**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the website accuweather.com, and review of the facility's policies, it was determined the facility failed to have an effective system to address an ongoing problem with its cooling system by ensuring the room temperatures were safely maintained between seventy-one (71) degrees Fahrenheit (F) and eighty-one (81) degrees F. The facility also failed to ensure a safe, comfortable and homelike environment was provided to residents for ten (10) of fifty (50) sampled residents (residents that had room temperatures taken), Resident #23, #34, #47, #77, #81, #86, #94, #101, #108, and #118. Interviews with staff from two (2) Heating, Ventilation, and Air Conditioning (HVAC) companies revealed they had been involved with repairing the air conditioning (a/c) system numerous times. Review of estimates from the two (2) HVAC companies revealed on 04/17/2023, an estimate for the replacement of two (2) a/c units was given; on 04/19/2023, an estimate of compressor replacement was given; and on 04/26/2023, another estimate of compressor replacement was given. Review of the invoices from the two (2) HVAC companies revealed on 05/26/2023, the North Unit a/c had a new leak repaired, and it took five (5) days for repair; and on 06/24/2023, the a/c unit on the South Unit was not working, and it took three (3) days for repair. Resident #101, with a diagnosis of Chronic Obstructive Lung Disease (COPD), was observed on 07/05/2023 sitting in bed with a reddened face and beads of sweat on his/her upper lip. Resident #101 stated he/she was having difficulty breathing. Resident #101's room, room [ROOM NUMBER], on 07/05/2023 at approximately 4:48 PM had a temperature of 85.4 degrees F; on 07/05/2023 at 6:16 PM, the room had a temperature near the hallway of 88.7 degrees F, and by the window the temperature was 91.3 degrees F. This was also Resident #81's room. Resident #23, with diagnoses of Multiple Sclerosis and Diabetes, was observed on 07/05/2023 sitting in a motorized wheelchair on the South Unit. The resident was slumped over, and his/her face was red. The resident stated his/her room, room [ROOM NUMBER], was on the North Unit, but it was too hot to be in the room. Resident #23's room, on 07/05/2023 at approximately 4:50 PM, had a temperature 82.7 degrees F. This was also Resident #34's room. Resident #94, with diagnoses of Alzheimer's Disease and Stroke, resided in room [ROOM NUMBER]. The resident's daughter stated, in an interview on 07/05/2023, she had recently bought a portable cooling unit for the resident's room because it was so hot. She stated she reported her concern with the hot temperatures to the Executive Director on 04/08/2023. Resident #77 and #108 both resided in room [ROOM NUMBER]. The residents' room, on 07/05/2023 at approximately 4:49 PM, had a temperature of 83.3 degrees F. Resident #86 and #47 both resided in room [ROOM NUMBER]. The residents' room, on 07/05/2023 at approximately 4:44 PM, had a temperature of 83.3 degrees F. Resident #118 resided in room [ROOM NUMBER]. The resident's room, on 07/05/2023 at approximately 4:40 PM, had a temperature of 81.3 degrees F. The facility's failure to have an effective system to ensure a safe, comfortable homelike environment for the residents, and the facility's failure to ensure room temperatures were safely maintained between seventy-one (71) degrees F and (81) degrees F, is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 07/05/2023 and was determined to exist on 04/17/2023 in the area of 42 CFR 483.10 Resident Rights F584 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/06/2023. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/08/2023. The State Survey Agency (SSA) validated removal of the IJ as alleged on 07/17/2023, prior to exit which lowered the scope and severity (S/S) to an E at 42 CFR 483.10 Resident Rights F584, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, dated 2023, revealed the facility would maintain comfortable and safe temperature levels. Per the policy, the facility should strive to keep the temperature in common resident areas between seventy-one (71) and eighty-one (81) degrees Fahrenheit (F). Review of the facility's policy titled, Resident Rights Policy, revised 12/2016, revealed residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility's policy, Resident Abuse Prevention, dated 2019, revealed neglect was the failure to care for a person in a manner which would avoid harm and pain or failure to react to a situation which might be harmful. Per the policy, neglect meant failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of an HVAC company estimate, dated 04/17/2023, revealed an estimate was given for Squirrel Cage replacement of (two) 2 units. Review of an HVAC company estimate, dated 04/19/2023, revealed an estimate for a compressor replacement. Review of the website, accuweather.com, revealed the highest outside temperature on 07/05/2023 was ninety-two (92) degrees F for the facility's location. The temperatures were taken by one (1) State Survey Agency surveyor using a digital infrared thermometer provided by the Office of Inspector General. 1. Review of Resident #101's medical record revealed the facility admitted the resident, on 04/23/2023, with diagnoses of Chronic Obstructive Lung Disease (COPD) and History of Tracheostomy. Review of Resident #101's Quarterly MDS Assessment, dated 03/22/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #101 on 07/05/2023 at 5:16 PM, revealed the resident was in his/her room (room [ROOM NUMBER]A)sitting in the bed. The resident's face was red, and he/she had beads of sweat on his/her upper lip. During interview with Resident #101 on 07/05/2023 at 5:16 PM, the resident reported he/she was having difficulty breathing due to the heat. 2. Review of Resident #81's medical record revealed the facility admitted the resident, on 11/10/2019, with diagnoses to include Dementia, Depression and Muscle Weakness. Review of Resident #81's Quarterly MDS Assessment, dated 05/08/2023, revealed the facility assessed the resident to have a BIMS score of eight (8) of fifteen (15), indicating the resident had moderate cognitive impairment. Observation of Resident #81 on 07/05/2023 at 5:18 PM, revealed the resident was lying in bed, clean and groomed. The resident was wearing a short sleeved gown and had a sheet over the lower extremities. Interview with Resident #81 on 07/05/2023 at 5:18 PM was attempted, but was not successful. The resident was asleep and did not wake when his/her name was called twice. The temperature of room [ROOM NUMBER], where Resident #101 and #81 resided, 07/05/2023 at 4:48 PM was 85.4 degrees F near the hallway and Resident #101's bed. However, the temperature of Resident #81's room area, whose bed was next to the window, on 07/05/2023 at 4:48 PM was 91.0 degrees F. The temperature of room [ROOM NUMBER], where Resident #101 and #81 resided, on 07/05/2023 at 6:16 PM, was 88.7 degrees F near the hallway, and by the window, the temperature was 91.3 degrees F. 3. Review of Resident #23's medical record revealed the facility admitted the resident, on 12/13/2022, with diagnoses of Multiple Sclerosis and Diabetes. Review of Resident #23's Quarterly Minimum Data Set (MDS) Assessment, dated 06/07/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Observation of Resident #23 on 07/05/2023 at 5:07 PM, revealed the resident was sitting in a motorized wheelchair on the South Unit. The resident was slumped over, and his/her face was red. During interview with Resident #23 on 07/05/2023 at 5:07 PM, the resident stated he/she had an autoimmune disease, and the heat made it terrible. The resident stated his/her room was on the North Unit, but it was too hot to be in his/her room. Further, the resident stated the staff had been putting ice in a double garbage bag, then in a pillowcase, and placing it around his/her neck. Resident #23 stated the excessive heat had been going on for a couple of months. 