Every finding on record at Fleetwood Post Acute

Based on review of the facility policy, observation, record review, and interview, the facility failed to ensure fluid restriction was maintained for (Resident (R)50, for 1 of 1 resident reviewed for dialysis. Failure of following fluid restriction orders could lead to excess fluid in the tissues requiring additional dialysis chair time. Findings include: Review of an untitled and undated facility policy, revealed under the policy, Obtain a physicians order for fluid restriction that includes total amount of fluids allowed each day and the diagnosis/reason for the fluid restriction. Nursing notifies Dietary Services when a resident is placed on fluid restriction. The total of fluid allowed, and the amount allotted to dietary is specified by nursing. Remove bedside water pitcher from residents room. Record review of R50's face sheet revealed his initial admitted was 07/09/2019 with diagnoses that include but are not limited to, chronic congestive heart failure, end stage renal disease, dependence on renal dialysis and cardiac pacemaker. Record review of R50's Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/04/2025 revealed he had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating he had no cognitive impairment. Record review of R50's physician orders dated 01/22/2025 revealed an order for 1200 milliliters (ml) fluid restriction, give 240 ml's on meal trays. Additionally, an order dated 09/16/2024 revealed an order for (all caps) R50, NO FLUIDS AFTER DINNER PER DIALYSIS. 1200 ml fluid restriction, and a 3rd order for R50 dated 05/21/2024 of 1200 ml/24 hours fluid restriction, give 120 ml with each med pass. Record review of R50's recorded fluid intake over the 14 day lookback revealed on 04/30/2025, his intake was recorded as receiving 1340 ml of fluids and on 04/26/2025 it recorded 1260 ml of fluids. There are many shifts where no fluid intake was recorded. On 05/05/2025 at 11:10 AM, an observation revealed R50 sitting by the door in his room. He stated he was on fluid restriction and he goes to dialysis on Monday, Wednesday and Friday. On 05/05/2025 at 11:15 AM, a water pitcher was observed in R50's room. Licensed Practical Nurse (LPN)2 picked up the water pitcher and was looking for the dialysis emergency kit, and placed it back down on the bedside drawer. On 05/06/2025 at 8:40 AM, an observation revealed R50 sitting up at the table in the common area. His meal tray was in front of him. He had just eaten. R50's meal ticket was observed. It recorded 1200 ml fluid restriction. Double meat with gravy. No straws. 4 fl oz. cranberry juice. Double meat and eggs. No pork sausage. Puree, Renal, thin liquids. The cranberry juice was empty and the coffee mug was also empty. On 05/06/2025 at 8:52 AM, an observation of R50's room revealed a water pitcher at his bedside. It was full with ice and water. On 05/06/2025 at 8:55 AM, an interview was conducted with Certified Nurse Assistant (CNA)1. She said R50 had a cup of coffee, cranberry juice and he had double portion oatmeal, double meat, and sausage. She also confirmed he drank all the cranberry juice and his coffee, which was a full mug. On 05/06/2025 at 9:40 AM, an interview was conducted with the Nurse Practitioner (NP). She said the fluid restriction for R50 was from dialysis. She stated, They said they were pulling too much fluid off him. Since September 2024, he was placed on 1200 cc fluid restriction. Our Registered Dietician (RD) is in contact with dialysis and will send over recommendations or call them. When I go in and see R50, he does not have any kind of fluids on his table. I see R50 about every 30 days. On 05/06/2025 at approximately 10:04 AM, a second observation revealed the ice pitcher in R50's room. LPN2 was in the hallway by the door at the medication cart. This surveyor asked LPN2 to come in the room to confirm the water at bedside. At that time, the Assistant Director of Nursing (ADON) entered the room. On 05/06/2025 at approximately 10:05 AM, the ADON was in R50's room. She stated, R50 is on a fluid restriction. She said she poured the water out and placed it in the trash. She confirmed he should not have water at his bedside. On 05/06/2025 at 10:06 AM, an interview was conducted with LPN2. He stated he didn't think about it yesterday when in R50's room and he picked up the water pitcher to move it. LPN2 said, I think it's the night shift that must be putting it in his room. He's on 1200 ml in 24 hours. For each med pass, I give 120 ml. He confirmed if the nurses are giving him 120 ml with each med pass, that would be over the 480 ml nursing gives. He said, R50 gets 240 ml with his meal trays. It is ok to have the mug of coffee and his juice, they are 120 ml each. At least I think the coffee mug is 120 mls. On 05/06/2025 at 10:20 AM, an interview was conducted with the Unit Manager, LPN1. She measured out the coffee mug using a 240 ml calibrated cup. She confirmed the 240 ml filled the coffee mug. She confirmed there are 5 administration times that medication is given, not 4. LPN1 stated, I can have the NP change his medication time to give all at the same time. She also reviewed the fluid intake record for R50. She stated, According to the documentation, it shows he is receiving more fluid than he should receive, but that is a dialysis day. There are many shifts where nothing is recorded. It is a problem. On 05/06/2025 at 10:53 AM, an interview was conducted with the Director of Nurses (DON). She stated, R50 is on dialysis. He's on a 1200 ml fluid restriction. The kitchen should give him 240 ml with meals and nursing 120 ml with each med pass, 4 times a day. After reviewing the Medication Administration Record (MAR), she confirmed he does have 5 medication administration times recorded on the MAR. She said the juice came from the kitchen, nursing pours the coffee to residents who request it. She confirmed he received more fluids than he was supposed to receive. On 05/06/2025 at 1:15 PM, an interview was conducted with the Certified Dietary Manager (CDM). She said, We don't put coffee out on the resident's trays. Nursing passes out the coffee. We only give R50, 120 ml of juice with his breakfast, but he can have up to 240 ml with each meal.

Based on observation, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety for 1 kitchen and 3 of 3 unit nourishment refrigerators for residents. Specifically, concerns were noted with food not being labeled or dated. This had the potential to affect 94 of 95 residents (one resident received nutrition via tube feeding) who received food from the kitchen. Findings include: Review of the facility's policy titled, Food Storage: Dry Goods dated 5/2014 and revised 2/2023, revealed, All dry goods will be appropriately stored in accordance with the FDA Food Code . Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility's policy titled, Food Storage: Cold Foods dated 5/2014 and revised 2/2023, revealed, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code . All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Food from an Approved Source dated 5/2014 and revised 10/2022, revealed All food will be procured from sources approved or considered satisfactory by federal, state, and local authorities . Food may be brought into the facility by family, visitors, or other outside sources. The facility staff will assist with proper food storage and handling, as appropriate. Review of the facility's policy titled, Food Brought by Family/Visitors revised October 2017, revealed, Family members and visitors are requested to inform nursing staff of their desire to bring foods into the facility . Safe food handling practices will be explained to family/visitors in a language and format they understand . Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. a. Non-perishable foods will be stored in re-sealable containers with tight-fitting lids. b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date .Staff will discard perishable foods on or before the use by date. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). During the initial kitchen inspection on 12/27/23 from 8:03 AM through 8:50 AM with the Dietary Manager (DM). The following concerns were noted: a. In the reach in cooler a tray of unlabeled sandwiches with a prep date of 12/25 and no discard date was observed. b. A tray of unlabeled, undated pureed fruit was observed stacked on top of multiple other trays of food items. The DM stated that the pureed fruit has the same prep date as the foods underneath. The foods underneath had a prep date of 12/25 and no discard date. c. In the walk in cooler, a large, opened package of ham was observed with a date of 12/24/22. The DM stated that this was the opened date. There was no discard date on the package of ham. d. In the cooks' refrigerator there was a plate of sliced American cheese covered with plastic wrap dated 12/24/23 with no discard date. The DM stated she had to check on what the cheese was for. e. A container labeled baked beans with a prep date of 12/23/23 and a discard date of 12/26/23 was observed. The DM confirmed that this food item was past its discard date. f. A large plastic container of vanilla pudding with a prep date of 12/26/23 and no discard date was observed. g. A large plastic container of lima beans dated 12/26/23 and no discard date was observed. When asked how the staff know when to discard food items, she stated they know to discard it based on the date of the package. Further interview with the DM confirmed there was no longer any packaging on the item to show an expiration date. h. A tray of pureed sandwiches with a prep date of 12/26/23 and no discard date was observed. The DM stated these items were to be used today. i. A plastic bag of peanut butter and jelly sandwiches dated 12/24/23 with no discard date was observed. j. In the dry storage area a large plastic bin of corn meal, dated 12/16/23 with no discard date was observed. k. A large plastic bin of sugar dated 12/26/23 with no discard date was observed. The DM was not sure about the policy on dry food storage. l. A 36-ounce opened box of Potatoes Au Gratin dated 12/19/23 with no discard date was observed. m. Two loaves of white bread were observed to have a use by date of 12/26/23. During an observation and second visit to the kitchen with the DM on 12/29/23 at 10:32 AM, a 16-ounce container of Sysco Beef Base was observed with an open date of 12/23 and no discard date. During a tour of the unit nourishment refrigerators with the DM on 12/29/23 at 10:54 AM the following observations were made: a. In the Unit 3 refrigerator two bags of take-out were observed. One bag was dated 12/25/23 with no discard date. The other bag was dated 12/24/23 with no discard date. The Licensed Practical Nurse (LPN)1 on the unit was immediately interviewed. She stated that family can bring in food, but it must be labeled with the resident's name and date on it, and it should be discarded after three days. I was told dietary oversaw throwing out items past their discard date. A bag of unlabeled, undated sandwiches was also observed in the refrigerator. The DM stated that those were from the kitchen and should have been labeled and dated. b. The Unit 2 refrigerator was observed with multiple splatter stains along the top and bottom two shelves and along the door. An unlabeled, undated plastic bag of take-out was observed; an unlabeled, undated plastic bag of dinner rolls was observed; a red unlabeled, undated plastic container containing food was observed; opened, unlabeled, undated containers of salsa and mustard were also observed. The Unit Manager Station 2 (UM-S2) was immediately interviewed. She stated that when food was brought in by visitors it was dated and initialed. It can stay in the refrigerator for three days UM-S2 stated that she has cleaned out the refrigerator herself, usually on Saturdays. c. On Unit 1 the housekeeper (HSK) was in the process of cleaning the Unit 1 refrigerator. In the resident's refrigerator, an opened, unlabeled, undated, 2-liter bottle of Sprite was observed; an opened, unlabeled, undated jar of pickles was observed; and an opened, undated, unlabeled container of vegetable oil spread was observed. The LPN2 on the unit was immediately interviewed. LPN2 stated that food brought in by visitors is to be dated and discarded within 48 hours. She stated they go through it periodically to see if anything needs to be tossed and that it is everyone's responsibility to go through the refrigerator. The DM stated that if she just started throwing away the residents' food in the refrigerator, the staff and residents would not be happy, especially if the items were not labeled. During an interview with the Regional District Manager (RDM) on 12/29/23 at 11:46 AM revealed that anything we stock should be labeled and dated. Per the policy it states that facility staff can discard items after three days. The RDM stated that it is 90% their [the kitchen staff's] responsibility to discard food items in the unit refrigerators. He stated that as long as it [the food item] is labeled and dated within three days, if it is not labeled or dated then the kitchen staff member should go and check with nursing staff on the floor. He stated it was largely an oversight on their part [the kitchen's] that the food items were not being discarded in a timely manner. When asked where in the policy it indicated the three-day timeframe or the requirement for kitchen staff to consult the nursing staff to identify the owner of specific food items, he was not able to locate that reference in the documentation. During an interview with the Registered Dietitian (RD) on 12/29/23 at 12:35 PM revealed that he was not sure what the policy was on food from outside. Usually when family comes in they ask where to put the food for the resident. The unit staff are supposed to label it and educate the family on the policy. During an interview with Administrator on 12/29/23 at 1:29 PM he stated that everybody should take responsibility for correctly labeling and discarding food items in the unit refrigerators. He stated that the Unit Managers should be educating the family on what to do with the food, confirming if it's the correct diet, texture, and consistency.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure no smoking/oxygen in use signs were posted on the entry ways of residents' rooms or a no smoking sign was posted at the entrance of the facility to alert visitors that oxygen was in use for 4 of 12 residents (Resident (R) 29, R79, R87, R145) reviewed for accidents, out of 33 sampled residents. This failure had the potential to cause a fire if any visitors smoked in the facility while oxygen was in use. Findings include: Review of the facility's undated policy titled Oxygen Administration, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration . General Guidelines . 2. No smoking/oxygen in use signs should be posted at the major entrance(s) of the facility. 1. Review of R29's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with hypoxia (low levels of oxygen). Review of R29's Physician's Order dated 12/07/23, located in the EMR under the Orders tab, revealed an order for auto continuous positive airway pressure (CPAP) with oxygen (O2) at 3 Liters per Minute (LPM) via nasal prongs to be worn at bedtime and during the day when napping at bedtime for nocturnal hypoxia and as needed for nocturnal hypoxia when napping. During an observation on 12/28/23 at 1:41 PM revealed R29 was lying in bed in her room with O2 on via nasal cannula (NC) and there was no signage at the doorway or within view of the entryway to the resident's room to alert staff and visitors that oxygen was in use. 2. Review of R79's undated Admission Record located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure, unspecified with hypoxia or hypercapnia (build up of carbon dioxide in the bloodstream). Review of R79's Physician's Order, dated 12/07/23, located in the EMR under the Orders tab, revealed an order for O2 at 2 LPM via NC to maintain oxygen saturation at or greater than 90 % (percent) every shift. During an observation on 12/28/23 at 1:38 PM revealed R79 was lying in bed in his room with O2 on via NC and there was no signage at the doorway or within view of the entryway to the resident's room to alert staff and visitors that oxygen was in use. 3. Review of R87's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure, unspecified with hypoxia or hypercapnia. Review of R87's Physician's Order dated 12/07/23, located in the EMR under the Orders tab, revealed an order for O2 continuous via NC at 2 LPM. Monitor levels every (Q) shift every day and night shift. During an observation on 12/28/23 at 1:40 PM revealed R87 was lying in bed in his room with O2 on via NC and there was no sign on the resident's doorway alerting staff and visitors that oxygen was in use. 4. Review of R145's undated Admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia. Review of R145's Physician's Order dated 12/07/23, located in the EMR under the Orders tab, revealed an order for O2 at 2 LPM via nasal cannula to maintain oxygen saturation at or greater than 90 % every shift. During an observation on 12/28/23 at 1:33 PM revealed R145 was lying in bed in his room with O2 on via NC; however, there was no oxygen in use sign posted at the doorway to the resident's room. During an observation and interview on 12/28/23 at 2:34 PM with the Administrator and Maintenance Director (MD) confirmed there was not a No Smoking sign posted at the front entrance of the building. During an interview on 12/28/23 at 2:36 PM, the Administrator confirmed there were 14 residents that smoked in the courtyard, there were no signs posted in the facility on the outside of the residents' rooms of no smoking/oxygen in use, and a no smoking sign was not posted outside at the entrance of the facility. The Administrator stated the purpose of posting the signs was to alert visitors and residents that oxygen was in use in the building to prevent a fire. The Administrator indicated that they did not have a policy that stated either oxygen in use signs had to be posted on entryways of residents' rooms or a no smoking sign had to be posted on the front entrance of the building. During an interview on 12/28/23 at 2:37 PM, the MD stated there was a no smoking sign by the front door, but he didn't know what happened to it. The MD acknowledged he had worked at the facility for three years and had not seen signs on the entryways to the residents' rooms.

Based on review of the facility policy, record review, and interview, the facility failed to provide life saving practices in a timely manner for 1 of 1 residents. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide life-saving practices in a timely manner constituted Immediate Jeopardy (IJ) at F684. On [DATE] at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Quality of Care. On [DATE] at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at F684 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F684 constituting substandard quality of care. Findings include: Review of the facility policy titled Emergency Procedure-Chocking revised on [DATE], states, Trained staff will assist those who are choking by attempting to expel the foreign body from the airway. Unconscious Resident-Lying Down (or when Unable to Reach Around the Resident) 1. Ease the resident as gently as possible to the floor. 2. Call for help if assistance is not already present but do not leave the resident unattended. 3. Position the resident on his or her back with arms at his or her side. 4. Perform abdominal thrust as follows a. Facing the resident, kneel and straddle the resident's upper thigh with your body. b. Place the heel of one hand on the resident's upper mid-abdomen, below the rib cage, and above the navel with fingers pointed toward the resident's chest. c. Place the other hand directly over the positioned hand. d. Bring your shoulders forward over your hands. e. Use your body weight to press your hands into the resident's upper abdomen with a quick upward thrust. 5. Perform the finger sweep maneuver to check for a foreign body as follows: a. Keep the residents face up. b. Perform the tongue-jaw lift to open the resident's mouth. (Note: Moving the lower jaw moves the tongue off the throat and opens the airway. c. Perform the finger sweep using your index finger as a hook. 1. Insert your index finger into the resident's mouth alongside the cheek and across the base of the tongue 2. Try to remove any foreign objects. 3. Avoid pushing foreign objects deeper into the throat. 4. Turn the resident's head to one side if needed to sweep an object from the mouth. Under the documentation section states, The person performing this procedure should record the following information in the resident's medical record. 1. The date and time the procedure was performed. 2. The name and title of the individual (s) who performed the procedure. 3. The exact time the choking began. 4. The exact time of any unconsciousness. 5. All assessment data obtained during the procedure. 6. The time the procedure was started and stopped. 7. The resident's response to the procedure. 8. The signature and title of the person recording the data. Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation with a revised date of February 2018, states, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) . General Guidelines states, 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . Emergency Procedure - Cardiopulmonary Resuscitation states, 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing . Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admitted [DATE], and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Further review of R1's Face Sheet indicated R1 was a full code. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of [DATE] revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's Physician Orders revealed an active order for, Dysphagia Mechanical Texture Soft Diet. Review of R1's Progress Note dated [DATE] at 5:45 PM, revealed, Note Text: Resident at supper in the dining room. Passed by res and noted res not moving and not responding to any type of stimuli. Took res to room and noted pulse. Requested assist from other nurses; res placed on bed w large amt of food removed from the throat. Call to EMS. Res was given CPR at 17:54 as EMS was entering the building. EMS began CPR.DON was contacted. Review of R1's Hospital Emergency Department Encounter Note dated [DATE] revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on ,d+[DATE] - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. During an interview on [DATE] at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday ,d+[DATE] from the aspiration that occurred on ,d+[DATE]. During an interview on [DATE] at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray. CNA1 stated that she noticed that the sandwich that was on R1's tray was the same as the sandwich R1 took from the other resident. The only difference was that R1 had 2 sandwiches on her tray, the egg salad croissant, and an egg salad sandwich on regular bread. CNA1 stated she gave the other resident R1's egg salad croissant to replace the sandwich that R1 took. CNA 1 stated she observed R1 eat the rest of her food while talking and with a mouth full of food and CNA1 told her to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. Review of LPN1's witness statement dated [DATE] revealed, At 5:45 PM on [DATE], I was assisting with supper in the dining room and noticed that [R1] was quiet which is unlike her. The resident checked the pulse present, but the resident was unresponsive. Egg salad was noted on the face. I sent [CNA1] upstairs to get help. [LPN2] and [LPN3] arrived. Took the resident to her room, and she was still unresponsive. at 5:54 PM, [R1] lost her pulse. CPR was initiated and 911 was called. EMS arrived within minutes and took over the code. Called resident RP, after EMS arrived. During an interview on [DATE] at 10:56 AM, LPN1 stated that she was in the station 1 dining room, R1 was found unresponsive with a faint pulse, quiet, and not responding to verbal commands or physical touch. R1's head was down. LPN1 stated that she didn't know how long the resident was unresponsive before she saw her. LPN1 stated that she noticed R1 had egg salad on her face and was not aware of what R1's meal was that day and stated R1 was on a puree diet with thickened liquids. LPN1 further stated that the Heimlich maneuver was not done because R1 was already unresponsive and CPR was not done in the dining room due to the resident having a faint pulse. LPN1 stated that she sent CNA1, and another CNA to grab help for R1. Once helped arrived, LPN1 stated that she wheeled R1 to her room, layed R1 on her side, and cleared her throat while waiting for other staff to get to the room before calling 911. LPN1 further stated finger sweeps were not done until R1 was wheeled to her room and placed on the bed. LPN1 stated that the crash cart is in station 1 dining room, left of the piano, where R1 was located and does not remember if the crash cart was used. LPN1 stated the AED pads were not used while performing CPR, and she did compressions while LPN2 was doing breaths. LPN1 stated she did 1 set of 20 compressions, and EMS took over. On [DATE] the facility presented an acceptable removal plan, which included: Actions Taken: Facility leadership interviewed facility staff working on [DATE] Facility initiated education for facility staff related to identifying the need for and providing basic life-saving measures on [DATE] Facility initiated education for facility staff on facility's choking policy [DATE] Facility initiated skills checks for Licensed Nurses related to providing CPR, the Heimlich maneuver, and finger sweeps on [DATE] Facility to monitor staff's response to emergency situations by performing mock code drills 1 time per shift per month for 3 months - [DATE] Facility to continue daily audits on crash carts on the presence and availability of supplies - ongoing Facility reviewed emergency procedure - choking policy on [DATE] Date of compliance: [DATE]

