Every finding on record at Shandin Hills Behavior Therapy Center

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. A turkey meat product wrapped in foil was in the freezer, uncovered in a tray.2. One open box of fish filet was in the freezer with the inner plastic bag not properly sealed.3. One open box of frozen chocolate chip cookie dough had the inner plastic bag left open.4. Heavy grease, carbonized food residue (burnt food that has hardened and turned black due to heat and was not cleaned from surfaces) and burnt buildup were observed on cooking surfaces, ovens, and drip trays.5. Visible grease accumulation was observed on interior and exterior oven surfaces.6. Dark buildup and debris were observed on the oven door pane and bottom tray.7. The emergency food storage room was observed unclean with dust accumulation on the floor shelving, water bottles, and dry leaves on the floor.These failures had the potential for microorganism growth that could be inadvertently transferred to food of 78 medically compromised residents who received food from the kitchen. During a concurrent observation and interview on February 17, 2026, at 8:05 AM, with the Account Manager (AM 1), the walk-in refrigerator was inspected. On the right bottom shelf, a turkey meat product wrapped in aluminum foil was observed placed inside a metal tray. The foil wrapping was not tightly sealed, and no additional protective covering was observed. The tray contained visible yellow-dark liquid accumulation on the bottom. The tray label indicated item: Turkey, Preparation date February 16. 2026. The AM 1 stated the turkey should be covered with plastic wrap to prevent contamination.During a concurrent observation and interview on February 17, 2026, at 8:12 AM, in the kitchen freezer, there was an open box containing a blue inner plastic bag; inside the bag was some uncovered filets of white fish. The box was labeled 10 LB (LB - pounds, unit of measurement), with the Received Date (RD) February 9, 2026. The AM 1 confirmed the bag was not properly sealed and stated staff should have ensured the bag was fully closed to avoid freezer burn and to prevent contamination. During a concurrent observation and interview on February 17, 2026, at 8:15 AM, in the kitchen freezer, there was an open box labeled Chocolate Chip Frozen Cookie Dough, the inner clear plastic bag was open and the dough was exposed. The label indicated a Received Date (RD) of February 2, 2026, and Use by (UB) date of May 2, 2026; the bag did not indicate the date when it was opened. The AM 1 stated the bag should not be left open to prevent contamination and acknowledged the open date was not written. During a concurrent observation and interview on February 17, 2026, at 8:25 AM, in the kitchen, a heavy grease accumulation, carbonized food residue, and burnt buildup were observed on the cooking surface and surrounding areas. Thick, dark residue and accumulated grease were observed beneath the stove knobs on the drip tray (a removable metal tray designed to catch grease and food debris) with visible debris and food particles present on the foil lining. The AM 1 stated that the kitchen equipment is expected to be maintained in a clean and sanitary condition.During a concurrent record review and interview on February 20, 2026, at 11:58 AM, with the Account Manager (AM 1) the policy and procedure titled Food Storage: Cold Foods Revised 2/2023 was reviewed. The P&P indicated, . 5. All foods will be stored wrapped in covered containers, labeled and dated and arranged in a manner to prevent cross -contamination. The AM 1, confirmed that the policy was not followed.During a concurrent observation and interview on February 17, 2026, at 8:27 AM, with the AM 1, in the kitchen, visible grease accumulation was observed on the interior and exterior surfaces of the ovens located beneath the stove. Grease residue was observed along the oven door edges, exterior surfaces, and interior walls. The accumulation was visible on multiple surfaces of the equipment at the time of observation. The AM 1, acknowledged and stated that it should be clean. During a concurrent observation and interview on February 17, 2026, at 8:29 AM, with the AM 1, in the kitchen, dark buildup and debris were observed on the oven door pane and bottom tray of the ovens located beneath the stove. The left lower oven had heavier accumulation of dark residue and debris on the interior surfaces and bottom tray. The lower right oven also had dark buildup and debris present on interior surfaces and racks. The AM 1 confirmed and stated that it should be clean.During a concurrent interview and record review on February 20, 2026, at 12:29 PM, with Account Manager (AM 1), the facility policy titled Environment, revised June 2025, was reviewed. The Policy indicted, All food preparation areas, food services and dining areas will be maintained in a clean and sanitary condition. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. The AM 1 confirmed that the policy was not followed. During a concurrent observation and interview on February 17, 2026, at 8:46 AM, with the AM 1, in the emergency food storage room, the area was observed unclean. Visible dust accumulation was noted on the floor surfaces and shelving units. There was dust on multiple large blue water containers stored on the shelving. A total of nine large blue water containers were stored in the room. Additionally dry leaves and debris were scattered on the floor throughout the storage area. The surrounding floor surfaces appeared unclean with visible buildup and debris present. The AM 1, was present during the observation, confirmed the condition of the storage room and stated the area should be kept clean to ensure proper sanitation of stored emergency food and water supplies. During a follow up interview on February 20, 2026, at 12:18 PM, with the Admin, the Admin stated the facility did not have an established cleaning schedule for the emergency supplies room and confirmed that the last time it was cleaned was December 2025. The Admin further stated the facility did not have cleaning log in place and reported plans to initiate a cleaning log beginning February 20, 2026. During a concurrent interview and record review on February 20, 2026, at 12:23 PM, with Account Manager (AM 1), the facility policy titled Food Storage: Dry Goods Revised February 2023 was reviewed. The policy indicated that all dry goods will be appropriately stored in accordance with the FDA Food Code. 5. All packed and canned food items will be kept clean, dry and properly sealed. 6. Store areas will be neat, arrange for easy identification, and date marked as appropriate. The AM 1, confirmed that the policy was not followed. During a review of the FDA Food Code 2022, 6-501.12 Cleaning Frequency and Restrictions, indicated, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview, and record review, the facility failed to ensure a secure environment for 78 of 78 residents when multiples keys that open the main locked gate and doors to the facility were left hanging on the outside gate.This failure had the potential to place 78 residents at risk from unauthorized individual entering the building and or the residents leaving the facility through the unlocked door. During an observation on February 18, 2026, at 7:27 AM, surveyor found multiple keys that opened locked behavior doors and units hanging on the outside of the main entrance gate. There were no staff at the gate. Once the surveyors entered the building through the main entrance door, they proceeded through a second door, which leads directly to the resident's dining room.During a concurrent observation and interview on February 18, 2026, at 7:29 AM, with Licensed Vocational Nurse (LVN) 1 inside the building, LVN 1 stated, the main entrance door should be locked at all the time. LVN 1 stated, her keys were in her pocket, however as she Searched her pocket for the keys, she did not find them. LVN 1 stated, Oh may be at the door, let me see where I left it. LVN 1 walked to the main gate to look for her keys. Surveyor informed her she had the keys from the gate and gave them to LVN 1.During a concurrent interview and record review on February 18, 2026, at 8:28 AM, with Administrator (Admin), the facility's policy and procedure (P&P) titled, Facility Security and Locked Door, undated, was reviewed. The P&P indicated, The policy statement the facility maintains a secure therapeutic environment. Locked doors and controlled access measures are utilized. 6. Access control procedures, Exterior doors remain secured. Admin, stated, it is a safety issue, door must be always locked. Admin stated the keys should not have been left on the gate. Admin further stated, the keys must always be with staff and staff are not to leave keys anywhere. Admin stated, staff reviewed and signed the competency Skills for possession of door key. Admin acknowledged the facility P&P was not followed. During a concurrent interview and record review on February 19, 2026, at 1:51 PM, with LVN 1 the facility's Competency skills: Staff Possession of Door Key in A locked Unit, (date [undated]) was reviewed. The Competency Skills indicated, Staff must secure (as part of the uniform) the door/gate key used to enter and exit the facility, key to lock the unit and not leaving it anywhere. Staff must immediately inform the supervisor if door/gate key is missing. LVN 1 stated she should not have left the keys at the gate. LVN 1 stated, she was educated and signed the competency. LVN 1 stated the risk of leaving the key at the gate, that unwanted visitors can enter the building, and the safety of the residents can be compromised.

Based on observation, interview, and record review, the facility did not ensure proper disposal of garbage when the recycling dumpster located in the front area of the building was observed overflowing with cardboard and debris, preventing the lid from closing, with visible staining and debris on surrounding surfaces.This failure had the potential to attract vermin (pests or animals that spread diseases) in the facility that cares for 78 medically compromised residents.During a concurrent observation and interview on February 17, 2026, at 8:46 AM, with the Account Manager (AM 1), the recycling dumpster located in the front area of the building was inspected. The dumpster was overflowing with cardboard and debris, preventing the lid from fully closing. There was staining and buildup on the exterior surfaces, and debris was present on the surrounding ground area. The AM 1 confirmed the condition and stated the lid should remain close to prevent pest attraction.During an interview on February 19, 2026, at 1:54 PM, with the Administrator (Admin), the Admin, stated the lid should remain closed and the area maintained to prevent pest attraction.During a record review of the facility policy titled Food - Related Garbage and Refuse Disposal Revised October 2017, indicated, . 2. All garbage and refuse containers are provided with tight -fitting lids or covers and must be kept covered when stored or not in continuous use. 3. Housekeeping personnel will empty garbage and refuse containers daily and will clean the containers at least daily on the outside and at least weekly on the inside, taking care not to contaminate food, equipment, utensils, or food preparation areas while cleaning. 6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a review of the FDA (Food and Drug Administration) Food Code 2022, 5-501.15, indicated, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and measurement, the facility failed to ensure resident bedrooms provide a minimum of 80 square feet (the amount of space in the room) per resident in multiple resident rooms for 13 of 13 resident rooms reviewed (Rooms 30 through 42) located in Unit 2, affecting 29 of 29 residents residing in these rooms.This failure had the potential to limit residents' freedom of movement, increase the risk of accidents, interfere with safe mobility within the environment, and negatively impact on residents' health, safety, and quality of life.During an observation and measurement conducted on February 18, 2026, at 9:34 AM, in the presence of Maintenance Director (MDIR), resident rooms located in Unit 2 were measured using a tape measure to determine total livable floor space. Measurements were taken in inches and converted to square feet. The following measurements were obtained: room [ROOM NUMBER] (two Bed) measured 142 sq ft (71 sq feet per resident) room [ROOM NUMBER] (Two beds) measured 146 sq ft (73 sq feet per resident)room [ROOM NUMBER] (four beds) measured 233 sq ft (58.3 sq ft per resident) room [ROOM NUMBER] (three beds) measured 176 sq ft (58.6 sq ft per resident) room [ROOM NUMBER] (two beds) measured 143 sq ft (71.5 sq ft per resident) room [ROOM NUMBER] (two beds) measured 145 sq ft (72.5 sq ft per resident) room [ROOM NUMBER] (two beds) measured144 sq ft (72 sq ft per resident)room [ROOM NUMBER] (two beds) measured 145 sq ft (72.5 sq ft per resident) room [ROOM NUMBER] (two beds) measured 140 sq ft (70 sq ft per resident) room [ROOM NUMBER] (two beds) measured 141 sq ft 70.5 sq feet per resident) room [ROOM NUMBER] (two beds) measured 119 sq ft (59.5 sq feet per resident) room [ROOM NUMBER] (two beds) measured 142 sq ft (71 sq per resident) room [ROOM NUMBER] (two beds) measured 141 sq ft (70.5 sq ft per resident) The available square footage per resident in each of the rooms measured was below the required minimum of 80 square feet per resident as required by regulation and facility policy. During the observation, residents occupying the rooms were observed utilizing the available space without immediate safety concerns Room configurations appeared consistent with the current facility layout. During an interview conducted on February 18, 2026, 9:45 AM with MDIR, the MDIR confirmed the measurements obtained and stated there have been no additions or structural changes made to increase size of the resident rooms in Unit 2. During a concurrent interview and record reviewed on February 19, 2026, at 5:21 PM, with the Administrator, (Admin) the facility policy and procedure (P&P) titled Bedrooms revised January 2025. was reviewed. The P&P indicated, 2. Bedrooms measure at least 80 square feet or usable living space per resident in double rooms and at least 100 square feet of usable living space in single rooms. The Admin confirmed the policy requirements were not followed. Measurements obtained during the survey confirmed the resident rooms did not meet the minimum square footage required by facility policy.

