Failure to Maintain Safe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing dangerously elevated hot water temperatures in resident rooms. On 4/28/2025, water temperatures ranging from 128°F to 135°F were measured in six resident rooms, some of which had shared bathrooms. Facility policy required water temperatures to be kept at or below 115°F, and maintenance staff were responsible for regular checks and documentation, which was not consistently performed. Several residents affected by this deficiency were severely cognitively impaired, as indicated by low BIMS scores, and required varying levels of assistance with activities of daily living (ADLs). These residents included individuals with diagnoses such as psychosis, dementia, Parkinson's disease, and other conditions that increased their vulnerability. Observations confirmed that the hot water was present in shared bathrooms used by these residents, and staff interviews corroborated that excessively hot water was noticed during routine care activities. The Maintenance Director was unable to provide documentation of water temperature checks for a specified period, and the boiler serving the affected areas was found to be set above the recommended temperature. The facility's own policy and job descriptions outlined the need for regular monitoring and maintenance to prevent such hazards, but these procedures were not followed, resulting in the exposure of residents to unsafe water temperatures.