**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, family interview, clinical record review, hospital clinical record review, facility images, hospital images and policy review, the facility staff failed to ensure residents who required assistance to move around couldn't come into direct contact with the electric baseboard heater for 1 of 3 residents (Resident #1) reviewed. Resident #1 required the staff to utilize a mechanical lift to transfer in or out of the bed, needing significant assistance from the staff for all mobility. A staff member found Resident #1 with their legs laying on top of the electric baseboard heater on 12/8/24 at 12:44 AM. Staff interviews revealed Resident #1 potentially laid on the electric baseboard heater for approximately an hour before staff discovered him. When the staff moved Resident #1, they discovered he suffered burns to both legs. An observation of Resident #1's room on 12/30/24 revealed an electric baseboard heater, without a protective device, that had a surface temperature of 124 degrees Fahrenheit (F). Review of the facility staff documentation revealed that all of the rooms in the 100, 200, and 300 hallways had electric baseboard heaters similar to Resident #1's room. The staff documented the electric baseboard heaters had surface temperatures ranging from 124 degrees F to 130 degrees F. An interview with the maintenance staff indicated they believed the electric baseboard heaters could potentially reach a maximum temperature of 180 degrees Fahrenheit. The State Agency informed the facility of the Immediate Jeopardy on 12/31/24 at 1:56 PM that began on 12/8/24. The Facility Staff removed the Immediate Jeopardy on 12/31/24 through the following actions: -Resident #1 immediately positioned away from heater - 12/8/24 -Assessment and First aid initiated, primary care provider (PCP) and wife updated - 12/8/24 -Resident #1's room rearranged with beds moved to wall without a register - 12/8/24 -Bed placement audit performed for all resident beds with electric heaters and any beds with concern were moved to safe distance of 3 feet - 12/9/24 -Safe touch surface audits done on all electric registers - 12/9/24 -Room thermostats to be set no higher than 71-degree F unless management notified - 12/9/24 - Random safe touch audits with surface touch thermometer to include every room in 100, 200 and 300 halls for the remainder of the season. The facility will follow the safe water temperature of 100 degrees per Appendix PP in the State Operations Manual. - 12/31/24 -Facility will audit safe distance of beds from heater five times a week for 3 months and then quarterly, done by maintenance or assigned person - 12/31/24 -All staff training for identifying and reporting hazards, bed positioning and thermostats. All staff assigned safety hazard in-service training videos to be completed immediately. - 12/31/24 -Purchasing designee actively looking for a safe cover or similar mechanism, if one available - 12/31/24 The scope lowered from a K to a G at the time of the survey after removing the immediacy. The facility identified a census of 60 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition. The MDS identified Resident #1 required substantial/maximal assistance with rolling left and right in bed and listed them as dependent on staff with transfers. Resident #1's MDS included diagnoses of non-Alzheimer's dementia, malnutrition (inadequate intake of nutrients), depression, arthritis, hyperlipidemia (high cholesterol) and a urinary tract infection (UTI) in the past 30 days. The MDS documented Resident #1 had a risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcer/injuries. The MDS documented Resident #1 had one unstageable pressure ulcer present on admission or reentry. The MDS documented the following skin and ulcer/injury and treatments: pressure reducing device for chair/bed, nutrition/hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressing and application of ointments/medications. The Care Plan revised on 12/26/24 revealed Resident #1 had a potential impairment to skin integrity related to fragile skin, history of pressure wounds and current wounds/blisters to bilateral lower extremities. The Care Plan documented contributing factors included burns, risk for malnutrition, history of deep vein thrombosis (DVT) and transient ischemic attack (TIA) causing risk with circulation to extremities, and hyperlipidemia causing increased risk with wound healing. The Interventions directed the following: a. Wound management to include skin prep (skin protectant) to the blisters, mupirocin (topical ointment) to open areas, house supplement for wound healing, air mattress, winged mattress for positioning and a wheelchair cushion. b. Resident #1 needed help to complete Activities of Daily Living due to dementia. c. Use a mechanical lift for all transfers. Resident #1 couldn't ambulate. A Fall Scene Investigation Report (FSI) dated 12/8/24 at 12:44 AM revealed the staff observed Resident #1 lying sideways on the bed with his legs out of the bed. The fall huddle findings described Resident #1 as restless due to vascular dementia and recent decrease in the medication Seroquel (antipsychotic). The findings concluded Resident #1 attempted to climb out of bed and slid his legs outside of the low bed. The FSI documented an intervention to prevent falls as to increase the Seroquel and rearrange the room. The Director of Nursing (DON) signed the form on 12/9/24 at 8:15 AM. An Incident/Accident Report dated 12/8/24 at 12:44 AM reflected the staff found Resident #1 with his legs hanging out of the bed touching the heat register, resulting in burns to his bilateral lower extremities. The report documented interventions added to the Care Plan included the following: -Rearrange room with bed across room along east wall -Elevate legs and treatment as ordered -Maintenance to check heat registers in room and also audit other registers throughout the building -Boundary board checks The Skin/Wound Note dated 12/8/24 at 12:44 AM labeled as a late entry documented a Certified Nursing Assistant (CNA) found Resident #1 lying on his stomach with his legs off the bed. Resident #1's left leg touched the heater and caused two blisters (Blister A and Blister B). Blister A measured 6 centimeters (cm) x 5 cm and popped with movement. Blister B listed as intact and measured 1 cm x 3 cm. The note lacked documentation of treatment to the burn areas at the time of discovery and lacked documentation of immediate interventions. The Skin/Wound Note dated 12/8/24 at 12:00 PM documented Resident #1 had multiple fluid filled blisters of various sizes. The left knee had two blisters. Blister A measured 4.2 cm x 3 cm and Blister B measured 6 cm x 8 cm. The note documented the open blisters had a scant amount of bloody drainage. The note revealed Resident #1's right shin had a red area that measured 7.3 cm x 3.8 cm with a fluid filled blister in the center that measured 1.1 cm x 1.2 cm. The note documented they cleaned the areas, applied skin prep to the intact blisters, mupirocin and a nonstick dressing to the open blisters. The note documented the intervention as the staff moved Resident #1's bed away from the heater and rearranged the room. The facility notified Resident #1's wife and Physician of the incident. The Non-Pressure Skin Condition Record dated 12/8/24 documented 7 burn related areas (A through G) to the left knee/shin. The record described the areas as partial thickness (affected the second layer of skin) with scant amount of serous (clear or yellow, thin, watery fluid) drainage. A - Fluid filled blister - 1.2 cm x 1.3 cm B - Open area - 4.2 cm x 3 cm C - Open area - 6 cm x 8 cm D - Blister - 1 cm x 0.8 cm E - Blister - 1.2 cm x 1.1 cm F - Blister - 5.3 cm x 3.4 cm G - Dark red area - 5 cm x 2cm The Non-Pressure Skin Condition Record dated 12/9/24 (24-hour reassessment) and facility pictures/images dated 12/9/24 of the left knee/shin documented four burn related areas and the following measurements: #1 - fluid filled - 2 x 2.5 #2 - granulation - 12 x 6 #3 - fluid filled - 5.8 x 4 #4 - red, intact - 3 x 2 A Physician Progress note dated 12/10/24 documented a physical exam identified Resident #1 had blisters to the skin of the left knee and leg. The Physician directed to apply skin prep to the intact areas and mupirocin to areas that are open, continue the treatment until resolved. The Non-Pressure Skin Condition Record dated 12/16/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - fluid filled - 2 x 2.5 #2 - scab forming, red edges - 12 x 6 #3 - fluid filled - 5.6 x 4 #4 - intact, red - 2.8 x2 The Non-Pressure Skin Condition Record dated 12/20/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - scab covering - 1.5 x 2 #2 - scab covering 90% - 11.8 x 6 #3 - flat blister, partially scabbed - 5.6 x 3 #4 - 2 x 2 The Non-Pressure Skin Condition Record dated 12/23/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - superficial scab - 1.3 x 1.9 #2 - 70% covered with scab - 10 x 3.5 #3 - scab - 5.2 x 2.5 #4 - dark pink - 1.4 x 1.2 The Non-Pressure Skin Condition Record dated 12/23/24 documented 4 burn related areas to the left knee/shin and measurements: #1 - partial thick/superficial scab - 1 x 1.5 #2 - 70% covered with scab, scab lifting - 10 x 3 #3 - scab - 5 x 2.3 #4 - new skin, dark pink - 1.4 x 1.2 The Non-Pressure Skin Condition Record dated 12/8/24 documented a burn with a blister to the right shin. The red area measured 7.3 cm x 3.8 cm and the blister measured 1.1 x 1.2. The record documented they applied skin prep. A facility form titled Root Cause Analysis (RCA) and Plan of Correction (POC) for Resident #1 dated 12/8/24 documented the facility had audits in place to check heat register surface temperatures. The POC documented Resident #1's surface temperature for the electric baseboard heater was 124 degrees F which the facility considered was a safe temperature. A facility form/room map titled Heat Register Safe Touch dated 12/9/24 documented the electric baseboard heaters in all of the rooms in the 100, 200, and 300 hallways had surface temperatures ranging from 124 degrees Fahrenheit to 130 degrees Fahrenheit. The Non-Pressure Skin Condition Record dated 12/9/24 (24-hour reassessment) and facility pictures/images documented an intact fluid filled blister to the right shin that measured 3.6 cm (length) x 2.5 cm (width). The Non-Pressure Skin Condition Record dated 12/16/24 described the blistered area to the right shin as open at that time and measured 3.1 cm (length) x 2.6 cm (width). No signs of infection. Non-Pressure Skin Condition Record dated 12/23/24 documented the right shin area as scabbed and measured 3.4 cm (length) x 2.2 cm (width). The Communication with Family/NOK/POA Note dated 12/23/24 at 10:45 PM documented Resident #1's wife saw her husband and told the CNA she was going to call 911 to take her husband to the hospital. The note documented Resident #1's wife talked to a nurse about his burns and showed the nurse pictures she took of his knee. The wife voiced concerns about why they didn't send Resident #1 to the burn hospital right away. The wife reported Resident #1 was going to die and lose his leg. The note documented the nurse gave reassurance to the wife of the doctor's involvement and how they didn't feel he needed to go to the hospital at the time. The note documented that it takes time for the burns to heal. The wife reported the DON had voiced the Physician would be at the facility the following day. The wife reported she would be back in the morning when the Physician came. A Physician Progress note dated 12/24/24 documented Resident #1's chief complaint as his wound wasn't healing. The progress note documented Resident #1 had pain in the left knee, preferred to sit with his leg flexed at 90 degrees at the knee, had pain with extension of the knee, and had superficial wounds around the patella and