**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and interviews the facility failed to provide a safe and home like environment by not maintaining comfortable and safe temperature levels in the entire premises of the facility. This failure affected all 258 residents residing in the facility, who were all subjected to hazardous temperatures and one resident (R8) who was sent to the hospital and admitted due to hypothermia. This was identified as an Immediate Jeopardy which began on 1/16/24 at 10:30 am per (1/16/24) facility temperature log which documents a residents' rooms temperature range of 53F (Fahrenheit) to 63F. On 1/19/24 at 09:16 am V1 (Administrator) was notified of the immediate jeopardy. The facility presented a final removal plan on 1/22/24 at 4:49 am which was not approved. The facility presented a revised final removal plan on 1/23/24 at 04:59 pm which was not approved. The facility presented another revised final removal plan on 1/24/21 at 1:36 pm which was accepted/approved on 1/25/24 at 5:08 pm. The surveyor conducted additional interviews and record reviews on 1/26/24 to 1/31/24 verify the plan was implemented. The immediate jeopardy was removed on (1/24/24) based on actions from the removal plan. Findings include: On 01/16/24 at 04:00 pm surveyor arrived at the facility and noticed that there were 2 charter buses in front of the facility and in the entrance hall there were more than 15 people distributed between the reception, entrance and corridor leading onto the elevators. Everyone was wearing winter coats and jackets; some were wearing winter hats and gloves and scarfs. The temperature inside was very cold. There was a line of people coming from the elevator. After speaking with V1 (Administrator), surveyor learned that those people were residents being transferred to other facilities and staff were there to help with the transfer process. On 1/16/24 at 04:15 pm surveyor observed residents had been in process of being discharged to two other facilities due to inadequate heating. The weather forecast on 1/15/24 was 4 degrees Fahrenheit (F) with wind chills of minus 9 F. Temperatures on 1/16/24 was 5 degrees with wind chills of -5 degrees according to the weather forecast. On 1/16 24 at 04:15 pm V1 (administrator), said that on 01/15/24, around 8:30 am, it was noticed the temperature inside the building was dropping. The lack of heating was affecting all floors. The facility called a company to check the boiler and it was noticed the boiler temperature was at 130 instead of 160. V1 said the boiler malfunctioning was fixed, and the heating was restored for a while but then one of the radiator pipes burst. A plumbing company was called. The plumbing company arrived around 11am on 1/15/24, repaired the plumbing, but while they were working, other pipes burst and continued to burst because they were frozen due to the intense cold weather. V1 said, The plumbing company told me the problem would continue to occur even though they were trying to contain it. That's why I decided to evacuate all residents to other facilities. V1 said two facilities confirmed to receive residents. V1 said the census is 258 and all residents will be transferred and at this point to 2 facilities have that accepted their residents. V1 stated these two facilities will provide 150 beds to accommodate the residents. On 1/16/24 at 04:20 pm V1 said offices are located on the 1st floor; 2nd, 3rd, 4th floor is mix of skilled and non-skilled residents, but mostly skilled residents, need more assistance; 5th floor they are little more independent; 6th and 7th floor residents are independent, ambulatory and need less assistance. Copy of the census received and shows total of 258 residents. On 1/16/24 at 04:30 pm V3 (Assistant Administrator) said, The pipe burst happened initially on the second floor on (1/15/24) which caused flooding to both 2nd floor, and 1st floor. We have over 100 portable heaters that were brought in to help and they had been placed on residents' rooms to keep it warm until the heating system be repaired. The facility has also bought forced heaters and they have been placed on the floors. During facility tour surveyor noted some room did not have a portable heater in place, some other rooms had a portable heater placed in the floor unplugged. On 1/16/24 at 04:35 pm V2 (Regional Director of Operations) stated, We are implementing phase one of our emergency plan, which is to evacuate the most mobile/ independently residents first and then evacuate the ones who need more assistance, the ones on wheelchair, or not able to be transferred by bus and requires a wheelchair van for transportation. While we are doing this, I have my Chief Operating Officer (COO - V4) calling other facilities checking their availability to receive our residents. On 1/16/24 at 05:02 