F0921

K

Inadequate Heating, Emergency Protocol Failures, and Prolonged Hot Water Loss

Lacon, Illinois Survey Completed on 02-03-2026

Penalty

No penalty information released

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.