F0584

L

Failure to Maintain Safe Room Temperatures and Monitor Residents for Hypothermia

Rochester, Pennsylvania Survey Completed on 01-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain resident room temperatures within the facility’s own policy range of 71–81°F and to monitor and assess residents for hypothermia when the heating system was not functioning properly. The facility’s Safe and Homelike Environment policy required provision of a safe, comfortable environment, and the Loss of Heating or Cooling policy required immediate actions to maintain temperatures between 71–81°F, including monitoring temperatures, increasing rounding, layering clothing, providing extra blankets and warm foods/fluids, and monitoring for signs of hypothermia with physician notification as needed. The Nursing Home Administrator (NHA) reported being aware that the heat was not working the prior week and that a heating company came on a Saturday to install a control board, later determining that an additional gas valve was needed. The NHA presented audits of only 5–6 random rooms per floor and did not have staff check all resident rooms or assess/interview residents to ensure their needs were being met.

Observations on the third and fourth floors showed that the heating system was not working at full capability, with room temperatures ranging from 68°F to 81°F and some residents stating they were cold while others felt comfortable. Some windows were observed not fully closed, and some residents reported they had opened their windows. Although residents had extra blankets and clothing, all interviewed residents stated that no staff member had offered extra blankets or warm fluids. Subsequent facility-provided temperature audits documented that, during early-morning checks, the vast majority of rooms on both the third and fourth floors were below 71°F, with the lowest recorded temperatures at 63°F on the third floor and 58.6°F on the fourth floor. During a tour, surveyors noted that the third and fourth floors felt cold overall, and spot temperature checks with maintenance staff showed multiple rooms in the upper 60s to about 70°F.

Multiple residents were observed in bed with three or four blankets, winter coats, or tassel caps, and several reported feeling cold, especially at night or when getting up. One resident stated her legs were cold and that her window had been cracked open the previous night; another said he had been cold and that it gets very cold at night; others reported that their rooms were cold or that they had been cold but were warm at the time due to multiple blankets. Few residents were seen in hallways, and those present were covered with blankets. A nurse stated that residents complained of being cold and that she had brought in two bags of blankets to keep them warm.

Record review for selected residents showed that there were no physician orders to monitor for hypothermia or to monitor body temperatures in response to the environmental issue, despite the facility’s policy requiring monitoring for signs of hypothermia when heating is compromised. For one resident, the last documented temperature was from early in the month; for another, the last temperature was several days prior; and for a third, the last temperature was from the previous month. The NHA confirmed that the heaters were not working at 100%, that the facility had noticed the problem in the middle of the prior week, and that repairs were in progress. The NHA also confirmed that the facility failed to ensure comfortable air temperature levels between 71–81°F and failed to monitor and assess all residents for hypothermia, resulting in an Immediate Jeopardy situation for all 82 residents.

Removal Plan

• Complete heating system repair and continue ongoing monitoring of system performance.
• Conduct room temperature audits in every resident room every two hours until all resident rooms are at 71°F or higher, then once every four hours daily for seven days, weekly for three weeks, then monthly for three months.
• Include in temperature audits ensuring windows are closed and residents are offered plastic covering for windows.
• Evaluate all residents for signs and symptoms of hypothermia, including residents unable to independently express needs and residents with a temperature over the last three days and/or during whole house audit of 97.6°F or lower.
• Address any identified concerns immediately with individualized interventions and place orders for ongoing monitoring as needed.
• Document resident temperatures in the weights/vitals section of the electronic medical record and document hypothermia evaluation in progress notes.
• Conduct an audit of resident observations for cold intolerance, distress, or changes in condition related to temperature in every resident room every shift daily for seven days, weekly for three weeks, then monthly for three months.
• Ask interviewable residents about comfort level and offer interventions as needed.
• Evaluate non-interviewable residents for observable signs of discomfort related to temperature.
• Educate nursing staff (including agency) on signs and symptoms of hypothermia, risk factors, interventions to prevent hypothermia, comfort measures, and appropriate response when signs/symptoms are identified.
• Educate nursing assistants on non-clinical signs and symptoms of hypothermia and to alert a nurse if observed.
• Complete staff education; staff educated by phone/email to sign education prior to next working shift; reinforce education as needed.
• Provide additional blankets, layering, and environmental adjustments as needed.
• Offer room relocation as appropriate to maintain resident comfort.
• Implement a plan to utilize outside resources as necessary to maintain safe air temperatures during future weather events or mechanical issues, including an updated rental company in place.
• Review relevant policies and procedures related to environmental safety, resident monitoring, and emergency response.
• Update policies as indicated based on audit findings and QAPI review.
• Report audit findings, trends, and corrective actions to the QAPI committee; QAPI to evaluate effectiveness and recommend changes as needed.
• Apply plastic coverings to every resident room and hallway window in resident care areas to prevent drafts.
• Clarify/register controls after identifying some knobs on registers were turned off to prevent inadvertent turning off of heat.
• Have heating vendor send a technician back to ensure correct functionality and further explore the system for any additional needed corrections and complete repairs as soon as possible pending parts/resources.
• Install rental one-ton heating units and rent for at least one week.
• Order and install additional rental heating units.
• For rooms reading under 71°F with a laser thermometer, re-check using a room air thermometer and verify temperatures above 71°F.
• Order air thermometers for each room.