pm observation conducted on 2nd floor. Noticed a portable heater placed in the hallway and another one close to the nursing station. Surveyor observed water on the floor of 4 rooms. No residents observed in these rooms. At the top of the staircase that leads to the second floor, there were several black bags with debris, debris on the floor and signs of flooding. The pipe was uncovered and broken and according to the building's maintenance director V7, was where the leak started, and they had to isolate the pipe to fix it. On 1/16/24 at 5:10 pm on 3rd floor several residents observed in wheelchairs sitting in the hallway, or grouped in a room called the day room located in front of the nursing station. The residents were wearing winter clothing, such as coats, jackets, gloves, and hats. According to nurse (V6), the floor census is 47 residents. One nurse and one CNA observed working in the floor. On 1/16/24 at 05:12 pm R3 observed inside her room, sitting in a wheelchair, and noted to be wearing multiple layers. R3 stated, It's cold here and there is no heating. There is no portable heater in R3's room. Surveyor asked V6 to check R3's room to verify if there is a portable heater inside the room. V6 stated, I don't see one. On 1/16/24 at 05:15 pm noticed R4's room without a light on. R4 was in bed without a blanket, covered from the chest to the lower extremities with just a sheet. R4 kept saying, Help, help, help, black, black, back, back. R4 noted to be shivering and hunching his shoulders. R4 said he was cold, and then pointed to a wheelchair. The room was dark and cold. The room has 4 beds. A portable heater has been placed next to the R4's bed, but is not plugged in. Another portable heater found next to second bed D is plugged in. Surveyor asked V6 why the room is dark and cold and why the heater next to R4's bed is unplugged. V6 tried to plug the heater in, but the outlet was too far from the bed. V6 checked the headboard's light for all 4 beds and none of them worked. V6 said she heard that if the portable heater is plugged in, the lights above the headboard won't work properly. V3 (AADM) tried to plug in the portable heater placed close to R4's bed but was not able to. V3 stated, These are the things we have not planned. V6 unplugged the portable heater that was placed close to another bed and the lights came on. V6 said she will transfer R4 to the wheelchair but does not provide a blanket to resident. On 1/16/24 at 05:25 pm R9 was laying down in bed, wearing several layers of clothing and covered by a blanket. R9 has no roommate. Noted a portable heater placed on top of the nightstand. R9 said her son bought the heater for her yesterday because it was too cold and there is no heating in the room. R9 said the facility bought the portable heater today around 12 pm. The heater provided by facility is plugged in and placed on the top of the dresser. R9 said no one told her she will be transferred to another facility. On 1/16/24 at 05:28 pm R10 stated, They just brought the portable heater now. The heating went out during the weekend, and they should have moved us during the weekend. On 1/16/24 at 05:30 pm R5 said, They just brought this heater a few minutes ago. I'm freezing here. The heat stopped yesterday evening. I need more blankets. I've asked them, but they don't bring it. R5 was wearing 4 layers of clothing including a sweater and has one sheet and one blanket on top of her and said, and I'm still cold. On 1/16/24 at 06:00 pm there is no heating in the dining room, reception, lobby, therapy room and offices, all located on the 1st floor. Surveyor worked wearing a full set of winter clothes (heavy coat, hat, scarf). Facility's staff noted to be wearing a full set of winter clothing gloves and some of them using scarfs as well. There is no heating inside the elevators. Copy of the census received and shows total of 258 residents. On 1/16/24 the facility temperature log indicates temperatures were checked in residents' rooms, nursing station (NS), basement, Physical Therapy room, offices and dining room (PT & SO & IDNE). The temperature log shows rooms temperature were checked on intervals of about 1 hour and reflects the following: At 08:30 am temperature on rooms 702, NS and 721 were respectively 55F, 59F and 54F ; 602, NS, 620 - 55F, 57F 55F; 502, NS, 521 - 54F, 57F, 55F; 401, NS , 420 - 55F, 60F, 54F; 302, NS, 321 55F, 55F, 54F; 201,NS, 220 - 54F, 53F, 55F. At 09:40 am the temperature ranged from 59.7F on the 6th floor to 53F on 2nd floor. At 10:30 am the log reflects temperature of the following: 701 - 63F/ 720- 60F; 602- 59F/ 621- 54F; 501- 56F /520-54F; 402- 53F /419-53F; 302- 54F/ 320-53F; 202- 53 F/ 220-53 F; PT&SO& DINE (1ST floor) 51F - 52F. Facility's temperature log sheet dated 1/16/24 completed on interval of 30 minutes starting at 5 pm