**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #6 was admitted with a primary diagnosis of unspecified bundle branch block. Review of the clinical record revealed the resident had a BIMS score of 15 indicating the resident had intact cognition. Per the documentation in the clinical record, resident used a wheelchair for mobility. -Resident #48 was admitted with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris and long term us of anticoagulants. The clinical record revealed resident used a wheelchair for mobility and had a BIMS score of 15 indicating the resident was cognitively intact. An observation of the room of residents #6 and #48 who were roommates was conducted on June 19, 2023 at 3:29 p.m. The water from the cold-water faucet felt hot to the touch and had a temperature of 123 degrees F. -Resident #17 was admitted with diagnosis of cellulitis of buttock. The clinical record revealed resident used a wheelchair for mobility and had a BIMS score of 15 indicating the resident was cognitively intact. An observation was conducted on June 19, 2023 at 3:41 p.m. The cold-water faucet in resident #17's room had a water temperature of 134 degrees F. -Resident #1 was admitted on [DATE] with diagnoses of Parkinson's disease and rheumatoid arthritis. An MDS assessment dated [DATE] revealed a BIMS score of 4 indicating resident had severe cognitive impairment. An observation conducted on June 19, 2023 at 3:39 p.m. revealed that the hot water sink/faucet in the resident's room had a temperature of 120 degrees Fahrenheit. In another observation conducted on June 21, 2023 at 4:09 p.m. it revealed that the hot water sink/faucet in the resident's room had a water temperature of 122 degrees Fahrenheit; and, the cold-water sink/faucet had a temperature of 127 degrees Fahrenheit. -Resident #53 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis affecting the right dominant side, unspecified dementia, and muscle weakness. The MDS assessment dated [DATE] revealed a BIMS score of 0 indicating the resident had severe cognitive impairment. An observation conducted on June 19, 2023 at 3:42 p.m. revealed the hot water sink in the resident's room had a temperature of 127 degrees Fahrenheit. In a later observation conducted on June 19, 2023 at 4:49 p.m., the hot water sink revealed a temperature of 118.9 degrees Fahrenheit and the cold-water sink had a temperature of 136 degrees Fahrenheit. An observation on June 20, 2023 at 9:23 a.m. revealed a sink hot water temperature of 94.8 degrees Fahrenheit and a cold-water temperature of 86 degrees Fahrenheit. An observation on June 21, 2023 at 4:38 p.m. revealed a sink hot water temperature of 124 degrees Fahrenheit and a cold-water temperature of 128 degrees Fahrenheit. -Resident #424 was admitted on [DATE] with diagnoses of peripheral vascular disease, diabetes mellitus and muscle weakness. An MDS (minimum data set) dated April 30, 2023 revealed a BIMS (brief interview of mental status) score of 03, indicating severely impaired cognition. An observation on June 20, 2023 at 9:02 a.m. revealed a sink hot water temperature of 98.7 degrees Fahrenheit and a cold-water temperature of 87.2 degrees Fahrenheit. An observation on June 21, 2023 at 4:30 p.m. revealed a sink hot water temperature of 127 degrees Fahrenheit and a cold-water temperature of 122 degrees Fahrenheit -Resident #39 was admitted on [DATE] with diagnosis including type II diabetes mellitus with diabetic neuropathy, unspecified age-related cataract, unsteadiness on feet and a history of falling. An MDS assessment dated May, 27, 2023 revealed a BIMS score of 13, indicating the resident was cognitively intact. An observation on June 19, 2023 at 3:42 p.m. revealed the hot water sink in the resident's room had a water temperature of 127 degrees Fahrenheit. An observation on June 19, 2023 at 4:49 p.m. revealed the hot water sink had a water temperature of 118.9 degrees Fahrenheit and the cold-water sink had a temperature of 136 degrees Fahrenheit. An interview was conducted with an LPN (staff #107) on June 19, 2023 at 7:20 p.m. The LPN stated she had been working at the facility for about 4 years and generally works on the 200 unit. She stated that she had not noticed any issues with the water temperatures. The LPN using her hands she tested the temperature of both the hot- and cold-water sink/faucet in the resident's room. The LPN stated that she was surprised the cold water was running so warm. She stated that she initially thought the hot water lever was reversed with the cold; until she tested the hot water which she reported as running hot. She stated that the risk of both hot and cold water running hot, could include a resident 'burning' themselves. Another observation was conducted on June 21, 2023 at 4:38 p.m. and revealed that the hot water sink had a water temperature of 124 degrees Fahrenheit and the cold-water sink had a temperature of 128 degrees Fahrenheit. -Resident #13 was admitted on [DATE] with diagnoses of nontraumatic intracranial hemorrhage and hemiplegia affecting left nondominant side. An MDS assessment dated [DATE] revealed a BIMS score of 8 indicating resident had moderate cognitive impairment. In an observation conducted on June 21, 2023 at 4:21 p.m. the hot water sink had a temperature of 125 degrees Fahrenheit and the cold-water sink had a temperature of 119 degrees Fahrenheit -Resident #54 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side, muscle weakness and