Every finding on record at Anchor Care & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide a system for preventing and controlling infections and communicable diseases for residents by not offering hand hygiene to residents who ate in the dining rooms. This affected approximately 25 residents in the main dining room at lunch and 10 at dinner meals and approximately 10 residents in the small restorative dining room at the lunch meal each day. Findings: On 6/09/25 at 11:12 AM, 20 residents were located in the main dining room in preparation for lunch. Staff was observed as they put napkins on the tables for residents, but no hand hygiene was offered to residents before the meal. On 6/10/25 at 10:53 AM, 20 residents were again seated in the main dining room in preparation for lunch. Staff was seen placing linen tablecloths on the tables. At 11:07 AM, one staff member passed out napkins while another began the meal service by serving soup and another staff served beverages. By 11:13 AM, 25 residents total in the dining room had no hand hygiene offered prior to the meal. On 6/11/25 at 3:55 PM, in the main dining room, nine residents watched television while staff placed tablecloths on the tables. Some residents remained in the dining room after participating in the afternoon music activity. At 4:05 PM, staff served soup and drinks to the residents. No hand hygiene was offered to residents. On 6/12/25 at 11:30 AM, in the small restorative dining room, nine residents ate lunch, five were being assisted by staff. At 11:39 AM, Certified Nursing Assistant (CNA) J acknowledged there was no way to know if the residents completed hand hygiene before meals, and hand hygiene had not been offered in the dining room before the meal service. She confirmed it was important for everyone to sanitize their hands before meals to not spread germs. CNA J added residents touched items and then often touched their food when eating, which could spread germs. On 06/12/25 at 12:13 PM, CNA K she had never offered hand hygiene to the residents in the main dining room or in the small restorative dining room. She acknowledged it was important for residents to clean their hands before they ate, in order to not spread germs. On 6/12/25 at 1:51 PM, CNA I assisted a resident with their meal in the small restorative dining room and acknowledged she did not ensure the resident was provided with hand hygiene before she assisted him. She stated she knew residents who needed assistance with meals needed to be provided hand hygiene prior to assisting them from her CNA education. CNA I acknowledged she never considered why hand hygiene was not provided to residents before meals at this facility. On 6/12/25 at 2:25 PM, the Infection Control Nurse stated she trained staff on hand hygiene practices and policies, and staff should make sure residents' hands got washed before they brought residents to the dining room for meals. She acknowledged the facility should offer the residents hand sanitizer or wipes in the dining room as there was no way of knowing if they all washed their hands or if they touched things after they washed them. She stated hand hygiene was important to prevent infection, so germs weren't spread. On 6/12/25 at 3:16 PM, the Director of Nursing stated she expected staff to offer to wash residents' hands before and after meals to decrease the spread of infection and so illness was not spread to others. The facility's policy entitled Hand Hygiene, dated 5/21/22, specified staff should wash their hands with soap and water prior to and after eating, but did not specify when staff should offer hand hygiene to residents.

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 45 residents, (#62). Findings: Resident #62 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, essential hypertension, anemia, major depressive disorder, anxiety disorder, and sepsis. Review of the Minimum Data Set quarterly assessment with assessment reference date of 5/02/25 revealed resident # 62 was cognitively intact. A review of resident #62's medical record revealed no physician's orders for eyedrops, no assessments for self-administration of medications nor did it contain a care plan which reflected self-administration and storage arrangements. On 6/11/25 at 9:40 AM, resident # 62 was observed in her room seated in a wheelchair with a bedside table in front of her. On the bedside table there was a small green bottle of Refresh eyedrops and the resident stated it was her own eyedrops which she administered by herself in the morning and at night. The resident continued to explain that staff were aware she self administered the bottle of eyedrops and that she had the bottle with her since admission. A few minutes later at 9:45 AM, assigned nurse Licensed Practical Nurse ((LPN) G looked at resident #62's physician orders and confirmed there was no order for eyedrops nor was there an order to self-administer medications. LPN G immediately went into resident #62's room, confirmed the bottle of eyedrops on the table and educated the resident on self-administration of medications. The resident explained to the nurse that her son had brought the eyedrops and continued to explain how she administered it to herself, one drop in morning and one at night in both eyes, ever since I got here. LPN G examined the bottle, verified the expiration date, and explained to the resident that she would need a doctor's order and an assessment completed in order for her to self-administer her own eyedrops. On 6/11/25 at 9:51 AM, the Assistant Director of Nursing (ADON) and the Unit Manager (UM) for the Sea Breeze unit explained that residents were not allowed to have medications at the bedside unless they had a doctor's order and an assessment for self-administration. On 6/11/25 at 9:53 AM, the Director of Nursing (DON) confirmed eyedrops should not have been left unsecured for the resident to take by herself and acknowledged the resident was not previously assessed for self-administration of medications. The DON stated the unsecured eyedrops would be taken care of immediately, and that a physician's order to assess the resident for self administration of medications was needed. The facility's policy on Resident self-Administration of Medication implemented on November 2020 indicated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The policy described, the resident had the right to be assessed for self-administration of medications, directed nurses and aides to report to the charge nurse any medications found at the bedside, and ensure the care plan reflected resident self-administration and storage arrangements for the medications.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices for two of two residents reviewed for call bells, of a total sample of 45 residents, (#80 and #259). Findings: 1. Resident #80 was admitted to the facility on [DATE] for hypertension, depression, insomnia, emphysema, and a urinary tract infection. According to the discharge Minimum Data Set (MDS) dated [DATE] for a short-term hospital stay, it indicated the resident was able to make his own decisions regarding tasks of daily life and was able to communicate in a logical and coherent manner. Resident #80's care plan indicated he was at high risk for falls, and his use of his call light was to be encouraged for standing, transferring and ambulation. There was a care plan which included resident was at risk for skin breakdown due to incontinence with an intervention to check for incontinence after meals. The care plan also stated this resident had an active urinary tract infection and was taking antibiotics for it with date initiated 6/02/25. On 6/09/25 at 1:03 PM, after the lunch meal, resident #80 stated he had frequent bowel movements because he took potassium, which he couldn't help. He explained he felt the staff got upset with him due to the frequent need for assistance, but he couldn't help it. Resident #80 stated staff turned off the call light and said they would tell someone to help him, but it sometimes took up to an hour and a half to get the needed help. He added he asked staff to leave the call light on, but they turned it off anyway. The resident had the call light on at that time and stated he was currently waiting for his brief to be changed. On 6/09/25 at 1:08 PM, Licensed Practical Nurse (LPN) A came into the resident's room, turned the call light off and asked the resident what he needed. He told her he needed his brief to be changed. She stated she would get someone to help him. LPN A then left the room and returned shortly after carrying a gait belt. She stated she found out the gait belt needed to be used to transfer the resident, and then assisted him onto his bed. On 6/09/25 at 1:45 PM, resident #80 again requested staff assistance, this time to put his socks back on. He explained he was still waiting for someone to change his brief and was tired of waiting. Resident #80 conveyed he wanted to get back into his wheelchair and would wait until later to be changed. On 6/09/25 at 1:46 PM, LPN A explained she had told resident #80's Certified Nursing Assistant (CNA) to change him, but acknowledged she never provided that care. LPN A apologized to resident #80 and prepared to change him herself. She acknowledged resident #80 had waited over 45 minutes since he first turned on his call light for the requested service. On 6/09/25 at 1:48 PM, CNA B stated she had just returned from her break. She stated no one had informed her resident #80 needed to be changed, and after she finished care for another resident, she went on break. At 1:49 PM CNA C also stated no one told her resident #80 needed to be changed. A few minutes later at 1:52 PM, LPN A explained she had told CNA C that resident #80 needed to be changed but CNA C replied he was not her resident. LPN A added, she should have just changed the resident herself. On 6/11/25 at 4:18 PM, LPN A stated the expectation was for CNA's to provide assistance to any resident as long as they were not in the middle of caring for another resident. The nurse said she thought CNA C should never have said it was not her resident when asked to provide care. She acknowledged she should have provided re-education to CNA C at that time. LPN A added, when a CNA went on break, they told their hall partner and the nurse assigned to the unit they were going, but did not recall whether CNA B had informed her she was leaving for break. On 6/11/25 at 4:27 PM, the 200's Unit Manager (UM) stated call lights were for all staff to answer and if anyone saw a call light on and asked a resident what they needed, if they could take care of it themselves, they should. She explained if they could not take care of the issue themselves, staff were supposed to turn the light off, timely find someone else to help the resident, and if needed, assist as a 2nd person. The UM added, after a person turned off the call light, even if someone else acknowledged they would take care of the request, it was the responsibility of the person who answered the call light to follow up and make sure the task got done. The 200's UM stated most resident's needs could be provided by any nursing staff and added, if a CNA stated it was not their resident to provide care to, she would tell them that the residents were all of our residents. 2. Resident #259 was admitted to the facility on [DATE] for diabetes mellitus, urinary tract infection, hypertension, anemia, acute kidney failure and muscle weakness. Her admission MDS dated [DATE] indicated the resident had clear speech, could be understood, and was able to understand others. It specified the resident had good cognitive function. On 6/09/25 at 4:30 PM, resident #259 stated when staff responded to the call light, they would turn it off and tell her they would let someone else know her request. She explained the wait time to get the actual service could range between 20 minutes to 2.5 hours. Resident #259 added, the previous evening she put on her call light on three times to request pain medication and the aide told her she would let the nurse know each time. She said she got tired of waiting, so she got out of bed and went to the nurse's station herself to get it. She stated when her nurse, LPN F, saw her, she told her she should have used her call light if she needed something. Resident #259 said the nurse told her since she had refused a different medication earlier, she thought the resident didn't want any medication, instead of coming to find out what she needed. On 6/11/25 at 4:33 PM, in a phone interview, LPN F stated she recalled resident #259 came to the nurse's station for pain medication almost at the end of her shift, on 6/09/25. LPN F could not remember whether a CNA told her that resident #259 had called to request pain medication, and explained it was a busy night. On 6/12/25 at 3:16 PM, the Director of Nursing stated it was not appropriate for a staff member to respond, 'that is not my resident', to a request, and was a pet peeve of hers. She added, it was her expectation that staff who turned off a call light be sure the resident received the care they had requested. The facility's policy entitled Call Lights: Accessibility and Timely Response, dated 7/19/22, indicated all staff were responsible for answering call lights when they saw them on. The policy continued, if that staff member was unable to provide the requested service, they should then notify the person who was able.

Based on observation, interview, and record review, the facility failed to maintain the kitchen freezer (essential equipment), in safe operating condition. This had the potential to affect all 106 residents who ate meals at the facility. Findings: On 6/09/25 at 10:00 AM, during the kitchen tour with the Dietary Manager, it was noted in the walk-in freezer that ice [NAME] had built up on the evaporator and water was dripping onto the boxes stored below it. The Dietary Manager relocated approximately six boxes of food whose tops were covered in ice from the leak to a different shelf. She confirmed she needed to get with the maintenance department to have them come check out and repair the freezer. On 6/10/25 at 11:30 AM, the Director of Maintenance and Regional Manager of Maintenance stated they were not previously aware there was ice buildup and a leak from the evaporator in the freezer. They confirmed none of the kitchen staff had informed them of the issue, but said they would check it out. On 6/10/25 at 4:30 PM, the Director of Maintenance and the Regional Manager of Maintenance stated they had found a crack in the condenser, which they caulked, and would have an outside company come in to assess. On 6/11/25 at 11:00 AM, the Dietary Manager stated she had informed the Director of Maintenance of the leak on 6/09/25 and showed a message sent to him on the facility's manager chat at 10:28 AM that morning, and his response to the request. On 6/11/25 at 2:23 PM, the Regional Manager for Maintenance stated there had been a small crack in the outside wall of the freezer. The freezer's condenser hung from the wall and its weight pulled the sheet of metal away, which allowed hot air to get to the evaporator inside the freezer. The Regional Manager said this caused the water to drip. The Regional Manager stated he could not say why the Director of Maintenance said he had not been informed of the equipment issue before 6/10/25. The Dietary Manager stated maintenance issues were typically handled more quickly when put into the group chat. On 6/12/25 at 2:38 PM, the Director of Maintenance explained he now recalled he had been informed on the morning of 6/09/25 of the freezer issues, and thought it was caused by staff leaving the door opened. He acknowledged he did not personally check out the freezer when he was informed of the problem. He explained he must have forgotten about this request. On 6/12/25 at approximately 3:30 PM, the Administrator stated he and the Director of Maintenance were unable to locate a policy regarding expectations for equipment repair, even after they called other affiliated facilities. The Job Description for the Plant Operations Director, dated April 2020, indicated responsibilities of the position included to maintain the building's equipment in good working order and keep it free of hazards. The policy described this position was responsible to respond to work order requests and to establish policies and procedures of the maintenance department.