Based on record review and interviews, the facility failed to ensure Resident (R)1 received proper supervision to prevent asphyxiation. Specifically, R1 was found in the dining room unresponsive after R1 consumed an egg salad croissant that did not meet R1's therapeutic diet. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide proper supervision to prevent asphyxiation constituted Immediate Jeopardy (IJ) at F689. On [DATE] at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Quality of Care. On [DATE] at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at F689 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admitted [DATE], and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Further review of R1's Face Sheet indicated R1 was a full code. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of [DATE] revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's Physician Orders revealed an active order for, Dysphagia Mechanical Texture Soft Diet. Review of R1's Hospital Emergency Department Encounter Note dated [DATE] revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on ,d+[DATE] - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. Review of R1's Care Plan with a revision date of [DATE] revealed, I have the potential for alteration in cardiac function/output dx htn and hyperlipidemia. The goal with a target date of [DATE] revealed, Risk for complications of cardiac problems through the next 90 day review period. the interventions/tasks with a revision date of [DATE] revealed, provide my diet as ordered. Further review of R1's Care Plan with an initiated date of of [DATE] revealed, Altered diet r/t decrease with chewing, dx dysphagia, Vit D-defiency, gerd. The goal with a revision date of [DATE] revealed, I will have decreased risk for s/s of aspiration through next 90 day review period. The interventions/tasks with an revision date of [DATE] revealed, Provide diet as ordered. Review of R1's Progress Note dated [DATE] at 5:45 PM, revealed, Note Text: Resident at supper in the dining room. Passed by res and noted res not moving and not responding to any type of stimuli. Took res to room and noted pulse. Requested assist from other nurses; res placed on bed w large amt of food removed from the throat. Call to EMS. Res was given CPR at 17:54 as EMS was entering the building. EMS began CPR. DON was contacted. During an interview on [DATE] at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday ,d+[DATE] from the aspiration that occurred on ,d+[DATE]. During an interview on [DATE] at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray, which contained an egg salad croissant. CNA1 stated she observed R1 eat the rest of her food while talking with a mouth full of food and CNA1 told R1 to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. Review of LPN1's witness statement dated [DATE] revealed, At 5:45 PM on [DATE], I was assisting with supper in the dining room and noticed that [R1] was quiet which is unlike her. The resident checked the pulse present, but the resident was unresponsive. Egg salad was noted on the face. I sent [CNA1] upstairs to get help. [LPN2] and [LPN3] arrived. Took the resident to her room, and she was still unresponsive. at 5:54 PM, [R1] lost her pulse. CPR was initiated and 911 was called. EMS arrived within minutes and took over the code. Called resident RP, after EMS arrived. During an interview on [DATE] at 10:56 AM, LPN1 stated that she was in the station 1 dining room, R1 was found unresponsive with a faint pulse, quiet, and not responding to verbal commands or physical touch. R1's head was down. LPN1 stated that she didn't know how long the resident was unresponsive before she saw her. LPN1 stated that she noticed R1 had egg salad on her face and was not aware of what R1's meal was that day and stated R1 was on a puree diet with thickened liquids. On [DATE] the facility presented an acceptable removal plan which included: Actions Taken: Facility leadership interviewed facility staff working on [DATE] DON/Designee initiated dining observation audits on [DATE] Facility initiated education for facility staff related to providing adequate supervision during meal service including safe eating practices and appropriate time of cleaning trays on [DATE] Facility initiated education for direct care staff on utilization of the Nursing Observation for Therapy Screening form on [DATE] Facility implemented therapeutic diet binder on each nurse's station to include resident photos for residents receiving a therapeutic diet on [DATE] Facility initiated education for facility staff on therapeutic binder as it relates to residents that may require increased monitoring during meals on [DATE] Facility to implement monitoring process for any residents who receive an upgraded diet daily for 10 days, weekly for 4 weeks, and monthly for 2 months for meal safety on [DATE] Date of compliance: [DATE]

Based on review of facility policy, record review and interview, the facility failed to provide Resident (R)1 with a therapeutic diet as prescribed by the physician. Specifically, R1 had a physician order for Dysphagia Mechanical Texture Soft Diet and on [DATE] R1's meal did not reflect the prescribed diet orders resulting in R1 suffering asphyxiation requiring Cardiopulmonary Resuscitation (CPR) and being sent to a local hospital. On [DATE] at 2:55 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 2:55 PM, the Administrator and the Director of Nursing (DON) were notified that the failure to provide R1 with a prescribed therapeutic diet constituted Immediate Jeopardy (IJ) at F808. On [DATE] at 2:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.60 - Food and Nutrition Services. On [DATE] at 9:18 PM, the facility provided an acceptable IJ Removal Plan. On [DATE] at 10:00 AM, the survey team validated the facility's corrective actions and removed the IJ as of [DATE]. The facility remained out of compliance at F808 at a lower scope and severity of D. Findings include: Review of the facility's policy titled Therapeutic Diet with a revised date of ,d+[DATE] states, Policy Interpretation and Implementation 1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. 2. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . 4. If a mechanically altered diet is ordered, the provider will specify the texture modification. 6. The dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. Review of the undated Texture Modification Inservice provided by the facility states, Purpose: to educate all new hires and current employees on the importance of and guidelines for proper texture modification. Importance of texture Modification Some residents have problems chewing or use multiple swallows to swallow one bite . Proper preparation and delivery of texture modified diets is critical for resident safety and wellness. Dysphagia Mech Soft Consistency requires meat to be ground and moistened. Bread items are pureed to a smooth mousse-like texture. Items may be served as pureed for this consistency if they are not inherently fork-mashable or soft. Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with a re-admitted [DATE], and diagnoses including but not limited to; Parkinson's disease, diabetes mellitus, dementia, Schizoaffective Disorder, bipolar disorder and dysphagia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of [DATE] revealed R1 had a Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated R1 was severely cognitively impaired. Further review of the MDS revealed R1 requires supervision and set up help only while eating. Review of R1's physician orders revealed an active order for Dysphagia Mechanical Texture Soft Diet with a start date of [DATE]. Review of R1's meal ticket dated [DATE] revealed, Regular - Dys Adv. Nectar, double portions with meals, and no salt packets. Marinated green bean Salad- ,d+[DATE] Cup, Chocolate cake w/ Peanut Butter Frosting- 1 square. Nectar Tea -4 Oz, Nectar Thick, Nectar water- 4 Oz, Nectar Thick, Creamy Dill Macaroni Salad (no raw veg)- ,d+[DATE] cup, Egg Salad for sandwich - ,d+[DATE] cup, Savory Summer Soup - 6 Oz, Nectar Thick. Double portions w/All meals. Ground Meats w/gravy, Puree all other food, Puree dessert. Review of R1's Speech Therapy Discharge Summary revealed R1 was discharged from speech therapy due to highest Practical Level Achieved. The patient was seen for 2 days during the [DATE]-[DATE] progress period. Discontinued on [DATE]. The patient safely consumes mechanical soft consistency while facilitating safe swallow strategies exhibiting modified independence. R1's discharge status and recommendations state, Solids=Mechanical soft/chopped textures. Review of R1's Care Plan with a revision date of [DATE] revealed, I have the potential for alteration in cardiac function/output dx htn and hyperlipidemia. The goal with a target date of [DATE] revealed, Risk for complications of cardiac problems through the next 90 day review period. the interventions/tasks with a revision date of [DATE] revealed, provide my diet as ordered. Further review of R1's Care Plan with an initiated date of of [DATE] revealed, Altered diet r/t decrease with chewing, dx dysphagia, Vit D-defiency, gerd. The goal with a revision date of [DATE] revealed, I will have decreased risk for s/s of aspiration through next 90 day review period. The interventions/tasks with an revision date of [DATE] revealed, Provide diet as ordered. Review of R1's Hospital Emergency Department Encounter Note dated [DATE] revealed, . by EMS from her SNF after reported aspiration event which resulted in her going into cardiac arrest. Patient was intubated by EMS and received 3 rounds of epinephrine prior to receiving ROSC . Upon arrival to the ED, patient obtunded, unresponsive, GCS 3 T, tachycardic, hypotensive, coarse breath sounds that are worse in the right lung field. Further review of the Encounter Note revealed, Independent interpretation of chest x-ray demonstrates right upper lobe opacities consistent with aspiration . Case discussed with critical care team who agrees to evaluate the patient for admission due to cardiac arrest likely secondary to acute hypoxic respiratory failure from aspiration. Hospital Course, 1. S/P out of hospital cardiac arrest on ,d+[DATE] - at least 16 min downtime. Suspected to be secondary to aspiration event - continue supportive care. During an interview on [DATE] at 1:29 PM, R1's son stated, Everybody knows on the second floor, that my mom is on a puree diet which is like baby food. What idiot gave my mom a croissant sandwich and walked off, which is on the hospital report, she was left unattended for 20 minutes with no oxygen going to the brain, and when she got to the hospital, the hospital staff suctioned the food from her throat. Doctors told me that she was brain-dead because of the aspiration. My mom can't walk, she has Dementia, my mom can't even feed herself due to constant shaking due to Parkinson's. I trusted the facility to give my mom the care I could not give her, and she died on Sunday ,d+[DATE] from the aspiration that occurred on ,d+[DATE]. During an interview on [DATE] at approximately 4:41 PM, the Dietary Aide (DA) stated that his duties are dishes and the tray line. The DA further stated by looking at R1's meal ticket from [DATE], the vegetables would have been pureed, and the egg salad sandwich would have been given to her as a regular sandwich, with the croissant cut open and egg salad stuffed in the croissant and would have been given thicken liquids as well per meal ticket. Furthermore, the DA stated that if R1 had puree beside the egg salad sandwich, as noted on her meal ticket, then it would have been chopped up and served in a cup. During an interview on [DATE] at 12:10 PM, the District Kitchen Manager (DKM) revealed that looking at R1's meal ticket dated [DATE], R1 is advanced dysphagia mechanical soft which is one above a puree diet. The DKM states residents with a mechanical soft diet would be required to eat soft bread such as a croissant and by looking at the meal ticket R1 received a regular egg salad croissant sandwich. DKM states vegetables would be cooked down until soft, however not pureed, along with thickened liquids. During an interview on [DATE] at 12:43 PM, Certified Nursing Assistant (CNA)1 revealed that she was passing out trays on station 1, with the help of another CNA. As CNA1 was passing out trays, R1 grabbed an egg salad croissant sandwich from another resident's tray and took multiple bites of it. CNA1 then provided R1 with her meal tray. CNA1 stated that she noticed that the sandwich that was on R1's tray was the same as the sandwich R1 took from the other resident. The only difference was that R1 had 2 sandwiches on her tray, the egg salad croissant, and an egg salad sandwich on regular bread. CNA1 stated she gave the other resident R1's egg salad croissant to replace the sandwich that R1 took. CNA1 stated she observed R1 eat the rest of her food while talking and with a mouth full of food and CNA1 told her to chew her food and slow down while eating. CNA1 stated that she continued to pass out trays to other residents. CNA1 further stated approximately 5 minutes later, Licensed Practical Nurse (LPN)1 asked CNA1 and another CNA to transfer R1 to her room because she was unresponsive. On [DATE] the facility presented an acceptable removal plan which included: Actions Taken by Facility: Facility leadership interviewed facility staff working on [DATE] Facility reviewed policies on Therapeutic Diets on [DATE] Facility updated policy on Meal Ticket Process to include the process by which meal tickets are updated when a new diet order is entered for a resident on [DATE] DON/Designee audited all residents on therapeutic diets to ensure meal tickets match the residents' diets on [DATE] Dietary Manager and/or designee to monitor each meal tray for accuracy with meal ticket for all meals for 10 days, all meal trays for one meal per week for 4 weeks, and all meal trays for one meal per month for 2 months. Initiated facility staff education on therapeutic diets including what textures each diet consists of on [DATE] Initiated facility staff education on reviewing meal tickets for accuracy with the prescribed diet on [DATE] Date of Compliance: [DATE]

Based on observations, interviews, and record review, the facility failed to apply a splint for one resident (Resident (R) 40) of one resident reviewed for positioning and mobility in a total sample of 22 residents. Findings include: The facility's Resident Mobility and Range of Motion Policy, dated July 2017, read, in pertinent part, Resident with limited range of motion (ROM) will receive appropriate treatment and services to increase and/or prevent further decrease in ROM. Review of R40's undated Admission Record, found in the electronic medical record (EMR) under the Admission tab, indicated R40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/21, indicated the Brief Interview for Mental Status (BIMS) was unable to be completed due to R40's poor cognition with both short and long-term memory deficits. This MDS assessment also indicated R40 had Range of Motion (ROM) impairment to her upper and lower extremities on both sides of her body, and that a splint or brace had not been applied any of the seven days prior to the ARD. Review of R40's Contracture Care Plan, dated 02/17/21 and found in the EMR under the Care Plan tab, indicated R40 had limited ROM contractures of her bilateral joints. Interventions included the application of carrot splints to R40's hands as ordered. Review of R40's Occupational Therapy (OT) Discharge Summary, dated 05/13/21 and found in the EMR under the Therapy tab, read, The caregiver performs 100% return demonstration of RNP [Restorative Nursing Practice] focused on donning/doffing [putting on and taking off] of B/L [bilateral] hand carrots in conjunction with the discharge planning of OT services to decrease contracture progression, maintain joint mobility and skin integrity. Review of R40's facility provided Order Summary Report, dated 12/10/21 and found in the EMR under the Orders tab, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the carrot splints were to be applied in the morning and removed at bedtime. Review of R40's Treatment Administration Record (TAR), dated 12/2021, indicated the resident's bilateral hand carrots were to be applied at 9:00 AM each day and removed at 9:00 PM. Observation on 12/08/21 at 4:29 PM revealed R40 lying in her bed. R40's hands were contracted and observed with no hand carrots in place. R40 was observed on 12/09/21 at 12:39 PM, 1:53 PM, 3:45 PM, and 5:18 PM while lying in her bed. R40 did not have carrots in either of her hands at each observation. During the medication pass with Licensed Practical Nurse (LPN) 19 on 12/10/21 at 9:29 AM, R40 was observed lying in bed with no carrots in either of her hands. During an interview on 12/10/21 at 9:30 AM, LPN19 acknowledged R40 was not wearing her carrots as ordered, removed two soft carrots from the resident's bedside stand, and stated, Yes. She is supposed to have the carrots in both hands. During an interview on 12/10/21 at 11:06 AM, Certified Nursing Assistant (CNA) 20 stated she worked with R40 frequently and stated, I've never seen her wearing the carrots. I didn't know she had them. During an interview on 12/10/21 at 11:09 AM, CNA21 indicated she was familiar with R40 and worked with her often and stated, I have seen her carrots in her hands before and she is supposed to have them on. If the carrots are dirty the nurse will have us roll up a little towel or washcloth and put them in her hands. During an interview on 12/10/21 at 11:22 AM, the Director of Nursing (DON) stated, She [R40] should have them [the bilateral hand carrots] on.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a change in code status was reflected in the clinical record in a timely manner for one resident (Resident (R)42) of 29 residents reviewed for code status during the Initial Pool portion of the survey process. The facility had a total of eight residents receiving hospice services at the time of survey, and five of those residents were included in the Initial Pool review. Findings include: The facility policy titled, Hospice Program, with a revision date of [DATE], documented the facility was responsible for, .b. Communicating with hospice representatives and other healthcare providers participating in the hospice vision of care for terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. C. Ensuring the LTC communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with medical care provided by other physicians. D .(7) hospice physician and attending physician (if any) orders specific to each resident .14. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including a. Palliative goals and objectives; b. palliative interventions; and c. Medical treatment and diagnostic tests . The facility policy titled, Emergency and/or Alternative Physician Care, with a revision date of [DATE], documented, All residents shall be provided with emergency and/or alternative care .3. Backup coverage may be provided by another licensed physician or physician group or an appropriately licensed and supervised midlevel practitioner, consistent with state regulations . The facility policy titled, Do Not Resuscitate Order, with a revision date of [DATE], documented, 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R42's paper record kept at the Unit two nurses' station revealed the first item in the chart was a large green piece of paper which read Full Code in large black letters. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the EMR MDS tab revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of the EMR Prog [Progress] Notes tab revealed an Order Note dated [DATE] at 5:36 PM which documented a new order was received to admit R42 to hospice services. During an interview on [DATE] at 1:23 PM, Licensed Practical Nurse (LPN) 22 reported R42 was recently placed on hospice services. During the interview she reviewed the EMR and reported R42's code statues at that time was Full Code. During an interview on [DATE] at 1:30 PM, LPN23 stated she believed R42 recently accepted to begin hospice services and as far as she knew he remained a Full Code. During the interview she confirmed the resident had a code status of Full Code by showing the surveyor the documentation in both the EMR and paper record. Interview with the Social Services Director (SSD) on [DATE] at 1:37 PM revealed R42 had accepted to change his code status at the time of admission to hospice however she was waiting on a signature from the physician for one of the hospice forms prior to updating his code status in the clinical record. The SSD further reported, typically when a resident changed their code status it was updated in the record more timely, but the physician had been on vacation and when they returned to the facility on [DATE] they missed signing one of the forms. The SSD stated she faxed the form to the physician and was waiting for the returned signed form. At the time of interview, the SSD showed the surveyor the forms the facility had received already signed by the physician. One of the forms was the signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It was signed by the resident on [DATE] and by the physician on [DATE]. The SSD reported she thought she needed to wait for a physician signature on the carbon copy telephone order form, as this was the form she was waiting on via fax. During an interview on [DATE] at 2:23 PM the SSD reported the facility had no other residents with pending change in code status orders. An interview was conducted on [DATE] at 2:38 PM with the SSD, the Administrator, and the Director of Nursing (DON). The SSD explained when the Medical Director was out another physician from their practice covered until he returned. The staff further reported the covering physician had been in the facility to round on residents Wednesday of the previous week but must have missed the pending change in code status order for R42. The DON reported if a decline were noted on a resident admitted to hospice services who did not have an active DNR the facility was able to contact the hospice group at any time to obtain a 24-hour DNR order which could be renewed as needed. He further explained R42 had not displayed a decline in his status from [DATE] to [DATE] so they did not utilize this method and waited to obtain the signature from the Medical Director when he returned.

Based on observation, record review, and interview, the facility failed to ensure resident property was kept safe from loss or theft for one resident (Resident (R)69) of three residents reviewed for personal property in a total sample of 22 residents. Findings include: The facility policy titled, Dignity, with a revision date of February 2021, revealed, .6. Residents' private space and property are respected at all times. Staff do not handle or move resident's personal belongings without the resident's permission . The facility policy titled, Resident Rights, with a revision date of December 2016, revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. be free from abuse, neglect, misappropriation of property, and exploitation .r. manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes) .ee. Retain and use personal possessions to the maximum extent that space and safety permit . During an interview on 12/08/21 at 2:36 PM conducted in the resident's room, R69 reported her lock/cash box had gone missing from a shelf in her room in October of 2021. R69 further explained that she noticed it when she returned to the facility from a short hospital stay and reported the missing item to the nurse working at the time. R69 said the box contained $120 and a Ziplock bag holding multiple pieces of jewelry that were given to her by her mother. R69 reported the facility replaced her money, provided her with a new lock box, offered to replace the jewelry, and informed her they were conducting an investigation into the matter. Observation at the time of interview revealed a lock box rested on the bedside table and R69 wore a bracelet on her right wrist with a key. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/21 revealed R69 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. Review of the facility provided Initial 2/24-Hour Report, dated 10/03/21, and the Five-Day Follow-Up Report, dated 10/08/21, revealed the facility received an allegation of a missing lock box containing money and jewelry from R69. The facility reported the allegation of missing property to the state agency and the local police department in a timely manner. Interviews were conducted with all staff working the unit on which R69 resided on the days leading up to the allegation. All that were interviewed denied taking the box or witnessing any other staff or residents in R69's during the alleged timeframe. The Administrator also spoke with R69's family who reported they had provided her with some cash recently but were unsure of the amount she would have on hand. The Social Service Director completed interviews with residents on the unit related to misappropriation of resident property with no adverse findings. The facility completed staff education related to abuse and neglect with an emphasis on misappropriation. The investigation reports indicated the $120 cash was replaced, a new lock box was provided, and the facility offered to replace the jewelry.

