Every finding on record at Nspire Healthcare Plantation

Based on observations, interviews and record reviews, the facility failed to store and prepare food in a sanitary manner in accordance with standards for food safety professional standards. The findings included:During the initial kitchen tour, on 03/01/26 at 9:14 AM, accompanied by Staff R, Cook, the following observations were noted:a. Staff A was observed handling open foods while wearing a watch.b. Staff P, Diet Tech, failed to perform hand hygiene when changing single use gloves.c. Utensils that were stored hanging over a three-compartment sink were noted to be damaged to a point that they were no longer easily cleanable.d. There was an accumulation of ice in ice cream freezer.e. A glue trap was installed directly over equipment in ware washing area.f. The blades from a food processor were noted to be encrusted with food residues.g. A mop in the janitor's closet was noted to be stored in a manner that the contaminated water from the mop head would run down the handle.h. There was an accumulation of dust on an air conditioning vent over products in the dry storage area.i. In the walk-in refrigerator, a personal cellular device and a flat of eggs was stored on the top shelf of a 3-tier shelf with and over commercially processed and ready to eat foods. Staff R claimed that the cellular device was hers.j. The Teflon coating on the surface of skillets was peeling. During an interview at the conclusion of the initial kitchen tour, Staff R acknowledged understanding of the concerns. 2. During the follow-up kitchen tour, on 03/03/26 at 11:29 AM, accompanied by the Dietary Manager, the following were noted:a. The air conditioning vents attached to the exhaust system over the cooking equipment was noted to have an accumulation of dust.b. Staff Q, Dietary Aide, was observed donning a beard restraint with his bare hand. The Dietary Aide then touched his face and then proceeded to don a pair of clean single use gloves. The surveyor intervened and the Dietary Manager instructed the Dietary Aide to perform hand hygiene and don a new pair of clean single use gloves.At the conclusion of the follow up kitchen tour, the Dietary Manager and the staff acknowledged understanding of the concerns. 3. During a tour of the first-floor unit pantry, on 03/04/26 at 9:38 AM, accompanied by the Dietary Manager, it was noted that there was a mold-like substance in the water spout of the combination ice and water machine.During an interview at the time of the observation, the Dietary Manager acknowledged understanding the concern.

Based on observations, interviews, and record reviews, the facility failed to provide care and services in a dignified manner for 1 of 22 sampled residents reviewed during morning care observations, Resident #22; and failed to honor residents' dignity for 2 of 22 sampled residents reviewed for assistance during dining, Resident #70 and Resident #61. The findings included:Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 11/07/25, included the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.4. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. 5. When interacting with a resident, pay attention to the resident as an individual.6. Respond to requests for assistance in a timely manner. 1. Record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Rheumatoid Arthritis, Muscle Weakness (Generalized), and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 15, indicating the resident is cognitively intact. Review of section GG of the MDS showed that Resident #22 is fully dependent on staff regarding the ability to bathe, including washing, rinsing, and drying; and partial to moderate assistance regarding the ability to dress and undress above the waist. Review of the care plan dated 02/06/26 documented Resident #22 has an Activities of Daily Living (ADLs) self-care performance deficit related to Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Limited ROM, and Pain. Goals were to maintain current level of function in ADLs through the review date. Interventions were for staff to assist with bathing / showering daily and as necessary; and for staff to encourage to use bell to call for assistance. On 03/01/26 at 10:22 AM, during tour of the facility, Resident #22's privacy curtains was observed drawn closed and no staff were in the room. Further observation revealed Resident #22 was in bed, naked and covered with a towel which barely covered her torso. She was attempting to put on her shirt but was having difficulty getting her arms above her head to get the sleeves on. The over bedside table was located away from the resident and on top of it was a basin filled with cool water and a wash towel was in it. There were sheets and a blanket thrown on the floor and the call light was hanging off the side of the bed (not within reach of the resident), Photographic Evidence Obtained. At this time, Resident #22 stated the Certified Nursing Assistant (CNA) just left her in bed and told her she would be right back but has not returned. She then stated she was not sure how long it had been, but she started to get dressed. An interview was conducted on 03/01/26 at 10:40 AM with Staff C, Licensed Practical Nurse (LPN), who stated she has worked at the facility for over 20 years. She stated the aides were not supposed to leave the resident during the morning care. She would let the CNA know to get back to the resident soon. At 10:48 AM, Staff D, CNA, was observed entering Resident #22's room with a Hoyer Lift. A phone interview was conducted on 03/03/26 at 10:34 AM with Staff D, CNA, who stated she has worked at the facility for over 13 years. She stated that she cares for her patients as if they were her family. She stated Resident #22 is not usually assigned to her and the resident told her that she could take care of herself. Staff D stated that Resident #22 was to contact her when she was ready via the call light. Staff D confirmed the call light was within reach of the resident before she left the room. Photographic Evidence was Obtained of the call light not within reach of the resident on 03/01/26. An interview was conducted on 03/03/26 at 11:08 AM with Staff A, CNA, who stated she has worked at the facility for one year. She stated she provided care to Resident #22 this morning and is familiar with her. Staff A confirmed Resident #22 is never combative, but she has her own way of getting the care. She stated she picked up the breakfast tray this morning and Resident #22 told her that she was ready to get cleaned and out of bed. She then returned to the room and assisted with morning care. She stated Resident #22 likes to clean herself especially her private parts, but she does stay with the resident and puts on lotion and helps her to get dressed. Staff A acknowledged that Resident #22 has limited range of motion and still requires assistance with morning care. An interview was conducted on 03/03/26 at 3:48 PM with the Director of Nursing (DON) who stated she has worked at the facility for 3 months. She stated Staff D was placed on probation on 03/01/26 after she got her statement of what happened that morning. The DON confirmed the above findings. 2. Record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Cerebral Infarction, Dysphagia (Oropharyngeal Phase), and Need for Assistance with Personal Care. The MDS assessment dated [DATE] revealed a BIMS score is 13, indicating Resident #70 is cognitively intact. Review of section GG of the MDS showed Resident #70 has impairment on both sides of her upper extremity and requires substantial to maximal assistance from staff for eating. Review of the care plan dated 02/10/26 documented Resident #53 is at nutritional risk related to Past Medical History (PMH) diagnoses, mechanical soft altered consistency diet. Goals were to consume at least 75% of most meals daily. Intervention was to encourage and assist as needed and a calm, quiet setting at mealtimes with adequate eating time. During an observation conducted on 03/02/26 at 8:45 AM, Staff B, CNA, was observed standing over Resident #70 and feeding her. Resident #70 was in bed, the head of the bed was in a sitting position, and the bed was high to the level of Staff B's waist. An observation was conducted on 03/02/26 at 8:54 AM, and Staff B was observed standing over Resident #70 and feeding her. At this time, Staff B was interviewed. He stated he has been working at the facility for 6 months. He also stated he is aware that he should not be standing to assist the resident with meals, but that the resident needs to be sitting up high so it is easier to assist her with the meal. Staff B noted this is the only way Resident #70 can eat. An interview was conducted on 03/03/26 at 11:08 AM with Staff A, CNA, who stated the nurse would communicate to her if the resident required assistance with meals. She stated the protocol for assisting with meals is to position the resident to a sitting position, put on the clothing protector, communicate to the resident what is on the tray, then she would sit down and adjust the bed to make sure she has at eye contact with the resident while assisting with meals. On 03/03/26 at 3:48 PM, the DON was made aware of the above concerns. 3. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Unspecified Dementia, Anxiety and Encounter for Palliative Care. The resident is noted to be under hospice care services. The quarterly Minimum Data Set (MDS) assessment dated [DATE] section C revealed a Brief Interview for Mental Status (BIMS) score was 8 indicating the resident had moderate cognitive impairment. Section GG of the same MDS revealed the resident needed partial / moderate assistance for eating. On 03/01/26 at 9:33 AM Staff J, Certified Nursing Assistant (CNA), was observed feeding Resident #61 breakfast while standing up. Staff J was asked at the time of the observation if she was a CNA from the facility or from hospice. She stated she was employed in the facility, and she has been working in the facility for 1 year and a couple of months. On 03/03/26 at 1:50 PM, this observation was discussed with the Director of Nursing (DON) who stated she already started educating the staff about this and they know better than to stand while feeding a resident.

Based on observations, interviews, and record reviews, the facility failed to ensure the call lights were accessible to residents while in their beds to request assistance from staff for 3 of 22 sampled residents, Resident #42, Resident #92, and Resident #104, reviewed for call lights use.The findings included: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, dated 11/07/25, included the following: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and compliance guidelines:1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.5. Staff will ensure the call light is within reach of resident and secure, as needed.6. The call light system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses to include: Dementia, Muscle Weakness (Generalized), Need for Assistance with Personal Care, and Hydronephrosis with Renal and Ureteral Calculous Obstruction. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 09, indicating the resident is moderate cognitively impaired. Review of section GG of the MDS showed that Resident #42 has upper extremity impairment on one side.Review of the care plan dated 06/21/25 documented Resident #42 has Activities of Daily Living (ADLs) self-care performance deficit related to (r/t) Activity Intolerance, Confusion, Dementia, Fatigue, Impaired balance, Limited Mobility, Limited Range of Motion (ROM), Musculoskeletal impairment, and Pain. Goals were to maintain current level of function in bathing and dressing through the review date. Intervention is for staff to encourage to use bell to call for assistance. During an initial observation and interview conducted on 03/01/26 at 9:57 AM, Resident #42 was observed in his bed, wearing a hospital gown with the head of bed raised. There was a foam cup of water on top of the dresser located near the bathroom entrance and not within reach of the resident. Further observation revealed Resident #42's call light was laying on the floor on the left side of the bed. Photographic Evidence Obtained. At this time, an interview was conducted with Resident #42 who stated he wanted something to drink. The resident was asked to use the call light to get someone to get him water. He stated that he would use the call light but does not know where it is. As the surveyor was leaving the room to get a staff to assist Resident #42, Staff C, Licensed Practical Nurse (LPN), entered the room with medications for Resident #42. The surveyor overheard Staff C talking with Resident #42 that his call light was on the floor, she would clean it, attached it to the bed, and would get his water cup from the dresser.2. Record review revealed Resident #92 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Displaced Intertrochanteric Fracture of Right Femur, Need for Assistance with Personal Care, Chronic Kidney Disease, Stage 3 and Dementia. The MDS assessment dated [DATE] revealed a BIMS score of 13, indicating the resident is cognitively intact. Review of section GG of the MDS showed that Resident #92 has no upper extremity impairment.Review of the care plan dated 01/14/26 documented Resident #92 has ADLs self-care performance deficit r/t Activity Intolerance, Dementia, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Pain. Goals were to maintain current level of function in bathing and dressing through the review date. Interventions were for staff to encourage to use bell to call for assistance.During an initial observation and interview conducted on 03/01/26 at 9:29 AM, Resident #92 was observed sleeping in her bed, wearing a hospital gown with the head of bed raised. Further observation revealed call light button was hanging on the side of the bed and not within reach of the resident. Photographic Evidence Obtained. Resident #92's foam cup of water was on the bedside table but not within the reach of the resident.3. Record review revealed Resident #104 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Rhabdomyolysis, Hydronephrosis, Cardiomegaly, and Acute Kidney Failure. The MDS assessment dated [DATE] revealed the BIMS score is 15, indicating the resident is cognitively intact. Review of section GG of the MDS showed that Resident #92 has no upper extremity impairment.Review of the care plan dated 02/25/26 documented that Resident #104 has ADLs self-care performance deficit r/t Fatigue, Impaired balance, and Limited Mobility. Goals were to maintain current level of function in ADL's through the review date. Intervention was for staff to encourage to use bell to call for assistance.During an initial observation and interview conducted on 03/01/26 at 10:13 AM, Resident #104 was observed in bed wearing a hospital gown and had the head of the bed raised. She stated the care is okay and she can use the call light and she looked around for it. Further observation revealed Resident #104's call light button was on the floor behind the be. Photographic Evidence Obtained.During an interview conducted on 03/03/26 at 11:08 AM with Staff A, Certified Nursing Assistant (CNA), she stated she has worked at the facility for one year. She stated the call light should be within reach of the residents and they (staff) check it often, usually every hour or so.On 03/03/26 at 3:48 PM, the Director of Nursing (DON) was informed of the above findings.

Based on observations, interviews, and record reviews, the facility failed to honor resident and family's request to be out of bed daily; and failed to ensure the provision of showers as per facility schedule and resident's request for 2 of 2 sampled residents reviewed for choices, Resident #115 and Resident #108. The findings included:1. Record review revealed Resident #115 was admitted to the facility on [DATE] with diagnoses to include Traumatic Subdural Hemorrhage without Loss of Consciousness, Need for Assistance with Personal Care, and Dementia, Unspecified Severity. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 04, indicating severe cognitive impairment. Review of section GG of the MDS showed that Resident #115 requires substantial to maximal assistance from staff to transfer to and from a bed to a chair (wheelchair). Review of the Physician's Orders showed Resident #115 had an order dated 02/25/26 to get up and out of bed, daily as tolerated, one time a day. Resident #115's March 2026 Medical Administration Record (MAR) documented a check mark for the above order from 03/01/26 to 03/03/26. Record review of Resident #115's Preferences Evaluation dated 01/27/26 documented Resident #115 feels that it is somewhat important to do things with groups of people; somewhat important to do favorite activities; somewhat important to go outside to get fresh air when the weather is good; and somewhat important to participate in religious services or practices. On 03/01/26 at 11:25 AM, Resident #115 was observed in her room, she was in bed wearing a hospital gown and she smiled as soon as she saw the surveyor. On 03/01/26 at around 1:35 PM, Resident #115 was observed in bed wearing a hospital gown. She was holding her blanket, and she smiled as soon as she saw the surveyor. The television was not on, and the resident did not have a roommate. On 03/02/26 at 8:50 AM, Resident #115 was observed in bed wearing a hospital gown, holding her blanket and she smiled as soon as she saw the surveyor. On 03/02/26 at 1:40 PM, Resident #115 was again observed in bed wearing a hospital gown holding her blanket. While in the hallway from 1:45 PM to 3:40 PM, it weas observed that no one entered Resident #115's room, except the nurse to start the tube feeding. On 03/03/26 at 10:34 AM, Resident #115 was again observed in bed wearing a hospital gown holding her blanket. The tube feeding was not running; but the resident was still in bed, not dressed or out of bed. On 03/03/26 at 1:56 PM, Resident #115 was in bed wearing hospital gown, holding her blanket, and she smiled as soon as she saw the surveyor. On 03/04/26 at 9:05 AM, Resident #115 was in bed wearing a hospital gown, holding her blanket. An interview was conducted on 03/04/26 at 9:05 AM with Staff A, Certified Nursing Assistant (CNA), who stated she has been assigned to Resident #115 this week but has never gotten her out of bed. She stated the resident has a feeding tube and does not usually get out of bed. An interview was conducted on 03/04/26 at 9:14 AM with Staff B, CNA, who stated he has never gotten Resident #115 out of bed. A phone interview was conducted on 03/04/26 at 9:40 AM with Resident #115's relative who stated she lives out of State [State documented] but her other relatives [names documented] visit the resident often. She stated she requested for the resident to be out of bed daily to join activities because the resident is a social butterfly and would benefit from seeing the other residents. On 03/04/26 at 9:47 AM, an interview was conducted with Staff E, Licensed Practical Nurse (LPN). He stated that he has not gotten the resident out of bed, however she would be out of bed today. He stated that the check mark in the MAR represents that they attempted to get the resident out of bed. He stated Resident #115 is followed by Physical Therapy (PT) and they stated that she has refused to get out of bed during therapy. He confirmed Resident #115 can be in her wheelchair and receive the tube feedings and she does not have to stay in bed. Record review of the current PT notes dated 03/02/26 documented Resident #115 sometimes does not want to participate in treatment; but there's no mention of Resident #115 refusing to get out of bed. When the Rehabilitation Director was asked if therapists document every session to include refusal, she stated no. Record review of the nursing progress notes for the month of March 2026 revealed no notes documenting of Resident #115 refusing to get out of bed or that PT informed the nurse of Resident #115 refusing to get out of bed. An interview was conducted on 03/04/26 at 11:35 AM with the Director of Nursing (DON), who confirmed that a check mark in the MAR indicates yes the resident was out of bed or there was an attempt to get her out of bed. If the resident refuses, the doctor needs to be called, and this is to be documented in the progress notes. The DON stated if the therapist stated to the nurse that the resident refused to get out of bed during therapy session, the nurse is to document this information in the progress notes. The DON was informed of the observations of Resident #115 not being out of bed as per physician's order and family's request. 2. Record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with Hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. It also revealed she needed substantial / maximum assist for showering and bathing. On 03/01/26 at 2:33 PM, an interview with the resident's family member revealed she only received one shower since she was admitted to the facility. She is scheduled to receive showers on Tuesdays and Fridays on the 3-11 shift. An interview was conducted with the Director of Nursing (DON) on 03/02/26 at 2:05 PM regarding the resident's shower schedule. The DON stated the resident refuses showers. The surveyor asked for documentation for the refusals, but the DON could not produce a care plan for refusals or progress notes for refusals. There was no documentation on whether or not the resident received a shower. The DON stated it can't be documented in the Electronic Health Record (EHR), and they have to come up with a way for this to be documented. An interview was conducted with the resident with a Spanish speaking surveyor on 03/02/26 at 2:20 PM. The resident stated her primary language was Spanish. The resident was asked in Spanish if she would like to receive showers and she stated she would like showers and thinks she had one shower since she has been here.

