F0921

E

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

San Antonio, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to maintain resident room hot water temperatures within the required range of 100–110°F on both the 2nd and 3rd floors, resulting in water that was either too hot or too cold in multiple occupied rooms. During an observation of water temperature measurements conducted by the Maintenance Director, several resident room showers and sinks registered 118°F, while others measured as low as 77–94°F. A facility maintenance water temperature log from January documented multiple resident rooms with hot water temperatures around 80–94°F, further confirming ongoing problems with maintaining appropriate temperatures in resident areas.

Nursing staff interviews showed that the issue had been present for some time and that there was no consistent, formal process for reporting or addressing it. An LVN reported there had been no complaints of water being too hot but acknowledged that CNAs were instructed to use basins to mix water if it was too hot or too cold and to seek alternative rooms for showers when necessary. The LVN was unsure whether staff consistently reported water temperature problems through the computer system as required and stated that most of the time they simply informed the Maintenance Director in person. The LVN also stated that the Maintenance Director’s typical response was to advise staff to let the water run for a few minutes or to find an alternative location.

Interviews with facility leadership and maintenance staff confirmed that fluctuating water temperatures had been an ongoing issue since approximately the end of December 2025 or January 2026. The Maintenance Director admitted he was uncertain of the regulatory temperature range he was required to maintain and could not clearly describe what specific plumbing issues had been repaired or provide contact information for the plumbers. The Administrator acknowledged awareness of resident complaints about lack of hot water and confirmed that grievances had been received, including one from a resident’s family member. The Administrator and DON both indicated there was no facility policy for water temperatures or the physical environment. The Regional Maintenance Director and Maintenance Director both agreed that not maintaining water temperatures in resident rooms could cause scalding or other physical injuries, and they confirmed that responsibility for maintaining water temperatures rested with the facility’s maintenance department.