left anterior knee that were not healing. The Physician ordered x-rays of the left knee/hip, a wound culture of the left knee, lab work that included a CBC (completed blood count) and CRP (c-reactive protein), and a wound clinic referral. The Communication - with Doctor dated 12/24/24 at 2:40 PM indicated the staff reviewed Resident #1's labs with the Physician, who gave new orders to continue Keflex (oral antibiotic) TID for the knee wound. The Transfer to ER Note dated 12/26/24 at 4:36 PM documented Resident #1 went to the emergency room per family request via private vehicle. The Hospital emergency room (ER) Physician Note dated 12/26/24 documented Resident #1 reason for the ER visit as a wound check and nursing home placement. The note documented Resident #1 suffered fairly severe burns on his legs 19 days before and recently started antibiotics. The note documented his legs appeared to heal okay. The wound had a large amount of eschar (dead, nonviable tissue) present. The note documented the final diagnosis as a full thickness burn (3rd degree burn that extends through all layers of skin, completely destroying the skin) of the left lower extremity with the plan to admit to the hospital. The Hospital Wound Assessment and picture/image dated 12/27/24 documented Resident #1 had a thermal burn to the anterior left knee that measured 17 cm (length) x 5 cm (width) x 0.1 cm (depth) with 100% eschar to the wound bed. The Hospital Wound Assessment and picture/image dated 12/27/24 documented Resident #1 had a thermal burn to the right lower leg that measured 3 cm (length) x 1.7 cm (width) and 0.1 cm depth with 100% eschar to the wound bed. The Hospital record titled General Surgery Consult dated 12/27/24 documented they saw Resident #1 for an assessment of his lower legs burn wounds. The consult documented Resident #1 had a very large eschar to the left knee that overlies the patella. Resident #1 also had a dark eschar distal (farther away) to this as well as on the right shin. The progress note documented they managed to debride (remove dead tissue) majority of the dry eschar at the bed side, with very adherent dry eschar remaining over the knee. The note directed to start Santyl (topical enzymatic debridement) as a treatment. The Hospital record titled Wound Debridement Documentation dated 12/27/24 documented they performed excisional debridement (removal of nonviable tissue using a sharp instrument) to his left knee. The debridement involved subcutaneous tissue (deepest layer of the skin) and removal of necrotic, devitalized (tissue not savable due to a lack of blood supply), non-viable (non-savable) tissue. They debrided the wound to viable, fresh, and bleeding tissue. They listed the estimated wound area as approximately less than 20 square cm. Review of Appendix PP in the State Operation Manual (SOM) issued 8/8/24 revealed a safe water temperature of 100 degrees F. The SOM documented the degree of injury depends on factors including temperature, the amount of skin exposed, and the duration of exposure. Table 1 in Appendix PP in the SOM illustrated damage to skin in relation to the temperature of the water and the length of time of exposure for a 3rd degree burn to occur: 155-degree F - 1 second 148-degree F - 2 seconds 140-degree F - 5 seconds 133-degree F - 15 seconds 127-degrees F - 1 minute 124-degrees F - 3 minutes 120-degrees F - 5 minutes 100-degrees F - Safe temperature for bathing An article from Geographic Pedia titled, How Hot Can A Human Touch Without Getting Burned? dated 6/22/24 documented the industry standard for safe contact is 140 degrees F, but temperatures above 100 degrees F can still cause damage to the skin with prolonged contact. Researchers found the pain threshold for heat is around 112.3 degrees F and the highest threshold was found in the foot at 112.1 degrees F. The article further documented 140-degrees F could cause third degrees burn on human skin in just one second. On 12/30/24 at 9:18 AM, Resident #1's wife requested the surveyor check all the rooms in the memory care unit to ensure the facility didn't have beds against the heat registers. She stated they had her husband's bed positioned in front of the window and only 6-8 inches from the heat register. She stated he rolled out of bed onto the heat register. She stated she didn't know for sure how long he laid there. She reported he received burns to both of his legs. She reported the heat register as hot to touch and she could not keep her fingers on it. She stated the facility notified her around 12 noon the following day of his injuries. She stated the staff told her they were treating the burns and that the areas were healing. She stated she felt the facility should have sent him to the wound center for treatment. She stated the left knee cap had a really bad burn on it. She added her husband couldn't straighten his left leg as it is too painful. She reported he had a smaller burn on his right shin. She reported she took pictures of the burns at the facility on 12/23/24. She stated she tried to see the wound several times and was not able to. She stated the staff would tell her that they just wrapped his legs. She stated on 12/23/24 she demanded to see the wounds. She stated she told the staff if they didn't unwrap his legs she would remove the dressing herself. She reported she transported her husband to the emergency room on [DATE]. She stated the hospital admitted her husband and the hospital debrided some of the burn wounds. She stated the hospital applied an ointment to the wounds to soften up the big scab on the left knee. She reported her husband couldn't move without a lot of pain and that he kept his left knee bent. On 12/30/24 at 11:38 AM, an observation of the electric baseboard heater in Resident #1's room (room [ROOM NUMBER]) revealed it as hot to touch on the side of the room Resident #1 resided. On 12/30/24 at 11:28 AM, Staff A, Registered Nurse (RN), reported Staff B, Certified