Failure to Maintain Safe and Comfortable Temperatures Due to Boiler Malfunction
Penalty
Summary
Facility staff failed to maintain a comfortable and safe environment for residents by not ensuring adequate internal temperatures in two of three units due to malfunctioning boilers. The east and west wings experienced significant heating issues when the primary boilers were not operating properly. Residents and their family members reported that it was cold in the facility, with one resident stating she had to use multiple sheets and still felt cold, and her family member expressing concern to the point of requesting a welfare check from the police department. Documentation and interviews revealed that the facility's boilers had ongoing mechanical problems, including frequent shutdowns, water leaks, and malfunctioning recirculating pumps. Service logs indicated repeated failures and the need for manual resets to restore heat. The administrator and maintenance staff confirmed that the boilers would often trip and require intervention, and that parts were difficult to obtain due to the manufacturer no longer being in business. During this period, the facility resorted to using portable heaters and spot coolers to provide some heat, but temperature monitoring showed that several resident rooms remained below comfortable levels, with some rooms measuring between 60-67°F. The deficiency was further substantiated by service technician reports, which described a cracked heat exchanger and the inability of staff to consistently reset the boiler to maintain adequate temperatures. The lack of a reliable heat source persisted until a temporary boiler was installed, but prior to this, residents in affected wings were exposed to uncomfortably low temperatures for an extended period. The facility's failure to maintain a safe and comfortable environment directly impacted residents' well-being during the time the boilers were inoperable.