Based on observations, interviews and record reviews, the facility failed to provide an environment free from restraints for 1 of 22 sampled residents, Resident #106. The findings included:Review of the facility's policy, titled, Restraint Free Environment, with an implementation date of 06/01/25 and a review date of 1/06/25 documented:Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints.Physical Restraint refers to any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to:*Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising.Compliance Guidelines:1. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical condition. Record review for Resident #106 revealed that the resident was admitted to the facility on [DATE] and admitted to Hospice on 02/23/26. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS) with a reference date of 01/22/26, Resident #106 had a Brief Interview for Mental Status score of 07, indicating that the resident had severe cognitive impairment. The assessment documented that Resident #106 was independent for bed mobility and transfers and ambulated independently via a manual wheelchair as well as being able to walk independently. Resident #106's diagnoses at the time of the assessment included: Anemia, Heart failure, Hypertension, Diabetes Mellitus, Non-Alzheimer's dementia, Anxiety disorder, Encephalopathy, Dislocation of left hip, Presence of artificial left hip joint, Need for assistance with personal care, Abnormalities of gait and mobility, Rhabdomyolysis, Muscle weakness, Cognitive communication deficit, Dysphagia. It was determined that the resident was not interviewable based on not being able to provide answers to simple questions. Review of Resident #106's care plan for Activities of Daily Living (ADLs) documented:The resident has an ADL self-care performance deficit r/t Activity Intolerance, Fatigue, Impaired balance, History of multiple falls, Dementia Date Initiated: 02/12/2026 Revision on: 02/12/2026Interventions in the care plan included: BED MOBILITY: The resident is able to turn self in bed. Date Initiated: 02/12/2026 TRANSFER: The resident is able to transfer self. Date Initiated: 02/12/2026 Review of Resident #106's care plan for falls documented:The resident has had an actual fall with no injury, r/t: Poor Balance, Psychoactive drug use, Unsteady gait Date Initiated: 09/09/2025 Revision on: 09/09/2025The goal of the care plan was documented as:The resident will resume usual activities without further incident through the review date. Date Initiated: 09/09/2025 Target Date: 04/22/2026Interventions in the care plan included: Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Date Initiated: 09/09/2025 On 03/01/2026 at 2:12 PM, Resident #106 was observed sitting in her wheelchair in the second floor Activity/Dining Room. It was noted that the resident's wheelchair was pushed directly against the wall while one of the tables in the room was positioned directly over the resident's upper legs. The resident was observed repeatedly rising from the wheelchair and sitting back down. With each attempt to rise, the resident was unable to rise to a complete upright position and several times, the table that was positioned over her upper legs began to tilt on the base nearly falling over. It was noted that there was a blanket placed on the table in front of the resident that the resident showed no interest in, with no other means to keep the resident occupied and no other staff in the room to supervise the resident.For the duration of the observation, approximately 30 minutes, it was noted that no staff entered the room to check on or interact with Resident #106.It was unknown how long Resident #106 had been positioned in the manner described as the resident was already in the room by herself prior to the beginning of the observation. On 03/01/26 at approximately 3:30 PM, another member of the survey team joined the Surveyor and witnessed the resident continuing to rise and not being able to completely rise and ambulate. On 03/01/26 at approximately 2:40 PM, the surveyor brought the concern to the attention of Staff E, Licensed Practical Nurse (LPN). Staff E acknowledged the concern and intervened with the resident, and the resident was assisted in her wheelchair to the nurse's station where nursing staff were located. During an interview, on 03/02/26 at 1:20 PM, with Staff T, Certified Nursing Assistant (CNA) assigned to the second floor during the observation, when asked about the resident being positioned in a manner that prevented her from rising and ambulating, the CNA stated, We never put her chair against the wall. during the interview, the CNA denied positioning the resident in that manner. During an interview, on 03/02/26 at 1:29 PM, with Staff U, CNA assigned to the second floor at the time of the observation, when asked about the resident positioned in a manner that prevented her from rising and ambulating, the CNA stated, she can walk. During the interview, the CNA denied positioning the resident in that manner. During an interview, on 03/02/26 at 1:35 PM, with Staff H, CNA/Restorative CNA assigned to the second floor during the observation, when asked about the resident being positioned in a manner that prevented her from rising and ambulating, the CNA stated, she can walk, but it is dangerous for her. we have to always monitor her or let her push the chair while we walk beside her and behind her. During the interview, the CNA denied positioning the resident in that manner. During an interview, on 03/02/25 at 1:33 PM, with Staff B, CNA assigned to the second floor at the time of the observation, when asked about the resident being positioned in a manner that prevents her from rising and ambulating, the CNA did not provide a response and only stated that he was not aware of the situation. During the interview the CNA denied positioning the resident in that manner. During an interview, on 03/02/25 at 1:31 PM, with Staff E, the LPN stated, last week, she was declining, for safety she was placed on Hospice last week. She is ambulatory with the assistance of the w/c. She holds the side rails. Her family is in NY. She is declining in function - she was more ambulatory. During an interview, on 03/03/26 at 1:07 PM, with Staff V, CNA assigned to the second floor at the time of the observation, when asked about the resident being positioned in a manner that prevented her from rising and ambulating, the CNA stated, I am in disbelief, that is a restraint. During the interview the CNA denied positioning the resident in that manner.

Based on observation and interview, the facility failed to provide an environment which supported the residents' quality of life by failing to honor 8 of 16 sampled residents reviewed for preferences to open the dining room for meals on weekends, Residents #12, #14, #65, #20, #9, #73, #75 and #3.The findings included:During an unannounced survey which commenced on 03/01/26 (Sunday) morning, the surveyor observed residents in the dining room engaging in an activity. The surveyor heard the activity director tell the residents that they would have to go back to their rooms because the dining room is closed on the weekends.During a dining observation conducted on 03/04/26 between 1:20 PM and 1:45 PM, 8 of 16 residents sitting at the main dining room for lunch stated that they would like to have lunch in the dining room every day including Saturdays and Sundays:a. During an interview conducted on 03/04/26 at 1:20 PM with Resident #12, who stated she loves having lunch in the dining room, but she does not come to the dining room for lunch on the weekends, because she has been told it is not open on Saturdays or Sundays.b. An interview was conducted with Resident #14, who was sitting at the same table as Resident #12, on 03/04/26 at 1:25 PM. He stated the dining room is not open on the weekends and he eats his lunch in his room. He would like to come down to the dining room during the weekends as well.c. An interview was conducted on 03/04/26 at 1:29 PM with Resident #65, who stated she loves having lunch in the dining room. She stated if the dining room is open for lunch on the weekends, she would come to the dining room.d. During an interview conducted on 03/04/26 at 1:34 PM with Resident #20, who had finished her lunch and went out to the patio. She stated she likes coming down for lunch because she gets to socialize with other residents. She stated that she would love to see the dining room open on the weekends.e. An interview conducted with Resident #9, who was next to Resident #20 on the patio. He agreed with Resident #20 and would enjoy having the option of coming down for lunch on the weekends.f. During an interview conducted on 03/04/26 at 1:38 PM with Resident #73, who also had finished with lunch and was outside on the patio. She stated she likes coming to the dining room because she gets to see a different room and then she goes outside. She stated she would like to do the same during the weekends.g. An interview was conducted with Resident #75 and his private aide, who were sitting next to Resident #73. He agreed with Resident #73 and would like to have lunch in the dining room on the weekends. Resident #75's aide stated the family does come by on the weekends and takes him out for lunch, but it is nice for him to have the option to enjoy lunch with the other residents.h. During an interview conducted on 03/04/26 at 1:45 PM with Resident #3, who was sitting outside on the patio, she stated she has lunch in the dining room every day except the weekends because it is closed. She agreed that it would be nice to eat lunch in the dining room on Saturdays and Sundays.An interview was conducted with the Administrator and the Director of Nursing on 03/04/26 at 1:50 PM. They were asked about the dining room being closed on the weekends. The Administrator stated it has been closed since COVID [date around March 2023]. The residents were not complaining about the dining room not being open, so they didn't open it. He was then asked if he polled the residents to see if they wanted the dining room open on the weekend. He stated he will be doing that, and he has not done that yet.

Based on observations, interviews, and record review, the facility failed to appropriately use a two-person transfer via Hoyer Lift during a transfer from the resident's bed to wheelchair, placing the resident at risk for injury for 1 of 1 sampled resident reviewed for accidents, Resident #22. The findings included:Record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Rheumatoid Arthritis, Muscle Weakness (Generalized), and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score is 15, indicating the resident is cognitively intact. Review of section GG of the MDS showed that Resident #22 is fully dependent (2 or more helpers required) on staff regarding the ability to transfer to and from a bed to a chair (or wheelchair).Review of the care plan dated 02/06/26 documented that Resident #22 has an Activities of Daily Living (ADLs) self-care performance deficit related to Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Limited ROM, and Pain. Goals were to maintain current level of function in ADLs through the review date. Intervention was for staff to encourage the resident to use bell to call for assistance; Resident #22 is totally dependent on staff for transferring.On 03/01/26 at 10:48 AM observed Staff D, Certified Nursing Assistant (CNA), entering Resident #22's room with a Hoyer Lift (Mechanical assistive device for transfer). No other staff member entered the room with her.On 03/01/26 at 11:00 AM, the surveyor knocked and entered Resident #22's room, and observed Staff D, CNA, assisting the resident with dressing. The surveyor then left the room and relocated to the hallway right outside the resident's room.On 03/01/26 at 11:20 AM, the surveyor was in the hallway and saw no other staff member entering Resident #22's room. At this time, the surveyor entered the room and witnessed Staff D, CNA, using the Hoyer Lift to transfer the resident to her wheelchair without the assistance of another staff member. Resident #22 was observed strapped to the Hoyer Lift in mid-air while Staff D was using the remote control of the device to move Resident #22 towards her wheelchair. About 20 seconds later, Staff C, Licensed Practical Nurse (LPN) entered the room and witnessed the situation. Staff C was asked if Staff D, CNA, should be transferring a resident using the Hoyer Lift without another staff assistance. She stated no and she will be assisting Staff D now.A phone interview was conducted on 03/03/26 at 10:34 AM with Staff D who stated she has worked at the facility for over 13 years. She stated that she cares for her patients as if they were her family. She stated Resident #22 is not usually assigned to her. She stated that the Hoyer Lift is to be used with two staff present for transfers. Staff D stated that she had texted Staff C prior to transferring Resident #22 and she saw that the nurse came in at the same time with the surveyor to assist with the transfer.An interview was conducted on 03/03/26 at 11:08 AM with Staff A, CNA, who stated she has worked at the facility for one year. She stated the Hoyer Lift requires two-person transfer for every resident. She stated the protocol is to dress the resident, leave them in bed, then get another staff member to assist with the transfer using the Hoyer Lift.An interview was conducted on 03/03/26 at 3:48 PM with Director of Nursing (DON) who stated she has worked at the facility for 3 months. She stated Staff D, CNA, explained to her what happened on 03/01/26 with Resident #22. She stated Staff D told her that she went to provide care because she was asked by the nurse (Staff C, LPN) to help Resident #22. She thought Staff C was in Resident #22's room when she came into the room. The DON stated Staff D was educated and is currently on probation.

Based on observations, interviews, and record reviews, the facility failed to follow their own catheter care policy to ensure residents with indwelling catheters receive appropriate care and management: to minimize pressure and tension for 1 of 2 residents reviewed, for Resident #35; and to prevent infection for 1 of 2 residents reviewed for urinary catheter care for Resident #124. The findings included: Review of the policy titled, Catheter Care, implemented on 06/01/25, and revised on 11/07/25, documented that the facility's policy is to ensure residents with indwelling catheters receive appropriate catheter care. The policy also explains the following: Leg bags may be used per request (4). Leg bags will be attached to the resident's thigh or calf making sure to have a slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight (6). 1. Record review documented Resident # 35 was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Respiratory Failure Unspecified Whether with Hypoxia or Hypercapnia and Prostate Cancer. Review of the recent Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS), revealed it was disabled indicating severe cognitive impairment. Section H revealed Resident #35 had an indwelling catheter. Review of physician orders dated 02/12/26 documented, leg strap to anchor indwelling catheter in place every shift. Review of the Medication Administration Record (MAR) for 03/2026 revealed that the order for Resident #35's leg strap; to anchor indwelling catheter in place every shift had initials and check marks indicating the nurses ensured the order was followed. An observation conducted on 03/03/26 at 12:30 PM revealed Resident #35's urinary catheter tubing was not strapped to the leg. A closer observation on both legs and calves revealed no strap to secure the urinary catheter tubing in place. Staff H, Certified Nursing Assistant (CNA), stated she just performed care for the resident. When she was asked if the resident ever had a device, or a leg strap to ensure the urinary catheter tubing is in place, she responded, 'no, he has never had any strap'. When she was asked if she asked the nurses to provide a leg strap to secure the urinary catheter tubing for Resident #35, she did not respond. When she was asked who performs the urinary catheter care for the resident, she responded, she performs it daily in the morning and other CNAs perform it in the afternoon and at night. When she was asked if nurses check the catheter tubing during her shift, she responded, yes, they check it every shift to ensure that the reddish urine is monitored. When she was asked if any nurse had ever put a strap to secure Resident #35's catheter tubing, she responded, no, we just let the catheter tubing hang. In an interview conducted with Staff E, Licensed Practical Nurse (LPN), on 03/03/26 at 10:00 AM, when he was asked if he had taken care of Resident #35, he responded no. When he was asked if the facility ensured residents with urinary catheter receive the proper care, he responded, we give proper care by following infection control practices, performing hand washing before providing catheter care, donning gloves and gown, and following the doctor's order for irrigation, monitoring output, and application of a strap. When he was asked if nurses document the catheter care and management, he responded the staff document them in the progress notes and in MAR/TAR. In an interview conducted with Staff F, Registered Nurse (RN) on 03/03/26 at 4:05 PM, when she was asked if she had taken care of Resident #35's urinary catheter, she responded, yes. When she was asked if she checks the leg strap to ensure the urinary catheter tubing is secured, she responded, she is not sure. When she was asked how she documents any treatment or physician order for the residents, she responded, staff document in MAR. When she was asked what is documented in MAR to ensure the order was followed, she responded, check mark with my initials. When she was asked if she ensured the order for leg strap was checked and initialed by her, she did not respond. 2. Review of the policy titled, Catheter Care, revealed, With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Record review revealed Resident #124 was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Chronic Kidney Disease, Stage 3 Unspecified, Obstructive and Reflex Uropathy, and Retention of Urine. His Brief Interview for Mental Status (BIMS) score on the admission minimum data set (MDS) dated [DATE] revealed a score of 6 indicating the resident has severe cognitive impairment. Review of the physician orders revealed a leg strap was ordered to anchor the Foley catheter in place. An observation of Resident #124 on 03/01/26 at 1:34 PM revealed the resident in bed with his Foley catheter bag which was inside of a privacy bag and tubing was directly lying on the floor-fall-mat next to his bed. An observation on 03/02/2026 at 2:00 PM revealed the resident in bed with catheter tubing and catheter bag on the floor-fall-mat. On 3/03/26 at 1:30 PM, an observation of Foley care was done with Staff K and Staff L, who were both certified nursing assistants (CNAs). Staff K and Staff L both wore gown and gloves during care. Staff K prepared a basin and prepared the resident by undoing his brief and covering his genitals with a sheet. Staff K then cleaned the penis and proceeded to cleanse the tubing. The direction of the wiping went from the distal end of the tubing to the proximal end - the tubing was cleansed from the farthest away point of the tubing to the urinary meatus instead of starting at the urinary meatus moving outward. This was done multiple times. After the observation, the surveyor asked Staff K and Staff L if this was the way they were educated how to do Foley care. They stated that it was. The surveyor asked them if it made sense to bring the dirty area closer to where the tubing was inserted and they stated it did not. The surveyor also asked Staff K and Staff L if they had an anchor for the tubing and they stated that they did not. The resident had a Physician order for a leg strap to anchor indwelling catheter in place q (every) shift. The findings were reviewed with the Director of Nursing (DON) immediately after the observation who stated she would provide education and try to figure out how they could keep the tubing off the floor.