does not documents residents' rooms temperature, instead documents one temperature per floor (6th, 5th and 4th floor) where the residents were. The temp log reflects the following: At 5 pm 5th floor- 67.3F; 4th floor 66.1F. At 05:30 pm 5th floor - 66.4F; 4th floor 67.2F. At 6 pm 5th floor 66F; 4th floor 67.2F. At 6:30 pm 7th floor 64.1F; 6th floor 65.4F; 5th floor 66.5F. At 7 pm 7th floor 65.1F; 6th floor 68.1F; 5th floor 67.2F; 4th floor 67.9F. At 7:30 pm 6th floor 68.9 F; 5th floor 67.5F ; 4th 67.9F . The highest temperature recorded from 8 pm on 1/16/24 to 3 am on 1/17/24 on the 4th floor 71.1F. At 8 pm and 8:30 on 1/16/24 the 4th floor temperature was 61F. On 1/16/24 at 18:05 pm, noticed a crew member bringing another equipment into the facility. According to V1, it is to be installed to provide heat, because we still have to keep the building's temperature up. On 1/17/24 at 09:30 am noted 120 residents, according with census, remained at the facility with the heating system still not functionally operating. On 1/17/24 at 10:47 am 4th floor hallway north temp 57.3 degrees. At 11:08 am one resident's room on 4th floor temp was 56.6. degrees. On 1/17/24 at 01:50 pm V5 (Regional Maintenance Director) stated, The boiler malfunctioning affected the air handle system and the radiator system. The upstairs units were working at 75% capacity and warming the 7th, 6th, 5th and 4th floor. The air handles in the basement cover basement, 1st, 2nd and 3rd floor. The big units we are getting will fix the problem and they will be heating the building in 2 to 3 hours. The standing heater covers 750 square feet and we got 20 of those. The machine pumps up 80 degrees, but that does mean the rooms are 80 degrees. Forced heaters that covers 300 square feet, those are the best ones, and we have 3 of those per hall. We should have the standing heating unit, the portable heaters and the diesel fuel commercial make up air units, all working to provide heating the building so in 1:30 and 2 hours we should have everything done. On 01/17/24 at 09:40 am V1 said the heating is working on all floors, but after inspection with V7 (Maintenance Director) surveyor noted the temperature was below 71 degrees on the 4th floor. Temperature in the north corridor of the 4th floor was 57.3 degrees at 10:47 am on 01/17/24. At 11:08 a.m., the temperature in one resident's room was 56.6. degrees. On 1/17/24 at 03:02 pm Surveyor made rounds with V7 (Facility Maintenance Director). Despite all equipment brought to facility to heat up the building the temperature in residents' rooms still under the temperature required. Room temperatures were 64.9, 59.3, 63.3 63.8, 56.3, 61.9 in resident's rooms and 64.3 in the day room [ROOM NUMBER]th floor temp. The day room has one standing heating unit and two forced heaters in place. Facility entrance area temp 46.5. On 1/17/24 at 06:05 pm V1 said they were transferring residents from the 6th floor to another facility. V1 said, the boiler is working, it's just that the temperature was not holding up because the pipes burst. V1 stated, It reduced the power to keep the heat up. On 01/17/24 at 06:56 pm temperatures were 61.4, 62.8, 66.4, 60.2 degrees respectively in 4th floor residents' rooms and 68 degrees at Nursing station. On 1/18/24 at 10:47 am room's temperature checked randomly and were the following: 5th floor rooms 68.3 F, 68.1 F, 62F, 60 F, 70 F, 69.8F. 6th floor rooms 68.6F, 67.2F, 65.1F, 64.4F. On 1/18/24 progress notes documents R8 was sent to the hospital. Hospital records documents: 66.y male present to Emergency Department for evaluation. Patient brought by EMS for possible low oxygen saturation at nursing home. Per EMs the nursing home had a pipe burst and had patient was in a wheelchair sitting in the hallway. On initial assessment patient noted to be hypotensive and bradycardic. Physical exam reads: blood pressure 110/68; pulse 66' temperature 91.8 degrees. Medical decision making patient noted to be hypothermic, hypotensive, and bradycardic. Will give antibiotic and lab work. Patient placed in warming blanket. On 1/19/24 at 09:45 am R6 was in a wheelchair, fully dressed, wearing winter clothes. R6 stated, I was on the 4th floor on Monday (1/15/24), and it was cold. Cold enough to make me uncomfortable. There was no heating coming from the radiator or from the ceiling. It was very cold! I used my own blanket. On Tuesday (1/16/24) afternoon they brought the portable heater to other rooms, but never to our room. I asked V7 (maintenance director) for a heater, but he never brought one. For four days they are talking we are going to leave to another facility, and we are still here. On Tuesday (1/16/24) they put me in the room on the 6th floor that was cold and had water on the floor. I said if I am going to be in another cold room, I would prefer to stay