Based on observation, interview and record review, the facility failed to prevent one of four sample residents (Resident 1) from being abuse by another Resident (Resident 2), when Resident 2 struck Resident 1 while he was in line with many other residents for medication. This failure resulted in Resident 1 suffered a scratch below the left eyebrow, a bruise on the left forehead, and a scratch on the left arm. Findings: On February 25, 2025, at 9:15 AM, the facility was entered to investigate a facility-reported incident related to an injury to Resident 1 caused by Resident 2 struck Resident 1 without provocation. During an interview on February 25, 2025, at 9:41 AM with Resident 1, Resident 1 stated that as he was standing in line to receive his medication, Resident 2 approached him and punched him. He stated there were a lot of them waiting in line when it occurred. He further stated that he had a bruise on his left forehead, a scratch below his left eyebrow, his jaw felt tense, and a scratch on the left arm resulting from the incident. During a review of Resident 1's admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Schizophrenia (a serious mental health condition that affects how people think, feel and behave). During a review of Resident 1 record titled Change in Condition Evaluation , dated February 22, 2025, indicated, at approximately 8:55 AM, Resident 1 was waiting in the hallway for his medication when Resident 2 approached without warning and began hitting Resident 1 causing Resident 1 to fall to the ground. Code was called and Resident 2 was immediately verbally redirected, Resident 2 behavior instantly ceased and began to walk away toward his room. Neuro checks performed on Resident 1. Resident 1 is alert oriented, able to communicate and follow commands, Resident 1 stated 5/10 headache, and refused pain medication. Doctor and conservator notified. During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 14. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on February 25, 2025, at 9:58 AM with the License Vocational Nurse (LVN 1), LVN 1 stated she was the medication nurse when the incident happened and that there were approximately 10 to 15 residents in the hallway when there should have only been 4 to 5 people waiting in line for their medication. said she thinks the incident may have been avoided if the number of residents waiting in line had been kept at 4 to 5 people at a time. During an interview on February 25, 2025, at 10:23 AM with Resident 2, Resident 2 stated there were around 10 to 11 people there when he struck Resident 1 and there were couple of staff too. During a review of Resident 2's admission record, the document indicated Resident 2 was admitted to the facility on [DATE], with a diagnosis that included Schizophrenia (a serious mental health condition that affects how people think, feel and behave). During a review of Resident 2 record titled Change in Condition Evaluation , dated February 22, 2025, indicated, at approximately 8:55 AM, during the morning medication pass, staff reported Resident 2 approached Resident 1 without provocation and began striking Resident 1 multiple times with Right hand, closed fist, causing Resident 1 to fall and spill the water he was holding. Resident 2 continued to hit Resident 1 while hovering over Resident 1. Staff quickly intervened, called code, and verbally directed Resident 2 to stop the behavior. Resident 2 immediately ceased and walked to his room without further incident. A review of Resident 2's care plan for Aggressive Behavior with an initiation date of October 24, 2024, and last re-evaluated November 3, 2024, showed that Resident 2 is at risk for Aggressive Behavior . During a review of Resident 2 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 14. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on February 25, 2025, at 10:36 AM, with another resident (Resident 3), Resident 3 stated on Saturday, there were around 15 people in the hallway lining up to get their medication when Resident 2 struck Resident 1. During a review of Resident 3's admission record (a document that gives a summary of resident's information), the document indicated Resident 3 was admitted to the facility on [DATE], with a diagnosis that included Paranoid Schizophrenia (a serious mental health condition that affects how people think, feel and behave accompanied by paranoia). During a review of Resident 3 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 14. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on February 25, 2025, at 10:42 AM, with another resident (Resident 4), Resident 4 stated there was around 12 people lining up to get medication, when the incident happened. During a review of Resident 4's admission record (a document that gives a summary of resident's information), the document indicated Resident 4 was admitted to the facility on [DATE], with a diagnosis that included Schizophrenia (a serious mental health condition that affects how people think, feel and behave). During a review of Resident 4 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During interview on February 25, 2025, at 10:50 AM, with the Program Director (PD 1), PD 1 stated although staff seemed to be aware that a small number of people lining up at one time is ideal to prevent problems from developing, PD 1 indicated that the facility lacks policy and procedure (P&P) that specifies how many residents should be lining up at one time for medication administration. She acknowledged that the situation may have been exacerbated by the large number of individuals waiting in line for medication on the day of the incident. A review of the facility P&P titled Resident-to-Resident Altercations dated September 2022, indicated, .1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff .

Based on observation, interview, and record review, the facility failed to implement adequate monitoring and supervision for one of one resident (Resident 1) who had a history of elopement (leaving a designated area without permission), when the facility ' s back door was unlocked and Resident 1 left the facility without staff awareness on January 6, 2025, for 15 hours, before police brought Resident 1 back to the facility at midnight, on January 7, 2025. This failure placed Resident 1 at high risk for accidents and had the potential to place Resident 1's health and safety at risk and for him to experience some serious adverse outcome, due to exposure of the (outdoor) elements, as well as effects of his admitted use of marijuana ( a drug than can be smoke, vaporized or consume in milk) and alcohol while he was gone interacting with his prescribed medications. Findings: During a review of Resident 1's Admission Record (a document that gives a summary of resident's information), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (mental disorder in which people interpret reality abnormally). During a review of Resident 1 ' s Elopement Evaluation (a form used by the facility to assess the risk of a resident leaving the facility) dated November 14, 2024, indicated, Resident 1 has a history of actual elopement or attempted elopement. During a review of the Facility record titled, Investigation Worksheet (document containing Resident 1 interview statement). Resident 1 interview statement was reviewed. In the statement Resident 1 described on January 6, 2025, he left at 9:30 AM. He was pacing when he noticed Mental Health Counselor Programmer (MHCP 1) and the other MHCP (MHCP 2) conducting a group session. A Certified Nurse Assistant (CNA 1) departed for a break, while CNA 2 remained at the nurse's station. So, he walked and tested the door, which opened, and then he hurried out. He hopped over the fence near the laundry room. He had to hang down so he wouldn't fall into the yellow trash cans. Then he dashed down the driveway to the large bus stop beside the 7/11. He got the bus about 10:00 AM and paid $2.40. He rides it till he reaches the city of [NAME], where several people give him marijuana and he purchased some beer and a cigar from the liquor shop. He used the phone to contact his brother to pick him up, but the cops got him first. During an interview on January 7, 2025, at 12:39 PM, with the Program Director (PD 1), the PD 1 stated they had a faulty back door that Resident 1 opened; the magnet did not engage, and Resident 1 scaled the fence to exit the premises. During an interview on January 7, 2025, at 1:13 PM, with Resident 1, Resident 1 stated he escaped the facility by going through the back door and jumping over the fence. Resident 1 further stated the door was broken and it could be gently pushed open. Resident 1 stated the hallway was empty, with only a single person at the nurses' station, enabling him to slip away unnoticed. Resident 1 also mentioned he rode a bus to [NAME] and was brought back to the facility by the police. During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on January 7, 2025, at 1:20 PM with a Resident (Resident 2). Resident 2 stated the door was broken yesterday, at around 8:30 - 9:30 AM, stated he knows about it because he heard someone got out. During a review of Resident 2 ' s Minimum Data Set (facility assessment tool), dated November 25, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on January 7, 2025, at 1:24 PM, with a Resident (Resident 3). Resident 3 stated the door was broken yesterday and no staff was in the hallway. During a review of Resident 3 ' s Minimum Data Set (facility assessment tool), dated December 8, 2024, under Section C, it indicated his Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on January 7, 2025, at 1:27 PM with the CNA 2, the CNA 2 stated she doesn ' t know exactly the time when the elopement happened. Stated she start her shifts at 6:30 AM and went to lunch from 10:00 AM - 10:30 AM. She added per policy someone should be always on the floor. She further explained that they were having problems with that door not working properly yesterday before the elopement incident happened. During an interview on January 7, 2025, at 1:44 PM, with The MHCP 1, the MHCP 1 stated yesterday, January 6, 2025, she started her shift at 7:00 AM. She believes the elopement happen between 9:30AM - 10:00 AM, because she observed the back door was not locking when they return from coffee break outside. MHCP 1 stated she discovered the door did not close securely and could be easily opened, prompting her to inform the Maintenance Supervisor. During an interview on January 7, 2025, at 2:23 PM, with the Maintenance Supervisor (MS 1), the MS 1 stated he was informed around 9:00 AM, on January 6, 2025, the door was not locking, and he fixed it. During an interview on January 7, 2025, at 3:00 PM, with the PD 1, the PD 1 stated they are conducting in-service training about heightened supervision and staying at their posts consistently to oversee the residents. She further added, according to policy, there must be always personnel in the hallway. During a review of the facility Policy and Procedure (P&P), titled, Maintenance Service, undated, indicated, .1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner . During a review of the facility Policy and Procedure (P&P) titled, Emergency Procedure - Missing Resident, undated, indicated, .1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety .

Based on observation, interview, and record review, the facility failed to follow their daily approved menu for lunch when, on November 12, 2024, Dietary [NAME] served a mixture of lettuce, tomato, and cheese together to serve with tacos and used a #24 scoop (1.33 ounces or 2-2/3 tablespoons), instead of 1/4 cup (4 tablespoons) shredded lettuce and diced tomato topping and 1 tablespoon of shredded cheddar cheese. This failure had the potential for residents to compromise their nutritional status when menus are not followed for 78 of 78 medically compromised residents who received food from the kitchen. FINDINGS: During tray line (when cook serves food on plates for each resident according to the menu) observation on November 12, 2024, at 12:11 PM, In Unit 1 Dietary [NAME] served lettuce, tomato, and cheese mixture using a #24 handle scoop (1.33 ounces or 2-2/3 Tablespoon). During a tray line observation on November 12, 2024, at 12:37 PM. In Unit 2 Dietary Aide served lettuce, tomato, and cheese mixture using a #24 handle scoop (1.33 ounces or 2-2/3 tablespoon). During a review of the facility document titled, Diet Guide Sheet, dated November 12, 2024, indicated, Beef Soft Taco with Flour Tortilla .Shredded Lettuce & Diced Tomato Topping 1/4 Cup (4 tablespoons) .Shredded Cheddar Cheese 1 Tbl (tablespoon) . During an interview on November 15,2024, at 10:05 AM, with the Registered Dietician (RD), the RD stated the recipe, and the menu diet guide should be followed. During a review of facility's policy and procedure (P&P) titled, Menus, dated September 2017, the P&P indicated, .6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal .

Based on interviews and record review, the facility failed to ensure the residents rights to forms of communication were respected for three of six residents (Residents 24, 31 and 66) when Residents 24, 31 and 66 did not receive mail on Saturdays. This failure resulted in Residents 24, 31 and 66's not having means of communication with individuals inside or outside the facility, which could cause psychosocial harm and lead to low self-esteem, feeling irritated, sad, and anxious. Findings: During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility on [DATE], with the diagnoses of schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive, and interact with others), nicotine dependence (a condition where a person has a compulsive need for nicotine, the addictive chemical found in tobacco products) and hyperlipidemia (high levels of fat in the blood). During a review of Resident 31's Admission Record, the Admission Record indicated Resident 31 was admitted to the facility on [DATE], with the diagnoses of nicotine dependence and schizophrenia. During a review of Resident 66's Admission Record, the Admission Record indicated Resident 66 was admitted to the facility on [DATE], with the diagnoses of nicotine dependence and schizophrenia. During an interview on November 13, 2024, at 11:00 AM, with Residents 24, 31, and 66, during Resident Council meeting (a gathering of residents who come together to discuss concerns, share information, and make decisions) conducted , Residents 24, 31, and 66 stated they do not receive mail on Saturdays amd only received it during Monday through Friday. During an interview on November13, 2024 at 11: 40 AM, with the Social Services Director (SSD), the SSD stated, the facility did not have any staff member to distribute mail to the residents on the weekends. The SSD further stated, there just isn't anyone here with access to the mailbox on weekends. During a follow up interview on November 13, 2024, 12:18 PM with the SSD, the SSD stated, social services department is responsible for delivering mail. The SSD further stated, the post office delivered the mail on Saturdays into the mailbox, however the residents receive their mail until the following Monday. During a concurrent interview and record review on November 13, 2024, at 12:19 PM with the SSD, the SSD reviewed the facility's policy and procedure (P&P) titled, Mail and Electronic Communication, revised date May 2017. The P&P indicated, . 4. Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or to the facility's post office box (including Saturday deliveries). The SSD, stated, the policy was not followed but, the facility is working on getting an additional key. The SSD further stated, It is the patients right to receive their unopened mail in a timely manner. During an interview on November 13, 2024, at 12:25PM, with the Administrator, (Admin), the Admin stated, the Social services Director is responsible for the residents mail delivery. The Admin further stated, if the Residents, do get regular mail on Saturdays, then the mail gets distributed on Monday. The Admin stated, it is important the residents receive their mail on Saturdays, it is the Residents rights.

Based on observation, interview, and record review, the facility failed to follow the menu for dysphagia mechanical soft diet (texture-modified diet that restricts foods that are difficult to chew or swallow) when one of twenty two sampled resident (Resident 16) did not receive her physician ordered therapeutic diet (a meal plan that's prescribed by a doctor and created by a dietician to treat a medical condition) on the following days: Received regular tortilla and regular green chili rice instead of pureed tortilla and pureed green chili rice for lunch on November 12, 2024. Received a whole piece of bread and chopped roast pork instead of pureed bread and ground roast pork for lunch on November 13, 2024. This failure had the potential for Resident 16 that received this diet to be at risk for choking and impact the resident's nutritional needs and health outcomes. FINDINGS: A review of Resident 16's Admission Record, (contains demographic and medical information), indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (a condition where there are abnormally high levels of lipids, or fats, in the blood) During an observation on November 12,2024, at 12:23 PM, Dietary Aide 1 (DA 1) was plating the food for residents and served Resident 16 a regular diet which consisted of 2 regular beef tacos and scoop of green chili rice. During a record review of the facility's menu diet guide on November 12, 2024, at 1:30 PM, titled, Diet Guide Sheet, indicated on November 12,2024 for Dysphagia Mechanical Soft .Lunch .Pureed tortilla .pureed green chili rice . During an observation on November 13, 2024, at 01:12 PM, observed Resident 16's meal tray for lunch which consisted of chopped pork and slice of bread. During a record review of the facility's menu diet guide on November 13,2024, at 1:45 PM titled, Diet Guide Sheet, indicated on November 13,2024 for Dysphagia Mechanical Soft .Lunch .ground roast pork .pureed bread . During a review on November 13,2024, at 01:13 PM, Resident 16's clinical record physician order indicated on September 5, 2024, Consistent Carbohydrate diet Dysphagia (difficulty swallowing) mechanical soft texture, . for recent choking episode. During a review on November 13,2024, at 04:18 PM, Resident 16's progress note, dated September 2,2024, indicated, At approximately 1315 staff reported resident appeared to be choking while eating lunch in her room. Nursing staff proceeded with performing abdominal thrust which resulted in resident vomiting her food. No visible large object noted in throw up. Resident is currently sitting up in her bed with no signs of distress, no pain or discomfort. Resident is educated on chewing her food before swallowing . During a review of Resident 16's record on November 14,2024, at 09:57 AM, Interdisciplinary Progress Note, dated September 12, 2024, indicated, IDT discussed the patient's incident at mealtime where there was an incident where she appeared to be choking. Resident's diet was immediately changed to Dysphagia Mechanical Soft texture. During an interview on November 14, 2024, at 10:21 AM, the Dietary [NAME] (DC) stated she forgot to pureed the tortilla, the rice, and the bread. She confirmed that she should follow according to the menu diet guide. During an interview on November 15,2024, at 10:20 AM, with Registered Dietician (RD), RD stated it was his expectation that meals should be according to the recipe and what the diet guide calls for. During a review of the facility's Diet and Nutrition Care Manual under, Diet and Nutrition Care Manual, under National Dysphagia Diet Levels, Level 2 Dysphagia Mechanically Altered, cohesive, moist, semi-solid, requires some chewing ability, ground or minced meats with fork-mashable fruits and vegetables, moist, ground, soft textured , minced or fork mashable, simple to chew foods that are included in a transition from puree texture to mechanical soft texture, The food forms easily into a cohesive bolus, excludes most bread products, crackers, and other dry foods.

Based on observations, interviews, and record review, the facility failed to ensure when one of one sampled residents (Resident 278) food preferences were not honored when Resident 278 asked for ketchup for his lunch on November 12, 2024 and staff said no. This failure had the potential to result in unmet care of needs for Resident 278 which could potentially affect the residents nutrition status. FINDINGS: A review of Resident 278's Admission Record,(contains demographic and medical information), indicated Resident 278 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (s a mental health condition marked by hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), enlarged lymph nodes (swollen lymph nodes are your body's natural reaction to illness or infection. These small lumps are soft, tender, and often painful), and nicotine dependence (a chronic disease that makes it difficult to stop using tobacco, even when a person wants to quit). During an observation on November 12,2024, at 12:11 PM, Resident 278 was getting his food for lunch and asked the Dietary [NAME] for ketchup. Dietary [NAME] stated, no, You don't need it. We are not serving fries. During a review of Resident 278's progress note on November 13, 2024, at 11:09 AM, a note dated November 8, 2024, indicated, Resident was waiting in line for his tray when he asked for ketchup. Resident educated that he doesn't have a hot dog. Resident stated, yes I do. Grabbed his pants over his crotch area and stated, I got one right here. Resident educated on appropriate boundaries and redirected to cease inappropriate comments by PD. Resident understood. PD met with the resident to discuss safety planning for the weekend. Resident given another packet to do during his free time for extra group credit. He was able to identify he would remain safe with the mantra calm body, calm mind and identified he would ask staff for a PRN or fresh air outside if he was feeling frustrated or anxious. The resident was praised for identifying safety plans. Resident encouraged that PD would meet with him on Monday to review how his weekend went. Resident to remain on increased supervision to monitor. Continue with focus and goal. During a review of Resident 278's care plan titled, [Resident 278] Resident is at nutritional risk: dated November 1, 2024, the care plan indicated, Interventions .Honor food preferences within meal plan . During a concurrent observation and interview on November 14, 2024, at 1:42 PM, Resident 278 was sitting in his room. He appeared calm, able to make his needs known, and answered questions appropriately. He stated that he likes to have ketchup, salt and pepper, and sugar with his meals to add more flavor. During an interview on November 14, 2024, at 2:08 PM, Program Director stated, we were having fish tacos that day and we were verifying if he wanted ketchup. He can have ketchup from what I know. During an interview on November 15, 2024, at 10:05 AM, with Registered Dietician (RD), stated that based on Resident 278's diagnosis and diet order, ketchup should be ok. During a review of the facility's policy and procedure titled, Dining and Food Preferences, dated September 2017, the policy indicated, Policy Statement: Individual dining, food, and beverage preferences are identified for all residents/patients .

