**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of facility policies titled, Water Temperatures, Safety Of and Management of the Laundry, review of facility Maintenance Repair Log sheets, review of facility Water Temp (temperature) Log Sheets, and review of the laundry department's Dryer Log, the facility failed to: 1) monitor and maintain safe hot water temperatures, which were found to be up to 145 degrees Fahrenheit (F), on all residential wings/units of the facility, including the dementia unit. Further, staff failed to implement the system for reporting and acting upon ongoing concerns related to excessively hot water in resident care areas. Specifically, direct care staff with knowledge of excessively hot water temperatures did not record this information on the facility's Maintenance Repair Log sheets as the concerns were identified. In addition, maintenance staff were not performing weekly routine checks of facility water temperatures to ensure they were within safe ranges, nor did the facility implement any additional checks or safety precautions when they became aware there were concerns with their boiler system. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, the Administrator, was notified of the findings of substandard quality of care at the IJ level in the area of Quality of Care/Free of Accident Hazards/Supervision/Devices, F689; and 2) Further, the facility failed to ensure lint was removed from underneath the facility's dryer. These deficient practices had the potential to affect all 89 residents residing in the facility. Findings include: 1) Cross Reference F835 and F908. A review of a facility policy titled, Water Temperatures, Safety of, dated April 2010, revealed: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 [degrees] F (Fahrenheit), or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. On 01/31/2022 at 10:16 AM, while talking with Resident Identifier (RI) #82 in his/her room on the E Unit, the surveyor turned on the hot water faucet, noting the hot water seemed hotter than expected. The surveyor left the room and returned at 10:29 AM with a thermometer to check the water temperature. RI #82's bathroom sink water temperature was noted to be 124.8 degrees F. After noting this water temperature exceeded 110 degrees F, the surveyors began checking water temperatures throughout the facility. According to the facility's floor plan, the facility consisted of seven units, referred to as the A through G Units. Per the facility's Matrix listing all residents residing in the facility, residents resided on all units, except the B Unit. The following observations were made, listed by unit: A Unit: - On 01/31/2022 at 3:11 PM, observation revealed RI #31 and RI #9's shared bathroom had a hot water temperature at the sink of 131.8 degrees F. - On 01/31/2022 at 3:19 PM, observation revealed RI #23 and RI #52's shared bathroom had a hot water temperature at the sink of 118.2 degrees F. - On 01/31/2022 at 3:23 PM, in the shower room between Hall A and Hall C, the sink hot water temperature was 135.5 degrees F and the shower hot water was 131.0 degrees F. C Unit: - On 01/31/2022 at 2:37 PM in RI #79's bathroom, the hot water temperature was 120.4 degrees F. RI #79 stated the/she used to be a [NAME] and noted that the water from the sink was hot. - On 01/31/2022 at 3:02 PM RI #2's bathroom hot water temperature was 119.2 degrees F. D Unit: - On 01/31/2022 at 2:40 PM, the hot water temperature in the bathroom sink between Rooms D1 and D2 was 133 degrees F. - On 01/31/2022 at 2:40 PM, the hot water temperature in the bathroom sink between Rooms D3 and D4 was 128 degrees F. - On 01/31/2022 at 2:41 PM, the hot water temperature in the bathroom sink between Rooms D9 and D10 was 118 degrees F. - On 01/31/2022 at 2:41 PM, the hot water temperature in the bathroom sink between Rooms D11 and D12 was 118 degrees F. E Unit: - On 01/31/2022 at 10:34 AM, RI #78 stated that the hot water was warm but acceptable, noting they were able to simply turn on hot and cold water together. The surveyor checked the water temperature with a thermometer and found the hot water in RI #78's bathroom was 127 degrees F. F Unit (Dementia Unit): - On 01/31/2022 at 11:14 AM, the hot water temperature in the bathroom sink shared by Rooms F14 and F15 on the Dementia Unit was found to be 137 degrees F. - On 01/31/2022 at 11:28 AM, the hot water temperature in the bathroom sink shared by Rooms F8 and F9 on the Dementia Unit was found to be 140 degrees F. - On 01/31/2022 at 2:20 PM, the hot water temperature in the bathroom sink shared by Rooms F16 and F17 on the Dementia Unit was found to be 145 degrees F. The two residents in Room F17 were ambulatory and utilized water from the sink. - On 01/31/2022 at 2:42 PM, the Dementia Unit shower room's hot water temperature was found to be 136 degrees F. Per staff, this shower was used for any resident desiring a shower/scheduled for a shower on the unit. G Unit: - On 01/31/2022 at 11:10 AM, RI #139's bathroom sink hot water temperature was found to be 127 degrees F. RI #139, who was cognitively intact, stated the water was hot, but the resident had not gotten burned from the water. - On 01/31/2022 at 11:21 AM, the G Wing shower room water temperature was found to be 136 degrees F. - On 01/31/2022 at 11:35 AM, RI #140's bathroom sink hot water temperature was found to be 136 degrees F. RI #140, who was cognitively intact, stated he/she had been using the hot water from the sink, but had not been burned. On 01/31/2022 at 4:12 PM, Employee Identifier (EI) #1, the Administrator, was informed there was an issue with hot water temperatures. At that time, a request was made to review hot water temperature logs and interview staff from the Maintenance Department. Review of the Water Temp Log Sheets provided by the facility, revealed weekly water temperature checks on each unit of the facility, up until the last entry dated 01/11/2022. There was no evidence the subsequent weekly water