F0908

E

Failure to Maintain Boiler System Resulting in Prolonged Loss of Hot Water

Madera, California Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain essential equipment, specifically one of two boiler systems responsible for heating water, in safe operating condition. According to the Administrator, the Maintenance Supervisor reported on the morning of 2/21/26 that the boiler supplying hot water to stations 1 and 2 was not working. The Maintenance Supervisor identified that the fan motor to the boiler igniter was frozen and contacted the outside vendor, who came that day but did not have the necessary replacement part. The Maintenance Supervisor stated he informed the Administrator that stations 1 and 2 had no hot water but did not report that other stations were also affected, despite later acknowledging that stations 3, 4, 5, and 6 did not have hot water in their shower rooms, resident rooms, or nurses’ station sinks. The boiler did not receive routine service from an outside vendor and was only serviced when issues arose.

Multiple staff interviews confirmed that there was no hot water throughout the facility from 2/21/26 until 2/24/26. Certified Nursing Assistants reported that there was no hot water in resident rooms, shower rooms, or nurses’ station sinks on several stations over the weekend and into Monday, and that residents were offered cold showers or bed baths with cold water. A Registered Nurse also stated that there had been no hot water on her station since 2/21/26. The Director of Nursing reported receiving a text on 2/21/26 that stations 1 and 2 did not have hot water and stated that staff were told the laundry room, which was on a separate boiler, had hot water that could be used for bed baths. The Director of Nursing and Administrator both stated that their expectation was that water temperatures be checked with a thermometer for accurate readings, but the Maintenance Supervisor reported he only used his hand to assess water temperature and did not use a thermometer.

Residents confirmed the impact of the lack of hot water. One resident stated that there had been no hot water since Saturday and that she did not receive her scheduled shower on 2/23/26 because of this. Another resident stated he was told there had been no hot water since Saturday and that a CNA used cool water to clean him over the weekend. Facility policies and procedures for Maintenance Service and Water Temperatures, Safety of, required the maintenance department to maintain equipment in safe and operable condition, maintain heating and plumbing systems in good working order, and conduct and record periodic tap water temperature checks using thermostats and temperature controls. The Maintenance Supervisor acknowledged that the boiler did not receive routine service and that he did not follow the policy expectation of using a thermometer to check water temperatures, contributing to the prolonged period without hot water throughout the facility.

The facility’s failure to maintain the boiler system in safe operating condition resulted in a non-functioning boiler from 2/21/26 to 2/24/26, during which residents were unable to shower and nursing staff were unable to wash their hands in hot water, placing residents at risk for poor hygiene, infectious disease, and discomfort.