Every time they brought her a washcloth for personal care, the cloth was lukewarm at best. The aides would apologize, she told inspectors, but the water temperature in her bathroom measured just 82.7 degrees when inspectors checked on September 15.
The water problems extended far beyond her room. Inspectors found that all 11 residents they checked on Winter Hall were living without proper hot water, with temperatures ranging from 82 to 88 degrees across their bathrooms. Federal standards require water temperatures between 100 and 120 degrees for basic hygiene and infection control.
Resident 18 confirmed the pattern. She hadn't had hot water "in a while," she told inspectors. When aides provided care, the washcloths were lukewarm.
The facility's maintenance man had been sick for two weeks and returned to work the day inspectors arrived. He verified every bathroom problem they documented but said he had received text messages about the water temperatures while he was off. He couldn't remember who he had told about them.
The water wasn't the only problem.
Resident 13's bathroom light had been making a loud screeching noise for five or six days. She had told an aide about it, though she couldn't remember the aide's name. The light was still screeching when inspectors arrived.
Leaking faucets plagued seven of the 11 rooms inspectors checked. In Resident 20's room, water dripped steadily from the bathroom sink. The room also had what inspectors called a "potential trip hazard" between the bedroom and bathroom - a cement room divider raised three-quarters of an inch off the floor that appeared to be a repair job.
Outside, the problems continued.
The facility's blacktop parking lot was cracked throughout. On the sidewalk leading from the building's right side, chunks of broken cement lay scattered on the walkway where residents and visitors would walk.
Corporate Registered Nurse 300 acknowledged the parking lot "should have been taken care of" when inspectors showed her the cracked pavement and broken sidewalk chunks during their September 15 interview.
The facility couldn't produce a policy for maintaining a homelike environment. Officials said they followed "standard protocol" but never provided that protocol to inspectors.
The inspection covered 11 of the facility's 34 residents, and every single one lived with environmental problems that violated federal requirements for a "safe, clean, comfortable and homelike environment."
For three weeks, residents on Winter Hall had endured personal care with lukewarm water while their caregivers apologized for conditions beyond anyone's immediate control. The maintenance man was sick, the corporate nurse knew about parking lot problems, and residents like 13 and 18 adapted to substandard conditions that federal law says they shouldn't have to accept.
The screeching bathroom light continued making noise. The faucets kept leaking. And residents kept receiving lukewarm washcloths during the most basic moments of daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jamestown Place Health and Rehab from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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