Health inspection·July 15, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, document review, and facility policy and procedure review, the facility failed to maintain a sanitary and comfortable environment for residents and staff by failing to ensure hot water was available in resident rooms, resident shower rooms and employee bathrooms. This deficient practice had the potential to impact all 51 residents residing in the facility at the time of the survey. The findings include:On 07/14/25 at 12:41 PM, water temperatures in the facility were taken in the presence of the Regional Plant Operations. Using a dial stem thermometer, resident bathrooms, shower rooms and employee hand washing stations were measured and revealed the following:East Sideroom [ROOM NUMBER]: 78 [NAME] #2: 78 [NAME] #3: 91 [NAME] #4: 78 FRooms #5 and #7 (Jack and [NAME]/ shared bathroom): 70 FRooms #6 and #8: 80 FRooms #10 and #12: 80 [NAME] Side Shower Room: 78 FEmployee Restroom [ROOM NUMBER]: 80 FEmployee Restroom [ROOM NUMBER]: 80 FWest SideRooms #16 and #18: 78 FRooms #19 and #21:100 FRooms #20 and #22: 80 FRooms #24 and #26: 78 [NAME] #27: 98 FWest Side Shower Room: 90 [NAME] 07/14/25 at 11:01 AM, an interview was conducted with Employee C, who works in housekeeping. He reported he has worked at the facility for almost a year and complained that the lack of hot water affects his ability to clean effectively. He especially has a hard time waxing the floors, as he cannot use cold water for the waxing process and has to go to the kitchen to obtain hot water to wax the floors. On 07/14/25 at 11:04 AM, an interview was conducted with Employee B, CNA, who reported she has worked at the facility for 11 months and explained that the hot water has not worked since she started working at the facility. The shower room on the east and west hallway get somewhat warm and many resident bathrooms don't have hot water. Residents often refuse incontinent care or bed baths because they don't want to be bathed in cold water. A resident recently yelled at her that she was cruel for using cold water for incontinent care. She explained that residents are supposed to receive 2 showers each week. On 07/14/25 at 11:12 AM, an interview was conducted with the Infection Control Preventionist/Wound Care, RN, who reported she has worked at the facility since December of 2024. The lack of hot water has been a problem from the start and felt that the lack of hot water may affect effective infection control, as hot water is needed for all aspects of infection control. The lack of hot water forced CNAs to switch from using wash clothes with warm water to using disposable wipes. On 07/14/25 at 11:22 AM, an interview was conducted with Employee A, RN, who reported she has worked at the facility since September of 2024. She explained that the lack of hot water makes her job difficult. Residents have been complaining about the lack of hot water since she started working at the facility. Residents have refused incontinent care and hygiene assistance because they complain the water is too cold. During the last staff meeting, the Maintenance Director informed staff that the facility will soon spend $50K to fix the plumbing. On 07/14/25 at 1:15 PM, an interview was conducted with the Regional Plant Operations, who reported he has worked as the Regional Plant Operations for 1 1/2 years. He explained that he oversees the maintenance of Page 1 of 2 105665 105665 07/15/2025 Aviata at South Daytona 650 Reed Canal Rd South Daytona, FL 32119

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many buildings in this region. He usually communicates with the building's Maintenance Director through email. He further explained that we were made aware of the lack of hot water problem as a company in approximately April 2025. He said a plumber has been out to the facility and diagnosed the problem stems from the cold water leaking into the hot water. The building will need to be re-piped on the hot side. He verified that hot water temperature should be between 105 - 110 degrees Fahrenheit. An estimate for the plumbing work was submitted to the corporate office two months ago, and they are waiting for approval. On 07/14/25 at 2:17 PM, the Administrator was interviewed and reported she has worked at the facility since November of 2024. She mentioned that the immediate plan for residents without hot water in their room is a wipe warmer located at the nurse station. They also offer residents bed baths, and CNAs know which rooms they can obtain warm water from. She was notified about the problem with the lack of warm water in April of this year. She explained that the corporate office has known about the problem of a lack of hot water since April 2025. When asked about the facility's Performance Improvement Plan (PIP) for the lack of hot water, she explained that actions of the PIP are to gather resident feedback on water temperature preferences during resident council meetings and town hall meetings. She could not provide documented evidence resident feedback on water temperature preferences were obtained. On 07/14/25 at 3:00 PM, an interview was conducted with Resident #11. She described an incident which took place in May 2025, which she filed a facility grievance. She explained that while receiving incontinent care, a certified nurse assistant (CNA) wiped her with a cold washcloth. She explained that she had a stroke, and her body does not react well to cold water. She said she has not had a shower since the incident and uses disposable wipes to clean herself.Review of facility grievances documented that Resident #11 complained that on 05/27/25, a CNA. wiped her with a cold washcloth. The resident expressed dislike of coldness, and the CNA did it again. On 07/14/25 at 3:56 PM, the Administrator provided resident council meeting minutes. Review of the resident council meeting minutes lacked documented evidence of resident feedback on water temperature preferences. She stated that she spoke to a resident related to water temperatures at the 05/30/25 town hall meeting but didn't document the resident's water temperature preference. Review of the previous 3 months of maintenance work orders lacked documentation of work orders related to hot water. Review of the Ad Hoc Quality Assurance and Performance Improvement Meeting, which was created on 04/07/25 and documented the facility was to solicit resident responses to temperatures as a means of tracking. The PIP lacked documented evidence of obtaining resident responses to water temperatures. Review of the facility's policy Monitoring and Recording Facility Hot Water Temperature for Resident Rooms, Common Areas and Shower Rooms, Document Name: M-227; Effective: 11/30/14. Policy: To maintain and control hot water temperatures within the facility to federal and state standards. Hot water temperatures will be maintained to an acceptable level for the safety of the residents and staff. Page 2 of 2 documented.Hot water drawn for bathing and/or whirlpool usage must be between 100- 110 degrees Fahrenheit. 105665 Page 2 of 2