Facility Fails to Provide Adequate Hot Water to Residents
Penalty
Summary
The facility failed to ensure sufficient hot water was available to residents in their rooms and showers, affecting 8 out of 34 sampled residents. The deficiency was identified through observations, record reviews, and interviews. The facility's policy titled "Water Temperatures Safety Checks" requires water temperatures to be maintained between 105 and 115 degrees Fahrenheit, but several rooms had water temperatures significantly below this range, with readings as low as 80 degrees. The facility's policy for "Loss of Hot Water" outlines procedures for addressing hot water issues, but these were not effectively implemented. Multiple residents reported issues with the lack of hot water, impacting their ability to shower and maintain personal hygiene. For instance, one resident stated that the water was too cold to shower or shave, while another resident mentioned that the water had been an issue for at least two months. Staff interviews corroborated these complaints, with some staff members acknowledging the problem and others being evasive about the duration and extent of the issue. The maintenance director and plumbing company were aware of the problem, with the plumbing company identifying faulty check valves and a mixing valve that needed replacement. The deficiency was further evidenced by a resident council grievance and various communications between staff members, including texts and emails discussing the ongoing hot water issues. Despite attempts to address the problem, such as replacing check valves and ordering a new circulation pump, the facility failed to resolve the issue promptly, resulting in continued discomfort and inconvenience for the residents. The lack of hot water persisted for an extended period, with some residents reporting the issue had been ongoing for weeks or even months.
Plan Of Correction
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 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.11.25 the Director of Social Services/Designee completed a quality review of current residents to ensure physical 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 4.22.25 Director of Nursing completed education with current staff on the components of N111 physical 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 N111 physical 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 N111 physical 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 monitoring to be reported to the Quality Assurance/Performance improvement Committee monthly until the committee determines substantial compliance has been met.