Health inspection·December 10, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain room temperature at a comfortable and safe level for four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) out of a census of 88, when: 1. Resident 1 ' s, Resident 2 ' s, Resident 3 ' s, and Resident 4 ' s room temperatures were below 71 degrees Fahrenheit (°F; a unit of measure); and 2. The maintenance department did not provide alternative heat sources after the heating, ventilation, and air conditioning (HVAC) system broke. These failures increased the residents ' potential for discomfort and loss of body heat. Findings: 1. During an observation on 12/10/24 at 9:59 a.m., rooms [ROOM NUMBER] were located in the facility ' s back hallway. The rooms and hallway were cold. During a concurrent observation and interview on 12/10/24 at 11:30 a.m. with the Maintenance Director (MD), room temperatures were checked in rooms 33-35. MD stated the room temperatures were too low for the residents ' comfort and confirmed the following: -room [ROOM NUMBER] ' s temperature was 70.2 °F; -room [ROOM NUMBER] ' s temperature was 68.1 °F; -room [ROOM NUMBER] ' s temperature was 67.1 °F; and -The hall thermostat outside room [ROOM NUMBER] indicated a 67 °F. A review of Resident 1's admission Record, indicated he was readmitted to the facility on [DATE] with multiple diagnoses including heart failure and cerebral infarction (stroke; loss of blood flow to a part of the brain). A review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), indicated on 11/22/24 his brief interview for mental status (BIMS) score was 15 out of 15 with intact memory. Page 1 of 3 055497 055497 12/10/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0584 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 12/10/24 at 11:05 a.m. with Resident 1, in room [ROOM NUMBER], Resident 1 was wearing a hospital robe and covered with a sheet, coverlet, and velour blanket. Resident 1 stated the extra blankets were offered by staff and did not help. Resident 1 also stated he felt cold most of the time since Thanksgiving weekend and his daily requests for a floor heater had gone unanswered. Residents Affected - Few A Review of Resident 2s admission Record, indicated he was readmitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident 2 ' s MDS, indicated on 11/26/24 his BIMS score was 15 out of 15 with intact memory. During an interview on 12/10/24 at 11:11 a.m. with Resident 2, Resident 2 stated I have been begging them for a floor heater every day since the (main) heater quit working. They only bring me more blankets. Resident 2 also stated he constantly had a cold nose and ears and that was uncomfortable for him. A review of Resident 3's admission Record, indicated she was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident 3 ' s MDS, indicated on 11/22/24 her BIMS score was 15 out of 15 with intact memory. During a concurrent observation and interview on 12/10/24 at 11:17 a.m. with Resident 3, in room [ROOM NUMBER], Resident 3 was wearing a winter robe and sitting in her wheelchair by her bed. Resident 3 stated she had been freezing nonstop since the heater broke, and she was very upset about the issue. Staff offered her extra blankets for her bed - she already had three blankets and got two more from the Certified Nursing Assistants (CNAs). Resident 3 also stated, At nighttime, I get really cold. It ' s terrible. They tell us every day it ' s (heater) being fixed, but it never changes. A review of Resident 4 ' s admission Record, indicated he was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including heart failure and cirrhosis of the liver (a condition where the liver is permanently scarred and replaced with regenerative nodules and scar tissue). A review of Resident 4 ' s MDS, indicated on 11/4/24 his BIMS score was 14 out of 15 with intact memory. During a concurrent observation and interview on 12/10/24 at 12:14 p.m. with Resident 4, in room [ROOM NUMBER], Resident 4 was sitting in his wheelchair, wearing a jacket, and had a heavy plaid blanket on his bed. Resident 4 stated the heat had been out since he returned to the facility, staff had been offering him more blankets, and since readmission the nightly cold temperatures kept him awake for long hours almost every night. Resident 4 also stated the bathroom window was left slightly open for days and cold air was getting in, so he closed it. He also tried to warm himself at nighttime by placing his legs in front of his bedside oxygen compressor (was on oxygen therapy 20 hours per day), as it gave off heat while operating. During an interview on 12/10/24 at 12:22 p.m. with CNA 1, CNA 1 stated several residents from rooms 33-38 expressed their discomfort due to cold and she offered them extra blankets; however she was 055497 Page 2 of 3 055497 12/10/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to find heavy blankets, and the only blankets she could find were small, flimsy, and looked more like sofa throws. CNA 1 further stated the blankets did not provide residents extra warmth and residents told her they were still feeling cold. During an interview on 12/10/24 at 12:37 p.m. with Licensed Nurse (LN), LN stated residents complained about the cold in the back hallway and had extra blankets wrapped around them when they were sitting in their wheelchairs. 2. During an interview on 12/10/24 at 10:39 a.m. with the MD, MD stated he was notified on 12/2/24 by a CNA that the heat had quit working during the Thanksgiving holiday weekend in the south west corner of the building. MD also stated the HVAC heating element for rooms 33-38 was broken and he ordered floor heaters on 12/2/24. During an interview on 12/10/24 at 1:50 p.m. with the MD, MD stated he could not find a purchase order indicating the floor heaters were ordered on 12/2/24. During an observation on 12/10/24 at 1:43 p.m. beside the maintenance office, the MD ' s assistant was taking 18 floor heaters out of boxes and setting them on a cart. A review of a receipt, dated 12/10/24 at 10:18 a.m., indicated the floor heaters were ordered on 12/10/24 and purchased at the self-checkout lane. During an interview on 12/10/24 at 1 p.m. with the Director of Nursing (DON), DON stated she was made aware around 12/2/24 about the broken HVAC in the back hallway and noticed drastic differences in temperatures in areas of the building. DON confirmed she offered residents extra blankets and discussed ordering floor heaters with supervisory staff. During an interview on 12/10/24 at 2:05 p.m. with the Administrator (ADM) and DON, both ADM and DON stated the residents ' room temperatures should have been between 71 °F to 81 °F. DON also stated continuous cold interior temperatures could cause residents ' arthritis (joint inflammation) to flare up and they might also have hypothermia (when body temperature drops below 95°F). A review of the facility ' s undated policy titled, Physical Environment and Accommodations Policy, indicated, . A comfortable temperature for residents shall be maintained at all times .The facility shall heat rooms that residents occupy to a minimum of 68-degrees F .The facility shall cool rooms to a comfortable range, between 71 degrees F and 81degrees F . Temperatures in resident rooms are checked monthly or as needed and are logged in the maintenance binder at the facility. A review of the facility ' s undated policy titled, Physical Environment and Accommodations Policy, indicated, The facility shall be . in good repair at all times . The policy further indicated, Maintenance shall include provision of maintenance services . for the safety and well-being of residents . 055497 Page 3 of 3