Every finding on record at Solaris Senior Living North Naples

Based on observations, interviews and record review, facility failed to follow care plan interventions to prevent further falls for 1 (Resident #26) of 1 resident sampled for accidents. The findings included: Review of the facility's policy titled Care Plans-Comprehensive, revised on 12/10/24, showed the following: Each Resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the residents' strengths. d. Reflect on the residents' expressed wishes regarding care and treatment goals. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services responsible for each element of care.' g. Aid in preventing or reducing declines in the Resident's functional status and/or functional levels. h. Enhance the Resident's optimal functioning by focusing on a rehabilitative program and reflecting currently recognized standards of practice for problem areas and conditions. A record review showed Resident #26 was readmitted to the facility on [DATE] with diagnoses of Vascular Dementia, Depressive Disorder, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 07, which is severely cognitively impaired. A record review of the Event Report dated 1/25/25 revealed Resident #26 had a fall on 1/25/25 in his room and had a non-skid sock at the time of the incident. Immediate measures taken were safe footwear and neuro checks. The report stated that the call bell was within reach and that Resident #26 did not call for assistance. The Care plan was updated on 1/27/25 to remind Resident #26 to use the call light for assistance when needed. A record review of the Event Report dated 3/3/25 revealed Resident #26 had a fall on 3/3/25 in his room while ambulating to the bathroom wearing non-skid socks. Immediate measures taken were neuro checks on Resident #26. The call bell is within reach, and Resident #26 was encouraged to use it for assistance but does not always do so. The care plan was updated on 3/4/25 to remind Resident #26 not to ambulate unassisted. A record review of the Event Report dated 3/16/25 revealed Resident #26 had a fall on 3/16/25 and was found in the bathroom. He had slippers on at the time of this incident. Resident #26 was reminded to call for assistance, and he said, I understand. The care plan updated on 3/17/25 reminded Resident #26 to ask for assistance with toileting needs. A record review of the Event Report dated 3/17/25 revealed that Resident #26 fell in his room on 3/17/25. He had shoes on at the time of this incident. The bed was in the lowest position, and the call bell was within reach. The care plan updated on 3/18/25 for floor mats on the bilateral side of the bed. In an observation conducted on 4/21/25 at 11:00 AM, Resident #26 was noted in the bed in the lowest position, but no call light was within reach. Further observations showed no fall mats on either side of his bed. In an observation conducted on 4/22/25 at 9:32 AM, Resident #26 was noted in the bed, with the call light on his left side attached to the end of the bed not within arm's reach. Further observations showed no fall mats on either side of his bed. In an interview conducted on 4/22/25 at 11:40 AM with Staff A, the Certified Nursing Assistant (CNA) stated that Resident #27 is a fall risk. There are floor mats on each side of his bed, and the call light is within reach by his side. In an interview conducted on 4/22/25 at 11:50 AM, Staff B, MDS Coordinator, stated that after a resident falls, they will get together with the nursing team to review the care plan and the interventions in place. She will update or make changes to the interventions to reflect the circumstances of the fall and add any new interventions that are not already in place for the residents. Staff B reported adding the intervention of floor mats on 3/18/25 to the care plan for Resident #26. The Floor mats are placed as an order under the Physician's Orders tab. A review of the Physician's orders did not show that Resident #26 had an order for floor mats. In an observation conducted on 4/23/25 at 8:56 AM, Resident #26 was sitting at the end of the left side of the bed eating breakfast. The call light was noted to be attached to the curtain on the right side of the bed, away from Resident's #26 reach. Further observations showed no fall mats on either side of his bed. In an interview conducted on 4/23/25 at 10:49 AM with a CNA, Staff D stated that Resident #26 was at risk for falls and ensured the call light was within reach and floor mats were on each side of his bed. A review of the care plan initiated on 4/26/22 showed Resident #26 was at risk for falls related to weakness, unsteady gait at times, and a history of falls.

Based on observations, interviews and record review, the facility failed to ensure that the call light was within reach for 1 (Resident #26) of 1 resident sampled for accommodation of needs. The findings included: A record review showed Resident #26 was readmitted to the facility on [DATE] with diagnoses of Vascular Dementia, Depressive Disorder, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview of Mental Status (BIMS) score of 07, which is severely cognitively impaired. A progress note dated 3/18/25 showed Resident #26 on the floor between the bed and the nightstand in his room. He was unable to explain what happened and said he was trying to grab something off the table. Recently, Resident #26 overestimated his own ability and was encouraged by Staff to use the call light constantly. Further chart review showed that Resident #26 had four falls in the last five months in the facility. The care plan initiated on 1/27/2025 revealed that Resident #26 was reminded to use the call bell for assistance when needed. In an observation conducted on 4/21/25 at 11:00 AM, Resident #26 was noted in the bed, and no call light was within reach. After a few minutes of trying to find the call light, this Surveyor was able to locate the call light, which was attached to the back of the privacy curtain and not within reach of Resident #26. In this observation, Resident #26 was asked how he called Staff for assistance, and he looked for the call light and then said, It is here somewhere. In an observation conducted on 4/22/25 at 9:32 AM, Resident #26 was noted in the bed, with the call light on his left side attached to the end of the bed not within arm reach. In this observation, this Surveyor asked Resident #26 if he could reach the call light and Resident #26 said no. Resident #26 then attempted to reach the call light but was not able too. In an observation conducted on 4/22/25 at 10:45 AM, Resident #26 was noted in bed with the call light on his left side attached to the end of the bed, not within arm's reach. In this observation, Resident #26 stated he was told to use the call light when he needed help from Staff. In an observation conducted on 4/23/25 at 8:56 AM, Resident #26 was sitting at the end of the left side of the bed eating breakfast. The call light was noted to be attached to the curtain on the right side of the bed, away from Resident's #26 reach. In an observation conducted on 4/23/25 at 1:10 PM, Resident #26 was in his bed with the call light within reach. In this observation, Resident #26 was asked if he could use the call light, which was located near his right hand. Resident #26 was able to press the call light, and a light illuminated outside Resident #26's room indicating that the call light bell was used in Resident #26's room. After a minute, the Staff was seen walking toward Resident #26's room. In an interview conducted on 4/22/25 at 11:40 AM with Staff A, Certified Nursing Assistant (CNA) stated, Resident #26 is at risk for falls, and they have to ensure that the call light is within reach of the Resident. She further reported Resident #26 sometimes uses the call light when he needs assistance but not always. In an interview conducted on 4/22/25 at 12:02 PM with Staff C, the Licensed Practical Nurse stated that she had been working in the facility for about three years. When asked if Resident #26 was at risk for falls, she said, Not really, but kind of. Sometimes, he likes to do things by himself and gets out of bed without staff assistance. Resident #26 usually does not use the call light to call for assistance. In an interview conducted on 4/23/25 at 10:49 AM with Staff D, the CNA stated that she had worked in the facility for [AGE] years. She was very familiar with Resident #26 and said he was at risk for falls. They need to make sure that the call light is within reach, and sometimes, Resident #26 gets out of bed without listening. He knows how to use the call light and uses it when he wants to. Sometimes, he will not use the call light and just get up.

Based on observations, interviews, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 out of 1 resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube (Resident # 56) and 1 out of 1 resident on Transmission Based Precautions (Resident #37). The findings included: Review of the facility's policy titled, Care Plans - Comprehensive with a revised date of 12/10/24 included in part the following: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident. His/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on thorough assessment that includes but is not limited to the Minimum Data Set (MDS). Each resident's comprehensive care plan is designed to: incorporate identified problem areas. Incorporate risk factors associated with identified problems. Record review for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Traumatic Subarachnoid Hemorrhage without Loss of Consciousness Subsequent Encounter, Cognitive Communication Deficit, and History of Falling. The Minimum Data Set (MDS) for Resident #56 dated 4/3/25 documented in Section C a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. In Section K it was documented that on admission the resident had a feeding tube (abdominal PEG tube). Review of the Physician's Orders for Resident #56 revealed in part the following: An order dated 4/22/25 PEG tube stoma (surgical opening) care: Cleanse with NS (normal saline), pat dry skin prep (protective film) peri wound let dry. apply calcium alginate (W silver) and secure with clean bordered gauze split dressing once daily. There was no order for EBP (Enhanced Barrier Precautions). Review of the Care Plan for Resident #56 revealed no care plan for PEG tube or for Enhanced Barrier Precautions. During an interview conducted on 4/21/25 at 10:30 AM with Resident #56 who stated he has a peg tube. Resident #56's wife was at bedside and said her husband has been eating for about a month now and they are not using the PEG tube, and it is scheduled to be removed next week at the doctor's office. During an interview conducted on 4/23/25 Staff B MDS Coordinator who stated she has worked at the facility since July 2024 and Staff L MDS Coordinator who stated she has worked at the facility for 2 years. When asked who was responsible for putting in the nursing care plans for a resident, they said they were. When asked about Resident #56's care plan for having a PEG tube and EBP, they both acknowledged there was no care plan for the PEG tube or EBP. Staff L MDS Coordinator stated, I must have forgotten. 39026 2. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses of Sepsis, Cerebral Infarction, and Chronic Obstructive Pulmonary Disease (COPD). Her Brief Interview for Mental Status (BIMS) score was 15 on the quarterly Minimum Data Assessment (MDS) with an assessment reference date (ARD) of 3/12/25. This indicated the resident had intact cognition. A review of the Electronic Health Record (EHR) and the physician orders for Resident #37 was done and revealed the resident was on Contact Precautions since 4/19/25 for a Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase). ESBL are a type of enzyme or chemical produced by some bacteria. Contact precautions are indicated for someone with ESBL in the urine. A review of the resident's care plans revealed there was no care plan for contact precautions for Resident #37.

Based on record review, observations and interviews, the facility failed to ensure facility staff performed urinary indwelling catheter care technique consistent with accepted standards of practice and failed to follow the facility's policy titled, Catheter Care, Urinary as observed during indwelling urinary catheter care for 1 (Resident #22) of 1 resident sampled for urinary catheter. The findings included: Review of the facility's policy titled, Catheter Care, Urinary with a review date of 12/10/24 included in part the following: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter tubing free of kinks. Use standard precautions when handling or manipulating the drainage system. Ensure that the catheter remains secured to reduce friction and movement at the insertion site. (Note: Catheter tubing should be secured to the resident's inner thigh. Steps in the Procedure: 13. With nondominant hand separate the labia of female resident . maintain the position of this hand throughout the procedure. 15. For a female resident: use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. 18. Secure the catheter. Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Presence of a Right Artificial Hip Joint, History of Falling, and Need for Assistance with Personal Care. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #22 revealed in part the following orders: An antibiotic order for Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 mg oral every 12 hours for diagnoses of UTI (Urinary Tract Infection); E.coli (bacteria) from 4/18/25 to 4/255/25. An order dated 3/13/25 for Indwelling Urinary Catheter; May change / re-insert as needed for occlusion/accidental removal. Size:16fr Coude catheter 10cc balloon as needed. An order dated 3/13/25 to irrigate Indwelling Urinary catheter with 60cc normal saline as needed for blockage or leakage as needed. There was no order for catheter care or for the catheter to be anchored to the resident's thigh. On 4/21/25 11:30 AM an observation was made of Resident #22 lying in bed wearing pants with the legs pulled up above the knee, the resident had an indwelling urinary catheter tubing coming out from under her leg and the tubing was not anchored. On 4/24/25 at 9:10 AM an observation of indwelling urinary catheter care performed by Staff H Certified Nursing Assistant for Resident #22. The resident's catheter tubing was unsecured. Staff H CNA gathered supplies, washed hands and began catheter care by wiping top groin and side of groin next to leg, the resident started having a bowel movement and the washcloth Staff H CNA was using along with her gloved hand became soiled with the bowel movement. Staff H CNA initially did not change her gloves and proceeded to fold over the soiled washcloth and continue cleaning the resident. Staff H CNA stepped back and stated I am sorry then changed her gloves without performing hand hygiene. Staff H CNA stood holding a clean washcloth for several minutes. On 4/24/25 at 9:30 AM Staff I Certified Nursing Assistant (CNA) member knocked at the resident's door. The two CNAs proceeded to clean the bowel movement which included turning the resident from side to side without securing the catheter tubing. Staff H CNA then continued to provide catheter care by holding the left side of the resident's labia with her left hand and wiping with the washcloth from top to bottom and around the catheter tubing, then wiped the resident's groin from top to bottom over the catheter tubing, then folded over the towel, she changed gloves again without performing hand hygiene. Staff I CNA then proceeded to dress the resident with a pair of pants on the resident up to her knees. Staff I raised the drainage bag above the bladder to insert the drainage bag inside the left pant leg, decided the drainage bag needed to be emptied of the urine and lowered the drainage bag to empty the urine. Staff I proceeded to put the drainage bag inside the pant leg while the catheter tubing was being pulled. When asked of Staff H CNA and Staff I CNA if they were finished with the catheter care, they both agreed it was completed. The catheter tubing was never secured in place to the resident's leg. During an interview conducted on 4/24/25 at 9:55 AM with Staff J Licensed Practical Nurse (LPN) stated she has worked at the facility since 2020. When asked if she was the nurse for Resident #22 today, she said yes. When asked who documents the catheter care, she said the CNAs document the care. When asked if the catheter tubing needs to be anchored, she said what does that mean? When explained anchored means secured, Staff J LPN said yes but she did not have a chance to look at the resident's catheter today. When asked if there was an order for catheter care, she acknowledged there was no order for catheter care. During an interview conducted on 4/24/25 at 10:00 AM with Staff H CNA stated she has worked at the facility for 3.5 years. When asked if she documents the catheter care, she said document? When asked if she writes it down in the resident's chart that she did catheter care, she did not respond. Staff J LPN asked if she could help ask Staff H CNA the question. Staff J LPN asked Staff H CNA about documenting catheter care. Staff H CNA did not respond.