4. Review of Resident #34's medical record revealed the facility admitted the resident, on 07/29/2016, with diagnoses to include Alzheimer's Disease and Depression. Review of Resident #34's Quarterly MDS Assessment, dated 05/25/2023, revealed the facility assessed the resident to have a BIMS score of 6 (six) of fifteen (15), indicating the resident had severe cognitive impairment. The temperature of room [ROOM NUMBER], where Resident #23 and #34 resided, on 07/05/2023 at 4:55 PM, was 82.7 degrees F. 5. Review of Resident #94's medical record revealed the facility admitted the resident, on 07/13/2021, with diagnoses of Alzheimer's Disease, Renal Failure, and Stroke. Review of Resident #94's Quarterly MDS Assessment, dated 05/24/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating severe cognitive impairment. During interview with Resident #94's (resided in room [ROOM NUMBER]) daughter on 07/05/2023 at 5:30 PM, she stated she recently bought a portable cooling unit for his/her room because it was so hot, and they tried to keep the door closed to keep the room cool. She stated she reported her concern with the hot temperatures to the Executive Director on 04/08/2023. 6. Review of Resident #77's medical record revealed the facility admitted the resident, on 06/13/2022, with diagnoses to include Right Hip Joint Replacement, Polymyalgia Rheumatica, and Kidney Failure. Review of Resident #77's admission MDS Assessment, dated 06/11/2023, revealed the facility assessed the resident to have a BIMS score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. 7. Review of Resident #108's medical record revealed the facility admitted the resident, on 01/27/2023, with diagnoses to include Dementia and Heart Failure. Review of Resident #108's Quarterly MDS Assessment, dated 04/17/2023, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15), indicating severe cognitive impairment. The temperature of room [ROOM NUMBER] where Resident #77 and #108 resided, on 07/05/2023 at 4:50 PM, was 83.3 degrees F. 8. Review of Resident #86's medical record revealed the facility admitted the resident, on 03/10/2022, with diagnoses to include Heart Failure and Arthritis. Review of Resident #86's Quarterly MDS Assessment, dated 04/28/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. 9. Review of Resident #47's medical record revealed the facility admitted the resident, on 04/13/2022, with diagnoses to include Schizophrenia, Age Related Physical Debility, and Polyneuropathy. Review of Resident #47's Annual MDS Assessment, dated 05/22/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. The temperature of room [ROOM NUMBER], where Resident #86 and #47 resided, on 07/05/2023 at 4:46 PM, was 83.3 degrees F. 10. Review of Resident #118's medical record revealed the facility admitted the resident, on 06/28/2023, with diagnoses to include Stroke and Diabetes. Review of Resident #118's Five (5) Day MDS Assessment, dated 07/05/2023, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating intact cognition. The temperature of room [ROOM NUMBER], where Resident #118 resided, on 07/05/2023 at approximately 4:40 PM, was 81.3 degrees F. Observations on 07/05/2023 at approximately 5:00 PM revealed facility staff to be sweating with sweat beads to their foreheads During interview with State Registered Nurse Aide (SRNA) #13 on 07/13/2023 at 3:08 PM, she stated it had been hotter in the facility lately. She reported the facility would fix the air, and it would get better and then get worse again. She stated there were days when Resident #101 was sweating, and his/her face was red. She also stated Resident #64 told her he/she was hot and did not want the sheet to cover him/her. During interview with the North Unit Manager on 07/06/2023 at 2:38 PM, she stated she had been at the facility since 2009. She reported the air conditioner had gone out and would not work on both the North Unit and the South Unit at least once this year. She stated, to assist the residents when the air conditioner was not working, she had offered to move the residents, and she made sure the residents had plenty of water and ice. She stated she checked on the residents herself to make sure they had drinks and were not having any issues. During interview with the HVAC Account Manager on 07/07/2023 at 10:55 AM, he reported he had done maintenance on approximately ten (10) of the facility's a/c units in the past. During interview with the owner of another HVAC company on 07/07/2023 at 11:40 AM, he reported he had been contracted with the facility for about a month and a half. He stated the facility called him on 05/20/2023 due to an a/c problem. He stated he came to the facility on [DATE] and repaired the ten (10) ton unit that serviced Rooms 1 through 14 on the North Unit. He stated the a/c unit was not working from about 05/20/2023 to 05/26/2023. During further interview, he stated the a/c unit on the South Unit went out on 06/24/2023, and he finished the job on 06/27/2023. He stated an a/c unit usually lasted about twenty (20) years. During interview with the Director of Nursing (DON) on 07/06/2023 at 2:14 PM, she reported when the air conditioner was not working on the North Unit, on 07/04/2023, she offered to move the residents, but they declined. She stated a while back the air conditioner went out on the North Unit and was repaired the following day. The DON stated she did not do any training with the staff on how to assist the residents when the air conditioner was not working. She stated the air conditioner had gone out in the past few years. She stated the Executive Director (ED) talked with the Corporate Office about getting air conditioner units for the rooms without air conditioning, if the air conditioner did not get repaired. During interview with the ED, on 07/06/2023 at 3:00 PM, he stated he had been at the facility for ten (10) years. He stated the facility had experienced issues with air conditioning units every year since he had been at the facility. He stated he dreaded every year because there could be a problem with the air conditioner. He stated this year one (1) air conditioning unit was known to need replacement. He stated there were twelve (12) to fourteen (14) different air conditioner units. He stated some of the residents' rooms had air conditioner units in the wall. Further, he reported the temperatures increased in the facility as the day progressed. He stated he sent an email to the Regional Maintenance Directors, on 07/04/2023, when the air conditioner went out and stopped working. Further, he reported there were currently two (2) air conditioners not working, one (1) for the front lobby and one (1) for Rooms 14-28 on the North Unit. He stated maintenance personnel came on 07/05/2023, and it was expected the repairs would be completed by 07/05/2023. He stated additional fans were utilized on the morning of 07/05/2023. After he put the fans out, he stated, he and the DON checked on the residents. The ED stated he did not have a plan if the contracted company could not complete the repair other than to provide fans for the residents and hydration. Further, he reported he did not educate staff on hyperthermia. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/08/2023 as follows: 1. a) Resident #101, #23, and #94 were assessed for signs and symptoms of distress and heat exhaustion on 07/04/2023 by the Director of Nursing (DON) with documentation to include temperature, oxygen saturation, lung sounds, and current respiratory status. Assessment findings were negative for these residents. Respiratory assessments were completed for Resident #101, #23, and #94 twice by a Licensed Nurse on 07/05/2023, three (3) times by a Licensed Nurse on 07/06/2023, and once on 07/07/2023. All assessment findings were within normal limits (WNL) for these residents. The respiratory assessments consisted of body temperature, oxygen saturation, lung sounds, labored breathing, cough, respiratory symptoms, and gastrointestinal (GI) symptoms. All assessments from 07/04/2023 to 07/07/2023 were documented in the residents' Electronic Medical Record (EMR). Respiratory assessments were completed for the other residents that resided on the North 2 Unit, Rooms 14 to 28 by a Licensed Nurse on 07/04/2023 through 07/06/2023. No issues or concerns were noted for any resident residing on the North 2 Unit. Respiratory assessments were documented in each resident's electronic medical record. The respiratory therapist assessed each resident receiving oxygen or nebulizer treatments on the North 2 Unit on 07/05/2023. The respiratory therapist's observations revealed no residents with any noted distress, no residents with any increased need for oxygen supplementation or nebulizer treatments, and no noted changes in the residents' overall health status. b) Resident #101 and #23 were offered a room change by the DON on 07/04/2023 and 07/05/2023, and the residents declined. Resident #94 was not offered a room change by the DON because the resident's room already had a portable a/c unit in place. On 07/04/2023 and 07/05/2023, the DON offered temporary room changes to the all residents on the North 2 Unit, Rooms 14 to 28. Only one (1) resident accepted the room change. c) Review of Resident #101's, #23's, and #94's voiding patterns was completed on 07/04/2023 to 07/06/2023 by the Executive Director (ED). The review revealed the residents voided each shift on 07/04/2023, 07/05/2023, and 07/06/2023. These findings were similar to the residents' baseline voiding patterns. Resident #101, #23, and #94 had no signs or symptoms of dehydration. The ED the DON reviewed all other residents residing on the North 2 Unit, on 07/04/2023 to 07/06/2023, for their voiding patterns. No concerns were noted, and the voiding patterns were noted to be similar to the residents' baseline voiding patterns. d) Resident #101, #23, and #94 verbalized no complaints or concerns to the ED or DON, who followed up with these residents on 07/04/2023, 07/05/2023, 07/06/2023, and 07/07/2023. e) The Executive Director and Director of Nursing reviewed the residents' activities participation record for 07/04/2023, 07/05/2023, and 07/06/2023 revealing a normal activities pattern for residents. f) The ED, DON, Licensed Nurses, and State Registered Nurse Aides (SRNA), for residents on the North 2 Unit, from 07/04/2023 to 07/06/2023, encouraged fluids, offered to close blinds in rooms, dressed residents in light clothing, and checked residents for appropriate/light bed linen. g) The plan of care was reviewed and revised for each resident that resided in Resident Rooms 14 to 28 for 07/04/2023 through 07/06/2023. 2. a) Each resident in Rooms 14 to 28 were provided with a fan on the afternoon of 07/04/2023. On the morning of 07/05/2023 at approximately 11:30 AM, the ED purchased additional fans to ensure that each resident had a fan. b) On 07/04/2023 at approximately 6:40 PM, the DON made rounds and assessed residents in Rooms 14 to 28 on the North 2 Unit, where the a/c unit required repairs and was not working. No residents were noted with any distress. All resident rooms had fans in place. In addition, the DON completed a temperature check of the hallway and resident room temperatures, with all being noted in the 75 to 76 degree F range. c) Temperature checks were obtained from 07/04/2023 through 07/06/2023 of the North 2 Hall and Resident Rooms 14 to 28 beginning at 6:40 PM on 07/04/2023, and again at 10:00 PM on 07/04/2023. Temperature checks were obtained on 07/05/2023 at 7:40 AM, 8:56 AM, 9:42 AM, 10:36 AM, 11:50 AM, 1:10 PM, 2:40 PM, 3:50 PM, 4:25 PM, 6:10 PM, 8:30 PM, and 10:15 PM. On 07/06/2023 were done at 12:30 AM, 7:20 AM, 12:05 PM, 4:00 PM, and 10:05 PM. d) On 07/04/2023 at approximately 9:40 PM, the Maintenance Supervisor contacted a contractor specializing in heating and cooling (HVAC) related to family concerns about a resident's room temperature. The ED emailed the Regional Maintenance Supervisors, on 07/04/2023 at approximately 11:29 PM, informing them of the current a/c issues and inquiring about obtaining mobile cooling units in the event repairs could not be made timely. On 07/04/2023, the HVAC contractor recommended to turn off the heating/air unit as he thought it might be freezing. This action was completed by the DON, at approximately 10:00 PM. The contractor stated to turn the unit on again at 3:00 AM, after a few hours being off. This was done by the Charge Nurse on duty. e) On the morning of 07/05/2023 at approximately 7:40 AM, the North 2 Hallway and random room temperatures were obtained by the ED, which ranged from 74 to 77 degrees F. The ED determined that the a/c was still functioning below capacity, notified the HVAC representative, and was informed the company would be onsite on 07/05/2023 to diagnose and make repairs. f) On 07/05/2023 at approximately 11:00 AM, HVAC technicians arrived at the facility and began repairs. On 07/05/2023 at approximately 6:45 PM, the ED was notified by the HVAC company that the a/c repair would not be able to be finished today as previously stated and that the repairs would be finished on 07/06/2023. The delay was because the company could not obtain the amount of refrigerant needed for the repair. The facility's plan to purchase air conditioner (a/c) units for each room was then activated. The DON purchased twelve (12) window a/c units at approximately 8:00 PM, and each resident on the North 2-Unit was offered a window a/c unit. The residents in room [ROOM NUMBER] declined the a/c unit. g) The affected a/c unit was repaired (affecting Rooms 14 to 28) on 07/06/2023 at approximately 4:00 PM. All a/c units in the facility were inspected by the HVAC contractor on 07/05/2023 and 07/06/2023 with no other affected units identified. 