Every finding on record at Cypress Care Center

Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include:During an observation on 9/22/2025 at 9:15 AM, the facility posted nurse staffing information for September 15, 2025, September 16, 2025, September 17, 2025 and September 18, 2025. There was no nurse staffing information for 9/22/2025 (Photographic evidence obtained).During an observation on 9/23/2025 at 9:00 AM, the facility posted nurse staffing information for September 15, 2025, September 16, 2025, September 17, 2025 and September 18, 2025. There was no nurse staffing information for 9/23/2025.During an interview on 9/23/2025 at approximately 10:00 AM, the Administrator stated, The expectation is for the staffing to be posted daily by Staffing Coordinator. That should have been taken care of and updated yesterday.

Based on observation, interview, and policy review, the facility failed to ensure food is safely stored, covered, and cooked in a manner that preserves the nutritional value, and that sanitation was maintained in the kitchen. Findings include: A walk-through tour of the kitchen was conducted on 3/17/25 at 09:12 AM with the facility Administrator. An observation was made of a large bulk bin of flour with a partial open lid and food particles were observed in the bin with the flour. There were 3 bins that were dirty on the exterior with buildup of dirt and splashes. There was a large can opener with the base affixed to a stainless-steel prep table that had a buildup of brown, red, and black particles and food particles on the blade portion of the can opener. There was a deep fryer that was full of dirty oil, that was brownish in color and the oil had food particles and a buildup of food particles on the deep fryer top, edges, and sides. There were 3 dirty rags on the stainless food table and were not stored in sanitizing or cleaning buckets. There were approximately 34 food serving trays with chipped edges exposing metal. The food-catch-tray that pulls out under the pilot lights on the cooking range had a buildup of black food particles and 5 steam table pans of lunch food items were placed on the steam table at 9:30AM. During an interview on 3/17/25 at 09:12 AM the Morning [NAME] confirmed the 5 pans of food items on the steam table were for the lunch meal were vegetables both regular and pureed. The cook verified the food was on the tray line at 9:30AM. During an interview on 3/17/25 at 9:25AM the Administrator confirmed that the food particles were found on the can opener, in the flour bin, in the catch tray on the cooking range and on the deep fryer. The Administrator confirmed the dirty rags should have been in a sanitizing solution when not in use. The Administrator confirmed numerous food trays had chipped edges exposing metal that could pose a danger. During an observation on 3/18/25 at 6:30AM the male morning cook had a mustache and small goatee with no beard guard. There was a black cart loaded with clean dishes and a shelf with 24 regular, 3 divided, 8 scoop plates, approximately 50 fruit bowls, 6 scoop bowls, and approximately 53 bread plates that were not stored inverted. During an interview on 3/18/25 at 6:55 AM the Dietary Manager (DM) confirmed that the dishes were not stored inverted to keep them clean and the cook should be wearing a beard guard. During an interview on 3/20/25 at 10:40 AM the [NAME] President of Dietary and EVS [environmental services] stated that it is his expectation that the dietary manager and dietary staff follow the policies for preparing and holding of food and cleaning of equipment with good sanitation practices. Food should be placed on the steam table not more than 30 minutes prior to serving and that all soiled rags should be stored in sani[sanitation]-buckets and that food storage bin lids should be closed tightly to ensure foods are protected from exposure and spills. Review of the policy titled Food Serving Temperatures, last approval date of 1/29/25 read, Holding Temperatures 7. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat (stove, oven, steamer, etc.) and food is then transferred to the steam table not more than 30 minutes before meal service. Review of the policy titled Policy and Procedure Manual: Dietary Kitchen Sanitation dated 10/01/2023, last approval date of 1/29/25 read, 2. Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, seams, cracks and chipped areas that may affect their use or proper cleaning. 5. Between uses, clothes and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. 13. Staff will wear hairnets and/or beard guards when in the kitchen food preparation areas to prevent potential contamination of food products.

Based on observation, interview and record the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 5 out of 8 medication carts and 1 out of 4 units reviewed for unattended medication. Findings include: During an observation on [DATE] at 9:17 AM Resident #267 was lying on her bed with intravenous medication running. There was a medication cup on top of Resident # 267 which contained white circular tablets and a red color tablet. During an interview on [DATE] at 9:17 AM Resident #267 stated, The nurses leave my medication at bedside because I prefer to take them when I get out of bed. During an interview on [DATE] at 9:27 AM Staff A, Certified Nursing Assistant (CNA), stated, [Resident #267's name] has a medication cup that contains medications at her bedside. During an interview on [DATE] at 9:28 AM Staff B, License Practical Nurse (LPN), stated, I thought she (Resident #267) had taken her medications. The medications were in the room. I got sidetracked because the resident across the hall was yelling. During an observation on [DATE] at 9:44 AM with Staff B LPN of medication cart labeled [NAME] long cart there was 1 open Lyumjev Insulin pen with no open or expiration date and 1 bottle of glucose strips with no open date written on the bottle. (photographic evidence obtained) During an interview on [DATE] at 9:46 AM Staff B, LPN, stated, Insulin pen should be labeled with an open date and an expiration date once it is open. The glucose blood strip bottle should also have the open date written on the bottle. During an observation on [DATE] at 9:50 AM with Staff C, LPN, of Spanish Village North medication cart there was 1 open Insulin Aspart pen with no open or expiration date, there was 1 unopen Lantus insulin pen, and 2 loose white circular tablets in the medication drawers. (photographic evidence obtained) During an interview on [DATE] at 9:54 AM Staff C, LPN, stated, Insulin that is not open should be stored in the refrigerator. Any insulin that is open should be labeled with an open date and an expired date. Loose medication should be disposed of. During an observation on [DATE] at 9:55 AM with Staff D LPN of [NAME] Palm Medication Cart there was 1 unopened vial of Lantus insulin with a blue sticker that read refrigerate. There was 1 opened Fiasp Flextouch insulin pen with an open date of [DATE], 1 opened Insulin Aspart Pen with an expiration date of [DATE], 1 opened vial of insulin glargine with an open date of [DATE], 1 opened Lantus solostart insulin pen with no open or expiration date, 2 opened vials of Lispro with no open or expired date and 1 open vial of Lantus with no open or expired date. During an interview on [DATE] at 10:00 AM Staff D, LPN, stated, Expired medication should be discarded and not be kept in the medication cart. Open insulin should be labeled with an open and expired date and if the insulin is not open it should be refrigerated. During an observation on [DATE] at 10:14 AM with Staff E, LPN, French Quarter Cart #1 there was loose medication in the medication cart drawers, there was 1 opened insulin Aspart pen with no open or expired date and 1 unopen insulin Aspart insulin pen with a white label reading refrigerate. During an interview on [DATE] at 10:16 AM Staff E, LPN stated, Loose medication should be disposed of. Insulin should be dated once open and if it is not open it should be stored in a refrigerator. During an observation on [DATE] at 10:24 AM Staff F LPN of French Quarters Cart #2 there was 1 vial of Fiasp with an expiration date of [DATE], there were 2 vials of Lispro with an open date of [DATE], 1 insulin Aspart pen with an expiration date of [DATE], 1 insulin Aspart pen with an expiration date of [DATE], and 1 bottle of Timolol Maleate 0.5% with an open date of [DATE],1 open bottle of Latanoprost 0.005% with an open date of [DATE], 1 open bottle of Brimonidine Tart 0.2% eye drops with no open or expiration date, there were 3 opened insulin Aspart pens with no open or expired date, there was 1 opened vial of lispro insulin with no open or expired date, and 1 vial of Aspart insulin with no open or expire date. During an interview on [DATE] at 10:24 AM with Staff F, LPN, stated, Medication should be labeled when opened and expired medication should be dispose. Eye drops are good for 30 days after opening . During an interview on [DATE] at 7:19 AM with the Director of Nursing (DON) stated, Insulin pens and eye drops should be labeled when opened with an open and expiration date. If the inulin is not open it should be stored in the refrigerator. Medication that is expired should be disposed of and not kept in the cart and if there is loose medication in the cart it should also be disposed of and not kept in the medication cart. Insulin and eye drops once open are good for 28 days after the open date or based on manufactures guidelines. Medication should not be left unattended. We do not have any other policy available other than the one provided. Review of the facility policy and procedure titled Medication/Biological Storage with a last review [DATE] read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure:4. The facility shall not use discontinued, outdated up to including (7-Days) or deteriorated medications, drugs or biologicals.8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing system 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location .

Based on interview and record review, the facility failed to obtain a urinalysis when ordered by the physician for 1 (Resident #82) resident of 5 residents reviewed for unnecessary medications. Findings include: Review of Resident #82's admission record documented medical diagnosis including obstructive and reflux uropathy (a condition where urine flow is blocked or flows backward into the bladder). Review of Resident #82's physician order dated 3/12/2025 reads, UA(urinalysis) with C/S (culture and sensitivity). Review of Resident #82's medication administration record(MAR), treatment administration record (TAR), nursing progress notes and laboratory results revealed no documentation of a UA with C/S being completed or resident refusing laboratory test. During an interview on 3/17/2025 at 10:03 AM Resident # 82 stated, I am having pain in my abdomen, and it feels like I am getting a UTI (urinary tract infection). I told the staff several days ago and they said they would collect it(a urine specimen) but they haven't done it. During an interview on 3/18/2025 at 10:38 AM Staff N, Licensed Practical Nurse (LPN), stated, The UA (uranalysis) should have been collected on 3/12/2025.

