**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #10 (R10), the facility staff neglected to respond to the residents call for assistance to have incontinence care provided, which resulted in R10 being left to sit in feces for fifty minutes, which resulted in psychosocial harm. On 4/3/25 at 9:38 a.m., upon the surveyor's arrival to the south unit, it was noted that several call bells were engaged. A light could be seen outside of the rooms and an auditory sound could be heard beeping in the hallways. On 4/3/25 at 9:41 a.m., the surveyor entered the room of R10, whose call light was on. R10 acknowledged that he had his call light on and reported that he needed to be changed. When asked how long his call light had been on, R10 said, Go look for yourself. R10 then explained that the surveyor could go to the nursing station and observe how long his call light had been on. When asked how often he experiences an extended wait for care, R10 didn't respond. On 4/3/25 at 9:49 a.m., the surveyor went to the nursing station and observed a computer screen that listed three call bells that were engaged. The duration listed for R10's call light was noted to be 50 minutes and 17 seconds. On 4/3/25 at 9:52 a.m., licensed practical nurse (LPN #19) was observed to enter the room, the call light went out, and LPN #19 exited the room. As LPN #19 was coming down the hall, she reported to certified nursing assistant (CNA #4) who passed her in the hall, that R10 needed to be changed. On 4/3/25 at 9:54 a.m., an interview was conducted with LPN #19 and inquired as to what R10 needed. LPN #19 stated, He needs to be changed. When notified that the call light had been engaged for over 50 minutes, LPN #19 was asked if this was common. LPN #19 said, Sometimes it is and sometimes it isn't. I didn't know that was the case this morning. Normally he tells me about it, but he didn't today. On 4/3/25, facility staff were notified of the above concerns related to R10. On 4/9/25, a clinical record review was conducted of R10's chart. This review revealed that R10's diagnosis included, but were not limited to unspecified cord compression, central cord syndrome at C2 level of cervical spinal cord, person injured in unspecified motor-vehicle accident, and quadriplegia. According to R10's most recent minimum data set (MDS - an assessment tool) with an assessment reference date of 3/30/25, R10 was coded as having a BIMS (brief interview for mental status score) of 15 out of 15, which indicated he was cognitively intact. The assessment also noted that R10 was dependent upon the assistance of two staff persons for bed mobility, transfers, and toileting. R10 was also coded on that same assessment as having had no skin impairments. According to the care plan, R10 was noted to be at risk for pressure ulcers due to immobility, inability to turn and reposition independently, incontinence, and quadriplegia. Care plan interventions included, Keep skin clean and dry as possible. The care plan also stated, The resident requires assistance with ADLs [activities of daily living] related to chronic health conditions, inability to perform ADLs, weakness, quadriplegia and spinal cord compression. The interventions included, Hoyer lift for all transfers x 2 staff, 2 person assist for bed mobility as needed . Also in the care plan, it was noted that R10 was incontinent of bladder and bowel. The interventions included . provide toileting hygiene with brief changes . According to a skin observation conducted on 3/29/25, R10 was documented with no skin impairments. On 4/1/25, R10 was noted with an incontinence associated dermatitis (iad) to his right buttock that measured 3.5 x 3.5 x 0.1 cm and another area of iad on his left buttock that measured 0.8 x 1 x 0.1 cm. According to the 4/1/25 progress note, the wound care nurse practitioner noted that . wound assessment: location: left buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 0.8 cm x 1 cm x 0.1 cm, exposed tissue: dermis, peri wound: fragile, wound base: 100% epithelial; exudate: scant amount of serosanguineous . A second wound was noted on the .right buttock, primary etiology: incontinence associated dermatitis (IAD), stage/severity: partial thickness, wound status: new, size: 3.5 cm x 3.5 cm x 0.1 cm, wound base: 100% epithelial; peri wound: fragile, exudate: scant amount of serosanguineous, exposed tissue: dermis . The progress note went on to give the treatment plan for both areas, which read as: Treatment Recommendations: 1. Cleanse wound with wound cleanser and pat dry. 2. apply Hydrocolloid to base of the wound. 3. change 3 times per week . PREVENTATIVE MEASURES: The patient is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for swift incontinence management . NEW RECOMMENDATIONS: Staff report new incontinence associated skin breakdown to bilateral buttocks. See new treatment orders. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, comorbidities, incontinence of urine and stool. On 4/9/25 in the morning, a follow up interview was conducted with R10. R10 explained that he is totally dependent on staff for all care, including being fed, and must wait extended periods of time on a routine basis. R10 explained that he doesn't say anything because .what can I do? I have no choice. R10 confirmed that having to sit in his feces for extended periods of times makes him .angry, feel humiliated, and unimportant. I feel all of that but what can I do? R10 then was observed to have tears in his eyes that rolled down his check while talking to the surveyor. On 4/10/25 at 9:15 a.m-9:45 a.m., interviews were conducted with multiple staff, which included licensed practical nurses (LPN #6 & LPN #7) and certified nursing assistants (CNA #1, CNA #4, and CNA #5). All of whom reported that call bells should be answered within five minutes. On 4/10/25, the facility administration reported that they had no policy regarding incontinence care or call bell response times. The facility administration was made aware of the serious concerns related to the above findings. 3. The facility staff neglected to provide incontinent care in a timely manner for Resident #17(R17), which resulted in harm. R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to urinary tract infection, muscle weakness and underweight. R17's Reentry Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/3/25 coded R17 with severe cognitive impairment. R17 was dependent on the activity of daily living care. R17 was no longer a resident at the facility, so a closed record review was conducted. On 4/3/25 at 11:00 a.m., an interview was conducted with R17's daughter who was his responsible party. The daughter stated when she visited that she had found her dad in a saturated brief and the bedding was wet. The daughter stated she cleaned him up and took him to therapy. The daughter stated that she had marked R17's brief with a number 12 at 12 o'clock and when she returned to the facility around 8:00 p.m., he was in the same brief she had marked at noon. On 4/3/25 at 4:00 p.m., an interview was conducted with the administrator. The administrator stated that R17 was up and out of bed after doing therapy around 1:00 p.m., sitting at the nurse's station until the daughter came back in around 7:00 p.m., or 8:00 p.m. The administrator stated he spoke with two staff members that came in to work that evening and stated R17's brief did not appear to have been saturated. 