**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to: 1. Ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature level for six of 20 residents (Resident (R) 31, R23, R43, R22, R18, and R41) residing on the dementia care unit. 0n 07/19/24, water temperatures at the hand washing sinks on the dementia care unit were recorded to be 123.4 degrees Fahrenheit (F). Water temperatures were adjusted but no monitoring occurred. On 07/24/24, water temperatures in two resident bathrooms were noted to be 122 degrees F and 125 degrees F. The water temperatures were not adjusted after water was measured to be in excess of 120-degree F. The failure to maintain water temperatures at a safe level had the potential to cause serious burns or injuries for the residents, and 2. Provide supervision to prevent accidents related to falls for one of three residents (R42) reviewed for falls out of total sample of 23. The facility failed to assess R42 after falls and failed to attempt to identify and implement interventions to prevent future falls and/or injury. This had the potential to cause R42 to sustain additional falls and injury. The facility's failure to ensure the environment was free of accident hazards by not maintaining safe water temperatures placed residents at continued risk of serious injury, harm, or impairment. Immediate Jeopardy at §483.25(d) - Accidents, at a Scope and Severity of a J, was identified on 07/24/24 and was determined to exist on 07/19/24 when hot water temperatures in excess of 120-degree F were first noted on the dementia care unit, and resident rooms were not monitored for safe water temperatures. The Administrator and Director of Nursing (DON) were informed on 07/25/24 at 4:28 PM. The facility provided an acceptable removal plan on 07/25/24 at 8:15 PM. The survey team validated implementation of the removal plan through observations of water temperatures, review of education documentation, and by interview with staff and the professional plumber. Immediate Jeopardy was removed on 07/26/24 at 3:17 PM. After removal of the Immediate Jeopardy, the deficiency remained at an E scope and severity for a pattern of potential harm. Findings include: 1. Water Temperatures a. Review of R31's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/24 and located under the MDS tab of the electronic medical record (EMR) revealed R31 was admitted to the facility on [DATE] and had severely impaired cognition. It was recorded R31was able to walk independently. Review of R31's Diagnosis tab of the EMR revealed R31 had diagnoses that included diabetes mellitus, dementia, and depression. R31 resided on the dementia care unit. Review of R28's quarterly MDS, with an ARD of 03/21/24 and located under the MDS tab of the EMR, revealed R28 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated he was moderately cognitively impaired. It was recorded R28 utilized a wheelchair for mobility. Review of R31's Diagnosis tab of the EMR revealed R28 had diagnoses that included hemiplegia and depression. R28 resided on the dementia care unit. During an observation on 07/24/24 at 1:15 PM, the water temperature at the bathroom sink utilized by R31 and R28 was checked with the Maintenance (MD) using his thermometer. The water temperature was 122 degrees F. On 07/24/24 at 3:10 PM, Certified Nurse Aide (CNA) 1 stated R31 could turn the water on independently and R28 needed assistance with turning the water on. b. Review of R43's quarterly MDS, with an ARD of 05/27/24 and located under the MDS tab of the EMR, revealed R43 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making and was independent with walking. Review of R43's Diagnosis tab of the EMR revealed R43 had diagnoses that included schizophrenia, dementia with other behavioral disturbances, and cognitive communication deficit. Review of R22's significant change MDS, with an ARD of 06/14/24 and located under the MDS tab of the EMR, revealed R22 was readmitted to the facility on [DATE] and had a BIMS score of six out of 15, which indicated R22 was severely cognitively impaired. It was recorded R22required supervision with walking. Review of R22's Diagnosis tab of the EMR revealed R22 had diagnoses that included post-traumatic stress disorder, major depressive disorder, psychosis, anxiety disorder, and dementia. R22 was observed ambulating independently on 07/23/24 and 07/24/24. Review of R18's annual MDS, with an ARD of 04/06/24 and located under the MDS tab of the EMR, revealed R18 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making. It was recorded R18 walked independently. Review of R18's Diagnosis tab of the