Immediate Jeopardy Due to Unsafe Hot Water Temperatures at Accessible Hand Sink
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment under its control was free from accident hazards, specifically regarding unsafe hot water temperatures accessible to residents. The hand washing sink in the main dining room was found to have hot water temperatures significantly above safe levels, with one measurement reaching 139.2 degrees Fahrenheit and another at 125 degrees Fahrenheit. These temperatures were discovered after a surveyor noticed the water was uncomfortably hot to the touch and could not keep her hand under the stream without risk of burns. The maintenance director confirmed these readings using facility equipment. The maintenance director stated that he did not routinely check the water temperature at the hand sink in the dining room, focusing instead on shower rooms and resident rooms, which were found to have much lower water temperatures. Upon further investigation, it was determined that the hot water tank supplying the dining room sink was connected to the kitchen, which required higher water temperatures, explaining the elevated readings at the dining room sink. The facility identified a large number of residents who could potentially access the hand sink in the main dining room without staff assistance. The state agency determined that the unsafe water temperatures at the accessible hand sink placed residents at immediate risk for serious injury or death, constituting an Immediate Jeopardy situation. The risk was particularly acute given the number of residents who could independently use the sink, and the fact that water temperatures at these levels can cause severe burns in a very short period of time, as referenced in the CMS State Operations Manual.