**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision to one of three sampled resident (Resident 1), when Resident 1 was left unattended and unsupervised by staff while in the Memory Care Unit patio on a hot day. This failure potentially contributed to the death of Resident 1, a clinically compromised resident with dementia (memory loss), on [DATE]. Findings: An unannounced visit was conducted on [DATE], at 12:20 PM, to investigate a complaint regarding death of a resident (Resident 1). During the tour and observation of the facility's Memory Care Unit patio, with the Director of Nursing (DON), on [DATE], at 1:50 PM, the DON stated there was no door alarm to alert the staff that someone is going out to the patio. She stated, the facility recently installed a door alarm in Memory Care Unit double exit doors on [DATE]. During an interview with the DON, on [DATE], at 2:00 PM, the DON stated Resident 1 was found unresponsive, not breathing, with skin pale, and warm to touch by Certified Nursing Assistant (CNA 1) in Memory Care Unit patio on [DATE], at 4:30 PM. During a review of Resident 1's admission Record (contains demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses of Alzheimer's disease (memory loss), heart failure (a heart does not pump enough blood), and hemiplegia (caused by a brain injury resulting in varying degree of weakness on one side of the body). During a review of Resident 1's clinical notes Progress Notes , documented by Licensed Vocational Nurse (LVN), on [DATE], at 5:15 PM, it indicated, .at 4:15 PM during rounds, resident was not seen in his room or dining room. Upon checking patio, where resident goes at times, resident was seen sitting in patio bench. Upon approaching, resident was unresponsive and had no pulse. A code blue was called and simultaneously checked POLST (Physician Orders for Life-Sustaining Treatment), resident is a DNR (Do Not Resuscitate, a medical order written by a doctor to instruct health care providers not to do CPR (Cardio- Pulmonary Resuscitation an emergency life-saving procedure that is done when someone's breathing, or heartbeat stops) with comfort measures, CPR was not initiated. Resident was transferred from patio bench and hydroplaned (sliding over) using sheets back to bed. Time of death called at 5:10 PM by the DON. During an interview, on [DATE], at 1:20 PM, with Certified Nurse Assistant, (CNA 1), stated she was assigned to Resident 1 on [DATE], during the morning shift. CNA 1 stated, she started her shift from 7:00 AM to 3:00 PM. CNA 1 stated she last saw Resident 1 on the wheelchair, around 3:00 PM. She further stated she was clocking out to leave the unit, when she saw Resident 1 in the hallway, scooting in his wheelchair. CNA 1 stated Resident 1 was able to wheel himself alone, however she did not see Resident 1 going to the patio. She stated, she did not bring him in patio because Resident 1 was confused, and it was hot on [DATE]. During an interview, with the DON, on [DATE], at 2:00 PM, the DON checked the weather in Redlands (city where the facility was located) using a mobile phone. The DON stated the weather on [DATE], was at 94 Fahrenheit (F unit of measure) to 97 F from 3:00 PM to 6:00 PM. During a telephone interview, on [DATE], at 2:45 PM, with Certified Nurse Assistant, (CNA 2), she stated, she starts her shift from 3:00 PM to 11:00 PM. She further stated she was assigned to Resident 1 during the afternoon shift. CNA 2 stated it was a change of shift, and she did not do her afternoon rounds with CNA 1 (outgoing staff). She further stated she did not see Resident 1 since the start of her PM shift. CNA stated she was ready to prepare him for dinner around 4:15 PM and was unable to find him, so she went to the Memory Care Unit patio at 4:30 PM, and found Resident 1 sitting on the bench by himself, unresponsive and immediately notified the Charge Nurse. During a review of Resident 1's Care Plan , on [DATE], at 3:00 PM, it indicated, Resident 1 had a communication problem related to poor condition .Resident 1 is dependent on staff for activities, cognitive (relating to the mental process involved in knowing, learning, and understanding things) stimulation, social interactions related to cognitive deficient . During a review of Resident 1's MDS (Minimum Data Set, a standardized assessment tool that measures health status in nursing home residents) 3.0 Section C-Cognitive Patterns , on [DATE], at 3:00 PM, it indicated, Resident 1 has BIMS (Brief Interview for Mental Status, an initial tool to identify a resident's cognitive function changes) score of 4 as severely impaired (significantly limits the resident's physical or mental abilities to do basic work activities . During an interview, on [DATE], at 2:15 PM, with the Minimum Data Set Coordinator, he stated Resident 1 was confused, wanders, wheelchair bound but able to scoot himself with his wheelchair around the facility and needs to be re-directed. He further stated Resident 1 needed minimal assist in transfers from wheelchair to bed, bed to wheelchair. During a follow up interview with the DON, on [DATE], at 9:10 AM, the DON stated she did not call 911 for Resident 1 because the POLST was Do Not Resuscitate. She further stated she cannot remember if she saw Resident 1 in the patio. She stated they did not call the police, but able to call and notify Resident 1's physician and family member. During an interview with Activity Director Assistant, on [DATE], at 9:50 AM, she stated, she had seen Resident 1 trying to open the patio door, but she has not seen Resident 1 able to make it outside. She stated Resident 1 should not be left alone, unassisted, and unsupervised. She further stated Resident 1 had memory problems and needed to have constant re-direction. She stated resident's safety was the facility's concern and the facility cannot leave confused residents by themselves. She further stated they should have checked him more often and kept their eyes on him. She stated Resident 1's passing could have been avoided if there was adequate supervision. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents , dated [DATE], indicated, 2. Safety risks and environmental hazards are identified on an ongoing through a combination of employees training, employee monitoring, and reporting process .4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in the environment . During an interview, on [DATE], at 10:30 AM, with the Director of Nursing (DON), the DON further stated all residents in the Memory Care Unit were vulnerable for accident or harm and it was possible the death of Resident 1 might have been prevented or avoided if Resident 1 was seen earlier. An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 Free of Accident Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on [DATE], at 11:55 AM, in the presence of the Administrator and the Director of Nursing when Resident 1 was left unattended and unsupervised by staff while in the Memory Care Unit patio on a hot day and contributed to the death of Resident 1 on [DATE]. A corrective action plan was requested on [DATE], at 11:55 AM. A corrective action plan was provided by facility on [DATE], at 12:45 PM included: * Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator identified 31 wheelchair bound residents as clinically compromised, wheelchair bound residents including 15 residents located in the Memory Care Unit. *All identified residents have been assessed on their ability to sit on either patio, safely with supervision. Only 7 residents can safely sit on the patio with the line-of-sight supervision based on cognitive status and functional ability. The 7 residents identified are located on Station A. All 15 residents in Station B-Memory Care Unit require direct supervision if on the patio. * All 31 resident's person-centered care plans have been revised and updated. *Administrator and DON and other staff members conducted random rounds checking the outside patio on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], and at this time, there have been no other residents affected. * Maintenance Supervisor installed security alarm on Memory Care Unit double doors heading toward the outside patio on [DATE] to alert the staff when the double doors open, and it indicates that someone is going outside to the patio in Station B. *Maintenance Supervisor and/or Designee will check the door alarm once a day Monday through Friday and the Manager of the Day will check the door alarm once a day on Saturday and Sunday. *License Nurse assigned to Station B will check the door alarm function every 2 hours and the outside patio. At the change of shift, the License Nurses will check the outside patio and the door alarm to ensure it's alarmed, functioning, and will be endorsed to the next shift. The License Nurse will use the form, Door Alarm & Patio Check (every 2 hours and change of shift) . *CNA (Certified Nursing Assistant) will conduct safety rounds every hour during their shift to ensure every resident assigned to them is accounted for. The CNA's will document on Resident Safety Log . *DON and DSD (Director of Staff Development) in-serviced and re-educated the staff on [DATE], [DATE], and [DATE] on the door alarm and on the policy and procedure titled, Safety and Supervision of Residents , emphasizing that if the door alarm goes off to immediately check who is outside, ensure the resident is safe, and redirect them back inside especially on hot days. The staff were informed that no resident should be left outside unsupervised. *Any staff that is scheduled off, on vacation time, or on a leave of absence will be in-serviced before assigned to the floor by the Director of Nursing and/or the Director of Staff Development. *All new admissions and readmissions will be assessed during the Clinical Meeting (Monday through Friday), to assess potential risk and hazards and ensure that their person center care plan is revised and updated as needed. Friday Admission/readmission will be reviewed on Saturday by the MDS Assistant. Saturday admission will be reviewed on Sunday by DON. *The Department Heads and the Manager of the Day will conduct hourly rounds Monday through Friday including weekends to ensure that no residents are outside in the patio unsupervised. Any residents found outside will be supervised and/or re-directed inside. Any findings will be documented in the Angel Rounds Report and reported to the Administrator and the Director of Nursing immediately. *The QAPI Committee will evaluate the intervention and determine if identified goals re met or if new interventions are needed. The report will be reviewed monthly by the QAPI Committee for three months and quarterly thereafter. The immediate jeopardy was removed after the Corrective Action Plan was verified to be implemented through observations, interviews, and record reviews on [DATE], at 2:58 PM in the presence of the Administrator and the Director of Nursing.