F0675

E

Failure to Ensure Warm Water for Resident Bathing and Showers

Longview, Texas Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide residents with warm water for bathing and showers, resulting in cold bed baths and showers for at least two residents. One resident, an older female with fractures of the right tibia and fibula and chronic diastolic heart failure, had an admission MDS showing moderate cognitive impairment and a need for substantial assistance with bathing and total assistance with lower body dressing. Her care plan indicated she required two staff for bathing and that staff could provide a sponge bath when a full bath or shower could not be tolerated. She reported that during a winter storm, when the facility lost power and did not have warm water, she received a cold bed bath because she wanted to feel clean.

A social worker reported that the Hall A shower water was cold and stated she discovered this when she stayed in the facility over a winter storm weekend and attempted to take a shower. She said she did not think the facility was aware of the cold water until she tried to shower. On observation, the Hall A shower water was run for approximately three minutes and measured 71°F, never reaching the recommended 100–110°F. The social worker stated that six residents resided on Hall A and were using Hall B and D showers until the water was fixed, without specifying a timeframe for repair. An anonymous resident reported receiving a cold shower because the facility did not have hot water.

Multiple staff interviews showed ongoing awareness of hot water problems on Hall A (and at times Hall B) without consistent resolution or documentation. A CNA stated she knew the Hall A shower water was cold for 1–2 months, had reported it to maintenance and the DON, and that no one was taking showers in the Hall A shower room. Housekeeping staff and the housekeeping supervisor reported hearing CNAs complain about cold water, residents refusing showers, and staff having to take residents to other halls or carry hot water from one shower to another. An LVN reported that Hall A did not have hot water on and off, that residents had complained about not having hot water for hot beverages or to sponge off at their sinks, and that residents were taken to other halls for showers. The ADON and DON both stated that staff were expected to report water temperature issues immediately and ensure comfortable water temperatures, and the administrator acknowledged concerns with water not getting as hot as it should.

When the area maintenance specialist was interviewed, he stated he was not aware that Hall A water was running cold and noted that the prior maintenance man had been terminated. On testing with the facility’s thermometer, the Hall A shower water measured 98.7°F and the sink water was warm, and he stated that somehow the hot water temperature had been turned down. He presented temperature logs and stated the expected range was 100–110°F, but the last recorded weekly temperature checks were dated more than a month earlier, with no logs documented since. Facility grievance records over a several‑month period did not show any complaints about water temperature. The facility’s resident rights policy required care in a manner and environment that promotes or enhances quality of life, and a facility checklist required weekly testing and logging of hot water temperatures in resident rooms and showers to ensure they remained between 100°F and 110°F, but these checks were not documented as completed during the period when residents and staff reported cold water and residents received cold baths and showers.