Based on observations, interviews and record review, the facility failed to complete a Quarterly Nutritional Assessment for 1 (Resident #48) of 2 residents sampled for Nutrition. The findings included: A record review showed Resident #48 was readmitted to the facility on [DATE] with diagnoses of Legally Blind, Dementia, and Psychosis Disturbances. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #26 had a Brief Interview of Mental Status (BIMS) score of 08, which is moderate to severe cognitive impairment. Section GG of the above MDS revealed that Resident #48 was coded for set-up or clean-up assistance for eating. In an observation conducted on 4/21/25 at 11:55 PM, Resident #48 was noted in the room with her lunch tray. The staff set up the tray for Resident #48 and left the room. The lunch plate was noted with the following: hot dog on a plate, chocolate cake on a square plate, and mixed vegetables in a bowl with a tablespoon. The meal ticket noted the following: hot dog, mixed vegetables, chocolate cake, and to send sandwiches/hotdogs/or hamburgers instead of the meal. In this observation, Resident #48 said that they always give her the same foods (hamburger, hotdog, peanut butter sandwich, and grilled cheese) for lunch and dinner, and she would like to get what everyone else gets for dinner. The care plan for Resident #48, revised on 3/14/2025, showed the following: Resident is at risk for altered nutrition due to end-stage Cerebral Atherosclerosis and is on hospice care. Potential for the unavoidable decline in parameters of nutrition with risk factors of Dementia, underweight, and Legally Blindness. A review of the Quarterly Nutrition assessment dated [DATE] showed that Resident #48 has an inadequate oral and suboptimal intake, as evidenced by leaving 25% or more of most meals uneaten. The goal is to offer foods/fluids of choice to promote quality of life by the following review period. Further chart review did not reveal that a Quarterly Nutrition Assessment was completed on Resident #48 after 12/27/24. A review of the Care Plan dated 3/14/25 did not show that it was updated or revised by the facility Clinical Dietitian. In an interview conducted on 4/23/25 at 9:40 AM with Staff B, the MDS Coordinator stated that the Clinical Dietitian updates all the nutrition care plans. Staff B said that she had not made any of the changes or interventions under the nutrition plan and that it was the responsibility of the Clinical Dietitian. In an interview conducted on 4/23/25 at 9:44 AM, the Dietary Manager said Resident #48 used to eat finger food and asked for regular food a few weeks ago. When they provided her with regular foods, she changed her mind and wanted finger food instead. Usually, they provide residents with the same choice on the daily menu, but last week, Resident #48's roommate's family said they would help Resident #48 with her menu selections. The Dietary Manager noted that the Registered Dietitian does a Quarterly Nutrition Assessment on all residents. In a telephone interview conducted on 4/23/25 at 9:55 AM with the facility's Registered Dietitian, she stated that they do Quarterly Nutrition Assessments on all residents. She acknowledged that no Quarterly Assessment was done for Resident #48 and did not know why she did not complete the assessment. She is also responsible for updating the nutrition care plan for all residents. A review of the Quarterly Nutrition assessment dated [DATE] showed the following: Resident #48 with inadequate oral suboptimal intake as evidenced by being underweight and leaving 25% or more of meals uneaten. It further showed Resident #48 eats 1-75% of her meals in her room with assistance. She has declined all facility supplements (not documented previously) and remains under hospice care. The above assessment did not document that the Clinical Dietitian visited Resident #48 and spoke to her to obtain food preferences, likes, and dislikes.

Based on observations, interviews and record review the facility failed to ensure accurate and effective system for reconciliation of controlled drugs in sufficient detail to enable an accurate reconciliation (Resident #51) and remove discontinued medications (Resident #215) from the med cart for 2 of 2 med carts reviewed. The findings included: 1. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Pleural Effusion and Necrotizing Enterocolitis Unspecified. The Minimum Data Set (MDS) dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #51 revealed an order dated 4/8/25 for Xanax (alprazolam) 0.25 mg give 1 tablet oral every 6 hours PRN (as needed). Review of the Controlled Medication Utilization Record for Resident #15 for Alprazolam 0.25mg documented on 4/9/25 at 9:12 AM and again on 4/13/24 at 9:15 PM the medication was removed from the med cart. Review of the Medication Administration Record (MAR) for Resident #51 for the month of April revealed no documentation of Alprazolam 0.25mg being administered on 4/9/25 at 9:12 AM or on 4/13/24 at 9:15 PM. During an interview conducted on 4/23/25 at 1:35 PM Staff C (LPN) stated she has worked at the facility for 3 years. The LPN stated when the med is removed from the med cart we document it on the Controlled Medication Record and once the medication is administered she will document it on the Medication Administration Record for the resident. 2. Record review for Resident #215 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Need for Assistance With Personal Care and Muscle Weakness (Generalized). The MDS dated [DATE] documented in Section C a BIMS score of 13 indicating a cognitive response. Review of the Physician's Orders for Resident #215 revealed an order dated 3/18/25 for Alprazolam 0.25 mg give 1 tablet orally every 8 hours as need for anxiety/agitation. The medication was discontinued on 4/2/25. During an interview conducted on 4/23/25 at 1:45 PM Staff F LPN was asked about controlled medications. The LPN stated when the med is removed from the med cart we document it on the Controlled Medication Record and once the medication is administered she will document it on the Medication Administration Record for the resident. During an interview conducted on 4/23/25 at 3:02 PM with the Director of Nursing (DON) who was asked about discontinued controlled medications, the DON stated the meds should be removed from the med cart within a couple of days of the med being discontinued. The night shift nurse is responsible to check the cart nightly.

Based on interviews and record review the facility failed to ensure the facility's Consultant Pharmacist reported the monthly drug regimen review to the facility for 1 (Resident #19) of 5 residents reviewed for Unnecessary Medications and failed to ensure irregularities identified by the Consultant Pharmacist were addressed with a rationale by the Physician for 1 (Resident #2) of 5 residents reviewed for Unnecessary Medications. The findings included: Review of the facility's policy titled, Medication Regimen Review with a revised date of January 2018 included in part the following: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The findings are phoned, faxed, or e-mailed within (24 hours) to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the residents' (active record). The prescriber is notified if needed. Notification is dependent on severity of irregularity and is determined through consultation between consultant pharmacist and the director of nursing. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreement. Review of the facility's policy titled, Documentation and Communication of Consultant Pharmacist Recommendations with a revised date of January 2018 included in part the following: Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the prescriber responsible or physician's designee is contacted by the consultant pharmacist or facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Urinary Tract Infection, Anxiety Disorder Unspecified, and Depression Unspecified. The Minimum Data Set, dated dated dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #2 revealed in part the following: An order dated 12/9/24 for Ambien (zolpidem) 5 mg; amt: 1 tablet oral at bedtime for sleep/insomnia. An order dated 12/9/24 for Protonix (pantoprazole) tablet (reduces production of stomach acid), delayed release 40 mg oral once a day. Review of the Pharmacy Recommendations for Resident #2 documented the following: On 12/10/24 Pantoprazole 40 mg no stop date. On 12/11/24 the physician disagreed (with no rationale for disagreeing). On 12/10/24 Zolpidem 5 mg pleas attempt dose reduction to zolpidem 2.5 mg at bedtime. On 12/11/24 the physician disagreed (with no rationale for disagreeing). Review of the medical record for Resident #2 revealed no documentation of rationale for disagreeing with the pharmacy recommendations 12/10/24. During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. The Consultant Pharmacist stated that the recommendation date is listed at the top of the form next to where the form states Recommendation Date. The Created date on located on the bottom of the form is the date when the PDF report was printed from the consultant pharmacy interface system. The Consultant Pharmacist stated she sends the report the facility on the date the report is printed. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date. When asked about the Medication Regimen Review (MRR) for Resident #2 dated 12/10/24 in regard to the Pantoprazole 40 mg and the Physician disagreeing on 12/11/24, with no rationale, the CP stated the rationale may be written in the progress notes. When asked about the Medication Regimen Review (MRR) for Resident #215 dated 12/18/24 in regard to the Ativan 0.25 mg PRN greater than 14 days with the Physician documenting on 12/19/24 to continue the PRN order for 30 days with no rationale, the CP said again the rationale may be documented in the progress notes in the resident's record. During an interview conducted on 4/23/25 at 11:00 AM Staff N Nurse Practitioner (NP) was asked about psychotropic medications ordered PRN. She stated she believes the medications can be extended longer than 14 days, as she has sometimes seen the pharmacist recommendations that gives that option. If the recommendation asks for the rationale she will document the rationale. 39026 2. Record review revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included Acute Respiratory Disease, Encephalopathy, unspecified, and Chronic Obstructive Pulmonary Disease. The Brief Interview for Mental Status on the Quarterly Minimum Data Set assessment dated [DATE] was unable to be done. This indicated the resident had severe cognitive impairment. The resident was selected for an unnecessary medication review. Review of the monthly medication regimen review for October 2024 through April 2024 provided by the Director of Nursing (DON) revealed no medication review for November 2024. Review of the Electronic Health Record (EHR) failed to reveal a medication regimen review for Resident #19 for November 2024. An interview was conducted via telephone with the consultant pharmacist on 4/23/25 at 9:43 AM. She stated she has been working as the consultant pharmacist with the current pharmacy since 2023. When asked about the missing November 2024 pharmacy recommendation for Resident #19 she stated she saw it on her computer screen. An interview was conducted with the DON on 4/23/25 at 1:15 PM. She stated she contacted the Consultant Pharmacist to get a copy of the November 2024 recommendation. The pharmacist could not print it out because there was glitch in the system. She provided a screenshot without Resident #19's name on the screenshot. She verified that there was no recommendation for Resident #19 for November 2024 in the facility or in the resident's EHR.

3. Record review revealed Resident #37 was re-admitted to the facility on [DATE] with Diagnoses of Anxiety Disorder and Major Depressive Disorder. The Quarterly MDS dated [DATE] revealed Resident #37 scored 15 on the BIMS, indicating intact cognition. A review of the Pharmacy Recommendation to Prescriber dated 12/27/24 showed the following: Resident #37 has been on Alprazolam 0.5 milligram PRN with a start date of 12/5/24. It is required that all psychotropic medication be limited to 14 days of use. If the medication cannot be discontinued at this time the order may be extended beyond 14 days if the Prescriber documents the rationale for extended use and indicate duration. The recommendation was made 22 days after the PRN Alprazolam was started. The continuing review revealed that the Prescriber addressed the recommendation on 1/30/25, more than a month after the pharmacy recommendation. The Prescriber noted to continue the PRN medication for three months with a rationale to continue for anxiety control. A review of the Physician's orders dated 4/15/25 revealed an order for Alprazolam (Antianxiety Medication) 0.5 milligrams as needed (PRN) with an end date of 5/12/25. During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date. When asked about the Pharmacy Recommendation to Prescriber for Resident #37 dated 12/27/24 in regard to the Alprazolam 0.5 mg PRN started 12/5/24 that was not addressed by the physician until 1/30/25 she said the physician has 30 days to review the recommendation. The Consultant Pharmacist did not acknowledge that the Alprazolam PRN medication was in place for longer than 14 days. The Consultant Pharmacist added that none of the issues discussed for Residents #20, #215, and #37 would be considered urgent. In an interview conducted on 4/24/25 at 1:00 PM with the Director of Nursing, she said the Pharmacist sent them the reviews on 1/10/25 and not on 12/27/24, 35 days after the PRN medication of Alprazolam was started. She further acknowledged that this was too long and that they need to look into the process and make changes. Based on interviews and record review the facility failed to ensure 2 (Residents #37 and #215) of 5 residents reviewed for unnecessary medications and 1 (Resident #20) of 6 residents reviewed for medication storage had a documented duration and/or rationale for use of psychotropic PRN (as needed) medications beyond 14 days. The findings included: 1. Record review for Resident #20 revealed an admission date to the facility of 8/15/16. Diagnoses included in part: Unspecified Dementia Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Epilepsy. The Quarterly Minimum Data Set (MDS) with a target date of 2/26/25 documented Resident #20 scored 05 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the Physician's Orders for Resident #20 revealed an order dated 1/27/25 for Ativan (a psychotropic medication) 0.5mg give 1 tablet orally every 6 hours PRN (as needed) with no end date. Review of Resident #20's medical record revealed no documentation of rationale or indication of the duration for the PRN Ativan order. During an interview conducted on 4/23/25 at 3:02 PM the Director of Nursing (DON) was asked about the PRN order for Ativan for Resident #20. The DON acknowledged the PRN Ativan for Resident #20 was started on 1/27/25 was still an active order and had no stop date. The DON also acknowledged the recommendation from pharmacist in January identified the irregularity of PRN for more than 14 days with no stop date, but it was not addressed at that time. 2. Record review for Resident #215 revealed an admission date to the facility on [DATE]. Diagnoses included in part: Epilepsy Unspecified Not Intractable Without Status Epilepticus, Unspecified Dementia Unspecified Severity With Other Behavioral Disturbance, and Depression Unspecified. The Quarterly MDS assessment dated [DATE] documented Resident #215 scored 00 on the BIMS, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #215 revealed an order dated 12/16/24 for Ativan (a psychotropic medication) tablet; 0.5 mg; amt: 0.25 mg; oral Special Instructions: Give 0.25 mg (1/2 of a 0.5 tab) for increased Anxiety Every 8 Hours - PRN (as needed). Review of the Pharmacy Recommendations to Prescriber for Resident #215 revealed: On 12/18/24, PRN antianxiety or hypnotic medication greater than 14 days, Ativan 0.25 mg PRN. CMS (Center for Medicare and Medicaid Services) requires all prn orders for psychotropic medications to be limited to 14 day use. The Physician's response dated 12/19/24 was to continue the PRN order 30 days. There was no documentation of rationale. Review of Resident #215's medical record revealed no documentation of rationale or indication for the duration of the PRN Ativan order. On 12/27/24, the Consultant Pharmacist wrote a recommendation to the prescriber for PRN order for Ativan (Lorazepam) 0.5mg with a start date of 12/16/24. The Physician response dated 1/20/25 documented to please discontinue PRN Lorazepam tab 0.5 mg. The Ativan order was discontinued on 1/20/25. This indicated the PRN psychotropic medication had been in effect for longer than 14 days. During a telephone interview conducted on 4/23/25 at 9:43 AM Staff M Consultant Pharmacist (CP) stated she has been working with the facility since 2023. When asked about PRN (as needed) Psychotropic medications, she said they should only be for 14 days with a stop date, unless the doctor extends the order but still needs a stop date and documentation of rationale for the extended date. Reviewed the pharmacy recommendations dated 12/18/24, and 12/27/24 for the Ativan 0.25 mg prn with a start date of 12/16/24 for Resident #215. When asked about the lack of documentation of a rationale to continue the Ativan 0.25 mg for 30 days for Resident #215 in the physician's response dated 12/19/24, the Consultant Pharmacist said the rationale may be documented in the progress notes in the resident's record. Reviewed the pharmacy recommendation to the prescriber dated 12/27/24 and sent to the facility on 1/10/25 for the duration of the Ativan 0.25 mg PRN order for Resident #215 and the prescriber's response to the recommendation dated 1/20/25. The Consultant Pharmacist did not acknowledge that the Ativan PRN medication had been in place for greater than 14 days with no end date. During an interview conducted on 4/23/25 at 11:00 AM Staff N Nurse Practitioner (NP) stated she believes psychotropic medications ordered PRN, can be extended longer than 14 days, as she has sometimes seen the pharmacist recommendations that gives that option. If the recommendation asks for the rationale she will document the rationale.