Based on observations, interviews and record reviews, the facility failed to ensure a current physician order for oxygen for 1 of 4 sampled residents, Resident #10; failed to initiate a nursing care plan for oxygen for 1 of 4 sampled residents reviewed for respiratory care, Resident #10; and failed to ensure oxygen tubing, nasal cannula and mask were dated for 2 of 4 sampled residents, Resident #10 and Resident #35. The findings included: Review of the policy titled, Oxygen Administration, implemented on 06/01/25, and revised on 11/07/25 documented the following:Oxygen is administered under a physician order except in case of emergency.Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 1. Record review documented Resident #10 was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, and Acute and Chronic Respiratory Failure with Hypoxia. Review of Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview for Mental Status (BIMS), revealed it was disabled, indicating sever cognitive impairment. Section GG documented Resident #10 needed substantial maximal assistance in personal hygiene.Review of the physician order dated 01/05/26 documented oxygen at 2 liters per minute via nasal cannula, every shift for shortness of breath. An additional order documented to change tubing, mask and nasal cannula weekly every night shifts, every Monday, and as needed. Additional review revealed these orders was discontinued on 01/27/26.Record review of the pulmonary consultation dated 02/06/26 documented the following:*Auscultation reveals scattered rhonchi and wheezing, predominantly in the right lung field. Breath sounds are diminished on the right side compared to the left Plan: - Initiate treatment for acute respiratory failure with immediate oxygen therapy to maintain SpO2 >92%. Review of the nursing documentation for oxygen administration documented that on 03/02/26 at 9:34 PM that oxygen was administered via nasal cannula by Staff F, Registered Nurse (RN). Other nasal cannula oxygen administration was documented and performed by different staff on the following dates:03/02/26 at 00:09AM.02/27/26 at 12:46 PM.02/26/26 at 11:22 PM.02/26/26 at 8:00 PM.02/26/26 at 11:46 AM.An additional review of the nursing care plan did not include any documentation for respiratory care and oxygen therapy.During observations conducted on 03/01/26 at 9:27 AM and 11:57 AM, Resident #10's oxygen concentrator located on the right top side of the bed had a green light on and was making a very loud sound. The bubble indicator was observed at 1.5 liters per minute. The long oxygen tubing was undated, and the nasal cannula was not on located on Resident #10's nares. In an interview conducted with Staff F, Registered Nurse (RN) on 03/01/26 at 11:00 AM, when she was asked if she checked the oxygen therapy for this resident, responded, 'this morning. When she was asked if oxygen therapy was ordered for Resident #10, she responded, yes. When she was asked if oxygen therapy needs a physician order, she responded, yes. When she was asked how often they change the nasal cannula, oxygen tubing and mask for oxygen and nebulizing therapy, she responded according to physician order. When she was asked if nursing care plan is needed for oxygen therapy and nebulizing treatment, she responded, yes.Review of Medication Administration Record (MAR) for 03/2026 documented no oxygen administration for Resident #10 on 03/02/26. An additional review of the MAR and Treatment Administration Record (TAR) for 02/2026 had no documentation of oxygen administration. There was also no documentation of the changing of the mask, nasal cannula, and oxygen tubing.In an interview conducted with Staff E on 03/02/26 at 9:45 AM, when he was asked about oxygen therapy and nebulizing treatment for residents, he responded, they must be physician ordered. When he was asked how often they change the oxygen tubing, cannula and mask, he responded, according to physician order. When he was asked if the nursing care plans are initiated with interventions for oxygen therapy and nebulizing treatment, he responded, yes. 2. Record review documented Resident #35 was admitted to the facility on [DATE] with diagnosis that included Prostate Cancer, Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia, and Diastolic Congestive Heart Failure. Review of the recent MDS assessment dated 02/14//26 revealed the following: Section C for BIMS had a score disabled indicating the resident had severe cognitive impairment. Section I revealed yes responses to an indwelling catheter and ostomy (including nephrostomy). Section GG revealed Resident #35 was dependent for toileting, and Section O revealed not applicable responses or oxygen therapy on admission and while at the facility.Review of physician orders dated 02/16/26 documented to change tubing, mask and/or nasal cannula weekly, every night shift, every Sunday, and as needed. Additional review of the orders dated 09/26/25 revealed oxygen via nasal cannula at 2 liters continuously, every shift for shortness of breath (SOB).Review of MAR and TAR for 02/2026 revealed the oxygen tubing and mask were not changed as indicated by the absence of check marks and nurses' initials on 02/01/26, 02/08/26 and 02/15/26. There were initials and check mark documented for 02/22/26.Additional review of 03/26 MAR revealed the mask / tubing was changed on 03/01/26 as indicated by nurse's initials and a check mark in the line with the date and parallel to the order.During an observation conducted on 03/01/26 at 11:16 AM, the oxygen concentrator inside Resident #35's room was turned off. There was a plastic bag observed on the top part of the concentrator with a coiled clear tubing inside, and the remaining tubing was on the floor. The plastic bag had 2 dates written in black ink. The top date was 02/17/26 while the bottom date was 02/12/26.Additional observation revealed a gray colored nebulizing machine with a clear tubing attached on its front part and the remaining part of the tubing and mask were inside a plastic bag. The plastic bag, the tubing, and the mask were not dated.In an interview conducted with Resident #35 on 03/02/26 at 10:40 AM, when he was asked how often he gets oxygen therapy, responded, he no longer needs oxygen. When he was asked how often he gets the nebulizing treatment, he responded, he gets them every morning.In an interview conducted with Staff N, Licensed Practical Nurse (LPN) on 03/03/26 at 4:05 PM, when she was asked how they document that medication and treatment were administered, responded, staff put their initials with check marks electronically in MAR and TAR. When she was asked how other facility staff would know that the oxygen tubing, mask and cannula were changed, she responded, staff document in MAR/TAR, and label the plastic bag for the mask and tubing with the date they were changed.

Based on interview, record review, and observation, the facility failed to appropriately identify Post Traumatic Stress Disorder (PTSD) behavior triggers and implement a person-centered care plan for PTSD with behavior triggers for 2 of 2 sampled residents reviewed for behaviors, Residents #96 and #95. The findings included:1. On 03/01/26 at 1:26 PM, an interview was conducted with Resident #96 that identified the resident had some behavioral issues related to PTSD Post Traumatic Stress Disorder). On 03/03/26 at 11:30 AM, an interview was conducted with Resident #96 regarding PTSD. Resident #96 explained that he never discussed his triggers with anyone in the facility. He explained that he had two dramas in his life that have caused him severe PTSD, one was related to an automobile accident and the other was related to a personal incident when he was a child. Resident #96 disclosed the incidents and the triggers to the surveyor. These triggers included loud noises and bright lights. Resident #96 stated he was also concerned that he was not getting his proper medications for his PTSD. The Director Of Nursing (DON) discussed Resident #96's medication questions with the surveyor present at the request of Resident #96. Immediately following the interview, the DON was asked if she knew what Resident #96's triggers for PTSD were and she stated she was unaware that Resident #96 had specific triggers for his PTSD. On 03/03/26 at 12:51 PM, an interview was conducted with the Social Services Director (SSD) regarding Resident #96's PTSD triggers. The SSD identified being the one who performed the PTSD assessment of Resident #96 on 02/19/26, and stated the PTSD assessment is done as part of the assessments performed at admission. The SSD explained that after the PTSD assessment he requested a Psychiatric evaluation based on the answers from the PTSD assessment. The SSD stated he requested a Level 2 PASRR [Preadmission Screening and Resident Review] evaluation, which is currently pending at [Name documented]. After the Psychiatric consultation and based on the psychiatrist's evaluation, the SSD performed a second PTSD assessment. The SSD stated he asked about the triggers, what is usually happening when a flashback occurs. The SSD stated that he did not specifically ask what would trigger an event. On 03/04/26 at 10:03 AM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator, who works full time, Monday through Friday from 8:00 AM to 5:00 PM, stated that she came to work on Sunday, 03/01/26, and stated she was the person who initiated the PTSD care plan on 03/01/26, which was the first day of the survey. The MDS Coordinator stated that the Psychiatrist was present in the building on 03/01/26. The MDS coordinator stated that she discussed Resident #96 with the psychiatrist that morning. The MDS Coordinator stated she updated Resident #96's records to include PTSD in the care plan. The MDS coordinator stated that when she initiated the care plan the system generates choices of interventions and if they need to add some, they add some. The MDS coordinator stated that after she initiates the care plan for PTSD the Social Services Director updates the Behavior care plans. The MDS coordinator stated the SSD would be the one to include the resident's specific triggers, and knows the specific triggers are supposed to be in the care plan. The MDS Coordinator stated the IDT [interdisciplinary team] reviews the care plan to ensure all elements are included in the care plans before it is presented to the resident in his care plan meeting. The MDS coordinator reviewed the care plan and agreed the PTSD care plan did not contain the triggers for his PTSD. On 03/04/26 at10:41 AM, a second interview was conducted with the SSD, who stated he interviews the residents when there is a PTSD behavior identified and does ask them what their triggers are. The SSD stated he did not add the triggers to the care plan until after it was brought to his attention that they needed to be added on 03/04/26. 2. Record review documented Resident #95 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Sedative, Hypnotic or Anxiolytic Dependence, and Schizoaffective Disorder Bipolar type. Review of nursing care plan by the MDS Coordinator, dated 03/04/23, documented Resident #95 uses psychotropic medications related to diagnoses of Schizophrenia, Bipolar Disorder, post-traumatic stress disorder (PTSD), and nightmares. The care plan did not document any interventions regarding PTSD. There was also no documentation about any PTSD triggers. In an interview conducted with Resident #95 on 03/02/26 at 11:30 AM, when she was asked about any conditions and or situations that prevent her from acquiring her best practicable life in the facility, responded, she is ok. When she was asked if she had experienced trauma that made her vulnerable to outside factors, she responded, she gets stressed sometimes and that might be the one driving factors to make her feel unsafe. She added that she does not want people asking her questions, and that makes her feel insecure. When she was asked if she had spoken with the Social Services staff regarding her traumatic experience, she responded that they are aware. When she was asked if all staff know about her triggers, she responded, they are aware. In an interview conducted with Staff E, Licensed Practical Nurse (LPN) on 03/02/26 at 10:26 AM, when he was asked if had taken care of Resident #95, responded, yes. When he was asked if he knows the PTSD diagnosis, he did not respond. When he was asked if he knows Resident #95's triggers, he responded, he did not know and would like to think about it. When he came back after few minutes, he responded, he did not remember but thought it might be when someone opened the door. In an interview conducted with the Social Services Director on 03/03/26 at 1:08 PM, when he was asked if Resident #95 has a diagnosis of post-traumatic stress disorder (PTSD), responded, she was diagnosed back in 02/09/26 after a psychiatric evaluation to increase the dose of Resident #95's psychotropic medications. When he was asked if he initiated a nursing care plan for PTSD, he responded, he has not. When he was asked when he would initiate a nursing care plan for PTSD, he responded, he would start initiating it soon. When he was asked if staff are aware of Resident #95's triggers, he responded, he thinks it is when somebody opens her door. When he was asked if he had interviewed the resident regarding triggers, he did not respond. In an interview conducted with the MDS Coordinator, on 03/04/26 at 10:47 AM, when she was asked how she performs assessment after a new diagnosis, responded she reviews the electronic health records, the physician's referral, and she conducts resident's interviews. When there are significant changes, she makes sure she completes an updated assessment in 14 days. When she was asked if she had completed the assessment for Resident #95 after a new diagnosis of PTSD on 02/09/26, responded, she is still in the process of doing it. She added that she would also initiate a care plan based on the new diagnosis. She added that every time a resident had a psychiatric diagnosis, it would initiate a Trauma Informed Care or (PTSD) assessment and care plan. When she was asked what date, she had found out that Resident #95 was diagnosed with PTSD, she responded she found out about it last week. She added that the PTSD care plan would be added soon on 03/11/26. She added that Resident #95 had a neurology consult dated 02/26/26, and she would start assessing the resident now to update the MDS assessment and the diagnosis. She stated she has not spoken with Resident #95 about the PTSD diagnosis, so she does not know any triggers, but she would start assessing the resident now to update the MDS assessment and the diagnosis. When she was asked why she did not initiate a care plan about Resident #95's PTSD diagnosis which she documented back in 2023, she responded, she does not remember.

Based on observation, interview, and record review, it was determined the medication error rate was 8 percent. Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #119. The findings included:Review of Resident #119's clinical record documented her admission was on 01/30/26. The resident's Minimum Data Set (MDS) admission assessment dated [DATE] documented the Resident's diagnoses included Deep Venous Thrombosis, Hypertension, and Anxiety Disorder. Her Brief Interview for Mental Status (BIMS) was 15 which indicated she was cognitively intact. On 03/02/26 at 9:01 AM, medication administration observation for Resident #119 with Staff M, Licensed Practical Nurse (LPN), was performed. Medications ordered and due were:Klonopin 0.5mg(milligrams) 1 by mouth twice a dayBuspirone 150mg give 300mg by mouth one time a dayMetoprolol Tartrate 25 MG Oral Tablet 1 tab twice a dayEscitalopram 20 MG Oral Tablet once a dayApixaban 5 MG Oral Tablet 1 twice a day Staff M took the resident's blood pressure prior to medication administration. Her blood pressure was 92/67. Staff M stated to the surveyor that since her blood pressure was low, she would not be administering her Metoprolol. She proceeded to prepare 1 Klonopin, 1 Buspirone (150 mg), 1 Escitalopram and 1 Apixaban. She then administered those medications to the resident. After administering the medications, the surveyor asked her to look at the order for Buspirone. She then realized she should have given the resident 2 pills and proceeded to give her another Buspirone. On 03/02/26 at 1:00 PM, the surveyor asked Staff M if she had called the physician regarding holding the Metoprolol since the Metoprolol had no parameters on the order. She stated she did not. The Director of Nursing was present during the interview with Staff M and stated she would call the physician now.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI) failed to demonstrate that effective plans of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficiencies in F812 food procurement, store, prepare and serve. These repeated deficient practices have the potential to affect all 110 residents residing in the facility at the time of this survey. The findings included:Review of the facility's survey history revealed the facility was cited at F812 during the Recertification surveys with exit dates of 12/2020, 02/2022, 06/2023, and 08/22/2024. During an interview with the facility's Administrator on 03/04/26 at 1:20 PM, the Administrator was apprised that this deficiency will be cited again on this current survey. The Administrator was asked if he had a Performance Improvement Plan (PIP) as part of the QAPI program for this deficiency and he stated he did not. He was asked if education was being done and/or audits were being done regarding kitchen sanitation and he stated there was not.

Based on observations, interviews, and record reviews, the facility failed to perform appropriate hand hygiene during medication administrations for 2 of 6 residents, for Residents #79 and 18, and failed to properly disinfect blood pressure (BP) cuff during medication administration for 3 of 6 residents for medication administration observations, for Residents # 119, 110 and 37. The findings included: Review of facility's policy titled, Medication Administration, implemented on 06/01/25, and revised on 11/07/25, documented under policy that medications are administered by licenses nurses, and other staff who are legally authorized to do so in this state, as ordered by physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy and explanation guidelines documented the following: Wash hands prior to administering medications per facility protocol and product (4). Wash hands after observation of a resident consumption of medications (19). According to Center for Disease Control and Prevention (CDC), Enhanced Barrier Precautions (EBP), (In addition to Standard Precautions), recommended that everyone must clean hands when entering and leaving room. 1. During a tour of [NAME] facility on 03/02/26 at 9:20 AM, Staff F, Registered Nurse (RN), left Resident #79's room without performing hand hygiene. There was an Enhanced Barrier Precaution (EBP) post on the top door. Staff F went straight to the Medication Cart and stated she would give medications to Resident #18. Without performing hand hygiene, she filled up a small medicine cup with the Resident #118's medications scheduled for 9:00 AM. She locked the Medication Cart and went inside Resident #18's room, and without performing hand hygiene gave the medicine cup to the resident. Staff F left the resident's room without performing hand hygiene on 03/02/26 at 9:40 AM. In an interview conducted with Staff F on 03/02/26 at 9:40 AM, when asked if she had attended an infection control training, she responded, yes. When she was asked why she did not perform hand hygiene after leaving the room of Resident #79 who had an EBP post, she did not respond. When she was asked why she did not perform any hand hygiene before and after giving the medications to the Resident #18, she did not respond. 2. Review of the policy of the facility titled, Cleaning and Disinfection of Resident-Care Equipment, revealed Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. On 03/02/26 starting at 9:00 AM, Staff M, Licensed Practical Nurse (LPN) was observed taking blood pressures on Resident #119, Resident #110, and Resident #37. Staff M was not observed doing sanitizing of the blood pressure equipment before or after taking blood pressures on these 3 residents. Staff M was asked how often the blood pressure cuffs should be cleaned and she stated, After each use. I should have cleaned it.