EMR revealed R18 had diagnoses that included Alzheimer's disease and depression. Review of R41's quarterly MDS, with an ARD of 05/16/24 and located under the MDS tab of the EMR, revealed R41 was admitted to the facility on [DATE] and was severely impaired in cognitive skills for daily decision making. It was recorded R41 was unable to walk. Review of R41's Diagnosis tab of the EMR revealed R41 had diagnoses that included Alzheimer's disease and dementia. During an observation on 07/24/24 at 1:23 PM, the water temperature at the bathroom sink used by R43, R22, R18 and R41 was checked with the MD using the facility thermometer, and it was noted to be 125 degrees F. On 07/24/24 at 3:10 PM CNA1 stated R43 could turn the water on independently, and she felt the resident could ensure the water was not too hot. CNA1 stated R22 could only turn the water on with help. She stated R18 and R41 did not turn the water on independently but potentially could. c. Review of temperature monitoring logs, provided by the facility, revealed water temperatures were taken on 10 days during the previous three months. There was no documentation that water temperatures were taken in any resident room. It was recorded that on 07/19/24, the hot water temperatures in the North Hall Sink and South Hall Sink were 123.4 F. There was no documentation that water temperatures were tested in any resident rooms after the water was noted to be 123.4 F on 07/19/24 or that any monitoring occurred. During an interview on 07/25/24 at 8:25 AM, the MD stated he could not find a policy related to hot water temperatures, but he had been informed the water temperatures should be maintained between 110 F and 120 F. The MD stated on 07/19/24, he did adjust the hot water temperature and checked the temperature at the sinks in residents' bathrooms close to the North and South Hall sinks, but he did not document those results. The MD confirmed he did not check the hot water temperature in resident rooms unless the hot water temperatures at the hand sinks on the North and/or South halls exceeded 120 F. The MD stated that he had not monitored the resident room water temperatures after 07/19/24 until checking with the surveyor on 07/24/24. On 07/25/24 at 10:51 AM, the MD was asked to recheck the water temperatures at the bathroom sinks for R32, R28, R43, R22, R18, and R41. The MD obtained the water tempertures and reported they were 119 degrees F. He stated he did not adjust the hot water temperatures on 07/24/24 after the temperatures obtained were more than 120 F. The MD stated he adjusted the hot water on this date, 07/25/24, right after he learned of the surveyor's request to recheck them. During an interview on 07/26/24 at 3:17 PM, the plumber who came to service the water heaters stated the hot water heater servicing the dementia care unit needed a new mixing valve. He stated the hot water temperatures were steady at 110 degrees F for now. Review of the facility's policy titled, Preventive Maintenance Policies and Procedures PM202 Hot Water Temperatures: Inspection, with a revision date of 01/08/24, revealed the policy was to test water temperatures daily. The policy recorded, . Conduct test in at least three locations . These locations should be the closest, median, and farthest points from the source . If the temperature does not meet State or Local regulations, the facility will investigate and adjust the mixing valve . 2.Falls Review of R42's significant change MDS, with an ARD of 06/30/24 and located in the MDS tab of the EMR, revealed R42 was admitted to the facility on [DATE] and had a BIMS score of five out of 15, which indicated he had severe cognitive impairment. It was recorded R42 had inattention and disorganized thinking; had functional limitation in range of motion to both lower extremities; required substantial/maximal assistance with dressing, personal hygiene, lying down, and transfers; did not walk; and was always incontinent. It was recorded R42 had falls with injuries since the prior assessment. Review of R42's Diagnosis tab of the EMR revealed R42 had diagnoses that included alcoholic cirrhosis of the liver, encephalopathy, vascular dementia with agitation, major depressive disorder, hepatic encephalopathy, post-traumatic stress disorder, chronic migraine, paranoid schizophrenia, cognitive communication deficit, muscle weakness, abnormalities of gait and mobility, and a history of falling. Review of R42's Care Plan, dated 05/05/23 and located under the Care Plan tab of the EMR, revealed a problem related to being at risk for falls due to cognitive loss, lack of safety awareness, history