F0921

F

Failure to Maintain Consistent Hot Water Temperatures for Resident Care

Johnson City, New York Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain safe, adequate, and consistently warm domestic hot water for resident use, resulting in an environment that was not safe, clean, comfortable, or homelike on at least one resident unit. Facility policies required that hot water temperatures for resident use be maintained between 90°F and 110°F, that cooler-than-normal water be reported up the chain of command, and that a loss-of-hot-water policy be implemented when hot water was outside the allowable range. Despite these policies, work orders and interviews showed repeated reports of no hot water or inadequate hot water throughout the building over multiple days, including documented work orders for no hot water on various floors and in the building as a whole. A temperature check of a resident room sink showed water at 85.6°F, which the Regional Director of Facilities acknowledged was below the facility’s acceptable range.

Maintenance documentation and staff interviews revealed that the hot water system was malfunctioning intermittently, with maintenance staff repeatedly resetting an electronic mixing valve and boiler controls without consistently documenting these actions or verifying water temperatures afterward. The work order log showed multiple entries for no hot water on different dates and locations, but there were gaps in documentation, including missing work orders for repeated resets of the electronic mixing valve between certain dates. The Regional Director of Facilities stated that water temperatures were not taken on weekends because maintenance staff were only onsite Monday through Friday, and there was no documentation that shower water temperatures had been checked during the period in question. Maintenance staff confirmed that they had not always checked or recorded water temperatures before closing work orders and that they were not informed that the facility’s loss-of-hot-water policy had been activated.

Resident and staff interviews corroborated that residents experienced lukewarm or cold water for showers and that this persisted for weeks. One resident reported that their last shower had been lukewarm and uncomfortable and that they were later told they could not shower due to cold water. Another resident stated they had not had a shower for five weeks because the water was cold and that the water system was frequently being repaired. CNAs and an RN reported that hot water would be available only briefly after the boiler or mixing valve was reset, then turn cold again, sometimes remaining cold until the next day. One CNA reported that hot water had been brought from the kitchen to a unit for a bed bath when shower water was cold, and acknowledged that some residents had not received showers for ten or eleven days. Facility leadership, including the Administrator and Assistant Administrator, gave differing accounts of when they became aware of the hot water issues and confirmed that the loss-of-hot-water policy was not formally activated, that staff training on emergency procedures and work orders was not documented, and that there was no verification of the temperature of water brought from the kitchen for resident care.

Leadership interviews further showed inconsistent communication and oversight regarding the hot water problem. The Assistant Administrator stated they were aware of a hot water issue on one date and believed it had been resolved after a valve reset, and they were not aware that boiler parts were on order or that staff had transported hot water from the kitchen. The Administrator stated they first heard of hot water loss on a specific date, believed the issue had been addressed before going on vacation, and did not consider the intermittent hot water to be a significant impact at that time. The Director of Facilities and Maintenance described a two-boiler system problem that caused the hot water zone valve to shut off, but also indicated they assumed hot water was functioning after a reset and did not know the exact cause until informed by a vendor. Throughout this period, the facility did not provide documentation of staff training on the loss-of-hot-water policy, and there was no consistent process to ensure that water temperatures were within the required range for resident bathing and hygiene.