type II diabetes mellitus with diabetic neuropathy. An MDS assessment dated [DATE] revealed a BIMS score of 14, indicating that the resident was cognitively intact. An observation was conducted with a certified medical assistant (CNA/staff #110) on June 21, 2023 at 4:34 p.m. revealed the hot water sink had a temperature of 128 degrees Fahrenheit and a cold-water sink had temperature of 134 degrees Fahrenheit. The CNA viewed the temperature gauge and confirmed the values. In an interview conducted with maintenance manager (staff # 112) on June 19, 2023 at 4:28 p.m., the maintenance manager stated that water starts getting hotter in the summer and when this happens he stated he manually sets the hot water temperature to 120 degrees Fahrenheit. He stated that there are two 100-gallon water tanks that service the resident rooms, one for each side of the building; and there were 6 tankless water heaters that service the kitchen, laundry, showers and non-resident bathrooms. He stated that during the summer, residents are encouraged to shower early in the morning to avoid the high temperatures. Staff #112 further stated that he conducts audits by checking the water temperatures weekly, which he reported had been ranging from 124-138 degrees Fahrenheit. He stated that he also adjusts the hot water temperature when he receives a report via the TELS portal. however, he said that the cold water cannot be adjusted. The maintenance manager stated that he runs the water for about 5 minutes before checking the temperature and/or placing his hands under the sink/faucet in the resident room. He stated that he does not if resident know to run the water for about 5 minutes before using it. Further, the maintenance manager stated that he does not know what water temperature could scald/burn a resident; but, he could look the information up in TELS. In a subsequent interview with the maintenance manager conducted on June 21, 2023 at 1:02 p.m., he stated that he was responsible for the facility water supply; and that, he takes the water temperatures weekly and whenever there were complaints and then documents them in TELS. The maintenance manager stated that the computer-based TELS application only requires documentation of the hot water temperatures and not the cold-water temperatures; and that, the documentation he enters was available via reports in the corporate office. He stated that he did not specifically alert anyone else in the facility or corporate, as they have access to TELS and would be able to look at the reports. He stated that when he does not enter the hot water temperatures, it gets flagged and he receives a reminder notice. He stated the seasonal manual hot water temperature adjustments were not documented in TELS, but could be in the comments section. He stated that some of the water tanks had been converted to tankless about 3 to 6 months ago; and that, the reciprocating pump, which adjusts the rate of water coming into the system was replaced in February 2023. Staff #112 stated the risk of the cold-water temperature running hot in resident rooms could put a lot of residents at risk and could cause a resident to get burned. Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure water temperatures were within the safe water temperature range. The deficient practice put the residents at increased risks for serious injury and harm such burn and scalding. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On June 19, 2023 at 7:04 p.m., the Condition of IJ was identified. The Administrator (staff #143) and the Director of Nursing (DON/staff #70) were informed of the facility's failure to water temperatures were within the safe water temperature range. During the initial screening, hot- and cold-water sink/faucet had temperature exceeding 120 degrees Fahrenheit (F) were found in multiple resident rooms at different hall. Water temperature readings were conducted with the maintenance manager (staff #112) who tested the water temperature in multiple resident rooms using facility thermometer and stated that the water temperature readings exceeded 120 degrees F. Further, staff #112 tested the water temperature from the cold-water faucet which revealed a temperature reading of 130 degrees F; and that, after 3-5 minutes of running the water the water temperature for the cold-water faucet began to drop. The Administrator (staff #143) presented a POC (plan of correction) on June 19, 2023 at 8:26 p.m. The administrator was informed that the POC was not acceptable and failed to include the following: the in-service regarding high water temperature and for which staff will be in-serviced; projected completion date for the in-service; how to prevent the incident from reoccurring, since high water temperatures were prevalent starting in the afternoon; staff responsible for maintaining documentation of water temperature logs; actions/measures to take address high water temperature readings from the cold faucets; alternative sinks for residents to use if sinks are inoperable; explanation for selected sample size; and, the tool used to measure water temperatures. A revised POC was received June 19, 2023 at 9:49 p.m. The Administrator (staff #143) was informed that the POC failed to include a completion date for the in-service training for all staff. At 10:22 p.m., another POC was received and was accepted at 10:33 p.m. The accepted POC included the following: the north and south water heater were turned down to 