**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent heat exhaustion while outside in the courtyard for 1 (Resident #1) of eleven residents reviewed for accident hazards and supervision. The facility failed to provide necessary supervision to prevent accidents by failing to have measures in place to ensure residents who went outside on high heat days was provided with supervision, this failure resulted in Resident #1 being found in the courtyard unresponsive due to extreme heat exposure. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of not having proper supervision, dehydration and extreme heat exposure. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining . Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected: Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room. Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on [DATE]. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on 06/10/23, however, was she on-call on Monday 06/12/23. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, 06/12/23, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated although residents are welcome to go outside at any time, majority are outside during smoking times (9AM, 11AM, 2PM, 4 PM, 6:30 PM, 8:30 PM) when there was staff outside. The Administrator stated staff were not monitoring residents for heat exhaustion prior to the incident with Resident #1, however this is something staff should notice while outside monitoring residents for smoking. The Administrator stated on Monday June 12, 2023, she was reading through progress notes, and it was noted that on Saturday, June 10, 2023, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents as they have been trained to do. The Administrator stated The Director of Nursing is very through and firm with staff to follow protocol. During an interview on 06/15/23 at 10:018 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, pants, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying that was good. According to LVN A she responded No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit, and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, however she is aware of the facility policy and have been trained on what to do when there was a change of condition with residents, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. LVN A stated she had been trained and was aware to complete rounds, have eyes on residents, and address resident care needs at all times. LVN A stated The Administrator was the Abuse Coordinator and she had been trained on abuse and neglect policy. LVN A stated prior to the incident she would walk through the courtyard to as a short cut before and after lunch, LVN A stated she would see residents in the courtyard at that time and would have noted if a resident required assistance however, she would not have made it a point to walk to the courtyard and check on residents for heat exhaustion. LVN A stated staff were always present during smoke breaks. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility, he had a wander guard and was usually sat in front of the nursing station. LVN B stated Resident #1 required redirection, always asking for the restroom. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. LVN B stated he was aware to complete rounds to check on residents and has aides to assist him, LVN B stated this day he was very busy and was not aware that Resident #1 had went outside so he could not say how long Resident #1 was outside. LVN B stated he recalled last seeing Resident #1 around 7:30 AM on June 10, 2023. LVN B stated he did not monitor the courtyard before this day for heat exhaustion, several residents smoke and would visit the courtyard to smoke with staff and return inside the building, never staying outside for long periods of time. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweat pants, jeans, hoodies, and jackets because he was cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing when residents have a change of condition. LVN D stated she had been trained on recognizing the signs and symptoms of a change in condition. LVN D stated residents had access to the courtyard at any time of the day, there are designated smoking times that residents are outside with staff at that time for supervision. LVN D stated she had not gone to the courtyard to monitor residents for heat exhaustion, however due to this incident she had been inserviced to make rounds to the courtyard hourly to look for signs of dehydration and heat exhaustion. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out as this was the policy. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. LVN C stated she usually did not frequent the courtyard to monitor residents for heat exhaustion, during smoking breaks there was always staff outside with residents. LVN C stated during her shifts she monitors her residents closely those that have had an incident, injury or fall. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on [DATE]. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff had been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condition. The Director of Nursing revealed there was not a plan in place to monitor residents on the courtyard for heat exhaustion. A request for facility policy on 06/15/23 4:00 PM accident, hazards and supervision was made however the Administrator stated they did not have a policy to present at this time, and one was not provided prior to exit. On 06/15/23 at 4:00 PM the Administrator was notified of Immediate Jeopardy, Immediate Threat, and Substandard Quality of Care in the areas of Quality of Care, Resident Rights, and Resident Neglect and not following facility policy. The facilities Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised October 2022 titled Courtyard & Hydration Monito[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately inform the physician and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status (deterioration in health in either life-threatening conditions) for one (Resident #1) of eleven residents reviewed for physician notification. The facility failed to ensure LVN B notified the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. LVN A, LVN B, and LVN C were aware that Resident #1 was found outside in the heat and his temperature reached 106 degrees [Fahrenheit], reporting a change of condition from 06/10/23 - 06/12/23. Once the Immediate Jerporady was removed, the facility remained out of complaince at a scope of pattern and severity of actual harm. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room. Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on [DATE]. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on June 10, 2023, however, was she on-call on Monday June 12,, 2023. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, June 12, 2023, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated on Monday 06/12/23, she was reading through progress notes, and it was noted that on Saturday, 06/10/23, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents. During an interview on 06/15/23 at 10:18 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying it was good time to end the cold towels. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he is cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on [DATE]. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, 06/12/23, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status reflected: Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. .D. significant change in the resident's physical/emotional/mental condition. .G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised October 2022 titled Courtyard & Hydration Monitor indicated log started on 06/16/23 at 8:00 AM with slots for signatures, concerns, action taken, date, and a yes (Y) or no (N) for hydration. While the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from neglect was provided for one (Resident #1) of eleven residents reviewed for neglect. The facility failed to ensure Resident #1 was free from neglect when the facility failed to notify the physician when Resident #1 was unresponsive after extreme heat exposure and failed to provide Resident #1 with timely hospitalization following the incident. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of not having supervision or their needs adequately met. Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23 reflected: 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winter-like attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach [family members] to update her on resident's care and transfer to emergency room. Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on [DATE]. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on 06/10/23; however, she was on-call on Monday, 06/12/23. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, 06/12/23, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 10:18 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a sweatshirts. The Administrator stated on Monday 06/12/23, she was reading through progress notes, and it was noted that on Saturday, 06/10/23, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down, it was unknown how long Resident #1 had been outside or when the last time he had been seen by his nurse. The Administrator stated Resident #1 had a change of condition due to neglect so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, The Administrator and family, to alert them of any situation affecting residents. The Administrator stated all staff had been trained to recognize neglect and change of conditions so she was surprised to hear the ball had been dropped. During an interview on 06/15/23 at 10:18 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying that was a good place to stop. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside, he stated he last recalled seeing Resident #1 around 7:30 AM that morning during medication pass. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] family members but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline that he just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated he has had several trainings and inservices on neglect, LVN B stated many times he had made the call to send residents out to the hospital and just followed up with the physician, but did not feel this was one of those times to send Resident #1 out. LVN B stated not following protocol put [Resident #1] at risk of not having proper medical treatment. LVN B stated he was aware of abuse and neglect policy and was able to recognize signs and symptoms of neglect. LVN B stated The Administrator was the Abuse and Neglect Coordinator and he should have alerted her immediately. LVN B stated not being able to place eyes on your resident at all times is harmful to the residents, especially in this case, however LVN B stated he had many task going on during the lunch hour and he was only one person that could not be everywhere at the same time. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station at all times to have eyes on him because he liked to go to the restroom, and he was with an unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he was cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so it was odd to hear he was outside. LVN D stated she was informed by LVN C the morning upon arrival of her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also said Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. LVN D stated she had been trained on neglect, and was aware she needed to notify the Administrator immediately. LVN D stated she was able to recognize signs and symptoms of neglect, and in this situation knew that Resident #1 needed to be under further evaluation so she contacted the physician for further instructions. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on [DATE]. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Record review of facility policy revised 01/09/23 titled Abuse Prevention Program stated The Administrator is responsible for the overall coordination and implementation of our Center's prevention program policies and procedures. Our residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum training on neglect. As part of the resident abuse program, the administration will ensure that any further neglect is prevented. All allegged violations of neglect will be reported by the Administrator. All alleged violations of neglect will be reported to the Administrator. CMS defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. All violations involving neglect will be reported by the Center Administrator and the resident's Attending Physician and/or Medical Director immediately. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status stated Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. D. significant change in the resident's physical/emotional/mental condition. G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illn[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of eleven residents reviewed for incidents. The facility failed to implement their abuse and neglect policy by failing to ensure Resident #1 was free from neglect. Over several days, multiple staff did not provide goods and services of proper care. The facility failed to ensure LVN B did not neglect Resident #1 when she failed to notify the physician on 06/10/23 when Resident #1 suffered from heat exhaustion when the temperature reached 95 degrees Fahrenheit. Resident #1 was found unresponsive outside by the patio, which resulted in the resident having a change of condition. Once the Immediate Jeporady was removed, the facility remained out of complaince at a scope of pattern and severity of actual harm. An IJ was identified on 06/15/23, and while the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and following facility policy. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death Findings included: Record review of Resident #1's face sheet dated 06/17/23 revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage (complication of head trauma), history of falling, nausea with vomiting, adult failure to thrive, altered mental status, unsteadiness on feet, hypertension (high blood pressure), Type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and vascular dementia. Record review of Resident #1's admission MDS assessment, dated 06/02/23 revealed his BIMS score was 07 indicating severe cognitive impairment. His Functional Status for activities of daily living indicated he required limited assistance with one person assist with dressing and toileting. Resident #1 uses a wander/elopement alarm daily. Supervision for personal hygiene. Independent with bed mobility, transfers, walking in and out of the room, walking on and off the unit, and with eating. Record review of Resident #1's care plan, last care conference 05/24/23, revealed care areas 1-3 were revised on 06/16/23, 1. Resident #1 at risk for dehydration (problem started 06/02/23) due to complaints of frequently being cold and dresses in winter like attire. Goal: Resident will be free of signs and symptoms of dehydration/over-exposure to the sun, brought on by heat exposure while dressed in winter like attire. Approach: Encourage Resident #1 to drink cool fluids at least hourly while outside. Explain potential negative outcomes related to wearing winter like clothing while outside in warm weather. Allow him time and opportunity to process this information, ask questions and voice concerns or consent/refusal. If dehydration or over-exposure to the sun, notify the DON, Administrator and Medical Director/Nurse Practitioner. If noted for dehydration, remove Resident #1 from sun exposure, remove outer wear, apply cool towels, take vital signs, and encourage fluids. If Resident #1 is noted as being dressed in winterlike attire and wants to go out for sun exposure, offer alternate attire. Monitor Resident #1 for signs and symptoms of dehydration (dry mouth, extreme thirst, fatigue, dizziness, extreme sweating, or confusion). 2. Resident #1 at risk for wandering/attempting elopement (problem started 06/02/23) related to impaired memory/dementia as evidenced by resident wandering throughout the building often asking where he can go outside. Goal: Resident will remain inside long term care facility. Approach: Resident to have wander guard on at all times. Staff to redirect resident as needed. Staff will check functionality of wander guard daily. Staff will check to ensure wander guard is in place every shift. 3. Resident #1 has impaired cognition (problem started 06/02/23) with expected decline in cognitive impairment over a period of time as a natural progression of the disease process. Goal: Resident will be safe in his environment over the next 90 days. Approach: Reorient resident to person, place and time as needed when confusion is noted. Monitor resident whereabouts in the facility to ensure safe environment. Record review of Resident #1's progress notes dated 06/10/23 at 8:42 PM written by LVN B reflected, At about 1PM while the lunch was been served, resident was found in the courtyard sitting on a chair under the triple digit heat of the sun unresponsive, the attention of the nurses was called by the medication aide who noticed him while she was about to give him his medication his was sweating profusely under his thick jacket, his temp at this time was 106 degrees [Fahrenheit], he was rushed into the building while cold water was been poured on him continuously, he will not open his eyes and both temperature and blood pressure been taking at intervals of 5 mins until when these assessments record was at 97.8 [degrees Fahrenheit] and 133/78 [blood pressure] respectively, he was giving cold water and juice to drink, fed with food tray, then he started responding and talking as he used to, resident was praising God continually, saying God is good repeatedly, Resident Responsible Party cannot be reached as the phone number was declining. Record review of Resident #1's progress notes dated 06/11/23 at 5:50 AM written by LVN C reflected, Resident stayed up for some time refusing to stay in bed. Very weak to walk by himself. Dragging feet and would get frozen nearly falling. Put in wheelchair but is not able to propel self. Incontinent in the hallway times two - trying to sit down in his pee. Resident very upset when this nurse tried to redirect him stating that you think I don't think. Resident cleaned up and given incontinent brief. Eventually fell asleep. Has been sleeping since then. Bed in low position. Vitals taken 97.8 86 18 147/74 97% RA. Record review of Resident #1's progress notes dated 06/12/23 at 2:06 AM written by LVN C reflected, Resident in bed but keeps on getting up. He is kind of confused and has been asking for French Fries. Resident not able to walk with steady gait, has been using wheelchair if he agrees to. Continues using incontinence products. Resident a feeder at