4/3/25 at 5:08 p.m., an interview was conducted with certified nursing assistant CNA#18. CNA#18 stated that incontinent rounds should be made every two hours, adding, Sometimes those lines are not accurate. Sometimes those [moisture indicator] lines on the brief are clear and [the resident] will be sitting in a pool of urine. I open the brief to check. 4/3/25 at 5:08 p.m., an interview was conducted with CNA#19. CNA#19 said, I check the residents every two hours unless they use the call bell. Check the strips on the brief and roll them to make sure their bottom isn't wet. I will leave the same brief on for one round but the next round I will change the brief even if dry. I will let the nurse know if the resident goes eight hours without going to the bathroom. On 4/3/25 at 5:30 p.m., an interview with CNA#9 was conducted about the incident that happened on 3/15/25 with R17. CNA#9 said, [R17's] daughter came in at 7:55 p.m. She reported that her father was wearing the same brief she tagged at 12 o' clock. So I went back and looked at the brief and it was marked, like she said. Looking at the brief lines, I would not have changed him, but he was wet. He was wet enough to be changed. CNA#9 showed pictures of the wet brief and the time that was written on the brief. CNA#9 stated that the pictures the daughter had provided were time stamped. On 4/3/25 at 7:20 p.m., an interview was conducted with LPN#5 about the incident that happened on 3/15/25 with R17. LPN#5 stated that R17 had the same brief on that was numbered with a 12 by his daughter. R17's brief was wet, and that cream was applied to his scrotum that LPN#5 said, .was like a flush cheek red. LPN#5 stated that it was understandable why R17's daughter was upset by R17 being in the same brief for eight hours. On 4/7/25 at 12:10 p.m., an interview was conducted with the assistant director of nursing (ADON). The ADON stated that incontinent care was prn, and the typical standard is every two hours. The ADON said, I would pull back the brief to see if they had a bowel movement. Common sense tells me I would change them, and not leave the brief on for eight hours. The ADON stated that she would expect staff to change a patient's brief every other round, even if the brief lines are clear due to the brief holding moisture, and the patient can sweat, which can cause moisture associated dermatitis. The ADON stated patient's briefs can hold heat causing the patient to sweat, and the brief would need to be changed due to the moisture. On 4/8/25 at 11:00 a.m., an interview was conducted with LPN#13 the unit manager of the south wing. LPN#13 stated that R17's daughter sent her pictures of a saturated brief and a dirty bed pad with dried urine stains on the bed pad. LPN#13 stated that R17's daughter was in the facility around 8:00 p.m., and sent another picture to her with a brief marked with a 12, and of R17 sitting in his wheelchair in his room, and of the wall clock that had 8:00 p.m. On 4/8/25 at 2:00 p.m., a review of R17's clinical record was conducted. On 3/16/25 skin assessment was completed, which documented redness to R17's coccyx area. R17 was getting treatment for MASD (moisture associated skin damage) to sacrum, and groin areas but on 3/16/25 treatment was started to coccyx area. According to the National Institute on Health (NIH) moisture associated skin damage (MASD) is discussed and read in part, . Moisture-associated skin damage (MASD) occurs with exposure to various sources of moisture (bodily secretions or effluents) such as urine or fecal matter, perspiration, wound exudate, mucus, digestive secretions, respiratory secretions, or saliva . Accessed online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9093722/#fn-group1 According to Wounds International, Moisture-associated skin damage (MASD) represents a significant problem and can have a negative effect on patient wellbeing and quality of life MASD is a complex and increasingly commonly recognized condition. Overexposure of the skin to bodily fluids can compromise its integrity and barrier function, making it more permeable and susceptible to damage (Gray et al, 2001; [NAME] et al, 2017). Individuals with MASD experience persistent symptoms that affect quality of life, including pain, burning and pruritis (Gray et al, 2011; [NAME] et al, 2017). MASD is classified as an irritant-contact dermatitis; see Table 1 (WHO, 2020). Common irritants can include urine, stool, perspiration, saliva, intestinal liquids from stomas and exudate from wounds. As such, MASD is an umbrella term and forms of MASD may be subdivided into four types (see Figure 1): IAD Peristomal dermatitis (relating to colostomy, ileostomy/ ileal conduit, urostomy, suprapu-bic catheter, or tracheostomy) ? Intertriginous dermatitis (intertrigo: where two skin areas may touch or rub together) Peri wound maceration . The article went on to read, .Managing continence As a priority, wherever possible, the cause of incontinence should be identified and eliminated, and treatment options exam-ined if possible - although this may be due to a range of factors including health conditions and mobility issues (Wishin et al, 2008; Beeckman et al, 2020). This should include evaluation of bladder and kidney function regarding urinary incontinence, and that of the intestine and colon in the case of fecal incontinence (Beele et al, 2017). If continence enhancement is not possible, suitable incontinence products should be used and non-invasive behavioral interventions implemented (Beeckman et al, 2018). Behavioral interventions may include nutritional and fluid management, mobility enhancement, and use of different toileting techniques (Wishin et al, 2008; Beeckman et al, 2020). While IAD does not only affect elderly people, evidence from studies involving elderly nursing home residents suggests that structured toileting and exercise interventions can improve incontinence (Bates-[NAME] et al, 2003; Beeckman et al, 2020). The type and frequency of incontinence should be re-assessed on regular basis, in order to tailor incontinence management strategies to the individual and assess the risk of skin-related damage (Beeckman et al, 2018). Wherever possible, indirect risk factors should be mitigated . Accessed online at: https://woundsinternational.com/wp-content/uploads/2023/02/77ece7a46c5c084762956b97f9096e53.pdf On 4/10/25 at 2:40 p.m., following consultation with the SA that verified the existence of IJ, the survey team met with the facility's director of nursing, two regional director of clinical services nurses, and the vice president of operations (VPO) were made aware that the facility was in Immediate Jeopardy (IJ) in the care area of Free from Abuse, Neglect, and Exploitation. On 4/10/25 at 5:43 p.m., the facility administration submitted the following plan of removal for the IJ: F600 Abuse Removal Plan. Plan Corrective Action for those residents found to be affected by the deficient practice: R#10 and R#23 will have a psychosocial assessment completed by the Regional Director of Social Work to determine current state of wellbeing. Corrective Actions taken for residents with potential to be affected by deficient practice: Staff will interview residents with a BIMS of 13 or higher about abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. Residents with a BIMS of 12 or less will have their responsible party contacted about concerns related to abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. Skin assessments will also be conducted on the residents with a BIMS of 12 or less. Care plans will be updated based on findings and provider and RP notified as well. The call bell system will be audited for each room to ensure functionality of the call bells. Systemic Changes put into place to ensure the deficient practice does not recur: All facility staff will be educated on the abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. This education will be provided for all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they are educated. Audits will be randomly conducted weekly to assess call bell response times, timely incontinence care, and abuse and neglect by a member of the Interdisciplinary Team. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/10/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Regional Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the abuse policy to include neglect, reporting of abuse and neglect, call bell response time, and the importance of timely incontinence care Monitoring of corrective action to ensure the deficient practice does not recur. The Administrator or designee will monitor call bell response times to ensure they are answered within 15 minutes. Residents with BIMS of 13 or higher will be interviewed at random weekly to validate the timeliness of their incontinence care, call bell response time, abuse and neglect, and psychosocial well-being. Residents with a BIMS of 12 or less will have their responsible party contacted about concerns related to abuse, neglect, timely call bell response, timely incontinence care, psychosocial well-being, and resident rights are upheld. All residents will have a skin assessment completed weekly. Completion of removal plan 4/10/25 at 11:00pm. The [NAME] President of Operations made the Medical Director aware of the Immediate Jeopardy via telephone on 4/10/25 at 3:26 pm. Following review with the SA, the removal plan was accepted. On 4/11/25, the survey team returned to verify that the facility had fully implemented their removal plan. The survey team verified that R10 and R23 had a psychosocial assessment completed by the regional director of social work. The facility's documentation of resident interviews for all residents with a brief interview for mental status (BIMS) score of 13 or higher was reviewed. The survey team conducted a sample of resident interviews to ensure they had been interviewed, and any concerns were shared. The survey team verified that the facility staff had documentation of family interviews being conducted for residents with a BIMS score of less than 13. The survey team reviewed the staff education regarding abuse/neglect, including psychosocial well-being, timely call bell response, and timely incontinence care. The sign-in sheet for the education was compared to the schedule of staff working to ensure all staff had received education. A sample of staff across all departments was interviewed to verify they had received education and had knowledge of abuse/neglect, how to report such allegations, timely call bell response, timely incontinence care, and psychosocial well-being. No concerns noted. The survey team conducted observations on each of the three resident care units and monitored staff's response to call bells. Calls for assistance were responded to within 15 minutes of the call bells being initiated. The facility provided evidence of a call bell audit that was conducted. According to the facility documentation, they identified several residents whose call-bells were noted to not be operational. The survey team then went to those selected rooms and verified that the call bell was working. The surveyor identified two resident rooms, four residents affected, that the call bell was not working when checked. The facility's VPO was made aware of the above findings regarding the in operatable call bells and that they would not be able to abate the IJ. On 4/11/25 at 9:25 a.m., the survey team was made aware that the call bells in two rooms were replaced and functioning, while the residents in one other room had been distributed hand bells to use to notify staff if assistance was needed. The survey team verified this with no further concerns noted. On 4/11/25 at 10:15 a.m., the facility's administration and regional team were made aware that the survey team needed evidence that the facility was responding to concerns and/or allegations of abuse/neglect shared by residents and families during the interview process. The facility provided the survey team with evidence that three allegations of abuse/neglect were being investigated, and all other concerns were being addressed through the facility's grievance procedure. On 4/11/25 at 12 noon, after having verified that the removal plan had been fully implemented and that facility actions had eliminated the likelihood of serious injury, harm, impairment, or death, the facility was notified that the immediacy had been removed. The scope and severity of the remaining noncompliance was lowered to a level three, isolated. Based on observation, resident and staff interviews, clinical record review and facility documentation review, the facility failed to protect the residents' right to be free from neglect for three residents (Resident #17-R17, Resident #23-R23, and Resident #10- R10) in a survey sample of 26 residents, which resulted in harm for two residents (Resident #10- R10 and Resident #23-R23) and the identification of Immediate Jeopardy (IJ) and substandard Quality of Care. The findings included: 1. The facility staff neglected to provide timely incontinence care for Resident #23 (R23), which resulted in skin injury and psychosocial harm. According to clinical record review, R23 was admitted to the facility on [DATE]. Diagnoses for R23 included but were not limited to chronic diastolic heart failure, muscle weakness and chronic respiratory failure with hypoxia. R23's Quarterly Minimum Data Set (an assessment protocol), with an Assessment Reference Date of 3/25/25, coded R23 with no cognitive impairment. This assessment also documented that R23 was dependent on staff for toileting and required moderate to maximal assistance with bed mobility, transferring, and bathing. On 4/9/25 at 6:35 p.m., upon entering R23's room, it was noted that the privacy curtain had been pulled. When addressing the resident through the curtain, R23 replied, She's changing me. I'll talk to you in just a minute, she almost done. From behind the curtain, R23 was then heard saying, Ouch, Ouch! Be gentle, it burns. The CNA was heard to say, Ok, I'm being gentle. I'm almost done. On 4/9/25 at 6:45 p.m., an interview was conducted with R23. When questioned about care, R23 said, There have been several times that I have had to sit in my urine or feces for long periods of time. R23 said, Last Thursday [4/3/24], I was wearing the wrong size brief, and I sat in my own feces for two hours. When I rang for help, the aide came in at 8:30 a.m., and I told her I