**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 172818 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a.) hot water temperatures were maintained at safe levels to protect residents from third degree burns and/or serious injury. This deficient practice was identified on 1 of 3 nursing units (the Long-Term Care (LTC) unit). Hot water temperatures obtained on 3/4/25, in resident's rooms on the LTC unit registered between 138 degrees Fahrenheit (F) and 140 degrees F. Interviews with the Director of Maintenance (DM) confirmed that the water temperatures should be below 120 degrees F to be at a safe level. The facility's failure to ensure that residents were protected from excessive hot water temperatures posed the likelihood of serious harm and injury from third degree burns. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 3/4/25 at 10:47 AM, when the survey team identified hot water temperatures on the LTC resident unit in excess of 120 degrees F. The facility's Administration were notified of the IJ on 3/4/25 at 2:46 PM. The facility submitted an acceptable Removal Plan (RP) on 3/5/25. The survey team verified the implementation of the RP during the continuation of the on-site survey on 3/7/25. The facility further failed to b.) ensure fall interventions were in place for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #94) . The evidence was as follows: Part A Reference: State Operation Manual; Guidance to Surveyors for Long Term Care Facilities; 483.25 (d)(1); 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. Time and Temperature Relationship to Serious Burns Water Temperature and Time Required for Third degree Burn (Penetrate the entire thickness of the skin and permanently destroy tissue). Water temperature and time required for a third degree burn to occur: 148 degrees F - 2 Seconds 140 degrees F - 5 Seconds 133 degrees F - 15 Seconds 127 degrees F - 1 Minutes 124 degrees F - 3 Minutes 120 degrees F - 5 Minutes 100 degrees F - Safe temperatures for bathing A review of the facility's Water Management policy, dated reviewed June 2024, included 1. The Maintenance Director will maintain documentation that describes the facility's water system . 6. Based on the risk assessment, control measures will be established to address potential hazards. 7. Testing protocols and acceptable ranges (control limits) will be established for each control measure . A. Individuals responsible for testing or visual inspection will document findings. A review of the facility's Safe Water Temperature policy, dated reviewed October 2024, included 1. Direct care staff will monitor residents during prolonged exposure to warm or hot water . 5. Water temperatures will be set to a temperature of no more than 160 F at the heater, and no more and 110 F at the faucet, or the state's allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years. On 3/4/25 at 10:07 AM, during the Medication Administration Pass observation, the surveyor observed the Licensed Practical Nurse (LPN #1) perform hand hygiene in Resident room [ROOM NUMBER]'s sink. At that time, LPN #1 stated, Oh my God, it's too hot, I burned my skin. On 3/4/25 at 10:47 AM, the surveyor accompanied the DM to Resident room [ROOM NUMBER]. The DM, with a calibrated digital probe thermometer, obtained a hot water temperature from the resident's sink which registered 138 degrees F. At that time, a Certified Nursing Assistant (CNA #2) was assisting Resident #108 with morning care. The surveyor observed a wash basin filled with water on the sink. The DM obtained a hot water temperature in the wash basin which registered 113 degrees F. On 3/4/25 at 10:52 AM, the DM obtained a hot water temperature in Resident room [ROOM NUMBER], which registered 140 degrees F. On 3/4/25 at 10:54 AM, the DM obtained a hot water temperature in the central LTC shower room, which registered 118 degrees F. On 3/4/25 at 11:26 AM, the DM, in the presence of the survey team, stated the water temperatures were checked twice a day; once around 7:30 AM by himself and around 11:00 AM by the Maintenance Assistant (MA). The DM stated he checked the water temperatures in two randomly selected rooms on each unit, the kitchen, the salon, the activities room, the gym, and the shower rooms. The DM stated that the water temperatures should range from 100 to 114 degrees F, and no more than 120 degrees F. The DM then stated that he tried to ensure the water temperature was not higher than 120 degrees F. The DM explained that a pipe for the water boiler busted and the part was replaced a couple days prior. The DM stated that he thought the service company had turned the boiler up to 140 degrees F and it was never turned back down. The DM stated that the boiler was 114 degrees F the previous