Based on observations, interviews and record review, the facility failed to prepare and serve food in a sanitary manner in accordance with professional standards for food safety. The findings included: 1. On 08/19/24 at 8:48 AM, during the initial kitchen tour accompanied by Staff A, Cook, the Dietary Manager and the Registered Dietitian (RD), the following were noted: a. the handles of a spoodle and three spatulas were damaged to a point that they were no longer easily cleanable. b. there was an accumulation of food residues on the blade and the mounting bracket of the table mounted manual can opener. c. there was an accumulation of dust on the air conditioning vent over the food assembly area. d. the wall over and around the door to the walk-in cooler was damaged and tiles were missing. 2. The facility's policy, titled, Handwashing / Hand Hygiene, with a reference date of August 2019, documented, in part: this facility considers hand hygiene the primary means to prevent the spread of infections. The policy did not specifically address hand hygiene in the kitchen and for food safety concerns. During the follow up kitchen tour, on 08/21/24 at 10:52 AM, accompanied by the Dietary Manager and the RD/Licensed Deitician, the following were observed: a. Staff B, Dietary Aide, was observed entering the kitchen and proceeded through the kitchen to the locker room, went in the office, and left the kitchen through a back door to go on a break. Upon returning to the kitchen, the Dietary Aide did not perform hand hygiene prior to donning clean single use gloves after her hands had been potentially contaminated. The Dietary Manager acknowledged that she did not perform hand hygiene prior to donning the gloves. b. Staff C, Dietary Aide, was observed walking from the three-compartment sink, where the Dietary Aide was manually washing and sanitizing utensils and equipment, to the hand washing sink, upon reaching the hand washing sink, Staff C used paper towel to dry her hands without washing them and returned to the ware washing area. Staff C was observed returning from the ware washing area and again drying her hands without washing them in the dedicated hand washing sink. Staff C was observed preparing coffee to be served during the lunch meal, then proceeded across the kitchen to answer the telephone, and then returned to the coffee station. Staff C was then observed donning a clean pair of single use gloves without performing appropriate hand hygiene after her hands had been potentially contaminated at any time during the observation. Staff C acknowledged she did not perform hand hygiene prior to donning the gloves. c. Staff D, Dietary Aide, was observed was observed handling a wet floor sign that was on the floor and then proceeded to handle a cart. Staff D was then observed donning a clean pair of single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff D acknowledged she had not performed hand hygiene prior to donning the gloves. d. Staff A, Cook, was observed cleaning a cart with a wet towel with her bare hands. Staff A then donned a clean pair of single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff A acknowledged she did not perform hand hygiene prior to donning the gloves. e. Staff E, Dietary Aide, was observed returning to the kitchen from a service area where the ice machine was located. Staff E was observed donning a pair of clean single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff E acknowledged she did not perform hand hygiene. The surveyor intervened, and the [NAME] and the Dietary Aides were stopped from continuing working and instructed to perform hand hygiene by the Dietary Manager.

Based on observation, records review, and interviews, the facility failed to ensure it timely answered call lights in response to residents' needs for 3 of 24 sampled resident, Residents #13, #38, and #55. The findings included: 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. On the most recent Minimum Date Set (MDS) assessment, the Brief Interview for Mental Status (BIMS) was documented as a score of 15 of 15, indicating the resident was alert and oriented to person, time, and place (cognitively intact). On 08/20/24 at 1:25 PM, an interview was conducted with Resident #38 who stated she had voiced multiple complaints regarding the call light response to staff. Resident #38 said at times when the call lights is activated, the Certified Nursing Assistant (CNAs) could be observed passing by the room, but they do not bother to come in the room to check. Resident #38 complained that this situation is usually worse on the weekend. In a followup interview with Resident #38 on 08/21/24 at 11:07 AM, during the environmental tour with the Maintenance Staff and Housekeeping Staff present, Resident #38 reiterated that at times, it takes staff 45 minutes to one-hour to answer the call light. Resident #38 stated that the concerns have been reported to the nurses. Resident #38's call light was checked at this time, and it was noted to be functioning well. 2. Record review revealed Resident #13 was admitted to the facility on [DATE]. Review of the MDS revealed the BIMS score was 15 of 15, indicating intact cognition. On 08/19/24 at 10:20 AM, Resident #13 stated the call lights are not answered on time, especially during the night or the 11:00 PM to 7:00 AM shifts. Resident #13 said it sometimes takes 30-60 minutes to have the call light answered. On 08/21/24 at 10:56 AM during the environmental tour, Resident #38 restated the concern regarding call light response, especially at night. Resident #38 said that the call light response time was a chronic situation. Resident #38 stated she had complained to the Director of Nursing (DON) many times regarding that issue. Resident #38 said this issue was also discussed during resident council meetings. 3. Record review revealed Resident #55 was admitted to the facility on [DATE]. Review of the BIMS score for Resident # 55 noted the score was 1 of /15 indicting intact cognition. On 08/19/24 at 11:42 AM, Resident #55 also stated that the call light is usually answered about an hour later, especially at night during the 11:00 PM to 7:00 AM shifts. During a follow-up interview with Resident #55 on 08/21/24 at 10:49 AM, Resident #55 said she usually used the call light when she needed to be changed. When questioned about the time the interview was being conducted with the surveyor, Resident #55 answered correctly, stating the exact time observed on the clock on the wall.

Based on observations, interviews, and record review, the facility failed to follow the physicians' orders for wound treatment and failed to provide wound care in a timely manner for 1 of 2 sampled residents, reviewed for wound care, Resident #18. The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as a deep tissue injury (DTI), surgical wound. Review of the Physician's orders showed Resident #18 had an order for left dorsal foot and left lateral foot wound, Cleanse with Normal Saline (N/S) apply skin prep to peri wound non border foam abdominal and wrap with Kling; daily on the day shift. Review of the Care Plan dated 06/06/24 documented Resident #18 has a pressure ulcer to left plantar foot wound, left dorsal foot wound, left heel DTI and has a surgical wound to his Left lateral foot, r/t [related to] History of ulcers, Immobility. Goals were to show signs of healing and remain free from infection. Interventions were to administer treatments as ordered and monitor for effectiveness; Assess / record / monitor wound healing daily; report improvements and declines to the MD; Monitor dressing every shift to ensure it is intact and adhering. During an interview conducted on 08/20/24 at 10:36 AM, Resident #18 stated that he had an amputation of left pinky toe and believed that the dressing should be changed daily. He was concerned that the dressing has not been changed recently, and his left heel was bothering him. During an observation conducted on 08/20/24 at 10:40 AM of Resident #18's left foot revealed the foot was wrapped with a Kling dressing, taped and was dated 08/17/24 7-3 shift. Photographic Evidence Obtained. On 08/20/24, review of the August 2024 Treatment Administration Record (TAR) revealed the nurse signed for Resident #18's wound treatment on 08/17/24 and 08/18/24. No signature was recorded for 08/19/24 wound treatment. Review of the Nursing progress note dated 08/17/24 revealed the dressing change was done to Resident #18 lower extremity. The documentation inlcuded, Wound was observed: beefy red area with some bleeding. Resident #18 was medicated prior to dressing change. No other documentation regarding the left foot wound was found after 08/17/24. An interview was conducted on 08/21/24 at 3:44 PM with the Wound Care Nurse (WCN). She stated that she has worked at the facility for [AGE] years as the WCN. She noted that on 05/17/24, Resident #18 returned from the hospital after the amputation of the left pinky toe. She stated that the surgical wound was healing nicely, and some redness appeared in the area, and Resident #18 was seen by the wound doctor. She acknowledged that on Monday 08/19/24 she did not see Resident #18's wound nor had she changed the dressing. She noted that the floor nurses are aware to do the wound treatment if she did not. Upon review of the photograph of Resident #18's dressing, the WCN acknowledged that the dressing had not been changed since 08/17/24. The WCN stated that for Resident #18, she did the wound treatment on 08/20/24 and she thought that the old wound dressing was dated 08/19/24.

Based on review of policy and procedure, record review, observation and interview, the facility failed to administer the correct type of Aspirin medication, as per physician's order for 1 of 5 sampled residents observed during a Medication Administration Observation, Resident #94. The findings included: Review of the facility policy and procedure on 08/19/24 at 2:30 PM, titled, Specific Medication Administration Procedures, provided by the facility's Regional Nurse, reviewed May 2022 documented, in part, in the Policy Statement: Administration Procedures for all Medications - To administer medications in a safe and effective manner. Procedures: .C. Review five (5) rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer: a. Check Medication Administration Record (MAR)/Treatment Administration Record (TAR) for order e. Prepare resident for medication administration. 2) Prior to removing the medication from the container. a. Check the label against the order on the [DATE]: After the dose has been prepared and before returning the medication to storage .H. When applicable, explain to resident the type of medication being administered . Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction due to Embolism of Unspecified Cerebral Artery, Endocarditis and Heart Valve Disorders in Diseases Classified Elsewhere, Non-ST Elevation (NSTEMI) Myocardial Infarction, Presence of Prosthetic Heart Valve, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Cardiomegaly, Hypertension, Anemia, Diabetes Mellitus Type II, Acute Kidney Failure, Syncope and Collapse and Hydronephrosis with Renal and Ureteral Calculous Obstruction. She had a Brief Interview Mental Status (BIM) score of 15, indicating she was cognitively intact. On 07/09/24, the physician's order documented, Aspirin oral tablet Delayed Release 81mg; to give one (1) tablet by mouth one (1) time a day for Coronary Artery Disease (CAD). During a Medication Administration Observation conducted on 08/19/24 at 9:17 AM of Resident #94, Staff F, Registered Nurse (RN), was observed preparing and placing a chewable pink-colored Aspirin 81mg tablet, ordered daily, in the medication cup along with all of the resident's eight (8) other oral medications. She administered all nine (9) medications, in the medication cup to the resident; instead of preparing and administering the yellow-colored Aspirin 81 mg Delayed Release / Enteric coated tablet, as per the physician's order. Staff F did not separate this chewable Aspirin medication into a different cup, and did not first provide any direction to Resident #94 to inform her that the chewable pink-colored Aspirin 81mg tablet (that was incorrectly administered) should have been chewed. Photographic Evidence Obtained. An interview was conducted with Resident #94 on 08/19/24 at 9:35 AM, in which she was asked, in general, how important was to her that she always receive her correct medications, and she indicated that it was very important to her and added that it would bother her if this was not done. An interview was conducted with Staff F on 08/19/24 at 10:15 AM regarding the pink-colored Aspirin Chewable 81 mg, that she was observed administering to Resident #94, instead of the ordred yellow-colored Aspirin 81 mg Delayed Release/Enteric coated tablet. Staff F acknowledged the difference between the two (2) types of Aspirin and indicated that the correct Aspirin medication should have been administered as ordered. During an interview conducted on 08/19/24 at 1:41 PM with the facility Pharmacist, he acknowledged the difference between the yellow-colored Aspirin 81 mg Delayed Release / Enteric coated tablet and the pink-colored Aspirin Chewable 81 mg. The Pharmacist indicated that both medications are the same type of drug, same dosage and same route, but do not have the same methods of absorption. He stated the correct type of Aspirin medication should have been administered as ordered. A side-by-side direct observation and record review was conducted with the facility's Regional Nurse, in which the difference between the two (2) forms of Aspirin were revealed as 1) yellow-colored Aspirin 81 mg Delayed Release / Enteric coated one (1) tablet oral daily; and 2) pink-colored Aspirin Chewable 81 mg one (1) tablet oral daily. They both had the same name, same dosage, same timing and same route, but with the difference being that of color and method of absorption. The Director Of Nursing (DON) acknowledged that on 08/21/24 at 1:41 PM that the correct type of Aspirin medication should have been administered, as ordered, and this was not done.

Based on observations, interviews, and record review, the facility failed to ensure accurate records related to dressing change for 1 of 2 sampled residents reviewed for wound care, Resident #18; and failed to ensure complete and adequate documentation for 1 of 1 sampled resident reviewed as deceased in the facility, Resident #99. The findings included: Review of the facility's policy titled, Documentation of Progress, dated [DATE], included the following: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. 1. Record review for Resident #18 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as deep tissue injury (DTI), surgical wound. Review of the Physician's Orders showed that Resident #18 had an order for left dorsal foot and left lateral foot wound: Cleanse with Normal Saline (N/S) apply skin prep to peri wound non border foam abdominal and wrap with Kling; daily on the day shift. During an interview conducted on [DATE] at 10:36 AM, Resident #18 stated he had an amputation of left pinky toe and believed that the dressing should be changed daily. He was concerned that the dressing had not been changed recently, and his left heel was bothering him. During an observation conducted on [DATE] at 10:40 AM of Resident #18's left foot revealed the foot was wrapped with a Kling dressing and the tape was dated [DATE] ,d+[DATE] shift. Photographic Evidence Obtained. On [DATE], review of the August Treatment Administration Record (TAR) revealed that the nurse signed for Resident #18's wound treatment on [DATE] and [DATE]. No signature was recorded for [DATE] wound treatment. On [DATE], review of the August TAR revealed the Wound Care Nurse (WCN) signed on [DATE] and [DATE] acknowledging that Resident #18 received wound treatment on those days. An interview was conducted on [DATE] at 3:44 PM with WCN. She acknowledged that on Monday [DATE] she did not see Resident #18's wound nor changed the dressing. She noted that the floor nurses are aware to do the wound treatment if she does not. In addition, the WCN stated that for Resident #18, she did the wound treatment on [DATE] and she thought that the old wound dressing was dated [DATE]. She acknowledged signing in the TAR for the treatment on [DATE] even though she did not change the dressings that day. 2. Record review for Resident #99 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute on Chronic combined systolic (congestive) and Diastolic (Congestive) Heart Failure; Congestive Obstructive Pulmonary Disease; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Cardiomyopathy; Dementia; and Personal History of Malignant Neoplasm of Breast. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #99 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of Section GG revealed that Resident #99 required partial / moderate assistance for all her Activities of Daily Living (ADLs) and had a wheelchair. Review of Section J revealed that Resident #99 was not under Hospice Care. Review of the Physician's Orders showed that Resident #99 had an order for Advanced directive, Do Not Resuscitate (DNR). Review of the Recreational Services Note dated [DATE] documented Resident #99 preferred to be in her room watching TV and to maintain daily routine of reading and relaxing with her husband. Review of the Psych note dated [DATE] documented Resident #99 had a history of multiple medical problems and increased depression. She was cooperative with care and remains motivated to get well. Review of the Nursing Progress note dated [DATE] documented Resident #99 expired at 12:30 PM, MD [Medical Doctor] and Family notified, but no documentation recorded on [DATE] into [DATE]. An interview was conducted on [DATE] at 1:45 PM with Social Services Director. He stated that he was not aware that the nurses only documented that in their notes (referring to the note dated [DATE]). He acknowledged Resident #99's daughter was at the facility when the resident passed, but he did not write any documentation regarding Resident #99's passing. An interview was conducted on [DATE] at 2:50 PM with the Director of Nursing (DON). She stated that she was not in the facility when Resident #99 expired. She acknowledged Resident #99 was doing well and no health declined noted prior to [DATE]. She noted that Resident #99 was provided care on that day as documented in the Task by the Certified Nursing Assistant (CNA). She dis not have any other documentation of what transcribed on [DATE]. She stated that she was very upset with the nurse because of the lack of documentation on the passing of Resident #99.