needed to be changed, that I had a bowel movement, and that it leaked out of my brief. The aide turned the call bell off, said that state was here, so she had to take care of other residents first, and then she would come back to change me. R23 stated that approximately 10:10 a.m., .another certified nursing assistant [CNA# 7] came to the door, asked how I was doing, and if I needed anything. R23 stated that she told CNA#7 that she needed to be changed, had been sitting in a bowel movement for almost two hours, and that (CNA#6's name redacted) was supposed to come back to do it but had not been back. R23 stated that CNA#7 indicated that she would provide the needed care but had to go get all the supplies she needed. R23 stated that CNA#7 came back at 10:30 a.m. and provided the care. R23 said, My bottom was burning me as she was cleaning me up, and [CNA#7 name redacted] pointed out to me that it was some bad spots down there. R23 said, This made me feel others were more important to me. Made me feel like crap. I have never been treated like this before. R23 stated that CNA#6 had been her aide several times but had never left her waiting that long before. R23 stated that she had reported the incident to someone from Adult Protective Services who came to see her yesterday. When questioned if she had told anyone else, R23 stated that she reported this incident to CNA#7 on Thursday (4/3/25), she told the ADON on Friday (4/4/25), and told the administrator on Saturday (4/5/25). R23 then showed pictures that she stated had been taken that day. One photo showed that fecal material was outside of the incontinent brief, on both sides of her thighs, on the incontinent bed pad, and with a large brown stain on the lower bed sheet. R23 then displayed another picture on her cell phone that she had taken after care was provided, which showed bright red appearance of her groin area and thighs. When questioned if the areas were better, R23 stated that she was suffering with burning to her peritoneal area and thighs. Displaying her inner thighs and groin area, it was observed that R23's mid to inner thighs appeared deep beefy red in color, while the groin area was bright red. On 4/9/25 at 7:30 p.m., an interview was conducted with the assistant director of nursing (ADON). When questioned about R23's complaint, the ADON said, I talked to her sometime on Friday. She hollered at me from her bed. She told me it took [CNA#6's name redacted] a long time to get in here to take care of me. The ADON stated that she told R23 that she would look into it and check the assignment sheet. On 4/9/25 at 7:45 p.m., the ADON, the director of nursing (DON) and the regional director of clinical services (RDCS) were made aware of the above findings related to R23, during a meeting. The response was that they had not been aware that R23 was sitting in feces for two hours until this meeting. When the RDCS stated that the change in skin condition could be related to yeast, a joint observation was suggested and agreed upon. 4/9/25 at 8:00 p.m., an observation was conducted with the RDCS. R23 retold how she had been left in feces on 4/3/25 to the RDCS. When the RDCS asked to see the affected area, R23 consented and showed her. When the RDCS attempted to move R23's legs apart, R23 began grimacing, wincing, and moving away from the contact. The RDCS asked if she needed something for pain, R23 stated, No, I handle pain well. The RDCS asked R23 if the area itches, and R23 said, No, it burns! The RDCS asked R23 if she had ever had cream applied in that area before, and R23 said, Under my abdomen but never down there. I have never had anything down there until Thursday. On 4/9/25 about 8:10 p.m., an end-of-day meeting was conducted with the administrator, director of nursing and corporate staff, during which they were made aware of the above concerns and the potential for neglect. On 4/10/25 at 9:50 a.m. an interview with CNA#7 was conducted via phone call. CNA#7 stated that when she went to do her rounds, she asked R23 is she needed help or anything. That was when she told me she was needing to be changed and she had been sitting in it for a while. CNA#7 said, She was upset. [R23's name redacted] was sitting in a mess. The feces were up the front of the brief, down the sides of legs, on the chuck pad, on the sheets, and I had to change all bed linen. CNA#7 said, After cleaning her up, the creases of her thighs were red. CNA#7 stated that R23 was upset and mad because CNA#6 was supposed to come back to change her and never came back. CNA#7 stated that she did not report to anyone how she found R23, nor that R23 had reported that she had been laying there for 2 hours in feces waiting on CNA#6 to come back and change her. On 4/10/25 at 10:15 a.m., an interview with CNA#6 was conducted via phone call. CNA#6 stated that when she entered R23's room, she was needing to be changed. CNA#6 stated that she had been asking for help, but no one would come help her with answering the call bell lights. CNA#6 stated that she had another resident that she had to get ready for an appointment, who needed to bathed, dressed, transferred with a lift, and to the lobby for her pick up time or she would miss the appointment. CNA#6 stated that when CNA#7 showed up, she was taking care of R23. CNA#6 stated that she had taken care of R23 several times, and that R23 had no skin issues or red areas. CNA#6 stated that she did not mention state being her in the facility, but she did turn off the call light. CNA#6 stated that the administrator, and APS had talked with her about the incident. On 4/11/25, a review of Resident #23 clinical record was conducted. Resident #23 was seen by the nurse practition-er (NP) on 4/10/25. The progress note read in part, .patient was seen per nursing request for redness to groin/inner thighs. The NP note read in part, .MASD [moisture-associated skin damage], inner thighs/groin. The NP ordered .zinc bid [twice daily] until Greers goo arrives. Greers goo bid until healed. No additional information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide adequate supervision and an environment free of accident hazards to prevent injury to residents, that resulted in two instances of injury/harm to Resident #12 (R12) and one occurrence of harm for Resident #18 (R18). Having the potential to affect multiple residents residing on three of three nursing units, the noncompliance resulted in the identification of immediate jeopardy (IJ) and substandard quality of care. The findings included: 1. The facility staff failed to ensure the environment was free of accident hazards, which resulted in R12 ingesting body wash, requiring hospitalization for respiratory failure and intubation, and the subsequent placement of a trach and a feeding tube. On 4/4/25, a closed record review was conducted of R12's chart. This review revealed a progress note written by a licensed practical nurse (LPN #5) dated 3/17/25 at 5:45 a.m., that was titled, eInteract SBAR Summary for Providers. This note read in part, Blood pressure: 173/98- 3/17/2025 at 5:50 a.m., Position: Sitting r/arm [right arm]. Pulse: 110, R 22 [respirations] Temp 97.5- 3/14/25 23:00 route: Forehead non-contact . Pulse Oximetry: O2 90%- 3/17/2025 at 5:49 a.m Outcomes of Physical Assessment: . Respiratory Status Evaluation: Shortness of breath, abnormal lung sounds (rales, rhonchi, wheezing), Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50 . Nursing observations, evaluation, and recommendations are patient grabbed and ingested unknown specific amount of soap. patient bubbling from mouth with wheezing heard from lung sounds. tachycardia noted as well as hypertension. patient decreased response to stimuli. on call contacted, MD and NP [medical doctor and nurse practitioner] no answer. emergency contact was reached, and patient was sent to ER [emergency room] via 911. report [sic]. On 3/17/25 at 6:15 a.m., another nursing progress note entry by LPN #5 was entered into R12's chart that read, . patient grabbed and ingested unknown specific amount of soap. patient bubbling from mouth with wheezing heard from lung sounds. tachycardia noted as well as hypertension. patient decreased response to stimuli. on call contacted, MD and NP no answer. emergency contact was reached, and patient was sent to ER via 911 at 0615. report called to [name redacted] ER nurse at [hospital name redacted]. According to hospital records dated 3/17/25, and titled, Pulmonary & Critical Care Specialist- ICU intake note read in part, . In summary this [AGE] years old female with severe dementia who is functionally limited . found to be hypoxic with change in mental status but also the staff noticed that she has ingested liquid body wash of 20 cc which has not been witnessed but patient was smelling fruity like the body wash in the room. When EMS arrived, she was hypoxic and confused unresponsive. She came to ER on nonrebreather. She is found to have a new airspace disease involving the right lung, metabolic acidosis with anion gap, lactic acidosis, venous blood gas shows metabolic as well as respiratory acidosis . Assessment: 1. Acute hypoxic and hypercapnic respiratory failure- currently on high flow 2. Accidental ingestion poisoning of liquid body wash/unknown amount and duration at the nursing home . According to hospital records dated 4/1/25, titled, Physician Discharge Summary which read in part, . brought to the emergency room where she was hypoxic hypercapnic could not tolerate BiPAP and she was eventually intubated, patient was extubated in March 22 and she did not tolerate and has to be reintubated in March 22 after discussion with the family decision was made for tracheostomy and PEG tube placement . According to the facility provided documents regarding the incident of R12, the facility only talked with and interviewed licensed practical nurse (LPN #12) and a certified nursing assistant (CNA #3). According to the nursing schedule for the overnight shift from 3/16/25-3/17/25, two nursing assistants (CNA #3 and CNA #2) worked the unit where R12 was a resident, and two licensed practical nurses (LPN #12 and LPN #11) worked the unit. LPN #5, who made the entries into R12's chart had been assigned to another unit. On 4/4/25 at 9:40 a.m., an interview was conducted with resident #2 (R2), who was R12's roommate. R2 was asked about the day R12 was sent to the hospital, R2 stated, I remember hearing coughing, it sounded like she was choking. I kept ringing the buzzer. I heard her drinking something . I didn't know that kind of stuff was over there, she must have been thirsty. When asked what she drank, R2 said, Body wash. When asked how she knew this, R2 stated, I heard them [facility staff] saying she drank body wash. They said they could tell by her poop. She had a major blow out . It sounded like she was choking. R2 stated she couldn't see R12 because the privacy curtain was pulled. On 4/7/25 at 4:30 p.m., an interview was conducted with licensed practical nurse #11 (LPN #11), who also worked the unit where R12 was a resident the night of the incident. LPN #11 stated, I was fairly new. I was only working there two weeks, but she would grab you when you walk by. I was working night shift and the nurse assigned came and told me she swallowed soap. She had aspirated; she had soap coming from her nose and mouth, it was tan colored. The nurse from the other side came to help. She [R12] was having massive diarrhea. When asked if she thought R12 had drank shower gel, LPN #11 said, Definitely! I was a CNA for 20 years and I know for sure it was bath and body works, maroon colored. I saw the bottle when the EMTs [emergency medical technicians] came and most likely the CNA left it on the bedside table. She would grab things . It was a bunch of CNAs trying to help. [LPN #5's name redacted] was helping, [LPN #12's name redacted] was on the phone with the doctor and we got vitals. I saw her aspirating from her nasal, she sounded like she was under water. She was struggling to breathe. She was not at her baseline. She had a lot of fluid sounds. LPN #11 went on to report that when the EMT's came they had four trainees, and they were getting instructions on how to lift R12. They applied oxygen, she was in the wheelchair. I was doing something and remember [LPN #11's name redacted] saying this isn't good. I dropped what I was doing to go help. Yes, I was present. When asked if any of the facility administration had attempted to reach her to get information about what had happened, she stated, They never called or reached out. The next day they had a whole protocol on keeping stuff out of reach. On 4/7/25 at 4:53 p.m., the vice president of operations (VPO) provided the survey team with a plan of correction the facility had implemented in response to R12's incident. The VPO said, We can't tell for certain it happened, but we put a plan in place. The documents included a paper with a grid that noted, . Problem: Toiletry Items: Date of Implementation: 3/17/25. Problem: 1. Toiletry items not stored correctly in pt [patient] bedrooms. Immediate response- what was done at the time: 1. 100% audit of all rooms to ensure toiletry items stored correctly. How to identify other residents: 1. All residents have the potential to be affected. What measures were put in place to prevent reoccurrence: 1. Education to nursing staff, provided by DON [director of nursing], or designee: On ensuring toiletry items are stored in closet, nightstand drawer or with staff. Ensuring all cleaning supplies are locked up. How to monitor to ensure the problem does not reoccurrence [sic] 1. The DON or designee will audit 10 rooms weekly for 4 weeks then 3 rooms weekly for 4 weeks to ensure toiletry item and cleaning supplies are stored correctly. QA: [quality assurance] The results will be reported to the monthly quality committee for review and discussion. To ensure substantial compliance. Once the QA committee determines the problem no longer exists, then review will be completed on a random basis. ADHOC QAPI: 3/24/25. QAPI Meeting: 4/13/25. Date of compliance: 3/27/25. Also included in the documents provided by the VPO was a typed paragraph that read, On 3/17/25 resident #1 [identified as R12 in this survey report] noted with hypertension, tachycardia, wheezing, and secretions from mouth. The medical provider was notified and ordered resident to be sent to ED for further evaluation after it was discovered that the patient may have ingested shower gel that was used for her bed bath previously. The RP [responsible party] was notified. The resident was