day, but that morning, 3/4/25, after surveyor inquiry, when he checked the boiler and it was 140 degrees F. The DM did not know how or when it was turned back up to 140 degrees F. The DM then stated he was unable to provide the maintenance temperature logbook because he was unsure where the MA placed it. The DM verified that he turned the water boiler down to 114 degrees F after surveyor inquiry. Upon discovery of the high temperatures, the surveyor and the DM inspected other rooms. On 3/4/25 from 11:38 AM to 12:13 PM, the surveyor toured all three units (LTC, Subacute, and Memory Unit) with the DM. On 3/4/25 at 11:47 AM, the DM stated that since he started at the facility, there had been issues with leveling out of the water temperatures. The DM then stated it would either be too hot in the LTC unit, but fine on the Subacute unit. On 3/4/25, from 11:53 AM to 12:13 PM, the following hot water temperatures were obtained and reflected hot water temperatures of 110 degrees F and above: Resident room [ROOM NUMBER] - 111 degrees F. Resident room [ROOM NUMBER] - 110 degrees F. Resident room [ROOM NUMBER] - 116 degrees F. Resident room [ROOM NUMBER] - 118 degrees F. Resident room [ROOM NUMBER] - 118 degrees F. Resident room [ROOM NUMBER] - 119 degrees F. Resident room [ROOM NUMBER] - 119 degrees F. Resident room [ROOM NUMBER] - 118 degrees F. Resident room [ROOM NUMBER] - 117 degrees F. On 3/4/25 at 11:52 AM, the surveyor interviewed CNA #1, who stated that she was assigned to Resident room [ROOM NUMBER] that day. CNA #1 stated that the water temperature was hotter than usual today. CNA #1 then stated that the LTC shower was hot. CNA #1 stated if it felt hot to her, she knew it felt hot to the residents. CNA #1 stated that she had to add cold water to tone it down. On 3/4/25 at 11:55 AM, the surveyor interviewed CNA #2, who stated she was assigned to Resident Rooms #202, #203, #204, and #207. CNA #2 stated she had let the water run, but it was hotter than normal today. CNA #2 then stated that she mixed the hot water with cold water. CNA #2 further stated that the water temperature was hotter than normal half of the time. On 3/4/25 at 11:59 AM, the surveyor interviewed Resident #99, who resided in one of the affected rooms, who stated that the water temperature was normally cold, and they had to wait for the temperature to heat up. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 12/20/24, reflected that Resident #99 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severely impaired cognition. A further review of the MDS indicated for shower/bathe self: not attempted due to medical condition or safety concerns. On 3/4/25 at 12:02 PM, the surveyor interviewed Resident #83, who resided in one of the affected rooms, who stated they did not have any issues with the water temperatures. A review of the comprehensive MDS dated [DATE], reflected that Resident #83 had a BIMS score of 15 out of 15, which indicated an intact cognition. A further review of the MDS indicated that the resident required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. On 3/4/25 at 12:17 PM, the surveyor interviewed CNA #2, who stated that she was assigned to Resident #108, who stated that during morning care, she tried to fill the basin with water for the resident, but the resident wanted to do it on their own. CNA #2 further stated that after the resident filled the basin, she checked the water, and it was too hot, so she poured the water out, turned on both the hot and cold water and rechecked it. CNA #2 stated that the resident did not touch the water before she checked the temperature. CNA #2 then stated that normally she informed the supervisor that the water was too hot, but she was unable to at that moment because a CNA had asked her for assistance with another resident. A review of the comprehensive MDS dated [DATE], reflected that Resident #108 had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. A further review of the MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. On 3/4/25 at 12:27 PM, the surveyor interviewed LPN #1, who stated that today, 3/4/25, was the first time the water was too hot for his hands. LPN #1 then stated that his skin had been sensitive and a little cracked lately, so there was no need for a follow-up with the maintenance staff regarding the water temperatures. On 3/4/25 at 1:04 PM, the surveyor interviewed Resident #108, who resided in one of the affected rooms, who stated that the water temperature during morning care was comfortable. On 3/4/25 at 1:10 PM, the surveyor interviewed the Regional Nurse, who stated one of the three boilers had gone down and parts were replaced. The Regional Nurse stated that no residents were affected and the water was not shut down. On 3/4/25 