Health inspection·October 17, 2024

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interviews with residents and staff, and review of temperature logs, it was determined that the facility failed ensure that essential mechanical equipment ws maintain in working function to provide comfortable bathing temperatures on two of three nursing floors. (Second and Fourth floor) Residents Affected - Some Findings include: Review of the policy titled bathing, showering and use of tub dated February 2018 revealed that it was the responsibility of the nursing staff to promote cleanliness and provide a comfortable bathing experience for the residents. Review of the policy titled safe water temperatures dated December, 2009 revealed that it was the responsibility of the facility to provide a water temperatures used by the residents at safe levels to prevent burns. The maintenance staff was responsible for checking thermostats and temperature controls in the facility to ensure safe and comfortable bathing, showering and sink use for the residents. Interview with the Nursing Home Administrator, Employee E1, at 1:00 p.m., on October 17, 2024 revealed that the facility has been having water temperature issues since the month of June, 2024. The administer explained that water temperatures at outlets accessible to residents were varying based on the location of the building. The administrator explained that the nursing staff had to use different floors to bathe the residents; since the warm water for showers and tub baths would not last and become too cool and uncomfortable for bathing. Review of the facility's water temperature testing logs for the outlets (sinks, showers/tubs) frequently used by the residents revealed that on October 17, 2024, the facility continued to have cool water temperatures (90, 92 and 93 degrees Fahrenheit) on the Second floor nursing unit. Observations of the water temperature for the shower on the Second floor were confirmed with the director of maintenance, Employee E13, at 11:00 a.m., on October 17, 2024. Review of the facility's water temperature logs for the outlets continuously used by the residents for the months of August, September and October, 2024 confirmed that the facility was having mechanically equipment problems with its' essential water system throughout the facility. Interview with the maintenance director, Employee E13, at 1:15 p.m., confirmed that the essential equipment (mixing valves, holding tanks) used to operate the plumbing, piping and water systems throughout the facility were not fully functioning to provide potable hot and cold water at outlets at all times to ensure consistent and comfortable water temperatures for daily bathing and grooming for the residents. Page 1 of 2 395431 395431 10/17/2024 Majestic Oaks Rehabilitation and Nursing Center 333 Newtown Road Warminster, PA 18974

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interviews with alert and oriented residents Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14 on the Second and Fourth floor nursing units on October 17, 2024 between 1:00 p.m. and 2:30 p.m. revealed that the residents were being asked since June, 2024 to bath on different floors so that they could possible receive a warm and comfortable (not cool or cold) shower. The residents reported that on any given day, the hot water for comfortable bathing would run out. Nursing staff would then tell us that we would be on the bathing list for the following day and hope that the hot water lasts long enough for the postponed bathing. Interviews with the Nursing staff Employees E7, E8, E10, E12, E14, E15 E17 and E18) responsible for bathing and ensuring the cleanliness of the residents on October 17, 2024 between 1:30 p.m. and 2:00 p.m., revealed that the nursing staff were asked to take residents to different nursing units to perform bathing since, June, 2024. T`he nursing staff reported that the issue with insufficient hot water for bathing of the residents has been on-going from June, 2024 through October, 2024. 28 PA. Code 205.63(b)(c) Plumbing and piping systems required for existing construction 28 PA. Code 201.18(b)(3)(e)(1)(2.1)(3) Management 28 PA. Code 201.14(a)(b) Responsibility of licensee 395431 Page 2 of 2