of falling, bilateral primary osteoarthritis of knee, and sleep apnea. Interventions included a bed in low position and fall mats with a created date of 07/02/24; to provide safe place for the resident to lie on the floor with a created date of 07/02/24; to assist to organize belongings for a clutter-free environment in resident's room; and to encourage to attend activities. Review of R42's Progress Notes tab of the EMR and/or Incident Reports, provided by the facility revealed the following: A progress note, dated 06/05/24 and timed 3:08 PM, recorded the writer heard a loud noise then R42 called out, I fell down. Upon entering the room, R42 was sitting on the floor at the side of his bed. According to the note, the resident was not injured. A paper Fall incident report, dated 06/08/24 and timed 11:36 PM, recorded two nurse aides found the resident on the floor. The note recorded the fall had not been witnessed. R42 stated he needed to use the toilet, was walking across the room, and when he was in the doorway, he lost his balance and fell beside his toilet. According to the report, R42 had no visual injuries but stated he hit his head. A progress note, dated 06/09/24 and timed 2:17 AM, recorded two nurse aides found the resident on the floor. The note recorded the incident was not witnessed, and the resident claimed he hit his head and denied pain. A social service progress note, dated 06/20/24 and timed 11:24 PM, recorded the Social Service Director (SSD) was visiting another resident in the dementia care unit when the SSD heard R42 calling from his room. The SSD observed R42 lying on the floor outside of his bathroom. According to the note, the resident stated it was because he had a migraine. The SSD wrote she informed the south nurse and the nurse aide regarding the resident being on the floor. Review of the EMR revealed there was no nursing documentation related to this fall. A nursing note, dated 06/29/24 and timed 10:33 AM, recorded while the nurse was assisting with care, she noted a very large bruise to the left buttocks. The nurse wrote, . the bruise covers left buttocks and smaller bruise noted to left hip .Also, small spot noted to top of head with a small amount of blood noted . A nursing note, dated 06/29/24 and timed 5:46 PM, recorded clarification to the previous note and stated the area on the top of R42's head was soft, but the resident would not allow the nurse to touch it. The medical record was reviewed in its entirety and was silent for an investigation into how the injuries occurred or any additional interventions to prevent further injuries. A nursing progress note, dated 6/29/24 and timed 9:15 PM, recorded the resident fell on the floor in his room and hit his head. His pants and briefs were around his ankles. R42 stated he needed to use the bathroom. The note recorded he had a recent change in condition and was no longer aware of safety risks and the decline in physical abilities to do things. R42's EMR was reviewed in its entirety and was silent for further assessment of this fall or of additional interventions put in place to prevent further falls or injuries. A progress note, dated 07/13/24 and timed 8:14 PM, recorded the nurse aides reported that R42 had a small bruise and hematoma to the left side of his head. It was recorded that the writer had noted a large bruise on R42's forehead and the top of his head when she arrived on shift. She wrote there was no documentation of the bruise on the right side of the forehead and the top of his head. She wrote, . not sure how this resident ended up with these bruises. He was on the floor crawling around most of the night but stated he thinks he must have hit his head on the floor when he climbed out of bed but is not totally sure. The EMR was reviewed in its entirety and was silent for an assessment of how R42 could have obtained the hematoma and bruises. A nursing progress note, dated 07/20/24 and timed 6:31 AM, recorded upon receiving report from the night nurse, the night shift CNAs voiced to this nurse that R42 had a lot of bruising to right side of face. The nurse wrote upon entering the room, bruising was noted to the right side of his face, nose, eye, forehead, cheek, and the top of his head. It was recorded, . The bruising is red and purple in color. Resident is unable to tell me what happened at this time. Bruising also noted to bilateral knees and bilateral arms . The fall incident report, dated 07/20/24 and timed 6:31 AM, stated upon arriving to the evening shift it was noted the resident had swelling around the right eye and forehead. The note recorded the day nurse said