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F0584
F

Failure to Maintain Safe Ambient Temperatures During Air Conditioning Outage

Rockford, Illinois Survey Completed on 07-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring that ambient room temperatures remained within acceptable ranges during an extended air conditioning outage. Multiple temperature logs documented that temperatures in resident rooms and common areas consistently exceeded 80 degrees Fahrenheit, with some readings as high as 91 degrees. The facility's own policy required action when temperatures rose above 80 degrees, but logs showed that this threshold was repeatedly surpassed over several days. Despite the ongoing issue, temperature monitoring was not consistently performed, and the last available log was not current for the final days of the outage. Residents with significant medical conditions, including multiple sclerosis, congestive heart failure, chronic obstructive pulmonary disease, and cognitive impairments, reported discomfort and adverse effects due to the heat. One resident with multiple sclerosis stated that the heat exacerbated his symptoms, causing him to remain in bed for several days to avoid worsening his condition. Other residents described the environment as "really hot," with some noting increased fatigue, sweating, and respiratory discomfort. Staff interviews confirmed that the facility was "drastically hot" and that many residents stayed in their rooms with fans, though not all residents were offered fans or room changes to cooler areas. The facility's maintenance and administrative staff acknowledged the air conditioning failure and described efforts to contact repair services and monitor temperatures. However, it was revealed that temperature checks were being conducted using surface thermometers rather than devices capable of accurately measuring ambient air temperature. The administrator was unaware that this method was insufficient for monitoring room conditions. The facility's policies required routine monitoring and specific actions when temperatures exceeded safe levels, but these procedures were not fully implemented, and documentation of temperature monitoring was incomplete for the final days of the incident.

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