Failure to Maintain Safe Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms and shower rooms across all three nursing units. Observations revealed water temperatures ranging from 124 to 129 degrees Fahrenheit, exceeding the Commonwealth of Pennsylvania's regulatory maximum of 110 degrees Fahrenheit. Maintenance staff confirmed that the water temperatures were too high and that the boiler responsible for residential hot water was broken, resulting in the use of a service area boiler that could not be adjusted below 135 degrees Fahrenheit. The issue was first noticed by the maintenance employee shortly after starting employment, and documentation showed that the necessary repair part had been pending for several weeks. Facility documentation could not provide evidence that water temperatures were being regularly monitored, recorded, or logged in resident care areas. There were no thermometers or temperature logs available in the shower rooms, and staff interviews revealed inconsistent practices for checking water temperature before resident use. Some nursing assistants reported relying on residents' feedback regarding comfort, which was not feasible for nonverbal or cognitively impaired residents. When asked, staff were unable to demonstrate the use of a thermometer or locate one for testing water temperature. The Nursing Home Administrator was unaware of the water temperature issue until returning from an absence, and no policy could be provided regarding staff procedures for ensuring safe water temperatures prior to showers. The lack of monitoring, documentation, and clear procedures for verifying water temperature before resident care led to the identification of Immediate Jeopardy to resident safety due to the risk of burns from excessively hot water.