F0584

E

Failure to Maintain Safe and Consistent Hot Water Temperatures in Resident Rooms

San Antonio, Texas Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The facility failed to provide a safe, functional, sanitary, and comfortable environment by not maintaining appropriate hot water temperatures in multiple resident rooms. Surveyors measured water temperatures in five residents’ sinks and found that four rooms had water temperatures below 100°F, specifically ranging from 78.1°F to 80°F, and one room had water at 118°F, above the 110°F upper limit cited in the report. These findings involved residents with varying levels of cognitive function, including residents with severe cognitive impairment, moderate cognitive impairment, dementia, weakness, and a recent admission for sepsis.

During observations, the Maintenance Director used a dial instant-read thermometer at each resident’s sink and confirmed the out-of-range temperatures. One cognitively intact resident reported being told to use wipes or hand sanitizer when the water was not hot enough to ensure hand hygiene. Another resident’s responsible party reported that the water was too cold for bed baths, requiring nursing staff to obtain hot water from another location before the resident could receive a bath. A newly admitted resident’s family member stated they had not yet noticed the water temperature. One resident with hot water at 118°F reported that hot water was available and had not affected daily life.

Interviews with facility staff revealed that the water temperature problems began after work was done at a connecting facility that shared utilities, during which water had been shut off and, afterward, some rooms did not have hot water. The Maintenance Director stated that since that time, some rooms lacked hot water and residents were being moved or supplied hot water from elsewhere. The Interim Administrator and Operations Manager reported that the water temperature had been problematic for 2 to 3 weeks, and the DON stated that hot water had been out intermittently since a prior month, working on and off. The DON also stated that residents were made aware when their hot water was not working and were educated to use hand sanitizer or offered wipes for hand cleaning. When a policy specific to water temperatures was requested, the Operations Manager reported that the facility did not have a water-specific policy, though the existing Environmental Safety policy stated the facility provides a safe, functional, sanitary, and comfortable environment for residents.