Nursing Assistant (CNA), came to her and asked for help with repositioning Resident #1. She stated she thought it happened around midnight but couldn't say for sure regarding the time. She stated she thought Staff B got her right away and did not do anything in between. She stated she got in the room and observed Resident #1 laying with his lower legs off the bed with his torso and upper legs still in the bed. She described one leg on top of the other while still wearing his heel lift boots. She stated he had his right shoulder underneath him and he sort of on his stomach. She stated as soon as she got in the room, she moved his legs back into bed. She stated when she grabbed his legs, she felt moisture on his left knee and thought a blister might have popped. She stated his legs were a little warm. She stated on his right shin he had some redness like he laid on something. She stated he didn't have blisters and it didn't puff up at that point. She stated he later did develop blisters on his right leg. She stated they placed a body pillow on the bed on the side of the heater. She stated she left the areas open to air and then later that morning applied a dry dressing to the left knee. She stated the left leg was further down then the right leg and felt the left leg would have touched the heater more than the right. Staff A reported Resident #1 wiggled around a lot. She stated Resident #1 would flop his legs around and grab the hand rail to wiggle his hips. She described Resident #1 as confused and fiddled with things. Staff A reported the heat registers could get pretty warm where it could cause a burn. She stated the facility didn't have the beds right against the heater. She stated they have boards placed on the floor to create a little bit of space. She stated the boards prevent the bed from being smack against the wall/heater, prevent the bed from rubbing on the wall and to keep the blankets from being against the heater. She stated she didn't call the physician or family at the time of the incident. She stated she told the morning nurse to do the notification at a more appropriate time. She stated she text management about Resident #1 needing to be seen by the physician. She stated she continued to check on Resident #1 throughout the shift. She reported she filled out a paper for management about the incident. A hand-written staff statement dated 12/8/24 at 12:44 AM by Staff A documented a CNA came to the door and asked the nurse to help her reposition and change Resident #1. Staff A immediately came into the unit and walked down to Resident #1's room. Staff A observed Resident #1 laying across the bed almost sideways with his right arm under him leaning towards his stomach. He had his left arm up between his pillow and the side rail with his torso and stomach on the bed. He had his body pillow tucked under the fitted sheet on the side of the bed towards the door with the air mattress pad in place within the fitted sheet. Resident #1 appeared to have started on his right side with his head of the bed up and legs raised some. His legs hanged off the bed, knees flexed, between the bed, and the wall. His had his left leg underneath the right one with his heel boots in place. He had his left knee leaning on the heater and his right leg mostly lined up with the other leg but not completely. Staff A immediately ran over and lifted Resident #1's legs back into the bed while Staff B tried to pull him over more from the other side of the bed. When Staff A grabbed Resident #1's legs she felt some wetness, his blister. After Staff A and Staff B got Resident #1 positioned safely on the bed, Staff B stayed with him while Staff A grabbed measuring tools. Staff A and Staff B gently proceeded to change Resident #1's wet brief and reposition him with the body pillow on the other side of the window. On 12/30/24 at 1:15 PM, Staff A reported she left the burn open to air as she wanted the area to cool off. Staff A stated she didn't want to put anything cold immediately on it. She stated she kept going back to check on Resident #1. She described Resident #1 as restless and wiggly and would have picked off or removed a dressing. She stated she didn't want him rubbing or scratching the areas. On 12/30/24 at 2:15 PM, the Nurse Manager, Licensed Practical Nurse (LPN), reported the facility had boundary boards in the residents' room for years. She stated the boundary boards are in place to keep the beds away from the heaters. She reported she went down to Resident #1's room after the incident, measured the bed to the heat register, and it measured 3 feet away from the heat register. She stated they used a surface temperature gun to check the heat register safe touch temperatures documented in the plan of correction. She stated the facility used Occupational Safety and Health Administration (OSHA) guidelines for the safe temperatures of 140 degrees. On 12/30/24 at 2:28 PM, the Director of Maintenance stated that the heating system in the 100, 200, and 300 hallways were the electric baseboards heaters. He stated each resident room had their own thermostat that controlled the electric heaters. He stated the 400 and 500 hallways are heated by a boiler system, where hot water pumps water to a tube through the basement and produces radiant heat. He stated there are no safe temperatures with the electric baseboard heaters, he stated they could get up to 160 to 180 degrees F. He stated it's a timing thing. He stated the boundary boards on the floor are to keep everything away from the heaters, walls, and electrical outlets, he stated the boards are not the same measurement in each room because it depends on the beds, some rise up and down differently, and some have different legs on the beds. He stated staff are to keep the beds 3 feet away but sometimes the beds get moved and the staff or housekeeping have to move them back. On 12/30/24 at 3:10 PM, the Nurse Manager reported it was her idea to do