Every finding on record at St. Andrew Post-Acute Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to store, prepare and follow professional standards for food service safety in two (main and satellite) of two kitchens, as evidenced by: 1. two trash cans were not sanitarily maintained; 2. food was not maintained for safe consumption to include improper food handling practices; 3. kitchen shelving used for storage of food was observed rusted/oxidized, 4. temperature logs for the refrigerator and freezer were not documented accurately, and 5. one staff member (Q) not donning a hairnet upon entry to the kitchen during two (9/3/24 and 9/5/24) of three days of the survey. Findings included: On 9/3/24 at 9:20 a.m. a tour of the facility's main kitchen was conducted with Staff M, Certified Dietary Manager (CDM). From 9:24 a.m. to 9:38 a.m. observations of trash cans and refuse containers revealed a stand-up trash container with a double flap lid was open with trash/refuse overflowing from it. The trash container was against a food preparation/service table, where were observed preparing food on the stove. The lid and sides of the same trash container were observed with an unidentified liquid and hard food debris. (Photographic Evidence Obtained) An additional observation revealed the trash can near the hand washing sink was gray in color, round and stood approximately three and a half feet high. The lid was observed with a circular cut out to put the garbage/refuse through. Further observations revealed the entire outer container and lid contained a black, brown, and green sticky substance that covered many areas. (Photographic Evidence Obtained) On 9/3/24 at 9:38 a.m. observations of the walk-in refrigerator revealed an uncovered box of four whole cabbages. Staff M, CDM removed one cabbage that appeared wilted and damaged with black coloring on the outside layers. (Photographic Evidence Obtained) He handled the cabbage with ungloved hands, while peeling back the outer parts of it. Further observations revealed Staff M, CDM dropped the cabbage on the refrigerator floor, which appeared soiled with various small particles and debris. He picked up the cabbage and put it back in the box with the other three. During the observation, Staff M, CDM did not discard or wash the cabbage prior to putting it back in the box. On 9/3/24 an observation at 9:39 a.m. of the entry way of the walk-in refrigerator revealed a multi-shelf cart with various pans of prepared food. One of the pans of prepared food items was a sheet cake with approximately three quarters of the cake missing. There was clear plastic wrap on the remaining sheet cake, however, the plastic wrap did not cover the food entirely leaving it exposed to the air. (Photographic Evidence Obtained). Further observations of the walk-in refrigerator revealed multiple shelves on each side. Observations of the shelve racks revealed they were green, plastic coated, and slotted. Further observations of the shelves revealed the green coating on parts of the shelves were worn away and appeared rusted/oxidized. There were no barriers between the rusted/oxidized shelves, and the containers and boxes of food items. (Photographic Evidence Obtained) On 9/3/24 an observation at 9:40 a.m. of the walk-in freezer, located inside the walk-in refrigerator, revealed two frozen pie crusts stacked on top of each other were not covered and exposed to the air. Staff M, CDM confirmed the frozen pie crusts should have been covered, as well as, labeled/dated. He proceeded to remove them. On 9/3/24 at 9:42 a.m. a review of the refrigerator and freezer temperature logs revealed no documentation. Staff M, CDM stated the morning documentation of the refrigerator and freezer temperatures should have been completed by the cook. Staff M, CDM handed the log to Staff P, [NAME] to be completed. On 9/3/24 observations at 9:20 a.m. and 9:43 a.m. of the food preparation table revealed two yellow, whole honeydew melons. One melon was observed with a flat level surface that contained grey and black mold-like debris and spores growing on it. (Photographic Evidence Obtained) An interview with Staff M, CDM revealed the melon was okay to consume and he proceeded to cut off the top of the fruit where the mold spores and debris were located. Further observations revealed, he cut open the melon which appeared to have no mold inside. He stated he received a delivery of fresh produce to include the two melons, and it would be used for consumption on 9/3/24. Staff M, CDM discarded the melon although he confirmed he intended to use it. Further observations of the cutting board on the food preparation table revealed black residue, which derived from the top part of the melon that Staff M, CDM cut off. He attempted to wipe away the black residue with his ungloved hand, however, there were smudges of black residue left on the cutting board. On 9/5/24 at 10:55 a.m. observations in the satellite kitchen revealed a cellphone was laying on the drying rack with items such as cups, portion scoops, and other kitchenware. An interview with Staff G, Dietary Aide revealed it was her cellphone. She stated she knows the phone was not supposed to be there as the dish rack contained clean kitchenware and items that residents utilize during meals. An observation of the main kitchen on 9/5/24 at 11:28 a.m. revealed Staff Q, [NAME] entered the kitchen without a hair restraint. Staff Q, [NAME] was observed walking to what appeared to be a utility closet to include mops and cleaning products. She was observed leaving the closet, shortly after entering, and went to Staff M, Certified Dietary Manager (CDM)'s office. She was observed putting on a hair restraint while in the CDM's office. On 9/5/24 at 11:32 a.m. an observation in the main kitchen of Staff R, Dishwasher and another staff member, revealed a demonstration of the process for determining the sanitizing temperature of the dish machine. Staff R, Dishwasher took a plate out of the dish washing machine that was in the middle of a wash cycle. He tested the sanitizing solution by pressing the litmus strip to the plate, which was wet. Further observations revealed Staff R, Dishwasher put the same plate back in the machine to continue the cycle. During the observation, Staff R, Dishwasher was not wearing gloves, and he did not wash his hands or use a hand sanitizer. An observation at 11:34 a.m. of the dish machine temperature log revealed there was documentation for breakfast, lunch, and dinner on 9/5/24. (Photographic Evidence Obtained) An interview with Staff R, Dishwasher revealed he made a mistake and documented lunch and dinner temperatures before testing the sanitizing solution. He stated he should not have done that. An interview with Staff M, CDM stated he was not aware Staff R, Dishwasher had filled out the dish machine temperatures for lunch and dinner before testing the sanitizing solution. At 11:35 a.m. an observation of the dish machine area revealed a disposable beverage cup from a fast-food establishment located near the three-compartment sink. Staff R, Dishwasher, was observed taking a sip of the beverage and putting it on a cart next to the three-compartment sink, then he proceeded to continue using the dish machine. On 9/5/24 at 11:45 a.m. a review of the refrigerator and freezer temperature log, in the main kitchen, revealed no evidence of morning documentation for that day. Staff M, CDM observed the log and stated the cook should have documented the morning refrigerator and freezer temperatures. Staff M, CDM handed the log to Staff Q, [NAME] and another staff member, to be completed and stated, Second day in a row. On 9/5/24 at 11:03 a.m. an interview with the Registered Dietitian (RD) revealed it is expected if produce has mold, it should be thrown away. She stated the CDM should have called the food supplier company to request a refund for the produce that was damaged and had mold. The RD stated she would have discarded the food that was damaged and had mold. She confirmed it was not safe food handling practices to put food back that fell on the floor. The RD stated the produce that fell on the floor should have been thrown away. A review of the policy regarding receiving food and supplies, revised 4/1/14, contained the following information, Food items should be received and handled in accordance with good sanitary practice. Further review of the policy titled, Receiving Food and Supplies, under procedure, revealed the following, . b. Check for quantity, quality, weight, labels, etc. of all foods ordered. Do not accept and return to the supplier, any item that is: . 4) Damaged produce . A review of the policy titled, Food Preparation, revealed the following, Employees must use appropriate tools to identify and prevent potential hazards in the preparation of food process. Further review of the policy, under procedure, included the following, . 2. The proper cleaning and sanitizing of equipment and work surfaces are key to safe food preparation . A review of the policy titled, Food Storage, revealed the following, Employees use appropriate tools to identify and prevent potential hazards in the storing of food process. Further review of the policy, under procedure, included the following, . 4. In a freezer, for longer-term storage of perishable foods. D. Store frozen foods in their original containers or wrap tightly in moisture-proof material or containers to minimize loss of flavor, as well as discoloration, dehydration (drying out), and absorption of odors. Clearly label containers with the contents, delivery date, and/or use-by date.

Based on observations, record reviews, and interviews the facility failed to ensure Pre-Admission Screening and Resident Reviews (PASRRs) for six residents (#2, #9, #10, #15, #27, and #28) out of twenty sampled residents were accurate at the time of admission and updated when necessary. Findings included: 1. Review of Resident #2's Admission Record revealed the resident was admitted on [DATE] and 8/19/24. The record included diagnoses not limited to unspecified recurrent major depressive disorder (onset 3/27/22), generalized anxiety disorder (onset 4/25/22), and unspecified insomnia (7/23/22). Review of Resident #2's PASRR, dated 3/26/22, showed the resident did not have a mental illness (MI) or suspected mental illness (SMI), an intellectual disability (ID) or suspected intellectual disability (SID) per documented history. The screening revealed a Level II PASRR was not required due to no diagnosis or suspicion of a serious MI or ID. Review of Resident #2's medication list docuemented on the Psychology Subsequent Note report, dated 8/26/24, revealed the resident was receiving the antidepressants Bupropion Extended Release and Sertraline, as well as the sedative-hypnotic medication, Zolpidem as needed for insomnia. During an interview on 9/5/24 at 9:54 a.m. the Social Service Director (SSD) reviewed Resident #2's diagnoses and PASRR then stated it definitely should have been redone. 2. Review of Resident #9's Admission Record revealed the resident was admitted on [DATE] and 10/1/19. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (primary diagnosis with onset date of 8/20/14) and unspecified recurrent major depressive disorder (onset 10/1/19). Review of Resident #9's PASRR, dated 10/1/19, showed the resident had the mental illness of depressive disorder and other (specify): dementia. The decision-making revealed the resident was receiving services for MI and the findings were based on medications. The other indications for decision-making revealed the resident did not have a primary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the resident did have a secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis was a SMI or ID. The screening showed the resident had validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). The validating documentation was the resident's Brief Interview of Mental Status (BIMS). The instructions showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an SMI, ID, or both. A Level II may only be terminated by the Level II PASRR evaluator and accordance with 42 CFR 483. 128(m)(2)(i) or 42 CFR 483.128(m)(2)(ii). The completed screen revealed a Level II PASRR evaluation was not required. An interview was conducted on 9/5/24 at 9:48 a.m. with the SSD. The SSD reported doing the PASRR screenings and MDS (Minimum Data Set team) inputs them. The PASRR was reviewed and the SSD stated a Level II should have been done. 3. Review of Resident #10's Admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified severity unspecified dementia with other behavioral disturbance (primary diagnosis with an onset date of 7/26/24), cognitive communication deficit, brief psychotic disorder, and mild recurrent major depressive disorder. Review of Resident #10's PASRR, dated 6/28/24, revealed the resident did not have any MI or SMIs, and no IDs or SIDs based on documented history. The decision-making showed the resident had no disorder resulting in functional limitations in major life activities, no interpersonal functioning difficulty, no difficulty in sustaining focused attention for a period long enough to accomplish tasks, or any difficulty in adapting to typical changes. The decision-making showed the resident did not have a primary diagnosis of dementia or related neurocognitive disorder. The completion of the screening determined a Level II evaluation was not required. During an interview with the SSD on 9/5/24 at 9:58 a.m. the SSD reviewed Resident #10's diagnoses and PASRR stating they (the facility) was going through new admissions as a team. The SSD confirmed Resident #10's primary diagnosis was dementia and should have had a Level II done. 20536 4. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. Review of Resident #15's Admission Record revealed she was admitted to the facility on [DATE]. Review of the Admission Record revealed Resident #15's diagnoses to include altered mental status, cognitive communication deficit, dementia, major depression, mood disorder, and schizoaffective disorder. In addition, the medical chart contained a Level 1 PASRR. Further review of the Level I PASRR revealed the MI, Suspected MI Section I (a) showed Resident #15 was checked for diagnoses to include bipolar and schizophrenia. However, major depression was not checked. On 9/5/24 at 10:00 a.m. an interview with the SSD confirmed the current completed Level I PASSR screen did not reflect all the MI, Suspected MI diagnoses. She revealed Resident #15 did show a diagnosis of major depression and the facility should have completed a new PASRR Level 1 to reflect that. 50570 5. A review of Resident #27's Admission Record revealed an admitted [DATE]. Further review of Resident #27's Admission Record revealed diagnoses to include: major depressive disorder with an onset date of 7/19/22. A review of Resident #27's active physician orders, as of 9/5/24, revealed medications to include: Sertraline HCI (hydrochloride) 50 MG (milligrams) for depression. Start date 8/1/23. A review of Resident #27's current care plan revealed a focus of, Antidepressant Care Plan, with a date initiated and created on 7/20/22. Further review of the Antidepressant Care Plan focus revealed the following, Resident is at risk for adverse side effects related to use of antidepressant medications, Baseline care plan date 7/20/22. Interventions included the following, Administer ANTIDEPRESSANT medications as ordered by physicians. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. A review of Resident #27's PASRR Level 1, dated 7/22/22, revealed no documentation of a qualifying mental health diagnosis, to include depression. A review of Resident #27's electronic medical record revealed no evidence of an updated PASRR, Level 1 to include the qualifying mental health diagnosis of depression. On 9/5/24 at 9:48 a.m. an interview with the SSD revealed she does the screening for PASRRs and the MDS Coordinator puts them into the electronic medical record. She stated the facility is in the process of auditing PASRRs. The SSD stated Resident #27's PASSR Level 1 should have been updated with the diagnosis of depression. 6. A review of Resident #28's Admission Record revealed an admitted [DATE]. Further review of Resident #28's Admission Record revealed diagnoses to include: major depressive disorder with an onset date of 2/3/23. A review of Resident #28's active physician orders, as of 9/5/24, revealed medications to include: Mirtazapine Tablet 7.5 MG for MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. Start date 8/5/24. A review of Resident #28's current care plan revealed a focus of, Antidepressant Care Plan, with a date initiated and created on 2/6/23. Further review of the Antidepressant Care Plan focus revealed the following, Resident is at risk for adverse side effects related to use of antidepressant medications. Interventions included the following, Administer ANTIDEPRESSANT medications as ordered by physicians. Monitor/document side effects and effectiveness Q-SHIFT. A review of Resident #28's PASRR Level 1, dated 1/6/23, revealed no documentation of a qualifying mental health diagnosis, to include depression. A review of Resident #28's electronic medical record revealed no evidence of an updated PASRR Level 1 to include the qualifying mental health diagnosis of depression. On 9/5/24 at 9:48 a.m. an interview with the SSD stated Resident #28's PASSR Level 1 needs to be updated with the diagnosis of depression. A review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, implemented on 9/7/22, revealed the following, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Further review of the policy under the Policy Explanation and Compliance Guidelines, revealed the following, . 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority.

