F0584

E

Failure to Maintain Required Room Temperatures and Clean Memory Care Furniture

Delaware, Ohio Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain resident room temperatures at or above the required minimum of 71°F and to ensure a clean environment in a memory care common area. Temperature logs showed that from early in the month through the 10th, temperatures were recorded several times a week, with one documented reading as low as 70°F. There were no temperature records from the 11th through the 21st, despite the Maintenance Director stating that room temperatures should be checked daily. The Maintenance Director acknowledged awareness of room heating issues and reported that electricians had been onsite to review problems in several rooms, but there was no additional documentation of temperature monitoring. A facility audit later showed that 15 of 56 rooms were below 71°F, with only one of those documented as being at that level per resident preference, contrary to the facility’s policy requiring immediate action to maintain temperatures between 71°F and 81°F and routine inspections of heating systems.

Multiple residents were found to be residing in rooms with temperatures below the required minimum. One resident with traumatic brain injury, malnutrition, dementia with agitation, depression with psychotic features, and panic disorder had a PTAC unit that was off, with pants stuffed in the vent and an error light indicating the filter needed replacement; the Maintenance Director found a thick layer of dust in the unit and measured room temperatures between 66°F and 69.7°F, with the bathroom at 59.6°F. Another resident with pelvic fractures, dementia, emphysema, pulmonary hypertension, weakness, and dysphagia was observed in a room where the PTAC was off and the room felt cold; the Maintenance Director measured the room at 67.4°F and the bathroom at 54.4°F and confirmed that bathrooms had no temperature control. A newly admitted resident with cerebral infarct, type 2 diabetes, and bipolar disorder was found in a cool room where the PTAC would not turn on; maintenance measured the room at 66.5°F to 67°F, and the resident reported the room had been cold since admission.

Additional residents reported or were observed to have inadequate room heating. One resident with a history of cerebral infarction, atrial fibrillation, morbid obesity, orthostatic hypotension, venous insufficiency, obstructive and reflux uropathy, adult failure to thrive, dysphagia, major depressive disorder, and obstructive sleep apnea stated that the heater in the room was not working and that the room was very cold; temperatures taken in this room were 68°F and 67.7°F, with a bathroom temperature of 63°F, which the Maintenance Director confirmed did not meet minimum requirements. Another resident with hemiplegia and hemiparesis following CVA, dysphagia, flaccid hemiplegia, above-knee amputation, chronic pulmonary embolism, dysuria, anxiety disorder, and substance abuse reported feeling cold and being unable to reach the PTAC to adjust the temperature, and stated the PTAC had not worked for multiple weeks; the room temperature was measured at 69.6°F while the facility was in the process of replacing the unit.

The facility also failed to maintain a clean environment in the memory care unit’s common area furniture. A red leather chair in the memory care unit was observed with a brownish, caked-on splatter stain on the backrest, seat, and sides. Over the course of a day, various residents were observed sitting in this chair. A CNA later confirmed that the chair had a brownish splatter, likely food, and stated that housekeeping had wiped it before but that it should be kept clean. The CNA also confirmed that the chair’s two cup holders contained black crumbs resembling coffee grounds, trash, and wrappers, and that there were three wrapped straws and debris in the cracks around the seat cushion. These conditions were inconsistent with the facility’s policies on cleaning schedules and routine cleaning and disinfection, which require regular environmental service tasks and consistent surface cleaning of high-touch areas, including resident chairs, to provide a safe, sanitary environment and prevent infection transmission.