admitted to the hospital for further evaluation. No staff member witnessed patient grabbing or ingesting the shower gel. A midnight census report dated 3/17/25, which listed all residents in the facility was provided that had a handwritten note across the top that read, 3/17/25 100% audit all rooms. All toiletry items stored correctly. There were no other notes or marks on the forms. Also provided was In-service education records that noted subject: Storage of toiletries, cleaning supplies . Summary of content: All toiletry items for patients will be stored away in their close, nightstand, or with staff. The in-service education records were signed by 145 staff members. There was also evidence of audits that were conducted for three weeks. On 4/7/25 at 8:10 p.m., an interview was conducted with CNA #3. CNA #3 was asked about the night R12 was sent to the hospital. CNA #3 stated, I was working with one other CNA, we had 40-60 residents. The CNA working with me would not finish a full round. The only resident she got cleaned up was [R12's name redacted]. They let her sit from 3-11 p.m. in the chair. The CNA on the prior shift said she was acting crazy because she had been refusing medications for several days. The CNA [CNA #2] washed her up and changed her into her gown. I helped hold her up while she was washing her and got her in bed. I was walking by and on the bedside table I noticed soap was missing from the bottle. I went and told the nurse that on the table was a bottle of soap and it was missing soap out of it. I told the nurse. I think she went to check on her. I went back about 20 minutes later to check on her and she was still sitting there, she had diarrhea and was breathing heavy. The other CNA was sitting at the station. We were both working the floor together because she was new. [R12's name redacted] was sitting up with soap missing and the top off. It was something the family provided; it said black cherry [on the label]. She had taken her gown off . it was the reason I went in the room, and I noticed she was breathing weird. I told [LPN #12], and she wanted to know how much she had drank. I told her a good amount and she said she will probably just puke it out. When asked if she had worked with R12 previously and what she was like. CNA #3 said, I had worked with her. She was always reaching out, that night she was aggressive and hitting. We kept her at the nursing station until she was ready to go to bed. The other CNA was a new agency person. CNA #3 went on to report that . the rescue squad staff took the soap with them. She had red stuff in her mouth, I noticed foaming, we were wiping that off, it was pink tinted. When asked how R12 got the soap, CNA #3 said that the other CNA working that night, . heard the same things I did. She had dementia and is grabbing at things; she is off her meds. I think it is kind of negligent; why would you leave soap right there on the overbed table? On 4/8/25 at 8:47 a.m., an interview was conducted with LPN #5. LPN #5 reported he had walked to the unit where R12 was a resident to get a vital sign machine. LPN #5 reported, The nurses and CNAs looked like something was wrong. They said, 'She grabbed soap and ingested it.' I contacted 911, started her file to send with her. That was between 5-6 a.m. When asked how R12 got the soap, LPN #5 said, I'm not sure, I thought I heard them say she grabbed it off the bedside table. I'm not sure if while getting her cleaned up and stepped away to get a towel or something. One nurse said they thought she drank soap and had suds and bubbles coming out of her mouth and nose. So I started the ball rolling to get EMS there. That soap lines the esophagus and can be aspirated. When asked if she saw or assessed R12, LPN #5 stated, No. Usually my role in emergency situations is to get 911 there and do the paperwork. On 4/8/25 at 9:13 a.m., an interview was conducted with LPN #12. LPN #12 reported, I was on my med cart and had been on the hall and walked by the room and saw her [R12] laying sideways. She had a bowel movement, and it was all over her; it was bubbly and pink tinged, it even smelled like it [the soap]. The CNA said 'I think she may have drank it [the soap]' I could hear her in her respiratory, she was very congested. The CNA said she had washed her up. [R12's name redacted] was new to our hall and the CNA is a traveler. When asked if R12 was restless, confused or grabbing at things, LPN #12 said, All the time! When asked if R12 had any clinical symptoms, LPN #12 stated, Her lips were discolored, vitals surprisingly weren't too off baseline for her, which I've learned means nothing. She just looked at you with a stare. Respiratory was bad, I knew she had to go. That facility has a protocol you have to call three people to send someone out and no body answered, so I called on-call back. LPN #12 was asked if she suctioned R12. LPN #12 said, I didn't suction her because I wiped out of her mouth what was coming from her was deep you could wipe the bubbles and it kept coming; it smelled perfume, it was foamy bubbles with a pink tinge. When asked if anything else could have happened, LPN #12 said, No. I don't think it was intentional but there is no other explanation. On 4/8/25 at 9:32 a.m., an interview was conducted with CNA #2. CNA #2 reported, It was the first time I had worked with her, we gave her a bath. Prior to that she was sitting at the nursing station, when I came in at 11 p.m. I think we put her to bed maybe around 4 a.m. When we brought her to the bed, we washed her off and changed her brief. The other aide was doing rounds and called me to come. We saw bubbles coming out of her mouth, she was foaming. We called for the nurse at the desk, I think she said she was aspirated. We sat in the room until the ambulance came. We think she drank the soap on her nightstand. She literally had bubbles coming out. We didn't give her anything to drink, it was bubbles, it was on her nightstand when we brought her in the room. CNA #2 went on to state that she had seen the soap on the bedside table and said, So I didn't think anything about it. It was my first time with her, so I didn't really know her. When asked if she had gotten any kind of report on the residents she was to be assigned, CNA #2 said, I could have, I don't recall. CNA #2 continued the interview and said, She [R12] was demented. It was a nightmare. I feel horrible for her; she had bubbles coming out of her mouth, so I assume she drank the soap. You could hear her gurgling, at that point I'm thinking she aspirated, it was like she was choking. When asked if R12 was having any difficulty breathing, CNA #2 said, Yes, you could hear the sound like gurgling. During the survey on 4/3/25, 4/7/25 and 4/8/25, the shower rooms on the east and west units were noted to have the doors open and gallon jugs of shampoo & body wash were noted to be accessible to anyone entering the shower rooms. On 4/7/25, Resident #20 (R20) was noted to be sitting in the hallway near the nursing station. R20 was not able to answer questions and replied unintelligibly. A review of the clinical record revealed that R20 had a BIMS of 3. On 4/7/25 at 1p.m., during an interview with R20's roommate, who was Resident #9 (R9), observations of the room revealed that R9 had aerosol