Every finding on record at Brooksville Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) while providing care for residents on enhanced barrier precautions for 1 of 4 residents who were on enhanced barrier precautions (Resident #69) and for 3 residents who were on contact precautions (Resident #71, #154 and #148) and failed to ensure staff performed hand hygiene when required during medication administration to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 5/19/2026 at 7:02 AM, there was an enhanced barrier precautions signage on Resident #69's doorway. No personal protective equipment was available on or near the door, inside Resident #69's room or bathroom. There were no gowns available in the hallway. Staff T, Certified Nursing Assistant (CNA), was at Resident #69's bedside, providing incontinence care and changing the resident's brief and clothing. Staff T was not wearing a gown. During an interview on 5/19/2026 at 7:10 AM, Staff T, CNA, stated, She [Resident #69] is on enhanced barrier precautions for wounds. I should have put on a gown to change her. During an observation on 5/19/2026 at 7:22 AM, Staff K, Licensed Practical Nurse (LPN), entered Resident #69's room and assisted the resident with repositioning in bed. Staff K did not wear gloves or a gown. Staff K left the resident room. During an observation on 5/19/2026 at 7:25 AM, Staff K, LPN, returned to Resident #69's room, donned gloves without performing hand hygiene and assisted the resident with repositioning. Two paramedics entered the room and asked why the resident was on isolation. Staff K did not request the paramedics wear a gown on. Staff K assisted the paramedics to move the resident from the bed to the stretcher. Staff K was touching the resident's arms, assisting resident to hold up arms while the paramedics were repositioning the resident on the stretcher. During an interview on 5/19/2026 at 7:32 AM, Staff K, LPN, stated, She [Resident #69] is on enhanced barrier precautions because she has open wounds on her legs. There are no gowns in the room or outside the room. There are some in the supply room on unit 2. I did not put on a gown when I helped her. I should have. Review of Resident #69's physician order dated 5/13/2026 read, Enhanced Barrier Precautions: (Wound). During an interview on 5/21/2026 at 9:50 AM, the Director of Nursing (DON) stated, We should be storing the gowns in the residents' closet when they are on enhanced barrier precautions. All staff should follow the orders for any type of isolation. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last approval date of 1/21/2026 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Implementation o Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. 4. High-contact resident care activities include: a. Dressing; c, Transferring; d. Providing Hygiene; f. Changing briefs or assisting with toileting. 10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 2) Review of Resident #71's admission record showed the resident was diagnosed with chronic osteomyelitis left ankle and foot, type 2 diabetes mellitus, and MRSA (Methicillin-resistant Staphylococcus aureus) in toe wound. During an observation on 5/18/2026 at 11:38 AM, there was a contact isolation signage and personal protective equipment of gowns and gloves was on Resident #71's door. Staff E, Maintenance Staff, was in Resident #71's room. Staff E did not have personal protective equipment of gown and gloves. During an interview on 5/18/2026 at 11:40 AM, Staff A, LPN, stated, We are supposed to wear PPE when entering a contact isolation room. Review of the facility policy and procedure titled Transmission Based (Isolation) Precautions with the last review date of 1/21/2026 read, Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the CDC [Centers for Disease Control and Prevention], for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. (A table that depicts the types of PPE to use is attached to this policy.) 9. Contact Precautions: c. Healthcare personnel caring for residents on Contact Precaution's wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE [Vancomycin-resistant Enterococci], C difficile, noroviruses and other intestinal tract pathogens, RSV [Respiratory Syncytial Virus]). 3) During an observation on 5/18/26 at 10:36 AM, there were enhanced barrier and contact isolation signages on the Resident #148's room door. Staff D, Housekeeper, was cleaning the room with gloves on. Staff D had no other PPE. During an interview on 5/18/26 at 10:36 AM, Staff D, Housekeeper, stated, I am a new employee. I wear gloves, but do not gown up. I do not understand the signs on the door. During an interview on 5/18/2026 at 10:46 AM, the Assistant Director of Nursing (DON) stated, The resident is on contact isolation for c-diff. The ADON took the enhanced barrier precautions signage off the door and left contact isolation signage on the outside of the door. 4) During an observation on 5/19/2026 at 9:37 AM, there was an enhanced barrier precautions signage on Resident #155's room door. Staff C, LPN, was assisting the resident into the bathroom. Staff C had gloves on. Staff C did not have any other PPE. During an interview on 5/19/2026 at 9:38 AM, Staff C, LPN, stated that she should have put a gown on. 5) During an observation on 5/20/2026 at 1:35 PM, Staff F, CNA, obtained a blanket from the linen closet and walked into Resident #154's room. There was a contact precautions signage posted on the wall next to the door, and a rack containing gowns and gloves hanging on the door. Staff F did not don gloves or a gown and entered the room. During an interview on 5/20/2026 at 1:35 PM, Staff F, CNA, confirmed that she did not wear a gown or gloves when she went into Resident #154's room and she should have because the resident was on contact isolation. Review of Resident #154's physician order dated 5/19/2026 read, Contact Precautions d/t [due to] Conjunctivitis every shift until 05/25/2026 23:59 [11:59 PM]. 6) During an observation on 5/20/2026 at 8:24 AM, Staff H, LPN, was preparing medications for Resident #111. While pouring Clonazepam and Co Enzyme Q10, the medications fell unto the top of the medication cart. Staff H picked up the medication and poured them into the clear medication cup. Staff H did not perform hand hygiene or wear gloves. Staff H poured Furosemide, Albuterol, Eliquis and Clonidine from the medication blister packs into his ungloved hand and then poured them into the medication cup. Staff H proceeded to enter Resident #111's room and administer the medication. During an interview on 5/20/2026 at 8:34 AM, Staff H, LPN, stated, I know we are not supposed to touch medication with our hands. I prefer to wear gloves, but we are not allowed to in the hallway and when we are popping the medication from the blister pack, they go flying everywhere. I should have disposed of the medication that fell onto the medication cart. During an interview on 5/20/2026 at 10:49 AM, the DON stated, Staff should not be touching medication with their hands other than dropping it off into the medication cup directly. If medication falls outside of mediation cup, the staff should dispose of the medication. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 1/21/2026 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper hand hygiene technique consistent with accepted standards of practice. Hand Hygiene Table: Before preparing or handling medications. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/21/2026 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guideline: 14. Remove medication from source, taking care not to touch medication with bare hand. 17. Wash hands using facility protocol and product. 7) During an observation on 5/19/2026 at 8:52 AM, Resident #152's door was closed. There was an enhance barrier precautions signage posted on the side of the room door. There was no PPE outside the room. Staff L, CNA, was in the room and came around the privacy curtain and stated, patient care. Staff L was wearing gloves, but no gown. At 8:56 AM, Staff L exited Resident #152's room with a clear bag in her hand, which contained gloves and a brief. During an interview on 5/19/2026 at 1:12 PM, Staff L, CNA, stated, I changed [Resident 152's name] brief. I just wear gloves. I did not know he [Resident #152] was under enhanced barrier precautions. I should have worn a gown. Review of Resident #152's physician orders showed an order dated 4/14/2026 for changing the dressing to dialysis access port/line. During an interview on 5/20/2026 at 10:51 AM, the Director of Nursing stated, If the resident is under enhanced barrier precautions, I expect staff to wear gloves and gown when providing direct care to the resident.

Based on observation, interview, and record review, the facility failed to notify the physician of a change in condition for hypoglycemia that required treatment for 1 of 4 residents reviewed for insulin administration (Resident #122) and for skin condition for 3 of 3 residents reviewed for skin conditions (Resident #35, #80 and #87). Findings include: 1) Review of Resident #122's admission record showed the diagnoses that include nondisplaced spiral fracture of shaft of left tibia subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with diabetic neuropathy unspecified, hypertensive heart and chronic kidney disease without heart failure. Review of Resident #122's physician order dated 2/23/2026 read, Insulin Regular Human Injection Solution 100 unit/ml [milliliter] (Insulin Regular (Human)), Inject as per sliding scale: if 151-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400= 12 units. If BS [Blood Sugar] greater than 350 give 10 units and notify provider, subcutaneously before meals and at bedtime for DM [diabetes mellitus]. Review of Resident #122's Medication Administration Record (MAR) for May 2026 showed a blood glucose of 47 documented on 5/2/2026 at 9:00 PM and a blood glucose of 47 documented on 5/15/2026 at 9:00 PM. Review of Resident #122's nursing progress notes showed no notification to Resident #122's physician or nurse practitioner on 5/2/2026 and 5/15/2026. Review of Resident #122's MAR for April 2026 showed a blood glucose of 51 documented on 4/3/2026 at 9:00 PM and a blood glucose of 58 on 4/16/2026 at 9:00 PM. Review of Resident #122's nursing progress notes showed no notification to Resident #122's physician or nurse practitioner on 4/3/2026 and 4/16/2026. During an interview on 5/19/2026 at 3:55 PM, Staff S, Licensed Practical Nurse (LPN), stated, I did not notify the doctor or nurse practitioner of the blood sugar. We should notify them. During an interview on 5/21/2026 at 10:10 AM, the Director of Nursing (DON) stated, All staff should notify the doctor or nurse practitioner when there is a change of condition. A low blood sugar that requires treatment is a change that should be called. 2) During an interview on 5/18/2026 at 12:10 PM, Resident #35 stated, This bandage on my right arm is from me hitting it in the bathroom when I go in there. During an observation on 5/18/2026 at 12:12 PM, Resident #35 had a bandage on his left forearm that is dated 5/8/2026. During an interview on 5/19/2026 at 2:35 PM, Staff B, Registered Nurse (RN), stated, I cannot find any documentation relating to the resident's skin tear on the resident's left wrist/forearm. During an interview on 5/19/2026 at 2:54 PM, the Assistant Director of Nursing (ADON) stated, It is my expectation that when a resident gets a skin tear that the nurse assesses the skin care, documents the injury, contacts the physician and receives orders as needed and contacts the family. Review of the facility policy and procedure titled Skin Integrity- Skin Tears with the last review date of 1/21/2026 read, Policy: It is the policy of this facility to provide proper treatment and care to maintain skin integrity. This policy pertains to the prevention and management of skin tears. Policy Explanation and Compliance Guidelines: 2. Assessment a. Licensed nurses will conduct skin assessments in accordance with facility policy. c. When a skin tear is discovered, the nurse shall complete an incident report. The following information shall be recorded: i. The Resident's name ii. The name of the employee discovering the skin tear, iii. The site and description of the skin tear, iv. The date and time the skin tear was discovered, v. The date and time the injury occurred, if known, vi. The name(s) of the employee(s) who provided care for the resident for the previous 24 hrs, vii. Site care rendered and evaluation of the incident, viii. The name(s) of any witness(es) to the incident, ix. the date and time the physician and resident representative were notified. 5. Modification of Interventions a. The attending physician will be notified of the presence, progression toward healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. 3) During an observation on 5/18/2026 at 10:15 AM, Resident #80's left forearm had a tan bandage with no date. During an observation on 5/19/2026 at 12:44 PM, Resident #80's left forearm had a tan bandage with no date. Review of Resident #80's physician orders showed no physician order for left hand bandage. During an interview on 5/19/26 at 1:10 PM, Staff C, LPN, regarding the bandage on Resident #80's forearm, stated, I do not know anything about it. I need to see if there is an order for it. During an interview on 5/19/2026 at 1:15 PM, Staff Q, Wound Care Nurse, stated, I think [Resident #80's name] has a skin tear to her forearm. 4) During an observation on 5/18/2026 at 9:52 AM, Resident #87 was sitting in her wheelchair. There was a dressing on her left lower leg that was dated 5/16. During an interview on 5/18/2026 at 9:52 AM, Resident #87 stated that she had not bumped her leg and did not know what had happened. Review of Resident #87's progress notes from 5/1/2026 through 5/18/2026 showed no progress notes documenting the presence of a wound, notification to a provider or the resident representative. During an interview on 5/19/2026 at 11:55 AM, Staff H, LPN, stated, I removed the bandage from [Resident #87's name] leg. There is no order or anything on her MAR or TAR [Medication Administration Record, Treatment Administration Record]. During an interview on 5/20/2026 at 4:20 PM, the DON stated that the expectation was that if a resident had a wound, the nurse should notify the provider and the family and document the notification and any treatment or treatment orders. Review of the facility policy and procedure titled Notification of Changes with the last approval date of 1/21/2026 read, Policy: The purpose of this policy is to ensure that the facility promptly informs the resident, consults the resident's physician; and notifies consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on record review and interview, the facility failed to coordinate Preadmission Screening and Resident Review (PASRR) for the residents with newly evident or possible serious mental disorder for 2 of 6 residents reviewed for behavioral health (Residents #6 and #152).Findings include:1) Review of Resident #6's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder (onset date of 3/4/2026), brief psychotic disorder (onset date of 1/22/2026), other specified persistent mood disorders (onset date of 1/22/2026), adjustment disorder with depressed mood (onset date of 1/22/2026), and bipolar disorder (onset date of 8/4/2025).Review of Resident #6's PASRR dated 8/1/2025 showed bipolar disorder documented as the only mental illness (MI) or suspected MI under Section I. PASRR Screen Decision-Making.Review of Resident # 6's psychiatry evaluation note dated 8/7/2025 read, Visit Type: Psychiatry: New Evaluation. Chief Complaint: Mood disorder and psychosis. History of Present Illness: This is a [AGE] year old patient with past psychiatric history of depression, anxiety, mood disorder and psychosis. Patient was evaluated for underlying psychiatric conditions and treatment. Facility requested consult. Diagnostic Assessment and Plan: Brief psychotic disorder. Other specified persistent mood disorders.2) Review of Resident #152's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder (onset date of 10/30/2025) and other specified persistent mood disorders (onset date of 10/30/2025).Review of Resident #152's PASRR dated 4/22/2025 showed depressive disorder documented as the only MI or suspected MI under Section I. PASRR Screen Decision-Making.Review of Resident #152's psychiatric subsequent note dated 5/8/2025 read, Chief Complaint: Depression, insomnia, and mood disorder. Rationale behind diagnosis: MDD [Major Depressive Disorder], Recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use or organic brain pathology. Mood Disorder: The history suggest that the patient has experienced severe mood swings causing emotional distress. As the mood swings are severe requiring monitoring and as needed intervention, the patient qualifies for that diagnosis.During an interview on 5/20/2026 at 1:16 PM, the Social Services Director stated, I was not aware that [Resident #6's name] and [Resident #152's name] PASSR needed to be reviewed. For [Resident #6's name], I thought all the diagnosis fell under bipolar disorder. I did not think I needed to do another review. Psych comes in and have the ability to put new diagnosis. I do not see them. The communication portion would be between the Director of Nursing and the Assistant Director of Nursing. I am not part of their clinical meeting with psych. If they tell me about a significant new diagnosis or if the resident is having behaviors. Usually that is what they will notify me off, but if it's a diagnosis of like depression, it would not be something that they would necessarily tell me.During an interview on 5/21/2026 at 8:27 AM, the Director of Nursing stated, I would not be able to answer [when asked how new diagnosis found after resident is admitted would get updated in the PASSR]. You would have to speak to social services. There is psych in the building, and we have a list of patients that they see, and diagnoses are part of the list. I have only been here for 6 months and that has not been something I have been instructed to do. I have meetings with psych but social services does not sit with us in those meeting. You would need to ask social services if psych communicates with her regarding the new diagnosis.Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR program with the last review date of 1/21/2026 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for antibiotic use (Resident #24) and 2 of 4 residents reviewed for nutrition (Residents #55 and #67).Findings include: 1) Review of Resident #24's admission record showed the resident was most recently admitted on [DATE] with the diagnoses to include chronic respiratory failure with hypercapnia, unspecified dementia, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified protein-calorie malnutrition, heart failure, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, pulmonary hypertension, obstructive sleep apnea (adult) (pediatric), major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease without esophagitis, neuromuscular dysfunction of bladder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #24's physician order dated 9/21/2025 read, Macrobid Oral Capsule 100 MG [milligram] (Nitrofurantoin Monohyd Macro), Give 1 capsule by mouth every 12 hours for UTI for 7 Days and Give 1 capsule by mouth one time a day for prophylactic UTI indefinably. Order Status: Active. Review of Resident #24's care plan showed no focus for antibiotic use. During an interview on 5/21/2026 at 10:00 AM, the Director of Nursing (DON) stated, She [Resident #24] did not have any care plan developed for her antibiotic use. It should have been done. She has been on the antibiotic since September of 2025. 2) Review of Resident #55's physician order dated 3/9/2026 read, Regular diet Easy to Chew MM5 [Level 5 Minced and Moist] Meat texture, Regular consistency, fortified foods. Review of Resident #55's weights and vitals summary showed the resident weighed 175.4 lbs (pounds) on 12/5/2025, and 160.6 lbs on 4/27/2026, which is a -8.44% weight loss. Review of Resident #55's dietary progress note dated 1/15/2026 read, Summary: LDN [Licensed Dietitian Nutritionist] reviewed rt [resident] chart and discussed w/IDT [with intradisciplinary team] during wt [weight] loss meeting. Rt is on a mm5 meat texture and lvl [level] 2 mildly thick consistency of liquids. Medpass started 1/1. No new wt has been taken since last intervention. Plan: Recommend weekly weights. Review of Resident #55's care plan did not show a nutritional focus. 3) Review of Resident #67's physician order dated 3/27/2026 read, Pureed IDDSI4 [level 4 purred food] texture, Level 3 Moderately Thick consistency, assist with all meats, aspiration precautions, fortified foods with all meals, Double Portions with all meals. Review of Resident #67's weights and vitals summary showed the resident weighed 198.2 lbs 10/28/2025, and 169.4 lbs on 4/27/2026, which is a -14.53% weight loss. Review of Resident #67's physician order dated 4/23/2026 read, Weekly weight x4 [4 times] every day shift every Sun [Sunday] Restorative will get weight. Review of Resident #67's dietary progress note dated 4/2/2026 read, Summary: LDN reviewed rt chart and discussed w/ DON during wt loss meeting. Rt is at risk for unintentional wt loss d/t [due to] dx [diagnosis] of COPD [Chronic Obstructive Pulmonary Disease], Dysphagia, hypertensive heart disease w/ heart failure, CHF [Congestive Heart Failure], and dementia. Rt has been supplemented with medpass TID [three times a day] and Ensure TID along with double portions and fortified foods to encourage weight stabilization. Weights have been increasing until recently until 10 d [days] ago before rt was sent to hospital for SOB [Shortness Of Breath]. Rt may benefit from weekly weights to monitor wt status and intakes. Plan: Recommend weekly weights x 4 wks. Review of Resident #66's care plan did not show a nutritional focus. During an interview on 5/20/2026 at 2:10 PM, the Minimum Data Set Coordinator stated, Certain departments will do the care plan for their areas. The Registered Dietitian and CDM [Certified Dietary Manager] do the nutrition focus. A nutritional focus will need to be added for [Resident #55's name and Resident #67's name]. They do not have one. Review of the facility policy and procedure titled Comprehensive Care Plans with the last approval date of 1/21/2026 read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are defined in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS [Minimum Data Set] assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical. mental and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received services to prevent decrease in range of motion for 1 of 3 residents reviewed for rehabilitation services (Resident #64). Findings include: During an observation on 5/18/2026 at 9:17 AM, Resident #64 was lying in bed. The resident had contractures on both hands.During an interview on 5/18/2026 at 9:17 AM, Resident #64 stated, I am not receiving therapy and I have no splints.Review of Resident #64's physician order dated 11/30/2024 read, PT/OT/ST [Physical Therapy/Occupational Therapy/Speech Therapy] Eval and Treat as indicated.Review of Resident #64's Occupational Therapy Discharge Summary for the service period from 12/3/2024 through 3/7/2025 read, Discharge Recommendations. Range of Motion Program Established/Trained: Restorative Nursing trained and instructed to carry out ROM [Range of Motion] techniques appropriate w [with]/ prior progress in skilled therapy services.Review of Resident #64's medical record showed no occupational therapy evaluation since March 2025.Review of Resident #64's physical therapy encounter note dated 2/25/2025 read, Once in wc [wheelchair], pt [patient] did demonstrate ability to initiate some wc propulsion with BUE [bilateral upper extremities], R [right] > [less than] LUE [left upper extremity] due to hand function.Review of Resident #64's physical therapy encounter note dated 1/30/2026 read, Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: venous insufficiency, decreased circulatory function and contracture.Review of Resident #64's care plan initiated on 3/8/2025 read, Resident had a cerebral vascular accident. goal: the resident will be free form s/sx [signs/symptoms] of complications of CVA [Cerebrovascular Accident], DVT [deep vein thrombosis] , Contractures, aspiration, pneumonia, dehydration) monitor/document mobility status: if resident is presenting with problems or paralysis, obtain order for physical therapy and occupational therapy to evaluate and treat.During an interview on 5/20/2026 at 1:16 PM, Staff M, Physical Therapist, stated, I will try to fill in for OT as much as I can. He [Resident #64] does have active range of motion. He is able to pick up a napkin and clean his nose. He has lost range of motion in his left elbow. As PT, I would want to see what else could be done for him before turning to splints. If patients have a fall or come back from the hospital, we will assess the patients. I would not be able to tell you why he has not been evaluated for OT since last year. [Resident #64 's name] should have had at least an OT evaluation. I do not think screenings are sufficient. I think his progress is based on his medical history and OT not seeing him.During an interview on 5/20/2026 at 1:59 PM, the Director of Rehabilitation Services stated, At a minimal, we want patients to be assessed every 6 months. I would have loved for him to have had another OT evaluation in there, but his last one was done last year in January [2025].Review of the facility policy and procedure titled Prevention of Decline in Range of Motion with the last review date of 1/21/2026 read, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care.