Based on observations, interviews, and record reviews, the facility failed to ensure professional standards of practice were implemented for 2 (Resident #124 and #147) of 4 residents reviewed for gastric tubes. Findings include: 1.) During an observation on 3/19/2025 at 9:17 AM Staff G, License Practical Nurse, (LPN) entered Resident #147's room wearing a gown, gloves, and surgical mask. Staff G, without checking placement or residual, began to flush the gastric tube with 30 milliliters of water. Staff G began to administer medications via gastric tube performing flushes of 5milliters of water in between each medication administration. Staff G finished administering medications and flushed the gastric tube with 30 milliliters of water. Review of Resident #147's physician order dated 3/16/2025 read, Flush feeding tube with 30ML (milliliters) of water before and after medication administration every shift. Review of Resident #147's physician order dated 3/16/2025 read, Check tube placement and for residual before addition of feeding, flush, or medications. If residual is 100cc (milliliters) or more, hold feeding and notify MD (Medical Doctor). every shift. Review of Resident #147's physician order dated 3/16/2025 read, Crush medications that can be crushed and dilute each with 5-10 cc water. Flush with 5 ml of water between each mediation unless otherwise specified every shift for Prophylaxis. 2.) During an observation on 3/19/2025 at 1:55 PM, Staff G, License Practical Nurse (LPN) donned a gown and gloves and entered Resident #124's room. Staff G, without checking for placement or residual proceeded to flush Resident #124 gastric tube with 60 cc of water pre bolus and administer Glucerna 1.2 bolus and flushed the gastric tube post administration of the bolus. During an interview on 3/19/2024 at 2:20 PM, Staff G, LPN stated, I did forget to check for the residual of the gastric tube before starting the administration. We should check to ensure placement and if they have residuals we can communicate with the provider and let them know. Review of Resident #124's physician order dated 2/26/2025 read, Enteral Feed Order every 4 hours for Prophylaxis every 4 hours for nutrition and hydration Glucerna 1.2 bolus 6x (6 times) per day/1 can or 237 ml Q_4hours (per day 1 can or 237 milliliters every 4 hours). Flush with 60cc of water pre/post bolus. Review of Resident #124's physician order dated 2/25/2025 read, Check feeding tube placement every shift. During an interview on 3/20/2025 at 7:19 AM, the Director of Nursing stated, The nursing staff should be checking residuals before flushing a gastric tube or administering anything via the gastric tube of a resident. Review of the policy and procedure titled Medication Administration via Enteral Feeding Tube with a last review date of 1/29/2025 read, Policy: Medications shall be prepared and administered according to the following established guidelines. Licensed Staff should not administer a drug that is inadequately dissolved (i.e., particulate matter still evident); that may clog the enteral feeding tube. Tube placement will be verified prior to the administration of a medication. Procedure: 5. Verify feeding tube placement.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents environment was free from accident hazards when 2 (Resident #77 and Resident #139) of 4 residents were not assessed for safe smoking. Findings include: During an observation on 3/17/2025 at 9:20 AM, Resident #77 was observed with a pack of cigarettes and a lighter on the bedside table. During an observation on 3/17/2025 at 10:45 AM, Resident #77 was observed on the smoking patio smoking a cigarette. During an interview on 3/18/2025 at 1:15 PM, Resident #77 stated I keep my cigarettes and my lighter [with me]. In fact, I need to go and get cigarettes. During an interview on 3/20/2025 at 10:15 AM, Staff K, Certified Nursing Assistant (CNA), stated He [Resident #77] keeps his cigarettes and lighter with him. Review of the admission nursing assessment for Resident #77 documented in Section R, Smoking Safety, questions 7-12 were blank. These questions described resident observations for demonstrating safe smoking practices and the need for supervision. Review of the policy titled, Smoking Policy - Residents, last reviewed on 1/29/2025, reads, Policy Statement. This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation. 1. a. Smoking assessment is completed before or upon admission. 2. During an observation on 3/19/2025 at 1:30 PM, Resident #139 was observed sitting in his wheelchair, on the smoking patio, with a lit cigarette in his right hand. During an interview on 3/19/2025 at 3:00 PM, Staff J stated He [Resident #139] keeps his own cigarettes and lighter [with him]. Review of the Nursing Admission assessment dated [DATE] documented in Section P: Tobacco Use, that the resident was a Past Smoker. Review of Resident #139's clinical record documented no smoking screen or safe smoking assessment to demonstrate the resident's smoking practices and or the need for supervision.

Based on observation, interviews and record reviews, the facility failed to ensure that residents fed by enteral means received the care and services as prescribed by the physician for 1 Resident (Resident #134) of 3 residents reviewed for tube feeding services. Findings include: During an observation on 3/19/2025 from 12:39 PM until 3:00 PM of Resident #134, there was no bolus feed given as per physician's orders at 2:00 PM. During an interview on 3/19/2025 at 3:00 PM with Staff I, LPN, stated I did not have an enteral feeding to administer to (Resident #134 Name). Review of the physician's order dated 1/25/2025 for Resident #134 read, Enteral Feed. Every shift for GTF [gastric tube feed] Jevity 1.5 vis feeding tube at 100 cc/hr for 12 hours, off at 5 am and on at 5 pm. Bolus 325 ml (milliliters) via enteral feeding tube at 6 am and 2 pm. During an interview on 3/19/2025 at 3:00 PM following the review of the physician's orders for Resident #134, Staff I, LPN, stated I didn't see that portion of the order. During an interview on 3/19/2025 at 3:05 PM, Staff N, LPN stated, (Resident #134's Name) should have received that feeding and a risk associated with not receiving the ordered feedings could result in weight loss.