Based on observations, interview, and record review, the facility failed to consistently provide assistance, supplements, and/or preferred diets to prevent weight loss for one (Resident (R) 51) of six sampled residents reviewed for weight loss in a total sample of 22 residents. Findings include: Review of the facility's revised September 2008 Weight Assessment and Intervention policy revealed under the policy statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Under the Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the . b. Approximate calories, protein, and other nutrient needs compared with the resident's current intake and 2. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss . d. Medication-related adverse consequences; i. Inadequate availability of foods or fluids. 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss . Under the Interventions 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: c. Functional factors that may inhibit independent eating; g. The use of supplementation . Review of R51's Resident Face Sheet, located in the electronic medical record (EMR) under the Admission Record tab, revealed an admitted [DATE]. Review of R51's most current Minimum Data Set (MDS), located in the EMR under the MDS tab, was a significant change with an Assessment Reference Date (ARD) of 10/20/21. Review of R51's Brief Interview for Mental status (BIMS) located in this MDS assessment, revealed a score of 13, indicating R51 was cognitively intact. Further review of this MDS revealed R51 required extensive assistance with eating and had no weight loss during the assessment period. Review of the 11/01/21 Plan of Care Notes, located in the EMR under the Progress Notes tab, revealed Completed a significant change assessment for resident with ARD of 10/18/21. Due to decline in ADLs [activities of daily living] r/t [related to] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident now needs assistance with meals and had a recent weight loss. Review of R51's comprehensive Care Plan, initiated on 08/17/20 with a revision date of 12/09/21, located in the EMR under the Care Plan tab, revealed a focus area of I have a potential for alternation in nutrition r/t [related to] GERD [[CONDITION(S)]], [CONDITION(S)], H/O [history of] nausea, dysphagia [difficulty swallowing], HX [history] of weight loss, at risk for malnutrition. Goals included I will consume my diet as ordered without complication, meet my nutritional needs through meals and supplements through the next review period, and maintain my current body weight through the next 90 days. Interventions included provide my diet as ordered, provide my supplements as ordered, and staff to encourage meal intake. Further review of the care plan revealed no mention that R51 required extensive assistance with meals per the MDS with an ARD of 10/20/21. Review of the 10/18/21 Nutrition/Dietary Notes, located in the EMR under the Progress Note tab, revealed RD [Registered Dietitian] Eval [evaluation]: Res [resident] is [AGE] year old female, Wt [weight]: 212 lbs, Ht [height]: 67 [inches], BMI [body mass index]: 33.3. Diet: Regular diet, dysphagia mech [mechanical] soft, thickened nectar liquids. Res does not eat meat. Res has lost a sig [significant] amount of wt. RD Recommendation: Magic Cup q [every] day. M/E FU PRN [follow-up as needed]. Review of R51's weight summary, located under the Weight/Vitals tab in the EMR, revealed a weight loss of 5.5 pounds between 10/17/21 (212.9 pounds) and 11/15/21 (207.4 pounds). Review of the Treatment Administration Record (TAR) located in the EMR under the Orders tab and dated October 2021 and November 2021, revealed Magic cup supplement ended on 11/19/21 even though R51 continued losing weight. Further review of R51's weights summary revealed a weight loss of 8.5 pounds between 11/08/21 (206.1 pounds) and 12/06/21 (197.6). Review of the TARs dated November 19, 2021, through December 1-9, 2021, revealed no supplement was provided to R51 despite continued weight loss. On 12/09/21 at about 8:10 AM, R51 was observed in bed with her breakfast tray on her overbed table positioned over her lap. The food was untouched, and no one was assisting R51 with her meal. R51 sat in her bed staring at her food and did not respond when asked questions about her meal. R51's meal consumption records for this meal, provided by the Administrator, revealed she consumed 0-25%. On 12/09/21 at 11:52 AM, R51 was observed in bed with her lunch tray on her overbed table positioned over her lap. Her meal consisted of broccoli, mashed potatoes with gravy, a roll, peaches, thickened tea, and two small cups of juice. No meat substitute or Magic Cup was on the tray. No one was assisting R51 with her meal. R51 did not respond when asked questions about her meal. At 12:05 PM, R51's tray had been removed from the room. When Certified Nursing Assistant (CNA)7, was asked about R51's tray, CNA7 stated R51 didn't eat good. In fact, she was choking before she started eating. CNA9 found R51's tray on the cart with collected tray and only her tea and a few peach slices were consumed. At 1:40 PM, R51 was observed in bed with the same juices from lunch. No other food or supplement were observed. On 12/09/21 at 3:18 PM, when asked if any problems with lunch were reported to her, Licensed Practical Nurse (LPN)17 stated a CNA reported to her at lunch on her hall was R51 had been served meat, so she ordered a new tray without meat. Review of the facility's menus extensions for Wednesday to Friday [12/8-10/21], provided by the Certified Dietary Manager (CDM), revealed no vegetarian or non-meat diet. On 12/09/21 at 3:30 PM, when asked about how CNAs know who gets meal assistance, LPN17 stated they will know by looking up the residents the nurse aide information sheets located in green notebooks at the nurse station. The nurse looked up R51 and the section under meals reflected set-up even though the significant change MDS assessment with an ARD of 10/20/21 stated R51 required extensive assistance with feeding. On 12/10/21 at 9:24 AM, the RD was interviewed by phone concerning R51's weight loss. The RD stated a Magic Cup had been ordered but dropped off after 30 days, per the facility's policy. The RD went on to say she may not always know that a Magic Cup order dropped off. When asked about R51 not receiving a protein to replace the omitted meat, the RD stated an appropriate replacement should be provided such as rice and beans or milk as a high biological protein. The RD stated she would not expect the Certified Dietary Manager (CDM) to decide on a protein replacement for the R51's meat. The RD went on to say a protein should have been on R51's tray. The RD stated she was unaware the menus did not include a diet for someone who did not eat meat. On 12/10/21 at 11:54 AM, R51's lunch tray taken into her room. R51 was served collard greens, roll, tea, macaroni and cheese, pineapples, and two cups of a supplement-like beverage. R51 was observed attempting to feed herself. At 12:12 PM R51 was observed with her lunch tray and no assistance. At 1:05 PM, CNA13 was observed in R51's room and the resident's tray gone. When asked about meal assistance, CNA13 stated R51 did not require feeding assistance for lunch. Review of the 12/10/21 Nutrition/Dietary Notes for R51, located in the EMR under the Progress Note tab, revealed RD Eval: CBW [current body weight]: 197 lbs, Ht: 67, BMI: 30.9. Res has lost a sig amount of wt x 30 days. Res admitting dx: cerebral Infarction. Diet: Regular diet, dysphagia mech soft (ground texture), nectar thick fluids. Res does not eat meat. Res receives Magic Cup q day r/t wt loss. RD Recommendations: MVI (multivitamin) q day r/t low meat intake. Add milk to all trays for additional protein. Add large Egg and Bean portions to trays. Change Diet to Lacto-Ovo Vegetarian Diet. Update Food preferences in Meal Tracker. M/E FU PRN. During an interview on 12/10/21 at 2:20 PM, the CDM stated R51 was more interviewable before her stroke a few months ago. The CDM knew that R51 did not eat meat because of her love for animals. However, the RD had not given her any instructions on replacing the meat entrees until 12/10/21. The CDM stated that the RD had instructed her to double up on breakfast eggs, include milk on her tray and provide Med Pass 2.0 (nutritional supplement). Review of R51's meal percentages for 11/25/21 through 12/09/21, provided by the Administrator, revealed R51 consumed 15 of 34 meals at 0-25% and 10 of 34 meals at 26-50%. During this same period, R51 was documented as independent to supervision assistance with eating, per review of R51's eating: self-performance sheet, provided by the Administrator, although R51 required extensive assistance following her stroke. On 12/10/21 at 2:00 PM, the attending physician was interviewed by phone about R51's weight loss. The surveyor informed the physician that based on interviews, observations, and record review, the staff were not providing extensive feeding assistance, dietary supplement, and/or a meat substitute even though R51 continued to lose weight. The attending physician stated he was aware R51's weight loss and considered it unavoidable due to R51's recent stroke.

Based on interview and record review, the facility failed to protect 1 of 3 residents reviewed from abuse. Resident #1 (R1) was outside smoking during a break while a lawn care employee from a contracted company (LCE1) was weed whacking. Debris from his work flew onto the resident smokers, and R1 requested that LCE1 be more careful. At this point, LCE1 began shouting and swearing at R1 who verbally retaliated. Staff intervened and LCE1 was escorted away from the smoking area. The findings included: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1 Incident Report on 8/16/21 at 3 PM revealed the resident reported a verbal altercation with a landscaping employee during a smoke break. Review of licensed practicing nurse #1 (LPN1) witness statement on 8/16/21 at 3:20 PM revealed a certified nursing aide (CNA) called the LPN out to the smoking area for assistance due to R1 and LCE1 were in a verbal altercation. Review of R2 witness statement on 8/16/21 at approximately 3:20 PM revealed the following: R1 and LCE1 got into an argument. R1 told LCE1 to turn his back while cutting the grass, and the landscaper said the residents needed to go back inside. Both individuals started shouting, but LCE1 started cussing first.The CNA asked the landscaper to leave. Maintenance was called and had to arrive to resolve the situation. Review of R3 witness statement on 8/16/21 at approximately 3:22 PM revealed the following: LCE1 was blowing leaves in smoking area. R1 spoke to him about stopping blowing the leaves. Both people were cussing at each other. Review of R1 witness statement on 8/16/21 at approximately 3:24 PM revealed the following: R1 asked LCE1 to cut the other way so the grass wouldn't fly on them. LCE1 told R1 to leave and let him do his job or shut the f*** up. Interview with R1 on 8/16/21 at approximately 3:30 PM revealed the following: LCE1 was weed whacking and debris was coming at the residents while he worked. At first, R1 did not say anything, but then a piece of debris came right at him. R1 asked him to cut the other way (back turned) so the debris wouldn't come at the smoking area. LCE1 became loud and hateful and started swearing. He told R1 to Shut the f*** up. He began yelling at all of them (residents and certified nursing aide) like that. R1 was being nice about the situation when he made the request, but began to verbally retaliate with swearing and shouting. Review of CNA1 statement on 8/16/21 at 3:35 PM revealed the following: The residents were outside smoking. LCE1 was weedeating. CNA1 asked the landscaper to move away while the residents smoked, but he replied that he was on a deadline. A piece of debris from the lawn work hit R1. R1 and LCE1 started exchanging words. Multiple times CNA1 tried to intervene, but LCE1 became more confrontational. CNA1 went to the door to ask for help. Interview with LPN1 on 8/16/21 at 3:40 PM revealed the following: The smokers and CNA1 were already outside. LPN1 went over to station 3 when CNA1 threw the doors open and requested help. Outside, there was a free-for-all between R1 and LCE1. LCE1 was belligerent and cussing. LPN1 told LCE1 that he could not talk to the residents like that. CNA1 explained it was the residents' smoke time and the residents had a right to be outside. LCE1 was still swearing, saying they can shut up or go inside. Maintenance had to take the man away. That was the last they saw of him. R1 seemed angry, not frightened. Since the incident, however, there have been no changes in his psychosocial well-being. Interview with of CNA1 on 8/16/21 at 3:50 PM revealed the following: CNA1 was outside with residents on smoke break. LCE1 with a weed eater kept coming closer and closer. A piece of debris hit R1 in the face. R1 asked him not to go like that. At this point, R1 was still calm. It was the other man who escalated the situation. LCE1 flipped out and told him to shut up and take his a** back inside. LCE1 said R1 was stupid and that he had a job to do. Maintenance needed to escort LCE1 away. Interview with R2 on 8/16/21 at 4 PM confirmed his witness statement. The resident elaborated that he did not feel involved in the verbal abuse incident and had no other concerns related to abuse. Interview with R3 on 8/16/21 at 5 PM confirmed his witness statement. The resident elaborated that he did not feel involved in the verbal abuse incident and had no other concerns related to abuse.

Based on record review and interviews, the facility failed to ensure that a resident identified with behaviors was provided one to one supervision for 1 of 3 residents reviewed. Resident #2 was reviewed by the facility's Behavioral Management Program (BMP) and placed on 1:1 supervision that was not provided during resident to resident incident that occurred on 3/21/21. The findings included: The facility admitted Resident #2 on 3/18/20 and 8/18/20 with diagnoses that included Anxiety Disorder, Dementia with Behavioral Disturbances, Cognitive Communication Deficit, [CONDITION(S)] and Altered Mental Status. A review of the medical record on 4/05/21 at approximately 12:20 PM revealed Resident #2 had been in multiple resident to resident altercations (4/09/20, 5/11/20, 7/06/20 and 3/21/21). The resident was placed on 1:1 staff observation on 7/06/20. A review of nursing note dated 3/03/21 revealed Resident #2 continues 1:1 supervision with not behaviors noted. A 3/16/21 nursing note dated 3/16/21 indicated the resident became agitated prior to dinner and wandered throughout the building with sitter present. A 3/19/21 nursing note indicated the resident was discussed in the BMP meeting. It was reported that the resident was noted with agitation and remained on 1:1 supervision. A 3/21/21 nursing note indicated that 1:1 supervision was not being provided on 3/21/21 at approximately 8:15 PM when the assigned Certified Nursing Aide (CNA) left resident alone to assist a staff member in passing out meal trays. A review of CNA #1 signed witness statement on 4/05/21 revealed he/she left Resident #2 unsupervised for 5 to 8 minutes to pass out trays when he/she heard a commotion and yelling coming from the room. Upon entering the room CNA #1 found Resident #2 laying on top of Resident #1 with both of them swinging their arms. Resident #2 was reportedly calm and Resident #1 was yelling at cursing. A review of the care plan revealed Resident #2 was placed on 1:1 supervision on 7/06/20 due to behaviors. An interview on 4/05/21 at 1:25 PM with the facility's Interim Administrator revealed when resident's are placed on 1:1 supervision, they are to be monitored by staff at all times. The Administrator confirmed Resident #2 had a break in supervision during the 3/21/21 incident. An interview on 4/05/21 at approximately 2:05 PM with Registered Nurse #1 revealed Resident #2 was placed on 1:1 supervision and should have been monitored at all times. Several unsuccessful attempts were made to reach CNA #1 by telephone number provided by the facility.

Based on interview, review of facility files and review of the facility's Abuse policy the facility failed to implement the Abuse Prevention policy and the Reporting Abuse to State Agencies and Other Entities policy for 2 of 6 sampled residents reviewed for Abuse. The facility did not ensure agency staff had abuse prevention training prior to caring for Resident #5. In addition, the facility failed to report an allegation of resident to resident abuse involving Resident #3 within 2 hours. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 7/21/20 at 9:30 AM, revealed the facility substantiated an allegation of verbal abuse by Certified Nursing Assistant (CNA) #1. On 7/4/20, per the investigation, CNA #1 cursed at Resident #5 and told him/her s/he would not provide incontinence care. Review of the training file for CNA #1, on 7/21/20 at 3:15 PM, revealed no records to indicate CNA #1 had received training and education on abuse prevention prior to caring for residents at the facility. During an interview with the Nursing Home Administrator, on 7/21/20 at 3:30 PM, the NHA stated s/he had contacted the staffing agency and requested any training records related to abuse education for CNA #1. During an interview with the NHA, on 7/23/20 at 11:44 AM, the NHA stated the staffing agency did not send any files to indicate CNA #1 had received any abuse prevention training. The NHA stated it is facility policy for all staff to receive abuse prevention education prior to caring for residents. The NHA stated it was facility protocol to send the staffing agency an orientation packet, including abuse prevention training, for the staffing agency to sign off on prior to agency staff working in the facility. The NHA stated this did not happen for CNA #1. Review of the facility's Abuse Prevention policy revealed Staff receives orientation and ongoing training, at a minimum yearly, on: A. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. B. How to report their knowledge related to allegations and reasonable suspicion of a crime; C. Notification of their reporting obligations under the Elder Justice Act (EJA) to report a suspicion of a crime to the state survey agency; D. What constitutes a crime; E. What constitutes abuse, neglect, and misappropriation of resident property; F. How to recognize signs of burnout, frustration, and stress that may lead to abuse The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 7/22/20 at 10:08 AM, revealed Resident #3 was involved in a resident to resident altercation on 5/9/20 at 1:00 PM. The facility did not report the suspected violation of resident to resident abuse to the State Survey Agency until 5/11/20. During an interview with the Nursing Home Administrator, on 7/22/20 at 3:27 PM, the NHA confirmed facility policy was not followed for reporting of a suspected violation involving abuse. The NHA stated the altercation was not reported to him/.her or the Director of Nursing until 5/11/20. The NHA stated this should have been reported immediately to him/her or the Director of Nursing and to the State agency no later than two hours after the suspected violation. Review of the facility's Reporting Abuse to State Agencies and Other Entities policy revealed Should a suspected violation or substantiated incident of neglect, injuries of unknown source, or abuse (including resident to resident) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally or written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility. Verbal/written notices to agencies will be made no later than two (2) hours if an allegation involves abuse.

Based on review of facility files and interview the facility failed to report a suspected violation of resident to resident abuse not later than 2 hours after the incident involving Resident #3, 1 of 6 sampled residents reviewed for Abuse. The resident to resident altercation occurred on 5/9/20 and was not reported until 5/11/20. The findings including The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 7/22/20 at 10:08 AM, revealed Resident #3 was involved in a resident to resident altercation on 5/9/20 at 1:00 PM. The investigation revealed on 5/9/20 Certified Nursing Assistant (CNA) #4 intervened and separated Residents #1 and #3. CNA #4 reported the resident to resident altercation to Licensed Practical Nurse (LPN) #1. Review of LPN #1's written statement confirmed she/he was made aware of the altercation. During an interview with CNA #4, on 7/22/20 at 10:36 AM, CNA #4 stated s/he heard Resident #3 yell out and immediately went to the resident's room. S/he saw Resident #1 holding Resident #3 by the left arm. CNA #1 stated s/he immediately separated the residents and redirected Resident #1 out of the room. CNA #1 stated s/he then reported the incident to LPN #1. During an interview with the Nursing Home Administrator (NHA), on 7/22/20 at 3:27 PM, the NHA stated this incident was not reported to him or the Director of Nursing until 5/11/20. The NHA stated it should have been reported to him/her or his designee immediately. The NHA stated when s/he interviewed LPN #1, s/he did not have a good reason for not reporting this immediately. The NHA stated LPN #1 and all staff were re-educated on the reporting requirements for violations involving abuse. Multiple calls were made to LPN #1, but s/he could not be reached for interview. Resident #1 was placed on one to one supervision immediately following the altercation.

Based on record review, interview, and review of facility files the facility failed to keep Resident #5 free from verbal abuse, 1 of 6 sampled residents reviewed for abuse. Resident #5 was verbally abused during personal care. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 7/21/20 at 9:30 AM, revealed the facility substantiated an allegation of verbal abuse by Certified Nursing Assistant (CNA) #1. On 7/4/20, per the investigation, CNA #1 cursed at Resident #5 and told him/her s/he would not provide incontinence care. Review of a statement by Resident #5, dated 7/7/20, revealed CNA #1 began raising her/his voice and became angry shortly before the end of her/his shift and stated I don't want to clean your ass up. A statement, dated 7/4/20, by CNA #2 indicated s/he over heard CNA #1 yelling and cursing at the resident from the hallway. A statement by CNA #3, dated 7/4/20, indicated the resident had a bowel movement and required incontinence care. CNA #3, per the statement , assisted CNA #1 in transferring the resident to the bed and heard CNA #1 tell the resident s/he ruined her/his day. CNA #3 left the room to assist other residents. CNA#3 went back to Resident #1's room to help. Per the statement, CNA #3 overheard CNA #1 yelling and cursing at the resident. CNA #3 went into the room and then left to notify the nurse. During an interview with Resident #5, on 7/21/20 at 11:10 AM, Resident #5 stated CNA #1 got mad at him/her because s/he needed incontinence care and it was almost the end of her/his shift. The resident stated CNA #1 told him/her s/he wasn't going to clean your ass up. The resident stated CNA #1 did not use any other curse words or talk to him in an abusive manner after that. Resident #1 stated CNA #1 did provide incontinence care for him/her, but complained about her/his job and work duties while giving care, stating s/he wasn't going to put up with this anymore, was going to find a new job, and wasn't going to work at the facility anymore. Resident #5 stated CNA #2 brought him/her back to his/her room and notified CNA #1 that s/he needed incontinence care, but was not in the room when CNA #1 got mad at him./her The resident stated CNA #3 came into the room after care was complete. During the interview, Resident #5 was asked again if CNA #1 used any other curse words at him/her or threatened him/her in any other way and s/he stated no, s/he didn't. Resident #5 stated s/he was upset and a little scared by the CNAs behavior, but mostly surprised. The resident stated s/he had known CNA #1 for about a year and s/he had cared for him/her at the facility s/he was at prior to coming to this facility. The resident stated CNA #1 had never treated him/her this way before and s/he never had any issues with the care received from CNA #1. Resident #5 stated s/he was upset about the incident, but s/he got over it. The resident stated s/he was satisfied with the facility's response and interventions. S/he stated the social worker followed up frequently to make sure s/he was ok. Resident #5 stated s/he did not lose any sleep over the incident, had no changes in his/her mood and had lingering effects of any kind related to the incident. During an interview with Resident #7, on 7/21/20 at 11:25 AM, Resident #7 stated he had received assistance from CNA #1 on 7/4/20. The resident denied any abuse from the the CNA and stated s/he had no issues or concerns related to CNA #1. During an interview with CNA #2, on 7/22/20 at 3:40 PM, CNA #2 stated s/he had come in early that day to work 2nd shift. At 2:20 PM, s/he assisted Resident #5 from outside to his/her room. Resident #5 told her/him s/he needed a brief change. CNA #2 stated s/he went to get CNA #1 to let her/hin know the resident needed care. CNA #2 stated CNA #1 said ok and went to help the resident. CNA #2 stated s/he was out int he hall when CNA #1 went into the room. S/he stated s/he heard CNA #1 start yelling. CNA #2 couldn't recall everything CNA #1 was saying, but did recall CNA#1 told the resident You really ruined my day. CNA #1 shut the door and CNA #2 went to report to the nurse. During an interview with the Nursing Home Administrator, on 7/23/20 at 11:40 AM, the NHA stated CNA #1 was an agency CNA. 7/4/20 was the only day s/he worked in the facility. The NHA stated CNA #1 did not make her/himself available for interview as part of the facility investigation. Review of the care plan and social worker notes revealed psychosocial support was provided to the resident immediately after the incident and in the days following. CNA #1 was called on 7/24/2020 and did not answer. A detailed voicemail with contact information was left. No callbacks have been received from CNA #1. CNA #3 was on vacation and could not be reached.

