**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The handwashing sink in dish washing area was not providing enough hot water pressure to wash hands effectively, which had the potential to cause foodborne illness. 3. The microwave was not kept in sanitary condition which could transfer to residents' foods during reheating. This had the potential to contaminate the food and cause foodborne illness. 4. The floor under the stainless-steel counters and center island had food crumbs and trashes that had the potential to attract pests. 5. The floor under the shelves in the dry storage had food crumbs and three dead roaches that had the potential to attract pests. 6. The inside of a cabinet on the steamtable had black grime and food crumbs that had the potential to attract pests and harbor bacteria growth. 7. The can opener in the kitchen was not kept in sanitary condition which could transfer to residents' foods. This had the potential to cause foodborne illness. 8. The storage space on the stove had food crumbs and black grime that had the potential to attract pests and harbor bacteria growth. 9. The shelves in dry storage room, across from the family room, were not smooth and easily cleanable that had the potential to attract pests. 10. The three compartment sinks (three sinks used for washing dishes, one for washing, one for rinsing and one for sanitizing dishes) that was also used for food preparation did not have an air gap (an air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the sink and possibly contaminating the area used for washing food. An air gap is a way to make certain wastewater and contaminants never re-enter the clean water supply), which had the potential for back flow from the drain to contaminate the sink. This had the potential to cause foodborne illness. 11. The dish machine wash temperature was not reaching the appropriate temperature per the manufacturer guidelines. This had the potential for dishes to not be washed properly and potentially cause food borne illness. 12. There were three boxes of food that were open and the food was not sealed. Having the food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which would cause food-borne illness to a population of 91 of 92 residents who received food from the kitchen and are medically compromised. Findings: 1. During a concurrent observation and interview with Maintenance Supervisor (MS) on February 1, 2022, at 10:19 AM, there was black and red slime buildup on the ice chute inside ice machine storage bin. Surveyor used a white paper towel to remove a chunk (spoonful) of the black and red slime from around the rim of the ice chute, where ice drops and enters the ice storage bin. Verified black and red slime with MS. MS stated he cleaned the inside top part of the ice machine, where ice was made monthly. When he cleaned the top part of the ice machine, he had housekeeping clean the ice storage bin. MS stated the housekeeping may need to adjust deep cleaning twice per month instead of once per month to prevent the buildup of slime. He stated that he thinks that housekeeping may have missed that area where the buildup was found because it is hard to reach. During an interview on February 1, 2022, at 12:31 PM, with Housekeeping 1 (HK1) and the MS, in front of ice machine. HK 1 stated she just cleaned the ice machine storage bin with bleach and water mixture. After she cleaned the ice machine storage bin, she needed to write down the date in the ice machine sanitation log located next to ice machine. But today she forgot to write the date. HK 1 showed the sanitation log to surveyors and stated her coworker just cleaned the ice machine yesterday on January 31, 2022. Surveyor used white napkin to wipe the ice chute inside the ice storage bin. There still was black slime buildup. Verified finding with HK 1 and MS. HK 1 stated she had no idea why after she cleaned the internal ice machine storage bin with bleach, the black slime was still there. During an interview on February 1, 2022, at 4:27 PM, with ice machine Service Technician (ST) from company name, ST stated he provided services for the facility's ice machine many years. There was an area where the gasket (rubber piece that lined the top of the ice bin where the ice maker sat on top) was damaged in the ice machine. He stated that dirt could enter there, had that was how the slime buildup developed. ST recommended they replace the gasket of the ice machine and use bleach to sanitize ice machine ice storage bin to remove slime. During a record review of the FDA Federal Food Code 2017,, it indicates that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During a record review of the Federal FDA 2017 Food Code 4-204.17, indicated The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form . are difficult to remove and present a risk of contamination to the ice stored in the bin. During a record review of the Ice machine Cleaner and Sanitizer Usage titled, [Company name], undated, provided by MS indicated, Cleaning the Ice Bin and Drop Zone. Ice is held in ice bins and dispensers until it's ready to be used. As this is where ice spends the majority of its time, it's imperative to clean the ice bin thoroughly. Mold, slime, and algae can grow in an ice bin, feeding off dust and yeast from the air and enjoying relative privacy in the dark, moist bin environment. Get a bead on these contaminants and wipe them out during deep cleaning .Descale Your Ice Bin 2. Remove any visible