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. There was two plastic drawers with food crumbs and spill stains inside the drawers. The plastic drawer base and the shelf that the drawers were sitting also had a build-up of food crumbs. 2. There was a black build-up on floor under the three compartment sinks. Looks like black sludge with food. The had the potential for microorganism growth and to attract pests. 3. The meat slicer had old meat crusted on the blade. This had potential to contaminate meat sliced on the slicer. 4. The steam table in unit one dining room was dirty, had grease and grime on the front of the unit and the shelf under the steam table had a buildup and food crumbs.The steam table in unit two dining room had a build-up of a brown substance and food crumbs. And the stainless-steel shelf had a rust like substance on the shelves. This had a potential to contaminate food and attract pests. 5. A dresser was being used in unit two next to the steam table to store condiments and food. The drawers had a buildup of crumbs and stains. The front of the drawers had water damage and warping. this had the potential to contaminate food and for microorganism growth. 6. There was a plumbing repair done that required a wall to be patched. The wall patch was not smooth and easily cleanable. The mesh patch was still visible, and the spackle was bumpy and not smoothed out or painted. This had the potential for buildup to occur and microorganism growth. These facility failures had the potential to attract pests and cause foodborne illness to a population of 78 residents eating facility prepared meals. FINDINGS: 1. During an observation on November 12, 2024, at 08:14 AM, two plastic drawers on a shelf under the coffee maker had food crumbs and spill stains inside the drawers. The plastic drawer base and the shelf that the drawers were sitting also had a build-up of food crumbs. During an interview on November 12, 2024, at 08:14 AM, with the Dietary Manager Consultant (DMC), DMC acknowledged that the plastic drawers need to be cleaned. During an interview on November 15,2024, at 10:05 AM, with the Registered Dietitian (RD), the RD stated his expectation is that the surfaces of the drawers should be maintained clean. During a review of the facility's policy and procedure titled, Environment, dated September 2017, indicated, All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 2. During an observation on November 12, 2024, at 08:19 AM, under the three-compartment sink had black build up that appeared to be black sludge with food. During an interview on November 15,2024, at 10:05 AM, with the RD, the RD stated, the floors should be cleaned on daily basis, everything should be cleaned on the floor. During a review of the facility's policy and procedure titled, Environment, dated September 2017, indicated, All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 3. During an observation on November 12,2024, at 08:24 AM, the meat slicer had meat crusted on the blade. During an interview on November 12,2024, at 08:25 AM, with the Dietary Manager he acknowledged that there is meat crust on the blade of the meat slicer. During an interview on November 15,2024, at 10:06 AM, with the RD, the RD stated the meat slicer should be cleaned and sanitized after every use. During a review of the facility's policy and procedure titled, Environment, dated September 2017, indicated, All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. In addition, Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 4. During an observation on November 12,2024, at 08:39 AM, the steam table in unit one dining room had grease and grime on the front of the unit and the shelf under the steam table had brown build-up and food crumbs. During an observation on November 12, 2024, at 08:45 AM, the steam table in unit two dining room had brown buildup of brown substance and food crumbs. During an observation on November 12,2024, at 08:46 AM, the stainless-steel shelf had rust like substance on the shelves. During an interview on November 15,2024, at 10:07 AM, with the RD, the RD stated the steam tables in Unit 1 and Unit 2 should be cleaned daily. During a review of the facility's policy and procedure titled, Environment, dated September 2017, indicated, All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 5. During an observation on November 12,2024, at 08:47 AM, there was a dresser being used in unit two next to the steam table that had three drawers and was storing condiments and food. The drawers had a buildup of crumbs and stains. There was a banana stored in the top drawer with the condiments and a banana stored in the second drawer that was empty but had food crumbs and buildup in the drawer. There was a piece of glass covering the top of the dresser that had water damage. The front of the drawers had water damage and warping. During an interview on November 15,2024, at 10:08 AM, with the RD, the RD stated there should not be water damage. 6. During an observation on November 12,2024, at 08:24 AM, there was a drain under the dishwasher that was repaired and wall patch that was completed was rough, raw spackled, not smooth or painted. Able to see the mesh to repair the hole and not completely covered with spackle. During an interview on November 15,2024, at 10:05 AM, with Registered Dietician (RD), RD stated there should be nothing falling off or peeling from the patch. During a review of the facility's policy and procedure titled, Equipment, dated September 2017, was reviewed. The policy indicated, Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order . During further review of the FDA Federal Food Code, dated 2022, under Section: Equipment, Utensils, and Linens, Section 4-101.19 titled, Nonfood-Contact Surfaces, indicated, Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects. During a review of the FDA Federal Food Code, dated 2022,4-101.19 indicated, NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a CORROSION-RESISTANT, nonabsorbent, and SMOOTH material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects.h

Based on observation and interview, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for 13 rooms (Rooms 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42). This failure had the potential to limit freedom of movement and affect the health and safety of 29 residents who reside in these rooms. Findings: During an observation and interview with the Facility Maintenance Director (FMD) on November 14, 2024, at 1:53 PM, 13 rooms were measured and found to be less than the required 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: i. room [ROOM NUMBER] (two beds) measured 142 sq./ft. (71 sq. ft. per resident) ii. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) iii. room [ROOM NUMBER] (four beds) measured 234 sq./ft. (58.5 sq. ft. per resident) iv room [ROOM NUMBER](three beds) Measured 178 sq./ft. (59.3 sq. ft. per resident) v. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) vi. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) vii. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) viii. room [ROOM NUMBER] (two beds) measured 143 sq./ft. (71.5 sq. ft. per resident) ix. room [ROOM NUMBER] (two beds) measured 143 sq./ft. (71.5 sq. ft. per resident) x. room [ROOM NUMBER] (two beds) measured 141 sq./ft. (70.5 sq. ft. per resident) xi. room [ROOM NUMBER] (two beds) measured 120 sq./ft. (60 sq. ft. per resident) xii. room [ROOM NUMBER] (two beds) measured 142 sq./ft. (71 sq. ft. per resident) xiii. room [ROOM NUMBER] (two beds) measured 141 sq./ft. (70.5 sq. ft. per resident) During an interview with the Administrator (Admin), on November 14, 2024, at 3:04 PM, the Admin stated, he is aware of the measurement. There were no complaints of space or room issues from the residents that occupying these rooms. The Residents can walk around the room safely. These rooms appear to be spacious not crowded and did not impose any safety hazards on the Residents at this time. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. There were eight outdated cups of prune juice found in the kitchen refrigerator, and one box of outdated saltine crackers was found in the dry food storage and were available for use. 2. There were food crumbs and trash under the stove. These failures had the potential to expose 77 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings: 1. During an observation and interview with Cook 1, on October 30, 2023, at 8:20 AM, in the kitchen, one of the refrigerators were inspected. Inside the refrigerator, there was a food storage container holding eight cups of outdated prune juice. It had a label, Prune juice .UB 10-18-23 [October 18, 2023]. During further observation and interview with Cook 1, on October 30, 2023, at 8:30 AM, in the kitchen, the dry food storage was inspected. One box of outdated saltine crackers with a label, Saltine cracker .UB 10-13-23 was found in the dry food storage. Cook 1 stated the outdated prune juice and crackers should be removed. During an interview with the Dietary Services Director (DSD), on October 31, 2023, at 2:15 PM, the DSD stated, The prune juice cups were outdated and should have been removed from the refrigerator and the outdated box of saltine cracker should also be removed in the dry food storage. An interview with the Registered Dietician (RD) was conducted on October 31, 2023, at 2:30 PM. The RD stated the outdated cups of prune juice should have been removed and not left inside the refrigerator. The RD further stated the saltine crackers in the dry food storage should be discarded. The RD stated, The cooks are to remove any food items with outdated labels out of the containers and carts every morning. During a concurrent interview and record review on October 31, 2023, at 2:40 PM, with the RD, the RD reviewed and acknowledged the facility's policy and procedure (P&P), titled, Food Receiving and Storage, dated September 2017, indicated, Policy: Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use .All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). A review of the Food and Drug Administration Food Code 2022, 3-701.11, indicated, Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food. (A) A FOOD that is unsafe, ADULTERED, or not honestly presented as specified under $ 3-101.11 shall be discarded or reconditioned according to ab APPROVED procedure. 2. During a concurrent observation and interview, with the DSD, on October 30, 2023, at 8:45 AM, in the kitchen, there were food crumbs and trash under the stove, in the cook prep area. The DSD stated the area should be kept clean and free of crumbs, trash, and dirt. He stated the dietary staff were not able to do the regular cleaning. During an interview with the RD, on October 31, 2023, at 2:20 PM, the RD stated the cook preparation area should be kept clean. The RD further stated the area under the stove should be swept up regularly. During a concurrent interview and record review, on October 31, 2023, at 2:30 PM, with the RD and DSD, the RD and DSD reviewed and acknowledged the facility's policy and procedure (P&P), titled, Environment, dated September 2017, indicated, All food preparations areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. A review of the FDA Federal Food Code 2022, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

Based on observation, interview, and record review, the facility failed to implement the water management plan in accordance with their own policy and procedure. This failure had the potential to result in causing water borne illness(illness caused by ingestion of contaminated water) to 77 residents in the facility. Findings: During an interview, on November 2, 2023, at 1:00 PM, with the Maintenance Supervisor 1 (MS 1), the MS 1 stated he was not following the water management plan as per facility policy and procedure except for checking the water temperature. During a concurrent interview and record review, on November 2, 2023, at 3:00 PM, with the Administrator in Trainee (AIT), the AIT reviewed the facility's undated policy and procedure (P&P) titled, Legionella Water Management Plan, and stated,We [the facility] are not following the steps that was documented in the policy and procedure for the Legionella water management plan except the temperature checking daily. During a review of the facility's undated policy and procedure titled, Legionella Water Management Plan, it indicated, .instructions 3 identify areas where Legionella could grow and spread .

