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P4030

Non-compliance with Hot Water Temperature Regulations

Lafayette Hill, Pennsylvania Survey Completed on 12-23-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain water temperatures below the required 110 degrees Fahrenheit in two resident rooms and one resident spa on the 3rd floor. Observations on December 23, 2024, revealed that the water in the resident spa located inside rooms 312 and 313 was very warm to the touch. Water temperatures were measured by a maintenance employee and found to be 116 degrees Fahrenheit in the spa shower handheld sprayer, 113 degrees Fahrenheit in room 312's sink, and 111.9 degrees Fahrenheit in room 313's sink. Interviews with the maintenance employee and the administrator confirmed that the water temperatures should be below 110 degrees Fahrenheit and that the water supply to rooms 312 and 313 did not have a mixing valve to regulate the temperature, with the shower room connected to a 120-degree Fahrenheit line.

Plan Of Correction

On occupancy inspection of an unoccupied resident unit, two bathrooms, water ran for a few minutes, and temperatures obtained. Maintenance immediately adjusted water control. Temperatures checked in every resident room on 3 North, and spa, and all below 110 degrees. No residents were affected as this was an unoccupied unit. All areas where residents occupy have been checked per policy, and below 110 degrees Fahrenheit. Completed 12/23/24. Maintenance will increase water temp checks to the 3 North unit to two random rooms, and spa daily times 2 weeks, then random audits of two rooms on 3 North daily x 2 weeks. Will also add additional water temp checks to include the second, and third floor south daily x 2 weeks. Results will be reviewed by the NHA, director of facilities and reviewed at QAPI. Digital thermometers are installed on all new showers. Nursing will continue to follow policy to ensure the temperature remains below 110 degrees Fahrenheit prior to, and during shower. Start Date 12/27/2024. Maintenance, and nursing will be re-educated on water temp policy. Audits will be completed and reviewed. All new showers have a digital thermometer, so shower temperature is evaluated throughout shower. All new construction rooms will have water temp checked daily x 5 days prior to occupancy inspection. Policies will remain in place. Audits will be completed by maintenance, and reviewed by NHA, and director of facilities. Audits and results will be brought to QAPI for review, and determination.

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