Based on observations, staff and resident interviews, and record review, the facility failed to provide three of twenty sampled residents (#15, #10, and #28) with activities of daily living related to showers/baths (#10, #15) and personal hygiene related to shaving (#15) and eating assistance (#28) as per their request and scheduled timeframes. Findings included: 1. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. She revealed she yells out rather than uses the call light, because they (staff) respond faster. Resident #15 revealed she has missed her shower days the past few days, and she has missed many shower days the past couple of months. Resident #15 appeared with disheveled hair and she had long hair growing around her mouth and chin area. Some of the hair on her chin were approximately one inch to one and a half inches long. She was also noted to be wearing a hospital gown. On 9/3/2024 at 12:20 p.m. Resident #15 was in her room. She was still noted lying in bed and wearing a hospital gown. Resident #15's hair was still observed disheveled and she still had long facial and chin hair. Resident #15 stated, I just need a razor if they (staff) won't help me. She replied, I don't like having face hair and I have not had a shower in three days. She revealed there is never enough staff to help her with her personal hygiene or showers. On 9/4/2024 (Wednesday) at 9:30 a.m. Resident #15 was in her room. She was noted in bed lying flat with her head on a pillow and the linen pulled up over her head. She removed the linen from her face area and she was still noted with long facial hair around her mouth and chin area. Resident #15 revealed she still had not bathed. She again confirmed she does not like having mouth and chin hair, and that she could not remove it herself. On 9/4/2024 at 1:32 p.m. Resident #15 was in her room and confirmed again that she had not had a shower or bath yet and someone told her earlier she may get one today. She could not remember who that was. Resident #15 stated she needed a razor so she could shave. She started to tear up and revealed she does not like hair on her face and she could shave it if she had a razor. On 9/4/2024 at 12:40 p.m. Staff C, Certified Nursing Assistant (CNA) explained that she does shower/bathing today for a list of residents. She revealed that she does not assist with showers during meal services and that she will resume with showers/bathing after lunch. Staff C confirmed her entire assignment today was showers/bathing only. She also confirmed she will be giving Resident #15 a shower in a little while and that she is on her list. On 9/5/2024 at 8:07 a.m. Resident #15 was overheard calling out from her room. She was observed wearing a hospital gown and still had a lot of long facial and chin hair. She confirmed she had a shower yesterday (9/4/2024). She was asked if staff offered to clean up the hair on her face and chin and she revealed that the aide did not. She teared up and stated she wanted no hair on her face. She mentioned she has spoken to staff about it, but there are rare times when she is even given a bath/shower. She confirmed she does not like bed baths and would want only showers. She confirmed staff miss her shower days often. Review of Resident #15's Admission Record revealed she was admitted to the facility on [DATE]. Resident #15's diagnoses included sepsis, pressure ulcer unspecified stage, cognitive communication deficit, contracture, muscle weakness, abnormalities of gait, altered mental status, dementia, major depression, mood disorder, and schizoaffective disorder. Review of the Admission Minimum Data Sheet (MDS) assessment, dated 7/11/2024, revealed in Section E - Behaviors rejection of care was not exhibited. Section GG Functional Abilities and Goals revealed Resident #15 was dependent with substantial/maximal assistance for Shower/Bathing, and dependent on staff for personal hygiene. Review of the nurse progress notes dated from admission on 7/11/2024 to the current date of 9/5/2024 revealed no documentation that reflected missed showers or refusal of showers/personal hygiene. Review of the current care plan, with a next review date of 7/5/2024, revealed the following Focus areas: - ADL the resident has an ADL self - care performance deficit r/t (related to) weakness, AMS (altered mental status), multiple wounds. Interventions included: Bathing/Showers: Resident is totally dependent on 1 staff to provide bathing activity. - Personal Hygiene/Oral Care: The resident is totally dependent on 1 staff for personal hygiene and oral care. Review of the electronic medical record under the Tasks section revealed: Showers scheduled for Wednesdays/Saturdays. Last shower documented was documented on 8/24/2024 at 17:59 (5:59 p.m.). The medical chart contained a skin sheet that identified the resident was provided with a bed bath on 8/24/24. There was no documentation in the medical record to support the resident received a shower on Wednesday 8/28/2024, nor documentation to support the resident received a shower on Saturday 8/31/24. Further review of the Task section revealed no documentation to support Resident #15 was provided with a shower/bath since her admission on Saturday 7/27/24 to include the days of Wednesday 7/31/24, Saturday 8/3/24, Saturday 8/10/24, Wednesday 8/14/24. 2. On 9/3/2024 at 2:00 p.m. Resident #10 was observed seated in her wheelchair and waiting to attend a group activity. An attempted interview was conducted and Resident #10 was able to answer some simple yes and no questions related to her day but was not able to speak to her medical care and services. Review of Resident #10's Admission Record revealed she was admitted to the facility on [DATE]. The Admission Record revealed diagnoses to include: dementia, muscle weakness, Parkinsonism. Review of the electronic medical record under Tasks section revealed: Receive Showers/Baths on Tuesdays/Fridays. Review of the shower task sheet dated from 7/26/2024 - 9/5/2024 did not support Resident #10 was given a shower/bath on; Tuesday 7/30/2024, Friday 8/2/2024, Tuesday 8/20/2024, There were no notes on this sheet, nor in any nurse progress note of Resident #10 refusing a bath or shower. Review of the current care plan, with a next review date of 10/9/2024, revealed the following Focus areas: - Resident requires assistance with activity participation related to: Cog (cognitive) deficits, Physical limitations, with interventions in place. - ADL the resident has an ADL self- care performance deficit r/t the following areas; Transfer resident utilizes transfer equipment with 2 care givers physical help; Bathing/Showering - Resident is totally dependent on 1 staff to provide bathing activity; Personal Hygiene the resident requires assistance by 1 staff with personal hygiene and oral care. On 9/5/2024 at 10:00 a.m. an interview with Staff A, Registered Nurse/Unit Manager (RN/UM) revealed upon admission, residents are provided with a shower schedule based on their room number. She stated a resident could change the day or add shower days if they request. Staff K explained the direct care staff will look into the resident's record under the Task section or Kardex, to see when the resident is to have their shower/bath. After the shower, staff are to document in that record of completion, or refusal. Staff K revealed if there is a refusal, a nurse will reflect that in the nurse progress notes. Staff K will follow up and monitor a resident's record to see if staff have documented completed or not completed for showers/baths. She revealed there has been a documentation problem the past few months and she, along with the Director of Nursing have been trying to educate staff that they need to document a completed shower, otherwise if it is not documented, it did not happen. Staff K could not provide any other documentation to support Resident #15 and Resident #10 had showers for the above listed showers missed. She also could not provide evidence that Resident #15 and #10 ever refused showers on those days. 50570 3. On 9/3/2024 at 11:08 a.m. an observation of Resident #28 revealed he was laying down in bed, with the bedsheets pulled to slightly over his waist, and his hands were over the bedsheets. An observation of his hands revealed long fingernails. Observations of his right hand revealed his ring fingernail was splitting horizontally, in the middle of his nail bed. The ring fingernail on his right hand was lifted up from splitting. An observation of Resident #28's left hand revealed his thumb nail was jagged and splitting horizontally from about half of the nail. On 9/4/2024 at 1:24 p.m. Resident #28 was observed sitting in a wheelchair with the bedside table in front of him. Resident #28's family member was observed sitting on the bed beside him. An observation of his hands revealed long fingernails. Observations of his right hand revealed his ring fingernail was splitting horizontally, in the middle of his nail bed. The ring fingernail on his right hand was lifted up from splitting. An observation of Resident #28's left hand revealed his thumb nail was jagged and splitting horizontally from about half of the nail. He stated he didn't want his nails long. Resident #28 stated staff will cut his nails, When they have time. He stated he receives a shower twice a week. Resident #28 stated he received a shower today and his nails were not cut. He stated his nails that are splitting get caught when he's running his hands through his hair. A review of Resident #28's Admission Record revealed an admitted [DATE]. A review of Resident #28's Order Summary Report revealed the following diagnoses to include: muscle weakness, major depressive disorder, cognitive communication deficit, and Post-Traumatic Stress Disorder, Chronic. A review of Resident #28's Minimum Data Set (MDS) Quarterly Assessment - Section C, Cognitive Patterns, dated 7/22/24, revealed a Brief Interview Mental Score (BIMS) of 13, cognitively intact. A review of Resident #28's current care plan for Activities of Daily Living (ADL) revealed the following, The resident has an ADL self-care performance deficit r/t [related to] weakness, date initiated and created on 02/15/23. Further review of Resident #28's ADL care plan revealed the following interventions, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 02/03/2023. A review of Resident #28's current care plan revealed a behavior care plan to include the following, Potential for impaired or inappropriate behaviors related to . Refuses hygiene care (cutting nails), date initiated and created on 06/15/23.Further review of the skin integrity focus revealed the following interventions to include, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, date initiated and created on 2/6/23. On 9/4/2024 at 1:59 p.m. an interview with the MDS Coordinator revealed Resident #28's nails have been long since he was admitted to the facility. She stated he refuses that staff trim his nails. The MDS Coordinator said he does allow staff to clean his nails. The MDS Coordinator stated Resident #28's care plan related to nail cutting refusals was created because he will not let anyone cut his nails. She stated the resident doesn't participate in care plan meetings. She said as far as she knows, Resident #28 has never had his nails cut. The MDS coordinator stated staff have never informed her they've cut his fingernails. A review of Resident #28's progress notes, from 8/2/24 to 9/5/24, revealed the following: a) A Skin observation progress note, dated 9/2/24, Resident skin is clear no impairment. Resident nails cleaned and trimmed. Resident prefers long nails. b) A Skin observation progress note, dated 8/30/24, Resident nails cleaned and trimmed Resolved Abrasion Skin impairment resolved on. c) A Skin observation progress note, dated 8/25/24, Resident skin is clear no impairment. resident prefers his nails long. d) A Skin observation progress note, dated 8/23/24, Resident nails cleaned and trimmed scratch to middle of upper back- almost healed. Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , e) A Skin observation progress note dated 8/16/24, Resident nails cleaned and trimmed scratch to middle of upper back. Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , f) A Skin observation progress note, dated 8/11/24, Resident nails cleaned and trimmed Abrasion to middle of upper back. Existing abrasion Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , g) A Skin observation progress note, dated 8/9/24, Resident skin is clear no impairment. Resident declines to have nails trimmed. They are long. h) A Skin observation progress note, dated 8/9/24, Resident nails cleaned and trimmed no new skin issues, lotion ordered to dry skin i) A, Skin observation progress note, dated 8/2/24, Resident skin is clear no impairment. Resident declines to have nails trimmed. They are long. On 9/4/2024 at 2:38 p.m. an interview with Staff H, Certified Nursing Assistant (CNA) revealed if the resident has diabetes, then CNAs don't cut the resident's nails. She stated the specialist cuts the resident's nails, if they have diabetes. Staff H, CNA stated her role is to clean the resident's nails. She stated she cleans the resident's nails by soaking them in water. Staff H, CNA stated there is a staff member dedicated to showers only. She stated, There's a CNA every day to do showers. She said Resident #28 has never asked her to cut his nails. Staff H, CNA confirmed she checks his nails, but said she doesn't know what his nails look like currently. She confirmed Resident #28 received a shower today, but stated it was a different CNA who completed the task. On 9/4/2024 at 3:12 p.m. an interview with Staff C, CNA revealed there's documentation that's completed after providing showers. She stated she lets the CNA know if the resident's nails are cut during showers, so they could document that. Regarding shower sheets, Staff C, CNA said there's a Paper up front and the nurse signs it. She confirmed Resident #28 received a shower today. Staff C, CNA stated she's not sure if staff are able to cut his nails. She said she's never cut his nails. Staff C, CNA stated Resident #28's nail looks, Regular, to her. She stated she uses a rag to clean his nails. Staff C, CNA stated if the resident were to ask her to cut his nails she would confirm if it's okay, before doing so. She stated Resident #28 had never asked her to cut his nails. Staff C, CNA stated she doesn't know why it's documented that his nails were cut/trimmed. She stated again during the interview that the CNA assigned to him would document if his nails were cut. On 9/4/2024 at 4:48 p.m. an interview with the DON revealed Resident #28 sometimes lets staff trim his nails, and sometimes he doesn't. Regarding the skin observation progress note on 9/2/24, the DON confirmed that she documented the note which revealed the following, Resident skin is clear no impairment. Resident nails cleaned and trimmed. Resident prefers long nails. The DON stated the electronic medical record doesn't allow other options other than, Resident's nails cleaned and trimmed. She stated the other option would be his nails were dirty, if she documented she didn't cut his nails. The DON stated the note on 9/2/24 was related to her attempt at intervening with Resident #28. She stated the progress note could be clearer about his nails not being trimmed, but cleaned, on 9/2/24. A review of the facility's Activities of Daily Living (ADLs) policy, reviewed on 9/7/22, revealed the following, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Further review of the policy revealed the following, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; . Further review of the ADLs policy under Policy Explanation and Compliance Guidelines revealed the following, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 37999 4. On 9/3/2024 at 12:25 p.m. Resident #9 was observed lying in bed with eyes closed. An over-bed table was located out of reach of the resident on the left-side of the bed with a meal tray on top of it. The meal tray contained a covered plate and clear plastic wrapped cups of liquids. On 9/3/2024 at 12:32 p.m. Resident #9 was observed in the same position with the tray covered. The observation revealed no staff member entered the room to assist the resident with the noon meal. On 9/3/2024 at 12:46 p.m. Resident #9 continued to lay in bed with eyes closed, the nearby meal tray was observed with a covered plate, one clear plastic wrapped cup of opaque liquid and one containing a red- colored liquid. The observation revealed no staff member entered the room. On 9/3/2024 at 12:53 p.m. Resident #9 was observed lying in bed with eyes closed, the plate and liquids continued to be covered, and no staff member had entered the room. On 9/3/2024 at 12:58 p.m. Staff C, CNA was observed in the hallway of Resident #9's room picking up lunch trays from residents who had eaten in their rooms. On 9/3/2024 at 1:01 p.m. (36 minutes after the first observation), Staff C entered Resident #9's room and began to verbally and tactile stimulate the resident. The staff member informed the resident it was lunchtime and called out the resident's name. Staff C stated whoever had time was to assist residents with eating and feeding residents. The staff member reported Resident #9 required 100% assistance with eating and was the staff member's only assisted diner but she passing trays on another hall. Review of Resident #9's Admission Record revealed the resident was admitted on [DATE] and 10/1/2019. The record included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was rarely/never understood and did not have a BIMS score. The assessment showed the resident required partial/moderate assistance with eating. Review of the CNA Assignment sheet, provided by the facility on 9/5/2024 at 9:41 a.m., showed the resident was one of four dependent/full assist diners, which was confirmed at that time by the Director of Nursing (DON). An interview was conducted on 9/5/2024 at 9:08 a.m. with the DON. The DON stated (meal) trays for dependent diners should be left on the tray cart until staff could assist (them). The DON provided documentation showing Resident #9 had eaten 76-100% of the observed lunch meal on 9/3/2024 and stated the resident's meal sitting in the room for 36 minutes was not acceptable. During an interview on 9/5/2024 at 9:41 a.m. the DON stated the facility did not have a policy regarding assisting residents with eating or a policy related to dining. On 9/5/2024 at 5:22 p.m. Resident #9's dinner tray was observed, with a covered plate, drink cups covered with a clear plastic wrap, and the resident's eating utensils continued to be wrapped in a paper napkin. The observation showed no staff member was in the room. Staff K, Licensed Practical Nurse (LPN) observed the meal tray a moment later and stated staff were passing (meal) trays and it was the policy for them to pass trays then return to the room and assist the resident. A review of the facility's Activities of Daily Living (ADLs) policy, reviewed on 9/7/22, revealed the following, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Further review of the policy revealed the following, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; . Further review of the ADLs policy under Policy Explanation and Compliance Guidelines revealed the following, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interviews and record review the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of infection related to staff not offering hand hygiene to residents prior to a meal and two staff members (R, and G) not performing hand hygiene with the potential to affect a census of 41 residents. Findings included: On 9/3/24 observations of the lunch service in the dining room from 11:51 a.m. to 12:55 p.m. revealed no hand hygiene was offered to multiple residents prior to eating. At 12:01 p.m. Staff E, Registered Nurse (RN) entered the dining room area. At 12:27 p.m. an observation of Staff E, RN revealed she sat down and attempted to assist a resident by setting them up to eat, which included touching utensils and other items on the table and did not perform hand hygiene prior to assisting this resident. At 12:33 p.m. Staff E, RN was observed serving beverages without performing hand hygiene before and after handling the beverages. At 12:38 p.m. an observation of Staff E, RN revealed she was feeding Resident #10, stopped feeding her at 12:41 p.m., and then resumed at 12:48 p.m. Observations of Staff, E feeding Resident #10 revealed she was standing up next to her and no hand hygiene was observed before and after feeding the resident. From 12:51 p.m. to 12:53 p.m. Staff E, RN was observed assisting another resident at a different table with dining. Observations of Staff E, RN revealed no hand hygiene was performed before and after feeding this resident. On 9/4/24 at 11:29 a.m. testing and recording of food temperatures were observed in the satellite kitchen. Staff G, Dietary Aide was designated to test the food temperatures. At 11:36 a.m. observations of Staff G, Dietary Aide revealed she entered the satellite kitchen pushing the meal cart with the food items for lunch. Further observations of Staff G, Dietary Aide, as she prepared to test the food temperatures, revealed she did not practice hand hygiene such as using hand sanitizer or washing her hands. At 11:39 a.m. observations of Staff G, Dietary Aide revealed she handled food on the steam table to include removing a clear, plastic film that was covering the items. Throughout the observation of testing and recording the lunch meal temperatures, Staff G, Dietary Aide touched approximately nine food items and surrounding surfaces/areas without gloves or proper hand hygiene practices. A review of facility policy titled, Infection Prevention and Control Program, last revised July 2023, revealed under the section titled Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed and nine errors were identified for two (#27 and #7) of three residents observed. These errors constituted a 25% medication error rate. Findings included: 1. On 9/4/24 at 8:04 a.m. an observation of medication administration with Staff D, Registered Nurse (RN) was conducted with Resident #27. The staff member dispensed the following medications: - Acidophilus lactobacillus otc (over-the-counter) capsule - Amlodipine 10 mg (milligram) tablet - Biotin 1000 mcg (microgram) otc tablet - Loratadine 10 mg otc tablet - Cranberry 2- 450 mg otc tablets - Doxycycline 50 mg capsule - Methenam hiprex 1 gram tablet - Montelukast 10 mg tablet - Valsartan 40 mg tablet - Amoxicillin/Potassium clavulanic 875-125 mg tablet - Tamsulosin 0.4 mg capsule - Lactulose 10 gram/15 milliliter (gm/mL) - 30 mLs. Staff D, RN searched through multiple bottles in the medication cart and reported having to reorder Resident #27's Lactulose. Staff D removed a bottle of Lactulose labeled with a female resident's name (#12) on it and poured 30 mLs of it into a medication cup. The staff member confirmed dispensing 12 tablets and one liquid. The staff member reported on 9/4/24 at 8:15 a.m. of having to borrow Lactulose from Resident #12 as Resident #27 did not have any. The staff member was dressed in personal protective equipment (PPE) necessary for entering the resident's room, Resident #27 was observed swallowing the oral tablets and drinking the liquid medication Lactulose. Review of Resident #27's September 2024 Medication Administration Record (MAR) showed the following order: - Biotin - Give 500 mcg by mouth one time a day for hair and nails. 2. On 9/4/24 at 8:25 a.m. an observation of medication administration with Staff E, RN was conducted with Resident #7. The staff member dispensed the following medications: - Amoxicillin/Potassium clavulanic 875-125 mg tablet - Eliquis 5 mg tablet - Jardiance 10 mg tablet - Metoprolol Succinate 50 mg Extended Release (ER) - Acidophilus lactobacillus 20 mg otc capsule - Felodipine 10 mg ER - Gabapentin 300 mg - 2 capsules - Xifaxan 550 mg tablet - Spirolactone 50 mg tablet - Cranberry 450 mg otc tablet - Cetirizine 10 mg otc tablet - Docusate sodium 100 mg gelcap - Acetazolamide 125 mg tablet - Zinc 50 mg otc tablet - Meclizine 12.5 mg otc tablet - Benzonatate 100 mg capsule Staff E stated the resident was to receive Lactulose, however the resident did not like liquid (medications) and did not have any (Lactulose), but staff were still supposed to offer it. The staff member confirmed dispensing 17 tablets (did not count them), mixed oral medications with applesauce at bedside and assisted the resident with taking them. The resident asked for eye drops. Staff E returned to the cart and removed a bottle of generic Tetrahydrozoline 0.05%, sanitized hands at the cart, donned gloves while standing in the hallway then entered the room. Staff E placed one drop in the right eye and one drop in the left eye. The staff member returned to the cart and documented the Silver Sulfamide cream had been applied, saying they come and get the staff member to apply it when they assist the resident with hygiene. Staff E documented under Lactulose awaiting pharmacy and confirmed the resident was to receive Furosemide, Oyster Shell Calcium, and Vitamin B12 but did not have any and was waiting for pharmacy to deliver. Review of Resident #7's September 2024 Medication Administration Record (MAR) revealed the following medications were to be administered: - Lactulose 10 gm/15 mL - Give 30 mL by mouth three times a day for constipation. The nurse documented 5. Review of the chart codes showed 5=Hold/See Nurse Notes. The order was discontinued on 9/4/24 at 10:08 a.m., approximately 1 hour and 30 minutes after the observation. The order was reinstated to begin on 9/5/24 at 9:00 a.m. - Silver Sulfadiazine Cream 1% - Apply to bilateral buttocks topically every shift for Moisture-Associated Skin Damage (MASD). The Medication Administration Audit Report revealed the cream was applied on 9/4/24 at 8:56 a.m., during the observation period. - Cholecalciferol 1000 unit (Vitamin D3) - Give 1 tablet by mouth in the morning for Vitamin D deficiency. This medication was scheduled during the liberalized medication administration time of 7:15 a.m. to 11 a.m. The Medication Administration Audit Report revealed the medication was administered on 9/4/24 at 2:57 p.m. - Metoprolol Succinate ER tablet 24-hour 50 mg - Give 1 tablet by mouth one time a day for hypertension. Hold if less than systolic blood pressure (SBP) 100, diastolic blood pressure (DBP) 60, heart rate 60. A review of the MAR showed no area to document either blood pressure or pulse. The observation did not reveal Staff E, RN obtained a blood pressure or pulse prior to the administration. An interview was conducted on 9/4/24 at 10:06 a.m. with Staff E. The staff member stated that night shift takes Resident #7's blood pressure and Resident #7 takes it when the resident asks or doesn't feel good. The staff member was unable to provide a blood pressure for the resident. - Oyster Shell Calcium 500 mg tablet - Give 1 tablet by mouth in the morning for Vitamin D deficiency, take with food. This order was discontinued on 9/4/24 at 10:14 a.m., approximately 1 hour and 46 minutes after the observation of medication administration. The September MAR did not show the medication was administered on 9/4/24. - Refresh Tears Ophthalmic solution (Carboxymethylcellulose sodium) - Instill 1 drop in both eyes every 12 hours for dry eyes. The observation revealed Tetrahydrozoline 0.05% eye drops had been administered. - Vitamin B12 500 microgram (mcg) tablet (Cyanocobalamin) - Give 1 tablet by mouth in the morning for Vitamin B12 deficiency. The observation did not show this medication was administered. The Medication Admin Audit Report showed Cyanocobalamin was administered on 9/4/24 at 2:57 p.m. Review of Resident #7's progress notes, on 9/4/24 at 4:10 p.m., did not show the physician had been notified of the lateness of medications or the unavailability of Lactulose. An interview was conducted on 9/4/24 at 4:00 p.m. with the Director of Nursing (DON). The DON was notified of the observation for Resident #27. The DON was notified of the observation with Resident #7 and stated vital signs should be taken within one hour of the Metoprolol. After reviewing the Vital Summary and MAR for Resident #7, the DON confirmed there were no blood pressures recorded for the resident's Metoprolol. The DON stated the physician had been notified at 11:00 a.m. (on 9/4/24) of Resident #7's late medications, confirming there was no note revealing the notification. Review of the policy titled, Liberalized and Standardized Medication Administration Schedules, approved on 4/24/24, revealed, In keeping with the philosophy of person centered care and resident rights, medications will be delivered in a manner that is least restrictive and intrusive while allowing for optimal therapeutic effect of medications. This practice minimizes the number of times the resident's/ patient's schedule must be interrupted for Drug Administration and allows person centered choices as to when to receive their medication unless specific hour of administration is ordered by the medical provider. The liberalized schedules well allow for medication administration during the defined window of time; these are represented by a descriptor (e.g. in the morning) or time frame (e.g. 0400-0700) on the MAR/EMAR. Medications scheduled are considered timely as long as they are administered within one (1) hour before or after the define time or window of time. Review of the policy titled, Medication Administration, implemented 3/24/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. - 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. - 15. If any medication is not available, or the possibility of late administration, the nurse will contact the attending physician. - 18. Sign MAR after administered. For those medications requiring vital signs, record the vital signs on to the MAR.

Based on observations, interviews and record review, the facility failed to provide administration of intravenous medication in accordance with professional standards of practices for one resident (#11) of four residents sampled. Findings included: On 9/3/2024 at 9:55 a.m. a loud alarm sound was overheard close to the nurse station area. The alarm sound was observed to be emitting from an Intravenous (IV) therapy system pump, which was at Resident #11's bedside down the hallway. At this time, Resident #11 was observed lying flat in bed and with his head propped up on a pillow. Resident #11 stated, The [explicative] thing goes on all the time. He stated the IV system provided an antibiotic to heal a wound infection, and he could not remember exactly how long he has been treated with IV antibiotic therapy. Resident #11 stated the IV machine must have problems to alarm that way. He stated, They [staff] take a long time [to respond]; it happens enough. Further observations, at this time, of the alarming IV therapy system revealed a hanging liquid medication bag with a line leading from it to a pump. The line continued from the pump to the resident's right arm. The loud alarming pump had a read out that showed, Air in the line. Following the interview on 9/3/2024 with Resident #11, the alarm was still sounding and the resident was overheard yelling nurse at 10:13 a.m. Then at 10:14 a.m. the Staff A, Registered Nurse/Unit Manager (RN/UM) walked out from another resident's room over to Resident #11's room. An interview was conducted on 9/3/24 at 10:15 a.m. with Staff A, RN/UM, who exited Resident #11's room. She stated the alarm was sounding and she had to get the air out from the line. She revealed it happens at times and only IV trained nurses can remove the air from the line when air builds up. She was not sure how long the resident was on the IV therapy and was not sure what the medication was or what type of infection he had. On 9/3/2024 at 10:46 a.m. Resident #11's IV pump was again observed and overheard alarming. The pump read, Air in the line. The alarm kept sounding and there were no staff in the area to report to the room to fix the alarm. At 11:00 a.m., 11:02 a.m., and 11:03 a.m. Resident #11 was again overheard calling out loud, Nurse. There were no staff in the area to answer. On 9/3/2024 at 11:06 a.m. a Staff O, Licensed Practical Nurse (LPN) was observed walking down the hallway from another hall, and then went into Resident #11's room to fix the alarm. Staff O was interviewed and replied, I did hear the alarm and I fixed the air line alarm. He was not sure how long the alarm was sounding and expressed that if aides hear the alarm, they are to report it to a nurse immediately. During the interviews with both Staff O, LPN and Staff A, RN/UM on 9/3/2024 they revealed when the alarm sounds and there is air in the line, the system does not provide the fluid antibiotic to the resident. They both confirmed the air in the line has to be flushed out in order for the medication to flow again. Review of Resident #11's Admission Record revealed he was admitted to the facility on [DATE] and readmitted from hospital on 8/23/2024. Resident #11's diagnoses included osteomyelitis, urinary tract infection, and prostatic hyperplasia with lower urinary tract symptoms,. Review of the Order Summary Report for the month of 9/2024 revealed the following active physician orders: - Vancomycin HCI IV solution Reconstituted 1 GM (gram) - 1 dose IV BID (two times a day) for infuse 1.25 into vein until 9/9/2024. (Order start date - 9/2/2024). - Cleanse and irrigate wound in Right heel area with normal saline pat dry with gauze, and apply Dakins moistened gauze to wound bed and cover with boarder dressing x shift for wound and as need for if soiled or falling off. (Order date 9/2/2024) - Cefepime HCL IV solution Reconstituted 2 gm - Use 2 gm times 12 hours for wound infection until 9/9/2024. (Order start date - 8/29/2024). - IV - PICC (peripherally inserted central catheter) all types change primary intermittent tubing x 24 hrs (hours) x day shift. (Order date 8/26/2024). - IV - PICC all types change needleless connector on admission, weekly and PRN (as needed) x day shift x Tue and as need (Start date 8/26/2024). - IV - PICC all types monitor site Q (every) shift for signs/symptoms of infection and or infiltration x shift. (Start date 8/26/2024). - IV - PICC change transparent dressing on admission, then weekly and PRN thereafter x day shift and Tue and as need. (Start order date 8/27/2024). Review of the nurse progress notes dated from date of admission 8/6/2024 through to current date 9/5/2024 did not indicate any documentation of concerns related to the IV therapy system, nor any documentation of Resident #11 ever refusing the IV antibiotic therapy. Review of the current care plan, with a next review date 11/19/2024, revealed the following Focus areas: - Diagnosis of Osteomyelitis with interventions in place to include administer IV antibiotics as ordered, monitor for adverse side effects and report findings to MD. - Infection on the right heel/sacrum, with interventions in place to include administer antibiotic as per MD orders. - Infection care plan the resident is on IV antibiotic therapy r/t (related to) infection to right foot. Interventions included administer antibiotic medications as ordered by physician. On 9/5/2024 at 10:00 a.m. an interview was conducted with Staff A, RN/UM. She confirmed Resident #11 has an IV therapy system that provides a liquid antibiotic. She revealed only qualified nurses are able to hang and operate the IV therapy system. Staff A revealed the IV pump will walk you through each step on how to operate it. She was asked what it means when the pump read out reveals; Air in the line. She stated; It means air has accumulated in the line and the line needs to be cleared. Staff A also confirmed that once the IV machine tubing has air accumulated in it, the medication will not flow at all to the resident. She revealed the air has to be flushed for the medication to flow again. Staff A revealed if the air is in the line, a very loud alarm will sound and it will not stop until the air has been flushed properly. She also confirmed the alarm can be overheard outside the room, down the hall and if other staff hear it, they should report it a nurse or herself immediately. A review of the policy titled, Intravenous Therapy, implementation date of 12/2/2022, documented, The facility will adhere to accepted standards of practice regarding infusion practices. Definitions included; Intravenous (IV) therapy is the administration of parenteral fluids or medications through an IV catheter to treat a condition. The compliance guidelines of the policy revealed the following: 8. Whenever possible, an infusion pump will be used when administering intravenous fluid or medications. 9. When an infusion pump is not used, a mechanical flow control device will be used. 10. A doctor's order is obtained before starting IV therapy. 11. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. Under the Procedures Continuous Infusion section following was documented: 8. Spike solution/medication and prime tubing, maintaining spike sterility. Clamp tubing when primed and all air is out of tubing. 13. Observe infusion site for any adverse reactions and stop infusion, if so noted, and notify practitioner. Under the Intermittent Medication Infusion section of the policy, it revealed the following: 5. Check medication expiration date, leaks, cracks, change in clarity, or particulate matter. 9. Prepare infusion by spiking medications, priming tubing, ensuring all air is out of tubing.

