Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss
Summary
The deficiency involves the facility’s failure to maintain safe, comfortable indoor temperatures and to follow its emergency protocols during periods of extreme cold, as well as its failure to provide adequate hot water throughout the building. The facility’s own Homelike Environment and Cold Weather policies require maintaining comfortable and safe temperature levels, conducting regular maintenance and inspections of heating systems, and routinely monitoring indoor temperatures when outdoor temperatures fall below 65°F. Despite these policies, surveyors observed on 1/29/26 that the St. [NAME] wing (100 Hall) was chilly, with hallway thermostats reading 64–65°F and multiple room thermostats between 62–68°F. When the Maintenance Director used a temperature gun, hallway and room air temperatures on that wing ranged from 54–63°F. Staff interviews confirmed that the wing had been cold for an extended period, with staff wearing fleece jackets and stating they could not recall when it had not been cold on that wing. Residents reported ongoing cold conditions and associated discomfort. One resident in room 117, with diagnoses including spinal stenosis, diabetes with foot ulcer, morbid obesity, and restless legs syndrome, and documented as cognitively intact with frequent severe pain and chronic lower back pain requiring opioid medication, stated that it had been cold in his room since earlier in the month and that being cold all the time made him tense, increased his back spasms and pain, and prevented him from getting comfortable. Another resident in room 106-1 stated it was always cold on the wing and that it affected his breathing. A resident in room 118 reported that the constant cold made her tense and increased her pain. The Director of Nursing could not explain why residents had not been moved to open rooms on a warmer hall or why additional heating sources had not been obtained, and stated she was not part of those conversations with corporate while the Administrator was on vacation. The Administrator later acknowledged that staff had contacted her around 2:00 a.m. when temperatures began dropping, and that the Maintenance Director had checked temperatures and reported higher readings than those later observed by surveyors, indicating a lack of effective implementation of the facility’s emergency protocol as temperatures continued to fluctuate and remain low. The deficiency also includes the facility’s failure to provide adequate hot water to the entire building, particularly on the St. [NAME] side. Residents and staff reported that there had been hot water issues for weeks, with residents from the affected side needing to come to the other side to shower, and staff using kettles to warm water for face, hands, armpits, and perineal care. On 1/30/26, surveyors measured hot water temperatures and found zero hot water on the St. [NAME] wings, with room readings as low as 15.4°F, while the other side of the building had lukewarm water in the 86.7–93.7°F range. The Administrator stated that not all mixing valves had been replaced on the St. [NAME] wings and that this side of the building had been without hot water since a prior complaint survey on 1/12/26. Multiple residents confirmed that there had been no hot water on their side for about a month. The Maintenance Director and Regional Maintenance Director stated that the St. [NAME] side had been with and without hot water throughout the month, describing the problem as intermittent and related to mixing valves in the main system, the main shower, and individual room showers, with several room mixing valves identified as broken.
Removal Plan
- In-service all staff members present on the facility's Comprehensive Emergency Manual Policy by the Administrator and Human Resources.
- In-service the Maintenance Director on the facility's Cold Weather Policy by the Administrator.
- Notify the Medical Director of the Immediate Jeopardy and update on the plan by the Administrator.
- Move residents on the affected wing to available rooms on the same wing; offer remaining residents a transfer to another facility or warmer parts of the building; provide extra blankets and warm beverages to residents who choose to stay.
- Immediately assess identified residents by the DON and Nurse Practitioner to ensure needs are met and comfort is maintained; assess all other residents by nursing staff and outside physicians.
- Assess the air handler, determine the cause of fluctuating temperatures, install new blower fans into the air handler, and complete repairs to ensure adequate hot air circulation.
- Monitor temperatures in each resident room on the affected unit every hour.
- Initiate shift-by-shift temperature monitoring and continue until extreme cold weather has abated as determined by the QAPI committee.
- Assess and continuously monitor all residents remaining on the affected unit for pain, respiratory comfort, and general comfort until heat is fully stabilized; implement interventions to address identified distress or pain and monitor effectiveness.
- Install temporary flannel window coverings to reduce heat loss in rooms on the affected wing.