grime or debris by wiping the interior . with warm water and a cloth . During a record review of the facility's policy titled, Sanitation, Revised 2017, indicated, 2. All . equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks and chipped areas . During a record review of the Food and Nutrition Monthly Kitchen Audit Checklist/Report, dated November 30, 2021, December 28, 2021, and January 25, 2022, the RD 1 put a check mark met on the box 40 that indicated The interior and exterior of the ice Machine is clean and operable, free of rust. Ice scoop is covered when not in use. Passes white paper towel test. Record Review of the facility document titled Diet Order Listing Report. dated February 1, 2022, indicated there were 91 residents on PO (by mouth) diet. Review of the facility document titled Diet Order Listing Report, dated February 1, 2022, indicated there was one resident on NPO (nothing by mouth) means not receiving food by mouth. An immediate jeopardy (IJ) was called on 483.60(i)(2) - Store, prepare, distribute, and serve food in accordance with professional standards for food service safety, on February 1, 2022, at 3:00 PM, the survey team verbally notified the facility Administrator, Director of Nursing, and Maintenance Supervisor of the IJ due to the ice machines not being kept in sanitary condition. Failure to maintain sanitary ice machines had the potential to cause food-borne illness to the highly susceptible residents who received ice from the ice machines. The Corrective Action Plan (CAP) included the following: 1. Turned off the ice machine for servicing and sanitizing, until the issue(s) have been resolved. 2. Contacted a third party licensed vendor for immediate servicing and cleaning ice machine. 3. Provided in service training to maintenance staff, and dietary staff by the third party licensed vendor. 4. Purchased ice from the store while the ice machine was being serviced. 5. Based on the third party licensed vendor's recommendations, the ice storage bin gasket was replaced. 6. The ice machine bin will be cleaned twice a month and as needed. 7. The maintenance Supervisor will inspect the ice machine and document in the cleaning log every 2 weeks and as needed. Action plan completed on February 2, 2022. 1. Third party licensed ice machine service vendor was contacted, and ice machine service technician was in the facility on February 1, 2022. Service Technician recommended replace the bin gasket of the ice machine. Service Technician also provided in service on cleaning and sanitizing ice machine and ice storage bin with Maintenance Supervisor and Interim Dietary Manager. 2. The ice machine gasket replaced on February 1, 2022. 3. The Maintenance Supervisor received training on cleaning and sanitizing ice machine and ice storage bin. 4. The Interim Dietary Manager received training on cleaning and sanitizing ice machine and ice storage bin. During an interview on February 2, 2022, at 11:31 AM, with MS and Interim Dietary Manager (IDM), in front of ice machine. MS stated he replaced old gasket of ice machine per ST recommendation. In future, dietary and maintenance will clean and disinfect ice machine biweekly, housekeeping clean and disinfect exterior ice machine daily. Verified with IDM, he stated he is going to clean internal ice machine biweekly. When cleaning internal ice machine, he would remove ice from ice storage bin. Then he cleaned the ice storage bin with sanitizer solution including ice chute. Any build up and any color slime should not be in ice machine storage bin. During an interview on February 2, 2022, at 3:18 PM, with Registered Dietitian 1 (RD 1) and Interim Dietary Manager (IDM), at Sun patio dining room. RD 1 stated she only checked ice machine sanitation log; checked that there was no ice scoop inside internal ice machine storage bin; She used a white paper tower to check the cover of the ice bin. She stated she does not check the ice chute for cleanliness. During an interview on February 3, 2022, at 9:45 AM, with IDM. IDM stated ice from the ice machine is for everyone (residents, employee) in this building and also used for food preparation in the kitchen. During an interview on February 3, 2022, 12:40 PM, with HK 1. HK 1 stated when she clean ice machine on February 1, 2022, she only used bleach and water. There was a little slime (look like Jell-O) come out from ice storage bin. HK 1 admitted she may miss the ice chute because it hard to reach. During an interview on February 4, 2022, at 10:08 AM, with MS, MS stated the manufacturer guidelines for the ice machine indicated that the ice machine needed to be cleaned every six months and did not provide instruction on how to clean or scrub the interior of the ice storage bin, so he developed a cleaning protocol. He stated despite using the cleaning protocol, he thought that housekeeping probably did not reach into the ice storage bin and look up into ice chute to clean it. That is why surveyor found the slime build up. During an observation on February 2, 2022, at 11:01 AM, ice machine was clean, no slime buildup. During a review of facility invoice for ice machine service vendor [Company name], dated February 1, 2022, indicated Start time: 3:40. Time finish: 4:40. Service Performed: Give instructions on cleaning and sanitizing ice machine and bin with maintenance supervisor and Dietary supervisor. Replacement of bin gasket should be done. During a review of facility's receipt [Company name], dated February 1, 2022, at 6:41 PM provided by MS, indicated purchasing of ice machine gasket. During a review of facility document titled, In-service on how to properly clean the ice machine, dated February 1, 2022, at 4:30 PM indicated Maintenance Supervisor and Interim Dietary manager completed the competency training on February 1, 2022. The Immediate Jeopardy was abated on February 2, 2022, at 3:11 PM, in the presence of the Administrator, at the Administrator office, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews, and document review. 