Failure to Manage Hot Water Temperatures Creates Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator failed to effectively manage the facility's hot water system, resulting in water temperatures above 110 degrees Fahrenheit on all floors. Observations and interviews confirmed that the water was leaving the boiler at 135 degrees and could not be lowered due to a needed repair. The boiler designated for service areas was being used for residential areas, and there was no documented evidence that water temperatures were being monitored during this period. The Administrator was made aware of the issue upon returning from a leave of absence, but no new interventions were implemented to address the excessively hot water until the necessary boiler part could be installed. This lack of action and monitoring placed residents at risk for serious injury from burns and resulted in an Immediate Jeopardy situation.