Based on observations, interviews, and record reviews, the facility failed to ensure services for respiratory care, consistent with professional standards of practice ,were provided for 2 (Resident #124 and # 91) of 6 residents reviewed for oxygen therapy. Findings include: During an observation on 03/17/25 at 11:25 AM, Resident #124 was resting calmly with eyes closed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an observation on 3/18/2025 at 8:27 AM, Resident #124 was resting calmly with eyes closed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an observation on 3/19/2025 at 2:15 PM with Staff G, License Practical Nurse (LPN), Resident #124 was lying in bed; oxygen was being administered via nasal cannula at 3.5 liters per minute. During an interview on 3/19/2025 at 2:15 PM, Staff G, LPN, stated, [Resident #124's name] has orders for 2 liters per minute. The flow rate is incorrect and needs to be adjusted. Review of Resident #124's physician order dated 2/25/2025 read, May apply O2 @ 2 LPM (oxygen at 2 liters per minute) via nasal cannula as needed for maintaining O2 sats > or = 92%. (greater than or equal to 92 percent). During an interview on 3/20/2025 at 8:54 AM the Director of Nursing (DON) stated, Staff should follow physician orders and make sure the oxygen flow rate is at the correct rate. The staff should be checking every shift what the flow rate is on the oxygen concentrator. Review of the policy and procedure titled Respiratory Care with a last review date 1/29/2025 read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration of meet the needs of the residents. Procedure: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/PleurX care, BiPAP, CPAP, or medication administration. 51447 2. Review of the admission record for Resident #91 documented an admitted [DATE] with diagnosis that included metabolic encephalopathy (admitting diagnosis), altered mental status, (unspecified), essential hypertension, seizures, and history of falling. During an observation on 3/17/2025 at 10:18 AM, Resident #91 was observed laying in her bed; she was not wearing any oxygen during the observation. There was an oxygen concentrator stored by a bedside table not in use. During an observation on 3/17/2025 at 12:53 PM, Resident #91's was observed sitting in her room resting. She did not have any oxygen on during the time of the observation. During an observation on 3/18/2025 at 8:37 AM, Resident #91 was observed sitting up in her bed eating breakfast. She was not wearing any oxygen during this observation. During an observation on 3/18/2025 at 11:45 AM, Resident #91 was observed sitting in a common area in her wheelchair. She was not wearing any oxygen during the observation. Review of the document titled, Change of Condition dated 2/11/2025 read, Nursing observation, evaluation and recommendations are: I observed resident with an acute cough, oxygen 83% (2 liters of oxygen was placed on the resident, oxygen is now 96%). [Name of Medical Doctor] ordered stat [Stat comes from the Latin word statim, which translates to immediately] chest x-ray, stat labs, covid test came back negative, and midline placement for anticipation for antibiotics. Review of the physician's order dated 2/11/2025 for Resident #91 read, Continuous O2 at 2L/MIN [2 liter per minute] via NC q shift. During an interview on 3/19/2025 at 9:01 AM, Staff I, Licensed Practical Nurse (LPN) confirmed the orders for oxygen were continuous and the resident [Resident #91] was not on oxygen.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was provided with an assessment which accurately reflects the resident's status for 3 (Resident #111, #24, #4) of 10 residents reviewed for communication, nutrition and activities of daily living. Findings include: 1.) During an interview conducted in Spanish on 3/17/2025 at 10:42 AM with Resident #111, she stated, Communication with staff can be hard. I speak Spanish and it is very hard to communicate with staff. They have a few staff members that speak Spanish, but they may not be always available. I am Hispanic of Cuban decent. Review of Resident #111's Minimum Data Set (MDS) Comprehensive Quarterly assessment dated [DATE] documented Resident #111 was not Hispanic, and her preferred language was English. Review of Resident #111's Social Service Admission Evaluation dated 11/22/2024 read, Ethnicity: E2d. Yes, Cuban. Summary /Additional Comments: .Patient speak Spanish. During an interview on 3/19/2025 at 10:05 AM, Staff H, License Practical Nurse (LPN), stated, [Resident #111's Name] sometimes will not understand our conversation, she speaks Spanish. I will get the Environmental Service Supervisor or a restorative aide that speak Spanish in order to better communicate with her. During an interview on 3/19/2025 at 10:15 AM the Environmental Service Supervisor stated, [Resident #111 Name] speaks Spanish and she is one of the residents included in my rounds do to that [speaking Spanish]. I will translate for her or ask her if she needs anything so that I can tell the nurse for her. During an interview on 3/20/2025 at 12:55 PM, the Minimum Data Set Lead License Practical Nurse, stated, Hispanic should have been marked and a correction her prefer language needs to be made. 50123 2.) During an observation on 3/17/2025 at 12:30 PM, Resident #24 was sitting up in bed feeding self, following set-up assistance. During an observation on 3/19/2025 at 12:10 PM, Resident #24 was sitting up in bed, feeding self, following set-up assistance. During an interview on 3/19/2025 at 10:00 AM, Staff K, Certified Nursing Assistant (CNA), stated, She's [Resident #24] set up assist; she usually eats 50-75% of her meals; set her up and leave if you want her to eat. During an interview on 3/19/2025 at 1:00 PM, Staff L, Licensed Practical Nurse (LPN) stated, She'll [Resident #24] feed herself if we set it up. If we try and feed her, she starts yelling and throwing things. Review of the Minimum Data Set (MDS) Comprehensive Quarterly Assessment completed on 2/4/2025 documented under Section GG0130-Self-Care the resident was listed as being dependent with eating. Review of the MDS Quarterly Assessment completed on 2/4/2025, Section K0300-Weight Loss, no was selected. Review of the clinical record documented Resident #24 had a 10.2% weight loss in the last 6 months. 51447 3.) Review of Resident #4's admission record included the following diagnosis: metabolic encephalopathy, abnormalities of gait and mobility, need for assistance with personal care, muscle weakness and morbid obesity. Review of Resident #4's MDS comprehensive quarterly assessment dated [DATE] documented under section C a BIMS (Brief Interview for Mental Status) of 00, indicating severely impaired cognition. Review of Resident #4's MDS comprehensive quarterly assessment dated [DATE] documented Resident #4 was independent for the following functional abilities: eating, oral hygiene, toileting hygiene, shower/bathing, dressing both upper and lower body, putting on footwear and personal hygiene. Review of Resident #4's comprehensive plan of care dated 2/25/2025 revealed a focus for self-care deficits with dressing, grooming and bathing related to impaired mobility, generalized weakness, limited endurance. Review of Resident #4's task documentation for showering and bathing herself from 2/21/2025 through 3/18/2025 revealed no documentation of Resident #4 independently completing the task. Review of Resident #4's last documented PT (physical therapy)/ OT (occupational therapy)/ Restorative Note dated 4/7/2024 revealed that for the following activities the resident needed some form of assistance: oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During an interview on 3/20/2025 at 2:18 PM with the MDS Coordinator, stated I get the information to fill out the MDS section GG from staff documentation, communicating with direct care staff or independently observing the resident. During an interview on 3/20/2025 at 2:40 PM with Staff I, LPN (Licensed Practical Nurse) stated (Resident #4's Name) is not independent with any of her ADL's and hasn't been for some time now. During an interview on 3/20/2025 at 2:48 PM, Staff M, CNA (Certified Nursing Assistant) stated that (Resident #4's Name) is not independent with any of her ADL's (Activities of Daily Living) and at best, she would require at least partial assistance.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 2 (Resident #111 and #91) of 5 residents reviewed for communication and respiratory care. Findings include: 1.) During an interview in Spanish on 3/17/2025 at 10:42 AM, with Resident #111, she stated, Communication can be hard. I speak Spanish and it is very hard to communicate with staff. They have a few staff members that speak Spanish, but they may not be always available. During an interview on 3/19/2025 at 10:01 AM, Staff G, License Practical Nurse (LPN,) stated, [Resident #111 Name] can speak a little bit of English. If she does not understand what I am saying to her [Resident #111] I will get a Spanish speaking employee to translate. During an interview on 3/19/2025 at 10:05 AM, Staff H, LPN, stated, [Resident #111 name] sometimes will not understand our conversation, she speaks Spanish. I will get the Environmental Service Supervisor or a restorative aide that speak Spanish in order to better communicate with her. During an interview on 3/19/2025 at 10:15 AM, the Environmental Service Supervisor stated, [Resident #111 Name] speaks Spanish and she is one of the residents included in my rounds for that reason. I will translate for her or ask her if she needs anything so that I can tell the nurse for her. Review of Resident #111's Social Service Admission Evaluation dated 11/22/2024 read, Ethnicity: E2d. Yes, Cuban. Summary /Additional Comments: .Patient speak Spanish. Review of Resident #111's comprehensive care plan did not document a focus of communication. During an interview on 3/20/2025 at 9:39 AM, the Social Service Assistant stated, [Resident #111 Name], when I have spoken to her she can speak broken English. I am not too familiar with [Resident #111 name] but we do have staff in the building that speak Spanish and can be used to translate. During an interview on 3/20/2025 at 12:55 PM, the Minimum Data Set Lead LPN, stated, Social Services will do an admission assessment and would be the one to develop that section of the care plan. If a resident has a communication need it should be care planned. Usually, staff will come and tell us or during meetings we will be informed of each residents needs. Review of the facility policy and procedure titled Comprehensive Assessments and Care plans with a last review date 1/29/2025 read, Standard: It will be standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI). Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth .that includes measurable objectives and timeframes to meet a resident's medical nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 51447 2.) Review of the admission record for Resident #91 documented an admitted [DATE] with diagnosis that included metabolic encephalopathy (admitting diagnosis), altered mental status, (unspecified), essential hypertension, seizures, and history of falling. Review of the physician's orders for Resident #91 documented Levetiracetam Oral Solution 100 MG/ML [milligrams over milliliters]. Give 5 ml by mouth two times a day for seizures. Review of the comprehensive care plan for Resident #91 did not document any care plan related to seizures. During an interview on 3/19/2025 at 2:45 PM, the Director of Nursing stated, I would expect that if they (residents) had a history of seizure and are treated for it [seizures], it would be part of their comprehensive care plan. Review of the policy and procedure titled, P & P Seizures, last reviewed on 1/29/2025, read, Policy: It will be the policy of this facility to provide safe care and services for resident with the potential for or actual seizures. Procedure. 13. Residents with a seizure disorder or receiving medication to prevent seizures specifically should have a person-centered plan of care related to potential for seizures.

Based on observations, interviews and record reviews the facility failed to provide care and services in accordance with professional standards of practice for 2 (Resident #267, #118)) of 10 residents reviewed for central venous access devices and medication administration. Findings include: 1.) During an observation on 3/17/2025 at 9:17 AM, Resident #267 was lying in bed. A single lumen midline was observed on the upper right arm with a transparent dressing dated 3/7/2025 in black marker. Review of Resident #267's Medical Certification for Medicaid Long Term Care Service and Patient Transfer form dated 3/7/2025 documented a midline dated 3/7/2025. Review of Resident #267's physician orders did not document any intravenous catheter dressing changes orders. Review of Resident #267's physician orders did not document orders for flushing intravenous central line. Review of Resident #267's physician orders dated 3/10/2025 read, Fetroja Intravenous Solution Reconstituted 1 GM [Gram] (Cefiderocol Sulfate Tosylate) Use 1500 mg [milligrams] intravenously every 8 hours for Wound infection/UTI [Urinary Tract Infection] for 10 Days. During an interview on 3/20/2025 at 7:04 AM the Director of Nursing (DON) stated, IV dressing changes should be done every 7 days and there should be orders in the system for flushes and dressing changes, so we are able to track that staff are doing them. Review of the policy and procedure titled PICC IV (Peripherally Inserted Central Catheters) Line with a last review date 1/29/2025 read, Policy: It will be policy of this facility to adhere to IV/PICC line administration guidelines as set for by infection control, state and federal regulations. Licensed nurses shall provide care according state and federal law. Dressing Changes: 1. Sterile dressing change using transparent dressing is performed: At least weekly. 2.) Review of Resident #118's physician order dated 8/21/2024 read, Losartan Potassium Oral Tablet 25 MG (milligrams) give 25 mg by mouth one time a day for hypertension hold for SBP (systolic blood pressure) less than 120. Review of Resident #118's Medication Administration Record (MAR) for the month of March 2025, Losartan was given out of parameters at 0800 (8:00AM) on 3/3/2025 with a SBP of 112, on 3/5/2025 with a SBP of 115, and on 3/6/2025 with a SBP of 118. Review Resident #118's physician order dated 9/13/2024 read, Clonidine HCI (Hydrochloride) Tablet 0.1mg give 1 tablet by mouth every 8 hours for hypertension for systolic pressure over 160. Review of Resident #118's Medication Administration Record (MAR) for the month of March 2025 Clonidine HCI Tablet 0.1 MG was administered out of parameters at 0600 (6:00 AM) on 3/1/2025 with a SBP of 129, 3/2/2025 with a SBP of 130, 3/33035 with a SBP of 117, 3/4/2025 with a SBP of 134, 3/9/2025 with a SBP of 133, 3/10/2025 with a SBP of 137, 3/12/2025 with a SBP of 141. At 1400 (2:00 PM) on 3/1/2025 with a SBP of 128, 3/4/2025 with a SBP of 135, 3/7/2025 with a SBP of 122, 3/11/2025 with a SBP of 107, 3/12/2024 with a SBP of 141. At 2200 (10:00 PM) on 3/1/2025 with a SBP of 127, 3/2/2025 with a SBP of 136, 3/3/2025 with a SBP of 121, 3/4/2025 with a SBP of 124, 3/6/2025 with a SBP of 115, 3/7/2025 and 3/8/2025 with a SBP of 145, 3/10/2025 with a SBP of 134 and 3/11/2025 with a SBP of 144. During an interview on 3/18/2025 at 2:30 PM the Director of Nursing stated, [Resident #118's Name] blood pressure medication was given out of parameters. Nursing staff should follow physician orders or contact the provider with any questions they may have. During an interview on 3/20/2025 at 2:05 PM, Medical Doctor #1 stated, I expected nursing staff to follow physician orders and the parameters for the medication that are in place. Review of the policy and procedure titled Medication Administration with a last review date of 1/29/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availably of medication or refusals of medications by the resident.