he had been on the floor throughout the day but did not know what happened. The note recorded the swelling and bruising became extremely worse. The EMR was reviewed in its entirety and was silent for an assessment of how he potentially obtained the hematoma and bruises. A nursing note, dated 07/21/24 and timed 5:00 PM, recorded the resident was found lying on floor mat with his feet facing towards this bed and his head towards the roommates' bed near the wall. It was recorded R42 already had bruising to the right side of his face, and he stated he was trying to pull the call light out of the wall so it could call 911 because he had a migraine headache. During an observation on 07/23/24 at 10:32 AM, R42 was seen sitting on the floor in his room, holding onto the wall close to the bathroom and across the room from his bed. Staff were immediately notified and Licensed Practical Nurse (LPN) 2 and Certified Nurse Aide (CNA) 2 came down to the room with the gait belt. They lifted him up into the wheelchair with the gait belt and asked him if he wanted to go to the common area or to bed or in room and he stated no to all the questions. CNA2 stated he had been in bed prior to finding him on the floor. The bed was low, and the fall mat was beside the bed; however, the call light was not in reach as it was clipped to the wall and not within reach of his bed. LPN2 verified the call light was not in reach. LPN2 and CNA2 stated R42 typically did not use the call light by his bed and would attempt to go into the bathroom to pull the bathroom call light. They left the room leaving the resident in his room in a wheelchair by the window. CNA2 and LPN2 both stated R42 frequently got out of bed and attempted to walk or crawl around on the floor. R42 was noted to have fading bruise to his right eye, right side of his face, and the top of his forehead. During an interview on 07/25/24 at 2:30 PM, the DON was interviewed about R42's incidents. When ask if R42 had any interventions added to his care plan after the falls, the DON stated he was moved from the 200 unit to the last room on the dementia care unit, furthest way from the nursing station; had floor mats and low bed put in place on 06/04/24; and had some blood draws/laboratory completed on 06/12/24. Continuing with the interview on 07/25/24 at 2:30 PM, the nursing progress notes dated 06/20/24 and timed 11:24 PM; 06/29/24 and timed 9:15 PM; 06/29/14 and timed 10:33 AM; 07/13/24 and timed 8:14 PM; 07/20/24 and timed 6:31 AM; 07/21/24 and timed 5:00 PM were reviewed with the DON. The DON was unable to provide any additional documentation to show assessments were completed to determine the cause of R42's bruising or that any additional interventions were put in place to prevent further falls and/or injuries. The DON stated that she and her staff discussed moving him to a private room closer to the nursing station earlier that week; however, they had not moved him. During an interview on 07/26/24 at 10:58 AM, the Social Worker from R42's hospice company stated she had been providing services for the resident since he was admitted to hospice on 06/24/24. She stated she was very concerned about the bruising the resident had. She stated the staff tell her he crawls around on the floor. She stated that on 07/02/24 at 3:00 PM she had a meeting with the facility social worker and a Registered Nurse, and during the meeting they discussed the falls and injuries. The hospice social worker stated she was told they would move R42 to a room closer to the nursing station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to prevent accidents by not ensuring 1 (R #1) of 14 (R #'s 1-14) residents reviewed for therapeutic diets, were receiving the proper therapeutic diet (diet consistency to meet resident ability to consume it) and failed to implement corrective measures to ensure residents receive their order therapeutic diets following the choking incident. This failure likely resulted in R #1 to have a choking episode and loss of consciousness (ability to be aware) requiring medical intervention. The findings are: A. On 12/20/22 at 12:54 pm, during an interview the Complainant stated that during a visit on 12/14/22 to the facility she was told of an incident (12/13/22) where a resident (R #1) had suffered a choking incident, and that he was receiving the wrong texture diet from the kitchen. The Complainant stated that she spoke to R #1 who had stated that he was ok, but that it was scary. B. Record review of facility face sheet for R #1 revealed he was admitted on [DATE] with diagnosis which included: Cellulitis Of Left Lower Limb (skin