Failure to Maintain Boiler Heating System
Penalty
Summary
The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all 95 residents and all five smoke compartments. During an onsite investigation and interview with the Administrator, surveyors observed that the boiler heating system located in the mechanical room was not operational. This deficiency was identified through direct observation and confirmed by facility staff. As a result of the inoperable boiler, the facility was unable to maintain the required temperature levels throughout the building. The deficiency impacted the entire resident population, as the heating system is essential for maintaining a safe and comfortable environment. The report notes that the boiler could not be repaired after multiple attempts by heating and air system vendors, and the system remained nonfunctional for a period of time. The failure to maintain the boiler system and ensure its operability led to the inability to provide adequate heating for the residents. The deficiency was directly related to the lack of a functioning heating system, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
1/5/26: POC approved by Cynthia Luc, SSM-I The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. HVAC - Operating Features: The facility will follow the Emergency Operations Plan for notification to state survey agency of nursing home situation. Immediately upon discovering the failure to report the unusual occurrence, the facility discussed the incident in question with the CDPH surveyor who was conducting an abbreviated survey. An internal review of the incident was completed to determine root causes. The Administrator was interviewed and re-educated on reporting requirements. To ensure no similar oversight occurred, the previous 30 days of incident logs, nursing notes, and daily shift reports were audited by the Administrator on 12/19/25. Any event fitting CDPH's definition of an unusual occurrence was reviewed to verify it had been properly reported. No additional unreported unusual occurrences were identified. On 12/16/25, the Administrator received education from the Regional Operations Director on Title 22 §72541 reporting requirements, definitions of unusual occurrences, and required timelines and reporting processes. A CDPH Reporting Log was implemented to track all facility reported incidents from initial notice through CDPH submission. To ensure sustained correction, the Administrator will perform a weekly audit of all incidents for 12 weeks. After 12 weeks, audits will continue monthly for an additional 6 months. Findings will be reported at the Quality Assurance Performance Improvement (QAPI) meeting each month. Any identified gaps will result in immediate retraining and corrective action. All corrective actions will be fully implemented by 1/4/2026.