Based on observations, interviews, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during medication administration for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to ensure Personal Protective Equipment (PPE) gowns were available on the 2nd floor for 8 of 11 residents who were on EBP; failed to have appropriate signage posted to indicate precautions for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to properly utilize hand hygiene and discard a used lancet after Blood Glucose check during medication administration observation for 1 of 1 sampled resident, Resident #3; and failed to ensure a sanitary environment during perineal care for 1 of 1 sampled resident reviewed for Urinary Tract Infection (UTI), Resident #56. The census at the time of the survey was 90 residents. The findings included: Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 09/01/22, included in part the following: EBP [Enhanced Barrier Precautions] is used to reduce the spread of Multidrug-Resistant Organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Procedure: 1. Identify residents who are appropriate for EBP including: b. Residents who have a wound and/or indwelling medical devices. 2. Place an identification outside the resident room to include type of precaution, required PPE [Personal Protective Equipment], and high-contact areas that require use of PPE. 4. Educate the staff on EBP including but not limited to: a. Use of PPE b. High-contact care activities. Review of the facility's policy, titled, Hand Hygiene, dated 02/05/21, included iin part the following: Hand hygiene should be performed: After contact with inanimate objects (including medical equipment) in the immediate patient vicinity. After glove removal. 1. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Dysphagia following Cerebral Infarction; Type 2 Diabetes Mellitus with Hyperglycemia; Gastrostomy status; and Hypoxic Ischemic Encephalopathy. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of the Physician's Orders showed Resident #53 had an order dated 08/16/24 for Nothing by mouth (NPO) every shift for PEG [Percutaneous Endoscopic Gastrostomy] Tube; Enteral feed order every shift continuous enteral feeding: Glucerna 1.5 at 80ml/hour x 20 hours; Enhanced Barrier Precautions for PEG Tube, every shift (dated 08/19/24). Review of the Care Plan dated 08/16/24 documented Resident #53 required EBP: PEG tube feeding. Goals were for EBP will be maintain for the duration of stay and/or until medical device is discontinued. Interventions were to educate staff on EBP including use of PPE, high contact care activity, hand hygiene, and resident activity; Place an identification outside resident room to include type of precaution required PPE, and high contact areas they require use of PPE. During an observation conducted on 08/21/24 at 8:06 AM, noted Staff L, Licensed Practical Nurse (LPN), entered Resident #53's room. He was observed entering Resident #53's room with medications without donning proper PPE. Further observation revealed Staff L was administering Resident #53's medication via PEG tube without a PPE gown. An interview was conducted on 08/21/24 at 1:28 PM with Staff L who stated he has been working at the facility for 3 years, and was the assigned nurse for Resident #53. Staff L stated EBP is assigned to residents with wounds, PEG tubes, Dialysis sites, etc. he stated EBP signage are placed outside their doors to make sure staff utilize proper PPE. When asked about Resident #53, he stated that the resident should be under EBP because he has a PEG tube and staff would wear PPE only if there was exposure to bodily fluids, however there was no need for PPE during medication administration. During an interview conducted on 08/21/24 at 4:30 PM, the corporate nurse acknowledged that PPE is to be donned during medication administration for residents with a PEG tube. 2. During the initial tour of the facility's 2nd floor conducted on 08/19/24 at 9:40 AM, it was observed that there were 11 brown and white plastic containers in the hallways for the residents on EBP. Further observation of these containers revealed that they were to contain PPE for the EBP residents. The observation revealed there were no gowns noted to be in 8 of these containers. During the morning of 08/19/24, no observation was noted of staff donning on PPE to provide morning care for the residents under EBP. On 08/19/24 at 12:54 PM, another observation was conducted of the PPE plastic containers and no gowns were found in these 8 containers. Again, staff were observed not donning on PPE to provide after-lunch care to the residents under EBP. During an observation conducted on 08/20/24 at 8:44 AM of the 2nd floor of the facility, the PPE plastic containers were inspected and again no gowns were found in the containers. Staff I, Registered Nurse (RN), and the Infection preventionist (IP), noticed the surveyor inspecting the PPE containers and a few minutes later, Staff I was observed stocking the containers with PPE gowns. An interview was conducted on 08/20/24 at 9:20 AM with the Director of Maintenance. He stated that it was his fault as to why the PPE kits were not replenished. He acknowledged he received the order for the gowns and did not get the order to Central supply in time for the kits to be restocked on the floor by staff. An interview was conducted on 08/22/24 at 12:33 PM with Staff I, RN. He stated he realized there were no PPE gowns in the plastic containers when he noticed the surveyor looking in the containers on 08/20/24. He stated he is the Infection Preventionist and is responsible for making sure that the containers are restocked, and the Certified Nursing Assistants (CNAs) are the ones that usually stock them. An interview was conducted on 08/22/24 at 1:06 PM with Staff G, CNA, who stated she has been working at the facility for 1 year. She stated that EBP in-service education was recently provided, and PPE is required when providing care to residents with IVs [intervenous], wounds, and PEG tubes. She acknowledged working on Monday 08/19/24 on the 2nd floor and did notice that there were no PPE gowns in the containers. She stated she was not assigned to any residents under EBP and did not require PPE gowns. 3. During the initial tour of the facility's 2nd floor conducted on 08/19/24 at 9:40 AM, obsrvtions noted that several residents had EBP signage posted outside of their doors. Further observation revealed that Resident #53 did not have a EBP signage posted outside of his room. Review of the Physician's Orders showed that Resident #53 had an order dated 08/16/24 for Nothing by mouth (NPO) every shift for PEG Tube; Enteral feed order every shift continuous enteral feeding: Glucerna 1.5 at 80ml/hour x 20 hours; Enhanced Barrier Precautions for PEG Tube, every shift (dated 08/19/24). During an observation conducted on 08/20/24 at 8:44 AM of the 2nd floor of the facility, Resident #53's room still had no EBP signage posted on the door or anywhere inside the room. During an observation conducted on 08/21/24 at 1:05 PM of the 2nd floor of the facility, Resident #53's room continued without EBP signage posted on the door or anywhere inside the room. During an interview conducted on 08/21/24 at 1:28 PM with Staff L, he stated EBP is assigned to residents with wounds, PEG tubes, Dialysis sites, etc. Staff L stated Resident #53 should be under EBP because he has a PEG tube. At this time, Staff L realized there was no EBP signage posted on Resident #53's door. An interview was conducted on 08/21/24 at 1:36 PM with Staff H, CNA, who stated she has been working at the facility for 4 months, and that Resident #53 was on her schedule assignment. Staff H stated she received in-service education for infection control, but could not recall as to why residents would be under EBP. She noted she follows the instructions on the precaution's signage posted outside of the rooms when providing care to the resident. Staff H acknowledged that there was no EBP sign posted outside of Resident #53's room. 4. A medication administration observation was conducted for Resident #3 on 08/20/24 at 4:02 PM with Staff K, LPN, who stated she has worked at the facility for 1 year. Staff K was observed entering the resident's room for a Blood Glucose (BG) check. Upon entering the room, she donned gloves, without performing hand hygiene, and performed the BG check. While holding the used lancet in her left gloved hand, she removed the glove, wrapping the used lancet in the glove, and then held it with her right gloved hand. Staff K walked out of the resident's room still holding the glove-wrapped used lancet in her right gloved hand. She then proceeded to remove the right glove and throw both gloves with the used lancet into the medication cart trash container. Without performing hand hygiene, Staff K moved to her computer and started her documentation. An interview was conducted on 08/20/24 at 5:07 PM with Staff K who was questioned on where she had disposed of the used lancet after the BG check. Staff K stated that she disposed it in the sharp's container on her medication cart. Staff K was asked to check the discarded gloves in her trash container. Without donning gloves, Staff K removed the used gloves from the trash container and found the used lancet inside the gloves. She then discarded the used lancet in the sharp's container. 38349 5. Review of the facility policy and procedure on 08/21/24 at 2:35 PM, titled, Policies and Procedures---Perineal Care, provided by the Director of Nursing (DON) revised 09/05/17, documented, in part, in the Policy Statement: Procedure .Wash, rinse and dry the skin .exposed skin surfaces are soiled Review of the facility policy and procedure on 08/21/24 at 2:45 PM, titled, Policies and Procedures---Personal Protective Equipment Program, provided by the Director of Nursing (DON), revised 03/01/15, documented, in part, in the Policy Statement: Policy the objectives of the Personal Protective Equipment (PPE) Program is to protect employees from the risk of injury by creating a barrier against workplace hazards Record review revealed Resident #56 was readmitted to the facility on [DATE] with diagnoses that included Calculus of Kidney, Severe Sepsis without Septic Shock, Obstructive and Reflux Uropathy, Major Depressive Disorder, Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Fracture of Unspecified Part of Neck of Left and Right Femur, Presence of Cardiac Pacemaker, Morbid (Severe) Obesity, Hypertension, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. the resident's Brief Interview Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. On 08/14/24, a Physician ordered Eccolab Urine Culture documented, Enterococcus Faecium; with a colony count of: >100,000 cfu/ml. On 08/16/24, the Physician's Order Summary Report documented, Nitrofurantoin Monohyd Macro oral capsule 100mg to give one (1) capsule by mouth two (2) times for Urinary Tract Infection (UTI) for seven (7) days. On 07/03/24, the UTI care plan documented, Focus: the resident has a UTI requiring Antibiotics. Interventions: . Good hygiene practices. Goal: the resident's UTI infection will resolve without complications by the review date. A peri-care observation was conducted on 08/21/24 at 10:10 AM with Resident #56. The resident's pericare was being performed by Staff G, Certified Nursing Assistant (CNA), who washed her hands for 35-40 seconds. Staff G was assisted by Staff H, CNA, who also washed her hands for 35-40 seconds. There was no protective gown donned by Staff G or Staff H prior to performing the peri-care. Staff G raised Resident #56's bed to her (staff) waist level and both Staff G and H went to the bathroom to wash their hands, obtained water (2 basins) for the cleaning, and added some peri-wash soap (Rinse-free) to the water. Staff G again washed her hands and gathered her supplies and donned a clean pair of gloves. It was observed that Resident #56 had had a bowel movement (not cleaned before the periocare). Staff G gently washed Resident #56's peri area from front to back on each separate side of the resident's labia, while the resident was lying on her back. Staff G was observed cleaning the resident, washed her hands, changed her gloves, and used a clean wash cloth and a package of Procare Large Adult Washcloths, and continued to do peri-care. Staff G then cleaned and dried the area 3 separate times. Staff G then removed the old gloves, sanitized and washed her hands, and applied a clean pair of gloves. Staff G turned the resident, cleaned and dried her buttock area from front to back with the Procare Large Adult Washcloths. Staff G obtained 2 clean basins of water, rinsed and dried Resident #56's Peri-area a second time after utilizing the peri-wash and using the Peri-clean spray 3 separate times in the peri-area. Throught the pericare, it was observed that Staff G's long hair braids were unsecured, loose, and hanging down freely in very close proximity to the resident and touching Resident #56's bed sheets, bedding, contaminated diaper and exposed skin, during the peri-care observation. This created the potential for resident-to-employee (vice versa) cross-contamination. Staff G then removed the used gloves, washed her hands, applied a clean pair of gloves and then turned Resident #56 and gently washed her buttock area from front to back, rinsed and then dried the area. She changed the 2 basins of water in between. Staff G was observed replacing Resident 56's diaper, after applying barrier cream to the resident's bottom and peri-area. Staff G then washed her hands for 35-40 seconds. Resident #56's skin was observed with slight redness with mild skin irritation. The resident had expressed this as a concern during the care. On 08/21/24 at 10:50 AM, an interview was conducted with Staff G, Staff H, Staff I, the Second Floor Registered Nurse, Unit Manager, and with Staff J, the covering RN/Director Of Nursing, regarding the above observations. Each acknowledged that staff members hair should not be allowed to come into contact with the resident's exposed skin during procedures. The DON acknowledged on 08/21/24 at 1:28 PM that a sanitary environment should always be maintained during the resident's care to avoid any type of cross-contamination, and this was not done.

Based on record review and interview, the facility failed to follow-up on monitoring residents with a change in condition for 1 of 2 sampled residents reviewed for death in the facility, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses to include Syncope (fainting), Heart Attack, Chronic Pulmonary Edema (fluid in lungs), Diabetes, Heart Disease, and Alcohol Use. Review of the admission progress note dated [DATE] at 7:08 AM documented the resident was admitted to the facility and was receiving oxygen at 2 liters a minute via nasal canula. The progress note further documented the resident's vital signs were within normal limits, and the resident was very drowsy and lethargic, hard to arouse, and appeared confused. Review of Resident #1's physician orders revealed orders dated [DATE] revealed an order for vital signs every shift. Further review of Resident #1's records revealed the last documentation of the resident's condition / vital signs was on [DATE] at approximately 8:30 PM. Review of the progress note documented the following: On [DATE] at 5:08 PM, the resident's oxygen level appeared to be below normal range (no oxygen level documented). Physician was notified, oxygen increased to 4 liters minute, and endorsed to oncoming nurse. On [DATE] at 11:00 PM, patient in stable condition; Awake, alert and oriented times one; Lungs were clear bilaterally; Oxygen 2 liters via nasal cannula noted; Tolerating well. No signs or symptoms of distress noted, voiced and/or reported. On [DATE] at 1:00 AM, nursing aide conducted rounding; No signs or symptoms of distress noted, voiced and/or reported; and monitoring ongoing. On [DATE] at 3:00 AM, lab rounded and ordered labs were drawn / collected by phlebotomist. Writer (nurse) conducted rounding; No signs or symptoms of distress noted, voiced and/or reported. The lab results had a collection time of 4:55 AM. On [DATE] at 5:00 AM, routine medications administered; No signs or symptoms of distress noted, voiced and or reported. On [DATE] at 5:30 AM, aide conducted AM care; No signs or symptoms of distress noted voiced and or reported. On [DATE] at 6:40 AM, Advanced Registered Nurse Practitioner (ARNP) rounded and found patient unresponsive; code called and 911 notified. On [DATE], at 6:45 AM, CPR (Cardiopulmonary Resuscitation) started, and Emergency Medical Services (EMS) and police arrived. The resident expired on [DATE] at 6:48 AM. Review of the Physician Services history and physical progress note dated [DATE] at 6:45 AM, documented a chief complaint of weakness. Resident presented to the hospital after found outside supermarket with a pint of vodka near. Unsure of downtime. Was medically managed for a heart attack and was transferred to the facility for rehabilitation. Resident #1 was found unresponsive on rounds, 911 and code blue called at 6:44 AM. An interview was conducted with the Nurse Practitioner (NP) via telephone on [DATE] at 12:00 PM. The NP stated she was rounding on the resident on [DATE] at 6:44 AM, and found the resident unresponsive, cold, and rigor mortis (rigidness) had set in. The NP stated the resident had obviously been deceased for a while. The NP stated none of the nursing staff could tell her when the resident was last seen/assessed, but just stated they had 'just seen the resident'. The surveyor questioned the NP on the laboratory results documented as collected on [DATE] at 4:55 AM. The NP stated she questions the validity of the results documented for Resident #1, are they Resident #1's. The NP stated the lab results for Resident #1 were impossible due to the condition the resident was found by the NP on [DATE] at 6:44 AM (less than 2 hours later). On [DATE], an attempt was made to call the assigned night nurse and CNA (Certified Nursing Assistant) but there were no return calls. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:30 PM. The DON stated she was unaware of the above. The DON stated she was told that a resident had expired, and the resident was being seen by the NP at the time. The DON acknowledged there were no documented vital signs / condition of the resident for night shift, after the change in condition documented on evening shift. The DON acknowledged Resident #1 had a roommate.