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by their failure to ensure staff maintained a secure environment and implemented measures to mitigate the risk to prevent elopement for 1 of 1 resident reviewed for elopement, of a total sample of 5 residents, (#1). On 7/31/24 at approximately 7:48 PM, resident #1 left the facility unsupervised without the knowledge of staff. The resident walked along a busy roadway with a speed limit of 40 miles per hour and accepted a ride with strangers to get to her home. The facility staff were not aware of resident #1's whereabouts for approximately one hour and twenty minutes. Due to her cognitive deficits, and diagnosis of dementia, the elopement placed her at risk of falling, being severely injured, abducted, or hit by a motor vehicle. The facility's failure to provide adequate supervision and a secure environment contributed to resident #1's elopement and threatened all residents who were at risk for elopement. This failure resulted in Immediate Jeopardy which started on 7/31/24 and was removed on 8/02/24. The noncompliance at F600 and F689 was determined to be past noncompliance. Findings: Cross Reference F689 Resident #1, an [AGE] year-old female directly admitted from home to the facility on [DATE] at approximately 1:00 PM. Her diagnoses included dementia, unspecified severity/other behavioral disturbance, diabetes mellitus type II, generalized anxiety disorder, major depressive disorder, and chronic systolic (congestive) heart failure. Review of the Summary notes of the resident's visit on 6/26/24 with her community Primary Care Physician, revealed the resident had, dementia with behavioral disturbances and the document read, She has some agitation she is forgetting words and she started to wander around. Review of the Admit/Readmit Screener with effective date of 7/31/24 at 1 PM, revealed resident #1 arrived at the facility ambulatory from home, with admitting diagnosis of dementia, and anxiety. The document indicated the resident was oriented to person, place, time and situation, walked frequently, and had no limitation with mobility. The Elopement Risk assessment in conflict with the Summary notes from resident #1's provider on 6/26/24, indicated the resident was ambulatory, with no risk factors selected, and the selection, Not at risk for elopement was checked. On 8/28/24 at 12:08 PM, in an interview with resident #1 with translation provided by Receptionist F, the resident said she wanted to go back home to see her granddaughter. She stated she got anxious, so she got up and left the facility. Resident #1 explained a visitor was going out of the facility, so she followed the visitor out. She said she went out of the facility, turned right, walked up the street for about five to ten minutes then a couple gave her a ride to her home. On 8/28/24 at 4:06 PM, the incident was reviewed with the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant (RNC). The Administrator gave a timeline of the incident based on the facility's investigation. He said resident #1 was a direct admit to the facility on [DATE] at 1:00 PM, bought from home accompanied by her granddaughter, and son- in law. He stated that at 7:45 PM, the Licensed Practical Nurse (LPN)/ Evening Supervisor was alerted by a resident that people were in the lobby waiting to be let out. At 7: 48 PM, the Evening Supervisor entered the lobby, and observed another resident's wife, and resident #1 standing in the lobby. After asking if the visitor was there to visit her husband, the evening Supervisor entered the door code, and both the visitor, and resident #1 exited the facility. The Administrator stated the facility had cameras in the lobby and courtyards, and in review of the camera footage, resident #1 was observed on camera to exit the facility and turn to the right until she was out of range of the camera. The investigation revealed that at 8:40 PM, LPN E noticed the resident was not in her room, and when she did not locate the resident, she notified the Evening Supervisor, who called the elopement code, and a search was initiated. The Administrator recalled he was notified by the Evening Supervisor at 8:55 PM, and at approximately 9:07 PM the resident returned to the facility accompanied by her granddaughter and son-in law. The DON stated that prior to the elopement, the facility's visitor process was that visitors would sign in and get a yellow visitor's badge to be worn while in the facility. She said resident #1 did not have a visitor's badge on, and the Supervisor assumed the two women were together. The facility stated their Root Cause Analysis (RCA) showed they failed to confirm that resident #1 was not a visitor and failed to adhere to the facility's visitation process. On 8/28/24 at 5:11 PM, the LPN/Evening Supervisor recalled that on 7/31/24 the facility had three admissions. She stated she was entering admission orders in the Electronic Medical Record (EMR), and a resident was yelling out that people were at the door that needed to leave. The Supervisor stated she went to the door, and two older women were standing there, both holding belongings in their arms. She said she was familiar with one of the women and assumed resident #1 who she did not know was assisting her to take stuff to her car. She recalled she punched in the door code and walked with them out of the facility while conversing with the familiar person. When asked if the women had visitor badges on, the Supervisor said she could not recall, stating she had seen the familiar visitor several times before, accompanied by different persons. On 8/29/24 at 1:35 PM, resident #1's granddaughter stated she was at home when the resident was dropped off, but did not see the persons who gave her a ride. The granddaughter recalled she was told by the facility that her grandmother was talking to another resident's family member and exited the building. The granddaughter said she was not happy, and when she returned her grandmother to the facility, she asked, You have cameras how could you let a resident out who has dementia? She stated the facility said they were going to become more vigilant with ensuring that visitors signed in and out of the visitor log, and give badges to all visitors, to differentiate between visitors and residents. The facility policy, Elopements and Wandering Residents implemented 11/2020, and reviewed/revised 3/16/2023, read, The facility is equipped with door locks/alarms to help avoid elopements. Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: *On 7/31/24 at approximately 9:07 PM, resident # 1 returned to the facility from home accompanied by her granddaughter. Resident #1 was placed on one-on-one supervision and re-evaluated for elopement risk. Nurse evaluation of the resident was completed with no signs of injury or distress. *On 7/31/24 education was initiated related to elopement standards and guidelines, Abuse and Neglect, and visitor process to ensure residents are identified to prevent elopement. Post-tests were completed to validate competency. The Key Points on Visitors included, Visitors entering the building are required to sign in on the visitor log form. Visitors are also required to wear a visitor badge. Visitors exiting the building are required to sign out on the visitor log form. Visitors are also required to return the visitor badge. If staff is unable to verify the identity of the visitor, they are directed not to let the person exit the facility until another staff member is able to identify the visitor(s). *From 7/31/24 to 8/06/24, facility employees were provided education by the Leadership Team. 152 total facility employees (Nursing, Dietary, Laundry, Housekeeping, Therapy, Administrative staff, Maintenance Department employees) received the above mentioned education as follows: * On 8/01/24, 112 out of 152 staff members completed the education. * On 8/02/24, 26 out of 152 staff members completed the education. * On 8/03/24, 13 out of 152 staff members completed the education. * On 8/06/24, 1 out of 152 staff members completed the education. *Newly hired staff to receive the above education during orientation and prior to working an assignment. *On 8/01/24, Elopement Risk Binders were reviewed to ensure they contained photos and demographic information of residents evaluated to be at risk for elopement. *On 8/01/24, an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed with the Medical Director, Administrator, Director of Nursing and additional IDT (Interdisciplinary Team) members related to Elopement. The Performance Improvement Plan was accepted by the committee. Root Cause Analysis completed. *On 8/02/24, the Front lobby receptionist hours were extended from 6:00 PM to 9:00 PM. *On 8/02/24, as part of the ongoing QAA (Quality Assessment and Assurance) process, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on elopement. No additional recommendations were made at that time. *Additional QAPI meetings were held on 8/06/24, 8/13/24, and 8/16/24, to review PIP (Performance Improvement Plan) progress related to the elopement. No concerns were identified during ongoing quality reviews. *Ongoing Quality Reviews were completed by the DON/designee to review visitor process with staff weekly x 4 weeks, then once every 2 weeks, then monthly to ensure staff were able to verbalize the visitor process. 100 reviews were completed during Week 1 (8/04/24), 110 reviews were completed during Week 2 (8/11/24) with 100% compliance. * Administrator/designee to review 10 residents in LOA (Leave of Absence) book weekly x 4 weeks, then once every 2 weeks, then monthly to ensure LOA process is followed. Reviews were completed on 8/06/24 and 8/13/24 with 100% compliance. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Elopement Process, Visitor Process, and Abuse/Neglect Education. Review of audits revealed Visitor process/Leave of Absence Process were reviewed with staff weekly x 4 weeks, then 1 x every 2 weeks, then monthly. Results were reported to QAPI: 8/2/24, 8/05/24, 8/06/24, 8/07/24, 8/08/24, 8/09/24,8/10/24, 8/11/24,8/12/24, 8/13/24, 8/14/24, 8/15/24, 8/16/24, 8/17/24, 8/18/24, 8/21/24, 8/23/24, 8/25/24, and 8/27/24. On 8/28/24 through 8/30/24 interviews were conducted with 5 Registered Nurses, 7 Licensed Practical Nurses, 13 Certified Nursing Assistants, 1 Rehabilitation staff, 2 Receptionists, and 1 Housekeeping staff. All verbalized understanding of the education provided.

Based on interview, and record review, the facility failed to ensure the Admission process was thoroughly completed by accurately evaluating and providing needed supervision to prevent elopement for 1 of 5 residents at risk for elopement, of a total sample of 5 residents, (#1). On 7/31/24 at approximately 7:48 PM, resident #1 left the facility unsupervised without the knowledge of staff. The resident walked along a busy roadway with a speed limit of 40 miles per hour and accepted a ride with strangers to get to her home. The facility staff were not aware of resident #1's whereabouts for approximately one hour and twenty minutes. Due to her cognitive deficits, and diagnosis of dementia, the elopement placed her at risk of falling, being severely injured, abducted, or hit by a motor vehicle. The driving distance from the facility to resident #1's home was 2.7 to 3.0 miles away from the facility depending on the route taken, (retrieved on 9/16/24 from www.googlemaps.com). The temperature in Palm Bay on 7/31/24 at 7:53 PM, was 85 degrees Fahrenheit (F), and at 8:53 PM it was 84 F, (retrieved on 9/10/24 from www.wunderground.com). The facility's failure to provide adequate supervision and a secure environment contributed to resident #1's elopement and threatened all residents who were at risk for elopement. This failure resulted in Immediate Jeopardy which started on 7/31/24 and was removed on 8/02/24. The noncompliance at F600 and F689 was determined to be past noncompliance. Findings: Cross reference F600 Resident #1, an [AGE] year-old female directly admitted from home to the facility on [DATE] at approximately 1:00 PM. Her diagnoses included dementia, unspecified severity/other behavioral disturbance, diabetes mellitus type II, generalized anxiety disorder, major depressive disorder, and chronic systolic (congestive) heart failure. Review of the Medical Certification For Medicaid Long-Term Care Services And Patient Transfer Form (3008) dated 3/11/24 revealed the resident's primary diagnoses were dementia, anxiety, and depression. The document revealed the resident ambulated independently, and was alert, oriented, and followed instructions. Review of the Summary notes of the resident's visit on 6/26/24 to her community Primary Care Physician, revealed the resident had dementia with behavioral disturbances and the document read, She has some agitation she is forgetting words and she started to wander around. Review of the Admit/Readmit Screener with effective date of 7/31/24 at 1 PM, revealed resident #1 arrived at the facility ambulatory from home, with an admitting diagnosis of dementia, and anxiety. The document indicated the resident was oriented to person, place, time and situation, walked frequently, and had no limitation with mobility. The Elopement Risk assessment indicated the resident was ambulatory, but contrary to the information in the Primary Care Physician's Summary notes of 6/26/24, none of the elopement risk factors were selected, and Not at risk for elopement was checked. On 8/28/24 at 12:08 PM, an interview was conducted with resident #1 with translation provided by Receptionist F. The resident was sitting on the side of her bed finishing her lunch. When asked what happened when she left the faciity on [DATE], the resident said she wanted to go back to see her granddaughter. She explained she got anxious so she got up and left the facility. Resident #1 explained a visitor was going out of the facility, and she followed the visitor out. She said she went out of the facility, turned right, walked up the street for about five to ten minutes until a couple gave her a ride. She stated she gave the Latino couple who picked her up from the side of the road her address, and confirmed she did not know the couple previously. She recalled the incident happened in the evening, and said it was, not that dark, but it was hot, and she was sweating. The Interview Statement from resident #1 dated 8/01/24 conducted by the Director of Nursing (DON), revealed the resident said she ate dinner, went to the bathroom, and then wanted to go home. The resident stated she used her walker and started to walk down the street, a young couple picked her up, and she gave them her address. The resident could not recall where the couple picked her up, and she reported that when she got home, she sat for a little bit, then her granddaughter brought her back to the facility. On 8/28/24 at 1:14 PM, Certified Nursing Assistant (CNA) B confirmed she was resident #1's assigned CNA on 7/31/24. CNA B recalled when she came on for the 2:00 PM to 10:00 PM shift, the off going CNA reported she had a new resident. The CNA recalled she went into the resident's room and introduced herself to the resident. She stated she tried to talk with the resident, but communication was hard, she served her dinner, checked on her sporadically, and walked with her to the bathroom. CNA B recalled when she returned to the unit from her lunch break, resident #1 and her roommate who also spoke Spanish were having some disagreement regarding whether to close or open the room door. The CNA verbalized she went to give another resident a bath, and heard the code for elopement paged for the room resident #1 was in. She recalled she went into the room, and noted resident #1's bed was made up as if it was never laid on, and everything was gone. CNA B stated staff were given specific areas to search, and she left in her car along with another CNA to conduct a search. She verbalized that when she came back to the facility, she saw the resident walking through the facility's parking lot, with some keys in her hand. CNA B said when she asked the resident where she went, the resident started laughing, and she took her inside. The CNA recalled the resident's son and granddaughter were in the building, and they explained the resident caught a ride home with strangers. On 8/28/24 at 4:06 PM, the incident was reviewed with the Administrator, the DON, and the Regional Nurse Consultant (RNC). The Administrator gave a timeline of the incident based on the facility's investigation. He said resident #1 was a direct admit to the facility on [DATE] at 1:00 PM, brought from home accompanied by her granddaughter, and son-in law. The Administrator said reports from the family were they had no concerns regarding wandering, or elopement risk, and the family described the resident as, low maintenance, not needing much care, was independent in activities of daily living, and they were looking for Long-term Care placement. At 1:30 PM, CNA C introduced herself to the resident, and no concerns were voiced. At 1:45 PM, the admission evaluation was completed with assistance from the family members present. During the 2:00 PM shift to shift rounding by CNAs, the resident was observed sitting on her bed. The resident had dinner at approximately 5:00 PM, and Registered Nurse (RN) A was in the room administering medications to the resident's roommate. At 6:00 PM, RN A observed the resident sitting on her bed, she was calm, and no concerns were identified. Walking rounds were completed by off going and on-coming nurses at 7:00 PM, and the resident was again observed in her room at that time. At 7:30 PM, Licensed Practical Nurse (LPN) E introduced herself to the resident who was ambulating around her room. At 7:45 PM, the LPN/ Evening Supervisor was alerted by a resident that people were in the lobby waiting to be let out. At 7: 48 PM, the Evening Supervisor entered the lobby, and observed another resident's wife, and a woman (resident #1) standing in the lobby. After asking if the visitor was there to visit her husband, the evening Supervisor entered the door code, and both the visitor, and the woman (resident #1) exited the facility. The Administrator stated the facility had cameras in the lobby and courtyards, and in review of the camera footage, resident #1 was observed on camera to exit the facility and turn to the right until she was out of range of the camera. At 8:40 PM, LPN E noticed the resident was not in her room, and when asked, the roommate said she had left the room. LPN E did not locate the resident, and she notified the Evening Supervisor, who called the elopement code, and a search was initiated. The Administrator recalled he was notified by the Evening Supervisor at 8:55 PM, and at approximately 9:07 PM, the resident returned to the facility accompanied by her granddaughter and son-in law. The Administrator stated he arrived in the facility shortly after the resident returned with her family. He shared that in an interview with the resident's family members, they reported having a general telephone conversation with the resident at approximately 5:00 PM, and there was no mention of her wanting to leave the facility. He recalled the resident's granddaughter said she went into the living room, and the resident was sitting on the couch watching television. When she asked the resident what she was doing there, the resident said she wanted to come home, and a nice Spanish couple bought her home. The granddaughter did not