Failure to Maintain Hot Water and Adequate Water Pressure for Resident Care
Penalty
Summary
The facility failed to maintain the appropriate temperature range and sufficient water pressure for resident-use hot water in two of four halls, specifically Halls C and D. Multiple residents reported ongoing issues with lack of hot water and low water pressure, which had persisted for months. Residents were unable to receive scheduled showers or proper bathing due to these deficiencies, and staff had to resort to carrying hot water from the kitchen or laundry in basins to provide bed baths. Observations confirmed that water temperatures in resident rooms were below acceptable levels, with one measurement showing 72 degrees at the sink. Residents affected by this deficiency included individuals with significant medical histories, such as type 2 diabetes, morbid obesity, hypertension, cerebral infarction, nonrheumatic mitral valve insufficiency, cardiomegaly, bradycardia, schizoaffective disorder, and generalized anxiety disorder. These residents were dependent on staff for bathing and personal hygiene. Interviews revealed that residents missed scheduled showers and expressed dissatisfaction with the lack of hot water and water pressure, with some noting that their families were also concerned about the situation. Resident Council meeting notes documented repeated complaints about water issues over several months without resolution. Staff interviews corroborated the residents' accounts, indicating that the water issues had been ongoing for an extended period. Maintenance logs and interviews with the Maintenance Supervisor and a plumber detailed recurring problems with lime buildup in pipes, malfunctioning backflow valves, and the need for a new water filtration system. The facility's own policy required a safe, clean, and homelike environment, but the persistent water issues prevented staff from providing basic hygiene care as scheduled, impacting the residents' quality of life.