Based on observations, record reviews, and interviews the facility failed to monitor the oxygen saturation level for one resident (#9) of one resident sampled for respiratory care. Findings included: On 9/3/24 at 12:25 p.m. Resident #9 was observed lying in bed with eyes closed. An oxygen concentrator was sitting on the floor next to the bedside dresser. Review of Resident #9's Admission Record revealed the resident was admitted on [DATE] and 10/1/19. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, shortness of breath, and unspecified organism other pneumonia. Review of Resident #9's Minimum Data Set assessment, dated 6/16/24, revealed in Section C - Cognitive Patterns the resident was rarely/never understood and had a no score for the Brief Interview for Mental Status. Review of Resident #9's September 2024 Medication Administration Record (MAR) revealed a physician order for Resident with history of shortness of breath while lying flat. Head of bed was elevated this shift to prevent shortness of breath. every shift, start date 3/20/24. The MAR showed for the 12 Da (day shift) and 12 Ng (night shift) from 9/1/24 to 9/4/24 the staff documented four out of seven shifts that the resident's head of bed was elevated and three times it was not. The MAR showed the resident was to be administered oxygen at 2 lpm (liters per minute) via n/c (nasal cannula) as needed for SOB (shortness of breath) related to shortness of breath. The MAR did not reveal the resident had been administered oxygen. Review of Resident #9's June 2024 through September 2024 Treatment Administration Records (TAR) showed an order for Check oxygen saturations q (every) shift every shift. The TAR revealed staff documented a checkmark on each 12 Da and 12Ng shift, without documentation of an oxygen saturation level. The TAR did not have an area to document the saturation level with the order. According to the chart codes, a checkmark equaled administered. Review of Resident #9's care plan revealed a focus showing the resident had oxygen therapy r/t (related to) SOB when lying flat. The interventions included, Give medications as ordered by physician. Observe/document side effects and effectiveness. Review of the policy - Medication Administration, implemented on 3/24/23, instructed staff to Obtain and record vital signs, when applicable or per physician's orders. The policy showed staff were to Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. An interview was conducted with the Director of Nursing on 9/4/24 at 4:21 p.m. The DON stated staff should be documenting oxygen saturation levels if they have an order and if the nurse thought the order need to be clarified, the physician should be contacted.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for three (#19, 28, 146) out of four residents sampled. Findings Included: 1. On 09/06/22 at 12:33 p.m. Resident #19 was observed sitting in her wheelchair in her bedroom, and smiled when approached. Resident #19 stated I can't leave my room as she pointed to her nose that contained oxygen tubing. The tubing was attached to concentrator, which was turned on and registered at 2 liters. The tubing reflected the date 08/24/2022. Additionally on the bedside table a small volume nebulizer machine was observed with the tubing and mask dated 08/24/2020. The nebulizer aerosol mask was lying on top of a gait belt and not stored in a clean manner (photographic evidence obtained). On 09/07/22 at 11: 00 a.m. Resident #19 was observed sitting up in her wheelchair with nasal cannula in place and attached to the concentrator running at 2 liters. On 09/08/2022 at 2:34 p.m. resident #19 lying in bed sleeping with oxygen running at 2 liters per nasal cannula. Medical record review revealed Resident #19 Physician orders for small volume nebulizer 3 ml [MEDICATION(S)]-[MEDICATION(S)] solution 0.5-2.5 mg (3) MG (milligram)/3ML (milliliter) via neb (nebulizer) every (Q)12 hours (H) dated 8/15/2022 for pneumonia (PNA) supplementary, and Oxygen at 2L (liters) via nasal cannula to maintain a sat (saturation) above 90 as needed related to [CONDITION(S)] start date 08/14/2022. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Vitals Summary reflected the use of oxygen on 09/02/2022, 09/03/2022, 09/04/2022, 09/05/2022, 09/07/2022 and 09/08/2022. Review of the treatment administration record did not contain orders to change oxygen tubing nor nebulizer equipment weekly. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed if an as needed order (PRN) is being used it should be documented. 2. On 09/06/22 at 12:41 p.m. Resident #28 bedroom revealed a small volume nebulizer machine with oxygen tubing attached that was dated 08/24/2020. The tubing was attached to an aerosol mask that was not stored in a clean nor sanitary manner. Medical record review contained physician orders for [MEDICATION(S)] Sulfate Nebulization Solution 1.25 MG/3ML 1 applicator inhale orally one time a day for COVID/Pneumonia (PNA) start Date 07/12/2022. Review of the treatment administration record (TAR) read to change nebulizer mask and tubing every week by respiratory therapist (RT) every day shift every Tue for Infection control Start date 10/13/2020. The TAR revealed documentation on 09/06/2022 that the nebulizer mask and tubing were changed yet photographic evidence does not depict. 3. On 09/06/22 at 12:19 p.m. random observation revealed Resident # 146 oxygen tubing stored on the floor. Upon closer observation the tubing did not contain a date. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed oxygen tubing should not be stored on the floor. 4. Review of Resident #27's record revealed that he was admitted to the facility on [DATE] has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Observations of the resident on 09/06/22 at 11:06 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 11:50 AM revealed that a oxygen (O2) concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 12:38 PM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 9/7/22 at 8:41 AM revealed the resident lying on his bed, with the O2 concentrator not running and the tubing bagged, The resident was noted with no O2 on. observations of the labeled tubing still indicated a date of 8/24/22. Observations of the resident on 09/07/22 at 10:31 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/07/22 at 11:28 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Review of the residents current physician orders revealed an order dated 8/19/22 which indicated the following: O2 at 2liter/min via nasal cannula continuous for sob/comfort-every shift related to SHORTNESS OF BREATH Review of the September treatment administration record (TAR) revealed that the resident was administered O2 on all 3 shifts for 9/6/22 Review of the residents care plan dated 8/22/22 revealed the following: The resident has oxygen therapy r/t Ineffective gas exchange, with interventions that included Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Review of the skilled nursing noted for the month of September revealed the following: Skilled nursing note dated 9/6/22 indicates N/A for respiratory. Skilled nursing note dated 9/5/22 indicates N/A for respiratory. Skilled nursing note dated 9/4/22 indicates N/A for respiratory. Skilled nursing note dated 9/3/22 indicates N/A for respiratory. Skilled nursing note dated 9/2/22 indicates N/A for respiratory. Skilled nursing note dated 9/1/22 indicates N/A for respiratory. Interview on 09/07/22 at 11:29 AM with Staff D, Licensed Practical Nurse (LPN) revealed that there is no documentation in the TAR yet for her residents because she has not yet started her treatments. Interview on 09/07/22 at 11:36 AM with the DON, confirmed that he did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . the DON confirmed that current tubing for Resident #27 is more than a week old per the existing labeled tape. (Photographic evidence obtained) The DON confirmed that based on the physician order the resident should be getting O2 continuously which means at all time. He reported that the expectation is to follow the doctors orders for O2 use. Review of the facility policy titled Oxygen Administration dated 8/25/22 revealed the following: b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and seven errors were identified for five (#8, 6, 24, 30 and 9) of six residents observed. These errors constituted a 22.58% medication error rate Findings Included: 1. On 09/08/2022 at 9:15 a.m. medication observed task was conducted alongside Staff Member D, Licensed Practical Nurse (LPN) as she prepared medications for Resident #8. She confirmed the medications that were prepared was all that was due at that time except the [MEDICATION(S)] dose pack. She said it was not available to be given. She stated when the order was put in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 09/08/2022 at 9:41 a.m. Staff D prepared the following medications for Resident #6 Ibuprofen tablet 200 mg (milligrams) three tablets, [MEDICATION(S)]-[MEDICATION(S)] 25 -100 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 5 mg two tablets, [MEDICATION(S)] tablet 500 mg, [MEDICATION(S)] capsule 34 mg, [MEDICATION(S)] tablet 5 mg, [MEDICATION(S)] tablet 0.5 mg, and one multivitamin tablet. Resident #8 was observed sitting up in his bed with the over bedside table positioned in front of him. The table contained a toothbrush, toothpaste, water, and a basin. The resident was receptive with the observation and accepted his medications. Medication reconciliation revealed Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 09/08/2022 at 10:08 a.m. an observation was conducted with Staff Member I, Registered Nurse (RN) as she prepared the following medications for Resident #24. Zinc tablet 50 mg, vitamin D tablet 25 mcg (micrograms), aspirin tablet 325 mg, vitamin C tablet 500 mg, cranberry 425 mg one tablet, [MEDICATION(S)] tablet 1 gr (gram), tamsulosin HCL capsule 0.4 mg, [MEDICATION(S)] 10 mg, and [MEDICATION(S)] 40 mg. Medication reconciliation revealed zinc tablet 25 mg give 1 tablet by mouth one time a day dated 07/30/2022, and cranberry tablet 400 mg give 2 tablet by mouth one time a day for vitamin supplement dated 07/20/2022. 4. On 09/08/2022 at 11:53 p.m. Staff Member I was observed as she prepared insulin for Resident #30 at his bedside. The flex pen read [MEDICATION(S)] 70/30 flex pen Staff I turned the dose selector to 2 units; the pen was held down and pressed the injector button. The pen was then turned the dose selector to 4 units and administered the insulin into his right upper extremity. 5. On 09/08/2022 at 12:05 p.m. Staff member D, was observed as she prepared [MEDICATION(S)] an insulin pen for Resident #7 the pen dose selector was dialed to 2 units. The pen was held sideways as she pressed the injector pen. When asked she stated it's not perfectly straight as she selected 16 units. The insulin was administered into Resident #7 left upper abdomen. On 09/08/2022 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON); he confirmed medication should be administered as ordered. Review of policy titled Medication Administration dated 8/25/2022 Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this stated, as ordered by the Physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 11. Compare medication source (bubble pack, vial, etc.) with MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Examples guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medications requiring administration on an empty stomach: [MEDICATION(S)]. Accessed on 09/09/2022 at: https://pi.lilly.com/ca/[MEDICATION(S)]-ca-ifu-kp.pdf Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps.

Based on record review and interview, the facility failed to ensure the Physician was informed of medication refusal over a period of 12 days (08/22/22, 08/23/22, 08/29/22, 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22) days for one (#346) of five sampled residents. Findings included: During the medical record review for Resident#346 revealed that she was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#346 cognitive status on the most current Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired. Review of the MAR (medication administration record) revealed the resident had refused several medications and the physician was not notified. Medications included but not limited to: hypertension, depression, high cholesterol, protein liquid and [MEDICATION(S)]. The following medications were refused by the resident with no notification to the physician. Resident#346 refused: -[MEDICATION(S)] Tablet Extended Release 24-hour 25 MG (milligrams) related to: Hypertension on the following dates: 8/22, 8/28, 8/30 and 8/31/22. Documentation was not present of notification to the physician. -[MEDICATION(S)] HCI Suspension 125 mg orally 6 hours for C-diff for 10 days, start date 8/29/22- medication was refused on 9/2 at noon, 9/3 at 0600 and not given at 1800, 9/4 0600 and 1200 refused and refused on 9/7 at 1200. Documentation was not present of notification to the physician. -[MEDICATION(S)] Tablet 7.5 MG for depression was refused on 8/30/22, and not provided on 9/1, 9/3 and 9/7/22. Documentation was not present of notification to the physician. -[MEDICATION(S)] Tablet 5 MG related to [CONDITION(S)] refused on 8/30/22. Documentation was not present of notification to the physician. -Protein Liquid two times a day for low [MEDICATION(S)] levels and promote wound healing for 30 days start date 8/19/22- refused 8/22, 8/28, 8/29, 8/30 and 8/31/22, 9/2, 9/4, 9/5, 9/6 and 9/7/22. Facility failed to notify the physician. -[MEDICATION(S)] HCI ER (SR) 150 MG for Depression- refused on 9/2, 9/4, 9/5, 9/6 and 9/7/22. Documentation was not present of notification to the physician. A review of Resident#346 plan of care for Depression indicates as an intervention to administer antidepressant medications as ordered by physician date initiated 8/18/22. Care plan for nutrition with an effective date of 8/18/22 indicates to administer Liquid Protein as ordered. On 9/8/2022 an interview was conducted with Staff H, Licensed Practical Nurse (LPN). He reported the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/2022 at 9:15 a.m. the Director of Nursing (DON) was interviewed. He reported staff must document the refusal and follow up with notification to the physician and document. He was made aware of Resident#346 ongoing refusals for medications and the lack of notification. On 9/09/2022 at 11:27 a.m. a telephone call was made to Resident#346's Physician and a voicemail was left. A return call was received at 12:01 p.m. He confirmed he would need to be notified of medication refusals. At 12:07 p.m. a telephone call was also made to the Nurse Practitioner who reported the facility called her yesterday to have a psychiatry evaluation to determine why the resident was refusing medications. She said the facility notified her of medication refusal in August and September yesterday. A facility policy was requested; however, none was provided by completion of the survey.

Based on observation, interview and record review, the facility failed to ensure a report was filed as a formal grievance and acted upon, for one (#37) of 19 sampled residents related to missing clothing. Findings included: During the initial tour conducted on 09/06/22 at 10:41 AM, Resident#37 stated she had no clothes since she arrived. She had notified staff and feels they are not doing anything. Resident#37 reported she had been at the facility since 8/19/22. She stated, No one has gone to get my clothes from my home. With permission from the resident an observation of her closet was made. The closet had one item hanging which was a gray sweater. She stated the sweater did not belong to her. The clothing cabinet drawers were observed empty, she confirmed they have been like that since she arrived to the facility. The resident was observed sitting on the edge of her bed with a white sweatshirt and no bottoms. She confirmed the sweatshirt was brought for her today but did not have any pants on. A record review was conducted for Resident #37 which revealed she had been initially admitted to the facility on [DATE] with a readmitted [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. On 09/07/22 at 11:25 AM an interview with Director of Nursing (DON), who confirmed the resident had no clothing, and the facility was aware. The DON reported they have been trying to get clothing for her from her home. The facility was aware of the voiced concern and did not file a concern for the resident until she voiced her concern to the surveyor on 09/06/22. An additional interview with Resident#37 was conducted on 09/08/22 at 10:54 A.M. Resident#37 reported she still did not have any clothing. She said the Laundry did bring her a pink shirt and a pair off leggings, which she was wearing. An observation, with the resident's permission, of her closet revealed one grey sweater, and the drawers were empty. On 09/09/22 at 11:42 A.M. an interview with Social Service Director was conducted. She confirmed she had no prior knowledge of the resident's missing clothing until she was informed by on 9/7/22. She provided a copy of the grievance, completed on 9/7/22 and a letter to the resident's family member requesting clothing, dated 9/7/22. She confirmed she did not attempt to get clothing for the resident prior to 09/07/22 as she was not aware of the issue. A review the facility Grievance policy with a revision date of 2017 indicated residents and their representatives have a right to file a grievance, either orally or in writing, to facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Based on observation, interview, and record review, the facility failed to ensure an accurate comprehensive assessment for one (#13) of one residents reviewed. Findings Included: Medical record review of Resident #13 minimum data sheet (MDS) dated [DATE] reflected a restraint was used. The restraint was coded as used daily and used in chair or out of bed and coded: Other. On 09/06/2022 at 12:20 p.m. Resident #13 was observed sitting in a high back wheelchair in the dining room eating his lunch. His legs were elevated and resting on foot pedals. No restraints were identified at the time. On 09/07/2022 at 03:37 p.m. an interview was conducted with the Minimum Data Sheet Coordinator (MDSC), who stated the restraint was an abdominal binder for his peg tube. She said the binder was to prevent him from pulling the tube out. The MDSC was asked about the peg tube placement as he was observed eating orally. The MDSC stated his peg tube was removed and did not recall the date. Further review of the MDS dated on 07/04/2022 revealed the box was checked indicating resident had a feeding tube while a resident. Medical record review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Peg tube removal. History of Present Illness Gastrostomy Malfunction: Mr. (Resident #13 name) is here for gastrostomy malfunction. The peg tube was no longer needed because patient is eating without difficulty. Treatment notes: Peg tube was removed without difficulties. On 09/07/2022 at 3:57 p.m. during an interview, the MDSC stated I just pulled over the prior assessment and did not review the areas indicating Resident #13 did not have a peg tube or a restraint during the assessment period on 07/04/2022.

Based on record review and interview, the facility failed to ensure a Baseline Admission Care Plan was completed with the input of Resident#37, and that a summary was provided to the resident for one (#37) of 18 sampled residents. Findings included: A review of the Baseline Care Plan policy for the facility dated 8/25/2022 revealed the following: the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality of care. UNDER THE HEADING Policy Explanation and Compliance Guideline reads: The base line care plan will be developed within 48 hours of a resident's admission. #3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. #4. A written summary of baseline care plan shall be provided to the resident and representative in a language that the resident or the representative can understand. The summery shall include, at a minimum, the following: A.- the initial goals of the resident. B. -a summary of the residents' medications and dietary instructions. C. -services and treatments to be administered by the facility and personnel acting on behalf of the facility. #5-A supervising nurse or MDS coordinator is responsible for providing the written summary of the baseline care to the resident and representative. 6.- The person providing the written summary of the baseline care plan shall: A.- Obtain a signature from the resident/representative to verify that the summary was provided. B.- make a copy of the summary for the medical record. A record review was conducted for Resident #37 which revealed she was initially admitted to the facility on [DATE] with a readmitted [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. During an interview with Resident#37 on 9/6/22 at 10:41 a.m. Resident#37 reported she never participated in her plan of care and was not provided with a copy of the treatments and services. A review of the medical record revealed no entries for a baseline plan of care or that a summary was provided to the resident. On 9/9/22 at 9:00 a.m. an interview was conducted with the Director of Nursing (DON). He reported the care plan should be in the electronic medical record. He confirmed the residents' medical record was silent in regard to a baseline plan of care and the resident's participation.

Based on observations, record review and interview, the facility failed to ensure 1.) skin condition was accurately assessed and documented for one resident (#27) of three residents reviewed; and 2.) wound care was provided as per Physician's orders for one resident (#10) of three residents reviewed. Findings included: 1. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skilled nursing note dated 9/1/22 indicated the resident is oriented to person and has impaired decision making ability. Observations of Resident #27 on 09/06/22 at 11:06 AM revealed the resident lying on his bed with his right tennis shoe on and his left tennis shoe off. The residents left foot was noted to be red with abrasions, and had no socks on. Observations on 09/06/22 at 11:50 AM of Resident #27 revealed him seated in the dining room for his midday meal. The resident was noted to be wearing his tennis shoes with no socks to cushion his feet. Observations on 09/06/22 at 12:38 PM revealed the resident lying on his bed. It was noted at this time the resident had bare feet and black wounds were noted to the toe area on bilateral feet, with his toenails long and not manicured. Skilled nursing note dated 9/6/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/5/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/4/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/3/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/2/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Skilled nursing note dated 9/1/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON) revealed the resident's skin check dated 9/2/22 revealed the resident had Rash to Trunk, redness to left heel, bruising on dorsal left foot. He reported nurses notes should indicate what is actually present, and that the expectation is for staff to provide foot care. Interview on 09/07/22 at 12:48 PM with the Social Service Director revealed she sets up podiatry services, but did not know if Resident #27 had been seen by the podiatrist. Review of the physician order dated 8/19/22 revealed the following: Weekly Skin evaluation FRIDAY on 7-3 Shift -Complete weekly check in [electronic medical record] evaluations. every day shift every Fri for monitoring **Report all new positive findings to the treatment nurse Immediately** RECORD IN SKIN: HEAD TO TOE ASSMNT Review of the Head to Toe Weekly Skin Checks dated 8/26/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, Other (specify): dorsal left foot: Bruising: Width = , Right elbow - Other (specify): scab: Width =, Left elbow - Other (specify): scab: Width =, Right heel - Other (specify): redness: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Review of the Head to Toe Weekly Skin Checks dated 9/2/22 revealed the following: Resident has existing skin impairment-Resident nails cleaned and trimmed-Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, - Other (specify): dorsal left foot: - Bruising: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Resolved Bruise, Skin impairment resolved on Review of the Head to Toe Weekly Skin Checks dated 9/7/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing rash discoloration and eschar-Right toe(s) - Other (specify): eschar: Length = .8cm, Width = .6, Depth = 0, - Stage Unstageable, - Other (specify): dorsal left foot: - Other (specify): redness: Width =, Left toe(s) - Other (specify): discoloration: Width =, Right toe(s) - Other (specify): discoloration: Width =, Left toe(s) - Other (specify): discoloration: Width =, Left heel - Other (specify): callus: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Interview on 09/07/22 at 03:18 PM with the Regional Director of Risk Management and the DON revealed an Assessment done by a nurse today 9/7/22 should be accurate and reflect both of the residents feet. They confirmed that there was no documentation in the record that would indicate the the physician had been notified of the residents wounds. They reported that assessments should be accurate and reflect the actual condition of the residents skin. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. 2. On 09/06/22 at 12:49 p.m. Resident #10 was observed sitting up in bed, smiled when approached and was receptive to an interview. Her lower legs were noted wrapped with a kerlix dressing. On closer observation the dressing did not contain a date that would indicate when the dressing was last changed. The right dressing contained a dark yellow shadow drainage. Resident #10 had a personal care giver in the bedroom with her at the time. The care giver said she has been caring for the resident three days a week for over two years, and confirmed the dressing to her legs did not contain a date. Medical record review of the Admission Record form revealed Resident #10 had resided at the facility just over a year and was geriatric in age. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the wound Visit Report by the Advanced Practical Registered Nurse (APRN) Certified Wound Specialist dated 09/01/2022 revealed assessment of wound #2 left posterior left lower leg chronic full thickness arterial ulcer orders to Cleanse wound with normal saline Apply collagen- with hydrogel gauze and dry dressing (DD) every day (QD). Wound #3 left medial ankle is a chronic full thickness arterial ulcer orders to: Cleanse with normal saline, apply collagen with hydrogel gauze and DD QD Wound #9 Left lateral ankle -there is no change noted in the wound progression. Orders to Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD Wound #10 Right posterior Lower Leg orders to: Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD. Review of Resident #10 treatment administration record (TAR) did not reflect the APRN orders from 09/01/2022. It reflected orders that were dated on 08/10/2022 to cleanse left lateral ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with abdominal (ABD) pads and dry dressing (DD)/[MEDICATION(S)] tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Left Medial Ankle with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/[MEDICATION(S)] tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse left posterior lower leg with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/[MEDICATION(S)] tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Right Posterior Lower Leg ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/[MEDICATION(S)] tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. On 09/07/2022 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON); he confirmed the Wound APRN comes to the facility weekly. He stated last week (09/01/2022) Staff Member H Licensed Practical Nurse had made rounds with her at the time. On 09/07/22 02:59 p.m. an interview was conducted with Staff Member H and indicated he had performed rounds with the Wound APRN. He said during the rounding the APRN will discuss changes that are needed to the treatments. He said prior to APRN leaving the facility for the day she always prints out her reports that can include changes to treatments. He was asked if he reads the reports he stated yes and confirmed that he will make the changes in the TAR. Staff H stated I didn't go with the APRN on 09/01/2022. The DON went with her that week On 09/08/2022 at 09:15 a.m. an interview was conducted with the Wound APRN and confirmed she sees Resident #10 every week. She confirmed she had changed the resident wound orders last week from every three days to daily. She said it was due to the amount of drainage the wounds were producing. And due to the delay in wound progression. The APRN confirmed at that time it is her expectation her orders are followed. Review of policy Wound Treatment Management dated 8/25/22 Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physicians orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type if dressing, and frequency of dressing changes.

Based on interview, and record review, the facility failed to ensure communication and coordination with an external service were conducted on days of treatment for one (#32) out of three residents who receive hemodialysis. Findings Included: On 09/06/22 at 10:05 a.m. Resident #32 call light was on she stated, I going to [CONDITION(S)] pretty soon and I'm waiting for the nurse to apply cream to my site. The resident said she was at the facility for short term therapy services and was hoping to return home some. Medical record review for Resident #32 revealed admission to the facility a month prior. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/22 at 11:30 a.m. an interview was conducted with Staff Member N, Licensed Practical Nurse, who said the normal process when a resident has a [CONDITION(S)] appointment the nurse is to perform the pre-[CONDITION(S)] assessment. After the resident returns a post [CONDITION(S)] assessment is completed, and the [CONDITION(S)] center communication form is completed and reviewed for any changes or new orders. On 09/07/2022 at 11:55 a.m. the Regional Director of Risk Management was asked where the communication forms were located for Resident #32 outside [CONDITION(S)] services. She stated, we have a difficult time getting communication forms from [CONDITION(S)] center. Review of Resident #32 Pre/Post [CONDITION(S)] forms and the [CONDITION(S)] Communication Form form from 08/04/2022 to 09/06/2022 revealed the following omissions of either pre-[CONDITION(S)], post-[CONDITION(S)] or the outside [CONDITION(S)] Communication Form on 08/04, 08/06, 08/13, 08/18, 08/20, 08/23, 08/25, 08/27/2022, 08/30, 09/01, 09/03, and 09/06/2022, indicating a lack of communication between the two entities. Review of Care Plan with a focus on Renal failure with [CONDITION(S)]. The goal: Resident will be free of complications at [CONDITION(S)] access site thru next review. The Interventions included: review [CONDITION(S)] communication form(s). Review of policy tilted Hemodialysis dated 08//20/2022 Policy This facility will provide the necessary care and treatment, consistent with professional standards of practice. Purpose: Ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care ands services. Definitions: End stage Renal Disease - the stage of renal impairment that appears irreversible and permeant and requires a regular course of [CONDITION(S)] or kidney transplantation to maintain life. [CONDITION(S)]- A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. The two types that are currently common are hemodialysis (HD) and peritoneal [CONDITION(S)] (PD). Review of the Nursing Facility [CONDITION(S)] Agreement that did not contain a date C. Communication Nursing facility shall reasonably cooperate with center.

Based on observation, interviews and record review, the facility failed to ensure a paid caregiver for one (Resident#30) of 18 sampled residents had specific competencies and skill sets necessary to care for the Resident#30 care needs. Findings included: During an observation of Resident#30 on 9/6/22 at 2:49 p.m. a private paid caregiver (Staff C) was observed providing care. An immediate interview with private sitter who was providing perineal care to Resident#30 was conducted. She reported she has been his private paid caregiver for the last three years. She was asked if she is here everyday and reported that she is here from 7:30 a.m. to 3:30 p.m. Monday through Friday. She said Resident#30 has an additional private caregiver here on the weekends until Sunday afternoon when his wife arrives. During the interview she was asked if the resident was incontinent, as she was observed putting on a brief to the resident. She confirmed that she places a brief on the resident while he is in bed and demonstrated the brief. She also confirmed that Resident#30 has a catheter and she empties the catheter bag. The medical record review for Resident #30 revealed he was admitted to the facility on [DATE] with a readmitted [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident#30 had an indwelling catheter, and was not interviewable due to poor cognition. A review of Resident#30 plan of care dated 7/12/2022 for skin impairment indicates: The resident has potential/actual impairment to skin integrity r/t (related to) fragile skin. Left posterior hip, sacrum, open area to penis, bilateral heel boggy. Intervention: Date initiated 8/24/22-Do not use briefs while in bed. Use a bed pad under resident while in bed/chair unless resident having loose stools. On 09/08/22 at 1:40 PM an interview with Certified Nursing Assistant (CNA) staff member (A) reported she only provides care to the resident after the sitter leaves. Today CNA staff member (B) assisted the resident with a bath. CNA (A) stated she has been at the facility for 2 weeks, and this was her first time working with Resident #30. On 09/08/22 1:19 P.M. an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted. The DON confirmed there was no education provided to her and they would start education as soon as possible. He was asked if she had any credentials, and said he was unsure. During the interview the NHA reported she was unaware that Resident#30 had a caregiver in his room. A continued review of the medical record revealed only one note documenting the paid caregiver's presence, dated 8/23/2022. A facility policy on private caregivers/sitters was requested; the DON reported the facility did not have a policy.

