The incident at Northwood Skilled Nursing and Rehabilitation occurred during morning incontinence care on November 19, when federal inspectors observed two certified nursing assistants washing Resident 72 with water that measured 93.7 degrees Fahrenheit.
The 72-year-old woman suffers from disorganized schizophrenia, heart failure, Alzheimer's disease, and the effects of a stroke. She requires substantial help moving in bed and depends on staff for toileting and transfers. She is frequently incontinent of bladder and always incontinent of bowel.
During the 6:16 a.m. care, one nursing assistant went into the bathroom to prepare water but had to leave the room to find warmer water elsewhere. She returned with only lukewarm water.
As the assistants washed the resident's face, under her arms, and provided perineal care, she repeatedly pulled away from the washcloths. The nursing assistants acknowledged the resident was cold from the water they were using.
They continued the care.
When the Director of Nursing measured the water temperature at 6:30 a.m., her thermometer read 93.7 degrees Fahrenheit. She confirmed the water was too cold.
One of the nursing assistants explained that water temperature "had been a problem lately." The facility had brought in someone to fix it, she said, and "it worked for a while and now it was not working anymore."
The plumbing problems had persisted for over a week. On November 11, a plumbing company replaced the mixing valve for the hot water system. But by November 19, another invoice shows the facility had to replace that newly installed mixing valve because it had already malfunctioned.
Water temperature logs for the 200-hall showed normal readings on November 18, just one day before inspectors witnessed the cold water bathing.
Federal regulations require nursing homes to maintain safe water temperatures for resident care. The facility administrator told inspectors they follow regulatory guidelines, though no written policy was available for review.
Resident 72 has lived at Northwood since July 27, 2021. Her quarterly assessment revealed she needs setup or cleanup assistance with eating and substantial help with bed mobility. Her severe cognitive impairment means she cannot effectively communicate her needs or advocate for herself during care.
The nursing assistant who had to search for warmer water said she tried to find a better solution but could only locate lukewarm water. The facility's hot water system had left staff without adequate resources to provide comfortable care.
For a resident who depends entirely on staff for basic hygiene and cannot move away from uncomfortable situations, the cold water bathing represented a failure of the facility's most fundamental responsibility. She could only pull away from the washcloths as her caregivers continued washing her with water they knew was too cold.
The incident occurred in a facility housing 76 residents, where three residents were reviewed for water temperature issues. Only Resident 72 was affected by the cold water problem on the day inspectors observed care.
Northwood's maintenance issues created a situation where nursing assistants had to choose between skipping necessary incontinence care or proceeding with inadequate water temperature. They chose to continue, despite the resident's obvious discomfort and their own acknowledgment that the water was too cold.
The facility's hot water problems had required two separate plumbing repairs within eight days, suggesting ongoing mechanical failures that staff could not quickly resolve. Yet the daily care needs of residents like Resident 72 could not wait for repairs.
As one nursing assistant searched unsuccessfully for warmer water that morning, Resident 72 remained dependent on staff who ultimately provided care that caused her to recoil from their touch. Her pulling away from the washcloths served as her only means of communicating discomfort in a situation where she had no power to stop the care or demand better conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northwood Skilled Nursing and Rehabilitation from 2025-11-20 including all violations, facility responses, and corrective action plans.
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