3. A Resident Council meeting was held on 07/05/2023 with no concerns/issues noted related to the a/c unit requiring repair or facility temperatures (Resident Rooms 14 to 28). 4. a) All care team members including nursing, contracted therapy, housekeeping/laundry, and dietary were educated on 07/07/2023 on the Emergency Operations plans, with loss of cooling, residents rights, signs and symptoms of hyperthermia, dehydration, heat exhaustion, safe/homelike environment, acceptable temperatures (temperatures between 71-81 degrees F) for the facility, and grievances. The education was given by the ED, DON, the Assistant Director of Nursing (ADON), or the Infection Preventionist. No care team member would be permitted to work until education was completed. Staff members on vacation could receive the education over the phone, and department managers were notified on 07/06/2023 to review work schedules and schedule education for those staff members not currently working on 07/06/2023 or 07/07/2023. All new hire care team members would receive the education described above in orientation. The Maintenance Director was educated by the ED on 07/07/2023 to complete temperature checks on all areas of the facility including hallways and resident rooms daily for two (2) weeks. The ED and/or DON could assist with temperature monitoring. b) Routine HVAC service checks would be completed monthly on all units by an HVAC company beginning August 2023. c) Resident room temperatures would be emphasized/discussed in the daily (Monday-Friday) Magic Moment program (facility internal program utilization for quality improvement purposes by the Interdisciplinary Team, consisting of the ED, DON, ADON, Infection Preventionist/Staff Development Coordinator (IPSD), Dietary Manager, Social Services Director, MDS Coordinator, Maintenance Supervisor, Medical Records Coordinator, and Registered Nurse (RN) Unit Managers. d) Post tests would be conducted for care team members on Emergency Operations plans with loss of cooling, resident rights, signs and symptoms of hyperthermia, dehydration, heat exhaustion, safe/homelike environment, and grievances. The IPSD would conduct the post tests weekly for one (1) month and then monthly for three (3) months to ensure retention of the education. The IPSD/ADON would forward the post tests the Quality Assurance Committee for review by Executive Director or Director of Nursing. The Quality Assurance Performance Improvement (QAPI) Committee consisted of the ED, DON, ADON, IPSD, Social Services, Dietary Manager, RN Unit Managers, MDS Coordinators, Maintenance Supervisor, Medical Records Coordinator, and the Medical Director. 5. a) An ad hoc QAPI Committee meeting was held on 07/07/2023 with the ED, DON, Medical Director, Regional [NAME] President, Director of Social Services, ADON, IPSD, and MDS Coordinator present. The meeting reviewed a plan of action, education, audit tools being performed by the facility regard the alleged deficiencies. An ad hoc QAPI meeting would be held weekly for four (4) weeks by the ED and the DON. b) After the initial daily air temperature monitoring for two (2) weeks, air temperatures of random resident rooms, hallways, and other areas of the facility would be conducted weekly for one (1) month and then monthly for three (3) months by the ED, the DON, or the Maintenance Supervisor. Emergency Preparedness drills, specifically loss of cooling, would be completed weekly for one (1) month and then monthly for three (3) months. The results would be forwarded to the QAPI committee by the Maintenance Director or the ED. The State Survey Agency (SSA) validated removal of the IJ on 07/08/2023, as alleged by the facility, as follows: 1. a) Review of respiratory assessment forms for Resident #101, #23, and #94 revealed there was documentation that indicated assessments were completed for 07/04/2023, 07/05/2023, 07/06/2023, and 07/07/2023 regarding signs and symptoms of distress and heat exhaustion. The assessments included temperature values, oxygen saturation, lung sounds, and current respiratory status. No abnormal assessment values were noted. Review of respiratory assessment forms for the residents that resided in Rooms 14 to 28 revealed lungs clear, no shortness of breath, and oxygen levels WNL, except for residents residing in room [ROOM NUMBER]B, room [ROOM NUMBER]A, and room [ROOM NUMBER]B, who refused an assessment but had no signs/symptoms of distress. Observations on 07/06/2023 initiated at 10:10 AM of Residents #46, #38, #101, and #23, all residents of North 2 Unit, Rooms 14 to 28, revealed no respiratory distress. Review of resident assessment forms done on 07/05/2023 and 07/06/2023, revealed there were no concerns noted per documentation for residents residing in Rooms 14A, 14B, 15A, 15B, 16A, 16B-EMPTY, 17A, 17B, 18A, 18B EMPTY, 19A, 19B, 20A, 20B, 21A, 21B, 22A, 22B, 23A, 23B, 24A, 24B, 25A, 25B, 26A, 26B, 27A, 27B, 28A EMPTY, and 28B. Review of an attestation letter, undated and signed by the ED and the DON with no signature date, revealed no resident declines were reported on 07/04/2023, 07/05/2023, and 07/06/2023. Review of a signed statement from the Respiratory Therapist, dated 07/06/2023, attested no residents were in any distress or had an increased need for oxygen, and there were no changes in their health status. Observations on 7/05/2023 initiated at approximately 9:00 AM, revealed residents in Rooms 9, 19, 23, and 27 had oxygen therapy and appeared in no distress. b) Review of an attestation letter dated 7/04/2023 at 5:10 PM, confirmed the DON offered residents room changes on 07/04/2023, including Resident #101, #23, and #94. Further review revealed Resident #101, #23, and #94 declined the offer. In an interview with the DON on 07/06/2023 at 2:14 PM, she verified room changes were offered. In an interview with the ED on 07/06/2023 at 3:00 PM, he stated room changes were offered to residents but they had declined. In an interview with Resident #101 on 07/05/2023 at 4:48 PM, the resident stated he/she was offered a room change on 07/04/2023 and 07/05/2023 and declined offer the offer. Resident #46 stated in an interview on 07/07/2023 at 10:37 AM, that a room change was offered, but he/she declined. c) Review of resident output records revealed Resident #101's, #23's, and #94's assessment by the ED of their voiding patterns was completed on 07/04/2023, 07/05/2023, 07/06/2023, with no signs or symptoms of dehydration noted. Review of resident output records revealed voiding pattern assessments for the other residents on the North 2 Unit, on 07/04/2023, 07/05/2023, and 07/06/2023 and done by the ED and DON, showed no concerns for dehydration. d) In an interview with Resident #101 on 07/06/2023 at 9:45 AM, the stated an a/c unit had been placed last night and the temperature was better now. Observation during the interview revealed the resident had drinks at the bedside on the