in my room. They took me back to the 4th floor. I did not get any medicine last night. I did not get my insulin and the Keppra. I take Keppra because I have seizures. They did not check my blood sugar this morning. The nurse said she did not have the equipment to do it. They said the nurse on duty did not know where the medication was. They said they had packed the medication because we were about to leave, and the nurse didn't know where they put it. On 1/19/24 at 09:50 am R7 stated, They transferred me to 6th floor on Wednesday (1/17/24). On 1/15 and 1/16/24 the 4th floor was cold. I was fully dressed, with coat and I had to cover my head with the blanket. That's how cold it was. Everybody was wearing coat, gloves, boots and hats. It really started on Monday afternoon. The temperature was dropping. It came back a little bit and then was cut off. They told us the furnace was broken and they will bring a new one. On Tuesday they said they will transfer us. But my question is, why the let people who can walk go and left us on a wheelchair, behind? From Monday to Wednesday, when they started bringing the heating units here, we had no heating. I was transferred to this floor (6th) on Wednesday. I did not receive my medication last night. On 1/23/24 at 10:57 am V1 stated, Right now we have our residents on 6th floor, temps are between 71 and 81 F. It was checked 30 minutes ago. We are checking every 30 minutes. No residents have been sent to hospital since Friday. The resident sent to the hospital is still at the hospital. After we are able to get the entire building complete and any water damage fixed we will bring the residents back. The equipment going to ceiling through plastic tubes is to eliminate moister. We will have a meeting to discuss the progress of the work that is being done and learned about the time frame for the completion of it. On 1/23/24 at 01:30 pm surveyor made rounds with V22 (Maintenance). Random temperatures were taken on the 6th floor where 46 residents remained were 81.7 F, 83.1F, 84.4F, 85.3F, 84.9F, and 84.6F. The South hallway was 85.1F; Room in front of the nursing station (day room) north wall was 87.3 F and Nursing station was 87.3F. Residents noted to be wearing light clothes and were complaining the temperatures were now too hot. Staff no longer wearing winter clothes. Nurses and CNAs noted to be wearing scrubs only. On 01/23/24 at 3:29 pm V5 (Regional Maintenance Director) stated, The purpose of the generator that was brought into the facility (placed outside the facility) was to supply hot water that will flow to the radiator pipes and fans to create heat. The radiator's heat goes to the air coils which will push hot air through ductwork throughout the building while the pipes and coils are being repaired. V5 said the boiler was repaired, but the pipes froze, and the dampers and controls were damaged due to the cold. V5 stated the coils weren't working yet, so the 4th floor was cold. It should be done by tomorrow afternoon. The patching of the air handles should be done by Friday. Hopefully, and in the worst case, Monday. I turned off the heating as it was getting very hot on the upper floors as there is now some heat coming from the radiators as well. On 1/30/24 at 01:34 pm V15 (Attending physician) stated, I don't think this is predictable. It depends on whether the person is exposed to lower temperatures. Was the resident outside the facility? Yes, lower temperature can cause bradycardia. A body temperature of 91.8F is considered hypothermia and the resident has go to the hospital. The nursing home may provide a blanket and provide hot liquids, but this needs to be closely monitored. If the resident develops septic condition and requires treatment with antibiotics. The following corrective actions to remove the Immediate Jeopardy were taken: 6TH FLOOR TEMPERATURE: A. Temperatures are being checked in the resident rooms and resident areas on the 6th floor every 30 minutes. B. The temperatures on the 6th floor are maintained between 71°F to 81°F. HEATING SYSTEM: A. On 1/15/2024, the boiler is functional and was validated by the HVAC company. B. Per HVAC company report, the boiler supplies heat to radiators at all exterior walls in stairwells and patient rooms. The boiler also supplies heat to coils in the two air handlers. The Air handler number #1 which is located in the basement of the facility covers floors 1, 2 and 3. Air handler #2 also provided heat from the boiler is located on the 7th floor penthouse and covers floors 4,5,6 and 7. Air handler #2 also has two sets of coils. Dampers were closed to try and conserve heat and push through floors 4,5,6 and 7. C. The facility contracted HVAC company to get two (2) make up air units to pump heat to air handler #1 to push hot air into floors 1, 2 and 3. D. The facility has also