infection in left leg), Seizures (uncontrolled muscle spasms), Traumatic Brain Injury (brain damage), Major Depressive Disorder (feeling of sadness), Bipolar Disorder (mood swings), Dysphagia (difficulty swallowing), Hypertension (high blood pressure), Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side (partial paralysis after a stroke), Gastro-Esophageal Reflux Disease (acid reflux), Cognitive Communication Deficit (difficulty communicating), Long Term Use Of Opiate Analgesic (long use of high risk medication), Acute Respiratory Failure With Hypoxia (stopped breathing with loss of oxygen to the brain), Need For Assistance With Personal Care (help with care), Vascular Dementia with Behavioral Disturbance (memory loss with behaviors). C. Record review of current swallowing care plan, dated 12/15/22, for R #1, revealed the following: Focus: R #1 is at risk for impaired swallowing related to dysphagia; Resident choked on dinner and was sent to hospital and admitted on [DATE]. R #1 choked on ham during breakfast, Heimlich was performed and resident sent to ER (Emergency Room) for further evaluation on 12/13/22. D. Record review of dietary orders dated 09/19/22 for R #1 revealed a therapeutic diet of dysphasia - advanced (chopped meat/mechanical soft pieces no bigger than 1/2 inch). E. Record review of Complaint NM-00063366 revealed that R #1 had received an incorrect meal consistency (whole meats) during the breakfast meal on 12/13/22, in which he tried to consume full size portion of breakfast meat causing a choking episode with loss of consciousness. F. Record review of Complaint NM-00063365 (related facility self report) revealed that the Heimlich Maneuver was initiated on R #1 by the charge nurse and RA (Restorative Aide) #1 during the choking episode. G. Record review of nursing progress notes for R #1 Revealed the following: 12/13/2022 at 12:00 pm, General Note: Staff alerted this nurse that resident was given wrong diet consistency for breakfast and had noticed he had some food in his mouth. This nurse brought plate into kitchen to get a new plate with correct consistency. Staff alerted this nurse that resident started to choke on food, and yelled for help. This nurse and Restorative Aide attempted to get resident to cough up food. Back thrusts were administered, no success. CNA (Certified Nurse Assistant), Restorative Aide and this Nurse lowered resident to floor and continued back thrusts with knee and chest thrusts simultaneously. Additional staff brought crash cart down for oxygen and suction as needed. Resident turned blue in face during these attempts. Additional nurse assisted was able to get resident to vomit and food was released. Color returned to resident's face and was able to get some words out and gestured to his throat that there was another piece. High flow O2 (Oxygen) applied to via face mask when EMS (Emergency Medical Services) arrived and took over. Attempted to call (name), POA (Power of Attorney). Unable to reach and left a voicemail. PCP (Primary Care Physician) was also notified. H. On 12/20/22 at 1:35 pm, during an interview the Administrator/Center Executive Director (ADM/CED) stated that he did remember the incident of resident (R #1) choking. He stated that he had been the ADM/CED since August 2022 for the building. He stated that the Dietary Manager (DM #1) was the one on during that time, and DM #1 had been hired on 12/01/22. He stated that a triple check of the meal was being conducted to help with ensuring that meals were served correctly, since the incident occurred with R #1. When asked what was different from the original plan, he admitted that it was still a triple check and nothing was changed in that sense. He stated that R #1 had received a regular texture tray (12/13/22 instead of prescribed dysphasia-advanced). Restorative Aide (RA) #1 had noticed that it was the wrong texture diet (whole meats) and returned it to the kitchen. He stated that the kitchen staff, Dietary Manager in Training (DMIT), had brought the same type of meal (whole meats) back out to the resident (R #1). So, R #1 was served the wrong type of meal texture (whole meats) twice. He stated that the resident (R #1) started choking on the food and that the Heimlich maneuver had to be performed to clear his airway by the charge nurse and RA #1. He stated that R #1 was transported to the hospital for observation and treatment if necessary following that incident. He stated that meal texture for residents are prescribed by the physician and evaluated by the Speech Therapist upon a residents arrival. The ADM stated that R #1 was supposed to be