F0689

L

Failure to Maintain Safe Baseboard Heaters and Bed Placement Resulting in Severe Resident Burns

Pekin, Illinois Survey Completed on 03-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain baseboard heaters in a safe manner and to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. During a tour, all resident rooms were noted to have six-foot baseboard heaters beneath the windows, with measured surface temperatures as high as 172°F. In one room, a stuffed animal pillow was resting directly on top of the heater and a bag was positioned immediately adjacent to it; in another room, a window curtain was draped over the heater. In multiple rooms, thermostats were missing from the heaters, and one resident’s bed was positioned directly against the heater, with the resident’s hand and arm within reach of the hot surface. The resident, who was hard of hearing, stated that the heater gets very hot. The surveyor found the heater surface too hot to safely touch.

The facility’s Maintenance Director confirmed that the facility did not maintain the manufacturer’s operating and preventive maintenance instructions for the baseboard heaters, including the parts list with component descriptions and the air-balance report, and that a complete set of these documents was not available on-site. He also stated that he had not previously monitored or documented the surface temperatures of baseboard heaters or heater covers and was not aware of any established process for doing so. Following a burn incident involving a resident, he reported conducting only a visual inspection of all heaters to identify units needing repair or replacement and measuring the surface temperature of only four heaters, confirming that no formal process for routine temperature monitoring had been implemented. The Administrator-in-Training verified that curtains, personal items, and residents should be kept approximately 12 inches from the heaters to prevent burns and fire hazards and acknowledged that the facility did not have the manufacturer’s operating and preventive maintenance instructions.

One resident involved in the incident was an older adult with diagnoses including hemiplegia, convulsions, respiratory failure, type II diabetes mellitus with diabetic hemiplegia, chronic kidney disease stage III, depression, and dementia with anxiety. This resident was cognitively severely impaired and dependent or required extensive assistance for all ADLs, received hospice care, and had no signs or symptoms of pain prior to the burn incident. A CNA reported that around midnight she was unable to turn the resident because the resident’s arm was stuck between the bed and the baseboard heater; when she moved the bed, she observed a large burn up and down the resident’s left arm and immediately notified the nurse. Progress notes and emergency room documentation describe partial-thickness, second-degree burns with blistering extending from the pinky finger up the arm to near the shoulder, requiring emergency treatment and ongoing painful wound care. The coroner stated that the resident was non-verbal and could not have yelled for help when being burned and characterized the situation as neglectful of the facility to have allowed the burns to reach that severity.

Another resident whose room was observed during the survey was moderately cognitively impaired, with a care plan that did not include measures to keep the resident at a safe distance from the baseboard heater or to protect from burns. This resident’s bed was positioned directly against a heater with a missing thermostat, and the resident’s right hand and arm were within reach of the heater surface. Across multiple rooms, the combination of high heater surface temperatures, missing thermostats, lack of manufacturer guidance, absence of a monitoring system for heater temperatures, and unsafe placement of beds and combustible items near heaters constituted the actions and inactions that led to the identified deficiency. These failures resulted in a resident becoming entrapped between the bed and a baseboard heater and sustaining painful burns that required emergency room treatment, and had the potential to affect all 87 residents residing in the facility.