Based on facility record review, observation, clinical record review, and staff interviews the facility failed to provide care and services to prevent neglect of 1 out of 1 residents resulting in a death (Resident #1) out of a total of 11 sampled residents at risk for heat related illness. The resident had prolonged continuous direct sun exposure without staff monitoring for 3 hours and 45 minutes, from late morning to early afternoon, when the outside temperature range was from 85 to 88 degrees Fahrenheit with partly cloudy skies. During that time, the resident was not taken inside the facility for his lunch meal with the other residents. A significant change in the resident ' s condition occurred during the prolonged sun exposure, as evidenced by abnormal head and upper body movements, loss of consciousness, swelling [MEDICAL CONDITION] the body, upper and lower extremities, [MEDICAL CONDITION] and death. The facility staff failed to identify the changes in the resident ' s condition for approximately (01) one hour and (50) fifty minutes. The failure to provide these services resulted in immediate jeopardy for Resident #1. The findings include: Clinical record review revealed Resident #1 was admitted to the Nursing Home on [DATE] and re-admitted on [DATE]. The resident's active [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) Assessment on [DATE] documented the resident as alert with impaired cognition (indicating memory impairment), was unable to recall the year, month and day of the week, cognitive score of 6 out of 15. Impaired mobility and uses a wheelchair. The resident exhibited no mood and behavior issues during the evaluation period. The resident required extensive assistance for transfer, dressing, toileting, personal hygiene and total assistance for bathing. No skin condition was identified. The facility investigation report documented Resident #1 was found unresponsive outside at approximately 1:20 PM on [DATE]. A nurse (Staff #1) assessed the resident and 911 was called for emergency assistance and transported the resident to the hospital. Observation of the facility's [DATE] courtyard video recording (without audio) revealed Resident #1 was sitting in a wheelchair in the direct sun continuously for 3 hours and 45 minutes without supervision by the facility staff. The video recording shows an activity assistant, a licensed nurse and therapy staff in the courtyard interacting with other residents for brief periods but no staff interaction with Resident #1 was observed. The video recording shows at 11:35 AM the resident started having abnormal upper body jerking movement involving the head and trunk. The resident remained in a sitting position in the wheelchair beside a wooden table. The resident ' s back is facing the camera. The head and upper body movements continued intermittently for approximately 1 hour from 11:35 am to 12:35 PM. No movement of the resident was noted after 12:35 PM. At 1:16 PM a dietary aide goes to the courtyard and appears to be talking to the resident. The resident did not appear to respond. The dietary aide started to leave the courtyard but returned to the resident a second time, the resident did not move. The dietary aide left the courtyard. The resident remained sitting in the sun. At 1:17 PM, a certified nursing assistant arrived in the courtyard, and appears to talk to the resident. The resident did not respond. The certified nursing assistant left the courtyard and the resident still remained sitting in the sun. At 1:19 PM a registered nurse and a certified nursing assistant arrived in the courtyard and pushed the resident inside the building at 1:20 PM. An interview was conducted with both the Administrator and Director of Nursing on [DATE] at 10:30 AM. The Administrator stated the courtyard is monitored by camera, and the monitoring station is at the front entrance desk and the first floor nurse's station. On [DATE] (Saturday) the front desk was staffed at 9 AM to 9 PM. The receptionist and the nursing staff at the first floor nurse's station are supposed to check the residents in the courtyard but they were not required to document that they checked the residents. Resident #1's hospital record review revealed the resident arrived in the emergency department via fire rescue on [DATE] at 13:53. The triage nurse documented "EMS (emergency medical services) stated upon arrival, patient was found sitting in wheelchair, unresponsive, pulseless and Apneic (breathless)". Assessment revealed "2nd [MEDICAL CONDITION] to bilateral upper and lower extremities, head and abdomen, with sloughing of the skin noted". Patient arrived in [MEDICAL CONDITION]. Patient was hot to touch. EMS applied multiple ice packs to patient. Patient axillary temperature was 104.4 Fahrenheit, despite ice packs. CPR was terminated at 14:01 on [DATE] and patient pronounced dead. The hospital called the police and medical examiner and reported a suspicious cause of death. The emergency department physician documented [MEDICAL CONDITION] as the primary clinical impression and Hyperthermia [MEDICAL CONDITION] multiple sites as secondary". Interview on [DATE] at 12:05 PM, with the Activity Assistant (Staff #7), verified that she was in the courtyard under the gazebo on [DATE] with a group of residents that did not include Resident #1. She stated she does not recall seeing Resident #1 on [DATE] because he did not participate in any group activities; he liked to be by himself and did whatever he wanted independently. The Activity Assistant also stated she could not tell the surveyor anything about the resident's condition on [DATE]. In an interview with the Dietary Aide (Staff #6) on [DATE] at 3:00 PM, she stated that she was cleaning up in the first floor dining room after lunch on [DATE]. A resident in a motorized wheelchair said "I should come with him outside. There is a man outside, and something serious had happened to him. The resident stayed in the dining room and showed me the resident through the glass". During a further interview, the Dietary Aide stated that she went outside to the resident. "I called the resident's name twice, he did not respond". She stated she was about to come back inside when she went back and called his name again and he did not answer. She came back in and ran to the first floor nurse's station, saw the nurse and she told the nurse a resident outside is not answering when she called his name. The nurse and a C.N.A (Certified Nursing Assistant) brought him inside and she went back to work. Upon interview, conducted on [DATE] at 3:15 PM, with the Certified Nursing Assistant (Staff #4) who was assigned to Resident #1 on [DATE], stated that she checked the resident's blood pressure before breakfast and the blood pressure was high, so she informed the nurse. She assisted the resident with morning care and transferred him to the wheelchair. The resident went to the dining room and had breakfast. She observed the resident going toward the elevator after breakfast. She stated it was her second time working with the resident and she did not know the resident well. At lunch time, she fed two residents lunch and then went to the dining room. The resident (Resident #1) was not at the table so she went to find him. She told the nurse she could not find the resident and the nurse told her the resident is always sitting in the courtyard. When she went to the courtyard, the resident was unresponsive. She left the resident in the courtyard and went back inside the building to get the Registered Nurse (RN) on the first floor. She went back outside with the RN and they brought the resident inside the building to the first floor nurse's station. The resident's skin was very warm. His hands were swollen and darker than before. His hands were not swollen in the morning when she washed him. The resident was not smoking. During an interview the Registered Nurse Manager (Staff #2) on [DATE] at 11:25 AM, she stated Resident #1 was able to make his needs known and attempted to do simple tasks. His main activity was staying outside in the courtyard and doing word search puzzles. The resident goes out after breakfast and usually comes back in for lunch between 12:15 PM and 1:30 PM. The nurse stated the activity staff in the main dining room on the first floor is supposed to keep an eye on the resident activities in the courtyard and call nursing for any concerns. An interview was conducted at 2:45 PM on [DATE], with Licensed Practical Nurse (Staff #3), assigned to Resident #1 on [DATE]. The nurse stated she saw the resident in morning of [DATE] during breakfast and administered his morning medication around 9:00 AM. She stated it was an usual morning, as she was doing her assigned tasks when the nursing supervisor called for her to come down stairs. When she arrived to the first floor, the resident was sitting in a wheel chair at the nurse's station, with his head hanging down. His skin was very warm and his hands were swollen and skin broken. He looked different. The change in his skin was significant, swollen and very dark. "I immediately called 911 and started to cool him down with a wet cloth. The fire rescue arrived in less than 5 minutes. Fire rescue transferred the resident to a stretcher and started CPR." An interview was conducted at 6:00 PM on [DATE], with the Certified Respiratory Therapist (CRT, Staff #5). The CRT stated on [DATE], when he came off the elevator on the first floor at approximately 1:28 PM, he observed 3 to 4 nurses around a resident in front of the nurse's station. The resident was in a wheelchair and he asked what happened. The nurses said they were not sure but the resident is unresponsive. He asked if they checked the blood pressure and they reported the blood pressure was ,[DATE] and the pulse was 78. Then he asked about oxygen saturation and they said it was 95%. The resident was on 2 L oxygen via nasal cannula. The CRT checked the resident's pupils and observed his pupils were fixed and dilated. He told the nurses to get the resident to an empty bed. When they got to the room he applied a non-rebreather mask and fire rescue arrived. The resident was taken from the wheelchair to the fire rescue stretcher. The resident was pulseless and the fire rescue team initiated the ACLS (Advanced Cardiovascular Life Support) protocol. He observed as fire rescue took the resident to the truck continuing CPR and drove away. Based on the corrective measures implemented by the facility, immediate jeopardy for Tag F 224 was removed on [DATE] at 8:45 PM. The scope and severity level was decreased from a "J" level to a "D" level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The following includes the facility's corrective measures that were implemented after the Quality Assurance Ad Hoc committee met on [DATE]: The facility in-serviced all staff at the facility in all departments on all shifts on the following subject matters from [DATE] to [DATE]: courtyard monitoring guidelines, identifying changes in the resident ' s status and emergency procedures for handling changes in the resident's condition, medication management and pacemaker checks. See below for the specific training dates, subject matters and attendees: Courtyard monitoring/sign and symptoms of heat exhaustion: [DATE]: 11 CNA's; 3 LPN's; 4 RN's. [DATE]: 18 CNA's, 6 LPN's and 2 RN's [DATE]: 35 CNA's, 4 RN's, 13 LPN's, 14 Admin. Staff /Ancillary, 13 Physical Therapy/ Occupational Therapy staff members and 7 Dietary staff members. [DATE]: 1 RN, 4 LPN's, 2 CNA's [DATE]: 1 LPN, 7 Dietary staff members, 2 RN. 25 other staff members [DATE]: 1 Speech Therapist, 5 LPN's, 3 RN's, 27 CNA's, 7 other staff members Change in condition documentation (including: "seems different than usual; talks or communicates less; overall needs more help; pain-new or worsening; participated less in activities; ate less; no bowel movement in 3 days; or diarrhea; drank less; weight change; agitated or nervous more than usual; tired, weak confused, or drowsy; change in skin color or condition; help with walking, transferring, and toileting more than usual"): [DATE]: 3 LPN's, 1 RN. [DATE]: 13 LPN's and 3 RN's. [DATE]: 1 RN and 5 LPN's, [DATE]: 3 RN's and 3 LPN's. Emergency response to residents: [DATE]: 5 LPN's and 7 CNA's [DATE] 28 CNA's and 7 LPN's [DATE] 13 LPN's, 5 RN's and 7 CNA's. [DATE]: 1 RN, 4 LPN's and 2 CNA's [DATE]: 3 LPN's, 3 RN's and 35 other staff members [DATE]: 87 other staff members, 45 CNA's, 5 RN's and 5 LPN's Medication Management: [DATE]: 8 LPN's and 2 RN's Pacemaker checks: [DATE] :25 LPN's, 2 RN's [DATE]: 22 LPN's and 2 RN's. [DATE]: 3 RN's [DATE]: 5 LPN's and 14 RN's, The facility assessed and care planned all "at risk " dependent and independent residents, related to their safety and well-being, while using the patio. The facility implemented the use of the "Courtyard Monitoring" Guidelines, which entails a monitoring system for residents while outside. Monitoring is ongoing. A staff is assigned to the courtyard area from 8 AM - 8 PM. The receptionist at the front entrance checks the video monitor and documents courtyard activities on a "courtyard monitoring form" every 30 minutes. The guidelines also instruct the facility staff is required to utilize the courtyard monitoring check list and monitor the following: offer residents fluids while outside, offer sun screen, hats/ visors and sunglasses, encourage residents to wear appropriate clothing according to the weather conditions, offer residents assistance as needed while outside and offer to assist residents inside as needed. The facility also implemented a door alarm code to access the courtyard. The residents must request to go outside from the facility staff to ensure their safety and well-being. Reviewed the evaluation of residents for their level of assistance to get to the courtyard as well as while outside. Reviewed the resident's care plan in relation to their choice to go outside. Evaluated the courtyard times and when the area will be locked for evening and night (courtyard is open with an assigned staff present from 8 AM - 8 PM). The facility will identify residents upon new admission that prefer to go outside and will determine their level of assistance. On [DATE], the facility staff were observed implementing the Courtyard Monitoring guidelines to include, staff assigned to courtyard were observed and interviewed about courtyard guidelines; the every 30 minutes monitoring checklist was observed to be used by receptionist and the staff assigned to the courtyard and the hydration cart was observed in the courtyard area. (Cross reference to F 226, F 279 and F 323)

Based on record review, observation, resident and staff interviews, and review of the facility's policy, "Abuse/Neglect and Misappropriation of Patient Property," and "Courtyard Monitoring Guidelines" the facility failed to ensure the written policy to prevent neglect was implemented on [DATE] and neglected to implement the "Courtyard Monitoring Guidelines", utilized to provide for the ongoing supervision and safety of residents who enjoy the outdoor courtyard on [DATE]. The facility's nursing staff neglected to assess, and provide care to prevent injury and death related to prolonged exposure to the sun heat environment. This affected 1 out of 1 residents resulting in death (Resident #1) out of a total of 11 sampled residents at risk for heat related illness. The resident had prolonged continuous direct sun exposure without staff monitoring for 3 hours and 45 minutes, from late morning to early afternoon, when the outside temperature range was from 85 to 88 degrees Fahrenheit with partly cloudy skies. During that time, the resident was not taken inside the facility for his lunch meal with the other residents. A significant change in condition occurred during the prolonged sun exposure, as evidenced by abnormal head and upper body movements, loss of consciousness, swelling [MEDICAL CONDITION] the body, upper and lower extremities, [MEDICAL CONDITION] and death. The facility staff failed to identify the changes in the resident ' s condition for approximately (01) one hour and (50) fifty minutes. The failure to provide these services resulted in immediate jeopardy for Resident #1. The findings include: A review of the facility's "Abuse, Neglect and Misappropriation of Property Prevention" policy dated [DATE] revealed "Neglect" means "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness". A review of the facility's policy titled "Courtyard Monitoring Guidelines" dated [DATE]" revealed the "guidelines are utilized to provide for the ongoing supervision and safety of patients who enjoy the outdoor courtyard. The elderly are more at risk for heat/cold exposure and associated symptoms". The courtyard doors and other exits doors are alarmed to alert staff that a patient has entered the courtyard. Nursing staff responds immediately to determine which patient is outside and appropriateness of courtyard usage secondary to patient abilities and weather conditions. Evaluate patient who may participate in outside activities and develop plan of care to address risk factor related to outside activities. Complete re-evaluations with changes in the patient condition or as clinically indicated. Clinical record review revealed Resident #1 was admitted to the Nursing Home on [DATE] and re-admitted on [DATE]. The resident's active [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment on [DATE], documented Resident #1 as alert with impaired cognition (indicating memory impairment), and was unable to recall the year, month and day of the week, cognitive score of 6 of 15. Impaired mobility with use of a wheelchair. The resident exhibited no mood and behavior during the evaluation period. The resident requires extensive assistance for transfer, dressing, toileting, personal hygiene and total assistance for bathing. No skin condition was identified. The facility investigation report documented the resident was found unresponsive outside at approximately 1:20 PM on [DATE]. A nurse (Staff #1) assessed the resident and called 911 for additional assistance and transported the resident to the hospital. Clinical record review revealed the resident had multiple risk factors for heat exposure hazard due to the resident's advanced age, dementia, [DIAGNOSES REDACTED]. The resident's assessment did not include an evaluation of potential risk for heat exposure injuries. The care plans did not describe specific interventions for providing adequate supervision of the resident with assessed cognitive loss and short term memory problems. Observation of the facility's [DATE] courtyard video recording (without audio) revealed Resident #1 was sitting in a wheelchair in the sun continuously for 3 hours and 45 minutes without supervision by the facility staff. The video recording shows an activity assistant, a licensed nurse and therapy staff in the courtyard interacting with the other residents for brief periods but no staff interaction with Resident #1 was observed. The video recording shows at 11:35 am, the resident started having abnormal upper body jerking movement involving the head and trunk. The resident remained in a sitting position in the wheelchair, beside a wooden table. The resident ' s back is facing the camera. The head and upper body movements continued intermittently for approximately 1 hour from 11:35 am to 12:35 PM. No movement of the resident was noted after 12:35 PM. At 1:16 PM, a dietary aide went to the courtyard and appears to be talking to the resident. The resident did not appear to respond. The dietary aide started to leave the courtyard but returned to the resident a second time. The resident did not move. The dietary aide left the courtyard. Resident #1 remained sitting in the sun. At 1:17 PM, a Certified Nursing Assistant arrived in the courtyard, appeared to talk to the resident. The resident did not respond. The Certified Nursing Assistant left the courtyard, and the resident remained sitting in the sun. At 1:19 PM, a Registered Nurse and a Certified Nursing Assistant arrived in the courtyard and pushed the resident inside the building at 1:20 PM. An interview was conducted with both the Administrator and Director of Nursing on [DATE] at 10:30 AM. The Administrator stated the courtyard is monitored by camera, and the monitoring station is at the front entrance desk and the first floor nurse's station. On [DATE] (Saturday) the front desk was staffed at 9 AM to 9 PM. The receptionist and the nursing staff at the first floor nurse's station are supposed to check the residents in courtyard but they were not required to document that they checked the residents. Resident #1's hospital record review revealed the resident had arrived in the Emergency Department via fire rescue on [DATE] at 1:53 PM. The triage nurse documented "EMS (emergency medical services) and stated upon arrival, "the patient was found sitting in wheelchair, unresponsive, pulseless and Apneic (breathless)." Assessment revealed "2nd [MEDICAL CONDITION] to bilateral upper and lower extremities, head and abdomen, with sloughing of the skin noted." The patient arrived in [MEDICAL CONDITION]. The patient was hot to touch. EMS applied multiple ice packs to the resident. The patient's axillary temperature was 104.4 degrees Fahrenheit despite ice packs. CPR was terminated at 2:01 PM on [DATE] and the patient was pronounced dead". The hospital called the police and medical examiner and reported a suspicious cause of death. The emergency department physician documented [MEDICAL CONDITION] as the primary clinical impression and Hyperthermia [MEDICAL CONDITION] multiple sites as secondary. An interview was conducted on [DATE] at 2:00 PM with Resident #3, who is alert and oriented with no short term memory deficit. Resident #3 stated Resident #1 was sitting in the sun for the whole time he was in the courtyard. At about 11:15 am, he left the courtyard and went to lunch. When he returned to the courtyard it was after 1 PM. Resident #1 was still sitting in the sun in the same spot. The resident was not moving and did not appear to be breathing. His head was down and he did not look good so, he went back inside to the main dining room and told a person who was coming out of the kitchen that another resident outside had something seriously wrong. The person went to the courtyard and came back inside, then left the dining room to get the nurse. The resident stated on Saturday ([DATE]), he did not see any staff person in the courtyard checking on the residents. In the past 2 days they have someone out there checking and offering us water and juice. Staff tells residents that they should not sit in the sun for too long. During an interview with the Dietary Aide (Staff #6) on [DATE] at 3:00 PM, she stated she was cleaning up in the first floor dining room after lunch on [DATE]. A resident in a motorized wheelchair said "I should come with him outside, there is a man outside, and something serious had happened to him. The resident stayed in the dining room and showed me the resident through the window." She stated she went outside to the resident. Staff #6 stated "I called the resident's name twice, but he did not respond". She was about to come back inside but went back to him and called his name again, he did not answer. She came back in and ran to the first floor nurse's station, saw a nurse and she told the nurse a resident is outside and is not answering when she called his name. The nurse and a C.N.A brought him inside and she went back to work. Upon interview on [DATE] at 12:05 PM, with the Activity Assistant (Staff #7), she verified that she was in the courtyard under the gazebo on [DATE] with a group of residents that did not include Resident #1. She stated that she does not recall seeing Resident #1 on [DATE] because he does not participate in any group activities; he likes to be by himself and does whatever he wants independently. The Activity Assistant also stated she could not tell the surveyor anything about the resident ' s condition on [DATE]. An interview was conducted on [DATE] at 3:15 PM, with the Certified Nursing Assistant (Staff #4) who was assigned to Resident #1 on [DATE]. The Certified Nursing Assistant stated that she checked the resident's blood pressure before breakfast and the blood pressure was high so she informed the nurse. She assisted the resident with AM care and transferred him to the wheelchair. The resident went to the dining room and had breakfast. She observed the resident going toward the elevator after breakfast. She stated it was her second time working with the resident and she did not know the resident well. At lunch time she fed two residents lunch and then went to the dining room. Resident #1 was not at the table so she went to find him. She told the nurse she could not find the resident and the nurse told her the resident is always sitting in the courtyard. When she went to the courtyard, the resident was unresponsive. She left the resident in the courtyard and went back inside the building to get the Registered Nurse (RN) on the first floor. She went back outside with the RN and they brought the resident inside the building to the first floor nurse's station. The resident's skin was very warm. His hands were swollen and darker than before. His hands were not swollen in the morning when she washed him. The resident was not smoking. On [DATE] at 11:25 AM the Nurse Manager (Staff #2) stated Resident #1 was able to make his needs known and attempted to do simple tasks. His main activity was staying outside in the courtyard and doing word search puzzles. She stated the resident goes out after breakfast and usually comes back in for lunch between 12:15 PM and 1:30 PM. The nurse stated the activity staff in the main dining room on the first floor is supposed to keep an eye on the resident activities in the courtyard and call nursing for any concerns. An interview was conducted at 2:45 PM on [DATE], with a Licensed Practical Nurse (Staff #3) assigned to Resident #1 on [DATE]. The nurse stated she saw the resident on morning of [DATE] during breakfast and administered his morning medication around 9:00 AM. She stated it was a usual morning; she was doing her assigned tasks when the nursing supervisor called for her to come down stairs. When she arrived to the first floor, the resident was sitting in a wheelchair at the nurse's station, with his head hanging down, his skin was significantly swollen and very dark. "I immediately called 911 and started to cool him down with a cold wet cloth. Fire rescue arrived in less than 5 minutes. Fire rescue transferred the resident to a stretcher and started CPR." Based on the corrective interventions implemented by the facility, immediate jeopardy for Tag F 226 was removed on [DATE] at 8:45 PM. The scope and severity level was decreased from a " J " level to a " D " level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The following includes the facility's corrective measures that were implemented after the Quality Assurance Ad Hoc committee met on [DATE]: The facility in-serviced all staff at the facility in all departments on all shifts on the following subject matters from [DATE] to [DATE]: courtyard monitoring guidelines, identifying changes in the resident ' s status and emergency procedures for handling changes in the resident's condition, medication management and pacemaker checks. See below for the specific training dates, subject matters and attendees: Courtyard monitoring/sign and symptoms of heat exhaustion: [DATE]: 11 CNA's; 3 LPN's; 4 RN's. [DATE]: 18 CNA's, 6 LPN's and 2 RN's [DATE]: 35 CNA's, 4 RN's, 13 LPN's, 14 Admin. Staff /Ancillary, 13 Physical Therapy/ Occupational Therapy staff members and 7 Dietary staff members. [DATE]: 1 RN, 4 LPN's, 2 CNA's [DATE]: 1 LPN, 7 Dietary staff members, 2 RN. 25 other staff members [DATE]: 1 Speech Therapist, 5 LPN's, 3 RN's, 27 CNA's, 7 other staff members Change in condition documentation (including: "seems different than usual; talks or communicates less; overall needs more help; pain-new or worsening; participated less in activities; ate less; no bowel movement in 3 days; or diarrhea; drank less; weight change; agitated or nervous more than usual; tired, weak confused, or drowsy; change in skin color or condition; help with walking, transferring, and toileting more than usual"): [DATE]: 3 LPN's, 1 RN. [DATE]: 13 LPN's and 3 RN's. [DATE]: 1 RN and 5 LPN's, [DATE]: 3 RN's and 3 LPN's. Emergency response to residents: [DATE]: 5 LPN's and 7 CNA's [DATE] 28 CNA's and 7 LPN's [DATE] 13 LPN's, 5 RN's and 7 CNA's. [DATE]: 1 RN, 4 LPN's and 2 CNA's [DATE]: 3 LPN's, 3 RN's and 35 other staff members [DATE]: 87 other staff members, 45 CNA's, 5 RN's and 5 LPN's Medication Management: [DATE]: 8 LPN's and 2 RN's Pacemaker checks: [DATE] :25 LPN's, 2 RN's [DATE]: 22 LPN's and 2 RN's. [DATE]: 3 RN's [DATE]: 5 LPN's and 14 RN's, The facility assessed and care planned all "at risk " dependent and independent residents, related to their safety and well-being, while using the patio. The facility implemented the use of the "Courtyard Monitoring" Guidelines, which entails a monitoring system for residents while outside. Monitoring is ongoing. A staff is assigned to the courtyard area from 8 AM - 8 PM. The receptionist at the front entrance checks the video monitor and documents courtyard activities on a "courtyard monitoring form" every 30 minutes. The guidelines also instruct the facility staff is required to utilize the courtyard monitoring check list and monitor the following: offer residents fluids while outside, offer sun screen, hats/ visors and sunglasses, encourage residents to wear appropriate clothing according to the weather conditions, offer residents assistance as needed while outside and offer to assist residents inside as needed. The facility also implemented a door alarm code to access the courtyard. The residents must request to go outside from the facility staff to ensure their safety and well-being. Reviewed the evaluation of residents for their level of assistance to get to the courtyard as well as while outside. Reviewed the resident's care plan in relation to their choice to go outside. Evaluated the courtyard times and when the area will be locked for evening and night (courtyard is open with an assigned staff present from 8 AM - 8 PM). The facility will identify residents upon new admission that prefer to go outside and will determine their level of assistance. On [DATE], the facility staff were observed implementing the Courtyard Monitoring guidelines to include, staff assigned to courtyard were observed and interviewed about courtyard guidelines; the every 30 minutes monitoring checklist was observed to be used by receptionist and the staff assigned to the courtyard and the hydration cart was observed in the courtyard area. (Cross reference to F 224, F 279 and F 323)

