Facility Fails to Provide Adequate Hot Water to Residents
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment by not providing sufficient hot water to residents in their rooms and showers. This deficiency affected eight residents, as observed by surveyors who found water temperatures significantly below the required range of 105 to 115 degrees Fahrenheit. The facility's policy titled "Water Temperatures Safety Checks" was not adhered to, as water temperatures were recorded at 80 to 90 degrees Fahrenheit in several rooms. Additionally, the facility's "Loss of Hot Water" policy, which outlines procedures for addressing hot water outages, was not effectively implemented. Residents and staff reported ongoing issues with hot water availability, with some residents unable to shower or perform personal hygiene tasks due to the lack of hot water. Text messages and emails reviewed by the surveyor indicated that the facility was aware of the problem, with reports of a malfunctioning circulation pump and faulty check valves contributing to the issue. Despite these communications, the problem persisted, and residents continued to experience discomfort and inconvenience. Interviews with residents and staff revealed that the hot water issue had been ongoing for weeks, with some residents stating it had been a problem for months. Maintenance staff and external plumbing services were involved in attempts to resolve the issue, but the deficiency remained unaddressed at the time of the survey. The lack of hot water not only affected residents' comfort but also their ability to maintain personal hygiene, as evidenced by multiple resident complaints and observations by the surveyor.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents # 29, 27, 13, 302, 68, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #303 discharged on 3.18.25 and is no longer residing in the facility. Resident #301 discharged on 4.1.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. The Maintenance Director contacted an external plumbing vendor to repair hot water and additional mixing valve ordered as additional precaution; repairs completed on 4.4.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services/Designee completed a quality review of current residents to ensure safe/clean/comfortable/homelike environment with emphasis ensuring sufficient hot water available to residents in their rooms and showers; no concerns identified. On 4.8.25 the Director of Maintenance completed a quality review of resident rooms and shower rooms to check water temperatures to ensure at appropriate temperature, no concerns identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficiencies. On 4.22.25 Director of Nursing completed education with current staff on the components of F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee. Newly hired nursing staff will be educated on the components of F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Maintenance Director/Designee to conduct random audits of 5 resident times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure sustained compliance with F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.