the moment, is not able to steadily hold silverware when eating and would need cueing. Staff continue keeping constant checks on resident to maintain safety. Bed in low position and call light within reach. Will continue to monitor. Record review of Resident #1's progress notes dated 06/12/23 at 11:31 AM written by LVN D reflected, Resident alert and oriented to name and present situation. Resident has been ambulatory, with un-steady gait resident was then placed in wheelchair for safety. Neurochecks done within normal limits. Resident extensively assisted with all activities of daily living and transfers. Resident's wander guard in place and functional. Fluids by mouth offered and encouraged. Able to make needs known responds appropriately when spoken to in conversation. Record review of Resident #1's progress notes dated 06/12/23 at 11:49 AM written by LVN D documented Notified Nurse Practitioner in regard to recent heat exposure. New orders received as follows: 1) STAT CBC, BMP (urgent overall blood lab test gives an overall view of your health, lab test that show how well your kidneys work) 2) UA C&S (test that checks for bacteria in urine). Unable to reach Resident's Responsible Party message left on answering machine to return call back to facility when available. Nursing to follow. Record review of Resident #1's progress notes dated 06/12/23 at 1:15 PM written by LVN D reflected, Reported to Director of Nursing of new orders given via Nurse Practitioner, Director of Nursing stated to call emergency medical transportation and send resident out to the emergency room for further evaluation and treatment. Nurse Practitioner made aware of resident's transfer to hospital. 12:10 PM emergency medical services arrives via stretcher accompanied by 2 attendants to transport resident to hospital. 12:20 PM [LVN D] was able to reach ex-wife or son to update her on resident's care and transfer to emergency room. Record review of accident and incident reports dated 03/14/23 - 06/14/23 did not indicate Resident #1 was found unresponsive on 06/10/23 or went to the hospital on [DATE]. Attempts were made to contact Resident #1's family members by phone on 06/15/23 at 9:16 AM; however, the attempts were not successful. Review of weather temperatures for the city in which the facility was located for 06/10/23 retrieved at www.accuweather.com and https://www.timeanddate.com/weather/usa/[NAME]/historic reflected the high for 06/10/23 was 95 degrees Fahrenheit (35 degrees Celsius). During an interview on 06/15/23 at 9:34 AM with the Nurse Practitioner revealed she was not on-call on June 10, 2023, however, was she on-call on Monday June 12,, 2023. The Nurse Practitioner stated LVN D notified her on 06/12/23 at 10:57 AM that Resident #1 was going to the hospital, he was found outside, on the ground unresponsive. The Nurse Practitioner stated she was not aware of the situation or a significant change of condition until Monday, June 12, 2023, according to the weekend notes, the on-call phone was not contacted about Resident #1's situation. The Nurse Practitioner stated had she been on call or notified about the situation she would have sent Resident #1 to the hospital for further evaluation and or treatment. Being exposed to heat could cause a range of reactions for example Resident #1 was found unresponsive. The Nurse Practitioner stated not sending Resident #1 to the hospital immediately could prevent medical treatment. During an interview on 06/15/23 at 9:52 AM with the Administrator revealed Resident #1 ambulated around the facility without assistance, did wear a wander guard, liked to dress with shoes, socks, pants, long-sleeved shirt, and a hoodie. The Administrator stated on Monday June 12, 2023, she was reading through progress notes, and it was noted that on Saturday, June 10, 2023, Resident #1 was found unresponsive outside. The Administrator stated LVN A and Medication Aide E brought him inside to cool him down. The Administrator stated Resident #1 had a change of condition so the protocol should have been followed. The Administrator stated the charge nurse on the floor should have competed an assessment, notified the physician or nurse practitioner and 911 to send the resident out to the hospital. The Administrator stated not following protocol could result in residents having a delay in treatment. The Administrator stated it was the responsibility of the nursing staff to contact the physician, director of nursing, and family to alert them of any situation affecting residents. During an interview on 06/15/23 at 9:52 AM with LVN A revealed Resident #1 was usually observed in his room, sitting at the nursing station, or walking around the building. LVN A stated she was sitting at the nursing station documenting, about 1:25 PM when she heard Medication Aide E saying something and walking fast. She stated Medication Aide E then grabbed a wheelchair and headed towards the courtyard and LVN A followed. LVN A stated once the doors opened, she saw Resident #1 sitting in a chair, and she could not tell if Resident #1 was sleeping or not. LVN A stated she could not tell how long Resident #1 had been outside. LVN A stated he was leaned back, head arched back, face towards the sky, and his arms were open branched out to his sides. LVN A stated she knew it was hot outside and noted he had on a big bubble coat and pants. She stated the first thing she did was unzip his coat. LVN A stated Resident #1 did not have on a shirt, and was sweating a lot under the coat. LVN A stated LVN B came out behind her, and she then stated she needed a thermometer, cold towels and to get him inside the building. LVN A stated Resident #1 was really hot, his skin was hot, and his face started to turn red, and he was very weak. LVN A stated once back inside the facility at Resident #1's room she removed wool socks, shoes, joggers, his briefs and administered cold towels to his face and body. LVN A stated chest rubs were being done. She stated Resident #1's eye were closed, he was not moving much because he was very weak, and he was trying to respond but could not. LVN A stated she kept applying fresh wet towels and rubbing his sternum for at least 30 minutes until he finally started to come to. LVN A stated there was several attempts at checking his