see who dropped the resident off but verified the time resident #1 arrived home via a ring doorbell camera was 8:30 PM. On 8/28/24 at 5:11 PM, the LPN /Evening Supervisor recalled that on 7/31/24 the facility had three admissions. She stated she was entering admission orders in the Electronic Medical Record (EMR), and a resident was yelling out that people were at the front door and needed to leave. The Supervisor stated she went to the door, and two older women were standing there, both holding belongings in their arms. She said she was familiar with one of the women and assumed the other woman (resident #1) was assisting her to take stuff to her car. She recalled she entered the door code and walked with them out of the facility while conversing with the familiar person. When asked if the women had visitor badges on, the Supervisor said she could not recall, but stated she had seen the familiar visitor several times before, accompanied by different people. The Evening Supervisor could not recall how long after the women exited the facility that resident #1's assigned nurse came and said they could not find resident #1. She called a code silver for elopement and initiated a search. The Evening Supervisor said when they could not locate the resident after the second search, she called the Administrator to notify him of what was going on. She recalled the resident's family then came to the facility and said the resident had come home, and she had a set of keys to the house, so she opened the door and let herself in. On 8/28/24 at 5:46 PM, in a telephone interview RN A confirmed she worked on the 7:00 AM to 7:00 PM shift and was resident #1's assigned nurse on 7/31/24. She verified she completed the admission process for resident #1. RN A recalled the resident was awake and alert, and the resident's family members helped the resident to understand the admission paperwork she signed. The RN recalled the family said the resident was, low maintenance and would settle into the facility well. She said she, did not dig any deeper, as she did not think there would be any elopement risk when the family indicated the resident was, low maintenance. RN A stated she did not actually ask the family about any prior elopement risk/ wandering by the resident and recalled when she returned to work the following day, she was made aware of the resident's elopement. The RN said she heard after the elopement, that information in the resident's history and physical indicated she had a previous, wandering situation. She said she should have asked more probing questions when she was told the resident was low maintenance. She verbalized the resident responded appropriately, and so she thought she was okay. On 8/29/24 at 1:35 PM, in a telephone interview with resident #1's granddaughter, she recalled she was at home when the resident was dropped off, but did not see the persons who gave her a ride. She recalled she was told by the facility her grandmother was talking to another resident's family member, exited the building, and started walking down the road, when a random person picked her up and took her home. She stated her neighbor has a door camera, and gave her a copy of the footage, and she did not recognize/know any of the persons in the car. The granddaughter said she was not happy about the elopement, and when she returned the resident to the facility, she said to them, You have cameras, how could you let a resident who has dementia out? She stated the Administrator said they reviewed the camera footage, which showed her grandmother had all her stuff with her, and a nurse put in the code to the door and let her out. The granddaughter said she felt, Bad, scared, and was stressed out. She verbalized she was scared for her grandmother's health. Resident #1's granddaughter stated that before her admission to the facility, the resident had wandered away from home multiple times, had walked in the main road, and neighbors and others that knew her would call and let her know she had wandered out of the house again. She explained she lived about seven to eight minutes away from the facility, and shared when resident #1 came home that night, she was, sweaty, frantic, and was, under the impression that the granddaughter had left her at the facility to get checked out by the doctor, then return home. The granddaughter said the resident got frustrated, and said no one came in to see her, so she left the facility. She stated the resident had issues with balance, had vertigo, and dizziness, and had previously fallen a number of times. She said it was dark at the time the resident came home, and she was thankful her grandmother arrived home safely. On 8/30/24 at 7:50 AM, in a telephone interview LPN E recalled she worked on 7/31/24 on the 7:00 PM to 7:00 AM shift and was resident # 1's assigned nurse. She stated she received shift report from the resident's off going nurse RN A, who reported the resident was, a bit confused. LPN E stated they did the narcotic count, did a walk around to put faces to names, and she introduced herself to resident #1. The LPN stated the resident seemed put together and she noted no agitation, or behaviors. She recalled she went to do medication administration on the opposite hall, which took approximately twenty to thirty minutes. She recalled when she started medication administration on the hall the resident was on, she went in to give the resident's roommate her medications, and did not see resident #1, her bed was made, and she did not see a purse/bag. LPN E said she started looking around, she looked in the hallways since resident #1 could ambulate, and when she did not locate the resident, she notified the Evening Supervisor, and the code green for elopement was called. LPN E stated the Evening Supervisor assigned staff to search different areas, and approximately one hour after the search was started, the resident came back to the facility with her family. The LPN said that during the time she observed the resident, she did not notice any signs/symptoms of agitation/exit seeking behaviors. She stated the resident spoke English as well as Spanish, and had instructed the resident to call if she needed anything. She explained that an elopement risk assessment would be done by the admitting nurse. The resident's baseline care plan with admitted [DATE], signed by the resident, and RN A dated 7/31/24 did not select at risk for elopement/exit seeking as a, Potential Concern. An Elopement Risk Evaluation dated 7/31/24 at 11:29 PM, after the incident, revealed a score of 1.0 indicating the resident was now assessed as At Risk for Elopement. Review of a Brief Interview for Mental Status assessment dated [DATE] revealed the resident's cognition was severely impaired with a score of 06 out of 15. Although there was no baseline care plan for elopement risk, a care plan for risk for elopement related to history of wandering, unauthorized leave of absence, newly admitted to nursing facility, accustomed to living at home, independently ambulatory with assisted device, impaired safety awareness was initiated on 8/01/24 after the incident, with revision on 8/07/24. Interventions included, observe resident for, tailgating when visitors are in the building. The facility's policy, Elopements and Wandering Residents implemented on 11/2020 and reviewed/revised on 3/16/2023 read, The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk . Residents will be assessed for risk of elopement and unsafe wandering upon admission. The policy Admission of a Resident implemented on 11/03/20, and revised on 11/16/23 read, The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care .Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: *On 7/31/24 at approximately 9:07 PM, resident #1 was returned to the facility from home, accompanied by her granddaughter. *Resident #1 was placed on one-on-one supervision and re-evaluated for elopement risk. Nurse evaluation of the resident was completed with no signs of injury or distress. *On 7/31/24, education was initiated related to elopement standards and guidelines, Abuse and Neglect. Post-tests were completed to validate competency. *From 7/31/24 to 8/03/24, licensed nurses were educated on elopement standards and guidelines to include how to accurately conduct an elopement risk evaluation and implementation of appropriate immediate interventions to prevent the risk for elopement. * On 8/01/24, 22 out of 33 licensed nurses completed the education. * On 8/02/24, 5 out of 33 licensed nurses completed the education. *On 8/03/24, 6 out of 33 licensed nurses completed the education. * As of 8/03/24, 100 % of licensed nurses completed the education. *Newly hired licensed nurses will receive education on elopement standards and guidelines to include how to accurately conduct an elopement risk evaluation and implementation of appropriate immediate interventions to prevent the risk for elopement during orientation and prior to working on an assignment. *On 8/01/24, current residents were re-evaluated for elopement risk to ensure assessments were current and accurate. No additional residents were newly identified at risk for elopement. Care plans for current residents at Risk for Elopement were reviewed to validate appropriate interventions were in place related to Elopement Risk. *On 8/01/24, Elopement Risk Binders were reviewed to ensure they contained photos and demographic information of residents evaluated to be at risk for elopement. *On 8/01/24, the facility created and implemented a Community Admission Worksheet to include review for behaviors and history of wandering/elopement risk. Visual meet and great to occur with perspective admissions from the community. The Administrator educated admission team on the new process. *From 8/01/24 to 8/07/24, Elopement drills were conducted on every shift. Drills continued weekly. As of 8/16/24, 25 Elopement drills had been conducted. * On 8/01/24, an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed with the Medical Director, Administrator, Director of Nursing and additional IDT (Interdisciplinary Team) members related to Elopement. The Performance Improvement Plan (PIP) was accepted by the committee. Root Cause Analysis (RCA) completed. *On 8/02/24, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on elopement. No additional recommendations were made at that time. *On 8/02/24, an additional review was completed by the IDT on current residents at risk for elopement. Hourly safety checks were initiated for residents at risk for elopement. Care plans were reviewed/updated. *Additional QAPI meetings were held on 8/06/24, 8/13/24, and 8/16/24, to review the PIP progress related to the elopement. No concerns were identified during the ongoing quality reviews. *Ongoing Quality Reviews: DON/designee to review new admissions/re-admissions and residents with significant change in condition for Elopement Risk Status twice weekly x 4 weeks, then weekly x 1 month, then monthly to ensure elopement risk evaluation is current and accurate for residents identified at risk, the resident's care plan reflects the risk with appropriate/person-centered interventions. Reviews were completed on 8/06/24, 8/09/24, 8/13/24, and 8/16/24 with 100% compliance. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Evaluating Resident for Elopement Risk, safety checks, and Abuse and Neglect. Review of the audit titled, Resident Elopement Risk, revealed a Quality Indicator was to identify if the elopement risk evaluation was current and accurate for residents reviewed. Audits were conducted and reviewed and modified by the facility's QAPI committee based on findings. On 8/28/24 through 8/30/24, interviews were conducted with 5 Registered Nurses, 7 Licensed Practical Nurses, 13 Certified Nursing Assistants, 1 Rehabilitation staff, 2 Receptionist, and 1 Housekeeping staff. All verbalized understanding of the education provided.

Based on interview and record review, the facility failed to provide care and services to promote healing of pressure ulcers for 2 of 4 residents reviewed for pressure ulcers of a total sample of 13 residents, (#1 and #5). Findings: 1. Review of resident #1's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including osteomyelitis of the left ankle and foot, Methicillin Resistant Staphylococcus Aureus (MRSA), type 2 diabetes, and stroke. MRSA is an infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat ordinary staph infections. (Retrieved from www.mayoclinic.org on 6/30/23). Review of resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The assessment showed resident #1 had a Stage 3 pressure ulcer. A stage 3 pressure injury is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible. (Retrieved on 6/30/23 from www.npuap.org). Review of resident #1's medical record revealed a care plan for actual skin breakdown related to a Stage 3 pressure ulcer on the left ankle initiated on 3/21/23. Interventions included performing Wound care as ordered, see current treatment record and physician's orders; monitor effectiveness of / response to treatment as ordered. Review of resident #1's physician orders revealed the following wound care orders: *From 3/28/23 to 4/11/23 Left ankle - Cleanse site with NS (normal saline), pat dry apply collagen powder to wound bed followed by honey fiber and cover with border foam dressing. Every day shift. *From 4/12/23 to 4/24/23 Left ankle - Cleanse with NS, pat dry apply Medi honey to wound bed followed by collagen powder and calcium alginate then cover with border foam dressing daily every day shift. *From 4/25/23 to 5/23/23 Left ankle - Cleanse with NS, pat dry apply Medi honey to wound bed followed calcium alginate then cover with border foam dressing daily every day shift. Review of a SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 5/16/23 revealed resident #1 had a change in condition related to ESBL (Extended-spectrum beta-lactamases) infection to the left ankle wound. Review of a Hospital Transfer Form revealed resident #1 was transferred to an acute hospital on 5/16/23. ESBLs are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics. (Retrieved from www.webmd.com on 6/30/23). Review of the Treatment Administration Record (TAR) for April 2023 showed wound care to the left ankle was not performed on 4/5, 4/10, 4/11, 4/21, 4/24, 4/26, 4/27 and 4/29. The TAR for May 2023 showed wound care not performed on 5/9, 5/10, and 5/11. There was no documentation in resident #1's medical record explaining why wound care was not performed on those 11 days. Review of resident #1's Weekly Pressure Wound Evaluation form dated 5/08/23 described the wound on the left ankle as worsening. 2. Review of resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses including osteomyelitis of the right ankle and foot, quadriplegia, and failure to thrive. Review of resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 which indicated intact cognition. The assessment showed resident #5 had one Stage 2 and one Stage 3 pressure ulcers. A stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. (Retrieved on 6/30/23 from www.npuap.org). Review of resident #5's medical record revealed a care plan for actual skin breakdown related to one Stage 3 pressure ulcer of the right heel and one Stage 2 pressure ulcer of the coccyx revised on 6/07/23. Interventions included to perform Wound care as ordered, see current treatment record and physician's orders; monitor effectiveness of / response to treatment as ordered. Review of resident #1's physician orders revealed the following wound care orders: *Coccyx - Cleanse with wound cleanser, pat dry apply zinc oxide paste and leave open to air every day shift dated 5/23/23. *Right heel - Cleanse with wound cleanser, pat dry apply honey fiber to wound bed secure with border foam daily every day shift dated 6/08/23. Review of the TAR for June 2023 showed wound care was not performed on the right heel on 6/14 and on the coccyx on 6/8, 6/9 and 6/14. There was no documentation in resident #5's medical record explaining why wound care was not performed those days. On 6/19/23 at 5:00 PM, Licensed Practical Nurse (LPN) A stated she was the wound care nurse and she performed wound care for residents with all wounds except skin tears. She indicated her responsibilities included rounding with the wound care physician weekly, identifying newly admitted residents with wounds, and entering and implementing new wound care orders. Later at 6:52 PM, LPN A explained she misunderstood whose responsibility was to document the wound care performed. She stated there were days she did not document the wound care she performed as she thought it would be done by the nurse assigned to the resident. On 6/19/23 at 6:49 PM, the Director of Nursing (DON) stated she was made aware wound care was not always documented when a nurse brought it to her attention during a Standards of Care meeting a few weeks ago. She explained the nurse asked if she was supposed to sign off for wound care performed by the wound care nurse. The DON indicated she educated LPN A and the nurses whoever performed the wound care signed it as done on the TAR. There was no evidence of the education provided. The DON acknowledged there was no evidence in residents #1 and #5's medical records showing the wound care was performed or residents refused the treatments on the above noted days. She stated nurses were expected to document the wound care performed and follow the physician's orders. The facility's Wound Treatment Management policy and procedure revised on 11/23/22 read, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The form revealed guidelines for the nurses to follow which included, The facility will follow specific physician orders for providing wound care. Treatments will be documented on the Treatment Administration Record or in the electronic health record. The facility assessment dated [DATE] read, Staff are trained on policies and procedures, consistent with their roles.

