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F0561
E

Failure to Ensure Resident Choice Due to Lack of Hot Water for Showers

Houston, Texas Survey Completed on 11-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promote and facilitate resident self-determination by not ensuring the availability of hot water, which prevented residents from taking showers according to their preferences. One resident, who had normal cognitive functioning and required staff assistance for bathing due to impaired mobility and contractures, was unable to exercise his right to choose when and how to bathe because the water temperature was consistently too cold. Documentation showed that the resident repeatedly expressed dissatisfaction with the lack of hot water, refusing to shower until the water temperature met his preference. Multiple records and interviews confirmed that the hot water issue persisted for an extended period, with several residents reporting that they could not bathe or shower for weeks due to cold water. Staff, including an RN, acknowledged that the facility frequently lost hot water in the residential areas, particularly in the showers, and that residents' complaints were communicated to both administration and the ombudsman. Maintenance staff identified a failed pump in the boiler room as the cause, which affected water temperatures throughout the building, especially when the kitchen and laundry were in use. The facility's own policies required maintaining a safe, clean, and homelike environment, including reasonable accommodation of resident preferences and support for daily living activities. Despite these policies, the lack of hot water directly impacted residents' ability to maintain personal hygiene and exercise their rights regarding daily routines, as confirmed by resident and ombudsman interviews and facility documentation.

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