Based on observations and staff interviews, the facility failed to maintain the kitchen and its equipment in good repair and adequately cleaned, dried, and stored according to standard practice for one of one main kitchens observed. Also, the facility failed to ensure the residents' snack/nourishment refrigerator was used for residents only and that all items were dated, labeled, and with a safe consumption date for two of three snack/nourishment refrigerators observed/reviewed. The findings included: The initial tour of the kitchen on 3/3/20 at 10:08 AM revealed the following: A freezer was not working and not in use. There was a large dirty (food residue on it) mixer covered with a large black bag. The ice-maker door was in disrepair (cracking sound when opening, and its insulation tape was torn and exposed at the top). Six large pans stored in the clean area were wet and greasy, and 4 of them had paper stickers still on it. The hood vent and stove appeared greasy, and the kitchen floor sticky. The kitchen supervisor was present during observation, (s/he) acknowledged findings. On 3/4/20 at 8:33 AM, the surveyor found a box containing ice-pop with use by date January 2020 (10-ice-pops), a half-full bottler of water, a bottler of ice-tea, and a bottler of coffee-creamer without a name or an opened date on it in the residents' snack refrigerator. Registered Nurse (RN) #2 confirmed the findings and removed items. On 3/4/20 at 9:00 AM, the second snack/nourishment refrigerator observed contained two frozen dinners with no name or use by date, three 16 oz bottles of sodas with the name of employees on it, and 2-liter soda bottles with no name on it. The kitchen supervisor was present during observation, and (s/he) confirmed the soft drinks belonged to employees. On 3/6/20, at approximately 11: 00 AM, all concerns were shared with the food and nutrition service director.

Based on observations, record reviews, and interviews, the facility failed to implement a resident-centered care plan related to communication cue cards and the use of assistive devices for self-feeding for one of three sampled residents reviewed for nutrition. The findings included: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/3/20 at 11:59 AM, observed Resident #77 using regular utensils during lunch. Resident #77 was eating on (his/her) own and dropped the fork three times during observation. The Surveyors and the resident sitting at (his/her) table got the staff attention every time (s/he) dropped the fork. The staff brought the resident a clean fork but did not assist the resident with her/his meal or provide assistive devices or communication cue cards. Resident #77's nutrition assessment reviewed on 3/4/20 at approximately 11:30 AM stated that the resident received meals on a divided plate with built-up utensils and handled cup to increase independence with self-feeding. On 3/4/20 at 10:11 AM, the surveyor attempted to interview Resident #77. However, the resident exhibited a communication deficit. The resident was unable to communicate even though (s/he) was trying to. Registered Nurse (RN) #2 came into the room to try to aid in communication. S/he tried to guess what the resident was saying but was unable to. RN #2 brought a certified nursing assistant (CNA) to see if (s/he) could help. The CNA tried to guess what the resident was trying to say but was not able to. At this time the resident was very frustrated, and the communication attempt was stopped Resident #77's care plan reviewed on 3/5/20 at 11:31 AM, revealed that the resident was care-planned for impaired verbal communication. The resident has little to no speech, and (his/her) speech is unclear. The goal includes maintenance of current communication through gestures and cue cards. The resident was also care-planned for self-care and activity of daily living related to self-feeding. Interventions included the provision of assistive devices as appropriate to increase self-participation. In an interview with the speech therapist on 3/4/20 at 2:12 PM, s/he stated that Resident #77 was receiving services from 8/14/19 through 11/4/19. S/he said that the resident is supposed to get assistance with eating and use a spelling board and word binder to maintain/improve current communication. In an interview with the medical record coordinator and the administrator on 3/5/20 at 9:46 AM, the concerns that the facility did not provide Resident #77 with assistive devices, during mealtime, and the communication cue card/board were not used to aid communication were shared.

Based on interview and record review the facility failed to protect resident dignity for 2 of 2 residents reviewed for dignity. Resident #20 was observed multiple times over the survey to be wearing a hospital gown. Resident #84 was observed twice to be laying in bed in his/her briefs, uncovered, and visible from doorway. The findings included: Observation of Resident #20 on 3/3/20 at approximately 10:19 AM revealed the resident was wearing a hospital gown. Observation of Resident #20 on 3/4/20 at approximately 11:17 AM revealed the resident was wearing a hospital gown. Interview with Certified Nursing Assistant (CNA) #1 on 3/4/20 at approximately 11:17 AM confirmed that Resident #20 was wearing a hospital gown. The CNA stated the resident did not have many clothes that fit comfortably, but s/he was not sure if Social Services was aware of this. Review of the Care Plan for Resident #20 on 3/4/20 at approximately 3:05 PM revealed no care planned interventions regarding clothing preferences for hospital gowns. Interview with the Social Services Director (SSD) on 3/4/20 at approximately 3:56 PM revealed that Social Services only just found out about the resident's ill fitting clothes. SSD clarified that family would bring in new clothing and they would be reimbursed. Interview with SSD on 3/5/20 at approximately 10:34 AM revealed CNAs normally inform nursing / social if a resident needs new clothes. S/he did not know why s/he was not informed until yesterday. Interview with CNA #1 on 3/5/20 at approximately 10:40 AM revealed the CNA had not informed nursing of clothing not fitting until yesterday -- after the previous interview with the surveyor. Observation of Resident #84 on 3/4/20 at approximately 8:45 AM revealed the resident was in briefs with no other clothing or covering. S/he was visible from outside the doorway. Observation of Resident #84 on 3/4/20 at approximately 3:15 PM revealed the resident was in briefs with no other clothing or covering. S/he was visible form outside the doorway. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 3/4/20 at approximately 3:15 PM confirmed the resident was in bed with briefs. According to LPN #1 it was a resident preference and should be care planned. Review of the Care Plan on 3/4/20 at approximately 3:20 PM revealed the resident was care planned for preferring to wear kaftans. The resident was not care planned for preferring to wear briefs in bed. Review of the Care Plan on 3/4/20 at approximately 3:56 PM revealed the resident was care planned for preferring briefs, but the care plan was revised on 3/4/20. Interview with Registered Nurse (RN) #1 on 3/5/20 at approximately 10:59 PM confirmed the resident's care plan was altered on 3/4/20 relating to preferences for briefs. Review of the policy for Resident Rights on 3/5/20 at approximately 11:16 AM revealed that residents .have the right to be treated with dignity and respect in a manner that promotes or enhances your quality of life and .The right to have a choice over preferences that are important to you.

Based on observation and interview, the facility failed to provide comfortable and safe wheelchairs for three residents who had wheelchairs with cracked armrest upholstery and one resident's wheelchair had no armrest padding for 4 out of 77 wheelchairs observed. The findings included: Random observations were conducted on March 3 and 4, 2020 throughout the facility. The surveyor observed three residents who had cracked upholstery on the armrests of their wheelchairs. The surveyor observed one resident who had no padding on the armrests of their wheelchair, and their arms were resting on the metal frame. On 3/4/2020 at approximately 10:30 am the surveyor interviewed the Director of Maintenance (DoM). When asked about the residents' wheelchairs, the DoM stated I did not know about it. When asked about a wheelchair maintenance schedule or checklist, the DoM stated No, I do not have a system for checking on wheelchair repair. However, Physical Therapy will tell me if there is a problem with a wheelchair. This is only for residents who go to Physical Therapy. The DoM also stated I agree, this is my fault.

The facility failed to ensure each resident was afforded the required 80 square feet of living space for 15 residents in 4 of 4 rooms that did not meet the required square feet of living space for each resident. None of the 15 residents were negatively affected by the less than 80 square feet of living space. The findings included: room [ROOM NUMBER] provides each of the 4 residents with an average of 79.4 square feet of living space. room [ROOM NUMBER] provides each of the 3 residents with an average of 79.5 square feet of living space. room [ROOM NUMBER] provides each of the 4 residents with an average of 73.3 square feet of living space. room [ROOM NUMBER] provides each of the 4 residents with an average of 73.8 square feet of living space.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policy provided by the facility entitled "Cleansing and Disinfecting Diagnostic Equipment", facility nursing staff failed to adhere to accepted professional standards and practice to prevent the spread of potentially infectious blood borne pathogens. Nursing staff on 2 of 3 units (Station 1 and 2) had used expired disinfectant wipes to clean glucometers between resident use. Expired disinfectant wipes were observed on 3 of 3 Nursing Stations, Stations 1, 2, and 3. Concerns were identified with 7 residents on Stations 1 and 2 (Residents #7, #17, #21, #22, #23, #24, and #25) who had received Fingerstick Stick Blood Sugar (FSBS) monitoring through the time period from [DATE]- [DATE]. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that expired Sani-Cloth disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Observation of a medication pass on [DATE] at 11:25 AM revealed Licensed Practical Nurse (LPN) #4 using a multiple-resident use glucometer to check Resident #7's blood sugar. The nurse placed the supplies (which included 2 individually wrapped disinfectant wipes) on a paper towel on an overbed table. After sticking the resident's finger and obtaining a blood sample, the nurse indicated that the glucometer reading was not correct. S/he removed his/her gloves, washed hands, donned gloves, and opened an individually packaged Sani-Cloth bleach wipe and wiped down the glucometer. The nurse then disposed of the wipe in a plastic garbage bag. When asked to see the wipe package that had been discarded, the nurse provided the second wipe for the surveyor (that had been on the paper towel on the overbed table). S/he indicated this was the same type of wipe that had been discarded. Examination of the wipe revealed an expiration date of ,[DATE] imprinted on the wrapper. LPN #4 was preparing to stick the resident's finger again when the surveyor stopped the nurse and asked to speak with him/her out in the hall. During an interview in the hall on [DATE] at 11:35 AM, LPN #4 was asked about the timing of when nursing staff clean the glucometers. LPN #4 stated the glucometers are cleaned after each resident use. S/he stated that the glucometer did not require cleaning before use since the glucometer should have been cleaned after it had been used last. When asked, LPN #4 stated s/he knew to check to see if the wipes had expired, but stated s/he had not done so prior to checking the blood sugar for Resident #7. After examining the wipe, LPN #4 verified the expiration date imprinted on the wrapper indicated the wipe had expired [DATE]. S/he stated that this meant the wipe would no longer be good after [DATE]. S/he stated the wipe s/he had used to clean the glucometer was exactly the same as the wipe being examined and had come from the same box. When asked where s/he had gotten the wipes to clean the glucometer, LPN #4 stated there was a caddy in the medication room. Observation of the Station 2 Medication Room on [DATE] at approximately 11:40 AM with LPN #4, LPN #3, and another surveyor revealed there were 10 Sani-Cloth bleach wipes in a caddy, 14 Sani-Cloth bleach wipes left in an opened, (currently in use) box of wipes that had originally contained 40 wipes; and one unopened box of 40 Sani-Cloth bleach wipes. All of the wipes had expired in [DATE]. The Lot # was listed as being 163 with "exp ,[DATE]" printed on the inside of the box. The individual wrappers also included imprinted information that the wipes had expired in [DATE]. Observation of the Station 1 Medication Room on [DATE] at approximately 11:45 AM with LPN #6 revealed individually packaged Sani-Cloth bleach wipes that had expired in [DATE]. There was one wipe in a caddy and 30 wipes in an opened, currently in use box of wipes (originally contained 40 wipes). This was verified by LPN #6. Observation of the Station 3 Medication Room/Cabinet behind the nurses station on [DATE] at 11:47 AM revealed 1 unopened box of 40 individually packaged Sani-Cloth bleach wipes that expired [DATE]. One box of Sani-Cloth bleach wipes that was currently in use had not expired. There were no bleach wipes noted in the caddy. This was verified by LPN #1. During further interview on [DATE] at 12:25 PM, LPN #4 stated that the blood sugar check for Resident #7 was his/her first blood sugar check of the day and that was the only expired wipe s/he had used that day. After going to the soiled utility room, LPN #4 along with the surveyor examined the wrapper of the Sani-Cloth bleach wipe that had been discarded after being used to clean the glucometer after the initial blood sugar for Resident #7. LPN #4 verified that the wipe used to clean the glucometer had expired in [DATE]. During an interview on [DATE] at 12:33 PM, LPN #5 stated that glucometers are cleaned before and after each resident use. When asked if s/he had been checking the wipe before use for an expiration date, s/he stated "from what I've heard- no". When asked, LPN #5 went on to state that s/he had used the expired wipes that morning to clean the glucometer after 2 resident blood sugar checks. During an interview on [DATE] at 12:42 PM, LPN #6 stated that the multiple use glucometers were cleaned in between each resident and that bleach wipes were used.. When asked if s/he checked the wipes for anything before s/he used them, s/he stated "I looked and looked and didn't see it (the expiration date) stamped on the end". S/he went on to state that s/he knew another brand of wipes that had been used previously had an expiration date and that the expiration date on that container was "plain as day". S/he stated "I looked on these wipes and didn't see one (expiration date). I thought maybe with bleach wipes there was no expiration date-that they were good". When asked, s/he went on to say that s/he had not checked any blood sugars that morning. During an interview on [DATE] at 12:47 PM, LPN #3 stated s/he had been using the bleach wipes to clean the glucometers for about a year. When asked if s/he had been checking the wipes for an expiration date before using them to clean the glucometer, s/he stated, "I will now". When asked, LPN #3 stated s/he had used the expired wipes to clean the glucometer after 2 resident blood sugar checks that morning. During an interview on [DATE] at 2:25 PM, the Director of Nursing (DON) stated that glucometers are to be cleaned before and after each resident use. S/he stated that just recently, the individually wrapped bleach wipes were obtained for use to clean the glucometers. S/he stated that nursing staff know to check the wipes for an expiration date and have received education and inservices related to this. The DON could not recall when the inservices/education had been given. S/he was asked to supply any education related to glucometer cleaning or checking for expirations dates on supplies. When asked who was responsible for checking the expiration date of supplies, the DON stated that the Central Supply person was responsible for checking the expiration dates of supplies in the medication rooms and the expiration date of any supplies distributed. The DON stated that the nurses are responsible to check the wipe before use to ensure the wipe is not expired. During an interview on [DATE] at 2:35 PM, the Central Supply Certified Nursing Assistant (CNA) stated that s/he and the unit nurses were responsible for checking the wipes for an expiration date. During an interview on [DATE] at 5:07 PM, the DON stated that all expired wipes were in his/her office to be disposed of. Review of Infection Control Inservices dated [DATE] on [DATE] at 9:20 AM revealed information that nursing staff had been inserviced on the facility policy for "Cleaning and Disinfecting Diagnostic Equipment" (Revised ,[DATE]). The policy included information that a bleach wipe was to be used to disinfect glucose meters, but did not include information to check the bleach wipe for an expiration date prior to use. Review of individual nursing checkoffs on glucometer cleaning revealed 4 nurses had been checked off on the policy for cleaning an disinfecting diagnostic equipment from [DATE] thru [DATE]. However, the checkoff was the facility policy and did not include information to check the wipes for an expiration date. During an interview on [DATE] at 9:02 AM, the DON stated the pharmacy did monthly checks of medcarts and medication rooms but did not think they checked the wipes for an expiration date. The DON stated the facility did not have a policy on checking supplies for expiration dates, but it was expected that the Central Supply person would do this. Review of the Assure Platinum Blood Glucose Monitoring System User Instruction Manual (the facility's blood glucose monitor) revealed on page 47 under Cleaning and Disinfecting Guidelines, that "Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use". The instructions continued with information that cleaning and disinfection can be completed using a commercially available EPA-registered disinfectant detergent or germicidal wipe. During a phone interview on [DATE] at 11:05 AM, the Medical Director stated s/he was aware the disinfectant wipes used to clean glucometers had expiration dates. S/he stated that s/he would expect someone in the facility to monitor the wipes for expiration dates, but would not necessarily anticipate that nursing staff would check the wipe each time before using it. When asked who the "someone" was for this facility that was responsible for checking the wipes, s/he did not know who was responsible. When asked about any possible outcomes due to nursing staff using expired wipes to clean glucometers used for multiple residents; s/he stated that since a new glucose test strip and lancet was used for each resident, s/ he would not expect any potential for an adverse consequence. During a phone interview on [DATE] at 4:23 PM, a customer service representative for the manufacturer of the Sani-Cloth bleach wipes Professional Disposables Incorporated (PDI) was asked about the expiration date for their individually packaged Sani-Cloth bleach wipes. According to the representative, the product has an 8 month shelf life. The individually packaged bleach wipes with an expiration date of ",[DATE]" expired [DATE]. The representative went on to say that while the wipe may still be wet, they couldn't guarantee the efficacy of the product after that date. Record review on [DATE] of the facility provided Physician order [REDACTED].#17, #21, #22, #23, #24, and #25) on Stations 1 and 2 that had current orders for a FSBS at least 4 times a day. This was verified by the DON. The following review provided information as to how many times these residents received FSBS checks during the time period the wipes used to disinfect the glucometers had been expired: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"FSBS AC (Before Meals) and HS (Bedtime), SSI (Sliding Scale Insulin) humalog". A sliding scale was provided. Further review revealed the scheduled blood sugar checks were to be done at 6:00 AM, 11:30 AM, 4:30 PM, and 9:00 PM. Fingerstick blood sugars were documented from [DATE] at 4:30 PM through [DATE] at 11:30 AM with ,[DATE] entries circled indicating a blood sugar had not been checked. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the documentation, Resident #17 received FSBS monitoring 4 times a day from [DATE] through [DATE] at noon time. Seven entries had been marked indicating the resident did not have a blood sugar checked during that time period. The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the documentation, the resident received FSBS checks 4 times daily from [DATE] at 11:30 AM through [DATE] at 11:30 AM. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the [DATE] Diabetes Monitoring Record, the resident received FSBS checks 4 times a day from [DATE] through [DATE] at 11:00 AM. According to documentation, the resident missed 7 blood sugar checks during that time period. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the documentation, the resident had received fingerstick blood sugar checks 4 times daily from [DATE] through [DATE] at 6:00 AM. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Two entries had been marked to indicate a blood sugar had not been checked during that time frame. Immediate Jeopardy was determined to exist on [DATE] after expired disinfectant wipes were found on 3 of 3 nursing units. Based on observations and interviews, it was determined that expired wipes on 2 of 3 nursing units had been used to clean multiple-resident use glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. The Sani-Cloth bleach wipes had expired on [DATE]. CFR 483.20 Professional Standards F-281 was identified at a scope and severity of "K". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean Glucometers used for multiple residents with an appropriate cleansing agent. On [DATE], based on observations, interviews, and review of education provided to nursing and Central Supply Staff (from [DATE]-[DATE]); it was determined that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE] removing the immediacy of the deficient practice. Interviews on [DATE] from 9:50 AM to 10:00 AM revealed all of the unit nurses (a total of 6) working on stations 1, 2, and 3 were able to correctly state that an expiration date would be checked prior to using the disinfectant wipe to clean multiple-resident use glucometers. The citation at F-281 remained at a lower scope and severity of "E". The Immediate Jeopardy was removed upon exit from the facility.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policy provided by the facility entitled "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection. Nursing staff on 2 of 3 units (Station 1 and 2) had used expired disinfectant wipes to clean glucometers between each resident use. Expired disinfectant wipes were observed on 3 of 3 Nursing Stations, Stations 1, 2, and 3. Concerns were identified with 7 sampled residents on Stations 1 and 2 who had received Fingerstick Stick Blood Sugar (FSBS) monitoring from the time period [DATE]- [DATE]. Residents #7, #17, #21, #22, #23, #24, and #25 were identified with these concerns. Additionally, during one meal observation, facility staff was observed handling residents' food with their bare hands and a facility Nurse failed to change contaminated gloves pror to providing wound care. (Resident # 1) The findings included: Cross refer to F 281 as it relates the the facility failure to provide acceptable standards of practice related to the cleaning of multi-resident use Glucometers with an expired product. Observation of a medication pass on [DATE] at 11:25 AM revealed Licensed Practical Nurse (LPN) #4 using a multiple-resident use glucometer to check Resident #7's blood sugar. When asked to see the wipe package that had been discarded, the nurse provided a wipe for the surveyor (that had been on the paper towel on the overbed table). S/he indicated this was the same type of wipe that had been discarded. Examination of the wipe revealed an expiration date of ,[DATE] imprinted on the wrapper. LPN #4 was preparing to stick the resident's finger again when the surveyor stopped the nurse and asked to speak with her out in the hall. During an interview in the hall on [DATE] at 11:35 AM, LPN #4 was asked about the timing of when nursing staff clean the glucometers. LPN #4 stated the glucometers are cleaned after each resident use. She stated that the glucometer did not require cleaning before use since the glucometer should have been cleaned after it had been used last. When asked, LPN #4 stated she knew to check to see if the wipes had expired, but stated she had not done so prior to checking the blood sugar for Resident #7. After examining the wipe, LPN #4 verified the expiration date imprinted on the wrapper indicated the wipe had expired [DATE]. Observation of the Station 2 Medication Room on [DATE] at approximately 11:40 AM with LPN #4, LPN #3, and another surveyor revealed there were 10 Sani-Cloth bleach wipes in a caddy, 14 Sani-Cloth bleach wipes left in an opened, (currently in use) box of wipes that had originally contained 40 wipes; and one unopened box of 40 Sani-Cloth bleach wipes. All of the wipes had expired in [DATE]. The Lot # was listed as being 163 with "exp ,[DATE]" printed on the inside of the box. The individual wrappers also included imprinted information that the wipes had expired in [DATE]. Observation of the Station 1 Medication Room on [DATE] at approximately 11:45 AM with LPN #6 revealed individually packaged Sani-Cloth bleach wipes that had expired in [DATE]. There was one wipe in a caddy and 30 wipes in an opened, currently in use box of wipes (originally contained 40 wipes). This was verified by LPN #6. Observation of the Station 3 Medication Room/Cabinet behind the nurses station on [DATE] at 11:47 AM revealed 1 unopened box of 40 individually packaged Sani-Cloth bleach wipes that expired [DATE]. One box of Sani-Cloth bleach wipes that was currently in use had not expired. There were no bleach wipes noted in the caddy. This was verified by LPN #1. During an interview on [DATE] at 12:33 PM, LPN #5 when asked if she had been checking the wipe before use for an expiration date, she stated "from what I've heard- no". When asked, LPN #5 went on to state that she had used the expired wipes that morning to clean the glucometer after 2 resident blood sugar checks. During an interview on [DATE] at 12:42 PM, LPN #6 when asked if she checked the wipes for anything before she used them, she stated "I looked and looked and didn't see it (the expiration date) stamped on the end". During an interview on [DATE] at 12:47 PM, LPN #3 stated she had been using the bleach wipes to clean the glucometers for about a year. When asked if she had been checking the wipes for an expiration date before using them to clean the glucometer, she stated, "I will now". When asked, LPN #3 stated she had used the expired wipes to clean the glucometer after 2 resident blood sugar checks that morning. During an interview on [DATE] at 12:55 PM, LPNs #2 and #7 stated they had been checking the wipes for an expiration date before using them to clean the glucometers in between resident use. During an interview on [DATE] at 2:25 PM, the Director of Nursing (DON) stated that glucometers are to be cleaned before and after each resident use. She stated that nursing staff know to check the wipes for an expiration date and have received education and inservices related to this. . When asked who was responsible for checking the expiration date of supplies, the DON stated that the Central Supply person was responsible for checking the expiration dates of supplies in the medication rooms and the expiration date of any supplies distributed. The DON stated that the nurses are responsible to check the wipe before use to ensure the wipe is not expired. During an interview on [DATE] at 2:35 PM, the Central Supply Certified Nursing Assistant (CNA) stated that she and the unit nurses were responsible for checking the wipes for an expiration date. She stated that she did not see an expiration date on the outside of the box before she put the wipes out onto the nursing units. She stated that it's crazy that the expiration date is on the inside of the box. The Central Supply CNA provided documentation and verified that 20 boxes (each containing 40 bleach wipes) were ordered on [DATE] and delivered on [DATE]. She stated that she had put 2 boxes of Sani-Cloth bleach wipes onto Stations 1, 2, and 3 on [DATE]. When asked about the process of how the bleach wipes were ordered, the Central Supply CNA stated that she checked the supplies on Tuesdays and Fridays and restocked the nursing stations. She stated that once a week she ordered supplies from the facility's supplier. When asked how often she had to order wipes, she stated every few months. When asked, she stated that she knew that the Dispatch wipes had an expiration date, but was not aware of an expiration date for the Sani-Cloth bleach wipes. According to the Central Supply CNA, all the remaining boxes of the Sani-Cloth bleach wipes in the Central Supply room are in date. Observation of the Central Supply room with the CNA revealed 8 boxes of Sani-Cloth bleach wipes that were in date and not expired. Observations of each Nursing Station Medication Room/Cabinet with the Central Supply CNA on [DATE] between 3:00 PM and 3:10 PM revealed Stations 2 and 3 had 2 boxes of Sani-Cloth bleach wipes in date, while Station 1 had 3 boxes of Sani-Cloth bleach wipes in date. The expired wipes had been removed. During an interview on [DATE] at 5:07 PM, the DON stated that all expired wipes were in her office to be disposed of. Review of Infection Control Inservices dated [DATE] on [DATE] at 9:20 AM revealed information that nursing staff had been inserviced on the facility policy for "Cleaning and Disinfecting Diagnostic Equipment" (Revised ,[DATE]). The policy included information that a bleach wipe was to be used to disinfect glucose meters, but did not include information to check the bleach wipe for an expiration date prior to use. Review of individual nursing checkoffs on glucometer cleaning revealed 4 nurses had been checked off on the policy for cleaning an disinfecting diagnostic equipment from [DATE] thru [DATE]. However, the checkoff was the facility policy and did not include information to check the wipes for an expiration date. During an interview on [DATE] at 9:02 AM, the DON stated the pharmacy did monthly checks of medcarts and medication rooms but did not think they checked the wipes for an expiration date. The DON stated the facility did not have a policy on checking supplies for expiration dates, but it was expected that the Central Supply person would do this. Review of the Assure Platinum Blood Glucose Monitoring System User Instruction Manual (the facility's blood glucose monitor) revealed on page 47 under Cleaning and Disinfecting Guidelines, that "Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use". The instructions continued with information that cleaning and disinfection can be completed using a commercially available EPA-registered disinfectant detergent or germicidal wipe. During a phone interview on [DATE] at 10:34 AM, the consultant Pharmacist stated random checks are made almost monthly and at least twice a year that includes a check of emergency kits, and a spot check of common things. She stated the consultant pharmacy nurse did a more thorough check, but that she would need to ask her what supplies if any were checked for expiration. The consultant Pharmacist stated that as a general rule, she did not think checking for expired germicidal wipes would be high on the radar, but that she wouldn't say that they never look at them. The consultant Pharmacist called back later to state the consultant nurse was on leave and not available for interview. During a phone interview on [DATE] at 11:05 AM, the Medical Director stated he was aware the disinfectant wipes used to clean glucometers had expiration dates. He stated that he would expect someone in the facility to monitor the wipes for expiration dates, but would not necessarily anticipate that nursing staff would check the wipe each time before using it. When asked who the "someone" was for this facility that was responsible for checking the wipes, he did not know who was responsible. When asked about any possible outcomes due to nursing staff using expired wipes to clean glucometers used for multiple residents; he stated that since a new glucose test strip and lancet was used for each resident, he would not expect any potential for an adverse consequence. During a phone interview on [DATE] at 4:23 PM, a customer service representative for the manufacturer of the Sani-Cloth bleach wipes Professional Disposables Incorporated (PDI) was asked about the expiration date for their individually packaged Sani-Cloth bleach wipes. According to the representative, the product has an 8 month shelf life. The individually packaged bleach wipes with an expiration date of ",[DATE]" expired [DATE]. The representative went on to say that while the wipe may still be wet, they couldn't guarantee the efficacy of the product after that date. Record review on [DATE] of the facility provided Physician order [REDACTED].#17, #21, #22, #23, #24, and #25) on Stations 1 and 2 that had current orders for a FSBS at least 4 times a day. This was verified by the DON. CFR 483.65 Infection Control F-441 was identified at a scope and severity level of "K". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that glucometers used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. The cleansing agent used by the facility had an manufacturer's expiration date of [DATE]. On [DATE] at 4:23 PM it was verified with the Manufacturer that the product was not to be used after [DATE]. There were 7 residents residing in the facility on Stations 1 and 2 who required ongoing blood glucose testing at least 3 or 4 times a day with the use of the Glucometer through the time period [DATE] through [DATE]. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk at for serious harm. On [DATE], based on observations, interviews, and review of education provided to licensed nurses and Central Supply Staff (from [DATE]-[DATE]); it was determined that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE] removing the immediacy of the deficient practice. Interviews on [DATE] from 9:50 AM to 10:00 AM revealed all of the unit nurses (a total of 6) working on stations 1, 2, and 3 were able to correctly state that an expiration date would be checked prior to using the disinfectant wipe to clean multiple-resident use glucometers. The citation at F-441 remained at a lower scope and severity of "E". The Immediate Jeopardy was removed upon exit from the facility. The facility admitted Resident #1 with [DIAGNOSES REDACTED].# 1 (Licensed Practical Nurse) began wound care to a sacral ulcer. Stool was noted and the nurse stopped to clean the resident. She cleaned the area and then proceeded to clean the wound with ,[DATE]'s and normal saline. The nurse did not change her gloves between cleaning feces and cleaning the wound. When interviewed, the nurse stated she should have changed her gloves before cleaning the wound. On [DATE] at 6:20 PM, during the evening meal observation, the residents were served fish sandwiches. Three (3) Certified Nursing Assistants (CNA) and the Assistant Director of Nursing (ADON), were observed touching the resident's bread with their bare hands to apply tarter sauce on the sandwiches. At 6:35 PM on [DATE], during an interview with the ADON, the ADON confirmed she and the CNAs touched the resident's food with their bare hands. The ADON also stated that they should have used a napkin or eating utensil to pick up the resident's bread.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policy provided by the facility entitled "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers with a disinfectant wipe that had not expired. Concerns were identified with 7 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring through the time period from [DATE]-[DATE]. Residents #7, #17, #21, #22, #23, #24, and #25 were identified with these concerns. The findings included: 1. Cross refer to F441. Based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. 2. The facility Administration failed to adequately monitor staff responsible for checking the wipes for an expiration date and could provide no documentation that they had trained staff to check the wipes for expiration before using them. There was no information included within the facility policy "Cleansing and Disinfecting Diagnostic Equipment" (which had been used for training of nursing staff) that indicated the germicidal wipe should be checked before use to ensure it had not expired and was therefore effective against potential blood borne pathogens. During an interview on [DATE] at 2:25 PM, the Director of Nursing (DON) stated that glucometers are to be cleaned before and after each resident use. She stated that nursing staff know to check the wipes for an expiration date and have received education and inservices related to this. The DON could not recall when the inservices/education had been given and was not able to supply staff education related to checking expiration dates on disinfectant wipes used to clean glucometers. Review of Infection Control Inservices dated [DATE] on [DATE] at 9:20 AM revealed information that nursing staff had been inserviced on the facility policy for "Cleaning and Disinfecting Diagnostic Equipment" (Revised ,[DATE]). The policy included information that a bleach wipe was to be used to disinfect glucose meters, but did not include information to check the bleach wipe for an expiration date prior to use. Review of individual nursing checkoffs on glucometer cleaning revealed 4 nurses had been checked off on the policy for cleaning and disinfecting diagnostic equipment from [DATE] thru [DATE]. However, the checkoff was the facility policy and did not include information to check the wipes for an expiration date. During an interview on [DATE] at 8:50 AM, the Administrator stated she knew most of the supplies had expiration dates. S/he stated she would expect nursing staff to check the wipes for an expiration date before using them. Further interview at 9:05 AM revealed the Administrator had not identified any concerns prior to [DATE] related to nursing staff using expired wipes. During a phone interview on [DATE] at 11:05 AM, the Medical Director stateds/ he was aware the disinfectant wipes used to clean glucometers had expiration dates. He stated that he would expect someone in the facility to monitor the wipes for expiration dates, but would not necessarily anticipate that nursing staff would check the wipe each time before using it. When asked who the "someone" was for this facility that was responsible for checking the wipes, s/he did not know who was responsible. When asked about any possible outcomes due to nursing staff using expired wipes to clean glucometers used for multiple residents; s/he stated that since a new glucose test strip and lancet was used for each resident, s/he would not expect any potential for an adverse consequence. Immediate Jeopardy was determined to exist on [DATE] after expired disinfectant wipes were found on 3 of 3 nursing units. Based on observations and interviews it was determined that expired wipes on 2 of 3 nursing units had been used to clean multiple-resident use glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. The Sani-Cloth bleach wipes had expired on [DATE]. CFR 483.75 Administration F-490 was identified at a scope and severity level of "K". The facility Administration failed to assure that appropriate polices and procedures were in place and implemented related to the cleaning of Glucometers used for multiple residents. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk for serious harm. On [DATE], based on observations, interviews, and review of education provided to licensed nurses and Central Supply Staff (from [DATE]-[DATE]); it was determined that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE] removing the immediacy of the deficient practice. The citations at F-490 remained at a lower scope and severity of "E". The Immediate Jeopardy was removed upon exit from the facility.