Based on observations, interviews and record review the facility failed to ensure medications were secured at all times for 2 (Residents #213 and #214) of 16 sampled residents. The findings included: Review of the facility's policy titled, Storage of Medications with a revised date of January 2018 included in part the following: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility's policy titled, Self-Administration of Medications with a revised date of January 2018 included in part the following: In order to maintain the residents' hi level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medication by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. Record review for Resident #213 revealed an admitted to the facility of 3/4/25. Diagnoses included in part: Fracture of Unspecified Part of Neck of Right Femur, Generalized Muscle Weakness, and Need for Assistance with Personal Care. The Admission Minimum Data Set (MDS) assessment with a target date of 3/25/25 documented Resident #213 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. On 4/21/25 at 10:50 AM Resident #213 was observed sitting up in bed. The resident's spouse was sitting in a chair next to her. Two medicine cups were observed on the overbed table in front of Resident #213. One cup contained five different pills and a capsule. The other cup contained a liquid medication. During an interview conducted on 4/21/25 at 10:50 AM Resident #213 was asked about the medications in front of her. She said she cannot take all of the medication at the same time. Her husband then said he watches his wife take the medications. He said she takes too many medications at the same time, and she will get sick to her stomach. Resident #213 said she did not recognize all the medications in the cups, her husband was better at that. During a side by side observation conducted at the bedside of Resident #213 on 4/21/25 at 11:05 AM with Staff F Licensed Practical Nurse (LPN), she acknowledged she left the medications at the bedside for the resident to take because the husband insists. She said Resident #213 has been at the facility for about five days and the husband has been insisting to have the medications left at the bedside. Staff F LPN added there should be a care plan and an order for the medications to be left at the bedside. When asked if the resident had an order for self-administration, she said she was not sure. When asked if the resident had a care plan for the meds to be left at the bedside or self-administration, she said she did not do the care plans. During an interview conducted on 4/21/25 at 11:10 AM Staff E Registered Nurse (RN) stated she has worked at the facility for several years. When asked if Resident #213 had an order for self-administration of medications or an order to leave medications at the bedside, RN Staff E acknowledged there was no order. She also acknowledged the resident did not have a care plan or an evaluation for self-administration. On 4/21/25 at 11:22 AM, observation of Resident #213's room revealed the medicine cup with five pills and one capsule and the medicine cup with the liquid medication remained at the resident's bedside. Record review for Resident #213 revealed no order for self-administration of medications, no evaluation for self-administration of medications, and no care plan for self-administration of medications. 2. A record review for Resident #214 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part: Generalized muscle weakness, and need for assistance with personal care. The Admission MDS dated [DATE] documented Resident #214 scored 13 on the BIMS, indicating a cognitive response. On 4/21/25 at 10:10 AM an observation was made of Resident #214 sitting up in bed. A bottle of Sterile Eye Drop Lubricant was observed on the overbed table in front of the resident. During an interview conducted on 4/21/25 at 10:10 AM, Resident #214 was asked about the eye drops. She said she needed the eye drops. She said she had Macular Degeneration (eye disease), and her eyes get dry from reading. When asked if she put the drops in herself, she said no, her husband puts them in for her. During a side-by-side observation conducted on 4/22/25 at 9:55 AM, Staff K Licensed Practical Nurse (LPN) acknowledged Resident #214 had eye drops at the bedside on her overbed table, did not have an order for eye drops nor was the resident evaluated for self-administration. Staff K LPN instructed Resident #214's husband to take the eye drops home and she would obtain an order from the physician for the eye drops. Review of the clinical record for Resident #214 revealed no physician's order for eye drops, no evaluation for self-administration of the eye drops and no care plan for self-administration of medications. The record for Resident #214 revealed no order for eye drops, no order to self-administer, no evaluation for self-administration, and no care plan for self-administration of medications.

Based on observations, record review, review of facility's policies and procedures, and interviews, the facility failed to follow infection prevention and control guidelines for 1 (Resident #37) of 1 resident on contact precautions. The facility failed to ensure the proper storage of respiratory care equipment for 2 (Residents #33 and #110) of 2 residents receiving nebulizer treatment and failed to perform hand hygiene as appropriate for 1(Resident #22) of 1 resident observed for catheter care. The findings included: The facility's policy titled Transmission Based Precautions reviewed 12/10/24 revealed Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. PPE (personal protective equipment) utilized included gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. 1. Record review for Resident #37 revealed an admitted to the facility of 5/5/23. Diagnoses included Sepsis (life threatening complication of an infection), Cerebral Infarction (stroke), and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/12/25 noted Resident #37 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. Review of the Electronic Health Record (EHR), including physician orders for Resident #37 revealed the resident was on Contact Precautions since 4/19/25 for a Urinary Tract Infection with ESBL (Extended-spectrum beta-lactamase). ESBL are a type of enzyme or chemical produced by some bacteria. Contact precautions are indicated for someone with ESBL in the urine. On 4/24/25 at 9:00 AM, observed Registered Nurse (RN) Staff G prepare an injection of Ertapenem (antibiotic) solution 1 gram mixed with Lidocaine (anesthetic) for an intramuscular injection. RN Staff G prepared the injection by her medication cart and went into Resident #37's room. The sign on the door said contact precautions. RN Staff G went into the room with gloves on, pulled the curtain, repositioned the resident and pulled apart the brief to give the injection with gloves on. She did not don a gown or change her gloves prior to administering the injection. After she administered the injection, the resident asked the nurse reposition her. Staff G took off her gloves and repositioned the resident, the under pad, linen and blanket. In an interview, Staff G was asked if she saw the contact precaution sign. She stated yes, my mistake. On 4/24/25 at 10:00 a.m., during an interview the Administrator was informed of RN Staff G's failure to follow contact precautions for Resident #37. 2. Record review for Resident #33 revealed an admitted to the facility of 11/25/24. Diagnoses included Acute Respiratory Failure with Hypoxia (low oxygen level), Acute or Chronic Diastolic (Congestive) Heart Failure, and Type 2 Diabetes Mellitus without Complications. Review of the Quarterly MDS assessment with an assessment reference date of 4/10/25 revealed Resident #33 scored 15 on the BIMS, indicating intact cognition. On 4/21/25 at 1:42 PM observation of Resident #33's room revealed a nebulizer (machine used to inhale aerosol medications into the lungs) on top of the dresser next to the resident's bed. The nebulizer tubing and mask were observed lying on top on the nebulizer uncovered. In an interview during the observation, Resident #33 stated she recently had a nebulizer treatment and the tubing and masks were put back on the machine uncovered. 3. Record review revealed Resident #110 was admitted to the facility on [DATE] with diagnoses that included Lymphedema (swelling), Polyneuropathy (peripheral nervous system disorder) and Unspecified Systolic (Congestive) Heart Failure. Review of the Admission MDS with an assessment reference date of 3/21/25 revealed Resident #110 scored 15 on the BIMS, indicating intact cognition. On 4/21/25 at 10:49 AM an observation and interview were conducted with the resident. A nebulizer tubing and mask were observed uncovered on the resident's bedside dresser. In an interview Resident #110 said that he did not remember the last time he had a nebulizer treatment. He stated, It's supposed to be in a bag. On 4/23/25 at 1:30 PM during an interview, the Administrator was informed of the nebulizer tubing and mask stored uncovered on Resident #110's bedside dresser. 41837 4. Record review for Resident #22 revealed an admitted to the facility of 3/13/25 with diagnoses that included in part the following: Presence of a Right Artificial Hip Joint, History of Falling, and Need for Assistance with Personal Care. The Admission MDS dated [DATE] documented Resident #22 scored 15 on the BIMS, indicating a cognitive response. The MDS noted Resident #22 was always incontinent of bowel. Review of the Physician's Orders for Resident #22 revealed in part the following orders: An order dated 3/13/25 for Indwelling Urinary Catheter (Catheter inserted in the bladder to drain urine). An order dated 3/13/25 to irrigate the Indwelling Urinary catheter with 60 cc normal saline as needed for blockage or leakage as needed. There was no order for catheter care. On 4/21/25 at 11:30 AM Resident #22 was observed lying in bed wearing pants with the legs pulled up above the knee. The resident had an indwelling urinary catheter. On 04/24/25 at 9:10 AM Certified Nursing Assistant (CNA) Staff H was observed performing catheter care for Resident #22. As CNA Staff H began catheter care Resident #22 started having a bowel movement. CNA Staff H gloved hands became soiled with the bowel movement. CNA Staff H changed her gloves without performing hand hygiene. CNA Staff H changed her gloves an additional time during the catheter care procedure without performing hand hygiene. During an interview conducted on 4/24/25 at 10:00 AM CNA Staff H stated she has worked at the facility for three and a half years. When asked about hand hygiene with changing gloves, she said she washed her hands before she started the catheter care for Resident #22 and washed her hands again when she was finished with the catheter care.

Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure 3 (Resident #3, #27 and #51) of 6 residents reviewed for accidents were assessed for alternative interventions prior to the use of side rails. This had the potential to have side rails installed when alternatives with less chance of negative consequences could be utilized. The facility census was 59 with 31 residents who had side rails in use. The findings included: The facility policy, Proper Use of Side Rails (revised 1/25/23) documented, The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a residents' medical symptoms. General Guidelines: #6. Less restrictive interventions that will be incorporated include: a. Providing restorative care to enhance abilities to stand freely and walk. b. Providing trapeze to increase bed mobility c. Placing the bed lower to the floor and surrounding the bed with a soft mat. d. Equipping the resident with a device that monitors attempts to rise. e. Providing staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom. f. Furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 1. Review of the clinical record showed Resident #3 was admitted [DATE] with diagnoses including dementia, weakness, and depression. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/21/23 documented Resident #3 required extensive assistance with bed mobility and limited assistance with transfers. The MDS noted Resident #3's cognitive skills for daily decision making were moderately impaired. The clinical record showed a physician order dated 3/16/23 for assist rails on bilateral sides of the bed for mobility. On 9/5/23 at 2:34 p.m., and 9/6/23 at 10:27 a.m., Resident #3 was observed with side rails in the raised position on both sides of the bed. Resident #3 said she did not know how the side rails got there but they had been in place for a long time. 2. Review of the clinical record revealed Resident #27 was admitted on [DATE] with diagnoses including chronic kidney disease stage 3 unspecified, weakness, and unilateral primary osteoarthritis. The Quarterly MDS dated [DATE] documented Resident #27 required supervision with transfers and ambulation. The MDS noted Resident #27's cognitive skills for daily decision making were intact. The clinical record showed a physician order dated 12/1/21 for grab bars as enablers on both sides of the bed for mobility. On 9/5/23 at 2:05 p.m., Resident #27 was observed with side rails raised on both sides of the bed. The resident said she did not ask to have the rails placed on the bed but said she did use them to move in bed. 3. Review of the clinical record revealed Resident #51 was admitted on [DATE] with diagnoses including dementia, history of falls, muscle weakness, anxiety, and depression. The Admission MDS with ARD 8/18/23 documented Resident #51 required extensive assistance of 1 with bed mobility and transfers. The MDS noted Resident #51's cognitive skills for daily decision making were severely impaired. The physician order dated 8/19/23 specified assist rails to bilateral bedside for mobility. On 9/5/23 at 3:05 p.m., Resident #51 was observed in bed with side rails in the raised position on both sides of the bed. On 9/6/23 at 11:51 a.m., in an interview the Assistant Director of Nursing (ADON) said the process for side rails was for the therapy department to assess the resident to see if they can benefit from the side rails. The ADON said if the resident qualified to have the side rails placed, then we get a consent form signed by the resident or family. The ADON said once an order is received from the physician, maintenance will come and place the side rails. On 9/6/23 at 12:25 p.m., in an interview the Director of Nursing (DON) said all bed rails in the facility are considered side rails. The DON said the process for side rails was for Occupational Therapist (OT) to complete an assessment to see if they can use the side rail or not. If they can benefit from the side rails to move in bed and transfer then the OT completes the Brief Initial Therapy Eval Review and the nurse obtains an order from the physician. On 9/6/23 at 12:39 p.m., in an interview the Therapy Director, said OT completes the side rail evaluations for the residents and determines if they are necessary or not. On 9/6/23 at 12:55 p.m., in an interview the OT said she completes the side rail screens with the Physical Therapist (PT) during treatment. If a resident can turn and use the side rail to reposition themselves then they would benefit from the use of the side rail. The OT said prior to initiating the side rails, we assess the resident for 30 minutes to 70 minutes and sometimes over 1-4 days to see if they benefit from the side rail use. The OT said all the interventions attempted prior to use of the rails were documented in the therapy notes. On 9/6/23 at 1:37 p.m., a review of the OT notes for Residents #3, #27 and #51 revealed no documentation of a side rail assessment or interventions attempted prior to installation of the side rails. On 9/6/23 at 2:26 p.m., the OT confirmed she did not have documentation of the interventions attempted prior to the use of the side rails for Residents #3, #27 and #51. On 9/6/23 at 3:15 p.m., in an interview the Therapy Director said the therapy notes do not document any information regarding side rails or interventions attempted prior to use. The Therapy Director said the therapist completes the Brief Initial Therapy Eval Review for use of the side rails. She said if the residents benefit from it and they can turn, get up and reposition themselves with the side rails then we recommend it. The nurse is responsible for obtaining the physician order and the consent from the resident and or family. The Therapy Director confirmed the form used did not have documentation of interventions attempted or the reason for the side rails. On 9/6/23 at 3:35 p.m., the DON, she said the facility used the Brief Initial Therapy Eval Review form as the assessment for use of the side rails. The DON said we call them side rails not enablers or assist bars. The therapy department determines if the resident should have the side rails or not. It is not used as a restraint; it is used to assist the resident and improve their function and ability. The DON said she was not aware alternate interventions were required before placing the side rails.

Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure eye drops and insulin were properly dated when opened and stored 2 of 3 medication carts reviewed. Without an open date on the medication there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The findings included: The facility policy Medication Storage in the Facility (revised 1/18) documented Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Expiration dates (beyond use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or recommendations/guidelines require different dating. On 9/5/23 at 10:20 a.m., during an observation of medication cart #2 with Licensed Practical Nurse (LPN) Staff A the following was observed: 1. One open Humalog Kwik Pen insulin without a date of when it was opened. The pharmacy label documented to discard after 28 days. Photographic evidence obtained. 2. One open Humalog Kwik Pen insulin with the resident name partially removed from the label. There was no open date on the insulin pen and no open date on the pharmacy bag containing the insulin pen. Photographic evidence obtained. The findings in medication cart #2 were verified by Staff A. On 9/55/23 at 10:43 a.m., during an observation of medication cart #3 with LPN Staff B the following was observed. 3. One Humalog Kwik Pen insulin with no open date on the pharmacy bag or the insulin pen. The pharmacy label specified to discard the medication after 28 days. Photographic evidence obtained. 4. One opened bottle of Dorzolamide 2% eye drops with no open date on the bottle or pharmacy bag. The Pharmacy label specified to discard the eye drops in 60 days. Photographic evidence obtained. The findings in medication cart #3 were verified by LPN Staff B.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards to prevent the development of pressure ulcers for 1 (#1) of 3 Residents admitted to the facility without pressure ulcers but at risk for developing pressure ulcers. The lack of interventions resulted in the resident developing a stage 4 full thickness coccyx pressure wound with bone visible. The findings included: Review of the facility Policy Pressure injury(s)/Skin Breakdown - Clinical Protocol revised on 1/7/20, Assessment and Recognition #4 . The physician will assist the staff to determine the etiology and characteristics of the skin alteration . Monitoring #2 The physician will help the staff review and modify the care plan as appropriate, especially when new wounds develop. Review of the Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 11/16/21 Section C revealed Resident #1 was admitted to the facility on [DATE] with moderately impaired cognition and a Brief Interview of Mental Status Score of 12. Section G for functional status indicated Resident #1 required the assistance of 2 staff for bed mobility, transfers, and toileting. Section M indicated Resident #1 did not have any pressure wounds when she was admitted to the facility on [DATE]. Review of the (Agency for Health Care Administration) AHCA Form 5000-3008 (hospital transfer form) dated 11/9/21 revealed Resident #1 had redness to the coccyx. Review of the AHCA Form 5000-3008 dated 11/10/21 revealed Resident #1 had no pressure ulcers before she was admitted to the facility. Review of Resident #1's Baseline Care Plan dated 11/12/21 revealed a summary of goals including, I will remain free from all preventable skin breakdown with all interventions in place . Review of Resident #1's admission progress note dated 11/9/21 revealed the resident's skin was dry and intact with normal color and no skin issues when she was admitted to the facility. Review of the progress note of 11/10/21 revealed Resident #1 was unresponsive to verbal stimulus at the facility and was transferred to the hospital for evaluation. Review of Resident #1's 2nd admission progress note dated 11/12/21 revealed the resident's skin was dry and intact with normal color and no skin issues when she was admitted to the facility the 2nd time. Review of the nursing progress note of 11/20/21 revealed Resident #1 found to have a blister in the left buttock that was not open with no redness or warmness. Review of Resident #1's orders included an order from the attending physician for Skin Prep to fluid filled blisters every shift to left buttock starting on 11/21/21. Review of the nursing progress notes of 11/22/21 revealed Resident #1 had 2 blisters on her right coccyx yesterday and a new small one on her left buttock. Review of the Advanced Registered Nurse Practitioner note of 11/23/21 revealed a change is the description of the blister including, Resident #1 has a blister that is ecchymotic (area of the skin forming a flat, rounded or irregular blue or purplish patch). Review of Resident #1's Care Plan for alteration in skin integrity revealed an approaches/intervention was added on 11/20/21 to Apply treatment to rash/[CONDITION(S)] as ordered and and another on 11/21/21 for Skin Prep to intact fluid filled blisters every shift to left buttocks as ordered. These 2 approaches/interventions were also in the physician's orders and not necessarily a new nursing approach/intervention to prevent pressure ulcers. Review of Resident #1's care plan did not include Repositioning and off-loading the coccyx as approaches/interventions to prevent pressure ulcers. Review of the medical record revealed no evidence an alternating air mattress to help with off loading was ever provided for Resident #1. Review of the physician's orders for Resident #1 included House Supplement 120 milliliters by mouth once a day starting on 11/12/21. Review of the physician's orders from 11/9/21 - 12/8/21 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no preventative orders put in place to prevent the development of pressure ulcers to the coccyx area at the time Resident #1 was admitted to the facility. Review of the nursing progress notes dated 11/28/22 revealed Resident #1 has a dry flat blister to right lower buttocks and one clear filled blister intact to left lower buttocks. Review of the progress note of 11/29/21 revealed Resident #1 has dry flat blisters to right lower buttock. Review of the ARNP progress note of 12/13/21 revealed Resident #1 was examined at the request of family. A Stage 3 pressure ulcer was found on her coccyx. The entire wound bed was covered with slough tissue (a yellow material). Resident #1 to see wound care physician this week. Review of the Initial Wound Evaluation and Management Summary by the Wound Care Physician dated 12/17/21 noted; Resident #1 had an unstageable coccyx wound for at least 10 days duration (due to necrosis, which means cell death in an organ or tissue). The wound size (Length x Width x Depth) was 2 centimeters (cm) x 1.5 cm x Not measurable for depth. The surface area was 3.00 cm squared. There was moderate serous exudate (any fluid or semisolid that has exuded out of a tissue or its capillaries, more specifically because of injury or inflammation). The etiology (cause of a disease or condition) was listed as pressure and the duration of the wound was listed as greater than 10 days. The tissue was 100% necrotic. The wound was surgically debrided during the evaluation to remove the necrotic tissue. The wound care physician recommended laboratory work for Hemoglobin A1C on 12/17/21 and Pre-[MEDICATION(S)] on 12/17/21. The Individualized Treatment Plan Included Repositioning per the facility protocol and off-load wound. Review of the subsequent Wound Evaluation and Management Summaries completed by the Wound Care Physician from 12/23/22 - 1/20/22 did not indicate Resident #1's pressure ulcer was unavoidable. Review of the medical chart indicated there was lab work done for Resident #1 on 11/30/21, during the time she was at the facility. There was no Hemoglobin A1C or Pre-[MEDICATION(S)] level included in the lab work. The lab work recommended by the Wound Care Physician during the Initial Evaluation of Resident #1 had not been completed. On 10/31/22 at 1:59 p.m., in an interview, the Assistant Director of Nursing (ADON/wound care nurse) for the facility said Resident #1 came back to the facility with the blister, then it popped and turned into the wound. She said there was only 1 blister despite what the records say. She said the specialty wound care physician got involved with Resident #1's treatment once the blister became open. The ADON said the blister skin was the same color as the normal tissue, however raised. She said she is the wound care nurse at the facility, but she does not inspect every new resident's skin. She said turning and repositioning every 2 hours and sometimes every hour is necessary to prevent pressure ulcers or existing pressure ulcers from getting worse. The ADON acknowledged Resident #1's care plans did not include approaches/interventions of turning and repositioning and there was no documentation indicating it was ever done. She said the Certified Nursing Assistants (CNAs) do not document when they turn or reposition residents. On 10/31/22 at 5:44 p.m. During a 2nd interview with the ADON/wound care nurse she said she first saw Resident #1's blister when she did rounds with the wound care physician on 12/17/21. She said staff did not make her aware of the blister when it was first discovered. She said obviously staff needs re-education regarding wounds. The ADON said she is responsible for staff development and training but she said there was no recent training on wounds for the nursing staff. She said staff were supposed to be turning Resident #1, but the nurses really must stay on top of it. On 11/1/22 at 9:30 a.m., in an interview, the Registered Dietician (RD) said she was familiar with Resident #1 and ordered the House Supplement when she was first admitted to the facility. The RD said she was not made aware Resident #1 had a buttocks blister that evolved into a Stage 3 pressure ulcer. She said if she had known she would have included additional nutritional interventions for Resident #1. On 11/1/22 at 11:16 a.m. during an interview with Registered Nurse (RN) Staff A said she's worked at the facility for one year and has been a Registered Nurse for 4-5 years. She said if there is a blister on the buttocks you are supposed to put a treatment in place and refer the resident to the wound-care specialists. She said the ADON reviews the Wound Evaluation Summary and Management and orders any new labs included in the summary. On 11/1/22 at 12:53 p.m. the ADON said she did not recall when she first saw Resident #1's buttocks. She confirmed the wound care physician recommended lab work for a Hemoglobin A1C and Pre-[MEDICATION(S)] when he saw Resident #1 on 12/17/21, but she did not put the orders in the computer and they were not drawn. On 11/1/22 at 2:28 p.m. during a telephone interview with the wound care physician he said a blister to the coccyx with clear fluid would be a stage 2, but if you cannot see through the blister it would be unstageable. He said off-loading to decrease the pressure to the area is important as well as keeping the area dry. He said the repositioning and off-loading the wound is important regardless of whether the resident has an air mattress or not. He said he is usually involved when a resident gets a Stage 2 pressure ulcer and even with smaller pressure ulcers he is involved. He said the lab work is more for dietary to review and make recommendations. He said he does not include a wound is unavoidable unless there is a general decline in the resident. Review of Resident #1's medical record showed no evidence of general decline. There was no documentation the pressure ulcer was unavoidable.

Based on record review, review of facility's policy and procedure and staff interview, the facility failed to assess, evaluate, and plan care to provide individualized approaches to restore as much normal elimination function as possible for 1 (Resident #4) of 6 residents reviewed with bladder incontinence. The findings included: The facility's Activities of Daily Living (ADL), supporting Policy Statement revised on 1/7/20 read, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . Elimination (toileting) . Interventions to improve . a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice . On 12/13/21 at 2:00 p.m., in an interview Resident #4 said when she presses the call light, she waits too long for staff to come and ends up having accidents and wets herself in her adult brief. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment), was frequently incontinent of urine and required staff assistance with toileting. The quarterly MDS with a target date of 12/8/21 showed Resident #4 had a BIMS score of 10 (moderate cognitive impairment), was frequently incontinent of urine and required limited physical assistance of one person with toileting. Review of the facility Observation Detail List Reports completed on 9/15/21 and 12/13/21 showed a completed a bladder screen noting Resident #4's urinary pattern was upon arising, before meals, after meals and before going to bed. Each screen documented Resident #4 was a candidate for scheduled/prompted toileting. The Certified Nursing Assistant (CNA) documentation for bladder function for September and December 2021 failed to show documentation of tracking over several days to establish the urinary pattern. The care plan with a start date of 9/21/21 noted Resident #4 had episodes of bladder incontinence. The goal was to report a decrease in episodes of incontinence when asked and remain clean and comfortable daily. The approaches included to assist to the toilet upon rising, before and after meals, prior to sleep and as needed and desired. On 12/14/2021 at 2:40 p.m., the MDS coordinator verified the lack of a bladder patterning to assess Resident #4's incontinence and develop individualized interventions to maintain or improve Resident #4's bladder continence. She said residents were to be evaluated for continence on admission and a monitoring record in place to assess elimination patterns. All incontinent residents were re-assessed on a quarterly basis using the Incontinence Reassessment form to determine if residents qualify for a toileting plan. Individualized plans and goals were developed based on the results of the assessment. Each resident on the monitoring program will have individual plans and goals established by the care plan team to assist the resident in acquiring lost functions or to maintain present function. On 12/14/21 at 2:35 p.m., CNA Staff A said Resident #4 will alert staff when she needs to urinate, but sometimes has already urinated in her brief when she gets to her. On 12/14/21 at 3:00 p.m., in a telephone interview, Resident #4's daughter said her mother is now incontinent, but it was not always that way. She said she visits twice a week on Wednesday and Saturday and spends two hours at the facility. Daughter said she used the call light during visits and witnessed that it takes a while for staff to answer the call bell. She said she has had to seek out staff herself so they would assist with toileting. Resident #4's daughter recalled that her mother once contacted her at 2:00 a.m. upset that staff would not come to assist her with toileting after she pressed her call bell. On 12/16/21, the Director of Nursing (DON) confirmed resident #4 was not on a toileting program based on voiding pattern and the interventions were not individualized to assist staff (licensed nurses and certified nursing assistants) to maintain and promote continence. The DON confirmed the facility failed to implement a tailored approach to improve and maintain resident's urinary function.

Based on observation, staff and resident interviews, the facility failed to ensure medications were secured and remained under direct observation during medication administration for 1 (Resident #16) of 1 resident observed with unsecured medications at the bedside. The failure to properly secure medications has the potential to lead to inaccurate amount of medication taken by the resident or possible ingestion of the medication by another resident. The findings included: On 12/13/21 at 9:55 a.m., seven unidentified pills were observed on a napkin on Resident #16's over the bed table. There was also a paper cup with a prescription bottle of [MEDICATION(S)] nasal spray inside a plastic bag. Resident #16 said it took her a while to get the pills down so the nurse left the pills with her. During the Resident's interview Licensed Practical Nurse (LPN) Staff C walked into Resident #16's room to collect the bottle of [MEDICATION(S)] nasal spray. The resident told her she hadn't used it yet. Staff C left the nasal spray with the resident and left the room. Photographic evidence obtained On 12/14/21 at 11:30 a.m., in an interview, the Assistant Director of Nursing (ADON) said the facility currently did not have any resident who were allowed to self-medicate. She said when the nurses are doing medication pass, they are supposed to stay at bedside with the resident until all the medications are administered. Upon seeing the photographic evidence of the medications left at the bedside, the ADON said this was not part of facility practice. She said the nurse was new and she would reeducate her. On 12/14/21 at 2:15 p.m., in an interview the Director of Nursing verified there were no residents in the facility self-medicating and the nurses were not allowed to leave any medication unattended at bedside. On 12/15/21 at 9:50 a.m., in an interview LPN Staff C said she didn't know she couldn't leave medications unattended at the bedside for the residents. She said she was reeducated and would not leave medications at bedside anymore.

Based on observation, facility policies review, and staff interview the facility failed to handle clean laundry in a sanitary manner to prevent contamination. The facility failed to maintain infection control prevention during catheter care for 1 (Resident #48) of 1 resident observed for catheter care. The facility failed to prevent cross contamination during wound care for 1 (Resident #257) of 1 resident observed during wound care. The facility failed to store a urinal in a sanitary manner for 1 (Resident #19) of 1 resident who used a urinal. The findings included: 1. On 2/24/20 at 10:58 a.m., during an observation of the laundry room, Housekeeping Supervisor Staff A was observed folding clean linen. Staff A was holding the clean linen against her uniform as she was folding. During the observation, Staff A put a gown on to prevent the clean linen from coming into contact with her uniform as she finished folding the clean linen. On 2/24/20 at 2:29 p.m., during an observation on the B hall, Laundry/Housekeeping Staff B and Laundry/Housekeeping Staff C were removing clean laundry for the residents from a large rolling rack. Staff B and Staff C removed the clean laundry hanging on the rack and laid it over their arms. Staff B and Staff C were holding the clean laundry against their uniforms as they delivered it into resident rooms and hung the laundry in the closets. The staff were observed repeating this action from room to room on the B hall and then proceeding to the A hall. On 2/24/20 at 2:34 p.m., in an interview Laundry/Housekeeping Staff B said, they were helping with the laundry today. Staff B said she was not aware that the clean laundry should not come into contact with her uniform when handling the clean laundry. On 2/24/20 at 3:14 p.m., Certified Nursing Assistant (CNA) Staff D, was observed taking a stack of clean towels from the linen room. Staff D placed the clean towels in her left arm, holding them against her uniform. Staff D walked down the B hall taking the clean towels into a resident room and placed some of the towels on the bedside table. Staff D proceeded to go into several resident rooms, taking the clean towels and placing a few towels in each room. On 2/27/20 at 8:17 a.m., during a tour of the laundry room, the door separating the clean linen and soiled linen rooms was propped open with a linen cart. There was a portable fan in the soiled section of the laundry circulating air, while the door separating the clean and soiled room remained propped open. On 2/27/20 at 8:25 a.m., the Maintenance Director confirmed the door separating the clean linen room and soiled linen rooms was propped open with the linen cart and said it should always be closed. 2. The facility policy Handwashing/Hand Hygiene (revised 11/1/18) specified to Vigorously lather hands with soap and rub them together, . for a minimum of 20 seconds (or longer) under . running water. The facility policy G-[AGE], [MEDICATION NAME] Care (revised 2/10/19), specified . if the resident has an indwelling catheter (a tube in the body that drains urine from the bladder), gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Do not reuse the same washcloth or water to clean the urethra. On 2/27/20 at 9:45 a.m., during an observation of urinary catheter care, CNA Staff G washed her hands with soap and water for 7 seconds, she dried her hands and then donned a pair of gloves. Staff G approached Resident #48's bedside and pulled the privacy curtain closed with her gloved hands. Staff G realized she did not have water in the wash basin and took it into the bathroom to fill with water. Staff G returned and placed the washbasin on the bedside table and pulled the privacy curtain closed. Staff G continued to keep the same gloves on as she placed clean wash cloths into the basin. Staff G took a washcloth from the basin, applied liquid soap and proceeded to wash Resident #48's penis, scrotum and groin area. Using the same washcloth, Staff G wiped the juncture of the urethra and catheter tubing and placed the washcloth into a plastic bag. Staff G took a clean washcloth from the basin and wiped Resident #48's penis, scrotum and groin area to remove the soap. Using the same washcloth, Staff G wiped the juncture of the urethra and catheter tubing. Staff G said she needed to change Resident #48's catheter drainage bag to a leg bag so Resident #48 could go to therapy. Staff G opened the privacy curtain and entered the bathroom to remove her gloves. Staff G turned on the water on and flicked her fingers under the water for 3 seconds without applying soap to her hands and applied clean pair of gloves to complete the care for Resident #48. On 2/27/20 at 9:05 a.m., in an interview Staff G said she was supposed to wash her hands for 20 seconds and confirmed she had not washed her hands for the required length of time. Staff G confirmed she should have changed gloves after touching the privacy curtain and filling the basin at the bathroom sink to prevent contamination during catheter care for Resident #48. 3. On 2/26/20 at 2:30 p.m., Licensed Practical Nurse Staff F was observed providing wound care to the right heel for Resident #257. Staff F washed her hands and applied clean gloves. Staff F removed and discarded the soiled dressing. Staff F cleaned the wound with a gauze wet with normal saline solution. Staff F applied the Physician ordered ointment using a cotton tip applicator. Staff F applied a collagen powder to the wound and used a clean foam dressing to cover the wound. Staff F used rolled gauze and tape to secure the dressing, completing the wound care. Staff F removed her gloves and washed her hands. On 2/26/20 at 2:45 p.m., in an interview, Staff F confirmed she should have washed her hands and changed her gloves after cleaning Residents #257's wound and applying the medication and clean dressing. 4. During observations on 2/24/20, 2/25/20, and 2/27/20 the hand-held urinal for Resident #19 was observed in various locations around the resident's bed: on the windowsill, on the floor, and on the bedside table near a meal tray and toiletries. In some instances, urine was observed in the urinal. There was no cover on the urinal. The urinal was not inside a bag. On 2/27/20 at 03:16 p.m., in an interview CNA Staff M said the urinal should be rinsed and bagged after Resident #19 used it. On 2/27/20 at 03:19 p.m., during an interview LPN Staff N confirmed Resident #19's urinal was on the windowsill without a lid, un-bagged. Staff N confirmed Resident #19's urinal should be in a bag for infection control. ***Photographic evidence obtained***