temperature; once he was alert his temperature reading was 102 degrees Fahrenheit. Resident #1's head of bed was lifted slowly, and they began giving him something to drink (ice water, Gatorade, and juice). Medication Aide E checked his blood pressure to read 157/98, LVN A rechecked his temperature to read 98.3 degrees Fahrenheit, LVN B was saying it was good time to end the cold towels. According to LVN A she said. No, we are not done, let me check his hands and feet (which were still warm), it took a while before his legs were coming to a reasonable temperature. LVN A stated it was the end of the shift, Resident #1 was drinking more, continued to check his vitals which his temperature was 99.4 degrees Fahrenheit and his blood pressure was 136/80. LVN A stated she told LVN B you may want to call the physician and see if they want to send him out for further evaluation. LVN A stated Resident #1 was not her resident, so she left his care in LVN B's hands, and she was not sure if he contacted the doctor. LVN A stated she gave report to the nurse that was replacing her for the next shift. LVN A stated from what she could see at the time he was back at his baseline. LVN A stated it was the responsibility of the charge nurse to contact the physician, Director of Nursing, Administrator, and the family, and not doing so would be harmful to resident care. According to LVN A Resident #1 should have been sent out to the hospital for further evaluation. An attempted phone call interview on 06/15/23 at 11:20 AM with Medication Aide E was unsuccessful. During an interview on 06/15/23 at 11:27 AM with LVN B revealed Resident #1 was ambulatory, liked to walk around the facility and was usually sitting in front of the nursing station. LVN B stated he was the charge nurse for Resident #1 on June 10, 2023. LVN B stated it was a very terrible day for him because he had both nursing and certified nursing aide responsibilities and could not recall when Resident #1 went outside or how long he had been outside. LVN B stated around 1:00 PM Medication Aide E stated she was looking for Resident #1 to administer his medication. LVN B stated Medication Aide E ran into the facility stating Resident #1 was sitting out in the courtyard sweating, and another nurse ran out behind her. LVN B stated he assisted with getting Resident #1 inside to his room, he was observed sweating, skin was hot, and his temperature was high, around 106 degrees Fahrenheit or something like that. According to LVN B staff immediately began interventions with cold water, bed baths and checking vitals every 5 minutes. LVN B stated Resident #1's temperature came down to between 101 - 97.8 degrees Fahrenheit and his blood pressure reading was 133/77. According to LVN B after 15 minutes or so Resident #1 was fine. LVN B stated Resident #1 was administered orange juice to drink and completed his lunch tray. LVN B stated Resident #1 started praising God which was something he would usually do. LVN B stated after an hour Resident #1 got up from bed and requested to go outside and see the sun. LVN B stated, [Resident #1] did not go to the hospital at that time because I just felt he was back to normal, he was fine, and he was his normal self. LVN B stated he did not contact the physician, Director of Nursing, or the Administrator, however attempted to contact [Resident #1's] responsible party and family but had not spoken with anyone. LVN B stated he was so happy that [Resident #1] was ok and was at his baseline. I just entered the progress note. I did not find it necessary to contact the physician or the Director of Nursing. LVN B stated the protocol was to immediately complete an assessment, call the physician if I need, most of the time I don't want to take a chance to call the physician or emergency medical services because they are busy or may take long to call me back. LVN B stated, In this case I should have checked the vitals, called 911, and documented. LVN B stated I should have notified the physician, Director of Nursing, and the Administrator along with the family. According to LVN B it was his responsibility to follow facility policy and alert the medical team of the resident's change of condition. LVN B stated not doing so put [Resident #1] at risk of not having proper medical treatment. During an interview on 06/15/23 at 12:02 PM with LVN D revealed Resident #1 was pleasant, disoriented, required redirection, and usually sat at the nursing station. LVN D stated she encouraged the resident to sit at the nursing station to have eyes on him because he liked to go to the restroom, and he is with unsteady gait and now required assistance. He is usually dressed in sweats, jeans, hoodies, and jackets because he is cold natured. LVN D stated she never saw Resident #1 go outside during her shift, so the it was odd to hear he was outside. LVN D stated she was informed by LVN C in the morning upon her shift beginning at 6:00 AM, on June 12, 2023 that Resident #1 was found outside with an elevated temperature on Saturday, June 10, 2023. Nursing staff brought Resident #1 inside to cool him down with cold compress towels and hydrated him with fluids. LVN D stated she was told by LVN C during the weekend that Resident #1 required assistance with incontinent care and feeding during meals. LVN D stated LVN C also stated Resident #1 was not sent out to the hospital, that she may want to contact the physician. According to LVN D she observed Resident #1 to have signs of weakness, which was a change in condition from the last time she saw him (Friday, June 09, 2023) and considering what happened over the weekend, she needed to notify the physician. LVN D stated she contacted the doctor on June 12, 2023 about 11:30AM, followed up with the Director of Nursing and it was discussed to send him out to the hospital. LVN D stated not sending Resident #1 to the hospital in a timely manner prevented a quicker turn around for care. LVN D stated it was the responsibility of the charge nurse to make the proper calls to the physician and the Director of Nursing. During an interview on 06/15/23 at 12:24 PM with Administrator revealed the facility was continuing to complete the investigation and in-services that started on Monday June 12, 2023, on abuse and neglect, accidents, hazards, and supervision regarding heat illnesses, and staying hydrated during high temperatures and reporting changes. The Administrator stated the facility was continuing to educate residents to come inside when temperatures were high. The Administrator stated staff had been trained to monitor for proper clothing, staying hydrated, and the use of the water cooler on the patio. The facility would also provide Gatorade. The Administrator stated she, and the Director of Nursing are doing frequent checks along with staff outside during smoking times throughout the day to ensure resident are not showing signs and symptoms of heat exhaustion. During an interview on 06/15/23 at 12:40 PM with LVN C revealed when she entered for her shift on June 10, 2023 at 2:30 PM, she observed staff working with Resident #1 after he was found outside; she saw staff trying to give him drinks and food. LVN C stated Medication Aide E explained Resident #1 was found sitting outside in the sun, not under the shade and could not open his eyes. Staff brought him inside for cold water because his temperature was 106 degrees Fahrenheit. According to LVN C when she worked with him later that night, he was very weak and confused. LVN C stated Resident #1 urinated twice on the floor and wanted to sit in it, and he would get upset when he attempted to redirect him. LVN C stated she had to watch him closely because he would try walking but was not steady and unbalanced, he was very weak. LVN C stated at that point she provided him with briefs so that he did not have to attempt going to the restroom and risk falling. LVN C stated he would usually be up walking very slow or sitting at the nursing station however at that time he was too weak. LVN C stated on Sunday, June 11, 2023, Resident #1 was the same, not strong, and was too weak to walk. LVN C stated she monitored him and had frequent vital checks which were within normal limits. LVN C stated she questioned if his temperature read 106 degrees Fahrenheit why wouldn't they send him out to the hospital, and stated if it was me, I would have sent him out. LVN C stated on Sunday his vitals were ok, the only difference with him was that he was weak, briefs was placed on him so he would not attempt to toilet alone. According to LVN C it was the nurse's responsibility to make the call to contact the physician and the Director of Nursing and inform what is going on. LVN C stated she was not sure if that happened but thought when she had seen staff working with him in his room with the wet bed, feeding him and giving him drinks that the physician had been contacted and the nurses were following physician's orders. During an interview on 06/15/23 at 1:36 PM from the hospital case worker revealed Resident #1 was brought in by emergency medical services on June 12, 2023, for evaluation. Resident #1 was usually alert times 2 (Resident #1 was aware of his name and surroundings), however was showing signs of confusion and alert times 1(Resident #1 was aware of his name). Resident #1 presented with warm, dry skin, able to transfer, no fever, no wounds and would be discharged on this day. Case Worker stated Resident #1 was presented with fluids due to acute kidney injury on 06/13/23 until his discharge on [DATE]. During an interview on 06/15/23 at 2:05 PM with the Director of Nursing revealed when she entered the facility on Monday, June 12, 2023, she was notified during a clinical meeting that Resident #1 had an incident. The Director of Nursing stated she was reviewing the notes from the weekend, she started asking questions and it was told to her that Resident #1 was outside, and staff had to bring him inside to get his body temperature down. The Director of Nursing stated, No one had informed her of the incident. The Director of Nursing stated she had the charge nurse contact the physician while she contacted their regional consultant. According to the Director of Nursing it was decided by corporate to send Resident #1 to the hospital. The Director of Nursing stated staff followed up with the hospital later that day and it was revealed there were no critical findings and they were waiting on the doctor to complete an evaluation and then he would discharge. The Director or Nursing stated her expectations were to have immediately notify the physician and have contacted her about Resident #1 having heat exhaustion and found unresponsive. The Director of Nursing stated she would have had the nurse to send Resident #1 out immediately to the hospital for further evaluation. The Director of Nursing stated she started in-services on Monday June 12, 2023, on heat exposure and what to do, signs and symptoms of heat exposure along with a quiz for understanding. The Director of Nursing stated it was the responsibility of the nursing staff to act quickly to notify the physician and then The Director of Nursing if there is a change of condition with residents. The Director of Nursing stated not notifying the physician or The Director of Nursing of the incident could have caused delayed treatment for the resident. The Director of Nursing stated during her investigation with LVN B he stated he did not alert the physician or the Director of Nursing because the resident was brought back inside and got him back to his baseline and he was fine. The Director of Nursing stated LVN B was placed on suspension during the investigation. According to Director of Nursing, the staff has been trained and is aware of how she liked the floor to operate, which was by policy and procedures, and to notify her of any change of condtion. Record review of facility policy revised 01/09/23 titled Abuse Prevention Program stated The Administrator is responsible for the overall coordination and implementation of our Center's prevention program policies and procedures. Our residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. Our Center will implement and permanently maintain an effective training program for all staff, which includes, at a minimum training on neglect. As part of the resident abuse program, the administration will ensure that any further neglect is prevented. All allegged violations of neglect will be reported by the Administrator. All alleged violations of neglect will be reported to the Administrator. CMS defines Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. All violations involving neglect will be reported by the Center Administrator and the resident's Attending Physician and/or Medical Director immediately. Review of facility policy revised 04/20/23 titled Change in a Resident's Condition or Status stated Our facility promptly notified the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a(an): Accident or incident involving the resident. D. significant change in the resident's physical/emotional/mental condition. G. Need to transfer the resident to a hospital/treatment center. A significant change of condition is a major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff . B. impacts more than one area of the president's health status. C. requires interdisciplinary review and/or revision to the care plan; and D. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. On 06/15/23 at 4:00 PM the Administrator was notified of an Immediate Threat had been identified. The facility's Plan of Removal was accepted on 06/16/23 at 9:51 AM. The Plan of Removal reflected the following: .Charge Nurse assigned to [Resident #1] member [sic] identified in the alleged deficient practice was suspended pending investigation. Education: In-services was conducted on the following policies: 1. Abuse/Neglect. (All Staff) 2. Heat and dehydration Signs and symptoms. Accidents, hazards and supervisions. (All Staff) 3. Hydration during warm weather. (All Staff) 4. Reporting to include when to notify the administrator and DON of reportable incidents or other serious incidents. (All Staff) 5. Assess for change of condition, physician/family/POA notification, significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard clinical interventions (is not self-limiting) will result in a call to emergency services. Change in Condition will be documented in the progress notes in the electronic medical record. All residents with new progress notes will be reviewed in clinical meeting, daily, x5 days by Director of Nursing and or designee. (Charge Nurses) All current staff will be in-serviced prior to working their next shift, all new staff will be in-serviced regarding the above information prior to working their first shift. Completed by Director of Nurses, Assistant Director of Nurses, and/or designee. Review and identify residents who wander and have an increased risk of exposure to elements. Monitor: 1. Staff assigned to Monitor Courtyard hourly. (staff are aware of their assignment through education, staff responsible for monitoring will vary.) Staff will monitor courtyard for residents who wander; wandering residents have been identified through audit and will be communicated to staff for monitoring. Administrator and or designee will provide oversight of monitoring. This will include the log audit for completion. Administrator and/or designee has created a schedule for courtyard monitoring. The courtyard monitoring log will be reviewed/audited, daily, x5 days. Any concerns noted on the log will result in education and up to disciplinary action for staff assigned/responsible. 2. Staff responsible for monitoring will offer hydration during their assigned monitoring time and as needed. 3. DON/designee to correct any noted concerns and report to the Administrator. 4. Administrator will report, in summary, noted concerns to QAA Committee. Out of Cycle QAPI meeting to discuss concerns and approaches to correct. During observation and interview on 06/16/23 at 10:13 AM with Resident #1 revealed Resident #1 in bed under a blanket. The head of the bed was elevated, and Resident #1 was slumped over leaning to the right side. Resident #1 has his knees bent. According to Resident #1 he did not recall going to the hospital. He stated he did not have breakfast but would like to have some juice. Resident #1 stated he was having some pain in the right hand and right knee. Resident #1 requested pain medication. Further monitoring on 06/16/23 during re-interviews and interviews consisting of both day and night shifts revealed the following: Interviews on 06/16/23 from 1:00 PM through 06/17/23 10:30 AM with the Business Office Manager, LVN A, LVN B, LVN C, LVN D, Medication Aide E, Medication Aide F, LVN G, LVN H, LVN I, RN J, RN K , CNA L, CNA M, CNA N, CNA O, CNA P, who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00PM and 6:00 PM-6:00 AM were able to verify education was provided to them; nursing staff were able to accurately summarize abuse and neglect policy, definitions and examples of change of condition and how, who, and when to report changes. The nursing staff revealed signs and symptoms of heat illnesses and what to look for and do if heat exhaustion is identified. The nursing staff expressed understanding of the importance of accidents, hazards, and supervision and how that plays in part to resident safety. During observations on 06/16/23-06/17/23 between 8:00 AM-5:00 PM revealed staff walking outside hourly to monitor residents in the courtyard. Staff were observed engaging with residents, offering water, and completing education about heat exhaustion and wearing proper attire when outside. Record review of the facility plan of correction monitoring tool form revised 10/2022 titled Courtyard & Hydration Monitor indicated log started on 06/16/23 at 8:00 AM with slots for signatures, concerns, action taken, date, Y/N to Hydration . While the IJ was removed on 06/17/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on change in condition, physician notification, and resident neglect and follow[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident # 67) of 18 residents reviewed for smoking. CNA D failed to comply with the facility's smoking policy, when she failed to provide continuous direct supervision to residents during their smoke break, which resulted in Resident #67's hair and scalp being burned. Another resident had to pat out the burning hair, and Resident #67 sustained a superficial burn (affecting the top layer of skin) to her scalp. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #67's face sheet revealed the resident was a [AGE] year-old female admitted to the facility 06/15/22 with diagnoses to include depression (mental health disorder), insomnia (lack of sleep), gastro-esophageal reflux disease, schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), hypertension, and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area). Record review of Resident #67's quarterly MDS assessment, dated 12/22/22, revealed the resident's cognitive skills for daily decision making were intact. Resident #67's BIMS score was 15. Record review of Resident #67's care plan revised 01/13/23 revealed the resident was a smoker. She was supposed to smoke in the designated area at designated times with staff supervision and remain free of injuries. Record review of Resident #67's Smoking Risk Assessment, dated 12/23/22, revealed the resident had a score of 3 indicating she was a safe smoker and needed to follow the facility's smoking policy. Resident #67's Smoking Risk Assessments, dated 08/18/22 and 01/18/23, revealed the resident had a score of 10 indicating she was a potentially unsafe smoker and needed to follow the facility's smoking policy. Review of Resident #67's incident report, dated 01/18/23, reflected the resident was out smoking in the designated smoking area when a gust of wind blew her hair into her face. She attempted to remove the hair from her face using the hand in which she held a cigarette, which caused the resident's hair to burn. The incident report reflected the resident had gone to a beauty shop with her son earlier in the day and her hair was held in place with hair spray which had a potential to accelerate combustion. The resident was assessed by the nurse, and she had a superficial burn to the scalp. The resident was referred to the emergency room for further management. Review of Resident #67's hospital records revealed the resident presented to the ER on [DATE] after her hair caught fire while smoking a cigarette. She was noted to have singed hair to the front left side of her head that extended to the back of her head. The resident sustained a superficial burn to her scalp, and she was discharged back to the facility with orders for silver sulfadiazine 1% cream to be applied topically for 7 days to the burn. Interview with the Administrator on 02/23/23 at 2:08 PM revealed CNA D was suspended because of Resident #67's hair catching fire while she was under the supervision of CNA D. Just before Resident #67's hair caught fire on 01/18/23, CNA D was assigned to supervise residents during the smoking break. CNA D left the residents alone during the smoking area, and she went back inside the facility to use the bathroom. CNA D did not ask other staff to watch over the residents. The Administrator stated CNA D failed to supervise the resident as directed by the facility policy. CNA D was not available for interview as she was not a regular staff and only worked as needed. The Administrator stated it was important for facility staff to follow the facility's smoking policy regarding supervision and safety to prevent accidents and resident injury. She stated CNA D was suspended and later reinstated. She stated assessments were done for all residents and those who were safe smokers were put on a liberalized smoking schedule and those who needed supervision were identified. She stated all residents smoked at the same time and there was always staff supervising. She stated they did some modifications to the smoking shade to block the wind in the smoking area, and they had a blanket and fire extinguisher readily available in the smoking area. She stated she did one-on-one training with CNA D and all other staff regarding safe smoking, fire safety, liberalized smoking, and abuse and neglect. Interview with the DON on 02/23/23 at 2:39 PM revealed she was new when the incident happened. She stated when they reviewed the document all smoking residents had a smoking assessment. She stated they did another assessment, and they identified the residents who were safe smokers and did not need supervision and those who needed supervision. She stated they all went to the smoking area at the same time with supervision. She stated when they got the information a resident was screaming, they ran out to the smoking area and Resident #67 stated she was smoking when her hair caught fire. The DON stated when she got out CNA D was not there, and the residents were left alone. She stated CNA D was away less than 5 minutes. The Administrator and the DON called the doctor, and they received an order to send the resident to the emergency room. She stated they have since educated the staff and the residents on smoking safety and on the smoking policy. Observation of residents while smoking during the smoking breaks on 02/22/23 at 9:07 AM, 02/23/23 at 9:30 AM and 02/23/23 at 4:04 PM revealed staff were supervising the residents. Some residents that needed assistance with smoking were observed wearing smoking aprons. An Immediate Jeopardy (IJ) was identified to have existed from 01/18/23 through 01/25/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-service records dated 01/19/23 through 01/25/23 revealed all nursing staff including CNA D were educated on safe smoking, liberalized smoking, abuse and neglect, and fire safety. In case of fire the facility had implemented fire safety items located in the designated smoking area including a fire blanket, fire extinguisher and smoking aprons. The in-service reflected in case of fire staff should PASS: Pull. Aim Squeeze, Sweep with a fire extinguisher, and smoke blankets should be used to smolder fires immediately. The center had adopted a liberalized smoking policy for residents. Residents were now allowed to smoke during non-designated times. Interviews were conducted with four CNAs and four LVNs on 02/23/23 from 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shifts. The nursing staff were able to accurately summarize the smoking safety and fire safety training they received, and the facility's no leaving smoking residents unattended policy. The records revealed a plan of action had been initiated to include supervision prior to entry on 02/21/23. Review of the following reflected the facility was in compliance on 02/23/23. Review of the facility's policy entitled Smoking Policy-Residents dated August 2019 revealed in part: .9. All resident shall have the direct supervision of a staff member while smoking. 11. All residents smoking paraphernalia (equipment's, apparatus used for the activity of smoking.) must be checked in with the nurse.