Deficiency in Maintaining Comfortable Water Temperatures
Penalty
Summary
Edenbrook of Yeadon was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. The deficiency was identified during an abbreviated survey conducted in response to two complaints and a reportable event. The survey revealed that the facility failed to maintain comfortable water temperatures in two of its four nursing units, specifically the First and Second Floor Nursing Units. The facility's policy on water temperatures for bathing, dated February 1, 2025, mandates that domestic hot water should ideally be maintained between 105 to 110 degrees Fahrenheit, with an acceptable range of 100-110 degrees. However, observations and interviews indicated that the water temperature in a resident's bathroom sink was only 45.3 degrees Fahrenheit, far below the required range. Further investigation by the maintenance assistant revealed that the hot water tank supplying the First and Second Floor Nursing Units was malfunctioning, with water pouring out of the tank through its emergency overflow line. This necessitated turning off the water supply to the hot water heater, preventing the maintenance of adequate water temperatures. Additionally, the hot water in the Central Shower Room on the First Floor Nursing Unit was found to be 90.1 degrees Fahrenheit, and the shower stall water was 81 degrees Fahrenheit, both below the facility's policy requirements. The maintenance assistant was unable to provide an explanation for the failure to maintain comfortable water temperatures.
Plan Of Correction
Facility had a plumber who was currently on site addressing another concern, evaluated, quoted and fixed the issues identified. The plumber's findings were addressed fixing and/or replacing the boiler (hot water units) for 3 affected areas. Facility staff will be educated on how to address fluctuations with water temps that do not meet the policy. The administrator or designee conducted daily water temp audits for a week, weekly for 4 weeks, then monthly for 3 months to ensure compliance. The administrator or designee will conduct random employee interviews for three months to ensure their competency on methods of on the water temperature policy including acceptable water temperature ranges and appropriate methods to check water temps. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.