Based on observation, record review, and staff interview the facility failed to develop and update a care plan that accurately reflects the resident's condition and addresses the specific care needs of 8 (Residents #6, #27, #22, #33, #17, #26, #40, and #4) of 38 resident care plans reviewed. The findings included: 1. A review of the medical record revealed Resident #6's medical [DIAGNOSES REDACTED]. The admission nursing progress note dated 11/15/19 documented, Resident #6 had stiffness and rigidity of bilateral upper and lower extremities with noted contractures to left and right forearm. A nursing progress note dated 11/17/19 documented Resident #6 was totally dependent with all activities of daily living (ADLs). On 2/25/20 at 8:38 a.m., in an interview Certified Nursing Assistant Staff H said Resident #6 would turn to her side but did not move anything else. The care plan (document that provides for individualized nursing care) edited on 2/25/20 documented Resident #6 was limited in all ADLs due to cognitive decline and functional mobility. The goal for Resident #6 documented the resident would perform independent ADLs after setup. On 2/27/20 at 10:00 a.m., in an interview the Care Plan Coordinator said the care plan for Resident #6 was updated on 2/25/20 and confirmed the ADL care plan goal was for the resident to perform self ADLs after setup. The Minimum Data Set (MDS) Coordinator said Resident #6 was not able to do self-care and confirmed the care plan did not accurately address the residents specific care needs. 2. A review of the Admission Minimum Data Set (MDS) Assessment, completed on 5/8/19, revealed Resident #27 was assessed as having impaired range of motion for the upper extremities on one side of her body and lower extremities on both sides of her body. A review of the most recent Quarterly MDS Assessment, completed on 1/1/20, revealed the resident was assessed as having impaired range of motion for the upper extremities on one side of her body and lower extremities on both sides of her body. A review of the Plan of Care (POC) for Resident #27 failed to reveal any goals or intervention for range of motion for the resident. On 2/26/20 at 9:35 a.m., in an interview the MDS Coordinator confirmed the POC did not contain any goals or interventions for range of motion for Resident #22. 4. A review of the Annual MDS Assessment, completed on 6/19/19, revealed Resident #22 was assessed as having impaired range of motion on both sides of her body. A review of the most recent Quarterly MDS Assessment, completed on 1[DATE], revealed Resident #22 was assessed as having impaired range of motion on both sides of her body. A review of the Plan of Care (POC) for Resident #22 failed to reveal any goals or intervention for range of motion for the resident. There is no is requirement for staff to observe changes in posture and no requirement to ensure the resident is properly positioned in the Broda Chair to reduce the decline in range of motion. On 2/26/20 at 9:48 a.m., the MDS Coordinator confirmed the POC did not contain any goals or interventions for range of motion for Resident #22. Observation of the lunch meal on 2/25/20 at 12:10 p.m., found Residents #22, #33, #17, #26, #40, and #4 in the assisted dining section of the main dining room positioned at tables in tilt positioning wheelchairs (Broda Chairs). Residents were observed with their legs dangling or drawn, with feet not in contact with the ground or chair footrests. The residents' feet had no resistance for flexion or comfort. Observation of the dining room at the breakfast meal on 2/26/20 at 8:10 a.m., found Residents #22, #33, #17, #26, #40, and #4 in Broda Chairs being assisted with dining. They were not positioned so that their feet were properly supported. 5. Resident #33 was observed in a High-back reclining wheelchair (Broda Chair) on 2/25/20 at lunch and 2/26/20 at breakfast. The resident's feet were not touching the footrest on the chair. The resident was wearing shoes and toes were pointing down. The care plan created on [DATE] does not include interventions to ensure the resident was properly positioned in the Broda Chair to reduce the decline in range of motion. 6. Resident #17 was observed in a Broda Chair on 2/25/20 at lunch and 2/26/20 at breakfast. The resident's feet were not able to reach footrest attached to the chair. The resident's heels were up and the toes pointing down. The care plan created on 1[DATE] does not include interventions to ensure the resident is properly positioned in the Broda Chair to reduce the decline in range of motion. 7. Resident #26 was observed in a Broda Chair on 2/25/20 at lunch and 2/26/20 at breakfast. The resident's chair had a leg platform to keep the legs up. The leg platform was extended horizontally. On 2/25/20 at 12:15 p.m., the resident was observed at dining table with left leg hanging off the extended leg platform. Staff H did not reposition the resident with legs on the platform. The care plan revised on 1/12/20 does not include interventions to ensure the resident was properly positioned in the Broda Chair to reduce the decline in range of motion. 8. Resident #40 was observed in a High-back reclining wheelchair on 2/25/20 at lunch and 2/26/20 at breakfast. The resident's feet were not able to reach footrest on the chair. The resident was wearing socks. The resident's legs were resting on calf support pads attached to the chair. The resident's toes were pointing down. The care plan revised on 1/28/20 does not include interventions to ensure the resident was properly positioned in the Broda Chair to reduce the decline in range of motion. 9. Resident #4 was observed in the resident lounge on 2/25/20 at 10:53 a.m., in a Broda chair with legs crossed and feet in foam boots resting on the footrest. Legs bent up with knees above his thighs. The resident did not have the opportunity to extend his legs and the legs were not elevated. At lunch on 2/25/20 the resident's right foot was extended past the footrest with the back of the ankle resting on the edge of the footrest. The care plan revised on 2/28/20 does not include interventions to ensure the resident was properly positioned in the Broda Chair to reduce the decline in range of motion. There was no documentation of he evaluation of the identified residents for properly fitting wheelchairs. There was no documentation of baseline contractures and no documentation of assessment or monitoring of developing leg contractures or foot drop or of a worsening condition. In an interview on 2/26/20 at 8:20 a.m., the two CNAs, Staff H and Staff L, said they were unaware the residents' feet were not properly positioned. The CNAs said they adjusted the angle of recline on the chairs, but they did not adjust the footrests. During an observation on 2/26/20 at 8:50 a.m., the Director of Therapy (DOT) while adjusting the wheelchairs for the 6 identified residents, attempted to flex or extend the residents' joints with much difficulty and some grimaces of pain. The DOT said not all of the footrests could be adjusted to properly support the residents' feet so he would have to get adaptive blocks and pads to attach to the wheelchairs to slow the loss in range of motion. The DOT acknowledged the wheelchairs were not properly fitted to the residents. In an interview on 2/27/20 at 2:40 p.m., the MDS Coordinator confirmed the care plans did not address positioning in wheelchairs to prevent decline in range of motion.

Based on observation, record review, and staff interview the facility failed to accurately assess the functional limitations of 1 (Resident #6) of 38 resident assessments reviewed. The findings included: On 2/24/20 at 4:30 p.m., Resident #6 was observed in her room in bed. Resident #6 had her hands in a closed fist and her elbows were bent with her hands resting on her chest. On 2/25/20 at 8:38 a.m., in an interview Certified Nursing Assistant Staff H said, Resident #6 was not capable of moving. Staff H said, sometimes she was restless and would turn to her side but did not move anything else. A review of the medical record revealed Resident #6 was admitted to the skilled nursing facility on 11/15/19. Resident #6 had a medical [DIAGNOSES REDACTED]. The admission nursing progress note dated 11/15/19 documented the resident had stiffness and rigidity of bilateral upper and lower extremities with noted foot drop to both feet. Resident noted to have contractures to left hand and right forearm. A review of the admission MDS completed on 11/21/19, identified Resident #6 had a functional limitation in range of motion with impairment on both sides of the lower body and no impairment of her upper body. A review of the MDS completed on [DATE] identified Resident #6 had a functional limitation in range of motion with impairment on both sides of her upper and lower body. On 2/27/20 at 10:00 a.m., in an interview the MDS Coordinator said Resident #6 was not accurately assessed at the time her admission MDS was completed. The MDS Coordinator said Resident #6 had limitations in her range of motion to both her upper and lower extremities at the time of her admission. The MDS Coordinator confirmed the admission MDS completed on 11/21/19 was not correct.

Based on record review and resident and staff interview the facility failed to provide a Baseline Care Plan summary with required components for 1 (Resident #307) of 5 residents identified as new admissions. The findings included: The Baseline Care Plan reflects the resident's stated goals and objectives and includes interventions to address his or her current needs. The Baseline Care Plan summary must be in a language and conveyed in a manner the resident and/or representative can understand. The summary must include: - Initial goals for the resident; - A list of current medications and dietary instructions, and - Services and treatments to be administered by the facility and personnel acting on behalf of the facility On 2/24/20 at 3:11 p.m., in an interview Resident #307 said he was admitted on Friday [DATE] after a fall at home which resulted in a broken neck, injured elbow, and pain in left ankle. He said staff spoke to him, but he did not understand what was written on the paper. A paper titled Care Plan Summary was observed on the resident's bed side table. Resident #307 said he was not able to chew his food over the weekend because of the rigid neck brace he wore. He said he had pain and was not able to complete his therapy earlier in the day. A family member said he was told the resident has a PRN (as needed) order for [MED]. The family member believed the resident forgot to ask for the medication. There was no Baseline Care Plan for pain management to improve tolerance of rehabilitation therapies. The Care Plan summary was presented to the resident on Monday 2/24/20. A review of the Care Plan Summary revealed the summary did not take into account the resident's concerns, and was not easy to understand. The Care Plan Summary read: Good rehab potential We would like to take this opportunity to share with you a summary of goals or ways that we plan to assist (resident's name) in maintaining their highest level of independence, promote comfort and assist with their healing process. The Summary of goals are as follows: I will perform self ADL's (activities of daily living) after set up assistance only by the time of discharge. I will be at a decreased risk for falls and have injuries minimized with all interventions in place. I will have all s/s (signs and symptoms) of bleeding promptly detected and treated with all interventions in place. We currently have the following Advanced Directives in place for (resident's name) Full Code Other (Resident's name) has the following Physician and Nursing Orders in Place: This was followed by an alphabetical list of all admission orders [REDACTED]. There are 64 physician orders [REDACTED]. The first medication identified, Afrin, is the 11th item in the list. The last medication identified, [MED], is the 61st item in the list. The other 13 medications are dispersed throughout the list. The diet orders were not on the printed list. The diet order was handwritten without a time or date. OT to evaluate and treat as indicated is identified on line 46 PT to evaluate and treat as indicated is identified on line 51 ST to evaluate and treat as indicated is identified on line [AGE] In an interview 2/25/20 at 9:30 a.m., the Certified Dietary Manger (CDM) said she met with the resident on Monday and adjusted the diet consistency to 'mechanically ground meat'. The CDM said the resident was given a regular diet on Saturday and Sunday. The CDM said there was no documentation of the resident being questioned about eating difficulties while establishing the Baseline Care Plan. The CDM acknowledged the resident was not able to chew his food over the weekend because of the rigid neck brace he wore. She said the resident ability to eat was not taken into consideration until after the Baseline Care Plan was presented to the resident. In an interview on 2/26/20 at 1:48 p.m., the Unit Manager (UM) said Resident #307 complained a lot The UM said the physician saw Resident #307 on Tuesday evening, 2/25/20 and adjusted the pain medications, ordering [MEDICATION NAME] and [MEDICATION NAME] to begin administration on 2/26/20. The UM said there was no discussion with the therapy staff about medicating the resident before therapy sessions. The UM confirmed the admission orders [REDACTED]. The UM acknowledged the residents pain level and discomfort during therapy was not taken into consideration when developing the Baseline Care Plan. In an interview on 2/27/20 at 1:43 p.m., the Physical Therapist (PT) said the resident was complaining of ankle pain and had a drop in blood pressure on Monday during the therapy session. The PT said she always checked with the nurse before starting therapy in the morning to be sure the medications were given. The PT said it is up to physician and nurse to ensure pain medication was prescribed and administered. The rehabilitation therapy goals were not identified in the Baseline Care Plan Summary. Prior to the completion of the comprehensive care plan, the therapy plan was implemented, the diet was modified, and pain management was implemented. The Baseline Summary was not updated as a reference for the resident. In an interview on 2/27/20 at 2:40 p.m., the MDS Coordinator confirmed the Baseline Care Plan summary was not updated to reflect changes in pain medication, therapy modalities, and food consistency. The MDS Coordinator said she went over the summary with the resident because it was hard to understand and explained things about the resident's care that was not in the summary. The MDS Coordinator said the electronic medical record program produced the care plan summary and only the first paragraph can be modified. She said there was no mechanism for grouping the medications together into a list, and no way to add the diet order. The MDS Coordinator said she was using the company mandated print out and had not considered creating a better summary. The MDS Coordinator said she did not update the Baseline Summary even when changes to the care and services being provided to the resident were implemented prior to the completion of the comprehensive care plan.