at 1:17 PM, the Director of Nursing (DON) provided an invoice from a service company. At that time, she stated that the water boiler parts were replaced on 2/28/25. On 3/4/25 at 2:00 PM, the surveyor interviewed the DON, who stated that there were no resident accidents or incidents related to the hot water temperatures. When asked if water temperatures were taken on 2/28/25, the DON replied yes, but he thought they were in the maintenance temperature logbook. On 3/5/25 at 8:46 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, the Chief Operating Officer (COO), and the survey team. The LNHA stated that it was not the entire boiler that went down, and that it was the mixing valve (combines two or more fluid streams at different temperatures to produce a mixed stream at a desired temperature) that needed to be repaired. The LNHA stated that the DM should be checking the water temperatures, and for abnormal findings, they adjusted the mixing valve. An acceptable Removal Plan (RP) was received on 3/5/25 at 1:50 PM, which indicated the action the facility would take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included: the DM immediately checked the boiler mixing valve to check the temperatures and adjusted the valve; the Regional DM immediately rechecked the temperatures in the affected rooms; random rooms were tested throughout the day and evening shifts; all staff were educated to check water temperatures and adjust the faucets according to the residents' satisfaction, notify the DM immediately if the water was too hot or too cold; the Maintenance staff will check the water temperatures daily; the Maintenance staff will check any abnormal findings and adjust water temperatures by adjusting the mixing valve, then recheck water temperatures in the residents' rooms and all units randomly until safer water temperatures are reached; and all temperatures will be documented in the maintenance logbook. On 3/5/25 at 2:27 PM, the LNHA provided the maintenance temperature logbook. A review of the logbook included water temperatures, but it did not include all of the rooms and water temperatures from the Removal Plan. A review of the facility's Water and Air Temperature Log from 1/1/25 to 3/5/25, revealed water temperatures above 120 degrees F as follows: -On 3/2/25, in Resident room [ROOM NUMBER], the water temperature was documented as 120 degrees F. -On 3/3/25, in Resident room [ROOM NUMBER], the water temperature was documented as 122 degrees F. -On 3/3/25, in Resident room [ROOM NUMBER], the water temperature was documented as 121 degrees F. -On 3/3/25, in Resident room [ROOM NUMBER], the water temperature was documented as 120 degrees F. -On 3/3/25, in Resident room [ROOM NUMBER], the water temperature was documented as 120 degrees F. -On 3/3/25, in Resident room [ROOM NUMBER], the water temperature was documented as 121 degrees F. -On 3/3/25, in the LTC shower rooms, the water temperature was documented as 121 degrees F. A further review of the Water and Air Temperature Log, from 1/1/25 to 3/5/25, reflected water temperatures that were documented above 110 degrees F, ranging from 111 degrees F to 119 degrees F on all three units. The units included resident rooms, shower rooms, activity rooms, and the hair salon. There was no documented evidence that the affected rooms with water temperatures above 120 degrees were rechecked prior to surveyor inquiry. On 3/6/25 at 11:01 AM, the surveyor conducted a telephone interview with the Medical Director (MD), who stated that he was not made aware of the water temperatures being above 120 degrees F. The MD stated that he was at the facility once a week, and he was unable to speak about the water temperatures. The MD confirmed that 140 degrees F was too hot and there was potential that a resident could be burned. On 3/6/25 at 12:29 PM, the LNHA stated that the Regional Director of Maintenance (RDM) had the documentation for the remaining water temperatures and that he was not currently in the facility. On 3/6/25 at 2:17 PM, the surveyor interviewed the LNHA, in the presence of the survey team, who stated that his role was to manage the entire facility and to ensure the residents, the staff, and the visitors were safe. The LNHA stated that he was the leader of the building and was responsible for operating the entire facility. The LNHA stated he was aware of all concerns that were brought to his attention. On 3/7/25 at 8:30 AM, the LNHA provided the remaining water temperature logs. On 3/7/25 at 11:58 AM, the surveyor interviewed the RDM, who stated that the water temperatures should be checked and documented daily at different times of the day because you never know. The RDM further stated that the temperatures were documented in the maintenance logbook