Based on interview and record review, the facility failed to ensure guidance was provided to 2 of 3 residents, Residents #1 and #2, of informed health status treatment and changes related to the enrollment/disenrollment from health plan coverage, and failed to develop a written policy and procedure regarding the process of assisting beneficiaries with changing their health care coverage. Findings include: 1) Review of the medical record for Resident #2 contained disenrollment paperwork signed by Resident #2 for the disenrollment from the resident's current health insurance coverage to different health insurance coverage. The record did not provide documentation of an attestation signed by the facility staff that assisted with the change in enrollment for Resident #2 attesting that Resident #2 or the representative requested the change or that the beneficiary or representative received and understood the minimum required information. The documentation was requested from the Community Liaison/Admissions Director. The Community Liaison/Admissions Directed stated, The facility staff did not sign an attestation. No additional documentation was provided. During an interview on 3/4/2025 at 12:00 PM, the Community Liaison/Admissions Director stated, Nursing, Therapy and MDS [Minimum Data Set] sit down and see what the residents' needs are and anticipate if a resident will need more than 100 days [in facility care and services]. If they are not progressing and need longer than 100 days, residents are provided with the option to disenroll from their insurance and go to regular Medicare, so they are not threatened to be cut off for therapy based on their insurance managed plan. There are weekly updates sent to the resident's insurance company and the insurance company usually gives us a heads up that they are only provided [the resident] a set number of days after the progress reports are received from us. We need to offer the option to dis-enroll prior to the first of the next month. We discuss the options of Medicare Part D, but [Name of Company] provides a zero deductible for all drugs that we provide here at this facility. We provide them the information to re-enroll. We do go over everything with them verbally, have the resident sign to disenroll and provide the resident with a copy of the documents. This is not mandatory. They have 60 days to re-enroll and the member has to be present, which can be on the phone. A policy and procedure for the process of assisting beneficiaries with changing their health care coverage was requested. The Community Liaison/Admissions Director stated, We do not have a policy and procedure in place describing the process. 46523 2) Review of Resident #1's medical record provided a request signed by Resident #1 dated 09/30/2024 for the disenrollment from the resident's current health insurance coverage to different health insurance coverage. The record did not provide documentation of an attestation signed by the facility staff that assisted with the change in enrollment for Resident #1 attesting that Resident #1 or the representative requested the change or that the beneficiary or representative received and understood the minimum required information. During an interview on 3/4/2025 at 11:50 AM the Community Liaison stated, We do not have a sign attestation that we as a facility have reviewed all the information with the resident [Resident #1] and that the resident is the one requesting to dis-enroll and enroll into traditional Medicare.

Based on observation, record review, and interview, the facility failed to ensure that opened blood glucose test strips were labeled in 3 of 6 medication carts observed. Findings include: During an observation of Medication Cart #1 in Hall 200- Spanish Village Unit on [DATE] at 9:10 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:10 AM, Staff D, Licensed Practical Nurse (LPN), stated, I do not write the date on the bottle when I open them. I do not know what the policy for this facility is. During an observation of Medication Cart #2 on Hall 200- Spanish Village Unit on [DATE] at 9:30 AM, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 9:30 AM, Staff C, LPN, stated that the glucose strips were supposed to be dated when the bottle was opened and were good for 90 days after they were opened. During an interview on [DATE] at 10:54 AM, Staff F, LPN, stated that the glucose strips were opened, and the date opened should be written on the bottle. Staff F confirmed the strips would expire 30 days after the bottle was opened. During an interview on [DATE] at 11:20 AM, Staff G, LPN, stated that glucose strips should be dated with the open date when the bottle of strip were opened and would be good for 90 days after they were opened. During an observation of Medication Cart #1 on French Quarter Hall on [DATE] at 12:10 PM, with Staff J, LPN, Nursing Manager, there was one opened bottle of blood glucose strips with no open date written on the bottle. During an interview on [DATE] at 12:10 PM, Staff K, LPN, stated, The dates should be written on the strips when it is opened. I do not know how long they are good for after they have been opened. I thought we went by the expiration date on the bottle from the manufacturer. During an interview on [DATE] at 12:18 PM, Staff J, LPN, Nursing Manager for French Quarter, stated, Blood sugar strips are to be dated when the bottle of strips are opened. The date the bottle is opened should be written on the top of the strips. I do not know for sure how long the strips are good after they are opened. I will have to check. There is an expiration on the bottle of strips by the manufacturer. During an interview on [DATE] at 12:41 PM, the Director of Nursing (DON) stated, My expectation is for the nurses to write the open date on top of the glucose strips. We go by the expiration date written on the bottle by the manufacturer. Review of Assure Prism Multi Blood Glucose Monitoring System Quality Assurance/Quality Control Reference Manual reads, Storage and Handling . Use all of the test strips within the expiration date printed on the test strips bottle/box label. Do not use the expired strips and dispose the expired test strips immediately because using test strips past the expiration dates can produce incorrect test results . Warnings and Precautions . Do not use beyond 3 months (90 days) after opening the bottle. Record the discard date (3 months from the day the bottle was opened) on the bottle label.

