**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R8's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), chronic pain, chronic kidney disease, dementia (a progressive mental disorder characterized by failing memory, confusion), muscle weakness, difficulty in walking, and neurocognitive disorder (dysfunction with ability to think and reason). R8's Annual Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R8 rejected care four to six days of the observation period and had wandering behavior which occurred one to three days of the observation period, and behavioral symptoms that had worsened. R8 had no functional range of motion impairment and used a walker and wheelchair. R8 was independent with bed rolling, sitting on the edge of the bed, and sit-to-stand transfers, and required set-up assistance with walking 10 to 50 feet. The MDS further documented R8 was frequently incontinent of urine and bowel. R8 had two or more non-injury falls and used bed and chair alarms daily. R8 also received scheduled pain medication and took an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), and an antiplatelet (medication used to slow blood from clotting). R8's Care Plan, dated 05/15/24, documented R8 was at risk for falls. The care plan direct staff R8 should have slipper socks on at night and a gripper strip placed beside the bed. The plan directed staff to ensure the alarm was with the resident at all times, functioning properly, plugged in and out of reach. The plan directed staff should strongly encourage the use of a call light, and keep the environment clutter-free with frequently used items within reach. R8 should use a wheelchair to go to meals. The Progress Notes and Investigation Notes documented the following falls: On 08/18/23 at 07:45 PM, staff were called to R8 rooms and found the resident sitting on the floor next to the bed. R8 reported he was getting up to go to the bathroom. The investigation, dated 08/19/23, documented the care plan was followed and remained appropriate, an exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 08/19/23 at 02:00 AM, R8's alarm sounded, and the resident was sitting on the floor next to the bed. R8 was incontinent of urine and reported he slipped on blankets. Staff assisted the resident to the bathroom. The investigation, dated 08/19/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 08/31/23 at 05:52 PM, R8's roommate told staff R8 had been leaving the bathroom, had a misstep, and fell. The facility failed to provide an investigation and the care plan lacked new resident-specific intervention related to the fall. On 09/10/23 at 11:13 AM, R8 reported heading to the bathroom and R8's feet got caught in the blanket causing the fall. The investigation, dated 09/20/23, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning. The care plan lacked a new resident-specific intervention related to the fall. On 10/03/23 at 04:20 AM, staff found R8 on the floor by staff. The note further documented the care plan was followed and the alarm was in place but did not sound when the resident got up. The investigation, dated 10/03/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 10/03/23 at 06:38 PM, R8 was lowered to the floor by staff while assisting to transfer to a wheelchair and fell onto his knees. The investigation, dated 10/03/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/06/23 at 03:30 AM, R8 had been getting up to use the bathroom and staff saw R8 lying on the floor. R8 reported he hit his head when he fell. The investigation, dated 11/06/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/15/23 at 03:29 PM, the nurse was called to R8 room where R8 fell onto his knees and then lowered himself onto his buttocks on the floor. R8 reported his knees were sore. The investigation, dated 11/15/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 11/19/23 at 02:16 AM, R8 got up to the bathroom, unplugged the bed alarm, and stood up. R8's roommate reported the fall and that R8 hit his head. The investigation, dated 11/19/23, documented the care plan was followed and remained appropriate, and the exit alarm was in place and functioning. The care plan lacked new resident-specific interventions related to the fall. On 12/29/23 at 03:41 PM, R8 was found on his hands and knees on the floor, leaning his head on his roommate's reclining chair. The investigation, dated 12/29/23, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 01/04/24 at 07:00 AM, R8 fell out of bed and the alarm sounded. The investigation, dated 01/04/24, documented the care plan was followed and remained appropriate, the exit alarm was in place and, functioning, and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 02/14/24 at 07:10 AM, R8 was sitting on the floor next to his bed. R8 reported he was getting up. The investigation, dated 02/14/24, documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning, and R8 was noncompliant with interventions. A care plan update, dated 02/22/24, documented R8 had a room change to be closer to the nurse's station. On 02/20/24 at 07:56 PM, R8 was found on his hands and knees, next to the bed. R8 reported he was getting out of bed. The investigation on 02/20/24 documented the care plan was followed and remained appropriate, the exit alarm was in place and functioning, and R8 was noncompliant with interventions. The care plan lacked new resident-specific interventions related to the fall. On 06/11/24 at 09:42 PM, observation revealed R8 remained in his room, in bed, leaning over to eat breakfast in bed. R8's bed was flat. R8 ate independently by leaning over to his left side. On 06/11/24 at 10:01 AM, Certified Nurse Aide (CNA) M reported to prevent falls for R8, staff were to make sure the alarms were in place. CNA M stated that R8 wore gripper socks and the staff checked on the resident frequently. On 06/12/24 at 10:08 AM, Licensed Nurse (LN) H reported staff could look over the care plan for intervention to prevent falls. LN H reported R8 had alarms which staff monitored to ensure function and properly placed. LN H verified R8 had numerous falls and the interventions were not changed and were not effective in preventing falls until R8 was moved closer to the nurse's station. On 06/12/24 at 04:02 PM, Administrative Nurse D verified new interventions should have been implemented to prevent falls for R8. Administrative Nurse D verified interventions were not always created or implemented. The facility's Falls-Clinical Protocol policy, dated 03/2018, documented the treatment and management the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling and also reconsider the current interventions. The facility failed to identify and implement interventions to prevent R8 from falling which placed the resident at risk of further falls and injuries. The facility had a census of 34 residents. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the facility failed to ensure water temperatures in areas with resident access and in Resident (R)18, R17, R25, R1, and R4's rooms remained at a safe temperature when temperatures above 140 degrees Fahrenheit (F) were recorded. This common area and sink were open to the center hallway and accessible to any independently mobile residents. The facility identified seven independently mobile, cognitively impaired residents. This placed twelve residents in immediate jeopardy. The excessively high hot water temperatures of 128-139 degrees F were also recorded in resident room sinks, placing an additional seven residents at risk for burns. The facility failed to identify and implement interventions to prevent R8 from falling which placed the resident at risk of further falls and injuries. Findings included: - On 06/12/24 at 07:53 AM, observation revealed the water temperature of the center living room/café area sink was 152.6 degrees F by surveyor thermometer. On 06/12/24 at 08:00 AM, Certified Nurse Aide (CNA) N obtained a facility thermometer and tested the sink at 161 degrees F and verified the temperature was too hot. On 06/12/24 at 08:05 AM, an assessment of other resident room sink water temperatures were performed to ascertain the extent of the problem. The following sink water temperatures were found: R18's room measured 147 degrees F. R4's room measured 143.4 degrees F. R17's room measured 139.2 degrees F. R7's room measured 138.2 degrees F. R20's room measured 129.8 degrees F. R9's room measured 129.4 degrees F. R8's room measured 129.2 degrees F. R2's room measured 129 degrees F. R22's room measured 128.5 degrees F. R21's room measured 129 degrees F. R27's room measured 124.5 degrees F. R11's room measured 122.4 degrees F. On 06/12/24 at 08:07 AM, Maintenance Staff U stated the water heater that runs the north resident rooms, north shower bathroom, and common area quit working a couple of days ago, 06/09/24. He stated he opened the valve to the laundry heater to go through the resident hot water heater system. After switching the line, he stated he tested the common area but did not document that and did not test the common areas or resident rooms daily while the line was coming from the laundry heater. On 06/12/24 at 08:30 AM, Administrative Staff A was informed of the hot water temperatures, and she reported the maintenance person stated he repaired the resident hot water heater on 06/11/24 but had not turned the valve to stop the laundry water heater hot water from going to the resident lines. On 06/12/24 at 9:24 AM, R18 stated he had not noted the water to be too hot. On 06/12/24 at 09:38 AM, R31 stated she had no problems with hot water being too hot to touch. On 06/12/24 at 09:40 AM, R22 stated she had not had any issues with the water being too hot. On 06/12/24 at 09:44 AM, R17 stated her bathroom sink water was scalding hot, every morning when the girls (CNAs) get her up, she warns them to be careful the hot water temperature is really hot, because they let it run for a while, and one of them put her hand underneath it and told her she was right it was very hot. On 06/12/24 at 09:30 AM, Licensed Nurse (LN) H stated she had not noted any issues with the water being too hot and would inform maintenance if she thought the water temperature too hot. She stated no staff nor residents had complained about the water being too hot. On 06/12/24 at 09:50 AM, Administrative Staff A stated the maintenance person informed her he checked water temperatures weekly but did not document them. On 06/12/24 at 04:45 PM to 05:00 PM, Re-check of water temperatures indicated the following: R17's room measured 149 degrees F. R4's room measured 144 degrees F. R25's room measured 150.3 degrees F. R28's room measured 139.6 degrees F. R1's room measured 141 degrees F. On 06/12/24 at 05:00 PM, surveyors notified the administrator who checked the temperatures and verified they were still too hot for some of the rooms. She contacted the maintenance person who informed her there was a separate water heater for those rooms. The administrator stated she would ensure the heater was turned down or off immediately. On 06/12/24 at 05:45 PM, Administrative Staff A obtained water temperatures from resident rooms and all temperatures were below 114.2 F. The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) recorded temperatures at 124 degrees F can cause a third-degree burn (serious burn which affects the outer layer of skin as well as the entire layer beneath and requires immediate medical attention) in three minutes of exposure; temperatures at 127 degrees F can cause third degree burn with one minute of exposure; temperatures at 133 degrees F can cause third-degree burn in 15 seconds of exposure, and water temperatures at 140 degrees F can cause a third-degree burn in five seconds of exposure. The facility's Safety of Water Temperatures policy, dated 12/2009, stated the tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and shower areas would be set to temperatures of no more than 120 F. Maintenance staff were responsible for checking thermostats and temperature controls in the facility and recording those checks in a maintenance log. Maintenance staff would conduct periodic tap water temperature checks and record the temperatures in a safety log. If hot water temperatures felt excessive to the touch staff were to report that to the immediate supervisor. On 06/12/24 at 11:26 AM, Administrative Staff A received the Immediate Jeopardy Template and was informed the facility's failure to ensure the environment remained free of accidents when unsafe hot water temperatures were found in the handwashing sink in R18, R17, R25, R1, and R4's room, placing the five residents in immediate jeopardy related to potential burns from the hot water. Unacceptably hot water was also found in seven other resident rooms placing the twelve affected residents at risk for hot water related burns and/or injuries. On 06/13/24 the surveyor verified the following corrective actions to remove the immediacy: Maintenance Staff U immediately adjusted the valve on the hot water line so the excessively hot water for the laundry would not go into the residential hot water line which was set at 120 degrees F. The water heaters were adjusted to maintain an acceptable level between 105-120 degrees F. Education was provided to the maintenance supervisor of the water temperature requirements and documentation of auditing water temperature. Accident education was assigned to all staff to be completed by 08:00 AM Monday 06/17/2024. Medical Director was notified. The scope and severity remained at the level of E, after removal of the immediacy.