UNITED METHODIST VILLAGE

Facility Identification Number: 0014506
1616 Cedar
Lawrenceville, IL 62439

Date of Survey: 3/13/01

LICENSURE ANNUAL

"A" VIOLATION(S):

Every facility shall have an effective written plan for maintenance. Mechanical systems shall be tested, balanced and operated to demonstrate that the installation and performance of these systems conform to the requirements of these standards.

Any surface exceeding a temperature of 140 degrees Fahrenheit (such as radiators, hot water or steam pipes, baseboard heaters, or therapy equipment) that is accessible to residents shall be provided with partitions, screens, shields, or other means to protect residents from injury.

These requirements are not met as evidenced by:

Based on observation, record review and interview the facility failed to keep all radiators within an appropriate temperature range to prevent burns or keep protected from resident access for 3 of 4 radiators tested.

The findings include:

During an environmental tour of the facility on 3/7/01 with E3 (maintenance) on the 3rd floor of Holden Center 3 of the 4 radiators tested were found to have a surface temperature of equal to or greater than 180 degrees Fahrenheit and there was no protection from resident access to the units. All temperatures were measured with the surveyor’s thermal temperature labels when available.

Interview with E3 at the time of the observations found he was unaware of any regulation of thermal hazards. Neither he or the maintenance staff had tested the units’ surface temperatures in any way and no records of the radiator temperatures were recorded.

Interview with E4, LPN, at the time of the observations found all 28 residents of the 3rd floor of Holden Center are ambulatory. E4 indicated 8 residents use walkers and 3 use a cane to assist with ambulation.

Review of the facility’s roster sample matrix found 15 of the 28 residents on the 3rd floor of Holden Center are considered at risk for falls.

One resident, R25, who resides in room 346 across from the woman’s bath 345, is blind and uses the bathroom unassisted. R25 was observed by a surveyor on 3/12/01 using this facility without assistance.

At the time of the observation in the North solarium, 1 resident and 2 visitors were in the room and commented to the surveyor about the excess heat in the room coming from the radiator. At that time the first temperature was taken. E3 acted to lower the excessive heat.

E3 was made aware of the excessive temperatures at the time of the observations and E3 turned the North Solarium and Bath 345 units’ regulation devices down to lower the temperatures. E3's staff on the floor at the time of the 3rd observation at 12:30p.m. lowered the temperature of the unit in the women’s bath across from room 326.

All staff interviews and facility incident reports confirm that no residents have been injured due to the excessive temperatures of the radiators within the facility.