Based on clinical record review, staff interview and facility policy review, the facility failed to: (1) develop a care plan regarding supervision to address the associated risk factors related to heat and sun exposure during the resident's participation in outside activities; and (2) develop a care plan to address the use and monitoring of an Automatic Implantable Cardioverter Defibrillator. This affected 1 out of 1 sampled residents resulting in death (Resident #1) out of a total sample of 11 residents. A significant change in the resident ' s condition occurred during the prolonged sun exposure, as evidenced by abnormal head and upper body movements, loss of consciousness, swelling [MEDICAL CONDITION] the body, upper and lower extremities, [MEDICAL CONDITION] and death. The failure to address these risk factors resulted in immediate jeopardy for Resident #1. The findings include: Clinical record review revealed Resident #1 was admitted to the Nursing Home on [DATE] and re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident as alert with impaired cognition (indicating memory impairment), was unable to recall the year, month and day of the week, a cognitive score of 6 out of 15. Impaired mobility- uses wheelchair. The resident exhibited no mood and behavior patterns during the evaluation period. The resident requires extensive assistance for transfer, dressing, toileting, personal hygiene and total assistance for bathing. No skin condition, were identified. The facility investigation report revealed at 1:20 PM on [DATE], Resident #1 was found unresponsive outside sitting in the sun. The resident suffered from a [MEDICAL CONDITION] at the facility and cardio- [MEDICAL CONDITION] resuscitate (CPR) was unsuccessful. The resident was pronounced dead at the hospital emergency department on [DATE] at 2:01 PM. Review of Resident #1's care plan with a Registered Nurse/Care Plan/MDS Coordinator on [DATE] at 1:30 PM, revealed the care plans in the medical record did not describe interventions for supervision of the resident during outside activities or interventions for risk factors related to heat and sun exposure. The following related care plans were reviewed on [DATE]. Page 1. (Initiated [DATE] and revised [DATE]) "Resident continues to require cues and simple explanation of activities and encouragement for group. Activity Intervention: Resident was encouraged to attend Catholic services and entertainment/music program and be provided with direction. Resident receives in room weekly catholic services and pet therapy throughout the week. Family is very supportive". Page 3. (Initiated [DATE]) "Need to monitor for complication related to potassium supplement needed secondary to diuretic therapy." Page 4.(Initiated [DATE] and revised [DATE]) "ADL self-care deficit as evidenced by decreased UE( Upper Extremity) strength, decreased activity tolerance, decreased function mobility due to AMA (altered mental status) with increased agitation. Resident eats with his hands at times." Page 5. (Initiated [DATE]) "Requires assistance/potential to restore function for dressing as evidenced by assistance needed for dressing as related to impaired mobility and physical limitation". Page 6. (Initiated [DATE]) "Requires assistance to restore function for mobility as evidenced by decreased balance and impaired cognition". Page 7. (Initiated [DATE] and revised [DATE]) "Cognitive Impairment [DIAGNOSES REDACTED]. Page 8. (Initiated [DATE]) "Resistive/noncompliant with treatment care does not want to wear depend. Cognitive impairment and believes treatment is not needed". Page 9. (Initiated [DATE]) "History of smoking in community/ Inappropriate smoking related to cognitive impairment, noncompliance with policy". Page 10. (Initiated [DATE] and revised [DATE]) "Cognitive loss as evidenced by exhibiting short term memory problem related to effect [MEDICAL CONDITION] Dementia and on medication". Page 11. (Initiated [DATE] and revised [DATE]) "Difficulty communication related to decline in cognitive status secondary to dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]". Page 12. (Initiated [DATE] and revised [DATE]) "Urine incontinence related to [MEDICAL CONDITIONS], physical limitation". Page 13. (Initiated [DATE]) 'Bowel incontinence related to loss of sphincter control". Page 15. (Initiated [DATE] and revised [DATE]) "At risk for alteration in hydration due to diuretic use". Page 18. (Initiated [DATE] and revised [DATE]) "History of falls due to impaired balance and poor coordination, unsteady gait potential medication side effect". Page 21. (Initiated [DATE] and revised [DATE]) "Cardiovascular disease related to Hypertension, history of [MEDICAL CONDITIONS] right [MEDICAL CONDITION] and [MEDICAL CONDITION] Fibrillation". Page 26. (Initiated [DATE]) "At risk for adverse effects related to diuretic therapy". During an interview the Registered Nurse Manager (Staff #2) on [DATE] at 11:25 AM, she stated Resident #1 was able to make his needs known and attempted to do simple tasks. His main activity was staying outside in the courtyard and doing word search puzzles. She stated the resident goes out after breakfast and usually comes back in for lunch between 12:15 PM and 1:30 PM. The nurse stated the activity staff in the main dining room on the first floor is supposed to keep an eye on the resident activities in the courtyard and call nursing for any concerns. Further review of the clinical record for Resident #1 revealed an operative report dated [DATE]. The patient was taken to the operating room for exchange of an AICD (Automatic Implantable Cardioverter Defibrillator) generator. The procedure performed was the Exchange of Medtronic AICD and revision of subcutaneous pocket. Postoperative [DIAGNOSES REDACTED]. An (AICD) Automatic Implantable Cardio converter Defibrillator is a small battery powered electrical impulse generator that is implanted in patients who are at risk for sudden cardiac death. The device is programmed to detect cardiac arrhythmia and corrects itself by delivering jolts of electricity. A physician documented in a History and Physical report on [DATE] "Post AICD interrogation, showing normal functioning. The patient had recent AICD generator exchanged on ,[DATE]". No subsequent testing of the AICD or cardiology evaluation was found in the medical record or provided upon request. There was no evidence Resident #1 had testing or evaluation of his device for approximately 1 year and 9 months after placement. Further review of the care plan revealed the facility did not develop a written care plan to identify the use of the AICD and establish interventions for monitoring the AICD function. The facility "Pacemaker Check Telephonic" policy, dated ,[DATE] requires upon admission the nurse will check the resident's pacemaker for model and Manufacturer Number. Pacemaker check will be scheduled according to the manufacturer's recommendation and/or physician orders. Based on the corrective interventions implemented by the facility, immediate jeopardy for Tag F 279 was removed on [DATE] at 8:45 PM. The scope and severity level was decreased from a " J " level to a " D " level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The following includes the facility's corrective measures that were implemented after the Quality Assurance Ad Hoc committee met on [DATE]: The facility in-serviced all staff at the facility in all departments on all shifts on the following subject matters from [DATE] to [DATE]: courtyard monitoring guidelines, identifying changes in the resident ' s status and emergency procedures for handling changes in the resident's condition, medication management and pacemaker checks. See below for the specific training dates, subject matters and attendees: Courtyard monitoring/sign and symptoms of heat exhaustion: [DATE]: 11 CNA's; 3 LPN's; 4 RN's. [DATE]: 18 CNA's, 6 LPN's and 2 RN's [DATE]: 35 CNA's, 4 RN's, 13 LPN's, 14 Admin. Staff /Ancillary, 13 Physical Therapy/ Occupational Therapy staff members and 7 Dietary staff members. [DATE]: 1 RN, 4 LPNs, 2 CNA's [DATE]: 1 LPN, 7 Dietary staff members, 2 RN. 25 other staff members [DATE]: 1 Speech Therapist, 5 LP's, 3 RN's, 27 CNA's, 7 other staff members Change in condition documentation (including: "seems different than usual; talks or communicates less; overall needs more help; pain-new or worsening; participated less in activities; ate less; no bowel movement in 3 days; or diarrhea; drank less; weight change; agitated or nervous more than usual; tired, weak confused, or drowsy; change in skin color or condition; help with walking, transferring, and toileting more than usual"): [DATE]: 3 LPN's, 1 RN. [DATE]: 13 LPN's and 3 RN's. [DATE]: 1 RN and 5 LPN's, [DATE]: 3 RN's and 3 LPN's. Emergency response to residents: [DATE]: 5 LPN's and 7 CNA's [DATE] 28 CNA's and 7 LPN's [DATE] 13 LPN's, 5 RN's and 7 CNA's. [DATE]: 1 RN, 4 LPN's and 2 CNA's [DATE]: 3 LPN's, 3 RN's and 35 other staff members [DATE]: 87 other staff members, 45 CNA's, 5 RN's and 5 LPN's Medication Management: [DATE]: 8 LPN's and 2 RN's Pacemaker checks: [DATE] :25 LPN's, 2 RN's [DATE]: 22 LPN's and 2 RN's. [DATE]: 3 RN's [DATE]: 5 LPN's and 14 RN's, The facility assessed and care planned all "at risk " dependent and independent residents, related to their safety and well-being, while using the patio. The facility implemented the use of the "Courtyard Monitoring" Guidelines, which entails a monitoring system for residents while outside. Monitoring is ongoing. A staff is assigned to the courtyard area from 8 AM - 8 PM. The receptionist at the front entrance checks the video monitor and documents courtyard activities on a "courtyard monitoring form" every 30 minutes. The guidelines also instruct the facility staff is required to utilize the courtyard monitoring check list and monitor the following: offer residents fluids while outside, offer sun screen, hats/ visors and sunglasses, encourage residents to wear appropriate clothing according to the weather conditions, offer residents assistance as needed while outside and offer to assist residents inside as needed. The facility also implemented a door alarm code to access the courtyard. The residents must request to go outside from the facility staff to ensure their safety and well-being. Reviewed the evaluation of residents for their level of assistance to get to the courtyard as well as while outside. Reviewed the resident's care plan in relation to their choice to go outside. Evaluated the courtyard times and when the area will be locked for evening and night (courtyard is open with an assigned staff present from 8 AM - 8 PM). The facility will identify residents upon new admission that prefer to go outside and will determine their level of assistance. On [DATE], the facility staff were observed implementing the Courtyard Monitoring guidelines to include, staff assigned to courtyard were observed and interviewed about courtyard guidelines; the every 30 minutes monitoring checklist was observed to be used by receptionist and the staff assigned to the courtyard and the hydration cart was observed in the courtyard area. (Cross reference to F 224, F 226, and F 323)