Based on record review and interview, the facility failed to monitor weights for residents who were at nutritional risk for 2 of 4 residents reviewed for weight loss (Residents #55 and #67).Findings include: 1) Review of Resident #55's weights and vitals summary showed the resident weighed 175.4 lbs (pounds) on 12/5/2025, and 160.6 lbs on 4/27/2026, which is a -8.44% weight loss.Review of Resident #55's dietary progress note dated 1/15/2026 read, Summary: LDN [Licensed Dietitian Nutritionist] reviewed rt [resident] chart and discussed w/IDT [with intradisciplinary team] during wt [weight] loss meeting. Rt is on a mm5 meat texture and lvl [level] 2 mildly thick consistency of liquids. Medpass started 1/1. No new wt has been taken since last intervention. Plan: Recommend weekly weights.Review of the nutritional recommendation form dated 1/15/2026 read, [Resident #55's name] 1. Weekly weights x [times] 4wks [weeks].Review of Resident #55's weight records showed the resident weighed 171 pounds on 1/10/2026 and 175.4 pounds on 2/2/2026. There was no weekly weight documented since January 2026.2) Review of Resident #67's weights and vitals summary showed the resident weighed 198.2 lbs 10/28/2025, and 169.4 lbs on 4/27/2026, which is a -14.53% weight loss.Review of Resident #67's dietary progress note dated 1/15/2026 read, Plan: Recommend Weekly weights.Review of Resident #67's dietary progress note dated 4/2/2026 read, Summary: LDN reviewed rt chart and discussed w/ DON during wt loss meeting. Rt is at risk for unintentional wt loss d/t [due to] dx [diagnosis] of COPD [Chronic Obstructive Pulmonary Disease], Dysphagia, hypertensive heart disease w/ heart failure, CHF [Congestive Heart Failure], and dementia. Rt has been supplemented with medpass TID [three times a day] and Ensure TID along with double portions and fortified foods to encourage weight stabilization. Weights have been increasing until recently until 10 d [days] ago before rt was sent to hospital for SOB [Shortness Of Breath]. Rt may benefit from weekly weights to monitor wt status and intakes. Plan: Recommend weekly weights x 4 wks.Review of Resident #67's physician order dated 4/23/2026 read, Weekly weight x4 [4 times] every day shift every Sun [Sunday] Restorative will get weight.During an interview on 5/20/2026 at 3:32 PM, the Registered Dietitian stated, [Resident #55's name] weight loss is unavoidable due to his medical condition. I don't put orders in. For weekly weights, the facility has a timeline of 4 weeks. I give my recommendations to the DON [Director of Nursing] and they put them into the system and go from there. After four weeks, I was expecting to have weekly weights. Every time we have a weight meeting if he had recommendations of weekly weights, it has been spoken about. In reviewing [Resident #67's name] notes, there was a note in April [2026] recommending weekly weights. He has had a lot of trouble swallowing, so he is on pureed diet and if he gets in the wrong mood, he will not want to eat. I don't see weekly weights for him [Resident #67]. It is helpful when we get weight in.During an interview on 5/21/2026 at 8:21 AM, the DON stated, I was unable to locate any additional weight for [Resident #55's name or Resident #67's name]. Usually, recommendations go to the CDM [Certified Dietary Manager], and she will communicate with the restorative aides. Weekly weight recommendations do not need to be approved by the provider. I don't know what happened that I was not able to locate the weights.During an interview on 5/21/2026 at 11:58 AM, the DON stated, The weights go to the CDM. I do not do weights. I have not asked the CDM about the weights. I just could not locate them.During an interview on 5/21/2026 at 12:00 PM, the CDM stated, For [Resident #67's name], I do not have any other weights for the month of April 2026 other than on 4/26/2026, which was 235.5 pounds. For [Resident #55's name], for January, I only have on 1/10/2026 of 171 pounds; no other weights for that month. The DON will give me the recommendations, and she will be the one to put the orders in.Review of the facility policy and procedure titled Nutritional Management with the last review date of 1/21/2026 read, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.

Based on record review, observation, and staff interviews, the facility failed to implement an effective staffing system to ensure sufficient nursing staff for meeting the resident needs. Findings include:During an interview on 5/19/2026 at 11:18 AM, Staff R, Licensed Practical Nurse (LPN), stated, I spoke to the staffing coordinator and told her I needed to leave. I have a situation with my daughter and she went to speak with the DON [Director of Nursing] and told me I needed to call my agency in order to find a replacement. I came back here and kept doing what I needed to do while I was waiting on them. I then went back to the staffing coordinator and told her I was behind on my medication administration. No one came to help me or ask me if I was okay. The DON has come to the nursing station and has been on her phone and talking to the other nurse on the other side. She never came to talk to me. I am behind. I have a total of 29 patients and 10 have not gotten their medication and now they are red in the system. Is this a medication error? I don't know what to do. This unit is crazy. There is 3 g-tube [gastric tube] patients. Now I have to do blood sugar checks and give coverage for meals. I have worked in this facility before and not had this happened to me.During an observation on 5/19/2026 at 11:18 AM, Staff R, LPN, had a total of 10 residents in red [medications are late] in the computer screen. Staff R was doing accu-checks for residents and providing insulin coverage for the residents. At 12:20 PM, Staff R, LPN, walked to the nursing station to call Resident #15's provider to notify Resident #15 had refused her medications that were supposed to be administered at 9 AM, and make a list of the residents she was running behind on and the providers' names they belong to in order to notify them that the residents' medications were running late and get further instructions. While sitting at the nursing station, the Assistant Director of Nursing (ADON) came to the nursing station and Staff R called her over to the computer station and informed the ADON she was running behind with medication administration of the ten residents, showing her the computer screen. The ADON had a surprised facial expression and stated, You are behind on all these residents. Staff R replied, Yes. The ADON proceeded to ask for the list of residents and stated she would take care of the situation.During an interview on 5/19/2026 at 12:49 PM, the DON stated, No one told me [Staff R, LPN's name] was behind on her medication administration. The Staff Coordinator came to me this morning and told me [Staff R's name] was having issues with her daughter or sister and needed to leave. I did not have anyone to relieve her and told the Staff Coordinator to tell her she needed to reach out to her agency and they would need to send a replacement. I did not speak to the staff, the Staffing Coordinator did.During an interview on 5/19/2026 at 12:53 PM, the Staffing Coordinator stated, She [Staff R, LPN] came to me in tears in her eyes that she needed to leave due to a situation with her daughter. I told her I did not have anyone to relieve her and I went to speak to the DON. The DON told me she needed to call her agency. I also called the agency and opened a shift, no one was picking up the shift. The nurse [Staff R] came to me again asking me if I had forgotten about her and asked if one of us could relieve her. She basically told me she was behind. I went back again and I let the ADON and DON know. I saw her MAR [Medication Administration Record] and. I did let the ADON know. I don't remember if I told the DON she was behind, but I did go and speak to the DON about replacement. I don't know if she [Staff R] asked another nurse for help. I always do my best to help and go to the person that can help her. The ADON said she was going to see what she could do to help her. I do not know what happened after that. I spoke to the DON. She was right there by the nurse [Staff R] and it is kind of frustrating because she didn't go speak to the staff. I am a CNA [Certified Nursing Assistant]. If I was a nurse, I would have helped. I tried to reach out staff that normally work here, but it did not work out because they had appointments. If we need coverage, the unit supervisor could help, the wound care nurse, the ADON or the DON would cover. I remember it was about 10 [o'clock] when she came to me and as soon as I saw the MAR red, I know I told the ADON.During an interview on 5/19/2026 at 2:32 PM, the ADON stated, I was not aware that the staff member was running late. I only found out when you were sitting with the nurse at the nursing station. The staff coordinator did not tell me. I know they were trying to find a replacement for her. I try not to interfere in the DON decisions.Review of Resident #117's admission record showed the resident was admitted on [DATE] with diagnosis to include transient paralysis, dysphagia, conversion disorder with seizures or convulsion, spinal stenosis, major depressive disorder, and anxiety disorder.Review of Resident #117's administration note dated 5/19/2026 read, Per MD [medical doctor], okay to hold flush and continue with schedule as ordered.Review of Resident #117's administration note dated 5/19/2026 read, Per MD Okay to administer medication at 2 pm, continue with dosing as ordered.Review of Resident #117's administration note dated 5/19/2026 read, Per MD, okay to hold dose and resume normal dosing as scheduled.Review of Resident #117's administration note dated 5/19/2026 read, Per MD, okay to administer eye drops at 2pm x 1 dose.Review of Resident #117's administration note dated 5/19/2026 read, Per MD okay to administer eye drops at 2p, resume does time at HS [bedtime].Review of Resident #117's administration note dated 5/19/2026 at read, Per MD okay to reschedule medication at 2 pm, resume normal dosing at 9p.Review of Resident #117's administration note dated 5/19/2026 read, Ok for staff administer aspirin 81 mg [milligram] x 1 dose at 2p.Review of Resident #38's admission record showed the resident was admitted on [DATE] with diagnoses to include multiple sclerosis, ulcerative colitis, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease heart failure, major depressive disorder, atrial fibrillation, and hypokalemia.Review of Resident #38's administration note dated 5/19/2026 read, Copaxone Subcutaneous Solution Prefilled Syringe 20 MG/ML [milligram per milliliters] Inject 1 ml subcutaneously one time a day for MS [Multiple Sclerosis] ARNP [Advanced Registered Nurse Practitioner] aware of administration time, ok to move medication to 1700 [5:00 PM].Review of Resident #38's administration note dated 5/19/2026 read, Methadone HCl [Hydrochloride] Oral Tablet 10 MG give 1 tablet by mouth two times a day for non-acute pain. ARNP aware of administration time, ok to hold and give and next schedule dose.Review of Resident #38's administration note dated 5/19/2026 read, Miralax Oral Powder 17 GM/Scoop give 17 gram by mouth tow times a day for constipation Mix with 4-6 ounces of fluid of choice. ARNP aware of administration time, okay to give.Review of Resident #38's administration note dated 5/19/2026 read, Ferrous Sulfate oral tablet 325 (65 FE) MG give 1 tablet by mouth one time a day for age related vitamin deficiency ARNP aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Claritin Oral Tablet 10 MG give 1 tablet by mouth one time a day for seasonal allergies. ARNP aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Cholecalciferol Tablet 1000 Unit give 1 tablet by mouth one time a day for age related vitamin deficiency ARNP aware of administration time, ok to give.Review Resident #38's administration note dated 5/19/2026 read, Potassium Chloride Crys Oral Tablet Extended Release 20 MEQ [milliequivalent] give 1 tablet by mouth one time a day for hypokalemia, APRN aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Nitrofurantoin Microcrystal oral capsule 50 mg give 1 capsule by mouth in the morning for UTI [Urinary Tract Infection] for 90 Days ARNP aware of administration time , ok to give.Review of Resident #38's administration note dated 5/19/2026 read, ARNP aware of administration time, ok to give.Review of Resident #38's administration note date 5/18/2026 read, Cardizem CD oral capsule extended release 24 hour 180 mg give 1 capsule by mouth one time a day related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease. ARNP aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Duloxetine HCl Capsule Delayed Release Particles 30 mg give 1 capsule by mouth tow times a day for depression related to Major Depressive Disorder Recurrent Moderate ARNP aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Clopidogrel Bisulfate Tablet 75 mg give 1 tablet by mouth one time a day for blood clot prevention APRN aware of administration time, ok to give.Review of Resident #38's administration note dated 5/19/2026 read, Midodrine HCl Oral Tablet 5 mg give 1 tablet by mouth three times a day for hypotension hold if SBP [Systolic Blood Pressure] greater than 130.Review of Resident #38's administration note dated 5/19/2026 read, Resident #38 stated she will take the next dose and wants to wait till after lunch.Review of Resident #97's admission record showed the resident was admitted on [DATE] with diagnoses to include epilepsy, dementia, chronic kidney disease, adjustment disorder, essential tremor, and chronic kidney disease.Review of Resident #97's administration note dated 5/19/2026 read, Sertraline HCl Oral Tablet 50 MG give 1 tablet by mouth one time a day for MDD [Major Depressive Disorder] ARNP notified that agency nurse did not administer residents scheduled 9 AM medications at the scheduled time. ARNP gave order to reschedule Sertraline to 9 PM. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #97's administration note dated 5/19/2026 read, ARNP notified that agency nurse did not administer resident's schedule 9 AM medication at the schedule time. ARNP gave order that it is acceptable to miss scheduled 9 AM ASA [Aspirin] and Keppra. Re-schedule Sertraline for 9 PM. Resident monitored with no noted distress.Review of Resident #97's administration note dated 5/19/2026 read, Keppra Oral Tablet 1000 mg give 1 tablet by mouth every 12 hours for seizures APRN notified that agency nurse did not administer resident scheduled 9 AM medications at the scheduled time. ARNP gave orders that it is acceptable for resident to miss scheduled 9 AM medication or today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #97's administration note dated 5/19/2026 read, Aspirin Oral Tablet Delayed Release 81 MG give 1 tablet by mouth one time a day for CAD [Coronary Artery Disease] ARNP notified that agency nurse did not administer resident's scheduled 9 AM medications at the scheduled time, ARNP gave orders that it is acceptable for resident to miss schedule 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #103's admission record showed the resident was admitted on [DATE] with diagnoses to include type 2 diabetes, heart failure, chronic kidney disease stage 5, major depressive disorder, and gastroesophageal reflux disease.Review of Resident #103's administration note dated 5/19/2026 read, gt [gastric tube] flush with 260 ml of water 5 times a day five times a day, md made aware, ok to administer now.Review of Resident #103's administration note dated 5/19/2026 read, in addendum, change time of administration to 0600 [6:00 AM].Review of Resident #103's administration note dated 5/19/2026 read, Keppra oral solution 100 mg/ml give 2.5 ml via peg tube in the morning related to narcolepsy without cataplexy, md modified new orders to change administration time to 1700 [5:00 PM].Review of Resident #103's administration note dated 5/19/2026 read, Iron oral liquid give 20 ml via peg tube one time a day for supplement house stock 220 mg/5 ml, md notified new order clarification to change time to 0600 [6:00 AM].Review of Resident #103's administration note dated 5/19/2026 read, Hydralazine HCl Tablet 25 MG give 1 tablet via G tube two time a day for HTN [hypertension] hold if BP [Blood Pressure] less than 105/60 or HR [Heart Rate] less than 55, md notified received orders to hold am [morning] dose and resume at next schedule dose.Review of Resident #116's admission record showed the resident was admitted on [DATE] with diagnoses to include hypertensive heart disease, heart failure, PVD [peripheral vascular disease], and hyperlipidemia.Review of Resident #116's administration note dated 5/19/2026 read, Lasix oral tablet 40 mg give 1 tablet by mouth two times a day for CHF, ARNP aware of administration time, ok to give.Review of Resident #116's administration note dated 5/19/2026 read, Metoprolol Tartrate Oral Tablet 100 mg give 1 tablet by mouth two times a day for heart failure hold for HR <60, ARNP aware of administration time, ok to hold until last scheduled dose current heart rate 64.Review of Resident #116's administration note dated 5/19/2026 read, Apixaban Oral Tablet 5mg give 1 tablet by mouth two times a day for Hx [history]: DVT/PE [Deep Vein Thrombosis/Pulmonary Embolism], ARNP aware of administration time, ok to hold until next scheduled dose.Review of Resident #116's administration note dated 5/19/2026 read, Omega 3 oral capsule 100 mg give 1 capsule by mouth one time a day for HLD [hyperlipidemia], ARNP aware of administration time, ok to give.Review of Resident #116's administration note dated 5/19/2026 read, Potassium Chloride ER [Extended Release] Oral Tablet Extended Release 20 MEQ give 1 tablet by mouth two times a day for diuretic use. ARNP aware of administration time, ok to hold until next scheduled dose.Review of Resident #116'a administration note dated 5/19/2026 read, Multivitamin Oral Tablet give 1 tablet by mouth one time a day for age related supplement, ARNP aware of administration time, ok to give.Review of Resident #116's administration note dated 5/19/2026 read, Coenzyme Q10 Oral Tablet 100 mg give 1 tablet by mouth one time a day for heart supplement, ARNP aware of administration time, ok to give.Review of Resident #116's administration note dated 5/19/2026 read, Cholecalciferol Oral Tablet 25 mcg (1000 UT [unit]) give 1 tablet by mouth one time a day for age related vitamin deficiency. ARNP aware of administration time, ok to give.Review of Resident #116's administration note dated 5/19/2026 read, Multivitamin Oral Tablet give 1 tablet by mouth time a day for age related supplement. ARNP notified that agency nurse did not administer resident's scheduled 9 AM medication at the scheduled time. ARNP gave order that is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #116's administration note dated 5/19/2026 read, ARNP notified that agency nurse did not administration resident's scheduled 9 AM medications at the schedule time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #116's administration note dated 5/19/2026 read, Cholecalciferol Oral Tablet 25 MCG [microgram] (100UT) give 1 tablet by mouth one time a day for age related vitamin deficiency. ARNP notified that agency nurse did not administer resident scheduled 9 AM medications at the scheduled time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #116's administration note dated 5/19/2026 read, Coenzyme Q10 Oral Tablet 100 mg give 1 tablet by mouth one time a dad for heart supplement, ARNP notified that agency nurse did not administer resident's scheduled 9 AM medications at the scheduled time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with not noted distress.Review of Resident #116's administration note dated 5/19/2026 read, Apixaban Oral Tablet 5 MG give 1 tablets by mouth two times a day for Hx: DVT/PE, ARNP notified that agency nurse did not administer resident's scheduled 9 AM medication at the scheduled time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #63's admission record showed the resident was admitted on [DATE] with diagnoses to include traumatic ischemia of muscle, dementia, essential hypotension, and brief psychotic disorder.Review of Resident #63's administration note dated 5/19/2026 read, Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 50 MG give 1 tablet by mouth one time a day for HTN Hold for HR <60 or BP <105/55, ARNP notified that agency nurse did not administer resident's scheduled 9 AM medications at the scheduled time. ARNP gave order that it is acceptable for resident to miss schedule 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #63's administration note dated 5/19/2026 read, Medpass two times a day for weight maintenance 90 ML, ARNP notified that agency nurse did not administer resident's scheduled 9 AM medications at the scheduled time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #63's administration note dated 5/19/2026 read, Docusate Sodium Capsule 100 mg give 1 capsule by mouth two time a day for constipation, ARNP notified that agency nurse did not administer resident's scheduled 9 AM medications at the scheduled time. ARNP gave order that it is acceptable for resident to miss scheduled 9 AM medications for today. No new orders received at this time. Resident monitored with no noted distress.Review of Resident #118's admission record showed the resident was admitted on [DATE] with diagnoses to include type 2 diabetes, essential hypertension, benign prostatic hyperplasia, major depressive disorder, and gastroesophageal reflux disease.Review of Resident #118's administration note dated 5/19/2026 read, Flomax Capsule 0.4 mg give 1 capsule by mouth one time a day for beginning prostatic hyperplasia order clarification for time change. MD given new orders to change time of medication.Review of Resident #118's administration note dated 5/19/2026 read, Gabapentin Capsule 400 mg give 1 capsule by mouth three times a day for pain, ok to hold am dose per MD.Review of Resident #118's administration note dated 5/19/2026 read, Cyanocobalamin Tablet 1000 MCG give 1 tablet by mouth two time a day for age related vitamin deficiency. OK to hold am dose per MD.Review of Resident #118's administration note dated 5/19/2026 read, Nu-Iron Oral Capsule 150 mg give 1 capsule by mouth one time a day for anemia. Order Clarification for time change. MD given new order to change time of medications.Review of Resident #118's administration note dated 5/19/2026 read, Cardizem Oral Tablet 30 mg give 1 tablet by moth two time a day for HTN. Ok to hold am dose per MD.Review of Resident #118's administration note dated 5/19/2026 read, Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 25 MG give 1 tablet by mouth one a day for HTN Hold or HR < 60 & notify MD, Order clarification for time change. MD given new order to change time of medication.Review of Resident #118's administration note dated 5/19/2026 read, Metformin HCl ER tablet extended release 24 hour 500 mg give 2 tablet by mouth two times a day for DM [Diabetes Mellitus] give 2 tabs=1000 mg, ok to hold am dose per MD.Review of Resident #118's administration note dated 5/19/2026 read, Acetaminophen Tablet 325 mg give 2 tablet by mouth two times a day for non-acute pain ok to hold AM dose per MD.Review of Resident #118's administration note dated 5/19/2026 read, Glipizide Oral Tablet give 5 mg by mouth one time a day for DM, order clarification for time change. MD given new order to change time of medication.Review of Resident #118's administration note dated 5/19/2026 read, Insulin Glargine Solution 100 UNIT/ML inject 65 unit subcutaneously two times a day for diabetes order clarification for time change. MD given new order to change time of medication.Review of Resident #126's admission record showed the resident was admitted on [DATE] with diagnoses to include heart failure, chronic kidney, chronic atrial fibrillation, major depressive disorder, anxiety disorder, PVD, rheumatic heart disease, cardiomyopathy, and brief psychotic disorder.Review of Resident #126's administration note dated 5/19/2026 read, Tramadol HCl tablet 50 mg give 1 tablet by mouth two times a day for none acute pain. Ok to hold morning dose per MD.Review of Resident #126's administration note dated 5/19/2026 read, Sodium Chloride Oral Tablet 1 GM give 2 tablets by mouth one time a day for hyponatremia. Order clarification for time change. MD given new order to change time of medication.Review of Resident #126's administration note dated 5/19/2026 read, Senna S Tablet 8.6 -50 MG give 1 tablet by mouth two times a day for constipation. OK to hold morning dose per MD.Review of Resident #126's administration note dated 5/19/2026 read, Potassium Chloride ER Oral Capsule Extended Releasee 10 MEQ give 1 capsule by mouth one time a day for supplement. Order clarification for time change. MD given new order to change time of medication.Review of Resident #126's administration note dated 5/19/2026 read, Eliquis Tablet 2.5 MG give 1 tablet by mouth two times a day for a-fib. OK to hold morning dose per MD.Review of Resident #15's admission record showed the resident was admitted on [DATE] with diagnoses to include hypertensive chronic kidney disease, dementia, dysphagia, major depressive disorder, and type 2 diabetes.Review of Resident #15's administration note dated 5/19/2026 read, Medication declined, unable to redirect, will f/u with MD.Review of Resident #6's admission record showed the resident was admitted on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease, dementia, pneumonia, chronic systolic heart failure, type 2 diabetes, and acute kidney failure.Review of Resident #6's administration note dated 5/19/2026 read, Amlodipine Besylate Oral Tablet 5 MG give 1 tablet via Peg [Percutaneous Endoscopic Gastrostomy]-Tube one time a day for HTN Hold for B/P <105/60 or hr <55 & notify MD/ARNP. Order clarification for time change. MD given new order to change time of medication.Review of Resident #6's administration note dated 5/19/2026 read, Benztropine Mesylate Oral Tablet 0.5 MG give 1 tablet via Peg-Tube one time a day related to Bipolar Disorder, Unspecified. Order clarification for time change. MD given new order to change time of medication.Review of Resident #6's administration note dated 5/19/2026 read, Multivitamin Oral Tablet give 1 tablet via PEG-Tube one time a day for nutritional support or wound healing. MD notified of medication being held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Zinc Oral Tablet 50 MG give 1 tablet via PEG-Tube one time a day for nutritional support for wound healing. MD notified of medication being held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Ivabradine HCl Oral Tablet 5 MG give 1 tablet via PEG-Tube one time a day for heart failure. Order clarification for time change. MD given new order to change time of medication.Review of Resident #6's administration note dated 5/19/2026 read, Cefuroxime Axetil Oral Tablet 500 MG give 1 tablet via PEG-Tube two times a day for Pneumonia for 14 Days. MD notified of medication being held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Magnesium Oxide Oral Tablet 400 MG give 1 tablet via PEG-Tube one time a day for supplement. MD notified of medication held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Eliquis Oral Tablet 5 MG give 1 tablet via PEG tube two times a day for DVT. MD notified of medication being held. Ok to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Ascorbic Acid Tablet 500 mg give 1 tablet via PEG-Tube one time a day for nutritional support for wound healing MD notified medication held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Iron Supplement Oral Solution 220 give 10 ml via PEG Tub one time a day for supplement. MD notified of medication being held. OK to skip am dose.Review of Resident #6's administration note dated 5/19/2026 read, Amiodarone HCl Oral Tablet 200 MG give 1 tablet via PEG-Tube tow times a day for arrhythmia. MD notified of medication being held. OK to skip am dose.During an interview on 5/20/2026 at 11:20 AM, Medical Doctor #1 stated, The facility notified me. There are no concerns of harm. We reschedule some medications. There is no concerns regarding patient health or safety.During an interview on 5/20/2026 at 5:08 PM, the Medical Director stated, The facility reached out to me and we are looking at the root cause analysis. This has never happened here before. Nobody knew she was behind in her medications she did not tell anybody.During an interview on 5/21/2026 at 9:27 AM, the Advanced Registered Nurse Practitioner #1 stated, I was in the building when this happened and I saw the residents. There were no concerns or potential harm. The following day there was no health concerns. This is not something that happens normally here in the facility. We have a charge nurse and also an Assistant Director of Nursing. You will help if anything like this is happening. She needed to tell them. I spoke to the ADON and she never asked for help. The ADON would have jumped in and helped take care of the patients. She is always around. There was no health concerns regarding the residents involved.Review of the facility policy and procedure tiled Nursing Services and Sufficient Staff with the last review date of 1/21/2026 read, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skills set to assure resident safety and attain or maintain the highest practical physical, mental and psychosocial well being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 5. Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and respond to resident's needs.Review of the Facility Assessment Tool revised on 1/21/2026 read, Part 2: Services and Care we offer based on our Resident's Needs: Medications: Awareness of any limitations of administering medications. Administering of medications that residents need.

Based on observation, interview, and record review, the facility failed to accurately document urinary catheter care for 1 of 3 residents reviewed for catheter care (Resident #6), failed to ensure change in condition was documented for 3 of 3 residents reviewed for skin conditions (Residents #35, #80 and #87), and failed to ensure treatment documentation was accurate for 1 of 3 residents reviewed for rehabilitation services (Resident #1). Findings include: 1) During an observation on 5/18/2026 at 10:28 AM, Resident #6 was lying in bed. There was a urinary catheter bag, covered with a privacy bag, hanging from the side of the bed. The urinary tubing was clear and free of any kinks. Review of Resident #6's physician order dated 4/25/2026 read, Urinary Catheter: Change Indwelling Catheter and Drainage Bag every 30 days and PRN [as needed] due to clinical indications of infection (sediment, foul odor, dark in color), obstruction (slow drainage), or when the closed system is compromised. Every night shift every 30 day(s) for Preventative and as needed for s/s of infection (sediment, foul odor, dark in color). Review of Resident #6's physician order dated 4/25/2026 read, Urinary Catheter: Indwelling Catheter in place. Size: 16 FR [French scale], Bulb:10 mL [milliliter], Diagnosis: neuromuscular dysfunction of bladder, unspecified. Review of Resident #6's physician order dated 4/25/2026 read, Enhanced Barrier Precautions due to catheter/wound. Review of Resident #6's physician orders did not show order for providing catheter care. During an interview on 5/20/2026 at 10:47 AM, the Director of Nursing (DON) stated, There should be orders in the system for residents who have catheters for catheter care. During an interview on 5/20/2026 at 12:02 PM, Staff N, Licensed Practical Nurse (LPN), stated, Every shift foley care is done and as needed. There should be an order in the system, but we do it anyways. We have a standing order for anyone who has a catheter to do catheter care. During an interview on 5/20/2026 at 12:30 PM, Staff O, Certified Nursing Assistant (CNA) stated, We will always do catheter care on [Resident 36's name] every shift and as needed. During an interview on 5/21/2026 at 11:00 AM, the Assistant Director of Nursing stated, When [Resident #6's name] came back from the hospital, the orders for catheter care fell off. The treatment record would be the only way to document that the care was provided. It is a batch order set. I would expect for orders to be in place in order for staff to have a place to accurately document the care that is being provided. Review of the facility policy and procedure titled Catheter Care with the last review date of 1/21/2026 read, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 24. Document care and report any concerns to the nurse on duty. 2) During an interview on 5/18/2026 at 12:10 PM, Resident #35 stated, This bandage on my right arm is from me hitting it in the bathroom when I go in there. During an observation on 5/18/2026 at 12:12 PM, Resident #35 had a bandage on his left forearm that is dated 5/8/2026. Review of Resident #35's nursing notes from 5/8/2026 through 5/18/2026 did not show any skin tear to left forearm/wrist or an application of a bandage to the left forearm/wrist. Review of Resident #35's physician orders from 5/8/2026 through 5/18/2026 showed no physician orders for the left forearm/wrist wound. During an interview on 5/19/2026 at 2:35 PM, Staff B, Registered Nurse (RN), stated, I cannot find any documentation related to the resident's skin tear on his left forearm. During an interview on 5/19/2026 at 2:54 PM, the Assistant Director of Nursing (ADON) stated, It is my expectation that when a resident gets a skin tear that the nurse assesses the skin care, documents the injury. Review of the facility policy and procedure titled Skin Integrity- Skin Tears with the last review date of 1/21/2026 read, Policy Explanation and Compliance Guidelines: 2. Assessment a. Licensed nurses will conduct skin assessments in accordance with facility policy. b. The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for skin tears. Examples, include, but ae not limited to: Advanced age, poor locomotion, and presence of ecchymosis. c. When a skin tear is discovered, the nurse shall complete an incident report. The following information shall be recorded: i. The Resident's name ii. The name of the employee discovering the skin tear, iii. The site and description of the skin tear, iv. The date and time the skin tear was discovered, v. The date and time the injury occurred, if known, vi. The name(s) of the employee(s) who provided care for the resident for the previous 24 hrs, vii. Site care rendered and evaluation of the incident, viii. The name(s) of any witness(es) to the incident, ix. the date and time the physician and resident representative were notified, and x. Any other information relevant to the incident. 3) During an observation on 5/18/2026 at 10:15 AM, Resident #80's left forearm had a tan bandage with no date. During an observation on 5/19/2026 at 12:44 PM, Resident #80's left forearm had a tan bandage with no date. Review of Resident #80's physician orders showed no physician order for left hand bandage. Review of Resident #80's progress notes showed no documentation of left forearm bandage. During an interview on 5/19/26 at 1:10 PM, Staff C, LPN, regarding the bandage on Resident #80's forearm, stated, I do not know anything about it. I need to see if there is an order for it. During an interview on 5/19/2026 at 1:15 PM, Staff Q, Wound Care Nurse, stated, I think [Resident #80's name] has a skin tear to her forearm. During an interview on 5/19/2026 at 2:43 PM, Staff Q, Wound Care Nurse, stated, I do not see any documentation of [Resident #80's name] left forearm. I have not seen her yet. 4) During an observation on 5/18/2026 at 9:52 AM, Resident #87 was sitting in her wheelchair. There was a dressing on her left lower leg that was dated 5/16. During an interview on 5/18/2026 at 9:52 AM, Resident #87 stated that she had not bumped her leg and did not know what had happened. Review of Resident #87's physician orders from 5/1/2026 through 5/18/2026 showed no orders for wound care to her left lower leg. Review of Resident #87's Medication Administration Record/Treatment Administration Record (MAR/TAR) from 5/1/2026 through 5/18/2026 showed no documentation of wound care. During an interview on 5/19/2026 at 11:55 AM, Staff H, LPN, stated, I removed the bandage from [Resident #87's name] leg. There is no order or anything on her MAR or TAR. Staff H confirmed that there was nothing documented about an injury and he had not received any information in report. Staff H stated, There should be documentation of the wound and the incident that caused it and there should be an order for the dressing or wound care. During an interview on 5/19/2026 at 4:11 PM, the DON stated, If a resident has a bandage on their leg, I expect to see a treatment order and something on the TAR. 5) Review of Resident #1's physician order dated 2/18/2026 read, Apply left and right resting hand splint. Hand splints to be worn at night as tolerated. Check skin integrity before and after placement/removal two times a day ON at HS [bedtime], OFF in AM [morning time]. Review of Resident #1's physician order dated 3/12/2026 read, Apply left and right resting hand splint. Hand splints to be worn at night as tolerated. Check skin integrity before and after placement/removal two times a day ON at HS, OFF in AM. Review of Resident #1's TAR from 2/12/2026 through 5/18/2026 for application of hand splint showed documentation of application and removal of the splint per physician order. During an interview on 5/19/2026 at 11:55 AM, Staff H, LPN, stated, I need to discontinue the order for Resident #1's splints because she hasn't worn them in a long time. During an interview on 5/19/2026 at 3:50 PM, Staff I, LPN, stated, I have never seen [Resident #1's name] wearing splints. Staff I confirmed that there was an order on Resident #1's TAR, which had been signed off daily, indicating splints were being applied. During an interview on 5/19/2026 at 3:53 PM, Staff G, LPN, stated, I routinely worked 3-11 [PM] and overnights [11:00 PM- 7:00 AM]. I am familiar with [Resident #1's name]. I am not familiar with the splints and I haven't used them. During an interview on 5/19/2026 at 4:11 PM, the DON stated, [Resident #1's name] should not have splint orders. The expectation is that if a nurse signs off a treatment on the TAR that they are doing it [the treatment]. The DON confirmed that the application of resting hand splints was being signed off daily on Resident #1's TAR. During an interview on 5/20/2026 at 4:50 PM, Staff J, LPN, stated, I remember [Resident #1's name] wearing hand splints a long time ago, but I don't think she had them on recently. I recall signing off on her TAR that I applied the splint. During an interview on 5/20/2026 at 4:57 PM, Staff K, LPN, stated, [Resident #1's name] used to have hand splints but no longer wears them. I signed off removal of splints when [Resident #1's name] has not been wearing them to be removed. Review of the facility policy and procedure for documentation with the last review date of 1/21/2026 read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident center. i. False information shall not be documented. B. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on record review and interview, the facility failed to ensure the resident representative was notified of the accident requiring physician intervention for 1 of 6 residents reviewed for enteral medication administration, Resident #86, and for 1 of 4 residents reviewed for falls, Resident #17. Findings include: 1) Review of Resident #86's admission record showed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses including but not limited to dysphagia, moderate protein calorie malnutrition, iron deficiency anemia, and gastro-esophageal reflux disease. Review of Resident #86's progress note dated 11/26/2024 showed it read, Orientee, [the Orientee's first name], training with this nurse 11/26/2024. During first med pass, around 5 pm, resident's roommate's medications were pulled by this nurse and given to orientee to be given to roommate. CNA [Certified Nursing Assistant] stepped out of the room a bit after meds [medications] were given to orientee and stated that the cup of fluids that were with meds were on this resident's bed side table. This nurse confronted orientee about who she gave the medicine to and she stated she gave to this resident. I informed orientee that before meds were given I confirmed with her who to give medications to by name. Orientee stated she had A and B beds mixed up from names on wall. MD [Medical Doctor] was notified of incident. Resident was given eliquis, senna, and hipprex. Resident currently on eliquis and senna. I informed MD that resident did not choke or cough. MD stated to keep an eye on resident. No other orders given. Review of Resident #86's physician order dated 6/5/2024 showed it read, NPO [nothing by mouth] diet NPO texture. During an interview on 12/17/2024 at 11:19 AM, Staff F, Registered Nurse (RN), stated, I was passing medication with [Staff E, RN's name], and she gave me medication to give to [Resident #86's name]. [Staff E's name] told me it was for him. They were PO [oral] medications. I tried to confirm with her [Staff E] again. [Staff E's name] said yes it is for A Bed. I gave the medication to B Bed. [Resident #86's name] had no signs of watery eyes, sneezing or coughing. [Resident #86's name] was NPO. He was not supposed to get oral medication. I mixed the residents up. When we realized the medication error, [Staff E's name] was going to notify the provider. I do not know if the family was notified or anyone else in the facility because [Staff E's name] said she would do the notifications. During an interview on 12/18/2024 at 11:23 AM, the Assistant Director of Nursing (ADON) stated, Staff are supposed to notify the Risk Manager, DON, notify the family of any change in condition. During an interview on 12/18/2024 at 11:25 AM, the Director of Nursing (DON) stated, The staff are supposed to notify the supervisor, the Risk Manager, myself, Administrator, medical director and family. During an interview on 12/18/2024 at 11:31 AM, Staff H, RN, Risk Manager, stated, No staff notified me. The staff are expected to call me if there is a major incident. A major incident are medication error, falls, major skin tears. I do not care what time of the day; they need to call me. They also have to notify the provider and the family. During an interview on 12/19/2024 at 9:02 AM, the Administrator stated, Staff should immediately report medication errors to the DON, ADON or myself. They should notify MD and family. 45576 2) Review of Resident #17's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to Parkinsonism, type 2 diabetes mellitus with diabetic neuropathy, hypertensive heart disease without heart failure, chronic myeloid leukemia, atherosclerotic heart disease of native coronary artery, moderate protein calorie malnutrition, polyneuropathy, paranoid schizophrenia, major depressive disorder, anemia, drug induced subacute dyskinesia, and insomnia. Review of Resident #17's nursing progress note dated 7/12/2024 showed it read, Notified by another staff member that resident was on the floor. Upon entering the room resident was hanging off the bed on his right side holding himself up with his right hand. Myself and other staff members assisted resident back into bed. ROM [range of motion] performed and vitals obtained which were WNL [within normal limit]. Quick assessment of resident, I observed bruising to residents [Sic.] right thumb, resident c/o [complaint of] pain in thumb but could not rate pain on a scale of 1-10. Notified physician and order obtained for xray of the right thumb and to monitor resident throughout shift. Resident in his own responsible party. Review of Resident #17's face sheet showed it documented Emergency Contact #1 with phone number and address. Review of Resident #17's SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 7/12/2024 at 2:15 AM showed it read, Other resident or family preferences for care: n/a [Not Applicable]. During an interview on 12/18/2024 at 12:32 PM, Staff I, RN, stated, That family needs to be contacted with any change in condition. It was not documented on 7/12/2024 that family was notified of [Resident #17's name] had a fall. During an interview on 12/18/2024 at 1:11 PM, Staff H, RN, Risk Manager, stated, It is not documented that family was notified on 7/12/2024 of resident fall. Any change of condition the family is to be notified. During an interview on 12/19/2024 at 4:19 PM, the DON confirmed the family was not notified of Resident #17's fall on 7/12/2024 and stated, The family has to be notified for any change in condition. If the resident is responsible for self, then they must tell us not to call family. We document their request not to call their emergency contact. Review of the facility policy and procedure titled Notification of Changes with the last review date of 3/20/2024 showed it read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines . Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. B. A family that wishes to be informed would designate a member to receive calls.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for 1 of 3 residents reviewed, Resident #65. Findings include: Review of Resident #65's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, heart failure, major depressive disorder, and generalized anxiety disorder. Review of Resident #65's physician order dated 12/9/2023 showed it read, May admit under [local hospice name and contact number] Hospice as of 12/9/2023 for services. Review of Resident #65's annual Minimum Data Set (MDS) dated [DATE] showed hospice care was not indicated under Section O- Special Treatments, Procedures and Programs. During an interview on 12/18/2024 at 12:45 PM, the MDS Coordinator stated, [Resident #65's name] is on hospice and it should have been marked yes. It has been coded wrong. Review of the facility policy and procedure titled Conducting an Accurate Resident Assessment with the last review date of 3/20/2024 showed it read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).

Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 of 6 residents reviewed for medication administration, Resident #20. Findings include: Review of Resident #20's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to chronic atrial fibrillation, essential hypertension, and cognitive communication deficit. Review of Resident #20's physician order dated 5/24/2024 showed it read, Pradaxa Oral Capsule 150 MG [milligram] (Dabigatran Etexilate Mesylate), Give 1 capsule by mouth two times a day for afib [Atrial Fibrillation]. Review of Resident #20's Medication Administration Record for December 2024 showed the resident received Pradaxa 150 mg twice a day at 9:00 AM and at 5:00 PM from 12/1/2024 through 12/17/2024. Review of Resident #20's care plan did not document a focus area or interventions for Atrial Fibrillation or anticoagulant medication. During an interview on 12/18/2024 on 11:40 AM, the MDS Coordinator stated, After reviewing [Resident #20's name] medications, she [Resident #20] should be care planned for atrial fibrillation and anticoagulants. Review of the facility policy and procedure titled Comprehensive Care Plan with the last review dated of 3/20/2024 showed it read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 1 of 6 residents reviewed for medication administration, Resident #13. Findings include: Review of Resident #13's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to heart failure, chronic kidney disease, and syncope and collapse. Review of Resident #13's physician order dated 2/28/2023 showed it read, Bisoprolol Fumarate Tablet 5 mg [milligram], Give 1 tablet by mouth one time a day for hypertension, Hold for HR<60 & notify MD [Heart Rate less than 60 and notify Medical Doctor]. Review of Resident #13's Medication Administration Record for December 2024 showed the resident received Bisoprolol Fumarate 5 mg on 12/3/2024 at 9:00 AM with a pulse of 59, 12/10/2024 at 9:00 AM with a pulse of 57, 12/11/2024 at 9:00 AM with a pulse of 59, and 12/16/2024 at 9:00 AM with a pulse of 56. During an interview on 12/18/2024 at 3:11 PM, the Advanced Practice Registered Nurse (APRN) #1 stated, We put parameters in place and hope that the staff will follow them. I would expect the nurse to hold the medication and not give it if it is out of parameters. Nurse can use vitals taken within the hour of when the medication is going to be given. During an interview on 12/18/2024 at 3:20 PM, the Director of Nursing stated, Staff is expected to follow physician orders and follow the parameters the provider has given. If a nurse is going to administer blood pressure medication, they should be taking the blood pressure and pulse right before administering the medication. If the pulse is close to the parameters, I would manually take the apical pulse to make sure the pulse is accurate. If it continues to be below the parameter, I would expect the nurse to hold the medication and notify the physician. 49289 3) Review of Resident #13's physician order dated 2/28/2023 showed it read, Verapamil HCl ER [Extended Release] Oral Tablet Extended Release 180 MG (Verapamil HCl), Give 1 tablet by mouth one time a day for HTN [hypertension], Hold for BP [blood pressure] less than 105/60 or HR less than 55 & notify MD. During a medication pass observation on 12/17/2024 at 9:56 AM, Staff D, Licensed Practical Nurse (LPN), prepared medications for Resident #13 at the medication cart. The medications included one Bisoprolol 5 mg tablet and one Verapamil 180 mg tablet. The LPN prepared the medications in a medicine cup, entered Resident #13's room at 10:05 AM and administered the medications to the resident. During an interview on 12/17/2024 at 10:07 AM, Staff D, LPN, stated, I checked [Resident #13's name] vital signs [heart rate and blood pressure] shortly after 8 AM this morning. [Resident #13's name] blood pressure was 106 over 75 and the pulse was 65 at 8 AM. I don't know if I should have checked it closer to the time I gave her the medications. I figured it's not going to change that much over two hours. Review of the facility policy and procedure titled Medication Administration with the last review date of 3/20/2024 showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. right drug, c. Right dosage, d. right route. Review of the facility policy and procedure titled Medication Errors with the last review date of 3/20/2024 showed it read, Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring resident receive care and services safely in an environment free of significant medication errors. Definitions: Medication error means the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order; manufacture's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services . Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders . c. In accordance with accepted standards and principles which apply to professionals providing services . 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible . d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report.