temperature monitoring had been performed. On 01/31/2022 at 4:17 PM, two maintenance staff were assembled in EI #1's office. EI #1 stated EI #4, the Maintenance Director, had only been at the facility since December of 2021, and EI #5, the Maintenance Assistant, had only been at the facility one week. EI #4, the Maintenance Director, went with a surveyor to verify water temperatures. Hot water temperatures were measured, in degrees F, with EI #4 on 01/31/2022 at the times noted below: -4:21 PM: shower room sink at the beginning of the DEFG wings measured 137.3 per EI #4's thermometer and 138 per the surveyor's thermometer -4:23 PM: shower at the beginning of the DEFG wings measured 136.4 per EI #4's thermometer and 138 per the surveyor's thermometer. -4:25 PM: The shared bathroom for Rooms D1 and D2 measured 133.7 per EI #4's thermometer and 133 per the surveyor's thermometer. -4:27 PM: The shared bathroom for Rooms D3 and D4 measured 130.1 per EI #4's thermometer and 128 per the surveyor's thermometer. -4:29 PM: The shared bathroom for Rooms D9 and D10 measured 114.6 per EI #4's thermometer and 118 per the surveyor's thermometer. -4:31 PM: The shared bathroom for Rooms D11 and D12 measured 115.1 per EI #4's thermometer and 118 per the surveyor's thermometer. -4:38 PM: The shared bathroom for Rooms F8 and F9 measured 140 per EI #4's thermometer and 140 per the surveyor's thermometer. During and after verification of hot water temperatures with EI #4 throughout the facility, surveyors questioned residents as well as staff regarding their knowledge of hot water temperature issues: During an interview on 01/31/2022 at 11:51 AM, RI #57, a cognitively intact resident who resided on the F Unit, stated the hot water temperature was so hot it could have scalded them during their last shower. RI #57 stated the water temperature was uncontrollable. On 01/31/2022 at 2:42 PM, an interview was conducted with EI #27, Certified Nursing Assistant (CNA), regarding water temperatures. EI #27 stated they had worked at the facility since September 2021 and, during that time, the water in the F Unit shower room was always hot or cold and that there seemed to be no in-between. EI #27 stated she was unable to give a decent shower because the hot water temperatures were so hot, it was scalding. EI #27 stated that maintenance staff had been aware of the issue for months. Per EI #27, sometimes staff took the F Unit residents to the D Unit shower room for better water pressure, but the water was just as hot in the D shower room as in the F shower room. On 01/31/2022 at 04:15 PM, an interview was conducted with EI #17, a CNA working on the F Unit (Dementia Unit). EI #17 stated they had worked at the facility since September of 2021. Per EI #17, water in the F Unit shower was seemingly either hot or cold, stating there was no in-between. EI #17 reported it took forever for the water to heat up but stated once the water warmed up it was super-hot. EI #17 reported it had been like that since she started working at the facility back in September. Per EI #17, staff knew there were water issues, but maintenance never fixed it. On 01/31/2022 at 4:30 PM, an interview was conducted with EI #19, a Registered Nurse (RN) who had worked at the facility since December of 2021. EI #19 stated water temperatures had been an issue since she began working at the facility. Per EI #19, the water on the F Unit would get really hot or cold and, in the shower, there was just a trickle of water at times. Per EI #19, the water concerns had been brought to EI #1's attention for months, but the issue was not fixed. On 01/31/2022 at 4:14 PM, an interview was conducted with EI #57, a CNA who was working on the D Unit. EI #57 said she believed the water temperature between Rooms D1 and D2 was too hot. EI #57 stated that when a resident was brought into the bathroom, the hot water would not be turned on all the way; instead, both the hot and cold water were turned on at the same time and adjusted as needed. However, EI #57 stated the facility had not provided any training addressing how to check if the water was too hot. On 01/31/2022 at 4:21 PM, an interview was conducted with EI #23, LPN, who revealed they had previously noticed water temperatures being too hot and having to regulate it with cold water. EI #23 stated problems with water could be reported via a work order in the maintenance log book located at the nurse's station; however, EI #23 confirmed she had not reported the problem with the water temperature in the maintenance log book. On 01/31/2022 at 5:12 PM, a meeting was attended by EI #1 (Administrator), EI #4 (Maintenance Director), EI #5 (Maintenance Assistant) , EI #6 (Regional Life Safety Director), and the survey team. EI #6 stated he was a resource if the new maintenance staff had any questions or problems. EI #6 stated he would come to the facility to help if needed. EI #6 stated EI #4 and EI #5 were new employees. EI #6 stated the facility had worked on their boiler system twice in January of 2022. He stated the facility saw problems with water temperatures up to 110, 111, and 114 degrees F and the facility had made adjustments. He said water temperatures began getting high, noting he did not like the hot water temperature to rise above 109 degrees F. During the meeting, EI #1 stated the hot water started fluctuating and temperatures were getting high. EI #1 indicated 01/10/2022 was when the facility started to notice the water temperatures fluctuating and getting high. EI #1 further indicated they had outside contractors come to the facility on [DATE] and 01/21/2022, respectively. When asked how often water temperatures were measured, EI #6 stated, one time a week. He further explained that he instructed maintenance staff to take the water temperature in one room on each wing of the facility. During the meeting on 01/31/2022, the survey team asked about the Water Temp Log Sheets that had no log entries recorded after 01/11/2022. It was noted