2. During a record review of the FDA Federal Food Code 2017, 6-103.12, indicated, Water under pressure shall be provided to all fixtures, equipment, and nonfood equipment that are required to use water and inadequate water pressure could lead to situations that place the public health at risk. For example, inadequate pressure could result in improper handwashing. During a record review of the FDA Federal Food Code 2017, 5-202.12, indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 38° C (100°F) through a mixing valve or combination faucet, and Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM Standards for testing the efficacy of handwashing formulations specify a water temperature of 40°C ± 2°C (100 to 108°F). During an observation on February 1, 2022, at 11:12 AM, the handwashing sink located in the dish washing area, was not providing enough hot water pressure. When cold water was used to increase the water pressure, it caused water to came out from faucet cold. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated he had brought up to maintenance that the hand washing sink located in dish washing area had inadequate water pressure, but maintenance claimed they could not fix it because of the location. RD 1 stated she expected the handwashing sink to meet adequate temperature and pressure to meet the Food Code. 3. The Federal Code 2017 indicates food contacted surface and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, and decomposition. During an observation on February 1, 2022, at 9:42 AM, the microwave was dirty with food crumbs and yellow grime on the top inside where food is placed to be warmed. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the microwave should be cleaned weekly. RD 1 expected microwave should have a weekly deep clean and kept clean with wipe down after meal service. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner .2. All .equipment shall be kept clean. 3. All equipment, food contact surfaces .shall be washed to remove or completely loosen soils. 4. During a concurrent observation and interview with the IDM, on February 1, 2022, at 9:21 AM, the floor under the stainless-steel counters, between juice machine and coffee maker, had a build-up of dust, trash and black grime. The floor under the center islands had food trash, debris, and used gloves. The IDM stated it should not be like that. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the floor should be cleaned four times per day. Cleaned after each meal trayline and 4th time cleaned was end of the day. She stated after New year, this facility had hired lot of new employees. Possibly there was some job responsibility confusion. Will continue to do in-service and request Dietary Assistant supervisor do spot check. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the facility policy's titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, Kitchen areas and dining area shall be kept clean, free from litter and rubbish .15. Kitchen .not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 5. During a record review of the FDA Federal Food Code 2017, Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. During a concurrent observation and interview with the IDM, on February 1, 2022, at 9:32 AM, at dry food storage. The floor under dry food storage shelves had a build-up of food crumbs, cheerios. Three dead roaches were found on the floor underneath a black crate. IDM stated Dietary staff had not done cleaning under shelves in dry food storage. Dietary staff sweep and mop dry food storage room twice per week. Every two-week, dietary staff clean the storage room underneath shelves. Once per month dietary staff do the deep cleaning at dry food storage room. There is no cleaning log for food dry storage room done bi-weekly. I do not notice any pests in the kitchen. If there is pest issue, I will inform Maintenance Supervisor. Maintenance Supervisor will contact pest control vendor. IDM admitted it is not enough cleaning in dry food storage room since there was build up food crumbs and dead roaches. During an interview on February 1, 2020, at 10:51 AM, with MS, MS stated that pest control company come one per month at the beginning of the month. The pests contract company came out and sprays for free if they have to call between the one-month time frame. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the floor needed to be swept regularly, there should not be food crumbs, cheerios, and roaches. Dietary would notify maintenance if there was pest issue. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, Kitchen areas and dining area shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. During a review of the facility's policy titled Food Receiving and Storage, Revised October 2017, indicated Foods shall received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff. Will maintain clean food storage area all times. 