Failure to Address Elevated Water Temperatures Through QAPI
Penalty
Summary
The facility failed to ensure that its QAPI committee systematically identified and addressed a known safety concern regarding elevated water temperatures in resident-accessible areas. Although the Safety Committee had previously documented water temperature issues in its February 2025 meeting minutes, there was no documentation of required actions or evidence that the issue was escalated to or addressed by the QAPI committee. During interviews, the Administrator confirmed that the QAPI committee's focus areas did not include water temperature concerns, and was unable to provide any records showing QAPI involvement in addressing the issue. Surveyors measured water temperatures exceeding 124°F in multiple resident areas, confirming the ongoing concern.