Based on record review, observation and interview, the facility failed to: (1) implement the facility's courtyard monitoring policy to prevent heat exposure of residents at risk for heat related illness due to age and multiple medical conditions specifically, heart disease, hypertension and the use of photosensitive medications; and (2) access, develop and implement interventions to address heat exposure risk factors for a resident resulting in death with abnormally high body temperature and prolonged exposure to sun for 3 hours and 45 minutes on [DATE] from late morning to early afternoon, when the outside temperature range of ,[DATE] degrees Fahrenheit with partly cloudy skies. During that time, the resident was not taken inside the facility for his lunch meal with the other residents. This affected 1 of 1 resident resulting in death (Resident #1) out of a total sample of 11 residents at risk for heat related illness. The failure to provide these services resulted in immediate jeopardy for Resident #1. The findings include: The facility's policy titled "Courtyard Monitoring Guideline" dated [DATE] revealed the guidelines are "utilized to provide for the ongoing supervision and safety of patients who enjoy the outdoor courtyard. The elderly are more at risk for heat/cold exposure and associated symptoms. The courtyard doors and other exits doors are alarmed to alert staff that a patient has entered the courtyard. Nursing staff responds immediately to determine which patient is outside and appropriateness of courtyard usage secondary to patient abilities and weather conditions. Evaluate patient who may participate in outside activities and develop plan of care to address risk factor related to outside activities. Complete re-evaluations with changes in the patient condition or as clinically indicated". "Patient determined by the inter-disciplinary team to be cognitively impaired, have impaired communication, require extensive assistance with mobility and have poor decision making skills are not permitted to go outside unless accompanied by a staff or family member. Many medications can cause photosensitivity that makes the skin of the patient unusually sensitive to light. Sunburns may develop from sun exposure that would not normally affect the patient. Provide patient education to keep these residents out of direct sunlight as able". Clinical record review revealed Resident #1 was admitted to the Nursing Home on [DATE] and re-admitted on [DATE]. The resident's active [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS), documented assessment dated [DATE] the resident as alert with impaired cognition (indicating memory impairment), was unable to recall the year, month and day of the week, cognitive score of 6 out of 15. Impaired mobility- uses wheelchair, The resident exhibited no mood and behavior during the evaluation period. The resident requires extensive assistance for transfer, dressing, toileting, personal hygiene and total assistance for bathing. No skin condition concerns were identified. The facility accident investigation report dated [DATE] documented Resident #1 was found unresponsive outside at approximately 1:20 PM on [DATE], a nurse (Staff #1) assessed the resident and 911 was called for emergency assistance and transported the resident to the hospital. The facility investigation revealed the resident self- propelled his wheelchair around the facility and often went outside in the courtyard area to socialize. Clinical record review revealed the resident had multiple risk factors for heat exposure hazard due to the resident's advanced age, dementia, [DIAGNOSES REDACTED]. Further investigation revealed the facility nursing and activity staff are aware the resident often goes outside to the courtyard to sit in the sun and socialize. The resident assessment did not include an evaluation of potential risk for heat exposure injuries. The care plans did not describe specific interventions for providing adequate supervision of the resident with assessed cognitive loss, short term memory problems due to Dementia and CVA. Observation of the facility's courtyard video recording (no audio) revealed Resident #1 was sitting in a wheelchair in the sun continuously for 3 hours and 45 minutes without supervision by the facility staff. The video recording shows an activity assistant, a nurse and therapy staff in the courtyard, interacting with other residents for brief periods, but no staff interaction with Resident #1 was observed. The video recording shows at 11:35 AM the resident started having abnormal upper body jerking movement involving the head and trunk. The resident remained in a sitting position in the wheelchair beside a wooden table. The resident ' s back is facing the camera. The head and upper body movements continued intermittently for approximately 1 hour (11:35 AM to 12:35 PM). No movement of the resident was noted after 12:35 PM. At 1:16 PM a dietary aide (Staff #6) goes to the resident and appears to be talking to the resident. The resident did not appear to respond. The dietary aide started to leave the courtyard but returned to the resident a second time. The resident did not move. The dietary aide left the courtyard. The resident remained sitting in the sun. At 1:17 PM a certified nursing assistant arrived in the courtyard, appears to talk to the resident, the resident did not respond and the certified nursing assistant left the courtyard. The resident was still sitting in the sun. At 1:19 PM a Registered Nurse (Staff #1) and a certified nursing assistant arrived in the courtyard and pushed the resident inside the building at 1:20 PM. An interview was conducted with both the Administrator, and Director of Nursing on [DATE] at 10:30 AM. The Administrator stated the courtyard is monitored by camera, and the monitoring station is at the front entrance desk and the first floor nurse's station. On [DATE] (Saturday) the front desk was staffed at 9 AM to 9 PM. The receptionist and the nursing staff at the first floor nurse's station are supposed to check the residents in courtyard but they were not required to document that they checked the residents. Resident #1's hospital record review revealed the resident arrived in the Emergency Department (ED) via fire rescue on [DATE] at 13:53. The triage nurse documented "EMS (emergency medical services) stated upon arrival patient was found sitting in wheelchair, unresponsive, pulseless and Apneic (breathless)". Assessment revealed "2nd degree burns noted to bilateral upper and lower extremities, head and abdomen, with sloughing of the skin noted. " Patient arrived in cardiac arrest. Patient was hot to touch. EMS applied multiple ice packs to patient. Patient ' s auxiliary temperature was 104.4 degrees Fahrenheit despite ice packs. CPR was terminated at 14:01 on [DATE] and patient pronounced dead". The hospital called the police and medical examiner and reported a suspicious cause of death. The ED physician documented Cardiac Arrest as the primary clinical impression and Hyperthermia and burns of multiple sites as secondary. An interview was conducted on [DATE] at 1:30 PM with Resident #2, who is alert and oriented with no short term memory deficit. The resident stated last Saturday ([DATE]) when she came out to the courtyard, Resident #1 was already out here; he usually comes out every day after breakfast and goes back in for lunch. On Saturday he was sitting in the sun beside a table. Resident #2 reported Resident #1 did not wear a hat and he likes to sit in the sun. He pushes the wheelchair with his feet to move around. Resident #1 was talking to her and another resident and he (Resident #1) seemed his usual self. Resident #2 stated an activity person and other persons were out in the courtyard, they were in the shade under the gazebo. The activity person did not speak to the resident or offer him anything to drink. The resident stated she went back inside at about 11 AM for lunch; she ate her lunch and went to her room. When she came back to the courtyard, Resident #1 was still at the same place sitting in the sun, with his head down and foam coming from his mouth. He was not moving, his hands looked different, they were swollen very big and real dark. His hands did not look like that in the morning. Another resident went inside to tell staff something was wrong with him. A staff person came out, looked at him, and went back inside, when one of the girls from the second floor came and checked on him, she went back inside and then two staff persons came back out and took him inside. An interview was conducted on [DATE] at 2:00 PM with Resident #3, who is alert and oriented with no short term memory deficit. Resident#3 stated Resident #1 was sitting in the sun the whole time he was in the courtyard. At about 11:15 AM, he left the courtyard and went to lunch. When he returned to the courtyard it was after 1 PM. Resident #1 was still sitting in the sun in the same spot. The resident was not moving and did not appear to be breathing. His head was down and he did not look good so, he went back inside to the main dining room and told a person who was coming out of the kitchen that another resident outside had something seriously wrong. The person went to the courtyard and came back inside, then left the dining room to get the nurse. The resident stated on Saturday ([DATE]), he did not see any staff person in the courtyard checking on the residents. Resident #3 reported in the past 2 days they have someone out there checking and offering us water and juice. Staff tells residents that they should not sit in the sun for too long. During an interview with the Dietary Aide (Staff #6) on [DATE] at 3:00 PM, she stated she was cleaning up in the first floor dining room after lunch on [DATE]. A resident in a motorized wheelchair said "I should come with him outside, there is a man outside, and something serious had happened to him. The resident stayed in the dining room and showed me the resident through the window." She stated she went outside to the resident. "I called the resident's name twice, but he did not respond". She was about to come back inside but went back to him and called his name again, he did not answer. She came back in and ran to the first floor nurse's station, saw a nurse and she told the nurse a resident is outside and is not answering when she called his name. The nurse and a C.N.A brought him inside and she went back to work. Upon interview on [DATE] at 12:05 PM, with the Activity Assistant (Staff #7), she verified that she was in the courtyard under the gazebo on [DATE] with a group of residents that did not include Resident #1. She stated that she does not recall seeing Resident #1 on [DATE] because he does not participate in any group activities; he likes to be by himself and does whatever he wants independently. The Activity Assistant also stated she could not tell the surveyor anything about the resident's condition on [DATE]. An interview conducted on [DATE] at 3:15 PM, with the Certified Nursing Assistant (Staff #4) who was assigned to the Resident #1 on [DATE]. The Certified Nursing Assistant stated she checked the resident's blood pressure before breakfast and the blood pressure was high so she informed the nurse. She assisted the resident with morning care and transferred him to the wheelchair. The resident went to the dining room and had breakfast. She observed the resident going toward the elevator after breakfast. She stated it was her second time working with the resident and she did not know the resident well. At lunch time she fed two residents lunch and then went to the dining room. Resident #1 was not at the table so she went to find him. She told the nurse she could not find the resident and the nurse told her the resident is always sitting in the courtyard. When she went to the courtyard, the resident was unresponsive. She left the resident in the courtyard and went back inside the building to get the Registered Nurse (Staff #1) on the first floor. She went back outside with the RN and they brought the resident inside the building to the first floor nurse's station. The resident's skin was very warm. His hands were swollen and darker than before. His hands were not swollen in the morning when she washed him. The resident was not smoking. In an interview with the Registered Nurse Manager (Staff #2) on [DATE] at 11:25 AM, it was reported that Resident #1 was able to make his needs known and attempted to do simple tasks. His main activity was staying outside in the courtyard and doing word search puzzles. She stated the resident goes out after breakfast and usually comes back in for lunch between 12:15 and 1:30 PM. The nurse stated the activity staff in the main dining room on the first floor is supposed to keep an eye on the resident activities in the courtyard and call nursing for any concerns. Interview was conducted at 12:25 PM on [DATE], with (Staff #1) Registered Nurse in charge of the nursing care on [DATE]. The nurse stated she was at the nurse's station on the first floor when a Dietary Aide came to the nurse station and said "I need a nurse". The nurse rushed outside with a Certified Nursing Assistant. The resident's head was hanging down and he was drooling. They pulled him inside to the first floor nurse station. The resident was still sitting in the wheelchair and another nurse was helping to check his vital signs. He had a blood pressure of ,[DATE] and his pulse was 72. They checked his oxygen saturation and blood glucose. The resident's skin was very, very warm. Both hands were edematous, his armband was very tight and it was cut off. The nurse did not recall the resident temperature reading and was not documented. It was reported that a cold wet cloth was applied to the resident's face, neck, chest back and abdomen and 911 called. The resident was moved to a room on the first floor and rescue came and took over. The nurse stated she did not document the significant change in condition in the medical record. She stated she was concerned about the safety of the other resident on the patio. The police arrive after the resident had been transferred and alleged the staff had burned the resident's body. The police closed the courtyard and declared it a crime scene. The Administrator, Director of Nursing and Medical Director were notified. An interview was conducted at 2:45 PM on [DATE], with a Licensed Practical Nurse (Staff #3) assigned to the resident on [DATE]. The nurse stated she saw the resident on morning of [DATE] during breakfast and administered his morning medication around 9:00 AM. She stated it was a usual morning; she was doing her assigned tasks when the nursing supervisor called for her to come down stairs. When she arrived to the first floor the resident was sitting in a wheel chair at the nurse's station, with his head hanging down, his skin was significantly swollen and very dark. "I immediately called 911 and started to cool him down with cold wet cloth. The fire rescue arrived in less than 5 minutes. Fire rescue transferred the resident to a stretcher and started CPR." An interview was conducted at 6:00 PM on [DATE], with Certified Respiratory Therapist (CRT, Staff #5). The CRT stated on [DATE] when he came off the elevator on the first floor at approximately 1:28 PM, he observed 3 to 4 nurses around a resident in front of the nurse's station. The resident was in a wheelchair and he asked what happened, the nurses said they were not sure but the resident was unresponsive. He asked if they checked the blood pressure and they reported his blood pressure was ,[DATE] and the pulse was 78. And the oxygen saturation was 95%. The resident was on 2 L oxygen via nasal cannula. The CRT checked the resident's pupils and observed his pupils were fixed and dilated. He told the nurses to get the resident to an empty bed. When they got to the room he applied a non-rebreather mask and fire rescue arrived. The resident was taken from the wheelchair to fire the rescue stretcher. The resident was pulseless and fire rescue initiated advanced cardiac life support protocol. He observed as fire rescue took the resident to the truck continuing CPR and drove away. Based on the corrective interventions implemented by the facility, immediate jeopardy for Tag F 323 was removed on [DATE] at 8:45 PM. The scope and severity level was decreased from a " J " level to a " D " level. Although the facility implemented multiple corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and the monitoring of the corrective actions. The following includes the facility's corrective measures that were implemented after the Quality Assurance Ad Hoc committee met on [DATE]: The facility in-serviced all staff at the facility in all departments on all shifts on the following subject matters from [DATE] to [DATE]: courtyard monitoring guidelines, identifying changes in the resident ' s status and emergency procedures for handling changes in the resident's condition, medication management and pacemaker checks. See below for the specific training dates, subject matters and attendees: Courtyard monitoring/sign and symptoms of heat exhaustion: [DATE]: 11 CNA's; 3 LPN's; 4 RN's. [DATE]: 18 CNA's, 6 LPN's and 2 RN's [DATE]: 35 CNA's, 4 RN's, 13 LPN's, 14 Admin. Staff /Ancillary, 13 Physical Therapy/ Occupational Therapy staff members and 7 Dietary staff members. [DATE]: 1 RN, 4 LPN's, 2 CNA's [DATE]: 1 LPN, 7 Dietary staff members, 2 RN. 25 other staff members [DATE]: 1 Speech Therapist, 5 LP's, 3 RN's, 27 CNA's, 7 other staff members Change in condition documentation (including: "seems different than usual; talks or communicates less; overall needs more help; pain-new or worsening; participated less in activities; ate less; no bowel movement in 3 days; or diarrhea; drank less; weight change; agitated or nervous more than usual; tired, weak confused, or drowsy; change in skin color or condition; help with walking, transferring, and toileting more than usual"): [DATE]: 3 LPN's, 1 RN. [DATE]: 13 LPN's and 3 RN's. [DATE]: 1 RN and 5 LPN's, [DATE]: 3 RN's and 3 LPN's. Emergency response to residents: [DATE]: 5 LPN's and 7 CNA's [DATE] 28 CNA's and 7 LPN's [DATE] 13 LPN's, 5 RN's and 7 CNA's. [DATE]: 1 RN, 4 LPN's and 2 CNA's [DATE]: 3 LPN's, 3 RN's and 35 other staff members [DATE]: 87 other staff members, 45 CNA's, 5 RN's and 5 LPN's Medication Management: [DATE]: 8 LPN's and 2 RN's Pacemaker checks: [DATE] :25 LPN's, 2 RN's [DATE]: 22 LPN's and 2 RN's. [DATE]: 3 RN's [DATE]: 5 LPN's and 14 RN's, The facility assessed and care planned all "at risk " dependent and independent residents, related to their safety and well-being, while using the patio. The facility implemented the use of the "Courtyard Monitoring" Guidelines, which entails a monitoring system for residents while outside. Monitoring is ongoing. A staff is assigned to the courtyard area from 8 AM - 8 PM. The receptionist at the front entrance checks the video monitor and documents courtyard activities on a "courtyard monitoring form" every 30 minutes. The guidelines also instruct the facility staff is required to utilize the courtyard monitoring check list and monitor the following: offer residents fluids while outside, offer sun screen, hats/ visors and sunglasses, encourage residents to wear appropriate clothing according to the weather conditions, offer residents assistance as needed while outside and offer to assist residents inside as needed. The facility also implemented a door alarm code to access the courtyard. The residents must request to go outside from the facility staff to ensure their safety and well-being. Reviewed the evaluation of residents for their level of assistance to get to the courtyard as well as while outside. Reviewed the resident's care plan in relation to their choice to go outside. Evaluated the courtyard times and when the area will be locked for evening and night (courtyard is open with an assigned staff present from 8 AM - 8 PM). The facility will identify residents upon new admission that prefer to go outside and will determine their level of assistance. On [DATE], the facility staff were observed implementing the Courtyard Monitoring guidelines to include, staff assigned to courtyard were observed and interviewed about courtyard guidelines; the every 30 minutes monitoring checklist was observed to be used by receptionist and the staff assigned to the courtyard and the hydration cart was observed in the courtyard area. (Cross reference F 224, F 226 and F 279)