6. During a record review of the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. During an observation on February 1, 2022, at 9:26 AM, there was black grime and food crumbs inside cabinet of the steamtable. Cabinet was not used for storage, but it was a potential area to attract pests. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated the cabinet of the steamtable had not been cleaned in a long time. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 15. Kitchen .not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 7. During a record review of the FDA Federal Code 2017, indicates food contact surface and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, and decomposition. During an observation on February 1, 2022, at 9:43 AM, there was black grime at the base of can opener and sticky residue on blade. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated he expected can opener should be clean after each used. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 2. All .equipment shall be kept clean. 3. All equipment, food contact surfaces .shall be washed to remove or completely loosen soils . 8. During a record review of the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. During an observation on February 1, 2022, at 9:29 AM, the storage space on stove had food crumbs, and was dirty and dusty. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the storage space on stove should be kept clean. During a review of the facility's policy titled, Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner.15. Kitchen .not in contact with food shall be cleaned . 9. During a record review of the FDA Food Code 2017, Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. During a concurrent observation and interview with DM (Dietary Manager) and IDM on February 2, 2022, at 9:09 AM, dry food storage room located across from the family room, observed tears in the linoleum shelves covering. Interviewed DM who works in sister facility come to this facility helping. DM stated It is not acceptable to have tears in the linoleum shelves coverings, they need to remodel the shelves. Debris that gets caught under the torn linoleum will attract pests. Interviewed IDM, IDM stated Maintenance aware the tear and torn shelves, pending approval to get shelves fix. IDM admitted it is not acceptable to have tear and torn shelves in dry food storage. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated shelves in the dry food storage cannot be sanitized correctly because the linoleum was peeling on the shelves. IDM stated maintenance will take out the shelves and replaced new shelves. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 2. All ., shelves shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams and chipped areas that may affect their use or proper cleaning. 10. During a record review of the FDA Federal Food Code 2017, indicates A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under 5-202.12. 5-202.13 indicated An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. In addition, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of the plumbing fixture or equipment prevents contamination that may be caused by backflow. During a concurrent observation and interview on February 2, 2022, at 9:42 AM, with the MS, the three compartment sinks that was also used for food preparations did not have air gap. MS stated that a plumbing company recently come to fix the pipes because they were backing up. He stated they did a drain clean out. 11. During an observation on February 2, 2022, at 10:10 AM, the dish machine wash water temperature gauge was observed at 100 degrees Fahrenheit (Fahrenheit unit of measurement °F). Verified dish machine wash temperature with DA 2, she stated it was 102 °F. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated will request dish machine [company name] come in checked the inadequate dish machine wash water temperature. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner . 8. Dishwashing machines must be operated using the following specifications: Low Temperature Dishwasher (Chemical sanitization). a. Wash temperature (120 °F). 12. During a concurrent observation and interview on February 2, 2022, at 9:22 AM, with IDM, reach in freeze, observed a box of 20-pound opened bread stick exposed to the air. Another box of opened 20.5-pound Ranch style roll exposed to the air. Walk in freeze had a box of opened Cinnamon French toast exposed to the air. Interviewed IDM. IDM stated, opened foods items need to be seal. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM 1 stated he needed to do in service opened food items need to be seal. During a review of the facility policy statement Food Receiving and Storage, Revised October 2017, indicated Foods shall received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator and freeze will be covered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of hazards when water temperatures within the facility reached 136.6 °F (Fahrenheit - unit of measure for temperature) in areas where hot water was accessible to residents. This failure lead to unsafe hot water temperatures which had the potential to cause severe burns and scalding to a vulnerable population of 103 Residents. Findings: On April 12, 2019, at 8:46 AM, during the recertification survey, a surveyor returned from using the common restroom located near Nurses Station 2 and across from room [ROOM NUMBER]. The surveyor informed the survey team, the water coming from the sink was noted to feel extremely hot to the touch. The surveyor stated he had to pull his hands back quickly due to how hot the water was despite his attempts to try and balance the temperature with cold water. On April 12, 2019, at 8:51 AM, a surveyor calibrated a digital probe thermometer per the manufacturers recommendations and requested the presence of a member from the maintenance department. The Assistant Maintenance Supervisor (AMS) arrived to assist the surveyor. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:00 AM, The AMS placed his hand under the running water from the sink in the common restroom and snatched his hand back immediately and stated the water was really hot . The AMS further stated he did not have a thermometer with him and that he would use the surveyor's thermometer to test the temperature of the hot water in the sink. The AMS filled a cup with hot running water from the sink and placed a thermometer into the cup for the reading. The AMS read the hot water temperature reading aloud 133.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F. During an observation and interview with AMS, on April 12, 2019, at 9:17 AM, the AMS stated the water temperature in the common restroom was too high and could cause an accident. The AMS rechecked the hot water temperature from the sink in the common restroom located near Nurses Station 2 and stated the temperature was 133.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:24 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 131 °F. The surveyor viewed the thermometer reading for verification and the display showed 131 °F. The AMS stated the temperature was too high and could cause injury. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:28 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 129.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 129.4 °F. The AMS stated the temperature was too high. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:32 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 132 °F. The surveyor viewed the thermometer reading for verification and the display showed 132 °F. The AMS stated the temperature should be less than 120 °F. He further stated he did not understand why the temperature was so high. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:37 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 132.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 132.4 °F. The AMS stated he would need to discuss the findings with the Maintenance Supervisor (MS). During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:41 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 136.6 °F. The surveyor viewed the thermometer reading for verification and the display showed 136.6 °F. The AMS stated the water temperature was not getting better. He further stated the water temperature needed to be adjusted for safety. During an observation and concurrent interview with the AMS, on April 12, 2019, at 9:47 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The AMS stated he needed to discuss the high water temperatures with the Maintenance Supervisor (MS). He stated the temperatures needed to be adjusted immediately. He further stated he knew it would take only a minute or two for a burn to occur with water temperatures at 136 °F. During an observation and concurrent interview with the MS, on April 12, 2019, at 9:58 AM, the MS stated he had turned the water temperature up for residents to shower and had forgot to turn the water temperature back down. He further stated the water temperature was turned up to 136 °F, from 6:00 AM to 8:30 AM. The MS stated he monitors the temperature of the water by the gauge in the boiler room. He stated he rarely monitored the water with a thermometer in individual resident rooms. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:15 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 135.7 °F. The surveyor viewed the thermometer reading for verification and the display showed 135.7 °F. The MS stated the water temperature should be between 105-120 °F and water temperatures above 120 °F could cause injury to the residents and staff. MS further stated he had been turning the water up to 136 °F since 2017. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:24 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The MS stated too hot. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:33 AM, in the boiler room, the MS stated the boiler room gauge was previously set at 136 °F but he recently adjusted the temperature back to 118 °F after the AMS had notified him of the water temperature findings. The MS demonstrated on the gauge where he set the temperature. He stated he would set the boiler temperature at 136-138 °F. The MS stated it was no determining factor about turning the temperature to 136 °F versus 138 °F, he stated those numbers were just the ones he had used. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:48 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 134.2 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.2 °F. The MS stated he did not know how long it took for the temperature of the water to reach 120 °F after turning the boiler/heater down. He stated the cooling of the water would depend on if the shower was in use or the hot water was being used. He further stated the water in the resident's sink could possibly burn a resident during shower time. During an observation and concurrent interview with the MS, on April 12, 2019, at 10:55 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 133.9 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.9 °F. The MS stated the water temperature was not safe. During an observation and concurrent interview with the MS, on April 12, 2019, at 11:05 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from room [ROOM NUMBER]'s bathroom sink and stated it was 134.