Based on observation, interview, and policy review, the facility failed to maintain drugs and biologicals in a safe and secure manner in one (A) out of two medication carts. Findings Included: On 09/06/22 at 09:03 a.m. upon entrance to the facility lobby multiple residents were observed sitting in their wheelchairs. Staff and family members were also observed walking through the area to enter adjoining units. An unlocked medication cart was observed positioned next to one of the residents. Upon closer observation a souffle cup sat on top of the cart that contained multiple different colored capsules and tablets. The cart top also contained a blister card facing the lobby entrance revealing a resident name. There were no licensed staff members in the immediate vicinity (photographic evidence obtained). Approximately three minutes later the Nursing Home Administrator (NHA) was observed walking down the hallway toward the facility lobby. Upon approaching, the NHA reached past the surveyor and locked the medication cart. She then reached forward with her right hand to the cart were the souffle cup sat with multiple pills. The NHA indicated at that time she did not know which nurse was responsible for the cart. She stated, I will be looking into it. On 09/06/22 at 10:00 a.m. an interview was conducted with Staff Member H, Licensed Practical Nurse, he confirmed he had left his medication cart unlocked, with medications on top of the cart. Review of policy Medication Storage dated 8/25/22 Policy: It is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. all drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperate controls. c. during a medication pass medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on record review and interview, the facility failed to make attempts to ensure hospice services were appropriately coordinated related to effective communication and consistent delivery of services was maintained for one (#27) of two residents sampled for hospice services. Findings included, 1. Review of the agreement between the facility and the hospice vendor dated September 1, 2021 revealed the following: 2.1 Hospice Plan of Care-Hospice will furnish to facility a copy of the most recent Hospice Plan of Care specific to each patient provided Hospice services (including Respite Care Services, Inpatient Services and Purchased Hospice Services) under this agreement. The Hospice Plan of Care shall reflect the participation of Hospice, Facility, and Hospice Patient and Hospice Patient's family to the extent possible, and must specifically identify which provider or party is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. 3.1 Facility Plan of Care. Facility will develop a Facility Plan of Care to coordinate with the Hospice Plan of Care for each Hospice Patient. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Review of the resident's record revealed the resident's payer source changed on 8/19/22 to hospice. Continued review of the record revealed no documentation in the record from the hospice vendor Review of the residents care plan dated 8/22/22 indicated that the resident chooses to have death with dignity, advanced directive established. Resident is hospice. Interview on 09/07/22 at 10:52 AM with Staff D Licensed Practical Nurse (LPN) revealed there is no hospice book, and the hospice staff start their documentation in the facility and then finish at their office; they send them to the facility electronically and then they are scanned into the residents record. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON), revealed all residents on hospice should have an physician's order for hospice services, and the hospice plan of care (POC), and the hospice notes should be in documents section of the resident record. He reported he could not determine when hospice was last in the building to see Resident #27, and was unable to verbalize what disciplines the resident receives from the hospice vendor, He reported all this information would be in the hospice care plan. He confirmed there was no physician orders for hospice, no hospice plan of care from the hospice vendor and no hospice notes from the hospice vendor. Interview on 09/07/22 at 12:27 PM with the Resident Assessment Coordinator revealed the hospice care plan in place does not mirror the hospice care plan from the hospice vendor as she has never seen a hospice care plan from the hospice vendor. She reported she did not know she was supposed to mirror the hospice vendors care plan to ensure continuity of care. Interview on 09/07/22 at 12:48 PM with the Social Service Director, revealed she was not sure who is supposed to ensure that hospice documentation is in the building. She reported she sets up and runs care plan meetings, but does not do anything related to continuity of care with hospice. Interview on 09/09/22 at 08:54 AM with the Hospice Nurse, Registered Nurse, (RN), revealed the resident started on hospice services on 8/19/22. She reported she shares info with the facility and talks to the nurse. She reported she will normally will call and collaborate with the facility and that the communication is word of mouth with nursing and CNAs (certified nursing assistants). The Hospice nurse reported she provides the written notes and plan of care to the facility and visits this resident weekly, and the aide comes in one time a week as of last week. Continued interview with the Hospice nurse at this time revealed this facility did not get a plan of care for this resident until this week.

Based on observations, record reviews, and interviews, the facility failed to implement the care plan related to the use of an elopement alarm for one resident (Resident #1) out of the sampled three residents. Findings included: On 09/29/21 at 9:41 a.m., Resident #1 was observed lying flat on her back in the bed with her eyes open and dressed for the day. A wander/elopement alarm was observed on the resident's right wrist. A review of the Admission Record for Resident #1 revealed she was admitted into the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan for Resident #1 revealed a focus for elopement risk initiated on 09/05/21 and included but was not limited to the following interventions: -15-minute checks, -assess for pain, hunger, and toileting needs, -check exit door alarms daily, -elopement risk assessment per protocol, -[elopement monitoring bracelet] to right wrist and check for placement and functioning every shift. A review of the Order Recap Report for Resident #1 dated 09/01/21 to 09/30/21 did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) for Resident #1 for September 2021 did not reflect documentation for checking the placement and functioning of the wander/elopement alarm every shift. On 09/29/21 at 2:00 p.m., an interview as conducted with the Nursing Home Administrator (NHA). The NHA confirmed there was no documentation related to checking the placement and functioning of the wander/elopement alarm. The Administrator stated the previous Director of Nursing (DON) was responsible for initiating the order for the wander/elopement alarm and failed to do so. A review of a facility-provided policy titled 'Wandering and Elopements,' dated March 2019 showed: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, interview, and record review the facility's quality assurance (QA) and assessment committee failed to implement an effective plan of action related to implementation of care plans (F656) to address the risk of elopement for 3 of 3 (#1, #2, #3) residents sampled for elopement risk. Findings included: 1. Review of the facility's plan of correction for the survey ending 9/29/21 with a completion date of 10/19/21 revealed the following measures would be taken to correct the deficient practice which was identified at F656: .DON [Director of Nursing]/designee initiated re-education for licensed nurses on 9/29/2021, on the components of this regulation with emphasis on ensuring comprehensive person-centered care plans are in place and implemented regarding monitoring placement and function of wander guards in relation to checking placement of wander guard every shift and function of wander guard every night shift. Newly hired licensed clinical staff will receive this education during orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; Director of Clinical Services/designee will conduct quality review of current residents requiring a wander guard weekly x 4 weeks, and then every 2 weeks x 2 months and PRN [as needed] as indicated to ensure physician order and comprehensive person-centered care plans are in place and implemented regarding wander guards. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months and PRN as indicated until committee determines substantial compliance has been met. 2. A review of the facility's plan of correction documentation revealed an undated sign in sheet titled TRAINING PARTICIPATION LOG. Review of the training documentation to show what was discussed revealed the training focus was responding to alarms and obtaining an order to check function and placement of the wanderguard device. The training did not relate to carrying out the testing to check the function of the device. Review of the Risk Management/Quality Improvement (QA) Audit form used to monitor compliance with F656 revealed the goal for implementation of compliance was to ensure orders were in place for checking placement and function of wanderguard. The QA did not contain a component to ensure these orders were carried out and the systems/tools were in place to check the function of wanderguard devices. 3. Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program with a revised date of February 2020 revealed the following: -This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents . Implementation .2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance; b. Establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed . 4. On 10/21/21 a revisit survey was conducted to ensure compliance with F656. The revisit survey identified the following on-going concerns with F656: *Review of Resident #1's physician orders dated 9/29/21 revealed active orders to Check Wander guard placement every shift Right wrist every shift for maintenance, and Check Wanderguard function every night shift every shift for maintenance. Review of Resident #1's Elopement Risk Care Plan initiated on 9/7/21 revealed an intervention initiated 9/8/21 of Wander guard to right wrist. Check for placement and functioning qs [every shift]. *Review of Resident #2's active physician orders revealed an order dated 7/3/21 to Check wander guard to left wrist for placement and function. Every shift for safety. Review of Resident #2's wandering/elopement care plan initiated on 6/8/21 revealed interventions dated 6/8/21 that included check placement and function every shift, and wander guard applied to left wrist. *Review of Resident #3's active physician orders revealed an order dated 9/29/21 for Wander guard in place to left ankle every shift monitor placement, and an order dated 9/30/21 to Check wander guard function every shift, every shift for maintenance. Review of Resident #3's elopement risk care plan initiated 10/1/21 revealed interventions initiated 10/1/21 that included Check bracelet for placement each shift (left ankle); Check exit door alarms daily; Check functioning of bracelet daily. Interview on 10/21/21 at 11:16 AM with Staff A, Maintenance, revealed that he does not have the device needed to test the functionality of the doors secured with the wander guard system. Staff A reported that this same device was needed to check each wander guard bracelet/tag placed on a resident, unless you push each resident to the door to see if it works. He reported that he does not know how often the batteries were checked and that he would have to go to the Assisted Living Facility (ALF) to obtain the checker. Staff A obtained the checker and found that it was inoperable. Staff A walked through the facility to try and find a 9 volt battery to replace the device. On 10/21/21 at 11:20 AM, Staff A was able to obtain a 9 volt battery from the maintenance office located in the ALF. Observation and interview with Staff A on 10/21/21 at 11:40 AM revealed that the functionality of the Wander Guard located on the service hall exterior door was not working with the device as the Wander Guard tag had to be programmed which could only be done by the Maintenance Director who was not in the building at this time. Interview on 10/21/21 at 11:45 AM with the NHA revealed that the Wander Guard system must be set for a new tag and this can only be done by the Maintenance Director. She reported that the tags must be scanned with the tester to confirm the tags functionality, and that the only person who has a scanner was the Maintenance Director. Observations on 10/21/21 at 12:10 PM of the NHA revealed that she searched 2 of 2 medication carts and was unable to locate a tester that would allow the testing of the Wander Guard tags/bracelet worn by residents. Interview at this time with Staff B, Licensed Practical Nurse (LPN) and Staff C, LPN revealed that they had no knowledge of a Wander Guard tester being present in the medication carts. Phone interview on 10/21/21 at 12:13 PM with Staff D, LPN revealed that she works the 3:00 PM-11:00 PM shift. She reported that per the physician orders she checks placement of the Wander Guard tag on the assigned residents who are wearing the tag. She reported that they do not check for the functionality of the tag. Interview on 10/21/21 at 1:30 PM with Staff B, LPN revealed that she was a new employee and started working in the facility about 5 weeks ago. She reported that she had received training on how the Wander Guard system worked. She reported that she has not checked placement for residents with Wander Guards, and that she has not checked functionality for the Wander Guard tags being worn by residents. She reported that she does not know if she was assigned to any residents with a Wander Guard. Interview on 10/21/21 at 1:35 PM with Staff C, LPN revealed that he was aware that the facility had a Wander Guard system and knows how it works. He reported that he checked for placement and documented this but did not check for functionality as he did not have access to a tester. Phone interview on 10/21/21 at 4:35 PM with Staff E, LPN revealed that she works at the facility on the 11:00 PM-7:00 AM shift. She reported that she checks the applicable assigned residents for placement of the wander guard during her shift. She reported that she does not check for the functionality of the device because she does not have the machine that checks to see if the devices were working. Interview on 10/21/21 at 1:52 PM with the NHA revealed that monitoring of the Wander Guard system through QAPI needed improvement due to the fact that she did not have a device to check the functionality of the wander guard devices. The NHA confirmed that the Performance Improvement Plan (PIP) was not working.

Based on interview and record review the facility failed to implement policies to prevent neglect to ensure residents, who utilized the front porch and surrounding area, were provided oversight for one (Resident #1) of five residents reviewed for safety. The facility allowed a resident who was at risk for dehydration related to diuretic use and Diabetes Type 2 to remain outside in the direct Florida sunlight on a day when the temperature was 95 degrees Fahrenheit and the heat index was 109.7. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative and nursing services with the goal to return home alone as per her prior level of function. Per her care plan, she was resistant to activities of daily care and assistance by the staff. The documentation on the Minimum Data Set (MDS) Admission assessment reflected the resident needed extensive assistance for locomotion in her wheelchair on and off the unit. On 7/5/2017 the resident was found on the sidewalk, in her wheel chair, in front of the facility in direct sunlight and was assessed as being unresponsive and flushed with an internal body temperature of 103.4. The resident subsequently sustained [REDACTED]. The facility's failure to implement policies and procedures to ensure residents were not neglected and were provided oversight supervision while on the front porch and surrounding area, resulted in the findings of immediate jeopardy, which was removed on 8/1/2017 at 4:00 p.m. Findings included: Per the facility's Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy with an effective date of 5/31/2016, Policy Statement, It is the policy of the community that: a) Every reasonable effort within its control is taken to prevent the abuse, neglect, and exploitation of residents. Team members must not engage in nor permit anyone else to engage in, abuse, neglect or exploitation of any resident. b) Team members of the community are mandated reporters and have a duty to report known or suspected abuse, neglect, and/o exploitation to local, state, federal and/or provincial authorities in accordance with applicable law and regulation. c) In addition, team members who know of or suspect abuse, neglect, or exploitation of any resident must immediately notify the Executive Director/designee, to ensure appropriate action is timely taken for the safety of the resident and those potentially impacted. Definitions: Neglect the failure to provide goods and services necessary to protect the resident from health and safety hazards. Mandatory Reporting: 4) Every team member is a mandatory reporter and has the duty to report known or suspected abuse, neglect, and/or exploitation to local and state/provincial authorities in accordance with applicable law and regulation. a) These authorities may include law enforcement, licensing regulator, the Long Term Care Ombudsman, and/or adult protective services. The report of abuse, neglect, or exploitation must be made within the timeframe and through the format required by applicable law and regulation. b) Allegations of or suspicions of abuse, neglect, and/or exploitation are to be reported. Protecting the Resident: 7) In addition to initial mandatory reporting, to ensure the safety and protection of residents, any team member who knows of or suspects abuse, neglect, or exploitation of a resident must also immediately notify the ED/SNA/designee. a) Notification of the Executive Director (ED)/Skilled Nursing Administrator (SNA) designee is not a substitute for mandatory reporting. 8) The ED/SNA/designee: a) Upon receiving notification of any known or suspected abuse, neglect, or exploitation of a resident contacts the Licensed Nurse who evaluates the resident and provides the necessary intervention, for example, calls 911 if emergent. b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area i. Ensures that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. ii. Ensures that non-team members alleged to be involved in the abuse, neglect, or exploitation will be asked to leave the resident area and wait further instructions. c) Ensures that the resident's (i) physician, (ii) legal representative and (iii) family or other individual regularly involved in the resident's day to day care are notified as soon as practicable within timeframes established within laws/regulations. d) Initiates the internal loss prevention/incident reporting process. e) The ED/SNA/designee will notify the internal Sunrise Crisis Hotline. Investigation: 9) The ED/SNA/designee a) Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal/provincial requirements 10) The ED/SNA/designee manages and directs the investigation of all abuse, neglect, and/or exploitation. 11) The ED/SNA/designee implements corrective actions as indicated by the results of the investigation. 12) If a written report of the investigation findings is required by applicable law or regulation, the ED/SNA completes such report and ensures it is submitted timely. On 7/26/2017 at 11:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Initially, neither the NHA nor the DON had any recollection of an event related to sun exposure. The surveyor read the nurse's note for Resident #1, Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, and ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. to them. The question was asked again if either one of them remembered this event. At that time, they both agreed they had heard something about it. The DON said we tried to convince her to go to the hospital. We called her son to convince her but she still did not want to go. At that time, the DON nor the NHA offered or had any additional information. Additional questions were asked related to Resident #1 and her usual routine and care needs. At that time the DON said, that on the day of the event (7/5/2017) the resident went outside around lunchtime. The DON said she did not know if the resident went out before or after lunch but said she only stayed out for a few minutes. She said, sometime later that day, someone from Therapy was with the resident and took her to her room because she was not feeling well. She said the resident's skin was red because she had a fever due to an infection. The DON offered no additional information at that time. The NHA and DON were asked if the facility had a policy to ensure that residents that go outside to the front porch and surrounding areas were monitored for heat or sun exposure. The NHA said, No. When asked, since the incident on 7/5/2017, had the facility investigated, reported, educated staff, and/or put interventions in place to ensure the safety of the residents that choose to go outside. The DON shook her head to indicate No and the NHA said, No. On 7/5/ 2017, in Tampa, Florida, the average outside temperature was 86 degrees Fahrenheit and the average humidity was 72 %. In Tampa at 1:35 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 112.2 degrees Fahrenheit. At 2:15 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 109.7. The humidity was 77% (www.Wunderground.com). On 7/26/2017 at 12:30 p.m.an interview was conducted with the Physical Therapy Assistant (Staff #1). He said he punched out at 2:30 p.m. on 7/5/2017 (this was verified by the punch detail provided by the Nursing Home Administrator). He said he went out the front door and saw the resident sitting in her wheelchair to the left of the door on the sidewalk in the sun. He attempted to speak to the resident but she did not respond. When she did not respond he looked closer and saw that she appeared flushed. He assumed this was from the sun. He did a sternal rub, the resident did not respond. He immediately rolled her inside and told the nurse We have a problem. The resident was taken to her room and transferred to bed. The nurse applied oxygen and EMS was called. Her vital signs were taken, her clothes were loosened, and ice packs were applied to her body. At that time, he felt he could be of no more assistance so he left the room. He said when he left the resident was still unresponsive. On 7/26/2017 at 3:17 p.m., a second interview was conducted with the Director of Nurses. She said on the day of the event, she saw commotion in the hallway and went in the room. A therapist and the nurse were in the room. The resident had ice packs on her due to a high fever. The resident was unresponsive at that time. When EMS arrived, she refused to go to the hospital. EMS left. The DON said the resident's skin was red/flushed. After the occurrence no other skin assessments were done. On 7/27/2017 at 9:15 a.m., the Staff #1 was interviewed again to obtain additional information. He said on the day of the event, the resident was wearing a short sleeve shirt with Capri pants. He said the resident frequently went outside and sat in the sun. He said, We were constantly telling her to be careful and encouraged her to stay out of the sun, but she was a strong-willed woman. Staff #1 and this surveyor went out to the front porch and surrounding areas so the Staff #1 could show the exact spot the resident was found. He stood on the spot and said, Right here in the sun. The spot was on the sidewalk to the left side of the front door if looking from the inside to the outside of the building. At that time, the area was shaded due to the time of day and position of the summer sun. The area was re-checked at 12:30 p.m. 1:30 p.m. and 2:30 p.m. and was noted to be in full sun. Photographic evidence was obtained. On 7/27/2017 at 10:21 a.m., an interview was conducted with the Director of Nurses (DON). She said the physician saw the resident after the event and gave orders. When asked what orders? She said, chest X-ray, Electrocardiogram, Doppler of the upper extremities, and laboratory tests. When asked if he assessed the skin or wrote orders related to the skin she said no. She said, since the physician did not say anything about the skin we thought the high temperature was from an infection not sun exposure. The DON said after this event, there was no incident report done, investigation conducted, or steps put into place to prevent this from happening again because they did not feel there was anything to investigate. On 7/26/2017 at 1:50 p.m., an interview was conducted via the telephone with the resident's direct care nurse about the day of the event. He said he only vaguely remembered the day the resident was found unresponsive and brought back into the facility. He said he remembered she had a fever of over 100 degrees, maybe 102, maybe 103. He could not remember the exact temperature. He verified that her skin was red but said he did not know why it was red. He said, Emergency Medical Services were called but when they arrived, the resident refused to go to the hospital. The nurse was questioned about documentation on the Medication Administration Record [REDACTED]. He said the resident was sitting in her wheelchair outside her room when he administered the medication. The nurse said he did not see the resident again until she was brought back into the facility by the therapist. Per www.medicinnet.com: Those most susceptible (at risk) individuals to heat stroke include: The elderly (often with associated [MEDICAL CONDITION], lung disease, or who are taking medications that make them vulnerable to dehydration and heat [MEDICAL CONDITION]). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Sunburn and sun poisoning facts oSunburn is an inflammation of the skin caused by overexposure to UV [MEDICAL CONDITION] from the sun. oUV [MEDICAL CONDITION] damages the skin and also can damage the eyes. oUV rays are most intense at noon and the hours immediately before and after (between 10 a.m. and 4 p.m.). oImmediate symptoms of sunburn are hot, red, tender skin; pain when the skin is touched or rubbed; and dehydration; several days after exposure the skin may, swell, blister, peel, and itch. Sunburn may cause permanent skin damage and [MEDICAL CONDITION] ([DIAGNOSES REDACTED], [DIAGNOSES REDACTED], squamous cell [MEDICAL CONDITION]). o Some medications may increase sensitivity to sunburn (photosensitivity). o Sun poisoning is caused by severe sunburn; its symptoms include o fever, o nausea, o chills, o dizziness, o rapid pulse, o rapid breathing, o dehydration, and o shock. The resident was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. On 7/27/2017 at 11:00 a.m., and, again on 7/31/2017 at 11:46 p.m., interviews were conducted with the resident's primary care physician while she was a resident at the facility. He said when he was in the facility on 7/6/2017, during his routine rounds; he went to the therapy gym to see the resident. He said while he was there, the resident's treating Physical Therapy Assistant (Staff #14) told him that on 7/5/2017, the resident had a syncopal episode, was found outside in the sun, and refused to go to the hospital. The physician said he assessed the resident and recommended that the resident should go to the hospital for an evaluation due to increased confusion; however, the resident refused to transfer the hospital. The physician said he did note that the resident had minimal redness on her arms but did not see blistering. He said the resident's main concern was pain in her right arm and right wrist. He said he ordered a Doppler study to rule out a blood clot, a chest X-ray and an Electrocardiogram due to a change in her overall condition. He verified that the nursing staff did not notify him that the resident was found in the sun, unresponsive, and had a body temperature of 103.4 degrees Fahrenheit. When asked if he would have done anything different had he known, he said, No, I would have sent her to the hospital as the facility tried to do. However, he said, I would have expected a call from the facility regarding this significant change in condition and her refusal the go to the hospital. He said he did not see her in the emergency room , because he was her physician only while she was at this facility. On 7/3/2017, the resident completed five days of [MEDICATION NAME] for a urinary tract infection. During the above interview with the physician, he said since the [MEDICATION NAME] was completed two days prior to the event, he did not believe it caused the resident to be more susceptible to harm from the sun. The resident was not on any other medication that would increase sensitivity to sun exposure. On 7/31/2017 at 12:35 p.m., an interview was conducted with the resident's physical therapy assistant treating Physical Therapy Assistant (Staff #14). She said the day after the event (7/6/2017); the physician came in to the therapy gym to see the resident. At that time, the therapist informed the physician about the resident's syncopal event from the day before. She also informed him that she had noted a functional decline in the resident. She said she did see the resident's arms after the event and said they were both red and had small blisters on them. On 7/26/2017, per a review of the nurse's notes for Resident #1, the following note was documented as a Late Entry with a created date of 7/13/2017. The event was documented by the nurse as having occurred on 7/6/2017 at 2:26 p.m. However based on record review and interviews the event occurred on 7/5/2017 and the note read as follows: Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, ice packs applied by staff, assessed by Emergency Medical Services (EMS) refused to be transferred to the hospital. MD/son aware will cont. to monitor. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (Staff #14) the day following the event. Per the nurses notes for Resident #1 dated 7/5/2017 10:14 p.m., alert and oriented x 3, stayed in bed and able to use call light, uses 02 as ordered and appears in no acute distress. Re-checked temperature: 98.2 at 8:00 p.m. Right arm elevated with pillow and medicated for pain x 1 and with good effect. Per the Weights and Vitals Summary on 7/6/2017 at 12:46 a.m. the resident's Temperature was 98.3 degrees. Per the nurse's notes dated 7/6/2017 at 6:12 a.m., alert and oriented x 3 with cooperative attitude. As needed, [MEDICATION NAME] given for mild anxiety and observed to be effective. As needed, oxygen in place. Oxygen effective and saturations were stable. Complained of mild pain to right wrist but refused as needed pain medication. Right arm elevated on pillow overnight for comfort. Will continue to monitor. No shortness of breath or acute distress observed. Call light in reach and is compliant with use. Additional nurses notes as follows: 7/6/2017 at 6:14 a.m., follow-up: Abrasions noted above bilateral knees from fall 7/4/2017. No signs or symptoms of infection noted, left to open to air. Neuro checks were within normal limits. 7/6/2017 at 12:57 p.m., resident did not participate in occupational or physical therapy. Resident was alert and oriented x3, cooperative with staff, diet and medications tolerated, remains on oxygen at 2 liters per minute for shortness of breath, bilateral [MEDICAL CONDITION] awaiting Doppler ultrasound to rule out clot. Physician and son aware. Will continue to monitor. 7/6/2017 at 10:48 p.m. Alert x 2, up in wheelchair with assist of one, not in acute distress. The resident was seen by the physician and with orders. Son aware. Right arm elevated with pillow in bed. 7/7/2107 at 2:19 a.m., resident has orders for two views chest X-ray in a.m. due to shortness of breath and electrocardiogram in a.m. due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Reason for portable X-ray: Resident has generalized muscle weakness. 7/8/2017 at 10:51 a.m. resident refused to participate in therapy due to pain in her right upper arm and lower extremities. Resident is alert and oriented. Tolerated medications and meals well. Moderate assistance with Activities of Daily Living (ADLs) and transfers. Continent. Pain voiced with pain medication administered with effectiveness. 7/8/2017 at 12:03 a.m. Alert and able to voiced her needs. Right arm elevated with pillow. Incontinent of bowel and bladder. No signs and symptoms of respiratory distress. Call light in reach. She took her medications and diet well. 7/8/2017 at 6:05 a.m., resident alert with increased confusion. Resident awake most of night yelling out other resident's names. Resident oxygen saturations were 85% on room air; saturations were 97% on 2 liters of oxygen, slightly labored respirations. Resident having hallucinations of other residents in her room eating turkey. At other times stating her son is sitting in the chair waiting for her to pack her things. Resident's anxiety is not re-directable at times. Resident yelling at nurse, why are you keeping me here, I don't want to be in the hospital. Resident unaware that she is in her room at the rehab facility. Resident unaware of the time screaming she was not offered breakfast, attempted to redirect resident to the time that was 4:00 a.m. and that breakfast was at 7:00 a.m. Redirection had limited effect. Resident's son was contacted and agreed to come in and talk with his Mom. Son arrived at 7:30 a.m. and agreed that his mother was confused and requested her to be sent to the hospital. 7/8/2017 at 8:57 a.m. Reason for transfer: AMS, hallucinations, [MEDICAL CONDITION]. Condition of resident at time of transfer: alert with confusion. Vital signs: BP: 88/57, Pulse: 60, Respirations: 22, O2 sat: 86% on room air, 97% on 2L/min. Resident transported by EMS. Son was in the facility at the time of transfer, MD made aware. Per the emergency room report dated 7/8/2017, History of Present Illness: The patient presents with altered mental status. The onset was 3 days ago. The course/duration of symptoms is constant. The character of symptoms is disoriented and confused. The degree at onset was moderate. The degree at present is moderate. Baseline status: alert and oriented x4. The patient is a poor historian secondary to altered mental status and disorientation. Per son at bedside, the patient was left out in the sun after she fell asleep. She was found with blisters to her bilateral forearms and with a temperature of 104 degrees Fahrenheit. No fever at present time. Since then, patient has acted confused and disoriented. Per son, patient's baseline is alert and oriented x4. Last known normal was 4 days ago. Also notes that the patient had a chest X-ray and was told this morning that she had pneumonia. Skin: Warm, dry, normal for ethnicity, bilateral dorsal forearm with few areas of mild [DIAGNOSES REDACTED] and small blisters about 1 by 3 centimeters, no evidence of infection. Per the hospital discharge summary dated 7/13/2017, Final Diagnoses: [REDACTED].>1. Altered mental status-acute [MEDICAL CONDITION], resolved. 2. Solar exposure to the arm causing blistering. 3. [MEDICAL CONDITION] 4. Possible left lower lobe pneumonia. 5. [MEDICATION NAME] coagulopathy with supra therapeutic INR. 6. Chronic [MEDICAL CONDITION], on [MEDICATION NAME]. 7. Diastolic dysfunction. 8. Underlying Dementia 9. Mildly elevated troponin Per University of Rochester Medical Center-Keesler Burn Center at http://www.rochester.edu, the classification [MEDICAL CONDITION] as follows: First-degree (superficial) burns. First-[MEDICAL CONDITION] only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and usually consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-[MEDICAL CONDITION] the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third Degree (full thickness) burns. Third-[MEDICAL CONDITION] the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear white or charred. Fourth degree burns. Fourth [MEDICAL CONDITION] damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed. Per the Brief Interview for Mental Status (BIMS) dated 6/7/2017, the resident had a score of 14. A score of 13-15 indicated the resident is cognitively intact. Per the Admission Minimum Data Set with an Assessment Reference date of 5/31/2017, Section G, Functional Status: E. Locomotion on unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. F. Locomotion off unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. On 7/26/2017 at 1:00 p.m., an interview with the MDS Coordinator revealed the resident was alert and oriented with periods of confusion. She was resistant to care, non-complaint, and yelled at staff. A review of the care plan revealed the following information: Focus: Resident is/has potential to be verbally aggressive related to ineffective coping skills, and poor impulse control (accusatory of staff). Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will demonstrate through verbal/non-verbal expressions an understanding of need to control verbally abusive behavior. Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide the resident with positive reinforcement for appropriate behavior. Observe for signs and symptoms of agitation: Intervene with non-medicinal interventions to avoid increased agitation. Focus: The resident is resistive to care Activities of daily living (ADL) and care related to adjustment to nursing home, Anxiety. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will cooperate with care through next review date. Interventions: Allow the resident to make decisions about treatment regimen and establish their ADL routines to provide a sense of control. Give clear explanation of all care activities prior to and as they occur. Give one to one attention as needed, when necessary. If resident resists with ADLs, stop, ensure resident safety, and resume/reapproach at a later time. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Focus: Resident has special needs related to medical diagnosis. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: Resident will have all of their needs met daily. Interventions: Coordinate all care and services as needed. Provide resident with daily staff assist as needed. Notify MD and family of any changes as needed. Focus: The Resident has limited physical mobility related to weakness. Date initiated 5/24/2017. Revision date 7/9/2017. Goal: The resident will demonstrate the appropriate use of (wheelchair) to increase mobility through the next review date. Intervention: Provide supportive care and assistive devices (wheelchair) with mobility as needed. Document assistance as needed. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. Per the Medication Administration Record [REDACTED]. Per Web MD at www.webmd.com, [MEDICATION NAME] HCL is a diuretic and used for hypertension, heart failure and [MEDICAL CONDITION]. Adverse reactions include the potential for dehydration. The resident was also receiving [MEDICATION NAME] tablet 2 mg, give 1 tablet by mouth one time a day for [MEDICAL CONDITION], hold if systolic blood pressure is less than 110. Per RxList at www.rxlist.com, [MEDICATION NAME] is a diuretic and use includes treatment of [REDACTED]. Adverse reactions include the potential for dehydration. An interview was conducted with Resident #1 (she was receiving rehabilitative and nursing services at another facility) on 7/28/2017 at 9:30 a.m. She was alert, oriented, pleasant and freely engaged in conversation. She said she was doing well and was anxious to go home. She volunteered the following information. She said she came to Florida in March for her son's surprise birthday party. Her plans were to stay a few weeks and return home to New York. She said, prior to her visit to Florida, she was independent, lived alone, and was going about her business as she had always done. She said unfortunately due to medical problems she was hospitalized at the end of March, had been either in the hospital or a rehab center since that time. She said she had several set- backs which had delayed her return home. The resident was questioned regarding the day she was found unresponsive in the sun. She said she did not remember much about the day in question except that she usually sat with her friend outside but her friend had a doctor's appointment and was not there. She said she never sat in the sun because she could not tolerate it related to asthma that developed after the 9/11 tragedy in New York City. (She was among those in the area when the towers collapsed). She said, I always sat in the shade on the porch. Then she said, My friend sat in the sun and I sat with her. My friend always told me when it was time to go inside. She said, I do not know why I was sitting in the sun by myself, I think someone must have put me there, I do not remember how I got there. She said she did not remember that she had been found in the sun resulting in a high body temperature or that she had ice packs on her body to reduce her temperature. An observation of her bilateral upper extremities revealed several scabbed areas on the left posterior forearm. One scabbed area was covered with a Tega-derm dressing. As per the Nursing Home Administrator, the resident was receiving Keflex for [MEDICAL CONDITION]. The resident said she was in no pain but said the area was very warm to touch. The area was moderately red. The right posterior forearm had two small scabs areas and were open to air. When the resident was asked about the scabbed areas, she said they were from the sun. She said, after she was left in the sun her skin on both arms peeled off in sheets. She said, It was painful and looked horrible. She said, I don't know why they did not check on me. Somebody should have checked on me. Prior to the visit with Resident #1, a family member was called to verify the resident's location. At that time, he said the facility called him on the day she was left out in the sun. He was very upset and said he did not want the resident to go back to the facility after she was released from the hospital. He said he did not feel as though the facility took very good care of the resident and hoped that no one else had been treated like her. Facility steps taken to remove the Immediate Jeopardy: An interview was conducted with the Nursing Home Administrator on 7/28/2017 at 4:00 p.m. He said the education on abuse, neglect, and patio monitoring began on the morning of 7/27/2017 and was complete. He said the facility implemented a new plan to monitor the front porch more closely. The facility initiated measures to remove the immediate jeopardy beginning on 7/27/2017. The NHA presented a document titled, Patio Checks with the following information: 1. Checks will occur on the (TRUNCATED)