overbed table, and an a/c unit was in the window. Review of a written statement/follow-up on Resident #23 on 07/04/2023, 07/05/2023 and 07/06/2023 revealed the follow-up was performed by the ED and the DON. The statement revealed Resident #23 had no complaints or concerns for air temperatures. In an interview with Resident #23 on 07/06/2023 at 10:00 AM, he/she stated the room temperature was adequate. The resident also stated he/she had experienced no declines and did not report the room temperature being hot. Observation, during the interview, revealed Resident #23 was covered in a blanket. In an interview with Resident #94's daughter, on 07/05/2023 at 5:50 PM, she stated the family had purchased an a/c unit about three (3) weeks ago. She also stated the resident had not experienced any decline in health. Observation of Resident #94's room temperature on 07/05/2023 at 5:40 PM, revealed it was within the acceptable temperature range of 71 degrees F and 81 degrees F. and the daughter reported no health declines of her mother. e) Review of Resident #101's Activity Participation Record for 07/04/2023, 07/05/2023, and 07/06/2023 revealed Resident #101 attended activities on both 07/05/2023 and 07/06/2023. On 07/05/2023, the resident attended Current Events and Tablet, Laptop Technology at 11:01 AM. On 07/06/2023, the resident attended the Social at 12:25 PM and Family/Friends Visit at 5:39 PM. Review of activities records for Resident #23 per a notation on the Legend Report, revealed Resident #23 had refused, or was out of the facility, for activities from 07/04/2023 through 07/06/2023. Review of Resident #94's Activity Participation Record for 07/04/2023, 07/05/2023, and 07/06/2023 revealed Resident #94 attended activities on both 07/05/2023 and 07/06/2023. On 07/05/2023, the resident attended Music/Singing/Dance/Memory and Social at 11:00 AM, Reminiscing/Life Reflection at 3:51 PM, and Family/Friends Visit at 7:47 PM. On 07/06/2023, Resident #94 attended the Social at 10:48 AM, Religious Bible Study at 3:45 PM, and Exercise/Walking/Senior Fitness at 3:54 PM. Re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The State Survey Agency (SSA) Surveyor, on 07/15/2023, requested the facility's policies on safety and supervision of residents, as well as a policy on the use of mechanical lifts. However, the facility did not provide those policies. Review of the facility's maintenance logs revealed the Maintenance Director inspected the EZ Way Sit-to-Stand lift (brand of lift that assist residents to stand) on 05/18/2023 and 06/21/2023, but marked the section, Check foot platform assembly pins on sit to stand to assure they have to pushed in and still engage into base, as NA, or not applicable. Review of Resident #1's admission Record revealed the facility admitted the resident, on 11/01/2012, with diagnoses including Multiple Sclerosis, Diabetes with Diabetic Neuropathy, and Anxiety Disorder. Review of Resident #1's Annual Minimum Data Set Assessment, dated 05/12/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring extensive assistance of a two (2) person physical assistance for transferring from wheelchair to bed. Review of Resident #1's care plan, revised 07/07/2023, revealed the facility assessed Resident #1 to require a sit-to-stand lift with at least one (1) staff assist to transfer. Observation on 07/10/2023 at 4:15 PM, revealed State Registered Nurse Aide (SRNA) #4 and SRNA #8 using a sit-to-stand lift to transfer Resident #1 from his/her wheelchair to his/her bed. Further observation revealed the footplate of the lift was crooked, with the right side of the footplate lower than the left side. In an interview on 07/10/2023 at 4:25 PM, SRNA #4 stated she had not noticed that the footpad of the lift was crooked. She stated she would place an out of order sign on the lift so it would not be used with another resident because it might be unsafe. SRNA #4 stated inspection of the lifts was performed by the Maintenance Director. However, she did not know how often the inspections were performed. The SSA was unable to interview the Maintenance Director, as the facility had terminated his employment during the survey. In an interview on 07/16/2023 at 10:21 AM, the Assistant Director of Nursing (ADON) stated she expected staff not to use a lift that appeared to be in disrepair and to notify management immediately. In an interview on 07/17/2023 at 3:15 PM, the Director of Nursing (DON) stated she expected staff to inspect mechanical lifts before use with a resident to ensure the lift was in good working order and place an out of order sign on the lift if it was not. She stated staff should put the lift out of order on the lift. The DON stated it was important because if there was a problem residents could be hurt if parts of the lift were loose or not in the correct placement. The DON stated she had personally inspected the sit-to-stand lift that SRNA #4 had shown her with the crooked footplate. She explained that the footplate was designed to come off the lift for cleaning and had pins that held it in place. Per interview, the DON stated she inserted the pins in the correct slots and ensured all pieces were in working order before returning the lift to service. The DON stated the Maintenance Director inspected mechanical lifts once per month. She stated she could not explain why the Maintenance Director had marked NA for inspecting the pins of the footplate in the inspections completed on 05/18/2023 and 06/21/2023. In an interview on 07/17/2023 at 5:06 PM, the Executive Director (ED) stated it was his expectation that staff would place a mechanical lift with a loose piece, out of order, because using equipment in poor condition could hurt a resident. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/13/2023 as follows: 1. a) A new thermostat was placed on the affected hot water heater on 07/11/2023 at approximately 9:40 PM by the Maintenance Director. Water temperatures were checked and documented in every resident room, sink, and shower room in the facility on the evening of 07/11/2023 at approximately 10:00 PM by the Maintenance Director and ED. b) A body audit was completed on every resident by the DON, Assistant Director of Nursing (ADON), or Infection Preventionist/Staff Development Coordinator (IPSD) on 07/11/2023 with no skin issues related to water temperatures. Resident interviews were also conducted for each resident able to communicate, and had a Brief Interview for Mental Status of eight (8) and higher regarding water temperatures. No resident reported any uncomfortable water temperatures. 