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.8 °F. The MS stated he had not ever timed how long it took for the water temperature to reach a safe temperature in the residents' room after he had turned the water temperature back to 118 °F. During an interview with Resident 66, on April 12, 2019, at 11:25 AM, Resident 66 stated sometimes the water temperature in the shower gets too hot. Resident 66 further stated while showering, she has tried to turn the knob to balance the water temperature but due to weakness of her hands, she cannot balance the water temperature and would throw the nozzle away from her body to keep from being scalded. During an interview with Resident 75, on April 12, 2019, at 11:33 AM, she stated the water in the sink gets too hot. During an interview with Resident 51, on April 12, 2019, at 11:39 AM, she stated the water gets hot and the knobs are hard to turn due to her hand weakness. During an interview with the Registered Nurse Supervisor (RN/SUP) on April 12, 2019, at 11:50 AM, the RN/SUP stated contact with water temperatures in excess of 120 °F can cause burns within seconds. During a follow up interview with MS, on April 12, 2019, at 12:20 PM, the MS stated he would manually increase or decrease the water temperature on the water heaters/boilers. The MS stated he routinely overrode the automatic shutoff temperature control safety valve. He further stated if the temperature was set at 120 °F, when the temperature reached 120 °F, the boiler would shut off. The MS stated he knew the valve was a safety device but he would override the safety device to warm up the water quickly and had been doing so since January 2017. The MS stated he forgot to decrease the boiler temperature on April 12, 2019. The MS stated he could not explain how each resident was monitored to ensure there were no accidents when the water was turned up during shower time. During an interview with the ADMIN, on April 12, 2019, at 1:44 PM, the ADMIN stated the override of the water temperatures were very disappointing. She further stated she was not aware the water temperatures were being overridden at any time. Review of the facility policy and procedure titled Policy and Procedure on Patient's Safety dated October 2014, indicated Policy. It is the policy of this facility to provide services to each resident that will allow them to maintain their highest practicable level of function and well-being, without jeopardy to their safety. Review of the facility policy and procedure titled Maintenance Service dated December 2009, indicated Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards .j. Maintaining water temperatures daily in patient rooms and nursing areas M-F (selected areas on floor plan) maintaining the degrees between 105 degrees to 120 degrees. An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on April 12, 2019, at 1:38 PM, after water temperature readings taken from one common facility restroom sink and ten resident's bathroom sinks reached temperatures of up to 136.6 ° F. It was discovered a staff member of the facility manually overrode the automatic shutoff temperature control safety valve for the hot water and increased the water temperature of the heaters/boilers to 136 ° F for two and a half hours every day (between 6:00 AM and 8:30 AM). The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) , and the RN Supervisor (RN/SUP). A Corrective Action Plan (CAP-a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and was received on April 12, 2019, at 4:22 PM. A review of the CAP conducted on April 12, 2019, at 4:57 PM, indicated water heaters/boilers supplying hot water to shower rooms, common restrooms, and residents bathrooms, were returned or remained at a maximum temp of 120 °F and hot water temperature checks were to be taken every hour to ensure water temperatures were no longer a danger to residents. Residents were assessed for burns and/or scalding and the staff member who manually overrode the automatic shutoff temperature control safety valve, was given directives to never override the water safety valve. Additionally, an in-service was conducted with all staff members instructing them to report to the maintenance department, any water temperatures that feel too hot. During a follow up interview with the ADMIN, on April 15, 2019, at 9:46 AM, the ADMIN stated she was shocked the MS was manually adjusting the water temperature on the water heaters and increasing the temperature above the safety guidelines indicated by the state. She further stated it is not ok to override the automatic shutoff temperature control safety valve and increase the water temperature of the boilers because it can cause burns to the residents. During an interview with the ADON on April 15, 2019, at 10:18 AM, the ADON stated the water temperature in sinks and showers should always be between 105 °F and 120 °F. She further stated if the water exceeds 120 °F, it can cause burns to the residents. After the acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review the IJ was lifted on April 15, 2019, at 1:50 PM, in the presence of the ADMIN, ADON and RN/SUP.