that two routine water temperature monitoring entries were missing for the dates of 01/18/2022 and 01/25/2022 to bring the log up to date, given the expected frequency of measurements, per EI #1 and the facility policy. EI #1 stated if an entry was not on the log, then it was not done. EI #1 stated the dates of the missing entries were around the time that they were identifying issues. During the meeting, EI #6 explained the facility's boiler and the chiller provided the hot water to the halls. EI #6 indicated if you mess with the boiler temperature, you must adjust the water to the halls. EI #6 stated it was a complicated system, and someone would have to be called in to work on it. EI #6 was asked if he was familiar with the Maintenance Repair Log entry on 11/26/2021 for the G shower room, which documented water temperatures hot enough to scald. EI #6 stated he had not seen it, and that would have been when EI #55, a former employee, was employed as the Maintenance Director. During the meeting, EI #4, the current Maintenance Director, acknowledged signing off on a shower issue and recalled trying to adjust the water temperature. EI #4 stated these issues may have been going on for some time and may have been a valve issue. EI #4 was asked how water temperatures were adjusted. EI #4 stated he had to adjust the temperature with the dial on the hot water heater. EI #4 stated that, after he made adjustments, it was not re-tested to determine what water temperatures it was producing after that. During the meeting, EI #1 stated it was not uncommon for water temperatures to fluctuate; however, too many water temperature issues alerted them to the problem. EI #1 stated they wanted to keep the water temperature between 105 and 110 degrees F and EI #6 concurred, noting the hot water temperature should not exceed 110 degrees F. EI #1 stated they would have to make an adjustment or get an outside contractor to come if the hot water temperature was over 110 degrees F. When questioned why no additional monitoring of water temperatures had been performed after making adjustments to the water heater, EI #1 agreed it would have been critical to check temperatures after maintenance was conducted. A review of the facility-provided Maintenance Repair Logs for 11/2021 through 1/2022 ( a log for staff to record concerns/issues requiring maintenance intervention) revealed the following entries related to water temperatures: - an entry dated 11/26 (2021). This entry documented the G shower room had an issue of, water temp is scalding hot + [and] there is standing water that is pooling by the walls. There was no signature of the staff member who made this entry onto the log. In addition, the completion/repair date for this entry was blank. The maintenance signature, indicating this issue had been addressed, was also blank. - An entry dated 12/19 (2021). This entry documented the residents were complaining about the shower room on the F Unit not having water pressure and the temperature going from extreme hot to cold. This entry was not signed by the staff member that made the entry onto the log; however, it was initialed by EI # 4, the Maintenance Director on 1/22/2022. - An entry dated 12/29 (2021). This entry documented a shower water temperature issue in an unspecified shower room. There was no signature of the staff member who made this entry onto the log; however, it was noted EI #4 initialed this entry as completed/repaired with a date of 12/21/2021, indicating a repair date eight days prior to staff reporting the concern. Following the meeting with facility staff regarding the water temperature concerns, the following additional hot water temperatures were measured, in degrees F, with EI #5 on 01/31/2022 at the times noted below: -5:36 PM: The bathroom of Room E5 measured 116 per EI #5's thermometer and 124.8 per the surveyor's thermometer. -5:38 PM: The bathroom of Room E8 measured 125.2 per EI #5's thermometer and 127 per the surveyor's thermometer. -5:41 PM: The bathroom of Room G11 measured 129.9 per EI #5's thermometer and 127 per the surveyor's thermometer. -5:44 PM: The bathroom of Room G13 measured 131.7 per EI #5's thermometer and 136 per the surveyor's thermometer. -5:47 PM: The shared bathroom of Rooms F14 and F15 measured 136.7 per EI #5's thermometer and 137 per the surveyor's thermometer. -5:49 PM: The shared bathroom of Rooms F16 and F17 measured 136.7 per EI #5's thermometer and 145 per the surveyor's thermometer. -5:50 PM: The F Unit shower measured 135 per EI #5's thermometer and 136 per the survey's thermometer. On 01/31/2022 from 5:57 PM to 6:08 PM, EI #4 measured the following hot water temperatures with the facility's thermometer: -Room C5's sink water was 116.7 degrees F -Room C13's sink water was 116.6 degrees F -Room A3 and A4's bathroom sink water was turned off. EI #4 stated he was unaware why the water was turned off and turned it back on below the sink. The temperature of the hot water was 123.2 degrees F. After obtaining the temperature and turning the water off at the sink, the water kept running, and EI #4 turned the water off below the sink and stated they would need to fix the sink. -Room A7 and A8's shared bathroom sink water was 126.5 degrees F -Room A999's sink water was 123.5 degrees F -While the surveyor accompanied EI #4 to obtain these temperatures, it was noted there were no maintenance logs located on the A/C Units during this time. On 2/01/2022 and 02/02/2022, the following additional water temperature observations and additional resident and staff interviews were obtained by the survey team: On 02/01/2022 at 9:17 AM, the G Unit shower room hot water temperature was found to be 129 degrees F. On 02/01/2022 at 9:20 AM, RI #139's bathroom sink hot water temperature was found to be 126 degrees F. On 02/01/2022 at 9:27 AM, the hot water temperature in the bathroom sink shared by Rooms F16 and F17 on the Dementia Unit was found to be 139 degrees F. On 02/01/2022 at 9:27 AM, RI #35, a