Unsafe Hot Water Temperatures, Inadequate Fall Response, and Unsupervised Tobacco Use
Penalty
Summary
The facility failed to ensure that hot water temperatures in resident care areas were maintained within the safe and comfortable range of 100-120 degrees Fahrenheit. Multiple observations revealed that water temperatures in several resident rooms, including those occupied by individuals with severe and moderate cognitive impairment, were significantly above the recommended maximum, with some readings as high as 152.6 degrees Fahrenheit. The facility's maintenance logs did not reflect these excessive temperatures, and there were missing documentation sheets for the required monitoring period. Staff interviews indicated inconsistent practices in temperature monitoring and a lack of immediate recognition or reporting of hazardous water temperatures. Additionally, the facility did not adequately investigate or implement interventions following multiple falls experienced by a resident with severe cognitive impairment and a history of wandering and difficulty walking. Despite several documented falls, including one resulting in a head laceration and hospitalization, the care plan was not updated with new interventions, and incident reports or investigations were not consistently completed. Observations further showed that safety measures, such as ensuring the resident's walker and call light were within reach, were not reliably maintained. The facility also failed to prevent potential accidents by allowing a visually impaired resident unsupervised access to chewing tobacco and a spit cup in his room. Staff were aware of the resident's use of chewing tobacco, but there was no specific policy addressing its use, and the tobacco was left accessible at the bedside. Interviews with staff and family confirmed that the resident had been using chewing tobacco in his room for an extended period, and the facility's smoking policy did not address smokeless tobacco products or their safe storage and supervision.
Plan Of Correction
F689 - Free of Accidents/Hazards/Supervision/Devices DPS A: 1. 100% of community residents were assessed by the Director of Nursing and designees on 05/06/25 to ensure no negative effects related to water temperatures. Resident showers were taken offline to ensure safety of water temperatures, to include bed baths. The water temperature was adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conducted a 100% community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance. 2. The Administrator reviewed the policy and procedure related to Safe Water Temperatures on 05/06/2025 with changes completed as necessary. Community staff will be educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule by 05/09/25. 3. The Maintenance Director or designee will conduct an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 06.20.2025 DPS B: Element #1: R58 was assessed by the Director of Nursing or designee to ensure incident report, care plan, and interventions are updated to reflect resident current status. R38 was assessed by the Director of Nursing or designee to ensure no adverse effects related to their use of chewing tobacco. Behavior was care-planned and interventions put in place to prevent recurrence. Element #2: The Director of Nursing and/or designee conducted a 100% audit of residents with falls in the last 30 days to ensure documentation is complete to include updated care plans and interventions. The Director of Nursing and/or designee will conduct a 100% sweep of resident rooms to ensure no tobacco products are improperly stored. Element #3: The Administrator reviewed the policies related to Fall Prevention Program and Resident Smokeless Tobacco and revised as necessary. Community staff were provided education regarding the fall prevention program and smokeless tobacco. Element #4: The Director of Nursing and/or designee will conduct an audit of 10 residents weekly for 12 weeks to ensure appropriate documentation, care planning and interventions related to resident incidents. The Director of Nursing and/or designee will conduct an audit of 10 resident rooms weekly to ensure no tobacco products are stored inappropriately. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Removal Plan
- Community residents are assessed by the Director of Nursing and designees to ensure no negative effects related to water temperatures. Resident showers are taken offline to ensure safety of water temperatures, including bed baths.
- The water temperature is adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conduct a community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance.
- The Administrator reviews the policy and procedure related to Safe Water Temperatures with changes completed as necessary. Community staff are educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule.
- The Maintenance Director or designee conducts an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits are brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process are determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance.