Every finding on record at Vivo Healthcare Gateway

Based on record review and policy review, the facility failed to perform a thorough investigation following an allegation for one resident out of three, (#1). Findings Included: During an interview on 01/07/2026 at 10:18 AM, Resident #1 stated an incident happened two weeks prior while she was being changed by a CNA (Certified Nursing Assistant). Resident #1 stated she was on her bed being pressured by an aide, while being changed. The resident stated the right and left forearms were crossed, both palms facing down and stated having asked the CNA, What are you doing. The resident stated she was on the right side of the bed. The wheelchair was facing a nightstand on the right of the bed. She stated the arms were crossed one over the other and pressed against the surface of the bed and wheelchair. Resident #1 stated having hurt wrists and bruising on her forearms. Resident #1 was observed with two- penny sized dark pink spots on both inside forearms near the wrists. The resident explained being confused about the CNA's actions.Review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses to include traumatic subarachnoid hemorrhage without loss of consciousness, hemiplegia and hemiparesis, need for assistance with personal care, unsteadiness of the feet, epilepsy, aphasia and major depressive disorder.Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE], showed in section C a Brief Interview Mental Status (BIMS score), of 14, which indicated cognition was intact. Section GG revealed Resident #1 had functional limitation in range of motion with impairment on one side. Resident #1 used a walker and a wheelchair. Section GG revealed for toileting hygiene, showering hygiene and personal hygiene, the resident required partial or moderate assistance.An interview was conducted on 01/07/2026 with Staff A COTA, (Certified Occupational Therapy Assistant). Staff A stated having worked with Resident #1 for balance and coordination, bilateral integration, strengthening, independence and self-care. Staff A stated the resident had a balance deficit and weakness in the right side. Staff A stated during a visit in therapy, later identified as happening on 12/22/2025, upon asking Resident #1 to show her forearms for an exercise, she noticed bruising on the inside forearms. Staff A explained asking Resident #1 about the bruising and stated Resident #1 requested to speak with the person in charge. Staff A stated the bruising's color was dark purple and definitely appeared to be fresh. Staff A stated having been told the bruising was related to two aides the resident was mad at.Review of a psychiatry progress note dated 12/24/2025 revealed, The patient was seen today at staff request after alleging that a CNA grabbed her in a manner, she found uncomfortable during assessment. Patient was unable to describe the CNA involved or provide specific details regarding the alleged event. The patient appeared calm during the evaluation. No injuries or signs of distress were noted at the time of the assessment.Review of a Nurse Practitioner skin and wound assessment note dated 12/22/25 revealed under HPI (History of Presenting illness); Information necessary for today's visit was obtained from the patient evaluated for comprehensive skin assessment for in house skin sweep. scattered bruises noted to upper extremities . Assessment showed: contusion of unspecified upper arm, initial encounter.Review of a social services progress note dated 12/23/25 revealed, Due to an injury of unknown origin, other SW (social worker) was asked to conduct a BIMs (Brief Interview for Mental Status) interview . [Resident #1] declined to answer any of the questions and expressed that she did not want to participate. Review of Resident #1's care plan revealed a focus of potential/actual impairment to skin integrity related to decreased cognition, decreased mobility, fragile skin, incontinence, initiated 11/07/2025. The intervention was to monitor/document location size and treatment of skin injury. The intervention included: report abnormalities, failure to heal, signs and symptoms of infection, maceration and more to the medical doctor, initiated 11/07/2025. The intervention included: use caution during transfers and bed mobility to prevent striking arms, legs, and hands up against any sharp or hard surfaces. The intervention included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated 11/07/2025.During an interview on 01/07/2026 at 03:40 PM, with the Director of Nursing (DON) and the Nursing Home Administrator, the (NHA), the NHA stated on 12/22/25 at an unknown time, [Resident #1] had requested to speak with the NHA. The NHA stated there was an incident that happened on 12/18/25. The NHA stated Therapy staff had noticed bruising on the resident. The NHA stated during the interview the resident was upset and was having difficulty speaking due to Aphasia. The DON stated not knowing about the resident having bruising prior to the incident even though the resident was taking an anticoagulant. The DON stated the resident was seen by a psych and there were no bruises noted at the time. The NHA stated they interviewed everyone on shift, but the resident did not know who the CNA was. The NHA stated not having spoken to the Nurse Practitioner who documented the bruising on the resident. They both confirmed the resident had acquired bruising which she alleged occurred during care. The facility could not identify the resident's perpetrator or how the resident acquired the bruising. Review of a policy titled Clinical Guideline Skin & Wound Effective, dated 04/01/2017, revealed: Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury.Process: On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record Braden Risk Evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition Licensed Nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record CNA to complete skin observations and report changes to Licensed Nurse Licensed Nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record Develop individualized goals and interventions and document on the care plan and the CNA Kardex Refer to therapy as indicated Monitor residents' response to treatment and modify treatment as indicated Evaluate the effectiveness of interventions, and progress towards goals during the care management meeting and as needed QAPI: Patterns and trends of newly developed and/or worsening skin conditions will be reviewed by the QAPI team.

Based on observations, interviews, and record review, the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner, and food was prepared and stored in accordance with professional standards for food safety in one out of one facility kitchen and two out of two nourishment rooms. Findings included: An observation was conducted on 12/10/24 at 2:36 p.m. in the north unit nourishment room of: -Cups and trash on the floor under the table. -The shelf above the refrigerator had dirt, dry spilled liquid, and a container with an unknown liquid. -The refrigerator and freezer contained undated, unlabeled food. -There thermometer in the refrigerator was broken and there was no thermometer in the freezer. -The seal around the refrigerator and freezer door was broken and there were icicles hanging from the freezer door and food was spilled on the shelf. -The refrigerator contained an unlabeled container of liquid that had a date of 11/19. -There was a plunger sitting on the floor next to the refrigerator. An observation was conducted on 12/10/24 at 2:45 p.m. in the south unit nourishment room of: -A container of pudding in the refrigerator opened, undated with a rubber band wrapped around it. -The floors in the room were also observed to be dirty and the baseboards were missing. -There was a pitcher of unlabeled and undated liquid in the refrigerator. An observation was conducted on 12/10/24 at 3:35 p.m. during a kitchen tour of: - Gnats in the kitchen and food storage areas. -A container of thickener powder with a cup stored in the powder. -A second container of thickener powder contained a small brown foreign object. -Shelves being used to store food in the dry storage area were rusty and had dust and debris on them. -The walk-in refrigerator had a covered plate of deviled with no date. -The walk-in refrigerator had an unlabeled paper bag on the shelf that contained an unlabeled plastic bag with unidentifiable food and liquid inside. -The walk-in refrigerator had a box of bacon wrapped in plastic. The plastic had been torn open and the bacon was sitting unwrapped. -The walk-in refrigerator had milk crates sitting directly on the floor. -The walk-in refrigerator had a lunch box containing a sandwich sitting on top of a tray eggs. -The walk-in refrigerator contained a rack with spilled mandarin oranges and a pan covered in liquid. -The walk-in freezer contained a blue unlabeled plastic bag tied in a knot. -There was a half empty bottle of green tea sitting on the food preparation table. -There were wires and a piece of insulation in the middle of the kitchen floor under a preparation table. -There was trash and spilled liquids on the floor behind the cart containing the coffee maker. -Two bottles of salad dressing were sitting on the floor being used to prop open the door to the dry food storage room. -The kitchen walls had dirt, grease, and spilled liquid on them. -There was a section of wall by the door in the kitchen that the tile had come off and there was an uncleanable surface. The section of missing tile was sitting on top of a preparation table. -The stainless food preparation tables in the kitchen were corroded and rusting. -There were dead bugs on the table with the coffee maker. -One of the stainless food preparation tables was broken and uneven. -A live roach was observed running across the floor under the three-compartment sink. -A plastic two drawer organizer was sitting on the second shelf of a food preparation area. The organizer was covered in dust, and spilled substances. The top drawer contained cereal and cake mix stored with disposable cups, lids, plastic bags and wrapping paper. The second drawer contained cups and disposable containers along with a stapler, highlighter and pair of eyeglasses. A second plastic storage bin was sitting on the shelf and it was also covered in dust and spilled substances. -Plates were sitting face up on the bottom shelf of the stainless preparation table and stainless bowls were sitting on a shelf with the useable surface face up. -The electrical outlet at the center food preparation area was heavily coated with dust, dirt and a stick substance. On 12/10/2024 at 3:45 p.m. an observation and interview was conducted in the facility's kitchen. Staff A, Dietary Aide was observed in the process of washing dishes with the dishwasher. Staff A demonstrated sanitizer testing. The test strip showed a result of less than 50 PPM (parts per millions). Staff A confirmed the results and stated the results should be between 50-100 PPM. Staff A stated dishes should be run back through. The Certified Dietary Manager (CDM) arrived in the dishwasher area and performed a second test and confirmed the results were less than 50 PPM. The CDC stated, It should be darker. The CDM confirmed the dishwasher was a low temperature/ chemical sanitizer dishwasher. An observation and interview was conducted on 12/10/24 at 3:53 p.m. with the CDM. The CDM was observed leaving her desk from doing paperwork without performing hand hygiene. She walked into the walk-in refrigerator and said the deviled eggs should have been dated/labeled. She looked at the paper bag containing the plastic bag of unidentifiable food and said, That shouldn't be in here. She said it was not labeled and was for a staff party. The CDM said the bacon should be wrapped in plastic and not left uncovered. She said the lunch box belonged to a staff member and should not be in the refrigerator. She then picked up the deviled eggs, lunch box, and paper bag and removed them from the refrigerator. The CDM said the gnats had been a problem in the kitchen since the beginning of October and they were treating them. She also looked in the dry storage room and said the bottles of dressing should not be on the floor propping the door open. She was observed moving the bottles to a shelf. She also said the cup should not have been stored in the thickening powder and she was observed removing it. The CDM had still not performed any hand hygiene. She was observed reaching into the second container of thickening power with her bare hands and taking out the brown foreign object. When asked what she would do with that thickening powder she said they would use it because It wasn't a bug or anything. The CDM reviewed pictures of the nourishment rooms. She said the rooms should be cleaned by housekeeping and cleaning the refrigerators and freezers is a team effort. She said juice should not have been in the refrigerator from 11/19/24 and all food should be labeled/dated. When discussing the broken seals on the refrigerator and freezer she stated Oh that's north unit. That fridge needs to be replaced. The CDM said there should be working thermometers in the refrigerator and freezer and she would replace them. She also said the freezer should not look the way it does and should not be dirty. On 12/11/2024 at 9:17 a.m., an observation and interview was conducted with Staff B, Dietary Aide. Staff B was in the process of washing dishes with the dishwasher. Staff B stated she had washed numerous trays of dishes through the dishwasher and stated she had not tested the dishwasher in the morning. Staff B performed a test strip with results less than 50 PPM. Staff B performed another with results less than 50 PPM and stated, It's getting there. The assistant CDM came to the service area and agreed the test strip was less than 50 PPM as Staff B continued to wash the dishes. The assistant CDM performed four separate tests and on the fourth test the results were at 50 PPM. The assistant CDM stated the dishwasher should be run through several times and tested each time until it reaches the goal of 50-100 PPM. The CDM stated she will have the dishwasher serviced immediately. Staff B was observed putting the previously washed items on a rack with clean dishes to dry. A follow-up observation was conducted on 12/11/24 at 9:27 a.m. in the kitchen of: -The two bottles of salad dressing remained on the floor propping open the dry storage room door. -The shelves in the dry storage room had spilled sugar and small ants crawling on them. -There was a puddle of liquid in the middle of the dry food storage room. -The plastic storage containers continued to be covered in dust and crumbs. -The bacon in the refrigerator remained unwrapped. -The unlabeled blue plastic bag remained in the walk-in freezer. The bag was opened and observed to contain vegetables. -The milk cartons remained sitting directly on the floor in the walk-in refrigerator. -The plastic storage bins under the preparation table continued to have cake mix and cereal stored with disposable cups and lids. -The front of the reach-in refrigerator had dried liquid and food particles on the doors. An observation and interview was conducted on 12/11/24 at 9:27 a.m. in the kitchen. The CDM was sitting at her desk with her office door open five feet from the dry storage room. She walked out of her door and was asked about the two bottles of salad dressing sitting on the floor being used as a door prop. She stated, Oh, they put them back. The CDM said she did not know there were ants in the dry storage room. She observed the ants and said the shelves needed to be cleaned and she would call maintenance to see about getting a treatment. The CDM was asked about the unlabeled blue plastic bag in the walk-in freezer. She was adamant It was ice. The assistant dietary manager opened the bag and confirmed it was vegetables and not ice. The CDM said,It needs to be thrown out. It felt like ice An interview was conducted on 12/11/24 at 10:15 a.m. with the Maintenance Director and Regional Maintenance Director. They observed the wires and insulation in the middle of the kitchen floor and said it should be covered with a box, not exposed. An interview was conducted on 12/11/24 at 10:18 a.m. with the Assistant Dietary Director. She said the milk crates should not be sitting on the floor in the walk-in refrigerator. She looked at the dirty containers in the kitchen and said they should be cleaned daily. She looked inside the drawer of the two drawer storage container and said she did not know why food was in there with nonfood items. She was also observed looking at the food preparation tables and confirmed they have rust and corrosion on them. An interview was conducted on 12/11/24 at 12:30 p.m. with a service representative from the dishwashing chemical company. He reviewed the pictures of the sanitation test strips and confirmed the chemical concentration did not reach 50 PPM. He said they chemicals should have been tested on a plate surface instead of the trough and the concentration would probably be less there. He said the machine should be run 2-3 times then tested to ensure the temperature was up to 120 degrees Fahrenheit and the chemical sanitizer reached 50 PPM prior to washing dishes. A review of the facility's policy titled, Dishwasher Temperature, revised 10/19/2022 showed the following: Policy statement: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperature. A further review of the policy, showed the following explanation and compliance guidelines: 4. For low temperature dishwashers (chemical sanitization) a. The wash temperature shall be 120 degrees Fahrenheit. b. The sanitizing solution shall be 50-100 PPM (parts per million) hypochlorite chlorine on dish surface in final rinse. 5. If needed, run several empty dish racks through dishwasher to obtain the correct temperature and parts per million. 6. Chemical solutions shall be maintained at the correct concentration, based on periodic testing at least once per shift , and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 7. Water temperature shall be measured and record prior to each meal and/or after the Dishwasher has been emptied or re-filled for cleaning purposes. 8. Immediate action will be taken if dishwasher temperatures and/or chemical levels are inadequate. A review of the facility's policy titled, Food Safety Requirements, revised on 10/19/2022, showed the following: Policy statement: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety. Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. a. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. c. f. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. . b. Dry food storage-keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. d. Refrigerated storage foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. ii. iii. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use -by date, or frozen (where applicable)/ discarded; and v. Keeping foods covered or in tight containers. 6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. a. Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. b. 7. Staff shall adhere to safety hygienic practices to prevent contamination of foods from hands or physical objects a. Staff shall wash hands according to facility procedures. (Photographic evidence obtained).

Based on observations, staff interviews, and facility record review, the facility failed to ensure a working and properly maintained dish washing machine in the kitchen, during two of four days observed, (3/18/2024, and 3/19/2024). It was determined the low temperature chemical sanitizer dish washing machine either; 1. Was not meeting required wash and rinse temperatures, and 2. The chemical sanitizer was allocated and delivered well over acceptable ranges. Findings included: On 3/18/2024 at 9:10 a.m. an observation of the kitchen was conducted with Staff C, Dietary Manager, Staff C revealed the facility operates a low temperature dish washing machine and the expectations for wash temperatures was 125 degrees Fahrenheit (F)., and rinse temperatures was 125 degrees F. She was asked what the sanitizer level Parts Per Million (PPM) should range, and she replied, over 100 ppm. The dish washing machine was observed and the specification plate posted on the front revealed it was a low temperature chemical sanitizing machine where the wash temperature should reach 120 degrees F., the rinse temperature should reach 120 degrees F. and the chemical sanitizer should reach a ppm of 50 - 100. At 9:40 a.m. the kitchen was again toured with Staff C, Dietary Manager. Staff D and Staff E, Dietary Aides were noted in the dish machine area and starting to load crates with dishes into the machine. Staff C then stated, I will be back, I need to leave the kitchen to go out to my car and call the Dietician. She left the kitchen at 9:43 a.m. Continuing the kitchen tour, Staff D was observed to start running crates of dishes through the dish washing machine. At 9:52 a.m. (over nine minutes later), Staff C returned to the kitchen. At this time, Staff D had completed three crates of dishes through the machine. Staff C was asked if she or her staff could now perform a demonstration on how the dish machine operated. At 9:58 a.m. an interview with Staff D, Dietary Aide revealed he had been working in the facility for awhile and he uses the dish washing machine every day. Staff D explained the dish machine was a low temperature chemical sanitizing machine and explained the wash temperature should reach around 140 degrees F. and the rinse temperature should reach around 125 degrees. After consultation of the specification plate on the machine, he said the wash temperature should reach 120 degrees F., and the rinse temperature should reach 120 degrees F. Continuing the interview, Staff D confirmed there was chemical which ran through the dish machine, and the sanitizer level is tested via litmus paper test strips. He stated the test strips should show 200 ppm, before correcting himself, stating 200 ppm was for the three compartment sink sanitizing agent, and the dish machine should be at 50 ppm. At 9:59 a.m. Staff D was asked to run a crate of dishes through the machine when he was ready. Staff C confirmed the machine was operating correctly with both the water temperatures and the chemical sanitizer level. Once the crate of dishes were placed in the machine, and during the wash cycle, observation showed the temperature reached a maximum of 118 degrees F. After the wash cycle ended, the rinse cycle started and continued observation showed the rinse water temperature reading 117 - 119 degrees F. The temperature readings were found on an analog thermometer gauge attached to the machine. Staff C then grabbed a cylinder container of paper litmus test strips and pulled one out and placed it in the water return catch tray on the machine to test the chemical sanitizer ppm. He kept the test strip in the catch tray for about ten seconds and pulled it out and placed it on top of the litmus paper test strip bottle, which had color ranges. The test strip was a very deep blue/purple color, which indicated the ppm was over 200. Staff C confirmed the ppm on this test was over 200 ppm. Photographic evidence was taken. At 10:01 a.m. Staff D was asked to do a second demonstration of the use of the machine. Staff D pushed a crate full of soiled dishes through the machine and started the wash. The analog gauge was observed to reach a maximum of 117 degrees F. The machine then clicked and the rinse cycle started, and during the cycle the analog temperature gauge reached an maximum of 118 degrees F. Staff D and Staff E both confirmed the needle on the gauge was below the 120 degree F. mark and it should be 120 degrees F. and above. After the wash/rinse cycle Staff D was asked to test the chemical sanitizer again and he proceeded to take a new paper litmus test strip and placed it in the water catch tray. He held the strip in for ten second and removed it and placed it on the test strip bottle. The test strip was observed a very dark blue/purple color and when placed on the test strip bottle confirmed the ppm was over 200 ppm. Staff D confirmed there was too much sanitizer going through the machine. Staff C, Dietary Manager returned, and looked at the bottle legend and the strip and confirmed the color denoted over 200 ppm and said the machine should not be allocating that much sanitizer. She confirmed the ppm should be in a range of 50 - 100 ppm, which should be a very light blue/light purple color. Staff C provided the dish washing machine temperature logs for the past three months for review. It was determined for each meal service (breakfast, lunch, and dinner), and each day of the month, it was documented temperatures for wash and rinse reached over 120 degrees F. It was further revealed staff had documented for each meal service, the chemical sanitizer ppm reached 100. Staff C, Dietary manager only provided months 12/2023, 1/2024, and 2/2024 for review. Staff C was asked during the course of the survey for the logs 3/18/2024 through 3/21/2024, to include the current 3/2024 month's log, but was able to provide, or provide a reason for their absence. Therefore, it could not be identified if the machine was running at appropriate temperatures for the last twenty-one days in 3/2024. On 3/18/2024 at 2:00 p.m. Staff C provided paperwork to show the dish machine maintenance company previously came out to assess and fix the machine related to low wash and rinse temperatures. The report which was dated 2/23/2024 at 9:07 a.m. revealed upon testing, the machine wash temperature was at 109 degrees F., and the final rinse temperature was at 109 degrees F. The test further revealed a chemical sanitation test reading 100 ppm. The notes reflected: Water temp is too low, only at 109 degrees F. and should be 120 - 159 degrees F. Staff C also provided a maintenance request log which revealed date 3/15/2024, Temperature not adequate. Maintenance Department notified. The log revealed an action performed to include; Adjusted temperature on the boiler to 130 degrees F. and Monday was adjusted again to 125 degrees F. on the dishwasher. On 3/19/2024 at 8:45 a.m. Staff C was interviewed and confirmed staff should be running the dish machine around 9:30 a.m., 9:40 a.m. She replied, to be fair when you [state surveyor] tested the dish machine temperatures the day before on 3/18/2024, they had not primed the machine and her staff had not ran any dishes through the machine yet. Staff C was reminded in her absence from the kitchen on the previous day Staff D and Staff E were observed running three crates of dishes through the machine. Staff C responded, oh, I didn't know my staff ran crates of dishes when I left the kitchen to make a call to the dietician. On 3/19/2024 at 9:50 a.m. the kitchen was toured with the Staff C, Dietary Manager. She revealed the dish machine was operating appropriately and she had inserviced her staff how to use the machine and how to identify errant temperatures. Staff D, Dietary Aide was observed operating the machine and stated he had already ran crates of dishes through the machine. He noted he had been using the machine for approximately five to ten minutes. Staff D was asked to do a demonstration and the following was observed: The first demonstration at 9:53 a.m. revealed per review of the analog gauge, the wash temperature reached a maximum of 118 degrees F. The rinse temperature reached 121 degrees F. Staff D stated the gauge was wrong and maintenance had come in yesterday and used a digital thermometer to take the temperature of the wash and rinse cycle. Staff D revealed he did not have a stick analog or digital thermometer and that he nor Staff E did not use any thermometers today to see if the temperatures reached 120 degrees F. for the wash or rinse cycles. After the wash and rinse cycle was completed, Staff D then tested the sanitizer by using a litmus paper test strip. The results of the test strip revealed a very dark blue/purple color with a range of over 150 - 200 ppm. Staff D revealed the PPM should be at 50 - 100 ppm. At 9:55 a.m. Staff D performed a second dish washing machine demonstration. It was determined per review of the machine's analog temperature gauge, the wash temperature reached a maximum of 119 degrees F. and the rinse cycle temperature reached 121 degrees F. Staff D also tested the sanitizer by inserting a litmus paper test strip in the water catch container of the machine. The paper turned dark blue/purple and indicated the chemical sanitizer PPM was over 150 - 200 ppm. Staff D confirmed the results of the PPM was too high and he had mentioned this to Staff C. Staff E also confirmed the dietary manager had been told the machine had not been working appropriately in the past. Both Staff D and Staff E declined to comment further. Staff C revealed they would be using the three compartment sink to wash all the dishes and would do so at 12:00 p.m. On 3/19/2024 at 11:33 a.m. an interview was conducted with Staff C and an outside service technician who maintains the dish machine. The technician revealed he was out at the facility just last month in 2/2024 and had to make adjustments to the machine water temperature, as the temperatures were not meeting the low temperature machine specifications. He believed his report revealed the wash and rinse temperatures were only reaching 109 degrees F. and he had to increase the booster temperature to meet 120 degrees F. for wash and 120 degrees F. for rinse. The technician further revealed he had tested the sanitizer and it met requirements to be between 50 - 100 ppm (parts per million). He further revealed he did not have to do anything else back in 2/2024 with the dish machine during that visit. The technician confirmed verbally, and pointed out the machine specifications plate, that the machine was to be operated as a low temperature chemical sanitizing machine, with wash temperatures to reach 120 degrees F., and rinse temperatures to reach 120 degrees F. He further again confirmed that the chemical sanitizer range should be within 50-100 ppm. The technician revealed he was called out to the facility today on 3/18/2024 to look at the wash and rinse temperatures and found that the analog gauge on the machine was not working properly and he had to order a new one. He revealed the acceptable water temperature testing each shift would be to use a digital stick thermometer in the water return catch can on the machine to test water temperatures until a new gauge is installed. He was not sure when the new gauge would arrive and be installed. The technician revealed he had been called out to the facility again today, on 3/19/2024 because of a complaint there was too much sanitizer overflowing into the machine. The technician revealed the problem with the machine was a cam wheel was open too much and that was the reason for getting too much sanitizer. It was determined the dish machine was not working appropriately to include heavy use of sanitizer allocated for two days 3/18/2024, and 3/19/2024, and affecting at least four meal services in between those dates. A policy related to the use and maintenance of the dish washing machine was requested; however, the facility was unable to provide by completion of the survey.

Based on observations, interviews, and record review, the facility failed to provide a clean and homelike environment for one resident unit (Secured Unit) out of two resident units in the facility. Finding included: 1. An observation on 03/18/24 at 10:27 a.m., revealed the secured unit dayroom had ceiling tiles that were pushed up and not flush with the ceiling. The blinds that hung in the window of the dayroom were broken and pulled apart. The walls in the secured unit dayroom were scratched and a piece of the wall near the locked storage closet was cracked. The main door of the dayroom was scratched and was missing paint. During an interview on 03/20/24 at 11:30 a.m., Staff F, Director of Maintenance (DOM) stated Staff I, Maintenance Worker (MW) just changed the blinds in the window this morning. Staff J, DOM stated staff saw Surveyor taking pictures of the blinds. Staff J, DOM was interviewed and shown the piece of wall near the locked storage closet that was cracked. Staff J, DOM stated he had extra pieces to this wall and could get that fixed today. Staff J, DOM recognized the two ceiling tiles that were pushed up from the ceiling exposing the roof area and stated, Yes, I just fixed a tile like that in the kitchen today. Staff J, DOM pointed out a third tile in the ceiling that had a hole in it and stated it would need to be fixed as well. Staff J, DOM was then directed to the main door of the secured unit dayroom. Staff J, DOM confirmed the door was scratched and was missing paint and stated it would look so much better with a new coat of paint on it. Staff J, DOM stated I got some paint last week, I could have that painted in about 45 minutes. Staff J, DOM stated these concerns were not in the maintenance log or brought to maintenance attention. Staff J, DOM stated he expected staff to report environmental concerns to maintenance when items in the facility were damage or needed to be repaired. During an interview on 03/20/24 at 11:37 a.m., Staff I, MW confirmed he was just instructed to replace the blinds in the secure unit dayroom this morning because they were broke and in poor repair. Review of the facility's policy Safe and Homelike Environment dated 07/24/23 showed, Orderly is defined as an uncluttered physical environment that is neat and well-kept. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 37999 2. On 3/18/24 at 9:43 a.m. an observation was made of two lumps of a brown substance on the floor of a small alcove next to the patio entrance in the memory care unit, and a white powdery substance was observed on an over-bed table located in the alcove. On 3/18/24 at 10:01 a.m. an observation was of an uncovered dusty ceiling vent in the bathroom of room [ROOM NUMBER]. On 3/18/24 at 10:24 a.m. an observation revealed a brown substance was smeared on the wall of the alcove near the patio entrance on the memory care unit. Two dressers were observed in the alcove, one contained personal belongings and the other contained an incontinent device, the outside of both dressers were stained with an unknown substance. On 3/18/24 at 10:35 a.m., an observation was made in the bathroom of room [ROOM NUMBER] of a hole in the wall and missing floor tiles under the sink. On 3/18/24 at 12:03 p.m. an observation was made of a missing transition between the bathroom and room in room [ROOM NUMBER]. Photographic evidence was obtained.

Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#7, #13, #14, #20, #50, #53, #65, #80, #88 and #170) of fifteen residents sampled for PASRR review. Findings included: 1. A review of the Admission Record showed Resident #65 had an original admitted [DATE] with diagnoses including repeated falls, essential hypertension, and unspecified psychosis not due to a substance or known physiological condition. Review of Resident #65's annual Minimal Data Set (MDS) assessment, dated 12/31/23, revealed under Section C-Cognitive Patterns, Resident #65 had a Brief Interview for Mental Status (BIMS) of 00 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #65 had diagnoses of Non-Alzheimer's Dementia and Psychotic disorder. A review of Resident #65's Level I PASRR assessment, dated 01/19/21 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections psychotic disorder was not checked. During an interview on 03/21/24 at 11:51 a.m., the Director of Nursing (DON) confirmed Resident #65's PASRR was inaccurate at admission and should have reflected the diagnosis of Psychotic Disorder. The DON stated because Resident #65's PASRR was inaccurate a new PASRR should have been re-submitted to reflect Resident #65's admitting diagnosis. 20536 2. On 3/18/24 at 10:00 a.m., 3/19/24 at 1:00 p.m., and on 3/20/2024 at 7:30 a.m. Resident #7 was observed in his room and either seated in his wheelchair or was lying in bed. Each time observed, Resident #7 was observed dressed for the day and not presenting with any behaviors, pain, or discomfort. Resident #7 was pleasant to speak with and was able to speak related to his medical care and services. Resident #7 confirmed he had been routinely seen and assisted by a psychologist and felt the services helped him. Review of Resident #7's medical record, revealed he was admitted to the facility on [DATE]. Review of the advance directives section of the chart revealed Resident #7 was his own responsible party but had family as emergency contacts only. Review of the admission diagnosis sheet revealed the following but not limited to diagnoses; BiPolar disorder (onset date 10/11/2016); Epilepsy (onset date 12/15/2020); Major Depression (onset date 7/5/2022); Anxiety (onset date 7/5/2022) and (onset date 1/10/2023). Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 2/1/2024 revealed; (Cognition/Brief Interview Mental Status or BIMS score - 13 of 15, which indicated Resident #7 would be able to answer questions related to his care and service.) Review of the medical record revealed two Level 1 Pre Admission Screening Resident Review (PASRR) tools/assessments. The following PASRRs revealed; -Level 1 PASSR completed by an Assistant Registered Nurse Practitioner (ARNP) from a outside agency on 9/23/2016. Under section I (a) of the PASRR screen, which asks what type of Suspected Mental Illness (SMI) the resident had; revealed it was only checked for Other diagnosis - TBI. Section I (b) was not checked for any Intellectual Disability (ID). Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #7 was not in the need for a Level 2 PASRR to be completed. It was determined upon admission Resident #7 had a diagnosis of BiPolar disorder with an onset date of 10/11/2026. This diagnosis was not identified on the 9/23/2016 Level 1 PASRR. -Level 1 PASRR screen on 10/12/2016, competed by a Registered Nurse from the current facility. Review of Section I (a) of the PASRR screen, which asks what type of SMI the resident had; revealed diagnoses to include Bipolar disorder, and Depression disorder. There was nothing checked in Section I (b). Also, Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #7 was not in the need for a Level 2 PASRR to be completed. During Resident #7's admission he had developed diagnoses to include Epilepsy with an onset date of 12/15/2020. Neither of the current Level 1 PASRR screens identified Resident #7 of having Epilepsy in Section I (b). There was no other Level 1 PASRR screens in the electronic record that reflected Resident #7 with a diagnosis of Epilepsy. On 3/21/2024 at 1:00 p.m. the Director of Nursing revealed the above mentioned Level 1 PASRR screens were conducted well before his employment at the facility, but did confirm when a resident develops any SMI or ID diagnosis, a new and revised Level 1 PASRR should be completed. He confirmed Resident #7 had a diagnosis of Epilepsy and neither of the current Level 1 PASRR in the chart reflected this diagnosis. On 3/18/24 at 10:15 a.m. and on 3/19/24 at 7:45 a.m. Resident #20 was observed in her room and was either lying in bed or was noted in a wheelchair at bedside. An attempted interview revealed she did not speak when she was spoken with. She appeared to just want to be in her room and left alone. Resident #20 had been observed dressed for the day and well groomed. She was not otherwise presenting with any behaviors, pain or discomfort. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed Resident #20 had a guardian in place to make her medical and financial decisions. Review of the admission diagnosis sheet revealed diagnoses to include: Cerebral Palsy (onset date 10/19/2015); Schizoaffective Disorder (onset date 2/9/2021), Bipolar Disorder (onset 10/19/2015), Schizophrenia (onset date 10/19/2015.) The record revealed an incapacity statement signed and dated by the Medical Doctor on 1/23/2013. Review of the medical record revealed a Level 1 PASRR screen dated 12/15/2010, and was completed by a Registered Nurse at a Hospital. The Level 1 PASRR screen revealed primary diagnosis to include: Scoliosis, Cerebral Palsy; and with a secondary diagnosis of Schizophrenia. It was determined at Resident #20's admission, she also had a diagnoses to include Bipolar disorder with an onset date of 10/19/2015. The PASRR dated 12/15/2010 did not identify Resident #20 of having BiPolar disorder, nor were there any other Level 1 revised or new Level 1 PASRR in the chart that identified Resident #20 having a SMI diagnosis. On 3/21/2024 at 1:00 p.m. the Director of Nursing confirmed Resident #20 had a diagnosis of BiPolar and it should have been identified in the SMI diagnosis section with a more current and revised PASRR. 50434 3. On 03/18/2024, 03/19/2024, 03/20/2024 Resident #53 was observed either in her room and in bed, in her room and seated in a wheel chair, or seated in therapy doing exercises, or hanging out in the front lobby area. Resident #53 had been dressed for the day and was not presenting with any behaviors, pain or discomfort. The room was clean and free from foul odors. Review of Resident #53's medical record, revealed she was admitted to the facility on [DATE]. Review of the advance directives section of the chart revealed Resident #53 had a responsible party to make her medical and financial decisions. Review of the admission diagnosis sheet revealed the following diagnoses; Adjustment Disorder with mixed Anxiety and Depressed Mood (11/29/2023); Pseudobular Affect (11/07/2023) Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 01/29/2024 revealed; (Cognition/Brief Interview Mental Status or BIMS score - 07 of 15, which indicated Resident #53 would not be interview able.) Review of the medical record revealed one Level 1 Pre Admission Screening Resident Review (PASRR) tools/assessments. The following PASRR revealed; Level 1 PASSR completed by an Completed by RN at an outside facility on 08/16/2023. Under section I (a) of the PASRR screen, which asks what type of Suspected Mental Illness (SMI) the resident had; revealed it was not checked for any diagnosis. Section I (b) was not checked for any Intellectual Disability (ID). Section II (1, 2, 3, and 4) were not checked with yes, which would indicate a Level 2 PASRR would need to be completed. It was determined Resident #53 was not in need for a Level 2 PASRR to be completed. During Resident #53's admission she had developed diagnoses to include Adjustment Disorder with mixed Anxiety and Depressed Mood with an onset date of 11/29/2023. Neither of the current Level 1 PASRR screens identified Resident #53 of having Adjustment Disorder with mixed Anxiety and Depressed Mood in Section I (b). There was no other Level 1 PASRR screens in the electronic record that reflected Resident #53 with a diagnosis of Adjustment Disorder with mixed Anxiety and Depressed Mood. The facility failed to update the Level 1 PASSRR Screening to reflect the current diagnosis for Resident #53. On 3/21/2024 at 1:00 p.m. the Director of Nursing confirmed Resident #53 had a diagnosis of Adjustment Disorder with mixed Anxiety and Depressed Mood and the current Level 1 PASRR in the chart reflected this diagnosis. 48823 4. On 3/20/2024 at 9:20 AM Resident # 170 was observed sitting on the side of his bed. Resident stated he had open heart surgery on 12/8/2023 which left him with no use of his right hand, a tracheostomy, and a feeding tube. The feeding tube had been removed and healed and the tracheostomy had been removed and he still had a small area to heal. He has had his colostomy since 2018 post surgery for a bowel obstruction. He stated he lost both of his sons but did not elaborate. The resident uses oxygen at three liters via nasal cannula continuously. Review of admission record, dated 3/20/2024, revealed Resident #170 was admitted on [DATE]. with diagnoses of: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Type two Diabetes Mellitus, Morbid (severe) Obesity, Colostomy, Pneumonitis due to inhalation of food and vomit. Review of medical certification for Medicaid long-term care services and patient transfer form (AHCA Form 5000-3008) for Resident #170, dated 3/7/2024, revealed: primary diagnosis - pneumonia, chronic obstruction pulmonary disease exacerbation, patient wears glasses, is on insulin, anticoagulants, has methicillin-resistant staphylococcus aureus (MRSA0 in his nasal area, no attached reports, incontinent, colostomy left lower abdomen, ambulates with an assistive device - wheelchair, requires assistance of one, skin care with a stage two on right buttock. Review of the Level I Preadmission Screening and Resident Review for Resident #170 dated 2/20/24 revealed: Level I Section 1 A Bipolar Disorder, B finding based on documented history, no level II PASRR required. No attached identifying documentation Review of the Level Preadmission Screening and Resident Review for Resident #170 dated 3/13/2024 revealed: Level I Section I B finding based on documented history no Level II PASRR required. No attached identifying documentation Review of Minimum Data Set (MDS) Resident assessment and Care Screening dated 3/11/2023 for Resident #170 revealed: Section C - Cognitive Patterns - Brief Interview for Mental Status (BIMS) Summary Score 15, indicating the resident was cognitively intact. An interview was conducted with the Director of Nursing (DON) on 3/21/2024 at 1:30 PM. The DON stated that when a resident has a psychiatric or psychotherapy evaluation the nursing department is responsible to review the evaluation and update the PASRR if needed and the person in nursing that is accountable is the DON. 37999 5. Review of Resident #14's Admission Record showed the resident was admitted on [DATE] with the diagnoses of Pseudobulbar affect (PBA), unspecified mood (affective) disorder, unspecified anxiety disorder, moderate recurrent major depressive disorder (MDD), cognitive communication deficit, and unspecified severity unspecified dementia with other behavioral disturbance. Review of Resident #14's Preadmission Screening and Resident Review (PASRR), dated 3/4/19, showed the resident had Mental Illness (MI) diagnoses of anxiety and depressive disorders. The PASRR did not reveal the resident had a secondary diagnosis of dementia and a Level II evaluation was required and did not include the resident's diagnosis of PBA. During an interview on 3/21/24 at 12:02 p.m. the Director of Nursing (DON) stated Resident #14's PASRR should have been redone. Review of Resident #80's Admission Record showed the resident was admitted on [DATE] with secondary diagnoses of severe unspecified dementia with other behavioral disturbance, and cognitive communication deficit. The record included other diagnoses of unspecified recurrent major depressive disorder (onset 10/10/23) and unspecified persistent mood (affective) disorder (onset 6/13/23). Review of Resident #80's PASRR, dated 2/6/23, showed the resident did not have any Mental Illness (MI) or suspected MI (SMI), or Intellectual Disability (ID). The PASRR showed the resident had a disorder resulting in functional limitations of major life activities, had serious difficulty in concentration, persistence, and pace, and had a serious difficulty of adaption to change. The PASRR revealed the resident's primary diagnosis was dementia. The PASRR revealed Resident #80 was admitted under a 30-day Hospital Discharge Exemption and if the resident's stay was anticipated to exceed 30 days the Nursing Facility (NF) must notify the Level I screener on the 25 th day of stay and the Level II evaluation must be completed no later than the 40 th day of admission. The evaluation showed a Level II PASRR was not required. During an interview on 3/21/24 at 11:57 a.m., the Director of Nursing stated Resident #80's PASRR was a definitely resubmit. Review of Resident #13's Admission Record showed the resident was admitted on [DATE]. The record revealed the primary diagnosis of the resident was depressive-type schizoaffective disorder (onset 2/16/21), and other diagnoses of moderate recurrent major depressive disorder (onset 8/2/22), unspecified mood disorder due to known physiological condition (onset 6/9/22), unspecified anxiety disorder (onset 6/9/22), other specified eating disorder (onset 6/9/22), and tertiary diagnosis of unspecified recurrent major depressive disorder. Review of Resident #13's Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview of Mental Status (BIMS) score was 6 out of 15, indicating a severe cognitive impairment. Review of Resident #13's PASRR, dated 9/12/13, revealed the resident had a Serious Mental Illness of Schizophrenia with a serious difficulty of concentration, persistance, and pace and had experienced an episode of significant disruption resulting in an intervention by housing or law enforcement officials. The evaluation revealed the resident was being admitted from a hospital after receiving acute inpatient care and required Nursing Facility services fro the condition received in the hospital. A Level II was determined to be required prior to the facility admission. Review of Resident #13's Level II Determination report showed the resident had a mental health diagnosis of Undifferentiated type Schizophrenia with an unknown onset date. The evaluation revealed a Brief Interview of Mental Status was conducted and indicated a score of 13 which suggests intact cognitive status. Review of Resident #13's Level I and Level II PASRR evaluations did not included the diagnoses of schizoaffective disorder, moderate recurrent major depressive disorder, unspecified mood disorder due to known physiological condition, unspecified anxiety disorder, and other specified eating disorder was not included in the evaluations. (The resident's care plan showed a diagnosis of Pica). During an interview on 3/21/24 at 12:02 p.m., the Director of Nursing stated Resident #13's PASRR and Level II should have been redone. Review of Resident #88's Admission Record revealed the resident was admitted on [DATE] with a primary diagnosis of unspecified Alzheimer's disease. The record included additional diagnoses of severe vascular dementia with other behavioral disturbance (onset 11/29/22) and generalized anxiety disorder (onset 6/13/23). Review of Resident #88's PASRR, dated 6/6/22, did not reveal the resident had any Mental Illness or Intellectual Disability, and did not have a primary diagnosis of a related neurocognitive disorder (Alzheimer's disease). The PASRR revealed 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 Serious Mental Illness, Intellectual Disability, or both. The PASRR showed a Level II evaluation was not required. During an interview on 3/21/24 at 12:06 p.m., the Director of Nursing reviewed Resident #88's PASRR and stated it should have been redone. The DON stated when a resident gets a new diagnosis, the PASRR should be redone. Review of Resident #50's Admission Record revealed the resident was admitted on [DATE] and a readmission on 3/14/23. The record showed the resident was admitted with a primary diagnosis of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The record included diagnoses of unspecified anxiety disorder (onset 8/7/23), and unspecified recurrent major depressive disorder (onset 8/31/20). Review of Resident #50's PASRR, dated 8/12/20, revealed in Section I a diagnosis of depressive disorder and was receiving services for mental illness (MI). The evaluation showed in Section II the indicators for decision-making showed the resident had a disorder resulting in functional limitations, serious difficulty with interpersonal functioning, concentration, persistence, and pace, and a serious difficulty with adaption to change. The PASRR revealed the resident had received treatment for MI with psychiatric treatment more intensive than outpatient care and an episode of significant disruption to normal living situation. The PASRR revealed a Level II PASRR evaluation must be completed prior to admission if any box in Section I.A. or I.B. is checked and there is a yes checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. The PASRR showed the resident did have a primary diagnosis of dementia with validating documentation. 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 of diagnosis of an Serious Mental Illness, Intellectual Disability, or both. The evaluation showed the resident may not be admitted to the Nursing Facility as a Level II was needed and telephone consent for a Level II was obtained. The resident's electronic record did not include a Level II evaluation for Resident #50 nor did the facilty provide one. The PASRR did not include the resident's diagnosis of anxiety disorder. During an interview on 3/21/24 at 11:51 a.m., the Director of Nursing (DON) reported having to look at the Past Medical History (PMH) to be considered a Serious Mental Illness (SMI) and schizophrenia would trigger a Level II, so if there were hospitalization s or receiving mental health services would trigger a Level II or a ID, if dementia, might not only if there is mental health also. The DON reported a Performance Improvement Plan (PIP) was started a month ago, the Social Service Director (SSD) would audit the PASRR's and if something was noted, the DON was notified and it was addressed. Review of the PASRR Completion PIP, dated 2/1/24, showed the Quality review for all current residents PASRR's was completed to ensure accuracy and prompt completion, the status of this action step was documented as complete. The policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22, showed This facilty 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. The guidelines directed: - 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. - 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability has determined as appropriate for admission. - 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observations, interviews, and record review the facility failed to have activities available and provide adequate space for activities for 52 residents residing on one of one memory care units. Findings included: The initial tour of the memory care unit was conducted on 3/18/24, the observation of the unit and resident rooms did not reveal any posted activity calendar. On 3/18/24 at approximately 10:00 a.m., Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), took approximately 6-7 memory care residents outside to a patio to play with a football. On 3/18/24 at 10:04 a.m., an observation was made of 12 residents sitting, either in a dining chair or wheelchair, in the day room on the memory care unit. The television was playing a sitcom. Staff M, Patient Care Assistant (PCA) was sitting in the corner of the room without any verbal or physical interaction with the residents. Staff K, Certified Nursing Assistant (CNA) directed an ambulatory male resident into the room then left the area. The male resident leaned up against the wall, Staff M stood up, pushed wheelchairs out of the way (from middle of room) and directed the resident to a dining chair. A continued observation of the memory care's day room revealed 12 residents in the room, without a staff member and the sitcom continued. The residents were in sitting at tables along walls or in wheelchairs in different positions throughout the room. The area did not reveal any other activities were ongoing. The approximated dimensions of the memory care units dining room was 14 feet (ft) x 16 ft and a section 8 ft x 6 ft for approximate square footage of 272 sq ft, five 3 ft x 3 ft (approximate) tables were in the room (45 square ft), 272 sq ft - 45 sq ft = 227 sq ft. 227 sq ft divided by 12 residents and one staff member = 17.46 sq ft per person, approximately a 4.2 ft square per person in the dining room. On 3/18/24 at 9:54 a.m. Resident #54 was observed ambulating in the hallway of the memory care unit pushing a wheelchair. On 3/18/24 at 10:45 a.m., Resident #54 was observed sitting in the day room with 11 other residents with the television playing. The resident was sitting in the middle of the room in between tables lining the walls with others residents sitting in wheelchairs. Staff M was sitting in the corner of the room without any interaction with residents. On 3/21/24 at 9:41 a.m. Resident #54 was observed sitting in hallway across from nursing station with other residents when Staff G asked if the resident wanted to go for coffee (off unit). On 3/18/24 at 10:00 a.m., Resident #23 was observed sitting on side of bed, yelling about getting self up. On 3/18/24 at 10:52 a.m., Resident #23 was observed sitting in hallway across from the nursing station with other residents. The observation revealed no activity was occurring. On 3/18/24 at 10:52 a.m., Resident #23 was observed sitting in hallway across from nursing station, no activity was occurring in the area. On 3/20/24 at 11:00 a.m., Resident #23 was observed coming from outside patio, grasping handrail with left hand, utilizing the handrail to propel self in wheelchair. On 3/18/24 at 10:51 a.m., Resident #50 was observed sitting in wheelchair outside the door of the memory care's dining room, across from nursing station. The observation revealed no activities were ongoing other than a television playing in the dining room. On 3/21/24 at 9:43 a.m. Resident #50 was observed in the unit's dining room with seven (7) other residents with movie playing on the television. The observation revealed one of the seven residents was facing the hallway, one was facing out the window, one resident was in the corner adjacent to the television, and one was sitting under the television with head bowed down. Staff A began encouraging residents to use hand sanitizer and handed a bottle to a staff member sitting in the corner. Resident #50 was taken from the dining room to the resident room. On 3/18/24 at 11:48 a.m., 13 residents were observed in the dining area of the memory care unit. Unknown staff member brought a male resident into the room, having to move a female resident away from a table where she sat to place the male resident in the room. On 3/18/24 at 1:40 p.m., Staff A, Registered Nurse (RN) came out of the nursing station and asked residents (who were sitting around the station) if they wanted hand sanitizer then the staff member started up music. On 3/18/24 at 2:33 p.m., an observation of the memory care unit did not reveal any ongoing activities for the residents who were sitting around the nursing station. On 03/19/24 4:01p.m., an observation was made of nine (9) residents sitting in wheelchairs and dining chairs around the memory care nursing station. At the same time nine (9) residents were observed in the dining room with 4 residents facing the television, two with eyes open and five residents not facing the television. No other activity was occurring. An interview was conducted with the Recreation Director on 3/20/24 at 9:14 a.m. The staff member stated activities in the memory care unit have to do more with calming, do a lot of music, and do a lot outside. She reported a previous aide (who used to work at facility) came back to assist with activities today and tomorrow. She stated the more high functioning residents were taken to the main Dining Room for activities, coffee, games, parties, church, and bible studies when the unit was not on isolation. (Memory care unit has been on isolation for COVID+ resident (#80)). The director reported unit activities included a lot of crafts, having markers and papers printed off computer, life reminiscing about past and things, and coffee at 10:00 a.m. She pointed to a bright yellow and pink rolled up material and small ball on desk, saying she saw Staff G with parachute and ball. The director pointed to a closed door beside the patio entrance and reported it was the activity room and had a posted Activity calendar, however, the room needed to be deep cleaned, it had a smell. An observation of the room with the Recreation Director and Staff G was made, revealing a room with a sewer-type smell and multiple totes of activity materials and a large Activity calendar was posted on the wall. (photo of calendar obtained) The Director reported not having any documentation regarding which resident did what activity or who had attended any of the activities, probably should, will start. The Director reported not having an assistant for approximately one month, relies on staff to assist with activities. The calendar posted in the closed Activity room of the memory care unit revealed on 3/18 the following activities had been scheduled with times: - 9:00 a.m. Stretch - 10:00 Coffee Social - 11:00 Sunshine stroll - 1:30-3:30 Quiet time - 2:00 Snacks and Drinks - 2:00 Bible Study with [NAME] - 3:15 Music Therapy - 4:00 Sunshine Time On 3/20/24 at 9:32 a.m., the Recreation Director stated Resident #80 enjoyed music and coffee, likes to walk so the resident will go outside and walk, loves music and snacks. The staff member reported snacks are provided on the unit at 10 a.m. and 2 p.m. The Director stated the activity room had been closed for a week and games and puzzles were kept in there. An observation was made on 3/20/24 at 9:43 a.m. of Staff G reporting to the Recreations Director residents were going to be taken outside and informing the director residents could be taken off the unit for coffee. The Director took 4 residents, including Resident #80 off unit for coffee. An observation on 3/20/24 at 9:46 a.m. showed seven (7) residents in the dining room with television playing. Five of the seven residents were not watching the movie, heads were bent down, and no interaction was occurring between Staff M (sitting in corner) and an unknown female aide standing in the doorway facing the television. An observation on 3/21/24 at 11:27 a.m. revealed 11 residents sitting in the unit's dining room with Staff Y, CNA, sitting in corner. The staff member reported only interacting with residents if they talk to her. One of the eleven residents in the room appears to be watching the movie, no other activity occurring in the room. The staff member stated residents could pick the movie if they wanted to. An observation on 3/21/24 at 11:33 a.m. revealed Staff G had 14 residents on the patio listening to music and playing with parachute. An interview was conducted with Staff L, CNA, at 3/21/24 at 11:37 a.m. The staff member reported staff do not document specific activities but do document when a resident participates in an activity. Review of Resident #54's Admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified persistent mood (affective) disorder, and cognitive communication deficit. Review of Resident #54's Admission Minimum Data Set (MDS), dated [DATE], showed listening to music was somewhat important to the resident. Review of Resident #23's care plan revealed the resident required assistance with activity participation, identified as Catholic, always enjoys exercising/walking, being outdoors, TV/movies, coffee and music, and needed verbal invites, encouragement, and escort. The goal was the resident would attend/participate in/with activities of preference at least 3-5 times (x) weekly as tolerated/as will allow thru Next Review Date (NRD). Review of Resident #54's Quarterly/Comprehensive Participation Review, dated 1/8/24, revealed the resident resided on the memory care unit, attended and participated in/with activities of preference mostly on unit but was verbally invited and escorted to parties and music off unit. Progress toward the resident's goal was met. Review of Resident #54's March CNA Task documentation did not reveal any documentation of activities the resident had participated in or had refused. Review of Resident #23's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to bipolar-type schizoaffective disorder, unspecified intellectual disabilities, and Parkinson's disease without dyskinesia without mention of fluctuations. Review of Resident #23's Quarterly MDS, dated [DATE] revealed a Brief Interview of Mental Status score of 5 out of 15 indicating a severe cognitive impairment. The Annual MDS, 10/27/23, revealed listening to music participating in favorite activities, and going outside was somewhat important to the resident. Review of Resident #23's care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs, enjoyed TV/movies & soap opera's, basketball, coloring/painting, coffee/snacks (junk food), Diet MT. Dew, music = country and R&R and needed verbal invites/encouragement, reminders and escort. The goal of the residents activity was to attend/participate in/with activities of preference at least 3-5x. weekly, as tolerated/as will allow thru NRD. Review of Resident #23's Quarterly/Comprehensive Participation Review, dated 1/29/24, revealed the resident always watched TV/soap opera's & movies, enjoyed country and R&R music, coloring/painting & basketball. Enjoys Diet MT. Dew. Is verbally invited & offered activities of his preference, as tolerated/as he will allow on & off the Memory Care Unit. Continues to attend coffee social & parties/music off the unit often throughout the week. The review revealed the resident's activity goal had been met. Review of Resident #23's March CNA Task documentation showed the resident had not participated in any as needed snacks, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. Review of Resident #50's Admission Record showed the resident was admitted on [DATE] and 3/14/23. The record included the resident's diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Sequelae (of) traumatic subdural hemorrhage without loss of consciousness, and other seizures. Review of Resident #50's Quarterly MDS, dated [DATE], revealed a BIMS score of 99, revealing the resident was rarely or never understood. The resident's Annual MDS, dated [DATE], revealed the resident did not have any activity preferences per staff interview. Review of Resident #50's care plan showed the resident was at risk for social isolation due to residing on the memory care unit, a language barrier related to Spanish being the resident's primary language, and in the past as to having little interest or pleasure of doing things - used to enjoy parties/music, food related events, used to enjoy playing cards and being outdoors,and needed verbal invites and escort. The resident's activity goal was to be verbally invited/offered & encouraged to participate in activities of (resident's) preference at least 1x. daily, as tolerated/as he will allow thru NRD. The interventions show staff are to Document (resident) response to interventions. Review of Resident #50's Quarterly/Comprehensive Participation Review, dated 2/2/24, revealed Has Language Barrier as Spanish is (resident) Primary Language, but (resident) does seem to understand some very simple English. Can become easily anxious/agitated at times. Is up in (resident) w/c daily & out of (resident) room daily. Is verbally invited & escorted to activities, such as: small group acts., socials, parties & music & outside social/walks. The review showed Goals were not met but resident progress was achieved. Review of Resident #50's March CNA Task documentation showed the resident had not participated in any as needed snacks, additional fluids, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. Review of Resident #80's Admission Record showed the resident had been admitted on [DATE] and included diagnoses not limited to severe unspecified dementia with other behavioral disturbance, low vision right eye category 1, and blindness left eye category 5. Review of Resident #80's Annual MDS, dated [DATE], revealed a BIMS score of 3, indicating a severe cognitive impairment. The family/representative of Resident #80 revealed listening to music and going outdoors were somewhat important to the resident. Review of Resident #80's care plan showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs and hobbies and interests were unknown at this time but does seem to enjoy parties/music, coffee, snacks/hydration, walking/outdoors. and required verbal invites and escort. The goal was for the resident to attend/participate in/with activities of her preference at least 1x daily, as tolerated/as resident will allow thru NRD. The interventions instructed staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Review of Resident #80's Quarterly/Comprehensive Participation Review, dated 2/7/24, revealed the resident was verbally invited, encouraged and escorted to activities, both on (and) off the Unit, such as: coffee social, parties (and) music and outside walk on the patio area, ambulates self independently and is out of room daily - has the potential for exit seeking and elopement. The progress towards goals were met. Review of Resident #80's March CNA Task documentation showed the resident had not participated in any as needed snacks, 1:1 activities, group activities, church/prayer/religious/spiritual, bingo/games, or self-directed activities. The policy - Activities, implemented and revised date unknown, revealed the following: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction with the community. 2. Activities will be designed with the intent to: a. Enhance the resident sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self esteem, dignity, pleasure, comfort, education, creativity, success, and independence. g. Reflect residence interest in age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents. 4. Activities may be conducted in different ways: a. One-to-One programs. b. Person Appropriate activities relevant to the specific needs, interest, culture, background, etcetera for the resident they are developed for. c. Program of activities to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. 5. Scheduled activities are posted in the residence room, where appropriate, in in a prominent place in the facility. 6. Residents are encouraged, but not mandated, to participate in scheduled activities. 7. Space and equipment necessary are provided to ensure the residents care plan is followed. 9. Special considerations will be made for developing meaningful activities for residents with dementia and /or special needs. These include, but are not limited to, considerations for: a. Residents who exhibit unusual amounts of energy or walking without purpose, b. Residents who engage in behaviors not conducive with a therapeutic homelike environment, c. Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space, d. Residents who go through others belongings, e. Residents who have withdrawn from previous activity interest/ customary routines, and isolate self in room/ bed most of the day, f. Residents who excessively seek attention from staff and/ or peers, g. Residents who lack awareness of personal safety, h. Residents who have disillusioned and hallucinatory behavior that is stressful to themselves. 10. Staff will assist residents to and from activities when necessary. 12. Activities can occur at any time and are not limited to formal activities provided by the activity staff and can include other facility staff members, volunteers, visitors, residents, and family members. 14. The facility will provide one or more rooms designated for resident dining and activities. These rooms will be: a. Well lighted b. Well ventilated c. Adequately furnished; and d. Have sufficient space to accommodate all activities. During an interview on 3/21/24 at 1:16 p.m. the Director of Nursing stated residents should be treated as equals and would expect staff to interact with the residents. The DON stated the facility did have an activity aide quit about a month ago and have interviewed a couple of people.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and five errors were identified for five ( #57, #83, #7, #76, and #98) of eleven residents observed. These errors constituted a 18.52% medication error rate. Findings included: 1. On 3/19/24 at 11:01 a.m., an observation of medication administration with Staff N, Registered Nurse (RN) was conducted with Resident #57. The observation showed the residents electronic medication profile was colored red, showing the medications were late. The staff member dispensed the following medication: - Venlafaxine 150 milligram (mg) Extended Release (ER) capsule Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), informed the staff member Resident #57 was in the Main Dining Room. Staff Z, Interim Staff Educator, arrived, stood at the medication cart with Staff N and reported being there to help Staff N. The Director of Nursing (DON), also arrived to the area, stood behind the staff member, stating the resident was in therapy. The resident was brought to the unit and the medication was administered. Review of Resident #57's March Medication Administration Record (MAR) showed the resident was scheduled at 9:00 a.m. to receive Venlafaxine 150 mg ER capsule by mouth one time a day for depression. The observation revealed Resident #57 had received the antidepressant Venlafaxine two hours after the scheduled time. Review of Resident #57's progress notes, on 3/19/24 at 11:24 a.m. did not reveal the physician had been notified prior to the administration of the late medication. 2. On 3/19/24 at 11:11 a.m., an observation of medication administration with Staff N, Registered Nurse (RN) was conducted with Resident #83. The observation showed the residents electronic medication profile was colored red, showing the medications were late. The staff member dispensed the following medication: - Amlodipine 5 mg tablet The resident was observed sitting in the common area of the unit and was taken to room at 11:13 a.m. where the medication was administered. Review of Resident #83's March MAR showed the resident was scheduled at 9:00 a.m. to receive Amlodipine 5 mg - one tablet by mouth one time a day for hypertension (HTN). The observation showed Resident #83 received the calcium channel blocker (antihypertensive) medication, Amlodipine two hours after the scheduled time. Review of Resident #83's progress notes on 3/19/24 at 11:25 a.m., did not reveal documentation the physician had been notified prior to the administration of medication According to mayoclinic.org, (https://www.mayoclinic.org/drugs-supplements/amlodipine-oral-route/proper-use/drg-20061784), Amlodipine should be taken at the same time each day. 3, On 3/19/24 at 5:01 p.m., an observation of medication administration with Staff O, Registered Nurse (RN) was conducted with Resident #7. The staff member dispensed the following medications, laying packaging on top of med cart. - Ascorbic Acid 250 mg - 2 tablets - Trileptal 300 mg tablet - Trileptal 300 mg 1/2 tablet - Potassium 15 milliequivalent's (meq) Extended Release tablet - Carvedilol 25 mg tablet - Baclofen 5 mg tablet - Baclofen 10 mg tablet - ClearLax 17 gm mixed in small plastic cup with water The staff member confirmed eight tablets had been dispensed. Staff O administered medications to the resident. Review of the Resident #7's March MAR showed the resident was to receive 2 tablets of Potassium ER twice a day for hypokalemia. 4. On 3/20/24 at 11:39 a.m., an observation of medication administration with Staff P, Registered Nurse (RN) was conducted with Resident #76. The staff member obtained a blood glucose level of 264 from the resident. The staff member removed the resident's Insulin Aspart Flexpen from the medication cart, applied a needle, dialed the pen to 6 units and with gloved hands injected the insulin into the left arm of the resident. Immediately following the administration, Staff P confirmed not priming the insulin pen prior to administration. According to the manufacturer's information, accessed on 3/27/24 at 4:12 p.m. at https://www.novo-pi.com/novolog.pdf, users were instructed in the following procedure: Giving the airshot before each injection. - Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units; F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; G. Keep the needle pointing upwards, press the push-button all the way in (see diagram G). The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog FlexPen and contact Novo Nordisk at [PHONE NUMBER]. A small air bubble may remain at the needle tip, but it will not be injected. 5. On 3/20/24 at 4:27 p.m., an observation of medication administration with Staff Q, (LPN) was conducted with Resident #98. The staff member obtained a blood glucose level of 266 from the resident. Staff Q returned to the medication cart and removed the resident's Insulin Lispro pen, dialed the dose selector to 2 units and while holding the pen parallel to the floor primed the pen. The staff member dialed the pen to 9 units and injected the insulin into the left upper arm of the resident. Immediately following the observation, Staff Q confirmed holding the pen parallel to floor thinking the bubble would be at the top. According to the manufacturer's information, accessed on 3/27/24 at 4:29 p.m., (https://uspl.lilly.com/lispro/lispro.html#ug1), user's are instructed in the following procedure: 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 6: To prime your Pen, turn the Dose Knob to select 2 units. - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: 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 priming steps 6 to 8, no more than 4 times. -- If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. On 3/20/24 at 4:52 p.m., an interview was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON) regarding the observation of medication administration for Resident's #57 and #83. The RNC stated she had noticed Staff N's medication profiles were in the red and had informed Staff G the physician needed to be notified. Staff G showed this writer a text message sent at 10:58 a.m. on a cell phone to the provider revealing state was in the building and meds were late. Staff G and the RNC confirmed the message to the nurse practitioner (NP) did not specify which resident or which medications were late. The observed message did not reveal any specific information regarding residents, medications, or how late were the medications. The staff members confirmed the message was a generic meds were late message. Staff G stated the NP was notified state was in the building otherwise they would have shrugged shoulders. The policy - Medication Administration, implemented 3/24/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines include the following: 10. Review MAR to identify medication to be administered. 11. Compare medication source parenthesis bubble pack, vile, etc. Parentheses with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 14. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, interviews and review of the facility's policy titled Pest Control Program, the facility failed to maintain an effective pest control program, for two of two units and the kitchen, as evidenced by observation of pests on four (03/18/2024, 03/19/2024, 03/20/2024 and 03/21/2024) of four survey days. Findings included: 1. An observation on 03/18/24 at 10:05 a.m., revealed a corner on the secured unit near the smoking area door that had multiple flying insects on the walls. Photographic evidence obtained. An observation on 03/18/24 at 10:25 a.m., revealed a cockroach crawling around Resident room [ROOM NUMBER]'s bathroom. Photographic evidence obtained. An observation on 03/19/24 at 1:00 p.m. revealed multiple flying insects that flew around the secured unit nurses' station. During an interview on 03/19/24 at 09:40 a.m., Staff H, Pest Management (PM) stated that his company provides pest services to the facility on a weekly basis. Staff H, PM stated the company provided services that included outside area with exterior sprays, general pest services, kitchen services, setting of baits and interior services when needed. Staff H, PM stated he had not been notified of any pests concerns lately. An observation on 03/20/24 at 1:42 p.m. revealed two flying insects that flew around the conference room. An observation on 03/21/24 at 10:53 a.m. revealed one flying insect that flew around conference room. During an interview on 03/20/24 at 11:35 a.m., Staff J Director of Maintenance (DOM) stated staff were to report any insect activity to maintenance. Staff J, DOM stated the facility had a local pest company who came to the facility on ce a week to provide pest control. Staff J, DOM stated staff had not had any complaints lately regarding bugs in the facility. Review of the facility's Pest Sighting Log Sheet showed the following entries: -01/15/24- the nurses station bathroom had rat feces. -01/29/24- Ants in room [ROOM NUMBER]. -02/12/24- No issues reported. -02/26/24- Big roach in room [ROOM NUMBER] -03/20/24- No issues reported. Review of the local pest management company's Invoice and Service Report showed the following reports: - 03/19/24- room [ROOM NUMBER] suspected insect activity. Treated common areas, front office, nurses' stations, break room and dining room. - 03/05/24- Inspections of books and logs and discussion with management regarding building progress. - 01/29/24- Kitchen, dining rooms [ROOM NUMBERS] treated for ants. - 01/02/24- Kitchen sprayed and baited and dusted. Dining room, breakroom, administrator's offices and all exits. No issues reported. - 12/18/23- Rooms kitchen, break room, dining, hallways and exits were sprayed. Beauty salon treated as well. 37999 2. On 3/18/24 at 10:24 an observation was made of a brown substance smeared on the wall of a small alcove located next to patio exit door. The observation revealed multiple small flying gnats on the wall near the brown smear. (Photographic evidence was obtained) 20536 3. On 3/18/2024 at 9:10 a.m. a tour was conducted in the kitchen. During the initial tour of the kitchen there were four small flying insects flying around the food preparation tables and also in the dish machine room. There were also more than three small flying insects flying around the three compartment sink and near the floor drain. During an interview at the time of the observation, Dietary Aides Staff D and E revealed they were not aware at first of the insects, but then did see them flying around after they were pointed out. Staff D and E were not sure how long the insects have been in the building but added pest control comes into the kitchen routinely to treat for these type of flying insects. They could not remember exactly the last time pest control was in the kitchen. On 3/18/2024 at 9:50 a.m. through 10:10 a.m. observation of the High 100's hall to include rooms 172 - 183 revealed small black flying insects flying around, to include rooms: -room [ROOM NUMBER] Bathroom (one insect flying); -room [ROOM NUMBER] Bathroom (over three insects flying); -room [ROOM NUMBER] between A and B bed (two insects flying). The 100 hall nurse station was observed with four small insects flying around the hallway and at the nurse desk. On 3/19/2024 at 8:50 a.m. through 9:10 a.m. observations revealed over five small black flying insects flying around in resident rooms 176 bathroom, 177 room, and at the 100 hall nurse station. Review of the facility's Pest Control Program revised date 02/2023 showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observations, interviews, and record reviews, the facility 1) failed to maintain the dignity of one resident (#80) related to clean clothing out of fifty three residents sampled, 2) failed to ensure the preferred name was utilized for one resident (#169) out of fifty three residents sampled, 3) failed to ensure the name of one resident (#70) was spelled correctly on the resident's door, and 4) failed to ensure the name of one resident (#102) was displayed on the resident's door out of fifty three residents sampled. Findings included: 1. On 3/18/24 at 12:54 p.m. Resident #80 was observed walking in the hallway of the secured memory care unit wearing a pair of plaid Capri pants inside out with spots of a brown substance near the waistband, down the left pant leg, and on the back of the right anklet sock. The resident was observed walking from one end of the unit to the other end with multiple staff in the hallway. Staff K, Certified Nursing Assistant (CNA) watched the resident walk away from them to the other end of hallway and when the resident was coming back to there area, the staff member asked the resident to Come here so I can clean you up, the staff member did not intervene further with the resident. Resident #80 continued to walk in the hallway and at 1:00 p.m., Staff K was observed passing meal trays to other residents in their rooms as Resident #80 was observed wearing the same pants inside out with the same substance attached to them and sock. Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM), was observed donning Personal Protective Equipment (PPE) followed by the resident, Staff K entered the room with a meal tray and on 3/18/24 at 1:22 p.m. Resident #80 was observed walking in the hallway with a cleaned plate and fork, when directed by an unknown staff member the resident returned to room, the brown substance was seen on the right sock and multiple spots on back of the left leg and waistband of the inside out pants. An observation was made on 3/18/24 at 1:25 p.m., of Resident #80 speaking with Staff K at the end of the hallway, the resident walked with the staff member to the resident room and at 1:27 p.m., the staff member asked the resident to go check if glasses were in there, the resident went into the room and Staff K left the area, the resident promptly left the room, continuing to wear pants inside out with a brown substance attached to the pants and sock. On 3/18/24 at 1:28 p.m., Resident #80 was observed walking into another resident's room at the end of the unit then back out, continuing to walk in the hallway, standing behind Staff K (who was at a kiosk hanging on the wall on the opposite side of the unit from where the resident's room was located) before continuing on. An observation was made on 3/18/24 at 1:33 p.m. of Staff G handing Resident #80 a facial mask asking the resident to put it on, the resident was observed walking away from the staff member holding the mask in hand. On 3/18/24 at 1:40 p.m., another surveyor reported a member of the Maintenance department stated Someone catch her, she needs to be changed. On 3/18/24 at 1:40 p.m., Staff G responded, directed the resident into resident's room, then left, followed by the resident who was observed walking on the opposite end of the unit. The Activity Director assisted the resident back to the resident's room, the Activities Director entered the room then left, the resident promptly left the room. On 3/18/24 at 1:44 p.m., a paperback word search puzzle book was observed sitting on top of the medication cart assigned to Staff A, Registered Nurse (RN). The staff member tossed the book to the nursing station desk next to the desktop computer and keyboard. Staff A sat down in front of the desktop and picked up a pink inkpen. The staff member looked up, noted this writer, stood up, left the nursing station, and began assisting residents with applying hand sanitizer outside of the unit's dining room. (Photographic evidence was obtained). An observation on 3/18/24 at 1:50 p.m. showed the word search book had been repositioned from the previous position. Staff A was observed assisting Resident #80 back to the room. On 3/18/24 at 1:51 p.m., Staff A was observed encouraging Resident #80 to leave the bathroom of another resident room, and assisting the resident back to her room. Staff A was observed dressing in PPE while Resident #80 remained in her room. An interview was conducted with Staff G on 3/18/24 at 1:58 p.m. The staff member reported noticing the bowel movements areas on Resident #80 About a hour ago, during lunch but was told by staff Resident #80 had refused (to be changed). The staff member stated she had attempted to assist resident but was dressed in PPE so guessed the resident did not know who she was. Staff G did not voice the expectation regarding staff assisting the resident with toileting hygiene. Staff G reported going to ask Staff A to try to assist (Staff A was in the room with the resident). Review of the Admission Record showed Resident #80 was admitted on [DATE] and included diagnoses not limited to severe unspecified dementia with other behavioral disturbance, cognitive communication deficit, and need for assistance with personal care. Review of Resident #80's Annual comprehensive assessment showed the resident had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating a severe cognitive impairment, the resident was able to independently maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal, and was frequently incontinent of bowel. Review of Resident #80's care plan showed the resident had a potential for Activities of Daily Living (ADL) self-care performance deficit related to (r/t) severe Dementia with cognitive impairment, chronic encephalopathy (and) currently independent/supervision with all ADL's. The interventions included staff were to encourage the resident to participate to the fullest extent possible with each interaction. Review of the Registered Nurse Job Description, copyrighted 2023, explained the purpose was May provide direct nursing care to the resident's and supervises the day-to-day nursing activities performed by the licensed practical/vocational nurse and certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Performs rounds to ensure resident needs are being met and personnel are performing their assigned duties. 20311 2. Review of Resident #169's medical record revealed he was admitted to the facility on [DATE] with diagnosis that included Fusion of spine, and Torticollis. Review of the residents Brief Interview For Mental Status (BIMS), dated 3/1/24, revealed a score of 13 (Cognitively intact). Observation on 03/18/24 at 11:17 AM of Resident #169's name posting located on the wall outside of his room door revealed a name normally referred to a female. Observation of the resident at this time revealed the resident had facial hair consisting of a beard and goatee. Interview with Resident #169 at this time revealed that they identify as he/him/they and prefers to be referred to as an alternate name he had provided to staff. The resident reported he prefers to have his provided name posted outside of his room. Interview on 03/20/24 at 09:31 AM with Staff U, Certified Nursing Assistant (CNA) revealed she had worked with Resident #169 before. During the interview Staff U continuously referred to Resident #169 as his given name and she and was continuously corrected by this surveyor. Staff U reported she could not help how she referred to the resident and she had to get use to it, but that she is trying. Interview with Staff V, Licensed Practical Nurse (LPN), Unit Manager on 03/20/24 at 09:42 AM revealed she was very aware of Resident #169's preference and staff are all aware and are trained and honor the resident's preference. Interview on 03/20/24 at 01:24 PM with the Social Service Director revealed she has addressed the resident's preference of how he identifies. She reported she does nothing with the resident's name tag on the door, and the residents given name is official and must reflect the residents legal name on the door. Interview on 03/20/24 at 02:22 PM with the Nursing Home Administrator (NHA) revealed the residents rights are honored related to his preference of how he wants to be identified. She reported the resident's name tag on his door was an oversight and will be changed right away and all staff have been trained. Review of the facility policy titled Resident Rights with a review/revised date of 6/2023 revealed the following: 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. 41015 3. An observation on 03/18/24 at 9:56 a.m., revealed a name plate on Resident #70's door with the last name spelled incorrectly. The incorrect spelling would cause a different pronunciation of Resident #70's last name. During an interview on 03/18/24 at 9:57 a.m., Resident #70 confirmed the door name plate was the incorrect spelling of her last name. A review of the Admission Record showed Resident #70 was initially admitted to the facility on [DATE] with diagnoses included but not limited to unspecified dementia, unspecified severity with other behavior disturbance, brief psychotic disorder, heart failure, major depressive disorder, recurrent unspecified. Review of the Census List page showed Resident #70 had a room change to her current room on 12/14/23. During an interview on 03/20/24 at 12:02 p.m., Staff F, Certified Nursing Assistant (CNA) stated, They left the R out of her name. Staff F, CNA confirmed Resident #70's last name was misspelled on the door name plate. During an interview on 03/20/24 at 12:18 p.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated the admission department adds names to the door name plates when residents are admitted . Staff G, LPN, UM stated she would expect the name to be on the door the same day a resident was admitted or changed rooms. Staff G LPN, UM confirmed Resident # 70's last name was misspelled on the door name plate. An observation on 03/18/24 at 11:46 p.m., revealed the name plate on Resident #102's door did not match the resident's name. The name was from a previous resident that was discharged on [DATE]. Photographic evidence obtained. During an interview on 03/18/24 at 11:47 p.m., Resident #102 stated his name did not appear on the door name plate. Resident #102 confirmed he had a different last name than the last name revealed on the door name plate. A review of the Admission Record showed Resident #120 was admitted to the facility on [DATE] with diagnoses included but not limited to unspecified dementia, unspecified severity without behavior disturbance, type II diabetes, solitary pulmonary nodules and major depressive disorder, recurrent, unspecified. The Admission Record also included the Resident #102 full name which was not available on the door name plate during observation. Review of the Census List page showed Resident #102 had a room change to her current room on 10/01/23. During an interview on 03/20/24 at 12:18 p.m., Staff G Licensed Practical Nurse (LPN), Unit Manager (UM) stated the admission department adds names to the door name plates when residents are admitted . Staff G, LPN, UM stated that she would expect the name to be on the door the same day a Resident was admitted or changed rooms. Staff G LPN, UM confirmed Resident #102's name was not on the door name plate. Review of the facility's policy Promoting/Maintaining Dignity dated 09/07/22 showed, It is the practice to protect and promote residents' rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on interviews and record review, the facility failed to refer three residents (Residents #5, #54 and #70) of fifteen residents reviewed for Level I Pre-Admission Screening and Resident Review (PASRR), for a newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II PASARR resident review upon a significant change in status assessment. Findings included: A review of the Admission Record showed Resident #5 had an original admitted [DATE] with diagnoses included but limited to anxiety disorder, unspecified, hyperthyroidism, chronic obstructive pulmonary disease and unspecified convulsions. Resident #5 was later identified with new diagnoses that included: -Other specified anxiety disorders on 08/02/22 -Other specified Depressive Episodes on 08/02/22 -Unspecified dementia, unspecified severity, with other behavioral disturbance on 10/01/22 -Major depressive disorder, recurrent, unspecified on 10/10/23 -Schizoaffective Disorder-Bipolar type on 02/15/21 Review of Resident #5's quarterly Minimal Data Set (MDS) assessment, dated 02/22/24, revealed under Section C-Cognitive Patterns, Resident #5 had a Brief Interview for Mental Status (BIMS) of 02 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #5 had diagnoses of Non-Alzheimer's Dementia, Anxiety disorder, Depression, and Schizophrenia. A review of Resident #5's Level I PASRR assessment, dated 08/08/15 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections schizoaffective disorder was not checked. A review of the Admission Record showed Resident #70 had an original admitted [DATE] with diagnoses included but limited to unspecified dementia, unspecified severity, with other behavioral disturbance, brief psychotic disorder, heart failure, and essential primary hypertension. Resident #70 was later identified with new diagnoses that included: -Major depressive disorder, recurrent, unspecified on 12/05/23 Review of Resident #70's quarterly (MDS assessment, dated 02/06/24, revealed under Section C-Cognitive Patterns, Resident #70 had a BIMS of 04 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #70 had diagnoses of Non-Alzheimer's Dementia, Depression (other than bipolar) and Psychotic disorder. A review of Resident #70's Level I PASRR assessment, dated 10/24/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections depressive disorder was not checked. During an interview on 03/21/24 at 11:51 a.m., the Director of Nursing (DON) confirmed residents who are diagnosed with new mental health diagnoses should have their PASRRs updated and resubmitted to reflect those changes. The DON stated Resident #5 should have had an updated PASRR that reflected the new mental health diagnosis of schizophrenia and Resident #70 should have had an updated PASRR that reflected the new mental health diagnosis of depressive disorder. Review of the facility's policy Resident Assessment-Coordination with PASARR Program dated 09/07/22 showed, .9. Any resident who exhibits a newly evident or possible serious mental illness, intellectual disability, or a related condition will be referred to the state mental health or intellectual disability authority for a level II resident review. 37999 3. On 3/18/24 at 9:54 a.m. Resident #54 was observed ambulating in the hallway of the secured memory care unit pushing an empty wheelchair. On 3/18/24 at 10:45 a.m., Resident #54 was observed sitting in the unit's dining room with other residents and the television was playing. Review of Resident #54's Admission Record showed the resident had been admitted on [DATE] and included the diagnoses of cognitive communication deficit(onset 7/5/23) unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 7/5/23), brief psychotic disorder (onset 7/14/23), and unspecified persistent mood (affective) disorder (onset 7/14/23). Review of Resident #54's Preadmission Screening and Resident Review (PASRR), dated 7/5/23, did not reveal the resident had a mental illness (MI), suspected MI (SMI), or Intellectual Disability (ID). The PASRR did not reveal the resident had a primary diagnosis of dementia or related neurocognitive disorder. The review showed question 7 had been answered Yes the resident had validating documentation to support the dementia or related neurocognitive disorder, Medical history. Section IV revealed the resident did not have a diagnosis or suspicion of SMI or ID and a Level II PASRR was not required. Review of Resident #54's PASRR revealed in Section II A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis or dementia or related neurocognitive disorder, and a suspicion or an Serious Mental Illness, Intellectual Disability, or both. During an interview on 3/21/24 at 12:00 p.m., the Director of Nursing stated Resident #54's PASRR should have fixed this one. The DON reported the facility had recognized an issue with PASRR's and had initiated a Performance Improvement Plan (PIP). Review of the facility PIP - PASRR Completion, 2/1/2024, showed the status of the Quality review for all current residents PASRR's was completed to ensure accuracy and prompt completion. was complete. The policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22, showed 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. The guidelines directed: - 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission i. Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. - 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability has determined as appropriate for admission. - 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment.

Based on observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 (#98, #100) residents reviewed for vision and dental services. Findings included: Review of the facility policy titled Comprehensive Care Plans with an implemented date of 9/7/22 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident #98's medical record revealed she was admitted to the facility on [DATE] with diagnosis that included Type 2 Diabetes Mellitus foot ulcer, Peripheral Vascular Disease, and Basal Cell Carcinoma of skin. Review of the record revealed a Brief Interview for Mental Status (BIMS) dated 2/8/24 with a score of 14 (Cognitively intact). Interview on 03/18/24 at 11:33 AM with Resident #98 revealed she has been in the facility since November 2023, had dental and vision concerns but has not been seen by the dentist or the optometrist. The resident reported she only has 1 tooth. Interview on 03/20/24 at 10:01 AM with Resident #98 revealed she still has not had an appointment for dental or vision. Review of Resident #98's record revealed there was no care plan in the record that reflected the residents needs related to dental and vision. Review of the resident records revealed an Admission Evaluation dated 12/14/23 which indicated the following: -ORAL/NUTRITION Resident teeth are broken and/or have carious. -SENSORY Eyesight is impaired resident wears glasses. Hearing adequate. Review of the residents 5-day Minimum Data Set (MDS) dated [DATE] revealed the following: -Vision-Impaired -Dental indicates no dentures or mouth pain or difficulty chewing Review of the residents physician order dated 12/15/23 revealed the following: -May have Dental, Dermatology, Ophthalmic, Podiatry, Wound, Psychology and Psychiatry consults as needed to eval and treat Review of the record revealed no indication that appointments related to vision and dental had been completed. Interview on 03/20/24 at 03:10 PM with the Social Serviced Director (SSD) revealed anyone who needs dental or vision is on the list to be seen unless they have a private vendor or the family says no to services, or if they can't afford it. Interview on 03/21/24 at 10:22 AM with Resident #98 revealed she only has 1 tooth and gums her food. She reported she would like to be seen by the dentist to evaluate the need to remove the one tooth or not. She reported she had old glasses that were for seeing near and far and she also has a newer pair of glasses for reading but neither of them work. Review of Resident #100's medical record revealed she was admitted to the facility on [DATE] with diagnosis that included Dementia/Alzheimer's with behaviors. Review of the record revealed that the resident was alert with confusion at times. Interview on 03/18/24 at 11:33 AM with Resident #100's family member and Health care proxy revealed the resident has been in the facility since October 2023, had dental and vision concerns but had not been seen by the dentist or the optometrist. The residents family member reported the resident only had a few teeth. Interview on 03/20/24 at 10:01 AM with Resident #100's family member revealed the resident still has not had an appointment for dental or vision. Review of Resident #100's record revealed there was no care plan in the record that reflected the residents needs related to dental and vision. Review of Resident #100's records revealed an Admission Evaluation dated 10/26/23 which indicated the following: -ORAL/NUTRITION Resident teeth are broken and/or have carious. -SENSORY Eyesight is adequate. Review of Residents #100's Quarterly MDS dated [DATE] revealed the following: -Vision-Adequate with no corrective lenses -Dental indicates no dentures or mouth pain or difficulty chewing Review of the resident's physician order dated 10/26/23 revealed the following: -Ophthalmology/Podiatry//Psych Services as needed Review of the record revealed no indication that appointments related to vision and dental had been completed. Interview on 03/20/24 at 03:10 PM with the Social Serviced Director (SSD) revealed anyone who needs dental or vision is on the list to be seen unless they have a private vendor or the family says no to services, or if they can't afford it. Interview on 03/21/24 at 10:22 AM with Resident #100's family member revealed Resident #100 only has 7 teeth which all need to come out. She reported her family member is not in any pain at this time but was seen by an oral surgeon when residing in another city who said they need to come out but then the resident ended up in facility. Resident #100 opened his mouth and showed the 7 teeth remaining in his mouth. Resident #100's family member reported Resident #100 does not have glasses but needs glasses to read because he can't see the print. Interview on 03/21/24 at 10:32 AM with Staff W, Social Service revealed he was not aware of Residents #98 and #100 vision and dental status. He reported he had to call the dental and vision vendors. He indicated he was able to find a email from the vision vendor who accepted the residents as patients and that they were requesting additional information. He was unable to verbalize if the documentation had been provided to the vendor or if the resident had been seen. Interview on 03/21/24 at 10:39 AM with Staff X, Licensed Practical Nurse (LPN), MDS Coordinator revealed she completes the appropriate sections of the MDS and does a screen which includes a full physical observation of the resident to include vision and oral. She reported if there is a need or concern then she develops a care plan and then informs social services so they can schedule needed services. She reported she was not aware of the need for dental or vision for Residents #98 and #100 and is not sure why there was no dental or vision care plan developed for the two residents.

Based on observations, interviews, and record review, the facility failed to consistently provide a packaged meal for one resident (#87) out of four residents receiving dialysis. Findings included Review of Resident #87's medical record revealed that she was admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus, End Stage Renal Disease. The record revealed the resident receives dialysis from a local vendor on Monday, Wednesday and Friday. The record included a Brief Interview for Mental Status (BIMS) dated 2/14/24 with a score of 14 (Cognitively intact). Interview on 03/20/24 at 09:06 AM with Resident #87 revealed her lunch has not been brought up to her yet for her 10:00 AM pick up for dialysis. She reported usually the packaged lunch comes up at 6:00 AM but sometimes they forget so her (family member) is bringing her a lunch before she leaves. Observations on 03/20/24 at 09:56 AM of Resident #87 in her room revealed her (family member) was present and that they were waiting for transportation. Interview with the resident at this time revealed she was told that her lunch would be up but that it hasn't come up yet. Resident #87 reported that she was anxious about the timeliness of her pick-up and reported that although her pick-up time is 10:00 AM the transportation usually comes by 9:50 AM to get her to dialysis. Observations on 03/20/24 at 10:04 AM transportation for Resident #87 arrives. It was noted at this time there is still no lunch present for the resident. Staff U, Certified Nursing Assistant (CNA) verbalized to herself she had to go to the kitchen to get the residents lunch and walked down the hallway. Observations on 03/20/24 at 10:11 AM Resident #87's transportation was leaving the residents room with resident and (family member) walking behind. It was noted there was still no lunch present for the resident to take to dialysis. Observations on 03/20/24 at 10:13 AM while exiting the facility the transportation personnel was noted to ask the receptionist if she could get a lunch for the resident. At this time the resident verbalized she did not want to wait for the lunch because it was late. The transportation team exited the building with the resident and loaded the resident into the transportation van. After resident was loaded into the transportation a kitchen aide noted to run out of the facility and hand a bagged lunch to the transport personnel for the resident. Inspection of the bagged lunch revealed it consisted of a peanut butter and jelly sandwich, graham crackers, and soda. The resident's (family member) verbalized at this time that the resident goes without a lunch at least 1 time a week, but he comes to the facility daily and is here before she leaves for dialysis and is at the facility when she returns so if it appears that there will be no packed meal he will bring something for her. Review of the resident's physician order dated 2/13/24 revealed the following: Dialysis Days: Monday, Wednesday, Friday. Chair time: 11AM Transport Pick up Time: 10AM Review of Resident #87's care plan revealed the resident is at risk for complications r/t receives dialysis with an Initiated date of 05/15/2023 and a revision date of 08/01/2023. Continued review of the residents care plan related to dialysis revealed interventions that included Send snack with resident on dialysis days with an Initiated date of 05/15/2023. Review of Resident #87's progress notes revealed no entries of the resident refusing any of her meals for dialysis. Interview on 03/20/24 at 10:26 AM with the Certified Dietary Manager (CDM) revealed dialysis residents always gets a packed meal when going to dialysis. She reported if the resident has an early appointment the lunch is prepped from the night before. For later dialysis appointments bagged lunches are made fresh for the resident. She reported usually the lunches are ready and prepped before the resident has to leave, but today they were behind because of the dish machine. This surveyor shared with the CDM a report that dialysis packed lunch is not provided every time the resident has dialysis. The CDM reported that I don't know that I can contest to that because there are a lot of moving parts in the kitchen. The CDM stated, I cannot confirm that she gets a meal each time she goes to dialysis. The CDM reported that as an alert the kitchen gets a sheet listing the dialysis patients which indicates the days and time of pick-up and that We try to have target times to mitigate problems, but there are a lot of moving parts so things come up. Interview on 03/20/24 at 11:46 AM with the Nursing Home Administrator (NHA) revealed the kitchen usually provides a meal for residents who go out of the facility for dialysis. She reported sometimes residents refuse to take a lunch and that this information is documented in the residents record. The NHA reported she is not aware of anything going on in the kitchen that would cause the kitchen to fall behind. Review of the facility policy titled Hemodialysis with an implemented date of 8/25/22 revealed the following: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.

Based on observations, interviews, and policy review, the facility failed to ensure one (South #2) of four medication carts was locked while unattended, medications were secured, medications were stored per manufacturer guidelines, one (South) of two treatment carts were locked while unattended, and medications were not stored with cleaning materials. Findings included: On 3/18/24 at 9:41 a.m. while standing at an unlocked medication cart, Staff A, Registered Nurse (RN) offered to obtain a face mask for writer. The staff member left the nursing station, leaving the cart unlocked, went into the room opposite the station, returning a moment later with a box of face masks. A housekeeper was in the nursing station mopping while the cart was unlocked and unattended. The South #2 medication cart was parked in the nursing station; however the cart was parked against a half wall and within reach of residents on a memory care unit. Staff A confirmed the cart was reachable and had been unlocked. On 3/18/24 at 12:10 p.m., an observation was made of a blue oval tablet on the floor in the doorway of room [ROOM NUMBER]. Staff Z, Interim Staff Educator, observed the blue tablet, picked it up (using a glove) and said it looked like a thyroid pill. On 3/20/24 at 9:48 a.m., an observation was conducted with Staff R, Licensed Practical Nurse (LPN) of the South #2 medication cart. The observation revealed an unopened bottle of Latanoprost Ophthalmic solution. The pharmacy bag containing the bottle was labeled Refrigerate. The observation revealed 2 containers of pudding sitting on top of the insulin containers. On 3/20/24 at 10:23 a.m., an observation was conducted with Staff P, RN of the South #1 medication cart. The observation revealed an opened undated bottle of Latanoprost Ophthalmic solution, a vial of insulin dated 2/14/24, with a pharmacy label showing to discard after 28 days (3/13/24 - 7 days prior to the observation), an undated, unopened Insulin Lispro pen labeled with a sticker to discard after 28 days and contained within a pharmacy bag revealed 2/4/24 opened. (3/3/24 - 17 days prior to the observation), and an undated opened Breo Ellipta 100 microgram/25 microgram (Fluticasone furoate/vilanterol) inhaler, contained within a pharmacy bag revealing an open date of 1/10/24. The inhaler label showed an area to date when the tray was opened and to discard 6 weeks (2/21/24 - 28 days prior to the observation). On 3/20/24 at 3:59 p.m., an observation was made of an unlocked unattended treatment cart on the memory care unit, parked outside of the nursing station. The cart contained medicated ointments and creams. Staff P and Staff R reported Staff G, Unit Manager, had been the last one in it. Staff G confirmed, at 4:02 p.m. on 3/20/24, she was the last one in it and had left it unlocked. On 3/20/24 at 4:27 p.m. an observation was conducted with Staff Q, LPN of one medication cart on the North unit. The observation showed a container of [vendor name] Disinfectant wipes lying on its side with a wipe sticking out of the container. The wet wipe was lying against extra medications stored in the bottom drawer and a wet spot was observed on the packaging of a full card of the medications. The staff member confirmed the findings. The policy - Medication Storage, implemented 8/25/22, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The compliance guidelines included the following: - 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments (see attached listing). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. - 3. External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications. - 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on observations, interviews, and record reviews, the facility failed to implement an appropriate infection control program related to ensuring staff were aware precaution measures for one (#80) of one residents with precautions, provide a cleanable mattress for one (#95) out of 52 residents, and to ensure adequate hand hygiene was performed for staff and residents. Findings included: 1. An interview on 3/18/24 at 9:37 a.m. was conducted with an unknown Certified Nursing Assistant (CNA) on the memory care unit. The CNA stated there was no COVID infection on the unit and Staff A, Registered Nurse (RN) confirmed this information. On 3/18/24 at 9:47 a.m., an observation was made of Resident #80's room, hanging from the door was a Personal Protective Equipment (PPE) caddy and a sign showing Droplet precautions. The caddy held gowns, N95 masks, faceshields, and gloves. During the observation, Resident #80 was observed walking out of the room. On 3/18/24 at 12:54 p.m., Resident #80 was observed walking independently in the hallway of the unit, not wearing any personal protective equipment (PPE). On 3/18/24 at 1:03 p.m., an observation was made of Staff G, Licensed Practical Nurse/Unit Manager (LPN/UM) asking Resident #80 who was ambulating in the unit, to go back to room to eat. The staff member dressed in gown, gloves, mask, and face shield, stating Resident #80 had tested positive for COVID a week ago Friday, and comes off precautions on the 22nd, the 10th day (after testing positive). Staff G directed the resident into the room. On 3/18/24 at 1:06 p.m. Staff K, CNA, walked into Resident 80's room to the window side of the room and handed a meal tray to Staff G. The room continued to be posted for Droplet precautions as Staff K entered the room without any PPE. On 3/18/24 at 1:20 p.m., Staff K walked into Resident #80's room, putting gloves on and calling for Resident #80. Staff G called to the staff member from a room across the hall and the staff member left the area. On 3/18/24 at 1:33 p.m. Staff G handed Resident #80 a face mask as the resident ambulated past the nursing station, asking the resident to put it on. The resident held the mask in hand walking away from staff. 2. On 3/18/24 at 9:35 a.m., an observation was made of Resident #95's mattress on the memory care unit. The mattress' plastic/vinyl covering was missing, the top of the mattress was whitish-light blue in color. The room was designated (by sign on door) to be scheduled for Deep Clean. On 3/18/24 at 12:48 p.m., an observation continued of Resident #95's mattress. The mattress was torn in an area approximately the size of a dinner plate, revealing an interior of green foam. Review of the policy - Cleaning and Disinfection of Resident-Care Equipment, implemented/revised on 9/6/22, revealed Resident care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current Center for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymic products. Disinfection refers to the thermal or chemical destruction of pathogenic and other types of microorganisms. Reusable single-resident items are items that may be used multiple times, but for one resident only. Examples include bed pans, urinals, and disposable blood pressure cuffs/stethoscopes. 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: c. Direct care staff are responsible for cleaning single resident equipment when visibly soiled, and according to routine schedule parentheses where apical parentheses. e. Most equipment may be cleaned/ disinfected in the areas in which the equipment is used. Review of the policy - Infection Prevention and Control Program, implemented 8/25/22 and revised 7/13/23, revealed This 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. 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. e. Environmental Cleaning and disinfection shall be performed according to the facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside their scope to the appropriate department. 5. Isolation protocol (Transmission-Based Precautions- contact, droplet, neutropenic): a. A resident with infection or communicable disease shall be placed on transmission based precautions. b. Residents will be placed on the list of restrictive transmission based precaution for the shortest duration possible under the circumstances. 9. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. 41015 3. An observation on 03/18/24 at 12:20 p.m., revealed fifteen residents seated in the Secured Unit dayroom. An observation on 03/18/24 at 12:35 p.m., revealed the lunch cart being delivered to the Secure Unit. Staff was observed immediately passing out the lunch trays to all fifteen residents. One resident (#83) was observed eating beef stroganoff with her hands. The lunch observation revealed no hand hygiene practices by staff. During an immediate interview on 01/18/24 at 12:35 p.m., Staff F Certified Nursing Assistant (CNA) stated the facility protocol was to provide every resident a hand sanitizing wipe for hand hygiene prior to meals but stated today, it just did not happen and was not sure why. Staff F, CNA stated the hand sanitizer and sanitizing wipes were in the locked storage unit in the dayroom. During an interview on 03/20/24 at 10:52 a.m., the Administrator stated she expected the staff to ensure residents were provided hand hygiene in the form of either hand sanitizer or sanitizer wipes prior to being served each meal. 50434 4. On 3/19/2024 at 9:51am Staff B, Dietary Aide was observed in the kitchen working at the food prep station with parfaits dishes. Staff B was observed wrapping parfait dishes with plastic wrap with bare hands. She then removed what appeared to be electronic phone ear bud devices from her ears with bare hands. She then placed the earbuds into her pocket and continued wrapping parfait cups with plastic wrap with bare hands. Once the parfait containers were wrapped and placed on a silver tray, Staff B wrapped the entire tray of parfaits, wrote a date on the top of wrapped parfait tray and placed them into the cooler. Staff B was then observed putting on gloves and placing bread directly onto the service station table. Staff B did not perform hand hygiene during the observation. During an interview with Staff B on 03/21/2024 at 11:50a.m., she stated she should wash her hands before and after food preparation. She also stated that she is only to use her ear buds while operating the dish machine. She then stated that she should not touch her face or skin while preparing food without washing her hands and the prep stations are wiped down once an hour. Review of the facilities Food and Safety Requirement Procedure states: Dated Reviewed: 10/19/2022 Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions: Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Food Distribution means the process involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Food Service means the process involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e., down a hallway, to a different unit or floor). Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages. Policy Explanation and Compliance Guidelines: 1. Food safety practices hall be followed through the facility's entire food handling process. This process begins when food is received from the vendor and ends with deliver of the food to the resident. Elements of the process include the following: D. Distribution and service of food to the resident, including transportation, set up, and assistance. F. Employee hygienic practices 2. The Director of food and Nutrition service shall order food from approved sources and maintain invoices from food vendors that show the source of food acquisition and the date of delivery. 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. 5. Food and Beverages d. washing hands between contact with residents and after collecting soiled plates and food waste. e. Use of gloves when touching and assisting with ready-to-eat foods. f. Timely distribution of all meals/snacks. 6. All equipment used in the handling of the food shall be cleaned and sanitized, and handled in a manner to prevent Contamination. c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. staff shall wash hands according to facility procedures. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. e. Hairnets should be worn when cooking, preparing, or assembling food, such as stiffing pots or assembling the ingredients of a salad. However, staff do not need to wear hairnets when distributing food to residents at the dining table(s) or when assisting residents to dine. h. Gloves will be worn when directly touching ready-to-eat foods and when serving residents who are on transmission-based precautions. However, staff do not need to ear gloves when distributing food to residents at the dining table(s) or when assisting residents to dine unless touching ready-to-eat food. 8. Additional strategies to prevent foodborne illness include, but are not limited to: a. preventing cross-contamination of foods.

Based on observations, interviews, and record reviews, the facility failed to ensure the handrail in one (South - Memory Care) of two units was secure and did not cause a safety issue regarding the presence of broken and/or missing components. Findings included: 1. An observation on 03/18/24 at 12:23 p.m. revealed three decorative fence posts pulled from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was loose and wobbly when touched. Photographic evidence obtained. An observation on 03/19/24 at 10:24 a.m. revealed three decorative fence posts pulled away from the wall outside room [ROOM NUMBER]. The hallway handrail attached to the wall through the decorative fence post was now unsecured from the wall. Photographic evidence obtained. During an interview on 03/19/24 at 10:26 a.m., Staff J, Director of Maintenance (DOM) stated, I did not know this was like this. Staff F, DOM stated the unsecured hallway handrail was certainly a safety concern and he would have expected the staff to have informed the maintenance department so the handrail could have been fixed. Review of the Maintenance Log from 02/29/24-03/19/24 revealed no entries for loose or broken hallway handrails. During an interview on 03/21/24 at 1:29 p.m., the Director of Nursing (DON) stated anything that is visibly broken or needs fixed should be put in the maintenance log and reported. The DON stated, I heard about the hallway handrails and would have expected the rails to have been reported and fixed. Review of the facility's policy Accidents and Supervision dated 09/07/2022 showed, Policy: The resident environment will remain as free of accident hazards as possible. 1. Identification of Hazard and Risks- a. All staff (professional, administrative, maintenance) are to be involved in observing and identifying potential hazards in the environment. 37999 2. On 3/18/24 at 10:32 a.m. an observation was made of two broken handrail brackets between room [ROOM NUMBER] and nursing station on the South-Memory Care unit. On 3/18/24 at 12:33 p.m. an observation showed a metal bracket attached to one side of the underneath of a handrail between room [ROOM NUMBER] and the nursing station. The bracket was not attached to the other side and a space between the bracket and handrail was approximately 1/2 inch. On 3/18/24 at 12:36 p.m. an observation was made of a missing handrail cap near room [ROOM NUMBER]. On 3/18/24 at 12:48 p.m. an observation was made of a missing handrail cap near room [ROOM NUMBER]. On 3/19/24 at 10:35 a.m. an observation was conducted of the handrails on the South-Memory Care Unit, which revealed: - a missing end cap near room [ROOM NUMBER] - a missing end cap and a broken handrail bracket near room [ROOM NUMBER] - a broken handrail bracket between rooms [ROOM NUMBERS] - a broken handrail bracket near room [ROOM NUMBER] - a missing end cap near room [ROOM NUMBER] - a broken handrail bracket near room [ROOM NUMBER] - a loose end cap next to room [ROOM NUMBER] On 3/20/24 at 11:39 a.m. Resident #23 was observed grasping the handrail to propel self in wheelchair from the patio to the nursing station. An interview and observation of the South-Memory Care unit handrails was conducted with the Maintenance Director on 3/20/24 at 12:12 p.m. The director stated the expectation was for staff to notify him of any issues but he also should have noticed them. He stated he did have end caps and had fixed many. The Maintenance Director asked this writer to observe one handrail that had been fixed. We went into the North unit and the director explained he had tightened screws to one section of the handrail. The interview continued on 3/20/24 at 12:58 p.m. with the Maintenance Director. The director provided a handrail audit completed on 3/18/24 by a Maintenance Assistant. Review of the handwritten audit (provided by Maintenance Director) of the handrails in the facility was completed. The audit revealed the section of the South-Memory Care unit between rooms 152 to 160 was ok, the section of handrail between room [ROOM NUMBER] to nursing station fail, and a section by South nursing station fixed. The audit did not show any other section of handrail was determined to be ok or fail on the South unit. The audit showed the majority of the handrail evaluations were completed on North unit.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, and homelike environment on 2 of 2 hallways on the South (memory care) Unit, 1 of 2 day rooms (#2), and 1 of 1 shower room observed. The findings include: On 7/11/2023 at 3:05 PM, photographic evidence was obtained for each of the following concerns noted during a tour of the facility's South (memory care) Unit: 165 - One of three drawers of the dresser in room [ROOM NUMBER] which was designated for A bed contained missing knobs. The particle board leg on the left side of the dresser was deteriorated to the extent that the dresser sloped downward to the left. The dresser was originally white, but contained a mismatched drawer replacement on the bottom that was brown. The particle board dresser top was warped and contained patches where the material had bubbled and the surface coating was discolored or absent. The footboard side of the room spanning both A and B beds contained approximately 10 areas of patched wall. This was evidenced by white smears on top of the yellow paint. The seat of a wheelchair designated for A bed was heavily soiled. The left armrest was in disrepair as evidenced by approximately two-thirds of the armrest had the interior foam exposed. The black exterior coating that was peeling away around the edges created a jagged surface. Two cigarettes were situated between the wheelchair seat cushion and the left side panel. To the left of the bathroom door there was a missing wall corner guard. The corner contained a long vertical crack, and the surrounding wall was rough and uneven. This corner contained white smears approximately four feet up the wall from the floor. 164 - One of two doors on the wardrobe in room [ROOM NUMBER] designated for A bed contained a missing knob. Dark brown drip marks from a dried liquid spanned approximately two-thirds of the width of the wardrobe at the base and rose to about 1.5-2 feet from the floor. To the left of the air conditioning unit, approximately 3 feet of the rubber baseboard was peeled away from the wall. Also to the left of the air conditioning unit was a damaged floor tile that was missing a corner. 163 - room [ROOM NUMBER] was a private room with two patched areas on the headboard side wall. The top left corner of the top nightstand drawer was missing. 162 - One of two drawers located at the bottom of the wardrobe in room [ROOM NUMBER] designated for A bed had no handle. The top of this wardrobe was being used for storage as a pile of clothes and a faux plant were sitting on top. Red lettering was affixed to the top of the wardrobe that read: FIRE & SAFETY LAWS PROHIBIT ANYTHING ON TOP SHELVES as items located near fire sprinklers may impact the effectiveness of the system. The wall above A bed's headboard contained a patched area of wall approximately the size of a soccer ball. The edges of the bathroom mirror were de-silvering. A raw piece of lumber was nailed vertically to the left side exterior of the bathroom vanity. One of three vanity lightbulbs was missing. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. 161 - The edges of the mirror in room [ROOM NUMBER]'s bathroom were de-silvering. One of three vanity lightbulbs was out. The wall mounted toilet paper dispenser was missing the toilet paper holder rod. The wall behind room [ROOM NUMBER]'s door contained a golf ball sized hole within a softball sized patched area. The dresser designated for B bed had missing laminate/vinyl which spanned the length of the dresser top and exposed the underlying particle board. 160 - room [ROOM NUMBER] contained two residents and had no privacy curtains. The dresser designated for A bed had one of six drawers with functional handles/knobs. Some of the hardware present was mismatched. The front and top of the dresser showed wear and tear as evidenced by scratch marks on all forward facing surfaces and discoloration on the top where the original dark wood stain had worn away. 158 - room [ROOM NUMBER] was a double occupancy room, but only B bed was occupied at the time. The wall behind A bed's headboard contained an approximately 4-foot-long patched area. The door of A bed's nightstand was missing a knob. The window wall and headboard wall for B bed contained approximately 4 patched areas. 156 - Across from the bathroom door in room [ROOM NUMBER] is an area of patched wall approximately 1.5 x 2.5 feet. The side and rear wall surrounding the wardrobe belonging to A bed contained approximately 3 patched areas. The wall above B bed's headboard contained 3 patched areas. The wall above the rear left corner of B bed's dresser contained two patched areas, one of which was approximately 1.5 x 1.5 feet. The bathroom mirror was de-silvering around the edges and most notably in the bottom left corner. The bathroom floor is originally beige in color but stained black around the toilet from the vanity to the wall. The bathroom walls were visibly rough and uneven with layers of patchwork. 154 - In room [ROOM NUMBER], the floor in front of the air conditioner contained a broken tile. The wall in-between A and B bed's nightstands contained a patched area approximately 1.5 x 1 feet. 152 - In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. Two of three vanity lightbulbs were out. The floor around the toilet was dirty and in disrepair. 146 - The top of the dresser in room [ROOM NUMBER] designated for B bed was scratched and peeled away in the front middle and front left corner. In room [ROOM NUMBER]'s bathroom, the wall mounted toilet paper dispenser was missing the toilet paper holder rod. One of three vanity lightbulbs was out. The left side of the bathroom vanity had a raw piece of plywood nailed to it. The bathroom contained a light-colored floor but the areas around the base of the toilet and vanity contained a buildup of a dark brown substance. 144 - The wardrobe in room [ROOM NUMBER] designated for A bed contained a mismatched set of drawers, one of which had no handle. 143 - The dresser in room [ROOM NUMBER] designated for B bed contained 3 of 6 drawers with no knobs. The stain on the top of the dresser was also worn away in areas exposing the lighter color below the surface. 142 - The wall in room [ROOM NUMBER] next to A bed's wardrobe contained black horizontal scuff marks and a patched area of wall. There were also approximately 5 small, patched areas of wall above A bed's headboard. The dresser designated for B bed had four of eight knobs missing. The dresser contained signs of wear and tear like chipped surfaces. The set of drawers on the wardrobe designated for B bed contained mismatched hardware. The wheelchair cushion designated for B bed contained dried food debris. 141 - In room [ROOM NUMBER], the floor at the base of the left side doorframe (from hallway) contained broken tile. The wall next to A bed was missing the rubber baseboard leaving the damaged wall behind it exposed. The rubber baseboard was also peeled away from the wall in the bathroom behind the toilet, around the vanity, and on two other walls. 140 - The wardrobe in room [ROOM NUMBER] designated for B bed contained a set of drawers with a missing handle. The exterior coating of the wardrobe door was peeling away around the bottom edges. All three drawers of the nightstand designated for B bed were misaligned and in need of repair. In the bathroom, a potent urine smell was present, and the floor contained yellow discoloration around the toilet. The bathroom contained a white patch of unpainted wall the size and shape of a soap dispenser to the right of the vanity. Approximately 5 patched areas were present on other walls of the bathroom. 139 - In room [ROOM NUMBER], the floor at the base of the right-side doorframe (from hallway) contained broken tile. 138 - In lieu of hardware, the wardrobe door in room [ROOM NUMBER] designated for A bed contained a makeshift handle made of fabric. The A bed was made but contained a stained pillowcase and soiled bed linens. 136 - In room [ROOM NUMBER], the dresser designated for A bed contained four of four drawers with loose knobs and one of these drawers was missing a knob. The dresser contained signs of wear and tear like chipped and scratched surfaces. The top of the nightstand designated for B bed contained a warped surface and liquid stains. In the bathroom, the rubber baseboard was missing from the wall to the right of the door. 135 - In room [ROOM NUMBER], the wall corner just to the left of the doorway (from the hall) was in disrepair and missing the rubber baseboard. The flooring at the base of both sides of the doorframe was damaged as it contained broken tiles. The wall beneath the air conditioning unit was damaged as evidenced by discoloration and exposed layers of drywall material. 134 - In room [ROOM NUMBER], the wardrobe designated for B bed was missing one of two drawers. 133 - The blinds in room [ROOM NUMBER] were in disrepair as evidenced by broken slats. 132 - In room [ROOM NUMBER], the dresser designated for B bed contained a broken handle, scratches, and chipped paint. Day room [ROOM NUMBER] contained a rusted two-drawer filing cabinet. Day room [ROOM NUMBER] also contained damaged wall where a sink and soap dispenser had been removed. A wooden box was nailed to the wall to conceal the plumbing. The door to the closet that stores the activities supplies in day room [ROOM NUMBER] has a hole where a doorknob had previously been as well as missing paint around the knob. The mosaic tile floor of the shower room contained mismatched sections of tiles. The shower floor contained dark brown stained tiles and grout. The shower walls contained areas of brown stained grout. The ceiling air vent by the nurses' station contained droplets of condensation and black biological growth. The mechanical lift by the smoking patio was uncovered and contained a layer of gray film. Hair was spun around the wheels. On 7/11/2023 at 3:27 PM, during the aforementioned tour, the Nursing Home Administrator (NHA) approached this surveyor to inquire about the concerns identified so she could get them addressed overnight. The surveyor stated that it would be difficult for the facility to address all environmental areas of concern by tomorrow. Due to the extent of concerns and the fact that evidence gathering was still in progress, the surveyor walked the NHA through room [ROOM NUMBER] as an example and pointed out the concerns noted in the tour above. Regarding the wheelchair utilized by A bed, she stated housekeeping is responsible for deep cleaning wheelchairs every other month and nursing staff are supposed to be wiping down resident equipment daily/after each use. The NHA questioned the environmental concerns pointed out by the surveyor. When asked if her home looks like this (patched areas of wall, furniture in disrepair, etc.), she replied No. On 7/12/2023 at 9:56 AM, an interview was conducted with the Director of Maintenance/Environmental Services. He stated he has been in this role since the end of October (2022). He added that he has an assistant that started around the middle to end of January (2023). When asked if there's a system in place to ensure all resident rooms were audited at some regular interval to identify needed repairs/maintenance, he replied No. He added that the rooms he is in regularly are those of residents who clog the plumbing several times a day. When asked for the primary reason the memory care unit appeared in its current condition, he stated that it has been a slow process because they try not to have maintenance activities affect the residents, so they try to keep work and projects limited and confined to small areas. He added that he would like to make faster progress. When asked if there was any furniture that had been reported on any maintenance logs as needing replacement, he replied No. He added that the previous administration had mentioned the intent of having some furniture replaced. On 7/12/2023 at 10:26 AM, an interview was conducted with Staff I, Housekeeper. She stated she works 4 days per week and strictly on the memory care unit (South). She further stated she has worked at the facility for about 6-7 months. When asked to describe the protocols and procedures for cleaning shared resident equipment (e.g., lifts) and individual resident equipment (e.g., wheelchairs and walkers), she stated that housekeeping does not clean those items. She added that housekeeping handles linens, but not resident equipment. Staff I continued that she is also a certified nursing assistant (CNA) and when she is working as a CNA, she will wipe down equipment after use. Staff I stated that when she is working as a housekeeper, if she sees a wheelchair that is really bad, she will wipe it down. Staff I further stated that the night staff sometimes get a team together to clean resident wheelchairs while residents are asleep. When asked how she handles identified items in need of repair or replacement while she is in resident rooms cleaning, she stated she often sees the Maintenance Director in passing and will verbally express needs and he will write it down, or she will have him paged or she will write it down in the logbook. When asked what type of memory care unit concerns she has brought to the Maintenance Director's attention over the last 6 months, she stated clogged plumbing, mold, and hand sanitizer dispensers coming loose from the wall in common areas. On 7/12/2023 at 10:48 AM, an interview was conducted with the Housekeeping Manager. She stated she has been at the facility for about a year. When asked to walk through housekeeping's cleaning process, she stated their routine is to wipe down windowsills, air conditioning units, tops of wardrobes, handles, bedrails as well as empty bed mattresses, clean cords, dust off lights, disinfect call lights, and clean IV (intravenous) poles containing obvious spills. When asked about the cleaning process for resident equipment, she stated that wheelchairs are power washed on a bi-monthly basis for each unit, the South Unit is done one month and then the North Unit the next, but her team is not responsible for this. When asked if that included lifts she replied, No. The Housekeeping Manager added that there was a meeting held by the NHA about a month ago in which they were directed to start cleaning the lifts once a month. The Housekeeping Manager explained that there was an individual in central supply who used to have this duty, but they are no longer doing it and it has since been reassigned to housekeeping. When asked who is responsible for bed linens, she replied that CNAs change out bed linens, but housekeeping washes them. When asked if she conducts any quality assurance checks of staffs' work, she said there are rooms that are assigned to be deep cleaned daily and she checks those rooms which includes completion of a form in which she checks a box for satisfaction or unsatisfaction. When asked how she handles unsatisfactory audits, she stated she approaches the staff and lets them know it was a miss and that it needs to be redone. When asked if there is any sort of re-education that is provided as part of that process, she replied that she just refers them back to the terminal cleaning checklist which covers all items to address. On 7/12/2023 at 12:09 PM, an interview was conducted with Staff F, CNA. Staff F stated she has worked at the facility for approximately 5 years and is solely assigned to the memory care unit (South). When asked to provide examples of items she would report to maintenance for repair/replacement, she stated broken furniture, broken toilets, stuff hanging off the wall, broken lights, and problems in the shower room such as a non-functional shower hose or no warm water. When asked to explain the facility's process for reporting these concerns, she stated there's a maintenance logbook at the nurses' station to enter the date, time, location (e.g., resident room, dayroom, etc.), reporter's name, and summary of concern. When asked if she had identified any reportable issues today, she replied Yes, we noticed the hand sanitizer dispenser was hanging off the wall in the dayroom. Maintenance took care of it right away. When asked if there was anything else that seemed in need of repair/replacement, particularly in resident rooms, she replied No. When asked if the furniture all appeared to be in good working condition, she replied, Well, no, there are drawers that are broken but maintenance is aware of that, and I'm told it is going to be replaced. When asked if the resident rooms appeared homelike, she replied No, not all of them, it could be better. Review of the facility's Safe and Homelike Environment policy and procedure implemented 6/24/2023 revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. The policy defined environment as any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. The policy further provided the following definition of sanitary includes but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. Section 3 of the policy revealed Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Section 4 of the policy revealed The facility will provide and maintain bed and bath linens that are clean and in good condition. Section 6 of the policy stated, The Maintenance Director will perform periodic rounds to ensure functioning lights. Review of section 9 which included general considerations revealed Report any furniture in disrepair to Maintenance promptly. Review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy and procedure implemented 6/24/2023 revealed the Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention) recommendations in order to break the chain of infection. Item 3 under Policy Explanation and Compliance Guidelines revealed Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable).

Based on interview and record review, the facility failed to report a reasonable suspicion of a crime to law enforcement for 1 of 4 incidents reviewed. (Resident #3). Law enforcement was not notified after a 30-day supply of the anti-anxiety/ anti-seizure medication Klonopin was found to be missing from the medication cart, was never signed in as received and was not entered on the facility's controlled substance inventory list. The findings include: Review of a facility reported incident that was submitted on 5/6/2022 regarding an allegation of misappropriation of resident property revealed the Nursing Home Administrator (NHA) at the time of the incident submitted the report and initiated an investigation. According to the report's investigative findings, Resident #3 had diagnoses of autistic disorder, schizophrenia, anxiety disorder, and hypertension. Further review revealed the nurse caring for Resident #3 on 5/5/2022 noticed that the card for Klonopin 0.5 mg was not in the narcotic box on the cart. A nurse then called the pharmacy and confirmed that it was delivered on 5/4/2022. Staff A, Licensed Practical Nurse (LPN), was the nurse to receive the medication from the pharmacy on the morning of 5/4/2022. The medication was not entered on the controlled substance inventory list and the requisition sheet from the pharmacy was missing. The nurse and evening supervisor searched for the card of medication on all medication carts, but it was not located. The report indicated that the resident representative and the abuse registry were both notified on 5/6/2022. There was no indication the incident had been reported to law enforcement. Upon entrance to the facility on [DATE] at approximately 8:20 AM, the surveyor met with the Director of Nursing (DON) and requested all documentation pertaining to the aforementioned facility reported incident. On 7/12/2023 at approximately 11:00 AM, a telephone interview was conducted with the former Nursing Home Administrator (NHA) in the presence of the current NHA, the Regional Clinical Director, and the Divisional Risk Manager. The surveyor stated that so far during this complaint investigation, there has been no evidence that law enforcement was notified. When asked if the incident was reported to law enforcement for investigation, the former NHA responded, Yes, it was. It would be in the investigative file. When asked who would have been responsible for notifying law enforcement, she replied the (former) DON. Following this interview, the current NHA went to search for evidence that a report was made to law enforcement but was unable to locate the documentation in the facility's investigative file. On 7/12/2023 at approximately 12:00 PM, the current NHA reported that she called the Pinellas Park Police Department and was informed she would have to submit a public record request since the incident was from 2022. The surveyor invited the NHA to share any documentation received from the request even if it was after survey exit. By 7/18/2023, no additional information pertaining to the police report had been received from the facility. On 7/18/2023 at 10:38 AM, a telephone interview was conducted with Police Records Technician from Pinellas Park Police Department. At the request of this surveyor, the Police Records Technician reviewed the 2022 reports/intakes in their computer system and stated that no report in which Resident #3 was the alleged victim or Staff A was the alleged perpetrator had been received by the department. Review of the facility's Narcotic Management and Destruction policy and procedure implemented 2/18/2023 revealed that the drug diversion process includes Notify police and follow additional guidance provided by them. Review of the facility's Reporting Reasonable Suspicion of a Crime policy and procedure implemented 9/27/2022 revealed It is the policy of this facility pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime against a resident of this facility. Review of section 5 under Policy Explanation and Compliance Guidelines revealed notification will include Each covered individual's independent obligation to report the suspicion of a crime against a resident or individual receiving care and services from the facility directly to law enforcement. Further review of section 5 revealed the timeframe requirements for reporting reasonable suspicion of crimes as follows: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later than 24 hours after forming the suspicion. The policy also stated, Although it remains the responsibility of each covered individual to ensure that his/her individual reporting responsibility is fulfilled, in addition to reporting directly to law enforcement and the State Survey Agency, it is the policy of this facility that employees also report suspicions to the Administrator, or designee. The policy continued that The Administrator, or designee, will then assist the covered individual with reporting requirements and ensure specified timelines are met accordingly for both the initial and follow-up investigation reports and any other State level required reporting. Further review revealed Examples of situations that would be considered crimes in all subdivisions include, but are not limited, to: . g. Drug diversion for personal use or gain.

Based on observation, interview, and record review the facility failed to follow professional standards of practice for wound care for two residents (#7 and #8) of six sampled residents related to improper wound cleansing and inadequate hand washing between wounds and after wound care. Findings included: 1. On 12/21/22 at 10:00 a.m. an observation was conducted of Resident #8's wound care for an abscess on the left side of his back that was draining moderate yellow. Staff E, Licensed Practical Nurse (LPN) set up supplies on the overbed table with a clean towel as a barrier, cleansed her hands very quickly and donned gloves. Staff E was observed to cleanse the wound with a saline gauze in an up and down motion over the open wound and back instead of a circular motion. Staff E used a cotton tip applicator and applied Santyl to the center of the wound. Staff E touched all over the dressing when folding the gauze with a gloved hand then applied a border gauze. Staff E then washed her hands. An interview took place immediately after this observation. Staff E stated, related to the need to wash hands for 20 seconds and careful wound care, that she would be more careful. Review of Resident #8's Admission Record revealed an admitted [DATE] with a diagnoses to include unspecified protein-calorie malnutrition. Physician orders dated 12/21/22 included: *11/13/22 Start Date: Santyl Ointment 250 Unit/GM (collagenase) Apply to Left back topically every day shift for abscess until healed. *12/22/22 Start Date: Santyl Ointment 250 Unit/GM (collagenase) Apply to Left back topically every day shift for abscess until healed apply clean dry dressing. Record Review of the Wound Assessment Details, dated 12/20/22, revealed the open abscess of the left back had been in treatment for 6 weeks and measured 0.7 cm (centimeters) length x 2.5 cm width x 0.2 depth. The Wound Assessment Details, dated, 12/13/22 revealed the wound measured 1 cm length x 3 cm width x .1 cm depth. 2. On 12/21/22 at 10:15 a.m. observation of Resident #7's wound care provided by Staff E, LPN revealed the resident had two open wounds left shoulder and coccyx. Both previous dressings were removed. Staff E washed her hands quickly and applied gloves. Staff E cleansed the left shoulder terminal ulcer with normal saline (NS) using a straight motion going from skin to wound instead of a circular motion from center of the wound out. The resident moaned when the NS gauze touched her. Staff E applied Santyl ointment, to the center of the wound, with a cotton tip applicator. She then applied a dry dressing. Staff E doffed her gloves and washed her hands very quickly, for 12 seconds timed. Then Staff E applied new gloves and cleansed the coccyx terminal ulcer with NS using a straight down motion instead of a circular motion from center of the wound out. Staff E applied Santyl using a cotton tip applicator, to the center of the wound. Staff E applied a dry dressing. She disposed of the dressings, repositioned, and covered the resident. Staff E washed her hands for 15 seconds and dried them with a paper towel. At this time, Staff E stated the resident was considered terminal and has comfort measures only. A record review of a listing titled, Non Pressure Wounds, provided by the Director of Nursing, showed Resident #7's wounds as a coccyx terminal ulcer [NAME] (in house acquired), and a left shoulder terminal ulcer [NAME]. A review of the wound care notes showed both wounds as pressure wounds: Left shoulder as acquired Stage III with granulation tissue present 25% no odor, tunneling or undermining, and the coccyx as Unstageable, granulating 25% of the wound bed has an odor present .no signs of infection. The wounds were first noted on 12/20/22. Review of Resident #7's Admission Record revealed an initial admitted [DATE] with a diagnosis of Alzheimer's Disease and unspecified protein-calorie malnutrition. In addition, the resident was readmitted to the facility on [DATE] from the hospital with a displaced intertrochanter fracture closed fracture with routine healing and Aftercare following joint replacement surgery. Physician orders dated 12/21/22 included: *12/20/22 Phone order: coccyx and left shoulder, cleansed with NS apply Santyl, cover with dry dressing daily and prn (as needed), as needed for pressure wound. *12/21/22 Verbal order: coccyx and left shoulder, cleansed with NS apply Santyl cover with dry dressing daily and prn, as needed for terminal wound. 12/16/22 Verbal order: Comfort measures only every shift for comfort measures. Review of the policy titled, Wound Treatment Management, dated 8/25/22, revealed: 1. Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and frequency of dressing changes. Review of the policy titled, Hand Hygiene, dated 9/7/22, revealed: 5. Hygiene technique when using soap and water: a. Wet hands with water. Avoid hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off faucet.

Based on observations, interviews and policy review the facility did not ensure dignity was maintained for residents on one unit (South Unit) of two units for four days (12/13/21, 12/14/21, 12/15/21, and 12/16/21) of 4 days related to failure to provide furnishings in resident rooms to include lack of pillows, blankets, and personal effects and 2. failed to ensure fitted clothing for one resident (#306) of a total of sample of 41 residents. Findings included: 1. During a facility tour of the South Unit on 12/13/21 at 9:43 a.m., observations were made of resident rooms without personal effects. The rooms were observed without pillows or blankets on the beds. All the beds were furnished with uniform white sheets, a top sheet, and a bottom sheet. The rooms were observed without any personal memorabilia, pictures, or decorations. The rooms observed without pillows included rooms 162, 164 beds A and B,158, 160 beds A and B, 168 bed A,146 bed B and 158. During the tour on 12/13/21 at 9:43 a.m., Staff H, Registered Nurse/ Unit Manager (RN/UM) indicated the South Unit was a secured area housing residents with primary diagnoses of dementia and or Alzheimer's and they would not be interviewable. Residents were observed wandering the halls during the tours. On 12/14/21 at 9:00 a.m., resident rooms in the South Unit were observed without any pictures on the walls in their rooms and without any personal possessions. The rooms were furnished with a bed with two sheets, wooden nightstand, and dressers. The walls were noted bare without any pictures, decorations, or personal effects. On 12/15/21 at 9:30 a.m., Resident #92 was observed lying in bed, his head resting on a rolled-up hospital gown for a pillow. The resident pointing to the rolled-up gown under his head stated, I need a foreign word for pillow Resident was asked if he wanted a pillow. Resident said, Yes. Resident spoke limited English but was able to communicate his needs. During a facility tour on 12/15/21 at 12:26 p.m. observations were made of resident rooms without pillows in the South Unit. On 12/15/21 at 12:40 p.m., an interview was conducted with a resident in room 160 bed B, the resident stated she did not know why she did not have a pillow. An interview was conducted on 12/15/21 at 12:29 p.m. with Staff G, Certified Nurse Assistant (CNA). Staff G stated that residents should have pillows on their beds. Staff G said, I'll correct that, I will make sure we get pillows. The residents should have comfortable furnishings in their rooms. On 12/15/21 at 1:30 p.m., an interview was conducted with the Staff H, RN/UM who confirmed that all residents are supposed to have appropriate linens. They should have pillows. Staff H said, I will conduct a walk through and make sure all residents have pillows. A follow up interview was conducted on 12/15/21 at 4:19 p.m. with the Director of Nursing (DON). The DON said residents should have pillows and personal effects and they were auditing all the rooms. The DON said, We will make sure the resident rooms look like the residents live here, not like we are housing them. The DON said, We will reach out to families to bring personal effects such as pictures. The DON stated this would help calm them down and dignify them. On 12/16/21 at 10:05 a.m., a facility tour of the South Unit was conducted. Rooms were noted with pillows and uniform white sheets. The resident rooms were observed without any personal effects, no blankets or bed covers, no pictures, memorabilia, or decorations. These rooms included 152, 143, 144, 156 158 bed B, 159, 161, 163, 162, 165, 164, 167 and 168. On 12/16/21 at 10:08 a.m., an interview was conducted with Staff H, RN/UM. The Staff H stated they have replaced pillows in the resident rooms and have contacted families about helping to personalize the rooms. Staff H, RN/UM said, We want residents to be comfortable. The UM did not know why the rooms did not have blankets or covers. 2. On 12/13/21 at 2:11 p.m. and on 12/14/21 at 12:51 p.m., Resident #306 was observed with loose blue jean pants, and holding onto his pants as he walked around so they did not fall. Resident #306 stated he would like a belt to keep his pants up. Resident #306 did not know what happened to his belt. On 12/15/21 at 12:56 p.m., an interview was conducted with Staff H, RN/UM. Staff H was asked why Resident #306 did not have a belt or fitted clothing. The UM stated that sometimes safety was the priority. Staff H was asked if a safety concern was the reason Resident #306 did not have access to a belt. Staff H said, No, not really. The UM stated he would call the resident's family and ask them to bring one. Staff H stated he thought the family took it [belt] home. On 12/15/21 at 2:55 p.m., Resident #306 was observed wearing a pair of jeans shorts, he was noted holding on to them as he walked around in his room. Resident #306 did not have access to his belt. On 12/15/21 at 1:45 p.m. the Regional Director Clinical Service stated there was no reason why the residents should not be wearing belts if they wanted to. The Regional Director Clinical Service said, They should be wearing fitted clothes. There is no rule about the belts. It is not our policy. The Regional Director Clinical Service stated they would make sure Resident#306 had a belt. An interview was conducted on 12/15/21 at 4:19 p.m. with the DON. The DON said, I reached out to my administration. They [residents] can have belts. It is not a facility policy. The DON stated that she preferred they have clothes that fit. A follow up was conducted with the Nursing Home Administrator (NHA) and DON on 12/16/21 at 10:40 a.m. The NHA stated the expectation would be for their residents to have comfortable facilities. The NHA stated she stressed the need for a clean comfortable environment. In an interview conducted with the Social Services Director (SSD) on 12/16/21 at 1:25 p.m. the SSD presented documentation showing an audit conducted for all the residents in the North and South Units. The audit confirmed the rooms in the South Unit did not have personal effects such as pictures on walls. The audit further identified eight residents with clothing that was poorly fitted or did not have a belt. The SSD said, We will definitely correct this. Review of a facility policy titled, Dignity, revised February 2021, showed that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. #2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, and beliefs. #13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observations, interviews, record review and policy review the facility failed to ensure resident smoking materials were secured for three of four days (12/13/21, 12/14/21 and 12/15/21) on one unit (North Unit) of two units for seven residents (#39, #91, #18, #76, #74, #37, and #15) for a total sample of seven residents who smoked on the North Unit. Findings included: 1. During a facility tour on 12/14/21 at 12:12 p.m., Resident #39 was observed in her room, sitting on her bed. Resident #39 stated that she smokes whenever she likes day or night. Resident #39 stated she was an independent smoker and holds on to her cigarettes and lighter. Resident #39 stated that she holds on to a pack of cigarettes at a time. Resident #39 stated that she hides them under the seat of her wheelchair cushion. The Admission Record showed Resident #39 was admitted to the facility on [DATE]. A Quarterly Minimum Data Set (MDS) for Resident # 39 Section C for Cognitive Patterns showed a Brief Interview for Mental Status score of 15, indicating intact cognition. Section G, Functional Status showed Resident #39 requires limited assistance with ADLs (activities of daily living). A care plan initiated on 04/28/21 showed that Resident #39 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #39 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 10/07/21 under the Summary of Review Section C, Maintenance of Smoking Materials showed Resident #39 must request smoking materials from staff. 2. On 12/14/21 at 3:52 p.m. a tour of the smoking area was conducted and seven residents (#15, #18, #91, #37, #74, #39 and #76) from the North Unit were observed in the courtyard smoking independently. An observation of the area showed designated smoking area signs, smoking aprons hanging by the door, and metal cigarette receptacles available on each table. An interview was conducted with Resident #91. Resident #91 stated they smoke anytime they want to. Resident #91 stated he holds on to a pack of cigarettes at a time, but the rest are locked up. Resident #91 said, I keep my lighter and smokes on my person. The Admission Record showed Resident #91 was readmitted to the facility on [DATE]. The Admission MDS for Resident #91 dated 11/04/21 Section C-Cognitive Patterns, showed the resident was unable to complete the BIMS assessment. A smoking care plan initiated on 01/27/21 showed Resident #91 smokes independently and has been informed of the new facility smoking policy. The goal indicated that Resident #91 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 11/02/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #91 must request smoking materials from staff. 3. An interview was conducted with Resident #18 on 12/14/21 at 3:54 p.m. Resident #18 confirmed they [residents on the North Unit] smoke anytime. Resident #18 stated that he keeps his cigarettes and lighter on him. The Admission Record showed Resident #18 was readmitted to the facility on [DATE]. A Quarterly MDS for Resident #18 dated 09/22/21 Section C - Cognitive Patterns showed Resident #18 had a BIMS of 15 indicating intact cognition. A smoking care plan initiated on 01/27/21 showed Resident #18 smokes independently and has been informed of the new facility smoking policy. The goal indicated Resident #18 will demonstrate safe smoking practices. An intervention of the goal stated the resident will maintain smoking materials in a designated area. A Quarterly Smoking Evaluation conducted on 12/14/21, under Summary of Review, Section C, Maintenance of Smoking Materials showed Resident #18 must request smoking materials from staff. 4. A review of the smoking care plans and smoking evaluations for Residents #15, #37, #37, #74 and #76 also showed the residents should maintain smoking materials in a designated area and must request smoking materials from staff. On 12/14/21 at 3:57 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D was observed walking into the smoking area where the seven residents (#15, #18, #91, #37, #74, #39 and #76) were smoking. Staff D stated that the residents who were smoking at the time were independent and did not require supervision. Staff D explained that residents who need assistance or are assessed as dependent smokers follow a smoking schedule. Staff D stated that an assigned staff member comes to the courtyard with the residents' cigarettes and lighters stored in a box. Staff D stated the box is secured in the nurses' unit. Staff D stated this was not the practice for independent smokers in North Unit. Independent smokers hold on to their smoking materials. On 12/14/21 at 3:59 p.m., an observation was made of Staff E, Registered Nurse (RN) and evening supervisor in the smoking courtyard. Staff E approached Resident #18 and asked him if she could use his lighter. Resident #18 handed his lighter to Staff E. Staff E was observed lighting a cigarette for an unidentified resident. An immediate interview was conducted with Staff E. Staff E confirmed that independent smokers have been assessed to come and go on their own. Staff E said, they keep their lighters and smokes on them. On 12/15/21 at 9:25 a.m. an observation was made of Resident #39, #15 and #76 outside on the courtyard smoking. The residents had their cigarettes on them and lighters. These residents stated they keep their smoking materials on them all the time. On 12/15/21 at 1:55 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that North Unit smokers [#15, #18, #91, #37, #74, #39 and #76] have a box where they keep cigarettes and lighters. The NHA stated they have a schedule, but if they are deemed to smoke unsupervised, they can come and go on their own. When asked about their smoking materials the NHA stated the residents should get their articles for smoking and then go outside. When asked if the residents were permitted to hold on to their cigarettes and lighters the NHA said, No, they are supposed to turn them in. Residents should not be holding on to their cigarettes and lighters they acknowledged the policy. The NHA said, If staff are allowing them to, they should not. Now that I know, I will follow-up with the residents and staff. On 12/16/21 at 10:26 a.m., an interview was conducted with Staff F, Staffing Coordinator. Staff F was observed stationed by the North area exit door. Staff F was noted with a sign in/out log. Staff F stated that each resident has to sign in/out when receiving their cigarettes and lighters. Resident # 39 was observed signing out her smokes and lighter. Review of the facility's smoking policy titled, Smoking Policy - Residents, revised 02/14/2020, showed, #12 residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Resident's smoking paraphernalia will be kept in a designated secure location.

Based on interviews and clinical record review, the facility failed to provide pain relief for one (Resident #2) of three residents sampled for effective pain management, and failed to provide the appropriate trauma wound care for one (Resident #3) of three residents sampled for non-pressure wound care. Findings included: On 10/11/16 at approximately 6:10 p.m. an interview was conducted with Resident #2. Resident #2 stated that there had been a problem a few weeks ago when her prescription for pain medication had run out, and the facility was unable to get a timely refill, and she had to go over 23 hours without pain medication. She stated that she had chronic, generalized pain, pain in her legs, and a painful rash. She stated that she had been taking pain medication regularly, and when it ran out, her pain had been excruciating, and she had even called the Director of Nursing at home in the middle of the night because she was in such distress. The resident was sitting upright in bed, was alert, oriented, and interview-able. She stated that she especially needed the medication before dressing changes for the open wounds that she had to her legs. A clinical record review revealed Resident #2 had a comprehensive assessment completed 8/2/16. Section I had medical [DIAGNOSES REDACTED]. Section J revealed that she received prn (as needed) pain medications, and experienced frequent pain that limited her daily activities. A review of the September, 2016 physician's order [REDACTED]. On 10/11/16 at 6:40 p.m. the clinical record was reviewed with the Director of Nursing (DON). She confirmed the resident had been experiencing pain, and recently there had been a delay in getting the pain medication refilled. She stated the pharmacy had required a new written order for the narcotic pain medication from the physician, and although the physician had been notified multiple times, the new order had not been obtained prior to Resident #2 ' s pain medication running out. The Medication Administration Record [REDACTED]. Further review revealed an entry dated and timed 9/26/16 at 2:30 p.m. that stated a call was placed to the physician, and a new prescription was required for the pain medication, and the last tablet had been administered. The next entry timed 8:26 p.m. indicated a call had been placed to the pharmacy regarding the prescription, but the pharmacy stated that it had not yet received the prescription from the physician. The following entry at 2:30 a.m. on 9/27 revealed the resident had refused wound care due to being out of her pain medication, and an authorization was received to remove meds from the emergency medication kit. The DON confirmed this is when Resident #2 had called her at home at 1:30 a.m., and she had notified the on- call physician herself to get authorization to enter the emergency kit for a one time only order. The DON produced a controlled substance authorization that revealed two [MEDICATION NAME] tabs were administered from the emergency kit at 3:35 a.m. on 9/27/16. The DON stated the facility finally received a thirty tablet supply on 9/27/16 at 12:00 p.m. The DON confirmed that there was no consistent and accurate documentation of the administration of Resident #2 ' s pain medications that included consistent assessments of pain. She confirmed that if a resident has pain, and has an order for [REDACTED]. On 10/11/16 at 6:55 p.m. an interview was conducted with the DON and the Administrator. They stated that Resident #2 ' s physician had been repeatedly notified of the need for a prescription refill for her pain medication, but he did not act on this request. The DON stated that managing the resident ' s pain is a problem, and stated there had been no orders for a pain management consultation. She confirmed that the resident is receiving regular doses of [MEDICATION NAME], which also contains [MEDICATION NAME], and care should be taken not to exceed a maximum dose of this medication. She confirmed that this medication is ordered as needed every 4 hours. They were asked if the Medical Director could assist with this problem and they stated that this particular physician actually is the Medical Director. A phone call was made to the Medical Director, and a voice mail was left with his answering service, but there was no return call received. On 10/11/16 at 11:00 a.m. an interview was conducted with the licensed nurse practitioner from a consulting wound care group of physicians. She stated that Resident #3 had two wounds to his right foot: one that was due to trauma (medial wound) and one that was a pressure ulcer to the lateral aspect. She stated that both appeared to be healing. Review of the Resident ' s Wound Form dated 9/20/2016 showed Wound #6, Right Foot, Medial, etiology Trauma, treatment Santyl and calcium alginate with roll gauze every day. A clinical record review revealed Resident #3 had physician's order [REDACTED]. Pat dry. Apply triple antibiotic ointment to open area and skin prep to intact skin. Cover with roll gauze daily. On 10/11/16 at approximately 6:15 p.m. the physician's order [REDACTED]. They both confirmed that there was no documentation of care for the right foot medial trauma wound until 9/13/16 when a new order was written. They confirmed that there was no care documented to the wound until a new order was written on 10/4/16, approximately twenty-two days later. They confirmed that it was unknown what care had been provided to the right medial trauma wound from 9/13-10/4/16. On 10/11/16 at 11:10 a.m. an observation was made of Employee C, a a licensed practical nurse, as she provided wound care to Resident #3 ' s right foot medial trauma wound. She washed her hands, gloved, and removed the dressing to reveal an open wound bed. Employee C used the skin prep wipes directly to the open wound bed, wiping it repeatedly and also the intact surrounding skin. She squeezed antibiotic ointment onto her gloved finger and applied it directly to the wound bed, and still wearing the same gloves, covered the open area with a dry dressing. She picked up the cling wrap and placed it over the dressing, securing it to the foot and leg. ON 10/11/16 at 11:25 a.m. an interview was conducted with Employee C, and the Unit Manager. Employee C confirmed that she had applied the skin prep to the actual wound bed as well as the intact skin surrounding the wound bed. She confirmed that she had applied the ointment using a gloved finger directly to the wound bed, and then applied the dry dressing and tape using the same gloves. The Unit Manager stated the facility did have applicators that should have been used to apply ointment to the wound bed without using a gloved finger, and then possibly spreading infection by then touching other surfaces. The Unit Manager confirmed the skin prep should only be applied to the intact skin, and not the wound bed itself, and this was not consistent with the physician's order [REDACTED].

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 four residents reviewed for accidents and safety. The facility did not provide supervision or hydration offerings on the patio during non-smoking times and allowed a resident who was assessed as being at risk for dehydration, with a history of wandering, poor safety awareness, impaired cognition, and a history of falls, to remain outside & unsupervised on a day with temperatures in excess of 88 F with a Heat Index range of 89.6 F-91 F. Resident #1, a [AGE] year old long term care resident, had a [DIAGNOSES REDACTED]. Documentation in the latest Minimum Data Set (MDS), dated [DATE], reflected the resident needed extensive assistance for locomotion off the unit. On [DATE], the facility failed to ensure the resident had oversight supervision during non-smoking hours on the outdoor patio. Subsequently at 5:15 p.m., the resident was spotted outside by another resident, slumped in his wheelchair, in the direct sunlight, and unresponsive. The resident was transferred to the hospital where he was pronounced dead at 7:02 p.m. The facility ' s failure to honor Resident #1 ' s basic right to be free from neglect by not providing the necessary goods, oversight and supervision resulted in the findings of immediate jeopardy which was removed on [DATE] at 6:30 p.m. Findings included Per the facility ' s Abuse Prevention , policy with an effective date of [DATE], Sub Heading D Definitions; Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. On [DATE] at 2:37 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the events of [DATE]. When he was asked by the surveyor What was put into place after the event involving (Resident #1)? The NHA said, I will have to ask the nurse. Communication at first was [MEDICAL CONDITION]. It wasn ' t until after midnight to 1:00 when the detective spoke to me. The NHA said he had worked at the facility since [DATE]th, 2015 and nothing like the event on [DATE] had happened at the facility since his hire date. The NHA said, We still don ' t have any confirmation of sunburn, blisters. We met with everyone to determine what was fact or fiction in this case. We reached out to (Primary Care Physician) and the (Medical Director). They said they couldn ' t get anything, any information. Per Weather Underground the weather on, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm temperature was 89.1F. Dew Point 64.9, Humidity 45%, and Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity 46%, Heat Index: 89.6%, scattered clouds. Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. Sheet and physician ' s progress note of [DATE]. Random staff interviews described the resident as pleasant, quiet, cooperative, and strived to be as independent as possible. Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE]. The resident was referred to physical therapy due to a recent fall with no injury. Short and long term goals had been set for the resident with the long term goal as follows: 1. Patient will safely perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for use of side rails and for task segmentation in order to enhance safe functional mobility and increase ability to attend activities of choice. (Target date: [DATE]) 2. Patient will safely perform functional transfers with minimum assistance and 25% verbal cues for correct hand/foot placement with reduces risk of falls in order to safely maneuver in/out of bed and increase performance skills with functional tasks. (Target date [DATE]) 3. Patient will be able to ambulate using quad-cane 25 feet or more with minimum assistance with steady balance and gait pattern. (Target date [DATE]) The patient goal was documented as: To get stronger. A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]. Per the nurses notes dated [DATE] at 6:30 p.m. the resident was found on the patio sitting next to his wheelchair. The resident denied hitting his head and there were no apparent injuries. On [DATE] at 12:30p.m., an interview was conducted with the risk manager regarding Resident # 1 ' s unwitnessed fall on the patio on [DATE]. She said, at 6:30 p.m. on [DATE], the resident was found sitting outside on the patio in front of his wheelchair. She said the smoking aide did not witness the fall but turned around and saw him sitting on the ground in front of his wheelchair. The resident was assessed by the nurse and noted to have no injuries. Per the risk manager the resident said he slid out of his chair so Dycem was placed in the seat of his wheelchair and a request for therapy to evaluate the resident for positioning was submitted. The risk manager said the resident had a wheelchair alarm in place. She said the alarm was in place and sounded when the resident slid out of the wheelchair. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed the reason for referral to therapy was due to a fall. Under the section for area of concern, the form indicated fell while participating in a task/ experienced a fall, Date of Fall: [DATE]. The screen indicated resident had a fall from wheelchair on outside patio. Would benefit from positioning. Therapy Evaluation indicated a check mark for Occupational therapy. Review of the record revealed that an Occupational Therapy Evaluation was conducted on [DATE] and a plan of treatment developed. Per the nurse ' s notes, dated [DATE] at 2:45 p.m., the resident was found lying on the floor of his room on the left side of his bed. The resident was lying on his left side on top of the wheel chair cushion. The resident denied pain/discomfort and the nurse documented mental status intact, range of motion (ROM) exercises performed and intact, skin intact, no injuries present . Non-skid socks were applied for safety and the fall education was reinforced. The resident verbalized understanding. On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m., on [DATE], the resident ' s alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath him. The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The wheelchair brakes were locked. The call light was within reach, the floor was dry, and he was wearing regular socks. The intervention was for non-skid socks and a therapy referral. Physical therapy picked up the resident for skilled services for bilateral lower extremity strengthening and balance training for transfer safety. She stated the resident sustained [REDACTED]. Per the nurse ' s notes dated [DATE] at 10:00 p.m. the resident had an alarm to the bed and wheelchair due to poor safety awareness related to Dementia. The note said the resident checked often. The resident was able to slowly propel himself in the wheelchair around the unit. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced a fall, date of fall: [DATE] and Resident would benefit from skilled PT for B LE (Bilateral Lower Extremity) strengthening and balance training for safety and transfers. Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] ,revealed that physical therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for [REDACTED]. Review of Resident # 1 ' s care plan for Risk for falls/injury related to h/o falls, poor safety awareness and impaired mobility with a problem onset date of [DATE] and a next review date of [DATE], revealed [DATE] - fall occurred from w/c - see nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff assist with all transfers, Skilled therapy services as indicated, Restorative nursing services as indicated, Up and about ad lib via w/c, Med review prn and quarterly for need of and or any dose changes (sic), Keep bed in lowest position, Call light within reach of- encourage to use and staff to answer same asap, Keep area obstruction free as possible, [DATE] Therapy screen for positioning and Dycem. Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio. On [DATE] 1: 45 p.m., an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment dated , [DATE], Brief Interview for Mental Status (BIMS) score of 12 out of 15 (Total score: 8 -12: moderately impaired)). On [DATE] at 11:00 a.m. Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside in the patio at times and reads her bible. When asked if she was offered anything to drink when she was out there, she stated No . When asked, if prior to this past weekend was staff supervising or present on the patio, she stated only when the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment dated , [DATE], BIMS score 12 out of 15). On [DATE] at 11:15 a.m., Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from the smokers bothers her. She stated prior to this weekend there was never any staff out there except when the smokers were out. She emphasized again never. She stated when she was out in the patio; she was never offered anything to drink. (MDS quarterly assessment dated , [DATE], BIMS score 15. (Total score ,[DATE]: cognitively intact)). On [DATE] at 11: 30 a.m., Resident #21 was interviewed. The resident was extremely hard of hearing. Stated she goes outside to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she just got a new hearing aid and it was crackling and buzzing. When asked if she had asked staff to adjust it for her? She stated no, they ( .) someone this weekend and they are all very distracted because of it, not sure if I will get the help I need. (MDS annual assessment dated , [DATE], BIMS score 12 out of 15). On [DATE] at 1:15 p.m., an interview was conducted Resident #16. The resident stated he only goes outside when it is smoking time. He stated there was no point going out any other time. He said during smoking time there was staff out there, doesn ' t know other times. He stated there was water out there now but does not recall there being any water before this past weekend when he would be outside smoking. (MDS annual assessment dated , [DATE], BIMS score 15). On [DATE] at 1:17 p.m., an interview was conducted with Resident #17. She said she goes out to the patio to smoke and sometimes goes out there at other times. She confirmed there was staff on the patio only during smoking times. She stated there was no staff outside in the patio when smokers were not out. She stated she gets her own drinks to bring out with her. (MDS quarterly assessment dated [DATE], BIMS score 15). On [DATE] at 1:35 p.m., an interview was conducted with Resident #18. She was seated in the patio using a personal electronic device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music, check Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here in the patio at smoking times prior to this past weekend. (MDS quarterly assessment dated , [DATE], BIMS score 15). On [DATE] at 1:40 p.m., an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking times and other times also. He stated there was water available now and also there was the soda machine to get your own drinks. He stated he sits in the shade and moves to the other side when the shade moves. He stated there was no staff outside in the patio other than at smoking times until this week and no beverages unless he brought his own. (MDS quarterly assessment dated , [DATE], BIMS score 15). On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This was the resident who notified staff of Resident #1 being in distress. He stated he saw the man who died on the patio. He stated it was nasty and indicated it looked like he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad as the man died anyway in spite of trying to get him help. (MDS quarterly assessment [DATE] BIMS score 15). Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m., the resident (Resident #1) was Found on the outside patio unresponsive-[MEDICAL CONDITION] with agonal respirations-Temperature was 105.7. Review of the Nursing Evaluation for Resident # 1, dated [DATE], under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: [MEDICAL CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist Total score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be completed. The resident was also on Nectar thickened liquids. A comprehensive record review revealed an At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical record. On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He said at approximately 5:15 p.m. -5:20p.m., a resident came to him and said You need to go look at this guy he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident. On [DATE] at 3:45 p.m. an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse (Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even anoxia. Reference: Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see [MEDICAL CONDITION] blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined. Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease Control at http://stacks.cdc.gov/view/cdc/ ) Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to deal with the heat coming from the environment. Heat fatigue, heat [MEDICAL CONDITION] (sudden dizziness after prolonged exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors, some especially common among older people, that may increase risk of hyperthermia include: · Being dehydrated. · Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands. · Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever. · High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be at increased risk. However, salt pills should not be used without first consulting a doctor. Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness. (Source: National Institute of Health [DATE]) On [DATE] at 12:15 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant (CNA) (Staff E) for Resident #1. She said she assisted the resident with his morning care at approximately 10:30 a.m. She assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo type shirt, and yellow non-skid socks. She assisted him to transfer to his wheelchair at approximately 11:00 a.m. and took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA took the resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling himself toward the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be late. Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1 on [DATE] at 3:10 p.m. and [DATE] at 3:30 p.m. She said she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said, at approximately 4:15 p.m., the smoking aide told her that the resident did not want to come back inside and was still on the patio. Staff (F) said at 4:30 p.m., the resident was sitting next to the snack machine and the glass exit/entry door under the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed the resident to his table on the far side of the dining room in front of the windows. She said there were no other residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m. another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his wheelchair and would try to stand alone and get in another resident ' s bed. On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the smoking on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day. At approximately 4:00 p.m. she said she noticed Resident #1 sitting in his wheelchair near the soda machines in the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The resident ' s CNA (Staff F) said, Ok thank you. On [DATE] at 2:30 p.m., an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on [DATE]. She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said she did not see Resident #1 at 4:30 p.m. or anytime during dinner. She said at approximately 5:10 p.m. another CNA (Staff G) came into the dining room with Resident #1 ' s tray and said the resident wasn ' t in his room. Staff R told Staff G that the resident was not in the dining room. Staff R told Staff G to take the tray back to the resident ' s room and go look for the resident. Staff R said she could not leave the other residents in the dining room and was unable to assist with locating Resident #1. Staff R verified that at no time during her dining duty did she leave the dining room or see Resident #1 in the dining room. An interview was conducted, on [DATE] at 11:00 a.m., with Staff G. He said he left the facility at 3:00 p.m. to get his car and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the dining. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N) told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to talk to the supervisor. Staff G said the resident moved slow but was able to wheel himself around the facility. Staff G verified he did not see the resident that day. On [DATE] at 12:00 p.m., an interview was conducted with unit manager (Staff D). He said the resident was able to communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio. On [DATE] at 11:30 a.m., an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse (Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m., the resident was in the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She said at about 1:50 p.m. the CNA took the resident to his room for afternoon care. That was the last time she saw the resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the handrail. A tour of the facility, on [DATE], found that the building was a 120 bed nursing home, rectangular in shape, with a middle enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and had glass panels with a glass automatic door which was accessible by an automatic door push to open button at wheelchair height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between ,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass door to the patio. The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Yet, Staff R said she was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15 p.m. He said the resident was not in the dining at that time, nor was the resident in his room when staff G took the tray to the resident ' s room. Record review of the nurse ' s notes dated, [DATE] (no time), revealed the nurse was called out to the patio by another resident. The nurse found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The resident was transferred to the hospital. A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of [MEDICAL CONDITION]: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Under subsection GO400- Functional Limitation in Range of Motion: The resident was coded as a 1 for the upper and lower extremities on one side of the body. The resident was unable to walk and used a wheelchair for mobility. A review of the care plan, with problem onset date of [DATE] and next review date of [DATE], found Resident #1 needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to dementia and left [MEDICAL CONDITION]. A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE] (date of death ), did not indicate that he received breakfast, lunch, or dinner and

Based on interview and record review the facility failed to develop and implement policies and procedures to ensure residents who utilized the outdoor patio area were not neglected for one (Resident #1) of four residents reviewed for safety. Resident #1 was permitted to go outside unsupervised even though he was at risk for dehydration, wandering, poor safety awareness, impaired cognition, and had a history of [REDACTED].#1 was outside and did not look good or sound good. No one in the facility had seen the resident from 4:30 p.m. until 5:15 p.m. when he was found outside on the patio, unsupervised, slumped in his wheelchair, in the direct sun and unresponsive. The facility ' s failure to implement policies and procedures to ensure residents are not neglected and are provided oversight supervision during non-smoking times on the patio resulted in the findings of immediate jeopardy which was removed on [DATE] at 6:30 p.m. Findings included Per the facility ' s Abuse Prevention , policy with an effective date of [DATE], The facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, friends, etc. The facility has implemented and designed processes, which strive to ensure the prevention and reporting of suspected or alleged abuse, neglect, mistreatment, and/or misappropriation of property. Under the heading ' Process ' : Sub heading B. The Administration and Director of Nursing are responsible for the investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Implementation Ongoing monitoring Reporting Investigation Tracking and trending Sub heading C. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting Sub Heading D Definitions: Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness Sub Heading G Prevention: 1. Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration and stress. 2. Identify, correct and intervene in situations where abuse, neglect and /or mistreatment are more likely to occur. This includes, but is not limited to, identification and analysis of: a. Secluded areas of the facility b. Sufficient staffing on each shift to meet the needs of the individual resident ' s needs c. Sufficient and appropriate supervisory staff to identify inappropriate behaviors d. Residents with needs and behaviors which might lead to conflict or neglect. Review of a policy entitled Policy: Routine Resident Checks : 2001 Med-Pass, Inc. (revised [DATE]): Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation: 1. To ensure the safety and well- being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 hour shift. 2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to determine if the resident ' s needs are being met, identify any change in the resident ' s condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident ' s condition and medical needs. 4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and provide it to Nurse Supervisor/Charge Nurses.) This policy was reviewed with the Administrator, Assistant Director of Nursing (ADON), Regional Clinical Nurse, and Director of Nursing, on [DATE] at 3: 17 p.m. The Regional Clinical Nurse Regional nurse stated that residents are to be checked at least once every 8 hours but the standard of practice is every couple of hours check. She stated that there was no other policy for resident checks, just the one you have there and stated there is no documentation recorded of resident checks. Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. An interview was conducted with the ADON, on [DATE] at 2: 45 PM. She stated that prior to finding Resident #1 unresponsive on [DATE], there was no staff in the patio to monitor residents and offer hydration except during smoking times. Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio. On [DATE] 1: 45 p.m. an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental Status (BIMS) score of 12. (Total score: 8 -12: moderately impaired)). On [DATE] at 11:00 a.m. Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside in the patio at times and reads her bible. When asked if she is offered anything to drink when she is out there, she stated No . When asked if prior to this past weekend were there staff supervising or present in the patio, she stated only when the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE] BIMS score 12). On [DATE] at 11:15 a.m. Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from the smokers bothers her. She stated prior to this weekend there was never any staff out there except when the smokers were out. She emphasized again never . She stated when she was out in the patio; she was never offered anything to drink. (MDS quarterly assessment [DATE] BIMS score 15. Total score ,[DATE]: cognitively intact). On [DATE] at 11: 30 a.m. Resident #21 was interviewed. The resident was extremely hard of hearing. Stated she goes outside to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she just got a new hearing aid and it is crackling and buzzing. Asked if she had asked staff to adjust it for her? She stated no, they ( .) someone this weekend and they are all very distracted because of it, not sure if I will get the help I need. (MDS annual Assessment [DATE] BIMS score 12). On [DATE] at 1:15 p.m. an interview was conducted Resident #16. The resident stated he only goes outside when it is smoking time. He stated there was no point going out any other time. He said during smoking time there is staff out there, doesn ' t know other times. He stated there is water out there now but does not recall there being any water before this past weekend when he would be outside smoking. ([DATE] MDS annual assessment BIMS score 15). On [DATE] at 1:17 p.m. an interview was conducted with Resident #17. She said she goes out to the patio to smoke and sometimes goes out there at other times. She confirmed there was staff on the patio only during smoking times. She stated there was no staff outside in the patio when smokers were not out. She stated she gets her own drinks to bring out with her. ([DATE] MDS quarterly assessment BIMS score 15). On [DATE] at 1:35 p.m. an interview was conducted with Resident #18. She was seated in the patio using a personal electronic device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music, check Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here in the patio at smoking times prior to this past weekend. ([DATE] MDS quarterly assessment BIMS score 15). On [DATE] at 1:40 p.m. an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking times and other times also. He stated there is water available now and also there is the soda machine to get your own drinks. He stated he sits in the shade and moves to the other side when the shade moves. He stated there was no staff outside in the patio other than at smoking times until this week and no beverages unless he brought his own. ([DATE] MDS quarterly assessment BIMS score 15). On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This is the resident who notified staff of Resident #1 being in distress. He stated he saw the man who died , in the courtyard, he stated it was nasty and indicated it looked like he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad as the man died anyway in spite of trying to get him help. ([DATE] Quarterly MDS assessment BIMS score 15). Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm temperature was 89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity 46%, Heat Index: 89.6%, scattered clouds. Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease Control at <http://stacks.cdc.gov/view/cdc/ > Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to deal with the heat coming from the environment. Heat fatigue, heat [MEDICAL CONDITION] (sudden dizziness after prolonged exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors, some especially common among older people, that may increase risk of hyperthermia include: · Being dehydrated. · Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands. · Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever. · High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be at increased risk. However, salt pills should not be used without first consulting a doctor. Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness. (Source: National Institute of Health [DATE]) A tour of the facility, on [DATE], found that the facility is a 120 bed nursing home, rectangular in shape, with a middle enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and had glass panels with a glass automatic door which was accessible by an automatic door push to open button, accessible at wheelchair height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between ,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass door to the patio. Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m., the resident (Resident #1) was Found on the outside patio unresponsive-[MEDICAL CONDITION] with agonal respirations-Temperature was 105.7. Review of the Nursing Evaluation dated [DATE] under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: [MEDICAL CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist Total score: 9. Score of 8 or more indicates at risk for dehydration. At Risk Dehydration Care Plan must be completed. The resident was also on Nectar thickened liquids. The comprehensive record review revealed an At Risk Dehydration Care Plan could not be located in Resident # 1 ' s clinical record. On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He said at approximately 5:15 p.m. -5:20p.m., a resident came to him and said You need to go look at this guy he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident. On [DATE] at 3:45 p.m. an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and prepare Resident #1 for transport to the hospital. He said on, [DATE] between 5:25 p.m. and 5:30p.m., the other nurse (Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (muscle spasms or jerking. Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even anoxia.) Reference: Wikipedia, the free encyclopedia) Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see [MEDICAL CONDITION] blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined. On [DATE] at 12:15 p.m. an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant (CNA) (Staff E) for Resident #1 .She said she assisted the resident with his morning care at approximately 10:30 a.m. She assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo type shirt, and yellow non-skid socks. She assisted him to transfer him to his wheelchair at approximately 11:00 a.m. and took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA took the resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling himself toward the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be late . Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1, on [DATE] at 3: 10 p.m. and [DATE] at 3: 30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the patio. Staff (F) said at 4:30 p.m. the resident was sitting next to the snack machine and the glass exit/entry door under the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed the resident to his table on the far side of the dining room in front of the windows. She said there were no other residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m. another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his wheelchair and would try to stand alone and get in another resident ' s bed. On [DATE] at 3:40 p.m. an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the smoking on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day. At approximately 4:00 p.m. she said she noticed Resident #1 sitting in wheelchair near the soda machines in the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The resident ' s CNA (Staff F) said, Ok thank you. On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on [DATE]. She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said she did not see Resident #1 at 4:30 p.m. or anytime during dinner. She said at approximately 5:10 p.m. another CNA (Staff G) came into the dining room with Resident #1 ' s tray and said the resident wasn ' t in his room. Staff R told Staff G that the resident was not in the dining room. Staff R told Staff G to take the tray back to the resident ' s room and go look for the resident. Staff R said she could not leave the other residents in the dining room and was unable to assist with locating Resident #1. Staff R verified that at no time during her dining duty did she leave the dining room or see Resident #1 in the dining room. An interview was conducted on [DATE] at 11:00 a.m. with Staff G. He said he left the facility at 3:00 p.m. to get his car and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the dining. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N) told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to talk to the supervisor. Staff (G) said the resident moved slow but was able to wheel himself around the facility. Staff G verified he did not see the resident that day. On [DATE] at 12:00 p.m. an interview was conducted with unit manager (Staff D). He said the resident was able to communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio. On [DATE] at 11:30 a.m. an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse (Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m. the resident was in the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She said at about 1:50 p.m. the CNA took the resident to his room for afternoon care. That was the last time she saw the resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the handrail. On [DATE] at 1:20 p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding Resident #1. He said he saw, The man on the patio who died , and stated it was nasty and indicated it looked like he had vomit all over his face and said, He didn ' t look good . He went and told the nurse and said he felt bad as the man died anyway in spite of him trying to get him help. The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE].Per the time line the facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. yet Staff R said she was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15 p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the tray to the resident ' s room. Record review of the nurse ' s notes, dated [DATE] (no time), revealed the nurse was called out to the patio by another resident. The nurse found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The resident was transferred to the hospital. A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of [MEDICAL CONDITION]: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Under subsection GO400- Functional Limitation in Range of Motion: The resident was coded as a 1 for the upper and lower extremities on one side of the body. The resident was unable to walk and used a wheelchair for mobility. A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]: Per the nurses notes dated [DATE] at 6:30 p.m. the resident was found on the patio sitting next to his wheelchair. The resident denied hitting his head and there were no apparent injuries. On [DATE] at 12:30p.m., an interview was conducted with the risk manager regarding Resident # 1 ' s unwitnessed fall on the patio on [DATE]. She said, at 6:30 p.m. on [DATE], the resident was found sitting outside on the patio in front of his wheelchair. She said the smoking aide did not witness the fall but turned around and saw him sitting on the ground in front of his wheelchair. The resident was assessed by the nurse and noted to have no injuries. Per the risk manager the resident said he slid out of his chair so Dycem was placed in the seat of his wheelchair and a request for therapy to evaluate the resident for positioning was submitted. The risk manager said the resident had a wheelchair alarm in place. She said the alarm was in place and sounded when the resident slid out of the wheelchair. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed the reason for referral to therapy was due to a fall. Under the section for area of concern, the form indicated fell while participating in a task/ experienced a fall, Date of Fall: [DATE]. The screen indicated resident had a fall from wheelchair on outside patio. Would benefit from positioning. Therapy Evaluation indicated a check mark for Occupational therapy. Review of the record revealed that an Occupational Therapy Evaluation was conducted on [DATE] and a plan of treatment developed. Per the nurse ' s notes, dated [DATE] at 2:45 p.m., the resident was found lying on the floor of his room on the left side of his bed. The resident was lying on his left side on top of the wheel chair cushion. The resident denied pain/discomfort and the nurse documented mental status intact, range of motion (ROM) exercises performed and intact, skin intact, no injuries present . Non-skid socks were applied for safety and the fall education was reinforced. The resident verbalized understanding. On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m. on [DATE] the resident ' s alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath him. The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The wheelchair brakes were locked. The call light was within reach, the floor was dry, and he was wearing regular socks. The intervention was for non-skid socks and a therapy referral. Physical therapy picked up the resident for skilled services for bilateral lower extremity strengthening and balance training for transfer safety. She stated the resident sustained [REDACTED]. Per the nurse ' s notes dated [DATE] at 10:00 p.m. the resident had an alarm to the bed and wheelchair due to poor safety awareness related to Dementia. The noted said the resident checked often The resident was able to slowly propel himself in the wheelchair around the unit. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE] ,revealed fell while participating in a task/experienced a fall, Date of Fall: [DATE] and Resident would benefit from skilled PT for B LE ( Bilateral Lower Extremity) strengthing and balance training for safety and transfers. <

Based on interview, observation of an enclosed outdoor patio and record review, the facility failed to provide the supervision needed for one (Resident #1) of four sampled residents who were identified as needing closer supervision. Resident #1 was on the facility outdoor patio in 88 degree weather in direct Florida sunlight for an undetermined amount of time without consistent supervision and monitoring and without evidence of hydration and sun protection. Resident # 1 was determined to be at risk for dehydration, had a history of [REDACTED]. The resident was found on the outside patio and was assessed as being unresponsive, tachycardic with agonal respirations and an internal body temperature of 105.7. The resident was transported to the hospital emergency room where he subsequently died . All residents who utilized the patio were at risk for neglect/ illness injury and even death as a result of the facility failing to have a system in place to supervise and monitor residents at all times while outside on the patio. This failure created a situation that resulted in serious injury and harm to Resident # 1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 6:30 p.m. and the severity and scope was reduced to a D. Findings Included: Record review of the nurse ' s notes, dated [DATE] (no time), revealed the nurse was called out to the patio by another resident. The nurse found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The resident was transferred to the hospital. Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to deal with the heat coming from the environment. Heat fatigue, heat syncope (sudden dizziness after prolonged exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors, some especially common among older people, that may increase risk of hyperthermia include: · Being dehydrated. · Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands. · Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever. · High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be at increased risk. However, salt pills should not be used without first consulting a doctor. Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness. (Source: National Institute of Health [DATE]) Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease Control at <http://stacks.cdc.gov/view/cdc/ > Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53 p.m. temperature was 89.1F. Dew Point 64.9, Humidity 45%, and Heat Index: 91%, skies were clear. At 4:53 p.m. Temp. 88 F, Dew Point 64.9, Humidity 46%, Heat Index: 89.6%, scattered clouds. Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m., the resident (Resident #1) was Found on the outside patio unresponsive-tachycardic with agonal respirations-Temperature was 105.7. Review of the Nursing Evaluation dated [DATE] under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: Renal Insufficiency/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist Total score: 9. Score of 8 or more indicates at risk for dehydration. At Risk Dehydration Care Plan must be completed. The resident was also on Nectar thickened liquids. The comprehensive record review revealed an At Risk Dehydration Care Plan could not be located in Resident #1 ' s clinical record. On [DATE] at 3:45 p.m., an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He said at approximately 5:15 p.m. -5:20 p.m., a resident came to him and said You need to go look at this guy he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for and the nurse said it was an Exelon patch for the Dementia. The nurse then pulled the patch off the resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident. On [DATE] at 3:45 p.m. an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse (Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme hypoxia or even anoxia Reference: Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see any burns or blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined. On [DATE] at 12:15 p.m. an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant (CNA) (Staff E) for Resident #1.She said she assisted the resident with his morning care at approximately 10:30 a.m. She assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo type shirt, and yellow non-skid socks. She assisted him to transfer to his wheelchair at approximately 11:00 a.m. and took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling himself around the TV room and in front of the north wing nurses station. Between 2:15 p.m. -2:30 p.m. the CNA took the resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m., she saw the resident propelling himself toward the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be late . Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1, on [DATE] at 3: 10 p.m. and on [DATE] at 3: 30 p.m. She said she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the patio. Staff (F) said at 4:30 p.m. the resident was sitting next to the snack machine and the glass exit/entry door under the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed the resident to his table on the far side of the dining room in front of the windows. She said there were no other residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m. another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his wheelchair and would try to stand alone and get in another resident ' s bed. On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the smoking on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day. At approximately 4:00 p.m. she said she noticed Resident #1 sitting in his wheelchair near the soda machines in the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The resident ' s CNA (Staff F) said, Ok thank you. On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on [DATE].She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said she did not see Resident #1 at 4:30 p.m. or anytime during dinner. She said at approximately 5:10 p.m. another CNA (Staff G) came into the dining room with Resident #1 ' s tray and said the resident wasn ' t in his room. Staff R told Staff G that the resident was not in the dining room. Staff R told Staff G to take the tray back to the resident ' s room and go look for the resident. Staff R said she could not leave the other residents in the dining room and was unable to assist with locating Resident #1. Staff R verified that at no time during her dining duty did she leave the dining room or see Resident #1 in the dining room. An interview was conducted on [DATE] at 11:00 a.m. with Staff G. He said he left the facility at 3:00 p.m. to get his car and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the dining room. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N) told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to talk to the supervisor. Staff G said the resident moved slow but was able to wheel himself around the facility. Staff G verified he did not see the resident that day. On [DATE] at 12:00 p.m. an interview was conducted with unit manager (Staff D). He said the resident was able to communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio. On [DATE] at 11:30 a.m. an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse (Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m. the resident was in the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She said at about 1:50 p.m. the CNA took the resident to his room for afternoon care. That was the last time she saw the resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the handrail. On [DATE] at 1:20 p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding Resident #1. He said he saw, The man on the patio who died , and stated it was nasty and indicated it looked like he had vomit all over his face and said, He didn ' t look good . He went and told the nurse and said he felt bad as the man died anyway in spite of him trying to get him help. The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE].Per the time line; the facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining room for evening meal. However, the staff interviews revealed conflicting information regarding the resident ' s location from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Yet, Staff R said she was in the dining room between 4:25 p.m. and 4:30 p.m., until approximately 5:10 p.m., and did not see the resident in the dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15 p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the tray to the resident ' s room. A tour of the facility, on [DATE], found that the facility was a 120 bed nursing home, rectangular in shape, with a middle enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and had glass panels with a glass automatic door which was accessible by an automatic door push to open button accessible at wheelchair height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the left. The alcove led to a large rectangular unshaded area. Due to sun movement, the alcove area was shaded differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between ,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass door to the patio. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of Delirium: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Under subsection GO400- Functional Limitation in Range of Motion: The resident was coded as a 1 for the upper and lower extremities on one side of the body. The resident was unable to walk and used a wheelchair for mobility. A review of the care plan (Onset date [DATE] with a revision date of [DATE]) for Resident #1 indicated the resident needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to dementia and left hemiparesis. A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE] (date of death ), did not indicate that he received breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner. Per the physician's order [REDACTED]. A review of the resident ' s latest laboratory results, dated [DATE], revealed Sodium, Potassium, Chloride and Calcium were all within normal limits. Per a physician's order [REDACTED]. On [DATE], at 2:27 p.m., an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the facility called him to inform him that the resident was on his way to the hospital. He said he was not aware of any concerns related to being outside until the next day when he heard it on the news. He said he was not sure of the exact time he was called but said he went on call at 6:00 p.m. He said he received a call from the emergency room doctor later in the evening after the resident had expired. He said initially he agreed to sign the death certificate but the case was referred to the medical examiner. He said the ER MD did not mention anything about the resident ' s skin condition i.e. blisters, sunburn. He said he had recently seen the resident at the facility ([DATE]). The resident was medically stable and he had no concerns about the resident. He said the resident did not have any conditions that made him more sensitive to the sun or the heat. On [DATE] at 2:00 p.m., an interview was conducted with the pharmacist. The pharmacist reviewed the medications that the resident was receiving prior to his death to see if any of the medications would cause photosensitivity or heat sensitivity. The review revealed that none of the medications would cause photosensitivity or heat sensitivity. At 11:30 a.m. on [DATE], an interview was conducted with the facility ' s Medical Director. He said he was notified by the facility on, Monday ([DATE]), that the resident had been found outside unresponsive, sent to the hospital, and that there was concern by the EMTs regarding sun exposure. He said he had not spoken with the facility regarding the corrective plan or root cause analysis as of yet but would expect to be included in the process. Per the Physician ' s progress note, dated [DATE], the resident was a [AGE] year old with [DIAGNOSES REDACTED]. Per the physician ' s progress note, dated [DATE], the physician documented that the resident had been stable since his last physician ' s visit with no cough or dyspnea reported, no new pain or discomfort, no tremors or convulsions, no palpitations, stable reports of elimination and stable nutrition. Physical examination revealed: General appearance: appears stated age. Heart rate: Regular. Heart sounds: Normal: S1S2. Lungs: no wheezing/rhonchi/rales. Abdomen: Soft. Extremities: No clubbing or cyanosis. Per review of the Routine Resident Checks policy (Nursing Services Policy and Procedure Manual, 2001 MED-PASS, Inc., Revised [DATE]), the policy was as follows; Policy Statement : Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation : 1. To ensure the safety and well- being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 hour shift. 2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to determine if the resident ' s needs are being met, identify any change in the resident ' s condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident ' s condition and medical needs. 4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. (Note: CNAs may also record this information and provide it to Nurse Supervisor/Charge Nurses.) This policy was reviewed with the Administrator, Assistant Director of Nursing (ADON), Regional Clinical Nurse, and Director of Nursing, on [DATE] at 3: 17 p.m. The Regional Clinical Nurse Regional nurse stated that residents are to be checked at least once every 8 hours but the standard of practice was every couple of hours check. She stated that there was no other policy for resident checks, just the one you have there and stated there was no documentation recorded of resident checks. An interview was conducted with the ADON, on [DATE] at 2: 45 PM. She stated that prior to finding Resident #1 unresponsive on [DATE], there was no staff in the patio to monitor residents and offer hydration except during smoking times. A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]: Per the nurse ' s notes, dated [DATE] at 6:30 p.m., the resident was found on the patio sitting next to his wheelchair. The resident denied hitting his head and there were no apparent injuries. On [DATE] at 12:30p.m., an interview was conducted with the risk manager regarding Resident # 1 ' s unwitnessed fall on the patio on [DATE]. She said, at 6:30 p.m. on [DATE], the resident was found sitting outside on the patio in front of his wheelchair. She said the smoking aide did not witness the fall but turned around and saw him sitting on the ground in front of his wheelchair. The resident was assessed by the nurse and noted to have no injuries. Per the risk manager the resident said he slid out of his chair so Dycem was placed in the seat of his wheelchair and a request for therapy to evaluate the resident for positioning was submitted. The risk manager said the resident had a wheelchair alarm in place. She said the alarm was in place and sounded when the resident slid out of the wheelchair. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed the reason for referral to therapy was due to a fall. Under the section for area of concern, the form indicated fell while participating in a task/ experienced a fall, Date of Fall: [DATE]. The screen indicated resident had a fall from wheelchair on outside patio. Would benefit from positioning. Therapy Evaluation indicated a check mark for Occupational therapy. Review of the record revealed that an Occupational Therapy Evaluation was conducted on [DATE] and a plan of treatment developed. Per the nurse ' s notes, dated [DATE] at 2:45 p.m., the resident was found lying on the floor of his room on the left side of his bed. The resident was lying on his left side on top of the wheel chair cushion. The resident denied pain/discomfort and the nurse documented mental status intact, range of motion (ROM) exercises performed and intact, skin intact, no injuries present . Non-skid socks were applied for safety and the fall education was reinforced. The resident verbalized understanding. On [DATE] at 12:30 p.m., an interview was conducted with the risk manager. She said at 2:45 p.m. on [DATE] the resident ' s alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath him. The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The wheelchair brakes were locked. The call light was within reach, the floor was dry, and he was wearing regular socks. The intervention was for non-skid socks and a therapy referral. Physical therapy picked up the resident for skilled services for bilateral lower extremity strengthening and balance training for transfer safety. She stated the resident sustained [REDACTED]. Per the nurse ' s notes dated [DATE] at 10:00 p.m. the resident had an alarm to the bed and wheelchair due to poor safety awareness related to Dementia. The noted said the resident checked often The resident was able to slowly propel himself in the wheelchair around the unit. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced a fall, Date of Fall: [DATE] and Resident would benefit from skilled PT for B LE ( Bilateral Lower Extremity) strengthening and balance training for safety and transfers. Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] ,revealed that physical therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for [REDACTED]. Review of Resident # 1 ' s care plan for Risk for falls/injury related to h/o falls, poor safety awareness and impaired mobility with a problem onset date of [DATE] and a next review date of [DATE], revealed [DATE] - fall occurred from w/c - see nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff assist with all transfers, Skilled therapy services as indicated, Restorative nursing services as indicated, Up and about ad lib via w/c, Med review prn and quarterly for need of and or any dose changes (sic), Keep bed in lowest position, Call light within reach of- encourage to use and staff to answer same asap, Keep area obstruction free as possible, [DATE] Therapy screen for positioning and Dycem. Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio and were as follows: On [DATE] 1: 45 p.m. an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental Status (BIMS) score of 12 out of 15. (Total score: 8 -12: moderately impaired)). On [DATE] at 11:00 a.m. Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside in the patio at times and reads her bible. When asked if she was offered anything to drink when she was out there, she stated No . When asked if prior to this past weekend were there staff supervising or present in the patio, she stated only when the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE] BIMS score 12 out of 15). On [DATE] at 11:15 a.m. Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from the smokers bothers her. She stated prior to this weekend there was never any staff out there except when the smokers were out. She emphasized again never . She stated when she was out in the patio; she was never offered anything to drink. (MDS quarterly assessment [DATE] BIMS score 15.

Based on interview, and record review and observation of the facility and outside patio area, the facility failed to ensure that fluid needs were identified and met for one (Resident #1) of two residents identified at risk of dehydration of four sampled residents who used the patio during non-smoking times. Resident #1, a [AGE] year old resident, was described as having poor safety awareness which put the resident at risk when allowed to remain outdoors. Resident #1 was on the facility patio in 88 degree weather in direct sunlight in Florida without sunscreen, for an undetermined amount of time without consistent supervision nor evidence that hydration needs were assessed and met. Resident # 1 was determined to be at risk for dehydration, was identified with impaired cognition, and left [MEDICAL CONDITION], along with [DIAGNOSES REDACTED]. The resident was found unresponsive on the outdoor patio, [MEDICAL CONDITION] with agonal respirations and an internal body temperature of 105.7. The resident was transported to the hospital emergency room where he subsequently died . All residents who utilized the patio were at risk for neglect/ illness injury and even death as a result of the facility failing to have a system in place to ensure sufficient fluids for hydration throughout the day and while outside on the patio. This failure created a situation that resulted in serious injury and harm to Resident # 1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 6:30 p.m. and the severity and scope was reduced to a D. Findings Included: Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. note of [DATE]. At 11:30 a.m. on [DATE] an interview was conducted with the facility ' s Medical Director. He said he was notified by the facility on, Monday ([DATE]), that the resident had been found outside unresponsive, sent to the hospital, and that there was concern by the EMTs regarding sun exposure. He said he had not spoken with the facility regarding the corrective plan or root cause analysis as of yet but would expect to be included in the process. Review of the Nursing Evaluation, dated [DATE], under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: [MEDICAL CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist. Total score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be completed. The resident was also on Nectar thickened liquids. A comprehensive record review revealed an At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical record. A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section G -Functional Status: subsection H - Eating-how resident eats and drinks, regardless of skill. The resident was coded as a ,[DATE] indicating he needed limited assistance with one person physical assist. Under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of [MEDICAL CONDITION]: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Review of the care plan with Problem onset, dated [DATE], and the next review date of [DATE] indicated the resident was over his ideal body weight and received a mechanical soft/no added salt diet with thickened liquids. A Problem onset dated [DATE] and the next review date of [DATE] found the resident was at risk for aspiration related to dysphasia treatment for [REDACTED]. A review of the care plan for resident #1 indicated Problem onset , dated [DATE] with the next review date of [DATE], resident needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to dementia and left [MEDICAL CONDITION]. A review of the CNA ADL Flow Sheet for Resident #1 dated [DATE] did not indicate for [DATE] (day of death) that he received breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner. In addition, out of 29 possible offerings for a snack, 26 opportunities were left blank. There was no documentation on the Activities of Daily Living (ADL) flow sheet that indicated the resident received a bedtime snack as per the physician's order [REDACTED].>Per the physician's order [REDACTED]. A review of the resident ' s latest laboratory results, dated [DATE], revealed Sodium, Potassium, Chloride and Calcium were all within normal limits. Per a physician's order [REDACTED]. Random staff interviews described the resident as pleasant, quiet, cooperative, and strived to be as independent as possible. Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE],the resident was referred to physical therapy due to a recent fall with no injury. Short and long term goals had been set for the resident with the long term goal as follows: 1. Patient will safety perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for use of side rails and for task segmentation in order to enhance safe functional mobility and increase ability to attend activities of choice. (Target date: [DATE]) 2. Patient will safely perform functional transfers with minimum assistance and 25% verbal cues for correct hand/foot placement with reduces risk of falls in order to safely maneuver in/out of bed and increase performance skills with functional tasks. (Target date [DATE]) 3. Patient will be able to ambulate using quad-cane 25 feet or more with minimum assistance with steady balance and gait pattern. (Target date [DATE]) The patient goal was documented as: To get stronger. On [DATE] at 3:00 p.m. an interview was conducted with the Director of Nurses (DON). Regarding documentation of the resident ' s daily fluid intake, she said there was no documentation of offerings or intake of fluids other than at meals. An interview was conducted with the ADON, on [DATE] at 2: 45 PM. She stated that prior to finding Resident #1 unresponsive on [DATE], there was no staff in the patio to monitor residents and offer hydration except during smoking times. And On [DATE] at 3:45 p.m. an interview was conducted with the Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He said at approximately 5:15 p.m. -5:20 p.m., a resident came to him and said You need to go look at this guy he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident. On [DATE] at 3:45 p.m. an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse (Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even anoxia Reference: Wikipedia, the free encyclopedia). Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see [MEDICAL CONDITION] blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined. Record review the nurse ' s notes dated, [DATE] (no time), revealed the nurse was called out to the patio by another resident. The nurse found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The resident was transferred to the hospital. Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m., the resident (Resident #1) was Found on the outside patio unresponsive-[MEDICAL CONDITION] with agonal respirations-Temperature was 105.7. On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on [DATE]. She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said all the other fluids i.e. juice, water, milk, etc. come with the meal. She said did not see Resident #1 at 4:30 p.m. or anytime during dinner. Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida, was as follows: At 3:53 p.m. temperature was 89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53 p.m. Temp. 88 F, Dew Point 64.9, Humidity 46%, Heat Index: 89.6%, scattered clouds. Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to deal with the heat coming from the environment. Heat fatigue, heat [MEDICAL CONDITION] (sudden dizziness after prolonged exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors, some especially common among older people, that may increase risk of hyperthermia include: · Being dehydrated. · Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands. · Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever. · High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be at increased risk. However, salt pills should not be used without first consulting a doctor. Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness. (Source: National Institute of Health [DATE]) Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease Control at http://stacks.cdc.gov/view/cdc/ Resident interviews were conducted with questions asked related to supervision and fluid offerings on the patio and were as follows: On [DATE] 1: 45 p.m., an interview was conducted with Resident #20. He stated he only goes outside at smoking times, no other times. He said he was never offered any water or other beverages when he was outside. He could not say if there were any beverages outside in the smoking area. (Minimum Data Set (MDS) quarterly assessment, [DATE], Brief Interview for Mental Status (BIMS) score of 12 out of 15(Total Score ,[DATE]: Moderately Impaired).) On [DATE] at 11:00 a.m., Resident #13 was interviewed. She was in her room reading her bible. She stated she does go outside in the patio at times and reads her bible. When asked if she is offered anything to drink when she is out there, she stated No . When asked if prior to this past weekend were there staff supervising or present in the patio? She stated, only when the smokers came out. She stated there were no staff present at non- smoking times. (MDS quarterly assessment [DATE] BIMS score 12 out of 15). On [DATE] at 11:15 a.m., Resident #15 was interviewed. She stated she goes outside to the patio. She stated the smoke from the smokers bothers her. She stated prior to this weekend there was never any staff out there except when the smokers were out. She emphasized again never. She stated when she was out in the patio; she was never offered anything to drink. (MDS quarterly assessment [DATE] BIMS score 15 (Total score: ,[DATE] Cognitively Intact)). On [DATE] at 11: 30 a.m., Resident #21 was interviewed. The resident was extremely hard of hearing. She stated she goes outside to smoke but was not able to hear/ understand the surveyor when asked about offerings of hydration. She stated she just got a new hearing aid and it was crackling and buzzing. She was asked if she had asked staff to adjust it for her? She stated no, they ( .) someone this weekend and they are all very distracted because of it, not sure if I will get the help I need. (MDS annual Assessment [DATE] BIMS score 12 out of 15). On [DATE] at 1:15 p.m., an interview was conducted Resident #16. The resident stated he only goes outside when it was smoking time. He stated there was no point going out any other time. He said during smoking time there was staff out there, doesn ' t know other times. He stated there was water out there now but does not recall there being any water before this past weekend when he would be outside smoking. (MDS annual assessment [DATE] BIMS score 15). On [DATE] at 1:17 p.m., an interview was conducted with Resident #17. She said she goes out to the patio to smoke and sometimes goes out there at other times. She confirmed there was staff on the patio only during smoking times. She stated there was no staff outside in the patio when smokers were not out. She stated she gets her own drinks to bring out with her. (MDS quarterly assessment [DATE] BIMS score 15). On [DATE] at 1:35 p.m., an interview was conducted with Resident #18. She was seated in the patio using a personal electronic device. She stated she comes outside to patio to smoke and also during non- smoking times to listen to music, check Facebook etc. She stated she had her own beverages but could get water from staff. She stated staff was only out here in the patio at smoking times prior to this past weekend. (MDS quarterly assessment BIMS score 15) On [DATE] at 1:40 p.m., an interview was conducted with Resident #4. He stated he comes out to the patio when it is smoking time and other times also. He stated there was water available now and also there was the soda machine to get your own drinks. He stated he sits in the shade and moves to the other side when the shade moves. He stated there was no staff outside in the patio other than at smoking times until this week and no beverages unless he brought his own. (MDS quarterly assessment BIMS score 15). On [DATE] at 1:20 p.m., an interview was conducted with Resident # 12. This was the resident who notified staff of Resident #1 being in distress. He stated he saw the man who died , in the patio. He stated it was nasty and indicated it looked like he had vomit all over his face and he didn ' t look good . He stated he went and told the nurse. He said he felt bad as the man died anyway in spite of trying to get him help. (MDS quarterly assessment [DATE] BIMS score 15). On [DATE] at 12:15 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant (CNA) (Staff E) for Resident #1 .She said she assisted the resident with his morning care at approximately 10:30 a.m. She assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo type shirt, and yellow non-skid socks. She assisted him to transfer to his wheelchair at approximately 11:00 a.m. and took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling himself around the TV room and in front of the north wing nurse ' s station. Between 2:15 p.m. -2:30 p.m., the CNA took the resident to his room to provide care. She said between 2:45 p.m. -3:00 p.m. she saw the resident propelling himself toward the patio door. She stopped him and said Where are you going? The resident responded, Outside . The CNA said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be late. Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1 on [DATE] at 3:10 p.m. and on [DATE] at 3:30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the patio. Staff (F) said at 4:30 p.m. the resident was sitting next to the snack machine and the glass exit/entry door under the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed the resident to his table on the far side of the dining room in front of the windows. She said there were no other residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m. another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his wheelchair and would try to stand alone and get in another resident ' s bed. On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the smoking on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day. At approximately 4:00 p.m. she said she noticed Resident #1 sitting in his wheelchair near the soda machines in the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The resident ' s CNA (Staff F) said, Ok thank you. An interview was conducted on [DATE] at 11:00 a.m. with Staff G. He said he left the facility at 3:00 p.m. to get his car and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the dining. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N) told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to talk to the supervisor. Staff G said the resident moved slow but was able to wheel himself around the facility. Staff G verified he did not see the resident that day. On [DATE] at 12:00 p.m., an interview was conducted with unit manager (Staff D). He said the resident was able to communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio. On [DATE] at 11:30 a.m. an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse (Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m., the resident was in the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She said at about 1:50 p.m., the CNA took the resident to his room for afternoon care. That was the last time she saw the resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the handrail. On [DATE] at 1:20p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding Resident #1. He said he saw, The man on the patio who died , and stated it was nasty and indicated it looked like he had vomit all over his face and said, He didn ' t look good . He went and told the nurse and said he felt bad as the man died anyway in spite of him trying to get him help. The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m., yet, Staff R said she was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15 p.m. He said the resident was not in the dining at that time, nor was the resident in his room when Staff G took the tray to the resident ' s room. A tour of the facility, on [DATE], found that the facility is a 120 bed nursing home, rectangular in shape, with a middle enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and had glass panels with a glass automatic door which was accessible by an automatic door push to open button accessible at wheelchair height. The patio was not within line of sight from the North Unit nurse ' s station and there was no phone or call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between ,[DATE] and [DATE]). She said prior to the new canopy there was no other shaded areas except along the outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass door to the patio. A review of the resident ' s latest laboratory results, dated [DATE], revealed Sodium, Potassium, Chloride and Calcium were all within normal limits. Per a physician's order [REDACTED]. On [DATE], at 2:27 p.m., an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the facility called him to inform him that the resident was on his way to the hospital. He said he was not aware of any concerns related to being outside until the next day when he heard it on the news. He said he was not sure of the exact time he was called but said he went on call at 6:00p.m. He said he received a call from the emergency room doctor later in the evening after the resident had expired. He said initially he agreed to sign the death certificate but the case was referred to the medical examiner. He said the ER MD did not mention anything about the resident ' s skin condition i.e. blisters, sunburn. He said he had recently seen the resident at the facility ([DATE]). The resident was medically stable and he had no concerns about the resident. He said the resident did not have any conditions that made him more sensitive to the sun or the heat. On [DATE] at 2:00 p.m., an interview was conducted with the pharmacist. The pharmacist reviewed the medications that the resident was receiving prior to his death to see if any of the medications would cause photosensitivity or heat sensitivity. The review revealed that none of the medications would cause photosensitivity or heat sensitivity. Per the Physician ' s progress note, dated [DATE], the resident was a [AGE] year old with [DIAGNOSES REDACTED]. Per the physician ' s progress note, dated [DATE], the physician documented that the resident had been stable since his last physician ' s visit with no cough or dyspnea reported, no new pain or discomfort, no tremors or convulsions, no palpitations, stable reports of elimination and stable nutrition. Physical examination revealed: General appearance: appears stated age. Heart rate: Regular. Heart sounds: Normal: S1S2. Lungs: no wheezing/rhonchi/rales. Abdomen: Soft. Extremities: No clubbing or cyanosis. Per review of the Routine Resident Checks policy, the policy is as follow; Policy Statement : Staff shall make routine resident checks to help maintain resident safety and well-being. Policy Interpretation and Implementation : 1. To ensure the safety and well- being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 hour shift. 2. Routine resident checks involve entering the resident ' s room and/or identifying the resident elsewhere on the unit to determine if the resident ' s needs are being met, identify any change in the resident ' s condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident ' s condition and medical needs. 4. The Nursing Supervisor/Charge Nurse shall keep documentation related to thes

Based on record review, policy and procedure review, staff and administrative interview, and 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 four sampled residents who was 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: Resident #1 was on a facility patio in 88 degree weather in direct sunlight for an undetermined amount of time, without consistent supervision and monitoring and without evidence of hydration and sun protection. Resident # 1 had a history of [REDACTED].V.A.) was determined to be at risk for dehydration, wandering, poor safety awareness, impaired cognition, and a history of falls with [DIAGNOSES REDACTED]. The resident was found on the outside patio and was assessed as being unresponsive, [MEDICAL CONDITION] with agonal respirations and an internal body temperature of 105.7. The resident was transported to the hospital emergency room where he subsequently died . All residents who utilized the patio were at risk for neglect/illness injury and even death as a result of the facility failing to have a system in place to supervise and monitor residents at all times while outside on the patio. This failure created a situation that resulted in serious injury and harm to Resident # 1 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] at 6:30 p.m. and the severity and scope was reduced to a D. Findings Included: Review of the job description provided by the facility (unsigned and undated) for the Nursing Home Administrator (2003 Med-Pass, Inc.) revealed the following relevant information; Purpose of Your Job Position : The primary purpose of you job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Administrative Functions : Plan, develop, organize, implement, and direct the facility ' s programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operations of the facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility ' s established policies and procedures. Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. Personnel Functions : Assist in the recruitment and selection of competent department directors, supervision, facility non- licensed staff, consultants, etc. Delegate administrative authority, responsibility, and accountability to other staff personnel as deemed necessary to perform their assigned duties. Staff Development : Assist department directors in the topic selection, planning, conducting, and scheduling of in-service training classes and on-the-job training and orientation programs to assure that current material and programs are continuously provided. Safety and Sanitation : Review accident/incident reports (e.g., falls, injuries of an unknown source, abuse, etc.). Monitor to determine the effectiveness of the facility ' s risk management program. Equipment and Supply Functions : Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. On [DATE] at 2:37 p.m. an interview was conducted with the Nursing Home Administrator NHA regarding the events of [DATE]. When he was asked by the surveyor What was put into place after the event involving (Resident #1)? The NHA said, I will have to ask the nurse. Communication at first was [MEDICAL CONDITION]. It wasn ' t until after midnight to 1:00 when the detective spoke to me. The NHA said he had worked at the facility since [DATE]th, 2015 and nothing like the event on [DATE] had happened at the facility since his hire date. The NHA said, We still don ' t have any confirmation of sunburn, blisters. We met with everyone to determine what was fact or fiction in this case. We reached out to (Primary Care Physician) and the (Medical Director). They said they couldn ' t get anything, any information. Resident #1 was a [AGE] year old long term care resident admitted on [DATE] with [DIAGNOSES REDACTED]. Sheet and physician progress notes [REDACTED]. Random staff interviews described the resident as pleasant, quiet, cooperative, and strived to be as independent as possible. Per the physical therapy evaluation and treatment plan dated ,[DATE]-[DATE],the resident was referred to physical therapy due to a recent fall with no injury. Short and long term goals had been set for the resident with the long term goal as follows: 1. Patient will safely perform sit to stand transfers with minimum assistance with use of side rails and 25% verbal cues for use of side rails and for task segmentation in order to enhance safe functional mobility and increase ability to attend activities of choice. (Target date: [DATE]) 2. Patient will safely perform functional transfers with minimum assistance and 25% verbal cues for correct hand/foot placement with reduces risk of falls in order to safely maneuver in/out of bed and increase performance skills with functional tasks. (Target date [DATE]) 3. Patient will be able to ambulate using quad-cane 25 feet or more with minimum assistance with steady balance and gait pattern. (Target date [DATE]) The patient goal was documented as: To get stronger. A review of the facility ' s occurrence log revealed that Resident # 1 had two unwitnessed falls in the month of [DATE]. Per the nurses notes dated [DATE] at 6:30 p.m. the resident was found on the patio sitting next to his wheelchair. The resident denied hitting his head and there were no apparent injuries. On [DATE] at 12:30p.m., an interview was conducted with the risk manager regarding Resident # 1 ' s unwitnessed fall on the patio on [DATE]. She said, at 6:30 p.m. on [DATE], the resident was found sitting outside on the patio in front of his wheelchair. She said the smoking aide did not witness the fall but turned around and saw him sitting on the ground in front of his wheelchair. The resident was assessed by the nurse and noted to have no injuries. Per the risk manager the resident said he slid out of his chair so Dycem was placed in the seat of his wheelchair and a request for therapy to evaluate the resident for positioning was submitted. The risk manager said the resident had a wheelchair alarm in place. She said the alarm was in place and sounded when the resident slid out of the wheelchair. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed the reason for referral to therapy was due to a fall. Under the section for area of concern, the form indicated fell while participating in a task/ experienced a fall, Date of Fall: [DATE]. The screen indicated resident had a fall from wheelchair on outside patio. Would benefit from positioning. Therapy Evaluation indicated a check mark for Occupational therapy. Review of the record revealed that an Occupational Therapy Evaluation was conducted on [DATE] and a plan of treatment developed. Per the nurse ' s notes, dated [DATE] at 2:45 p.m., the resident was found lying on the floor of his room on the left side of his bed. The resident was lying on his left side on top of the wheel chair cushion. The resident denied pain/discomfort and the nurse documented mental status intact, range of motion (ROM) exercises performed and intact, skin intact, no injuries present . Non-skid socks were applied for safety and the fall education was reinforced. The resident verbalized understanding. On [DATE] at 12:30 p.m., an interview was conducted with the Risk Manager. She said at 2:45 p.m. on [DATE], the resident ' s alarm sounded. Staff responded to his room and observed him lying on his left side with wheelchair cushion underneath him. The resident said he said he tried to get up from the wheelchair without assistance but did not give a reason why. The wheelchair brakes were locked. The call light was within reach, the floor was dry, and he was wearing regular socks. The intervention was for non-skid socks and a therapy referral. Physical therapy picked up the resident for skilled services for bilateral lower extremity strengthening and balance training for transfer safety. She stated the resident sustained [REDACTED]. Per the nurse ' s notes, dated [DATE] at 10:00 p.m., the resident had an alarm to the bed and wheelchair due to poor safety awareness related to Dementia. The noted said the resident checked often. The resident was able to slowly propel himself in the wheelchair around the unit. Review of a Multidisciplinary Rehabilitation Screen , dated [DATE], revealed fell while participating in a task/experienced a fall, date of fall: [DATE] and Resident would benefit from skilled PT for B LE (Bilateral Lower Extremity) strengthening and balance training for safety and transfers. Review of the Physical Therapy Evaluation and Plan of Treatment revealed that physical therapy commenced on [DATE], nine days after the fall of [DATE]. Review of the Physical Therapy discharge summary ,dated [DATE] , revealed that physical therapy was discontinued due to being unexpectedly discharged to the hospital and Resident # 1 was only treated for [REDACTED]. Review of Resident # 1 ' s care plan for Risk for falls/injury related to h/o falls, poor safety awareness and impaired mobility with a problem onset date of [DATE] and a next review date of [DATE], found [DATE] - fall occurred from w/c - see nursing notes, [DATE] on floor. Approaches included Report any falls to physician and responsible party, Requires staff assist with all transfers, Skilled therapy services as indicated, Restorative nursing services as indicated, Up and about ad lib via w/c, Med review prn and quarterly for need of and or any dose changes (sic), Keep bed in lowest position, Call light within reach of- encourage to use and staff to answer same asap, Keep area obstruction free as possible, [DATE] Therapy screen for positioning and Dycem. Continued record review of the nurse ' s notes, dated, [DATE] (no time), found that a nurse was called out to the patio by another resident. The nurse (Staff N) found Resident #1 unresponsive and slumped in his wheelchair. The resident was taken back to his room and placed in bed. Vital signs were as follows: Blood pressure: ,[DATE], Respirations 16, Pulse: 147. 911 was called. The resident was transferred to the hospital. Per the Medicaid Non-emergency Ambulance Authorization Request Form (completed by the facility) dated, [DATE] at 5:30p.m., the resident (Resident #1) was Found on the outside patio unresponsive-[MEDICAL CONDITION] with agonal respirations-Temperature was 105.7. Hyperthermia is an abnormally high body temperature caused by a failure of the heat-regulating mechanisms of the body to deal with the heat coming from the environment. Heat fatigue, heat [MEDICAL CONDITION] (sudden dizziness after prolonged exposure to the heat), heat cramps, heat exhaustion and heat stroke are commonly known forms of hyperthermia. Risk for these conditions can increase with the combination of outside temperature, general health and individual lifestyle. Health-related factors, some especially common among older people, that may increase risk of hyperthermia include: · Being dehydrated. · Age-related changes to the skin such as impaired blood circulation and inefficient sweat glands. · Heart, lung and kidney diseases, as well as any illness that causes general weakness or fever. · High blood pressure or other conditions that require changes in diet. For example, people on salt-restricted diets may be at increased risk. However, salt pills should not be used without first consulting a doctor. Heat stroke is a life-threatening form of hyperthermia. It occurs when the body is overwhelmed by heat and unable to control its temperature. Heat stroke occurs when someone ' s body temperature increases significantly (generally above 104 degrees Fahrenheit) and has symptoms such as mental status changes (like confusion or combativeness), strong rapid pulse, lack of sweating, dry flushed skin, faintness, staggering, or coma . Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put them at risk for a heat-related illness. (Source: National Institute of Health [DATE]). Elderly people ([AGE] years and older) are more prone to heat stress than younger people for several reasons: Elderly people do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that impair the body ' s ability to regulate its temperature or that inhibit perspiration. (Source: Extreme Heat by Centers for Disease Control at http://stacks.cdc.gov/view/cdc/ ). Per Weather Underground the weather on Saturday, [DATE], in Pinellas Park, Florida was as follows: At 3:53pm the temperature was 89.1F. Dew Point 64.9, Humidity 45%, Heat Index: 91%, skies were clear. At 4:53pm Temp. 88 F, Dew Point 64.9, Humidity 46%, Heat Index: 89.6%, scattered clouds. On [DATE] at 3:45 p.m. an interview was conducted with Resident #1 ' s 3:00p.m. - 11:00 p.m. direct care nurse (Staff N). He said at approximately 5:15 p.m. -5:20p.m., a resident came to him and said You need to go look at this guy he doesn ' t look or sound good. The nurse went to the patio and found Resident #1 on the patio in the direct sun, slumped in his wheelchair, and unresponsive with mucous coming from his mouth and nose. The nurse asked a CNA to take the resident to his room while the nurse gathered his equipment (stethoscope, accu-check machine, pulse -oxygen machine). Once in the resident ' s room the resident ' s pulse was 147 and he was still unresponsive. The nurse asked the CNA to stay with the resident. The nurse called out to his fell ow nurse on the unit for assistance and 911 was called. The nurse said the 911 operator was told that they had put ice on the resident to cool him down. (Body temperature was 105.7 F). The paramedics arrived and took over. The resident had a medication patch on his left shoulder. The paramedics asked the nurse what the patch was for and the nurse said it was an [MEDICATION NAME] for the Dementia. The nurse then pulled the patch off the resident ' s shoulder and pulled the skin under the patch off as well. A paramedic asked the nurse if the resident looked sunburned. The nurse said No . The nurse said he assisted the paramedics with the transfer of the resident from his bed to the gurney and gathered the paperwork. The resident left the facility at approximately 5:30 p.m. The nurse said he noted a raised area on the resident ' s abdomen (Keloid-like scar) but did not see any open areas or blisters on the resident. On [DATE] at 3:45 p.m., an interview was conducted with the nurse (Staff Q) that assisted Resident #1 ' s nurse to assess and prepare Resident #1 for transport to the hospital. He said, on [DATE] between 5:25 p.m. and 5:30p.m., the other nurse (Staff N) on the unit yelled and said he needed help. Staff Q entered the resident ' s room and saw the nurse was getting a set of vital signs. Staff Q said he quickly assessed the resident and found him to be really hot and dry. He said the resident was hot to the touch all over. Staff Q noticed agonal breathing (Abnormal pattern of breathing and [DIAGNOSES REDACTED] reflexes characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (muscle spasms or jerking). Possible causes include cerebral ischemia, extreme [MEDICAL CONDITION] or even anoxia. Reference: Wikipedia, the free encyclopedia) Staff Q asked the CNA in the room to get cold wet wash cloths and a couple bags of ice. Staff Q put a washcloth on the resident ' s forehead and rubbed the ice on the resident ' s chest and arms. The Emergency Medical Technicians (EMTs) arrived and took over the care of the resident. Staff Q said he did not see [MEDICAL CONDITION] blisters on the resident ' s arms or chest. He said the resident had a jagged raised scar on his abdomen. The scar was a dull black color about ¼ inches wide and the length was undetermined. Review of the Nursing Evaluation dated, [DATE], under Section M : Dehydration Risk Analysis : subsection 1 : Fluid Intake/ Eating Risk: Limited Assistance and swallowing problems were checked. Under subsection 2 : Risk Factors: [MEDICAL CONDITION]/Failure and Diabetes were checked. Under subsection 3 : Cognition/Communication: Moderate/Severe Decision Making and Comprehensive/Communication Problems were checked. Under subsection 4 : Mobility: Body control problems and Hand dexterity Impaired were checked. Under subsection 6 Skin: Turgor less than 3 sec-mucous membranes, lips, tongue moist Total score: 9. Score of 8 or more indicates at risk for dehydration. At risk Dehydration Care Plan must be completed. The resident was also on Nectar thickened liquids. A comprehensive record review revealed no At risk Dehydration Care Plan could not be located in Resident #1 ' s clinical record. On [DATE] at 12:15 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. direct care Certified Nurse ' s Assistant (CNA) (Staff E) for Resident #1. She said she assisted the resident with his morning care at approximately 10:30 a.m. She assisted him to dress in black and white checkered pajamas pants (his preference), a charcoal-greyish short sleeve polo type shirt, and yellow non-skid socks. She assisted him to transfer to his wheelchair at approximately 11:00 a.m. and took him to the TV room. She said the resident ate lunch in the dining room and after lunch an unknown CNA returned the resident to the TV room. The CNA said she passed by the resident several times during the 7:00 a.m. - 3:00 p.m. shift propelling himself around the TV room and in front of the north wing nurses ' station. Between 2:15 p.m. -2:30 p.m., the CNA took the resident to his room to provide care. She said, between 2:45 p.m. -3:00 p.m., she saw the resident propelling himself toward the patio door. She stopped him and said, Where are you going? The resident responded, Outside . The CNA said, Ok let ' s fix your sock. The CNA pulled the resident ' s sock up and another CNA pushed the automatic door button and the resident ' s CNA pushed the resident outside in front of the soda machine (under the roof -in the shade). She said she did not do rounds with the on-coming CNA but rather told another CNA (staff G) because the 3:00 p.m. - 11:00 p.m. CNA was going to be late . Interviews were conducted with the 3:00 p.m. - 11:00 p.m. direct care CNA (Staff F) for Resident #1 on [DATE] at 3:10 p.m. and on [DATE] at 3:30 p.m. She said, she did rounds at 3:00 p.m. and checked on Resident #1. She said the resident was sitting under the covered portion of the patio between the snack machine and the glass entrance/exit doors. She said at approximately 4:15 p.m. the smoking aide told her that the resident did not want to come back inside and was still on the patio. Staff (F) said at 4:30 p.m. the resident was sitting next to the snack machine and the glass exit/entry door under the shaded portion of the patio. She pushed the resident to the dining room from the patio for dinner. She said she pushed the resident to his table on the far side of the dining room in front of the windows. She said there were no other residents or staff members in the dining room when she left the resident at his table. She said at approximately 5:15 p.m. another CNA (Staff G) approached her with Resident #1 ' s dinner tray and told her that Resident #1 was not in the dining room. Staff F said she and Staff G began looking for the resident in other resident ' s rooms. She said the resident had a history of [REDACTED]. She said she was not sure who found the resident. She said that Resident #1 was very active in his wheelchair and would try to stand alone and get in another resident ' s bed. On [DATE] at 3:40 p.m., an interview was conducted with the Certified Nurse ' s Assistant (Staff O) who was assigned to the smoking patio on [DATE] from 3:30 p.m. to 4:00 p.m. She said she had never seen Resident #1 on the smoking patio before that day. At approximately 4:00 p.m., she said she noticed Resident #1 sitting in his wheelchair near the soda machines in the direct sun. She asked him if he wanted to go inside. The resident shook his head, no. Staff O said she noticed that the resident was sweating so she pulled the resident under the covered portion of the patio in front of the soda machine into the shade. She said she found the resident ' s CNA (Staff F) and told her the resident was outside and refused to come inside. The resident ' s CNA (Staff F) said, Ok thank you. On [DATE] at 2:30 p.m. an interview was conducted with the CNA (Staff R) that was assigned to the dining room for dinner on [DATE]. She said she went to the dining room at 4:30 p.m. The residents that are able to ambulate or propel themselves come down to the dining room and as they arrive she serves them either coffee or hot chocolate per their preference. She said she did not see Resident #1 at 4:30 p.m. or anytime during dinner. She said at approximately 5:10 p.m. another CNA (Staff G) came into the dining room with Resident #1 ' s tray and said the resident wasn ' t in his room. Staff R told Staff G that the resident was not in the dining room. Staff R told Staff G to take the tray back to the resident ' s room and go look for the resident. Staff R said she could not leave the other residents in the dining room and was unable to assist with locating Resident #1. Staff R verified that, at no time during her dining duty, did she leave the dining room or see Resident #1 in the dining room. An interview was conducted on [DATE] at 11:00 a.m. with Staff G. He said he left the facility at 3:00 p.m. to get his car and returned to the facility at approximately 4:50 p.m. He did not have a specific assignment but was there to help out until 7:00 p.m. He said he started passing trays on the north wing and about 5:15 p.m. he took Resident #1 ' s tray to the dining room. The CNA (Staff R) told him that the resident was not in the dining room and to put the tray in the resident ' s room. Staff G said he took the tray to the room and continued to pass trays. He said within minutes the nurse (Staff N) told him to find the supervisor. He found the supervisor in the office but she was on the phone and he didn ' t want to interrupt so he waited outside the office door. He said the Emergency Medical Services (EMS) arrived before he was able to talk to the supervisor. Staff G said the resident moved slow but was able to wheel himself around the facility. Staff G verified he did not see the resident that day. On [DATE] at 12:00 p.m. an interview was conducted with unit manager (Staff D). He said the resident was able to communicate his needs. The resident could propel himself around the unit and throughout the facility including to the patio. On [DATE] at 11:30 a.m. an interview was conducted with Resident #1 ' s 7:00 a.m. - 3:00 p.m. primary care Registered Nurse (Staff P). She said she gave the resident his 9:00 a.m. medications while the resident was finishing up his breakfast in bed. She said the CNA got the resident up between 10:45 a.m. and 11:00 a.m. At approximately 1:30 p.m. the resident was in the hallway and attempted to stand up from his wheelchair without assistance. The nurse redirected him to the TV room. She said at about 1:50 p.m. the CNA took the resident to his room for afternoon care. That was the last time she saw the resident. She said the resident was able to propel himself with one foot and would pull himself along the wall with the handrail. On [DATE] at 1:20 p.m., an interview was conducted with the resident (Resident #12) that reported to the nurse regarding Resident #1. He said he saw, The man on the patio that died , and stated it was nasty and indicated it looked like he had vomit all over his face and said, He didn ' t look good . He went and told the nurse and said he felt bad as the man died anyway in spite of him trying to get him help. The facility provided a Timeline of Resident #1 ' s location from 6:00 a.m. - 5:15 p.m. on [DATE]. Per the time line the facility said the resident was Outside from 3:00 p.m. until 4:30 p.m. At 4:30 p.m. the resident was, Taken to the dining room for evening meal . However, the staff interviews revealed conflicting information regarding the resident ' s location from 4:30 p.m. when he was taken to the dining room until 5:15 p.m. when he was found outside slumped in his wheelchair, in the direct sun, and unresponsive. Staff F said she took the resident to the dining room at 4:30 p.m. Staff R said, however, she was in the dining room between 4:25 p.m. and 4:30 p.m. until approximately 5:10 and did not see the resident in the dining room. In addition, Staff G said he took the resident ' s tray from the cart and took it to the dining room at about 5:15 p.m. He said the resident was not in the dining at that time nor was the resident in his room when Staff G took the tray to the resident ' s room. A tour of the facility, on [DATE], found that the facility is a 120 bed nursing home, rectangular in shape, with a middle enclosed patio. The facility ' s egress to the outside patio on the North Unit was located on the middle hall (D Hall) and had glass panels with a glass automatic door which was accessible by an automatic door push to open button at wheelchair height. The patio was not within line of sight from the North Unit nurses ' station and there was no phone or call system observed on the patio. The patio had a covered alcove just outside the glass door with a soda and snack machine to the left. The alcove led to a large rectangular unshaded area. Due to sun movement the alcove area was shaded differently throughout the day with the afternoon having less shade than the morning. Once out from under the shaded portion, the patio had no other shaded areas except for a small white canopy with an ice chest and water receptacle. An interview was conducted with the CNA (Staff S) assigned to the patio on [DATE] at 10:30 a.m. She said the canopy was new (put up between ,[DATE] and [DATE]). She said prior to the new canopy, there was no other shaded areas except along the outside walls under the eaves of the building, depending on the time of day. (Photographic evidence was collected at the time of observation). Only one quarter of the outside patio could be seen from inside the building looking out from the door. Based on Staff N ' s description of where Resident #1 was found, the resident could not be seen from inside the facility through the glass door to the patio. A review of the Quarterly Minimum Set ((MDS) dated [DATE] under section C - Cognitive Patterns sub section CO 400: Recall: the Brief Interview for Mental Status (BIMS) was left blank. Under sub section CO700: short term memory and CO800: long term memory: The resident was coded as a 1 which indicated long and short term memory problems. Under subsection CO900: Memory/Recall: The resident was unable to recall the current season, location of his room, staff names and faces, did not know he was in a nursing home. Under subsection C1000: Cognitive Skills for Daily Decision Making: The resident was coded as 2 indicating moderately impaired-decisions poor; cues/supervision required. Under subset C1300: Signs and symptoms of [MEDICAL CONDITION]: the resident was coded a 2 indicating Behaviors of inattention and disorganized thinking were present, fluctuates (comes and goes, changes in severity. Under Section E - Behavior: subsection EO900- wandering- presence and frequency, the resident was coded as a 1 indicating the behavior occurred 1 to 3 days during the Assessment Reference Date of [DATE]. Under the section G - Functional Status: subsection F - Locomotion off unit- how resident moves to and returns from off - unit locations (e.g., areas set aside for dining, activities, treatments). If the facility has only one floor, how the resident moves to and from distant areas on the floor. If in a wheelchair, self- sufficiency once in the chair. The resident was coded as a ,[DATE] indicating he needed extensive assistance with one person physical assist. Under subsection GO400- Functional Limitation in Range of Motion: The resident was coded as a 1 for the upper and lower extremities on one side of the body. The resident was unable to walk and used a wheelchair for mobility. A review of the care plan for Resident #1 found Problem onset, dated [DATE], with the next review date of [DATE], for resident needed extensive assistance from staff with his daily care needs i.e. Dressing, grooming, bathing, and hygiene needs related to dementia and left [MEDICAL CONDITION]. Review of the care plan with Problem onset dated [DATE] and the next review date of [DATE] indicated the resident was over his ideal body weight and received a mechanical soft/no added salt diet with thickened liquids. For Problem onset dated [DATE], and the next review date of [DATE], the resident was at risk for aspiration related to dysphasia treatment for [REDACTED]. A review of the CNA ADL Flow Sheet for Resident #1, dated [DATE], did not indicate for [DATE] (day of death) that he received breakfast, lunch, or dinner and did not indicate he received fluids for lunch or dinner. In addition, out of 29 possible offerings for a snack, 26 opportunities were left blank. There was no documentation on the Activities of Daily Living (ADL) flow sheet that indicated the resident received a bedtime snack as per the physician's order [REDACTED].>Per the physician's order [REDACTED]. A review of the resident ' s latest laboratory results, dated [DATE], revealed Sodium, Potassium, Chloride and Calcium were all within normal limits. Per a physician's order [REDACTED]. On 2:27 p.m. [DATE] an interview was conducted with the resident ' s primary care physician MD. He said on [DATE] the facility called him to inform him that the resident was on his way to the hospital. He said he was not aware of any concerns related to being outside unti

Based on interview and record review of the residents' facility medical record, resident hospital records and facility policies, and interviews with facility staff, the Medical Director, residents, and resident family, the facility failed to prevent accidents resulting in harm for two (Resident #1 and #4) of seven residents reviewed for the use of mechanical lift devices out of twenty-seven residents in the facility requiring the use of the mechanical lift for transferring. Also, the facility failed to ensure that the care plan was followed for two (Resident #9 and #13) of seven residents reviewed for the use of mechanical lift devices out of twenty-seven residents in the facility requiring the use of the mechanical lift for transferring. Findings include: 1. Review of the Face Sheet dated [DATE] revealed that Resident #1 was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of the Accumulative [DIAGNOSES REDACTED].#1dated [DATE] revealed the following relevant Diagnosis: [REDACTED]. Review of the Kardex Pictorial Care (no date) revealed that Resident #1 required the assistance of two or more persons with the mechanical Lift (Hoyer Lift) for transfers. The " Dependency Status " dated [DATE] revealed that the resident was a full sling lift with two person assist for bed to chair and chair to bed transfers, chair to chair and wheel chair to toilet transfer, bathing and weighing transfer; and lift from floor transfer. Review of the Care Plan dated [DATE] revealed that Resident #1 was dependent on staff for all her care needs. The approaches noted that the resident required " mechanical lift x2 " for all transfers. Review of the nursing notes For Resident #1 revealed the following: ? [DATE] 10:50 a.m. Resident had nose bleed as well as (Right) eye laceration noted this AM after shower: Resident slid out of lift and impacted her head on shower chair. Resident appeared to be in ,[DATE] pain per Wong-Baker Facial Scale. Call doctor (Medical Director) and received order to (discharge) to (emergency room ) due to epitaxis. Paramedics present with 4 attendees and taking resident to (the first Acute Care Hospital). Responsible party notified. (Signed by the Unit Manager). Review of the (the first Acute Care Hospital) records for Resident #1 revealed the following: ? Exam date [DATE] CT brain w/o contrast; GLF, Head Hematoma; Findings: There is high density 4.8 cm x 2.7 cm intracerebral hemorrhages with surrounding edema in the right to frontal temporal parietal region. There is impression on the frontal horn of the right lateral ventricle. There is minimal 1mm shift of the septum from right to left. There is marked cortical atrophy and ventricular dilation. There are chronic microvascular white matter changes also noted. There is opacification of the right maxillary sinus. Impression: Acute 4.8x2.7 cm right frontal temporal parietal intercerebral hemorrhage with minimal shift of midline structure. Inspection of the Hoyer sling that was used during the incident with Resident #1 revealed that the sling was a size large and noted that the Model was a fabric with the maximum sling weigh capacity being 600lbs. Review of the Manufactures Operational Manual noted the following: (Page 3) Using the proper lifter and the correct sling is also very important. Select the proper fit and sling is determined by patients: disability; size; weight; and by specific type transfer. (Page 8)Specifications for the specific model and type of sling noted the flowing: Size Small weight capacity ,[DATE] pounds; Size Medium weight capacity ,[DATE] pounds; Size Large weight capacity ,[DATE] pounds. Review of the residents Admitting Weight was noted as 108 pounds per the face sheet. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted on [DATE] at 11:13 a.m. Per the Director of Nursing on [DATE] at 10:30 a.m. Resident #1 fell during a transfer from the shower bed to her wheelchair using the mechanical Hoyer Lift. She stated that during the transfer process, the resident tipped forward out of the Hoyer swing and hit her face on the shower chair and fell on her knees. She stated that the resident had a small laceration over right eye and a nose bleed. She confirmed that there were two Certified Nursing Assistant ' s (CNA ' s), Staff F and Staff G, involved in the incident and that they were the only two people in the shower room during the incident. She stated that the resident was transferred to the emergency room for evaluation and treatment and was admitted to the hospital for subdural bleed and facial fractures. She stated that it was determined after the internal investigation that the sling that was used during the transfer of Resident #1 was not appropriate for the mechanical Hoyer Lift that was used during the transfer. She stated that, at the time of the incident, there were two types of mechanical Hoyer Lifts being used in the building (Vanguard and Invacare). She confirmed that the Hoyer sling that was used for the resident was not compatible with either of the mechanical lifts that were currently being used in the facility. She stated that it could not be determined where the sling came from that was used in the incident The Nursing Home Administrator (NHA) stated that she cannot be sure which mechanical Hoyer was used during this incident but that she can confirm that the sling did not match the Vanguard Hoyer or the Invacare Hoyer. The DON stated that Resident #1 was readmitted to the facility on [DATE] and was admitted to hospice care directly after readmit to the facility. She stated that on [DATE] the resident expired. An interview with Staff G, a CNA, was conducted on [DATE] at 1:16 p.m. She stated that Resident #1 was up in her wheel chair when she arrived for her shift that morning. She stated that there was a green Hoyer sling under the resident while she was seated in her wheelchair. She stated that when it was time for the resident to shower, she and another staff used the mechanical Hoyer Lift to place the resident on the shower bed. She stated that after the shower was complete, she dried and dressed the resident while the resident was on the shower bed and used the same Hoyer sling that was originally under the resident. She stated that Staff F, a CNA, came in to help get the resident back into the chair. She stated, "The first time, she slid and we caught her. The top of the Hoyer then tipped over and (Resident #1) slipped over with it. She hit her face on the shower." She then stated that she and Staff F were trying to hold the Hoyer up and the resident slid out of the Hoyer sling, fell on her knees, and hit her face on the shower chair. She stated, " She just fell and we picked her up and put her in the chair." She stated that she went out to get the Unit Manager while staff F stayed with the resident. She said, " (Unit Manager) took the Hoyer pad and told me to go throw it in the garbage." She said that she took the Hoyer sling and threw it in the garbage but that the DON asked her where the Hoyer sling was and told her to go get it out of the garbage. She stated that she went and retrieved the sling and gave it to the DON. During an interview with the Unit Manager on [DATE] at 1:46 p.m. Staff G came and told her that the resident had fallen in the shower room. She stated that she went into the shower room and the resident was in the wheel chair. She stated that the resident looked calm but had blood coming from her nose. She stated that the DON came into the resident ' s room to assess the resident. She stated that she went to call the doctor, received an order to discharge the resident to the emergency room within the hour, and then the paramedics took the resident to the hospital. Interview with the Medical Director was conducted on [DATE] at 10:50 a.m. She stated that they discussed that the resident fell and was escorted to the emergency room at (the first Acute Care Hospital). She stated that she received a call from (the first Acute Care Hospital) that they had found facial fractures and intracranial bleed and that Resident #1 needed to be sent to the trauma center at (the second Acute Care Hospital). Interview with Staff F, a CNA, on [DATE] at 12:42 p.m. she confirmed that she was not assigned to Resident #1 on the day of the incident. She stated that she was coming down to the shower room to shower another resident and walked in to see Staff G showering Resident #1. Since the resident that she was getting ready to shower was a male, she stated that she waited outside the shower room for Staff G to finish. She stated, " We stayed outside and waited. She came and asked me to assist. " She stated that when she came into the shower room the resident was "already up in the air." She stated that the wheelchair was caddy-cornered to the mechanical Hoyer Lift and the resident was up in the Hoyer sling and she confirmed at that time that it was the green sling that was being used. She stated, " Before I could get to (Resident #1), she slipped out onto the floor. It happened so fast that she just slipped out." She stated that she does not really know how she slipped out because it happened so fast but stated that the resident was on the floor. She stated, "She was on her side. She hit the bar seat part of the shower chair. Her nose was bleeding really really bad. " She stated that she stayed with the resident while Staff G went for help. She stated, " She was crying crying so bad. You can tell she was in pain." She stated that Staff G came back with the Unit Manager and that the Unit Manager examined her and told them to get her up. She stated that she and Staff G picked the resident up and put her into her wheelchair. She stated that she and Staff G escorted the resident to her room. She stated that the DON went into the bathroom and Unit Manager and the DON stated that the sling was the "wrong sling." 2. Review of the Face Sheet for Resident #4 revealed that the resident is an [AGE] year old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The Physician order [REDACTED]. Review of the nursing notes For Resident #4 revealed the following: ? Nursing Notes dated [DATE] at 3 p.m.: Resident continues to work with PT and OT on transfers. Strengthen for LE Weakness continues. Requires increased cueing for poor motivation. Training on self-care and standing balance continues. ? Nursing Notes dated [DATE] "Resident continues to need increased cueing for poor motivation ...remains on PT and OT for self-care, standing balance, transfers and lower extremity strength." ? Nursing Notes dated [DATE] at 11:30 a.m.: while aide was assisting resident with sit to stand lift, resident let go of stand while bearing weight on belt Velcro straps gave away causing resident to fall butt first. Blood noted on curtain during observation myself and staff log rolled resident supporting resident neck and head. Large amount of bright red blood noted to back of head. Ice pack applied EMT called Dr. __ and made aware. (Contact person) called left message to return call. 12:00 p.m. resident transferred via stretcher and neck brace to Northside hospital for evaluation and treatment. ? Nursing Notes dated [DATE] 10:00 p.m.: (resident) returned to facility from hospital via stretcher ... two staples to back of head. An interview was conducted with the Director of Nursing on [DATE] at 11:13 a.m. She stated that on [DATE] Resident #4 was transferred from the wheelchair to bed by one Certified Nursing Assistants, Staff H, and one Licensed Practical Nurse, Staff E using the Mechanical Sara Lift. The DON stated that during the transfer, the resident let go of the lift grab bar. She stated that the resident leaned forward and then leaned back and her arms went over her head and she slide down to the floor on her bottom. She stated that the resident hit the back of her head on wheelchair and was sent out to the emergency room for a laceration to the back of the head. She stated that the resident received two staples and came back the same day. She stated that upon return to the facility, the resident was reassessed for her transfer needs by therapy. She stated that the resident was determined to no longer be a candidate for the mechanical Sara Lift and was transitioned to a mechanical Hoyer Lift for her transfer needs. Interview with Staff E, an LPN, on [DATE] at 1:09 p.m. she stated that she came into the room with the Staff H to watch her transfer Resident #4 using the mechanical Sara Lift. She stated that the resident said, "My hands are slipping." She stated the resident "slipped out of the machine and when I looked back she was on the floor. We went to sit her up. I noticed blood on the ground and the curtain." She stated that the resident was still on the floor. She stated, "I went to get an ice pack." She stated that the DON came in to assess the resident; 911 was called; and EMT came escorted the resident to the hospital. On [DATE] at 9:59 a.m. an interview was conducted with Staff H. She stated that she was not assigned to care for Resident #4 on the day of the incident but that the nurse asked her to change the resident because the aide was off the floor. She stated, "I went to put the sling on her and she said that her arms were getting weak and fell back." She confirmed that only her and Staff E was in the room at that time. She stated that the nurse told her that the resident was bleeding; she went to get the Blood Pressure Cuff; the nurse called 911; and the resident was sent out to the hospital. An observation of Resident #4 was conducted on [DATE] at 1:15 p.m. She was observed in her room in her wheel chair. When asked about her recent fall, she stated, "I did have a fall. I was on the machine and I told them my hands were slipping. I fell and had to go to the hospital. " The resident stated that she went out to the hospital and received two stitches in the back of her head. She stated that when she returned to the facility, they started using a "different machine" and confirmed that she does not have to hold on and that this "machine" was better. Review of the Admission Minimum Data Set ((MDS) dated [DATE] it was revealed that the resident had a cognitive Brief Interview for Mental Status (BIMS) score of 15. Section G Functional Status noted that the resident was "Extensive assistance -resident involved in activities, staff provide weight-bearing support" for Transfer: Self Performance; "Two+ person physical assist" for Transfer: Support Provided. On [DATE] at 1:47 p.m. an interview was conducted with the Rehabilitation Director. She stated that the rehab department does not evaluate the residents for the use of the Mechanical Lifts. She stated that is not a skilled service and therefore they do not conduct any evaluations related to the mechanical lifts. She stated that they only inform nursing of the resident capabilities. She stated that on the initial PT evaluation of [DATE], the resident's capabilities were total dependence with attempts to initiate. She stated that on [DATE] a recertification was completed and the resident was showing progress (30% of the time she was moderate assist and 70% she was maximum assistance with transferring). She stated that according to the Discharge Summary of [DATE], it was noted that the resident was at maximum assist with 50% verbal cues. She stated that was an improvement from total assist because that meant she was able to help some with transferring. She stated that on [DATE], PT did an evaluation due to the resident returning from a hospital stay and that the resident was determined to be total dependence without attempts to initiate. She stated that meant there was a decline from when she went out to the hospital and returned. She stated that there was a recertification completed on [DATE] and the long term goal of standing was continued. She stated that the resident was able to stand for 1.5 to 2 minutes with assistive devices such as a walker. She stated that the resident had improved to moderate assist with sit to stand transfer meaning that she could help some. She stated that on the Discharge Summary conducted on [DATE] the resident was noted as needing moderate assistance with transferring and her standing was from 1 to 3 minutes with support (an adaptive equipment and staff assistance). She stated that at that time, the resident was at her highest practical level. She started that the resident could be fearful at times and that sometimes the resident was nervous about trying to stand. She stated that the resident Discharges Summary from OT on [DATE] noted that the resident was able to grasp and hold on to things; was able to push up to assist staff with standing but confirmed that the resident could not push to stand independently; but it further noted that the resident was inconsistent at times due to her fear. She stated that the resident was discharged from OT because she had reached her highest practical level and that after a review of the weekly progress notes, it was noted that the resident was inconsistent with her functional status. Per review of the Lift Program and Gait Belt Policy with Effective date of ,[DATE]/ provided by the facility NHA and confirmed to be used prior to [DATE] the following was noted: The policy notes on Page 19: " Based on the resident ' s classification and the MDS reports, specific methods of transferring and lifting will be designated for each resident. These designated methods will be clearly recorded and accessible to all staff that perform lifting and transferring task and contained in the care plan, assignment sheet or pocket care plan. All residents classifies as total dependence should be lifted and transferred between beds, chairs, toilets, and bathing and weighing facilities by means of a full sling mechanical lift device by two trained staff. "The policy further notes on page 21" At time of admission, an initial assessment will be completed using the initial assessment upon admission " template." Per review of the Lift, Transfer, and Repositioning Policy and Procedure dated [DATE] (Revised Date of [DATE]) provided by the facility NHA and confirmed to be used after [DATE] the following was noted: "Nursing staff, in conjunction with the rehabilitation staff (when applicable), shall evaluate individual residents ' needs for transfer assistance on admission, quarterly, with significant changes, and on an ongoing basis with the use of this policy and the Lift Evaluation form." Review of the Operational Manual for the Invacare Lift (no date), it was noted provided by the facility revealed the following: Individuals that use the Standing Sling MUST be able to support the majority of their own weight, otherwise injury can occur. 3. Review of the record for resident # 13 revealed that he resides on the secured unit and has [DIAGNOSES REDACTED]. On [DATE], the resident was observed seated in his wheelchair with a waist belt in place. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed that the resident was coded under Functional Status as: Transfer - Self Performance- Total dependence - full staff performance every time during an entire 7 day period Transfer - support provided - Two person physical assist. Balance - Moving from seated to standing position - Not steady, only able to stabilize with staff assistance. Balance- surface to surface transfer - Not steady, only able to stabilize with staff assistance. Review of care plans for Resident # 13, noted as last reviewed and updated [DATE], revealed the following care plans: Care plan dated [DATE] with a last review date of [DATE] ,for a problem/need of "Mostly dependent on staff for his daily care needs." On [DATE] the problem/need section was updated to read " Extensive to total assist with ADL'S." Goals are listed as " Reduce the risk for complications from current ADL status through next review date "and" Staff to anticipate and meet needs daily through next review date. Approaches include: "Sara lift for all transfers." Care plan dated [DATE] with a last review date of [DATE] for a problem/need of " At risk for falls and injury reference to decreased cognition, [DIAGNOSES REDACTED]. The goal is listed as " Reduce the risk for serious injury from falls with interventions daily thru next review date.Approaches include "Transfer with assist of 2 with Sara Lift." Review of the CNA Activities of Daily Living (ADL) book revealed a Pictorial Care Card for resident # 13 which indicated the resident the resident required the assist of two or more persons with a Sara lift. Also in the ADL book was a form entitled "Initial Evaluation Upon Admission" form, dated [DATE], indicating that the resident required a " Stand Assist Lift " for Bed to Chair to Bed transfer, Chair to Chair wheelchair to Toilet transfer, and Bathing and Weighing transfer. An interview was conducted with the Unit Manager of the South hall, on [DATE] at 3: 15 p.m. regarding the resident ' s transfer status with a Stand Assist Lift/ Sara Lift. The Unit Manager indicated that the resident had a change within the last couple of days and he is unable to stand and bear weight and is unable to follow instructions to use the Sara Lift for transfer and he needs to be evaluated for a change in transfer status. He stated the resident will be evaluated by him and therapy either " today or Monday. " An interview was conducted with Employee B, a 3 p.m. to 11 p.m. CNA who indicated that she has provided care to resident # 13, on [DATE] at 3: 27 pm. She stated that the resident is a two person assist for transfer and no mechanical lift is required to transfer him. She stated she has transferred him within the last month without the use of a mechanical lift. An interview was conducted with Employee A, a 3 p.m. to 11 p.m. CNA, who indicated that she has provided care and service to resident # 13, on [DATE] at 3: 35 p.m. She stated that she is not sure of the resident's transfer status but she has transferred him with two people and no mechanical lift. She stated "I do it with two people, not sure if he is a Hoyer lift, but transfer with two of us, but not with a lift. " An interview was conducted with Employee C, a 3 p.m. to 11 p.m. LPN who indicated that he regularly provides care and services to Resident # 13. He stated that the resident requires the use of a Hoyer lift for transfer and staff have used the Hoyer lift for him for " a long time. " 4. Review of the record for Resident # 9 revealed that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Resident Data Admission/Readmission form was completed by a nurse on [DATE]. Review of the form indicated the resident required total assistance for transfer and was a 2 person assist with device - Hoyer - for ambulation. A fall risk assessment was also completed indicating that the resident was at risk for falls and an interim care plan for fall risk was developed. A "Lift Evaluation" form was completed on [DATE] and indicated the resident that the resident was "Total Dependence" The form indicated " The resident is not involved with the transfer and staff provides the full transfer. They are considered Total Dependence with the use of the Full Sling Lift and proceed to Part II. " Part II of the form indicated that the resident's care plan was updated and there was CNA notification. Of the resident's transfer type. Review of the Activities of Daily Living (ADL) book for Resident # 9 revealed a Pictorial Care Card indication that the resident required a Hoyer Lift for transfer. On [DATE] at 2: 30 p.m., the resident's ,[DATE] aide and the LPN were interviewed and both stated that the resident was able to stand and transfer without the use of a mechanical lift. The CNA said she transfers the resident using another staff without the lift.

Based on observations, interviews and record review, the facility failed to report and investigate an unexplained injury for 2 (#1, #2) of 6 sampled residents that resulted in the medical [DIAGNOSES REDACTED].#1, and a [MEDICAL CONDITION] humeral neck (shoullder) for resident #2. Findings included: 1. A review of Resident #1's clinical record revealed that he was originally admitted to the facility on [DATE] and was most recently readmitted to the facility after a hospitalization on [DATE] for comminuted and displaced fractures of the left proximal tibia and fibula shafts, (leg bones). His medical [DIAGNOSES REDACTED]. Further review of the clinical record revealed a History and Physical that was dated 7/12/12 with a chief complaint of " left fibular and tibular fracture " and the history included the following statement by the admitting physician at the acute care hospital regarding how the fracture occurred stated, " Per nursing, there were no documented falls. The patient is wheelchair bound at the nursing home, needing help with transferring. However, per the patient, he states that " a man did it. " On 9/7/12 at approximately 9:50 a.m. Resident #1 was observed lying on his back in his bed. He appeared to be asleep with his mouth open, and did not respond to verbal stimuli. Employee A, who identified herself as being the certified nursing assistant that was assigned to Resident #1, was present in the room at the same time, and was checking the resident ' s vital signs. His left leg was observed to be in a hard cast that appeared to extend from his toes to above his knee. Employee A confirmed that the resident had a cast to his left leg and stated that she did not know how he broke his leg. The resident opened his eyes to his name being called but did not greet the surveyor. On 9/7/12 at approximately 10:15 a.m. Employee A and Employee B returned to Resident #1 ' s room with a Hoyer lift and transferred him using appropriate technique from his bed to a wheelchair. Employee B attached the foot rests to the wheelchair and placed both lower extremities on the foot rests. He made eye contact with the surveyor and stared for a moment, and did not respond to the question. Employee A then returned to the room and the resident was repositioned in his wheelchair. He stated " yes " to the question if he felt better after the re-positioning. The resident was then observed holding his water cup and drinking independently. On 9/7/12 at approximately 1:35 p.m. an interview was conducted with the MDS Coordinator, who stated that Resident #1 last had a comprehensive assessment that was dated 6/5/12. Section G revealed that Resident #1 required extensive assistance for bed mobility, and transfers, and she stated that this included the use of a Hoyer Lift. She stated that Resident #1 did not ambulate, and uses a wheelchair for locomotion, and required extensive assistance for dressing and toileting. She confirmed that he was discharged from the facility on 7/12/12 and returned to the facility on [DATE] after a hospitalization at an acute care facility. A review of Resident #1 ' s care plans revealed a care plan that was last updated on 6/5/12 that that interventions that included, " call light within reach at all times " and " promptly report any adverse change in resident condition to physician. " Further review of Resident #1 ' s clinical record revealed the following entry on the Skilled Daily Nurses Note that was dated 7/7/12 at 12 p.m., and stated, " Resident states severe pain to left leg. Left foot externally rotated. No bruising. Raised hardened knot area below left knee, fist size. Gave [MEDICATION NAME] 50mg. Informed Dr. of condition. " An additional entry that was dated 7/7/12 at 8:05 pm stated, " X-ray results called in to Dr. No new orders given. " An entry dated 7/8/12 at 11:55 a.m. stated, " Gave PRN [MEDICATION NAME] 50mg and Tylenol Extra Strength two tabs for complaints of left leg pain. X-ray results were negative for fracture. " There was no further documentation of the appearance of Resident #1 ' s left leg regarding the external rotation and swollen area below his left knee. An entry that was dated 7/9/12 at 12:30 p.m. stated, " This writer attempted to set up appointment with orthopedic and no one answered the phone, will try again later. He had complained of pain, medicated with PRN pain med with some effect. " There was no documentation of calling the physician back regarding Resident #1 ' s on going complaints of pain, and no documentation regarding the appearance of his left leg. An entry that was dated 7/11/12 at 11:00 a.m. stated, " Order to increase resident [MEDICATION NAME] 50mg to q(every) 6 hours PRN (as needed). " On 7/12/12 at 5:00 a.m. an entry stated, " Noted ecchymosis (bruising) is more dark on left affected leg. " On 7/12/12 at 2:00 p.m. an entry stated, " Placed call to Dr. to make aware of increasing pain, received orders to send Resident to hospital. " A review of the radiology results revealed x-rays dated 7/7/12 of Resident #1 ' s left lower extremity that stated, " Normal left tibia and fibula. " The repeat x-ray on 7/12/12 stated, " There is a recent fracture involving proximal tibia and fibula with angulation, impaction, and mild displacement. Conclusion: Recent left lower leg fracture as described. The findings are unchanged from 7/7/12. " A call was made to the Radiology provider for an explanation , but no return call was received. On 9/10/12 at approximately 10:30 a.m. an interview was conducted with Resident #1 ' s primary care physician. He stated that he recalled the events surrounding Resident #1 ' s left leg fractures, and that he was only notified of the resident complaining of pain to his left leg on 7/7/12. He stated that he was not aware of the fist sized swollen area that was below the resident ' s knee. He stated that if he had known of that, regardless of the results of the x-rays that were done at the facility, he would have sent the resident out to an acute care hospital immediately. He confirmed that untreated fractures are painful and may have serious complications. He stated that when he learned that the resident continued to complain of pain, he gave orders to send the resident out to an acute care hospital on [DATE]. He confirmed that transferring a resident in and out of bed that has an untreated fracture put him at risk for further complications. He stated that he was not aware that the resident had stated to the admitting physician at the acute care hospital that " a man did it " when the resident was asked how he broke his leg. He stated that the facility had not reported the allegation of abuse to him. On 9/10/12 at approximately 12:45 p.m. an interview was conducted with Employee C who identified herself as the nurse that was assigned to the resident on the 7:00a.m. to 3:00 p.m. shift on the dates of 7/9/12, 7/10/12, 7/11/12 and 7/12/12. She stated that on 7/12/12, she notified the physician that Resident #1 had worsening bruising to his left leg and continued to complain of left leg pain, and that is when she received orders to send him to the hospital. She stated that the signs and symptoms of a fracture are pain, swelling and bruising. She confirmed that fractures required treatment in the emergency department of an acute care hospital. She stated that she was not aware of the fist-sized swollen area that had been assessed and documented on 7/7/12. She stated that she had observed an increase in bruising by lifting up the resident ' s left pants leg on 7/12/12 to view his shin area, and this is when she notified the physician. She stated that she had not assessed the resident ' s entire leg. She stated that she was not aware that the resident had complained of abuse to the acute care hospital physician as was documented in the resident ' s clinical record. An interview was conducted on 9/7/12 at approximately 4:10 p.m. with the Director of Nursing (DON), and the Social Services Director/Abuse Coordinator. She confirmed the documentation of the change in the resident ' s assessment regarding pain and swelling to his left leg on 7/7/12. She also confirmed that there was no further documentation of an assessment until five days later regarding the appearance of Resident #1 ' s leg when it was noted that the bruising was worse, and there had been no documentation of bruising prior. She confirmed that on 7/12/12, five days after the resident had first began complaining of left leg pain and the fist sized knot appeared on his left leg, the physician was notified of the continued increasing pain, and an order was received to transfer him to an acute care hospital. She confirmed that the x-rays at the hospital revealed comminuted and displaced fractures to the left proximal fibula and tibia. She stated that the mobile x-rays sometimes are not as reliable as x-rays done in the hospital. She also confirmed that the History and Physical that was dated 7/12/12 that was taken by a physician at the acute care hospital indicated that the resident had complained of abuse, and that he had specifically reported to the physician, " a man did it " in answer to a question on how he had broken his leg. She confirmed that the fracture was an unexplained injury, and she stated that an investigation had been completed. She provided a copy of the investigation that was dated 7/16/12 and stated, " Resident was interviewed on return from the hospital, stated he did not know how he fractured his leg, no one hurt him. " She stated that there had been no incident report filed regarding Resident #1 ' s injury/fracture, and no adverse or federal reports made regarding the possibility and allegation of abuse. She confirmed that no staff had been interviewed regarding the care that had been provided to the resident surrounding 7/7/12 when Resident #1 ' s injury had first been noted. A review of the facility ' s policy and procedure for " Reporting Abuse to State Agencies and Other Entities/Individuals " dated and revised December 2006, stated, " Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident." An additional policy and procedure titled, " Investigating Unexplained Injuries " updated in December 2006 stated, " An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized, " and under Policy Interpretation, number five, is stated, " With the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc. who have had contact with the resident during the past 48 hours. " 2. Record review of the record for resident #2 revealed she had been a resident for approximately [AGE] years, but her last readmission to the facility was on 4/14/12. Resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set last completed on 5/17/12 revealed that the resident scored 15/15 on the Brief Interview of Mental Status (BIMS) demonstrating good short term and long term memory. Review of the nurses notes reveals that one nurse wrote, on 5/3/12 at 9:35 a.m., that a Certified Nursing Assistant (CNA) was in the room with resident #2 to give AM care. She stated to the CNA's that she thought her left shoulder may be broken because someone pulled her up by the arms in bed last night and now it hurts. As a result of this complaint the resident's doctor was called and a Mobile X-Ray of the left shoulder was ordered. Results of the X-Ray: "There is a fracture involving left humeral neck with no significant displacement..." An incident report was completed. The facility abuse coordinator wrote in her notes on 5/3/12 "Spoke with resident regarding fractured shoulder, resident stated that her aid on third shift was lifting her up in bed and it happened.' The resident indicated she did not think it was intentional, and when asked by the abuse coordinator if she wanted to make a report of abuse the resident stated no that it was an accident. Review of the facility incident log shows that the incident was included in their statistics, but that whether it was reportable or not they indicated it was not. A request was made to the Administrator and the Director of Nursing (DON) on 9/7/12 at about 3:00 p.m. to locate the investigation that took place after the resident complained about being hurt by a staff member. When asked for documentation that the CNA(s) had been identified and inserviced after the incident on 5/3/12 the DON was not able to provide documentation that any inservices on resident handling/positioning had been completed at around the time of resident #2's injury. Per interview with the Nursing Home Administrator and DON on 9/7/12 at 5:30 p.m. they indicated that the above mentioned concern expressed by resident #2, who no longer resided at the facility, was not documented as having been investigated and resolved.

Based on observations, interviews and record review, the facility failed to operationize their policy and procedure for investigating injuries of unknown origin for 2 (#1, #2) of 6 sampled residents related to Resident # 1 who was noted to have an injury that was diagnosed as multiple fractures five days after it was first noted resulting in prolonged pain and Resident #@ who complained of pain from being pulled up in bed by her arms and was found to have a fractures shoulder. Findings included: 1. Review of the clinical record for Resident #1 revealed a History and Physical that was dated 7/12/12 with a chief complaint of " left fibular and tibular fracture " and the history included the following statement by the admitting physician at the acute care hospital regarding how the fracture occurred stated, " Per nursing, there were no documented falls. The patient is wheelchair bound at the nursing home, needing help with transferring. However, per the patient, he states that " a man did it. " The clinical record also revealed that the he was most recently readmitted to the facility after a hospitalization on [DATE] for comminuted and displaced fractures of the left proximal tibia and fibula shafts, (leg bones). His medical [DIAGNOSES REDACTED]. On 9/7/12 at approximately 9:50 a.m. Resident #1 was observed lying on his back in his bed. He appeared to be asleep with his mouth open, and did not respond to verbal stimuli. Employee A, who identified herself as being the certified nursing assistant that was assigned to Resident #1, was present in the room at the same time, and was checking the resident ' s vital signs. His left leg was observed to be in a hard cast that appeared to extend from his toes to above his knee. Employee A stated that the resident is confused, and requires extensive assistance with activities of daily living, and this includes transfers from the bed to the wheelchair using a Hoyer Lift. She confirmed that the resident had a cast to his left leg and stated that she did not know how he broke his leg. On 9/7/12 at approximately 10:15 a.m. Employee A and Employee B returned to Resident #1 ' s room with a Hoyer lift and transferred him using appropriate technique from his bed to a wheelchair. Employee B attached the foot rests to the wheelchair and placed both lower extremities on the foot rests. She left the room. The resident then complained to the surveyor that he was uncomfortable in the wheelchair, and stated, " I need to be pulled up. " His hips appeared to be shifted to the left and both lower extremities were more to the right, and the resident did not appear to be in proper alignment. The resident was asked at this time by the surveyor how he hurt his leg. He made eye contact with the surveyor and stared for a moment, and did not respond to the question. Employee A then returned to the room and the resident was repositioned in his wheelchair. He stated " yes " to the question if he felt better after the re-positioning. The resident was then observed holding his water cup and drinking independently. Further review of Resident #1 ' s clinical record revealed the following entry on the Skilled Daily Nurses Note that was dated 7/7/12 at 12 p.m., and stated, " Resident states severe pain to left leg. Left foot externally rotated. No bruising. Raised hardened knot area below left knee, fist size. Gave [MEDICATION NAME] 50mg. Informed Dr. of condition. " An additional entry that was dated 7/7/12 at 8:05 pm stated, " X-ray results called in to Dr. No new orders given. " An entry dated 7/8/12 at 11:55 a.m. stated, " Gave PRN [MEDICATION NAME] 50mg and Tylenol Extra Strength two tabs for complaints of left leg pain. X-ray results were negative for fracture. " There was no further documentation of the appearance of Resident #1 ' s left leg regarding the external rotation and swollen area below his left knee. An entry that was dated 7/9/12 at 12:30 p.m. stated, " He had complained of pain, medicated with PRN pain med with some effect. " There was no documentation of calling the physician back regarding Resident #1 ' s on going complaints of pain, and no documentation regarding the appearance of his left leg. An entry that was dated 7/11/12 at 11:00 a.m. stated, " Resident has an appointment on 7/16/12 for an orthopedic consult. Order to increase resident [MEDICATION NAME] 50mg to q6hours PRN. " On 7/12/12 at 5:00 a.m. an entry stated, " Noted ecchymosis (bruising) is more dark on left affected leg. " On 7/12/12 at 2:00 p.m. an entry stated, " Placed call to Dr. to make aware of increasing pain, received orders to send Resident to hospital. " A review of the radiology results revealed x-rays dated 7/7/12 of Resident #1 ' s left lower extremity that stated, " Normal left tibia and fibula. " The repeat x-ray on 7/12/12 stated, " There is a recent fracture involving proximal tibia and fibula with angulation, impaction, and mild displacement. Conclusion: Recent left lower leg fracture as described. The findings are unchanged from 7/7/12. " A call was made to the Radiology provider for an explanation , but no return call was received. On 9/10/12 at approximately 10:30 a.m. an interview was conducted with Resident #1 ' s primary care physician. He stated that he recalled the events surrounding Resident #1 ' s left leg fractures, and that he was only notified of the resident complaining of pain to his left leg on 7/7/12. He stated that he was not aware of the fist sized swollen area that was below the resident ' s knee. He stated that if he had known of that, regardless of the results of the x-rays that were done at the facility, he would have sent the resident out to an acute care hospital immediately. He confirmed that untreated fractures are painful and may have serious complications. He stated that when he learned that the resident continued to complain of pain, he gave orders to send the resident out to an acute care hospital on [DATE]. He confirmed that transferring a resident in and out of bed that has an untreated fracture put him at risk for further complications. He stated that he was not aware that the resident had stated to the admitting physician at the acute care hospital that " a man did it " when the resident was asked how he broke his leg. He stated that the facility had not reported the allegation of abuse to him. On 9/10/12 at approximately 12:45 p.m. an interview was conducted with Employee C who identified herself as the nurse that was assigned to the resident on the 7:00a.m. to 3:00 p.m. shift on the dates of 7/9/12, 7/10/12, 7/11/12 and 7/12/12. She stated that on 7/12/12, she notified the physician that Resident #1 had worsening bruising to his left leg and continued to complain of left leg pain, and that is when she received orders to send him to the hospital. She stated that the signs and symptoms of a fracture are pain, swelling and bruising. She confirmed that fractures required treatment in the emergency department of an acute care hospital. She stated that she was not aware of the fist-sized swollen area that had been assessed and documented on 7/7/12. She stated that she had observed an increase in bruising by lifting up the resident ' s left pants leg on 7/12/12 to view his shin area, and this is when she notified the physician. She stated that she had not assessed the resident ' s entire leg. She stated that she was not aware that the resident had complained of abuse to the acute care hospital physician as was documented in the resident ' s clinical record. An interview was conducted on 9/7/12 at approximately 4:10 p.m. with the Director of Nursing (DON), and the Social Services Director/Abuse Coordinator. She confirmed the documentation of the change in the resident ' s assessment regarding pain and swelling to his left leg on 7/7/12. She also confirmed that there was no further documentation of an assessment until five days later regarding the appearance of Resident #1 ' s leg when it was noted that the bruising was worse, and there had been no documentation of bruising prior. She confirmed that on 7/12/12, five days after the resident had first began complaining of left leg pain and the fist sized knot appeared on his left leg, the physician was notified of the continued increasing pain, and an order was received to transfer him to an acute care hospital. She confirmed that the x-rays at the hospital revealed comminuted and displaced fractures to the left proximal fibula and tibia. She stated that the mobile x-rays sometimes are not as reliable as x-rays done in the hospital. She also confirmed that the History and Physical that was dated 7/12/12 that was taken by a physician at the acute care hospital indicated that the resident had complained of abuse, and that he had specifically reported to the physician, " a man did it " in answer to a question on how he had broken his leg. She confirmed that the fracture was an unexplained injury, and she stated that an investigation had been completed. She provided a copy of the investigation that was dated 7/16/12 and stated, " Resident was interviewed on return from the hospital, stated he did not know how he fractured his leg, no one hurt him." She confirmed that no staff had been interviewed regarding the care that had been provided to the resident surrounding 7/7/12 when Resident #1 ' s injury had first been noted. A review of the facility ' s policy and procedure for " Reporting Abuse to State Agencies and Other Entities/Individuals " dated and revised December 2006, stated, " Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident. " An additional policy and procedure titled, " Investigating Unexplained Injuries " updated in December 2006 stated, " An investigation of all unexplained injuries (including bruises, abrasions, and injuries of unknown source) will be conducted by the Director of Nursing Services, and/or other individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized, " and under Policy Interpretation, number five, is stated, " With the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc. who have had contact with the resident during the past 48 hours. " 2. Record review of the record for resident #2 revealed she had been a resident for approximately [AGE] years, but her last readmission to the facility was on 4/14/12. Resident had [DIAGNOSES REDACTED]. Review of the Minimum Data Set last completed on 5/17/12 revealed that the resident scored 15/15 on the Brief Interview of Mental Status (BIMS) demonstrating good short term and long term memory. Review of the nurses notes reveals that on nurse wrote on 5/3/12 at 9:35 a.m. that a Certified Nursing Assistant (CNA) was in the room with resident #2 to give AM care. She stated to the CNA's that she thought her left shoulder may be broken because someone pulled her up by the arms in bed last night and now it hurts. As a result of this complaint the resident's doctor was called and a Mobile X-Ray of the left shoulder was ordered. Results of the X-Ray: "There is a fracture involving left humeral neck with no significant displacement..." An incident report was completed. The facility abuse coordinator wrote in her notes on 5/3/12 "Spoke with resident regarding fractured shoulder, resident stated that her aid on third shift was lifting her up in bed and it happened.' The resident indicated she did not think it was intentional, and when asked by the abuse coordinator if she wanted to make a report of abuse the resident stated no that it was an accident. Review of the facility incident log shows that the incident was included in their statistics, but that whether it was reportable or not they indicated it was not. A request was made to the Administrator and the Director of Nursing (DON) on 9/7/12 at about 3:00 p.m. to locate the investigation that took place after the resident complained about being hurt by a staff member. Review of the grievance log for this time period showed that this concern was not entered as a grievance even though the resident said that she had been unintentionally hurt by a staff member. When asked for documentation that the CNA(s) had been identified and inserviced after the incident on 5/3/12 the DON was not able to provide documentation that any inservices on resident handling/positioning had been completed at around the time of resident #2's injury. Review of the facility grievance policy provided by the Social Service Director which is undated indicates: "Any employee receiving a concern from patient/family, visitor, or other will refer the individual to their supervisor if they cannot resolve it on the spot. Supervisors will assist in the completion of the Grievance Form." Under section 7 of the Grievance Policy it indicates: "The incident will be investigated by the Social Service and the involved coordinator and a response made within 48 hours to the complaining party. Per interview with the Nursing Home Administrator and DON on 9/7/12 at 5:30 p.m. indicate that the above mentioned concern expressed by resident #2(now discharged from the facility) was not documented as having been investigated and resolved.

Based on observation, interview and record review the facility failed to ensure the highest practicable quality of care by failing to appropriately assess and notify the physician of ongoing pain for Resident #1, a vulnerable individual, and one (#1) out of six sampled residents, when he sustained an injury of unknown origin that resulted in multiple fractures of his left lower leg. Findings included: On 9/7/12 at approximately 9:50 a.m., Resident #1 was observed lying on his back in his bed. He appeared to be asleep with his mouth open, and did not respond to verbal stimuli. Employee A, who identified herself as being the certified nursing assistant that was assigned to Resident #1, was present in the room at the same time, and was checking the resident ' s vital signs. His left leg was observed to be in a hard cast that appeared to extend from his toes to above his knee. Employee A left the room. The resident opened his eyes to his name being called but did not greet the surveyor. His call light was observed to be lying on the floor beside his bed, not within his reach. On 9/7/12 at approximately 9:52 a.m., Employee A was called back into the resident ' s room and she verified that the call light was on the floor and not within the resident ' s reach. She stated that the resident was able to use the call light and communicate his needs. She replaced the call light within reach of the resident by clipping it to his shirt. She stated that the resident is confused, and requires extensive assistance with activities of daily living, and this includes transfers from the bed to the wheelchair. She stated that she would be transferring him out of bed later using a Hoyer Lift, as he had an appointment with the orthopedic surgeon that afternoon. She confirmed that the resident had a cast to his left leg and stated that she did not know how he broke his leg. Resident #1's clinical record revealed that he was originally admitted to the facility on [DATE] and was most recently readmitted to the facility after a hospitalization on [DATE] for comminuted and displaced fractures of the left proximal tibia and fibula shafts, (leg bones). His medical [DIAGNOSES REDACTED]. Further review of the clinical record revealed a History and Physical that was dated 7/12/12 with a chief complaint of " left fibular and tibular fracture " and the history included the following statement by the admitting physician at the acute care hospital regarding how the fracture occurred stated, " Per nursing, there were no documented falls. The patient is wheelchair bound at the nursing home, needing help with transferring. However, per the patient, he states that " a man did it. " On 9/7/12 at approximately 10:05 a.m. Resident #1 was observed being repositioned in his bed by Employee A. He was placed on his left side and a pillow was tucked underneath his right side, the side rails were raised, and Employee A left the room. The resident was observed to be struggling to hold his head up. His pillow was observed to be a few inches lower than his head due to the way the pillow under his trunk had been positioned. Employee A was called back into the room and she confirmed that the resident's head was unsupported. She replaced the pillow under his head and stated that she would be transferring him out of bed into the wheelchair. She left the room to get a Hoyer Lift and another employee to assist in the transfer. On 9/7/12 at approximately 10:15 a.m. Employee A and Employee B returned to Resident #1's room with a Hoyer lift and transferred him using appropriate technique from his bed to a wheelchair. Employee B attached the foot rests to the wheelchair and placed both lower extremities on the foot rests. She left the room. The resident then complained to the surveyor that he was uncomfortable in the wheelchair, and stated, " I need to be pulled up. " His hips appeared to be shifted to the left and both lower extremities were more to the right, and the resident did not appear to be in proper alignment. The resident was asked at this time by the surveyor how he hurt his leg. He made eye contact with the surveyor and stared for a moment, and did not respond to the question. Employee A then returned to the room and the resident was repositioned in his wheelchair. He stated " yes " to the question if he felt better after the re-positioning. The resident was then observed holding his water cup and drinking independently. On 9/7/12 at approximately 10:20 a.m. Employee A stated that she usually does look at the resident after re-positioning to determine proper alignment and ensure comfort, but she had not earlier when the resident had been positioned in bed and in the wheelchair. On 9/7/12 at approximately 1:35 p.m. an interview was conducted with the MDS Coordinator, who stated that Resident #1 last had a comprehensive assessment that was dated 6/5/12. Section G revealed that Resident #1 required extensive assistance for bed mobility, and transfers, and she stated that this included the use of a Hoyer Lift. She stated that Resident #1 does not ambulate, and uses a wheelchair for locomotion, and required extensive assistance for dressing and toileting. She confirmed that he was discharged from the facility on 7/12/12 and returned to the facility on [DATE] after a hospitalization at an acute care facility. A review of Resident #1 ' s care plans revealed a care plan that was last updated on 6/5/12 that that interventions that included, " call light within reach at all times " and " promptly report any adverse change in resident condition to physician. " Further review of Resident #1's clinical record revealed the following entry on the Skilled Daily Nurses Note that was dated 7/7/12 at 12 p.m., and stated, " Resident states severe pain to left leg. Left foot externally rotated. No bruising. Raised hardened knot area below left knee, fist size. Gave [MEDICATION NAME] 50mg. Informed Dr. of condition. " An additional entry that was dated 7/7/12 at 8:05 pm stated, " X-ray results called in to Dr. No new orders given. " An entry dated 7/8/12 at 11:55 a.m. stated, " Gave PRN [MEDICATION NAME] 50mg and Tylenol Extra Strength two tabs for complaints of left leg pain. X-ray results were negative for fracture. " There was no further documentation of the appearance of Resident #1's left leg regarding the external rotation and swollen area below his left knee. An entry that was dated 7/9/12 at 12:30 p.m. stated, " This writer attempted to set up appointment with orthopedic and no one answered the phone, will try again later. He had complained of pain, medicated with PRN pain med with some effect. " There was no documentation of calling the physician back regarding Resident #1's on going complaints of pain, and no documentation regarding the appearance of his left leg. There was also an entry on 7/9/12 at 12:30 p.m. "Order to increase resident [MEDICATION NAME] 50mg to q6hours PRN. " On 7/12/12 at 5:00 a.m. an entry stated, " Noted ecchymosis (bruising) is more dark on left affected leg. " On 7/12/12 at 2:00 p.m. an entry stated, " Placed call to Dr. to make aware of increasing pain, received orders to send Resident to hospital." A review of the radiology results revealed x-rays dated 7/7/12 of Resident #1's left lower extremity that stated, " Normal left tibia and fibula. " The repeat x-ray on 7/12/12 stated, "There is a recent fracture involving proximal tibia and fibula with angulation, impaction, and mild displacement. Conclusion: Recent left lower leg fracture as described. The findings are unchanged from 7/7/12." A call was made to the Radiology provider for an explanation , but no return call was received. On 9/10/12 at approximately 10:30 a.m. an interview was conducted with Resident #1's primary care physician. He stated that he recalled the events surrounding Resident #1's left leg fractures, and that he was only notified of the resident complaining of pain to his left leg on 7/7/12. He stated that he was not aware of the fist sized swollen area that was below the resident ' s knee. He stated that if he had known of that, regardless of the results of the x-rays that were done at the facility, he would have sent the resident out to an acute care hospital immediately. He confirmed that untreated fractures are painful and may have serious complications. He stated that when he learned that the resident continued to complain of pain, he gave orders to send the resident out to an acute care hospital on [DATE]. He confirmed that transferring a resident in and out of bed that has an untreated fracture put him at risk for further complications. He stated that he was not aware that the resident had stated to the admitting physician at the acute care hospital that " a man did it " when the resident was asked how he broke his leg. He stated that the facility had not reported the allegation of abuse to him. On 9/10/12 at approximately 12:45 p.m., an interview was conducted with Employee C who identified herself as the nurse that was assigned to the resident on the 7:00a.m. to 3:00 p.m. shift on the dates of 7/9/12, 7/10/12, 7/11/12 and 7/12/12. She stated that on 7/12/12, she notified the physician that Resident #1 had worsening bruising to his left leg and continued to complain of left leg pain, and that is when she received orders to send him to the hospital. She stated that the signs and symptoms of a fracture are pain, swelling and bruising. She confirmed that fractures required treatment in the emergency department of an acute care hospital. She stated that she was not aware of the fist-sized swollen area that had been assessed and documented on 7/7/12. She stated that she had observed an increase in bruising by lifting up the resident's left pants leg on 7/12/12 to view his shin area, and this is when she notified the physician. She stated that she had not assessed the resident's entire leg. She stated that she was not aware that the resident had complained of abuse to the acute care hospital physician as was documented in the resident's clinical record. An interview was conducted on 9/7/12 at approximately 4:10 p.m. with the Director of Nursing (DON), and the Social Services Director/Abuse Coordinator. She confirmed the documentation of the change in the resident's assessment regarding pain and swelling to his left leg on 7/7/12. She also confirmed that there was no further documentation of an assessment until five days later regarding the appearance of Resident #1's leg when it was noted that the bruising was worse, and there had been no documentation of bruising prior. She confirmed that on 7/12/12, five days after the resident had first began complaining of left leg pain and the fist sized knot appeared on his left leg, the physician was notified of the continued increasing pain, and an order was received to transfer him to an acute care hospital. She confirmed that the x-rays at the hospital revealed comminuted and displaced fractures to the left proximal fibula and tibia. She stated that the mobile x-rays sometimes are not as reliable as x-rays done in the hospital. She also confirmed that the History and Physical that was dated 7/12/12 that was taken by a physician at the acute care hospital indicated that the resident had complained of abuse, and that he had specifically reported to the physician, " a man did it " in answer to a question on how he had broken his leg. She confirmed that the fracture was an unexplained injury, and she stated that an investigation had been completed. She provided a copy of an investigation that was dated 7/16/12 and stated, " Resident was interviewed on return from the hospital, stated he did not know how he fractured his leg, no one hurt him."