Based on interview and record review, the facility failed to provide necessary care and services as indicated in the plan of care to prevent an avoidable fall for 1 of 4 residents reviewed for mechanical lift transfers, of a total sample of 7 residents, (#1). The facility's failure to implement care plan interventions based on clinical assessment findings and accepted standards of practice resulted in actual harm, a fall with fracture. Findings: Resident #1, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included stroke with left side weakness and paralysis, generalized muscle weakness, lack of coordination, pain in the left ankle and joints of the left foot, abnormal posture, severe [CONDITION(S)], and generalized anxiety disorder. Review of resident #1's medical record revealed a care plan was initiated on 10/26/21 for risk for falls and fall related injury related to history of a stroke with left side weakness. The goal was the resident would not sustain a serious fall related injury. Fall prevention interventions directed Certified Nursing Assistants (CNAs) and licensed nurses to follow the facility's fall protocol. In addition, the care plan instructed CNAs, Physical Therapy (PT) staff and Occupational Therapy (OT) staff to educate the resident on measures to reduce her risk for falls. A care plan for decreased ability to perform activities of daily living was initiated on 2/02/22. The interventions indicated resident #1 required assistance from one staff member for bed mobility, and assistance from two staff members for transfers with a mechanical lift. The CNA care plan or Kardex Report revealed instructions for CNAs to complete Restorative Nursing Program (RNP) tasks as written and reflected the nursing care plan intervention that specified assistance from two staff to transfer resident #1 with a mechanical lift. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 1/28/22 revealed resident #1 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The document showed the resident did not exhibit behavioral symptoms nor reject care and services necessary to achieve her goals for health and well-being. The MDS assessment revealed resident #1 required extensive assistance of one person for transfers which conflicted with the plan of care. The document showed resident #1 had unsteady balance, was only able to stabilize herself with staff assistance, and had functional limitation in range of motion with impairment of upper and lower extremities on one side. She was 5 feet and 5 inches tall, weighed 275 pounds, and used a wheelchair for mobility. The MDS assessment inaccurately indicated resident #1 did not receive RNP services in the lookback period although it was noted in Therapy Department discharge recommendations completed on 12/27/21 by PT and 12/30/21 by OT. Signatures of RNP staff on 12/28/21 and 1/12/22 confirmed the RNP plan of care was active during the MDS lookback period. An Incident Note dated 3/29/22 at 10:30 AM read, CNAs called this nurse to resident room. Resident observed kneeling on floor. Licensed Practical Nurse (LPN) D noted resident #1 was assisted back to bed, then she notified the physician, Director of Nursing (DON) and the resident's family. A change in condition progress note dated 3/29/22 at 10:30 AM indicated resident #1 fell , reported pain and her physician ordered an x-ray. A Radiology Results Report dated 3/29/22 revealed resident #1 had an x-ray to evaluate her left knee pain. The document noted the resident sustained a displaced fracture of the distal shaft of the femur and had mild arthritis. On 3/31/22 at 3:20 PM, the DON discussed resident #1's fall and findings of the facility's incident investigation. She explained resident #1 required a mechanical lift for transfers but two CNAs attempted to do a manual stand and pivot transfer instead. The DON stated CNAs B and C informed her resident #1 told them she did not want to be transferred with the mechanical lift and requested a manual transfer. She stated during the investigation, Physical Therapy Assistant (PTA) A recalled CNAs B and C asked him to help them transfer resident #1 manually, but he refused and told them she required a mechanical lift. The DON stated the CNAs proceeded to attempt a manual transfer, but the resident's legs buckled, and she landed on the floor on her knee. She stated the CNAs notified the assigned nurse who then assisted them to manually lift resident #1 from the floor and transfer her into bed. The DON recalled she was in the hallway near resident #1's room that morning when the Sea Breeze Unit Manager (UM) came out of the room and exclaimed, Oh my God. You won't believe what they tried to do! The DON stated both CNAs were immediately removed from resident care responsibilities and as they were from a staffing agency, the facility notified the agency the CNAs were under investigation for completing an inappropriate transfer. She explained the CNAs should have reported the resident's refusal to comply with the plan of care to the assigned nurse, the UM, or herself. The DON said, They cannot decide how to transfer a resident on their own. On 3/31/22 at 1:38 PM, in a telephone interview, LPN D stated on 3/29/22 at about 10:30 AM, CNA C told her resident #1 fell and she asked for help to pick the resident up off the floor. LPN D stated when she entered the room, she noted resident #1 was slumped over on her knees on the floor and CNA B stood in front of her. LPN D explained resident #1 complained of knee pain so she assisted the CNAs to return the resident to bed. She said, We grabbed her by the arms and back. Once we got her on the bed edge, we put her legs back in. LPN D acknowledged she did not assess resident #1 for injury or confirm how she was to be transferred before manually returning her to bed. LPN D acknowledged CNAs B and C should have reported resident #1's refusal to use the lift to her. She stated CNAs were not authorized to make changes to the plan of care which was developed to ensure all staff were aware of required interventions. On 3/31/22 at 2:14 PM, the Director of Rehab Services stated resident #1 was last discharged from PT and OT caseload on 12/24/21. He reviewed therapists' documentation and confirmed the resident was discharged to long-term care with RNP services. The Director of Rehab Services stated resident #1 had a stroke and as a result she was flaccid on the left side of her body. He confirmed she required maximum assistance of two persons for transfers which would indicate use of a mechanical lift as a safety measure for staff and the resident. The Director of Rehab Services stated resident #1 was unable to maintain her balance without assistance and described the CNAs' attempt to complete a stand and pivot transfer as totally unsafe. He stated CNAs should follow the plan of care and escalate refusals or concerns to their supervisor. The Director of Rehab Services explained the nursing department could make therapy referrals at any time to address issues with transfers. On 4/01/22 at 10:18 AM, PTA A stated he worked with resident #1 when she was on PT caseload. He recalled she was paralyzed on her left side and could not safely transfer without maximum assistance. He explained it was even difficult for her to sit up on the side of the bed. PTA A stated after discharge from PT, the expectation was nursing staff would use a mechanical lift to transfer her between surfaces. He confirmed on 3/29/22, two CNAs stopped him as he walked in the hallway. PTA A stated they asked him to help transfer resident #1 to her wheelchair as she did not like the mechanical lift. He explained he knew the resident was no longer on therapy caseload, had possibly gained weight, and was probably weaker than before so he informed the CNAs the resident required a mechanical lift , and he left the area. He said, I did not think they would have tried to transfer her without the lift after that. I did not see the need to tell anyone else as I already explained it to them, and they had the [mechanical lift] right there. On 4/01/22 at 10:39 AM, in a telephone interview, CNA B stated on 3/29/22 resident #1 asked to be taken out of bed because it was her birthday. She stated her co-worker, CNA A, was assigned to the resident and asked for help with transferring the resident. She recalled CNA A brought the mechanical lift to the room, but resident #1 refused this method and told them she had bad experiences with this equipment in the past. CNA B confirmed she and CNA A were aware the resident was assessed to require a mechanical lift for transfers, but they complied with the resident's request. She explained, I have always been taught residents have rights. On 4/01/22 at 10:47 AM, in a telephone interview with CNA C, she confirmed she was assigned to resident #1 on the day she fell . She stated although she cared for the resident in the past, she had never transferred her from the bed to the wheelchair. She recalled a previous incident when resident #1 was scheduled for a shower, but she refused to use the mechanical lift that day and was given a bed bath instead. CNA C stated she never reported the resident's concerns regarding use of the lift to anyone. She recalled on 3/29/22, resident #1 asked her and CNA B to transfer her from the bed to the wheelchair using a stand and pivot method. CNA C stated the resident informed them she was weak on one side of her body. She stated they asked PTA A to assist them, but he refused and recommended they use the mechanical lift. CNA C stated she asked PTA A to provide them with a gait belt or transfer belt, which he did before he left. She explained they placed the gait belt around the resident's waist and used it to lift her. CNA C recalled as soon as the resident was in a standing position she said, No, no, no. I can't do it and she went to the floor. On 4/01/22 at 11:16 AM, PTA A was informed CNA C stated he provided her with a gait belt during their conversation regarding transferring resident #1 manually. PTA A verified he provided them with the gait belt but could not explain why he did so if he already instructed them to use the mechanical lift. On 4/01/22 at 4:53 PM, the Administrator confirmed the facility's investigation did not identify PTA A provided CNAs B and C with the gait belt they used to transfer resident #1. She stated on re-interview, PTA A informed her he did not realize the CNAs intended to use the gait belt with resident #1. The DON explained CNAs B and C were knowledgeable of and intended to follow care plan interventions, but the resident refused and requested an alternative transfer method. The DON asked, What about the resident's rights? She was asked to explain her expectations regarding approaches to situations that potentially endangered a resident's safety and well-being. The DON stated although residents had the right to refuse care and services, facility staff could exercise options such as resident education, referrals to other departments, and involvement of the physician, nurse management and/or family to ensure safety. Review of the facility's Fall Prevention Program policy (2021) read, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The document indicated the facility would implement appropriate interventions based on assessments and provide resident education and therapy services referral as indicated. Review of the job description for Certified Nursing Assistant (CNA) dated April 2020 revealed essential duties and responsibilities included transfer residents with appropriate devices and recognize a resident's ability to make choices and support these within the constraints of the care giving environment.

Based on observation, interview and record review, the facility failed to ensure the facility's oxygen concentrator external filters were clean and in safe operating condition for 3 of 6 residents reviewed for respiratory care out of a total sample of 51 residents, (#37, #84, #197). Findings: Review of resident #37's medical record documented he was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)]) and Acute and Chronic Respiratory Failure Review of the physician's orders revealed oxygen at 4 liters (L) per minute via nasal cannula. Review of the 5 day Minimum Data Set (MDS) assessment dated [DATE] documented resident received oxygen therapy. Review of resident #37's plan of care for at risk for cardiovascular complications dated 07/20/20 with intervention to administer oxygen as ordered. Observations conducted on 03/07/22 at 2:43 PM, 03/08/22 at 10:37 AM and on 03/09/22 at 10:21 AM revealed the oxygen concentrator's external filter was covered with gray dust. Review of resident #84's medical record noted she was admitted to the facility on [DATE] with diagnoses including Pneumonia and Acute Respiratory Failure with [CONDITION(S)]. Review of the physician's orders revealed oxygen at 2 L per minute via nasal cannula. Review of the Admission MDS assessment dated [DATE] documented resident received oxygen therapy. Review of the resident's plan of care for at risk for cardiovascular complications dated 01/24/22 with intervention to administer oxygen per physician order. Observations conducted on 03/07/22 at 1:44 PM, 03/08/22 at 10:32 AM, and 03/09/22 at 10:31 AM revealed the oxygen concentrator's external filter was covered with gray dust. Review of resident #197's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Pneumonia, [CONDITION(S)] and Malignant Neoplasm of Bronchus or Lung. Review of the physician's orders documented oxygen at 3 L per minute via nasal cannula. Review of the Admission MDS assessment dated [DATE] documented he received oxygen therapy. Review of resident #197's plan of care for at risk for cardiovascular complications dated 03/01/22 noted intervention to administer oxygen as ordered. Observations conducted on 03/07/22 at 11 AM, 03/08/22 at 11:09 AM, 03/09/22 at 9:45 and 11:02 AM revealed the oxygen concentrator's external filter covered with gray dust. On 03/09/22 at 11:02 AM, the Director of Nursing (DON) stated residents #37's, #84's and #197's oxygen concentrator external filters were soiled with gray dust and needed to be cleaned. She explained she was unsure who was responsible to clean the external filters. It may be maintenance staff or the central supply person. The DON explained the purpose of the external filters was to remove dust and particles from the room air entering the concentrator. The concentrator then delivers clean oxygen to the resident at the liter flow ordered by the physician. She then indicated if the external filter was soiled it would not function properly. 03/09/22 at 11:48 AM, the Central Supply employee stated he was not responsible for cleaning the oxygen concentrator filters. 03/09/22 at 12:40 PM, the Maintenance Director stated he had never been responsible for cleaning the external filters on the oxygen concentrators. Review of the Facility's Oxygen Administration Policy, not dated, read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . 5 . Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters . Review of the .Oxygen Concentrator Instruction Guide, not dated, read, . (page 8) Air Filter, The air filter should be inspected periodically and cleaned as needed by the user or care giver. Replace if torn or damaged. To clean, these steps should be followed: The frequency of inspection and cleaning of filter may be dependent upon environmental conditions like dust and lint. 1. Remove the air filter located on the back of the unit. 2. Wash in a solution of warm water and dishwashing detergent. 3. Rinse thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling .

Based on interview, and record review, the facility failed to provide showers as per resident's preferences and as per shower schedule for 2 of 8 residents reviewed for choices, out of a total sample of 51 residents, (#84 #34). Findings: 1. Review of resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, required extensive assistance with Activities of Daily Living (ADL) and total assistance with bathing. Review of the plan of care documented resident #84 was at risk for decreased ability to perform ADL's with bathing, grooming, personal hygiene and transfers related to [CONDITION(S)] and interventions to transfer resident using mechanical lift with 2 staff members. On 03/07/22 at 1:46 PM, resident #84 stated, I would like to have a shower but they told me I can't take a shower because I can't stand up. On 03/09/22 at 11:25 AM, an interview was conducted with resident #84 and the Director of Nursing. Resident #84 stated that she had never had a shower because the staff told her she could not walk so she could not have a shower. I have only been having bed baths. I would like to get out of bed and have a shower. Review of the 200 Unit Shower Schedule revealed the resident was given showers on Thursday and Friday on the evening shift. On 03/09/22 at 11:13 AM, the 200 Unit Manager (UM) explained when a resident received a shower, the Certified Nursing Assistant (CNA) completed a shower sheet for the nurse to review and sign. She noted the shower sheets were kept in a book. The 200 UM checked the book and stated there were no shower sheets for resident #84. On 03/09/22 at 11:28 AM, the Regional Nurse Consultant stated the resident's bathing preferences were included in the CNA's Kardex. Review of resident #84's CNA Kardex revealed Bathing section ADL - (Prefers: SPECIFY) was not completed. Review of the computerized CNA documentation for bathing from 02/12/22 to 03/09/22 revealed showers were not provided and the resident had not refused any showers. Review of the Facility's Resident Bathing Policy, not dated, read, Policy: Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 2. Partial baths may be given between regular shower schedules as per facility policy. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/21/21 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 09/15. The assessment revealed it was somewhat important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and the resident required extensive assistance for all her Activities of Daily Living (ADL) and had total dependence on staff for bathing. On 3/07/22 at 10:48 AM, resident #34 stated she liked to take showers and could not recall when she last had a shower. On 3/09/22 at 12:09 PM, the Director of Nursing (DON) stated showers were scheduled and listed in the shower book located at the nurses' station on each unit. She stated Certified Nursing Assistant (CNA) documented in the resident(s) electronic medical record (EMR) in the plan of care (POC). A Review of the POC Response History for Task ADL-Bathing from 2/08-3/09/22, showed the resident received showers on 2/11/22, and 2/19/22 which was confirmed by the DON. The resident did not receive her shower on her scheduled shower days on 2/08/22, 2/15/22, 2/22/22, 2/25/22, 3/01/22, 3/04/22, and 3/08/22. On 3/09/22 at 4:23 PM, resident #34 stated she had still not received a shower and again verbalized she could not recall the last time she received a shower. The resident stated she did not refuse her showers, and said she was always ready for a shower. When asked her preference, the resident stated she did not know she could have a preference, as she was never asked. On 3/10/22 at 9:58 AM, the A Wing Unit Manager (UM) stated if a resident refused showers, CNAs would document the refusal in the EMR/POC and on the shower sheet completed for each resident on the resident's shower day. Clinical record review revealed shower sheets could not be identified for resident #34, which was confirmed by the UM. Review of the POC Response History for Task ADL-Bathing was conducted with the UM. She verbalized showers were documented on 2/11/22, and on 2/19/22, and there was no documentation to indicate the resident refused her shower on her scheduled shower days. The UM stated showers should be provided as scheduled, unless refused by the resident. On 3/10/22 at 4:15 PM, Licensed Practical Nurse (LPN) J stated she worked on the 7 PM-7 AM shift and had never heard of the resident refusing showers. On 3/10/22 at 4:32 PM, CNA F stated she worked on the 2 PM-10 PM shift, and resident #34 was on her assignment. CNA F stated the resident was scheduled for showers in the afternoon, and she was not sure if she worked with the resident on her scheduled shower days. CNA F stated when she provided a shower, she would document on the shower sheet at the nurses' station. She verbalized the resident never refused care, and if she had refused, the refusal would be documented, and the resident's nurse made aware. CNA F could not say why the resident did not receive showers on her scheduled shower days. An intervention on the resident care plan At risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene related to [CONDITION(S)], initiated on 1/12/22, with revision on 3/08/22 read, Arrange resident/patient environment as much as possible to facilitate ADL performance.