Based on observation, record review, and interview, the facility failed to ensure medical records were accurate for 1 of 4 residents reviewed for PASRR, Resident #141, for 3 of 6 residents reviewed for nutrition, Residents #81, #141 and #156, for 1 of 5 residents reviewed for wound care, Resident #62, and for 1 resident transferred to the hospital, Resident #1. Findings include: 1. Review of Resident #141's admission record showed the resident was originally admitted on [DATE] and was diagnosed with brief psychotic disorder on 4/3/2023. Review of Resident #141's PASRR dated 11/1/2023 showed no diagnosis of psychotic disorder. During an interview on 12/6/2023 at 8:38 AM, the Director of Nursing confirmed Resident #141's PASRRs was inaccurate. 2. Review of Resident #141's weight summary showed the resident weighed 85.6 pounds on 11/3/2023 and 82.1 pounds on 12/4/2023. Resident #141's historical weight record showed the resident had a body mass index of 12.9 (underweight). Review of Resident #141's care plan revised on 11/3/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to a fracture of unspecified part of neck, moderate protein-calorie malnutrition, dementia, chronic obstructive pulmonary disease, dysphagia, low body mass index and the need of a therapeutic diet. Review of Resident #141's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 10 of 14 days reviewed. Review of Resident #156's weight summary showed the resident weighed 128.8 pounds on 9/28/2023 and 124.4 pounds on 12/4/2023. Resident #156's historical weight record showed the resident had a body mass index of 17.8 (underweight). Review of Resident #156's care plan revised on 10/3/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to unspecified dementia, Alzheimer's disease, major depressive disorder and hypertension. Review of Resident #156's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 3 of 12 days reviewed. Review of Resident #81's weight summary showed the resident weighed 169.6 pounds on 7/5/2023 and 153.4 pounds on 11/21/2023, which was a 9.55% weight loss. Review of Resident #81's care plan revised on 9/22/2023 revealed the resident was at risk for an alteration in nutrition and/or hydration related to mood disorder, hyperlipidemia, hypothyroidism, hypertension, dementia, depression, obese and planned weight loss program unrealistic based on diagnosis of dementia. Review of Resident #81's percentage of meal eaten data from 11/23/2023 through 12/5/2023 showed the percentage of meal intake was not recorded for all meals on 11 of 13 days reviewed. During an interview on 12/6/2023 at 1:45 PM, the Director of Nursing confirmed meal percentage intakes should have been consistently recorded daily for Resident #141, Resident #156 and Resident #81. 45576 3. During an observation on 12/4/2023 at 9:22 AM, Resident #62 was lying in bed with a dressing on the right upper arm dated 11/29/2023. During an observation on 12/4/2023 at 12:10 PM, Resident #62 had a dressing on the right upper arm dated 11/29/2023. Review of Resident #62's physician order dated 10/30/2023 showed the order to cleanse the right arm with normal saline, pat dry, apply Xeroform and cover with pad two times a day for skin tear. Review of Resident #62's Treatment Administration Record for November 2023 and December 2023 revealed the wound care and dressing change was completed on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023. During an interview on 12/6/2023 at 1:53 PM, the Director of Nursing stated that the dressing had not been changed since November 29, 2023, and that the nurses documented that the skin care on the upper right arm was completed. The Director of Nursing stated that the nurses documented the dressing changes in error when the dressing was not completed. She confirmed the dressing changes were not completed on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023. 4. Review of Resident #1's admission record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included fracture of unspecified part of neck of left femur. Review of Resident #1's physician order dated 1/2/2013 reads, Send to ER [emergency room ] to eval [evaluate] and treat as indicated. Review of Resident #1's nursing home to hospital transfer form dated 1/2/2023 revealed the resident was transferred to hospital on 8/26/2022 for abnormal white blood cell count (High). During an interview on 12/5/2023 at 3:00 PM, the Director of Nursing stated, Nursing home to hospital transfer form has the wrong date and reason for transfer written on the transfer form. It is dated correctly on the bottom. The patient was transferred after a fall on 1/2/2023 with complaint of leg pain after a fall. During an interview on 12/6/2023 at 3:14 PM, the Corporate Regional Registered Nurse stated, Nursing home to hospital transfer form had the wrong date and reason, but is time stamped on the bottom of the form with the correct date. During an interview on 12/6/2023 at 3:40 PM, the Assistant Director of Nursing stated, I do not know why wrong date or diagnosis is written on the nursing home to hospital transfer form. It must automatically fill in from the computer. He was transferred out because he fell and broke his hip on 1/2/2023. Review of the facility's policy and procedures titled Transfer and Discharge reviewed on 1/18/2023 reads 3. Appropriate documentation and forms will be sent to the receiving facility/accompany the resident during transport and attempt to have them singed by the resident/resident representative should be made.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents receiving intravenous infusion via Peripherally Inserted Central Catheter (PICC) Line, Residents #18 and #62. Findings include: 1. During an observation on 12/5/2023 at 9:15 AM, Resident #18's PICC line dressing was not dated and there was no gauze or bio-patch under the dressing. There was dry residue under the dressing and there was no needleless connector at the end of the valve (Photographic evidence obtained). During an interview on 12/5/2023 at 9:15 AM, Resident #18 stated, I had this line in the hospital before I came. No one has changed it [dressing] here. Review of Resident #18's admission records showed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin-Resistant Staphylococcus Aureus (MRSA) bacterial infection of the right lower leg. Review of Resident #18's Catheter Insertion Procedure Note dated 11/27/2023 showed the PICC line was placed on the resident's right upper extremity on 11/27/2023. Review of Resident #18's physician order dated 11/29/2023 reads, Daptomycin Intravenous Solution Reconstituted 350 mg [milligrams]. Use 350 mg/ml [milliliters] intravenously every 24 hours for MRSA Infection for 10 days . Start Date: 11/30/2023. Review of Resident #18's physician order dated 12/4/2023 reads, Observe IV [intravenous] site at every shift, every shift for IV site integrity Transparent dressing- change Q [every] seven days and PRN [as needed] Securement device with each dressing change as needed. During an interview on 12/5/2023 at 11:26 AM, the Director of Nursing (DON) stated, My expectation is that there is a date/time on the dressing change. If there is no connector on the valve, then it is at risk for infection. During an interview on 12/5/2023 at 11:27 AM, Staff E, Registered Nurse (RN)/ Unit Manager, stated, It [the dressing] came like this from the hospital. I changed the dressing yesterday and I put the date and time on a sticker on the dressing. I put a valve on the line as well. Someone must have taken it off. During an interview on 12/5/2023 at 11:32 AM, Staff B, Licensed Practical Nurse (LPN), stated, I did not assess the valve/connector. I did look for redness and signs of infection this morning. I am not trained in IV [intravenous] therapy. During an interview on 12/6/2023 at 9:50 AM, Staff E, RN, stated, We don't check arm circumferences here, we just monitor for signs and symptoms of infection, if the IV is infusing correctly and monitor the line. Review of the facility policy and procedures titled P&P PICC/Midline IV Line issued on 4/1/2022 reads, Policy: It will be the policy of this facility to adhere to IV/PICC/Midline administration guidelines as set forth by infection control, state, and federal regulations. Licensed nurses shall provide care according to state and federal law. Considerations: Central Venous Catheters include Peripherally Inserted Central Catheters (PICC)/Midline, Non-tunneled Catheters (Subclavian, jugular, femoral) Tunneled Catheters, Implanted Venous Ports. Guidelines: 1. Medications shall be administered in accordance with physician orders. 2. Medication administration shall be documented in the clinical record. Dressing changes: 1. Sterile dressing change using transparent dressings is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, if the integrity of the dressing has been compromised (wet, loose, or soiled). 2. Dressing changes will be documented in the clinical record. Review of PharmScript Infusion Intravenous (IV) Access Line Maintenance Protocol with an effective date of February 7, 2020 reads, Nurses must: 1. Follow individual therapy procedures for administration of infusion medications and line maintenance. 2) Assess the patient for conditions that may require concentration or volume changes. 3) Assess IV access patency (aspirate a blood return from the catheter. The blood return should be the color/consistency of whole blood. Note: Once a secondary set is detached from a primary set, the secondary set shall be considered a primary set for the instructions below. PICC- Flush Protocols: Maintenance Flush Each Lumen: Non-valved Q12, 10 ml NS [normal saline], 5 ml 10 units/ml Heparin; Valved 10 ml NS Q week. Intermittent non-valved: 10 ml NS, Medication, 10 ml NS, 5 ml 10 units/ml Heparin. Intermittent valved: 10 ml NS, Medication, 10 ml NS . Site Management: Transparent Dressing Changes: On admission or 24' post insertion, then weekly & PRN. Measure upper arm circumference and exterior catheter length with each dressing change and PRN. Needless [Sic.] Connector Changes: On admission Q week & prn, Q 24'with TPN Post Blood Draw Post Blood Transfusion. Administration Set Changes . Primary Intermittent: 24'. 45576 2. Review of Resident #62's admission record showed the was admitted with diagnoses including peripheral vascular disease and mild protein calorie malnutrition. Review of Resident #62's physician order dated 10/30/2023 showed the order to cleanse the right arm with normal saline, pat dry, apply Xeroform and cover with pad two times a day for skin tear. During an observation on 12/4/2023 at 9:22 AM, Resident #62 was lying in bed with a dressing on the right upper arm dated 11/29/2023. During an observation on 12/4/2023 at 12:10 PM, Resident #62 had a dressing on the right upper arm dated 11/29/2023. During an interview on 12/4/2023 at 9:22 AM, Resident #62 stated, I don't know why that is there. During an interview on 12/5/2023 at 7:31 AM, Staff L, LPN, stated, I don't know why she has that dressing really, but I removed it and changed it yesterday. It has not been changed since last week. I changed it yesterday when I saw that the dressing had not been changed since November 29, 2023. During an interview on 12/5/2023 at 7:55 AM, the Director of nursing stated, The physician orders need to be followed and the dressing should be changed twice a day. Review of the facility policy and procedures titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 6. Wound care procedures and treatments should be performed according to physician orders.

Based on observation, interview, and record review, the facility failed to ensure residents maintained the nutritional status for 1 of 6 residents reviewed for nutrition, Resident #81. Findings include: Review of Resident #81's physician order dated 10/27/2023 reads, NAS (No Added Salt) diet Finger Food texture, Thin consistency, Finger foods preferred. Review of Resident #81's care plan revised on 9/22/2023 revealed the resident was at risk for alteration in nutrition and/or hydration. Resident #81's care plan documented nutritional interventions that included Provide diet as ordered. Offer and provide alternate as needed and honor food preferences. Review of Resident #81's weight history showed a weight of 155 pounds on 10/25/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 1.03% weight loss. Further review showed a weight of 169.6 pounds on 7/5/2023 and a weight of 153.4 pounds on 11/21/2023, which was a 9.55% weight loss. During an observation on 12/4/2023 at 1:09 PM, Resident #81 received ham, scalloped potatoes, beets in juice and fruit in juice as her midday meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an observation on 12/5/2023 at 9:13 AM, Resident #81 received oatmeal, scrambled eggs, pancakes with syrup and bacon as her morning meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an interview on 12/5/2023 at 9:15 AM, Staff I, Certified Nursing Assistant (CNA), stated, [Resident #81's name] ate with her hands and she was supposed to be on finger foods. On 12/5/2023 at 12:26 PM, Resident #81 received spaghetti and meatballs, green beans and apple crisps as her midday meal. Resident #81 ate her meal using her hands. Resident #81 did not use utensils. During an interview on 12/6/2023 at 7:47 AM, the Dietary Manager stated, We are to provide finger friendly foods. Typically, we take the main course entree and serve it in a sandwich for finger friendly foods. I see the finger food order. Should have chosen the alternate meal and turned that into a sandwich. He confirmed that the meal items served to Resident #81 were not finger food friendly. He stated, It appears the diet was changed on 11/1/2023 and we did not get communication of it. Supposed to get notified by nursing. During an interview on 12/6/2023 at 8:50 AM, the Registered Dietician stated, We rely on nurses to let us know. [Resident #81's name] problem is not her appetite but more of function and [Resident #81's name] will benefit from being able to get food in her mouth.

Based on observation, interview, and record review, the facility failed to ensure medication error rate was below 5%. The facility's medication error rate was 7.14%. Findings include: 1. During an observation on 12/5/2023 at 8:50 AM, Staff G, Licensed Practice Nurse (LPN), administered Brimonidine Tartrate 0.1% Ophthalmic Solution for Resident #65's eyes. Record review of Resident #65's medication order showed the order for Brimonidine Tartrate 0.2% Ophthalmic Solution to instill one drop both eyes two times a day for glaucoma. Review of the medication package label reads Brimonidine 0.1% Ophthalmic solution, instill one drop in both eyes two times a day for glaucoma. During an interview on 12/6/2023 at 9:41 AM, Staff G, LPN, stated, I didn't check the medicine against the order. I should have. During an interview on 12/6/2023 at 12:34 PM, the Director of Nursing (DON) stated, The nurse would call the family, doctor, supervisor, and fill out an incident form for a wrong medication dose or wrong medication given. 2. During an observation on 12/5/2023 at 9:03 AM, Staff G, LPN, administered Mucous Relief DM Guaifenesin and Dextromethorphan HBr ER tablets 600 mg (milligrams)/ 30 mg for Resident #98. Record review of Resident #98's medication order showed the order for Mucinex Oral Tablet Extended Relief 12-hour 600 mg to give one tablet by mouth two times a day for cough for 10 days, with the start date of 12/1/2023. Review of the medication package label reads, Mucous Relief DM Guaifenesin and Dextromethorphan HBr ER tablets 600 mg/ 30 mg, expectorant and cough suppressant. During an interview on 12/6/2023 at 12:08 PM, Staff G, LPN, stated, The order does not match the medication label. We get over-the-counter medicine from central supply. During an interview on 12/6/12023 at 12:34 PM, the DON stated, The nurse would call the family, doctor, supervisor, and fill out an incident form. I was not notified of this. Review of the Facility policy and procedures titled P&P Medication Administration issued on 4/1/2022, reads Procedure . 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time, and right method of administration are verified.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurate for 1 of 3 discharged residents, Resident #167. Findings include: Review of Resident #167's medical records showed the resident was admitted to the facility on [DATE] and discharged to an Assisted Living Facility (ALF) on 11/13/2023. Review of Resident #167's physician order dated 11/7/2023 reads, Pt.'s [Patient's] spouse requested discharge to [ALF's name] on Monday, 11/13/23. [Staff Name] w [with]/ [ALF's name] to arrange Home Health (if needed) and transportation, PU [pick up] approx. [approximately] 11Am. DME: 18' WC [wheelchair] w/leg rest. DC [discharge] with all medications and belongings. Review of Resident #167's Discharge, Return Not Anticipated MDS dated [DATE] showed the resident was discharged on [DATE] to a short-term general hospital. The MDS was signed on 11/15/2023 at 2:54 PM. Review of Resident #167's modified MDS dated [DATE] showed the resident was discharged on [DATE] to home under care of organized home health service organization. The MDS was signed on 12/4/2023 at 2:25 PM. During an interview on 12/6/2023 at 3:50 PM, Staff M, Licensed Practical Nurse (LPN)/ MDS Coordinator, stated, The initial MDS was signed on 11/15/23. It was through an audit by our Regional MDS Manager that she [the Regional MDS Manager] caught that the MDS discharge status was coded wrong. She corrected it on 12/4/23. We would select number 01. Home/Community if the resident were going to an assisted living facility, but they want us to select number 12. Home under care of organized home health service organization if the resident is going home. During an interview on 12/7/2023 at 9:26 AM, when asked if the coding was accurate on Resident #167's modified MDS, Staff M, LPN/ MDS Coordinator, stated, I don't think the manager realized that she [Resident #167] did not go home, but that she went to an assisted living facility. She must have looked at an old order. Now we have to do a modification on the modification for incorrect coding.

