Inspection·December 21, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, staff and resident interviews and policy review,the facility failed to ensure a comfortable hot water temperatures were maintained throughout the facility. This affected nine (#37, #14, #18, #26, #27, #35, #36, #45 and #46) out of 15 residents sampled for the physical environment. Facility census was 46. Findings include: Observation of the shower room, across from the nursing station on Unit #1 was completed on 12/21/23 at 7:34 A.M. at which time the hot water temperatures in the sink was tested at 100 degrees Fahrenheit (F). Maintenance Director #26 went into the shower room with the surveyor at 7:40 A.M. and the hot water would not get any higher that 80 degrees F. Maintenance Director #26 confirmed the facility has been having issues off and on with the hot water temperatures. Interview with State Tested Nursing Assistant (STNA) #41 on 12/21/23 at 7:32 A.M. revealed the hot water temperatures in the shower room and residents rooms on Unit #1 are all over the place, sometimes to hot and sometimes cold. Interview with STNA #101 on 12/21/23 at 8:45 A.M. revealed the shower room, near the nursing station is always unpredictable for the hot water temperatures it can be cold, warm or to hot. Interview with Resident #37 on 12/21/23 at 8:53 A.M. revealed she was receiving a shower this morning and the hot water became cold, so the staff then had to take her to the other end of the hallway to finish her shower. Resident #37 identified she is really tired of the ongoing water temperature issues. Interviews were completed with Resident #14, #18, #26, #27, #35 and #36, all of who confirmed there is on-going issues with water temperatures in the facility. Resident #14, #18, #26, #27, #35 and #36 stated the shower hot water will start warm and then get cold and another identified you never know if the shower will be warm or turn cold in the middle of the shower. Tour of the facility with Maintenance Director #26 on 12/21/23 at 7:59 A.M. revealed the hallway bathroom hot water temperature was 93 degrees (F) and Resident #45 and #46's room hot water temperature was 85 degrees F. Review of the facility bath/shower water temperature monitoring policy, that was not dated was reviewed. The policy identified the purpose was to establish procedures to ensure the protection of individuals from hot water while bathing/showering. The policy identified hot water used for bath and shower shall be between 110-115 degrees F. Residents shall received the needed supports and supervision during bathing/showering that will ensure their protection from hot water injuries. The policy (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365118 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)