100 degrees F; residents and staff were informed of scalding risk and were asked not to use sink in room; staff in the building were in-serviced on scalding risk prevention; water in residents' rooms sink were drained to reach desirable temperatures; caution signs were posted at every resident sink warning them of scalding risks; daily water temperature taken each shift for 5 days in 8 randomly selected rooms (two per hall); consultation with outside contractor to diagnose the cause the hot water temperature from the cold water sink; and, the maintenance director or designee was responsible for ensuring water temperatures are taken according POC. Multiple observations were conducted of the facility implementing their POC which included caution signs posted in the residents' rooms near the sink, in-service training, contractors and plumbers present in the facility, and staff measuring water temperatures in rooms. On June 22, 2023 at 5:37 p.m. the Condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced and daily water temperatures were obtained; cold water faucets were turned off in resident rooms and as a result a sample of resident rooms were identified to have water temperature below 120 degrees F; plumbing experts identified that the exposed copper piping in the attic was being heated by ambient air during the heat of the day causing the temperature spikes in the uninsulated copper cold water lines; and verification that the cold faucets were shut-off. In addition, the facility provided a plan for long term resolution to include the installation of attic vents/fans and soffit vents to dissipate heat in the attic by circulating air as well as on-going monitoring of water temperature until the long-term resolution had been implemented and found to be effective. -Resident #276 was admitted on [DATE] with diagnoses of acute kidney failure, repeated falls, and malignant neoplasm of unspecified kidney. An observation of resident (#276) room was conducted on June 19, 2023 at 2:07 p.m. and revealed that hot and cold-water faucet was hot to the touch. The water temperature from the hot water faucet was 120.3 degrees F. Resident #276 stated that both faucets tend to be hot. In another observation conducted on June 19, 2023 at 4:12 p.m., the water temperature was at 121.5 degrees F. During an observation with the maintenance manager (staff #112) conducted on June 19, 2023 at 4:34 p.m., staff #112 attempted to let the faucet water run before checking the temperature. Staff #112 placed the Fieldpiece (brand name) thermometer directly under the running water as soon as the faucet was turned on. He tested the temperature from the cold faucet (right side) and revealed 122 degrees F and after 3 minutes it dropped to 100.4 degrees F. He then tested the temperature for the hot water faucet and it revealed 118.4 degrees F. In an interview conducted with resident #276 on June 19, 2023 at 9:06 p.m., he stated the water should have been checked a couple of days ago; and that when he went to wash his hands and it made him jump back because the water was very hot. Resident #276 stated he thought he did something wrong and checked to make sure he turned on the right one and saw that cold-water faucet was hotter than the hot water. Further, the resident stated that if his hands were not so thick he would have burnt his hands. On June 21, 2023 at 10:01 a.m. the Administrator (staff #143) stated that the replacement of two separate 2 valves, the closure of four cold water valves, and the adjustments to the water heaters were expected to have completely resolved the issue. However; at 3:59 p.m. the cold faucet water temperature in resident #276's room was 128.2 degrees F. -Resident #277 was readmitted to the facility on [DATE] with diagnoses of hereditary and idiopathic neuropathy, acute kidney failure, and fracture of unspecified part of neck of left femur. Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11 indicating the resident had a moderate cognitive impairment. An observation in the room of resident #277 was conducted on June 19, 2023 at 2:42 p.m. and revealed hot water temperature of 122.6 degrees F. -Resident #64 was admitted on [DATE] with diagnoses of alcoholic polyneuropathy, and peripheral vascular disease. The progress note dated May 25, 2023 revealed the resident was alert and oriented x 2. The MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. An observation of the room of resident #64 was conducted on June 19, 2023 at 3:06 p.m. The water temperature from the hot water faucet was 124 degrees F. In another observation conducted on June 19, 2023 at 3:43 p.m. the resident was sitting in a wheelchair and was able to move around the room while in his wheelchair. An observation was conducted on June 21, 2023 at 3:45 p.m. and revealed that the cold-water faucet had a temperature of 124.5 degrees F and the hot water faucet had a temperature of 124.7 degrees F. -Resident # 274 was admitted on [DATE] with diagnoses of psychotic disturbance, mood disturbance, and anxiety, and dementia. A progress note dated June 15, 2023 at 5:31 p.m. revealed resident #274 used a walker for mobility. An interview was conducted on June 19, 2023 at 3:38 p.m. with resident #274 who stated both hot and cold-water faucet were always running hot water. He said that he mentioned it to a CNA (name unknown) who tested the water temperature by touch and told him it was okay; however, the resident stated that it was still hot. During