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified as existing in the facility as of [DATE] related to the failure of the facility to ensure that each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Resident #1 exhibited symptoms of heat exposure on [DATE]. Resident #2's room temperature was 90 degrees on [DATE] at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. During the survey statements from 9 staff members, one family member, the county corner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on [DATE]. The findings included: Cross refers to F-157 as it related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased temperature on Unit 3. Residents #2 and #3 had heat related concerns which were not adequately addressed . Cross refers to F-257 as it related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of [DATE] around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on [DATE] at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-281 as it related to the failure of the facility to provide care and services that met professional standards of practice for all residents on Unit 3 (rooms ,[DATE] and 14) at risk for exposure to excessive heat. Cross refers to F-467 as it related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3 (rooms 5 - 12, and 14), the dining room and the hallway adjacent to the 8 resident rooms affected. On the evening of [DATE] around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room ,[DATE] at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer during a check of all affected resident rooms "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-490 as it related to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on [DATE] by a family member, that the heat on Unit 3 was extreme for the residents. On [DATE] a survey was conducted as a result of an Initial 24-Hour Report received by the State Survey Agency on [DATE] which stated under the heading "... Type of Alleged Abuse: neglect... Date/Time of Reportable Incident: [DATE] @ approx(imately) 7:45 pm. Brief Description of Reportable Incident: The ...Coroner and ...Police Department are investigating a possible heat related death of a resident (#1) in our facility. Investigation was initiated and is ongoing." Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status (BIMS) as "5" indicating problems with daily decision-making. Resident #1 required extensive assistance with transfer, mobility, and hygiene. She required limited assistance with dressing and eating. Her speech was unclear, she usually was understood and understands. Review of the Nurse's Notes indicated the provider saw Resident #1 between ,[DATE] and [DATE] related to 3 urinary tract infections, [MEDICAL CONDITION] of the right ankle and 1 episode of nausea and vomiting. The provider wrote new orders for labs related to the resident's ongoing [MEDICAL CONDITION]. Further review of the Nurse's Notes indicted that on "[DATE] at 9 AM Went in to give Res (resident) 9 AM meds, Resident was diaphoretic and was having SOB (shortness of breath) v/s (vital signs) 81, 23, 97.8 O2 Sat 80% asked Resident if she was hurting she stated "I'm ok" Sat Res. up in bed O2 sat came up to 90%, ausculated (sic) ABn (abnormal) breath sounds on (R) (right) side, Res also had cough, notified NP (nurse practitioner), she gave n/o (new order)... will cont (continue) to monitor, O2 in place 3L (liters) via NC (nasal canula). 9 PM N/O [MEDICATION NAME] tx (treatment) qid (four times a day) and qid prn (as needed) r/o (related to) wheezing/SOB, family notified O2 sat 98 on 3L O2 no c/o or Resp (respiratory) distress on this shift. Will cont. to monitor. [DATE] at 1 AM Res asleep... O2 via NC as ordered... Bp (blood pressure) ,[DATE] p (pulse) 70 r (respirations) 16 t (temperature) 98.1 2 P Resident continues oxygen via NC... All vitals wnl (within normal limits) including glucose... 4 PM Resident lying in bed with eyes closed. Awakes easily to verbal cues. Denies any discomfort... 6 P ,[DATE], 86, 18, 98.9 ax (axilla) O2 94% on O2, Resident with c/o (complained of) not feeling "right" to CNA (certified nurse aide). Nurse to the room. Resident assisted to sit upright by CNA due to nausea. Cool, damp towels applied to resident's skin to aid in cooling. Resident diaphoretic with gown being damp. Did verbalize feeling some better after several minutes of having cooling towels applied. Will continue to monitor. 6:30 P Insulin held r/t (related to) glucose 84 and resident not eating supper and with nausea. She also refused po (oral) meds. 1145 pm late entry for 715 pm. In report from previous nurse doing walking rounds it was stated Res. n/v (nausea/vomiting) earlier in day placed cold wet rags with fan on Resident. No distress noted. 1147 pm late entry for 730 pm checked on Resident, changed rags and replaced. Asked Resident if she was feeling better. Resident stated, "I feel fine." No distress noted at this time. 1150 pm late entry for 745 pm. CNA reported to nurse "something is wrong with Resident." Nurse entered room to check Resident. Resident showed s/sx (signs/symptoms) of Resp. distress attempted to check pulse Res ceased breathing sounds. Code called. EMS (emergency medical service) notified. CPR (cardiopulmonary resuscitation) cont till arrival. Res transported EMS to ...hospital." Review of the Supplementary Report from the police department indicated that on [DATE] a police officer was dispatched to the nursing home and met outside by a complainant/family member whose father (Resident #2) lives at the facility. The complainant stated that for the last 2 weeks they had complained to the Administrator about the extreme heat on the wing (Unit 3, rooms ,[DATE] and 14) where his father lives. The complainant stated at 1:30 PM Saturday afternoon ([DATE]) the temperature registered 94 degrees in his father's room. The officer walked into Resident #2's room at 7:45 PM, a thermometer was positioned on a table near the resident's bed that read 90 degrees. The officer asked CNA (certified nurse aide) #1 to accompany him and he began checking the other rooms and speaking to residents on the Unit to see how they felt about the temperature. The report stated that he "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. CNA #1 noticed that Resident #1 was not acting normal and asked the officer to stay with the resident while she got the nurse. The officer noted that Resident #1 was gasping for air. The report stated, "The room became flooded with other nurses... CPR was begun... the victim had no pulse." Emergency medical services and the fire department arrived at 8:01 PM and Resident #1 was transferred to the hospital. The officer's supervisor was notified and arrived at the facility. The facility Administrator was contacted. The officer and his supervisor decided at 8:26 PM to move the residents to an area in the facility with air conditioning. The officers along with the nurses moved residents into the common area on the adjoining unit. The Administrator arrived at the facility. Once the residents were moved the Administrator was advised by the officers not to move the residents back until the "air was fixed". An air conditioning repair company had arrived but had not determined the extent of the problem. The officers left the facility. At 11:45 PM the officer and the Coroner entered the facility, the Coroner checked every affected room on Unit 3 with a hand held laser thermometer, temperatures ranged from 83 degrees to 87 degrees. The residents had been moved back to their rooms on Unit 3 and the facility Administrator was advised by the Coroner "that it was still too hot". The Coroner, the police officer and his supervisor went back to the hospital to discuss their concerns related to the heat with the emergency room physicians. At 12:34 AM ([DATE]) the officer and his supervisor arrived back at the nursing home, the officer recorded multiple temperatures in resident rooms on Unit 3 that ranged from 84.5 degrees to 87.5 degrees. At that time the Administrator was asked and she agreed to move the residents back to the other wing where it was cooler and the air conditioner was functioning. The Administrator told the officers "that they were renting portable air units tomorrow in attempts to make the living area more tolerable." On [DATE] at 5:07 AM the officer returned to the facility and found that all the residents had been moved to Unit 1 and Unit 2. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident as a Brief Interview for Mental Status as "11" indicating problems with daily decision- making. Resident #2 required extensive assistance with most activities of daily living; he fed himself after the meal was setup. His speech was unclear, he usually was understood and he understands. Review of Resident #2's Nurse's Notes revealed no documentation on [DATE]; there was no mention of the resident's condition or the need to place wet towels on him to keep him cool. In a face-to-face interview with the surveyor on [DATE] at 2:05 PM Resident #2 stated that he had 3 fans in his room to keep him cool before the window unit was put in. He confirmed that the staff in an attempted to keep him cool on [DATE] put wet towels on him. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 was cared for by hospice. Review of Resident #3's Nurse's Notes for [DATE] at 0900 stated, "Resident with SOB and difficulty breathing. VS ,[DATE], P 128, R 42, T 97 axillary, O2 86% RA (room air), Glucose 184. She was very diaphoresic (sic) and with labored breathing. Med neb tx and O2 place on 2 L/m NC (nasal canula). Hospice called... 1 P(M) Hospice... in to see resident and family member. New orders given and processed. Resident refusing to keep O2 NC on - states she does not need it anymore. Respirations are less labored now after [MEDICATION NAME]" In a face-to-face interview with the surveyor on [DATE] at approximately 8:00 PM the Regional Vice President (RVP) and the Administrator confirmed that the family of Resident #2 called on Friday and several times on Saturday regarding the high temperatures on Unit #3. The Administrator stated that she called the facility on Saturday morning ([DATE]) to remind the staff to keep the residents hydrated. She confirmed that she brought fans to the facility on Saturday around 6:30 PM stayed for a while and left. On [DATE] at approximately 12:35 PM during an observation of the exterior of the facility and the air conditioning units repaired on [DATE] the Maintenance Director stated that he hung a thermometer in the hall across from room ,[DATE] because that end of the hall was hotter due to the afternoon sun coming in on that side of the building. He stated he did not log those temperatures. The Maintenance Director provided documentation that a heating and air conditioning company on [DATE] inspected the HVAC equipment, [DATE], and [DATE]; no inspection had been done since [DATE]. The Maintenance Director confirmed that he was out of town during the day on Saturday, returned around ,[DATE]:00 PM and was called by the Administrator around 8:00 PM about the problem with the AC. He stated that he came to the facility, that the mechanical company arrived around 9:00 PM and they learned that repairs needed to be made to one of the air handlers and a new compressor was needed. In a face-to-face interview with the surveyor on [DATE] at 12:45 PM CNA (certified nurse aide) #1 stated she had worked at the facility for [AGE] years, that it was always hot in the summer and that "Saturday was the hottest I've ever seen it" on Unit 3. She was unsure of the time but confirmed the temperature on Unit 3 Saturday was around 85 to 87 degrees. CNA #1 confirmed that she and the police officer found Resident #1 in distress while they were speaking to residents and checking the temperature in their rooms. She stated that she was not assigned to care for Resident #1 on Saturday [DATE], that she saw her around 6:30 PM on Saturday with wet towels on her chest and head with a basin for vomiting. In a face-to-face interview with the surveyor on [DATE] at 2:00 PM Registered Nurse (RN) #1 stated that Resident #1 on [DATE] at around 9:00 AM was short of breath and diaphoretic, that her oxygen saturation was 80% on oxygen at 3 liters. That she was pulled up in the bed and her oxygen saturation got better. "She was still breathing hard and coughing, gave her a neb (ulizer) treatment and moved her out to the dining room so I could watch her." RN #1 stated that she was fine the rest of the shift. On Saturday ([DATE]) RN #1 stated that she worked on the float cart and was back and forth but worked "Unit 2 primarily". She stated that around 2:00 PM she went to Unit 3 and spoke with Licensed Practical (LPN) #1, "that it was getting hotter than it should be". Licensed Practical Nurse (LPN) #1 had contacted the Administrator who was bringing fans. The thermostat was between 80 and 90 degrees. "I could not see well, the paper on the thermostat made it hard to read." When asked by the surveyor what paper? She said there was a note on the thermostat that stated that if you touched the thermostat disciplinary action would be taken. RN #1 stated she went back to Unit 3 around 4:00 PM it continued to be hot; she was again told that someone was bringing fans. She stated that she mentioned to LPN #1 that maybe they should "start moving people LPN #1 didn't respond". RN #1 stated that when she left the facility around 7:15 PM all the residents were still on Unit 3. RN #1 confirmed that it was always warm on Unit 3 that the staff complained to the supervisor and each other. In a face-to-face interview with the surveyor on [DATE] at 2:20 PM LPN #1 stated that at report on [DATE] at round 7:00 AM she was told that Resident #1 was on acute charting due to sweating, that her bowel sounds, vital signs were normal and she had been ok during the 11 PM -7 AM shift. She stated that it was humid but "not hot didn't pay attention to the temperature. The AC by the door at the nurse's station was on." LPN #1 stated that Resident #1 had her fan on, Resident #2 had 3 fans on and several others were noted with running fans when she made initial rounds that morning. LPN #1 stated that at 10 AM it was feeling warm, 82 degrees on the thermometer in Resident #2's room. "Complained at 10 (Resident #2) his sons had come and asked had someone been out to check the AC (air conditioning) since they were told the day before someone would come." She stated that the Administrator called to tell her about the problems with the air conditioning the previous day and that I could call her. She told me when she called at 10 that maintenance had checked it on Friday and it was OK; maintenance was out of town. At 11:30 AM LPN #1 stated that she told the Manager on Duty that it was 86 degrees in Resident #2's room; the Manager on Duty responded per LPN #1 that she didn't know what she was suppose to do, "everyone has strict orders not to touch thermostat". When asked about the condition of Resident #1 on [DATE] during her shift LPN #1 stated that right after breakfast around 8:30 AM she was brought out to the dining room and taken back to her room around 2 PM, "she was ok". Other residents started to complain about the heat around 4 PM, "Mr. (Resident #2) had complained all day, sometime during the day the CNAs put wet towels on him. At 5 PM LPN #1 stated it was smoke break time, "I sent the ADON (assistant director of nurses) a text about smokers." Her response to my text was to let them smoke one cigarette, bring them back in and make sure they were hydrated. LPN #1 stated that she tried to call the Administrator but her call went to voice mail "she didn't call me back." LPN #1 stated that she sent the ADON several text telling her it was way, way hot and could she adjust the air, "sick residents, hair getting damp, food trays coming out, not drinking and pushing back trays." She stated that around 5:55 PM Resident #1 complained of nausea, that her vital signs were checked, clothing changed and within ,[DATE] minutes she was feeling better; during this time the ADON text to tell her the Administrator was on her way. LPN #1 stated that the Administrator called her, stating that she was on her way and was bringing fans, I said fans are better than nothing, passing ice water all day. Mr. (Resident #2's) room was between 88 and 90 degrees about 6:30 PM, I told the Administrator it was 90 degrees in his room. She came with fans, put another fan in Resident #1's room. I told her it's not safe, way to hot. The Administrator replied that she would check with cooperate on Monday about window units. "She was here just a few minutes." She told me while she was here that maintenance was the only one with a key to open the box with the thermostat; that she knew the box could be manipulated. When the Administrator left, "I opened the box, turned down just a couple of degrees, went outside, checked not frozen. Thermostat setting on ,[DATE] when I left." LPN #1 stated that she did rounds before she left and Resident #1 was ok she stated that the police were coming up hill as she left. LPN #1 confirmed the presence of the note on the thermostat that stated "do not touch, disciplinary action will be taken". In a face-to-face interview with the surveyor on [DATE] at 1:20 PM CNA #2 stated that she had just recently started working on Unit 3, "about a month", always warm, "Saturday the hottest". When asked if the residents complained about the heat she stated that Resident #2 was actually complaining, "others didn't say anything not aware they are hot". She confirmed that Resident #1 on [DATE] sat in the dining room until around 2 PM when she was taken to her room. "I took her to restroom, put her gown on, gave her water." CNA #2 stated that Resident #1 wanted her blanket on her when she laid down and that she went back before she left for the day; removed the blanket and covered her with a sheet. She stated that the resident was asleep and not sweating when she saw her at around 3:00 PM. In a face-to-face interview with the surveyor on [DATE] at 4:15 PM LPN #2 confirmed that she worked the 7 PM - 7 AM shift on ,[DATE] -[DATE]. LPN #2 confirmed that it was hot on Unit 3 when she came to work, that LPN #1 reported to her that it was hot, fans had been brought in and that Resident #1 had over heated. She stated she was not sure about the time the police arrived maybe 7 - 7:30 PM, she was working with another resident (#3) when the police asked if "CNA could walk him around rooms". In a face-to-face interview with the surveyor on [DATE] at 3:04 PM CNA #3 assigned to Resident #1 on the ,[DATE] shift, stated that when she came to work around 3:00 PM the resident was sleeping; that the temperature in the room was hot, "always hot, fan on in room". At around 4:45 PM CNA #3 stated that she dried the resident and gave her water through a straw she stated she was "her usual wet, not sweating, I helped her push herself up in the bed. CNA #3 stated that between 5:45 and 6:00 PM she took Resident #1 her supper tray and she was sweating, her clothes and bed were wet, offered water, wet wash cloth and rolled her bed up. "I called the nurse, tried to cool her off, nurse helped me about 20 minutes, making sure she was ok. Sweat, not vomiting, sweat all over her." When asked if she took Resident #1's vital signs she replied, "No". CNA #3 stated that she took residents out to smoke and that when she came back in around 7:30 PM the police were in the building and she was told to get Resident #1's vital signs stat, "unable to get vitals, not breathing". In a face-to-face interview with the surveyor on [DATE] at 3:30 PM the Assistant Director of Nurses (ADON) confirmed LPN #1 account of the events of [DATE]. She stated that she received a telephone call from another nurse telling her that the police were in the building and Resident #1 had been sent to the emergency room . She stated that she arrived at the facility a few minutes before 9:00 PM that the resident had been moved, the Administrator was checking the temperatures in resident rooms and they were told that the residents could go back to their rooms. The ADON stated she was not aware of the temperatures at that time. She stated that around 10 PM they started moving residents back to their rooms, then after the coroner and police came back to the facility "we moved the residents again". She stated that around 1:00 PM on Sunday ([DATE]) the residents were moved back to Unit 3. In a face-to-face interview with the surveyor on [DATE] at 4:10 PM the Manager on Call for [DATE] confirmed it was hotter than normal on [DATE] on Unit 3. She stated that LPN #1 did not mention any residents that had complained about the heat. She stated that LPN #1 told her she had called the Administrator. In a telephone interview with the surveyor on [DATE] at 7:15 PM the Complainant/family member confirmed he and his brother's concerns related to the heat in his father's room on Unit 3. He stated that he had spoken to the facility 3 weeks ago when the outside temperatures were in the high 80's to 90's and the temperature in his father's room was between 81 and 82 degrees. "The reason they gave me was it's an old building and the air conditioning will freeze up. There is nothing wrong with it." The Complainant stated that on Friday he called... (Regional Vice President) and was told that he would speak with the Administrator and get back with him. The Regional Vice President's reply was that it was and old building... The Complainant stated that he called... (the Regional Vice President) at least twice on Saturday and when he could get no resolution to the problem with the air conditioning he called 911. He stated that when the police came out to check on his father on Saturday night, the family was putting cold towels on him and the temperature in the room was around 91 degrees at 7:45 PM. In face-to-face interviews with the surveyor on [DATE] four residents stated that it was hotter than usual in their rooms on [DATE]. Each stated the fans in their room were of little help with the heat. In a telephone interview with the surveyor on [DATE] at 9:15 PM the Coroner confirmed that she went to the facility with the police officers on [DATE] sometime close to midnight she stated that the temperatures ranged from 83 degrees to 87 degrees in the affected rooms. When she got to the facility the residents had been moved back to there rooms; she and the police officers told the Administrator that it was still too hot for the residents. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on ,[DATE]//2012 at 6:50 PM. The Immediate Jeopardy at F-224 was removed but the citation at F-224 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified as existing in the facility as of [DATE] related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of [DATE] around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on [DATE] at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. The findings included: Cross refers to F-157 as it related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased temperature on Unit 3. Residents #2 and #3 had heat related concerns which were not adequately addressed. Cross refers to F-224 as it related to the failure of the facility to ensure each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Residents #1, #2 and #3 exhibited symptoms of heat exposure on [DATE]. During the survey statements from 9 staff members, one family member, the county coroner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on [DATE]. Cross refers to F-281 as it related to the failure of the facility to provide care and services that met professional standards of practice for all residents on Unit 3 (rooms ,[DATE] and 14) at risk for exposure to excessive heat. Cross refers to F-467 as it related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3 (rooms 5 - 12, and 14), the dining room and the hallway adjacent the 8 resident rooms affected. On the evening of [DATE] around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room ,[DATE] at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer during a check of all affected resident rooms "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-490 as it related to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on [DATE] by a family member, that the heat on Unit 3 was extreme for the residents. On [DATE] a survey was conducted as a result of an Initial 24-Hour Report received by the State Survey Agency on [DATE] which stated under the heading "... Type of Alleged Abuse: neglect... Date/Time of Reportable Incident: [DATE] @ approx(imately) 7:45 pm. Brief Description of Reportable Incident: The ...Coroner and ...Police Department are investigating a possible heat related death of a resident (#1) in our facility. Investigation was initiated and is ongoing." Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident as a Brief Interview for Mental Status as "5" indicating problems with daily decision- making. Resident #1 required extensive assistance with transfer, mobility, and hygiene. She required limited assistance with dressing and eating. Her speech was unclear, she unusually was understood and understands. Review of the Nurse's Notes indicated that on [DATE] at 6 P ,[DATE], 86, 18, 98.9 ax (axillary) O2 94% on O2, Resident with c/o not feeling "right" to CNA. Nurse to the room. Resident assisted to sit upright by CNA due to nausea. Cool, damp towels applied to resident's skin to aid in cooling. Resident diaphoretic with gown being damp. Did verbalize feeling some better after several minutes of having cooling towels applied. Will continue to monitor. 6:30 P Insulin held r/t (related/to) glucose 84 and resident not eating supper and with nausea. She also refused po (by mouth) meds. 1145 pm late entry for 715 pm. In report from previous nurse doing walking rounds it was stated Res. (resident) n/v (nausea/vomiting) earlier in day placed cold wet rags with fan on Resident. No distress noted. 1147 pm late entry for 730 pm checked on Resident, changed rags and replaced. Asked Resident if she was feeling better. Resident stated "I feel fine." No distress noted at this time. 1150 pm late entry for 745 pm. CNA reported to nurse "something is wrong with Resident." Nurse entered room to check Resident. Resident showed s/sx (signs/symptoms) of Resp. distress attempted to check pulse Res ceased breathing sounds. Code called. EMS (emergency medical service) notified. CPR (cardiopulmonary resuscitation) cont (continue) till arrival. Res transported EMS to ...hospital." Review of the Supplementary Report from the police department indicated that on [DATE] a police officer was dispatched to the nursing home and met outside by a complainant/family member whose father (Resident #2) lives at the facility. The complainant stated that for the last 2 weeks they had complained to the Administrator about the extreme heat on the wing (Unit 3, room ,[DATE] and 14) where his father lives. The complainant stated at 1:30 PM Saturday afternoon ([DATE]) the temperature registered 94 degrees in his father's room. The officer walked into Resident #2's room at 7:45 PM, a thermometer was positioned on a table near the resident's bed that read 90 degrees. The officer asked CNA (certified nurse aide) #1 to accompany him and he began checking the other rooms and speaking to residents on the Unit to see how they felt about the temperature. The report stated that he "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. CNA #1 noticed that Resident #1 was not acting normal and asked the officer to stay with the resident while she got the nurse. The officer noted that Resident #1 was gasping for air. The report stated, "The room became flood with other nurses... CPR (cardiopulmonary resuscitation) was begun... the victim had not pulse." Emergency medical services and the fire department arrived at 8:01 PM and Resident #1 was transferred to the hospital. The officer's supervisor was notified and arrived at the facility. The facility Administrator was contacted. The officer and his supervisor decided at 8:26 PM to move the residents to an area in the facility with air conditioning. The officers along with the nurses moved resident into the common area on the adjoining unit. The Administrator arrived at the facility. Once the residents were moved the Administrator was advised by the officers not to move the residents back until the "air was fixed". An air conditioning repair company had arrived but had not determined the extent of the problem. The officers left the facility. At 11:45 PM the officer and Coroner entered the facility, the Coroner checked every affected room on Unit 3 with a hand held laser thermometer, temperatures ranged from 83 degrees to 87 degrees. The residents had been moved back to there rooms on Unit 3 and the facility Administrator was advised by the Coroner "that it was still too hot". The Coroner, the police officer and his supervisor went back to the hospital to discuss their concerns related the heat with the emergency room physicians. At 12:34 AM ([DATE]) the officer and his supervisor arrived back at the nursing home, the officer recorded multiple temperatures in resident room on Unit 3 that ranged from 84.5 degrees to 87.5 degrees. At that time the Administrator was asked and she agreed to move the residents back to the other wing where it was cooler and the air conditioner was functioning. The Administrator told the officers "that they were renting portable air units tomorrow in attempts to make the living area more tolerable." On [DATE] at 5:07 AM the officer returned to the facility and found that all the residents had been moved to Unit 1 and Unit 2. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident as a Brief Interview for Mental Status as "11" indicating problems with daily decision- making. Resident #2 required extensive assistance with most activities of daily living; he fed himself after the meal was setup. His speech was unclear, he usually was understood and he understands. Review of Resident #2's Nurse's Notes revealed no documentation on [DATE]; there was no of the resident's condition or the need to place wet towels on him to keep him cool. In a face-to-face interview with the surveyor on [DATE] at 2:05 PM Resident #2 stated that he had 3 fans in his room to keep him cool before the window unit was put in. He confirmed that the staff in an attempted to keep him cool on [DATE] put wet towels on him. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing; she was cared for by hospice. In a face-to-face interview with the surveyor on [DATE] at approximately 9:00 PM the Maintenance Director stated that he checked the temperature at the thermostat on Unit 3 every Wednesday between ,[DATE]:30 AM and the temps were 72 degrees. He stated that on Friday, the staff complained about the temperature and that he looked at the thermostat on and off during the day, the temperature was around 75 degrees. The Maintenance Director stated that he cleaned the coils on Wednesday or Thursday (,[DATE] - [DATE]), he confirmed that he was the only person who had a key to open the box that covered the thermostat. When the Maintenance Director was asked about preventive maintenance to the air conditioning unit for Unit 3 he stated that the company used a TELS check off system as a maintenance reminder. A review of the TELS check off sheet indicated two areas of maintenance for the air conditioning system "...HVAC (heating, ventilation, air conditioning) (PTAC) (packaged terminal air conditioning): Clean/change filter, inspect and clean coils. HVAC... : Inspect condenser coils; clean as necessary..." these two area were documented as performed in March, April, May and [DATE]. The Maintenance Director provided documentation that the HVAC equipment was inspected by a heating and air conditioning company on [DATE], [DATE], and [DATE]; no inspection had been done since [DATE]. The Maintenance Director confirmed that he was out off town during the day on Saturday, returned around ,[DATE]:00 PM and was called by the Administrator around 8:00 PM about the problem with the air conditioning. He stated that he came to the facility, that the mechanical company arrived around 9:00 PM and they learned that repairs needed to be made to one of the air handlers and a new compressor was needed. In a face-to-face interview with the surveyor on [DATE] at 12:45 PM CNA (certified nurse aide) #1 stated she had worked at the facility for [AGE] years, that it was always hot in the summer and that "Saturday was the hottest I've ever seen it". She was unsure of the time but confirmed the temperature on Unit 3 Saturday was around 85 to 87 degrees. CNA #1 confirmed she accompanied the police officer as he checked the residents and the room temperatures. She stated that she was not assigned to care for Resident #1 on Saturday [DATE], that she saw her around 6:30 PM on Saturday with wet towels on her chest and head with a basin like she was vomiting. In a face-to-face interview with the surveyor on [DATE] at 2:00 PM Registered Nurse (RN) #1 stated that on Saturday ([DATE]) she worked on the float cart and was back and forth but worked "Unit 2 primarily". She stated that around 2:00 PM she went to Unit 3 and spoke with Licensed Practical (LPN) #1, that it was getting hotter than it should be. LPN #1 had contacted the Administrator who was bringing fans. The thermostat was between 80 and 90 degrees. "I could not see well, the paper on the thermostat made it hard to read." When asked by the surveyor what paper? She said there was a note on the thermostat that stated that if you touched the thermostat disciplinary action would be taken. RN #1 stated she went back to Unit 3 around 4:00 PM it continued to be hot; she was again told that someone was bringing fans. She stated that she mentioned to LPN #1 that maybe they should "start moving people LPN #1 didn't respond". RN #1 stated that when she left the facility around 7:15 PM all the residents were still on Unit 3. RN #1 confirmed that it was always warm on Unit 3 that the staff complained to the supervisor and each other, Resident #2's family had never complained to her about the heat. In a face-to-face interview with the surveyor on [DATE] at 2:20 PM Licensed Practical Nurse (LPN) #1 stated that at report on [DATE] at round 7:00 AM she was told that Resident #1 was on acute charting due to sweating, that her bowel sounds, vital signs were normal and she had been ok during the 11 PM -7 AM shift. She stated that it was humid but "not hot didn't pay attention to the temperature. The AC by the door at the nurse's station was on." LPN #1 stated that Resident #1 had her fan on, Resident #2 had 3 fans on and several others were noted with running fans when she made initial rounds that morning. LPN #1 stated that at 10 AM it was feeling warm, 82 degrees on the thermometer in Resident #2's room. "Complained at 10 (Resident #2) his sons had come and asked had someone been out to check the AC since they were told the day before someone would come." She stated that the Administrator called to tell her about the problems with the air conditioning the previous day and that I could call her. She told me when she called at 10 that maintenance had checked it on Friday and it was OK; maintenance was out of town. At 11:30 AM LPN #1 stated that she told the Manager on Duty that it was 86 degrees in Resident #2's room; the Manager on Duty responded per LPN #1 that she didn't know what she was suppose to do, "everyone has strict orders not to touch thermostat". When asked about the condition of Resident #1 on [DATE] during her shift LPN #1 stated that right after breakfast around 8:30 AM she was brought out to the dining room and taken back to her room around 2 PM, "she was ok". Other residents started to complain about the heat around 4 PM, "Mr. (Resident #2) had complained all day, sometime during the day the CNAs put wet towels on him. At 5 PM LPN #1 stated it was smoke break time, "I sent the ADON (assistant director of nurses) a text about smokers." Her response to my text was to let them smoke one cigarette, bring them back in and make sure they were hydrated. LPN #1 stated that she tried to call the Administrator but her call went to voice mail "she didn't call me back." LPN #1 stated that she sent the ADON several text telling her it was way, way hot and could she adjust the air, "sick residents, hair getting damp, food trays coming out, not drinking and pushing back trays." She stated that around 5:55 PM Resident #1 complained of nausea, that her vital signs were checked, clothing changed and within ,[DATE] minutes she was feeling better; during this time the ADON text to tell her the Administrator was on her way. LPN #1 stated that the Administrator called her, stating that she was on her way and was bringing fans, I said fans are better than nothing, passing ice water all day. Mr. (Resident #2's) room was between 88 and 90 degrees about 6:30 PM, I told the Administrator it was 90 degrees in his room. She came with fans, put another fan in Resident #1's room. I told her it's not safe, way to hot. The Administrator replied that she would check with cooperate on Monday about window units. "She was here just a few minutes." She told me while she was here that maintenance was the only one with a key to open the box with the thermostat; that she knew the box could be manipulated. When the Administrator left, "I opened the box, turned down just a couple of degrees, went outside, checked not frozen. Thermostat setting on ,[DATE] when I left." LPN #1 stated that she did rounds before she left and Resident #1 was ok she stated that the police were coming up hill as she left. LPN #1 confirmed the presence of the note on the thermostat that stated "do not touch, disciplinary action will be taken". In a face-to-face interview with the surveyor on [DATE] at 1:20 PM CNA #2 stated that she had just recently started working on Unit 3, "about a month", always warm, "Saturday the hottest". When asked it the residents complained about the heat she stated that Resident #2 was actually complaining, "others didn't say anything not aware they are hot". She confirmed that Resident #1 on [DATE] sat in the dining room until around 2 PM when she was taken to her room. "I took her to restroom, put her gown on, gave her water." CNA #2 stated that Resident #1 wanted her blanket on her when she laid down and that she went back before she left for the day; removed the blanket and covered her with a sheet. She stated that the resident was asleep and not sweating when she saw her at around 3:00 PM. In a face-to-face interview with the surveyor on [DATE] at 3:04 PM CNA #3 assigned to Resident #1 on the ,[DATE] shift, stated that when she came to work around 3:00 PM the resident was sleeping; that the temperature in the room was hot, "always hot, fan on in room". At around 4:45 PM CNA #3 stated that she dried the resident and gave her water through a straw, she stated she was "her usual wet, not sweating, I helped her push herself up in the bed. CNA #3 stated that between 5:45 and 6:00 PM she took Resident #1 her supper tray and she was sweating, her clothes and bed were wet, offered water, wet wash cloth and rolled her bed up. "I called the nurse, tried to cool her off, nurse helped me about 20 minutes, making sure she was ok. Sweat, not vomiting, sweat all over her." When asked if she took Resident #1's vital signs she replied, "No". CNA #3 stated that she took residents out to smoke and that when she came back in around 7:30 PM the police were in the building and she was told to get Resident #1's vital signs stat, "unable to get vitals, not breathing". In a face-to-face interview with the surveyor on [DATE] at 3:30 PM the Assistant Director of Nurses (ADON) confirmed LPN #1 account of the events of [DATE]. She stated that she arrived at the facility a few minutes before 9:00 PM that the resident had been moved, the Administrator was checking the temperatures in resident rooms and they were told that the residents could go back to their rooms. The ADON stated she was not aware of the temperatures at that time. She stated that around 10 PM they started moving residents back to their rooms, then after the coroner and police came back to the facility "we moved the residents again". She stated that around 1:00 PM on Sunday ([DATE]) the residents were moved back to Unit 3. In a face-to-face interview with the surveyor on [DATE] at 4:10 PM the Manager on Call for [DATE] confirmed it was hotter than normal on [DATE] on Unit 3. In a telephone interview with the surveyor on [DATE] at 7:15 PM the Complainant/family member confirmed his and his brother's concerns related to the heat in his father's room on Unit 3. He stated that he had spoken to the facility 3 weeks ago when the outside temperatures were in the high 80's to 90's and the temperature in his father's room was between 81 and 82 degrees. "The reason they gave me was it's an old building and the air conditioning will freeze up. There is nothing wrong with it." The Complainant stated that on Friday he called... (Regional Vice President) and was told that he would speak with the Administrator and get back with him. The Regional Vice President's reply was that it was and old building... The Complainant stated that he call... (the Regional Vice President) at least twice on Saturday and when he could get no resolution to the problem with the air conditioning he called 911. He stated that when the police came out to check on his father, the family was putting cold towels on him and the temperature in the room was around 91 degrees at 7:45 PM. In a face-to-face interview with the surveyor on [DATE] at approximately 8:00 PM the Regional Vice President (RVP) and the Administrator confirmed that the family of Resident #2 called on Friday and several times on Saturday regarding the high temperatures on Unit #3. The Administrator stated that she called the facility on Saturday morning ([DATE]) to remind the staff to keep the residents hydrated. She confirmed that she brought fans to the facility on Saturday around 6:30 PM stayed for a while and left. The RVP and Administrator confirmed that the Mechanical Contractor arrived at the facility around 8:30 PM and told them the unit was frozen up, a wire was burned and they needed to get another compressor. The Administrator stated that the residents were moved on Saturday between ,[DATE] PM; the men were placed on Unit 1 and the women on Unit 2. She stated that the residents came back to their room on Sunday around 2:00 PM after the window units were installed. Review of the invoice dated [DATE] from the mechanical services that repaired the broke air conditioning unit for Unit 3 stated, "...compressor gone bad in A/C sta 3, dispatched to... on [DATE], aquired (sic) compressor on [DATE] and installed. Complete standard diagnostic charge applied..." Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on ,[DATE]//2012 at 6:50 PM. The Immediate Jeopardy at F-257 was removed but the citation at F-257 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record reviews and interviews, Immediate Jeopardy was identified as existing in the facility as of 06/30/2012 related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3 (room 5 - 12, and 14), the dining room and the hallway adjacent to the 8 resident rooms affected. On the evening of 06/30/2012 around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room 3-11 at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes as diaphoretic and having labored breathing on 06/30/2012; she was cared for by hospice. The findings included: Cross refers to F-157 as it related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased temperature on Unit 3. Residents #2 and #3 had heat related concerns which were not adequately addressed. Cross refers to F-224 as it related to the failure of the facility to ensure each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Residents #1, #2 and #3 exhibited symptoms of heat exposure on 06/30/2012. During the survey statements from 9 staff members, one family member, the county coroner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on 06/30/2012. Cross refers to F-257 as it related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of 06/30/2012 around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on 06/30/2012 at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on 06/30/2012 as diaphoretic and having labored breathing. Cross refers to F-281 as it related to the failure of the facility to provide care and services that met professional standards of practice for all residents on Unit 3 (rooms 5-12 and 14) at risk for exposure to excessive heat. Cross refers to F-490 as it related to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on 06/29/2012 by a family member, that the heat on Unit 3 was extreme for the residents. On 07/02/2012 a survey was conducted as a result of an Initial 24-Hour Report received by the State Survey Agency on 07/02/2012 which stated, "...The ...Coroner and ...Police Department are investigating a possible heat related death of a resident (#1) in our facility. Investigation was initiated and is ongoing." Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 was found in respiratory distress by Certified Nurse Aide (CNA) #1 and a police officer who was called to the facility due to a concerns that the air conditioning was not working and the temperature in the facility was too hot for the residents. When the nurse entered the room she found the resident in distress, no pulse or breath sounds. CPR (cardiopulmonary resuscitation) was initiated and Resident #1 was transferred to the emergency room . Review of the Supplementary Report from the police department indicated that on 06/30/2012 a police officer was dispatched to the nursing home due to a complaint that for the last 2 weeks the Administrator was aware of extreme heat on the Unit 3, rooms 5-12 and 14. The complaint stated at 1:30 PM Saturday afternoon (6/30/2012) the temperature registered 94 degrees in room 3-11. On arrival at the facility the officer walked into room 3-11 at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The officer asked CNA (certified nurse aide) #1 to accompany him and he began checking the other rooms and speaking to residents on the Unit to see how they felt about the temperature. The report stated that he "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. CNA #1 noticed that Resident #1 was not acting normal and asked the officer to stay with the resident while she got the nurse. The officer noted that Resident #1 was gasping for air. The report stated, "The room became flood with other nurses... CPR was begun... the victim had not pulse." Emergency medical services and the fire department arrived at 8:01 PM and Resident #1 was transferred to the hospital. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status as "11" indicating problems with daily decision- making. Resident #2 required extensive assistance with most activities of daily living; he fed himself after the meal was setup. His speech was unclear, he usually was understood and he understands. In a face-to-face interview with the surveyor on 07/03/2012 at 2:05 PM Resident #2 stated that he had 3 fans in his room to keep him cool before the window unit was put in. He confirmed that the staff in an attempted to keep him cool on 06/30/2012 put wet towels on him. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 was identified in the Nurse's Notes on 06/30/2012 as diaphoretic and having labored breathing; she was cared for by hospice. In a face-to-face interview with the surveyor on 07/02/2012 at approximately 9:00 PM the Maintenance Director stated that he checked the temperature at the thermostat on Unit 3 every Wednesday between 9-9:30 AM and the temps were 72 degrees. He stated that on Friday, the staff complained about the temperature and that he looked at the thermostat on and off during the day the temperature was around 75 degrees. The Maintenance Director stated that he cleaned the coils on Wednesday or Thursday (06/26 - 06/27/2012), he confirmed that he was the only person who had a key to open the box that covered the thermostat. When the Maintenance Director was asked about preventive maintenance to the air conditioning unit for Unit 3 he stated that the company used a TELS check off system as a maintenance reminder. A review of the TELS check off sheet indicated two areas of maintenance for the air conditioning system "...HVAC (heating, ventilation, air conditioning) (PTAC) (packaged terminal air conditioning): Clean/change filter, inspect and clean coils. HVAC... : Inspect condenser coils; clean as necessary..." these two area were documented as performed in March, April, May and June 2012. The Maintenance Director provided documentation that the HVAC equipment was inspected by a heating and air conditioning company on 05/19/2009, 04/23/2010, and 04/07/2011; no inspection had been done since 04/07/2011. The Maintenance Director confirmed that he was out off town during the day on Saturday, returned around 5-6:00 PM and was called by the Administrator around 8:00 PM about the problem with the AC. He stated that he came to the facility, that the mechanical company arrived around 9:00 PM and they learned that repairs needed to be made to one of the air handlers and a new compressor was needed. In a face-to-face interview with the surveyor on 07/03/2012 at 12:45 PM CNA #1 stated she had worked at the facility for [AGE] years, that it was always hot in the summer and that "Saturday was the hottest I've ever seen it". She she was unsure of the time but confirmed the temperature on Unit 3 Saturday was around 85 to 87 degrees. CNA #1 confined the information written in the Supplemental Police Report. She stated that she was not assigned to care for Resident #1 on Saturday 06/30/2012, that she saw her around 6:30 PM on Saturday with wet towels on her chest and head with a basin because she was vomiting. In a face-to-face interview with the surveyor on 07/03/2012 at 2:00 PM Registered Nurse (RN) #1 stated that on Saturday (06/30/2012) she worked on the float cart and was back and forth but worked "Unit 2 primarily". She stated that around 2:00 PM she went to Unit 3 and spoke with Licensed Practical (LPN) #1, that it was getting hotter than it should be. LPN #1 had contacted the Administrator who was bringing fans. The thermostat was between 80 and 90 degrees. "I could not see well, the paper on the thermostat made it hard to read." When asked by the surveyor what paper? She said there was a note on the thermostat that stated that if you touched the thermostat disciplinary action would be taken. RN #1 stated she went back to Unit 3 around 4:00 PM it continued to be hot, she was again told that someone was bringing fans. She stated that she mentioned to LPN #1 that maybe they should "start moving people LPN #1 didn't respond". RN #1 stated that when she left the facility around 7:15 PM all the residents were still on Unit 3. RN #1 confirmed that it was always warm on Unit 3. In a face-to-face interview with the surveyor on 07/03/2012 at 2:20 PM LPN #1 stated that at report on 06/30/2012 at round 7:00 AM she was told that Resident #1 was on acute charting due to sweating, that her bowel sounds, vital signs were normal and she had been ok during the 11 PM -7 AM shift. She stated that it was humid but "not hot didn't pay attention to the temperature. The AC by the door at the nurse's station was on." LPN #1 stated that Resident #1 had her fan on, Resident #2 had 3 fans on and several others were noted with running fans when she made initial rounds that morning. LPN #1 stated that at 10 AM it was feeling warm, 82 degrees on the thermometer in Resident #2's room. "Complained at 10 (Resident #2) his sons had come and asked had someone been out to check the AC since they were told the day before someone would come." She stated that the Administrator called to tell her about the problems with the air conditioning the previous day and that I could call her. She told me when she called at 10 that maintenance had checked it on Friday and it was OK; maintenance was out of town. At 11:30 AM LPN #1 stated that she told the Manager on Duty that it was 86 degrees in Resident #2's room; the Manager on Duty responded per LPN #1 that she didn't know what she was suppose to do, "everyone has strict orders not to touch thermostat". When asked about the condition of Resident #1 on 06/30/2012 during her shift LPN #1 stated that right after breakfast around 8:30 AM she was brought out to the dining room and taken back to her room around 2 PM, "she was ok". Other residents started to complain about the heat around 4 PM, "Mr. (Resident #2) had complained all day, sometime during the day the CNAs put wet towels on him. At 5 PM LPN #1 stated it was smoke break time, "I sent the ADON (assistant director of nurses) a text about smokers." Her response to my text was to let them smoke one cigarette, bring them back in and make sure they were hydrated. LPN #1 stated that she tried to call the Administrator but her call went to voice mail "she didn't call me back." LPN #1 stated that she sent the ADON several text telling her it was way, way hot and could she adjust the air, "sick residents, hair getting damp, food trays coming out, not drinking and pushing back trays." She stated that around 5:55 PM Resident #1 complained of nausea, that her vital signs were checked, clothing changed and within 10-15 minutes she was feeling better; during this time the ADON text to tell her the Administrator was on her way. LPN #1 stated that the Administrator called her, stating that she was on her way and was bringing fans, I said fans are better than nothing, passing ice water all day. Mr. (Resident #2's) room was between 88 and 90 degrees about 6:30 PM, I told the Administrator it was 90 degrees in his room. She came with fans, put another fan in Resident #1's room. I told her it's not safe, way to hot. The Administrator replied that she would check with cooperate on Monday about window units. "She was here just a few minutes." She told me while she was here that maintenance was the only one with a key to open the box with the thermostat; that she knew the box could be manipulated. When the Administrator left, "I opened the box, turned down just a couple of degrees, went outside, checked not frozen. Thermostat setting on 68-69 when I left." LPN #1 stated that she did rounds before she left and Resident #1 was ok she stated that the police were coming up hill as she left. LPN #1 confirmed the presence of the note on the thermostat that stated "do not touch, disciplinary action will be taken". In a face-to-face interview with the surveyor on 07/04/2012 at 1:20 PM CNA #2 stated that she had just recently started working on Unit 3, "about a month", always warm, "Saturday the hottest". When asked it the residents complained about the heat she stated that Resident #2 was actually complaining, "others didn't say anything not aware they are hot". She confirmed that Resident #1 on 06/30/2012 sat in the dining room until around 2 PM when she was taken to her room. "I took her to restroom, put her gown on, gave her water." CNA #2 stated that Resident #1 wanted her blanket on her when she laid down and that she went back before she left for the day; removed the blanket and covered her with a sheet. She stated that the resident was asleep and not sweating when she saw her at around 3:00 PM. In a face-to-face interview with the surveyor on 07/03/2012 at 3:04 PM CNA #3 assigned to Resident #1 on the 3-11 shift, stated that when she came to work around 3:00 PM the resident was sleeping; that the temperature in the room was hot, "always hot, fan on in room". At around 4:45 PM CNA #3 stated that she dried the resident and gave her water through a straw she stated she was "her usual wet, not sweating, I helped her push herself up in the bed. CNA #3 stated that between 5:45 and 6:00 PM she told Resident #1 her supper tray and she was sweating, her clothes and bed were wet, offered water, wet wash cloth and rolled her bed up. "I called the nurse, tried to cool her off, nurse helped me about 20 minutes, making sure she was ok. Sweat, not vomiting, sweat all over her." When asked if she took Resident #1's vital signs she replied, "No". CNA #3 stated that she took resident out to smoke and that when she came back in around 7:30 PM the police were in the building and she was told to get Resident #1's vital signs stat, "unable to get vitals, not breathing". In a face-to-face interview with the surveyor on 07/04/2012 at 3:30 PM the Assistant Director of Nurses confirmed LPN #1 account of the events of 06/30/2012. In a face-to-face interview with the surveyor on 07/04/2012 at 4:10 PM the Manager on Call for 06/30/2012 confirmed it was hotter than normal on 06/30/2012 on Unit 3. She stated that LPN #1 did not mention any residents that had complained about the heat. She stated that LPN #1 told her she had called the Administrator. In a telephone interview with the surveyor on 07/03/2012 at 7:15 PM the Complainant/family member confirmed his and his brother's concerns related to the heat in his father's room on Unit 3. He stated that he had spoken to the facility 3 weeks ago when the outside temperatures were in the high 80's to 90's and the temperature in his father's room was between 81 and 82 degrees. "The reason they gave me was it's an old building and the air conditioning will freeze up. There is nothing wrong with it." The Complainant stated that on Friday he called... (Regional Vice President) and was told that he would speak with the Administrator and get back with him. The Regional Vice President's reply was that it was and old building... The Complainant stated that he call... (the Regional Vice President) at least twice on Saturday and when he could get no resolution to the problem with the air conditioning he called 911. He stated that when the police came out to check on his father, the family was putting cold towels on him