ISSAQUAH, WA - Federal inspectors identified immediate jeopardy conditions at Providence Marianwood after discovering water temperatures hot enough to cause third-degree burns in as little as 15 seconds throughout the facility's resident rooms.
Water Temperatures Reached Dangerous Levels
During an inspection on July 23, 2024, surveyors documented water temperatures ranging from 124°F to 134°F across multiple resident rooms on all four units of the facility. These measurements occurred between 10:57 AM and 12:47 PM, revealing a systemic problem affecting the entire building.
The hottest temperature recorded was 134°F in one room, measured at 11:59 AM. According to Centers for Medicare and Medicaid Services guidelines, water at 133°F can cause third-degree burns after just 15 seconds of exposure. At 127°F, the same severity of burn occurs after one minute of contact with the hot water.
None of the rooms tested during the nearly two-hour inspection period had water temperatures within the safe range required by federal regulations and the facility's own policy.
Facility's Monitoring System Inadequate
The nursing home's Domestic Water Policy, revised in January 2019, required monthly checks to ensure hot water temperatures remained between 105°F and 115°F. However, the facility's implementation of this policy proved insufficient to protect residents from harm.
Records showed that staff checked water temperatures only twice monthly—once in the maintenance room and once in common areas such as the staff break room, dining room, or rehabilitation gymnasium. No temperature measurements were taken in actual resident rooms where people bathed and washed their hands daily.
The 2024 Hot Water Temperature Log revealed previous instances of unsafe temperatures that should have prompted corrective action. On February 27, the water measured 122°F in the gymnasium. On May 24, it registered 121.5°F in the same location. On June 24, the maintenance room showed 122°F. All three readings exceeded the maximum safe temperature limit.
Vulnerable Resident at Heightened Risk
The dangerous water temperatures posed particular risks for residents with physical limitations. One resident identified in the inspection report had experienced a stroke and lived with right-sided hemiplegia, causing partial paralysis and limited hand mobility.
This individual's fingers curled toward the palm, restricting movement and dexterity. The sink faucet in their room had separate levers for hot and cold water, with the hot water controlled by the left lever. For someone with right-hand impairment, quickly adjusting scalding water by mixing in cold water would be difficult or impossible.
The resident told inspectors they sometimes couldn't wait for staff assistance to use the bathroom, despite knowing they should. This created situations where the person might attempt to wash their hands independently, unable to properly regulate the water temperature due to their physical limitations.
Water temperature control becomes critical for nursing home residents who may have decreased sensation, slower reaction times, cognitive impairments affecting judgment, or mobility limitations preventing them from quickly moving away from hot water. A person without these challenges can immediately pull their hand away from uncomfortably hot water. Residents with dementia, paralysis, or sensory deficits face substantially higher risks of serious burns.
Maintenance Issues Went Unaddressed
The facilities manager acknowledged that hot water temperatures should not exceed 120°F. However, documentation revealed awareness of equipment problems that remained unresolved for months.
On April 11, 2024, an outside vendor provided an estimate for repairing a failed flow switch in the boiler system. The facilities manager signed this estimate on April 15. The vendor signature line remained blank, with no indication the work was ever completed or paid for.
When questioned during the inspection, the facilities manager confirmed knowing about the water valve repair needed since April 2024 but acknowledged failing to take appropriate action. The administrator stated this failure to address the known equipment problem put residents at risk for burns caused by scalding.
The facility maintained two boilers installed in December 2020. Standard practice called for contacting the vendor whenever problems with excessively hot water were identified. Despite having received the repair estimate three months earlier, the dangerous water temperatures persisted throughout the building.
Additional Safety Concerns Identified
Inspectors documented other hazardous conditions beyond the water temperature violations:
Unsecured Chemicals Accessible to Residents
On Unit A, the shower room door was found unlocked on July 23 at 1:38 PM. Inside, a cabinet containing cleaning chemicals had a key in the lock attached by a chain, but the door opened without turning the key. A spray bottle of disinfectant labeled "DANGER" and "keep out of reach of children" sat inside the unsecured cabinet.
On Unit C, another shower room had a sign requiring the door to remain locked at all times, but the combination lock was broken and the door stood unlocked. Inside, a gallon of bleach cleaning solution sat next to the toilet, and a spray bottle of disinfectant hung from the shower grab bar.
A shower aide who arrived to prepare the room for a resident discovered the broken lock and stated the maintenance department needed immediate notification. The aide explained the importance of keeping the door secured to prevent confused or wandering residents from entering and potentially ingesting chemicals or applying them to their skin.
Fall Risks Not Adequately Addressed
Another resident with visual impairment and cognitive difficulties had documented falls near their room door, bed, and bathroom. Despite these incidents, the person reported having only slippers to wear, with no proper shoes or socks available. The resident's toenails had grown long enough to curl into the bottom of the foot.
The individual's bed was observed tilted and unbalanced—appearing broken according to both the resident and nursing staff. The walker sat at the foot of the bed, out of reach from where the person was seated. These conditions created continued fall risks for someone already identified as high-risk.
Immediate Actions Required
The inspection identified these violations as immediate jeopardy, meaning the facility's practices created a situation where serious injury, harm, or death was likely to occur at any time. This represents the most serious category of deficiency in nursing home oversight.
The facility removed the immediate jeopardy designation on July 24, 2024, after taking several corrective steps. Management immediately contacted the outside vendor to assess and repair the boiler system. Staff identified other high-risk residents and placed temporary caution signs in resident room sinks and shower areas instructing occupants to mix cold and hot water.
The nursing home instituted audits to monitor the boiler gauge and water temperatures in all resident rooms. Staff updated the facility's rounding log and provided education to the facilities manager regarding proper implementation of the domestic water policy.
Federal and state standards require nursing homes to maintain environments free from accident hazards and provide adequate supervision to prevent foreseeable incidents. Temperature regulation of domestic water supplies represents a fundamental safety requirement. When water exceeds safe temperatures, the risk of scalding burns increases dramatically, particularly for elderly residents with thin, fragile skin and limited ability to respond quickly to danger.
The inspection report documents systemic failures in monitoring, maintenance, and resident protection at Providence Marianwood. The combination of equipment problems, inadequate oversight, and delayed repairs created conditions where vulnerable individuals faced daily exposure to potentially serious harm.
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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