2. a) All staff including nursing, contracted therapy, housekeeping/laundry, and dietary would be educated by the DON, ADON, or IPSD regarding the facility's policy on Safe Water Temperatures, with acceptable water temperature ranges (not to exceed 110 degrees F). The education would also include actions to complete if the water felt hot to the touch, such as using the facility provided digital thermometer available at each nurses' station to immediately take the water temperature. Education began on 07/11/2023 with no care team member being permitted to begin working prior to completing education. All new hire staff would receive the education described above in orientation prior to working. b) The Maintenance Director received individual one-to-one (1:1) education on 07/11/2023 by the ED regarding the facility's policy on Safe Water Temperatures, with acceptable water temperature ranges (not to exceed 110 degrees F). He was also educated on immediate actions to complete if any water temperature was found out of range or any equipment needed repair, as well as immediately communicating this to the ED. c) Water temperatures for the last thirty (30) days in four (4) resident rooms on each of the two hallways in the facility was completed by the ED on 07/11/2023. No water temperatures exceeding 110 degrees F or out of range temperatures were found. d) An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was held on 07/11/2023 with the ED, DON, MDS Coordinator, Central Supply/Scheduler, Maintenance Director, Director of Medical Records, and Director of Social Services. The meeting reviewed actions, education, and audit tools being used by the facility regarding the alleged deficiency. e) A contracted plumbing service inspected all water heaters/thermostats to ensure they were in good working order and provided any additional repairs as needed on 07/12/2023. f) A follow-up Resident Council meeting would be held on 07/12/2023 where participants would discuss the Safe Water Temperatures policy. The meeting would update the participants on the recent repairs to the hot water management system. 3. a) Water temperatures would be checked daily in four (4) resident rooms on each of the two hallways in the facility for one (1) week beginning on 07/11/2023, then moved to three (3) times per week for one (1) month, if no out of range temperatures reported. b) Post test questionnaires would be completed to ensure that the education provided was effective. Five (5) questionnaires/interviews would be completed daily (Monday-Friday) for one (1) month; then two (2) times a week for two (2) weeks; and then monthly for two (2) months. The post test questionnaire would be given by the Assistant Director of Nursing, Infection Preventionist/Staff Development, Director of Social Services or Director of Nursing who would forward results to the Quality Assurance Committee for review. This would begin on 07/11/2023. c) Water temperatures would be discussed at the monthly Resident Council meeting beginning August 2023. d) An ad hoc QAPI meeting would be held weekly for four (4) weeks, starting 07/07/2023. The State Survey Agency validated the IJ Removal Plan. The validation verified that the immediacy was removed on 07/14/2023, instead of 07/13/2023 as alleged. The water temperatures on 07/13/2023 remained elevated above acceptable levels. 1. a) Review of a signed statement, undated, from the ED revealed a new hot water heater thermostat was placed on the North Unit water heater, on 07/11/2023 at approximately 9:40 PM, by the Maintenance Director. Observation of the North Unit water heater's new thermostat was made on 07/17/2023 at 5:47 PM. Review of the water temperature log dated 07/11/2023 at 9:55 PM, revealed the facility had the water temperatures recorded for all residents' room's sinks and showers. The log revealed the water temperatures ranged from 103 degrees F to 110 degrees F, in the acceptable range. In an interview on 07/17/2023 at 2:11 PM with the ED, he confirmed he was with the Maintenance Director on 07/11/2023 and checked water temperatures in all residents' rooms and shower rooms. b) Review of the body audit skin assessments conducted by the DON and the ADON on all residents in the facility, dated 07/11/2023, revealed there were no skin issues related to water temperatures. Review of the Resident Roster list, dated 07/11/2023, revealed Brief Interview for Mental Status (BIMS) scores of all residents. All residents with a BIMS' score of eight (8) to fifteen (15) and were interviewable were interviewed on 07/11/2023 with their statements recorded. The statements revealed no reports of uncomfortable water temperatures mentioned by the residents. Review of a signed statement from the ED, undated, revealed residents with a BIMS' score of eight (8) to fifteen (15) were interviewed by him on 07/11/2023 regarding water temperature. No resident had reported any uncomfortable water temperatures. During an interview on 07/17/2023 at 2:11 PM, the ED stated he interviewed all residents with a BIMS' score of eight (8) to fifteen (15), and there were no reports of uncomfortable water temperatures. 2. a) Review of a staff roster sheet titled,Water Temperature Education, dated 07/10/2023, revealed all staff were listed and checked as receiving education on 07/10/2023 and 07/11/2023. Any new staff will be educated before starting work. A document titled, Education was attached to the staff roster with the education topics listed, including acceptable water temperatures of 110 Fahrenheit or below; and actions to complete if the water felt hot to the touch, such as keeping residents safe by removing them from the area if applicable; testing the water temperature with a facility provided thermometer; turning off the water under the sink if the temperature exceeded 110 degrees Fahrenheit, and notifying the supervisor on duty immediately so maintenance staff and the ED could be notified. In an interview on 07/17/2023 at 8:39 AM with the DON, she confirmed she assisted the ADON and the IPSD with providing water temperature education to all staff before they began their shifts. All staff members, including agency staff, were provided education before their shifts began. In an interview on 07/17/2023 at 10:06 AM, Licensed Practical Nurse (LPN) #11 stated the DON provided her education regarding water temperatures, water thermometers, and to whom to report abnormal water temperatures. In an interview on 07/17/2023 at 1:19 PM, Housekeeper #1 stated last week, before she started work, she had training on water temperatures, what to do if they were too hot, and to whom to report too hot water temperatures. In an interview on 07/17/2023 at 1:32 PM, Registered Nurse (RN) #1 stated she had a training on water temperatures last week before she could begin work. She stated the training included the safe water temperature range, and the thermometer at the nurses' station would be used to check water temperatures. RN #1 stated she was educated, if the water was too hot, to turn off the water. She stated she also learned to whom she was to notify about the water being too hot. In an interview on 07/17/2023 at 10:00 AM, State Registered Nurse Aide (SRNA) #28 stated she was provided safe water temperature education from the ADON last week before she could begin her shift at work. She stated she learned if the water temperature felt too hot in the resident's room, she would turn it off and report it immediately to the supervisor. In an interview on 07/17/2023 at 2:11 PM, the ED stated all new staff members would receive training and education regarding safe water temperatures in orientation before the start of their shift. b) Review of a statement, dated 07/11/2023 and signed by