Based on observation, interview, and record review, the facility failed to ensure adaptive eating equipment or devices were provided to 1 of 6 residents reviewed for nutrition, Resident #469. Findings include: During an observation on 12/4/2023 at 9:17 AM, Resident #469 was using plastic disposable utensils to eat his breakfast. During an observation on 12/5/2023 at 12:40 PM, Resident #469 was using plastic disposable utensils to eat his meal. Review of Resident #469's physician order dated 9/15/2023 showed the order reads, Pt [Patient] to utilize built-up utensils for all meals. During an interview on 12/4/2023 at 12:43 PM, the Speech Therapist stated that she was aware Resident #469 was supposed to be using built-up utensils. During an interview on 12/6/2023 at 8:00 AM, the Certified Dietary Manager (CDM) stated, The dishwasher is not functioning currently and residents are being given disposable dishware. The specialized utensils should have been going out to residents but the new staff is in need of further training.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received nail care for 1 of 3 reviewed residents, Resident #132. Findings include: During an observation on 12/3/2023 at 9:40 AM, Resident #132 was sitting outside of his room in his wheelchair. Resident #132's fingernails on his right and left hands were long with dark brown and black substances underneath the nails. There was an injury on the resident's right cheek. Review of Resident #132's care plan, revised on 10/24/2023, revealed the resident had a self-care deficit related to generalized weakness and psychomotor deficit. Resident #132's care plan documented activities of daily living self-care interventions that included assist with nail shaping, keep nails short and clean. Review of Resident #132's personal hygiene task documentation dated 11/23/2023 through 12/3/2023, revealed no documentation indicating the resident had refused to participate in personal hygiene care. During an interview on 12/3/2023 at 9:44 AM, Staff A, Certified Nursing Assistant (CNA), stated that Resident #132's nails needed to be trimmed and cleaned and the resident liked to dig and suggested that he might have scratched his face. During an interview on 12/6/2023 at 8:40 AM, the Director of Nursing stated that the CNA staff should have taken care of Resident #132's fingernails.

Based on interview and record review, the facility failed to ensure a resident's physician was immediately informed when there was a laboratory result that required physician notification for infection that resulted in a delay of care and transfer to a higher level of care and failed to ensure that a resident representative was notified of the change in condition for 1 of 3 residents reviewed for change in condition and wound care (Resident #1). Findings include: Review of the admission record for Resident #1 documented the resident was admitted to the facility on [DATE] with a diagnosis that included schizoaffective disorder, major depressive disorder, hypertensive heart disease without heart failure, Picks disease (frontotemporal dementia), hyperlipidemia, generalized anxiety disorder, unspecified dementia, and on 4/18/2023 a new diagnosis of pressure ulcer of right ankle. Review of the nursing progress note for Resident #1 dated 4/4/2023 at 8:29 AM reads, Observed reopened area on r (right) outer ankle size of a dime. Review of the wound care physician progress note for Resident #1 dated 4/7/23 read, Right lateral ankle. Wound status: New, Acquired in house: yes, Etiology: pressure wound unstageable, Drainage amount: moderate, Drain description: serosanguinous, Other: skin prep periwound. Review of the wound care physician progress note for Resident #1 dated 4/14/23 read, Right lateral ankle: 1.59 cm (centimeters) x 1.29 cm x 0.20 cm, Wound status: worsening, Etiology: pressure wound unstageable, Drainage amount: moderate, Drain description: serosanguinous, Periwound: erythema (redness), Other: skin prep periwound. Review of the wound care physician progress note for Resident #1 dated 4/20/23 read, Right lateral ankle: 2.06 cm x 1.98 cm x 1.30 cm, Wound status: worsening, Acquired in house: yes, Etiology: pressure ulcer Stage 4, Additional wound bed details: exposed bone, Drainage amount: moderate, Drain description: serosanguinous, Periwound erythema, Other: skin prep periwound, recommend wound cx (culture), CMP (complete metabolic profile), CBC (complete blood count), ESR (erythrocyte sedimentation rate), CRP (C reactive protein) and x-ray to rule out osteomyelitis (inflammation and infection of the bone) . Review of the physician's order for Resident #1 dated 4/20/23 read wound culture, right ankle. Review of Resident #1's medical record revealed no laboratory results for a CMP, CBC, ESR or CRP. Review of the physician orders documented no orders for a CMP, CBC, ESR or CRP. Review of the right ankle wound culture for Resident #1 documented a collection date of 4/20/23 at 2300 (11:00 PM) and a reported date of 4/24/23 at 10:57 AM that read, Final report: Gram stain: two plus gram negative rods, two plus gram positive cocci no, WBC (white blood cells) seen. Result moderate growth, normal skin flora, moderate growth gram negative rods: Escherichia coli isolate 1, morganella morgani isolate #2, providencia stuartii isolate #3. Review of the medical record for Resident #1 documented no notification of the wound culture results to the admission physician or nurse practitioner who ordered the tests. Review of the wound care physician progress note for Resident #1 dated 4/27/2023 read, Right lateral ankle: 2.94 x 2.71 x 1.30, Wound status: worsening, Etiology: pressure ulcer Stage 4, Additional wound bed details: exposed bone, Drainage amount: heavy, Drain description: serosanguinous, Other: skin prep periwound, refer to hospital ASAP (as soon as possible), stalled wound healing cycle despite treatment, underlying osteomyelitis. Review of the Skin/Wound care progress note for Resident #1 dated 4/27/2023 read, wound plan of care: wound culture positive for E coli, morganella morgani and providencia stuartii. This writer called PCP (Primary Care Physician), ARNP (Advanced Registered Nurse Practitioner) [ARNP's name] at the bedside and discussed deterioration of wound. Discussed high possibility for osteomyelitis. Recommended labs ordered last week was not done. X-ray was unremarkable. Discussed the need for resident to go to hospital ASAP (as soon as possible) for osteomyelitis treatment. PCP and ARNP agreed. During an interview on 5/8/2023 at 10:30 AM, Resident #1's son stated, I was not notified that her ankle [wound] was worsening until the day they sent her to the hospital. I did not know that they did a wound culture and then didn't give her any antibiotics until I got to the hospital with her. They should have let me know when it began to worsen. They should have called her doctor and gotten her some treatment before they did. My mother has dementia and could not tell me herself about her leg, or that it was worsening. When I saw her, she always had on socks and shoes. They should have done something before they did and maybe she would still have her leg. She has had a below the knee amputation because of this. During an interview on 5/8/2023 at 12:45 PM the Director of Nursing (DON) stated, The nurse practitioner did not place the orders in PCC (point click care) and gave the nurse a verbal order for the x ray, wound culture and all the labs in her note. The labs should have been done. I don't know why they weren't. I don't think the nurse practitioner can place the orders in for labs, the staff need to do that. I can't say why the culture wasn't called to the wound care APRN or the primary doctor. I don't see any notes indicating they were called. They should have been called right away. Staff should have completed documentation either in a progress note or change of condition SBAR (Situation, Background, Assessment, Recommendation) for the wound culture and we should have notified the family that the wound was worsening. I can't find any indication that her son was notified that the wound was worsening. During an interview on 5/8/2023 at 12:58 PM Staff A, Licensed Practical Nurse (LPN) stated, I missed this and did not order the labs, I just didn't hear her say them. I only heard for the x-ray and the wound culture. I did not hear the nurse practitioner say she wanted the labs. We put the labs in for the wound care. I was rounding with her (the wound care APRN) that day. I should have followed up and made sure I got everything that she wanted. We will usually notify the family that there has been a decline in the wound. I did not call her son. I did not call the family. I was involved the day she was sent to the hospital, although I wasn't her nurse. I got the culture, but did not see any wound culture results, but I know I passed along to his nurse that one was done, and they should be following up on that. Any wound culture should be called to the doctor. Any cultures at all should be called to them. During a telephone interview on 5/8/2023 at 1:11 PM APRN stated, I did ask for a CMP, CBC, CRP, ESR, wound culture, and x-ray as her [Resident #1] wound significantly worsened and wasn't getting better. I don't know why the labs weren't ordered, I asked for them. When I saw her the following week, her wound deteriorated even further, and I discussed with medical the need to send her out for probable osteomyelitis. That is when I saw that her labs weren't ordered. These were ordered to determine if she had an infection and osteomyelitis. I was not notified that her wound culture had come back, I saw it the day she was sent to the hospital. I would have liked it if I was notified. I do think that there was a delay in care and that the delay was potentially harmful to the patient. Had I been notified; I definitely would have recommended IV (intravenous) antibiotics and possibly vascular studies or to possibly been sent out to the hospital. When I saw the further wound deterioration, I felt we should immediately send her to the hospital for evaluation of her osteomyelitis. It was my opinion that she could not be treated here and needed to go to the hospital. I believe that there was a delay in getting antibiotics started and that did worsen her wound, and this could worsen her outcome. Review of the policy and procedure titled Change of Condition dated 4/1/2022, approval date of 01/2023 read, Policy: It will be the policy of this person's facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 1. Observe resident during routine care and during monthly/quarterly/annual assessment periods to identify significant changes in physical or mental conditions, orientation, change in vital signs, weights, etcetera. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative (if applicable) to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring.

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents (Resident #1) was free from neglect by failing to provide supervision when the resident was out of doors and found with a temperature of 107 degrees Fahrenheit, unresponsive and subsequently died . The facility failure to ensure a resident was supervised and to prevent neglect when out of doors resulted in Immediate Jeopardy. This has the potential to affect 161 of 161 residents requiring supervision. Cross reference to F689. The findings included: Review of the facility medical record for Resident #1 revealed an admitted (MONTH) 7, (YEAR). Resident #1 had [DIAGNOSES REDACTED]. That can lead to heat exhaustion and heat stroke, which is a medical emergency. [MEDICAL CONDITION] in diabetes is a neurological disorder ([MEDICAL CONDITION]) of all the nerves in the body as a result of diabetes. It can be accompanied by pain and/or loss of function when these nerves do not work property), [MEDICAL CONDITION] (body temperatures in excess of 104 degrees Fahrenheit will cause significant problems for the kidneys. Dehydration will lead to low blood pressure and decreased kidney function. Heart failure and shock can lead to kidney failure during episodes of severe heat stroke), adjustment disorder with depressed mood, hypertension (one of the most common causes of heat intolerance is medication. Blood pressure medications and decongestant may decrease the blood flow to your skin. This inhibits sweat production), abnormality of gait and mobility, muscle weakness, malignant neoplasm of prostate, history of falling. Review of medications for Resident #1 revealed [MEDICATION NAME] (used to treat high blood pressure). Review of Resident #1's Care Plan for Activities revealed Resident prefers to sit outside on patio, initiated (MONTH) 17, 2019. There were no measurable objectives or monitoring directives for the resident going outside unassisted. He has an objective for periods of forgetfulness requiring cues and supervision for decision making, dated (MONTH) 13, (YEAR). Review of the Minimum Data Set, dated dated dated (MONTH) 16, 2019 for Resident #1 revealed a Cognitive score of 9 = moderately impaired cognition. Review of the Social Services Progress Review notes, dated (MONTH) 16, 2019, stated Resident #1 has Impaired Cognitive/Mental Status and requires cues and supervision for decision making. Review of the Certified Nursing Assistant (CNA) Kiosk report note, dated (MONTH) 18, 2019, showed the resident consumed his lunch meal. Review of the Medication Administration Report revealed Resident #1 was administered the physician ordered medications due at 1:00 PM, between 12:30 PM and 12:45 PM. No additional documentation was provided for the supervision of the resident. During interviews conduced on (MONTH) 21, 2019 beginning at 7:00 AM with Certified Nursing Assistants Staff F-M and O-U, who worked on the 200, 300 and 400 halls, they stated all aides are supposed to know where their residents are at all times. They confirmed Resident #1 frequently was outside alone. During an interview on (MONTH) 21, 2019 at 2:00 PM Staff A, Licensed Practical Nurse (LPN) stated, I responded to the call for help from the Kitchen Manager. Resident #1 was outside the door in his wheelchair, but had become unresponsive. I attempted a sternum rub, but Resident #1 was unresponsive. He felt very warm to the touch. Emergency services were called. Resident #1 was transferred to the hospital where he later passed away. I did not know Resident #1 was sitting outside the side door, in the hot weather, but it is common for the resident to sit outside the side door. During an interview on (MONTH) 21, 2019 at 2:45 PM the Kitchen Manager stated, I walked by Resident #1 at about 2:30 PM on (MONTH) 18, 2019 and he looked at me. He was sitting by himself outside the entrance way on the side door of the facility. When I came back, he was unresponsive and drooling. I called the nurse immediately. He frequently sits outside unsupervised. Review of the Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated (MONTH) 18, 2019 with times of 3:10 PM and 3:18 PM revealed blood pressure elevated, blisters on skin noted by nurses providing ice packs for body temperature, bilateral pupils non-reactive to light, pinpoint, no reaction to sternum rub. Review of the Sumter EMS (Emergency Medical Services) Pre-Hospital Care Report, dated (MONTH) 18, 2019, revealed Physical Findings: Extremities: Positive: Burn - Superficial. Impression: Primary Impression: Environmental, Secondary Impression: Cardiac - [MEDICAL CONDITION]. Narrative: Arrived on scene to find Patient supine in bed with no clothes on. Patient was unresponsive. GCS (Glasgow Coma Scale) 5, (The Glasgow Coma Scale is the most common scoring system used. The GCS s scored between 3 and 15, 3 being the worse, and 15 the best). Ataxic Respirations (abnormal pattern of breathing, irregularity of breathing). Staff at the facility stated Patient was helped outside in the Spanish Villa around noon and when they spoke to him again approximately around 3:00 PM he was unresponsive and not following commands. Sumter FF (Fire Fighters) proceeded to take Patient's temperature which was 107 Fahrenheit. Patient's initial blood pressure was ,[DATE]. Patient was given ice packs to body for cooling. Given 500 ml of fluid. Presented with fluid in his lungs. Approximately 3 cycles of blood pressure monitoring showed abnormal blood pressures or timed out and gave us no reading. Patient was assisted onto EMS stretcher. Given oxygen at 15 L non-rebreather. Patient was then taken to the ambulance to attempt intubation. During reassessment Patient appeared to have constricted pupils. Another temperature was taken which was still 107 Fahrenheit. Suctioned airway and after retracting the Yankour the Patient appeared to start to gag and soon after started vomiting. Patient was placed on his right side to avoid aspiration in lungs and continued suctioning. Reassessment Patient appeared he was no longer breathing. Carotid checked and appeared Patient had no pulse, CPR (Cardiopulmonary Resuscitation) was started along with emergency transport to Leesburg Hospital. During rhythm checks Patient was in PEA (Pulseless Electrical Activity). Patient head to toe showed [MEDICAL CONDITION] to thighs. Patient care transferred to ER RN (emergency room Registered Nurse). Patient unable to sign due to death with a rectal temperature of 107 Fahrenheit at hospital. Review of the Leesburg Regional Medical Center Emergency Documentation, dated (MONTH) 18, 2019, revealed History of Present Illness: Presents to ED from Cypress Nursing Facility via EMS for unresponsiveness. Per EMS, patient was last seen normal at noon when staff members took the patient outside. Patient was left outside unattended until he patient was found unconscious by staff members at 3:00 PM. Per EMS, patient was unresponsive on scene with a rectal temperature of 107, GCS of 5, heart rate ranging from ,[DATE] beats per minute (BPM), Blood Glucose Level (BGL) 215, and blood pressure (BP) of ,[DATE]. After EMS loaded the patient into the ambulance he lost his pulse and was in asystole at approximately 3:25 PM. EMS started CPR and administered a total of three [MEDICATION NAME] and one [MEDICATION NAME] during transport. Physical Exam: General: Patient is unresponsive. Eye: Pupils 5 mm, fixed, dilated, and nonreactive to light. Lungs: No spontaneous respiratory movement, coarse breath sounds bilaterally with manual ventilation. Heart: No active heart tones. Abdomen: Soft, distended. Musculoskeletal: No [MEDICAL CONDITION], no spontaneous muscle movement, unresponsive to nay stimuli. Skin: Multiple blisters to anterior thighs. Neurologic: Unable to be assessed due to patient's condition. Psychiatric: Patient was unresponsive. Medical Decision Making: Time of death: 4:42 PM. Total Critical Care time 35 minutes spent engaged in work directly related to patient care. Reexamination/reevaluation: Patient arrived in emergency department at 4:16 PM where CPR and ACLS (Advanced Cardiac Life Support) protocol was taken over by nursing staff. Patient was intubated and had a central line placed. A total of eight [MEDICATION NAME], one calcium, and one [MEDICATION NAME] was administered by nursing staff throughout patient care. On exam the patient did not respond to verbal or physical stimuli. Patient remained PEA the entire time with absent peripheral pulses. Pupils are fixed and dilated; absent corneal reflex. Patient was pronounced at 4:42 PM. Assessment/Plan: Acute [MEDICAL CONDITION], Aspiration, [MEDICAL CONDITION], Hyperthermia (the condition of having a body temperature greatly above normal). During an interview on (MONTH) 21, 2019 at approximately 1:15 PM with the City Police Detective Sergeant he stated, I observed part of the autopsy of Resident #1. The physician stated Hyperthermia would be one of the causes of death. During an interview on (MONTH) 21, 2019 at 2:15 PM the Risk Manager (RM) stated, I expect the staff to be checking on the residents. The staff are trained frequently about knowing their residents and monitoring them. The nurses should be monitoring the Aides throughout the shift, to ensure they are doing their jobs. We did not know why Resident #1 was unresponsive before they called for Emergency Services. There was a mistake when the CNA did not know the location of the resident and his condition. He frequently sits outside. During an interview on (MONTH) 21, 2019 at 2:25 PM the Administrator stated, I expect the nurses and the CNAs to give the residents the care they need. I expect them to check on each resident at least once per hour. Residents may be fine one day and not the next, so do not assume everything is fine. There was a mistake when the CNA did not know the location of the resident and his condition. He frequently sits outside unsupervised. There are no policies or programs for residents going outside, including cognitively impaired residents who move in and out of the facility without supervision. During an interview on (MONTH) 22, 2019 at 2:15 PM the Weekend Supervising Nurse confirmed there is no process or program for residents staying outside unsupervised. I expect the CNA assigned to any resident to know the location of the resident at all times. There was a mistake when the CNA did not know the location of the resident and his condition.

