WILLOW CREEK REHABILITATION
Facility I.D. Number 0041939
Date of Survey:4/14/03
Notice of Violation:6/3/03
All necessary precautions shall be taken to assure that the residents' enviornment remains as free of
accident hazards as possible.
Each facility shall maintain all electrical, signaling, mechanical, water supply, heating, fire protection, and sewage disposal systems in safe, clean and functioning condition. This shall include regular inspections of these systems.
Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit.
Protective measures, such as but not limited to, installation of a mixing valve, limited access to controls, and checking water temperatures daily at various points, shall be implemented to insure that the temperature of hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit.
These requirements are not met as evidenced by:
Based on observation, record review and interview, the facility failed to have a system in place to monitor water temperatures. Water temperatures measured above 133 at 16 of 16 hand washing sinks in resident rooms on the 100 wing. The hot water at the bathtub in the 100 hall shower/tub/toilet room measured 135 degrees Fahrenheit.
On 4/8/03, the surveyor noted that the hot water at the handsink located in the toilet room attached to resident room 117 was extremely warm to touch. The surveyor then proceeded to take temperature readings of the hot water throughout the facility and found that the high water temperatures were specific to the 100 wing of the facility. (There are two resident wings within the Facility, the 100 and 200 wings.) Following is a list of the hot water temperatures, the time the temperature was taken and the location in the facility where the temperature was taken. Hot water temperatures taken in resident rooms were all taken at the handsink in the attached toilet room. All temperatures were taken using thermometer #A06:
Resident toilet room 100/102135 degrees Fahrenheit10:14 AM
Resident toilet room 101/103137 degrees Fahrenheit10:16 AM
Resident toilet room 108/110136 degrees Fahrenheit10:18 AM
Resident toilet room 105/107136 degrees Fahrenheit10:20 AM
Resident toilet room 130/128133 degrees Fahrenheit10:27 AM
The hot water at the bathtub in the 100 hall shower/bath room measured 135 degrees Fahrenheit at 10:22 AM.
The facility was notified of the high hot water temperatures at 10:30 A.M. The surveyor accompanied E9, maintenance employee, to examine the hot water heater which serves the 100 wing. The surveyor noted that the thermostatically controlled mixing valve located on the water heater, was set at approximately 132 degrees Fahrenheit. E9 stated that he had already turned it down several degrees. At 1:50 P.M., the facility notified the surveyor that the water temperature was now at 110 degrees Fahrenheit. The surveyor confirmed the 110 degree temperature by taking the hot water temperature at the bathtub on the 100 wing.
During an interview with facility maintenance staff, E9 and E10 stated that there has not been a Maintenance Director functioning in the Facility since December of 2002, as the Maintenance Director was injured. E9 was unaware that hot water temperatures needed to be monitored and stated that no one has been monitoring the hot water temperatures since December of 2002. The facility has no records of hot water temperatures taken since December 2002.
There are 10 residents on the 100 wing that utilize their toilet rooms. Of these 10, 2 have short term memory problems and moderately impaired cognitive skills. The remaining 8 are not cognitively impaired. There is no record of any residents sustaining burns due to hot water in the past 3 months.
On 04/08/03, when the hot water temperature measured between 133 and 137 degrees Fahrenheit on the 100 wing, and the facility could not provide any evidence that a monitoring system was in place.