cognitively intact resident, revealed the water in his/her bathroom sink was very hot. Per RI #35, a couple days prior, he/she had burned his/her hands when washing them in the sink. RI #35 reported his/her hands did not blister, but they were very red. RI #35 could not recall the specific day or time the incident occurred. On 02/01/2022 at 9:35 AM, an interview was conducted with EI #28, CNA. EI #28 stated that the water in the resident showers had been too hot. Per EI #28, the hot water had been an issue for a couple of months. On 02/01/2022 at 3:50 PM, an interview was conducted with EI #11, Staff Development Coordinator, who stated an in-service was conducted in the middle of January of 2022 after she noticed the water in the sink behind the nurse's station was too hot. Review of a typed document provided by the facility revealed the following: JANUARY 12, 2022 .ANY EMPLOYEE WHO HEARS OR SEES ANY ISSUES WITH WATER TEMPERATURES SHOULD REPORT THESE FINDINGS TO YOUR SUPERVISOR IMMEDIATELY AND PLACE THESE ISSUES IN THE MAINTENANCE LOG FOR THAT HALL The facility also provided two copies of a Record of Inservice Training and Attendance Form with this document. This form was also dated 01/12/2022 and listed a topic of Temps, and was signed off on by EI #11. These two forms contained only 34 total staff signatures of varying different job titles. During a follow-up interview with EI #11 on 02/03/2022 at 9:40 AM, EI #11 confirmed she had noticed the water temperature was too hot in mid-January of 2022. EI #11 said she reported the concern to EI #4, the Maintenance Director, as well as EI #1, the Administrator. However, EI #11 indicated she did not work the floor, so she was unsure if the water temperatures were actually fixed. On 02/01/2022 at 3:55 PM, an interview was conducted with EI #49, RN. EI #49 had worked at the facility for four to five months. EI #49 stated the water temperatures on the F Unit (Dementia Unit) had been hot. EI #49 was unsure who, if anyone, had reported it to maintenance staff. When asked why EI #49 did not report it to maintenance herself, EI #49 responded that she was too busy on the unit with the residents and had a heavy medication pass and had not taken the time to report it to maintenance. On 02/02/2022 at 8:33 AM, RI #290, identified by the facility as only requiring set-up assistance for bathing, was interviewed regarding his/her showers. RI #290 confirmed he/she had taken a few showers since being admitted to the facility 01/28/2022. RI #290 explained that an aide went with them to shower, but RI #290 turned the shower on and bathed them self. RI #290 stated that the water was too hot, and he/she had to turn on the cold water to 'tweak' it to make it a comfortable temperature. RI #290 stated that they had never been injured from the hot water, but if they were unable to add the cold water, the water would be too hot to shower. On 02/02/2022 at 8:34 AM, a telephone interview was conducted with the heating and cooling repairman who had provided service to the boiler in January 2022. According to the repairman, he had been contacted to specifically replace the start ignition control board, as it was not sparking to ignite the flame. The repairman stated his company did not usually work on boilers or chillers but did it that time to help the facility out on a late Friday afternoon. On 02/02/2022 at 8:45 AM, a telephone interview was conducted with an electric motor repairman, who also addressed issues with the facility's boiler in January 2022. This repairman also stated he did not usually work on boilers, but the facility's boiler would not fire, and he was able to clean the eye so that it would. The repairman explained that temperature parameters needed to be set so that the water temperatures would remain within that range. He further stated that the temperature of the water needed to be checked frequently. On 02/02/2022 at 10:02 AM, a hired construction manager contacted by the facility during the survey to see what was causing their water temperature issues, stated that he had determined the facility's boiler mixing valve had failed, which was creating the issue with elevated water temperatures. On 02/02/2022 at 10:10 AM, EI #4, Maintenance Director, took the surveyor through the facility to show the location of hot water heaters and boilers for the facility. EI #4 told the surveyor that they never knew where the mixing valve was located. During the tour of the facility's water heaters and boilers, when EI #4 was asked why the temperature logs had not been completed since 01/11/2022, EI #4 said that there were so many things that needed to be fixed and so many issues since he started, that he had not been able to do everything. EI #4 stated that he and EI #5 did not get much training. EI #4 noted he attended 'stand up' (a short, stand-up meeting) every morning and could meet with EI #1 as needed. EI #4 stated that all staff had to go through EI #1 for cost of repairs, noting that some repairs also had to go through corporate for approval. EI #4 explained that there were not a lot of places that used boilers now, and it was not easy to find anyone who worked on them. On 02/02/2022 at 1:05 PM, a Resident Group Meeting was conducted with six (RI #58, #48, #13, #70, #5, and #43) cognitively intact residents in attendance. During the meeting, RI #58 stated, The water is so hot on C Hall. A CNA told me I couldn't take a shower [because] it was so hot. On 02/02/2022 at 1:07 PM, an interview was conducted with EI #2, the Director of Nursing. EI #2 said about three weeks prior, EI #4 told her the sink water behind the nurse's station was too hot. Per EI #2, EI #1 (Administrator) was notified of the concern, and someone came out to look at it. EI #2 noted she took no other actions because EI #1 handled it. EI #2 denied any further knowledge of water temperature concerns. EI #2 further denied any knowledge of residents receiving burns but acknowledged water temperatures that were too hot