Based on record review and interview, the facility failed to ensure prompt investigation and timely resolution of concerns for 1 of 1 resident reviewed for grievances, out of a total sample of 51 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/10/22 at 11:15 AM, resident #1 stated during her stay in the facility, a suitcase which contained her birth certificate, passport and resident alien identification card had been lost when she was moved to another room. She explained the facility replaced the suitcase in December 2021, over a year after it was lost. She stated none of the contents of the suitcase were replaced. Resident #1 stated facility staff made several excuses. She said, They say they are waiting for corporate and waiting for the State. I don't know who corporate is. The resident stated she completed a grievance form in 2020 with assistance from the previous Social Services Director (SSD). She recalled the missing items listed included a resident alien identification card, a passport, her birth certificate, and a gift card. Resident #1 explained the total cost for replacing these items was approximately $700. She said, I grieved for weeks. I don't know how they threw away everything. I couldn't sleep. The resident confirmed she spoke to the facility's Administrator, SSD and the Key West Unit Manager (UM) regarding the missing items. On 3/09/21 at 1:35 PM, the SSD stated her responsibilities included providing support for residents and addressing their grievances or concerns. She described the facility's grievance process as very quick since resolution was usually achieved within 72 hours. She confirmed resident #1 had a room change in 2020 and reported her suitcase and its contents as missing soon after. The SSD stated the facility replaced the suitcase on 12/31/21. The SSD said, During COVID (Coronavirus Disease) outbreak, the facility threw out personal belongings, birth certificates, passport and the previous Social Service Director was reaching out to [the resident's country of birth]. She confirmed the original grievance form was submitted in 2020 and it included the missing passport and birth certificate. The SSD explained a passport could not be replaced without two forms of identification, and the resident could not get the required types of identification without a birth certificate. The SSD said, It's a circle. She acknowledged the facility's grievance log did not list the concern as closed or resolved. In addition, she explained the facility no longer had a copy of the original grievance documentation from 2020. The SSD stated a recent care plan meeting held in February 2022 was attended by resident #1 and her son. She validated the concerns related to the lost passport and birth certificate were discussed and the resident again requested assistance with replacing the valuable documents. The SSD stated she told resident #1 and her son she would assist them, but acknowledged she had no documentation of re-opening a grievance nor any follow up actions she accomplished in the four weeks that had passed since the care plan meeting. She said, I should have done a grievance then. The SSD confirmed she was aware of the long outstanding issue from 2020 through previous conversations with the Administrator. The SSD was asked to provide copies of social service notes and communications with outside entities regarding replacement of the resident's birth certificate and passport but was unable to do so. On 3/09/22 at 3:30 PM, the Director of Nursing (DON) stated the facility's Administrator was ultimately responsible for oversight of the grievance process. She explained the concerns were usually handled by the appropriate department and closed when resolved. She confirmed if a grievance was not resolved within the required period, the facility was required to explore additional options and utilize other resources to ensure satisfactory resolution. On 3/09/22 at 6:18 PM, the Administrator stated she did not have any record of resident #1's grievance that was submitted in 2020. She stated the resident spoke to her about a missing suitcase which was replaced. The Administrator recalled the previous SSD worked on other missing items for this resident but repeated that she did not have any written records to show details. On 3/10/22 at 11:07 AM, the Key West UM confirmed resident #1's suitcase with her passport and birth certificate were misplaced about one year ago. She said, I am sure Social Services was working on it. I am not aware of any resolution. On 3/10/22 at 11:42 AM, the Administrator stated the facility attempted to achieve resolution of all grievances within three to five days if possible. She explained the facility's SSD was the Grievance Officer, and she was responsible for making sure all grievances had appropriate follow-up and were designated as completed when resolved. The Administrator confirmed the previous SSD was aware of the resident's missing birth certificate and passport, but the facility could not find any documentation related to how the original grievance was addressed. A review of the Resident and Family Grievances policy dated 2021 noted, d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance and those actions, on the grievance form. e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS) Assessments within the required timeframe for 2 of 8 residents reviewed for MDS Assessments, of a total sample of 51 residents (#52 and #78). Findings: 1. Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/17/22 the resident was transferred from the facility to the hospital and returned to the facility on [DATE]. Review of the MDS Discharge Return Anticipated assessment dated [DATE] and Entry assessment dated [DATE], revealed both assessments were marked still in progress. On 3/11/22 at 1:33 PM, MDS Coordinator D stated the MDS assessments should be completed within 14 days. She confirmed the Discharge Return Anticipated dated 2/17/22 should have been completed by 3/03/22 and the Entry assessment dated [DATE] should have been completed by 3/07/22. She said she had other job duties and did not always have time to complete the assessments. On 3/11/22 at 1:58 PM, the Director of Nursing (DON) explained the facility was aware assessments were late and they were trying to allocate more hours to the part time MDS position. 2. Resident #78 was admitted on [DATE] and readmitted on [DATE]. Clinical record review, revealed the MDS assessments, Discharge Return Anticipated with Assessment Reference Date (ARD) of 2/15/22 and the Entry MDS with ARD of 2/23/22 was listed as in progress. On 3/11/22 at 1:33 PM, MDS Coordinator D stated they had 14 days from the ARD to complete assessments. A review of resident #78' s MDS assessments were conducted with the MDS Coordinator. She acknowledged the Discharge Return Anticipated with ARD 2/15/22, and the Entry MDS with ARD 2/23/22 were all in progress. MDS Coordinator D explained the MDS with ARD 2/15/22 should have been completed by 3/01/22, and the one with ARD of 2/23/22 should have been completed by 3/02/22. MDS Coordinator D reported she took over managed care and must send updates to the managed care companies. She verbalized she was in meetings half of the days, and MDS Coordinator E was only at the facility two days per week. MDS Coordinator D indicated there were days she did not get to touch MDS assessments due to other duties. The facility's policy Assessment Frequency/Timeliness read, An entry tracking record will be completed within 7 days of the reentry event.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessments accurately reflected health conditions for 2 of 6 residents of a total sample of 51 residents, (#69, #55). Findings: Resident #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] section O-Special Treatments, Procedures, and Programs reflected the Hospice section response was NO. Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE] section N-Medications indicated the resident did not receive a diuretic medication in the past 7 days. On 3/11/22 at 11:15 AM, MDS Coordinator E stated when completing a resident's MDS assessment, she interviewed the resident, interviewed the nursing staff and reviewed the residents' medical records. She reviewed residents #55 and #69's assessments and acknowledged resident #69 should have been coded for hospice services and resident #55's assessments should have noted the resident received a diuretic medication. She did not explain how the information was missed.

Based on observation, interview, and record review, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #53). Findings: Resident #53 was admitted from the hospital on 8/15/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Medicare End of Part A Stay assessment, with assessment reference date of 1/15/22 revealed resident #53 was totally dependent on two persons for assistance with activities of daily living. Section O of the MDS assessment showed the resident received neither Restorative Nursing Program (RNP) nor active and passive range of motion care and services. The documentation indicated she did not require splints or braces. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated staff could remove the right hand splint for routine skin checks, hygiene, and exercise. Review of Occupational Therapy (OT) Discharge Summary dated 11/11/21 showed a restorative program was established for resident #53, and staff were trained on a Restorative Splint and Brace Program. The document read, Patient to wear palm guard as tolerated/apply rolled washcloth when patient removes the palm guard usually 2-3 hours. Functional Maintenance Program not indicated at this time. A care plan initiated on 4/24/20 and revised on 12/29/21, indicated a focus area related to use of a right hand splint. On 3/07/22 at 11:27 AM, resident #53 was in bed. She was unable to open her tightly contracted right hand and did not have a splinting device or rolled washcloth in place. Additional observations on 3/07/22 at 2:27 PM, 3/08/22 at 11:02 AM and 5:12 PM , and on 3/09/22 at 10:17 AM, revealed the resident still lacked a splinting device or rolled washcloth in her contracted right hand. On 3/09/22 at 10:59 AM, Certified Nursing Assistant (CNA) B stated resident #53 never moved her right hand independently, and it always remained closed. CNA B stated she had been about to place a rolled towel in the resident's palm, but a therapist instructed her not to do it as Restorative CNA A would be applying a splint that had been ordered. During review of the electronic CNA care plan or Kardex, CNA B confirmed there was an instruction regarding placement of a splint to resident #53's right hand. She validated there was no splint in the resident's room and stated she would have applied it if it were available. On 3/09/22 at 11:54 AM, the Key West Unit Manager (UM) stated the RNP staff usually apply and remove residents' splints according to recommendation made by the Therapy department. On 3/09/22 at 12:53 PM, the Rehab Director stated resident #53 was on OT caseload from 10/13/21 to 11/11/21. He reviewed the treating OT staff's documentation and explained on discharge from this service, the OT recommended a palm guard with rolled wash cloth for resident #53's right hand to prevent contracture. The Rehab Director confirmed a palm guard device was not the same as a splint, as noted in the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Rehab Director stated the Therapy department developed the RNP interventions and the Director of Nursing (DON) and UMs were responsible for implementation of the RNP. On 3/09/22 at 1:12 PM, the Key West UM reviewed the list of residents on the unit who were included in the RNP. She validated resident #53 was not included on the list. She stated she obtained RNP recommendations in a written format and sometimes also verbally from the treating therapists, and nurses were responsible for entering orders into the electronic medical record as indicated. On 3/09/22 at 1:31 PM, the OT stated resident #53 was discharged from OT services with a palm guard. She explained the typical discharge process involved providing written RNP instructions to the Rehab Director who would review and sign them off and then follow up with the appropriate UM. On 3/09/22 at 2:14 PM, Restorative CNA A stated Therapy department staff regularly trained Restorative and direct care CNAs on required interventions including splint application. She confirmed resident #53 was to wear a palm guard but she was not listed on the restorative program census for this service. Restorative CNA A said, I think that is where there was the miscommunication. She explained direct care nursing staff would therefore be responsible for application of the palm guard during care, which is a Functional Maintenance Program (FMP). Restorative CNA A explained the resident was seen by RNP staff only for obtaining weekly weight. She explained when a resident was discharged from therapy services, RNP CNAs sign the paperwork with recommendation and then either the DON or UM enter the order into the computer so RNP staff can implement the interventions and complete required documentation. On 3/09/22 at 3:30 PM, the DON stated after residents were discharged from skilled therapy services, the UMs received RNP or FMP recommendations to be implemented by either restorative or assigned nursing staff on the units. She explained the clinical management team reviewed these recommendations and associated orders in daily morning meetings and residents who required RNP or FMP services would be identified at that time. The DON confirmed the Rehab Director was responsible for providing appropriate documentation to the UMs who were expected to follow up and enter orders into the computer system. She stated gentle placement of a rolled towel in the palm of a resident's contracted hand was a basic skill taught to CNAs in school, and should be included on the Kardex if recommended by therapy staff.

Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed as per professional standards of practice for 1 of 1 resident reviewed for infection of a total sample of 51 residents, (#149). Findings: Resident #149 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A PICC line is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart .It is used to give intravenous fluids, blood transfusion .and other drugs. (retrieved from www.cancer.gov Definition of PICC 3/21/22) On 3/07/22 at 4:36 PM, and on 3/08/22 at 4:20 PM, observations showed resident #149 with a PICC line to his right upper arm, with dressing dated 2/27. The resident stated the PICC line was inserted in the hospital, and he received intravenous (IV) antibiotic [MEDICATION(S)] at 9AM, and 9 PM. On 3/08/22 at 4:26 PM, the A Wing Unit Manager (UM) stated PICC line dressing was monitored every shift and changed weekly and PRN. The resident's PICC line dressing was observed with the UM and she confirmed the date on the dressing was 2/27/22. Review of the resident's Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed a signature to indicate the PICC line dressing was changed on 2/25/22, and on 3/04/22. However, the date observed on the PICC line dressing was 2/27/21 which was acknowledged by the UM. On 03/08/22 at 4:35 PM, the Director of Nursing (DON) was made aware of discrepancies with the date on the PICC line dressing, and the dates documented on the MAR/TAR regarding dressing changes. On 03/08/22 at 4:40 PM, Registered Nurse (RN) G stated she did not remember if she changed the PICC line dressing on 3/04/22 as indicated by her signature. RN G said she probably clicked on the dressing change order indicating it was done and did not change the dressing, because something happened and she had to leave. The RN stated and demonstrated a yes/no selection on the TAR for the resident's PICC line dressing change. She verbalized she would select yes, before providing the treatment, and when the treatment was provided, she would then save the response. RN G said she could have been pulled away, or the resident refused his dressing change. When asked the protocol if the resident refused the treatment, the RN stated the refusal would be documented. Review of the resident's progress notes with the RN regarding refusal of dressing /treatment could not be identified. RN D reported she usually dated dressings when completed. On 3/08/22 at 5:00 PM, the DON stated the MAR/TAR should not be signed off until the task was completed. The facility's policy PICC/Midline/CVAD Dressing Change copyright 2021 read, It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing, weekly or if soiled, in a manner to decrease potential; for infection and/or cross-contamination. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to ensure Oxygen (O2) therapy was administered as per physician's order for 1 of 5 residents reviewed for O2 therapy of a total sample of 51 residents, (#143). Findings: Resident #143 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's order on 3/02/22 read, Oxygen at 3 liters/minute (L/M) via nasal cannula (NC) as needed for shortness of breath/for saturations below 92%. On 3/07/22 at 12:07 PM, and 2:39 PM, and on 3/08/22 at 11:37 AM, showed resident #143 lying in bed with his eyes closed. The oxygen concentrator was infusing at 2 L/M. On 3/08/22 at 11:41 AM, Licensed Practical Nurse (LPN) K stated the resident was on oxygen at 2 L/M. The resident's physician's order was reviewed with LPN K and she verbalized the order was for oxygen at 3 L/M. The resident's O2 settings were observed with LPN K and she acknowledged the O2 setting was at 2 L/M. LPN K explained oxygen was considered a medication that was administered by physician's order. She recalled she did not check the resident's O2 setting at the beginning of her shift. She reported the expectation was oxygen settings should be checked daily to ensure the residents received oxygen at the ordered rate. On 3/08/22 at 11:48 AM, the A Wing Unit Manager (UM) said O2 was considered a medication, and staff must have physician's orders for administration. She stated O2 settings were to be checked every shift, to ensure the O2 was on the correct L/M. On 3/09/22 at 10:26 AM, the Director of Nursing (DON) stated O2 was a medication, administered by physician's order, and part of the duty of nurses was to ensure O2 was at the correct flow, and administered as ordered. The facility's policy, Oxygen Administration copyright 2021 read, Oxygen is administered under orders of a physician.