Based on record review and interview the facility failed to ensure 1 of 3 sampled residents (Resident #1) was provided adequate supervision out of doors and found with a temperature of 107 degrees Fahrenheit, unresponsive and subsequently died . The facility failure to ensure adequate supervision when outside resulted in Immediate Jeopardy. This has the potential to affect 161 of 161 residents requiring supervision. Cross reference to F600. The findings included: Review of the facility medical record for Resident #1 revealed an admitted (MONTH) 7, (YEAR). Resident #1 had [DIAGNOSES REDACTED]. That can lead to heat exhaustion and heat stroke, which is a medical emergency. [MEDICAL CONDITION] in diabetes is a neurological disorder ([MEDICAL CONDITION]) of all the nerves in the body as a result of diabetes. It can be accompanied by pain and/or loss of function when these nerves do not work property), [MEDICAL CONDITION] (body temperatures in excess of 104 degrees Fahrenheit will cause significant problems for the kidneys. Dehydration will lead to low blood pressure and decreased kidney function. Heart failure and shock can lead to kidney failure during episodes of severe heat stroke), adjustment disorder with depressed mood, hypertension (one of the most common causes of heat intolerance is medication. Blood pressure medications and decongestant may decrease the blood flow to your skin. This inhibits sweat production), abnormality of gait and mobility, muscle weakness, malignant neoplasm of prostate, history of falling. Review of medications for Resident #1 revealed [MEDICATION NAME] (used to treat high blood pressure). Review of Resident #1's Care Plan for Activities revealed Resident prefers to sit outside on patio, initiated (MONTH) 17, 2019. There were no measurable objectives or monitoring directives for the resident going outside unassisted. He has an objective for periods of forgetfulness requiring cues and supervision for decision making dated (MONTH) 13, (YEAR). Review of the Minimum Data Set, dated dated dated (MONTH) 16, 2019 for Resident #1 revealed a Cognitive score of 9 = moderately impaired cognition. Review of the Social Services Progress Review notes dated (MONTH) 16, 2019 stated Resident #1 has Impaired Cognitive/Mental Status and requires cues and supervision for decision making. Review of the Certified Nursing Assistant (CNA) Kiosk report note, dated (MONTH) 18, 2019, revealed the resident consumed his lunch meal. Review of the Medication Administration Report revealed Resident #1 was administered the physician ordered medications due at 1:00 PM, between 12:30 PM and 12:45 PM. No additional documentation was provided for the supervision of the resident. During interviews conduced on (MONTH) 21, 2019 beginning at 7:00 AM with Certified Nursing Assistants Staff F-M and O-U, who worked on the 200, 300 and 400 halls, they stated all aides are supposed to know where their residents are at all times. They confirmed Resident #1 frequently was outside alone. During an interview on (MONTH) 21, 2019 at 2:00 PM Staff A, Licensed Practical Nurse (LPN) stated, I responded to the call for help from the Kitchen Manager. Resident #1 was outside the door in his wheelchair, but had become unresponsive. I attempted a sternum rub, but Resident #1 was unresponsive. He felt very warm to the touch. Emergency services were called. Resident #1 was transferred to the hospital where he later passed away. I did not know Resident #1 was sitting outside the side door, in the hot weather, but it is common for the resident to sit outside the side door. During an interview on (MONTH) 21, 2019 at 2:45 PM the Kitchen Manager stated, I walked by Resident #1 at about 2:30 PM on (MONTH) 18, 2019 and he looked at me. He was sitting by himself outside the entrance way on the side door of the facility. When I came back, he was unresponsive and drooling. I called the nurse immediately. He frequently sits outside unsupervised. Review of the Situation, Background, Assessment, Recommendation (SBAR) Communication Form dated (MONTH) 18, 2019 with times of 3:10 PM and 3:18 PM revealed blood pressure elevated, blisters on skin noted by nurses providing ice packs for body temperature, bilateral pupils non-reactive to light, pinpoint, no reaction to sternum rub. Review of the Sumter EMS (Emergency Medical Services) Pre-Hospital Care Report dated (MONTH) 18, 2019 revealed Physical Findings: Extremities: Positive: Burn - Superficial. Impression: Primary Impression: Environmental, Secondary Impression: Cardiac - [MEDICAL CONDITION]. Narrative: Arrived on scene to find Patient supine in bed with no clothes on. Patient was unresponsive. GCS (Glasgow Coma Scale) 5, (The Glasgow Coma Scale is the most common scoring system used. The GCS s scored between 3 and 15, 3 being the worse, and 15 the best). Ataxic Respirations (abnormal pattern of breathing, irregularity of breathing). Staff at the facility stated Patient was helped outside in the Spanish Villa around noon and when they spoke to him again approximately around 3:00 PM he was unresponsive and not following commands. Sumter FF (Fire Fighters) proceeded to take Patient's temperature which was 107 Fahrenheit. Patient's initial blood pressure was ,[DATE]. Patient was given ice packs to body for cooling. Given 500 ml of fluid. Presented with fluid in his lungs. Approximately 3 cycles of blood pressure monitoring showed abnormal blood pressures or timed out and gave us no reading. Patient was assisted onto EMS stretcher. Given oxygen at 15 L non-rebreather. Patient was then taken to the ambulance to attempt intubation. During reassessment Patient appeared to have constricted pupils. Another temperature was taken which was still 107 Fahrenheit. Suctioned airway and after retracting the Yankour the Patient appeared to start to gag and soon after started vomiting. Patient was placed on his right side to avoid aspiration in lungs and continued suctioning. Reassessment Patient appeared he was no longer breathing. Carotid checked and appeared Patient had no pulse, CPR (Cardiopulmonary Resuscitation) was started along with emergency transport to Leesburg Hospital. During rhythm checks Patient was in PEA (Pulseless Electrical Activity). Patient head to toe showed [MEDICAL CONDITION] to thighs. Patient care transferred to ER RN (emergency room Registered Nurse). Patient unable to sign due to death with a rectal temperature of 107 Fahrenheit at hospital. Review of the Leesburg Regional Medical Center Emergency Documentation dated (MONTH) 18, 2019 revealed History of Present Illness: Presents to ED from Cypress Nursing Facility via EMS for unresponsiveness. Per EMS, patient was last seen normal at noon when staff members took the patient outside. Patient was left outside unattended until he patient was found unconscious by staff members at 3:00 PM. Per EMS, patient was unresponsive on scene with a rectal temperature of 107, GCS of 5, heart rate ranging from ,[DATE] beats per minute (BPM), Blood Glucose Level (BGL) 215, and blood pressure (BP) of ,[DATE]. After EMS loaded the patient into the ambulance he lost his pulse and was in asystole at approximately 3:25 PM. EMS started CPR and administered a total of three [MEDICATION NAME] and one [MEDICATION NAME] during transport. Physical Exam: General: Patient is unresponsive. Eye: Pupils 5 mm, fixed, dilated, and nonreactive to light. Lungs: No spontaneous respiratory movement, coarse breath sounds bilaterally with manual ventilation. Heart: No active heart tones. Abdomen: Soft, distended. Musculoskeletal: No [MEDICAL CONDITION], no spontaneous muscle movement, unresponsive to nay stimuli. Skin: Multiple blisters to anterior thighs. Neurologic: Unable to be assessed due to patient's condition. Psychiatric: Patient was unresponsive. Medical Decision Making: Time of death: 4:42 PM. Total Critical Care time 35 minutes spent engaged in work directly related to patient care. Reexamination/reevaluation: Patient arrived in emergency department at 4:16 PM where CPR and ACLS (Advanced Cardiac Life Support) protocol was taken over by nursing staff. Patient was intubated and had a central line placed. A total of eight [MEDICATION NAME], one calcium, and one [MEDICATION NAME] was administered by nursing staff throughout patient care. On exam the patient did not respond to verbal or physical stimuli. Patient remained PEA the entire time with absent peripheral pulses. Pupils are fixed and dilated; absent corneal reflex. Patient was pronounced at 4:42 PM. Assessment/Plan: Acute [MEDICAL CONDITION], Aspiration, [MEDICAL CONDITION], Hyperthermia (the condition of having a body temperature greatly above normal). During an interview on (MONTH) 21, 2019 at approximately 1:15 PM the City Police Detective Sergeant stated, I observed part of the autopsy of Resident #1. The physician stated Hyperthermia would be one of the causes of death. During an interview on (MONTH) 21, 2019 at 2:15 PM the Risk Manager (RM) stated, I expect the staff to be checking on the residents. The staff are trained frequently about knowing their residents and monitoring them. The nurses should be monitoring the Aides throughout the shift, to ensure they are doing their jobs. We did not know why Resident #1 was unresponsive before they called for Emergency Services. There was a mistake when the CNA did not know the location of the resident and his condition. He frequently sits outside. During an interview on (MONTH) 21, 2019 at 2:25 PM the Administrator stated, I expect the nurses and the CNAs to give the residents the care they need. I expect them to check on each resident at least once per hour. Residents may be fine one day and not the next, so do not assume everything is fine. There was a mistake when the CNA did not know the location of the resident and his condition. He frequently sits outside unsupervised. There are no policies or programs for residents going outside, including cognitively impaired residents who move in and out of the facility without supervision. During an interview on (MONTH) 22, 2019 at 2:15 PM the Weekend Supervising Nurse she confirmed there is no process or program for residents staying outside unsupervised. I expect the CNA assigned to any resident to know the location of the resident at all times. There was a mistake when the CNA did not know the location of the resident and his condition.