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F0921
E

Failure to Maintain Safe and Comfortable Temperatures Due to Inoperable Heating System

Galt, California Survey Completed on 11-22-2025

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 and comfortable environment for its residents, as evidenced by multiple complaints of cold temperatures and room temperatures consistently below regulatory requirements. Observations and interviews revealed that residents were dressed in multiple layers, using extra blankets, and still experiencing discomfort and difficulty sleeping due to the cold. Thermostats in several rooms registered temperatures as low as 61 to 65 degrees Fahrenheit, with no warm air coming from the vents, and staff were unable to adjust the thermostats or provide effective relief. Residents repeatedly reported their discomfort to staff, but the only response was the provision of additional blankets, and no effective action was taken to resolve the underlying issue. Staff interviews confirmed that the facility had been cold for at least a week, particularly at night, and that the heating system was not functioning properly. Staff members acknowledged their inability to adjust thermostats or confirm whether the heating system was operational. Maintenance staff and facility administration were aware of the heating issue, specifically a non-functioning boiler, but failed to act in a timely manner to restore adequate heating. The Director of Nursing and Administrator initially denied awareness of the problem, despite direct observations and multiple resident complaints. A review of facility policies indicated that immediate action was required when heating systems were inoperable, with a mandate to maintain temperatures between 71 and 81 degrees Fahrenheit. However, the facility did not follow these policies, as evidenced by the lack of timely repairs and inadequate interim measures to ensure resident comfort. Temperature logs provided by maintenance were inconsistent with observed room temperatures, and staff could not explain the discrepancies. The failure to maintain appropriate temperatures resulted in ongoing resident discomfort and a failure to provide a safe, homelike environment as required by facility policy.

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