could be a potential problem. On 02/02/2022 at 3:24 PM, EI #1 was asked what prompted the work on the boiler on 01/10/2022. EI #1 stated a potential problem had been noticed with the heat (air heating system also associated with the facility's boiler system), noting a contractor had been called to work on it. EI #1 stated the boiler operated both the heating and water systems. EI #1 stated he then called another contractor on 01/21/2022 and this contractor installed a new part. EI #1 stated someone said something about the water temperature around that time, but he could not remember who. EI #1 stated the person who may have first mentioned the hot water was EI #11, but he was not sure. EI #1 stated they checked and did not find issues, so they went on as usual. EI #1 stated they did not have logged temperatures for a week, which he noted he should have caught, but he did not recall anyone having major issues with water during that time. EI #1 was asked what temperature could cause a burn, and he stated, 110 [degrees F]. EI #1 was asked if the facility's water temperatures had exceeded 110 degrees F. EI #1 stated, yes, that has been identified. EI #1 acknowledged they had a hiccup in the facility's system of monitoring and acting upon hot water temperatures. On 02/03/2022 the following additional staff interviews were conducted regarding staff knowledge on how to report maintenance concerns, including excessively hot water temperatures: On 02/03/2022 at 7:54 AM, an interview was conducted with EI #28, a CNA. EI #28 stated water temperatures had been too hot for months and that maintenance staff were aware of the hot temperatures because she had seen maintenance staff working on it. However, EI #28 said she had not reported the concern in the maintenance log, because she thought maintenance staff were already aware. On 02/03/2022 at 9:28 AM, EI #13, LPN, stated that she reported maintenance problems by paging the maintenance department. EI #13 reported that maintenance staff did not check the Maintenance Repair Log books often. EI #13 said she has to chase maintenance staff down and indicated she did not know why they were not keeping a check on the Maintenance Repair Log books. On 02/03/2022 at 9:30 AM, an interview was conducted with EI #33, RN. EI #33 reported she began working at the facility in November of 2021. EI #33 reported she did not know where the maintenance log was kept for the G Unit. On 02/03/2022 at 9:35 AM, EI #63, Housekeeper, reported no knowledge of a maintenance log or its location. On 02/03/2022 at 9:36 AM, EI #8, CNA, stated that she reported maintenance problems to the charge nurse. EI #8 further stated there was supposed to be a book on each hall staff could write down any problems/concerns in but indicated she had not seen one on her hall. EI #8 did confirm having knowledge of hot water concerns and indicated the prior week she had reported to the nurse that the water temperatures were too hot. EI #8 was unable to give a specific date, time, or the name of the nurse she reported the issue to. According to EI #8, the nurse had told her they were handling it. On 02/03/2022 at 9:59 AM, EI #61, a CNA, stated she had heard many complaints from residents about the water being too hot initially, then getting cold and not being warm enough. EI #61 stated she had knowledge of the maintenance logs but had not put anything on it yet, noting she had just been telling someone verbally. On 02/03/2022 at 9:54 AM, EI #4, the Maintenance Director, was asked about the Maintenance Repair Log books. EI #4 said he was unsure where the maintenance logs were located on the A and C Units. EI #4 stated he did not check off on the log until an issue had been resolved/completed. EI #4 stated that they had not checked the log on the A and C Units and could not provide a date they last checked the logs on those halls. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F689 that outlined the following: . 1. When the surveyor informed administration that an abnormal temperature was discovered on January 31, 2022, facility staff were immediately notified of the issue and all 87 residents in house were observed for any burns on January 31, 2022 by Nursing Management, with no burns noted. 2. On January 31, 2022, the facility Administrator educated D.O.N., I.C.P. [Infection Control Preventionist] and Maintenance on water temperature policy. On January 31, 2022 the facility D.O.N. and I.C.P. educated Nurses, CNA's, Business Office Manager, Medicaid Specialist, Human Resource Director Environmental Services and Dietary on identification of water temperatures that should be maintained between 100 - 110 degrees F, and the adverse consequences that can be caused to the resident when water temperatures are outside of the normal range. Education also included the Maintenance Log and location of Maintenance Log. Education started on January 31, 2022 and continued through February 3, 2022. All employees not educated on the water temperature policy will be educated by February 4, 2022. Any facility employee not educated on the water temperature policy, maintenance log, location of maintenance, thermometer use and location of thermometer(s) by February 4, 2022, will not be allowed to return to work until education is received. On February 1, 2022, the facility Administrator educated the I.C.P. on the use of thermometers to check water temperatures, and that thermometers will be located in the shower room and all units. Any facility employee(s) not educated by February 4, 2022 on the use of thermometers to check water temperatures and their location, will not be allowed to work their schedule until e[TRUNCATED]

Based on interviews and review of the facility's, Administrator Job Description, administration failed to provide training and oversight to ensure the facility was free from the potential for injury related to identified concerns regarding elevated hot water temperatures. During the survey, the survey team identified hot water temperatures throughout all residential units/wings of the facility, including the Dementia Unit, that exceeded 110 degrees Fahrenheit (F). Temperatures were found to be as high as 145 degrees F in resident bathroom sinks, as well as resident shower rooms. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, Administrator, was notified of the findings of IJ in the area of Administration/F835. Findings include: During the survey, concerns were identified with hot water temperatures in excess of 110 degrees Fahrenheit (F). Hot water temperatures exceeding 110 degrees F were noted on all residential wings/units of the facility, including the Dementia Unit, despite prior staff knowledge about water temperature concerns. In addition, it was determined facility staff were not implementing the facility's system for reporting identified concerns requiring Maintenance intervention, nor was Maintenance staff consistently monitoring and addressing reported concerns related to hot water temperatures. Cross Reference F689 and F908. A review of the facility's Administrator Job Description, dated 06/01/2017, revealed: .Summary .Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives . On 02/01/2022, a review of the facility's maintenance staff members EI #4's (Maintenance Director) and EI #5's (Maintenance Assistant) personnel and training files was conducted. A review of competency documentation revealed maintenance staff received no specific training for water temperature monitoring to protect residents. A review of EI #4's and EI #5's job descriptions, which were signed by the staff members, revealed they would be responsible to conduct preventive maintenance, including keeping facility logs of water temperatures. EI #4 and EI #5's signed job descriptions also indicated their Supervisor was EI #1, the facility Administrator. On 02/01/2022 at 12:20 PM, an interview was conducted with EI #1, the Administrator, regarding orientation for maintenance staff. EI #1 stated that the maintenance staff received general orientation like all employees. EI #1 was not aware of specific maintenance competency check-offs or requirements. EI #1 stated that most of the training was on-the-job training with another maintenance supervisor or regional maintenance staff. On 02/02/2022 at 3:24 PM, EI #1 was asked what prompted work on the facility's boiler on 01/10/2022. EI #1 stated a potential problem had been noticed with the heat (air heating system), noting a contractor had been called to work on it. EI #1 stated the boiler operated both the heating and water systems. EI #1 stated he then called another contractor on 01/21/2022 and this contractor installed a new part. EI #1 stated someone said something about the water temperature around that same time, but he could not remember who. EI #1 stated the person who may have first mentioned the hot water was EI #11, Staff Development, but he was not sure. EI #1 stated they checked and did not find issues, so they went on as usual. EI #1 stated they did not have logged temperature monitoring for a week, which he noted he should have caught. EI #1 was asked what temperature could cause a burn, and he stated, 110 [degrees F]. EI #1 was asked if the facility's water temperatures had exceeded 110 degrees F. EI #1 stated, yes, that has been identified. EI #1 acknowledged they had a hiccup in the facility's system of monitoring and acting upon hot water temperatures. During this same interview, EI #1 was asked to describe maintenance staff training. EI #1 stated maintenance staff went through orientation. EI #1 stated EI #6, the Regional Life Safety Director, assisted with some of the maintenance training and was available by phone to answer any questions. EI #1 stated EI #14, the Corporate Environmental Life Safety Administrator, had now begun to assist with some of the training. EI #1 stated the maintenance staff had changed more than once since he started at the facility in April or May of 2021. EI #1 described how it was difficult to find people who knew how to work on boiler systems. EI #1 stated EI #4 was maintenance savvy but was not a boiler expert, so the facility relied on outside help. EI #1 stated they had no boiler-certified person on staff and were limited on the training that could be provided about boilers. EI #1 acknowledged training could be better, but indicated staff turnover made training difficult. EI #1 stated nursing homes were not the easiest place to work, and people got tired of being called on the weekends. During the same interview, EI #1 was asked if there was a check-off list used when training maintenance staff that included the things they would be responsible for. EI #1 stated EI #4 was an MDS nurse prior to taking the maintenance position and was aware of a lot of protocols for long-term care. EI #1 stated EI #4 had expressed an understanding of what needed to be done, but he had not had any help until about one week ago. EI #1 stated EI #5 was hired as a Maintenance Assistant about one week prior. He stated he had not had any time to spend with EI #5 yet. During the same interview, EI #1 was asked if he did environmental rounds himself. EI #1 stated most of the rounds were conducted informally. EI #1 stated he would get a notebook and pen, grab a maintenance person, and hit the floor. EI #1 stated they were not formal-type rounds and were not officially documented anywhere. During the same interview, EI #1 was asked what was on the top of the list that EI #4 was working on before the survey team entered. EI #1 stated the list could change day to day and was just whatever was needed for him to do, including blowing off debris from the parking lot or looking at the smoking area. EI #1 stated EI #4 had been there a month, running around by himself, and had to do a lot of things on his own. EI #1 stated EI #4 had not had help. During the same interview, EI #1 was asked how he provided oversight to the maintenance staff. EI #1 replied, in morning meetings. EI #1 stated he asked maintenance if their logs (Maintenance Repair Logs) were up to date, but indicated he did not ask them to bring the logs with them each day for him to review. EI #1 stated if he had inspected the Maintenance Repair Logs, he would have known about the hot water temperatures. EI #1 stated that at the end of the day, 'the buck stopped' with him. EI #1 stated he needed to look at logs daily or establish a system to review the logs weekly or biweekly. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F835 that outlined the following: . 1. On January 31, 2022, when the surveyor informed administration that an abnormal temperature was discovered, contractor was immediately notified to inspect the boiler. 2. Contractor was called on 1-31-22 to inspect the boiler and identified an issue with mixing valve. On 2-1-22, hot water to the facility was turned off and remained off until a new mixing valve was installed on 2-2-22. No further issues noted with excessive hot water temperatures in resident bathroom, showers, nursing station sinks and visitor bathrooms. 3. On January 31, 2022, Administrator instructed Maintenance staff to immediately check water temperatures in resident bathrooms, showers, nursing station sinks and visitor bathrooms, and identified additional abnormal water temperatures. At that time, the administrator educated Maintenance staff on correct water temperatures that should range between 100 - 110 degrees F. The Regional Environmental Director educated Administrator and Maintenance staff on monitoring water temperatures February 4, 2022. The Regional Environmental Director also educated on water temperature logs, maintenance logs, follow up of monitoring water temperatures and prioritization of entries in Maintenance Repair Log on February 4, 2022. Maintenance will also bring Repair Log to the daily morning meeting for review beginning February 4, 2022 for 60 days. 4. Maintenance will assess and do water temperature audits on 1 different unit weekly. The Regional Environmental Director will come to the facility 1 x per week for 2 months and 1 x per month for 3 months to provide oversight to Maintenance Department, education, checking water temperatures, reviewing the Maintenance Repair Log and inspection of boiler. The likelihood and/or potential of injury to all 87 in house residents began to be negated on January 31, 2022 r/t [related to] staff education on water temperatures policy along with additional education that included use and location of thermometers to check water temperatures, Maintenance Repair Log, and location of Maintenance Log on February 1, 2022 that will continue until all facility staff are educated by February 4, 2022. After this date, staff will not be allowed to work their schedule until education is completed. Member of Governing Body met with Administrator and is in agreement with the steps of the removal plan on February 4, 2022. On 02/06/2022 at 6:30 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations of safe hot water temperatures in the facility, the survey team determined the facility implemented the immediate corrective actions as of 02/04/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of a facility policy titled, Water Temperatures, Safety Of, review of facility Maintenance Repair Log sheets, and review of facility Water Temp Log Sheet documents, the facility failed to monitor and maintain the water heating/boiler system in safe operating condition to prevent hazardous hot water temperatures. Water temperatures were observed in excess of 110 degrees Fahrenheit (F) on all residential wings/units of the facility, including the Dementia Unit. Temperatures as high as 145 degrees Fahrenheit (F) were observed in resident bathrooms and shower rooms throughout the facility. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, the Administrator, was notified of the findings of IJ in the area of Essential Equipment/Safe Operating Condition, F908. Findings included: During the survey, concerns were identified with hot water temperatures in excess of 110 degrees Fahrenheit (F). Hot water temperatures exceeding 110 degrees F were noted on all residential wings/units of the facility, including the Dementia Unit, despite prior staff knowledge about water temperature concerns. Cross Reference F689 and F835. A review of a facility policy titled, Water Temperatures, Safety of, dated April 2010, revealed: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 [degrees] F (Fahrenheit), or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Review of the Water Temp Log Sheets provided by the facility, revealed weekly water temperature checks on each unit of the facility, up until the last entry dated 01/11/2022. There was no evidence the subsequent weekly water temperature monitoring had been performed. A review of the facility-provided Maintenance Repair Logs for 11/2021 through 1/2022 ( a log for staff to record concerns/issues requiring maintenance intervention) revealed the following entries related to water temperatures: - an entry dated 11/26 (2021). This entry documented the G shower room had an issue of, water temp is scalding hot + [and] there is standing water that is pooling by the walls. There was no signature of the staff member who made this entry onto the log. In addition, the completion/repair date for this entry was blank. The maintenance signature, indicating this issue had been addressed, was also blank. - An entry dated 12/19 (2021). This entry documented the residents were complaining about the shower room on the F Unit not having water pressure and the temperature going from extreme hot to cold. This entry was not signed by the staff member that made the entry onto the log; however, it was initialed by EI # 4, the Maintenance Director on 1/22/2022. - An entry dated 12/29 (2021). This entry documented a shower water temperature issue in an unspecified shower room. There was no signature of the staff member who made this entry