Based on observation, interview and record review, the facility failed to ensure medications were administered within professional guidelines/parameters for 1 of 5 residents reviewed for unnecessary medication (#145) and failed to ensure intravenous antibiotics were administered as per physician order for 2 residents, (#149, #193) of a total sample of 51 residents. Findings: 1. Review of resident #193's medical record documented he was admitted to the facility on [DATE] with diagnoses including Pneumonia, [CONDITION(S)] [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)] Perforation, with Intraabdominal infection, Elevated White Blood Cell Count and Abscess of the Stomach. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 03/03/22 documented the resident ambulated independently, was able to transfer self and was partial weight-bearing. Review of resident #193's plan of care dated 03/07/22 for resident has an active PNA (Pneumonia) infection with intervention to administer medications as ordered. On 03/09/22 at approximately 6 PM, a medication administration observation was conducted with resident #193. Registered Nurse (RN) T stated resident #193 was due for his [MEDICATION(S)] Solution 1 Gram (GM) intravenous (IV) every evening over 30 minutes. She was unable to find the medication in the medication cart so she went to the medication room. She returned with 6 bags of 100 milliliters (ml) of [MEDICATION(S)] 1 GM. The 6 bags were labeled with resident #193's name and [MEDICATION(S)] 1 GM over 30 minutes until 03/11/22, dated 03/09/22 to be refilled 03/10/22. RN T said, The Pharmacy sent the wrong medication. She then asked the facility's Nurse Practitioner (NP) if the [MEDICATION(S)] and [MEDICATION(S)] were the same medication. The NP responded, No they are different medications. At 6:19 PM, an empty IV bag labeled [MEDICATION(S)] 1 GM/100 ml normal saline was observed hanging on an IV pole in resident #193's room. RN T notified the 200 Unit Manager (UM) and at 6:24 PM the 200 UM stated, The pharmacy sent the wrong medication. At 6:49 PM, the 200 UM verbalized there were 2 more IV bags of [MEDICATION(S)] in the medication room and [MEDICATION(S)] is in the medication dispensing machine located in the medication room. On 03/09/22 at 6:55 PM, the Director of Nursing (DON) provided 4 more IV bags of [MEDICATION(S)] 1 GM. On 03/09/22 at 6:59 PM, the Regional Nurse Consultant (RNC) stated the pharmacy had not delivered any [MEDICATION(S)] to the facility and [MEDICATION(S)] may have been removed from the medication dispensing machine. At 7:10 PM the RNC stated, [MEDICATION(S)] had not been removed from the medication dispensing machine. Review of the Pharmacy Delivery Tracking Form for resident #193 dated 03/03/22-03/09/22 revealed [MEDICATION(S)] 1 GM/100ml normal saline had been delivered on 03/05/22 at 8 AM (9 bags), 03/07/22 at 7:43 PM (6 bags) and on 03/09/22 at 6:13 PM (6 bags). No [MEDICATION(S)] had been been delivered to the facility. On 03/09/22 at 7:11 PM, 6 bags of IV [MEDICATION(S)] 1 GM were observed in the 200 Unit medication room. On 03/09/22 at 7:30 PM, during a telephone interview, the Pharmacist in Charge explained that [MEDICATION(S)] was originally ordered from the hospital and the order for [MEDICATION(S)] was transcribed to the pharmacy. He said the pharmacy did a Therapeutic Exchange from [MEDICATION(S)] to [MEDICATION(S)]. The Pharmacist verbalized the therapeutic exchange information was included on the first [MEDICATION(S)] IV medication labels but was not included on the second [MEDICATION(S)] IV medication labels. He did not explain why the second order of [MEDICATION(S)] IV labels did not contain the information for the therapeutic exchange from [MEDICATION(S)] to [MEDICATION(S)]. The Pharmacist explained the two medications were in the same classification of antibiotic medications and resident #193 should have received the [MEDICATION(S)] 1 GM IV every 8 hours. On 03/10/22 at 9:34 AM, the DON and RNC stated, Resident #193 had missed 6 doses of his IV [MEDICATION(S)]. Review of resident #193's physician's orders revealed the following orders: [MEDICATION(S)] Solution Reconstituted 1 gram (GM) intravenously (IV) every 24 hours for intraabdominal infection with start date of 03/05/22 until 03/11/22. [MEDICATION(S)] 1 GM/100 milliliters (ml) Normal Saline 1 GM IV three times a day for intraabdominal infection/Gastrointestinal abscess/[CONDITION(S)] prolification with start date of 03/5/22 until 03/05/22. A second order dated 03/09/22 for [MEDICATION(S)] Solution Reconstituted 1 GM IV in the evening DO NOT SUBSTITUTE relate to Pneumonia until 03/12/22 with start date of 03/07/22 A second order dated 03/05/22 for [MEDICATION(S)] 1 GM/100ml normal saline IV three times a day for intraabdominal infection/gastrointestinal abscess/[CONDITION(S)] prolification until 03/05/22. A third order dated 03/09/22 for [MEDICATION(S)] Solution Reconstituted 1 GM IV every 8 hours for intraabdominal infection related to elevated White Blood Cell count (WBC) until 03/12/22 Review of the resident's Medication Administration Record (MAR) documented [MEDICATION(S)] 1 GM IV every 24 ours with start date of 03/05/22 and discontinue date of 03/04/22. No medication was administered. [MEDICATION(S)] 1 GM/100ml normal saline IV three time a day until 03/05/22 with start date of 03/05/22 was administered on 03/05/22 at 6 AM, 2 PM and 10 PM. On 03/06/22 no IV medication had been administered (3 doses omitted). Ertapenam 1 GM IV in the evening for DO NOT Substitute until 03/12/22 at 11:59 PM. The medication was administered on 03/07/22 at 7 PM, 03/08/22 at 7 PM and on 03/09/22 at 7 PM. The nurses signed they had administered Ertapenam when [MEDICATION(S)] had never been delivered to the facility and no [MEDICATION(S)] had been removed from the medication dispensing machine. A total of 6 doses of [MEDICATION(S)] were omitted. A total of 9 doses of [MEDICATION(S)] were omitted 03/06/22-03/09/22. On 03/11/22 at 1:10 PM, the NP stated she did complete an order to not exchange the [MEDICATION(S)] on 03/07/22. She said she had discussed this with resident #193's physician and he wanted the [MEDICATION(S)] administered once a day. The NP then recalled she had reviewed resident #193 Medication Administration Record (MAR) on 03/07/22 and she was aware that resident #193 had not received any of his ordered IV antibiotic on 03/06/22. She said she reordered the antibiotic again on 03/07/22. The NP did not indicate if she had notified the facility of the omission of resident #193's IV antibiotic medication. On 03/11/22 at 1:45 PM, a review of resident #193's MAR was conducted with the Administrator, RNC and DON. The Administrator, RNC and DON identified that resident #193 had missed a total of 9 doses of ordered IV [MEDICATION(S)]. The Administrator, RNC and DON verbalized the NP had not made them aware of the omission error for resident #193 [MEDICATION(S)] on 03/06/22. 2. Resident #149 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] of vertebra, lumbar region, [CONDITION(S)], hemoptysis, chronic pain syndrome, acute and subacute endocarditis, [CONDITION(S)] ([CONDITION(S)]), and chronic [CONDITION(S)]. Review of the resident's physician orders revealed the following: 3/02/22 [MEDICATION(S)] 1.0 gram (gm) every (Q) 8 hours related to [CONDITION(S)] of vertebra, end date 3/03/21. 3/03/21 [MEDICATION(S)] 1.25 gm two times a day, end date 3/07/21. On 3/07/22 at 4:36 PM, resident #149 stated he received intravenous (IV) antibiotic [MEDICATION(S)] at 9AM, and 9 PM daily, and had not received his 9 AM dose yet. The resident said he was told there was some mix-up with the pharmacy. On 03/08/22 at 4:20 PM, resident #149 verbalized he was previously on [MEDICATION(S)] 1 gm, but was now getting [MEDICATION(S)] 1 gm, and was told the facility was having some problem with the pharmacy regarding the dose. Progress note dated 3/07/22 at 5:15 PM read, Call placed to pharmacy at 0745 regarding dosage of [MEDICATION(S)] available. Per pharmacy medication to be delivered on later run. Per APRN (Advance Practice Registered Nurse) 0900 1.25 gm dose discontinued. New order received for 1700 (5 PM) dose of [MEDICATION(S)] 1 gm IV . Review of the Delivery Tracking obtained from the pharmacy for the resident's [MEDICATION(S)] for the period 2/24/22 to 3/09/22 revealed the following: Twelve doses of [MEDICATION(S)] 1 GM was delivered to the facility on [DATE] at 7:11 AM. Nine doses of [MEDICATION(S)] 1 GM was delivered on 3/02/22 at 11:32 AM, and on 3/02/22 at 5:27 PM three doses of [MEDICATION(S)] 1 GM was delivered to the facility. On 3/03/21 at 6:22 AM four doses of [MEDICATION(S)] 1.25 GM was delivered to the facility. Four additional doses of [MEDICATION(S)] 1.25 GM was delivered to the facility on [DATE] at 7:43 PM. [MEDICATION(S)] 1.25 GM was not available for the resident's 9 AM dose on 3/07/22. The Medication Administration Record (MAR) was compared with the Delivery Tracking and revealed the four doses of [MEDICATION(S)] 1.25 gm should have been administered on 3/03/22 at 9 PM, 3/04/22 9 AM and 9 PM, and the final dose should have been administered on 3/05/22 at 9 AM. Documentation on the MAR indicated [MEDICATION(S)] 1.25 gm was administered on 3/03/22 at 9 PM, 3/04/22 at 9 AM and 9 PM, 3/05/22 at 9 AM, and 9 PM, 3/06/22 at 9 AM and 9 PM. However, only four doses of the [MEDICATION(S)] 1.25 was delivered by the pharmacy. Another delivery of [MEDICATION(S)] 1.25 mg was not delivered until 3/07/22 at 7:43 PM. This was confirmed by the Director of Nursing (DON). 03/09/22 at 10:17 AM, the DON stated she spoke with some of the nurses who administered the [MEDICATION(S)] on 3/05/22 at 9 PM, and on 3/06/22 at 9 AM and 9 PM, and the nurses verbalized to her they administered the correct dose. The DON confirmed the pharmacy delivered four doses of [MEDICATION(S)] 1.25 G on 3/03/22 and could not say where the doses that were administered on 3/05/22 at 9 PM, and 3/06/22 at 9 AM and 9 PM came from. The DON stated protocol if medication was not available, the nurse should call the pharmacy, check the emergency kit, and if not available, notify the physician for adjustment of the order. On 03/09/22 10:38 AM, Registered Nurse (RN) H stated she worked on the 7 AM-3 PM shift on 3/05/22, and 3/06/22, and resident #145 was on 1.25 gm of [MEDICATION(S)] IV. RN H stated two bags of [MEDICATION(S)] 1.25 gm were in the refrigerator on Saturday 3/05/22. She said she checked the dosage prior to administration both days and administered [MEDICATION(S)] 1.25 gm at 9 AM on both days She stated, I cannot speak for the 9 PM dose. On 03/09/22 at 3:49 PM, the DON stated she reviewed the Delivery tracking of the medication from the pharmacy and four doses of [MEDICATION(S)] 1.25 gm were delivered on 3/03/22 at 6:22 AM. She reviewed the physician's order sheet (POS), which showed [MEDICATION(S)] 1.25 gm was ordered for 3/03/22 starting at 9 PM. The MAR showed [MEDICATION(S)] 1.25 gm was administered on 3/03/22 at 9 PM, 3/04/22 at 9 AM, and 9 PM, and the fourth dose was administered on 3/05/22 at 9 AM. She verbalized she spoke to the nurses, and they told her they gave [MEDICATION(S)] 1.25 gm. She said there was a lot of [MEDICATION(S)] 1 gm available in the medication room, and most likely 1 gm was administered instead of 1.25 gm, since the next delivery of [MEDICATION(S)] 1.25 gm was on 3/07/22 at 7:45 PM. The DON stated she could not confirm what dose of [MEDICATION(S)] was administer on 3/05/22 at 9 PM, and on 3/6/22 at 9 AM, and 9 PM. On 3/09/22 at 4:09 PM, the Regional Nurse Consultant (RNC) reported the DON obtained a statement from RN H who worked on 3/05/22, and 3/06/22 and documented administration of the 9 AM doses on those days. The RNC stated the DON was working on getting statements from the other nurses who signed off on the MAR. She said, it appears dosages of [MEDICATION(S)] 1 gm was available, but none of the 1.25 gm, and the DON would be reporting a medication discrepancy. In a telephone interview on 3/10/22 at 10:20 AM, Licensed Practical Nurse (LPN) J verbalized she worked 7 PM-7 AM on 3/05/22, and 3/06/22. LPN J stated she distinctly remembered getting [MEDICATION(S)] 1.25 gm from the refrigerator, two bags were available, and she administered 1.25 gm to the resident on both days. She verbalized she checked her order against the medication, and had it sit out for a while because it was cold. She stated she called the pharmacy and placed an order for the 1.25 gm dosage and reported to LPN K that the resident's dose was not available. She stated LPN K said some was in the medication room, and she told LPN K that it was the wrong dose. When informed that only four doses of [MEDICATION(S)] 1.25 gm was delivered from the pharmacy, LPN J stated she could not speak for other nurses regarding the dosage that was administered. The facility's policy Medication Administration copyright 2021 read, Review MAR to identify medication to be administered. Compare medication source .with MAR to verify resident name, medication name, form, dose, route, and time . 3. Resident #145 was admitted to the facility on [DATE] with diagnoses including, acute [CONDITION(S)] right ankle, [CONDITION(S)], [CONDITION(S)], hypertension, diabetes type II, and bacteremia. On 3/07/22 at 11:26 AM, resident #145 stated he had not received his regular morning medications yet and added his medications were late a number of times. The resident verbalized his medications were nearly two and a half hours late. He explained he had [CONDITION(S)], and if he did not get his medication, [MEDICATION(S)] on time, it caused pain and spasms. On 3/07/22 at 12:24 PM, Licensed Practical Nurse (LPN) K was observed standing at the resident's room pulling medications from her medication cart. On 3/07/22 at 2:13 PM, LPN K stated resident #145 received his 9 AM medications at noon. She said the protocol for medications administered late was to inform management, and to make the physician aware. LPN K stated she called the physician but did not document the communication. Review of the Medication Admin Audit Report for the day shift on 3/07/22 revealed the following: Resident #145 received his scheduled 9 AM medications between 12:21 PM and 12:33 PM including [MEDICATION(S)] 150 milligram (mg) ordered two times daily for chronic pain, [MEDICATION(S)] 10 mg, and [MEDICATION(S)] 12.5 mg ordered daily for high blood pressure, [MEDICATION(S)] 10 mg ordered daily for inflammation, [MEDICATION(S)] 5 mg ordered two times daily for clot prevention, [MEDICATION(S)] 1 mg ordered two times daily for [CONDITION(S)], and [MEDICATION(S)] 30 mg ordered two times daily for anxiety. His scheduled 2 PM antibiotic [MEDICATION(S)] 2 gram ordered every 8 hours for [CONDITION(S)] was administered at 4:16 PM. On 3/10/22 at 11:14 AM, the A Wing Unit Manager (UM) explained staff had one hour before and one hour after the scheduled time to administer medications. The resident's Medication Admin Audit Report was reviewed with the UM. She acknowledged the resident's 9 AM medications were administered outside of the parameters on 3/07/22. The resident's clinical records were also reviewed with the UM. She noted there was no documentation to indicate the physician was made aware of the resident's medications being administered late. On 3/10/22 at 11:27 AM, LPN K stated she was behind on medications on 3/07/22, just as I am today and resident #145 received his medications late. The Medication Admin Audit Report for the resident was reviewed with LPN K. She confirmed she gave the resident's medications outside of parameter of one hour before and one hour after the scheduled time. On 3/10/22 at 11:35 AM, the Director of Nursing (DON) stated nurses had a window of one hour before and one hour after scheduled time to administer medications. She said she expected staff would administer medications timely. The DON said if the nurse was late, she should make management and the physician aware. The Medication Admin Audit Report was reviewed with the DON. She indicated medications were administered outside of parameter on the day shift on 3/07/22. The facility's policy Medication Administration copyright 2021 read Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice.