and the temperature in the room was around 91 degrees at 7:45 PM. In a face-to-face interview with the surveyor on 07/02/2012 at approximately 8:00 PM the Regional Vice President (RVP) and the Administrator confirmed that the family of Resident #2 called on Friday and several times on Saturday regarding the high temperatures on Unit #3. The Administrator stated that she called the facility on Saturday morning (06/30/2012) to remind the staff to keep the residents hydrated. She confirmed that she brought fans to the facility on Saturday around 6:30 PM stayed for a while and left. The RVP and Administrator confirmed that the Mechanical Contractor arrived at the facility around 8:30 PM and told them the unit was frozen up, a wire was burned and they needed to get another compressor. The Administrator stated that the residents were moved on Saturday between 9-11 PM; the men were placed on Unit 1 and the women on Unit 2. She stated that the residents came back to their room on Sunday around 2:00 PM after the window units were installed. Review of the invoice dated 07/01/2012 from the mechanical services that repaired the broke air conditioning unit for Unit 3 stated, "...compressor gone bad in A/C sta (station) 3, dispatched to... on 6/30/2012, aquired (sic) compressor on 7/1/2012 and installed. Complete standard diagnostic charge applied..." Observations, interviews, and review of policy revealed the AOC submitted by the facility on 07/04/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on 07/04//2012 at 6:50 PM. The Immediate Jeopardy at F-467 was removed but the citation at F-467 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record reviews, interviews, review of the Clinical Nursing Skills and Techniques, 7th Edition, Perry and Potter page 69, and review of the facility Nursing Policy and Procedure Manuel, Heat- Ill Effects of , Immediate Jeopardy was identified as existing in the facility as of [DATE] related to the failure of the facility to provide care and services that met professional standards of practice for the identification, assessment and care of all residents (#1, #2, and #3) with the potential for heat related injury. The findings included: Cross refers to F-157 as it related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased temperature on Unit 3. Residents #2 and #3 had heat related concerns which were not adequately addressed. Cross refers to F-224 as it related to the failure of the facility to ensure each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Residents #1, #2 and #3 exhibited symptoms of heat exposure on [DATE]. During the survey statements from 9 staff members, one family member, the county coroner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on [DATE]. Cross refers to F-257 as it related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of [DATE] around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on [DATE] at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-467 as it related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3, room [ROOM NUMBER] - 12, and 14, the dining room and the hallway adjacent the 8 resident rooms affected. On the evening of [DATE] around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room ,[DATE] at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer during a check of all affected resident rooms "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-490 as it related to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on [DATE] by a family member, that the heat on Unit 3 was extreme for the residents. Review of the Supplementary Report from the police department indicated that on [DATE] a police officer was dispatched to the nursing home due to a complaint that for the last 2 weeks the Administrator was aware of extreme heat on the Unit 3, rooms ,[DATE] and 14. The complaint stated at 1:30 PM Saturday afternoon ([DATE]) the temperature registered 94 degrees in room ,[DATE]. On arrival at the facility the officer walked into room ,[DATE] at 7:45 PM, a thermometer was positioned on a table near the Resident #2's bed that read 90 degrees. The officer asked CNA (certified nurse aide) #1 to accompany him and he began checking the other rooms and speaking to residents on the Unit to see how they felt about the temperature. The report stated that he "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. CNA #1 noticed that Resident #1 was not acting normal and asked the officer to stay with the resident while she got the nurse. The officer noted that Resident #1 was gasping for air. The report stated, "The room became flood with other nurses... CPR was begun... the victim had not pulse." Emergency medical services and the fire department arrived at 8:01 PM and Resident #1 was transferred to the hospital. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status as "5" indicating problems with daily decision- making. Resident #1 required extensive assistance with transfer, mobility, and hygiene. She required limited assistance with dressing and eating. Her speech was unclear, she usually was understood and understands. Review of the Nurse's Notes indicted that on "[DATE] at 9 AM Went in to give Res 9 AM meds, Resident was diaphoretic and was having SOB v/s (vital signs) 81, 23, 97.8 O2 Sat 80% asked Resident if she was hurting she stated "I'm ok" Sat Res. up in bed O2 sat came up to 90%, ausculated (sic) ABn (abnormal) breath sounds on (R) side, Res also had cough, notified NP, she gave n/o... will cont to monitor, O2 in place 3L (liters) via NC (nasal canula). 9 PM N/O (new order) [MEDICATION NAME] tx (treatment) qid (four times a day) and qid prn (as needed) r/o (rule/out) wheezing/SOB, family notified O2 sat 98 on 3L O2 no c/o (complaint of) or Resp distress on this shift. Will cont. (continue) to monitor. [DATE] at 1 AM Res asleep... O2 via NC as ordered... Bp ,[DATE] p 70 r 16 t 98.1 2 P Resident continues oxygen via NC... All vitals wnl (within normal limits) including glucose... 4 PM Resident lying in bed with eyes closed. Awakes easily to verbal cues. Denies any discomfort... 6 P ,[DATE], 86, 18, 98.9 ax (axilla) O2 94% on O2, Resident with c/o not feeling "right" to CNA. Nurse to the room. Resident assisted to sit upright by CNA due to nausea. Cool, damp towels applied to resident's skin to aid in cooling. Resident (res) diaphoretic with gown being damp. Did verbalize feeling some better after several minutes of having cooling towels applied. Will continue to monitor. 6:30 P Insulin held r/t glucose 84 and resident not eating supper and with nausea. She also refused po meds. 1145 pm late entry for 715 pm. In report from previous nurse doing walking rounds it was stated Res. n/v earlier in day placed cold wet rags with fan on Resident. No distress noted. 1147 pm late entry for 730 pm checked on Resident, changed rags and replaced. Asked Resident if she was feeling better. Resident stated "I feel fine." No distress noted at this time. 1150 pm late entry for 745 pm. CNA reported to nurse "something is wrong with Resident." Nurse entered room to check Resident. Resident showed s/sx (signs/symptoms) of Resp. distress attempted to check pulse Res ceased breathing sounds. Code called. EMS (emergency medical service) notified. CPR (cardiopulmonary resuscitation) cont till arival. Res transported EMS to ...hospital." Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status as "11" indicating problems with daily decision- making. Review of Resident #2's Nurse's Notes revealed no documentation on [DATE]; there was no of the resident's condition or the need to place wet towels on him to keep him cool. In a face-to-face interview with the surveyor on [DATE] at 2:05 PM Resident #2 stated that he had 3 fans in his room to keep him cool before the window unit was put in. He confirmed that the staff in an attempted to keep him cool on [DATE] put wet towels on him. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing; she was cared for by hospice. In a face-to-face interview with the surveyor on [DATE] at 2:00 PM Registered Nurse (RN) #1 stated that on Saturday ([DATE]) she worked on the float cart and was back and forth but worked "Unit 2 primarily". She stated that around 2:00 PM she went to Unit 3 and spoke with Licensed Practical (LPN) #1, that it was getting hotter than it should be. LPN #1 had contacted the Administrator who was bringing fans. The thermostat was between 80 and 90 degrees. "I could not see well, the paper on the thermostat made it hard to read." When asked by the surveyor what paper? She said there was a note on the thermostat that stated that if you touched the thermostat disciplinary action would be taken. RN #1 stated she went back to Unit 3 around 4:00 PM it continued to be hot, she was again told that someone was bringing fans. She stated that she mentioned to LPN #1 that maybe they should "start moving people LPN #1 didn't respond". RN #1 stated that when she left the facility around 7:15 PM all the residents were still on Unit 3. RN #1 confirmed that it was always warm on Unit 3. In a face-to-face interview with the surveyor on [DATE] at 2:20 PM LPN #1 stated that at report on [DATE] at round 7:00 AM she was told that Resident #1 was on acute charting due to sweating, that her bowel sounds, vital signs were normal and she had been ok during the 11 PM -7 AM shift. She stated that it was humid but "not hot didn't pay attention to the temperature. The AC by the door at the nurse's station was on." LPN #1 stated that Resident #1 had her fan on, Resident #2 had 3 fans on and several others were noted with running fans when she made initial rounds that morning. LPN #1 stated that at 10 AM it was feeling warm, 82 degrees on the thermometer in Resident #2's room. "Complained at 10 (Resident #2) his sons had come and asked had someone been out to check the AC since they were told the day before someone would come." She stated that the Administrator called to tell her about the problems with the air conditioning the previous day and that I could call her. She told me when she called at 10 that maintenance had checked it on Friday and it was OK; maintenance was out of town. At 11:30 AM LPN #1 stated that she told the Manager on Duty that it was 86 degrees in Resident #2's room; the Manager on Duty responded per LPN #1 that she didn't know what she was suppose to do, "everyone has strict orders not to touch thermostat". When asked about the condition of Resident #1 on [DATE] during her shift LPN #1 stated that right after breakfast around 8:30 AM she was brought out to the dining room and taken back to her room around 2 PM, "she was ok". She stated that around 5:55 PM Resident #1 complained of nausea, that her vital signs were checked, clothing changed and within ,[DATE] minutes she was feeling better; during this time the ADON text to tell her the Administrator was on her way. LPN #1 stated that the Administrator called her, stating that she was on her way and was bringing fans, I said fans are better than nothing, passing ice water all day. Mr. (Resident #2's) room was between 88 and 90 degrees about 6:30 PM, I told the Administrator it was 90 degrees in his room. She came with fans, put another fan in Resident #1's room. I told her it's not safe, way to hot. The Administrator replied that she would check with cooperate on Monday about window units. "She was here just a few minutes." She told me while she was here that maintenance was the only one with a key to open the box with the thermostat; that she knew the box could be manipulated. When the Administrator left, "I opened the box, turned down just a couple of degrees, went outside, checked not frozen. Thermostat setting on ,[DATE] when I left." LPN #1 stated that she did rounds before she left and Resident #1 was ok she stated that the police were coming up hill as she left. LPN #1 confined the presence of the note on the thermostat that stated "do not touch, disciplinary action will be taken". In a face-to-face interview with the surveyor on [DATE] at 1:20 PM CNA #2 stated that she had just recently started working on Unit 3, "about a month", always warm, "Saturday the hottest". When asked it the residents complained about the heat she stated that Resident #2 was actually complaining, "others didn't say anything not aware they are hot". She confirmed that Resident #1 on [DATE] sat in the dining room until around 2 PM when she was taken to her room. "I took her to restroom, put her gown on, gave her water." CNA #2 stated that Resident #1 wanted her blanket on her when she laid down and that she went back before she left for the day; removed the blanket and covered her with a sheet. She stated that the resident was asleep and not sweating when she last saw her at around 3:00 PM. In a face-to-face interview with the surveyor on [DATE] at 3:04 PM CNA #3 assigned to Resident #1 on the ,[DATE] shift, stated that when she came to work around 3:00 PM the resident was sleeping; that the temperature in the room was hot, "always hot, fan on in room". At around 4:45 PM CNA #3 stated that she dried the resident and gave her water through a straw she stated she was "her usual wet, not sweating, I helped her push herself up in the bed. CNA #3 stated that between 5:45 and 6:00 PM she told Resident #1 her supper tray and she was sweating, her clothes and bed were wet, offered water, wet wash cloth and rolled her bed up. "I called the nurse, tried to cool her off, nurse helped me about 20 minutes, making sure she was ok. Sweat, not vomiting, sweat all over her." When asked if she took Resident #1's vital signs she replied, "No". In a face-to-face interview with the surveyor on [DATE] at 3:30 PM the Assistant Director of Nurses (ADON) confirmed LPN #1's account of the events of [DATE]. In a face-to-face interview with the surveyor on [DATE] at 4:10 PM the Manager on Call for [DATE] confirmed it was hotter than normal on [DATE] on Unit 3. She stated that LPN #1 did not mention any residents that had complained about the heat. Review of the facility policy and procedure Heat-Ill Effects of Policy: Residents who have been exposed to excessive heat will be given preventive treatment for [REDACTED]. Purpose: To prevent and treat residents suffering from heat exhaustion and heat stroke... Procedure: 4. Prevent excessive perspiration. 5. If resident complains of feeling unusually tired, headache or nausea, take temperature and notify physician. 6. If resident perspires profusely with pale, clammy skin, dizziness, and nausea, take temperature. 7. Pending arrival of physician, provide bed rest and undress the resident... 9. While waiting medical attention, sponge the resident with lukewarm water to reduce body temperature. 10. Chart on clinical record: treatment, exact timing, and vital signs. Include pertinent observations. Review of the Clinical Nursing Skills and Techniques, 7th Edition, Perry and Potter page 1220 defines hyperthermia as condition characterized by body temperature over 38 degrees centigrade (C) (100.4 degrees Farenheit) (F) ... page 67...Average usual temperature varies depending on the measurement site used. Research finding from numerous studies are contradictory; however, it is generally accepted that... Axillary and tympanic temperatures are usually 0.5 degrees C (centigrade) (0.9 degrees F) lower than oral temperatures... Measuring Body Temperature ...Box ,[DATE] Axilla Advantages *Safe and inexpensive *Used with newborns and unconscious patients Limitations *Long measurement time *Requires continuous positioning by nurse *Measurement lags behind core temperature during rapid temperature changes... Underestimates core temperature... Assessment 1. Determine need to measure patient's body temperature: a Note patient's risks for temperature alterations: (rationale Certain conditions place patients at risk for temperature alterations and require more frequent temperature measurements and nursing assessment) ... Exposure to temperature extremes... b Assess for signs and symptoms that accompany temperature alteration: (rationale Physical signs and symptoms alert nurse to alteration in body temperature) *Hyperthermia: Decreased skin turgor, dry mucous membranes; [MEDICAL CONDITIONS]; decreased venous filling; concentrated urine... c Assess for factors that normally influence temperature: (rationale allows nurse to accurately assess for presence and significance of temperature alteration. Older adults have a narrow range of temperature than younger adults. "Clinical Decision Point No single temperature is normal for all people. A temperature within an acceptable range in an adult may reflect a fever in an older adult..." Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on ,[DATE]//2012 at 6:50 PM. The Immediate Jeopardy at F-281 was removed but the citation at F-281 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record reviews and interviews Immediate Jeopardy was identified as existing in the facility as of 06/30/2012 related to failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on 06/29/2012 by a family member, that the heat on Unit 3 was extreme for the residents. On the evening of 06/30/2012 around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to the cooler Units 1 and 2; Resident #1 was taken to the emergency room , while the police were investigating the concern related to excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room [ROOM NUMBER]-11 at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. Resident #3 was identified in the Nurse's Notes on 06/30/2012 as diaphoretic and having labored breathing. The findings included: Cross refers to F-157 as it related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased temperature on Unit 3. Residents #2 and #3 had heat related concerns which were not adequately addressed. Cross refers to F-224 as it related to the failure of the facility to ensure each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Residents #1, #2 and #3 exhibited symptoms of heat exposure on 06/30/2012. During the survey statements from 9 staff members, one family member, the county coroner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on 06/30/2012. Cross refers to F-257 as it related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of 06/30/2012 around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on 06/30/2012 at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on 06/30/2012 as diaphoretic and having labored breathing. Cross refers to F-281 as it related to the failure of the facility to provide care and services that met professional standards of practice for all residents on Unit 3 (rooms 5-12 and 14) at risk for exposure to excessive heat. Cross refers to F-467 as it related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3 (rooms 5 - 12, and 14), the dining room and the hallway adjacent the 8 resident rooms affected. On the evening of 06/30/2012 around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room [ROOM NUMBER]-11 at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer during a check of all affected resident rooms "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes on 06/30/2012 as diaphoretic and having labored breathing. In a face-to-face interview with the surveyor on 07/02/2012 at approximately 8:00 PM the Regional Vice President (RVP) and the Administrator confirmed that the family of Resident #2 called on Friday and several times on Saturday regarding the high temperatures on Unit #3. The Administrator stated that she called the facility on Saturday morning (06/30/2012) to remind the staff to keep the residents hydrated. She confirmed that she brought fans to the facility on Saturday around 6:30 PM stayed for a while and left. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 07/04/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on 07/04//2012 at 6:50 PM. The Immediate Jeopardy at F-490 was removed but the citation at F-490 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified as existing in the facility as of [DATE] related to the failure of the facility to notify the Physician and the Responsible Party (RP) of a change in Resident #1's condition and the increased ambient temperature on Unit 3 (rooms ,[DATE], 14, the dining room and hall adjacent to the identified rooms). Resident #2 and Resident #3 experienced changes on [DATE] not thoroughly addressed by the staff. The findings included: Cross refers to F-224 as it related to the failure of the facility to ensure each resident was provided the necessary goods and services to maintain a comfortable and safe living environment. Record review and interviews revealed that Residents #1 exhibited symptoms of heat exposure on [DATE]. During the survey statements from 9 staff members, one family member, the county coroner and four residents residing on Unit 3 confirmed that the heat was extreme in the afternoon and into the evening on [DATE]. Cross refers to F-257 as it related to the failure of the facility to take action to ensure residents were provided a comfortable and safe environment. The facility failed to maintain safe and comfortable ambient temperature levels for the dining room, 8 resident rooms and the hallway adjacent to the 8 rooms on Unit 3. On the evening of [DATE] around 8:30 PM 26 residents were moved from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after the police was notified of excessive heat. Resident #2's room temperature was 90 degrees on [DATE] at 7:45 PM and he stated during interview that the staff used wet towels to keep him cool. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-281 as it related to the failure of the facility to provide care and services that met professional standards of practice for all residents on Unit 3 (rooms ,[DATE] and 14) at risk for exposure to excessive heat. Cross refers to F-467 as it related to the failure of the facility to ensure adequate mechanical ventilation for residents on Unit 3(rooms 5 - 12, and 14), the dining room and the hallway adjacent the 8 resident rooms affected. On the evening of [DATE] around 8:30 PM the police initiated the relocation of 26 residents from Unit 3 to Units 1 and 2; Resident #1 was taken to the emergency room , after they were notified of excessive heat in the facility. The Supplemental Police Report stated that on arrival at the facility the officer walked into room ,[DATE] at 7:45 PM, a thermometer was positioned on a table near Resident #2's bed that read 90 degrees. The report stated that the officer during a check of all affected resident rooms "stuck his hand up at every air vent in the ceiling to see how much air was exiting through the vent. There was little to no air flow." The officer checked the airflow in Resident #1's room and noted very little airflow. Resident #3 was identified in the Nurse's Notes on [DATE] as diaphoretic and having labored breathing. Cross refers to F-490 as it related to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and the Regional Vice President were made aware on [DATE] by a family member, that the heat on Unit 3 was extreme for the residents. On [DATE] a survey was conducted as a result of an Initial 24-Hour Report received by the State Survey Agency on [DATE] which stated under the heading "... Type of Alleged Abuse: neglect... Date/Time of Reportable Incident: [DATE] @ approx(imately) 7:45 pm. Brief Description of Reportable Incident: The ...Coroner and ...Police Department are investigating a possible heat related death of a resident (#1) in our facility. Investigation was initiated and is ongoing." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status (BIMS) as "5" indicating problems with daily decision-making. Resident #1 required extensive assistance with transfer, mobility, and hygiene. She required limited assistance with dressing and eating. Her speech was unclear, she usually was understood and understands. Review of the Nurse's Notes stated on [DATE] at "9 AM Went in to give Res (resident) 9 AM meds, Resident was diaphoretic and was having SOB (shortness of breath) v/s (vital signs) 81, 23, 97.8 O2 Sat (saturation) 80% asked Resident if she was hurting she stated "I'm ok" Sat Res. up in bed O2 sat came up to 90%, ausculated (sic) ABn (abnormal) breath sounds on (R) (right) side, Res also had cough, notified NP (nurse practitioner), she gave n/o (new order)... will cont (continue) to monitor, O2 in place 3L (liters) via NC (nasal canula). 9 PM N/O [MEDICATION NAME] tx (treatment) qid (four times a day) and qid prn (as needed) r/o (related to) wheezing/SOB, family notified O2 sat 98 on 3L O2 no c/o (complaint) or Resp (respiratory) distress on this shift. Will cont. to monitor. [DATE] at 6 P ,[DATE], 86, 18, 98.9 ax (axilla) O2 94% on O2, Resident with c/o not feeling "right" to CNA (certified nurse aide). Nurse to the room. Resident assisted to sit upright by CNA due to nausea. Cool, damp towels applied to resident's skin to aid in cooling. Resident diaphoretic with gown being damp. Did verbalize feeling some better after several minutes of having cooling towels applied. Will continue to monitor. 6:30 P Insulin held r/t (related to) glucose 84 and resident not eating supper and with nausea. She also refused po (oral) meds. 1145 pm late entry for 715 pm. In report from previous nurse doing walking rounds it was stated Res. n/v (nausea/vomiting) earlier in day placed cold wet rags with fan on Resident. No distress noted. 1147 pm late entry for 730 pm checked on Resident, changed rags and replaced. Asked Resident if she was feeling better. Resident stated, "I feel fine." No distress noted at this time. 1150 pm late entry for 745 pm. CNA reported to nurse "something is wrong with Resident." Nurse entered room to check Resident. Resident showed s/sx (signs/symptoms) of Resp. distress attempted to check pulse Res ceased breathing sounds. Code called. EMS notified. CPR cont till arrival. Res transported EMS (emergency medical service) to ...hospital." In a telephone interview with the surveyor on [DATE] at approximately 6:20 PM the Nurse Practitioner stated that she had seen Resident #1 on [DATE] after being called in the morning by the nurses related to the resident being short of breath. She stated she saw the resident between 5:30 and 7:00 PM, that the resident was standing with the CNA and said she was fine. The NP stated she did have some wheezing. When asked by the surveyor if it was hot in the facility on Friday ([DATE]) she said she remembered saying, "Why is it so warm? A resident said they are working on the AC." When asked if anyone had called her about the resident she stated the facility called on Sunday, that she had coded. When asked, "Is it reasonable to say that someone with her health problems should be monitored during heat or a problem with heat?" She stated, "Yes". In a telephone interview with the surveyor on [DATE] at approximately 5:00 PM the Medical Director stated that he had reviewed Resident #1's chart on Sunday ([DATE]) and that he felt she had had a cardio/respiratory event the day before. He stated he did not think her death was due to hyperthermia. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set coded the resident's Brief Interview for Mental Status as "11" indicating problems with daily decision-making. Resident #2 required extensive assistance with most activities of daily living; he fed himself after the meal was setup. His speech was unclear, he usually was understood and he understands. Review of Resident #2's Nurse's Notes revealed no documentation on [DATE]; there was no mention of the resident's condition or the need to place wet towels on him to keep him cool. In a face-to-face interview with the surveyor on [DATE] at 2:05 PM Resident #2 stated that he had 3 fans in his room to keep him cool before the window unit was put in. He confirmed that the staff in an attempt to keep him cool on [DATE] put wet towels on him. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 was cared for by hospice. Review of Resident #3's Nurse's Notes for [DATE] at 0900 stated, "Resident with SOB and difficulty breathing. VS ,[DATE], P 128, R 42, T 97 axillary, O2 86% RA (room air), Glucose 184. She was very diaphoresic (sic) and with labored breathing. Med neb(ulizer) tx and O2 place on 2 L/m NC (nasal canula). Hospice called... 1 P(M) Hospice... in to see resident and family member. New orders given and processed. Resident refusing to keep O2 NC on - states she does not need it anymore. Respirations are less labored now after [MEDICATION NAME]" Review of the medical records for Residents #2 and #3 failed to show that the physician was called related to the increased ambient temperature on Unit 3. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The facility nursing staff was educated and was knowledgeable regarding the identified concerns related to maintenance concerns/process, heat related illness, neglect, and physician/responsible party notification. The Administrator was informed of this on ,[DATE]//2012 at 6:50 PM. The Immediate Jeopardy at F-157 was removed but the citation at F-157 remained at a lower scope and severity of "E".

