**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review it was determined that the facility failed to maintain water temperatures less than 120 degrees Fahrenheit (F) in residents' rooms and failed to have a system in place to monitor the temperature of the boiler that supplies hot water to resident rooms. The failure identified has the potential to affect all residents in the facility. Water temperatures exceeding 120 degrees Fahrenheit were identified in 8 out of 8 rooms (Rooms 418, 417, 457, 461, 111, 204, 301 and 541A). In addition, the facility failed to provide supervision and interventions to ensure the safety of resident #208 when served a hot beverage(tea) in his room that caused 2nd degree burns to the lower extremities. As a result of these findings, a state of immediate jeopardy was declared on 2/27/23 at 2:45 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 5:06 PM and it was not accepted. The facility submitted a second plan at 5:19 PM and it was accepted by the state agency at 5:30 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of F. An extended survey was completed on 2/28/23, 3/1/23 and 3/3/23. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The findings include: Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulations regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Temperature Time Required for a 3rd Degree Burn to Occur 155°F 68°C 1 sec 148°F 64°C 2 sec 140°F 60°C 5 sec 133°F 56°C 15 sec 127°F 52°C 1 min 124°F 51°C 3 min 120°F 48°C 5 min 100°F 37°C Safe Temperatures for Bathing (see Note) NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows. First-degree burns involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. Second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. 1). The surveyor investigated a facility reported incident from 8/13/22 that Resident #191 in room [ROOM NUMBER] reported to facility staff that Staff #46 used hot water to wash him/her up that burned him/her. The Surveyor checked water temperatures with the Director of Maintenance on 2/27/23. The Director of Maintenance (DOM) with the Surveyor present checked the water temperature in room [ROOM NUMBER] at 9:35 AM and the water temperature was 156 degrees F with the facility thermometer. The DOM told the Surveyor he was going to get another thermometer. The DOM returned with another facility thermometer and rechecked the water temperature in room [ROOM NUMBER] at 9:40 AM and the water temperature was 163 degrees F. The DOM then obtained the following water temperatures with the facility thermometer: 1.room [ROOM NUMBER]-9:41 AM-133 degrees F 2. room [ROOM NUMBER]-9:44 AM-143 degrees F 3. room [ROOM NUMBER]-9:45 AM-145 degrees F During an interview with the DOM on 2/27/23 at 9:46 AM, the DOM stated water temperatures in resident rooms should be less than 120 degrees F. The Surveyor requested the DOM notify the Administrator about the findings of high-water temperatures. The Surveyor with another surveyor present checked additional resident rooms on all floors of the facility and obtained the following water temperatures on 2/27/23: 1.room [ROOM NUMBER]-9:52 AM-144 degrees F 2.room [ROOM NUMBER]-9:56 AM- 158 degrees F 3. room [ROOM NUMBER]-10:00 AM- 138 degrees F 4. room [ROOM NUMBER]A- 10:02 AM-154 degrees F The Surveyor returned to the conference room and called the Director of Nursing (DON) at 10:09 AM and asked to speak to the DON, Administrator and DOM in the conference room. The Surveyor reviewed the water temperatures obtained by the DOM and the Surveyors with the DOM, DON, and Administrator on 2/27/23 at 10:25 AM. The DOM was asked about the process for monitoring water temperatures and who was responsible. The DOM stated one person on the maintenance team depending who is here in the morning obtains water temperatures for 2 resident rooms on each unit daily. At that time the Administrator stated the plan now is to shut off the boiler that goes to resident rooms and call the contractor immediately. The DOM was asked if he keeps a log of the boiler temperatures and the DOM stated no. The 2 Surveyors then accompanied the Administrator, DON and DOM to the basement and boiler #3 that the DOM stated sends the hot water to resident rooms on 2/27/23 at 10:42 AM. The temperature gauge read 218 degrees F. The DOM stated the temperature gauge should read 190 on Boiler. The Surveyor again asked the DOM if he had any logs on water temperatures on boiler #3. The DOM stated no he did not have logs. After surveyor intervention, Interview with the Administrator on 2/27/23 at 10:48 AM confirmed boiler #3 has been shut off and the contractor has been called. Review of Residents ' medical records in the rooms identified revealed the Residents range from severely cognitively impaired to alert and oriented. Review of the most recent comprehensive medical assessments for residents living in the affected rooms revealed that two of eight residents could move independently in their rooms. One of those two mobile residents had a diagnosis of dementia (room [ROOM NUMBER]A). Six of eight residents were totally dependent on staff for bathing. As a result of these findings, a state of immediate jeopardy was declared on 2/27/23 at 2:45 PM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 5:06 PM and it was not accepted. The facility submitted a second plan at 5:19 PM and it was accepted by the state agency at 5:30 PM. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The provisions of the plan to remove the immediacy had a completion date of 3/2/23 and included the following: 1.Boiler was immediately turned off and contractor contacted to present to facility for same-day service. 2. All areas of building audited by Maintenance Director on 2/27/23 to ensure no further water temperatures were recorded out of acceptable range-120 degrees or less 3. Maintenance Director and Staff Development Coordinators were educated by Nursing Home Administrator (NHA) on acceptable temperature ranges for water in patient care areas (120 degrees or less), how to properly take and record temperatures in resident rooms/ care areas, how to take and record temperatures from Boiler servicing resident care areas (acceptable ranges per manufacturer guidelines), and how to use TELS system to communicate water temperatures found to be out of range. Education of all facility staff working the 3-11 shift on 2/27/23 was immediately performed by Staff Development Coordinators on acceptable temperature ranges for water and how to use the TELS system to communicate water temperatures found to be out of range. Staff Development Coordinators will ensure education of all facility staff will be completed by 3/2/23. Any staff member unable to be reached by 3/2/23 will be educated upon arrival at the facility; NHA will ensure that education has been provided to them prior to beginning their shift. Education will be validated by quizzes performed randomly by NHA, Director of Nursing, or Staff Development Coordinators weekly for a period of 3 months. 4. Maintenance technicians will continue to conduct daily audits of water temperatures in patient care areas and from Boiler to determine compliance with water temperatures remaining within acceptable range. In addition, validation audits will be performed by Asst. NHA, Staff Development Coordinators, and/or Maintenance Director accompanying the Maintenance Technician on temperature checks 3 times per week x 3 months to validate values. Findings will be reported by NHA at the monthly Quality Assurance Performance Improvement (QAPI) Meeting for a period of 3 months to monitor progress towards improvement and recommendations. The Immediate Jeopardy was removed on 3/6/23 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. 2). The BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. The test is usually administered by a social worker who asks a series of questions while noting the answers on the BIMS scorecard. Each question is scored according to a numeric value. The total BIMS score ranges between zero to fifteen points and is categorized into three cognitive groups: Intact, Moderate, and Severe. The objective of a BIMS assessment is not to diagnose cognitive illnesses like dementia or Alzheimer's but rather to assist facility staff with detecting early symptoms and the potential need for further evaluation. Record review on 03/09/2023 at 10:00 AM the surveyor review indicated that Resident #208 had a BIMS score of 15 on the Minimum Data Set (MDS) assessment dated [DATE]. Resident #208 required supervision; defined as oversight, encouragement or cueing in the eating section. Resident #208 has a documented medical history of; lack of coordination, muscle weakness (generalized), malignant neoplasm of vertebral column, unspecified abnormalities of gait and mobility and a history of cerebral infarction. Further review of the facility ' s investigation notes on 03/09/2023 at 2:00 PM revealed that Resident #208 asked the Geriatric Nursing Assistant (GNA) # 59 for a cup of tea after dinner. Further review of the record indicated that GNA# 59 went to the kitchen and retrieved a paper cup and filled the cup with hot water from the coffee/water machine located on a counter in the kitchen. The GNA made the tea and placed it on the resident's bedside table. According to the nurse's note dated 01/31/2023 at 9:58 AM, the Licensed Practical Nurse (LPN) #61 