Based on observation, interview and record review, the facility failed to obtain dental services for 1 of 2 residents reviewed for dental services out of a total sample of 51 residents, (#84). Findings: Review of resident #84's medical record documented she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented she had no cognitive issues, was on a mechanically altered/therapeutic diet and had obvious or likely cavity or broken teeth. Review of resident #84's plan of care noted resident had a dental or oral problem related to broken teeth dated 02/28/22. The goal included the resident to be free of infection, pain or bleeding in the oral cavity through review date of 06/03/22. The intervention included dental referral as needed. On 03/07/22 at 1:32 PM, resident #84 stated she had been missing her front bottom teeth and she told them that she had a tooth that was cracked and it needed to be fixed. They never offered me dental services. Review of the Admission Assessment Oral Evaluation dated 12/09/21 documented resident was edentulous (no natural teeth) and no dentures. On 01/20/22 and on 02/08/22 the Oral Evaluations documented no missing teeth and no dentures. On 03/11/22 at 3:43 PM, the Director of Nursing (DON) stated she had reviewed the three Oral Evaluations and she could not explain the documentation. The DON explained, If you are edentulous it means you have no teeth. The DON then noted she was not sure which documentation for resident #84's oral status was correct. On 03/09/22 at 11:55 AM, the Social Service Director (SSD) said she was responsible for the facility's dental program for residents with dental issues. She noted the process was to refer residents with dental issues to the contracted dental office. She said the dental office had a Medicaid funded program for residents with dental issues. The SSD explained she sends the resident's enrollment form and face sheet to the dental office and the resident is placed on a list to be seen by the dentist. The SSD confirmed resident #84 was on Medicaid, had a care plan for dental issues related to broken teeth, and was on a mechanically altered diet. The SSD checked the list and said the resident was not on the list to be seen by the dentist. Review of the dental list for March 2022 revealed resident #84 had not been placed on the list to be seen by the dentist. On 03/09/22 at 3:56 PM, the SSD explained resident #84 needed to be seen by and I am not sure why she was not put on the list when she was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/09/22 at 4:13 PM, the DON stated the admission care plan dated 2/28/22 documented the resident had dental issues related to broken teeth. She added, The dental process stopped and the facility did not obtain dental services for resident #84's needs. Review of the Facility's Dental Services Policy, not dated, read, Policy: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Definitions: Routine dental services means an annual inspection of the oral cavity for signs of disease . dental cleaning, fillings . Emergency dental services includes services needed to treat . broken or otherwise damaged teeth . that required immediate attention by a dentist . Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment process, and are addressed in each resident's plan of care . 2. Residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan . a. The facility will assist residents who are eligible and wish to participate to apply for reimbursement for dental services . 3. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at nominal cost.

Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 8 residents, (#1). This failure contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, become lost or been hit by a car. On 7/02/21 at approximately 5:55 PM, the facility failed to prevent resident #1 from exiting the facility through the front lobby door. Resident #1 stood by the unattended reception desk and a staff member unlocked the door for him at the request of another resident, without verifying his identity. He walked towards the facility's driveway and a heavily trafficked 4-lane road. The facility was unaware of resident #1's whereabouts until a staff member who was in the parking lot observed him walking away from the facility. There was a total of 27 residents who were identified at risk for elopement. The facility's failure to ensure a safe and secure environment placed all residents who wandered at risk. This failure resulted in Substandard Quality of Care and Immediate Jeopardy starting on 7/02/21. The Immediate Jeopardy was removed on 7/04/21. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: Resident #1 was admitted to the facility from the hospital on 6/10/21 with diagnoses including [CONDITION(S)] (COPD) with acute exacerbation, generalized muscle weakness, abnormal posture, lack of coordination, heart disease, [CONDITION(S)], and anxiety disorder. Review of a hospital psychiatry note dated 6/03/21 revealed resident #1 was not able to manage his healthcare decisions or provide adequate self-care and did not understand risks versus benefits and alternatives to treatment. The psychiatrist's mental status examination revealed resident #1 was oriented to person and place, had impaired recent and remote memory, an impaired fund of knowledge, apprehensive mood, confused thought processes, and poor insight and judgement. The note indicated resident #1 had diagnoses of [CONDITION(S)] and neurocognitive disorder with behavioral disturbance. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 6/10/21 revealed resident #1 was alert, oriented, and followed simple instructions but was forgetful. He required a surrogate for decision-making. The form indicated resident #1 walked independently and was at risk for falls. Review of resident #1's medical record revealed a Skilled Evaluation dated 6/10/21. Nursing documentation indicated he had difficulty breathing, wheezing throughout all lung fields and a dry cough. Resident #1 required continuous supplemental oxygen at 3 liters/minute via nasal cannula for shortness of breath on exertion. The nursing evaluation indicated he had an unsteady gait, poor balance, and a history of falls. Resident #1 was noted to be alert and oriented with . episodic periods of forgetfulness. Resident #1's admission Elopement Evaluation dated 6/10/21 revealed a score of 4 which indicated he was at low risk to wander. A Fall Risk Evaluation dated 6/10/21 revealed a score of 14 and deemed resident #1 to be at risk for falls. The document indicated he had intermittent confusion, poor vision, balance problems while walking and took medications and had diseases that predisposed him to falls. The Minimum Data Set (MDS) Admission assessment with assessment reference date of 6/17/21 revealed resident #1 required limited assistance for transfers and walking in his room. He required only supervision to walk in the hallway off the nursing unit. The MDS assessment indicated resident #1 had unsteady balance when walking and turning to change direction but was able to stabilize without staff assistance. He required a cane or crutch for mobility and used a walker prior to admission to the facility. Resident #1 had a fall during the 6-month period prior to admission and received antianxiety medications daily during the lookback period. On 7/08/21 at 4:04 PM, Certified Nursing Assistant (CNA A) stated she was assigned to resident #1 on the evening he left the facility unattended. She recalled when she last saw him it was after dinner, and he was with a group of residents in the hallway near the front lobby. CNA A stated she was not immediately informed of the incident after resident #1 was returned to the facility. Instead, she became aware when she passed by his room and observed a staff member seated with resident #1. CNA A stated the staff member informed her she was assigned to do one to one supervision with resident #1 as he had been found outside the facility. On 7/08/21 at 4:22 PM, Licensed Practical Nurse (LPN) C stated at about 5:55 PM on the evening resident #1 exited the building she was seated in her car in the front parking lot. LPN C stated she looked up from her meal and recognized resident #1 as he walked from the direction of the facility's front door, stood in the middle of the parking lot, and then continued to walk away from the facility towards the driveway. LPN C stated she ran towards him and attempted to get his attention. She stated it took three attempts to get resident #1 to stop walking, but she was not able to redirect him. LPN C recalled resident #1 became belligerent and repeated, I want to go home. I need to go home. She explained she saw CNA F in the courtyard at the front of the facility and signaled to her that she needed assistance with resident #1. LPN C stated after almost 20 minutes resident #1 was guided back into the facility by herself and two CNAs. LPN C stated she later learned another staff member let resident #1 out by mistake. She acknowledged it was fortunate she happened to be in her car and look up at that precise moment. She said, Nobody else knew he was outside. He was dressed in street clothes. Nobody would recognize him as a patient. It was only God. If I did not see him, he could have gotten far because he had made a decision that he was going home. On 7/08/21 at 4:50 PM, resident #1 explained he was hospitalized for a respiratory problem but did not know why he was transferred to the facility. He recalled leaving the facility recently through the front door. Resident #1 said, The door might have been unlocked, not wide open. I had to push it. He explained he simply wanted to go home that day. Although resident #1 was seated during the interview, he exhibited significant shortness of breath, coughed frequently and had to pause regularly during the conversation to catch his breath. His oxygen concentrator was on, but the nasal cannula lay on the bed beside him. Resident #1 stated he sometimes removed his oxygen and said, That's what I do at home. On 7/08/21 at 5:01 PM, in a telephone interview, the weekend receptionist stated she was responsible for securing and monitoring the front lobby door, but resident #1 exited the facility the previous Friday evening after she left for the day. She explained all nursing staff knew the code to unlock the front lobby door after hours for themselves and visitors. The weekend receptionist said, It's a puzzler. I don't know why the staff member wouldn't ask someone else or confirm with the nurse. The weekend receptionist confirmed there was a binder at the front desk which contained a list of residents at risk for elopement and their photographs. She was unsure if resident #1's name was on the list prior to the incident and said, To be honest I personally haven't looked at the book. On 7/08/21 at 5:25 PM, in a telephone interview, CNA D stated on the evening resident #1 exited the facility resident #8 asked her to unlock the front lobby door to allow a gentleman to leave. CNA D stated she was familiar with resident #8 who often had a male visitor, and she assumed he was that person. CNA D said, I had never seen that resident before. I did not know it was a resident. I opened the door, and he went out. He was alone. She described the resident as looking like a visitor because he wore shorts, t-shirt, and sneakers. CNA D confirmed she received education on the facility's elopement policy and procedure regularly but could not explain why she unlocked the front lobby door for someone without verifying his identity. On 7/08/21 at 7:10 PM, in a telephone interview with CNA B, he stated CNA F requested assistance with retrieving a resident who was found outside the facility and refused to return. CNA B recalled resident #1 was standing in the parking lot with LPN C when he got outside. He stated resident #1 was belligerent, adamant that he was leaving and said, I walked in here and I am walking out. CNA B explained he was very fearful resident #1 would be injured as he walked quickly towards the end of the parking lot which fell off into a deep ditch. CNA B stated he blocked resident #1 from that hazard and then the resident headed towards the driveway and the adjacent street. CNA B stated he had to focus on keeping resident #1 away from the ditch and the busy main road. He said, . I was afraid he would have jumped out into the road because he was getting so upset. CNA B stated he was able to stop resident #1 just before he reached the sidewalk and steered him back to the facility. On 7/09/21 at 9:48 AM, resident #8 recalled a gentleman standing near the receptionist's desk as she passed through the front lobby. She stated he appeared to be a visitor. Resident #8 said, It's normal to see people, visitors, standing there waiting for someone to come and put the code in so they can get out. I told [CNA D] to let him out. On 7/09/21 at 11:23 AM, CNA F stated on the day of the elopement incident she was on her way to the kitchen at about 5:30 PM. As she passed by the front lobby, resident #8 asked, Can one of you open the door for this guy? CNA F stated the hallway was busy as residents were exiting the dining room and returning to their rooms. CNA F stated she observed CNA D walk towards the front lobby door and a man followed her. CNA F was not aware the man was a resident as she had never seen him before that evening. She stated soon after she returned from the kitchen she decided to take her break outside and used the code to unlock the front lobby door. CNA F recalled she walked out of the facility and saw LPN C waving to her and pointing at the same man who stood in the middle of the parking lot. CNA F stated she then realized what happened. She said, This was a patient! I was surprised because I remembered he was just standing at the door! CNA F stated she joined LPN C and attempted to redirect resident #1 but when she was unsuccessful she returned to the facility to notify other staff. Resident #1's elopement route was retraced on 7/08/21 at 6:55 PM. He exited the facility through the front lobby door, walked past the courtyard and paused in the middle of the front parking lot after traveling approximately 170 feet. Resident #1 then turned left and continued to walk towards the driveway and the sidewalk that was approximately 125 feet away. The facility is located on a heavily trafficked 4-lane divided highway that had vehicles traveling at high rates of speed. The facility's parking lot ended in a steep-sided ditch approximately 3 to 4 feet deep. Photographic evidence was obtained. Review of historical weather data revealed on 7/02/21 at 5:55 PM, the temperature was 88 degrees Fahrenheit with scattered clouds (retrieved on 7/09/21 from www.timeanddate.com). The facility's elopement incident investigation was reviewed with the Administrator on 7/08/21 at 5:48 PM. She confirmed CNA D unlocked the front lobby door at resident #8's request and allowed resident #1 to exit the facility. The Administrator stated resident #1 walked to the front parking lot, approximately 175 feet from the front lobby door where he was seen by LPN C. She said, That was very fortunate. The Administrator stated during the incident reporting process she communicated with a local state agency and was informed resident #1 was well-known to the agency as they had made multiple visits to his home to investigate allegations of self-neglect. The Administrator stated after the incident, resident #1 was re-evaluated, deemed to be at risk for elopement and had one to one staff supervision initiated. Review of resident #1's medical record revealed a care plan for elopement, wandering and exit-seeking behaviors was initiated on 7/02/21. The interventions included One to one supervision for safety. On 7/09/21 at 9:51 AM, resident #1 was observed ambulating in the facility without supervision. He walked along the hallway from the A Wing nurses' station, passed by the lobby and front door, and headed towards the B Wing where his room was located. Resident #1 walked past the B Wing nurses' station and into his room with no staff member observed nearby. He sat in a chair in his room, replaced his oxygen via nasal cannula and had to wait a few minutes to catch his breath before speaking. Resident #1 did not know where his assigned CNA was, and said, She is outside, I think. On 7/09/21 at 9:58 AM, CNA E arrived at the doorway of resident #1's room. She confirmed she was assigned to provide one to one supervision for the resident and said, I should be staying with him. She did not respond when asked why she had not accompanied resident #1 from the A Wing to his room. CNA E acknowledged one to one supervision required her to remain with resident #1 at all times and document his whereabouts every 15 minutes. Review of the flowsheet in resident #1's room revealed CNA E last signed the form an hour before, at 9:00 AM that morning. On 7/09/21 at 10:06 AM, the Director of Nursing (DON) stated all staff received education on elopement in orientation and annually. She stated the education topics included checking the elopement binder at the start of every shift, monitoring and securing exterior exit doors and responding to alarms. The DON stated resident #1 was assessed as low risk for elopement on admission and initially appeared to be cognitively intact. She stated she interviewed the resident later in the evening after the elopement incident and noticed he was forgetful. She said, At this point, knowing what I know now about him, I think he could have gotten lost. The DON was informed that although resident #1 was supposed to have one to one supervision according to his care plan, he was observed ambulating from one unit to another by himself within the past hour. She was informed the resident was not supervised by the assigned staff member, CNA E, for at least seven minutes. The DON stated her expectation was staff would demonstrate a heightened level of awareness regarding residents who were known elopement risks. She acknowledged neither CNA D nor CNA E followed the facility's protocols and/or resident #1's care plan to ensure his safety. The DON confirmed the CNAs did not demonstrate understanding of elopement education. She stated the facility did not have a standardized method of testing all staff to ensure they retained the educational material that was taught. Review of the policy and procedure Elopements and Wandering Residents implemented on 4/01/20, revealed residents who were at risk for elopement would receive adequate supervision according to their care plans. The document defined an elopement as occurring . when a resident leaves the premises or a safe area without authorization . The policy indicated the facility would maintain a secure environment with door locks and alarms to help prevent elopements. The facility's Immediate Jeopardy Removal Plan included the following immediate actions the facility implemented, which the survey team verified: *On 7/02/21, resident #1 was returned to the facility and assessed, and found to have no injuries. He was immediately placed on one to one supervision, re-evaluated for elopement risk and his care plan was updated. *On 7/02/21, a complete head count was done to confirm all residents were present in the facility. *On 7/02/21, elopement drills and education on elopement, and abuse / neglect were initiated on the 2:00 PM to 10:00 PM shift, with a focus on verification of identity prior to permitting egress from the facility. *On 7/02/21, CNAs were suspended pending outcome of incident investigation. *On 7/03/21, all residents residing in the facility were re-evaluated for elopement risk. Six additional residents were identified, and care plan goals and interventions were updated as indicated. Increased supervision was initiated for all residents deemed to be at risk for elopement/wandering, to include hourly safety checks. A documentation requirement for wandering risk with increased supervision was initiated for nurses and CNAs. *On 7/03/21, all elopement risk alert binders were reviewed for accuracy and updated as indicated. *On 7/03/21, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. A Performance Improvement Plan (PIP) was developed and implemented after approval by the Medical Director. *On 7/03/21, staff education on abuse / neglect and elopement policy and procedures continued. No staff were permitted to work until education was received. Elopement drills were conducted at 12:30 AM, 1:00 PM and 2:29 PM. *On 7/03/21, the initial post-event quality monitor was completed to validate processes were in place. *On 7/04/21, staff education on abuse / neglect and elopement policy and procedures continued. The facility achieved 96% staff educated (98 of 102 staff). The four remaining staff were removed from the schedule until education is completed. *Review of in-service attendance sheets with staff signatures validated elopement education was completed using the facility's elopement policy and procedure, with 96% facility staff trained between 7/02/21 and 7/04/21. *Review of elopement drill sign-in sheets revealed scheduled staff participated in elopement drills conducted every shift after the incident, on 7/02/21 and 7/03/21. *Review of the QAPI committee quality monitoring sheets dated 7/03/21 to 7/07/21 revealed documentation was completed for each area according to the scheduled frequency required by the PIP. Audit forms validated (1) Elopement binders at the A and B Wing nurses' stations, the kitchen door and the receptionist's desk were updated and in place. (2) Elopement risk status was assessed for residents who were new admissions, re-admissions and those who had a change in condition. *Interviews conducted from 7/08/21 to 7/09/21 with three CNAs representing all shifts, three LPNs, three housekeepers, one dietary staff, one maintenance staff, one medical records staff and two receptionists revealed 24 of 25 staff were knowledgeable of the elopement policy and procedure, supervision of residents at risk for elopement, and the need to verify identity prior to permitting egress from the facility. Ongoing additional corrective actions include: On 7/05/21, an ad hoc QAPI meeting was held with all members of the interdisciplinary team and the Medical Director. The committee reviewed the status of PIP (Performance Improvement Plan) and quality monitoring of Elopement Process and Elopement Binders. No revisions were required. On 7/06/21, staff education was provided for 2 of the remaining 4 staff members. Total number of staff educated is 100 of 102 (98%). On 7/07/21, weekly quality review of elopement risk alert binders was completed. Ongoing quality monitoring. On 7/07/21 and 7/08/21, the facility conducted a review of new admissions/re-admissions and residents with changes in condition for elopement risk status. Ongoing quality monitoring. On 7/09/21, an elopement drill was conducted at 6:54 AM. On 7/09/21, ad hoc QAPI meeting was held with all members of the interdisciplinary team and the Medical Director. The PIP was reviewed, revised, and accepted by the Medical Director. Per the revised PIP, staff re-education was initiated and is ongoing to ensure retention of elopement education and provide validation through completion of a post-test. Staff will not be permitted to work until validation of re-education is done. The sample was expanded to include 6 additional residents, #2, #3, #4, #6, #7 and #8. Observations, interviews, and record reviews revealed no concerns related to accuracy of elopement risk evaluations and appropriateness of care plan interventions for these residents.