air freshener and two cans of Raid ant and roach spray in the room that was not secured. When questioned, R9 reported that she had the bug spray for ants. On 4/8/25 at 10:35 a.m., observations of R20 's room revealed that the over bed table was located by the sink, with the breakfast tray and a bottle of dove silver shampoo sitting on the table. On 4/8/25 at 11:17 a.m., an interview was conducted with licensed practical nurse #13 (LPN #13), who was the unit manager where R20 resided. When asked about R20, LPN #13 said, Some days are better than others, she does have dementia. Her decision making is impaired, she has very minimal safety awareness and is very impulsive. We try to keep her in high traffic areas, try to keep her busy and she goes to activities. When asked how toiletry items are to be stored, LPN #13 said, In the nightstand or closet. When asked why they are to be stored there, LPN #13 stated, Due to the potential of someone with impaired memory thinking it is something else. LPN #13 accompanied the surveyor to R20's room and confirmed the observation of the bottle of shampoo on the overbed table beside R20's cup of water and breakfast tray. LPN #13 said, This should not be out, and the breakfast tray should have been taken out. On 4/8/25 at 11:35 a.m., an interview was conducted with licensed practical nurse #3 (LPN #3), who was a unit manager. When asked about R12, LPN #3 stated, She was a sweet, demented lady. We tried to keep her up here with us to keep an eye on her, she was grabby, she would grab at you as you walk by and would touch other residents' arms if they stay by her. She was not oriented, she was total care for everything, was fed by staff, incontinent of bowel and bladder. When asked about her knowledge and involvement the day R12 was sent to the hospital, LPN #3 said, I was on call that morning when [LPN #12's name redacted] called me and said [R12's name redacted] had gotten a hold to some soap and drank it. She called for transport to send her out, she said she was still alert and at her baseline, was coughing up soap bubbles. Following that we put a plan of correction in place to be observant of toiletries being out of reach and stored in closets or bedside drawers. When asked if any consideration had been given to toiletry items in the shower rooms, LPN #3 stated, Nothing is to be left out in the shower rooms. When LPN #3 was notified that the survey team had observed gallon jugs of shampoo and body wash was unsecured on multiple occasions and even sitting on the floor while the shower room doors were open and accessible to anyone coming into the rooms, LPN #3 stated, There is a holder on the wall it should have been placed in. When I walk by, I try to shut the doors. On 4/8/25 at 1:02 p.m., following confirmation of IJ existence by the SA, the facility's administrator, director of nursing, and corporate staff were made aware that the survey team had identified the facility was in Immediate Jeopardy (IJ), which also constituted substandard quality of care. The IJ template was read and a copy emailed to the facility administrator and vice president of operations (VPO). Immediate Jeopardy was identified to have begun on 1/8/25, when R12 was not appropriately assessed for the risk of injury from hot liquids. On 4/8/25 at 4:45 p.m., the facility administration provided the following IJ removal plan: F689 Accidents and Hazards Removal Plan. Plan Corrective Action for those residents found to be affected by the deficient practice: A. R#12 is no longer residing in the facility. B. R#12 is no longer residing in the facility. All items for R#20 and R#9 have been stored appropriately. Corrective Actions taken for residents with potential to be affected by deficient practice: A. All residents who drink hot liquids have the potential to be affected by this deficient practice. Nursing team will conduct hot liquid assessments on all patients to determine an appropriate level of intervention for each patient. Care plans will be updated based on findings. B. All residents who reside in the facility have the potential to be affected by this deficient practice. The interdisciplinary team will audit all resident rooms to ensure items are stored appropriately in resident rooms and shower rooms. The Facility Administrator will conduct a town hall meeting on 4/8/25 at 6:00pm with the resident counsel to review appropriate items that can be in the room and how it can be stored. Those residents not in attendance will be given a handout with this information, and resident families will be called to be educated for patients who are not able to be educated. Systemic Changes put into place to ensure the deficient practice does not recur: A. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the [NAME] President of Operations on the policy which states the acceptable hot liquid temperatures. Starting 4/8/25 all facility staff will be educated on the hot liquids policy to include the appropriate temperatures to serve to residents before it leaves the kitchen. The kitchen will keep a temperate log of coffee temperatures prior to it leaving the kitchen. A list of residents with hot liquid interventions will be provided to the dietary staff and floor staff to ensure all interventions are in place. This education will be provided to all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they have been educated. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/8/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the hot liquids policy and procedure. B. The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Director of Housekeeping and Laundry, Human Resources, and Unit Managers) will be educated by the [NAME] President of Operations on what is appropriate to store in resident rooms and how they need to be stored. Starting 4/8/25 all facility staff will be educated on what is appropriate to store in resident rooms and how they need to be stored. This education will be provided to all new employees as part of new hire orientation to include agency staff. No employee will be allowed to work until they are educated. The [NAME] President of Operations to conduct an ADHOC Quality Assurance Performance Improvement Meeting on 4/8/25 including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the procedure for storing hazardous items in resident rooms and in shower rooms. Monitoring of corrective action to ensure the deficient practice does not recur. A. Facility will monitor the temperature of coffee that is poured for residents to ensure it is following the policy for proper temperature before leaving the kitchen. B. Facility will monitor resident rooms, common areas, and shower rooms to ensure items are stored appropriately. Completion of removal plan 4/8/25 at 10:00pm. The Regional Director of Clinical Services made the Medical Director aware of the Immediate Jeopardy via telephone on 4/8/25 at 3:08pm. Following consultation with the SA, the facility was notified of the acceptance of their IJ removal plan. On 4/9/25, the survey team verified the implementation of the facility's removal plan through clinical record reviews to ensure that all resident's had been assessed for risk of injury from hot liquids by facility staff's completion of a hot liquid safety evaluation. The resident's