the surface temperature on the heat registers. She stated she tried to come up with something else for the plan of correction. She reported she thought knowing how hot the surface temperatures of the heat registers were and monitoring periodically would help prevent further concerns. She stated the best intervention was to move the bed from the register. She stated the boundary boards are in place to keep the bed away from the heaters. She stated some rooms staff will put the bedside table in between the wall and bed. She stated if you move the bed too far out there is not enough space for the residents to live. On 12/30/24 at 4:20 PM, The Nurse Manager used the facility equipment with the surveyor present to obtain a surface temperature of the electric baseboard heater in room [ROOM NUMBER]. The surface temperature registered 124 degrees F. She took an additional surface temperature in room [ROOM NUMBER] with a temperature registered at 116 degrees F. On 12/30/24 at 4:23 PM, Staff B reported she as she did the first rounds, she made it to Resident #1's room, she observed him lying on his stomach, with his upper torso in bed, hands near the side rail, and legs off the bed by the heat register. She reported she thought it was around midnight. She stated she hadn't worked at the facility that long and didn't know about the heat register or it being on. She stated she pulled the call light in the bathroom for help. She stated the nurse came in after she pulled the light. She stated the nurse told her about the heat register. She stated they got Resident #1 off the heat register right away. She reported Resident #1 had slept during the incident. She stated she checked on Resident #1 after she got report from the second shift CNAs around 10:40 PM. She stated at that time he laid on his side facing the door and held onto the side rail. She reported after the incident she pushed the bed out, put the body pillow in place and tucked the pillow under the fitted sheet on the side of the bed with the heater. She stated after the incident she checked on him more frequently. She stated when she got him back into bed he had red marks and forming blisters on his bilateral lower legs. She stated the nurse wrapped his leg but did not remember which leg. A hand-written staff statement dated 12/8/24 by Staff B documented at midnight they went into Resident #1's room to change him for rounds. Staff B documented she did a visual check around 10:45 PM. When Staff B went into Resident #1's room, she found Resident #1 sleeping on his stomach with his legs off the bed. Staff B pulled Resident #1's call light for help. Staff B documented she didn't know he had a heat register there and on until Staff A said something. Staff B documented Staff A helped her get Resident #1 back into bed. On 12/30/24 at 4:43 PM, Staff C, RN, reported Staff A passed on in report the aide found Resident #1 with his legs out of the bed when she went in to change him. Staff C stated when Staff A went into the room to help she observed Resident #1 with his legs on the heater. Staff C stated Staff A told her Resident #1 had blisters on his legs. She stated she checked on him first and completed the needed paperwork. She stated she notified the Physician, family, nurse manager, and DON regarding the incident. She stated he had blisters and open areas on both lower legs. She stated the left knee developed a bigger wound as the areas came together. She stated the Nurse Manager obtained treatment orders to apply mupirocin to the open areas and skin prep to the unopen blisters. She stated she rearranged the room and moved the bed completely away from the heater. She stated Resident #1 had a wing mattress and an air overlay. She stated she got rid of the air overlay so the wing mattress would work better. She stated when she called the wife to report the incident, the wife wanted to know why someone didn't call her right away. She stated the wife relayed she wanted to be called anytime of the day. She stated the wife came in later that day and liked how the room rearrangement. On 12/31/24 at 9:15 AM observed a boundary board in front of the electric baseboard heater in room [ROOM NUMBER]. The board measured 7.5 inches (width) from the edge of the heater to the edge of the board. The electric baseboard heater didn't have a protective cover. The baseboard heater felt hot to touch, a person couldn't leave their hand/fingers on the electric baseboard heater for more than a couple of seconds. On 1/6/25 at 9:36 AM, the Director of Nursing (DON) reported she put the air mattress back in place the following day after the incident, once they rearranged Resident #1's bed and moved it away from the heater. A facility policy titled Accident and Supervision dated 2024 described the facility policy as to ensure the resident environment would remain free of accidents hazards as much as possible. The policy documented each resident would receive adequate supervision and assistance to prevent accidents which included: a. Identifying hazards and risks b. Evaluating and analyzing hazards and risks c. Implementing interventions to reduce hazards and risks d. Monitoring for effectiveness and modifying interventions when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to serve the correct diets to 2 out of 59 residents (Resident #2 and Resident #28). During an observation of lunch service, Staff F, Cook, dished up a general diet for both Resident #2 and Resident #28. Resident #2 and Resident #28 were to receive mechanical soft diets (A type of texture-modified diet for people who have difficulty chewing and swallowing.) During the lunch service it was noted that another 6 residents were not on the Diet Type Report. Of these 6 residents, 4 of them did not have a Doctor's order for a diet (Resident's #20, #46, #64 and #65). These incidents resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 58. On 8/24/23 at 5:43 PM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/25/23 