Based on observation, interview, and record review, the facility failed to ensure informed consents (process in which a health care provider educates a patient about the risk and benefits and alternatives) were obtained for a resident (Resident 54) reviewed for use of psychotropic medication (a drug which affects behavior, mood thoughts, or perception). This failure had the potential for Resident 54 and his representative to not be informed of Resident 54's current health condition and treatment options, which could negatively impact Resident 54's health and safety. Finding: During a review of Resident 54's Admission Record (contains demographic and medical information), it indicated Resident 54 was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia [a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly], insomnia [inability to sleep] and hypothyroidism [low activity of the thyroid gland]. During a record review of Resident 54's Physician Order Sheet, dated January 30, 2023, it indicated Resident 54 was ordered by the Physician to receive Topamax (anti-psychotic drug) 100 mg [milligrams-unit of mass] by mouth two times a day. During a record review of Resident 54's Physician Order Sheet, dated September 19, 2023, it indicated, Resident 54 was ordered by the Physician to receive Haloperidol (anti-psychotic drug) 5 mg by mouth two times a day. During a record review of Resident 54's Physician Order Sheet, dated September 19, 2023, it indicated Resident 54 was ordered by the Physician to receive Lithium Carbonate [mood disorder drug] 450 mg by mouth at bedtime. During a review of Resident 54's Physician Order Sheet, dated September 19, 2023, it indicated Resident 54 was ordered by the Physician to receive Buspirone HCL (anti-depressant drug) 15 mg by mouth three times a day. During a concurrent interview and record review with the Director of Nursing (DON), on November 3, 2023, at 3:25 PM, the DON reviewed Resident 54's clinical record and was unable to find documented evidence to indicate the facility obtained informed consenta for Resident 54's use of Topamax, Haloperidol, Lithium Carbonate, Gabapentin and Buspirone. During a review of the facility's policy titled Behavior Management, dated, August 25, 2023, it indicated, I. The Facility monitor identified resident will be used for Resident who: 3. Obtain the Psychotropic Medication Administration Disclosure (Forms on Demand or Psychotropic Medication Administration Informed Consent for California Sate specific).

Based on observation and interview, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for 13 rooms (Rooms 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42). This failure had the potential to limit freedom of movement and affect the health and safety of 29 residents who reside in these rooms. Findings: During an observation and interview, with the Maintenance Supervisor 1 (MS 1), on November 3,2023, at 9:00 AM, 13 rooms were measured and found to be less than the required 80 sq. ft. per resident. The resident's rooms and their measurements of livable space were noted as follows: i. room [ROOM NUMBER] (two beds) measured 141.6 sq./ft. (70.8 sq. ft. per resident) ii. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) iii. room [ROOM NUMBER] (four beds) measured 234 sq./ft. (58.5 sq. ft. per resident) iv. room [ROOM NUMBER] (three beds) measured 178.43sq/ft (14.66x12.16sq/ft per patient) v. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) vi. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) vii. room [ROOM NUMBER] (two beds) measured 144 sq./ft. (72 sq. ft. per resident) viii. room [ROOM NUMBER] (two beds) measured 141.96 sq./ft. (70.98 sq. ft. per resident) ix. room [ROOM NUMBER] (two beds) measured 139.9 sq./ft. (69.95 sq. ft. per resident) x. room [ROOM NUMBER] (two beds) measured 140.4 sq./ft. (70.2 sq. ft. per resident) [NAME]. room [ROOM NUMBER] (two beds) measured 120 sq./ft. (60sq. ft. per resident) xii. room [ROOM NUMBER] (two beds) measured 142 sq./ft. (71 sq. ft. per resident) xiii. room [ROOM NUMBER] (two beds) measured 142 sq./ft. (71 sq. ft. per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on interview and record review, the facility failed to ensure the dietary staff were properly trained on emergency procedures when the cook did not call a Code Red or use the fire extinguisher to put out a fire in the kitchen. This failure had the potential to flare up and consume the kitchen which could have negatively impacted the physical and emotional well-being of the residents in the facility. Findings: On August 1, 2023, an unannounced visit was made to the facility to investigate a complaint regarding Physical Environment. During an interview with the Dietary Aide (DA 1) on August 1, 2023, at 3:19 PM, DA 1 stated, The cook was cooking fried steak. The Assistant Manager (AM) noticed a flame. The oil in the pan under the top of the stove caught on fire. The flame was getting bigger. The cook said, I know the flame is getting bigger, but I'll turn it off after I finish cooking. The AM noticed the flame was getting higherr. I went outside because of the smoke in the kitchen. The AM called the maintenance assistant (MA 1) first. MA 1 got the extinguisher and put the fire out. It got too smoky, so the MA 1 evacuated everyone for an hour and a half. DA 1 stated further, the cook, should have reacted right away when she noticed the fire the first time. The cook was ignoring the fire. The cook should have got the fire extinguisher and put the fire out. The cook did not use the fire extinguisher and we did not know to call a code when there is a fire. During review of a Inservice for grease fires undated indicated Steps to take in case of a grease fire. 1. Turn off the source of heat. 2. Never pour water on a grease fire. 3. Cover grease fire with lid/pot/baking pan to limit oxygen. 4. If covering does not work; pour baking soda or salt on the fire to smother it (Never pour flour/baking powder as these have chemicals that will cause a fire to burn more). 5. If salt/baking soda does not work, use the silver metal series-K fire extinguisher. 6. If extinguisher does not work, pull fire alarm to activate Ansul system. 7. Get out/Call 911/Call code RED. The Dietary Service Manager stated he completed this in-service on July 31, 2023. The in-service did not indicate the first step was to call a CODE RED and evacuate if a fire is suspected as per their policy. During an interview with the Dietary Services Manager (DSM) on August 1, 2023, at 4:48 PM, the DSM stated, It was Sunday, from what I understand it was a grease fire. The flat to the grill had flames coming from underneath it. The cook did not know the correct procedure. So, they had a maintenance guy come and grab the series K extinguisher and put it out. Staff should have grabbed the series k extinguisher and put it out themselves. They should have called a code red so they could evacuate the residents. After reviewing the policy and procedure with the DSM, the DSM stated the staff should have: Removed everyone away from the fire, set the alarm and call a code red. After that confine the fire then use the extinguisher. The policy and procedure for fire emergencies indicated the dietary staff were not trained and or in-serviced on the proper procedures regarding fire emergencies. During an interview with the Administrator on August 1, 2023, at 5:16 PM, the Administrator stated, the dietary staff should have called a code red and used the fire extinguisher themselves. During a review of the facility's Policy and Procedure (P&P) titled, Emergency Procedure, Fire dated August 2018, indicated the facility has a designed procedure for fires that shall be followed if such an emergency arises. Staff receives training at least annually on fire procedures (R.A.C.E.) and the use of fire extinguishers. Emergency Procedure - Fire. Utilize the Fire Procedure in the event of an actual fire, smoke condition, or smell of smoke in the facility. 1. Activate the R-A-C-E response as soon as there is discovery of a fire or potential fire situation within the building .Rescue: Everyone in immediate danger and move them to a safe location away from the fire. Alarm: Activate the building's fire alarm system by pulling the nearest manual pull station. Announce Code Red and the fire location over the loudspeaker. Confine: Extinguish .

Based on observation, interview and record review the facility failed to maintain comfortable temperature levels for three of three sampled residents (Resident1, Resident 2 and Resident 3.) The failure resulted in three Residents not being provided a comfortable environment that led to a feeling of frustration and discomfort. Findings: An abbreviated survey was conducted on July 27, 2023, at 12:50 PM to investigate a complaint related to physical environment. During a review of Resident 1 's clinical record, the face sheet indicated an admitted [DATE], with diagnoses which included schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior.) During an observation on July 27, 2023, at 1:15 PM, in the hallway on Unit 1, Resident 1 was perspiring. Resident 1 then stated, The last three days it's been hot. I'm sweating in here. During a review of Resident 2's clinical record, the face sheet indicated an admitted [DATE], with diagnoses which included schizoaffective disorder. During an observation on July 27, 2023, at 1:17 PM, Resident 2 was on Unit 1, walking in the hallway. Resident 2 stated, Its hot in here. I sweat when I'm inside. During a review of Resident 3's clinical record, the face sheet indicated an admitted [DATE], with diagnoses which included paranoid schizophrenia (mental illness with delusions and hallucinations), tachycardia (increased heart rate) and high blood pressure. During an observational tour of Unit 1 with the Maintenance Director (MS) on July 27, 2023, at 1:19 PM, the MS checked the temperatures with a air thermometer and the temperatures below were recorded: 1. The Hallway near room [ROOM NUMBER] indicated a temperature of 84.5 Fahrenheit (unit of measure), 2. room [ROOM NUMBER] indicated a temperature of 84.9 degrees Fahrenheit, 3. room [ROOM NUMBER] indicated a temperature of 83.9 degrees Fahrenheit, 4. room [ROOM NUMBER] indicated a temperature of 84.7 degrees Fahrenheit, 5. the Hallway near room [ROOM NUMBER] indicated a temperature of 82 degrees Fahrenheit. The maintenance director confirmed the temperatures in the resident areas was above the maximum temperature range of 81 degrees Fahrenheit. During an observation on July 27, 2023, at 1:22 PM, in Resident 3's room, Resident 3 was lying in bed, perspiring with a dampened towel placed on her forehead. Resident 3 stated, I am hot. During an interview with the MS on July 27, 2023, at 1:42 PM, MS stated, The temperatures should be between 71 and 81 degrees Fahrenheit. They should not be over 81 degrees. The MS confirmed the room temperature should have been between 71 and 81 degrees Fahrenheit. During an interview with the Administrator in training (AIT), on July 27, 2020, at 2:08 PM, AIT stated, Temperatures are to be within range, from 71 degrees Fahrenheit to 81 Fahrenheit. The temperatures are not okay. The temperatures are to be within range for the safety of the resident. The facility policy and procedure titled Air Temperatures undated indicated, All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit or at a more restrictive range required by state or local requirements .

Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate monitoring and supervision for one out of the three residents (Resident 1) with impaired impulse control, insight, and judgment. Resident 1 had a psychiatric diagnosis of severe mental and emotional disorder and managed to elope (run away secretly) from the facility without staff's knowledge. This failure resulted in Resident 1 eloping from the facility on February 6, 2023, and Resident 1 was not found. Resident 1 had a history of elopement resolved on April 26, 2019. This current elopement has the potential for Resident 1 to sustain injury, fall, exposure to heat, cold, dehydration, drowning, getting hit by car and even death. Findings: A phone interview was conducted on February 8, 2023, at 12:11 PM, with the Administrator in training, regarding a facility reported incident of an elopement. He stated, Resident 1 was outside in the yard with the staff for social event. When residents were outside, staff did not count the residents who went outside for the social event. Resident 1 was left outside, and he hid behind the old vending machines. He broke the latch of the back gate and took off. The Administrator in training stated, they immediately searched premises, nearby stores, and parks and did not find resident 1. The Administrator in training further stated, Resident 1 was last seen by the staff at 3:00 PM on February 6, 2023. On February 8, 2023, at 2:27 PM, during the tour of the facility with the Program Director (PD) there were three working door alarms noted on the unit, three locked chain linked fence gates, and approximately 14 feet high chain linked fence was noted around the building. During a concurrent interview with the PD stated, they believe Resident 1 was hiding behind the shed, he broke the laundry room gate latch and escaped to the street. The PD further stated, facility staff went to nearby stores and parks looking for Resident 1 on February 6, 2023 at 4:06 PM. They did not find Resident 1. During an interview on, February 8, 2022, at 3:10 PM, with a Mental Health Counselor (MHC), she stated, a Certified Nursing Assistant (CNA 2) made rounds and noted Resident 1 was missing on February 6, 2023 at 4:06 PM. They searched on the unit, in the yard and did not find Resident 1. During an interview on, February 8, 2022, at 3:30 PM, CNA1 stated, when they searched, Resident 1 was not on the unit. During a telephone interview on, February 23, 2022, at 9:55 AM, with CNA 2, she stated, she last saw Resident 1 during her rounds on February 6, 2023, at 3:00 PM, Resident 1 was in the dining room and at 4:06 PM, she did not see the Resident 1 on the unit. CNA 2 informed the charge nurse, and the charge nurse informed the Program director and the Administrator in training. CNA 2 went out in the car with another programmer, searched side streets and a nearby store as soon as they found out Resident 1 was missing. Nobody was able to locate Resident 1. A review of Resident 1's clinical records indicated, Resident 1 was admitted to the facility on [DATE], with the diagnoses of schizoaffective disorder unspecified (mental illness that affects moods and thoughts) and insomnia unspecified (difficulty in falling asleep). A review of Resident 1's Nursing Progress Notes, dated, February 6, 2023 at 5 PM, indicated, Approximately 4:00 PM, nursing staff noted Resident 1 was not in the unit while conducting the hourly rounds as scheduled. Staff immediately notified CN, and an immediate head count was initiated, safety check on all rooms, toilets, bathrooms, and closets was done. Staff searched the yard adjacent to back door, no one was seen in the yard or observed on the roof deck .staff drove around the neighboring streets in vehicles with no resident in sight. A review of Resident 1's History and Physical Examination , dated September 5, 2020, indicated Resident 1 has fluctuating capacity to understand and make decisions. A review of Resident 1's Brief Interview for Mental Status (BIMS, an interviewing tool used to determine resident's ability to think) completed on December 7, 2022, indicated, Resident 1's, BIMS score of 15 which means cognition is intact (a BIMS score scale 0 to 7 points is severely impaired cognition, 8 to 12 is moderately impaired, and 13 to 15 is intact cognition). A review of Resident 1's Doctor's Progress Notes, dated February 6, 2023, indicated Resident 1 with poor impulse control, insight, and judgment was partially impaired A review of Facility's document, Quality Assurance Performance Improvement (QAPI) on February 7, 2023, indicated, A resident was able to leave the facility after the fresh air break in unit 2. The staff supervising the yard during break did not notice the resident was still out in the yard when they entered the facility. The staff supervising the yard did not have and account for the residents in the yard during break . A review of facility's policy and procedure (P&P) titled, Elopement of Resident, effective date March 22, 2022, the P&P indicated, Purpose: To provide a process for managing residents at risk for elopement. Policy: A resident whose does not have capacity who leaves the facility unaccompanied .3. Unwitnessed Elopement: 3.1. Notify the supervisor that the patient is missing. 3.2 Supervisor will alert all staff of missing patient with an announcement to activate missing patient protocol . A review of facility's Policy titled, Safety and Supervision of Residents, revised date July 2017, the policy indicated, Policy Statement: Our facility strives to make the environment as free form accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy interpretation and Implementation . Systems Approach to Safety 1. The facility- oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 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 resident's assessed needs and identified hazards in the environment . A review of facility's document name Supervision Level Protocol And Guidelines. Undated, it indicated, Protocol, The interdisciplinary team will continually evaluate the need for increased supervision of residents who present with cognitive, behavioral, medical, or other conditions that put them or others at risk. The team will provide increased levels of supervision as appropriate to ensure optimal resident safety and outcome. General Supervision: For all residents who do not have another supervision level recommended by IDT, general supervision will be maintained at all times. Residents on general supervision can move around the facility at will, except in areas that are designated as nonresident areas for safety reasons. Guidelines: .4. When residents are under general supervision, they are expected to stay in the building except when following standard polices for leaving (e.g., therapeutic pass, outing, appointments, and hospital stays). A staff member entering/exiting a secured a secured resident area is responsible for detecting any resident away from attempts to leave without permission. The staff member should verbally redirect the resident away from the area and alert other staff members for assistance so they can intervene to keep the resident safe .

Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate monitoring and supervision for a resident (Resident 1) with impaired impulse control, insight, and judgment. Resident 1 has severe mental and emotional disorder and managed to elope from the facility without staff's knowledge. This failure resulted in Resident 1 eloping from the facility and was found about one fourth of a mile away from the facility in the convenient store on December 19, 2022. Findings: A phone interview was conducted on December 20, 2022, at 8:56 AM, with the Administrator in training, regarding a facility reported incident of an elopement. He stated, Resident 1 got out from his room window. Resident 1 pushed his window, jumped on the chair, got on the filling cabinet, which was outside of his window, climbed the wired fence jumped on the generator and climbed another locked gate. He also stated, Resident 1 was found at 5:30 AM, on December 19, 2022, near convenient store by morning shift staff on his way to work. He stated the night shift staff was not aware Resident 1 was missing. Administrator in training stated staff is expected to check on resident ' s whereabouts two to three times per hour. The Administrator in training further stated, Resident 1 was with the convenient store clerk, since 1:00 AM. On December 20,2022 at 2:40 PM, an unannounced visit was conducted to investigate a facility reported incident regarding an elopement of a resident (Resident 1). During the tour of the facility with Director of Nursing on December 20, 2022, at 2:50 PM, there were three functioning door alarms noted on the three exit doors. During a concurrent observation and interview on December 20, 2022, at 3:00 PM, Resident 1 was resting comfortably in the bed. He was alert, oriented and able to make his needs known. His room was near the nursing station. Resident 1 stated he pushed the window and hopped on the fence and went out walking outside. He stated, he heard voices telling him to leave so he left. During an interview with Director of Nursing (DON) on December 20, 2022, at 4:04 PM, DON stated Resident 1 had been missing since 1:00 AM, he was found by incoming programmer staff on the way to work. Programmer called the facility to find out if Resident 1 was in the facility. DON also stated, Resident 1 was not monitored during the night. The CNA and Licensed Vocational Nurse (LVN 1) did not make their rounds. A review of Resident 1's clinical records indicated, Resident 1 was admitted to the facility on [DATE], with the diagnoses of schizoaffective disorder unspecified (mental illness that affects moods and thoughts) and insomnia unspecified (difficulty in falling asleep). A review of Resident 1's Progress Notes, dated, December 20, 2022, at 9:13 AM, indicated, Resident eloped this morning allegedly for few hours and was found by a staff member near gas station down the street from the facility. Resident 1 stated, he was hearing an increase in voices last night. Resident had a small cut on right shin with no active bleeding. A review of Resident 1's Doctor's Progress Notes, dated September 12, 2022, indicated Resident 1 with impulse control, insight, and judgment partially impaired. A review of Resident 1's Brief Interview for Mental Status (BIMS, an interviewing tool used to determine resident's ability to think) completed on December 7, 2022, indicated, Resident 1's, BIMS score of 15 which means cognition is intact (a BIMS score scale 0 to 7 points is severely impaired cognition, 8 to 12 is moderately impaired, and 13 to 15 is intact cognition). A review of facility's policy and procedure (P&P) titled, Elopement of Resident, effective date March 22, 2022, the P&P indicated, Purpose: To provide a process for managing residents at risk for elopement. Policy: A resident whose does not have capacity who leaves the facility unaccompanied .3. Unwitnessed Elopement: 3.1. Notify the supervisor that the patient is missing. 3.2 Supervisor will alert all staff of missing patient with an announcement to activate missing patient protocol . A review of facility ' s Policy titled, Safety and Supervision of Residents, revised date July 2017, the policy indicated, Policy Statement: Our facility strives to make the environment as free form accident hazards as possible. Resident Safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy interpretation and Implementation . Systems Approach to Safety 1. The facility- oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 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 resident ' s assessed needs and identified hazards in the environment .

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was protected from verbal and physical abuse. On September 29, 2014, a Certified Nursing Assistant (CNA) hit Resident 1 on the back of the head with a closed fist. This failure resulted in Resident 1's rights to be free from abuse were violated. Finding: During an observation conducted on October 1, 2014 at 3:30 PM, Resident 1 was alert and verbally responsive. During a review of the clinical record for Resident 1, it was documented that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a psychiatric history of hearing voices, paranoia, mood swings, depression, manic behavior, depression and assault. During an interview with Resident 1 on October 1, 2014 at 3:30 PM, in the dining room, he was asked about the incident that occurred on September 29, 2014. He stated, "I was hearing voices and began screaming about Christ and death." Resident 1 stated he hit CNA 1 on the left side top lip and pulled her hair. Resident 1 stated someone hit him on the head. A review of the Behavior Care Plan dated June 9, 2014, indicated that Resident 1 exhibits physical aggression towards staff. Staff intervention consists of stable and routine setting; rules, consequences and social counseling. During an interview with the director of nursing (DON) on October 1, 2014 at 2:55 PM, he stated on September 29, 2014 he was coming down the hall way and saw Resident 1 in Proact restraint (The use of staff's body to restrictive the resident's movement to prevent the residents from injuring themself or others) on the floor assisted by maintenance staff (MS) and three other staff. Resident 1 was observed holding on to CNA 1's hair. The DON stated he helped remove Resident 1's hand from grasping CNA 1's hair. Resident 1 then released CNA 1's hair. CNA 1 got up and curses at Resident 1 "Oh no M... F..." then CNA 1 hit Resident 1 with a closed fist to the back of the resident's head behind the right ear. The DON stated CNA 1 should not have hit Resident 1's head. CNA 1 was immediately removed from the unit. CNA 1 was terminated and was not available for interview during the investigation. A review of CNA 1's employee file, documented that CNA 1 was hired on April 21, 2014 and was terminated on September 29, 2014. Continued review of the file showed CNA 1 was provided Abuse prevention in-service on April 21, 2014. A review of the facility policy and procedure titled, " OPS302-CA Abuse Prohibition", dated July 1, 2013, documented " (Facility name) will prohibit abuse...for all patients... Verbal abuse is any use of oral...or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability. Physical abuse includes hitting..."