procured temporary heating units on 1/15/2024. The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. On 1/19/2024, at 1:15pm, the QAPI team (which includes the Administrator, DON - director of nursing, Assistant Administrator, Maintenance), and members of the executive management team (which includes, VP of Operations, VP of Physical Plant, Chief Regulatory Compliance & Clinical Officer, VP of Policy & Education and VP of Regulatory Compliance & Clinical Services) conducted an Ad-Hoc QAPI meeting to discuss the alleged deficiency and corrective actions. The Medical Director was not able to attend the meeting in person, therefore, the Administrator notified Medical Director of the Ad-Hoc QAPI meeting minutes via telephone on 1/19/2024, at 3:15pm. B. During the Ad-Hoc QAPI meeting, the QAPI team, members of the executive management team, and the VP of Physical Plant also discussed the Heating System Mitigation Plan which was developed for the facility in response to the extreme cold outside temperatures. C. The VP of Policy and Education will provide training to the Senior Leadership of the facility, which includes the Administrator, DON and Maintenance Director. The training will include but not be limited to: 1) The responsibility of the administrator to report all incidents to IDPH in a timely manner. 2) The responsibility of the Administration to provide a safe and homelike environment to all residents. 3) Emergency Management Plan focusing extreme temperatures and facility response. 4) Preventive maintenance related to the boiler and facility heating system. This training started on 1/19/23 and was completed on 1/23/2024. To validate retention of knowledge, posttests will also be used, and the acceptable score is 100%. If the score is less than 100%, a retraining will be completed. D. Nursing Staff Education. The DON/ADON will provide training to all nurses about symptoms of hypothermia. The training will be completed on or before 1/19/2024. E. All Staff Education. After training, the Administrator, Maintenance Director, DON, ADON will also provide training to all staff about extreme cold weather protocols. The training will also include posttests and the acceptable score is 100%. Any staff who did not achieve 100% test results was provided with additional retraining from the Administrator, Maintenance Director, DON, ADON. Training on the execution of the facility's emergency evacuation plan The training started on 1/19/2024 and completed on 1/23/2024. F. All staff members who are not available and/or currently on vacation will also receive the same education upon their return to work. The Administrator/DON/ADON will provide the same training. G. Agency staff. The facility is not using agency staff at this time. If agency staff are used in the future, the facility will utilize the same process of providing the education to ensure that they (agency staff) will receive the same training as the facility staff. H. In the future, when agency is used, the Administrator/ DON/ ADON will provide similar training prior to the start of their shifts. I. An agency staff will not start the shift without finishing the training first. J. Boiler. The Administrator will review the preventive maintenance schedule with the maintenance director, focusing on boiler maintenance. The Administrator will also provide training to the maintenance director to notify the Administrator, VP of Physical Plan and VP of Operations of any concern identified with the boiler. The training will be completed on or before 1/19/2024. K. The DON/ADON/charge nurses will conduct resident assessments every two (2) hours to ensure that residents are not experiencing any sign of hypothermia. The DON/ADON/charge nurses will notify the attending physician/Nurse Practitioner (NP) of any identified concern. This started on 1/15/2024, 9:00am. L. The Maintenance Director/designee will continue to conduct temperature checks of all rooms on the 6th floor every 30 minutes until the QAPI team decides to change the frequency of temperature checks. M. The Maintenance Director/designee will continue to conduct temperature checks of all rooms in floors, 1st, 2nd, 3rd, 4th, 5th, and 7th floor every hour until the QAPI team decides to change the frequency of temperature checks. N. The residents who have been evacuated will be allowed return to the facility once the facility stabilizes the temperature in all floors between 71°F to 81°F for at least 24 hours. This will be discussed during an Ad-Hoc QAPI meeting. O. All results of the temperature checks, unit rounds and resident assessments will be reported to the QAPI committee. P. An Ad-hoc QAPI meeting will be held weekly to determine if additional interventions are necessary to ensure compliance. Q. The Administrator will monitor completion of this plan of removal.