Unsafe Water Temperatures and Inadequate Smoking Safety Measures Identified
Penalty
Summary
The facility failed to ensure safe water temperatures in resident rooms, as observed during a survey. Water temperatures in shared bathrooms used by five residents were measured at over 140 degrees Fahrenheit, significantly exceeding the recommended safe limit of 120 degrees Fahrenheit. The Maintenance Director confirmed that the elevated temperatures were due to the hot water tank being connected to the kitchen dishwasher, and steam was visibly coming from the faucets. The facility's own policy noted the risk of third-degree burns at these temperatures. The affected residents had varying degrees of cognitive and physical impairment, with some requiring supervision or assistance with toileting. Despite these vulnerabilities, the excessively hot water was accessible in their bathrooms. Residents included individuals with diagnoses such as dementia, Alzheimer's disease, heart failure, ataxia, and traumatic brain injury. One resident independently reported that the sink water became very hot, confirming the hazard. Additionally, the facility failed to implement adequate smoking safety measures for a resident with severe cognitive impairment. The resident, who required significant assistance with daily activities, was observed smoking without a protective apron, resulting in cigarette ash falling onto his clothing. Although staff were present, they did not immediately address the safety concern until prompted by a surveyor. The resident's care plan did not include the use of a smoking apron, and staff had not communicated their concerns to nursing leadership, despite facility policy requiring individual assessment and reassessment for smoking safety.