the Executive Director, revealed the statement documented the Maintenance Director received one-to-one (1:1) education regarding the facility's policy on safe water temperatures. The ED stated the educational content was acceptable water temperatures were not to exceed 110 degrees F. The educational content also included immediate actions to complete if any temperatures were found out of range or any equipment needed repair, as well as communicating this to the ED. c) Review of the Logbook Documentation Water Temps, dated 06/07/2023, revealed water temperatures on the North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 109 degrees F; and North Hall room [ROOM NUMBER] at 109 degrees F. Further review revealed South Hall water temperatures for room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/15/2023, revealed water temperatures on North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 108 degrees F; and North Hall room [ROOM NUMBER] at 109 degrees F. Further review revealed the South Hall water temperatures for room [ROOM NUMBER] at 110 degrees F; South Hall room [ROOM NUMBER] at 110 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/22/2023, revealed water temperatures on the North Hall room [ROOM NUMBER] at 109 degrees F; North Hall room [ROOM NUMBER] at 110 degrees F; North Hall room [ROOM NUMBER] at 108 degrees F; and North Hall room [ROOM NUMBER] at 108 degrees F. Further review revealed the South Hall water temperatures for room [ROOM NUMBER] at 108 degrees F; South Hall room [ROOM NUMBER] at 109 degrees F; South Hall room [ROOM NUMBER] at 108 degrees F; and South Hall room [ROOM NUMBER] at 109 degrees F. Review of the Logbook Documentation Water Temps, dated 06/29/2023, revealed water temperatures on the North Hall Rooms #1, #10, #19, #28 were all within the normal temperature range. Further review revealed the South Hall water temperatures for Rooms #29 at 110 degrees F; South Hall room [ROOM NUMBER], #47 and #56 were all within the normal range. Review of the Logbook Documentation Water Temps, dated 07/04/2023, revealed water temperatures on the North Hall Rooms #1, #10, #19, #28 were within normal range. Further review revealed the South Hall water temperatures for Rooms #29, #38, #47 at 110, #56 were within the normal range. d) Review of the Ad hoc QAPI Meeting Attendance Form, Discussed IJ Removal Plan for F689 Quality of Care, dated 07/11/2023, revealed the ED, DON, Minimum Data Set Coordinator, Central Supply/Scheduler, Maintenance Director, Director of Medical Records, and the Director of Social Services, attended the meeting. Further review revealed an education sheet regarding safe water temperatures, actions to take for unsafe water temperatures, and audit tools used to include temperature logs and performed by the facility regarding the alleged deficiency. e) Review of a receipt from a plumbing company, dated 07/12/2023, revealed the job detail of hot water was too hot, and the facility wanted water heaters inspected and to also check the mixing valves. In an interview on 07/17/2023 at 2:11 PM with the ED, he confirmed the contracted plumbing company did inspect all water heaters and thermostats on 07/12/2023. He stated the contracted plumbing company ensured the thermostats were in good working order and provided any repairs that were needed. f) Review of the Resident Council meeting minutes, dated 07/12/2023, revealed Residents #41, #1, #4, #29, #18, #59, #42, #15, #49, #91, and #31 attended. Further review revealed the residents that attended were updated on the current hot water situation, safe water temperatures, and recent repairs to the hot water management system. 3. a) Review of Water Temperature Observations, dated 07/12/2023, revealed all resident room water temperatures were recorded at 9:40 AM. The temperatures ranged from 96 degrees F to 110 degrees F. Review of the Water Temperature Observations, dated 07/13/2023, revealed all residents' room water temperatures were recorded at 7:30 AM. The temperatures ranged from 100 degrees F to 109 degrees F. Review of theWater Temperature Observations, dated 07/14/2023, revealed all resident room water temperatures were recorded at 7:20 AM. The temperatures ranged from 102 degrees F to 109 degrees F. Review of the Logbook Documentation Water Temps, dated 07/15/2023, 07/16/2023 and 07/17/2023 revealed water temperatures for taken for the North Hall and South Hall rooms were within normal range. Observation on 07/17/2023 at 4:28 PM of the ED, revealed he was checking water temperatures in resident rooms. Review of a binder containing post tests, revealed post tests regarding safe water temperature were given to five (5) different staff members on 07/11/2023, 07/12/2023, 07/13/2023, 07/14/2023, and 07/17/2023. In an interview on 07/17/2023 at 8:39 AM, the DON stated that she administered the post test questionnaire to staff and forwarded the results to the QAPI Committee for review. She stated she reviewed them immediately with staff to address any questions or concerns. Based on observation, record review, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident hazards related to water temperatures outside the acceptable range for thirty-two (32) of one hundred ten (110) residents (Resident #94, #64, #98, #25, #16, #46, #90, #69, #108, #77, #60, #107, #95, #85, #414, #53, #99, #68, #34, #36, #54, #15, #73, #71, #100, #26, #21, #70, #31, #91, #9, and #164). Observation of water temperature checks on 07/10/2023 beginning at 4:43 PM, revealed water temperatures in Rooms 14, 15, 16, 19, 20, 23, 29, 48, 49, and 50 were not within the acceptable parameters for ensuring resident safety. The water temperatures ranged between one hundred twelve (112) degrees Fahrenheit (F) and one hundred twenty (120) degrees F. The water temperatures were taken utilizing a metal Bi-Therm hand held thermometer with a dial gauge. In an interview with the Maintenance Director (MD) on 07/10/2023 at 6:10 PM, he stated water temperatures were checked weekly in showers and random rooms; the thermostat was broken; and he was going to replace it with a dial type thermostat. However, during an interview with the Maintenance Director on 07/11/2023 at 6:12 PM, he stated the thermostat had not been replaced. In an interview with the Executive Director (ED) on 07/11/2023 at 7:25 PM, he stated he was made aware of problems with water temperatures on the evening of 07/10/2023. He stated a resident could be burned if the water temperature was too hot. The facility's failure to ensure water temperatures remained at safe levels is likely to cause serious injury, serious harm, serious impairment, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 07/11/2023 and was determined to exist on 07/10/2023 in the area of 42 CFR 483.25 Quality of Care F689 at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 07/11/2023. The facility provided an acceptable IJ Removal Plan on 07/14/2023 alleging removal of the IJ on 07/13/2023. However, on 07/13/2023 some water temperature readings were above the acceptable level. The SSA validated removal of the IJ on 07/14/2023, prior to exit on 07/17/2023, which lowered the scope and