onto the log; however, it was noted EI #4 initialed this entry as completed/repaired with a date of 12/21/2021, indicating a repair date eight days prior to staff reporting the concern. On 01/31/2022 at 5:12 PM, a meeting was attended by EI #1 (Administrator), EI #4 (Maintenance Director), EI #5 (Maintenance Assistant) , EI #6 (Regional Life Safety Director), and the survey team. EI #6 stated the facility had worked on their boiler system twice in January of 2022. He stated the facility saw problems with water temperatures up to 110, 111, and 114 degrees F and the facility had made adjustments. He said water temperatures began getting high, noting he did not like the hot water temperature to rise above 109 degrees F. During the meeting, EI #1 stated the hot water started fluctuating and temperatures were getting high. EI #1 indicated 01/10/2022 was when the facility started to notice the water temperatures fluctuating and getting high. EI #1 further indicated they had outside contractors come to the facility on [DATE] and 01/21/2022, respectively. When asked how often water temperatures were measured, EI #6 stated, one time a week. He further explained that he instructed maintenance staff to take the water temperature in one room on each wing of the facility. During the meeting on 01/31/2022, the survey team asked about the Water Temp Log Sheets that had no log entries recorded after 01/11/2022. It was noted that two routine water temperature monitoring entries were missing for the dates of 01/18/2022 and 01/25/2022 to bring the log up to date, given the expected frequency of measurements, per EI #1 and the facility policy. EI #1 stated if an entry was not on the log, then it was not done. EI #1 stated the dates of the missing entries were around the time that they were identifying issues. During the meeting, EI #6 explained the facility's boiler and the chiller provided the hot water to the halls. EI #6 indicated if you mess with the boiler temperature, you must adjust the water to the halls. EI #6 stated it was a complicated system, and someone would have to be called in to work on it. EI #6 was asked if he was familiar with the Maintenance Repair Log entry on 11/26/2021 for the G shower room, which documented water temperatures hot enough to scald. EI #6 stated he had not seen it, and that would have been when EI #55, a former employee, was employed as the Maintenance Director. During the meeting, EI #4, the current Maintenance Director, acknowledged signing off on a shower issue and recalled trying to adjust the water temperature. EI #4 stated these issues may have been going on for some time and may have been a valve issue. EI #4 was asked how water temperatures were adjusted. EI #4 stated he had to adjust the temperature with the dial on the hot water heater. EI #4 stated that after he made adjustments, it was not re-tested to determine what water temperatures it was producing after that. During the meeting, EI #1 stated it was not uncommon for water temperatures to fluctuate; however, too many water temperature issues alerted them to the problem. EI #1 stated they wanted to keep the water temperature between 105 and 110 degrees F, and EI #6 concurred, noting the hot water temperature should not exceed 110 degrees F. EI #1 stated they would have to make an adjustment or get an outside contractor to come if the hot water temperature was over 110 degrees F. When questioned why no additional monitoring of water temperatures had been performed after making adjustments to the water heater, EI #1 agreed it would have been critical to check temperatures after maintenance was conducted. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F908 that outlined the following:: The facility failed to monitor and maintain the water heating / boiler system in safe operating condition to prevent hazardous hot water temperatures On January 31, 2022, the state surveyor notified administration of water temperatures in the range of 124 - 145 degrees F. [Fahrenheit] D.O.N. [Director of Nursing], I.C.P. [Infection Control Preventionist] and Nurse Management educated Nursing and CNAs [certified nursing assistants] on January 31, 2022 on the water temperature policy, Maintenance Repair Logs, and location of Repair Log. On January 31, 2022, when the surveyor informed administration that an abnormal temperature was discovered contractor was immediately notified and came to the building on January 31, 2022 to inspect the boiler. Administrator educated Maintenance staff on correct water temperature policy on January 31, 2022. The Regional Environmental Director educated Maintenance staff on monitoring and preventative maintenance of boiler operations on February 4, 2022. The Regional Environmental Director educated Maintenance on, Repair Maintenance Log, and follow up on monitoring water temperatures. Contractor was called on 1-31-22 to inspect the boiler and identified an issue with mixing valve and a new mixing valve was installed on 2-2-22 with no further issues noted with excessive hot water temperature. The hot water to the boiler was cut off on 2-1-22 and remained disconnected until mixing valve was replaced on 2-2-22. The likelihood and/or potential of injury to any of the 87 in house residents began to be negated on January 31, 2022 r/t [related to] staff education on water temperatures and new mixing valve installed on February 2, 2022. Employees not educated on water temperature policy, thermometer usage and thermometer location by February 4, 2022 will not be allowed to work their schedule until education is received. Member of Governing Body met with Administrator on February 4, 2022 and is in agreement with these steps of the removal plan. On 02/06/2022 at 6:30 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations of safe hot water temperatures in the facility, the survey team determined the facility implemented the immediate corrective actions as of 02/04/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.