the interview, the water temperature for the cold-water faucet was tested and revealed 125 degrees F. At 4:15 p.m., the cold-water faucet water temperature was again tested and revealed temperature at 125.7 degrees F. An observation was conducted with the maintenance director (staff #112) on June 19, 2023 at 4:44 p.m. He tested the cold faucet water temperature and revealed water temperature at 125.6 degrees F. After a minute, the water from the cold-water faucet dropped to 123.4 degrees F; and, at 4:46 p.m., water temperature dropped to 119 degrees F. Review of the MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident was cognitively intact. The assessment included the resident required no setup or physical help from staff with transfer i.e. how that resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. -Resident #56 was admitted on [DATE] with diagnoses of peripheral vascular disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and unsteadiness on feet. Review of progress note dated May 29, 2023 revealed resident was oriented x 2. The MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident was cognitively intact. -Resident #374 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, muscle weakness, and cirrhosis of liver. Review of the MDS assessment dated [DATE] revealed a BIMS score of 10 indicating resident had moderate cognitive impairment. An observation of the room of resident #56 and #374 who were roommates was conducted on June 21, 2023 at 3:31 p.m. The cold water and the hot water faucet were tested. The cold-water faucet as at 126.5 degrees F; and, the hot water faucet was at 124.6 degrees F. -Resident #500 was admitted on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery, type 2 diabetes mellitus with hyperosmolarity, depression, and unsteadiness on feet. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 indicating resident was cognitively intact. The assessment included the resident required setup only for locomotion off unit i.e., how resident moves to and returns from off-unit locations. An observation was conducted on June 21, 2023 at 3:57 p.m. and revealed the cold-water faucet had a water temperature of 124.7 degrees F. Review of the facility's record for hot water temperatures from January through June 2023 revealed the following hot water temperature readings from multiple different resident and showers rooms on different dates with hot water temperatures that ranged from 120 to 160 degrees F. An interview was conducted on June 19, 2023 at 7:45 p.m. with a registered nurse (RN/staff #25) who stated she had worked in the facility for about eight years and she was aware of the issues with the water temperature in the residents' rooms. She said that when the outside temperature was over 100 degrees, the cold water was warm; however, if the water runs for a few minutes it will cool down. The RN stated she knew that at this time of year the water temperature can run warm and they let maintenance know and try and educate staff and residents. The RN said that a resident in the 400 hall had complained the other night about the water temperature; and that, she did not report the water temperature complaint to maintenance staff. She also said that she should have reported the complaint to the maintenance because a resident can get hurt if the water was too warm. During an interview with a certified medical assistant (CMA/staff #9) conducted on June 20, 2023 at 9:36 a.m., the CMA said that there were residents who complained to her about the water especially in the shower room. She stated that she had to let the water run in order for it to cool down. She said she had been working at the facility for two years and had found that the water temperature was a problem in the summer. The CMA stated that about a year ago there were a couple of residents who reported that they used the water which was too hot and their skin were reddened from the water being too hot, but returned to their color after a while. The CMA said that she informed the nurse who applied calamine lotion on the residents affected area. An interview was conducted on June 20, 2023 at 11:53 a.m. with resident #275 who stated that he washed his hands at the sink and realized the water was hot when he turned on the cold water. Resident #275 said that the longer the water ran the hotter it got. He also stated that the staff that gave showers told him that he needed to hurry to take a shower because the water gets hotter later in the day. Resident #275 said that during his shower yesterday (June 19, 2023) the water was very hot and the aide told him that they needed to hurry because the water was hot. He said he liked to take his time to shower but if he does, the water would burn his body. Further, resident #275 said the shower aide had to raise the shower handle high in the air so the water could cool off before the water touched his skin. During an interview with the Administrator (staff #143) conducted on June 23, 2023 at 9:55 a.m., the administrator stated that his expectation was for staff to notify him of any hazards in the building. The Administrator said in the past, hot water temperatures were recorded in TELS; and that, cold water temperatures were not. However, the administrator said that the system only alerted him when the task of measuring the temperature was completed but it did not alert him of high-water temperature readings or whether it was out of compliance. He stated that