Based on record review, interview, and observation of the open front porch and surrounding area, the facility failed to provide supervision needed for one (Resident #1) of five sampled residents who were identified as needing closer supervision when outside. Resident #1 was found on the sidewalk in front of the facility in weather that was 95 degrees Fahrenheit with a heat index of 109.7 in the direct, full Florida sun for an undetermined amount of time without consistent supervision, and monitoring, and without evidence of hydration and skin protection. Resident #1 was determined to be at risk for dehydration, had a history of [REDACTED]. The resident was assessed as being unresponsive and flushed with an internal body temperature of 103.4. The resident subsequently sustained [REDACTED]. All residents who utilized the patio were at risk for neglect and injury as a result of the facility failing to have a system in place to monitor the residents while on the front porch and surroundings area. This failure created a situation that resulted in harm to Resident #1 and resulted in a determination of Immediate Jeopardy. The findings of Immediate Jeopardy were determined to be removed on 8/1/2017 at 4:00 p.m. Findings Included: Resident #1 was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. Per the Medication Administration Record (MAR) for July 2017 the resident was receiving Amiloride HCL table 5 mg, give two tablets by mouth one time a day, every other day for Congestive Heart Failure (CHF). Per Web MD at www.webmd.com, Amiloride HCL is a diuretic and used for hypertension, heart failure and edema. Adverse reactions include the potential for dehydration. The resident was also receiving Bumex tablet 2 mg, give 1 tablet by mouth one time a day for CHF, hold if systolic blood pressure is less than 110. Per RxList at www.rxlist.com, Bumex is a diuretic and use includes treatment of [REDACTED]. Adverse reactions include the potential for dehydration. Prior to the visit with Resident #1 at another facility, a family member was called to verify the resident's location. At that time, he said the facility called him on the day she was left out in the sun. He was very upset and said he did not want the resident to go back to the facility after she was released from the hospital. He said he did not feel as though the facility took very good care of the resident and hoped that no one else had been treated like her. An interview was conducted with the resident (she was receiving rehabilitative and nursing services at another facility) on 7/28/2017. She was alert, oriented, pleasant and freely engaged in conversation. She said she was doing well and was anxious to go home. She volunteered the following information. She said she came to Florida in March for her son's surprise birthday party. Her plans were to stay a few weeks and return home to New York. She said, prior to her visit to Florida, she was independent, lived alone, and was going about her business as she had always done. She said unfortunately due to medical programs she was hospitalized at the end of March, had has been either on the hospital or a rehab center since that time. She said she had several set- backs which has delayed her return home. The resident was regarding the day she was found unresponsive in the sun. She said she did not remember much about the day in question except that she usually sat with her friend outside but her friend had a doctor's appointment and was not there. She said she never sat in the sun because she could not tolerate it related to asthma that developed after the 9/11 tragedy in New York City. (She was among those in the area when the towers collapsed). She said, I always sat in the shade on the porch. Then she said, My friend sat in the sun and I sat with her. My friend always told me when it was time to go inside. She said, I do not know why I was sitting in the sun by myself, I think someone must have put me there, I do not remember how I got there. She said she did not remember that she had been found in the sun resulting in a high body temperature or that she had ice packs on her body to reduce her temperature. An observation of her bilateral upper extremities revealed several scabbed areas on the left posterior forearm. One scabbed area was covered with a Tega-derm dressing. As per the Nursing Home Administrator, the resident was receiving Keflex for cellulitis. The resident said she was in no pain but said the area was very warm to touch. The area was moderately red. The right posterior forearm had two small scabs areas and were open to air. When the resident was asked about the scabbed areas, she said they were from the sun. She said, after she was left in the sun her skin on both arms peeled off in sheets. She said, It was painful and looked horrible. She said, I don't know why they did not check on me. Somebody should have checked on me. Per the Brief Interview for Mental Status (BIMS) dated 6/7/2017, the resident had a score of 14. A score of 13-15 indicated the resident is cognitively intact. Per the Admission Minimum Data Set with an Assessment Reference date of 5/31/2017, Section G, Functional Status: E. Locomotion on unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. F. Locomotion off unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. On 7/26/2017 at 1:00 p.m., an interview with the MDS Coordinator revealed the resident was alert and oriented with periods of confusion. She was resistant to care, non-complaint, and yelled at staff. A review of the care plan revealed the following information: Focus: Resident is/has potential to be verbally aggressive related to ineffective coping skills, and poor impulse control (accusatory of staff). Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will demonstrate through verbal/non-verbal expressions an understanding of need to control verbally abusive behavior. Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide the resident with positive reinforcement for appropriate behavior. Observe for signs and symptoms of agitation: Intervene with non-medicinal interventions to avoid increased agitation. Focus: The resident is resistive to care Activities of daily living (ADL) and care related to adjustment to nursing home, Anxiety. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will cooperate with care through next review date. Interventions: Allow the resident to make decisions about treatment regimen and establish their ADL routines to provide a sense of control. Give clear explanation of all care activities prior to and as they occur. Give one to one attention as needed, when necessary. If resident resists with ADLs, stop, ensure resident safety, and resume/reapproach at a later time. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Focus: Resident has special needs related to medical diagnosis. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: Resident will have all of their needs met daily. Interventions: Coordinate all care and services as needed. Provide resident with daily staff assist as needed. Notify MD and family of any changes as needed. Focus: The Resident has limited physical mobility related to weakness. Date initiated 5/24/2017. Revision date 7/9/2017. Goal: The resident will demonstrate the appropriate use of (wheelchair) to increase mobility through the next review date. Intervention: Provide supportive care and assistive devices (wheelchair) with mobility as needed. Document assistance as needed. Per www.medicinnet.com: Those most susceptible (at risk) individuals to heat stroke include: The elderly (often with associated heart diseases, lung diseases, kidney diseases, or who are taking medications that make them vulnerable to dehydration and heat strokes). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sunstroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Sunburn and sun poisoning facts oSunburn is an inflammation of the skin caused by overexposure to UV radiation from the sun. oUV radiation damages the skin and also can damage the eyes. oUV rays are most intense at noon and the hours immediately before and after (between 10 a.m. and 4 p.m.). oImmediate symptoms of sunburn are hot, red, tender skin; pain when the skin is touched or rubbed; and dehydration; several days after exposure the skin may, swell, blister, peel, and itch. Sunburn may cause permanent skin damage and skin cancer ([DIAGNOSES REDACTED], [DIAGNOSES REDACTED] [DIAGNOSES REDACTED], squamous cell [DIAGNOSES REDACTED]). o Some medications may increase sensitivity to sunburn (photosensitivity). o Sun poisoning is caused by severe sunburn; its symptoms include o fever, o nausea, o chills, o dizziness, o rapid pulse, o rapid breathing, o dehydration, and o shock. On 7/26/2017 at 12:30 p.m. an interview was conducted with the Physical Therapy Assistant (Staff #1). He said he punched out at 2:30 p.m. on 7/5/2017 (this was verified by the punch detail provided by the Nursing Home Administrator). He said he exited the front door and saw the resident sitting in her wheelchair to the left of the door on the sidewalk in the sun. He attempted to speak to the resident but she did not respond. When she did not respond he looked closer and saw that she appeared flushed. He assumed this was from the sun. He did a sternal rub. The resident did not respond. He immediately rolled her inside and told the nurse We have a problem. The resident was taken to her room and transferred to bed. The nurse applied oxygen and Emergency Medical Services (EMS) was called. Her vital signs were taken, her clothes were loosened, and ice packs were applied to her body. Staff #1 said at that time, he felt he could be of no more assistance so he left the room. He said when he left the resident was still unresponsive. On 7/27/2017 at 9:15 a.m., Staff #1 was interviewed again to obtain additional information. He said on the day of the event, the resident was wearing a short sleeve shirt with Capri pants. He said the resident frequently went outside and sat in the sun. He said, We were constantly telling her to be careful and encouraged her to stay out of the sun, but she was a strong-willed woman. Staff #1 and this surveyor went out to the front porch and surrounding areas so Staff #1 could show the exact spot the resident was found. He stood on the spot and said, Right here in the sun. The spot was on the sidewalk to the left side of the front door if looking from the inside to the outside of the building. At that time, the area was shaded due to the time of day and position of the summer sun. The area was re-checked at 12:30 p.m. 1:30 p.m. and 2:30 p.m. and was noted to be in full sun. Photographic evidence obtained. On 7/26/2017 at 1:50 p.m., an interview was conducted via the telephone with the resident's direct care nurse who was on duty the day of the event. He said he only vaguely remembered the day the resident was found unresponsive and brought back into the facility. He said he remembered she had a fever of over 100 degrees, maybe 102, maybe 103. He could not remember the exact temperature. He verified that her skin was red but said he did not know why it was red. He said, Emergency Medical Services were called but when they arrived, the resident refused to go to the hospital. The nurse was questioned about documentation on the Medication Administration Record (MAR) that indicated he had given the resident Percocet at 1:33 p.m. He verified that he gave the resident a Percocet at 1:30 p.m. well before she was brought back inside. He said the resident was sitting in her wheelchair outside her room when he administered the medication. The nurse said he did not see the resident again until she was brought back into the facility by the therapist. On 7/27/2017 at 11:00 a.m. and again on 7/31/2017 at 11:46 p.m., interviews were conducted with the resident's primary care physician while she was a resident at the facility. He said when he was in the facility on 7/6/2017, during his routine rounds; he went to the therapy gym to see the resident. He said while he was there the resident's treating Physical Therapy Assistant (Staff #14) told him that on 7/5/2017, the resident had a syncopal episode, was found outside in the sun, and refused to go to the hospital. The physician said he assessed the resident and recommended that the resident should go to the hospital for an evaluation due to increased confusion; however, the resident refused to transfer the hospital. The physician said he did note that the resident had minimal redness on her arms but did not see blistering. He said the resident's main concern was pain in her right arm and right wrist. He said he ordered a Doppler study to rule out a blood clot, a chest X-ray and an Electrocardiogram due to a change in her overall condition. He verified that the nursing staff did not notify him that the resident was found in the sun, unresponsive, and had a body temperature of 103.4. When asked if he would have done anything different had he known, he said, No, I would have sent her to the hospital as the facility tried to do. However, he said, I would have expected a call from the facility regarding this significant change in condition and her refusal the go to the hospital. He said he did not see her in the emergency room , because he was her physician only while she was at this facility. On 7/3/2017, the resident completed five days of Rocephin for a urinary tract infection. During the above interview with the physician, he said since the Rocephin was completed two days prior to the event, he did not believe it caused the resident to be more susceptible to harm from the sun. The resident was not on any other medication that would increase sensitivity to sun exposure. On 7/31/2017 at 12:35 p.m., an interview was conducted with the resident's treating Physical Therapy Assistant (Staff #14)). She said the day after the event (7/6/2017); the physician came in to the therapy gym to see the resident. At that time, the therapist informed the physician about the resident's syncopal event from the day before. She also informed him that she had noted a functional decline in the resident. She said she did see the resident's arms after the event and said they were both red and had small blisters on them. Per the nurses notes for Resident #1 dated 7/5/2017 10:14 p.m., alert and oriented x 3, stayed in bed and able to use call light, uses 02 as ordered and appears in no acute distress. Re-checked temperature: 98.2 at 8:00 p.m. Right arm elevated with pillow and medicated for pain x 1 and with good effect. Per the Weights and Vitals Summary on 7/6/2017 at 12:46 a.m. the resident's Temperature was 98.3 degrees. Per the nurse's notes dated 7/6/2017 at 6:12 a.m., alert and oriented x 3 with cooperative attitude. As needed, Xanax given for mild anxiety and observed to be effective. As needed, oxygen in place. Oxygen effective and saturations were stable. Complained of mild pain to right wrist but refused as needed pain medication. Right arm elevated on pillow overnight for comfort. Will continue to monitor. No shortness of breath or acute distress observed. Call light in reach and is compliant with use. 7/6/2017 at 6:14 a.m., follow-up: Abrasions noted above bilateral knees from fall 7/4/2017. No signs or symptoms of infection noted, left to open to air. Neuro checks were within normal limits. 7/6/2017 at 12:57 p.m., resident did not participate in occupational or physical therapy. Resident was alert and oriented x3, cooperative with staff, diet and medications tolerated, remains on oxygen at 2 liters per minute for shortness of breath, bilateral edema, awaiting Doppler ultrasound to rule out clot. Physician and son aware. Will continue to monitor. 7/6/2017 at 10:48 p.m. Alert x 2, up in wheelchair with assist of one, not in acute distress. The resident was seen by the physician and with orders. Son aware. Right arm elevated with pillow in bed. 7/7/2107 at 2:19 a.m., resident has orders for two views chest X-ray in a.m. due to shortness of breath and electrocardiogram in a.m. due to [DIAGNOSES REDACTED]and congestive heart failure. Reason for portable X-ray: Resident has generalized muscle weakness. 7/8/2017 at 10:51 a.m. resident refused to participate in therapy due to pain in her right upper arm and lower extremities. Resident is alert and oriented. Tolerated medications and meals well. Moderate assistance with Activities of Daily Living (ADLs) and transfers. Continent. Pain voiced with pain medication administered with effectiveness. 7/8/2017 at 12:03 a.m. Alert and able to voiced her needs. Right arm elevated with pillow. Incontinent of bowel and bladder. No signs and symptoms of respiratory distress. Call light in reach. She took her medications and diet well. 7/8/2017 at 6:05 a.m., resident alert with increased confusion. Resident awake most of night yelling out other resident's names. Resident oxygen saturations were 85% on room air; saturations were 97% on 2 liters of oxygen, slightly labored respirations. Resident having hallucinations of other residents in her room eating turkey. At other times stating her son is sitting in the chair waiting for her to pack her things. Resident's anxiety is not re-directable at times. Resident yelling at nurse, why are you keeping me here, I don't want to be in the hospital. Resident unaware that she is in her room at the rehab facility. Resident unaware of the time screaming she was not offered breakfast, attempted to redirect resident to the time that was 4:00 a.m. and that breakfast was at 7:00 a.m. Redirection had limited effect. Resident's son was contacted and agreed to come in and talk with his Mom. Son arrived at 7:30 a.m. and agreed that his mother was confused and requested her to be sent to the hospital. 7/8/2017 at 8:57 a.m. Reason for transfer: AMS, hallucinations, hypotension. Condition of resident at time of transfer: alert with confusion. Vital signs: BP: 88/57, Pulse: 60, Respirations: 22, O2 sat: 86% on room air, 97% on 2L/min. Resident transported by EMS. Son was in the facility at the time of transfer, MD made aware. Interviews were conducted with Certified Nurses Assistants (CNA) and nurses related to resident safety on the front porch and surrounding area. The interviews were as follows: On 7/26/2017 at 2:10 p.m. Staff #2 (CNA) said, sometimes the resident's tell the CNAs they are going outside, sometimes the nurse tells the CNA that the resident has gone outside. She said, while the residents are outside, someone will eventually check on them either someone coming in or going out of the building. The nurse, CNA, therapist, or activities staff will go get them for medications, personal care, activities, therapy, and/or meals. She said no one is specifically assigned to check on the residents outside. She said some residents do not tell the staff they are going outside; they just go. She said some residents go outside to sit in the sun to warm up. On 7/26/2017 at 2:20 p.m. Staff #3 (CNA-Restorative) said, before taking a resident outside, she asks the nurse if they can go out. If she takes them outside, she checks on them periodically. She said everybody checks on the residents while they are outside but no one was assigned to check on them. She said some residents like to sit in the sun. When asked if there were any special precautions done for a resident that wants to sit in the sun, she said we remind them not to stay out too long. When asked about sunscreen and whether or not it was provided by the facility she said No. On 7/26/2017 at 2:30 p.m. Staff #4 (CNA) said, we are supposed to check on the resident at least every two hours. Most of the residents let the staff know when they are going outside. When asked how she kept track of her residents she said I check on them at least every two hours and if I cannot find them in their room or on the unit, I start looking in other departments and on the porch. If a resident wanted to sit in the sun, she said she would try to convince them to get out of the sun. When asked about education related to residents going outside and/or sitting outside in the sun, she said, I do not remember any education done here but I know what to do by working in other facilities. On 7/26/2017 at 2:45 p.m. Staff #5 (LPN) said, Resident #1 was on her assignment but she was not working on the day of the incident (7/5/2017). She said the resident would let the nurse know when she was going outside. She said the nurse's station was right by the front door so it was easy for her to tell someone where she was going. She said both the nurses and CNAs take turns checking on the residents that are outside. She said there was no one specifically assigned to monitor the patio. She said she was not aware of the availability of sunscreen for the residents and has had no education related to resident safety when they are outside. On 7/26/2017 at 3:15 p.m. Staff #6 (LPN) said, the residents are to be checked every 2 hours. He said depending on the temperature, the residents should only stay outside maybe 15 minutes. He said no one was assigned to monitor the patio but when someone checks on the residents outside he or she should give hydration and encourage them to get out of the sun. He said there was no sunscreen in the facility. On 7/26/2017 at 3:30 p.m. Staff #7 (LPN) said, only alert and oriented resident are allowed to sit on the front porch alone. Activities takes them as a group. She said alert and oriented residents tell the nurse/CNA when they are going outside. She was unsure if the facility provided sunscreen to the residents. She said if they had it, it would be in the treatment cart, but was not sure. She said if a resident wants to sit in the sun, she would advise them not to sit in the sun. If they insisted then they should be checked every 10-15 minutes. She said, no one was assigned to monitor the patio because not enough residents go out on the porch. She said the patio is centrally located so it is a group effect to monitor the residents on the porch. On 7/26/2017 at 4:00 p.m. Staff # 8 (RN) said the residents usually tell the staff when they go outside. She said sunscreen is available and in the medication cart. She said no one was specifically assigned to check the patio; it was everyone's job to check the patio throughout the shift. On 7/26/2017 at 4:10 p.m. Staff #9 (CNA) said he checks his residents every two hours throughout the shift. No one was assigned to check the patio. On 7/26/2017 at 4:15 p.m. Staff #10 (CNA) said no one is assigned to check the patio. He checks on his residents at least every two hours throughout the shift. He said no one is allowed outside by themselves after dark unless accompanied by someone. On 7/26/2017 at 3:17 p.m., a second interview was conducted with the Director of Nurses. When asked is she was involved in any way with the event related to sun exposure for Resident #1. She said she saw a commotion in the hallway around the resident's room and went to check on it. She said, when she got to the room, she noted a therapist and nurse in the room with the resident. The resident had ice packs on her due to a high fever and was unresponsive at that time. She said her skin was flushed/red and the assumption was that the high temperature was from a recent infection. She said when EMS arrived the resident was alert enough to refuse to go to the hospital. She said she was unaware that the resident had been outside in the sun. She was unable to say why there were no follow up skin assessments or references to the sun exposure event in the resident's record. She offered no additional information On July 5 2017, in Tampa, Florida, the average outside temperature was 86 degrees Fahrenheit and the average humidity was 72 %. In Tampa at 1:35 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 112.2 degrees Fahrenheit. At 2:15 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 109.7. The humidity was 77% (www.wunderground.com). On 7/26/2017, per a review of the nurse's notes for Resident #1, the following note was documented as a Late Entry with a created date of 7/13/2017. The event was documented by the nurse as having occurred on 7/6/2017 at 2:26 p.m. However based on record review and interviews the event occurred on 7/5/2017 and the note read as follows: Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (Staff #14) the day following the event. Per the Medication Administration Record dated 71-7/31/2017, the resident was to receive Tylenol tablet 325 mg - give 2 tablets by mouth every 6 hours as needed for elevated temperature. There was no indication that the Tylenol was given per the physician's orders [REDACTED]. Per the emergency room report dated 7/8/2017, History of Present Illness: The patient presents with altered mental status. The onset was 3 days ago. The course/duration of symptoms is constant. The character of symptoms is disoriented and confused. The degree at onset was moderate. The degree at present is moderate. Baseline status: alert and oriented x4. The patient is a poor historian secondary to altered mental status and disorientation. Per son at bedside, the patient was left out in the sun after she fell asleep. She was found with blisters to her bilateral forearms and with a temperature of 104 degrees Fahrenheit. No fever at present time. Since then, patient has acted confused and disoriented. Per son, patient's baseline is alert and oriented x4. Last known normal was 4 days ago. Also notes that the patient had a chest X-ray and was told this morning that she had pneumonia. Skin: Warm, dry, normal for ethnicity, bilateral dorsal forearm with few areas of mild [DIAGNOSES REDACTED] and small blisters about 1 by 3 centimeters, no evidence of infection. Per the hospital discharge summary dated 7/13/2017, Final Diagnoses: [REDACTED].>1. Altered mental status-acute [DIAGNOSES REDACTED], resolved. 2. Solar exposure to the arm causing blistering. 3. Chronic Obstructive Pulmonary Disease 4. Possible left lower lobe pneumonia. 5. Coumadin coagulopathy with supra therapeutic INR. 6. Chronic Atrial fibrillation, on Coumadin. 7. Diastolic dysfunction. 8. Underlying Dementia 9. Mildly elevated troponin Per University of Rochester Medical Center-Keesler Burn Center at http://www.rochester.edu, the classification of burns is as follows: First-degree (superficial) burns. First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and usually consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third Degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear white or charred. Fourth degree burns. Fourth degree burns also damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed. On 7/27/2017 at 10:21 a.m., an interview was conducted with the Director of Nurses (DON). The DON said after this event, there was no incident report done, no investigation conducted, and no steps put into place to prevent this from happening to another resident, because the facility did not feel that there was anything to investigate. She said the physician saw the resident and gave orders. When asked what orders? She said, chest X-ray, Electrocardiogram, Doppler of the upper extremities, and laboratory tests. When asked if he assessed the skin or wrote orders related to the skin she said No. She said, since the physician did not say anything about the skin we thought the high temperature was from an infection. On 7/26/2017 at 11:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Initially, neither the NHA nor the DON had any recollection of an event related to sun exposure. The surveyor read the nurse's note for Resident #1, Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, and ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. to them. The question was asked again if either one of them remembered this event. At that time, they both agreed they had heard something about it. The DON said we tried to convince her to go to the hospital. We called her son to convince her but she still did not want to go. At that time, neither the DON nor the NHA offered or had any additional information. Additional questions were asked related to Resident #1 and her usual routine and care needs. At that time the DON said, that on the day of the event (7/5/2017) the resident went outside around lunchtime. The DON said she did not know if the resident went out before or after lunch but said she only stayed out for a few minutes. She said, sometime later that day, someone from Therapy was with the resident and took her to her room because she was not feeling well. She said the resident's skin was red because she had a fever due to an infection. The DON offered no additional information at that time. The NHA and DON were asked if the facility had a policy to ensure that residents that go outside to the front porch and surrounding areas were monitored for heat or sun exposure. The NHA (TRUNCATED)