Based on observation, interview, and record review, the facility failed to ensure that residents were consistently supervised and that a closet with an exposed sprinkler pipe was kept locked per facility protocol. This failure led to the death of Resident A. Because of the facility's failure to consistently supervise residents and follow facility protocol to ensure closets with exposed pipes are kept locked, Residents of the facility were at risk for injury, serious harm, or death for a universe of 47 residents. Immediate Jeopardy was called on February 22, 2013 at 6:35 PM with the Administrator. Findings: During an interview with the facility Administrator on February 22, 2013 at 3:06 PM, the Administrator stated that on February 21, 2013, Resident A was seen by the facility staff at 11:45 AM, entering the facility from the courtyard. At 12:00 PM, lunch was served in the dining room. At approximately 12:50 PM facility staff noticed that Resident A had not picked up his lunch ticket/diet card. The facility staff began to search for Resident A. At 12:50 PM, CNA 4 (Certified Nursing Assistant) and a house keeping staff member found Resident A in his room, inside the locked closet hanging from the pipe with a belt around his neck. The facility staff immediately called 911 and initiated cardio pulmonary resuscitation. According to the Administrator, Resident A was discovered with a belt around his neck hanging from a pipe that is a part of the facility fire sprinkler system. The Administrator stated that prior to the resident's admission to the facility, the resident had a history of [REDACTED]. A tour of the facility was conducted on February 22, 2013 at 3:18 PM with the AIT (Administrator In Training) to include Resident A's room and the closet where the incident took place on February 21, 2013. It was observed that the closet was a walk-in type closet with a bar for hanging clothes. There was a pipe noted near the ceiling of the closet. The facility maintenance director provided the measurement; the height of the pipe was measured 7' 6" up from the ground. All of the closets in the facility have an exposed pipe in them. The door to the closet has a lock in the doorknob that has to be unlocked by staff in order to enter. The door has to be pushed shut completely in order for the lock to engage. The door lock showed no evidence of tampering. A review of Resident A's clinical record on February 22, 2013, revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plans for "Psychosis -Disorganized Behavior" dated [DATE], documented that the resident had a history of [REDACTED]." The interventions for this care plan included "All staff to provide resident with a stable, consistent, and supervised environment in order to assist resident in the stabilization of their psychosis." During a review of the Psychological Evaluation dated February 12, 2013 indicated that the resident had a history of [REDACTED]. During a review of the "Psychiatrist Assessment Progress Note" dated February 18, 2013 indicated that the resident had no behaviors and had stated "I hear lots of voices". During an interview with the AIT on February 22, 2013 at 3:22 PM, she stated that all the staff will be in-serviced regarding locking the closets to include a demonstration of the process. She stated that the staff are expected to open the closet for the resident, stand back a few feet to give them privacy, and then close the door and ensure that the lock has engaged. The AIT stated that it has been the facility practice to do it this way. The AIT demonstrated the practice. During an interview with Resident B (Resident A's roommate) on February 22, 2013 at 3:20 PM, he stated that he did not want to be bothered with all the questions. On February 22, 2013 at 3:35 PM, a review was done of the facility document "Resident Supervision Rounds and Area Safety/Security Rounds" dated February 21, 2013. The form included a list all residents in the facility by their room numbers, and has an area for staff to document the residents' location every hour on the hour. The document showed that Resident A was seen by staff at 11:00 AM in the "Corridor." The 12:00 PM hour had an entry made that was scribbled out and illegible. During an interview with the Administrator on February 22, 2013 at 4:00 PM, she stated that the entry for 12:00 PM of February 21, 2013 was erroneously filled out. The Administrator stated that the staff (CNA 1) had "thought" she saw the resident at 12:00 PM but then realized that she had not seen the resident and scribbled the note out. The administrator also stated during her interview with CNA 1, who was assigned to Resident A, which CNA 1 admitted that she did not go and check Resident A at 12:00 PM. The Administrator stated that the facility has no policy and procedure for the "Resident Supervision Rounds and Area Safety/Security Rounds". She stated that the expected practice is that the staff member assigned the supervision rounds will find each resident and confirm their location each hour. The Administrator stated that CNA 1 who was assigned the supervision rounds for Resident A on February 21, 2013 at 12:00 PM did not do that. The Administrator stated that the facility practice was not followed and Resident A had not been visualized at 12:00 PM. The Administrator stated all closet keys held by facility staff have been accounted for, including the direct care staff and maintenance/housekeeping staff. The Administrator stated that their investigation showed that the resident's closet had not been shut completely and that is how the resident had access to the closet. The Administrator stated that she did not know which staff had last opened the closet door in Resident A's room on February 21, 2013. During an interview with the Administrator on February 22, 2013 at 4:00 PM, she stated that CNA 1, who was assigned to do rounds on February 21, 2013 at the time of the incident for all of the 47 residents including Resident A, was put on suspension. CNA 1 was not available for interview. During a telephone interview with the AIT on February 25, 2013 at 4:40 PM, she stated that the procedure for doing rounds every hour and for opening the closets for the residents is not in writing but is a practice that is demonstrated to the staff during orientation. On [DATE], a review was done of the facility resident "[DIAGNOSES REDACTED]. The report showed that all of the facilities 47 residents (current census) have a mental illness with one of the following diagnosis, Schizophrenia (a mental disorder that makes it hard to tell the difference between what is real and not real, marked by delusion or psychosis), Schizoaffective Disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems), or Bipolar Disorder (a mental condition where the person has extreme mood swings including extreme depression and mania). During an interview with the AIT on [DATE] at 11:10 AM, the AIT stated that all of the residents in the facility have been put on conservatorship or temporary conservatorship pending conservatorship, due to either being an extreme danger to themselves, others, or gravely disabled. All of the residents are placed in the facility by the Department of Behavioral Health because they are unsafe to be in the community. On [DATE] at 11:30 AM, a review of the documents "Resident Supervision Rounds and Area Safety/Security Rounds" from February 7, 2013 through February 21, 2013 was done. The review revealed 4 instances where there was no documentation of the location of the resident at a specific hour; Resident B was not visualized on February 7, 2013 at 6:00 AM, Resident C and Resident D were not visualized on February 8, 2013 at 7:00 AM, and Resident E was not visualized on February 12, 2013 at 5:00 PM. An interview was conducted with the AIT on [DATE] at 11:55 AM, regarding this issue. The AIT stated that she had no explanation as to why these times were left blank for these residents. She stated that since the incident they are auditing the rounds daily to ensure that they are being done properly and that all residents are accounted for at all times. On [DATE] at 11:40 AM, CNA 2 was interviewed. The CNA stated that the procedure for rounds is for the staff to go room to room to look for each resident and checks that all the closets are locked. If the resident is not in their room she has to go look for them face to face. The CNA further stated that she never waits for the residents to come to her; she has to go look for them. She stated that the reason the rounds are done is to ensure that the residents are safe and accounted for. On further interview the CNA stated that when the staff opens the closets for the residents they are to stand there with them the entire time and make sure they do not take anything that is not theirs. The staff then closes the door and checks it to make sure it is locked. CNA 2 stated that the closets need to be kept locked for safety and to ensure that the residents' items are secure and are not taken by other residents. She stated that she learned both procedures upon being oriented to the facility. On [DATE] at 12:12 PM, CNA 3 was interviewed. The CNA confirmed the process for doing the rounds is to go room to room to look for the residents and check that all of the closets are locked. The CNA stated that if the residents are not in their rooms then she goes to go look for the resident. CNA 3 stated that the reason that the facility does rounds is to ensure that everyone is safe and that they are able to find everyone. The CNA stated that when the staff opens closets for residents that they are to stand with the resident while they get their belongings and then close the door and make sure that it is locked. The CNA further stated that they keep the closets closed and locked for safety and to "keep things from disappearing". She stated that they are trained on these practices when they are oriented and have received in-services on these practices. On [DATE] CNA 4 was interviewed at 12:45 PM. The CNA stated that on the day of the incident, she was monitoring the hallway. The lunch started a few minutes late, at about 12:13. At 12:40 PM she asked what residents still needed to get lunch. She was given names and went to go prompt the residents to come for lunch. She prompted the other residents but was unable to find Resident A, so she went to the dining room to see if the resident was there. She checked with the staff in the dining room and the staff informed her they had not seen him (including the staff that had done the 12:00 rounds). She went to check the bathroom and the visiting room and when she was unable to find him everyone began a search. CNA 4 stated that she and the housekeeper went to the resident's room to check his closet and found the resident hanging from the pipe with a brown leather belt. She stated that she called a code blue and she and the housekeeper held the resident up to try to loosen the belt. She stated that the LVN came in then and they were able to get him down and started CPR. She stated that there were black shoe marks up the wall from the resident's shoes. The CNA further stated that they do rounds every hour and must go to look for the residents. She stated that they are trained on this practice when they get oriented and have in-services during the year. During an interview with the DON on [DATE] at 1:00 PM, the DON stated that the focus of the rounds is safety. He further stated that the expectation is for the staff to search for the resident the first minute that the resident is unaccounted for. Because of the facility's failure to have a system in place to ensure residents' were consistently supervised and the facility's failure to ensure that closets doors were kept locked per facility protocol, Immediate Jeopardy was called on February 22, 2013 at 6:35 PM with the Administrator. On February 22, 2013 at 9:00 PM, the Administrator presented a plan of corrective action to the survey team. The plan of correction consisted of the following elements: 1). All keys visually checked and accounted for, for all facility personnel on all shifts. 2). Administrator developed and governing body approved "supervision level protocol and guidelines" policy and procedures which includes visual checks of all residents every hour. 3). In-servicing of all facility personnel regarding the locking of closet doors and completing hourly "Resident Supervision Rounds and Area Safety/Security Rounds". 4). In-servicing of all facility personnel on the policy and procedure for "supervision level protocol and guidelines". 5). All facility personnel to be in-serviced by the Administrator or the AIT on the above prior to working in the facility with the residents by February 26, 2013. The Plan of Correction was accepted on February 22, 2013 at 9:15 PM. On February 22, 2013 at 9:15 PM, the survey team met with the facility Administrator and the facility AIT (Administrator in Training) and informed them that the team abated the Immediate Jeopardy.