Based on observation, record review, and staff interview the facility failed to update the care plan to accurately reflect the resident's change in condition and failed to addresses the specific care needs of 1(Resident #257) of 38 resident care plans reviewed. The findings included: 1. The admission MDS completed on 11/25/19 document Resident #257 was at risk for developing pressure ulcers but had no wounds. The medical record contained a wound management report dated 12/13/19 that documented Resident #257 had a left and a right heel pressure ulcer. A review of the medical record for Resident #257 revealed a care plan edited on 1[DATE] documenting the resident was at risk for alteration in skin integrity due to decreased mobility. The care plan did not document the left and right heel wounds identified on 12/13/19. On 2/26/20 at 2:42 p.m., in an interview the Care Plan Coordinator confirmed the care plan for Resident # 257 was not updated to reflect the change in the resident's condition or the specific care required to meet her needs after the left and right heel wounds were identified.

Based on record review, observation and interviews, the facility failed to prevent the development of urosepsis, resulting in hospitalization , for 1 (Resident #61) of 1 sampled resident reviewed for the use of an indwelling Foley catheter without adequate justification for use. The finding includes: On 1/5/15 at 1:50 p.m., the licensed nursing staff advised during interview that Resident #61 had an indwelling Foley catheter for "retention of urine and gets freaked out when we try to pull it out". The resident was observed on 1/5/15 at 2:00 p.m. and on 1/6/15 at 11:00 a.m. to have a Foley catheter to gravity drainage. Review of medical record on 1/6/15 revealed that the resident was admitted to the facility with a Foley catheter. The medical record revealed [DIAGNOSES REDACTED]. A Minimum Data Set (assessment) dated 12/9/14 identifies a score of 15 out of 15 on a BIMS (Brief Interview for Mental Status), indicating the the resident has no cognitive impairment. The comprehensive care plan dated 12/18/14 states "has an indwelling Foley catheter for [DIAGNOSES REDACTED]. Interventions included indwelling Foley catheter 16Fr/10 cc balloon, change catheter and drainage bag monthly and as needed, keep catheter bag covered, Foley catheter care with soap and water every shift and as needed, observe amount color, odor and consistency of urine, monitor output, assess for bladder distention, discomfort or leaking around site, secure catheter tubing with cath-secure. Review of a weekly Pressure Ulcer Report, relating to Resident #61, revealed that she had a Stage II right sacrum 1.0 cm x 1.0 open red moist area with scant drainage on admission date of [DATE]. On 12/17/14 this area was documented as healed. Review of medical (ARNP/MD) progress notes dated 12/4/14, 12/10/14, 12/13/14 and 12/25/14 revealed no reference to the reason for use of a Foley catheter or plan to evaluate the need to continue Foley catheter use. A nursing progress dated 12/25/14 at 4:41 p.m. states "Foley catheter patent; urine cloudy yellow colored with diminished output noted. Afebrile (no temperature). MD notified." This notification was not addressed in the MD note of 12/25/14 that was written at 5:49 p.m. The note stated "patient seen and examined due to cough and SOB, lungs positive expiratory wheezing, [MEDICAL CONDITIONS]exacerbation, cough. Add po (by mouth) [MEDICATION NAME] (antibiotic), f/u (follow up)." No subsequent Foley catheter progress note is on record (nursing or medical) for the time period 12/26/14 through 12/28/14. These notes reference that the resident was "on ABT (antibiotic) for URI (upper respiratory infection)." Continued review of the medical record revealed that the resident was originally admitted to the facility 12/3/14 and went to the hospital on [DATE] at 8:00 a.m. with the following progress note on record: "Resident continued to shiver c/o (complain) feeling very cold. BP 166/92, Temp 99.3, Resp 22, Heart Rate 122. Resident is lethargic. Blood glucose 89 at around 7:15 a.m. ARNP notified. Order received to transfer resident to ER (emergency room ) for evaluation. Family notified. Resident left via emergency service at 8:10 a.m." Upon interview on 1/6/15 at 1:00 p.m., the Director of Nursing (DON) stated that Resident #61 was admitted to the facility in early December and went to the hospital at the end of December and returned from the hospital 1/4/15. The resident was originally admitted to the facility from Hospice House, with a Foley catheter, for rehabilitation. The resident was refusing hospice care. When asked if there were any attempts to remove the Foley catheter or consult with a urologist, the DON stated that the catheter was maintained upon admission because the resident had an open area on her buttocks and the Nurse Practitioner (ARNP) wanted to promote healing of the area. The DON acknowledged, at this time, that the open area was very small and healed within 2 weeks of admission. The DON continued to state that she would contact the ARNP to secure an order to discontinue the Foley catheter A hospital history and physical dated 12/28/14, at 5:15 p.m., documented by the admitting physician, states "I do not know whether somebody noticed, but when she arrived at the emergency room , her fever was 103, but she also had a blood sugar of 46. She was very [DIAGNOSES REDACTED] (low blood sugar). She complained (of) very shortness of breath. Assessment and Plan: 1. Urinary tract infection/sepsis of urinary origin. It is not very clear to me whether the patient came with Foley catheter. It seems that way that she was with a Foley catheter at the Aristocrat, so this might be just a Foley catheter-associated urinary tract infection [MEDICAL CONDITION] of urinary origin. 4. Leukocytosis, secondary probably to the urinary infection. 7. [MEDICATION NAME], patient is malnourished with [MEDICATION NAME] 2.2". A hospital final summary, dated 1/3/14, revealed "in the hospital, it was noted that she was having significant urinary tract infection. She had demonstrated a septic picture and immediately she was given intravenous antibiotics. Her recovery was quite slow but steady. It was also noted that the patient was quite anemic. Infectious Disease specialist recommended for her antibiotic to be continued until January 10, 2015. A medical progress note, dated 1/6/15 at 6:29 p.m. states "Plan to remove catheter in AM and will also give extra fluids for next 48 hrs and if she cannot void in 8 hrs will reinsert Foley." A nursing progress note dated 1/7/15 at 6:00 a.m. states "Resident's Foley catheter discontinued this a.m. at 5:55 a.m. as ordered. 800 cc output clear yellow urine (3 days status [REDACTED]. Will pass on to oncoming nurse to monitor for voiding. Call bell in reach." Upon interview on 1/8/15 at 9:00 a.m., the Director of Nursing stated that the resident was voiding and doing well since the Foley catheter was discontinued yesterday. Resident #61 was observed sitting in her wheelchair at 11:15 a.m. on 1/8/15. A bedside commode was observed at the foot of her bed. Upon interview at this time the resident confirmed that her Foley catheter had been discontinued and stated that she was experiencing incontinence. She continued to state that they brought a bedside commode for her to use and "I put on my call light and wait, and wait and wait and wait; then I start yelling and screaming for help. I don't want to be wet. It takes them too long to help me. Right now I am waiting to go to therapy." When asked if she has ever refused to have the catheter removed in the past, the resident stated "No, I have had it taken out. I did not refuse." The ARNP entered the resident's room at this time and told the resident that her urinary output was good without the Foley catheter. There is no documented evidence that this oriented resident refused to have her Foley catheter discontinued. In addition, there was no documented plan developed to ascertain the resident's continued need for a Foley catheter upon admission to the facility; and upon readmission to the facility status [REDACTED]. No action, in this regard, was taken by the facility prior to the surveyor's inquiries regarding why the Foley catheter was being used, without adequate justification, for this comprised resident with [DIAGNOSES REDACTED]. During an exit conference on 1/8/15 at 6:45 p.m., the resident's physician stated he was aware of the Foley catheter being used (for Resident #61) and stated it as being used as a comfort measure because the resident has End Stage [MEDICAL CONDITION]. The physician acknowledged that the resident was admitted to the facility to receive physical and occupational therapy for reconditioning and that the resident refused hospice/comfort care services prior to admission.

Based upon observation, interview and record review the facility failed to develop and implement policies and procedures to ensure residents who utilize the outdoor courtyard area are not neglected. One (Resident #1) of 8 sampled residents sat in 90+ degree Fahrenheit weather in the direct sunlight for approximately 3 hours. As a result, he suffered acute injury from overexposure to sun, heat, and humidity. The resident's internal body temperature became overheated, and the resident became unresponsive. The resident was transported to the hospital emergency room with a [DIAGNOSES REDACTED]. Subsequently, Resident #1 expired 9 days later. Facility staff failed to offer the resident hydration or assist him out of the sun back into the air conditioning or shade. This failure created a situation that resulted in serious injury and harm to Resident #1, and required immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The Immediate Jeopardy was abated on [DATE], based upon the implementation of corrective action. Four (Residents #1, #2, #6, and #7) of the 8 sampled residents were identified as going outside without supervision. The facility's census was 57 at the time of the survey. All residents who utilize the courtyard were at risk for neglect, illness/injury and even death. The facility began to put corrective actions in place after the resident was harmed on [DATE]. The corrective actions reduced the scope and severity to D (that is, isolated, no actual harm with potential for more than minimal harm). The findings included: Elderly people (that is, people aged [AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body's ability to regulate its temperature or that inhibit perspiration. (source: "Extreme Heat" by Centers for Disease Control at <http://stacks.cdc.gov/view/cdc/ >) 1. Resident #1 was a [AGE] year old male who had been residing in the assisted living facility (ALF) attached to the skilled nursing facility (SNF). Review of clinical records showed his [DIAGNOSES REDACTED]. Recently he had lower extremity [MEDICAL CONDITION] (swelling due to excess fluid, a sign of heart failure) and was on [MEDICATION NAME] (a "water pill") 40 milligrams twice a day. Both of his legs were wrapped with zinc-paste wraps. He was alert and oriented and able to make his needs known. He was a new admission so his comprehensive assessment and care plan were not completed yet. The medical progress note dated [DATE] documented, "Resident was seen yesterday as he transferred to SNF from ALF d/t (due to) his increased debility and exit seeking from ALF. Presently up in his W/C (wheel chair) and he does self-propel in his W/C and he does like to sit outside in the sun but needs to be monitored." The Nurse Practitioner failed to write orders for monitoring the resident while outside in the sun. 2. Nursing note dated [DATE] at 4:46 p.m. documented, "Patient (Pt) wanting to go outside. CN (charge nurse) showed Pt that there was thunder and lightning outside. Nurse tried to discourage Pt from going out. Pt very HOH (hard of hearing), deaf and did not hear nurse. Pt continued outside in the storm." Five days later, nursing note dated [DATE] at 7:28 p.m. documented, "Pt was found outside by day CN and evening CN in his WC, unresponsive. Pt was not arousable, placed in his bed and vital signs taken. Temperature was 105 (very high). 911 was called while other nurses tried to cool Pt down with cold towels until EMS (emergency medical services) arrived. Pt taken to (name of hospital). Spouse notified and Dr. (doctor) notified." Upon transfer to the hospital on [DATE] at 5 p.m., the resident's vital signs were: temperature 105 degrees Fahrenheit (very high), blood pressure ,[DATE] (low), pulse 126 (high), and respirations 40 (high). Review of the emergency room care note dated [DATE] at 5:50 p.m. showed, "patient is a [AGE] year old male presenting to the ED (emergency department) due to hyperthermia. EMS was called today after the patient was left outside for too long. EMS reports that the patient was left outside on his wheelchair for approximately two hours. Upon arrival his oral temperature was 102 and rectal 107. History is limited due to patient's clinical state." emergency room care note at 8:07 p.m. documents the resident went into [MEDICAL CONDITION], and CPR (cardiopulmonary resuscitation) was performed. The resident was intubated and placed into the intensive care unit where he remains as of today, [DATE]. 3. The recorded the temperature in Naples on [DATE] was 93.9 degrees Fahrenheit at 3:53 p.m. and heat index of 100.8 degrees Fahrenheit with no precipitation. (source: Weather Underground website at http://www.wunderground.com/history/airport/KAPF/[DATE]/DailyHistory.html?req_c ) 4. During an interview on [DATE] at 10:32 a.m., the facility Medical Director said he would prefer to limit the time residents are outside. He said in order to prevent this from happening again, the residents need to be supervised. He said having water outside would not have made a difference for Resident #1. He said all the talk is about dehydration, but the Resident's problem was his temperature. He said the resident had a [MEDICAL CONDITION] at some point and that may have been why he was not able to bring himself back into the building. 5. During an interview on [DATE] at 1:18 p.m., the facility Administrator and the Director of Nursing (DON) said the outdoor video camera showed the resident entering the courtyard area at 1:52 p.m. He was in the shaded area for 2 minutes, then propelled himself out of the shade and into the direct sun. The video showed the Social Worker interviewing the resident at 2:53 p.m. The resident was outside until 4:57 p.m. The video camera shows the resident shifting himself around in the wheelchair. The DON said on the video you can only see the back side of the chair and a silhouette of the resident (photographic evidence presented is in the file). During an interview on [DATE] at 11:35 a.m., the Social Worker said she asked the resident questions. He was able to tell her the year, month and date and was able to repeat 2 of the 3 items she asked him to repeat. She then asked him some mood questions and he was able to answer them appropriately. She said he was sitting a little bit beyond the cover and his body was in the sun. Her conversation with the resident was on video at 2:53 p.m. During an interview on [DATE] at 11:41 a.m., Staff I said, "At lunch time, probably around 10 minutes to 2, the resident was trying to propel himself through the dining room where other residents were eating. He was not able to get outside at this point and I heard someone tell him he needed to go back out in the hall so they could bring the other residents out of the dining room (photographic evidence presented is in the file). The next time I saw him, I was sitting at the nurses station, and (Staff A) was charting in the back room. She asked me if 'he was outside' and 'was it raining?'" Staff I said, "I got up to look out and saw (Resident #1) sitting outside. I told (Staff A), 'Yes, he is there and it is not raining.' This may have been around 4 p.m., I am not sure." Staff I continued, "(Staff J), the ,[DATE] charge nurse (came in late around 4 p.m.) went into the assisted dining room around 4:30. I followed her into the dining room ... I do not remember the whole conversation, but she mentioned 'him' and I said, 'I am going to bring him in.' He appeared to be sleeping. I went to put his feet on his foot rest, and when I did I saw he had mucous coming from his nose and drool from his mouth. I put his feet up on the pedals so I could bring him inside and noticed he was not responding. He was breathing slightly labored and I went to get a pulse oximeter to check his oxygen, and it was 92%. (Staff J) touched his skin and said he felt hot. I took him down the hall and other staff came into the room. We put him into the bed. Staff began wetting towels to put under his arms, groins and behind his neck, and his temperature was 105. I think it was taken under his arm. Another nurse and I then took his shirt off, and at that point everyone kept changing the cloths to try and cool him down. We also elevated his feet because his blood pressure was low. He was then transported to the hospital. " She said before this incident, the facility did not have a protocol in place to supervise residents in the courtyard or a hot weather protocol. During an interview on [DATE] at 12:04 p.m., Staff A said, "I was the nurse assigned to the resident on [DATE]. I gave him his meds around 8:30 a.m., then tried to encourage him to eat a little more breakfast. Since he started on the [MEDICATION NAME] (an antidepressant medication) for the 'picking disorder' he has been sleeping a little more. I was told by the nurse practitioner that is was probably due to the [MEDICATION NAME]. He came down to my cart around a quarter to 12 and just sat there and waited by my cart. I took him to the main dining room around 12:15 p.m. and gave him 2 glasses of orange juice, soup and a cup of coffee. I went to lunch around 1:05 p.m. and came back around 1:35 p.m. and sat and charted for about 20 minutes. I saw him sitting outside of the door in the courtyard between 2 and 2:30 p.m. He was upright. I gave report to (Staff D), the evening nurse, around 3:10 or 3:15 p.m. and told her (Resident #1) was outside. I continued to chart and for some reason (I heard what sounded like thunder) I thought about Resident #1 and made the statement to (Staff I), '(Resident #1), isn't still setting outside is he?' Staff I went to check on him. He was hot, they brought him in, and he was not responsive." Staff A said, "I was told by the assisted living facility that he liked to spend several hours a day in the sun. He has a history of wanting to be outside and once he was outside he did not want to come back in. Most of the other residents who go outside to the courtyard have family or a caregiver with them." 6. During an interview on [DATE] at 9:44 a.m., the DON said the facility staff was aware the resident liked to go outside. The staff was aware the resident would self-propel his wheelchair to sit in the sun. She said he was able to make his wants and needs known and would often yell for assistance. She said when the wife was called about his condition on [DATE] she commented, "I bet he was out in the sun wasn't he?" The DON said before this incident there was no process in place for monitoring and supervising residents in the courtyard. She said an outdoor protocol (for temperature >85 degrees) has been established since the incident. She said it was developed with the assistance of Medical Director. The staff have also been in-serviced on rounding on the residents at the change of shift and every 2 hours. 7. During interviews, Residents #2, #3, #4, #6, #7, and #8 indicated the facility did not provide drinks, sun protection, or supervision when residents are outside in the hot weather. 8. In an interview on [DATE] at 3:05 p.m., Resident #2 said, "I go outside when they take me, not for very long, too hot. 10 or 15 minutes, that's all." 9. In an interview on [DATE] at 4:30 p.m., Resident # 3 said, "I never go outside unless my family is with me; we just take a walk or something, and my daughter brings me drinks. I don't know if they would check on me; I don't go out." 10. In an interview on [DATE] at 2:52 p.m., Resident #4's spouse stated, "We always sit in front of the building where we can be seen from the front desk. We don't go outside in this weather it's too hot." Resident #4 said she never goes outside alone. "We go out when it is cooler. No one ever comes out and offers us water or lotion, but we don't usually stay out that long, maybe 15 minutes or so. I see people walking in and out of the building, but I don't think they are checking on us." 11. In an interview on [DATE], at 2:36 p.m. Resident #6 said she frequently goes outside to sit in the sun. "I usually sit by the door so they can see me. No they never give us water outside; they give us water in our room. No, they never offer suntan lotion or a hat. I never see anyone come outside to check on me." 12. In an interview on [DATE] at 2:58 p.m., Resident #7 stated, "Yes, I like to go outside, but I didn't go outside today. No, they never bring us drinks or ask if we want one when we go outside. We get that in here. No, they don't check on me when I go outside, but I usually go outside with a friend (another resident in the facility). I usually stay outside for about 30 minutes or so." 13. In an interview on [DATE] at 4:45 p.m., Resident #8 stated, "I don't speak good English, just a little bit. I go out; too hot now. Don't know if they check, no drinks." 14. The skilled nursing facility is co-located with an assisted living facility (ALF). Resident #1 was admitted to the ALF on [DATE]. The staff there found the resident wanted to remain outside on their patio much of the time. In an interview on [DATE] at 2:40 p.m., an ALF Certified Nursing Assistant said they obtained sun screen from the resident's spouse for the resident to use daily. Upon rising the staff would apply the sun screen. The resident would put on his sunglasses and his hat and go outside. They assigned the activity person to go out and give the resident fluids every ,[DATE] minutes. They brought the resident inside the facility at various times throughout the day. The ALF Activity Person's responsibility was to check on the resident frequently. She brought Resident #1 ginger ale and snacks to ensure he would drink and eat. They had gotten Resident #1 a cup holder for his wheelchair so he would have a drink available at all times. In an interview on [DATE] at 3:00 p.m., ALF Registered Nurse Staff H said the resident had no concept of whether he was sitting in the sun or in the shade; he could not tell the difference. The SNF had no policy to address care of the residents when outdoors in hot weather which was confirmed in an interview with the DON (see above). 15. These systems failures created a situation resulting in critical harm for Resident #1 on [DATE]. See also citations at F271 (admit orders) and F490 (hazards). The facility began to put corrective actions in place after the resident was harmed. The Immediate Jeopardy was abated on [DATE] based upon the following corrective actions put into place by the facility: -Adopted policy entitled Resident Safety: Outdoor Monitoring Guidelines, -Installed a doorbell that rings upon exiting and entering the courtyard, -Placed a water cooler with cups in the courtyard, and -Assigned staff to monitor the courtyard area every 20 minutes. .

