F0584

E

Failure to Maintain Comfortable Indoor Temperatures During Heating System Malfunction

Kansas City, Missouri Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, comfortable, and homelike environment when the heating system could not sustain comfortable temperatures for residents. The facility had a policy titled “Extreme Weather” dated 08/25/23, which stated that during extreme cold weather the facility would provide extra blankets to residents who desired them, obtain additional warm clothing for residents with insufficient warm clothing, provide additional warm beverages, and have staff assess residents for comfort and take additional measures as necessary. The policy also required the Maintenance Department to maintain a log of facility temperatures and document measures taken if temperatures fell below 71°F or above 81°F. Despite this policy, the heating system malfunctioned, and the facility did not consistently implement measures such as relocation or provision of extra blankets for all affected residents.

One resident with lymphedema, repeated falls, asthma, depression, atrial fibrillation, and bilateral knee osteoarthritis, and with intact cognition per a BIMS score of 15, reported that it was very cold in the facility on a Sunday. This resident stated that the room was very cold, requiring extra blankets and a coat, and that staff later offered and completed a move to a warmer room on a different hall. The resident reported that no one had followed up about when they could return to the original room and that it was still too cold in the facility, requiring continued use of a coat and blanket while outside the room. Another resident with multiple sclerosis, dementia, cognitive communication deficit, and bipolar disorder, with moderately impaired cognition (BIMS score 12), reported that their room was very cold, that staff asked them to move rooms but they declined due to concern about leaving belongings unattended, and that they had to wear a coat, mittens, and an extra blanket to keep warm. Observation confirmed the room was very cool, the resident was in bed wearing a coat and mittens, and the in-room heating unit was not blowing air and had a blank control panel screen that did not respond to the on/off switch or temperature buttons.

A third resident with polyneuropathy, type 2 diabetes mellitus, chronic respiratory failure, weakness, and major depressive disorder, and intact cognition (BIMS score 14), stated that it had gotten “pretty cold” in the room. This resident reported that staff did not offer another room to move to temporarily or offer additional blankets, and that they would have moved to sleep in a warmer room. The resident said the heating unit was working but did not blow very warm air, and that maintenance had checked it that morning without explaining what was done. Observation showed this resident wearing a coat, gloves, and blankets. A fourth resident with CHF, alcohol-induced persisting dementia, tachycardia, seizures, major depressive disorder, and GAD, and moderately impaired cognition (BIMS score 12), reported that the room was very cold overnight, that the heating unit felt like it was blowing cool air, and that they had to wear a sweater, coat, and gloves to stay warm. This resident stated that staff did not offer a move to a warmer room or extra blankets and that they would have moved temporarily if given the choice.

A CMT reported working on the Sunday when the building became very cold, especially on one hall, due to a problem with the heating system. The CMT stated that some residents in affected rooms were offered moves to warmer rooms, two residents agreed to move, and two chose to stay, but the CMT did not know why all affected residents were not offered room changes. The Maintenance Director reported that one of the two boilers stopped working over the weekend and that while technicians were working on it, the second boiler also stopped working. The Maintenance Director acknowledged that temperatures in the facility became cool on that Sunday and again on the day of the survey, and noted that one resident room temperature had been 68°F that morning. The Maintenance Director stated they had been resetting individual heating units in resident rooms and that temperatures were returning to normal. The DON and Administrator both stated expectations that the facility temperature remain within 71–81°F, that residents should not need to wear mittens inside, and that residents should be relocated to warmer areas and offered extra blankets if rooms were too cold. Despite these stated expectations and the written policy, multiple residents experienced cold rooms, wore coats, gloves, and blankets indoors, and some were not offered relocation or additional blankets, demonstrating the failure to provide a safe and comfortable environment during the heating system failure.