Failure to Maintain Functional Room Heating and Comfortable Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a comfortable environment by ensuring proper room heating for two residents sharing a room. One resident, who was cognitively intact per an MDS dated 12/08/2025, reported feeling cold and was observed wearing a shawl to keep warm. She stated that the room’s heating unit had not been working since 1/10/2026 and that she had reported this to staff on that date. She further reported that a maintenance assistant assessed the unit on 1/12/2026, determined it could not be fixed, left it unplugged, and did not return to reassess it. During the survey on 1/13/2026 at 10 AM, the room felt cool and the heating unit was unplugged. The cognitively intact resident’s roommate, who was documented as severely cognitively impaired and nonverbal on her MDS, was unable to be interviewed about the room temperature. Nursing staff notified the receptionist on 1/12/2026 at 3 PM that the heating unit was not working; the receptionist then notified the maintenance assistant by telephone but did not enter a work order into the computer system as required by the facility’s process. The maintenance assistant confirmed he assessed the unit, found it nonfunctional, left it unplugged, and did not complete a work order. The maintenance director stated he was unaware of the problem and confirmed there was no active maintenance order. Upon his assessment, the unit’s motor was not working and an outside vendor would be needed. He noted the room felt cool with a temperature around 71°F and acknowledged that residents’ rooms needed properly operating heating units so residents could adjust temperatures to their comfort level. The facility’s policy required maintaining comfortable and safe temperature levels within a specified range to minimize susceptibility to loss of body heat and to ensure resident comfort.
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