Based on record review, policy and procedure review, staff and administrative interviews, job description review, it was determined that the facility failed to be managed in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for one (Resident #1) of five sampled residents who were identified as needing closer supervision. The administrator did not ensure that the direct functions and operations of the facility were in accordance with current regulations governing long-term care facilities and the facility's policies for supervision and neglect as evidenced by the following information. Resident #1 was found on the sidewalk in front of the facility in weather that was 95 degrees Fahrenheit with a heat index of 109.7 in the direct, full Florida sun for an undetermined amount of time without consistent supervision, and monitoring, and without evidence of hydration and skin protection. Resident #1 was determined to be at risk for dehydration, had a history of [REDACTED]. The resident was assessed as being unresponsive and flushed with an internal body temperature of 103.4. The resident, subsequently, sustained blistered, peeling, and painful skin to her bilateral upper extremities. All residents who utilized the patio were at risk for neglect and injury as a result of the facility failing to have a system in place to monitor the residents while on the front porch and surroundings area. The administrator's failure to implement policies and procedures to ensure residents were not neglected and provided oversight supervision while on the front porch and surrounding area resulted in the findings of immediate jeopardy, which was removed on 8/1/2017 at 4:00 p.m. Findings included: Review of the job description provided by the facility (signed and dated 8/1/2017 by the administrator) for the Nursing Home Administrator (updated 2016) revealed the following relevant information; Position Summary: The Executive Director is responsible for overall leadership, management, and success of their community. Their responsibilities include but are not limited to financial management, hiring, supervising, training, team member relations and recognition, communication, family services, resident well-being, quality assurance, and regulatory compliance. Essential Duties: Managing Vision and Purpose: Communications a clear, customer focused vision, based upon a Resident Centered Model of care Models a strong belief in mission, vision, and purpose. Essential Duties: Customer Focus: Achieves outstanding customer engagement and team member engagement survey results, realizing that this is key to achieving customer engagement. Leads the development and regular review of the engagement improvement plan. Effectively resolves customer concerns through consistent use of the problem resolution program. Essential Duties: Quality Assurance and Regulatory Compliance Strives for excellent quality car and service delivery as measures in the Quality Services Review process (QRS); institutes and ensures corrective action in a timely manner. Develops a thorough working knowledge of state regulations, policies and procedures dictated for residents, ensures compliance. Provides leadership and promotion of the Sunrise Safety and Risk Management policies. Reviews all incident reports; ensures corrective actions are in place in a timely manner. Essential Duties: Team Member Focus Ensures consistent and timely orientation and ongoing training is delivered to team members. On 7/26/2017 at 11:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Initially, neither the NHA nor the DON had any recollection of an event related to resident sun exposure. The surveyor read the nurse's note for Resident #1, Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, and ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. to them. The question was asked again if either one of them remembered this event. At that time, they both agreed they had heard something about it. The DON said we tried to convince her to go to the hospital. We called her son to convince her but she still did not want to go. At that time, the DON nor the NHA had or offered any additional information. Additional questions were asked related to Resident #1 and her usual routine and care needs. At that time the DON said, that on the day of the event (7/5/2017) the resident went outside around lunchtime. The DON said she did not know if the resident went out before or after lunch but said she only stayed out for a few minutes. She said, sometime later that day, someone from Therapy was with the resident and took her to her room because she was not feeling well. She said the resident's skin was red because she had a fever due to an infection. The DON offered no additional information at that time. The NHA and DON were asked if the facility had a policy to ensure that residents that go outside to the front porch and surrounding areas were monitored for heat or sun exposure. The NHA said, No. When asked, since the incident on 7/5/2017, had the facility investigated, reported, educated staff, and/or put interventions in place to ensure the safety of the residents that choose to go outside. The DON shook her head to indicate No and the NHA said, No. The Nursing Home Administrator offered no additional information. On 7/26/2017 at 2:25 p.m., the Nursing Home Administered said, Should I develop a policy about all this? (Referring to the event related to the resident that was found in the sun, unresponsive, and with a 103.4 body temperature). The NHA was informed we could not advise him on what to do. He said, That's what I'm going to do right now. On 7/28/2017 at 4:00 p.m., an interview was conducted with the Nursing Home Administrator. He said the education on abuse, neglect, and patio monitoring began on the morning of 7/27/2017 and was complete. He said the facility implemented a new plan to monitor the front porch more closely. He then said, Is there anything else I should do? I cannot think of anything else to do. This surveyor again informed the administrator that we could not advise him on what to do. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. Per the Medication Administration Record [REDACTED]. Per Web MD at www.webmd.com, [MEDICATION NAME] HCL is a diuretic and used for hypertension, heart failure and [MEDICAL CONDITION]. Adverse reactions include the potential for dehydration. The resident was also receiving [MEDICATION NAME] tablet 2 mg, give 1 tablet by mouth one time a day for [MEDICAL CONDITION], hold if systolic blood pressure is less than 110. Per RxList at www.rxlist.com, [MEDICATION NAME] is a diuretic and use includes treatment of [REDACTED]. Adverse reactions include the potential for dehydration. An interview was conducted with the resident (she was receiving rehabilitative and nursing services at another facility) on 7/28/2017. She was alert, oriented, pleasant and freely engaged in conversation. She said she was doing well and was anxious to go home. She volunteered the following information. She said she came to Florida in March for her son's surprise birthday party. Her plans were to stay a few weeks and return home to New York. She said, prior to her visit to Florida, she was independent, lived alone, and was going about her business as she had always done. She said unfortunately, due to medical programs she was hospitalized at the end of March, had been either in the hospital or a rehab center since that time. She said she had several set- backs which had delayed her return home. The resident was questioned by the surveyor regarding the day she was found unresponsive in the sun. She said she did not remember much about the day in question except that she usually sat with her friend outside but her friend had a doctor's appointment and was not there. She said she never sat in the sun because she could not tolerate it related to asthma that developed after the 9/11 tragedy in New York City. (She was among those in the area when the towers collapsed). She said, I always sat in the shade on the porch. Then she said, My friend sat in the sun and I sat with her. My friend always told me when it was time to go inside. She said, I do not know why I was sitting in the sun by myself, I think someone must have put me there, I do not remember how I got there. She said she did not remember that she had been found in the sun resulting in a high body temperature or that she had ice packs on her body to reduce her temperature. An observation of her bilateral upper extremities revealed several scabbed areas on the left posterior forearm. One scabbed area was covered with a Tega-derm dressing. As per the Nursing Home Administrator, the resident was receiving Keflex for [MEDICAL CONDITION]. The resident said she was in no pain but said the area was very warm to touch. The area was moderately red. The right posterior forearm had two small scabs areas and were open to air. When the resident was asked about the scabbed areas, she said they were from the sun. She said, after she was left in the sun her skin on both arms peeled off in sheets. She said, It was painful and looked horrible. She said, I don't know why they did not check on me. Somebody should have checked on me. Prior to the visit with Resident #1, a family member was called to verify the resident's location. At that time, he said the facility called him on the day she was left out in the sun. He was very upset and said he did not want the resident to go back to the facility after she was released from the hospital. He said he did not feel as though the facility took very good care of the resident and hoped that no one else had been treated like her. Per the Brief Interview for Mental Status (BIMS) dated 6/7/2017, the resident had a score of 14. A score of 13-15 indicated the resident is cognitively intact. Per the Admission Minimum Data Set with an Assessment Reference date of 5/31/2017, Section G, Functional Status: E. Locomotion on unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. F. Locomotion off unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. On 7/26/2017 at 1:00 p.m., an interview with the MDS Coordinator revealed the resident was alert and oriented with periods of confusion. She was resistant to care, non-complaint, and yelled at staff. A review of the care plan revealed the following information: Focus: Resident is/has potential to be verbally aggressive related to ineffective coping skills, and poor impulse control (accusatory of staff). Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will demonstrate through verbal/non-verbal expressions an understanding of need to control verbally abusive behavior Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide the resident with positive reinforcement for appropriate behavior. Observe for signs and symptoms of agitation: Intervene with non-medicinal interventions to avoid increased agitation. Focus: The resident is resistive to care Activities of daily living (ADL) and care related to adjustment to nursing home, Anxiety. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will cooperate with care through next review date. Interventions: Allow the resident to make decisions about treatment regimen and establish their ADL routines to provide a sense of control. Give clear explanation of all care activities prior to and as they occur. Give one to one attention as needed, when necessary. If resident resists with ADLs, stop, ensure resident safety, and resume/reapproach at a later time. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Focus: Resident has special needs related to medical diagnosis. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: Resident will have all of their needs met daily. Interventions: Coordinate all care and services as needed. Provide resident with daily staff assist as needed. Notify MD and family of any changes as needed. Focus: The Resident has limited physical mobility related to weakness. Date initiated 5/24/2017. Revision date 7/9/2017. Goal: The resident will demonstrate the appropriate use of (wheelchair) to increase mobility through the next review date. Intervention: Provide supportive care and assistive devices (wheelchair) with mobility as needed. Document assistance as needed. Per www.medicinnet.com: Those most susceptible (at risk) individuals to heat stroke include: The elderly (often with associated [MEDICAL CONDITION], lung disease, or who are taking medications that make them vulnerable to dehydration and heat [MEDICAL CONDITION]). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Sunburn and sun poisoning facts oSunburn is an inflammation of the skin caused by overexposure to UV [MEDICAL CONDITION] from the sun. oUV [MEDICAL CONDITION] damages the skin and also can damage the eyes. oUV rays are most intense at noon and the hours immediately before and after (between 10 a.m. and 4 p.m.). oImmediate symptoms of sunburn are hot, red, tender skin; pain when the skin is touched or rubbed; and dehydration; several days after exposure the skin may, swell, blister, peel, and itch. Sunburn may cause permanent skin damage and [MEDICAL CONDITION] ([DIAGNOSES REDACTED], [DIAGNOSES REDACTED], squamous cell [MEDICAL CONDITION]). o Some medications may increase sensitivity to sunburn (photosensitivity). o Sun poisoning is caused by severe sunburn; its symptoms include o fever, o nausea, o chills, o dizziness, o rapid pulse, o rapid breathing, o dehydration, and o shock. On 7/26/2017 at 12:30 p.m. an interview was conducted with the Physical Therapy Assistant (Staff #1). He said he punched out at 2:30 p.m. on 7/5/2017 (this was verified by the punch detail provided by the Nursing Home Administrator). He said he exited the front door and saw the resident sitting in her wheelchair to the left of the door on the sidewalk in the sun. He attempted to speak to the resident but she did not respond. When she did not respond he looked closer and saw that she appeared flushed. He assumed this was from the sun. He did a sternal rub, the resident did not respond. He immediately rolled her inside and told the nurse We have a problem. The resident was taken to her room and transferred to bed. The nurse applied oxygen and Emergency Medical Services (EMS) was called. Her vital signs were taken, her clothes were loosened, and ice packs were applied to her body. Staff #1 said at that time, he felt he could be of no more assistance so he left the room. He said when he left the resident was still unresponsive. On 7/27/2017 at 9:15 a.m., Staff #1 was interviewed again to obtain additional information. He said on the day of the event, the resident was wearing a short sleeve shirt with Capri pants. He said the resident frequently went outside and sat in the sun. He said, We were constantly telling her to be careful and encouraged her to stay out of the sun, but she was a strong-willed woman. Staff #1 and this surveyor went out to the front porch and surrounding areas so Staff #1 could show the exact spot the resident was found. He stood on the spot and said, Right here in the sun. The spot was on the sidewalk to the left side of the front door if looking from the inside to the outside of the building. At that time, the area was shaded due to the time of day and position of the summer sun. The area was re-checked at 12:30 p.m. 1:30 p.m. and 2:30 p.m. and was noted to be in full sun. Photographic evidence obtained. On 7/26/2017 at 1:50 p.m., an interview was conducted via the telephone with the resident's direct care nurse who was on duty the day of the event. He said he only vaguely remembered the day the resident was found unresponsive and brought back into the facility. He said he remembered she had a fever of over 100 degrees, maybe 102, maybe 103. He could not remember the exact temperature. He verified that her skin was red but said he did not know why it was red. He said, Emergency Medical Services were called but when they arrived, the resident refused to go to the hospital. The nurse was questioned about documentation on the Medication Administration Record [REDACTED]. He said the resident was sitting in her wheelchair outside her room when he administered the medication. The nurse said he did not see the resident again until she was brought back into the facility by the therapist. On 7/27/2017 at 11:00 a.m. and again on 7/31/2017 at 11:46 p.m. Interviews were conducted with the resident's primary care physician while she was a resident at the facility. He said when he was in the facility on 7/6/2017, during his routine rounds; he went to the therapy gym to see the resident. He said while in was there the resident's treating Physical Therapy Assistant (Staff #14) told him that 7/5/2017, the resident had a syncopal episode, was found outside in the sun, and refused to go to the hospital. The physician said he assessed the resident and recommended that the resident should go to the hospital for an evaluation due to increased confusion; however, the resident refused to transfer the hospital. The physician said he did note that the resident had minimal redness on her arms but did not see blistering. He said the resident's main concern was pain in her right arm and right wrist. He said he ordered a Doppler study to rule out a blood clot, a chest X-ray and an Electrocardiogram due to a change in her overall condition. He verified that the nursing staff did not notify him that the resident was found in the sun, unresponsive, and had a body temperature of 103.4. When asked if he would have done anything different had he known, he said, No, I would have sent her to the hospital as the facility tried to do. However, he said, I would have expected a call from the facility regarding this significant change in condition and her refusal the go to the hospital. He said he did not see her in the emergency room , because he was her physician only while she was at this facility. On 7/3/2017, the resident completed five days of [MEDICATION NAME] for a urinary tract infection. During the above interview with the physician, he said since the [MEDICATION NAME] was completed two days prior to the event, he did not believe it caused the resident to be more susceptible to harm from the sun. The resident was not on any other medication that would increase sensitivity to sun exposure. On 7/31/2017 at 12:35 p.m., an interview was conducted with the resident's treating Physical Therapy Assistant (Staff #14). She said the day after the event (7/6/2017); the physician came in to the therapy gym to see the resident. At that time, the therapist informed the physician about the resident's syncopal event from the day before. She also informed him that she had noted a functional decline in the resident. She said she did see the resident's arms after the event and said they were both red and had small blisters on them. Per the nurses notes for Resident #1 dated 7/5/2017 10:14 p.m., alert and oriented x 3, stayed in bed and able to use call light, uses 02 as ordered and appears in no acute distress. Re-checked temperature: 98.2 at 8:00 p.m. Right arm elevated with pillow and medicated for pain x 1 and with good effect. Per the Weights and Vitals Summary on 7/6/2017 at 12:46 a.m. the resident's Temperature was 98.3 degrees. Per the nurse's notes dated 7/6/2017 at 6:12 a.m., alert and oriented x 3 with cooperative attitude. As needed, [MEDICATION NAME] given for mild anxiety and observed to be effective. As needed, oxygen in place. Oxygen effective and saturations were stable. Complained of mild pain to right wrist but refused as needed pain medication. Right arm elevated on pillow overnight for comfort. Will continue to monitor. No shortness of breath or acute distress observed. Call light in reach and is compliant with use. 7/6/2017 at 6:14 a.m., follow-up: Abrasions noted above bilateral knees from fall 7/4/2017. No signs or symptoms of infection noted, left to open to air. Neuro checks were within normal limits. 7/6/2017 at 12:57 p.m., resident did not participate in occupational or physical therapy. Resident was alert and oriented x3, cooperative with staff, diet and medications tolerated, remains on oxygen at 2 liters per minute for shortness of breath, bilateral [MEDICAL CONDITION] awaiting Doppler ultrasound to rule out clot. Physician and son aware. Will continue to monitor. 7/6/2017 at 10:48 p.m. Alert x 2, up in wheelchair with assist of one, not in acute distress. The resident was seen by the physician and with orders. Son aware. Right arm elevated with pillow in bed. 7/7/2107 at 2:19 a.m., resident has orders for two views chest X-ray in a.m. due to shortness of breath and electrocardiogram in a.m. due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Reason for portable X-ray: Resident has generalized muscle weakness. 7/8/2017 at 10:51 a.m. resident refused to participate in therapy due to pain in her right upper arm and lower extremities. Resident is alert and oriented. Tolerated medications and meals well. Moderate assistance with Activities of Daily Living (ADLs) and transfers. Continent. Pain voiced with pain medication administered with effectiveness. 7/8/2017 at 12:03 a.m. Alert and able to voiced her needs. Right arm elevated with pillow. Incontinent of bowel and bladder. No signs and symptoms of respiratory distress. Call light in reach. She took her medications and diet well. 7/8/2017 at 6:05 a.m., resident alert with increased confusion. Resident awake most of night yelling out other resident's names. Resident oxygen saturations were 85% on room air; saturations were 97% on 2 liters of oxygen, slightly labored respirations. Resident having hallucinations of other residents in her room eating turkey. At other times stating her son is sitting in the chair waiting for her to pack her things. Resident's anxiety is not re-directable at times. Resident yelling at nurse, why are you keeping me here, I don't want to be in the hospital. Resident unaware that she is in her room at the rehab facility. Resident unaware of the time screaming she was not offered breakfast, attempted to redirect resident to the time that was 4:00 a.m. and that breakfast was at 7:00 a.m. Redirection had limited effect. Resident's son was contacted and agreed to come in and talk with his Mom. Son arrived at 7:30 a.m. and agreed that his mother was confused and requested her to be sent to the hospital. 7/8/2017 at 8:57 a.m. Reason for transfer: AMS, hallucinations, [MEDICAL CONDITION]. Condition of resident at time of transfer: alert with confusion. Vital signs: BP: 88/57, Pulse: 60, Respirations: 22, O2 sat: 86% on room air, 97% on 2L/min. Resident transported by EMS. Son was in the facility at the time of transfer, MD made aware. Interviews were conducted with Certified Nurses Assistants (CNA) and nurses related to resident safety on the front porch and surrounding area. The interviews were as follows: On 7/26/2017 at 2:10 p.m. Staff #2 (CNA) said, sometimes the residents tell the CNAs they are going outside, sometimes the nurse tells the CNA that the resident has gone outside. She said, while the residents are outside, someone will eventually check on them either someone coming in or going out of the building. The nurse, CNA, therapist, or activities staff will go get them for medications, personal care, activities, therapy, and/or meals. She said no one is specifically assigned to check on the residents outside. She said some residents do not tell the staff they are going outside; they just go. She said some residents go outside to sit in the sun to warm up. On 7/26/2017 at 2:20 p.m. Staff #3 (CNA-Restorative) said, before taking a resident outside, she asks the nurse if they can go out. If she takes them outside, she checks on them periodically. She said everybody checks on the residents while they are outside but no one was assigned to check on them. She said some residents like to sit in the sun. When asked if there were any special precautions done for a resident that wants to sit in the sun, she said we remind them not to stay out too long. When asked about sunscreen and whether or not it was provided by the facility she said No. On 7/26/2017 at 2:30 p.m. Staff #4 (CNA) said, we are supposed to check on the resident at least every two hours. Most of the residents let the staff know when they are going outside. When asked how she kept track of her residents she said I check on them at least every two hours and if I cannot find them in their room or on the unit, I start looking in other departments and on the porch. If a resident wanted to sit in the sun, she said she would try to convince them to get out of the sun. When asked about education related to residents going outside and/or sitting outside in the sun, she said, I do not remember any education done here but I know what to do by working in other facilities. On 7/26/2017 at 2:45 p.m. Staff #5 (LPN) said, Resident #1 was on her assignment but she was not working on the day of the incident (7/5/2017). She said the resident would let the nurse know when she was going outside. She said the nurse's station was right by the front door so it was easy for her to tell someone where she was going. She said both the nurses and CNAs take turns checking on the residents that are outside. She said there was no one specifically assigned to monitor the patio. She said she was not aware of the availability of sunscreen for the residents and has had no education related to resident safety when they are outside. On 7/26/2017 at 3:15 p.m. Staff #6 (LPN) said, the residents are to be checked every 2 hours. He said depending on the temperature, the residents should only stay outside maybe 15 minutes. He said no one was assigned to monitor the patio but when someone checks on the residents outside he or she should give hydration and encourage them to get out of the sun. He said there was no sunscreen in the facility. On 7/26/2017 at 3:30 p.m. Staff #7 (LPN) said, only alert and oriented resident are allowed to sit on the front porch alone. Activities takes them as a group. She said alert and oriented residents tell the nurse/CNA when they are going outside. She was unsure if the facility provided sunscreen to the residents. She said if they had it, it would be in the treatment cart, but was not sure. She said if a resident wants to sit in the sun, she would advise them not to sit in the sun. If they insisted then they should be checked every 10-15 minutes. She said, no one was assigned to monitor the patio because not enough residents go out on the porch. She said the patio is centrally located so it is a group effect to monitor the residents on the porch. On 7/26/2017 at 4:00 p.m. Staff # 8 (RN) said the residents usually tell the staff when they go outside. She said sunscreen is available and in the medication cart. She said no one was specifically assigned to check the patio; it was everyone's job to check the patio throughout the shift. On 7/26/2017 at 4:10 p.m. Staff #9 (CNA) said he checks his residents every two hours throughout the shift. No one was assigned to check the patio. On 7/26/2017 at 4:15 p.m. Staff #10 (CNA) said no one is assigned to check the patio. He checks on his residents at least every two hours throughout the shift. He said no one is allowed outside by themselves after dark unless accompanied by someone. On 7/26/2017 at 3:17 p.m., a second interview was conducted with the Director of Nurses. The surveyor asked her if she was involved in any way with the event related to sun exposure for Resident #1. She said she saw a commotion in the hallway around the resident's room and went to check on it. She said, when she got to the room, she noted a therapist and nurse in the room with the resident. The resident had ice packs on her due to a high fever and was unresponsive at that time. She said her skin was flushed/red and the assumption was that the high temperature was from a recent infection. It she said when EMS arrived the resident was alert enough to refuse to go to the hospital. She said she was unaware that the resident had been outside in the sun. She was unable to say why there were no follow up skin assessments or references to the sun exposure event in the resident's record. She offered no additional information. On July 5 2017, in Tampa, Florida, the average outside temperature was 86 degrees Fahrenheit and the average humidity was 72 %. In Tampa at 1:35 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 112.2 degrees Fahrenheit. At 2:15 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 109.7. The humidity was 77% (www.wunderground.com). On 7/26/2017, per a review of the nurse's notes for Resident #1, the following note was documented as a Late Entry with a created date of 7/13/2017. The event was documented by the nurse as having occurred on 7/6/2017 at 2:26 p.m. However based on record review and interviews the event occurred on 7/5/2017 and the note read as follows: Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (Staff #14) the day following the event. Per the Medication Administration Record [REDACTED]

