Failure to Maintain Safe Room Temperatures and Monitor Residents for Hypothermia
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unclean Bed Linens: A resident with hypothyroidism and chronic diastolic heart failure had a pillowcase with several dry dark brown/red areas and sheets that appeared gray and unclean. The resident could not remember the last time the linens were changed, and the DON confirmed the linens should have been changed.
Dirty Resident Room and Respiratory Equipment: A resident with dysphagia, a feeding tube, and a tracheostomy had a room observed with a dirty fan, debris on the mattress, dust and dried debris on the O2 concentrator and trach machine, and a dirty towel on the bed. A family member reported the area by the bed was often dirty from tube feeding, and an LPN Resident Care Manager agreed the room was dirty and needed daily cleaning.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
A resident room wall near the window was observed damaged and in disrepair, with a crack large enough for an ink pen to be inserted through it. The Maintenance Director said he knew about the damage after the resident reported it about 2 weeks earlier and believed it was caused by an AC leak. The damaged area covered about 6 square feet, while the Administrator said she was not aware of it and that the facility did not have a specific audit for wall or structural integrity checks.
Unsafe and Deteriorated Resident Room Conditions: Surveyors observed multiple resident rooms with broken, rusted, unsecured, and deteriorated conditions, including a hanging drawer front, scuffed and chipped walls, missing wall trim/chair rails, rust on a bedframe and AC shelf, a broken bathroom tile, and a gallon of Clorox stored in a bathroom. The Maintenance Director acknowledged the environmental conditions during the walkthrough, and photographic evidence was obtained.
The facility failed to maintain a clean, safe, and homelike environment. Surveyors observed dirty hallway vents, ceiling areas with residue, damaged walls, protruding door panel edges, missing tile and cracked flooring in shower areas, and multiple unsanitary conditions in resident rooms, including cracked light covers with bugs, uncovered soiled items, and substances on floors, mattresses, bed sheets, and bedside tables. Two residents’ wheelchairs also had dried substances and hair buildup, and staff acknowledged some areas needed repair or cleaning.
Unclean Bed Linens
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain clean bed linens for one resident. Facility policy stated bed linens are to be changed at least weekly and whenever clinically indicated or requested by the resident. The resident was admitted with diagnoses including hypothyroidism and chronic diastolic heart failure, and the care plan included an intervention to keep bed linen clean due to impaired skin. During observations, the resident’s pillowcase had several dry areas of a dark brown/red substance and the bed sheets had a gray hue and appeared unclean. The resident stated he/she could not remember the last time the sheets were changed. The DON later confirmed that the pillowcase had dark brown/red areas, the sheets appeared unclean, and the bed linens should have been changed.
Dirty Resident Room and Respiratory Equipment
Penalty
Summary
The facility failed to provide a homelike environment for Resident 6, who was admitted in 2022 with diagnoses including dysphagia and whose annual MDS dated 10/25/25 showed a feeding tube for nutrition and a tracheostomy in place. During observation, the resident’s room contained a small black fan that was very dirty and dusty and appeared not to have been cleaned for a long time. The resident’s room was later observed with a mattress on the floor near the bed that appeared dirty with dried clear debris, an oxygen concentrator with dried clear debris and dust on it, a tracheostomy machine with dried white debris all over it, the black fan covered in dust, and a dirty towel on the resident’s bed. A family member stated the area next to the resident’s bed was dirty and often had liquid on it from the tube feeding and appeared gross. An LPN Resident Care Manager observed the room and agreed it was dirty and needed to be cleaned daily.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Damaged Resident Room Wall Left in Disrepair
Penalty
Summary
The facility failed to provide maintenance services to keep a resident bedroom in good repair. In room [ROOM NUMBER], the wall near the window was observed to be damaged and in disrepair, with a crack large enough that the end of an ink pen could be inserted through the wall. The observation was made during a surveyor visit, and photographic evidence was obtained. When the wall was re-observed with the Maintenance Director, he stated he was aware of the damage and said the resident in the room had reported it about 2 weeks earlier. He stated he believed the damage was caused by the air conditioning leaking. The damaged area covered about 6 square feet and extended about 12 inches up the wall. The Administrator later stated she was not aware of the damage and said the facility had room rounds but did not have a specific audit to inspect walls and structural integrity. The facility policy stated that environmental repairs and upkeep would be addressed and corrected in a timely manner, with resident safety taking priority over cosmetic repairs.
Unsafe and Deteriorated Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment when multiple resident rooms and resident-use areas were observed in damaged, deteriorated, unsecured, or unsanitary condition in 8 of 64 rooms observed. During observations, surveyors found a broken and hanging drawer front on a built-in wall cabinet, scuffed walls with chipped and scraped paint, rusted air return vent grilles, unsecured trim adjacent to a grille, rust on a bedframe, a broken bathroom floor tile, missing wall trim/chair rail leaving unfinished wall areas, a gallon of Clorox in a bathroom, and a metal air conditioning shelf with visible rust. One room also had a dresser that was scratched and heavily exposed the wood underneath the paint. Additional observations showed more rooms with scuffed walls, chipped and scraped paint, missing wall trim/chair rail, exposed torn sheetrock, and chipped and scraped paint beneath a window. During an interview and walkthrough, the Maintenance Director acknowledged the identified environmental conditions requiring repair or correction. Photographic evidence was obtained of all the issues observed.
Cleanliness, Safety, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, and homelike environment. Surveyors observed multiple areas of disrepair and cleanliness concerns throughout the building, including shower room flooring with dark residue and chipped, open penetrations, hallway vents and ceiling areas with black, gray, and cobweb-like substances, wall gouges, and dining room ceiling vents and lights with dry splattering and rust-colored residue. The facility’s maintenance manager and maintenance director stated they were aware of some of the shower room and panel issues and knew repairs were needed. Surveyors also observed unsafe conditions in resident areas and common spaces. Plastic door panels outside two rooms had protruding edges, the south hall shower room had two large holes where tile was missing and a smaller crack, and staff acknowledged the flooring needed correction. In resident rooms, surveyors observed cracked light covers containing bugs, gouges in walls and railings, a missing bathroom door, a thick black substance at a room entrance threshold, and uncovered soiled items such as an isolation bin with soiled linen and a bedpan on the floor under the sink. Equipment cleanliness concerns were also identified. Two residents’ wheelchairs had dried substances on the cushions and wheels, with hair accumulated in the wheel mechanisms, and a CNA stated night shift should have cleaned the wheelchairs. In another room, surveyors observed mattresses with dried brown and white substances, a mattress leaning against the wall with dried white substance, dried substances on the floor and bed sheets, and a bedside table with dried brown substance. Facility logs reviewed did not document cleaning of hallway vents, mats, or mattresses at the bedside, and the Housekeeping Supervisor stated vents should have been cleaned and that nurse aides were responsible for cleaning body fluids from mattresses and mats before housekeeping cleaned them.
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