F0689

E

Unsafe Hot Water Temperatures and Improper Transfer Leading to Resident Fall

Denver, Colorado Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain resident water temperatures within safe bathing limits and to ensure appropriate transfer assistance, resulting in unsafe environmental conditions and a resident fall. The facility’s written Water Temperatures policy required tap water to be kept within a range that prevents scalding, with water heaters set to no more than 120°F and periodic tap water checks documented in a safety log. Despite this, surveyors measured hot water temperatures in multiple resident room sinks that exceeded 120°F, including readings of 133°F, 125.2°F, 126.9°F, 126.7°F, and 124.7°F. The facility’s own monitoring logs showed weekly checks in shower rooms and a small sample of resident rooms, with typical shower temperatures documented between 113°F and 117°F, and some readings below 100°F, indicating inconsistent temperature control.

During the survey, the maintenance director reported that he checked each floor’s water temperatures weekly in shower rooms and one to two resident rooms per floor, aiming to keep temperatures below 120°F. He described his method of running showers for five minutes and using the same temperature probe each week. However, when he rechecked temperatures with surveyors present, several resident room sinks again showed hot water at or above the 120°F threshold, including 126.8°F, 123.8°F, 122°F, 123.8°F, and 120.2°F. Staff interviews revealed that CNAs relied primarily on testing water with their hands and resident feedback, and thermometers were not consistently available in shower rooms. CNAs believed maintenance checked temperatures more frequently than the logs reflected, and there were reports of prior concerns about inconsistent hot water during showers.

The deficiency also includes a failure in fall management related to a resident with significant neurological and mobility impairments. Resident #2, an older adult with cauda equina syndrome, right-sided hemiplegia and hemiparesis following a stroke, a colostomy, and bladder cancer, was cognitively intact but dependent on staff for toileting and chair-to-bed transfers. The resident had an identified risk for falls due to impaired mobility, weakness, pain, and multiple neurologic conditions, and her care plan included an intervention for staff education on the use of a gait belt and two-person assist for transfers because of severe weakness from cauda equina syndrome. On the date of the incident, the resident sustained a witnessed fall during a morning transfer when her legs gave out and she slid from the edge of the bed to the floor. The incident report did not identify which CNA was involved, but records showed CNA #5 was working with the resident that day.

Further review and interviews established that CNA #5 attempted to transfer the resident from bed to wheelchair alone, using a gait belt and with the resident wearing non-slip socks. CNA #5 reported that the resident appeared wobbly and weak, and that she tried to sit the resident back on the bed before assisting her to the ground. CNA #5 stated that the resident usually required one-person assistance for transfers and was not aware that the resident had become a two-person assist. The DON later confirmed that the new intervention designating the resident as a two-person transfer had not been transcribed onto the CNA task list, which resulted in CNA #5 not knowing the resident’s updated transfer status at the time of the fall. This breakdown in communication and task transcription, combined with the resident’s known severe weakness and fall risk, led to the resident being transferred without the required level of assistance and experiencing a fall.

Overall, the deficiency centers on two main areas: environmental safety related to hot water control and clinical safety related to fall prevention. In the first area, the facility did not consistently maintain hot water temperatures within the safe range specified in its own policy, and monitoring practices did not prevent multiple resident room sinks from reaching temperatures above 120°F. In the second area, the facility did not ensure that updated fall-prevention interventions—specifically the requirement for two-person assistance for a high-risk resident’s transfers—were effectively communicated and implemented at the CNA level, resulting in a one-person transfer and a subsequent fall.