and decreased the scope to D, after the facility staff completed the following: a) The two residents that were served the incorrect diets are now being served the correct mechanical soft diets. b) The resident's that did not have diet orders in PCC (Point Click Care -electronic health records (EHR)), now have diet orders. c) All resident records have been reviewed to ensure that they have the correct diet order in the EHR. d) All resident diet cards have been reviewed to ensure that the correct diet order is on the diet cards as indicated per the EHR. e) The QAPI committee reviewed/revised the facility's Nutritional Management policy on 8/24/23. The revisions made outlined the method of communication between the Nursing Staff and the Dietary Staff. f) The facility initiated in-service training for all dietary and nursing staff that were in the facility on 8/24/23. The administrator completed the training with the rest of the dietary and nursing staff per phone. All dietary staff and Nurses were trained on 08/24/23 by 7:45 PM. g) In addition, the Facility Dietician will review all resident diet orders to ensure that they are accurate, in the resident's EHR, and that there is a correct diet card in place. h) A facility created quality assurance tool will be implemented and used by the Administrator to audit the diets of all residents weekly for a month, then monthly for 3 months, then quarterly for 1 year. This tool will monitor that the facility is following the Nutritional Management Policy and the procedure for managing diet orders. The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings. Any issues identified will be immediately addressed. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #2 included cancer and Parkinson's disease. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. This resident required set up help only for eating. It documented that this resident had a mechanically altered diet. A Care Plan for Resident #2 documented a Focus Area revised on 1/9/23, directed staff that Resident #2 had a swallowing problem related to complaints of difficulty with swallowing related to Parkinson's disease and decreased esophagus size. An intervention revised on 6/16/23, directed staff that Resident #2's diet was to be followed as prescribed-mechanical soft ground meat with sauce/gravy/thin liquids, avoid pasta. An Order Summary Report of all of Resident #2's current orders was printed on 8/24/23. It directed that Resident #2 had a mechanical soft diet with ground meat moistened with sauce, gravy or broth. It directed to avoid pasta. The diet order was dated on 9/1/22. Results from an Esophagram (video x-ray of the swallowing function of the esophagus) performed on 7/12/23, documented that the reason for this test was dysphagia (difficulty swallowing). Findings included abnormal peristalsis (esophageal muscles contract and relax to move food). The impression was documented as likely a stricture at the distal end of the esophagus. A Gastro Procedural Note dated 8/26/21, documented that Resident #2 had an esophageal dilation. A Progress Note dated 7/21/23 at 11:40 AM, documented that Resident #2 returned to the facility after having an esophageal dilation. A Progress Note dated 2/28/23 at 12:33 PM, documented that Resident #2 returned to the facility after having an esophageal dilation. A Progress Noted dated 9/20/22, documented that the entry was a follow up to an esophageal dilation. Resident #2 reported he was feeling much better and swallowing was becoming easier. 2. A MDS dated [DATE], documented that diagnoses for Resident #28 included Cerebrovascular Accident (CVA)(STROKE) and non-Alzheimer's dementia. A BIMS documented a score of 3 out of 15, which indicated severely impaired cognition. This resident required set up help only for eating. It documented that this resident had a mechanically altered diet. A Care Plan initiated on 7/23/22 and revised on 6/8/23, directed staff that a focus area for this resident was that she had a nutritional problem which required a mechanically altered diet related to a CVA (Cerebrovascular Accident (Stroke)), and swallow. An Intervention directed staff to provide and serve diet as ordered, regular diet with mechanical soft food texture. A Doctor's Order dated 7/22/22, directed that Resident #28 was to receive a mechanical soft textured diet. A Diet Spreadsheet dated Spring/Summer 2023, Week 1 Day; 4 Wednesday, documented that a regular diet for meatloaf was 3 ounces of meatloaf. This Diet Spreadsheet documented that a mechanical soft diet for meatloaf was a #8 scoop of ground meatloaf. A Diet Type Report, dated 8/21/23 at 11:03 AM, documented that Resident #2 and Resident #28 were to receive mechanical soft diets. This report did not have Residents #20, #46, #64, and #65 names and diets on it. On 8/23/23 at 11:27 AM, Staff F, [NAME] started lunch service. Staff F served regular meatloaf to Resident #28. When asked why the Diet Type Report showed that Resident #28 received a mechanical soft diet, Staff F changed the meat loaf from a piece of meatloaf to ground meatloaf. The [NAME] then gave Resident #2 a piece of meatloaf. When asked why the Diet Type Report showed that Resident #2 received a mechanical soft diet, Staff F stated that Resident #2 was a general diet and had been switched back to this (a general diet) for quite a while. The Dietary Manager (DM) stated that Resident #28 was changed from general to mechanical soft and her liquids were changed from nectar thickened to thin liquids a year ago. The DM stated that the diet card was not updated. She stated that she would update it 'now'. The DM added that she was not working at this facility a year ago. When asked about Resident #2's diet, she said that he was supposed to be a mechanical soft diet as well. During the meal service on 8/23/23, it was noted that 6 residents were not on the Diet Type Report. Record review after the service revealed