F0584

F

Failure to Maintain Safe and Comfortable Temperatures in Dining Room After Heating System Failure

Havana, Illinois Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, comfortable temperature in the dining room during very cold winter weather and after a primary heating unit malfunctioned. The facility’s own Code White-Extreme Weather Policy requires notification of the Maintenance Director and Administrator for heating failures, movement of residents to adequately heated areas if a unit fails or temperatures become uncomfortable, and ensuring the heating system is operable with extra blankets available. Resident rights documents state that residents must be kept safe, comfortable, and in a homelike environment that promotes quality of life. Despite these policies, the main dining room heating unit stopped working correctly, and the Maintenance Director acknowledged there were no maintenance records for the unit and that only random temperature checks were done, with no specific or documented monitoring of dining room temperatures after the unit failed.

Staff interviews and observations showed that the dining room remained uncomfortably cold for weeks while residents continued to be served meals there. Multiple CNAs and nursing staff reported that the dining room was “freezing,” that residents’ teeth were chattering, and that residents had to wear coats, gloves, stocking hats, and use extra blankets, which still did not alleviate the cold. Staff stated that management required them to bring residents to the dining room for meals despite the cold and that they would “get into trouble” if they did not. Dietary staff confirmed that all or many residents complained daily about the cold, that a small wall-mounted space heater had recently been installed but “did not help at all,” and that they were keeping the kitchen door open and placing blankets in window sills to try to reduce drafts. A door near the serving window, which had not been used for years, was observed and acknowledged by the Maintenance Director to be rusted, not sealed correctly, and allowing a noticeable draft into the dining room.

Residents consistently reported that the dining room was extremely cold, that they had to wear multiple layers and blankets, and that it was uncomfortable to eat under these conditions. Several residents stated they had stopped going to the dining room or left meals early because of the cold, with one resident reporting developing a sore throat and another stating they did not finish breakfast due to the temperature. On-site observation on the survey date confirmed an immediate temperature drop when entering the dining room from the hallway and a cold draft from the unsealed door. The Maintenance Director’s phone application showed a low temperature of 57°F in the dining room over a recent 24-hour period, and spot checks during the survey showed temperatures in the high 60s°F while approximately 25 residents sat in the dining room wearing coats and blankets before lunch. The Administrator initially stated being unaware of the cold conditions and later stated not being involved with the heating issue because the Maintenance Director was handling it with corporate, despite multiple prior grievances about heat issues documented in the facility’s grievance logs without recorded resolution or follow-up notification.