severity (S/S) to an E at 42 CFR 483.25 Quality of Care F689, while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. In addition, observation of staff using a sit-to-stand lift for one (1) of forty-four (44) sampled residents, Resident #1, on 07/10/2023, revealed the facility failed to provide a safe environment by staff using one (1) of the four (4) lifts that had an improperly maintained and crooked footplate. The findings include: 1. Review of the facility's policy titled, Safe Water Temperatures, dated February 2023, revealed the facility was to maintain appropriate water temperatures in resident care areas. The policy stated direct care staff would monitor residents' prolonged exposure to warm or hot water for any signs or symptoms of burns and respond appropriately. It stated staff members were to be educated on safe water temperatures, and thermometers would be available as needed by staff. Continued review revealed staff would report any abnormal findings such as complaints of water being too cold or too hot, burns, or redness. Per the policy, additional problems for staff to report were reddened areas to the residents' skin that were painful to the touch. The policy stated these abnormal findings were to be reported to the supervisor or maintenance supervisor. Continued review revealed water temperatures were to be no more than one hundred ten (110) degrees F or the state's allowable maximum water temperature. Per the policy, maintenance staff would check water temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. Additional review revealed documentation of testing would be kept for three (3) years and kept in the maintenance office. Observation on 07/10/2023 at 4:36 PM, revealed the hot water in Resident room [ROOM NUMBER] felt painfully hot to the touch. Observation on 07/10/2023 at 4:43 PM, revealed the hot water temperature in Resident room [ROOM NUMBER] measured 118 degrees F. Continued observations on 07/10/2023 for water temperature checks initiated at 6:07 PM, revealed water temperatures were between 112 degrees F to 120 degrees F for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50. Additional observations for water temperatures on 07/12/2023 with checks initiated at 9:05 AM, revealed water temperatures were between 98 degrees F to 116 degrees F for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50. Continued observations on 07/13/2023 for water temperature checks initiated at 2:36 PM, revealed water temperatures were between 112 degrees F and 120 degrees F for Resident Rooms 29, 47, 48, 50. There was no hot water for Resident Rooms 14, 15, 16, 20, and 23. Observations initiated at 2:20 PM on 07/14/2023 revealed water temperatures were between 92 degrees F and 98 degrees F for Resident rooms [ROOM NUMBER]. There was no hot water for Resident Rooms 14, 15, 16, 19, 20, and 29. Observations initiated at 4:00 PM on 07/15/2023 for Resident Rooms 14, 15, 16, 19, 20, 23, 29, 47, 48, and 50 revealed water temperature ranges between 94 degrees F and 110 degrees F. Continued observations for water temperatures on 07/16/2023 initiated at 9:12 AM, revealed water temperatures between 96 degrees F and 106 degrees F for Resident Rooms 14, 15, 16, 19, 20, 29, 47, 48, and 50. In an interview on 07/10/2023 at 4:36 PM, Resident #26 (lived in room [ROOM NUMBER]) stated he/she knew to turn some cold water on with the hot water when he/she washed hands to prevent getting burned. In an interview with the Maintenance Director on 07/05/2023 at 6:10 PM, he stated he had been the director for about (two) 2 years, and he was responsible for six (6) other buildings. He stated there were no other maintenance personnel for this facility. In another interview with the Maintenance Director on 07/10/2023 at 6:10 PM, he stated water temperatures were checked weekly in the showers and random rooms. He stated his expectation was for water temperatures to be maintained at 110 degrees F per State regulations. In a continued interview with the Maintenance Director on 07/10/2023 at 6:25 PM, he stated water temperatures were checked weekly and when complaints were reported to him. However, no complaints had been reported. He stated the process he followed was when complaints occurred, he adjusted the water temperature for the hot water tanks located in the mechanical room; waited about ten (10) minutes; and, rechecked the water temperatures again. In an additional interview with the Maintenance Director on 07/11/2023 at 6:12 PM, he stated the thermostat that controlled the hot water tanks for the North Hall, located in the mechanical room, was in disrepair. He stated the plan was to replace the thermostat with equipment already purchased. However, he stated, as of yet, he had not had time to install a new thermostat because he was the only maintenance staff at the facility. Observation of the North Hall hot water tank thermostat in the mechanical room on 07/11/2023 at 6:12 PM, revealed the thermostat was lying horizontally with what appeared to be a mercury looking substance split in half which placed the substance at each end of the thermostat and not in center. Because of this, reading a temperature could not be done with the broken thermostat. In an interview with the Maintenance Director at the time of the observation on 07/11/2023 at 6:12 PM, he stated the North Hall thermostat should not be like that, it should be vertical. He stated he thought the hot temperature in the mechanical room had caused the breakage of the mercury appearing substance. When asked how long the thermostat had been like that, he stated for a while now, but he was unable to give the exact date or timeline. He stated he would replace it with a dial like thermostat, and it should be done as soon as possible. The Maintenance Director stated the thermostats were checked two (2) times weekly for accuracy, but he did not state what method was used for the checks. He stated the maintenance guidance he received from the Corporate Office was for the hot water tanks to be drained monthly. He stated this task was performed last month, June 2023, and he thought the hot water system was about two (2) to three (3) years old. In an interview with the Executive Director (ED) on 07/11/2023 at 7:25 PM, he stated he was not aware of any problems with water temperatures. He stated he was first made aware last night, on 07/10/2023, and had not received any reports from residents or staff of water temperatures being too hot. He stated he was not aware of any residents getting burned, but a resident could be burned if the water temperatures were too hot. The ED stated to prevent elevated water temperatures, he reviewed the maintenance records two (2) to three (3) times a week, in addition a report was e-mailed to him each Sunday. He stated if there was an issue, he would report it to the Quality Assurance and Performance Improvement (QAPI) Committee. He added he relied upon the maintenance staff to report any elevated water temperatures. In another interview with the ED on 07/17/2023 at 11:22 AM, he stated his job was to provide oversight on a day-to-day basis for the facility and ensure regulations were followed.