receiving a Dysphasia - Advanced diet (chopped meat/mechanical soft pieces no bigger than 1/2 ) at the time of the incident and was downgraded to a Dysphasia - Puree diet (blended) after the incident. I. On 12/20/22 at 3:30 pm, during an interview R #1 stated that he was supposed to be getting a ground (meat) diet, but received a regular diet. He stated that it (the breakfast meat/ham) tasted good and so he was shoveling it in. He stated that he remembered that he did not chew up the meat (ham) and a piece got stuck in his throat. He stated that he started to choke and did not remember much after that. He said that he remembered being very tired after the incident. He stated that he was scared to eat much after that for a few days and that I'm still scared to eat things like bread and such. He stated that he has not been served a different meal texture other than puree since that day. J. Record review of the follow-up plan in the facility's report of incident submitted (12/21/22) in response to the choking episode endured by R #1 on 12/13/22, revealed that a supervisor would be placed in the kitchen during meal service to oversee that the correct meal texture was being placed on plate for residents and a schedule would be in place to show who was assigned. Those supervisors would also be conducting audits of the service to determine that errors were minimized/eliminated and results of audits would be brought to QAPI (Quality Assurance Performance Improvement) committee meetings. K. On 12/20/22 at 4:40 pm, an observation of the dinner meal service revealed the following: 1. The posted schedule for Supervisors to audit the service line had not been updated to reflect a change in the scheduled supervisor for that meal, making it unclear who watched for compliance. 2. During entry to kitchen to watch service line, there was no supervisor in place. 3. Food had been plated from the line and sitting on the transportation cart ready for delivery as room trays (north hall), and no supervisor was present to validate meal consistency. L. On 12/20/22 at 5:00 pm, during an interview DM #1 stated that she was not quite sure what happened during the process of the resident (R #1) receiving his tray on the day of the incident (12/13/2022). She stated that RA #1 brought a plate back for R #1 and that it was the wrong diet texture (whole meats). She had went to chop the meat (into 1/2 pieces) and that during that time DMIT had taken another tray out to R #1. When asked what new process was being done in the kitchen to eliminate residents receiving wrong texture diets, she was unsure. When she was asked where the schedule was for who was supposed to be monitoring the service line, she stated that she did not know what schedule the surveyor was talking about, and had not received one. M. Record review of supervisor audit forms to show compliance with follow-up plan, dated 12/13/22 to 12/20/22, against the scheduled/assigned staff revealed several uncorrected changes in the supervisor who was supposed to be monitoring the meal. The audit forms showed that meals were still coming out of the kitchen that were not meeting the proper texture. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J (an isolated of jeopardy to resident health and safety) being identified on 12/21/22 at 11:55 am with the facility Administrator (ADM), Director of Nursing (DON), Senior Administrator, and Regional Nurse On 12/21/22 at 11:55 am, the Administrator, Director of Nursing (DON), Senior Administrator, and Regional Nurse were notified of an Immediate Jeopardy (IJ) in the following area: Free of Accident Hazards. The survey team identified that measures put in place to correct/prevent improper food consistency being served to the residents were not being followed as outlined by the facility's self report follow up investigation and corrective actions (triple check) dated 12/13/22. A Plan of Removal was received and accepted on 12/22/22 at 3:00 PM. The removal plan included: 1. In-service trainings to explain diet texture and requirements for ordered diet, 2. That meal service will not begin to be plated until a supervisor is present to ensure correct ordered diet was plated per printed meal ticket, 3. A schedule for supervisors assigned to oversee plating with notation if changed, 4. Meal audits by supervisors, and 5. Results of amassed information taken to QAPI (Quality Assurance and Performance Improvement) committee. The survey team interviewed facility staff, observed meal practices, and reviewed staff training for practices. The survey team verified all elements of the facility's IJ Removal Plan.