that the following 4 residents did not have diet orders: -Resident #20 was admitted on [DATE]. When the Director of Nursing (DON), was asked about this resident not having an order for a diet around 2:10 PM on 8/23/23, she stated she did not know that this resident did not have a diet order. A general diet order was then added to Resident #20's orders on 8/23/23 at 2:15 PM. - Resident #46 was admitted to the facility on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was then added on 8/23/23 at 11:49 AM. -Resident #64 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A general diet order was added on 8/23/23 at 12:09. -Resident #65 was admitted on [DATE]. During the lunch service it was asked why she was not on the report. A mechanical soft diet was added on 8/23/23 at 12:10 PM. When the Assistant Director of Nursing (ADON) was asked about this, she stated Resident #65 was admitted from home and they can downgrade a diet, they just can't upgrade a diet as nurses. On 8/24/23 at 10:55 AM, the ADON stated that she had just written the diet card out for mechanical soft because the family said he had difficulty chewing meat. The ADON stated that when a resident comes in to the facility from home as Resident #65 did, they get their medication orders from the clinic. Then they (the nurses) put the orders in to the PCC. We don't talk with a doctor because we get the medication orders from the clinic. She stated that for Resident #65, she had just filled the diet sheet out for a mechanical soft diet. She then asked if she shouldn't have taken the family's input into what diet the resident should be on. When asked if she could write a doctor's order, she stated that the doctor would put a diet order in when the resident was seen on this day. On 8/23/23 at 2:32 PM, the DM stated that she did not have a policy for individual resident's diet orders from admission to diet cards and ongoing communication. She stated the DON would have that. Asked the DON for the policy and she stated she would get it. On 8/24/23 at 10:57 AM, Resident #2 was asked if he could eat the food the facility had been serving him or if he had any difficulties eating any of the food that the facility had served to him? Resident #2 replied that he has had his esophagus stretched several times. Resident #2 stated that he couldn't eat a lot of food. He stated that some meats he could eat and some he couldn't. Resident #2 stated that he just had to look at what was served and then decide if he could eat it. Resident #2 stated that it was hard for him to eat pasta. Resident #2 stated that 'yesterday they served my meat ground and I liked that'. Resident #2 stated he was able to eat the ground meat. Resident #2 stated that the facility hadn't served him ground meat before. When asked if he was talked to about what diet he was to receive, Resident #2 stated no. When told that he had been receiving a general diet and he was supposed to be receiving a mechanical soft diet Resident #2 stated no one had talked to him about that. He repeated that he liked the ground meat. On 8/24/23 at 11:25 AM, the Nurse Consultant and the Administrator acknowledged that a doctor's order should have been obtained upon admission. The Administrator stated they could not find a doctor's order for diets for Resident #20, #46, #64, and #65. They stated that they did have a diet order for Resident #64 because she came from the apartments and had been serving her all along because the kitchen serves the meals for the residents in the apartments. The Administrator stated they cannot find an order for her though, since she was admitted to the Long-Term Care side. When told about Resident #65 being admitted from home and the ADON had stated she got the medication orders from the clinic and put the diet order on the card and the doctor was to come on this day to write the orders, the Administrator said, no the ADON should have called the doctor and got an order the day of admission. On 8/24/23 at 12:32 PM, Resident #28's daughter stated that she was unaware that her mom was on a mechanical soft diet. She said she thought she was on a general diet. She stated that her son visited her mother recently and brought in a pizza. She stated her son said this resident enjoyed the pizza but only had a couple of bites. This resident's daughter said her son did not mention her mom having difficulty with swallowing the pizza. She said her mom coughs a lot with cookies, ice cream and pop. She stated this resident used to drink a lot of pop when she lived at home. She said as far as she knew, the facility had been giving her mom a general diet. On 8/24/23 at 2:37 PM, the Dietitian stated the diet order was correct for both Resident #2 and Resident #28 but these 2 residents were served the wrong diet. She stated the cook didn't follow the diet cards. The Dietitian stated that she was in the facility on Monday. A different cook was working and that cook was following the cards. She stated that she usually goes to the facility once a week. She stated that when she is in the facility she looks at the orders and assesses the residents. She stated that both residents were to be on mechanical soft diets and both of them do well with those diets. She stated that she had seen before when there wasn't a diet order in PCC. She said she let the facility know when that had happened in the past and they take care of it. When asked if she had observed either resident eating a mechanical soft diet, she stated she couldn't say for sure. On 8/25/23 at 11:52 AM, the Speech Therapist was meeting with and observing Resident #2 in the dining room assessing meal consumption. On 8/25/23 at 12:04 PM, Resident #2 was sitting in the dining room with his meal in front of him. Resident #2 stated he had tried different food. The Speech Therapist was no longer with him. Resident #2 was coughing. Had ground meat and breaded shrimp (not ground) setting in front of him. A Speech Therapy SLP