Based upon observation, interview and record review the facility failed to ensure residents had adequate orders for immediate care for 1 (Resident #1) of 8 sampled residents. Resident #1 had a history of [REDACTED]. The facility failed to have orders in place to provide care outside. As a result, he stayed outside overexposed to sun, heat, and humidity. He was hospitalized and subsequently expired 9 days. The facility's census was 57 at the time of the survey. The findings included: 1. Resident #1 was a [AGE] year old male who had been residing in the assisted living facility (ALF) attached to the skilled nursing facility (SNF). Review of records showed his [DIAGNOSES REDACTED]. Recently he had lower extremity [MEDICAL CONDITION] (swelling due to excess fluid, a sign of heart failure) and was on [MEDICATION NAME] (a "water pill") 40 milligrams twice a day. Both of his legs were wrapped with zinc-paste wraps. He was alert and oriented and able to make his needs known. The medical progress note dated [DATE] documented, "Resident was seen yesterday as he transferred to SNF from ALF d/t (due to) his increased debility and exit seeking from ALF. Presently up in his W/C (wheel chair) and he does self-propel in his W/C and he does like to sit outside in the sun but needs to be monitored." The Nurse Practitioner failed to write orders for monitoring the resident while outside in the sun. 2. Nursing note dated [DATE] at 4:46 p.m. documented, "Patient (Pt) wanting to go outside. CN (charge nurse) showed Pt that there was thunder and lightning outside. Nurse tried to discourage Pt from going out. Pt very HOH (hard of hearing), deaf and did not hear nurse. Pt continued outside in the storm." Nursing note dated [DATE] at 7:28 p.m. documented, "Pt was found outside by day CN and evening CN in his WC, unresponsive. Pt was not arousable, placed in his bed and vital signs taken. Temperature was 105 (very high). 911 was called while other nurses tried to cool Pt down with cold towels until EMS (emergency medical services) arrived. Pt taken to (name of hospital). Spouse notified and Dr. (doctor) notified." Review of the emergency room care note dated [DATE] at 5:50 p.m. showed, "patient is a [AGE] year old male presenting to the ED (emergency department) due to hyperthermia. EMS was called today after the patient was left outside for too long. EMS reports that the patient was left outside on his wheelchair for approximately two hours. Upon arrival his oral temperature was 102 and rectal 107. History is limited due to patient's clinical state." emergency room care note at 8:07 p.m. documents the resident went into [MEDICAL CONDITION], and CPR (cardiopulmonary resuscitation) was performed. The resident was intubated and placed into the intensive care unit where he remains as of today, [DATE]. 3. The recorded the high temperature in Naples on [DATE] was 94 degrees Fahrenheit at 4:53 p.m. and a heat index of 100.8 degrees Fahrenheit with no precipitation. (source: Weather Underground website at http://www.wunderground.com/history/airport/KAPF/[DATE]/DailyHistory.html?req_c ) 4. During an interview on [DATE] at 10:32 a.m., the facility Medical Director said he would prefer to limit the time residents are outside. He said in order to prevent this from happening again, the residents need to be supervised. He said having water outside would not have made a difference for Resident #1. He said all the talk is about dehydration, but the Resident's problem was his temperature. 5. During an interview on [DATE] at 1:18 p.m., the facility Administrator and the Director of Nursing (DON) said the outdoor video camera showed the resident entering the courtyard area at 1:52 p.m. He was in the shaded area for 2 minutes, then propelled himself out of the shade and into the direct sun. The video showed the Social Worker interviewing the resident at 2:53 p.m. The resident was outside until 4:57 p.m. The video camera shows the resident shifting himself around in the wheelchair. The DON said on the video you can only see the back side of the chair and a silhouette of the resident (photographic evidence presented is in the file). During an interview on [DATE] at 11:35 a.m., the Social Worker said she asked the resident questions. He was able to tell her the year, month and date and was able to repeat 2 of the 3 items she asked him to repeat. She then asked him some mood questions and he was able to answer them appropriately. She said he was sitting a little bit beyond the cover and his body was in the sun. Her conversation with the resident was on video at 2:53 p.m. During an interview on [DATE] at 11:41 a.m., Staff I said, "At lunch time, probably around 10 minutes to 2, the resident was trying to propel himself through the dining room where other residents were eating. He was not able to get outside at this point and I heard someone tell him he needed to go back out in the hall so they could bring the other residents out of the dining room (photographic evidence presented is in the file). The next time I saw him, I was sitting at the nurses station, and (Staff A) was charting in the back room. She asked me if 'he was outside' and was it raining." Staff I said, "I got up to look out and saw (Resident #1) sitting outside. I told (Staff A), 'Yes, he is there and it is not raining.' This may have been around 4 p.m., I am not sure." Staff I continued, "(Staff J), the ,[DATE] charge nurse (came in late around 4 p.m.) went into the assisted dining room around 4:30. I followed her into the dining room ... I do not remember the whole conversation, but she mentioned 'him' and I said, 'I am going to bring him in.' He appeared to be sleeping. I went to put his feet on his foot rest, and when I did I saw he had mucous coming from his nose and drool from his mouth. I put his feet up on the pedals so I could bring him inside and noticed he was not responding. He was breathing slightly labored and I went to get a pulse oximeter to check his oxygen, and it was 92%. (Staff J) touched his skin and said he felt hot. I took him down the hall and other staff came into the room. We put him into the bed. Staff began wetting towels to put under his arms, groins and behind his neck, and his temperature was 105. I think it was taken under his arm. Another nurse and I then took his shirt off, and at that point everyone kept changing the cloths to try and cool him down. We also elevated his feet because his blood pressure was low. He was then transported to the hospital. " During an interview on [DATE] at 12:04 p.m., Staff A said, "I was the nurse assigned to the resident on [DATE]. I gave him his meds around 8:30 a.m., then tried to encourage him to eat a little more breakfast. Since he started on the [MEDICATION NAME] (an antidepressant medication) for the 'picking disorder' he has been sleeping a little more. I was told by the nurse practitioner that is was probably due to the [MEDICATION NAME]. He came down to my cart around a quarter to 12 and just sat there and waited by my cart. I took him to the main dining room around 12:15 p.m. and gave him 2 glasses of orange juice, soup and a cup of coffee. I went to lunch around 1:05 p.m. and came back around 1:35 p.m. and sat and charted for about 20 minutes. I saw him sitting outside of the door in the courtyard between 2 and 2:30 p.m. He was upright. I gave report to (Staff D), the evening nurse, around 3:10 or 3:15 p.m. and told her (Resident #1) was outside. I continued to chart and for some reason (I heard what sounded like thunder) I thought about Resident #1 and made the statement to (Staff I), '(Resident #1), isn't still setting outside is he?' Staff I went to check on him. He was hot, they brought him in, and he was not responsive." Staff A said, "I was told by the assisted living facility that he liked to spend several hours a day in the sun. He has a history of wanting to be outside and once he was outside he did not want to come back in. Most of the other residents who go outside to the courtyard have family or a caregiver with them." 6. During an interview on [DATE] at 9:44 a.m., the DON said the facility staff was aware the resident liked to go outside. The staff was aware the resident would self-propel his wheelchair to sit in the sun. She said he was able to make his wants and needs known and would often yell for assistance. She said when the wife was called about his condition on [DATE] she commented, "I bet he was out in the sun wasn't he?" The DON said before this incident there was no process in place for monitoring and supervising residents in the courtyard. She said an outdoor protocol (for temperature >85 degrees Fahrenheit) has been established since the incident. She said it was developed with the assistance of Medical Director. The staff have also been in-serviced on rounding on the residents at the change of shift and every 2 hours. 7. The skilled nursing facility is co-located with an assisted living facility (ALF). Resident #1 was admitted to the ALF on [DATE]. The staff there found the resident wanted to remain outside on their patio much of the time. In an interview on [DATE] at 2:40 p.m., an ALF Certified Nursing Assistant said they obtained sun screen from the resident's spouse for the resident to use daily. Upon rising the staff would apply the sun screen. The resident would put on his sunglasses and his hat and go outside. They assigned the activity person to go out and give the resident fluids every ,[DATE] minutes. They brought the resident inside the facility at various times throughout the day. The ALF Activity Person's responsibility was to check on the resident frequently. She brought Resident #1 ginger ale and snacks to ensure he would drink and eat. They had gotten Resident #1 a cup holder for his wheelchair so he would have a drink available at all times. In an interview on [DATE] at 3 p.m., ALF Registered Nurse Staff H said the resident had no concept of whether he was sitting in the sun or in the shade; he could not tell the difference. These interventions were not put in place when Resident #1 was transferred to the SNF on [DATE]. During an interview on [DATE] at 9:44 a.m., the DON confirmed the SNF had no policy to address care of the residents when outdoors in hot weather. .

