests were to be submitted electronically, but no such requests regarding the temperature issue were found in the facility's communication log. The resident affected by the deficiency had significant medical needs, including severe intellectual disabilities, respiratory failure, contractures, and muscle weakness, and was unable to communicate preferences or discomfort. The facility did not have a documented policy or procedure for routine temperature monitoring or for staff to communicate environmental concerns to maintenance. Facility leadership, including the DON and NHA, were not aware of the temperature issue in the resident's room and had not noticed elevated temperatures in the affected area. The lack of routine monitoring and communication resulted in the resident being exposed to unsafe and uncomfortable temperatures for an extended period.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 06/30/2025, the outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results along with any concerns related to compliance will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.