Based on interview and record review the facility failed to report and investigate an incident of neglect that caused harm to one (Resident #1) of five residents that utilized the front porch and surrounding area. The facility allowed a resident who was at risk for dehydration related to diuretic use and Diabetes Type 2 to remain outside in the direct Florida sunlight on a day when the temperature was 95 degrees Fahrenheit and the heat index was 109.7. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative and nursing services with the goal to return home alone as per her prior level of function. She was resistant to activities of daily care and assistance by the staff and required extensive assistance for locomotion in her wheelchair on and off the unit. On 7/5/2017, the resident was found on the sidewalk, in her wheel chair, in front of the facility in direct sunlight and was assessed as being unresponsive and flushed. The resident subsequently sustained [REDACTED]. The facility's failure to report and investigate an incident of neglect to ensure residents are not neglected and are provided oversight supervision while on the front porch and surrounding area, resulted in the findings of immediate jeopardy, which was removed on 8/1/2017 at 4:00 p.m. Findings included: Per the facility's Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy with an effective date of 5/31/2016, Policy Statement, It is the policy of the community that: a) Every reasonable effort within its control is taken to prevent the abuse, neglect, and exploitation of residents. Team members must not engage in nor permit anyone else to engage in, abuse, neglect or exploitation of any resident. b) Team members of the community are mandated reporters and have a duty to report known or suspected abuse, neglect, and/or exploitation to local, state, federal and/or provincial authorities in accordance with applicable law and regulation. c) In addition, team members who know of or suspect abuse, neglect, or exploitation of any resident must immediately notify the Executive Director/designee, to ensure appropriate action is timely taken for the safety of the resident and those potentially impacted. Definitions: Neglect the failure to provide goods and services necessary to protect the resident from health and safety hazards. Mandatory Reporting: 4) Every team member is a mandatory reporter and has the duty to report known or suspected abuse, neglect, and/or exploitation to local and state/provincial authorities in accordance with applicable law and regulation. a) These authorities may include law enforcement, licensing regulator, the Long Term Care Ombudsman, and/or adult protective services. The report of abuse, neglect, or exploitation must be made within the timeframe and through the format required by applicable law and regulation. b) Allegations of or suspicions of abuse, neglect, and/or exploitation are to be reported. Protecting the Resident: 7) In addition to initial mandatory reporting, to ensure the safety and protection of residents, any team member who knows of or suspects abuse, neglect, or exploitation of a resident must also immediately notify the Executive Director (ED)/Skilled Nursing Administrator (SNA) designee. a) Notification of the Executive Director (ED)/Skilled Nursing Administrator (SNA) designee is not a substitute for mandatory reporting. 8) The ED/SNA/designee: a) Upon receiving notification of any known or suspected abuse, neglect, or exploitation of a resident contacts the Licensed Nurse who evaluates the resident and provides the necessary intervention, for example calls 911 if emergent. b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area i. Ensures that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. ii. Ensures that non-team members alleged to be involved in the abuse, neglect, or exploitation will be asked to leave the resident area and wait further instructions. c) Ensures that the resident's (i) physician, (ii) legal representative and (iii) family or other individual regularly involved in the resident's day to day care are notified as soon as practicable within timeframe's established within laws/regulations. d) Initiates the internal loss prevention/incident reporting process. e) The ED/SNA/designee will notify the internal Sunrise Crisis Hotline. Investigation: 9) The ED/SNA/designee a) Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal/provincial requirements. 10) The ED/SNA/designee manages and directs the investigation of all abuse, neglect, and/or exploitation. 11) The ED/SNA/designee implements corrective actions as indicated by the results of the investigation. 12) If a written report of the investigation findings is required by applicable law or regulation, the ED/SNA completes such report and ensures it is submitted timely. On 7/26/2017 at 11:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Initially, neither the NHA nor the DON had any recollection of an event related to sun exposure. The surveyor read the nurse's note for Resident #1, Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, and ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. to them. The question was asked again if either one of them remembered this event. At that time, they both agreed they had heard something about it. The DON said we tried to convince her to go to the hospital. We called her son to convince her but she still did not want to go. At that time, the DON nor the NHA had or offered any additional information. Additional questions were asked related to Resident #1 and her usual routine and care needs. At that time the DON said, that on the day of the event (7/5/2017) the resident went outside around lunchtime. The DON said she did not know if the resident went out before or after lunch but said she only stayed out for a few minutes. She said, sometime later that day, someone from Therapy was with the resident and took her to her room because she was not feeling well. She said the resident's skin was red because she had a fever due to an infection. The DON offered no additional information at that time. The NHA and DON were asked if the facility had a policy to ensure that residents that go outside to the front porch and surrounding areas were monitored for heat or sun exposure. The NHA said, No. When asked, since the incident on 7/5/2017, had the facility investigated, reported, educated staff, and/or put interventions in place to ensure the safety of the residents that choose to go outside. The DON shook her head to indicate No and the NHA said, No. On 7/5/ 2017, in Tampa, Florida, the average outside temperature was 86 degrees Fahrenheit and the average humidity was 72 %. In Tampa at 1:35 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 112.2 degrees Fahrenheit. At 2:15 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 109.7. The humidity was 77% (www.wunderground.com). On 7/26/2017 at 12:30 p.m. an interview was conducted with the Physical Therapy Assistant (Staff #1). He said he punched out at 2:30 p.m. on 7/5/2017 (this was verified by the punch detail provided by the Nursing Home Administrator). He said he went out the front door and saw the resident sitting in her wheelchair to the left of the door on the sidewalk in the sun. He attempted to speak to the resident but she did not respond. When she did not response he looked closer and saw that she appeared flushed. He assumed this was from the sun. He did a sternal rub, the resident did not respond. He immediately rolled her inside and told the nurse We have a problem. The resident was taken to her room and transferred to bed. The nurse applied oxygen and EMS was called. Her vital signs were taken, her clothes were loosened, and ice packs were applied to her body. At that time, he felt he could be of no more assistance so he left the room. He said when he left the resident was still unresponsive. On 7/26/2017 at 3:17 p.m., a second interview was conducted with the Director of Nurses. She said on the day of the event, she saw commotion in the hallway and went in the room. A therapist and the nurse were in the room. The resident had ice packs on her due to a high fever. The resident was unresponsive at that time. When EMS arrived, she refused to go to the hospital. EMS left. The DON said the resident's skin was red/flushed. After the occurrence no other skin assessments were done. On 7/27/2017 at 9:15 a.m., Staff #1 was interviewed again to obtain additional information. He said on the day of the event, the resident was wearing a short sleeve shirt with Capri pants. He said the resident frequently went outside and sat in the sun. He said, We were constantly telling her to be careful and encouraged her to stay out of the sun, but she was a strong-willed woman. Staff #1 and this surveyor went out to the front porch and surrounding areas so Staff #1 could show the exact spot the resident was found. He stood on the spot and said, Right here in the sun. The spot was on the sidewalk to the left side of the front door if looking from the inside to the outside of the building. At that time, the area was shaded due to the time of day and position of the summer sun. The area was re-checked at 12:30 p.m. 1:30 p.m. and 2:30 p.m. and was noted to be in full sun. Photographic evidence was obtained. On 7/26/2017 at 1:50 p.m., an interview was conducted via the telephone with the resident's direct care nurse about the day of the event. He said he only vaguely remembered the day the resident was found unresponsive and brought back into the facility. He said he remembered she had a fever of over 100 degrees, maybe 102, maybe 103. He could not remember the exact temperature. He verified that her skin was red but said he did not know why it was red. He said, Emergency Medical Services were called but when they arrived, the resident refused to go to the hospital. The nurse was questioned about documentation on the Medication Administration Record [REDACTED]. He said the resident was sitting in her wheelchair outside her room when he administered the medication. The nurse said he did not see the resident again until she was brought back into the facility by the therapist. On 7/27/2017 at 11:00 a.m., and, again on 7/31/2017 at 11:46 p.m., interviews were conducted with the resident's primary care physician while she was a resident at the facility. He said when he was in the facility on 7/6/2017, during his routine rounds; he went to the therapy gym to see the resident. He said while he was there, the resident's treating Physical Therapy Assistant (Staff #14) told him that on 7/5/2017, the resident had a syncopal episode, was found outside in the sun, and refused to go to the hospital. The physician said he assessed the resident and recommended that the resident should go to the hospital for an evaluation due to increased confusion; however, the resident refused to transfer the hospital. The physician said he did note that the resident had minimal redness on her arms but did not see blistering. He said the resident's main concern was pain in her right arm and right wrist. He said he ordered a Doppler study to rule out a blood clot, a chest X-ray and an Electrocardiogram due to a change in her overall condition. He verified that the nursing staff did not notify him that the resident was found in the sun, unresponsive, and had a body temperature of 103.4. When asked if he would have done anything different had he known, he said, No, I would have sent her to the hospital as the facility tried to do. However, he said, I would have expected a call from the facility regarding this significant change in condition and her refusal to go to the hospital. He said he did not see her in the emergency room , because he was her physician only while she was at this facility. On 7/3/2017, the resident completed five days of [MEDICATION NAME] for a urinary tract infection. During the above interview with the physician, he said since the [MEDICATION NAME] was completed two days prior to the event, he did not believe it caused the resident to be more susceptible to harm from the sun. The resident was not on any other medication that would increase sensitivity to sun exposure. On 7/31/2017 at 12:35 p.m., an interview was conducted with the resident's treating Physical Therapy Assistant (Staff #14). She said the day after the event (7/6/2017); the physician came in to the therapy gym to see the resident. At that time, the therapist informed the physician about the resident's syncopal event from the day before. She also informed him that she had noted a functional decline in the resident. She said she did see the resident's arms after the event and said they were both red and had small blisters on them. On 7/26/2017, per a review of the nurse's notes for Resident #1, the following note was documented as a Late Entry with a created date of 7/13/2017. The event was documented by the nurse as having occurred on 7/6/2017 at 2:26 p.m. However based on record review and interviews the event occurred on 7/5/2017 and the note read as follows: Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, ice packs applied by staff, assessed by Emergency Medical Services (EMS) refused to be transferred to the hospital. MD/son aware will cont. to monitor. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (Staff #14) the day following the event. Per the nurses notes for Resident #1 dated 7/5/2017 10:14 p.m., alert and oriented x 3, stayed in bed and able to use call light, uses 02 as ordered and appears in no acute distress. Re-checked temperature: 98.2 at 8:00 p.m. Right arm elevated with pillow and medicated for pain x 1 and with good effect. Per the Weights and Vitals Summary on 7/6/2017 at 12:46 a.m. the resident's Temperature was 98.3 degrees. Per the nurse's notes dated 7/6/2017 at 6:12 a.m., alert and oriented x 3 with cooperative attitude. As needed, [MEDICATION NAME] given for mild anxiety and observed to be effective. As needed, oxygen in place. Oxygen effective and saturations were stable. Complained of mild pain to right wrist but refused as needed pain medication. Right arm elevated on pillow overnight for comfort. Will continue to monitor. No shortness of breath or acute distress observed. Call light in reach and is compliant with use. Additional nurses notes as follows: 7/6/2017 at 6:14 a.m., follow-up: Abrasions noted above bilateral knees from fall 7/4/2017. No signs or symptoms of infection noted, left to open to air. Neuro checks were within normal limits. 7/6/2017 at 12:57 p.m., resident did not participate in occupational or physical therapy. Resident was alert and oriented x3, cooperative with staff, diet and medications tolerated, remains on oxygen at 2 liters per minute for shortness of breath, bilateral [MEDICAL CONDITION] awaiting Doppler ultrasound to rule out clot. Physician and son aware. Will continue to monitor. 7/6/2017 at 10:48 p.m. Alert x 2, up in wheelchair with assist of one, not in acute distress. The resident was seen by the physician and with orders. Son aware. Right arm elevated with pillow in bed. 7/7/2107 at 2:19 a.m., resident has orders for two views chest X-ray in a.m. due to shortness of breath and electrocardiogram in a.m. due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Reason for portable X-ray: Resident has generalized muscle weakness. 7/8/2017 at 10:51 a.m. resident refused to participate in therapy due to pain in her right upper arm and lower extremities. Resident is alert and oriented. Tolerated medications and meals well. Moderate assistance with Activities of Daily Living (ADLs) and transfers. Continent. Pain voiced with pain medication administered with effectiveness. 7/8/2017 at 12:03 a.m. Alert and able to voiced her needs. Right arm elevated with pillow. Incontinent of bowel and bladder. No signs and symptoms of respiratory distress. Call light in reach. She took her medications and diet well. 7/8/2017 at 6:05 a.m., resident alert with increased confusion. Resident awake most of night yelling out other resident's names. Resident oxygen saturations were 85% on room air; saturations were 97% on 2 liters of oxygen, slightly labored respirations. Resident having hallucinations of other residents in her room eating turkey. At other times stating her son is sitting in the chair waiting for her to pack her things. Resident's anxiety is not re-directable at times. Resident yelling at nurse, why are you keeping me here, I don't want to be in the hospital. Resident unaware that she is in her room at the rehab facility. Resident unaware of the time screaming she was not offered breakfast, attempted to redirect resident to the time that was 4:00 a.m. and that breakfast was at 7:00 a.m. Redirection had limited effect. Resident's son was contacted and agreed to come in and talk with his Mom. Son arrived at 7:30 a.m. and agreed that his mother was confused and requested her to be sent to the hospital. 7/8/2017 at 8:57 a.m. Reason for transfer: AMS, hallucinations, [MEDICAL CONDITION]. Condition of resident at time of transfer: alert with confusion. Vital signs: BP: 88/57, Pulse: 60, Respirations: 22, O2 sat: 86% on room air, 97% on 2L/min. Resident transported by EMS. Son was in the facility at the time of transfer, MD made aware. Per the emergency room report dated 7/8/2017, History of Present Illness: The patient presents with altered mental status. The onset was 3 days ago. The course/duration of symptoms is constant. The character of symptoms is disoriented and confused. The degree at onset was moderate. The degree at present is moderate. Baseline status: alert and oriented x4. The patient is a poor historian secondary to altered mental status and disorientation. Per son at bedside, the patient was left out in the sun after she fell asleep. She was found with blisters to her bilateral forearms and with a temperature of 104 degrees Fahrenheit. No fever at present time. Since then, patient has acted confused and disoriented. Per son, patient's baseline is alert and oriented x4. Last known normal was 4 days ago. Also notes that the patient had a chest X-ray and was told this morning that she had pneumonia. Skin: Warm, dry, normal for ethnicity, bilateral dorsal forearm with few areas of mild [DIAGNOSES REDACTED] and small blisters about 1 by 3 centimeters, no evidence of infection. Per the hospital discharge summary dated 7/13/2017, Final Diagnoses: [REDACTED].>1. Altered mental status-acute [MEDICAL CONDITION], resolved. 2. Solar exposure to the arm causing blistering. 3. [MEDICAL CONDITION] 4. Possible left lower lobe pneumonia. 5. [MEDICATION NAME] coagulopathy with supra therapeutic INR. 6. Chronic [MEDICAL CONDITION], on [MEDICATION NAME]. 7. Diastolic dysfunction. 8. Underlying Dementia 9. Mildly elevated troponin Per University of Rochester Medical Center-Keesler Burn Center at http://www.rochester.edu, the classification [MEDICAL CONDITION] as follows: First-degree (superficial) burns. First-[MEDICAL CONDITION] only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-[MEDICAL CONDITION] the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third Degree (full thickness) burns. Third-[MEDICAL CONDITION] the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear white or charred. Fourth degree burns. Fourth [MEDICAL CONDITION] damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed. Per www.medicinnet.com: Those most susceptible (at risk) individuals to heat stroke include: The elderly (often with associated [MEDICAL CONDITION], lung disease, or who are taking medications that make them vulnerable to dehydration and heat [MEDICAL CONDITION]). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sunstroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Sunburn and sun poisoning facts oSunburn is an inflammation of the skin caused by overexposure to UV [MEDICAL CONDITION] from the sun. oUV [MEDICAL CONDITION] damages the skin and also can damage the eyes. oUV rays are most intense at noon and the hours immediately before and after (between 10 a.m. and 4 p.m.). oImmediate symptoms of sunburn are hot, red, tender skin; pain when the skin is touched or rubbed; and dehydration; several days after exposure the skin may, swell, blister, peel, and itch. Sunburn may cause permanent skin damage and [MEDICAL CONDITION] ([DIAGNOSES REDACTED], [DIAGNOSES REDACTED], squamous cell [MEDICAL CONDITION]). o Some medications may increase sensitivity to sunburn (photosensitivity). o Sun poisoning is caused by severe sunburn; its symptoms include o fever, o nausea, o chills, o dizziness, o rapid pulse, o rapid breathing, o dehydration, and o shock. The resident was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. Per the Medication Administration Record [REDACTED]. Per Web MD at www.webmd.com, [MEDICATION NAME] HCL is a diuretic and used for hypertension, heart failure and [MEDICAL CONDITION]. Adverse reactions include the potential for dehydration. The resident was also receiving [MEDICATION NAME] tablet 2 mg, give 1 tablet by mouth one time a day for [MEDICAL CONDITION], hold if systolic blood pressure is less than 110. Per RxList at www.rxlist.com, [MEDICATION NAME] is a diuretic and use includes treatment of [REDACTED]. Adverse reactions include the potential for dehydration. Per the Brief Interview for Mental Status (BIMS) dated 6/7/2017, the resident had a score of 14. A score of 13-15 indicated the resident is cognitively intact. Per the Admission Minimum Data Set with an Assessment Reference date of 5/31/2017, Section G, Functional Status: E. Locomotion on unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. F. Locomotion off unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. On 7/26/2017 at 1:00 p.m., an interview with the MDS Coordinator revealed the resident was alert and oriented with periods of confusion. She was resistant to care, non-complaint, and yelled at staff. A review of the care plan revealed the following information: Focus: Resident is/has potential to be verbally aggressive related to ineffective coping skills, and poor impulse control (accusatory of staff). Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will demonstrate through verbal/non-verbal expressions an understanding of need to control verbally abusive behavior. Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide the resident with positive reinforcement for appropriate behavior. Observe for signs and symptoms of agitation: Intervene with non-medicinal interventions to avoid increased agitation. Focus: The resident is resistive to care Activities of daily living (ADL) and care related to adjustment to nursing home, Anxiety. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will cooperate with care through next review date. Interventions: Allow the resident to make decisions about treatment regimen and establish their ADL routines to provide a sense of control. Give clear explanation of all care activities prior to and as they occur. Give one to one attention as needed, when necessary. If resident resists with ADLs, stop, ensure resident safety, and resume/reapproach at a later time. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Focus: Resident has special needs related to medical diagnosis. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: Resident will have all of their needs met daily. Interventions: Coordinate all care and services as needed. Provide resident with daily staff assist as needed. Notify MD and family of any changes as needed. Focus: The Resident has limited physical mobility related to weakness. Date initiated 5/24/2017. Revision date 7/9/2017. Goal: The resident will demonstrate the appropriate use of (wheelchair) to increase mobility through the next review date. Intervention: Provide supportive care and assistive devices (wheelchair) with mobility as needed. Document assistance as needed. An interview was conducted with Resident #1 (she was receiving rehabilitative and nursing services at another facility) on 7/28/2017 at 9:30 a.m. She was alert, oriented, pleasant and freely engaged in conversation. She said she was doing well and was anxious to go home. She volunteered the following information. She said she came to Florida in March for her son's surprise birthday party. Her plans were to stay a few weeks and return home to New York. She said, prior to her visit to Florida, she was independent, lived alone, and was going about her business as she had always done. She said unfortunately due to medical problems she was hospitalized at the end of March, had been either in the hospital or a rehab center since that time. She said she had several set- backs which had delayed her return home. The resident was questioned regarding the day she was found unresponsive in the sun. She said she did not remember much about the day in question except that she usually sat with her friend outside but her friend had a doctor's appointment and was not there. She said she never sat in the sun because she could not tolerate it related to asthma that developed after the 9/11 tragedy in New York City. (She was among those in the area when the towers collapsed). She said, I always sat in the shade on the porch. Then she said, My friend sat in the sun and I sat with her. My friend always told me when it was time to go inside. She said, I do not know why I was sitting in the sun by myself, I think someone must have put me there, I do not remember how I got there. She said she did not remember that she had been found in the sun resulting in a high body temperature or that she had ice packs on her body to reduce her temperature. An observation of her bilateral upper extremities revealed several scabbed areas on the left posterior forearm. One scabbed area was covered with a Tega-derm dressing. As per the Nursing Home Administrator, the resident was receiving Keflex for [MEDICAL CONDITION]. The resident said she was in no pain but said the area was very warm to touch. The area was moderately red. The right posterior forearm had two small scabs areas and were open to air. When the resident was asked about the scabbed areas, she said they were from the sun. She said, after she was left in the sun her skin on both arms peeled off in sheets. She said, It was painful and looked horrible. She said, I don't know why they did not check on me. Somebody should have checked on me. Prior to the visit with Resident #1, a family member was called to verify the resident's location. At that time, he said the facility called him on the day she was left out in the sun. He was very upset and said he did not want the resident to go back to the facility after she was released from the hospital. He said he did not feel as though the facility took very good care of the resident and hoped that no one else had been treated like her. On 7/27/2017 at 10:21 a.m., an interview was conducted with the Director of Nurses (DON). She said the physician saw the resident after the event and gave orders. When asked what orders? She said, chest X-ray, Electrocardiogram, Doppler of the upper extremities, and laboratory tests. When asked if he assessed the skin or wrote orders related to the skin she said no. She said, since the physician did not say anything about the skin we thought the high temperature was from an infection not sun exposure. The DON said after this event, there was no incident report done, investigation conducted, or steps put into place to prevent this from happening again because they did not feel there was anything to investigate. Facility steps to remove the Immediate Jeopardy: On 7/28/2017 at 4:00 p.m., an interview was conducted with the Nursing Home Administrator. He said the education on abuse, neglect, reporting, and patio monitoring began on the morning of 7/27/2017 and was complete. He said the facility implemented a new plan to monitor the front porch more closely. The facility initiated measures to remove the immediate jeopardy beginning on 7/27/2017. The NHA presented a document titled, Patio Checks with the following information: 1. Checks will occur on the front patio hourly from 8 00 a.m. to 8: 00 p.m. by a specific designee. Nursing will ensure checks occur by concierge, DCM, etc. 2. Residents will be offered hydration, sunscreen or protective clothing during rounds. 3. If a resident leaves the shaded area, offer to bring them in and notify the nurse immediately if they refuse. The NHA said that the residents/families are to sign out and sign back in when the resident goes outside to the porch to sit on the porch and surrounding area. The sign out sheet is kept at the concierge's desk. A sign was placed on the front door to remind residents and families to sign out when going outside to the porch and sign back in when they come back(TRUNCATED)