Based upon observation, interview and record review the facility failed to ensure Resident #1 (1 of 8 records reviewed) was adequately supervised and monitored as he sat in 90+ degree Fahrenheit weather in the direct sunlight for approximately 3 hours. This resulted in the resident's internal body temperature overheating, and the resident becoming unresponsive. The resident was transported to the hospital. He remained on life support at the time of the survey. Subsequently, Resident #1 expired a week later. This failure created a situation that resulted in serious injury and harm to Resident #1, and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. Substandard Quality of Care was identified at F323. The Immediate Jeopardy was abated on [DATE], based upon the implementation of corrective action. The corrective actions reduced the scope and severity to D. Four (Residents #1, #2, #6, and #7) of the 8 sampled residents were identified as going outside without supervision. The facility's census was 57 at the time of the survey. All residents who utilize the courtyard were at risk for such illness/injury and even death. The findings included: Elderly people (that is, people aged [AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body's ability to regulate its temperature or that inhibit perspiration. (source: "Extreme Heat" by Centers for Disease Control at <http://stacks.cdc.gov/view/cdc/ >) 1. Resident #1 was a [AGE] year old male who had been residing in the assisted living facility (ALF) attached to the skilled nursing facility (SNF). Review of records showed his [DIAGNOSES REDACTED]. Recently he had lower extremity edema (swelling due to excess fluid, a sign of heart failure) and was on Lasix (a "water pill") 40 milligrams twice a day. He was alert and oriented and able to make his needs known. The medical progress note dated [DATE] documented, "Resident was seen yesterday as he transferred to SNF from ALF d/t (due to) his increased debility and exit seeking from ALF. Presently up in his W/C (wheel chair) and he does self-propel in his W/C and he does like to sit outside in the sun but needs to be monitored." The Nurse Practitioner failed to write orders for monitoring the resident while outside in the sun. 2. Nursing note dated [DATE] at 4:46 p.m. documented, "Patient (Pt) wanting to go outside. CN (charge nurse) showed Pt that there was thunder and lightning outside. Nurse tried to discourage Pt from going out. Pt very HOH (hard of hearing), deaf and did not hear nurse. Pt continued outside in the storm." Nursing note dated [DATE] at 7:28 p.m. documented, "Pt was found outside by day CN and evening CN in his WC, unresponsive. Pt was not arousable, placed in his bed and vital signs taken. Temperature was 105. 911 was called while other nurses tried to cool Pt down with cold towels until EMS (emergency medical services) arrived. Pt taken to (name of hospital). Spouse notified and Dr. (doctor) notified." Upon transfer to the hospital on [DATE] at 5 p.m., the resident's vital signs were: temperature 105 degrees Fahrenheit (very high), blood pressure ,[DATE] (low), pulse 126 (high), and respirations 40 (high). Review of the emergency room care note dated [DATE] at 5:50 p.m. showed, "patient is a [AGE] year old male presenting to the ED (emergency department) due to hyperthermia. EMS was called today after the patient was left outside for too long. EMS reports that the patient was left outside on his wheelchair for approximately two hours. Upon arrival his oral temperature was 102 and rectal 107. History is limited due to patient's clinical state." emergency room care note at 8:07 p.m. documents the resident went into cardiac arrest, and CPR (cardiopulmonary resuscitation) was performed. The resident was intubated and placed into the intensive care unit where he remains as of today, [DATE]. 3. The recorded the temperature in Naples on [DATE] was 93.9 degrees Fahrenheit at 3:53 p.m. and heat index of 100.8 degrees Fahrenheit with no precipitation. (source: Weather Underground website at http://www.wunderground.com/history/airport/KAPF/[DATE]/DailyHistory.html?req_c ) 4. During an interview on [DATE] at 10:32 a.m., the facility Medical Director said he would prefer to limit the time residents are outside. He said in order to prevent this from happening again, the residents need to be supervised. He said having water outside would not have made a difference for Resident #1. He said all the talk is about dehydration, but the Resident's problem was his temperature. 5. During an interview on [DATE] at 1:18 p.m., the facility Administrator and the Director of Nursing (DON) said the outdoor video camera showed the resident entering the courtyard area at 1:52 p.m. He was in the shaded area for 2 minutes, then propelled himself out of the shade and into the direct sun. The video showed the Social Worker interviewing the resident at 2:53 p.m. The resident was outside until 4:57 p.m. The video camera shows the resident shifting himself around in the wheelchair. The DON said on the video you can only see the back side of the chair and a silhouette of the resident (photographic evidence presented is in the file). During an interview on [DATE] at 11:35 a.m., the Social Worker said she asked the resident questions. He was able to tell her the year, month and date and was able to repeat 2 of the 3 items she asked him to repeat. She then asked him some mood questions and he was able to answer them appropriately. She said he was sitting a little bit beyond the cover and his body was in the sun. Her conversation with the resident was on video at 2:53 p.m. During an interview on [DATE] at 11:41 a.m., Staff I said, "At lunch time, probably around 10 minutes to 2, the resident was trying to propel himself through the dining room where other residents were eating. He was not able to get outside at this point and I heard someone tell him he needed to go back out in the hall so they could bring the other residents out of the dining room (photographic evidence presented is in the file). The next time I saw him, I was sitting at the nurses station, and (Staff A) was charting in the back room. She asked me if 'he was outside' and was it raining." She said, "I got up to look out and saw (Resident #1) sitting outside. I told (Staff A), 'Yes, he is there and it is not raining.' This may have been around 4 p.m., I am not sure." Staff I continued, "(Staff J), the ,[DATE] charge nurse (came in late around 4 p.m.) went into the assisted dining room around 4:30. I followed her into the dining room ... I do not remember the whole conversation, but she mentioned 'him' and I said, 'I am going to bring him in.' He appeared to be sleeping. I went to put his feet on his foot rest, and when I did I saw he had mucous coming from his nose and drool from his mouth. I put his feet up on the pedals so I could bring him inside and noticed he was not responding. He was breathing slightly labored and I went to get a pulse oximeter to check his oxygen, and it was 92%. (Staff J) touched his skin and said he felt hot. I took him down the hall and other staff came into the room. We put him into the bed. Staff began wetting towels to put under his arms, groins and behind his neck, and his temperature was 105. I think it was taken under his arm. Another nurse and I then took his shirt off, and at that point everyone kept changing the cloths to try and cool him down. We also elevated his feet because his blood pressure was low. He was then transported to the hospital." She said before this incident, the facility did not have a protocol in place to supervise residents in the courtyard or a hot weather protocol. During an interview on [DATE] at 12:04 p.m., Staff A said, "I was the nurse assigned to the resident on [DATE]. I gave him his meds around 8:30 a.m., then tried to encourage him to eat a little more breakfast. Since he started on the Zoloft (an antidepressant medication) for the 'picking disorder' he has been sleeping a little more. I was told by the nurse practitioner that is was probably due to the Zoloft. He came down to my cart around a quarter to 12 and just sat there and waited by my cart. I took him to the main dining room around 12:15 p.m. and gave him 2 glasses of orange juice, soup and a cup of coffee. I went to lunch around 1:05 p.m. and came back around 1:35 p.m. and sat and charted for about 20 minutes. I saw him sitting outside of the door in the courtyard between 2 and 2:30 p.m. He was upright. I gave report to (Staff D), the evening nurse, around 3:10 or 3:15 p.m. and told her (Resident #1) was outside. I continued to chart and for some reason (I heard what sounded like thunder) I thought about Resident #1 and made the statement to (Staff I), '(Resident #1), isn't still setting outside is he?' Staff I went to check on him. He was hot, they brought him in, and he was not responsive." Staff A said, "I was told by the assisted living facility that he liked to spend several hours a day in the sun. He has a history of wanting to be outside and once he was outside he did not want to come back in. Most of the other residents who go outside to the courtyard have family or a caregiver with them." 6. During an interview on [DATE] at 9:44 a.m., the DON said the facility staff was aware the resident liked to go outside. The staff was aware the resident would self-propel his wheelchair to sit in the sun. She said he was able to make his wants and needs known and would often yell for assistance. She said when the wife was called about his condition on [DATE] she commented, "I bet he was out in the sun wasn't he?" The DON said before this incident there was no process in place for monitoring and supervising residents in the courtyard. She said an outdoor protocol (for temperature >85 degrees Fahrenheit) has been established since the incident. She said it was developed with the assistance of Medical Director. The staff have also been in-serviced on rounding on the residents at the change of shift and every 2 hours. 7. During interviews, Residents #2, #3, #4, #6, #7, and #8 indicated the facility did not provide drinks, sun protection, or supervision when residents are outside in the hot weather. 8. In an interview on [DATE] at 3:05 p.m., Resident #2 stated, "I go outside when they take me, not for very long, too hot. 10 or 15 minutes, that's all." 9. In an interview on [DATE] at 4:30 p.m., Resident #3 stated, "I never go outside unless my family is with me; we just take a walk or something, and my daughter brings me drinks. I don't know if they would check on me; I don't go out." 10. In an interview on [DATE] at 2:52 p.m., Resident #4's spouse stated, "We always sit in front of the building where we can be seen from the front desk. We don't go outside in this weather it's too hot." Resident #4 said she never goes outside alone. "We go out when it is cooler. No one ever comes out and offers us water or lotion, but we don't usually stay out that long, maybe 15 minutes or so. I see people walking in and out of the building, but I don't think they are checking on us." 11. In an interview on [DATE], at 2:36 p.m., Resident #6 said she frequently goes outside to sit in the sun. "I usually sit by the door so they can see me. No they never give us water outside; they give us water in our room. No, they never offer suntan lotion or a hat. I never see anyone come outside to check on me." 12. In an interview on [DATE] at 2:58 p.m., Resident #7 stated, "Yes, I like to go outside, but I didn't go outside today. No, they never bring us drinks or ask if we want one when we go outside. We get that in here. No, they don't check on me when I go outside, but I usually go outside with a friend (another resident in the facility). I usually stay outside for about 30 minutes or so." 13. In an interview on [DATE] at 4:45 p.m., Resident #8 stated, "I don't speak good English, just a little bit. I go out; too hot now. Don't know if they check, no drinks." 14. The skilled nursing facility is co-located with an assisted living facility (ALF). Resident #1 was admitted to the ALF on [DATE]. The staff there found the resident wanted to remain outside on their patio much of the time. In an interview on [DATE] at 2:40 p.m. an ALF Certified Nursing Assistant said they obtained sun screen from the resident's spouse for the resident to use daily. Upon rising the staff would apply the sun screen. The resident would put on his sunglasses and his hat and go outside. They assigned the activity person to go out and give the resident fluids every ,[DATE] minutes. They brought the resident inside the facility at various times throughout the day. The ALF Activity Person's responsibility was to check on the resident frequently. She brought Resident #1 ginger ale and snacks to ensure he would drink and eat. They had gotten Resident #1 a cup holder for his wheelchair so he would have a drink available at all times. In an interview on [DATE] at 3:00 p.m., ALF Registered Nurse Staff H said the resident had no concept of whether he was sitting in the sun or in the shade; he could not tell the difference. The SNF had no policy to address care of the residents when outdoors in hot weather which was confirmed in an interview with the DON on [DATE] at 9:44 a.m. 15. These systems failures created a hazardous situation resulting in critical harm for Resident #1 on [DATE]. The facility began to put corrective actions in place after the resident was harmed. The Immediate Jeopardy was abated on [DATE] based upon the following corrective actions put into place by the facility: -Adopted policy entitled Resident Safety: Outdoor Monitoring Guidelines, -Installed a doorbell that rings upon exiting and entering the courtyard, -Placed a water cooler with cups in the courtyard, and -Assigned staff to monitor the courtyard area every 20 minutes. .

Based upon record review and interview, the facility leadership failed to ensure residents utilizing the outdoor area of the courtyard are supervised. The system failure began with the Nurse Practitioner's acknowledgement the resident's for monitored for time in the sun. The Administrator and the Director of Nursing failed to ensure the staff knew to supervise and monitor residents who utilize the courtyard. The facility failed to establish a hot weather protocol to protect all residents from the extreme heat and humidity in South Florida. Facility leadership failed to address this system-wide failure leading to one (Resident #1) being left on the courtyard in the sun resulting in serious harm. He remained on life support at the time of the survey. Subsequently, Resident #1 expired a week later. This failure created a situation that resulted in serious injury and harm to Resident #1, and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on [DATE] was identified on [DATE]. The Immediate Jeopardy was abated on [DATE], based upon the implementation of corrective action. Four (Residents #1, #2, #6, and #7) of the 8 sampled residents were identified as going outside without supervision. The facility's census was 57 at the time of the survey. All residents who utilize the courtyard were at risk for such illness/injury and even death. The findings included: Elderly people (that is, people aged [AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body's ability to regulate its temperature or that inhibit perspiration. (source: "Extreme Heat" by Centers for Disease Control at <http://stacks.cdc.gov/view/cdc/ >) 1. A copy of the administrator's job description signed by the Administrator [DATE] was provided by the facility. The Administrative Responsibilities section notes "The administrator is specifically responsible for the following functions: Patients Accept patients for admission...Maintain and implement programs of patient education and rehabilitation for the promotion of mental and physical health... Medical Staff Work with medical staff,... responsible for rendering professional and medical service to provide the best possible care to all patients." 2. Review of the medical progress note dated [DATE] documented "Resident was seen yesterday as he transferred to SNF (skilled nursing facility) from ALF (assisted living facility) d/t (due to) his increased debility and exit seeking from ALF. Presently up in his W/C (wheel chair) and he does self-propel in his W/C and he does like to sit outside in the sun but needs to be monitored." The Nurse Practitioner failed to include a plan to monitor the resident while in the sun in the orders. 3. The recorded the temperature in Naples on [DATE] was 93.9 degrees Fahrenheit at 3:53 p.m. and heat index of 100.8 degrees Fahrenheit with no precipitation. (source: Weather Underground website at http://www.wunderground.com/history/airport/KAPF/[DATE]/DailyHistory.html?req_c ) 4. During an interview on [DATE] at 1:18 p.m., the facility Administrator and the Director of Nursing (DON) said the outdoor video camera showed the resident entering the courtyard area at 1:52 p.m. He was in the shaded area for 2 minutes then propelled himself out of the shade and into the direct sun. The video showed the Social Worker interviewing the resident at 2:53 p.m. The video showed the resident remained outside until 4:57 p.m. During an interview on [DATE] around 3:00 p.m., the DON said Staff C assisted the resident outside to the courtyard on [DATE] at 1:52 p.m. The DON said because he did not offer Resident #1 fluids before he assisted the resident outside, Staff C was terminated. During an interview on [DATE] around 3:00 p.m., the DON said Staff D was the 3 p.m.-11 p.m. nurse assigned to Resident #1 on [DATE]. The DON said because she did not make rounds or find Resident #1, Staff D was terminated. During an interview on [DATE] around 3:00 p.m., the DON said Staff E was the 3 p.m. -11 p.m. aide assigned to Resident #1 on [DATE]. The DON said because she knew Resident #1 was outside in the courtyard and did not go and get him, Staff E was terminated. 5. During interviews on [DATE], Residents #2, #3, #4, #6, #7, and #8 indicated the facility did not provide drinks, sun protection, or supervision when residents are outside in the hot weather. Residents #2, #6, and #7 indicated they go outside without supervision. (refer to F323 for detailed interviews) 6. During an interview on [DATE] around 9:44 a.m., the DON admitted , before the incident with Resident #1, there was no process in place for monitoring and supervising residents in the courtyard. She said an outdoor protocol (for temperatures >85 degrees Fahrenheit) was established after the incident. She said it was developed with the assistance of the Medical Director. The staff have also been in-serviced on rounding on the residents at the change of shift and every 2 hours. 7. These systems failures created a situation resulting in critical harm for Resident #1 on [DATE]. The facility began to put corrective actions in place after the resident was harmed. The Immediate Jeopardy was abated on [DATE] based upon the following corrective actions put into place by the facility: -Adopted policy entitled Resident Safety: Outdoor Monitoring Guidelines, -Installed a doorbell that rings upon exiting and entering the courtyard, -Placed a water cooler with cups in the courtyard, and -Assigned staff to monitor the courtyard area every 20 minutes.