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F0584
E

Failure to Maintain Comfortable Temperatures Due to Broken HVAC

Spring Valley, California Survey Completed on 12-10-2025

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 provide a safe, comfortable, and homelike environment for three of four sampled residents due to a broken HVAC unit that was not repaired in a timely manner. The HVAC malfunction affected the temperature control in several rooms, resulting in residents being unable to adjust the thermostat to a warmer setting. Observations and interviews revealed that residents consistently felt cold, especially during the night and early morning hours. Residents coped by using multiple blankets or relying on space heaters provided by staff, but these measures were insufficient or inconsistently available. Resident 1, who had fibromyalgia and moderate cognitive impairment, reported feeling extremely cold at night despite using several blankets and resorted to sleeping with her head under the covers. Resident 2, with chronic obstructive pulmonary disease and bradycardia, also experienced discomfort due to the cold and noted that the space heater was not always available for her use. Resident 3, who had difficulty walking and a history of falls, depended on a space heater to sleep comfortably. The Maintenance Supervisor confirmed that the HVAC unit had been broken for several weeks and that repairs were delayed pending corporate approval. The facility's policy emphasized the importance of maintaining comfortable temperatures for residents, which was not achieved in this instance.

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