it was the responsibility of the maintenance manager to notify him of any issues. The Administrator stated that he never saw the water temperature readings until he printed the report from TELS; and, he was surprised and thought the readings could not have been accurate. He stated that he questioned that that there was no flag from TELS to look deeper. The administrator stated that prior to the survey, the process they had in place prior to the survey did not meet his expectation and the potential risk of having elevated water temperature was scalding and/or injury to the residents. An interview with a registered nurse (RN/staff #86) was conducted on June 20, 2023 at 8:43 a.m. The RN stated that she enters resident rooms and washed her hands in the sink located in the room; however, she stated that she does not notice the water temperature. She stated that neither the CNAs or residents had complained about the water being too hot. The RN said that if the water was excessively hot she would expect the CNAs to notify her; and that, the risks to the residents would include burns. In an interview with certified nurse assistant (CNA/staff #91) conducted on June 20, 2023 at 8:50 a.m., the CNA stated that he had worked at the facility for 9 years. He stated that in the summertime, they had to let the water run for a few minutes because the water was too hot; and that, after a few minutes the water cools down. He stated he had noticed that the water was really hot in the summer, and that he had told the nurse about it. The CNA also stated that if a resident was in the shower by themselves and the water was too hot the risks to the resident would include being burned. He further stated that the resident could turn the cold water on which was even hotter than the hot water. In an interview conducted with the administrator (staff #143) conducted on June 20, 2023 at 10:30 a.m., the administrator that the issue regarding the water temperatures being too hot had not been identified until now. He stated that staff had been aware of water temperatures rising in the summer and that the city where their facility was located was hot. In another interview with the administrator (staff #143) conducted on June 21, 2023 at 11:49 a.m., the administrator (staff #143) stated the facility did not have cold water logs. In a later interview with staff #143 conducted on June 21, 2023 at 1:47 p.m., he said that he absolutely had no idea that there were any issues with the water temperatures; and, he had never been told by anyone that there were any concerns regarding water temperature. During an interview with a restorative nurse aide (RNA/staff #20) conducted on June 22, 2023 at 8:46 a.m. the RNA stated that the water was very nice in the morning; however, the water can get very, very hot at around 11:00 a.m. or 12:00 p.m. He stated that this was very common every summer season and that every year they update the staff about this. However, he stated that no one had told him that the water was too hot yet, but someone will soon. During an interview with the Director of Nursing (DON/staff #70) and a corporate compliance representative (staff #191) conducted on June 23, 2023 at 5:37 p.m., the DON stated he stated that his expectation was for nursing staff keep him informed at all times if hazards are identified. He stated that no staff had ever complained to him that there was ever an issue with the water temperatures; and that when he interviewed staff after the IJ had been identified, staff responded that it was expected that the water temperatures would be higher in the city that they are located at. The DON that moving forward, he expected his staff to notify him of hot water temperatures since now they had been trained regarding the risks related to high water temperature. The facility's job description for a maintenance manager included a responsibility to supervise adjustment of water temperature valves to maintain required temperatures. Review of the facility policy titled, Safety and Supervision of Residents, revealed that the facility strives to make the environment as free from accident hazards as possible. The policy also included that as part of the facility-oriented approach to safety, employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. The facility policy on Maintenance Service revealed that the functions of maintenance personnel include, but not limited to, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards. The policy also included that maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Review of the facility policy on Safety of Water Temperatures revealed that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. The policy also that the water heaters that service resident rooms, bathrooms, tub/shower areas shall be set to temperatures of no more than 115 degrees F, or the maximum allowable temperature per state regulation; and, maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. It also included that if at any time water temperatures feel excessive to 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. Risk factors for scalding/burns that are more common in the elderly included decreased skin thickness, skin sensitivity, peripheral neuropathy, reduced reaction time, decreased cognition; the length of exposure to warm or hot water, the amount of skin exposed, and the resident's current condition affect whether or not exposure to certain temperatures will cause scalding or burn.