reported, During wound care the resident was noted with blisters to the right leg and right upper thigh. Upon assessment no other new skin issue was noted. Denies any pain or discomfort. Resident stated he/she mistakenly spilled hot tea to the right leg and right upper thigh. The wound physician #52 was made aware and visited the resident at bedside. A new medication order was given for Silvadene every shift. Resident #208 is the self-Responsible Party (RP). The sister of the resident was unable to be reached, a message was left for her to call the facility back. The resident remains in stable condition. On 03/09/2023 at 10:00 AM the surveyor reviewed Resident # 208's wound care medical record. It was revealed that on 01/31/2023, the resident had a 2nd degree burn with a ruptured blister on the resident's right posterior thigh and a second degree burn with an intact blister located on the right medial leg. During the surveyor's interview conducted on 03/09/2023 at approximately 10:45 AM, the Director of Nursing (DON) stated that the 7 AM - 3:00 PM wound care nurse (Staff # 53) assessed Resident #208 and identified second degree burns on the right thigh and right leg. The wound care nurse Staff # 53 immediately called the wound care physician (# 52) and the DON. The DON stated that she went to the resident's room and assessed the resident at bedside and initiated an incident report. The GNA (# 59) was suspended and later resigned. A plan of correction was created that consisted of: 1. Staff members who went against current procedures were reprimanded appropriately including GNA # 59. 2. In order to keep the Curtis Hot Water Boiler at the appropriate temperature, the setting will permanently be left on Holding. The machine was found to be set to boiling which produced hot water exceeding the safe temperature zone for hot beverages. 3. All staff members are allowed to retrieve their own beverages from the kitchen, they must sign a form indicating name, floor, position, and date prior to retrieving beverages. 4. To ensure that residents receive hot beverages at the correct temperature, staff will be required to sign for the hot beverage when requested in between meals. a. All hot beverages provided to residents must be in a designated handled cup with lid and tempted to ensure the resident's beverage will not exceed 145 degrees Fahrenheit upon receival. b. All staff members who retrieve a hot beverage from the kitchen for any resident must verify and sign that beverage was retrieved in the proper cup for delivery. The name of the resident, diet order/texture must be listed on the sign out form. A dietary staff member is required to sign for verification of appropriate beverage temp. 5. Carafes with hot water in the safe temperature zone may be held in the nourishment rooms for use in between mealtimes to assist the facility in meeting residents' dietary preferences. The surveyor interviewed staff member #58, Certified Dietary Manager, on 3/9/23 at 2PM.Staff # 58 showed this surveyor the coffee machine. He stated that when the kitchen staff turn on the coffee maker, it automatedly reaches a temperature of 168 degrees Fahrenheit (F). Staff # 58 stated that that temperature is too hot for a resident or anyone else to drink. The coffee is then poured into a designated handled cup and placed into a holding area where the temperature drops to 140-145 degrees Fahrenheit. At that point the coffee or hot water is ready to be taken to the residents. Staff # 58 stated he has temperature logs that are taken each day before food or hot drinks are served. He stated that with this incident, GNA # 59 came down to the kitchen and did not notify kitchen staff of what his/ her needs were and took water independently from the hot water dispenser without placing it in the holder to drop the temperature. The Director of Nursing and Certified Dietary Manager (#58) both stated this type of incident has never happened before. During an interview conducted on 03/09/2023 at 10:30 AM, the resident stated that he was reaching for something on the bedside tray table and mistakenly knocked the cup of hot tea onto himself which burned his right leg. The resident further stated that he continues to suffer from pain from the burns to his right leg and was currently in pain. On 3/9/2023 at 10:40 AM the surveyors told the RN Unit Manager (#60) that Resident #208 was in pain, and she replied that he gets pain meds before dialysis. Which is on Monday, Wednesday, and Friday (MWF). Oxycodone is administered every 4 hours before dialysis. The surveyors informed the Unit Manager (#60) and Licensed Practical Nurse (LPN) #61 that the resident was currently expressing pain due to his burns.