F0835

E

Improper Use of Radiant Space Heaters Creating Immediate Jeopardy

Lancaster, Pennsylvania Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failing to effectively utilize available resources to promote resident safety and maintain residents’ highest practicable physical well-being. Review of the NHA’s job description, dated October 06, 2025, showed that the NHA is responsible for managing the facility in accordance with applicable federal, state, and local standards and for ensuring that the highest degree of quality care is provided to residents at all times. The DON’s position description, dated August 11, 2022, indicated responsibility for planning, organizing, developing, and directing the Nursing Service Department in accordance with current regulations and as directed by the Medical Director, to ensure that the highest degree of quality care is maintained.

Survey findings under 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices) showed that the NHA and DON did not fulfill these essential job duties because they permitted the use of radiant space heaters in resident rooms and hallways, including areas accessible to residents with cognitive impairment. Observations, record review, and staff interviews confirmed that these heaters were in use in resident care areas. This failure to ensure an environment free from accident hazards placed residents at risk for serious injury or death and resulted in an Immediate Jeopardy situation, and was cited in conjunction with 28 Pa. Code 201.14(a), 201.18(e)(1), and 211.12(d)(1)(5).