- Educate all staff via phone or in-person on the Comprehensive Emergency Management Plan and the Cold Weather Policy; educate staff unavailable prior to their next scheduled shift.
- Develop and implement a plan to monitor preventative maintenance for the heating system, including regular audits of maintenance logs by the Administrator to ensure HVAC inspections and radiator filter cleanings are completed; review results during scheduled QAA meetings; continue audits.
- Implement a mandatory education schedule ensuring all staff are educated on the facility emergency policies and procedures; make training a permanent part of orientation for all new hires and conduct annually for all existing staff by Human Resources.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An open floor drain near the dish machine was observed without a grate, and the FSM confirmed it had no grate and was unsure how long it had been open. In the Hair Salon, the sink drain filter had a glob of hair, and 3 brushes plus a box of hair curlers had hair on them; the AD and HS both confirmed the unsanitary conditions, and the HS stated she might have forgotten to clean the salon after the beautician visit.
A resident room was observed in disrepair with unpainted wall areas, black marks, discoloration, ceiling staining, and scuffed, missing paint on the door frame, and the same conditions remained on follow-up. The memory care dining room floor also had food crumbs and debris under multiple tables; an LPN said it appeared not to have been cleaned after the prior night's meal, and the administrator confirmed the food was still present.
Leaking and Loose Faucets in Facility Sinks: During a facility tour, a beauty shop style sink was observed leaking where the faucet connected to the sink, and maintenance staff stated they were not aware it needed repair. A sink in the soiled linens room on D/F Hall was also observed with a loose swivel faucet that leaked when turned on, and maintenance staff confirmed the observation.
Sharps containers on a locked dementia unit were observed full to the point that they could not be opened, including one in a shower room with three uncapped used disposable razors sitting on top of it and another on a medication cart. The DON and an LPN confirmed the containers were unusable, and the LPN noted two residents on the unit required routine blood glucose monitoring with lancets that would need disposal in a sharps container.
Resident room walls were observed with moisture, black/gray staining resembling mildew or mold-like substance, bubbling paint, cracks, gouges, and dirty vents in multiple rooms, including B-2, B-4, B-6, B-8, B-10, and B-12. The Tel's record review showed no reports about the wall conditions for the past 6 months, and the ADM stated the moisture had been present for a while and had not previously been brought to the ADM and Maintenance Director's attention.
A resident with moderate cognitive impairment and anticoagulant use had a bedside table within reach that was observed to be broken, with an unfinished edge, exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed the table was in poor repair and accessible to the resident.
Unsanitary Hair Salon and Open Kitchen Drain
Penalty
Summary
The kitchen floor drain near the dish machine was observed on 6/09/2026 at 8:08 AM without a grate. The FSM confirmed the drain was open and stated she was not sure how long it had been without a grate. She also stated the facility had no pests and that they were waiting for the Maintenance Supervisor to start working at the facility so she could let him know about it. Later that day, the FSM stated she had told the prior Maintenance Supervisor about it a week or 2 weeks earlier, and that the new Maintenance Supervisor had started on 6/8/2026 after the former supervisor left on 6/5/2026. In the Hair Salon on 6/11/2026 at 11:07 AM, the sink drain filter contained a glob of hair, and 3 brushes in a cabinet had hair on them, along with a box of hair curlers with hair on them. The Activity Director confirmed these observations and stated Housekeeping was responsible for cleaning the Hair Salon sink. The Activity Director also stated the beautician had visited on 6/9/2026. The Housekeeping Supervisor confirmed the hair in the sink drain filter and stated she might have forgotten to clean the Hair Salon after the beautician visited that week.