and if there were any issues, the maintenance staff or the service company fixed it. The RDM stated that the managers and LNHA should be notified if the water felt too hot. The survey team verified the implementation of the RP during the continuation of the on-site survey on 3/7/25. Part B On 3/3/25 at 8:43 AM, the surveyor observed Resident #94 in bed. The resident had a floor mat in place to the resident's right side, but the floor mat for the resident's left side was folded up and not in place. The resident's call bell was also not within reach and was hanging down by the back of the bed frame and was touching the floor. On 3/5/25 at 8:30 AM, the surveyor observed Resident #94 in bed. The resident had a floor mat in place to the resident's right side, but the floor mat for the resident's left side was folded up and not in place. The surveyor reviewed the medical record for Resident #94. A review of the admission Record face sheet, an admission summary, revealed the resident had diagnoses which included but were not limited to; traumatic subdural hemorrhage (a brain bleed that can happen after a head injury), fracture of left pubis, fracture of sacrum, fracture with routine healing, wedge compression fracture of first thoracic vertebra (a type of spinal fracture), history of falling, and unspecified dementia. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/19/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident's cognition was severely impaired. A further review of the MDS revealed the resident had one fall without injury since the prior assessment. A review of the individualized comprehensive care plan (ICCP) included a focus that the resident was high risk for falls related to a history of falls and weakness. Interventions included: Be sure call light is within reach and encourage to use if for assistance as needed. The resident needs prompt response to all requests for assistance, and Bilateral floor mats in place while in bed to prevent injury. A review of the Order Summary Report (OSR) dated as of 3/6/25, included the following physician's order (PO): -A PO dated 5/21/24, for Device: Floor Mat B/L (bilateral) bed A review of the March 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include the above physician's order for nursing staff to sign off that the floor mats were being checked for proper placement. On 3/6/25 at 10:15 AM, the surveyor interviewed Certified Nursing Assistant (CNA #3), who stated Resident #94 was dependent on staff for care and that the resident was able to use the call bell for assistance. CNA #3 explained that the resident's call bell should be secured to the resident's sheet or gown to prevent it from falling on the floor. CNA #3 further stated that residents with floor mats should have the mats down whenever the resident is in bed to prevent injury. On 3/6/25 at 10:24 AM, the surveyor interviewed Licensed Practical Nurse (LPN #2), who stated that call bells should be secured to the side rail near the resident's hand so that the resident can call for assistance. LPN #2 also stated that residents with floor mats should always have the mats in place when the resident was in bed to protect the resident from falls. On 3/6/25 at 10:27 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #2), who stated call bells should be secured to the resident's blanket or sheet and be within reach so the resident could call for assistance. LPN/UM #2 further stated that residents with floor mats should have mats down in place any time the resident is in bed to decrease injuries from falls. On 3/6/25 at 12:38 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated that the call bell should be secured to the resident's bedsheet and within reach in case the resident needed assistance. The DON further stated that residents should have floor mats in place whenever the resident was in bed to prevent injuries from falls. At that time, the surveyor informed the DON of the observations made of Resident #94 on 3/3/25 and 3/5/25, and the DON confirmed that the resident's call bell should have been secured within reach and the floor mat should have been on the floor beside the bed. A review of the facility's Falls Management policy, revised October 2024, included the following: 3. If a resident/patient is found to be at significant risk for falls, intervention will be implemented which will include, but are not limited to the following: -Safety education and instructions to resident/patient i.e. use of call bell . 4. A care plan such as . constantly checking that call light is within reach . will be implemented. 5. Safety devices: CNAs and charge nurses will be responsible for checking all residents/patients at the beginning of each shift. NJAC 8:39-27.1 (a) NJAC 8:39-31.7 (h)