Combustible Materials on Heating Units
Summary
The facility failed to maintain heating units free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation conducted on January 22, 2025, between 12:30 p.m. and 1:15 p.m., it was noted that combustible materials were placed on top of heating units in resident rooms 240 and 108. This deficiency affected two of the three levels of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Combustible materials removed from HVACs in 108 and 240. Maintenance Director conducted facility rounds and there were no other HVACs covered with combustible materials. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0522-HVAs- Any Heating Device. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Penalty
The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all residents and smoke compartments. The heating system was observed to be nonfunctional during a survey, and multiple attempts to repair it were unsuccessful, leading to the inability to maintain required temperature levels throughout the building.
Surveyors found a hydrocollator machine used for hot pads placed directly on a towel in the therapy area, with the device hot enough to cause burns upon touch. The machine was not installed to prevent ignition of combustibles, as required, and this was confirmed by the Maintenance Director. This deficiency could potentially affect eight occupants in the therapy area.
The facility did not maintain heating units free of combustible materials, as required by NFPA 101. Combustible materials were observed on heating units in two resident rooms, which was confirmed by the Facility Administrator and Maintenance Director.
Failure to Maintain Boiler Heating System
Penalty
Summary
The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all 95 residents and all five smoke compartments. During an onsite investigation and interview with the Administrator, surveyors observed that the boiler heating system located in the mechanical room was not operational. This deficiency was identified through direct observation and confirmed by facility staff. As a result of the inoperable boiler, the facility was unable to maintain the required temperature levels throughout the building. The deficiency impacted the entire resident population, as the heating system is essential for maintaining a safe and comfortable environment. The report notes that the boiler could not be repaired after multiple attempts by heating and air system vendors, and the system remained nonfunctional for a period of time. The failure to maintain the boiler system and ensure its operability led to the inability to provide adequate heating for the residents. The deficiency was directly related to the lack of a functioning heating system, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
1/5/26: POC approved by Cynthia Luc, SSM-I The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. HVAC - Operating Features: The facility will follow the Emergency Operations Plan for notification to state survey agency of nursing home situation. Immediately upon discovering the failure to report the unusual occurrence, the facility discussed the incident in question with the CDPH surveyor who was conducting an abbreviated survey. An internal review of the incident was completed to determine root causes. The Administrator was interviewed and re-educated on reporting requirements. To ensure no similar oversight occurred, the previous 30 days of incident logs, nursing notes, and daily shift reports were audited by the Administrator on 12/19/25. Any event fitting CDPH's definition of an unusual occurrence was reviewed to verify it had been properly reported. No additional unreported unusual occurrences were identified. On 12/16/25, the Administrator received education from the Regional Operations Director on Title 22 §72541 reporting requirements, definitions of unusual occurrences, and required timelines and reporting processes. A CDPH Reporting Log was implemented to track all facility reported incidents from initial notice through CDPH submission. To ensure sustained correction, the Administrator will perform a weekly audit of all incidents for 12 weeks. After 12 weeks, audits will continue monthly for an additional 6 months. Findings will be reported at the Quality Assurance Performance Improvement (QAPI) meeting each month. Any identified gaps will result in immediate retraining and corrective action. All corrective actions will be fully implemented by 1/4/2026.
Improper Placement of Hydrocollator Machine Creates Fire Hazard
Penalty
Summary
A deficiency was identified when surveyors observed a hydrocollator machine, used for hot pads, placed on top of a towel in the therapy area. The machine was found to be hot enough to cause a heat burn upon contact, and it was not installed in a manner that would prevent combustible materials from being ignited, as required by code 19.5.2.2. The observation was confirmed by the facility Maintenance Director at the time of the survey. This situation could potentially affect eight occupants within the therapy area if ordinary combustibles come into contact with the heat source.
Plan Of Correction
Hydrocollator was removed from the shelf and towel location and installed on a metal shelf. All other heat producing equipment has been reviewed to ensure that combustible items are not touching them. Department Managers and Maintenance staff will be inserviced on the safe use of heat producing equipment. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for combustible materials are keep away from heat producing equipment.
Combustible Materials Found on Heating Units
Penalty
Summary
The facility failed to ensure that heating units were free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation on January 29, 2025, at 10:00 a.m., it was noted that combustible materials were placed on top of heating units in resident rooms 414 and 412. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 11:10 a.m. on the same day.
Plan Of Correction
Combustible materials were removed immediately from tops of heating units in resident rooms 412 and 414. Maintenance and nursing staff on fourth floor will be educated on the importance of heating units to be clear of combustible materials. Maintenance director or designee will conduct weekly audits x 4 weeks and monthly audits x 2 months to ensure compliance. Audit results will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.
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