Based on observation, interview, and record review, the facility failed to appropriately label a medical nutrition supplement prior to administration according to professional standards of practice for 1 of 6 residents reviewed for tube feeding, Resident #3 (photographic evidence obtained). Findings include: During an observation on 12/17/2024 at 8:50 AM, Resident #3 was resting in bed quietly with her eyes open. There was a feeding pump on a pole to the left side of her bed. The feeding pump was turned off. There was a 1000 ml (milliliter) bag of liquid hanging on the pole that read, Peptamen 1.5 kcal [kilocalorie; a unit of energy that is equal to 1000 calories]/ml nutritionally complete formula. There was no information written under Patient Name, Patient ID, Date/Time Started, or Tube Feeding Order label of the bag or no additional label or writing on the front or back of the bag. Review of Resident #3's physician order dated 1/23/2023 read, Peptamen 1.5 Cal Liquid (Nutritional Supplements), Give 45 ml/hr [hour] via G-Tube [gastrostomy tube] every shift for up at 10 am and down at 6 am. During a follow up observation on 12/17/2024 at 12:34 PM, Resident #3's feeding tube port was connected to the feeding tubing, receiving Peptamen 1.5 nutritional formula at 45 ml/hr through the feeding tube pump. There was no information written under Patient Name, Patient ID, Date/Time Started, or Tube Feeding Order label of the bag or no additional label or writing on the front or back of the bag. During an interview on 12/18/2024 at 1:38 PM, Staff A, Licensed Practical Nurse (LPN), stated, I noticed the bag of nutrition wasn't labeled and dated. I should have done it before I started the feeding pump. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, The tube feeding product needs to be labeled with the date, time, and the initials of the person that hung it. It is only good for so long, so the date and time are important. During an interview on 12/19/2024 at 8:33 AM, the Director of Nutritional Services stated, We don't have a specific policy on labeling the nutritional feeding product for feeding tubes, but it falls under labeling for medication administration. The nurse needs to fill out the information on the nutritional feeding product being hung for the resident with the resident's name, room, date, start time and rate, as shown on the label, before they hang the new bag of nutrition for tube feeding. Review of the facility policy and procedure titled Labeling of Medications and Biologicals with the last review date of 3/20/2024 showed it read, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during meal service in 1 of 3 units (300 Unit) and during medication administration in 2 of 8 medication pass observations, and failed to ensure staff used proper personal protective equipment in 1 of 3 units (300 Unit) while providing high contact care to the residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an afternoon meal service observation on 12/17/2024 at 12:58 PM, Staff C, Certified Nursing Assistant (CNA), carried a used plastic cup out of Resident #113's room and set it on the drink cart in the hallway. Without performing hand hygiene, Staff C grabbed a clean glass from the cart, filled it with sweet tea beverage and returned to Resident #113's room. At 1:00 PM, Staff C exited Resident #113's room and without performing hand hygiene, grabbed a tray for Resident #77 from the food cart, and without performing hand hygiene, entered Resident #77's room, assisted the resident with meal setup at the bedside table, and without performing hand hygiene, exited the room. At 1:02 PM, Staff C exited Resident #77's room, and without performing hand hygiene, entered Resident #115's room and assisted the resident with reaching his personal items on his bedside stand. At 1:04 PM, Staff C exited Resident #77's room, and without performing hand hygiene, went to the meal cart and grabbed the tray for Resident #64. Without performing hand hygiene, Staff C entered Resident #64's room, assisted the resident with tray setup on her bedside table, and cut up the resident's food for her. Without performing hand hygiene, Staff C exited Resident #64's room at 1:05 PM, and returned to the meal cart. Without performing hand hygiene, Staff C grabbed the meal tray and a cup for Resident #53 and entered Resident #53's room. At 1:06 PM, without performing hand hygiene, Staff C set the tray on the bedside table, raised the head of Resident #53's bed up, placed the bedside table over Resident #53's bed, and without performing hand hygiene, assisted Resident #53 with meal set up and opening the resident's drinks. Without performing hand hygiene, Staff C exited Resident #53's room at 1:08 PM and approached Resident #16 in the hallway. Without performing hand hygiene, Staff C wheeled Resident #16 in her Geri-chair to the resident's room. During an interview on 12/17/2024 at 1:11 PM, Staff C, CNA, stated, I didn't know about sanitizing my hands between tray delivery. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, Staff need to be performing hand hygiene after delivering meal trays to each resident. 2) During an observation on 12/17/2024 at 8:46 AM, Staff A, Licensed Practical Nurse (LPN), was wearing a black thumb and wrist brace [a brace covering the thumb and fingers with an open end at the tips of the fingers and thumb that provides support to limit movement of the thumb and is used for injuries] on her left hand. Without performing hand hygiene, Staff A prepared the medications for Resident #3 at the medication cart. At 8:53 AM, without performing hand hygiene, Staff A gathered the prepared medications and entered Resident #3's room. Staff A set the medications down on the bedside table at 8:54 AM. Without performing hand hygiene, Staff A donned a gown and left the neck and the waist areas of the gown untied. Without performing hand hygiene, Staff A donned a glove over her thumb and wrist brace on her left hand, and a glove on her right hand. During medication administration through the G-tube (Gastrostomy tube) from 8:55 AM to 8:59 AM, Staff A's gown around the neck area fell forward with the inside of the gown folding down over the outside of the gown. Staff A used her gloved hands to administer the medications and pulled the gown back up around her neck area four times while administering the medications. At 9:00 AM, Staff A doffed her gown and gloves and entered the resident's bathroom to wash her hands at the sink. While wearing the left-hand thumb and wrist brace covering her left hand, Staff A was scrubbing the tips of her left fingers with the soap. Staff A then exited the bathroom and returned to the medication cart to prepare medication for another resident. During an interview on 12/18/2024 at 1:38 PM, Staff A, LPN, stated, I should have performed hand hygiene before I prepared the meds and before I donned my gloves for [Resident #3's name] medication administration. I should have tied my gown at the neck. I always tie the gown and then put it around my neck. It kept falling down during administering the medications through [Resident #3's name] G-tube. It can cause contamination. 3) During an observation on 12/18/2024 at 10:53 AM, Staff B, Licensed Practical Nurse (LPN), gathered the blood glucose monitor and supplies to check Resident #124's blood glucose without performing hand hygiene. At 10:54 AM, Staff B entered Resident #124's room with the blood glucose monitor and supplies without performing hand hygiene. Staff B exited Resident #124's room and without performing hand hygiene, returned to cart with the blood glucose monitoring supplies to obtain alcohol wipes. At 10:55 AM, Staff B returned to Resident #124's room and without performing hand hygiene, donned gloves and performed the blood glucose monitoring. At 10:57 AM, Staff B exited Resident #124's room while still wearing her used gloves, accessed the bottom drawer of the medication cart, obtained a cleaning wipe, and cleaned the glucometer. At 10:59 AM, Staff B doffed her gloves and started preparing medication administration for another resident, without performing hand hygiene. During an interview on 12/18/2024 at 11:02 AM, Staff B, LPN, stated, I didn't sanitize my hands before entering [Resident #124's name] room. I didn't sanitize my hands when I returned to the cart. I should have removed my gloves in the room and re-sanitized my hands in the room before I returned to the cart to clean the glucometer. During an interview on 12/18/2024 at 2:53 PM, the Assistant Director of Nursing stated, Staff need to be performing hand hygiene during medication administration. They should be performing hand hygiene before administering the medication and after they are done. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 30/20/2024 showed it read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand Hygiene Table: Condition . Between resident contacts . Before applying and after removing personal protective equipment (PPE), including gloves; Before preparing or handling medications; Before performing resident care procedures. Review of the facility policy and procedure titled Medication Administration with the last review date of 3/20/2024 showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product . 16. Observe resident consumption of medication. 17. Wash hands using facility protocol and product. 46523 4) During an observation on 12/18/2024 at 9:47 AM, Staff C, CNA, entered Resident #8's room with a clear plastic bag with linen and towels. There was an enhanced barrier precautions signage posted outside next to the door. Resident #8 was lying in bed and Staff C provided personal hygiene care to Resident #8. Staff C was leaning over Resident #8, wearing gloves but no gown. During an interview on 12/18/2024 at 10:42 AM, Staff C, CNA, stated, I was changing [Resident #8's name] brief and socks. I gave her clothes to put on and then changed the linen to the bed. I forgot to put on a gown when providing care for [Resident #8's name]. You wear a gown for residents who are on enhanced barrier precautions for the protection of other residents. During an interview on 12/18/2024 at 1:50 PM, the Assistant Director of Nursing and Infection Preventionist stated, I tell my staff when a resident has any opening that should not be there, the resident needs enhanced barrier precautions. Staff are expected to use gloves and gowns any time they are doing direct contact care. Review of Resident #8's physician order dated 4/1/2024 showed it read, Enhanced Barrier Precautions due to (Tube Feeding). Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 3/20/2024 showed it read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO [Multidrug Resistant Organism] . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room . 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting.

Based on observations, interviews, resident record reviews, and review of the facility policies and procedures, the facility failed to ensure residents were free from medical neglect by failing to implement policies and procedures for safety and supervision when the facility staff failed to provide adequate supervision for Resident #33. On 5/08/2023, Resident #33 was left outside unsupervised resulting in physician ordered treatment for 7 days for exposed reddened, sunburned skin. On 6/15/2023, Resident #33 was left outside unsupervised resulting in dehydration, decreased alertness, difficulty responding, heat exposure, heatstroke, and sunstroke. On 7/07/2023, Resident #33 was left outside unsupervised for a significant amount of time resulting in dehydration, excessive sun exposure, with evidence of tanning. On 7/15/2023, Resident #33 was diagnosed with blister to the upper back and left shoulder. Resident #33 was outside unsupervised on the facility patio during inclement weather conditions with the high temperatures in the mid-90s (data collected from The National Weather Service for 7/15/2023). Resident #33 sustained third-degree sunburn to his cervical mid-back area and second-degree burns to his right shoulder. The facility's failure to provide supervision of Resident #33 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the immediate Jeopardy on 9/22/2023, at 9:23 AM. The Immediate Jeopardy began on 5/08/2023, and was removed on site on 9/22/2023. Heat exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, and people with high blood pressure. Symptoms may include heavy sweating; weakness or tiredness; cool, pale, clammy skin; fast, weak pulse; muscle cramps. Findings include: Review of the Admission Record for Resident #33 documented he is a [AGE] year-old male with diagnoses that include dementia, type 2 diabetes, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, heart failure, chronic kidney disease, peripheral vascular disease, and presence of cardiac pacemaker. Review of the Attestation of Physician that Resident is incapacitated for Resident #33 documented I, Dr. [Physician #1's Name], attending physician to [Resident #33's name], have evaluated him/her and determined that he/she lacks the capacity to make medical decision or give informed consent. This document was signed by Physician #1 and dated 3/29/2023. Review of the Quarterly Minimum Data Set, Comprehensive Assessment, dated 6/20/2023 for Resident #33 documented a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognition. Review of the APRN #1 (Advanced Practice Registered Nurse) Visit Note dated 5/8/2023 for Resident #33 documented in part, Problem list: Dehydration. History of present illness: 89 y/o (year old) male, pleasant and cooperative but confused. Noted to have significant redness to non-covered skin, reported to have been out on the patio for extended period of time over the weekend and was not in the shade. Psychiatric Orientation: abnormal - awake, alert oriented X1 [times one]. Assessment Plan: Condition 2 Diagnosis: Sunburn, Unspecified. Plan of Care: Encourage oral hydration, apply Aquaphor liberally to all exposed reddened skin q [every] shift until aloe containing lotion available. Monitor and ensure if he is outside, he is in the shade. Review of the progress note dated 5/8/2023 for Resident #33 documented, ARNP [sic] rounding in facility with new orders for Aquaphor [used for treatment of minor cuts and burns.] BUE [bilateral upper extremities], face, scalp, posterior neck bid [twice a day] for sunburn x 7 days, resident in agreement with POC [plan of care]. Author: [Staff Y, LPN's (Licensed Practical Nurse) name]. Review of the physician's order dated 5/8/2023 for Resident #33 documented, BUE, face, scalp, posterior neck - apply Aquaphor area and leave open to air every evening and night shift for sunburn for 14 days. Ordered by: [APRN #1's name]. Review of the progress note dated 6/15/2023 for Resident #33 documented, Resident was noted coming back from outside to have generalized erythema [superficial reddening of the skin]. Tired and weakness. Rt [right] eye was bright red at the lower lid of eye. No drainage noted. Resident stated he was a little sore. ARNP [sic] assessed resident and gave new order for labs in am [ante meridiem, before noon], U/A C & S [urinalysis with culture and sensitivity] and neuro checks [assesses an individual's neurological functions, motor and sensory response, and level of consciousness] to be initiated as protocol. Resident O2 [oxygen] sat [saturation, how much oxygen is in your blood] was 88% [Normal oxygen levels for elderly people are usually 90% to 95%, oxygen levels below 90% are considered low and may indicate the need for supplemental oxygen]. O2 at 1 liters has been placed on resident at this time. Resident was assisted to bed to rest and cool off. No acute distress noted at this time. Resting with eyes closed. Call light within reach. Author: [Staff X, LPN's name]. Heat exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, and people with high blood pressure. Symptoms may include heavy sweating; weakness or tiredness; cool, pale, clammy skin; fast, weak pulse; muscle cramps; dizziness; nausea or vomiting; headache; and fainting (Centers for Disease Control and Prevention). Certain diabetes complications, such as damage to blood vessels and nerves, can affect the sweat glands so the body can't cool as effectively. That can lead to heat exhaustion and heat stroke, which is a medical emergency. The very young and elderly, seniors (over 65) and children (especially those under the age of 4) are often more at increased risk of heat-related illness, as they typically tend to be less aware of temperature changes and their bodies generally don't regulate as well. Review of the APRN #1 Visit Note dated 6/15/2023 for Resident #33 documented in part, Problem List: Dehydration, Unspecified Dementia. Chief Complaint: Acute Visit for Vasovagal type episode [rapid drop in heart rate and blood pressure] after being outside for too long and becoming overheated. History of Present Illness: 89 y/o male, decreased alertness and difficulty responding initially after being outside on the patio in the sun and becoming overheated. Psychiatric Orientation: Abnormal - orientated to person only. Assessment/Plan: Diagnosis: Heatstroke and sunstroke, initial encounter, other disturbances of skin sensation. Care Plan: Removed clothing and allowed to rest which improved mentation/alertness to normal level for him. Orders to monitor when he is outside and not allow him to be out, without periodic monitoring. Do not recommend greater than 20-30 minutes without hydration in current summer weather/humidity/heat. Author: [APRN #1's name]. Review of the physician's order dated 6/15/2023 for Resident #33 documented, obtain neuro checks per protocol for heat induced weakness every shift for heat weakness DC [discontinue] when done. Ordered by: [Physician #1's name]. Review of Physician #1's Visit Note dated 7/7/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration. Chief Complaint: Acute visit - f/u [follow up] change in condition. History of present illness: This is an 89 y/o male being seen for follow up after noted yesterday that he was not his normal self. It is notable that he spends a significant amount of time outside, regardless of the fact that the temperature remains higher than normal. He admits he does not drink a lot of water. It is unclear how long he spends outside his skin shows evidence of tanning and sun exposure. Assessment/Plan: Condition 1. Diagnosis: effect of heat and light, unspecified, sequela [after effect of a disease/condition], dehydration. Care Plan: Pt [patient] with excessive sun exposures. Discussed risk of heat, dehydration, need for adequate hydration. F/u with staff regarding time outside for resident. Author: [Physician #1's name]. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 7/14/2023 for Resident #33 documented in part, Situation: The change in condition, symptoms, or signs observed and evaluated are: stroke/CVA [Cardiovascular Accident]/TIA [Transient Ischemic Attack]/New neurological signs. Blood Sugar: 388. Neurological Status Evaluation: Altered level of consciousness. Recommendations: Transfer to ER [emergency room ]. Review of the hospital emergency room documentation dated 7/14/2023 for Resident #33 documented in part, The patient presents with AMS [Altered Mental Status] per SNF [Skilled Nursing Facility] report. Differential Diagnosis: Dehydration, diabetic ketoacidosis, electrolyte imbalance, pneumonia, urosepsis, confusion. CBC [Complete Blood Count] notable for Leukocytosis. CMP [Complete Metabolic Panel] noted for blood glucose level of 356. [Target glucose range before meals for those with Type 2 Diabetes in older adults is 80 to 170]. Review of the progress note dated 7/14/2023 for Resident #33 documented in part, Returned from hospital via ambulance. Alert oriented to name and event. V/S WNL [Vital signs within normal limits]. Denies any pain or discomfort. Open blister on left shoulder. Open blister to left back. Author: [Staff B, LPN's name]. Review of the National Weather Service, Climatological Data for Brooksville area, dated 7/14/2023 documented the maximum temperature of 94 degrees Fahrenheit and the average temperature of 83.5 degrees Fahrenheit. Review of the Shower/Bath Sheet dated 7/15/2023 for Resident #33 documented in part, Reddened area: upper back right side, blister on upper neck. Review of the progress note dated 7/15/2023 for Resident #33 documented, Pt noted to have open blister to upper back and intact blister to left shoulder. Call placed to [Physician #1's name] new TX [treatment] orders initiated for Venelex [Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds, and dermal ulcers including: pressure ulcers, venous statis ulcer, first and second-degree burns .] to upper back. Skin prep to intact blister every shift. Orders for pt to not be able to go outside in the courtyard area without supervision. Author: [Staff Z, LPN's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Venelex External Ointment ([NAME]-[NAME] Oil) Apply to upper mid back topically every shift for open blister apply Venelex to upper mid back every shift. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, skin prep to left shoulder every shift for blister. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% [Silver sulfadiazine is an antibiotic and is used to treat or prevent serious infection areas of skin with second or third degree burns] Apply to see additional directions [sic] topically every shift for burns for 14 days. Cleanse with NS [normal saline], pat dry, and apply cream to [NAME] [sic] and lateral neck, posterior head, apply thin layer to areas. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Pt is not allowed to go outside in courtyard area without supervision. Ordered by [Physician #1's name]. Review of the skin/ wound progress note dated 7/17/2023 for Resident #33 documented, resident seen in r/t [related to] blister to right shoulder and open area to back of neck, resident observed resting in bed with eyes open, ruptured blister noted to right shoulder measuring 2.1 X 1.5 cm [centimeters] with small serosanguinous [containing or consisting of both blood and serous fluid] drainage, edges well defined no c/o [complaints of] pain to area, peri-wound intact, dry, intact fluid filled blister noted on right shoulder, open area noted to back of neck measuring 3.7 X 3.2 cm with moderate serosanguinous discharge, edges well defined, no c/o pain to area, peri-wound dry and intact, tx [treatment] and interventions in place resident in agreement with POC. Author: [Staff Y, LPN, Wound Care Nurse's name]. Review of APRN #1's Visit Note dated 7/17/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Acute visit for reported skin changes and bullae [blister] of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. History of Present Illness. 90 y/o male, DOB [date of birth] birthday today. Awake and alert but confused. On call provider notified over the weekend that he was found to have multiple areas of erythema and burns, some open blisters and some intact blisters. Treatment of intact blister with skin prep, and Silvadene to erythemic [redness] areas of skin. He denies any problems at this time. Was also sent to hospital on 7/14 for episode of AMS, syncopal episode after being out in the heat, humidity and sun an extended amount of time. Burns noticed the day after this event and time out in the sun for unknown duration. This is not the first occurrence of similar event, as there has been multiple times he was outside for extended periods and experienced syncopal/near syncopal events, staff is aware of these previous occurrences. Requests to have him accompanied outside, encourage fluids outside, limit time outside or to not allow him outside during certain hours were refused to be followed when given, and told that staff does not have the time or resources to do that. Requested staff to encourage hydration and requesting wound care NP [Nurse Practitioner] to eval [evaluate] and treat Condition 1: Sunburn of second degree. Assessment: new. Care Plan: Continue with skin prep to intact blisters, Silvadene to posterior head/neck, lateral neck, erythema around intact blisters. Avoid hot environments, avoid direct sun exposure especially between the hours of 1000-1600 [10:00 AM - 4:00 PM]. Encourage oral hydration. Condition 2: Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Normal pressure hydrocephalus [a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage]. Assessment: progressive. Care Plan: Poor memory/recall complicates education and reminders about limiting time outside, adequate hydration and importance of avoiding direct sunlight. Staff requested to ensure due to the severity of the sunburn and required ER visit 2/2 to being outside for extended time (mod-severe heat exposure) for him to not be allowed outside. Author [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, left shoulder-apply skin prep to area and leave open to air every shift for intact blister for 14 days. Ordered by [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% Apply to back of neck topically every shift for open blisters for 14 days cleanse areas with NS, pat dry, apply thin layer to open area and cover area with dry/foam dressing AND apply to left shoulder topically every shift for open blister cleanse area with NS, pat dry, apply thin layer to open area on shoulder and leave open to air. Ordered by [Physician #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Bactrim DS [Double Strength] Oral tablet 800/160 mg [milligrams] (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth 2 times a day for skin infection for 7 days. Ordered by [Physician #1's name]. Review of APRN #1's Visit Note dated 7/18/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Reevaluation of burns. History of Present Illness: 90 y/o male, awake and alert, but confused. Continues with burns and burn to posterior neck has worsened with darkened area of skin at the center. Silvadene currently in place. He reports [NAME] [sic] discomfort with wound care. Right shoulder blisters, 1 opened but 2nd remains closed and smaller in size. No repeated syncopal events or AMS, as he has not been outside. Requested staff to encourage hydration and requesting wound care NP to eval and treat. Condition 1: Diagnosis: Sunburn of second degree. Assessment: Continues. Care Plan: Continue skin prep to closed blister, Silvadene to eurythmic [sic] areas. Change hydrocolloid dressing q 3 days after cleansing with NSS [Normal Saline Solution] and gently pat dry given to nursing. Concern that burn is 3rd degree or slight discoloration secondary to Silvadene. Request eval/treat through wound care NP for management. Author [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented, received order from [APRN #1's name], new orders to place hydrocolloid dressing to back of neck and continue Silvadene to red areas. Review of the physician's order dated 7/18/2023 for Resident #33 documented, Back and neck every day shift for prophylaxis apply hydrocolloid dressing. Ordered by [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented in part, IDT [Interdisciplinary Team] review 7/17/2023 d/t [due to] blisters to resident's right shoulder, dorsal neck 7/15/2023 from sun exposure. Resident was wearing short sleeve shirt while outdoors. wound care treatment to areas. Author [Risk Manager's name]. Review of the incident progress note dated 7/18/2023 for Resident #33 documented in part, broken blister noted to back of neck and small blisters to upper back cream continues as per MD (Medical Doctor) order r/t prior extended sun time. During shift resident denies pain nor discomfort stating, 'cream feels good.' Author [Staff M, LPN's name]. Review of APRN Wound Nurse's Visit Note dated 7/19/2023 for Resident #33 documented in part, Chief Complaint: Acute visit for reported skin changes and bullae of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Initial exam. Current Thickness: Eschar [dry, dead tissue within a wound] covered. Current Exudate [liquid produced by the body in response to tissue damage] Amount: Small. Current Exudate Type: serous [type of fluid that comes out of a wound with tissue damage] Current Wound Margin: attached. Wound 4 Measurements: Current Length: 4.6 cm x Current Width: 3.2 cm. Current Area: 14.7. Wound 4 Bed: Eschar: 76-100%. Granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process]: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed .Skin Temperature: Warm. Wound 5 Description: Current Progress: Initial exam. Current Thickness: Partial. Current Exudate Amount: Small. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Current Length: 3.6 cm x Current Width: 4.5 cm. Wound 5 Bed: Epithelialization [process of becoming covered with or converted to a thin, continuous, protective layer of compactly packed cells]: 26-50%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Wound 5 Peripheral Skin Appearance: Texture: friable. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline Additional Comments: Dressing Chosen: Antimicrobial Benefit. SKIN: Abnormal - Open wound, dry, hyperpigmentation [darkened areas of skin], skin atrophy [thinning of top layers of the skin], tender, xerosis [skin has dry, scaly appearance due to lack of moisture content], noted sun damage on face, forearms, shoulders. Assessment. Diagnosis: Sunburn of second degree, Sunburn of third degree, exposure to sunlight, sequela. Visit Summary. Care Plan: New wounds from sunburn Cervical 3rd degree + RT Shoulder 2nd degree. Both PCP [Primary Care Physician] aware of circumstances surrounding this area. Cervical area might need enzymatic debridement [an ointment or gel with enzymes that soften unhealthy tissue] due to presence of non-viable tissue. Patient currently on Bactrim as ordered by PCP. Electronically Signed: APRN #2, CWOCN-AP [Certified Wound Ostomy Continence Nurse-Advance Practice], DNC [Dermatology Nurse Certified]. Review of the skin/wound progress noted dated 7/19/2023 for Resident #33 documented, IDT met in r/t to burns to back of neck and right shoulder, first observation by [Medical Clinic Name] wound care ARNP [sic], tx and interventions in place, resident in agreement with POC. Author [Staff Y, LPN, Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/24/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: f/u skin concerns. History of Present illness: This is a 90 y/o male being seen for follow up of skin issues, including an area on his right shoulder that now appears to have some fluctuance [sign of infection that indicates the presence of pus under the skin] to it. Wound care is following as well. Currently treating the area with skin prep as well as him recently being started on Bactrim for potential cellulitis [serious skin infection]. He denies any acute complaints aside from intermittent pain at site. He continues to want to go outside in the sun and needs to be reminded of risk of sunburn. Assessment/Plan: Condition 1. Diagnosis: Local infection of the skin and subcutaneous tissue, unspecified, Sunburn, Unspecified. Assessment: ongoing. Care Plan: Continue Bactrim, wound care f/u. if worsens may need I&D [Irrigation & Debridement. (Debridement is the process of removing nonviable tissue)]. Stressed importance of not being in sun for any period time during healing process. Review of APRN Wound Nurse's Visit Note dated 7/26/2023 for Resident #33 documented in part, Chief Complaint: F/u skin concerns. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree. Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Improving. Current Thickness: Eschar covered. Current Exudate Amount: Small. Current Exudate Type: serous. Current Wound Margin: attached. Wound 4 Measurements: Previous Length: 4.6 cm. Current Length: 4.3 cm. Previous Width: 3.2 cm. Current Width: 3.2 cm. Previous Area: 14.7 cm. Current Area: 13.8. Tunneling: No. Sinus Tract: No. Undermining: No. Hypergranulation: No. Wound 4 Bed: Eschar: 76-100%. Granulation: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency: QD [every day] Dressing: Foam Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed. Skin Temperature: Warm. Wound 5 Description: Current Progress: Improving. Current Thickness: Partial. Current Exudate Amount: None. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Previous Length: 3.6 cm. Current Length: 3.4 cm. Previous Width: 4.5 cm. Current Width: 4.4 cm. Previous Area: 16.2 cm. Current Area: 15.0. Wound 5 Bed: Slough [dead skin tissue that may have a yellow or white appearance]: 51-75%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 5 Peripheral Skin Appearance: Texture: friable (easily crumbled). Moisture: moist. Color: erythema Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: normal saline Additional Comments: Completely reabsorb blisters with erythema. Dressing Chosen: Antimicrobial [kills or slows the spread of microorganisms] Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of the physician's order dated 7/26/2023 for Resident #33 documented, right shoulder-apply betadine paint to area and leave open to air every shift for reabsorbing blisters. Ordered by [APRN Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/31/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: Acute visit for elevated glucose, c/o dysuria [pain or burning sensation while passing urine]. History of Present illness: One continues to follow for area on shoulder and back that are slowly improving. Assessment/Plan: Condition 2. Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia [too much sugar in your blood]. Assessment: worsening/exacerbation [flare up]. Care Plan: Due to underlying infection +/- stress of skin injury, FS [Finger Stick] frequency increased, monitor trend, ISS [Insulin Sliding Scale] as needed. Review of APRN Wound Nurse's Visit Note dated 8/2/2023 for Resident #33 documented in part, Wound 4 Assessment: History of Wound: Facility acquired. Wound type: Sunburn 3rd Degree. Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Improving. Current Thickness: Eschar covered. Current Exudate Amount: Small. Current Exudate Type: serous. Current Odor: Not Present. Current Wound Margain: attached. Wound 4 Measurement: Previous Length: 4.3 cm. Current Length: 4.2 cm. Diff: 0.9999999999996. Previous Width: 3.2 cm. Current Width: 3.2 cm. Diff: 0. Previous Area: 13.8 cm. Current Area: 13.4. Diff: 0.3199999999999. Tunneling: no. Sinus tract: no. Undermining: no. Hypergranulation: No. Wound 4 Bed: Slough: 76-100%. Eschar: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: no. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency : QD Dressing: Foam Wound Cleanser: normal saline Additional Comments: Santyl/Bactroban needed for debridement and antimicrobial benefit. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder 2 lesions. Wound Status: not healed. Skin Temperature: Warm. Wound 5 Description: Current Progress: Improving. Current Thickness: Partial. Current Exudate Amount: none. Current Exudate Type: serous. Current Odor: Not Present. Current Wound Margain: attached. Wound 5 Measurement: Previous Length: 3.4 cm. Current Length: 2.6 cm. Diff: 0.8. Previous Width: 4.4 cm. Current Width: 4.2 cm. Diff: 0.2 Previous Area: 15.0 cm. Current Area: 10.9. Diff: 4.04. Wound 5 Bed: Epithelialization: 26-50% Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: no. Wound 5 Peripheral Skin Appearance: Texture: firm. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: Normal Saline. Additional Comments: 50% crust. Completely reabsorb blisters with erythema. Dressing Chosen Antimicrobial Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of APRN Wound Nurse's Visit Note dated 9/6/2023 for Resident #33 documented Wound 5 was resolved. On 9/18/2023 at 9:45 AM, Resident #33 was sitting in a wheelchair in the 200 Hallway, propelling himself down the hall. The surveyor attempted to interview the resident by asking him his name. The resident was not able to respond to this question. During an interview on 9/19/2023 at 12:49 PM, the Administrator stated, He [Resident #33] is of his sound mind, and we asked him to come in several times, and he was adamant about staying outside. We can't wheel him in against his will. He knows when he is getting hot, and he can self-propel himself. We do have light duty staff that are assigned to the courtyard and round outside and offer hydration. We did an internal investigation, and I would have to see if we did an adverse incident report. I did not have a light-duty staff member out there on that day, but I did have one restorative aide who was assigned to monitor out there. It is the responsibility of all staff to know where their patients are at all times, and they are required to check on them. He has not been deemed incompetent and he is able to make decisions on his own. During an interview on 9/19/2023 at 1:40 PM, the Administrator stated, I talked to our regional about the incident and he did not feel it as an adverse incident since he was not sent out. He can self-propel himself and can go under shade if he wants. During an interview on 9/19/2023 at 3:21 PM, the Administrator stated her expectation of rounding of residents in the courtyard was Just expected to round on a routine basis. No audit just routine rounding. During a telephone interview on 9/19/2023 at 4:05 PM, the Medical Director stated, I am familiar with the incident [Resident #33's sunburns]. It was reviewed in the Quality Assurance (QA) meeting last month. I have been the Medical Director for only 3 months. I was not aware of his prior history in May of a sunburn, what I am aware of is the difference between nurse practitioner and the physician. My expectation is what was discussed in the QA meeting. We discussed setting an alarm on their phone [staff phones] for 5 minutes or 15 minutes on a sunny day. 60-degree vs 90 degree the exposure is not the same. Even if the residents are not able to communicate, they can be brought out for short periods and have two eyes on all patients that are outside. Tell the charge nurse, know your patients, and set an alarm. During an interview on 9/19/2023 at 5:40 PM, the Director of Nursing (DON) stated, I was not the DON back in May. I have only been in this position for about 3 months. I started in August 2022 as a unit manager. As a unit manager, I had no knowledge of the sunburn. It is the staff's responsibility to know where all their residents are at all times. We have a book. I can't answer if the staff is supposed to document for [Resident #33's name], or on everyone that goes outside. It is mainly the residents from the 200 unit that go outside. I am trying to find the documentation now; I don't know where it has gone. During an interview on 9/20/2023 at 9:06 AM, Physician #1 stated, The best I can recall of the incident, I got a call about some area on his [Resident #33] back, no one could recall from what it was from. They just said it was a raised area, not the best description, some type of skin change in the back. I would call the area that sun exposed area the cuspid area. Very gray area, each nurse described the area differently. When the wound started to blister, I deferred to wound care. He looked a little tanned, not out of the ordinary, I ordered skin prep to area. He was looking like he was getting a suntan. I instructed him to keep out of the sun. Maybe in July was [TRUNCATED]

Based on observations, interviews, resident record reviews, and review of the facility policies and procedures, the facility failed to ensure the residents received adequate supervision to prevent accidents by failing to implement the policies and procedures for supervision when the facility staff failed to provide adequate supervision for Resident #33. On 5/08/2023, Resident #33 was left outside unsupervised resulting in physician ordered treatment for 7 days for exposed reddened, sunburned skin. On 6/15/2023, Resident #33 was left outside unsupervised resulting in dehydration, decreased alertness, difficulty responding, heat exposure, heatstroke, and sunstroke. On 7/07/2023, Resident #33 was left outside unsupervised for a significant amount of time resulting in dehydration, excessive sun exposure, with evidence of tanning. On 7/15/2023, Resident #33 was diagnosed with blister to the upper back and left shoulder. Resident #33 was outside unsupervised on the facility patio during inclement weather conditions with the high temperatures in the mid-90s (data collected from The National Weather Service for 7/15/2023). Resident #33 sustained third-degree sunburn to his cervical mid-back area and second-degree burns to his right shoulder. The facility's failure to provide supervision of Resident #33 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the immediate Jeopardy on 9/22/2023, at 9:23 AM. The Immediate Jeopardy began on 5/08/2023, and was removed on site on 9/22/2023. Findings include: Review of the Admission Record for Resident #33 documented he is a [AGE] year-old male with diagnoses that include dementia, type 2 diabetes, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, heart failure, chronic kidney disease, peripheral vascular disease, and presence of cardiac pacemaker. Review of the Quarterly Minimum Data Set, Comprehensive Assessment, dated 6/20/2023 for Resident #33 documented a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognition. Review of the Attestation of Physician that Resident is incapacitated for Resident #33 documented I, Dr. [Physician #1's Name], attending physician to [Resident #33's name], have evaluated him/her and determined that he/she lacks the capacity to make medical decision or give informed consent. This document was signed by Physician #1 and dated 3/29/2023. Review of the APRN #1 (Advanced Practice Registered Nurse) Visit Note dated 5/8/2023 for Resident #33 documented in part, Problem list: Dehydration. History of present illness: 89 y/o (year old) male, pleasant and cooperative but confused. Noted to have significant redness to non-covered skin, reported to have been out on the patio for extended period of time over the weekend and was not in the shade. Psychiatric Orientation: abnormal - awake, alert oriented X1[times one]. Assessment Plan: Condition 2 Diagnosis: Sunburn, Unspecified. Plan of Care: Encourage oral hydration, apply Aquaphor liberally to all exposed reddened skin q [every] shift until aloe containing lotion available. Monitor and ensure if he is outside, he is in the shade. Review of the progress note dated 5/8/2023 for Resident #33 documented, ARNP [sic] rounding in facility with new orders for Aquaphor BUE [bilateral upper extremities], face, scalp, posterior neck bid [twice a day] for sunburn x 7 days, resident in agreement with POC [plan of care]. Author: [Staff Y, LPN's (Licensed Practical Nurse) name]. Review of the physician's order dated 5/8/2023 for Resident #33 documented, BUE, face, scalp, posterior neck - apply Aquaphor [used for the treatment of minor cuts and burns] area and leave open to air every evening and night shift for sunburn for 14 days. Ordered by: [APRN #1's name]. Review of the progress note dated 6/15/2023 for Resident #33 documented, Resident was noted coming back from outside to have generalized erythema [superficial reddening of the skin]. Tired and weakness. Rt [right] eye was bright red at the lower lid of eye. No drainage noted. Resident stated he was a little sore. ARNP [sic] assessed resident and gave new order for labs in am [ante meridiem, before noon], U/A C & S [urinalysis with culture and sensitivity] and neuro checks [assesses an individual's neurological functions, motor and sensory response, and level of consciousness] to be initiated as protocol. Resident O2 [oxygen] sat [saturation, how much oxygen is in your blood] was 88% [Normal oxygen levels for elderly people are usually 90% to 95%, oxygen levels below 90% are considered low and may indicate the need for supplemental oxygen]. O2 at 1 liters has been placed on resident at this time. Resident was assisted to bed to rest and cool off. No acute distress noted at this time. Resting with eyes closed. Call light within reach. Author: [Staff X, LPN's name]. Heat exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, and people with high blood pressure. Symptoms may include heavy sweating; weakness or tiredness; cool, pale, clammy skin; fast, weak pulse; muscle cramps; dizziness; nausea or vomiting; headache; and fainting (Centers for Disease Control and Prevention). Certain diabetes complications, such as damage to blood vessels and nerves, can affect the sweat glands so the body can't cool as effectively. That can lead to heat exhaustion and heat stroke, which is a medical emergency. The very young and elderly, seniors (over 65) and children (especially those under the age of 4) are often more at increased risk of heat-related illness, as they typically tend to be less aware of temperature changes and their bodies generally don't regulate as well. Review of the APRN #1 Visit Note dated 6/15/2023 for Resident #33 documented in part, Problem List: Dehydration, Unspecified Dementia. Chief Complaint: Acute Visit for Vasovagal type episode [rapid drop in heart rate and blood pressure] after being outside for too long and becoming overheated. History of Present Illness: 89 y/o male, decreased alertness and difficulty responding initially after being outside on the patio in the sun and becoming overheated. Psychiatric Orientation: Abnormal - orientated to person only. Assessment/Plan: Diagnosis: Heatstroke and sunstroke, initial encounter, other disturbances of skin sensation. Care Plan: Removed clothing and allowed to rest which improved mentation/alertness to normal level for him. Orders to monitor when he is outside and not allow him to be out, without periodic monitoring. Do not recommend greater than 20-30 minutes without hydration in current summer weather/humidity/heat. Author: [APRN #1's name]. Review of the physician's order dated 6/15/2023 for Resident #33 documented, obtain neuro checks per protocol for heat induced weakness every shift for heat weakness DC [discontinue] when done. Ordered by: [Physician #1's name]. Review of Physician #1's Visit Note dated 7/7/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration. Chief Complaint: Acute visit - f/u [follow up] change in condition. History of present illness: This is an 89 y/o male being seen for follow up after noted yesterday that he was not his normal self. It is notable that he spends a significant amount of time outside, regardless of the fact that the temperature remains higher than normal. He admits he does not drink a lot of water. It is unclear how long he spends outside his skin shows evidence of tanning and sun exposure. Assessment/Plan: Condition 1. Diagnosis: effect of heat and light, unspecified, sequela [after effect of a disease/condition], dehydration. Care Plan: Pt [patient] with excessive sun exposures. Discussed risk of heat, dehydration, need for adequate hydration. F/u with staff regarding time outside for resident. Author: [Physician #1's name]. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 7/14/2023 for Resident #33 documented in part, Situation: The change in condition, symptoms, or signs observed and evaluated are: stroke/CVA [Cardiovascular Accident]/TIA [Transient Ischemic Attack]/New neurological signs. Blood Sugar: 388. Neurological Status Evaluation: Altered level of consciousness. Recommendations: Transfer to ER [emergency room ]. Review of the hospital emergency room documentation dated 7/14/2023 for Resident #33 documented in part, The patient presents with AMS [Altered Mental Status] per SNF [Skilled Nursing Facility] report. Differential Diagnosis: Dehydration, diabetic ketoacidosis, electrolyte imbalance, pneumonia, urosepsis, confusion. CBC [Complete Blood Count] notable for Leukocytosis. CMP [Complete Metabolic Panel] noted for blood glucose level of 356. [Target glucose range before meals for those with Type 2 Diabetes in older adults is 80 to 170]. Review of the progress note dated 7/14/2023 for Resident #33 documented in part, Returned from hospital via ambulance. Alert oriented to name and event. V/S WNL [Vital signs within normal limits]. Denies any pain or discomfort. Open blister on left shoulder. Open blister to left back. Author: [Staff B, LPN's name]. Review of the National Weather Service, Climatological Data for Brooksville area, dated 7/14/2023 documented the maximum temperature of 94 degrees Fahrenheit and the average temperature of 83.5 degrees Fahrenheit. Review of the Shower/Bath Sheet dated 7/15/2023 for Resident #33 documented in part, Reddened area: upper back right side, blister on upper neck. Review of the progress note dated 7/15/2023 for Resident #33 documented, Pt noted to have open blister to upper back and intact blister to left shoulder. Call placed to [Physician #1's name] new TX [treatment] orders initiated for Venelex [Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds, and dermal ulcers including: pressure ulcers, venous statis ulcer, first and second-degree burns .] to upper back. Skin prep to intact blister every shift. Orders for pt to not be able to go outside in the courtyard area without supervision. Author: [Staff Z, LPN's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Venelex External Ointment ([NAME]-[NAME] Oil) Apply to upper mid back topically every shift for open blister apply Venelex to upper mid back every shift. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, skin prep to left shoulder every shift for blister. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% [Silver sulfadiazine is an antibiotic and is used to treat or prevent serious infection areas of skin with second or third degree burns] Apply to see additional directions [sic] topically every shift for burns for 14 days. Cleanse with NS [normal saline], pat dry, and apply cream to [NAME] [sic] and lateral neck, posterior head, apply thin layer to areas. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Pt is not allowed to go outside in courtyard area without supervision. Ordered by [Physician #1's name]. Review of the skin/ wound progress note dated 7/17/2023 for Resident #33 documented, resident seen in r/t [related to] blister to right shoulder and open area to back of neck, resident observed resting in bed with eyes open, ruptured blister noted to right shoulder measuring 2.1 X 1.5 cm [centimeters] with small serosanguinous [containing or consisting of both blood and serous fluid] drainage, edges well defined no c/o [complaints of] pain to area, peri-wound intact, dry, intact fluid filled blister noted on right shoulder, open area noted to back of neck measuring 3.7 X 3.2 cm with moderate serosanguinous discharge, edges well defined, no c/o pain to area, peri-wound dry and intact, tx [treatment] and interventions in place resident in agreement with POC. Author: [Staff Y, LPN, Wound Care Nurse's name]. Review of APRN #1's Visit Note dated 7/17/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Acute visit for reported skin changes and bullae [blister] of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. History of Present Illness. 90 y/o male, DOB [date of birth] birthday today. Awake and alert but confused. On call provider notified over the weekend that he was found to have multiple areas of erythema and burns, some open blisters and some intact blisters. Treatment of intact blister with skin prep, and Silvadene to erythemic [redness] areas of skin. He denies any problems at this time. Was also sent to hospital on 7/14 for episode of AMS, syncopal episode after being out in the heat, humidity and sun an extended amount of time. Burns noticed the day after this event and time out in the sun for unknown duration. This is not the first occurrence of similar event, as there has been multiple times he was outside for extended periods and experienced syncopal/near syncopal events, staff is aware of these previous occurrences. Requests to have him accompanied outside, encourage fluids outside, limit time outside or to not allow him outside during certain hours were refused to be followed when given, and told that staff does not have the time or resources to do that. Requested staff to encourage hydration and requesting wound care NP [Nurse Practitioner] to eval [evaluate] and treat Condition 1: Sunburn of second degree. Assessment: new. Care Plan: Continue with skin prep to intact blisters, Silvadene to posterior head/neck, lateral neck, erythema around intact blisters. Avoid hot environments, avoid direct sun exposure especially between the hours of 1000-1600 [10:00 AM - 4:00 PM]. Encourage oral hydration. Condition 2: Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Normal pressure hydrocephalus [a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage]. Assessment: progressive. Care Plan: Poor memory/recall complicates education and reminders about limiting time outside, adequate hydration and importance of avoiding direct sunlight. Staff requested to ensure due to the severity of the sunburn and required ER visit 2/2 to being outside for extended time (mod-severe heat exposure) for him to not be allowed outside. Author [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, left shoulder-apply skin prep to area and leave open to air every shift for intact blister for 14 days. Ordered by [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% Apply to back of neck topically every shift for open blisters for 14 days cleanse areas with NS, pat dry, apply thin layer to open area and cover area with dry/foam dressing AND apply to left shoulder topically every shift for open blister cleanse area with NS, pat dry, apply thin layer to open area on shoulder and leave open to air. Ordered by [Physician #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Bactrim DS [Double Strength] Oral tablet 800/160 mg [milligrams] (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth 2 times a day for skin infection for 7 days. Ordered by [Physician #1's name]. Review of APRN #1's Visit Note dated 7/18/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Reevaluation of burns. History of Present Illness: 90 y/o male, awake and alert, but confused. Continues with burns and burn to posterior neck has worsened with darkened area of skin at the center. Silvadene currently in place. He reports [NAME] [sic] discomfort with wound care. Right shoulder blisters, 1 opened but 2nd remains closed and smaller in size. No repeated syncopal events or AMS, as he has not been outside. Requested staff to encourage hydration and requesting wound care NP to eval and treat. Condition 1: Diagnosis: Sunburn of second degree. Assessment: Continues. Care Plan: Continue skin prep to closed blister, Silvadene to eurythmic [sic] areas. Change hydrocolloid dressing q 3 days after cleansing with NSS [Normal Saline Solution] and gently pat dry given to nursing. Concern that burn is 3rd degree or slight discoloration secondary to Silvadene. Request eval/treat through wound care NP for management. Author [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented, received order from [APRN #1's name], new orders to place hydrocolloid dressing to back of neck and continue Silvadene to red areas. Review of the physician's order dated 7/18/2023 for Resident #33 documented, Back and neck every day shift for prophylaxis apply hydrocolloid dressing. Ordered by [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented in part, IDT [Interdisciplinary Team] review 7/17/2023 d/t [due to] blisters to resident's right shoulder, dorsal neck 7/15/2023 from sun exposure. Resident was wearing short sleeve shirt while outdoors. wound care treatment to areas. Author [Risk Manager's name]. Review of the incident progress note dated 7/18/2023 for Resident #33 documented in part, broken blister noted to back of neck and small blisters to upper back cream continues as per MD (Medical Doctor) order r/t prior extended sun time. During shift resident denies pain nor discomfort stating, 'cream feels good.' Author [Staff M, LPN's name]. Review of APRN Wound Nurse's Visit Note dated 7/19/2023 for Resident #33 documented in part, Chief Complaint: Acute visit for reported skin changes and bullae of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Initial exam. Current Thickness: Eschar [dry, dead tissue within a wound] covered. Current Exudate [liquid produced by the body in response to tissue damage] Amount: Small. Current Exudate Type: serous [type of fluid that comes out of a wound with tissue damage] Current Wound Margin: attached. Wound 4 Measurements: Current Length: 4.6 cm x Current Width: 3.2 cm. Current Area: 14.7. Wound 4 Bed: Eschar: 76-100%. Granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process]: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed .Skin Temperature: Warm. Wound 5 Description: Current Progress: Initial exam. Current Thickness: Partial. Current Exudate Amount: Small. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Current Length: 3.6 cm x Current Width: 4.5 cm. Wound 5 Bed: Epithelialization [process of becoming covered with or converted to a thin, continuous, protective layer of compactly packed cells]: 26-50%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Wound 5 Peripheral Skin Appearance: Texture: friable. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline Additional Comments: Dressing Chosen: Antimicrobial Benefit. SKIN: Abnormal - Open wound, dry, hyperpigmentation [darkened areas of skin], skin atrophy [thinning of top layers of the skin], tender, xerosis [skin has dry, scaly appearance due to lack of moisture content], noted sun damage on face, forearms, shoulders. Assessment. Diagnosis: Sunburn of second degree, Sunburn of third degree, exposure to sunlight, sequela. Visit Summary. Care Plan: New wounds from sunburn Cervical 3rd degree + RT Shoulder 2nd degree. Both PCP [Primary Care Physician] aware of circumstances surrounding this area. Cervical area might need enzymatic debridement [an ointment or gel with enzymes that soften unhealthy tissue] due to presence of non-viable tissue. Patient currently on Bactrim as ordered by PCP. Electronically Signed: APRN #2, CWOCN-AP [Certified Wound Ostomy Continence Nurse-Advance Practice], DNC [Dermatology Nurse Certified]. Review of the skin/wound progress noted dated 7/19/2023 for Resident #33 documented, IDT met in r/t to burns to back of neck and right shoulder, first observation by [Medical Clinic Name] wound care ARNP [sic], tx and interventions in place, resident in agreement with POC. Author [Staff Y, LPN, Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/24/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: f/u skin concerns. History of Present illness: This is a 90 y/o male being seen for follow up of skin issues, including an area on his right shoulder that now appears to have some fluctuance [sign of infection that indicates the presence of pus under the skin] to it. Wound care is following as well. Currently treating the area with skin prep as well as him recently being started on Bactrim for potential cellulitis [serious skin infection]. He denies any acute complaints aside from intermittent pain at site. He continues to want to go outside in the sun and needs to be reminded of risk of sunburn. Assessment/Plan: Condition 1. Diagnosis: Local infection of the skin and subcutaneous tissue, unspecified, Sunburn, Unspecified. Assessment: ongoing. Care Plan: Continue Bactrim, wound care f/u. if worsens may need I&D [Irrigation & Debridement. (Debridement is the process of removing nonviable tissue)]. Stressed importance of not being in sun for any period time during healing process. Review of APRN Wound Nurse's Visit Note dated 7/26/2023 for Resident #33 documented in part, Chief Complaint: F/u skin concerns. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree. Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Improving. Current Thickness: Eschar covered. Current Exudate Amount: Small. Current Exudate Type: serous. Current Wound Margin: attached. Wound 4 Measurements: Previous Length: 4.6 cm. Current Length: 4.3 cm. Previous Width: 3.2 cm. Current Width: 3.2 cm. Previous Area: 14.7 cm. Current Area: 13.8. Tunneling: No. Sinus Tract: No. Undermining: No. Hypergranulation: No. Wound 4 Bed: Eschar: 76-100%. Granulation: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency: QD [every day] Dressing: Foam Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed. Skin Temperature: Warm. Wound 5 Description: Current Progress: Improving. Current Thickness: Partial. Current Exudate Amount: None. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Previous Length: 3.6 cm. Current Length: 3.4 cm. Previous Width: 4.5 cm. Current Width: 4.4 cm. Previous Area: 16.2 cm. Current Area: 15.0. Wound 5 Bed: Slough [dead skin tissue that may have a yellow or white appearance]: 51-75%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 5 Peripheral Skin Appearance: Texture: friable (easily crumbled). Moisture: moist. Color: erythema Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: normal saline Additional Comments: Completely reabsorb blisters with erythema. Dressing Chosen: Antimicrobial [kills or slows the spread of microorganisms] Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of the physician's order dated 7/26/2023 for Resident #33 documented, right shoulder-apply betadine paint to area and leave open to air every shift for reabsorbing blisters. Ordered by [APRN Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/31/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: Acute visit for elevated glucose, c/o dysuria [pain or burning sensation while passing urine]. History of Present illness: One continues to follow for area on shoulder and back that are slowly improving. Assessment/Plan: Condition 2. Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia [too much sugar in your blood]. Assessment: worsening/exacerbation [flare up]. Care Plan: Due to underlying infection +/- stress of skin injury, FS [Finger Stick] frequency increased, monitor trend, ISS [Insulin Sliding Scale] as needed. Review of APRN Wound Nurse's Visit Note dated 8/2/2023 for Resident #33 documented in part, Wound 4 Assessment: History of Wound: Facility acquired. Wound type: Sunburn 3rd Degree. Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Improving. Current Thickness: Eschar covered. Current Exudate Amount: Small. Current Exudate Type: serous. Current Odor: Not Present. Current Wound Margain: attached. Wound 4 Measurement: Previous Length: 4.3 cm. Current Length: 4.2 cm. Diff: 0.9999999999996. Previous Width: 3.2 cm. Current Width: 3.2 cm. Diff: 0. Previous Area: 13.8 cm. Current Area: 13.4. Diff: 0.3199999999999. Tunneling: no. Sinus tract: no. Undermining: no. Hypergranulation: No. Wound 4 Bed: Slough: 76-100%. Eschar: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: no. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency : QD Dressing: Foam Wound Cleanser: normal saline Additional Comments: Santyl/Bactroban needed for debridement and antimicrobial benefit. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder 2 lesions. Wound Status: not healed. Skin Temperature: Warm. Wound 5 Description: Current Progress: Improving. Current Thickness: Partial. Current Exudate Amount: none. Current Exudate Type: serous. Current Odor: Not Present. Current Wound Margain: attached. Wound 5 Measurement: Previous Length: 3.4 cm. Current Length: 2.6 cm. Diff: 0.8. Previous Width: 4.4 cm. Current Width: 4.2 cm. Diff: 0.2 Previous Area: 15.0 cm. Current Area: 10.9. Diff: 4.04. Wound 5 Bed: Epithelialization: 26-50% Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: no. Wound 5 Peripheral Skin Appearance: Texture: firm. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: Normal Saline. Additional Comments: 50% crust. Completely reabsorb blisters with erythema. Dressing Chosen Antimicrobial Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of APRN Wound Nurse's Visit Note dated 9/6/2023 for Resident #33 documented Wound 5 was resolved. On 9/18/2023 at 9:45 AM, Resident #33 was sitting in a wheelchair in the 200 Hallway, propelling himself down the hall. The surveyor attempted to interview the resident by asking him his name. The resident was not able to respond to this question. During an interview on 9/19/2023 at 12:49 PM, the Administrator stated, He [Resident #33] is of his sound mind, and we asked him to come in several times, and he was adamant about staying outside. We can't wheel him in against his will. He knows when he is getting hot, and he can self-propel himself. We do have light duty staff that are assigned to the courtyard and round outside and offer hydration. I did not have a light-duty staff member out there on that day, but I did have one restorative aide who was assigned to monitor out there. It is the responsibility of all staff to know where their patients are at all times, and they are required to check on them. He has not been deemed incompetent and he is able to make decisions on his own. During an interview on 9/19/2023 at 3:21 PM, the Administrator stated her expectation of rounding of residents in the courtyard was Just expected to round on a routine basis. No audit just routine rounding. During an interview on 9/19/2023 at 5:40 PM, the Director of Nursing (DON) stated, I was not the DON back in May. I have only been in this position for about 3 months. I started in August 2022 as a unit manager. As a unit manager, I had no knowledge of the sunburn. It is the staff's responsibility to know where all their residents are at all times. We have a book. I can't answer if the staff is supposed to document for [Resident #33's name], or on everyone that goes outside. It is mainly the residents from the 200 unit that go outside. I am trying to find the documentation now; I don't know where it has gone. During an interview on 9/20/2023 at 9:06 AM, Physician #1 stated, The best I can recall of the incident, I got a call about some area on his [Resident #33] back, no one could recall from what it was from. They just said it was a raised area, not the best description, some type of skin change in the back. I would call the area that sun exposed area the cuspid area. Very gray area, each nurse described the area differently. When the wound started to blister, I deferred to wound care. He looked a little tanned, not out of the ordinary, I ordered skin prep to area. He was looking like he was getting a suntan. I instructed him to keep out of the sun. Maybe in July was the incident, with his skin appears to be fair, maybe to be rosacea [skin condition that affects the face, causing redness, pimples and broken blood vessels]. Takes less sun exposure to easily burn, even a white t-shirt does not offer much SPF [sun protection factor], you can still get burned in some areas. I couldn't say it was from sun exposure, my concern was he had a skin concern and with his diabetes harder to control when there are skin issues. It was extremely hot with heat advisory during the summer this season. The elderly are more susceptible because they are more fragile. [APRN #1's name] is a nurse practitioner, we work together. In some, I have oversight sometimes she [APRN #1's name] acts independent, I try to be of help. We do not sit together and review charts, we do some verbal run down of some things over the phone. I don't recall that incident in May [previous sun exposure incident]. The staff do call me with concerns, they are helpful and receptive. I prefer to get a call than not know about a concern. Certain things are tangible, and some are intangible, a rash can be a lot of things for many people, skin exposure and dehydration. People don't realize it because they don't have the thirst drive and get sleepy and get even more dehydrated. We can't constrain [the] resident inside, it's not a perfect world. I would say to him [Resident #33's name], I know you like to go outside and ask him to stay out for 5 minutes. The same way a smoker understands smoki [TRUNCATED]

Based on interviews, resident record reviews, and review of the facility policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to implement policies and procedures for supervision when the facility staff failed to provide adequate supervision for Resident #33. On 5/08/2023, Resident #33 was left outside unsupervised resulting in physician ordered treatment for 7 days for exposed reddened, sunburned skin. On 6/15/2023, Resident #33 was left outside unsupervised resulting in dehydration, decreased alertness, difficulty responding, heat exposure, heatstroke, and sunstroke. On 7/07/2023, Resident #33 was left outside unsupervised for a significant amount of time resulting in dehydration, excessive sun exposure, with evidence of tanning. On 7/15/2023, Resident #33 was diagnosed with blister to the upper back and left shoulder. Resident #33 was outside unsupervised on the facility patio during inclement weather conditions with the high temperatures in the mid-90s (data collected from The National Weather Service for 7/15/2023). Resident #33 sustained third-degree sunburn to his cervical mid-back area and second-degree burns to his right shoulder. The facility's failure to provide supervision of Resident #33 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the immediate Jeopardy on 9/22/2023, at 9:23 AM. The Immediate Jeopardy began on 5/08/2023, and was removed on site on 9/22/2023. Findings include: Review of the job description titled Job Description. Job Title: Administrator signed on 10/21/22, documented in part, Reports to: Board of Directors. Job Functions: The ADMINISTRATOR is totally responsible for the organization and administration of the facility. This responsibility includes ensuring all facility services, professional and business, operates within the policy and under the direction of the Board of Directors. The Administrator is responsible to the Board of Directors and assumes such responsibilities as are delegated by the Board. Administrative Responsibilities: The Administrator shall assume those administrative responsibilities delegated by the Board of Directors and may delegate responsibilities to an appropriate staff member of the facility as necessary to provide a well-defined and operating organization. The Administration is responsible for the oversight of health, care, and treatment of residents in the nursing home. This responsibility also includes the maintenance and operation of the facility that will ensure safe, adequate and appropriate care, treatment, and health of the residents. Nursing Services. Assist the Director of Nursing Service to organize, evaluate and maintain the respective nursing services to ensure quality of care, resident rights, and regulatory compliance are adhered to. Keep informed regarding residents' condition, care rendered, and outcomes. Keep informed regarding unusual events pertaining to residents. Review of the job description titled Job Description. Job Title: Director of Nursing signed on 6/29/2023, documented in part, Reports to: Administrator. General Purpose: Organizes, directs, and oversees the work of the nursing team, nursing programs, compliance with facility policies and applicable state and federal regulations, and customizes procedures to ensure the highest degree of quality of care is offered. The Director of Nursing has administrative and managerial authority, responsibility, and accountability for the functions, activities, and training of the nursing team. Duties and Responsibilities: 17) Perform administrative duties as assigned (such as: complete various medical forms, reports, evaluations, studies, training, tracking and trending, audits, daily/weekly/monthly reviews, etc.). Some of these items may include (but are not limited to): Skin Conditions/Wounds-tracking and trending of wounds, monitoring compliance and appropriateness of treatments prescribed, verifying physician/resident notification, confirming completion of clinical documentation and accuracy of order transcription. Participate in wound rounds as directed. 40) Report and investigate all allegations of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown origin in accordance with facility abuse policy and state and federal regulations. Complete the Federal Immediate and 5-day report as required. Complete mandatory state reporting as required. The contents of the state and federal reports shall be reviewed/discussed with the Administrator and/or Risk Manager prior to submission. Review of the job description titled Job Description. Job Title: Assistant Director of Nursing documented in part, Reports to: Director of Nursing. General Purpose: Organizes, directs, and oversees the work of the nursing team, nursing programs, compliance with facility policies and applicable state and federal regulations, and customizes procedures to ensure the highest degree of quality care if offered as delegated by the Director of Nursing. Duties and Responsibilities: 17) Perform administrative duties as assigned (such as: complete various medical forms, reports, evaluations, studies, training, tracking and trending, audits, daily/weekly/monthly reviews, etc.). Some of these items may include (but are not limited to): Skin Conditions/Wounds-tracking and trending of wounds, monitoring compliance and appropriateness of treatments prescribed, verifying physician/resident notification, confirming completion of clinical documentation and accuracy of order transcription. Participate in wound rounds as directed. Review of the job description titled Job Description. Job Title: Risk Manager/Designee documented in part, Reports to: Reports to: Administrator. General Purpose: The designated individual is responsible for the implementation and oversight of the facility-wide Risk Management and Quality Assurance Program that includes: identifying, frequency trending, analyzing, minimizing risk, and developing corrective actions. The health care risk manager performs a variety of duties related to managing potential risks and liabilities within the facility in an effort to enhance each resident's quality of life. Duties and Responsibilities: 9) Oversee Risk Management and Quality Assurance activities including: Review, investigate, and analyze resident incident reports-the reporting of specific types of incidents as required under federal and state regulations. Evaluate security and safety practices and potential environmental hazards.13) Report and investigate all allegations of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown origin in accordance with the facility abuse policy and state and federal regulations. Complete the Federal Immediate and 5-day report as required. Complete mandatory state reporting as required. The contents of the state and federal reports shall be reviewed/discussed with the Administrator and/or Director of Nursing prior to submission. 20. Understand and adhere to established facility policies. Review of the Performance Requirements and Duties and Responsibilities of a Nursing Facility Medical Director documented in part, Duties and Responsibilities of a Medical Director (Essential Functions): 1. Provide medical decision input and support to the Administrator and governing body of the facility. 2. Implement resident care policies. 2.2. Implement resident care policies regarding: accidents and incidents, ancillary services such as laboratory, radiology and pharmacy; use of medications; use and release of clinical information; and overall quality of care. 3. Coordinate and oversee medical care and treatment, including physician services and services of other professionals as they relate to resident care. 4. Oversee that all necessary medical services provided to residents are adequate and appropriate. 5. Coordinate the facility's quality assurance process, to ensure the quality of medical and medically related care. 6. Advise the facility administration and governing body of current medical issues affecting the resident. 7. Provide on call availability and respond to medical or regulatory or other emergencies. 8. Participate in the development and presentation of education programs. Review of the Admission Record for Resident #33 documented he is a [AGE] year-old male with diagnoses that include dementia, type 2 diabetes, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, heart failure, chronic kidney disease, peripheral vascular disease, and presence of cardiac pacemaker. Review of the Quarterly Minimum Data Set, Comprehensive Assessment, dated 6/20/2023 for Resident #33 documented a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognition. Review of the Attestation of Physician that Resident is incapacitated for Resident #33 documented I, Dr. [Physician #1's Name], attending physician to [Resident #33's name], have evaluated him/her and determined that he/she lacks the capacity to make medical decision or give informed consent. This document was signed by Physician #1 and dated 3/29/2023. Review of the APRN #1 (Advanced Practice Registered Nurse) Visit Note dated 5/8/2023 for Resident #33 documented in part, Problem list: Dehydration. History of present illness: 89 y/o (year old) male, pleasant and cooperative but confused. Noted to have significant redness to non-covered skin, reported to have been out on the patio for extended period of time over the weekend and was not in the shade. Psychiatric Orientation: abnormal - awake, alert oriented X1 [times one]. Assessment Plan: Condition 2 Diagnosis: Sunburn, Unspecified. Plan of Care: Encourage oral hydration, apply Aquaphor liberally to all exposed reddened skin q [every] shift until aloe containing lotion available. Monitor and ensure if he is outside, he is in the shade. Review of the progress note dated 5/8/2023 for Resident #33 documented, ARNP [sic] rounding in facility with new orders for Aquaphor [used for the treatment of minor cuts and burns] BUE [bilateral upper extremities], face, scalp, posterior neck bid [twice a day] for sunburn x 7 days, resident in agreement with POC [plan of care]. Author: [Staff Y, LPN's (Licensed Practical Nurse) name]. Review of the physician's order dated 5/8/2023 for Resident #33 documented, BUE, face, scalp, posterior neck - apply Aquaphor area and leave open to air every evening and night shift for sunburn for 14 days. Ordered by: [APRN #1's name]. Review of the progress note dated 6/15/2023 for Resident #33 documented, Resident was noted coming back from outside to have generalized erythema [superficial reddening of the skin]. Tired and weakness. Rt [right] eye was bright red at the lower lid of eye. No drainage noted. Resident stated he was a little sore. ARNP [sic] assessed resident and gave new order for labs in am [ante meridiem, before noon], U/A C & S [urinalysis with culture and sensitivity] and neuro checks [assesses an individual's neurological functions, motor and sensory response, and level of consciousness] to be initiated as protocol. Resident O2 [oxygen] sat [saturation, how much oxygen is in your blood] was 88% [Normal oxygen levels for elderly people are usually 90% to 95%, oxygen levels below 90% are considered low and may indicate the need for supplemental oxygen]. O2 at 1 liters has been placed on resident at this time. Resident was assisted to bed to rest and cool off. No acute distress noted at this time. Resting with eyes closed. Call light within reach. Author: [Staff X, LPN's name]. Review of the APRN #1 Visit Note dated 6/15/2023 for Resident #33 documented in part, Problem List: Dehydration, Unspecified Dementia. Chief Complaint: Acute Visit for Vasovagal type episode [rapid drop in heart rate and blood pressure] after being outside for too long and becoming overheated. History of Present Illness: 89 y/o male, decreased alertness and difficulty responding initially after being outside on the patio in the sun and becoming overheated. Psychiatric Orientation: Abnormal - orientated to person only. Assessment/Plan: Diagnosis: Heatstroke and sunstroke, initial encounter, other disturbances of skin sensation. Care Plan: Removed clothing and allowed to rest which improved mentation/alertness to normal level for him. Orders to monitor when he is outside and not allow him to be out, without periodic monitoring. Do not recommend greater than 20-30 minutes without hydration in current summer weather/humidity/heat. Author: [APRN #1's name]. Heat exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, and people with high blood pressure. Symptoms may include heavy sweating; weakness or tiredness; cool, pale, clammy skin; fast, weak pulse; muscle cramps; dizziness; nausea or vomiting; headache; and fainting (Centers for Disease Control and Prevention). Certain diabetes complications, such as damage to blood vessels and nerves, can affect the sweat glands so the body can't cool as effectively. That can lead to heat exhaustion and heat stroke, which is a medical emergency. The very young and elderly, seniors (over 65) and children (especially those under the age of 4) are often more at increased risk of heat-related illness, as they typically tend to be less aware of temperature changes and their bodies generally don't regulate as well. Review of the physician's order dated 6/15/2023 for Resident #33 documented, obtain neuro checks per protocol for heat induced weakness every shift for heat weakness DC [discontinue] when done. Ordered by: [Physician #1's name]. Review of Physician #1's Visit Note dated 7/7/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration. Chief Complaint: Acute visit - f/u [follow up] change in condition. History of present illness: This is an 89 y/o male being seen for follow up after noted yesterday that he was not his normal self. It is notable that he spends a significant amount of time outside, regardless of the fact that the temperature remains higher than normal. He admits he does not drink a lot of water. It is unclear how long he spends outside his skin shows evidence of tanning and sun exposure. Assessment/Plan: Condition 1. Diagnosis: effect of heat and light, unspecified, sequela [after effect of a disease/condition], dehydration. Care Plan: Pt [patient] with excessive sun exposures. Discussed risk of heat, dehydration, need for adequate hydration. F/u with staff regarding time outside for resident. Author: [Physician #1's name]. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 7/14/2023 for Resident #33 documented in part, Situation: The change in condition, symptoms, or signs observed and evaluated are: stroke/CVA [Cardiovascular Accident]/TIA [Transient Ischemic Attack]/New neurological signs. Blood Sugar: 388. Neurological Status Evaluation: Altered level of consciousness. Recommendations: Transfer to ER [emergency room ]. Review of the hospital emergency room documentation dated 7/14/2023 for Resident #33 documented in part, The patient presents with AMS [Altered Mental Status] per SNF [Skilled Nursing Facility] report. Differential Diagnosis: Dehydration, diabetic ketoacidosis, electrolyte imbalance, pneumonia, urosepsis, confusion. CBC [Complete Blood Count] notable for Leukocytosis. CMP [Complete Metabolic Panel] noted for blood glucose level of 356. [Target glucose range before meals for those with Type 2 Diabetes in older adults is 80 to 170]. Review of the progress note dated 7/14/2023 for Resident #33 documented in part, Returned from hospital via ambulance. Alert oriented to name and event. V/S WNL [Vital signs within normal limits]. Denies any pain or discomfort. Open blister on left shoulder. Open blister to left back. Author: [Staff B, LPN's name]. Review of the National Weather Service, Climatological Data for Brooksville area, dated 7/14/2023 documented the maximum temperature of 94 degrees Fahrenheit and the average temperature of 83.5 degrees Fahrenheit. Review of the Shower/Bath Sheet dated 7/15/2023 for Resident #33 documented in part, Reddened area: upper back right side, blister on upper neck. Review of the progress note dated 7/15/2023 for Resident #33 documented, Pt noted to have open blister to upper back and intact blister to left shoulder. Call placed to [Physician #1's name] new TX [treatment] orders initiated for Venelex [Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds, and dermal ulcers including: pressure ulcers, venous statis ulcer, first and second-degree burns .] to upper back. Skin prep to intact blister every shift. Orders for pt to not be able to go outside in the courtyard area without supervision. Author: [Staff Z, LPN's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Venelex External Ointment ([NAME]-[NAME] Oil) Apply to upper mid back topically every shift for open blister apply Venelex to upper mid back every shift. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, skin prep to left shoulder every shift for blister. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% [Silver sulfadiazine is an antibiotic and is used to treat or prevent serious infection areas of skin with second or third degree burns] Apply to see additional directions [sic] topically every shift for burns for 14 days. Cleanse with NS [normal saline], pat dry, and apply cream to [NAME] [sic] and lateral neck, posterior head, apply thin layer to areas. Ordered by [Physician #1's name]. Review of the physician's order dated 7/15/2023 for Resident #33 documented, Pt is not allowed to go outside in courtyard area without supervision. Ordered by [Physician #1's name]. Review of the skin/ wound progress note dated 7/17/2023 for Resident #33 documented, resident seen in r/t [related to] blister to right shoulder and open area to back of neck, resident observed resting in bed with eyes open, ruptured blister noted to right shoulder measuring 2.1 X 1.5 cm [centimeters] with small serosanguinous [containing or consisting of both blood and serous fluid] drainage, edges well defined no c/o [complaints of] pain to area, peri-wound intact, dry, intact fluid filled blister noted on right shoulder, open area noted to back of neck measuring 3.7 X 3.2 cm with moderate serosanguinous discharge, edges well defined, no c/o pain to area, peri-wound dry and intact, tx [treatment] and interventions in place resident in agreement with POC. Author: [Staff Y, LPN, Wound Care Nurse's name]. Review of APRN #1's Visit Note dated 7/17/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Acute visit for reported skin changes and bullae [blister] of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. History of Present Illness. 90 y/o male, DOB [date of birth] birthday today. Awake and alert but confused. On call provider notified over the weekend that he was found to have multiple areas of erythema and burns, some open blisters and some intact blisters. Treatment of intact blister with skin prep, and Silvadene to erythemic [redness] areas of skin. He denies any problems at this time. Was also sent to hospital on 7/14 for episode of AMS, syncopal episode after being out in the heat, humidity and sun an extended amount of time. Burns noticed the day after this event and time out in the sun for unknown duration. This is not the first occurrence of similar event, as there has been multiple times he was outside for extended periods and experienced syncopal/near syncopal events, staff is aware of these previous occurrences. Requests to have him accompanied outside, encourage fluids outside, limit time outside or to not allow him outside during certain hours were refused to be followed when given, and told that staff does not have the time or resources to do that. Requested staff to encourage hydration and requesting wound care NP [Nurse Practitioner] to eval [evaluate] and treat Condition 1: Sunburn of second degree. Assessment: new. Care Plan: Continue with skin prep to intact blisters, Silvadene to posterior head/neck, lateral neck, erythema around intact blisters. Avoid hot environments, avoid direct sun exposure especially between the hours of 1000-1600 [10:00 AM - 4:00 PM]. Encourage oral hydration. Condition 2: Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Normal pressure hydrocephalus [a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage]. Assessment: progressive. Care Plan: Poor memory/recall complicates education and reminders about limiting time outside, adequate hydration and importance of avoiding direct sunlight. Staff requested to ensure due to the severity of the sunburn and required ER visit 2/2 to being outside for extended time (mod-severe heat exposure) for him to not be allowed outside. Author [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, left shoulder-apply skin prep to area and leave open to air every shift for intact blister for 14 days. Ordered by [APRN #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Silver Sulfadiazine Cream 1% Apply to back of neck topically every shift for open blisters for 14 days cleanse areas with NS, pat dry, apply thin layer to open area and cover area with dry/foam dressing AND apply to left shoulder topically every shift for open blister cleanse area with NS, pat dry, apply thin layer to open area on shoulder and leave open to air. Ordered by [Physician #1's name]. Review of the physician's order dated 7/17/2023 for Resident #33 documented, Bactrim DS [Double Strength] Oral tablet 800/160 mg [milligrams] (Sulfamethoxazole-Trimethoprim). Give one tablet by mouth 2 times a day for skin infection for 7 days. Ordered by [Physician #1's name]. Review of APRN #1's Visit Note dated 7/18/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Reevaluation of burns. History of Present Illness: 90 y/o male, awake and alert, but confused. Continues with burns and burn to posterior neck has worsened with darkened area of skin at the center. Silvadene currently in place. He reports [NAME] [sic] discomfort with wound care. Right shoulder blisters, 1 opened but 2nd remains closed and smaller in size. No repeated syncopal events or AMS, as he has not been outside. Requested staff to encourage hydration and requesting wound care NP to eval and treat. Condition 1: Diagnosis: Sunburn of second degree. Assessment: Continues. Care Plan: Continue skin prep to closed blister, Silvadene to eurythmic [sic] areas. Change hydrocolloid dressing q 3 days after cleansing with NSS [Normal Saline Solution] and gently pat dry given to nursing. Concern that burn is 3rd degree or slight discoloration secondary to Silvadene. Request eval/treat through wound care NP for management. Author [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented, received order from [APRN #1's name], new orders to place hydrocolloid dressing to back of neck and continue Silvadene to red areas. Review of the physician's order dated 7/18/2023 for Resident #33 documented, Back and neck every day shift for prophylaxis apply hydrocolloid dressing. Ordered by [APRN #1's name]. Review of the progress note dated 7/18/2023 for Resident #33 documented in part, IDT [Interdisciplinary Team] review 7/17/2023 d/t [due to] blisters to resident's right shoulder, dorsal neck 7/15/2023 from sun exposure. Resident was wearing short sleeve shirt while outdoors. wound care treatment to areas. Author [Risk Manager's name]. Review of the incident progress note dated 7/18/2023 for Resident #33 documented in part, broken blister noted to back of neck and small blisters to upper back cream continues as per MD (Medical Doctor) order r/t prior extended sun time. During shift resident denies pain nor discomfort stating, 'cream feels good.' Author [Staff M, LPN's name]. Review of APRN Wound Nurse's Visit Note dated 7/19/2023 for Resident #33 documented in part, Chief Complaint: Acute visit for reported skin changes and bullae of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Initial exam. Current Thickness: Eschar [dry, dead tissue within a wound] covered. Current Exudate [liquid produced by the body in response to tissue damage] Amount: Small. Current Exudate Type: serous [type of fluid that comes out of a wound with tissue damage] Current Wound Margin: attached. Wound 4 Measurements: Current Length: 4.6 cm x Current Width: 3.2 cm. Current Area: 14.7. Wound 4 Bed: Eschar: 76-100%. Granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process]: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed .Skin Temperature: Warm. Wound 5 Description: Current Progress: Initial exam. Current Thickness: Partial. Current Exudate Amount: Small. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Current Length: 3.6 cm x Current Width: 4.5 cm. Wound 5 Bed: Epithelialization [process of becoming covered with or converted to a thin, continuous, protective layer of compactly packed cells]: 26-50%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Wound 5 Peripheral Skin Appearance: Texture: friable. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Silvadene Frequency: BID Wound Cleanser: normal saline Additional Comments: Dressing Chosen: Antimicrobial Benefit. SKIN: Abnormal - Open wound, dry, hyperpigmentation [darkened areas of skin], skin atrophy [thinning of top layers of the skin], tender, xerosis [skin has dry, scaly appearance due to lack of moisture content], noted sun damage on face, forearms, shoulders. Assessment. Diagnosis: Sunburn of second degree, Sunburn of third degree, exposure to sunlight, sequela. Visit Summary. Care Plan: New wounds from sunburn Cervical 3rd degree + RT Shoulder 2nd degree. Both PCP [Primary Care Physician] aware of circumstances surrounding this area. Cervical area might need enzymatic debridement [an ointment or gel with enzymes that soften unhealthy tissue] due to presence of non-viable tissue. Patient currently on Bactrim as ordered by PCP. Electronically Signed: APRN #2, CWOCN-AP [Certified Wound Ostomy Continence Nurse-Advance Practice], DNC [Dermatology Nurse Certified]. Review of the skin/wound progress noted dated 7/19/2023 for Resident #33 documented, IDT met in r/t to burns to back of neck and right shoulder, first observation by [Medical Clinic Name] wound care ARNP [sic], tx and interventions in place, resident in agreement with POC. Author [Staff Y, LPN, Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/24/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: f/u skin concerns. History of Present illness: This is a 90 y/o male being seen for follow up of skin issues, including an area on his right shoulder that now appears to have some fluctuance [sign of infection that indicates the presence of pus under the skin] to it. Wound care is following as well. Currently treating the area with skin prep as well as him recently being started on Bactrim for potential cellulitis [serious skin infection]. He denies any acute complaints aside from intermittent pain at site. He continues to want to go outside in the sun and needs to be reminded of risk of sunburn. Assessment/Plan: Condition 1. Diagnosis: Local infection of the skin and subcutaneous tissue, unspecified, Sunburn, Unspecified. Assessment: ongoing. Care Plan: Continue Bactrim, wound care f/u. if worsens may need I&D [Irrigation & Debridement. (Debridement is the process of removing nonviable tissue)]. Stressed importance of not being in sun for any period time during healing process. Review of APRN Wound Nurse's Visit Note dated 7/26/2023 for Resident #33 documented in part, Chief Complaint: F/u skin concerns. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree. Wound Location: Cervical. Wound Status: not healed. Skin Temperature: Warm. Wound 4 Description: Current Progress: Improving. Current Thickness: Eschar covered. Current Exudate Amount: Small. Current Exudate Type: serous. Current Wound Margin: attached. Wound 4 Measurements: Previous Length: 4.6 cm. Current Length: 4.3 cm. Previous Width: 3.2 cm. Current Width: 3.2 cm. Previous Area: 14.7 cm. Current Area: 13.8. Tunneling: No. Sinus Tract: No. Undermining: No. Hypergranulation: No. Wound 4 Bed: Eschar: 76-100%. Granulation: 1-25%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 4 Peripheral Skin Appearance: Texture: edema. Moisture: moist. Color: erythema. Signs/symptoms of an infection were not present. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency: QD [every day] Dressing: Foam Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed. Skin Temperature: Warm. Wound 5 Description: Current Progress: Improving. Current Thickness: Partial. Current Exudate Amount: None. Current Odor: Not Present. Current Wound Margin: attached. Wound 5 Measurements: Previous Length: 3.6 cm. Current Length: 3.4 cm. Previous Width: 4.5 cm. Current Width: 4.4 cm. Previous Area: 16.2 cm. Current Area: 15.0. Wound 5 Bed: Slough [dead skin tissue that may have a yellow or white appearance]: 51-75%. Granulation: 26-50%. Granulation Texture: Firm. Granulation Color: bright red. Structure Exposed: No. Wound 5 Peripheral Skin Appearance: Texture: friable (easily crumbled). Moisture: moist. Color: erythema Signs/symptoms of an infection were not present. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: normal saline Additional Comments: Completely reabsorb blisters with erythema. Dressing Chosen: Antimicrobial [kills or slows the spread of microorganisms] Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of the physician's order dated 7/26/2023 for Resident #33 documented, right shoulder-apply betadine paint to area and leave open to air every shift for reabsorbing blisters. Ordered by [APRN Wound Nurse's name]. Review of Physician #1's Visit Note dated 7/31/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: Acute visit

Based on interviews, resident record reviews, and review of the facility policies and procedures, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility staff failed to provide adequate supervision for Resident #33. On 5/08/2023, Resident #33 was left outside unsupervised resulting in physician ordered treatment for 7 days for exposed reddened, sunburned skin. On 6/15/2023, Resident #33 was left outside unsupervised resulting in dehydration, decreased alertness, difficulty responding, heat exposure, heatstroke, and sunstroke. On 7/07/2023, Resident #33 was left outside unsupervised for a significant amount of time resulting in dehydration, excessive sun exposure, with evidence of tanning. On 7/15/2023, Resident #33 was diagnosed with blister to the upper back and left shoulder. Resident #33 was outside unsupervised on the facility patio during inclement weather conditions with the high temperatures in the mid-90s (data collected from The National Weather Service for 7/15/2023). Resident #33 sustained third-degree sunburn to his cervical mid-back area and second-degree burns to his right shoulder. The facility's failure to develop and implement appropriate plans of action to identify and correct process failures related to the facility's failure to provide supervision of Resident #33 led to a determination of Immediate Jeopardy at a scope and severity of isolated, (J). The Nursing Home Administrator was notified of the immediate Jeopardy on 9/22/2023, at 9:23 AM. The Immediate Jeopardy began on 5/08/2023, and was removed on site on 9/22/2023. Heat exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, and people with high blood pressure. Symptoms may include heavy sweating; weakness or tiredness; cool, pale, clammy skin; fast, weak pulse; muscle cramps. Findings include: Resident #33 is a [AGE] year-old male with diagnoses that include dementia, type 2 diabetes, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, heart failure, chronic kidney disease, peripheral vascular disease, and presence of cardiac pacemaker. The resident was determined he lacks the capacity to make medical decisions or give informed consent by Physician #1 on 3/29/2023. The resident has a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognition. Resident #33 was left outside unsupervised on 4 separate occasions, on 5/08/2023, resulting in physician ordered treatment for 7 days for exposed reddened, sunburned skin, on 6/15/2023, resulting in dehydration, decreased alertness, difficulty responding, heat exposure, heatstroke, and sunstroke, on 7/07/2023, resulting in dehydration, excessive sun exposure, with evidence of tanning and on 7/15/2023, resulting in third-degree sunburn to his cervical mid-back area and second-degree burns to his right shoulder, with blistering. (Cross Reference F600 and F689) Review of the APRN #1 (Advanced Practice Registered Nurse) Visit Note dated 5/8/2023 for Resident #33 documented in part, Problem list: Dehydration. History of present illness: 89 y/o (year old) male, pleasant and cooperative but confused. Noted to have significant redness to non-covered skin, reported to have been out on the patio for extended period of time over the weekend and was not in the shade. Psychiatric Orientation: abnormal - awake, alert oriented X1 [times one]. Assessment Plan: Condition 2 Diagnosis: Sunburn, Unspecified. Plan of Care: Encourage oral hydration, apply Aquaphor liberally to all exposed reddened skin q [every] shift until aloe containing lotion available. Monitor and ensure if he is outside, he is in the shade. Review of the APRN #1 Visit Note dated 6/15/2023 for Resident #33 documented in part, Problem List: Dehydration, Unspecified Dementia. Chief Complaint: Acute Visit for Vasovagal type episode [rapid drop in heart rate and blood pressure] after being outside for too long and becoming overheated. History of Present Illness: 89 y/o male, decreased alertness and difficulty responding initially after being outside on the patio in the sun and becoming overheated. Psychiatric Orientation: Abnormal - orientated to person only. Assessment/Plan: Diagnosis: Heatstroke and sunstroke, initial encounter, other disturbances of skin sensation. Care Plan: Removed clothing and allowed to rest which improved mentation/alertness to normal level for him. Orders to monitor when he is outside and not allow him to be out, without periodic monitoring. Do not recommend greater than 20-30 minutes without hydration in current summer weather/humidity/heat. Author: [APRN #1's name]. Review of the progress note dated 6/15/2023 for Resident #33 documented, Resident was noted coming back from outside to have generalized erythema [superficial reddening of the skin]. Tired and weakness. Rt [right] eye was bright red at the lower lid of eye. No drainage noted. Resident stated he was a little sore. ARNP [sic] assessed resident and gave new order for labs in am [ante meridiem, before noon], U/A C & S [urinalysis with culture and sensitivity] and neuro checks [assesses an individual's neurological functions, motor and sensory response, and level of consciousness] to be initiated as protocol. Resident O2 [oxygen] sat [saturation, how much oxygen is in your blood] was 88% [Normal oxygen levels for elderly people are usually 90% to 95%, oxygen levels below 90% are considered low and may indicate the need for supplemental oxygen]. O2 at 1 liters has been placed on resident at this time. Resident was assisted to bed to rest and cool off. No acute distress noted at this time. Resting with eyes closed. Call light within reach. Author: [Staff X, LPN's name]. Review of Physician #1's Visit Note dated 7/7/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration. Chief Complaint: Acute visit - f/u [follow up] change in condition. History of present illness: This is an 89 y/o male being seen for follow up after noted yesterday that he was not his normal self. It is notable that he spends a significant amount of time outside, regardless of the fact that the temperature remains higher than normal. He admits he does not drink a lot of water. It is unclear how long he spends outside his skin shows evidence of tanning and sun exposure. Assessment/Plan: Condition 1. Diagnosis: effect of heat and light, unspecified, sequela [after effect of a disease/condition], dehydration. Care Plan: Pt [patient] with excessive sun exposures. Discussed risk of heat, dehydration, need for adequate hydration. F/u with staff regarding time outside for resident. Author: [Physician #1's name]. Review of the SBAR (Situation, Background, Assessment, Recommendation) dated 7/14/2023 for Resident #33 documented in part, Situation: The change in condition, symptoms, or signs observed and evaluated are: stroke/CVA [Cardiovascular Accident]/TIA [Transient Ischemic Attack]/New neurological signs. Blood Sugar: 388. Neurological Status Evaluation: Altered level of consciousness. Recommendations: Transfer to ER [emergency room ]. Review of the hospital emergency room documentation dated 7/14/2023 for Resident #33 documented in part, The patient presents with AMS [Altered Mental Status] per SNF [Skilled Nursing Facility] report. Differential Diagnosis: Dehydration, diabetic ketoacidosis, electrolyte imbalance, pneumonia, urosepsis, confusion. CBC [Complete Blood Count] notable for Leukocytosis. CMP [Complete Metabolic Panel] noted for blood glucose level of 356 [Target glucose range before meals for those with Type 2 Diabetes in older adults is 80 to 170]. Review of APRN #1's Visit Note dated 7/17/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Acute visit for reported skin changes and bullae [blister] of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. History of Present Illness. 90 y/o male, DOB [date of birth] birthday today. Awake and alert but confused. On call provider notified over the weekend that he was found to have multiple areas of erythema and burns, some open blisters and some intact blisters. Treatment of intact blister with skin prep, and Silvadene to erythemic [redness] areas of skin. He denies any problems at this time. Was also sent to hospital on 7/14 for episode of AMS, syncopal episode after being out in the heat, humidity and sun an extended amount of time. Burns noticed the day after this event and time out in the sun for unknown duration. This is not the first occurrence of similar event, as there has been multiple times he was outside for extended periods and experienced syncopal/near syncopal events, staff is aware of these previous occurrences. Requests to have him accompanied outside, encourage fluids outside, limit time outside or to not allow him outside during certain hours were refused to be followed when given, and told that staff does not have the time or resources to do that. Requested staff to encourage hydration and requesting wound care NP [Nurse Practitioner] to eval [evaluate] and treat Condition 1: Sunburn of second degree. Assessment: new. Care Plan: Continue with skin prep to intact blisters, Silvadene to posterior head/neck, lateral neck, erythema around intact blisters. Avoid hot environments, avoid direct sun exposure especially between the hours of 1000-1600 [10:00 AM - 4:00 PM]. Encourage oral hydration. Condition 2: Dementia in other diseases classified elsewhere, unspecified severity, with agitation. Normal pressure hydrocephalus [a condition in which fluid accumulates in the brain, enlarging the head and sometimes causing brain damage]. Assessment: progressive. Care Plan: Poor memory/recall complicates education and reminders about limiting time outside, adequate hydration and importance of avoiding direct sunlight. Staff requested to ensure due to the severity of the sunburn and required ER visit 2/2 to being outside for extended time (mod-severe heat exposure) for him to not be allowed outside. Author [APRN #1's name]. Review of APRN #1's Visit Note dated 7/18/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration, Sunburn of Second Degree, Sunburn of Third Degree, Exposure to Sunlight Sequela. Chief Complaint: Reevaluation of burns. History of Present Illness: 90 y/o male, awake and alert, but confused. Continues with burns and burn to posterior neck has worsened with darkened area of skin at the center. Silvadene currently in place. He reports [NAME] [sic] discomfort with wound care. Right shoulder blisters, 1 opened but 2nd remains closed and smaller in size. No repeated syncopal events or AMS, as he has not been outside. Requested staff to encourage hydration and requesting wound care NP to eval and treat. Condition 1: Diagnosis: Sunburn of second degree. Assessment: Continues. Care Plan: Continue skin prep to closed blister, Silvadene to eurythmic [sic] areas. Change hydrocolloid dressing q 3 days after cleansing with NSS [Normal Saline Solution] and gently pat dry given to nursing. Concern that burn is 3rd degree or slight discoloration secondary to Silvadene. Request eval/treat through wound care NP for management. Author [APRN #1's name]. Review of APRN Wound Nurse's Visit Note dated 7/19/2023 for Resident #33 documented in part, Chief Complaint: Acute visit for reported skin changes and bullae of scalp, neck and shoulders, recent episode of AMS/weakness and syncope requiring evaluation at ER. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree Wound Location: Cervical. Wound Status: not healed. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed. Assessment. Diagnosis: Sunburn of second degree, Sunburn of third degree, exposure to sunlight, sequela. Visit Summary. Care Plan: New wounds from sunburn Cervical 3rd degree + RT Shoulder 2nd degree. Both PCP [Primary Care Physician] aware of circumstances surrounding this area. Cervical area might need enzymatic debridement [an ointment or gel with enzymes that soften unhealthy tissue] due to presence of non-viable tissue. Patient currently on Bactrim as ordered by PCP. Electronically Signed: APRN #2, CWOCN-AP [Certified Wound Ostomy Continence Nurse-Advance Practice], DNC [Dermatology Nurse Certified]. Review of APRN Wound Nurse's Visit Note dated 7/26/2023 for Resident #33 documented in part, Chief Complaint: F/u skin concerns. Pain Level: 5 out of 10. Wound 4 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 3rd degree. Wound Location: Cervical. Wound Status: not healed. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency: QD [every day] Dressing: Foam Wound Cleanser: normal saline. Wound 5 Assessment: History of Wound: facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder. Wound Status: not healed. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: normal saline Additional Comments: Completely reabsorb blisters with erythema. Dressing Chosen: Antimicrobial [kills or slows the spread of microorganisms] Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Review of Physician #1's Visit Note dated 7/31/2023 for Resident #33 documented in part, Problem List: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. Chief complaint: Acute visit for elevated glucose, c/o dysuria [pain or burning sensation while passing urine]. History of Present illness: One continues to follow for area on shoulder and back that are slowly improving. Assessment/Plan: Condition 2. Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia [too much sugar in your blood]. Assessment: worsening/exacerbation [flare up]. Care Plan: Due to underlying infection +/- stress of skin injury, FS [Finger Stick] frequency increased, monitor trend, ISS [Insulin Sliding Scale] as needed. Review of APRN Wound Nurse's Visit Note dated 8/2/2023 for Resident #33 documented in part, Wound 4 Assessment: History of Wound: Facility acquired. Wound type: Sunburn 3rd Degree. Wound Location: Cervical. Wound Status: not healed. Wound 4 Treatment: Treatment: Santyl/Bactroban Frequency : QD Dressing: Foam Wound Cleanser: normal saline Additional Comments: Santyl/Bactroban needed for debridement and antimicrobial benefit. Wound 5 Assessment: History of Wound: Facility acquired. Wound Type: Sunburn 2nd degree. Wound Location: RT Shoulder 2 lesions. Wound Status: not healed. Wound 5 Treatment: Treatment: Betadine Paint Frequency: QD Wound Cleanser: Normal Saline. Additional Comments: 50% crust. Completely reabsorb blisters with erythema. Dressing Chosen Antimicrobial Benefit. Assessment / Diagnosis: Sunburn of second degree, Sunburn of third degree, Exposure to sunlight, Sequela. During an interview on 9/19/2023 at 12:49 PM, the Administrator stated, He [Resident #33] is of his sound mind, and we asked him to come in several times, and he was adamant about staying outside. We can't wheel him in against his will. He knows when he is getting hot, and he can self-propel himself. We do have light duty staff that are assigned to the courtyard and round outside and offer hydration. We did an internal investigation, and I would have to see if we did an adverse incident report. I did not have a light-duty staff member out there on that day, but I did have one restorative aide who was assigned to monitor out there. It is the responsibility of all staff to know where their patients are at all times, and they are required to check on them. He has not been deemed incompetent and he is able to make decisions on his own. During a telephone interview on 9/19/2023 at 4:05 PM, the Medical Director stated, I am familiar with the incident [Resident #33's sunburns]. It was reviewed in the Quality Assurance (QA) meeting last month. I have been the Medical Director for only 3 months. I was not aware of his prior history in May of a sunburn, what I am aware of is the difference between nurse practitioner and the physician. My expectation is what was discussed in the QA meeting. We discussed setting an alarm on their phone [staff phones] for 5 minutes or 15 minutes on a sunny day. 60-degree vs 90 degree the exposure is not the same. Even if the residents are not able to communicate, they can be brought out for short periods and have two eyes on all patients that are outside. Tell the charge nurse, know your patients, and set an alarm. During an interview on 9/20/2023 at 10:11 AM, the Director of Nursing (DON) stated, There are no notes to be found for the monitoring book, as far as I know there were no other resident except [Resident #64's name] that go outside regularly. During an interview on 9/20/2023 at 12:13 PM, the Risk Manager stated, I was advised by a staff member that he had some blisters that she noted during his shower. I asked the DON and she spoke with the Administrator who informed me that we were not to report it as an adverse incident. I wasn't here the day of the incident, and I was contacted by the nurse supervisor here on the weekend. I saw him Monday morning and noted that he had a reddened area and [Physician #1's name] was in the facility and gave us orders for the Silvadene to be applied to his neck and back area. I was not aware of any issues in May or June. During an interview on 9/20/2023 at 4:46 PM, APRN #1 stated, At that time there was a possibility that the reddening of the skin was a sunburn [5/8/2023 and 6/15/2023 notes]. That was the differential diagnosis [on 6/15/2023] after resident was pulled back inside. He had an ER visit [7/14/2023] and on 7/17 was the first time I had seen him since he came back. I told my concerns in regard to the sun exposure to the Unit Manager and DON, I did not mention it to the Administrator. There were a couple of discussions about it. There were orders given to keep him inside. A resident over the age of 65 being exposed to sun and heat for an extended period of time can become overheated, dehydrated, problems with blood pressure, if diabetic, problems with blood sugars, since they are not able to regulate their temperature. Residents should make sure they are not outside for extended amount of time and hydration be provided. [Resident #33's name] has good days and bad days. Need to be limited time being outside. I think oversight should have been provided for [Resident #33's name] while he was outside. [Physician #1 name] is my oversight when I was working in the facility. I had open communication with [Physician #1's name] every day and sometimes more during the day. I would verbally speak to her and send her my notes. [Physician #1's name] has access to the system and is able to view the notes as well. During an interview on 9/20/23 at 5:10 PM, the Assistant Director of Nursing (ADON) stated, [APRN #1's name] did not express any concerns regarding [Resident #33's name]. I started to work in the facility on May 23, 2023. [Resident #33's name] was able to determine if he is too hot or needs to come inside. You can have a whole conversation with him. I did not know that [Resident #33's name] was deemed incompetent or that his BIMS was a three. There was a CNA in charge of the monitoring, and I think they had a book. I am not aware if they brought it up in QAPI [Quality Assurance and Performance Improvement] regarding the previous episodes [Resident #33's name] had. I saw the resident when he was already brought inside and he was red, he is always red, but he did have altered status. A request was made for the monitoring book for the period of 5/1/2023 through 7/17/2023. None was provided. During an interview on 9/21/2023 at 11:12 AM, the Administrator stated, An internal incident report was done. Family and physician made aware and wound care was involved. Root cause and investigation was completed. We did a subsequent root cause analysis, it evolved after survey team entered. We do 30 min checks in the courtyard for [Resident #33's name], a change in condition, and updated his care plan. We only did interventions for that resident. That's where we feel we fell short. We followed our decision tree, and we only did immediate interventions for [Resident #33's name]. We did not look at the risk for all of our residents. Review of the policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program last reviewed on 3/22/2023 read, Policy Statement. This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation. The objectives of the QAPI program are: 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 4. Establish systems through which to monitor and evaluate corrective actions. Implementation. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. The Immediate Jeopardy (IJ) was removed on site on 9/22/2023 after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated 9/22/2023 documented, On September 19, 2023, immediately upon notification of the alleged abuse/neglect related to F600 and Resident #33, the staff ensured the safety of the resident, completed a skin assessment of the resident, review of current skin treatments and protective clothing in relation to potential sun exposure. Completed on September 19, 2023, reported allegation of abuse/neglect to the Florida Agency for Health Care Administration. Completed on September 20, 2023, the facility had 18 residents considered to be potentially affected by this alleged deficient practice and received skin evaluations. Completed on September 22, 2023, the Director of Nursing, Risk Manager and Administrator in-servicing of staff to include CNAs, LPNs, RNs, contract and agency personnel prior to working the floor to include supervision of residents while in outside courtyard, 30-minute checks/rounding, offering hydration, offering/assisting with sun protection (SPF [Sun Protection Factor] sunscreen, protective clothing, etc.) medical abuse, identification and report of abuse/neglect, QAPI process, identifying signs and symptoms of sun exposure, heat exhaustion and sun stroke. Completed on September 19, 2023, Ad [NAME] {sic} [for this specific purpose] Quality Assurance Performance Improvement and Safety Committee [NAME] created/implemented 30-minute rounding form and procedure for the outside courtyard and sun exposure interventions to include offering/assisting with SPF 40 or greater sunscreen, aloe lotion, aide brim hats, sitting in the shade, offering fluids, protective clothing, and safety checks. Completed on September 21, 2023, Process Improvement Plan outlined staff education, identifying sun exposure, outside courtyard 30-minute rounding/monitoring, sun protection for residents at risk of sun exposure, reporting change in resident condition/ski, and QAPI plan. Completed on September 21, 2023, Root Cause Analysis determined facility failures in resident supervision while in outside courtyard staff education of reporting abuse/neglect, and changes in resident condition/skin. Review of the audit titled Skin Checks for Sun Exposure dated 9/20/2023 documented potentially affected residents were assessed for any skin impairments that may have been caused by sun exposure. Review of the inservice titled QAPI Program, Feedback, Data and Monitoring, Governance and Leadership, and QAPI Committee completed on 9/22/2023 documented the Administrator, DON, ADON, Risk Manager, Unit Managers and Wound Care Nurse received training. Review of the inservice titled Abuse/Neglect completed on 9/22/2023 documented 6 of 9 RNs, 18 of 23 LPNs, and 59 of 67 CNAs received training. Three RNs, 5 LPNs, and 8 CNAs were verified as on paid time off, illness or out of the country. Review of the inservice titled Change in Condition, Sun Exposure, Safety and Supervision of Resident While in Courtyard completed on 9/22/2023 documented 6 of 9 RNs, 18 of 23 LPNs, and 59 of 67 CNAs received training. Three RNs, 5 LPNs, and 8 CNAs were verified as on paid time off, illness or out of the country. Review of the inservice titled Abuse/Neglect, Change in Condition, Sun Exposure, Safety and Supervision of Resident While in Courtyard completed on 9/22/2023 documented 22 of 22 agency staff received training. Review of the Ad-Hoc QAPI meeting on 9/19/2023 documented in attendance included the Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Services, Risk Manager, Medical Director, Unit Managers, and LPN Wound Nurse. The committee reviewed resident safety and interventions related to sun exposure. Review of the root cause analysis and performance improvement plan verified completion on 9/21/2023. Record review and observations revealed the facility implemented the 30-minute courtyard rounding form for supervision of residents in the courtyard on 9/21/2023 and 9/22/2023. During staff interview completed on 9/22/2023, 5 of 8 Administrative staff verified having received education and verbalized understanding on QAPI process. During staff interview completed on 9/22/2023, One RN, 20 LPNs, and 28 CNAs verified having received education on Abuse/Neglect, Change in Condition, Sun Exposure, Safety and Supervision of Resident While in Courtyard.

Based on resident record reviews, interviews, and review of the facility policies and procedures, the facility failed to complete and submit a federal report of medical neglect for 1 of 4 residents reviewed for reportable incidents, Resident #33. Findings include: Review of the APRN #1 (Advanced Practical Registered Nurse) Visit Note dated 5/8/2023 for Resident #33 documented in part, Problem list: Dehydration. History of present illness: 89 y/o (year old) male, pleasant and cooperative but confused. Noted to have significant redness to non-covered skin, reported to have been out on the patio for extended period of time over the weekend and was not in the shade. Psychiatric Orientation: abnormal - awake, alert oriented X1 [times one]. Assessment Plan: Condition 2 Diagnosis: Sunburn, Unspecified. Plan of Care: Encourage oral hydration, apply Aquaphor liberally to all exposed reddened skin q [every] shift until aloe containing lotion available. Monitor and ensure if he is outside, he is in the shade. Review of the physician's order dated 5/8/2023 for Resident #33 documented, BUE [bilateral upper extremities], face, scalp, posterior neck - apply Aquaphor area and leave open to air every evening and night shift for sunburn for 14 days. Ordered by: [APRN #1's name]. Review of the progress note dated 6/15/2023 for Resident #33 documented, Resident was noted coming back from outside to have generalized erythema [superficial reddening of the skin]. Tired and weakness. Rt [right] eye was bright red at the lower lid of eye. No drainage noted. Resident stated he was a little sore. ARNP [sic] assessed resident and gave new order for labs in am [ante meridiem, before noon], U/A C & S [urinalysis with culture and sensitivity] and neuro checks [assesses an individual's neurological functions, motor and sensory response, and level of consciousness] to be initiated as protocol. Resident O2 [oxygen] sat [saturation, how much oxygen is in your blood] was 88% [Normal oxygen levels for elderly people are usually 90% to 95%, oxygen levels below 90% are considered low and may indicate the need for supplemental oxygen]. O2 at 1 liters has been placed on resident at this time. Resident was assisted to bed to rest and cool off. No acute distress noted at this time. Resting with eyes closed. Call light within reach. Author: [Staff X, LPN's name]. Review of the APRN #1 Visit Note dated 6/15/2023 for Resident #33 documented in part, Problem List: Dehydration, Unspecified Dementia. Chief Complaint: Acute Visit for Vasovagal type episode [rapid drop in heart rate and blood pressure] after being outside for too long and becoming overheated. History of Present Illness: 89 y/o male, decreased alertness and difficulty responding initially after being outside on the patio in the sun and becoming overheated. Psychiatric Orientation: Abnormal - orientated to person only. Assessment/Plan: Diagnosis: Heatstroke and sunstroke, initial encounter, other disturbances of skin sensation. Care Plan: Removed clothing and allowed to rest which improved mentation/alertness to normal level for him. Orders to monitor when he is outside and not allow him to be out, without periodic monitoring. Do not recommend greater than 20-30 minutes without hydration in current summer weather/humidity/heat. Author: [APRN #1's name]. Review of the physician's order dated 6/15/2023 for Resident #33 documented, obtain neuro checks per protocol for heat induced weakness every shift for heat weakness DC [discontinue] when done. Ordered by: [Physician #1's name]. Review of Physician #1's Visit Note dated 7/7/2023 for Resident #33 documented in part, Problem List: Unspecified Dementia, Dehydration. Chief Complaint: Acute visit - f/u [follow up] change in condition. History of present illness: This is an 89 y/o male being seen for follow up after noted yesterday that he was not his normal self. It is notable that he spends a significant amount of time outside, regardless of the fact that the temperature remains higher than normal. He admits he does not drink a lot of water. It is unclear how long he spends outside his skin shows evidence of tanning and sun exposure. Assessment/Plan: Condition 1. Diagnosis: effect of heat and light, unspecified, sequela [after effect of a disease/condition], dehydration. Care Plan: Pt [patient] with excessive sun exposure. Discussed risk of heat, dehydration, need for adequate hydration. F/u with staff regarding time outside for resident. Author: [Physician #1's name]. Review of the hospital emergency room documentation dated 7/14/2023 for Resident #33 documented in part, The patient presents with AMS [Altered Mental Status] per SNF [Skilled Nursing Facility] report. Differential Diagnosis: Dehydration, diabetic ketoacidosis, electrolyte imbalance, pneumonia, urosepsis, confusion. CBC [Complete Blood Count] notable for Leukocytosis. CMP [Complete Metabolic Panel] noted for blood glucose level of 356. [Target glucose range before meals for those with Type 2 Diabetes in older adults is 80 to 170]. Review of the progress note dated 7/15/2023 for Resident #33 documented, Pt noted to have open blister to upper back and intact blister to left shoulder. Call placed to [Physician #1's name] new TX [treatment] orders initiated for Venelex [Venelex Ointment is a wound dressing for topical use in the management of chronic and acute wounds, and dermal ulcers including: pressure ulcers, venous statis ulcer, first and second-degree burns .] to upper back. Skin prep to intact blister every shift. Orders for pt to not be able to go outside in the courtyard area without supervision. Author: [Staff Z, LPN's name]. Review of the incident progress note dated 7/18/2023 for Resident #33 documented in part, broken blister noted to back of neck and small blisters to upper back cream continues as per MD (Medical Doctor) order r/t prior extended sun time. During shift resident denies pain nor discomfort stating, 'cream feels good.' Author [Staff M, LPN's name]. Review of the Attestation of Physician that Resident is incapacitated for Resident #33 documented, I, Dr. [Physician #1's Name], attending physician to [Resident #33's name], have evaluated him/her and determined that he/she lacks the capacity to make medical decision or give informed consent. This document was signed by Physician #1 and dated 3/29/2023. During an interview on 9/19/23 at 12:49 PM, the Administrator stated, He [Resident #33] is of his sound mind, and we asked him to come in several times, and he was adamant about staying outside. We can't wheel him in against his will. He knows when he is getting hot, and he can self-propel himself. We did an internal investigation, and I would have to see if we did an adverse incident report. During an interview on 9/19/23 at 1:40 PM, the Administrator stated, I talked to our regional about the incident and he did not feel it as an adverse incident since he was not sent out. He can self-propel himself and can go under shade if he wants. During an interview on 9/19/23 at 5:40 PM, the Director of Nursing (DON) stated, I was not the DON back in May. I have only been in this position for about 3 months. During an interview on 9/20/23 at 12:13 PM, the Risk Manager stated, I was advised by a staff member that he had some blisters that she noted during his shower. I asked the DON and she spoke with the Administrator who informed me that we were not to report it as an adverse incident. If the Social Worker is not here, the backup person to submit an adverse incident report would be the facility Administrator. Review of the policy and procedure titled Identifying Neglect last reviewed on 3/22/23 reads, Policy Statement: As part of the strategy to prevent abuse, neglect, mistreatment and exploitation of residents, volunteers, employees and contractors hired by this facility are expected to be able to identify neglect as it may occur against residents. Policy Interpretation and Implementation . 3. Neglect is defined as the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. 4. Any situation in which the resident's care needs are known (or should be known) by staff (based on assessment and care planning), and those needs are not met due to other circumstances, can be defined as neglect. 5. Circumstances that can lead to neglect include: a. failure to monitor or supervise residents. Review of the policy and procedure titled Abuse Prevention Program last reviewed on 3/22/23 reads, Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will . 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframe as required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure assessments were completed accurately for 2 out of 2 residents reviewed for oxygen administration (Residents #346 and #39), 2 out of 2 residents reviewed for dietary services (Residents #7 and #29), and 1 out of 1 resident reviewed for dialysis (Resident #97). Findings include: 1. During an observation on 9/19/2023 at 9:32 AM, Resident #39 was lying in bed receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #19's physician order dated 11/15/2022 read, Administer O2 [oxygen] @ [at] 2 Liters via nasal cannula or mask continuously. Patient may remove as desired. Every shift. Review of Resident 39's Quarterly MDS (Minimum Data Set) dated 8/22/2023, under section O-Special Treatments, Procedures, and Program Oxygen was not identified as used for this residents - as indicated by an unchecked box. Review of Resident #39's Treatment Administration Record for August 2023 for continuous administration of oxygen at 2 liters via nasal cannula or mask revealed the treatment was administered during day, evening, and night shifts from 8/1/2023 through 8/31/2023. During an interview on 9/20/2023 at 10:18 AM, the MDS Coordinator stated, [Resident #39's name] does have an order for oxygen. It will be corrected. 2. Review of Resident #346's physician order dated 9/1/2023 read, Oxygen: Administer Oxygen @ 2_L [liter] via nasal cannula PRN [As Needed] for dyspnea. Review of Resident #346's Admission MDS dated [DATE] under Section O-Special Treatments, Procedures, and Programs; Oxygen was not identified as used for this resident - as indicated by an unchecked box. Review of Resident #346' Weights and Vitals Summary for September 2023 read, 09/01/2023, 18:43 [6:43 PM] 93% (Oxygen via Nasal Cannula) . 09/02/2023, 18:51 [6:51 PM] 95% (Oxygen via Nasal Cannula). During an interview on 9/20/2023 at 10:22 AM, the MDS Coordinator stated, [Resident #346's name] had an order for oxygen but nothing documented on the MAR [Medication Administration Record] or TAR (Treatment Administration Record). I see that in the vitals they recorded oxygen via nasal cannula. It would need to be corrected. 3. During an observation on 9/19/2023 at 12:53 PM, Resident #29 was eating in her room independently. The resident's plate contained mashed potatoes and ground meat. During an observation on 9/21/2023 at 12:48 PM, Resident #29 was eating in her room independently. The resident's plate contained yellow rice, okra, and chopped chicken. Review of Resident #29's physician order dated 8/15/2023 read, Regular diet, easy to chew MM5 [Level 5 Minced and Moist, Level 5 food contains lumps less than or equal to 4 millimeters], Meat texture, Regular consistency, for diet. Review of Resident #29's Quarterly MDS dated [DATE] under Section K-Swallowing/Nutritional Status, Nutrition Approaches; a mechanically altered diet was not identified as used for this resident - as indicated by an unchecked box. During an interview on 9/20/2023 at 10:25 AM, the MDS Coordinator stated, I see the orders. It should be corrected. 4. During an observation on 9/19/2023 at 12:45 PM, Resident #7 was eating independently. The resident's tray contained mashed potatoes, pureed meat, and pudding. During an observation on 9/21/2023 at 12:47 PM, Resident #7 was eating a pureed meal independently. Review of Resident #7's physician order dated 1/31/2022 read, Regular diet, Pureed IDDSI4 (International Dysphagia Diet Standardisation Initiative, Level 4, Level 4 is a pureed diet] texture, Nectar consistency, regular diet/puree consistency/fortified foods every meal/nectar liquids- extra moist/gravy, no rice, bean, peas, corn. Review of Resident #7's MDS Quarterly dated 8/16/2023 under Section K-Swallowing/Nutritional Status, Nutrition Approaches: a mechanically altered diet was not identified as used for this resident - as indicated by an unchecked box. During an interview on 9/20/2023 at 10:27 AM, the MDS Coordinator stated, The assessment needs to be corrected. 40559 5. Review of Resident #97's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease or end stage renal disease, and dependence on renal dialysis. Review of Resident #97's Medicare 5 Day Assessment MDS dated [DATE] under Section O-Special Treatments, Procedures, and Programs; Dialysis was not identified as a special treatment for this resident - as indicated by an unchecked box. During an interview on 9/20/2023 at 2:00 PM, the MDS Coordinator confirmed that Resident #97 had been a dialysis resident since admission and was inaccurately coded on her MDS assessment.