identified at risk had their care plan reviewed to ensure that the care plan included the risk for injury and interventions to prevent accidents from hot liquids. During the review, one resident was listed on a list titled, List of residents needing intervention for hot liquids that did not match the interventions identified on the hot liquid safety evaluation. There was an additional resident that according to the hot liquid safety evaluation required interventions and that resident was not listed on the list of residents needing interventions for hot liquids. These concerns were brought to the attention of the facility's administrator and corporate staff and were immediately corrected with a revised listing provided to the survey team at 10:03 a.m. On 4/9/25, observations were conducted throughout the facility, in the shower rooms, and in resident rooms to ensure that no potentially hazardous items were readily accessible to cognitively impaired residents. Interviews were conducted with a sample of residents to ensure they had been made aware of how to store toiletry items. Handouts were observed in resident rooms that included the safe storage of potentially hazardous items and the temperature of hot liquids being monitored. On 4/9/25, the survey team was provided with a revised policy titled, Hot Beverage Policy that read, 1. The dining services director will ensure that coffee temperatures of hot beverages will arrive for service at a temperature range of 150 F or less. 2. When beverages have been reheated in a microwave the following must occur: a. Time of microwaving should not exceed 2 minutes. b. Using a sanitized (alcohol wipe) probe thermometer, the temperature must not exceed 140 degrees before deliver of the hot beverage. c. The staff will be provided with a probe thermometer and alcohol wipes to sanitize the thermometer. Staff who take the temperature will have adequate training on the proper sanitizing and use of a probe thermometer. d. If the temperature exceeds 150 degrees the beverage shall remain under the direction of the person reheating until the beverage is less than 150-degree temperature range. 3. The hot beverage should be covered with a lid during transport back to the resident. On 4/9/25, the staff education sign-in sheets were compared to the working schedule to ensure that all present staff, in all departments, had received training regarding the appropriate serving temperature of hot liquids and the storage of potentially hazardous items. No concerns noted. On 4/9/25, the survey team conducted staff interviews with staff across all departments to verify education was provided and to confirm their understanding of the serving temperature for hot liquids and appropriate storage of hazardous items. No concerns noted. On 4/9/25, observations were conducted in the kitchen and noted that a new Hot Beverage Service Temperature Log had been implemented. The dietary staff were observed to be monitoring the temperature of the coffee being put into the thermal dispensers to ensure it was less than 150 degrees, and prior to the beverage carts being delivered to the unit. Dietary staff were interviewed to confirm their knowledge of the appropriate serving temperatures. No concerns noted. On 4/9/25 at 11:15 a.m., after having verified that the removal plan had been fully implemented and that facility actions had eliminated the likelihood of serious injury, serious harm, serious impairment, or death, the facility was notified that the immediacy had been removed. The scope and severity of the remaining noncompliance was then lowered to a level three, isolated. 2. The facility staff did not have a system or protocol to monitor the temperature of hot liquids served to residents, to ensure safety, which resulted in R12 sustaining an injury from spilled coffee that required medical treatment to prevent further severity On 4/4/25, a closed record review was conducted of R12's chart. According to the hot liquid safety evaluation completed on 1/8/25, the questions in section 2B that indicated easily agitated, mood varies, and impulsive acts was not checked as having applied to R12. Section 2A was checked as yes and 2B1g was checked. Section 3 noted, If two or more indicators are checked in safety factors section 2, than the resident is at risk for injury from hot liquids and requires an intervention selected from below. Section 3 was blank and did not indicate R12 was at risk, despite having two areas checked in section 2. According to progress notes dated 1/1/25-1/8/25, the week prior to completion of the hot liquid safety evaluation, there were multiple entries indicating that R12 was agitated, restless, disrobing, and was administered lorazepam on several occasions due to behaviors. The hot liquid safety evaluation did not have the section checked that easily agitated, mood varies, and impulsive acts as being applicable R12, which was inaccurate based on nursing documentation. A progress note dated 3/5/25, was noted to read, During dinner time patient spilled coffee on herself. Slight redness on her thigh noted. NP [nurse practitioner] made aware. patient doesn't seem to be in distressed. No new order. Zinc oxide was applied. Staff will continue to monitor. On 4/7/25 at 11:40 a.m., an interview was conducted with the dietary manager (Other Employee #1- OE#1). OE #1 stated that they do not monitor or measure the temperature of coffee served to residents. OE #1 stated, After it comes out of the machine, it is supposed to go down [the temperature], so we don't scald anyone. When asked if they check the temperature of coffee, OE #1 said, No. Are we supposed to? Because we don't. At another facility I worked, we did check the temperature to make sure it wasn't too hot because someone got burned. We made sure it was 140 degrees Fahrenheit (F) or below before we sent it out of the kitchen. It is not part of the routine here. The kitchen temperature logs were reviewed for the past month and revealed no evidence of the kitchen staff monitoring coffee or other hot liquids temperatures prior to serving to residents. On 4/7/25 at 4:45 p.m., OE #1 accompanied the surveyor to each beverage cart and checked the temperature of the coffee using a digital thermometer. The coffee being served on the East wing was 159 F. After the coffee on the west wing measured 153 F, OE #1 drank the coffee to see how hot it was and said, It's hot. The coffee on the south wing measured 150.8 F. On 4/8/25, the facility administrator provided a policy titled, Hot Beverage Delivery. According to the policy, which read in part, 1. The dining services director will ensure that coffee temperatures from the coffee machine do not exceed 165 degrees. 2. The dining services director will ensure that coffee temperatures of hot beverages will arrive for service at a temperature range of 150 F or less. On 4/8/25 at 10 a.m., OE #1 was observed in the kitchen to measure the temperature of the coffee after it was brewed, and it was noted to be at 176 F. OE #1 said, When it first brews, it is around 180 degrees F, and we have to let it sit to cool. When asked if he was monitoring the temperatures prior to today, OE #1 said, No, we didn't have a policy that I knew about until today, if I'm being honest with you. 3. T[TRUNCATED]