On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to provide residents and staff with adequate supervision to ensure it's system for safe transfer of residents was followed by Hospice and facility staff members for 1 of 1 resident reviewed who sustained injury from an inappropriate transfer (Resident #1). Resident #1 was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to [DATE] because of acute renal failure and congestive heart failure exacerbation. Several medications were discontinued on his return to the facility including the Prednisone the resident had taken for years. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to osteoporosis, risk for falls, risk for complications due to CVA with left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED]. The facility's investigation revealed the resident was given care on the morning of [DATE] by his Hospice CNA (CNA #1). After bathing and dressing the resident, CNA #1 requested help to transfer him to the recliner. CNA #1 and a facility CNA (CNA #2) manually transferred the resident to the chair. According to CNA #2's statement, a third CNA (CNA #3) was present in the room and steadied the recliner during the transfer. According to the information in the facility's investigation, the facility CNAs assisted in the inappropriate transfer. There was no evidence to show either of the facility CNAs requested that the mechanical lift be used for the resident.

On the days of the survey, based on observation, record review, and interviews the facility failed to ensure that care plans were followed for Resident #1, 1 of 3 sampled residents care planned for a mechanical lift with transfers, was transferred from bed to chair on [DATE] by manual lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to [MEDICAL CONDITION], risk for falls, risk for complications due [MEDICAL CONDITION] left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED]. The facility's investigation revealed the resident was given care on the morning of [DATE] by his Hospice CNA (CNA #1). After bathing and dressing the resident, CNA #1 requested help to transfer him to the recliner. CNA #1 and a facility CNA (CNA #2) manually transferred the resident to the chair. According to CNA #2's statement, a third CNA (CNA #3) was present in the room and steadied the recliner during the transfer. Cross Refers to F323 as it relates to the failure of the facility to follow an established care plan to prevent harm and ensure the safety of Resident #1 when moving the resident in bed or transferring the resident to allow for care.