Dirty resident room and unclean memory care dining room
Penalty
Summary
The facility failed to maintain a resident room in a clean, sanitary, and orderly condition for one resident, R5. During observations, R5 was lying in bed while the room showed multiple areas of disrepair: a section of wall below the mounted TV was not painted the same color as the rest of the wall, the wall across from the bed had multiple black marks and light brown discoloration, the ceiling above the window had a yellowish discolored area about the size of a basketball extending along the ceiling/wall, and the door frame had multiple scuff marks and missing paint. These same conditions were still present on follow-up observation, and R5's family member stated they had concerns about the environment, describing the facility as not clean, smelling bad, and reporting concerns about the room's smell, missing paint, and ceiling to staff. The facility also failed to keep the memory care dining room floor in a clean and sanitary condition. During observation, the floor under multiple dining tables had light-colored crumbs, brown crumbs, pieces of a white meat-like substance, and spaghetti noodles. An LPN stated it looked like the floors had not been cleaned after the prior night's meal and said housekeeping was supposed to clean the floors after meals were served. The administrator confirmed the food under the tables and stated any staff member who observed it should help clean it up, not just housekeeping. The maintenance policy stated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Leaking and Loose Faucets in Facility Sinks
Penalty
Summary
The facility failed to maintain plumbing in the building, as observed during a facility tour with maintenance employee C. On 05/27/2026 at 9:45 AM, the beauty shop style sink with a head rest and hair rinse hose was observed leaking where the faucet connects to the sink, and maintenance employee C also observed the faucet leaking and stated they were not aware it needed repair. Later, on 05/27/2026 at 10:16 AM, the sink in the soiled linens room in the D/F Hall was observed with a swivel faucet that was loose and leaking when the sink was turned on, and maintenance employee C confirmed this observation during interview at the time.
Sharps Containers Left Full and Unusable
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for residents by not maintaining sharps containers in a safe manner in two of four observed sharps containers. Record review of the facility’s Sharps Container Policy showed that the facility would use sharps containers for disposal of sharp items, including lancets, and that containers were to be sealed with tape and dated when disposed of, but the policy did not address when or how often the containers should be emptied. During observation, the sharps container in the shower room on the locked dementia unit was full to the point that it could not be opened, and three uncapped used aqua-blue disposable razors were sitting on top of the container. The DON confirmed the container should have been properly disposed of and replaced with a new one and stated the razors on top of the container could pose a potential safety hazard to residents. A second observation showed the sharps container on the medication cart for the locked dementia unit was also full to the point that it could not be opened. An LPN stated the unit had two residents who required routine blood glucose monitoring and that lancets used for blood glucose checks would need to be disposed of in a sharps container, but the container on the medication cart was not usable because it could no longer be opened. The Administrator stated she expected staff to provide for resident safety in the shower room and anywhere sharps containers were located, and confirmed that leaving uncapped or unsheathed disposable razors on top of the sharps container in the shower room could pose a safety hazard for residents.
Resident Room Walls Found Moist, Stained, and Damaged
Penalty
Summary
Resident room walls were not kept free from moisture, black/gray staining, gouges, bubbling paint, and dirt in multiple rooms. On 5/27/26 at 11:00 AM, an observation found room B-2 with dirty vents and a small gouge in the drywall; room B-4 with an outside wall that was moist and had a grayish stain about 1 foot by 1 foot resembling mildew or a mold-like substance; room B-6 with a moist outside wall, a black/gray substance resembling mildew, and several bubbles and cracks in the paint; room B-8 with an outside wall that felt moist to touch and had a blackish/gray substance about 2 feet by 2 feet resembling mildew or a mold-like substance; room B-10 with streaks and stains going down the outside wall; and room B-12 with cracks in the drywall, streaks down the wall, and bubbling paint. A record review of the Tel's program showed no report regarding the resident walls for the past 6 months. During an environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director, the same wall conditions were confirmed in rooms B-2, B-4, B-6, B-8, B-10, and B-12. In an interview at that time, the Administrator stated the moisture on the walls in the resident rooms had been there for a while and should have been reported by staff who see the wall daily, and also stated this was the first time the walls had been brought to the Administrator and Maintenance Director's attention.
Broken Bedside Table Within Resident Reach
Penalty
Summary
The facility failed to ensure that a bedside table was in good repair for Resident #59, who was admitted with diagnoses including cerebral infarction, schizophrenia, and acute embolism. The resident’s MDS assessment showed moderate cognitive impairment, no upper body impairment, and anticoagulant use, and the care plan identified risk for bleeding related to anticoagulant medications. During observation, the resident’s bedside table was within reach and was found to have an unfinished, broken edge with approximately three inches of exposed particle board, splinters, and wood chips on the tabletop. A CNA confirmed that the bedside table was broken with rough, exposed particle board and wood chips and was within reach of the resident.
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