ISSAQUAH, WA - State inspectors found dangerously hot water temperatures throughout Providence Marianwood nursing facility that could cause severe burns within seconds, along with unsecured hazardous chemicals and inadequate fall prevention measures for vulnerable residents.
Scalding Water Temperatures Throughout Facility
During a July 2024 inspection, surveyors documented hot water temperatures ranging from 124°F to 134°F across multiple resident rooms - far exceeding the facility's own policy limits of 105-115°F. The most alarming discovery occurred in resident bathrooms where water reached 134°F, a temperature that can cause third-degree burns in just 15 seconds according to Centers for Medicare and Medicaid Services guidelines.
The excessive temperatures were found in every area tested during the inspection period from 10:57 AM to 12:47 PM on July 23, 2024. In one shared room, water temperatures measured 127°F from one resident's sink while reaching 125°F at the neighboring sink. Another room showed even more dangerous readings with one sink at 133°F and another at 134°F.
These temperatures pose an immediate threat to nursing home residents, who often have slower reaction times, mobility limitations, and may be unable to quickly adjust water temperature or move away from scalding water. Residents with conditions like stroke or dementia are particularly vulnerable as they may not recognize the danger or be able to respond appropriately.
Maintenance Issues and Policy Failures
The facility's maintenance manager revealed critical gaps in safety monitoring during the inspection. Staff stated they only checked water temperatures monthly and limited their testing to areas near the boiler and common spaces like the dining room and gymnasium - never testing resident rooms where people actually used the water for personal hygiene.
The facility's 2024 temperature log showed they had already identified problematic readings in previous months, with temperatures recorded at 122°F in February, 121.5°F in May, and 122°F in June - all exceeding their stated maximum limits. Despite these elevated readings, facility management failed to take adequate corrective action.
An estimate from April 2024 showed the facility knew about a failed flow switch requiring repair, but maintenance staff admitted during interviews they "should have acted upon the identified water valve repair needed but did not." This delayed response allowed dangerous conditions to persist for months.
Vulnerable Resident at Risk
The inspection highlighted particular concerns for Resident 33, who had suffered a stroke and experienced right-side paralysis affecting hand function. This resident shared a room where water temperatures reached 127°F, and the sink configuration required using the right hand to control cold water - a significant challenge given their physical limitations.
"Sometimes they had to wait a long time for the bathroom," Resident 33 told inspectors, explaining they sometimes had to get up without assistance when staff didn't respond quickly enough. This combination of physical limitations, potential for unassisted bathroom use, and dangerously hot water created conditions for serious injury.
The resident's impaired memory and need for substantial assistance with personal hygiene made them particularly vulnerable to scalding injuries, as they might not remember safety precautions or be able to properly adjust water temperature.
Chemical Storage Violations Create Additional Hazards
Inspectors discovered multiple instances of improperly stored hazardous chemicals that could be accessed by confused or wandering residents. In Unit A, a shower room was left unlocked with a cabinet containing disinfectant labeled "DANGER, keep out of reach of children." The cabinet key was attached by a chain but the door could be opened without turning the key.
A more serious situation was found in Unit C, where a shower room had a broken combination lock despite a posted sign requiring the door to remain locked at all times. Inside, investigators found unsecured bleach and disinfectant solutions accessible to any resident who might wander into the area.
A certified nursing assistant confirmed the importance of keeping these areas secured, stating "it was important to ensure the door was kept locked at all times so confused and wandering residents could not enter the room and accidentally ingest or apply any chemicals on themselves."
Medical Consequences and Industry Standards
Water temperatures above 120°F pose serious burn risks, particularly for elderly residents with thinner skin and slower reflexes. At 127°F, third-degree burns can occur within one minute of exposure, while temperatures of 133°F can cause similar injuries in just 15 seconds. These injuries can lead to serious complications including infection, scarring, and prolonged healing times in elderly patients.
Industry best practices require nursing homes to maintain water temperatures between 105-115°F to prevent scalding while ensuring adequate warmth for comfort and hygiene. Facilities should conduct regular temperature monitoring in resident areas and have immediate response protocols when unsafe conditions are identified.
Additional Issues Identified
The inspection also documented fall prevention failures, including a resident with multiple recent falls who had long, curled toenails, improper footwear, and a broken bed that tilted to one side. The resident reported frequent falls and stated "every time I turn around, I am falling."
The facility has since implemented corrective measures including contacting vendors for boiler repairs, posting temporary warning signs about mixing hot and cold water, and establishing enhanced monitoring procedures. However, these violations highlight the critical importance of proactive maintenance and safety monitoring in protecting vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Marianwood from 2024-08-01 including all violations, facility responses, and corrective action plans.
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