Evaluation and Plan of Treatment dated 8/25/23, the Speech Therapist recommended the following: Patient will independently make diet request changes to staff over x2 consecutive sessions to demonstrate understanding of safe swallowing recommendations. (Target: 9/21/2023) Baseline Patient not consistently making requests and just avoiding foods. (8/25/2023) Patient will safely tolerate least restrictive oral diet in order to optimize nutrition and hydration, minimize risk of aspiration, and facilitate safe oral intake (Target: 11/22/2023) Esophageal: Patient/medical record indicates: Towards end of meal patient with increased coughing. He reported that after eating the shrimp and taking a drink he could feel it coming back up and that it stopped at his sternum. Difficulty with esophageal phase and patient has a history of esophageal dysphagia. On 8/25/23 at 12:14 PM, the Speech Therapist was sitting across from Resident #28 in the small dining room. Resident #28 was eating a piece of shrimp. The Speech Therapist stated Resident #28 was doing good, she was just getting started. A Therapy Communication Form dated 8/25/23, documented a recommendation by the Speech Therapist of thin liquids with mechanical soft with ground meats diet. An undated Nutritional Management policy, directed the following to staff: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Nutritional Status includes both nutrition and hydration status. Compliance Guidelines: 1. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary. 2. Identification/assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. b. The dietary manager or designee shall obtain the resident's food and beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay. c. A comprehensive nutritional assessment will be completed by a dietitian. Components of the assessment may include, but are not limited to: i. General appearance ii. Height/weight iii. Cognitive, physical, and medical conditions iv. Food and fluid intake v. Evidence of fluid loss or retention vi. Presence of persistent hunger, poor intake, or continued weight loss vii. Review of medication list viii. Review of laboratory/diagnostic data 3. Evaluation/analysis: a. The assessment shall clarify the resident's current nutritional status and individual risk factors for altered nutrition/hydration. b. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Current standards of practice/formulas are used in calculating these estimates. 4. Care plan implementation: a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: i. Diet liberalization unless the resident's medical condition warrants a therapeutic diet ii. Altered-consistency food/liquids after underlying causes of symptoms are addressed (i.e. new dentures, dental consult, dysphagia therapy) iii. Weight-related interventions iv. Environmental interventions v. Disease-specific interventions vi. Physical assistance or provision of assistive devices vii. Interventions to address food-drug interactions or medication side effects c. Real food will be offered first before adding supplements. d. Tube feeding or parenteral fluids will be provided in the context of the resident's overall clinical condition and resident goals/preferences. 5. Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: i. Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary. iv. Reviewing the resident-specific factors identified as part of the comprehensive assessment to determine if they are still relevant or if new concerns have emerged such as new diagnoses or medications. v. Evaluating the care plan to determine if current interventions are being implemented and are effective. b. The resident will be monitored for complications associated with interventions. c. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or the resident changes his or her goals, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified. d. The physician will be notified of: i. Significant changes in weight, intake, or nutritional status ii. Lack of improvement toward goals iii. Any complications associated with interventions. e. Nutritional recommendations may be made by the dietitian based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. f. Dietary orders may be written or modified by the qualified dietitian or other clinically qualified nutrition professional if the resident's attending physician/practitioner delegates the task. Nursing can downgrade a resident's diet for safety concern until qualified professional can address. g. Dietary orders and modifications will be communicated to the kitchen, immediately. The admitting nurse and/or the nurse manager is responsible for notifying dietary with a diet change form. The dietary manager will review the EMR diet order report, monthly, and compare it to the diet cards and make changes as needed. 6. Informed consent: a. The resident/representative has the right to choose and decline interventions designed to improve or maintain nutritional or hydration status. b. The facility shall discuss the risks and benefits associated with the resident/representative decision and offer alternatives, as appropriate. c. The comprehensive care plan should describe any interventions offered, but declined by the resident or resident's representative. Procedure for managing Diet Orders 1. Nurse will notify kitchen staff of new admission and modifications to diet orders via diet change form and the nurse manager for that resident will follow up to ensure of the notification. 2. The Dietary Manager or Cook, if manager is absent, is responsible for immediately updating the resident's diet card in the kitchen. They must also initial and date the diet slip received and keep in a file. 3. The dietary manager will review the EMR diet order report, weekly, and compare it to the diet cards and make changes as needed. The dietary manager will compare the current censes to the EMR diet order report weekly to ensure that all residents have a diet order in place.