Based on observation, interviews and record review, the facility failed to maintain an environment free of accident hazards. These failures placed 45 residents, in an universe of 45, at risk for accidental and possible injuries. 1. The facility failed to ensure hot water temperatures were maintained at safe levels, between 105 degrees Fahrenheit to 120 degree Fahrenheit, to prevent possible skin burns and tissue injury to the residents. Hot water temperatures on 2/14/11 were found to range between 131.2 degrees Fahrenheit to 171.4 degrees Fahrenheit in the residents bathroom, and water temperatures in the five resident shower rooms ranged from 119.5 degrees Fahrenheit to 164.4 degrees Fahrenheit. On 2/14/11 at 11:40 AM, the facility's administrator, assistant administrator, and director of nurses (DON) were notified of the immediate jeopardy situation (IJ -a situation that is likely to cause serious harm, injury, impairment, or death if not corrected immediately) based on the excessive hot water temperatures in the residents bathrooms and showers, which had the potential to result in serious burns and tissue injuries to the residents. The IJ was abated (lifted) on 2/14/11 at 2:13 PM, in the presence of the administrator, based on acceptable actions and plans made by the facility in an effort to correct the IJ situation and ensure the residents hot water temperatures were monitored and remained within safe temperature ranges. 2. The facility failed to ensure the outside yards used by residents were maintained and free of accident hazards. This failure resulted in residents being exposed to hanging wires and cables on the outside the building in areas used for activities. In addition, a bench used for seating was noted with exposed sharp nails. Tripping hazards, which included the ground around the residents benches, were noted with large protruding tree roots and muddy areas where the residents walked, old concrete footings left in the ground in areas used by the residents, and a concrete walkway with an open uncovered area in the middle of the walkway measuring approximately 12 inches long by 10 inches wide and 2 inches deep. Additionally, interior hazards that included exposed chemicals, open to air in the locked janitor's closet by room 20 were observed. A fire sprinkler dripping water onto the main hallway used by the residents by a linen closet was also noted. The facility's failure to ensure residents were provided with a safe environment by maintaining hot water temperatures within safe temperature ranges to prevent injuries and burns, had the potential to cause or were likely to cause residents serious injury, harm, impairment or death and had a reasonable degree of predictability of similar situation reoccurring in the future if immediate corrective actions were not taken. The facility's failure to ensure a safe environment by maintaining the residents activity area and removing potentially hazardous items used by the residents, had the potential to increase the risk of injuries to the residents and compromised the residents ability to maintain and/or reach their highest practicable physical, mental, and psychosocial well-being. Findings: 1. On 2/14/11 at 8:45 AM, during an initial tour, the water temperatures in the residents bathrooms were observed to be very hot to the touch. Water temperatures taken on 2/14/11 at 9:30 AM, in resident bathrooms and showers, and verified by the facility's program director and maintenance supervisor were: a. The bathroom sink hot water in the restroom shared by resident rooms 27 and 29, was 131.2 degrees Fahrenheit. b. The bathroom sink hot water in the restroom shared by resident rooms 4 and 6, was 171.4 degrees Fahrenheit. c. The hot water temperatures for 4 of the 5 residents shower rooms were above 120 degrees Fahrenheit on 2/14/11. The resident shower rooms hot water temperatures, starting from the front of the facility to the back of the facility, were as follows: Shower room (1) 119.6 degrees Fahrenheit, shower room (2) 144.5 degrees Fahrenheit, shower room (3) 164.4 degrees Fahrenheit, shower room (4) 134 degrees Fahrenheit, and shower room (5) 157.8 degrees Fahrenheit. On 2/14/11 at 9:35 AM, while obtaining the hot water temperature in the residents bathroom, the program director stated, "The water temperature should not be hotter than 110 degrees (Fahrenheit). The hot water is too hot in all these bathrooms it needs to be turned down." On 2/14/11 at 9:40, Resident 2 who used the bathroom between resident rooms 4 and 6 stated, "The water in the bathroom is really hot. I tried to turn down the hot water valve under the sink, but it didn't seem to make any difference. You have to be really careful. It is very hot, you can see the steam coming off it. I try not to use the hot water because it is too hot." On 2/14/11 at 10:20 AM, the administrator stated, "I have told our maintenance staff to turn down all the water heaters and to keep the residents away from the hot water. We must have a faulty thermostat." A review of the federal regulations for the safe water temperatures stipulated: "Water temperature may reach hazardous temperatures in hand sinks, showers and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding which include decreased cognitive ability and decreased ability to communicate." Review of the facility's policy for "Water Temperatures-Residents Areas," revealed the facility's hot water temperature goals were to maintain the hot water between 105 to 120 degrees Fahrenheit. "The policy's steps in the water testing included: (1) Ensure patient room water temperatures are 110 degrees Fahrenheit (or as specified by state requirements). (3) Test temperature in shower areas . (4) Check resident rooms at the end of each wing on a rotating basis. (5) Let the water run at 3 minutes before taking your reading." After testing the water temperatures the next steps included: (1) Note any discrepancies. (2) Adjust water heater setting as required. (3) Retest as necessary. Review of the logs of the "Water Temperatures-Resident Areas" for the period between October 2010 to the end of January 2011, revealed temperatures during that period had been recorded as being between 104 degrees Fahrenheit to 111 degrees Fahrenheit in the residents bathrooms and showers. The water temperatures taken in resident rooms and showers on 1/28/11 and 2/9/11, were above safe temperature ranges of 120 degrees Fahrenheit to 137 degrees Fahrenheit. Review of the "Maintenance Services" policy indicated the following: 1. The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance but are not limited to: a. Maintaining the building in compliance with all federal, state and local laws, regulations and guidelines. b. Maintain the building in good repair and free from hazards. d. Maintaining the heating/cooling system, plumbing fixtures, wiring, etc., in good working order. f. Establishing priorities in providing repair service. i. Preventive maintenance schedules are followed to assure that the building and equipment are maintained in a safe and operable manner. j. A safe and healthy work environment will be provided for all employees, residents and visitors. On 2/14/11 at 11:35 AM, the maintenance supervisor stated, "This facility's maintenance supervisor left in first part of January (2011), I have been working between here and our sister facility. The water has been running hot. When I test the water temperature, if the water temperature is above 120 degrees Fahrenheit, I adjust the water heater temperature down. I go back and test the water temperature later, but I don't have any place that I write down what the temperature is when it had been re-tested or at what time the water temperature had been re-tested ." On 2/14/11 at 11:35 AM, the maintenance supervisor further acknowledged it is his responsibility to ensure the water heaters are maintained and water temperatures are kept at safe temperature levels. On 2/14/11 at 11:40 AM, the Department of Public Health notified the administrator, assistant administrator and director of nurses of an immediate jeopardy (IJ) situation secondary to the high hot water temperatures in the residents bathrooms and shower, with the potential to cause serious tissue injury. On 2/14/11 at 11:45 AM, the facility stated its actions being taken to remove the IJ would be to have the maintenance department drain the water from the water heaters, monitor the water temperatures and prevent the residents from using the restrooms until the water temperatures were in the 105 degrees Fahrenheit to 120 degrees Fahrenheit range. The plan also included weekly monitoring of the water temperatures, and in-services to the maintenance staff and housekeeping staff regarding water temperatures. The maintenance and housekeeping personal were given thermometers to complete random hot water temperature readings for the residential portion of the facility. On 2/14/11 at 2:13 PM, the IJ was abated (lifted) with plan of correction which included: (1.) Lowering the hot water heater temperatures for all resident areas. (2.) The draining of the hot water heater and hot pipes until water temperatures reached the appropriate water temperature of 105 degrees Fahrenheit to 120 degrees Fahrenheit. (3.) Prevent residents from using restrooms and showers until water temperatures were safe. (4.) In-servicing the maintenance staff and housekeeping staff to test water temperatures and be knowledgeable on safe water temperature ranges. (5.) Weekly water temperature monitoring and interventions when needed if water temperature were out of a safe range. 2. On 2/15/11 at 2:30 PM, during the environmental tour with the maintenance supervisor and maintenance assistant, the following accident hazardous conditions were observed in the outside areas used by all the residents, in a universe of 45 residents. a. The bench built around a tree used as the main sitting area for the residents when on an outside break, had sharp ends of large nails exposed at all 4 corners. b. The ground area around the benches had raised tree roots and muddy slippery areas in the pathway and sitting areas of the benches. c. The facility had loose wires and cables hanging from the roof and across the stucco walls of the buildings near doorway areas and where the residents walked and sit when outside. d. There were four exposed old concrete footings approximately 12 inches in diameter protruding from the ground where residents walk. e. One of the concrete walkways had an open uncovered area in the middle of the walkway measuring approximately 12 inches long by 10 inches wide and 2 inches deep; the area included a release valve for the facility's plumbing. f. There were unsecured chemicals open to air, in a locked janitor's closet by room 20. g. There was a fire sprinkler dripping water onto the hallway floor by the linen closet. On 2/15/11 at 2:45 PM, the maintenance supervisor stated, "These things do need to be fixed, the residents could get hurt on them. Those nails are unsafe (referring to the nails on the residents bench). It looks like we need to replace that bench. We also need to find out what those cables and wires go to and see about tacking them up and out of the way. We can probably take those concrete footings out. It doesn't look like they have been used for a long time. I'm not sure how we will fix the walkway but maybe we can cover it with something. The container with the chemicals in the janitor's closet should be store with the lid on it. I am not sure why the sprinkle is dripping. It could be a safety hazard with a water puddle in the middle of the hallway. It needs to fixed."