**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observation, interviews with residents and staff, and review of facility documentation, it was determined that the facility failed to ensure water temperatures in the central shower room and resident bathroom sinks were maintained at a safe temperature for the Transitional Skilled Unit (TSU). This failure placed residents on the TSU at risk for serious injury from thermal burns and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled, Water Intrusion Response Algorithm, dated April 7, 2025, revealed that the facility was to maintain hot water temperatures allowable by state regulations or codes for nursing care facilities between 95 degrees Fahrenheit (F) and 110 degrees F to help minimize the risk of scalding. Observation of the TSU, on April 15, 2025, between 12:30 p.m. and 12:50 p.m., with the Employee 1 (Facilities Management) and Employee E2 (Engineering Maintenance), revealed the following: In room [ROOM NUMBER], the hot water from the resident hand sink in the bathroom was 122.5 degrees F. In room [ROOM NUMBER], the hot water from the resident hand sink in the bathroom was 126.1 degrees F. In room [ROOM NUMBER], the hot water from the resident hand sink in the bathroom was 125.0 degrees F. In room [ROOM NUMBER], the hot water from the resident hand sink in the bathroom was 130.0 degrees F. In room [ROOM NUMBER], the hot water from resident hand sink in the bathroom was 134.2 degrees F. In room [ROOM NUMBER], the hot water from the resident hand sink was 125.1 degrees F. Observation of the thermostatic mixing valves (valves that blend hot water with cold water to ensure constant, safe shower and bath outlet temperatures to prevent scalding, using a built-in thermostat to control the temperature of the mixed water) on April 15, 2025, at 12:52 p.m., with Employee E1 and Employee E2, revealed the temperature on two of three thermostatic mixing valves was identified between 120 and 130 degrees F. At the time of the observation, Employee E1, stated that the thermostatic mixing valves should not exceed 110 degrees F, and that the mixing valves regulated the hot water to all residents' rooms, the shower room, and all care areas on the TSU. He further stated that the temperatures were to be recorded weekly. A review of March and April 2025 water temperature logs revealed hot water temperatures were not recorded. In an interview on April 15, 2025, at 12:15 p.m., Resident 5, stated that the hot water from his hand sink inside his bathroom was too hot. During interviews on April 15, 2025, between 1:35 p.m. and 2:00 p.m., Residents 33, 35, 83, and 84 stated that the hot water was too hot and they were able to independently use the hand sink in their rooms. In an interview on April 15, 2025, at 2:05 p.m., a nurse aide (Employee 3) stated that the hot water temperatures in the shower rooms had been too hot for up to two months. In an interview on April 15, 2025, at 2:10 p.m., a nurse aide (Employee 4) stated that the hot water temperatures in the shower rooms had been too hot for a few weeks, and that there were no thermometers available to check the water temperature prior to providing showers. During an interview on April 15, 2025, at 2:24 p.m., the occupational therapist (Employee 12) stated that no thermometers were available in resident shower rooms. Based on the above findings, notification of Immediate Jeopardy to the safety of the residents on the TSU was provided to the Nursing Home Administrator on April 15, 2025, at 3:35 p.m., for failure to ensure that hot water temperatures were maintained to ensure the safety of residents in the facility. The Nursing Home Administrator was provided with the Immediate Jeopardy Template (document which included information necessary to establish each of the key components of immediate jeopardy) and an immediate action plan was requested. On April 15, 2025, at 6:15 p.m., the facility provided the following corrective action plan. - At 1:00 p.m., when the TSU was alerted regarding the high temperatures on the TSU, the facility also identified that a bypass valve was left in the open position which prevented the hot and cold water from mixing. The valve was immediately closed and high temperatures were reset. A lockout tag was installed on the bypass valve to prevent the bypass valve from being placed in the open position. - At 2:30 p.m., the water temperatures were rechecked after the bypass valve was closed and temperatures were noted to be 106 degrees F. - The facility checked the sink water temperature in all resident rooms and shower rooms on the TSU after a lockout tag was placed on the bypass valve. All temperatures were noted to be below the 110-degree F threshold. There were no additional high temperatures identified. - A policy for the TSU was to be developed to address water temperature safety and monitoring by April 16, 2025. - Employees that were working on the day and evening shift were educated on the water temperature policy, including acceptable hot water temperature ranges, appropriate methods to check hot water temperatures, and measures to take if temperatures were outside acceptable parameters. All staff were to be educated by the next shift worked. Methods included: - Water temperatures will be checked using a thermometer that is accessible and available on the unit prior to assisting a resident in the shower. - Facilities Management or designee will conduct random audits of a minimum of ten sinks daily for four weeks. Water temperatures will be recorded. - Facilities Management or designee will complete a daily log with visual inspection of the lockout tags being in place. - The logs (temperature and visual inspection) will be audited by the Nursing Home Administrator or designee weekly. The team will review the findings with the Quality Assurance Performance Improvement Committee for recommendations. - Facilities Management will educate maintenance staff on temperature monitoring required for random water temperature audits and on documentation of temperatures by the completion of their next shift. - Staff will be re-educated on temperature monitoring required for showers by the Nursing Home Administrator or designee by completion of the next working shift and documented on a sign-in sheet. - If the water feels or measures out of range, engineering will be contacted for immediate correction. - The Medical Director was updated on the Correction and Removal-Abatement Plan, as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above. Maintenance and supervisory staff were observed checking water temperatures and completing audit logs. Water temperature logs were reviewed and revealed appropriate water temperatures. The water temperature policy was reviewed on April 16, 2025, and safe processes for monitoring water temperatures had been developed. Interviews were conducted on April 15, 2025, between 4:00 p.m. and 7:00 p.m., with nursing staff. Nursing staff were able to verbalize the facility's water policy, including that water temperatures should not exceed 110 degrees F, what to do prior to assisting a resident in the shower, what to do if water temperatures were found to be too hot, and how to check water temperatures. The hot water on the TSU at residents' hand sinks and in the Central Shower Room were tested and verified that they did not exceed 110 degrees F. Following verification of the implementation of the immediate action plan, review of water temperature logs, and review of staff education documentation, the Immediate Jeopardy was lifted on April 15, 2025, at 7:37 p.m. 28 Pa. code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 211.12(d)(5) Nursing services. .