Based on record review and interview, the facility failed to provide goods and services necessary to ensure safety and prevent neglect for one (Resident #1) of five residents reviewed for accidents and safety. The facility did not provide supervision or hydration offerings on the front porch and surrounding area on a consistent basis. The facility allowed a resident who was at risk for dehydration related to diuretic use, Diabetes Type 2, and a history of a recent fall to remain outside on a day with a temperature of 95 degrees Fahrenheit and a heat index of 109.7. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative and nursing services with the goal to return home alone as per her prior level of function. She had [DIAGNOSES REDACTED]. The Admission Minimum Data Set, reflected the resident needed extensive assistance for locomotion in her wheelchair on and off the unit. The resident was found on the sidewalk, in her wheel chair, in front of the facility in direct sun and was assessed as being unresponsive and flushed with an elevated body temperature, for which the resident received blistered, peeling, and painful skin to her bilateral upper extremities. This facility's failure to honor Resident #1's basic rights to be free from neglect by not providing the necessary oversight and supervision resulted in findings of immediate jeopardy, which was removed on 8/1/2017 at 4:15 p.m. Findings Included: Per the facility's Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy with an effective date of 5/31/2016, Sub Heading Definitions, the definition of neglect is The failure to provide goods and services necessary to protect the resident from health and safety hazards. On 7/5/ 2017, in Tampa, Florida, the average outside temperature was 86 degrees Fahrenheit and the average humidity was 72 %. In Tampa at 1:35 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 112.2 degrees Fahrenheit. At 2:15 p.m., the temperature was 95 degrees Fahrenheit with a heat index of 109.7. The humidity was 77% (wunderground.com). On 7/26/2017 at 12:30 p.m., an interview was conducted with the Physical Therapy Assistant (Staff #1). He said he punched out at 2:30 p.m. on 7/5/2017 (this was verified by the punch detail provided by the Nursing Home Administrator). He said he went out the front door and saw the resident sitting in her wheelchair to the left of the door on the sidewalk in the sun. He attempted to speak to the resident but she did not respond. When she did not respond, he looked closer and saw that she appeared flushed. He assumed this was from the sun. He did a sternal rub, the resident did not respond. He immediately rolled her inside and told the nurse, We have a problem. The resident was taken to her room and transferred to bed. The nurse applied oxygen and EMS was called. Her vital signs were taken, her clothes were loosened, and ice packs were applied to her body. At that time, he felt he could be of no more assistance so he left the room. He said when he left the resident was still unresponsive. On 7/27/2017 at 9:15 a.m., the Physical Therapy Assistant (Staff #1) was interviewed again to obtain additional information. He said on the day of the event, the resident was wearing a short sleeve shirt with Capri pants. He said the resident frequently went outside and sat in the sun. He said, We were constantly telling her to be careful and encouraged her to stay out of the sun, but she was a strong-willed woman. Staff #1 and this surveyor went out to the front porch and surrounding areas so Staff #1 could show the exact spot the resident was found. He stood on the spot and said, Right here in the sun. The spot was on the sidewalk to the left side of the front door if looking from the inside to the outside of the building. At that time, the area was shaded due to the time of day and position of the summer sun. The area was re-checked at 12:30 p.m. 1:30 p.m. and 2:30 p.m. and was noted to be in full sun. Per the Brief Interview for Mental Status (BIMS) dated 6/7/2017, Resident #1 had a score of 14. A score of 13-15 indicated the resident is cognitively intact. Admission Minimum Data Set with an Assessment Reference date of 5/31/2017, Section G, Functional Status: E. Locomotion on unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. F. Locomotion off unit: Self Performance was a 3 which indicated the resident needed Extensive assistance- resident involved in activity; staff provide weight-bearing support. Activities of Daily Living (ADL) support provided was a 2 which indicated the resident needed One person physical assist. On 7/26/2017 at 1:00 p.m., an interview with the MDS Coordinator revealed the resident was alert and oriented with periods of confusion. She was resistant to care, non-complaint, and yelled at staff. A review of the care plan revealed the following information: Focus: Resident is/has potential to be verbally aggressive related to ineffective coping skills, and poor impulse control (accusatory of staff). Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will demonstrate through verbal/non-verbal expressions an understanding of need to control verbally abusive behavior. Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide the resident with positive reinforcement for appropriate behavior. Observe for signs and symptoms of agitation: Intervene with non-medicinal interventions to avoid increased agitation. Focus: The resident is resistive to care Activities of daily living (ADL) and care related to adjustment to nursing home, Anxiety. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: The resident will cooperate with care through next review date. Interventions: Allow the resident to make decisions about treatment regimen and establish their ADL routines to provide a sense of control. Give clear explanation of all care activities prior to and as they occur. Give one to one attention as needed, when necessary. If resident resists with ADLs, stop, ensure resident safety, and resume/reapproach at a later time. Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Provide the resident with opportunities for choice during care provision. Focus: Resident has special needs related to medical diagnosis. Date initiated 5/30/2017. Revision date 7/9/2017. Goal: Resident will have all of their needs met daily. Interventions: Coordinate all care and services as needed. Provide resident with daily staff assist as needed. Notify MD and family of any changes as needed. Focus: The Resident has limited physical mobility related to weakness. Date initiated 5/24/2017. Revision date 7/9/2017. Goal: The resident will demonstrate the appropriate use of (wheelchair) to increase mobility through the next review date. Intervention: Provide supportive care and assistive devices (wheelchair) with mobility as needed. Document assistance as needed. Resident #1 was an [AGE] year old admitted to the facility for rehabilitative services with a goal to return home alone as per her prior level of function. Per the resident's face sheet with an initial admission date of [DATE], the resident was admitted with [DIAGNOSES REDACTED]. Per the Medication Administration Record [REDACTED]. Per Web MD at www.webmd.com, [MEDICATION NAME] HCL is a diuretic and used for hypertension, heart failure and [MEDICAL CONDITION]. Adverse reactions include the potential for dehydration. The resident was also receiving [MEDICATION NAME] tablet 2 mg, give 1 tablet by mouth one time a day for [MEDICAL CONDITION], hold if systolic blood pressure is less than 110. Per RxList at www.rxlist.com, [MEDICATION NAME] is a diuretic and use includes treatment of [REDACTED]. Adverse reactions include the potential for dehydration. An interview was conducted with Resident #1 (she was receiving rehabilitative and nursing services at another facility) on 7/28/2017 at 9:30 a.m. She was alert, oriented, pleasant and freely engaged in conversation. She said she was doing well and was anxious to go home. She volunteered the following information. She said she came to Florida in March for her son's surprise birthday party. Her plans were to stay a few weeks and return home to New York. She said, prior to her visit to Florida, she was independent, lived alone, and was going about her business as she had always done. She said unfortunately due to medical problems she was hospitalized at the end of March, had been either in the hospital or a rehab center since that time. She said she had several set- backs which had delayed her return home. The resident was questioned regarding the day she was found unresponsive in the sun. She said she did not remember much about the day in question except that she usually sat with her friend outside but her friend had a doctor's appointment and was not there. She said she never sat in the sun because she could not tolerate it related to asthma that developed after the 9/11 tragedy in New York City. (She was among those in the area when the towers collapsed). She said, I always sat in the shade on the porch. Then she said, My friend sat in the sun and I sat with her. My friend always told me when it was time to go inside. She said, I do not know why I was sitting in the sun by myself, I think someone must have put me there, I do not remember how I got there. She said she did not remember that she had been found in the sun resulting in a high body temperature or that she had ice packs on her body to reduce her temperature. An observation of her bilateral upper extremities revealed several scabbed areas on the left posterior forearm. One scabbed area was covered with a Tega-derm dressing. As per the Nursing Home Administrator, the resident was receiving Keflex for [MEDICAL CONDITION]. The resident said she was in no pain but said the area was very warm to touch. The area was moderately red. The right posterior forearm had two small scabs areas and were open to air. When the resident was asked about the scabbed areas, she said they were from the sun. She said, after she was left in the sun her skin on both arms peeled off in sheets. She said, It was painful and looked horrible. She said, I don't know why they did not check on me. Somebody should have checked on me. Prior to the visit with Resident #1, a family member was called to verify the resident's location. At that time, he said the facility called him on the day she was left out in the sun. He was very upset and said he did not want the resident to go back to the facility after she was released from the hospital. He said he did not feel as though the facility took very good care of the resident and hoped that no one else had been treated like her. On 7/27/2017 at 10:21 a.m., an interview was conducted with the Director of Nurses (DON). She said the physician saw the resident after the event and gave orders. When asked what orders? She said, chest X-ray, Electrocardiogram, Doppler of the upper extremities, and laboratory tests. When asked if he assessed the skin or wrote orders related to the skin, she said no. She said, since the physician did not say anything about the skin we thought the high temperature was from an infection not sun exposure. The DON said after this event, there was no incident report done, investigation conducted, or steps put into place to prevent this from happening again because they did not feel there was anything to investigate. Interviews were conducted with Certified Nurses Assistants (CNA) and nurses related to resident safety and protection from heat and sun exposure for residents that choose to sit outside. The interviews were as follows: On 7/26/2017 at 2:10 p.m. Staff #2 (CNA) said, sometimes the resident's tell the CNAs they are going outside, sometimes the nurse tells the CNA that the resident has gone outside. She said, while the residents are outside, someone will eventually check on them either someone coming in or going out of the building. The nurse, CNA, therapist, or activities staff will go get them for medications, personal care, activities, therapy, and/or meals. She said no one is specifically assigned to check on the residents outside. She said some residents do not tell the staff they are going outside; they just go. She said some residents go outside to sit in the sun to warm up. On 7/26/2017 at 2:20 p.m. Staff #3 (CNA-Restorative) said, before taking a resident outside, she asks the nurse if they can go out. If she takes them outside, she checks on them periodically. She said everybody checks on the residents while they are outside but no one was assigned to check on them. She said some residents like to sit in the sun. When asked if there were any special precautions done for a resident that wants to sit in the sun, she said we remind them not to stay out too long. When asked about sunscreen and whether or not it was provided by the facility she said No. On 7/26/2017 at 2:30 p.m. Staff #4 (CNA) said, we are supposed to check on the resident at least every two hours. Most of the residents let the staff know when they are going outside. When asked how she kept track of her residents she said I check on them at least every two hours and if I cannot find them in their room or on the unit, I start looking in other departments and on the porch. If a resident wanted to sit in the sun, she said she would try to convince them to get out of the sun. When asked about education related to residents going outside and/or sitting outside in the sun, she said, I do not remember any education done here but I know what to do by working in other facilities. On 7/26/2017 at 2:45 p.m. Staff #5 (LPN) said, Resident #1 was on her assignment but she was not working on the day of the incident (7/5/2017). She said the resident would let the nurse know when she was going outside. She said the nurse's station was right by the front door so it was easy for her to tell someone where she was going. She said both the nurses and CNAs take turns checking on the residents that are outside. She said there was no one specifically assigned to monitor the patio. She said she was not aware of the availability of sunscreen for the residents and has had no education related to resident safety when they are outside. On 7/26/2017 at 3:15 p.m. Staff #6 (LPN) said, the residents are to be checked every 2 hours. He said depending on the temperature, the residents should only stay outside maybe 15 minutes. He said no one was assigned to monitor the patio but when someone checks on the residents outside he or she should give hydration and encourage them to get out of the sun. He said there was no sunscreen in the facility. On 7/26/2017 at 3:30 p.m. Staff #7 (LPN) said, only alert and oriented resident are allowed to sit on the front porch alone. Activities takes them as a group. She said alert and oriented residents tell the nurse/CNA when they are going outside. She was unsure if the facility provided sunscreen to the residents. She said if they had it, it would be in the treatment cart, but was not sure. She said if a resident wants to sit in the sun, she would advise them not to sit in the sun. If they insisted then they should be checked every 10-15 minutes. She said, no one was assigned to monitor the patio because not enough residents go out on the porch. She said the patio is centrally located so it is a group effect to monitor the residents on the porch. On 7/26/2017 at 4:00 p.m. Staff # 8 (RN) said the residents usually tell the staff when they go outside. She said sunscreen is available and in the medication cart. She said no one was specifically assigned to check the patio; it was everyone's job to check the patio throughout the shift. On 7/26/2017 at 4:10 p.m. Staff #9 (CNA) said he checks his residents every two hours throughout the shift. No one was assigned to check the patio. On 7/26/2017 at 4:15 p.m. Staff #10 (CNA) said no one is assigned to check the patio. He checks on his residents at least every two hours throughout the shift. He said no one is allowed outside by themselves after dark unless accompanied by someone. On 7/26/2017 at 1:50 p.m., an interview was conducted via the telephone with the resident's direct care nurse about the day of the event. He said he only vaguely remembered the day the resident was found unresponsive and brought back into the facility. He said he remembered she had a fever of over 100 degrees, maybe 102, maybe 103. He could not remember the exact temperature. He verified that her skin was red but said he did not know why it was red. He said, Emergency Medical Services were called but when they arrived, the resident refused to go to the hospital. The nurse was questioned about documentation on the Medication Administration Record [REDACTED]. He said the resident was sitting in her wheelchair outside her room when he administered the medication. The nurse said he did not see the resident again until she was brought back into the facility by the therapist. On 7/26/2017, per a review of the nurse's notes for Resident #1, the following note was documented as a Late Entry with a created date of 7/13/2017. The event was documented by the nurse as having occurred on 7/6/2017 at 2:26 p.m. However based on record review and interviews the event occurred on 7/5/2017 and the note read as follows: Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, ice packs applied by staff, assessed by Emergency Medical Services (EMS) refused to be transferred to the hospital. MD/son aware will cont. to monitor. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (Staff #14) the day following the event. Per the emergency room report dated 7/8/2017, History of Present Illness: The patient presents with altered mental status. The onset was 3 days ago. The course/duration of symptoms is constant. The character of symptoms is disoriented and confused. The degree at onset was moderate. The degree at present is moderate. Baseline status: alert and oriented x4. The patient is a poor historian secondary to altered mental status and disorientation. Per son at bedside, the patient was left out in the sun after she fell asleep. She was found with blisters to her bilateral forearms and with a temperature of 104 degrees Fahrenheit. No fever at present time. Since then, patient has acted confused and disoriented. Though the Late Entry nurse's note indicated the physician was notified, an interview with the physician verified that the nursing department did not notify him that on 7/5/2017 at 2:30 p.m., the resident was found sitting outside in her wheelchair unresponsive in the full Florida summer sun. He was notified by the Physical Therapist Assistant (PTA) the day following the event. Per son, patient's baseline is alert and oriented x4. Last known normal was 4 days ago. Also notes that the patient had a chest X-ray and was told this morning that she had pneumonia. Skin: Warm, dry, normal for ethnicity, bilateral dorsal forearm with few areas of mild [DIAGNOSES REDACTED] and small blisters about 1 by 3 centimeters, no evidence of infection. Per the hospital discharge summary dated 7/13/2017, Final Diagnoses: [REDACTED].>1. Altered mental status-acute [MEDICAL CONDITION], resolved. 2. Solar exposure to the arm causing blistering. 3. [MEDICAL CONDITION] 4. Possible left lower lobe pneumonia. 5. [MEDICATION NAME] coagulopathy with supra therapeutic INR. 6. Chronic [MEDICAL CONDITION], on [MEDICATION NAME]. 7. Diastolic dysfunction. 8. Underlying Dementia 9. Mildly elevated troponin Per University of Rochester Medical Center-Keesler Burn Center at http://www.rochester.edu, the classification [MEDICAL CONDITION] as follows: First-degree (superficial) burns. First-[MEDICAL CONDITION] only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long term tissue damage is rare and usually consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-[MEDICAL CONDITION] the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third Degree (full thickness) burns. Third-[MEDICAL CONDITION] the epidermis and dermis and may go into the subcutaneous tissue. The burn site may appear white or charred. Fourth degree burns. Fourth [MEDICAL CONDITION] damage the underlying bones, muscles, and tendons. There is no sensation in the area since the nerve endings are destroyed. Per www.medicinnet.com: Those most susceptible (at risk) individuals to heat stroke include: The elderly (often with associated [MEDICAL CONDITION], lung disease, or who are taking medications that make them vulnerable to dehydration and heat [MEDICAL CONDITION]). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Sunburn and sun poisoning facts oSunburn is an inflammation of the skin caused by overexposure to UV [MEDICAL CONDITION] from the sun. oUV [MEDICAL CONDITION] damages the skin and also can damage the eyes. oUV rays are most intense at noon and the hours immediately before and after (between 10 a.m. and 4 p.m.). oImmediate symptoms of sunburn are hot, red, tender skin; pain when the skin is touched or rubbed; and dehydration; several days after exposure the skin may, swell, blister, peel, and itch. Sunburn may cause permanent skin damage and [MEDICAL CONDITION] ([DIAGNOSES REDACTED], [DIAGNOSES REDACTED], squamous cell [MEDICAL CONDITION]). o Some medications may increase sensitivity to sunburn (photosensitivity). o Sun poisoning is caused by severe sunburn; its symptoms include o fever, o nausea, o chills, o dizziness, o rapid pulse, o rapid breathing, o dehydration, and o shock. On 7/26/2017 at 3:17 p.m., an interview was conducted with the Director of Nurses. When asked if she was involved in any way with the event related to sun exposure for Resident #1. She said she saw a commotion in the hallway around the resident's room and went to check on it. She said, when she got to the room, she noted a therapist and nurse in the room with the resident. The resident had ice packs on her due to a high fever and was unresponsive at that time. She said her skin was flushed/red and the assumption was that the high temperature was from a recent infection. She said when EMS arrived the resident was alert enough to refuse to go to the hospital. She said she was unaware that the resident had been outside in the sun. She was unable to say why there were no follow up skin assessments or references to the sun exposure event in the resident's record. She offered no additional information. Per the nurse's notes for Resident #1, dated 7/5/2017 10:14 p.m., Alert and oriented x 3, stayed in bed and able to use call light, uses 02 as ordered and appears in no acute distress. Re-checked temperature: 98.2 at 8:00 p.m. Right arm elevated with pillow and medicated for pain x 1 and with good effect. Per the Weights and Vitals Summary on 7/6/2017 at 12:46 a.m. the resident's Temperature was 98.3 degrees. Per the nurse's notes dated 7/6/2017 at 6:12 a.m., Alert and oriented x 3 with cooperative attitude. As needed, [MEDICATION NAME] given for mild anxiety and observed to be effective. As needed, oxygen in place. Oxygen effective and saturations were stable. Complained of mild pain to right wrist but refused as needed pain medication. Right arm elevated on pillow overnight for comfort. Will continue to monitor. No shortness of breath or acute distress observed. Call light in reach and is compliant with use. Additional nurse's notes as follows: 7/6/2017 at 6:14 a.m., follow-up: Abrasions noted above bilateral knees from fall 7/4/2017. No signs or symptoms of infection noted, left to open to air. Neuro checks were within normal limits. 7/6/2017 at 12:57 p.m., Resident did not participate in occupational or physical therapy. Resident was alert and oriented x3, cooperative with staff, diet and medications tolerated, remains on oxygen at 2 liters per minute for shortness of breath, bilateral [MEDICAL CONDITION] awaiting Doppler ultrasound to rule out clot. Physician and son aware. Will continue to monitor. 7/6/2017 at 10:48 p.m., Alert x 2, up in wheelchair with assist of one, not in acute distress. The resident was seen by the physician and with orders. Son aware. Right arm elevated with pillow in bed. 7/7/2107 at 2:19 a.m., Resident has orders for two views chest X-ray in a.m. due to shortness of breath and electrocardiogram in a.m. due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Reason for portable X-ray: Resident has generalized muscle weakness. 7/8/2017 at 10:51 a.m., Resident refused to participate in therapy due to pain in her right upper arm and lower extremities. Resident is alert and oriented. Tolerated medications and meals well. Moderate assistance with Activities of Daily Living (ADLs) and transfers. Continent. Pain voiced with pain medication administered with effectiveness. 7/8/2017 at 12:03 a.m. Alert and able to voiced her needs. Right arm elevated with pillow. Incontinent of bowel and bladder. No signs and symptoms of respiratory distress. Call light in reach. She took her medications and diet well. 7/8/2017 at 6:05 a.m., Resident alert with increased confusion. Resident awake most of night yelling out other resident's names. Resident oxygen saturations were 85% on room air; saturations were 97% on 2 liters of oxygen, slightly labored respirations. Resident having hallucinations of other residents in her room eating turkey. At other times stating her son is sitting in the chair waiting for her to pack her things. Resident's anxiety is not re-directable at times. Resident yelling at nurse, why are you keeping me here, I don't want to be in the hospital. Resident unaware that she is in her room at the rehab facility. Resident unaware of the time screaming she was not offered breakfast, attempted to redirect resident to the time that was 4:00 a.m. and that breakfast was at 7:00 a.m. Redirection had limited effect. Resident's son was contacted and agreed to come in and talk with his Mom. Son arrived at 7:30 a.m. and agreed that his mother was confused and requested her to be sent to the hospital. 7/8/2017 at 8:57 a.m. Reason for transfer: AMS, hallucinations, [MEDICAL CONDITION]. Condition of resident at time of transfer: alert with confusion. Vital signs: BP: 88/57, Pulse: 60, Respirations: 22, O2 sat: 86% on room air, 97% on 2L/min. Resident transported by EMS. Son was in the facility at the time of transfer, MD made aware. On 7/31/2017 at 12:35 p.m., an interview was conducted with the resident's treating Physical Therapy Assistant (Staff #14). She said the day after the event (7/6/2017); the physician came in to the therapy gym to see the resident. At that time, the therapist informed the physician about the resident's syncopal event from the day before. She also informed him that she had noted a functional decline in the resident. She said she did see the resident's arms after the event and said they were both red and had small blisters on them. On 7/27/2017 at 11:00 a.m., and, again on 7/31/2017 at 11:46 p.m. Interviews were conducted with the resident's primary care physician while she was a resident at the facility. He said when he was in the facility on 7/6/2017, during his routine rounds; he went to the therapy gym to see the resident. He said while he was there, the resident's treating Physical Therapy Assistant (Staff #14) told him that on 7/5/2017, the resident had a syncopal episode, was found outside in the sun, and refused to go to the hospital. The physician said he assessed the resident and recommended that the resident should go to the hospital for an evaluation due to increased confusion; however, the resident refused to transfer the hospital. The physician said he did note that the resident had minimal redness on her arms but did not see blistering. He said the resident's main concern was pain in her right arm and right wrist. He said he ordered a Doppler study to rule out a blood clot, a chest X-ray and an Electrocardiogram due to a change in her overall condition. He verified that the nursing staff did not notify him that the resident was found in the sun, unresponsive, and had a body temperature of 103.4. When asked if he would have done anything different had he known, he said, No, I would have sent her to the hospital as the facility tried to do. However, he said, I would have expected a call from the facility regarding this significant change in condition and her refusal the go to the hospital. He said he did not see her in the emergency room , because he was her physician only while she was at this facility. On 7/3/2017, the resident completed five days of [MEDICATION NAME] for a urinary tract infection. During the above interview with the physician, he said since the [MEDICATION NAME] was completed two days prior to the event, he did not believe it caused the resident to be more susceptible to harm from the sun. The resident was not on any other medication that would increase sensitivity to sun exposure. On 7/26/2017 at 11:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nurses (DON). Initially, neither the NHA nor the DON had any recollection of an event related to sun exposure. The surveyor read the nurse's note for Resident #1, Resident received in room lying in bed alert and oriented x1 at this time general redness to extremities, T-103.4, and ice packs applied by staff, assessed by EMS refused to be transferred to the hospital. MD/son aware will cont. to monitor. to them. The question was asked again if either one of them remembered this event. At that time, they both agreed they had heard something about it. The DON said we tried to convince her to go to the hospital. We called her son to convince her but she still did not want to go. At that time, the DON nor the NHA offered had or offered any additional information. Additional questions were asked related to Resident #1 and her usual routine and care needs. At that time the DON said, that on the day of the event (7/5/2017) the reside(TRUNCATED)