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility unnoticed, failed to monitor exit doors to maintain a safe and secure environment, and failed to perform thorough elopement risk evaluations to establish appropriate and individualized safety interventions, for 1 of 19 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a high likelihood he could have fallen, gotten lost or been hit by a car. On 1/22/21 at approximately 12:45 PM, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility unsupervised. Resident #1 was observed by a visitor in the facility's front parking lot, near a steep embankment and a busy 4-lane road. The facility was unaware of resident #1's whereabouts until a staff member noticed him at the rear of the facility, approximately 600 feet away from the front parking lot. Resident #1 had a small amount of blood at the corner of his mouth and scratches on his arms when he was found. Resident #1 would have traveled over uneven, sloping grassy areas, past an unsecured gate in a fence around a dry steep-sided retention pond and along cracked pavement. The facility failed to ensure resident #1 was adequately evaluated for elopement risk and failed to monitor and maintain properly functioning exit doors to ensure vulnerable residents did not exit the facility without supervision. There were 18 facility residents who were identified as at risk for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 1/22/21 and was removed on 1/25/21. F689 was determined to be past noncompliance when the facility fully corrected the noncompliance on 2/18/21. Findings: Resident #1, a [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type, is a mental health disorder that causes a combination of symptoms, including hallucinations, delusions and widely ranging emotions from abnormally elevated mood to [MEDICAL CONDITION] (retrieved on 3/05/21 from the Mayo Clinic website at www.mayoclinic.org). Extrapyramidal symptoms are involuntary or uncontrolled movements caused by the side effects of medications such as antipsychotic drugs. These tremors and muscle contractions commonly occur in the arms, legs, feet, and mouth, vary in severity, and can affect everyday movement and communication (retrieved on 3/05/21 from the Healthline website at www.healthline.com). Symbolic dysfunction is a speech disorder that causes difficulty in communication. The World Heritage Encyclopedia indicates the condition causes . simple sound substitution to the inability to understand or use one's native language (retrieved on 3/05/21 from http://self.gutenberg.org/articles/eng/symbolic_dysfunction). The Florida Agency for Health Care Administration 5000-3088 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 12/18/20 revealed resident #1 required a surrogate for healthcare decision and was alert, disoriented, but can follow simple instructions. The transfer form indicated that while in the hospital, resident #1 walked with a walker and assistance from one person and had a risk alert for falls. Review of resident #1's medical record revealed an admission Elopement Evaluation dated 12/19/21. The nursing evaluation was inaccurate and incomplete as it read, Does not move independently rather than Is ambulatory. The section of the form regarding previous episodes of wandering was left blank. The resulting elopement risk score of 6 indicated resident #1 was at low risk for wandering. The Minimum Data Set (MDS) admission assessment with assessment reference date of 12/24/20 revealed resident #1 had difficulty communicating some words or some thoughts. He had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. The MDS assessment revealed resident #1 displayed fluctuating inattention that changed in severity and also experienced delusions. Resident #1 required extensive assistance from staff for transfers between surfaces, standing, walking, and getting around his room and the facility. He had unsteady balance, was only able to stabilize with staff assistance and normally used a wheelchair for mobility. Resident #1 fell and suffered a fracture prior to admission to the facility, and in his first week in the facility had a fall with no injury. The MDS assessment revealed resident #1 had no skin conditions. A Psychiatry Evaluation Note dated 12/29/20 revealed resident #1 was confused, disheveled, unkempt, and maintained poor eye contact. He had fine tremors noted in both arms. The psychiatrist determined resident #1's insight, judgement and memory were poor, and noted his BIMS score was 6. Review of resident #1's medical record revealed a Health Status Note dated 1/22/21 at 2:05 PM. The progress note, signed by the Director of Nursing (DON) read, Resident observed in (a) non patient area. A change in condition progress note written by the DON a few minutes later at 2:30 PM revealed resident #1's blood pressure and heart rate were low, at 82/50 millimeters of Mercury (mm Hg) and 50 beats per minute respectively. The normal blood pressure range is between 90/60 mm Hg and 120/80 mm Hg and the normal heart rate is between 60 and 100 beats per minute. A low blood pressure and/or low heart rate can cause dizziness and [MEDICAL CONDITION], contributing to an increased risk for falls (retrieved on 3/05/21 from U.S. National Library of Medicine MedlinePlus at www.medlineplus.gov). A Skin Only Evaluation dated 1/22/21 at 2:15 PM revealed resident #1 had 3 open [MEDICAL CONDITION] on both arms, measuring 2 centimeters (cm) x 2 cm. He also had scattered [MEDICAL CONDITION] of various sizes on both legs. The area around these [MEDICAL CONDITION] were noted to be red. The document indicated resident #1 had a scabbed area to the top of his head. A Health Status Note dated 1/22/21 at 3:41 PM revealed the DON conducted a skin sweep on resident #1 after he was found in the non-patient area. The DON noted resident #1 had scabbed areas on both arms and legs and his head but did not include the open [MEDICAL CONDITION] described in the evaluation done less than 2 hours before. Review of the medical record revealed prior to the elopement incident, a Weekly Skin Evaluation dated 1/12/21 showed resident #1 had a pre-existing bruise, but no redness, open areas, or other skin conditions. Skin & Wound - Total Body Skin Assessment forms dated 1/11/21 and 1/18/21 revealed resident #1 had normal skin condition with good elasticity, and no new wounds. A late entry Medical Professional Progress Note dated 1/22/21 at 3:42 PM indicated resident #1 eloped from the facility earlier that day. The note read, ,,, thought he seen his car in parking lot when staff had opened door and (he) slipped out . On 3/01/21 at 11:14 AM, resident #1 was in his room with Certified Nursing Assistant (CNA) A. She explained she was assigned to provide 1:1 supervision for resident #1 as ordered by the physician. When asked why resident #1 required this level of supervision, CNA A said, He tried to escape. She stated she was told he rushed outside after a housekeeper opened the back door on the B Wing, but said, They really don't know for sure how he got out. CNA A described resident #1 as confused, unsteady when he walked, even needing assistance to stand and walk to the bathroom. She acknowledged he was at risk for falls. Later that afternoon at 5:16 PM, resident #1 was seated in his room with CNA F who said, He is 1:1 because he got out of the facility. She explained resident #1 was very unstable on his feet and needed support to walk short distances including going to the bathroom. CNA F stated resident #1 was likely to fall if left unattended. Resident #1 was asked if he recalled leaving the facility and he confirmed he went outside. He was unable to answer questions regarding the incident and held a brief rambling conversation about tags stolen from his car. On 3/01/21 at 11:46 AM, housekeeper B stated her regular assignment was on the B Wing. She explained all housekeepers used the exterior exit door on the A Wing, never the B Wing, as the laundry and housekeeping storage areas were outside the A Wing rear exit door. On 3/01/21 at 11:50 AM, CNA E stated she cared for resident #1 when he was newly admitted to the B Wing. CNA E recalled he was very confused. She said, He would get up suddenly like he was going to run, he would move quickly. CNA E demonstrated sudden, jerky, fast movements of all extremities. She said, He could walk but he wasn't steady, and sometimes he used a wheelchair. CNA E stated nobody was certain how resident #1 got outside the facility. In interviews conducted 3/01/21 at 11:58 AM and 4:29 PM, the Dietary Manager (DM) stated that on 1/22/21, cook D ran into her office and told her he saw someone, possibly a resident, near the dumpster. The DM stated she accompanied cook D outside and they observed resident #1 at the end of the kitchen driveway. The DM recalled she held resident #1's outstretched arms to lead him back into the facility through the kitchen door and noted raw, red areas on his forearms, and redness on his palms near his wrists. She said, Because I held his hands, I noticed a few scratches that looked new, and he did have a little blood on the corner of his mouth. He was very confused and kept repeating something about his car and going home. The DM stated she immediately returned resident #1 to the Administrator and the DON. The DM said, I think after that, they determined which door he got out of. I am not sure which one, but it was not the kitchen door. On 3/01/21 at 12:08 PM, the Maintenance Director stated he checked all doors once daily and to his knowledge the exterior door alarms were all functional on the day resident #1 eloped. He said, Nobody could make a certain decision on how he got out. He surmised resident #1 could have also exited through the front lobby door. The Maintenance Director stated the alarm annunciator panel for the entire facility was located on the A Wing, so if A Wing staff did not respond to a B Wing alarm when an exit door was breached, the B Wing alarm would re-set when the door closed. On 3/01/21 at 3:15 PM, the hospice CNA stated she arrived at the facility at approximately 1:30 PM on 1/22/21. She recalled parking in a spot near the covered walkway, facing the front entrance of the facility. The hospice CNA stated when she stood at the trunk of her car, she saw an elderly gentleman on the opposite side of the parking lot. She stated he was looking at the last 4 cars at the far end of the in the parking lot. She said, He went back and forth a few times, like he was choosing a car in a used car lot . No walker, no cane, no wheelchair. He just looked like he was trying to figure out which car was his. The hospice CNA explained she thought the gentleman was a visitor to the facility as there were 3 or 4 people seated near the facility's front door conducting window visits with residents. The hospice CNA said, There was a lot going on at the front desk. She explained it took a while to be screened at the front door as there were visitors, staff and a [MEDICAL TREATMENT] transport driver being checked in by the receptionist. The hospice CNA stated after she was in the facility for a few minutes she informed the receptionist and the social worker about the elderly gentleman looking at cars in the parking lot. On 3/01/21 at 4:21 PM, in a telephone interview, cook D confirmed he found resident #1 outside the facility. He stated he was not sure of the exact time, but . it was probably leading up to 2:00 PM. Cook D stated he was on the way to the dumpster and was startled when he saw resident #1 walk around the corner of the building nearest to the dumpster. Cook D asked resident #1 if he needed help and said, He didn't say anything I understood. Cook D stated he told resident #1 to stay put, then left him standing in the driveway and ran to get the DM. Review of the facility's investigative information on 2/05/21, 2/09/21 and 2/10/21, revealed resident #1 eloped from the facility and was . at risk of harm or injury. The information indicated on 1/22/21 at approximately 12:45 PM, resident #1's roommate observed him leaving their room after finishing lunch. The report revealed resident #1 was seen outside the facility by a visitor, a hospice CNA, at approximately 1:00 PM. The investigation report read, Resident was approximately 10 feet from facility and still on the premises. The document indicated the hospice CNA informed the receptionist and Social Worker (SW) and .coincidentally, (a cook was) at kitchen back entrance and also observed (resident #1) outside of the facility but still on facility premises. The report revealed the facility determined staff followed the plan of care as resident #1 was not previously identified as an elopement risk, and he was observed on the unit 15 minutes prior to being retrieved from outside the facility. The investigation report did not include a timeline to support the 15-minute absence since the time resident #1 was last seen by a staff member and the time he was found by the cook were not specified. On 3/01/21 at 3:30 PM, resident #1's elopement route was re-traced by the surveyors. He would have walked from his room on the M hall at the far end of the B Wing, past the nurses' station in the middle of the unit to the exit door on the C hall at the opposite end of the B Wing. He would have pushed on the fire door for 15 seconds while the door alarmed until the magnetic lock released and the door opened. The alarm would have stopped and re-set once the door closed behind resident #1. He traveled past the enclosed courtyard and under the covered walkway that ended in the parking lot. Resident #1 then crossed the parking lot and was approximately 150 feet away from the B Wing C hall exit door when he was observed by the hospice CNA. It is unknown how much time resident #1 spent inspecting the cars at the far end of the parking lot or how close he stood to the steep embankment that dropped to a ditch below. The short sloping driveway at the end of the parking lot led to the sidewalk, adjacent to a heavily trafficked 4 lane road in front of the facility. A commercial center with assorted businesses and a pharmacy with a drive through lane was located next door to the facility, and there was an active fire station about 0.5 miles away. Resident #1 could have been severely injured if he had fallen down the embankment or been hit by a car if he attempted to cross the road. Resident #1 crossed the parking lot again and headed towards the back of the building. The likely elopement route would have taken him past a fenced dry retention pond with steeply sloping sides. There was an unlatched, partially open gate in the fence approximately 100 feet from the area resident #1 was seen by the hospice CNA. Resident #1 would have walked over either an uneven sloping grassy expanse to the left of the fenced area, or along a cracked, uneven concrete pathway to the right of the fenced area. At the end of the grassy area there were low-hanging tree branches over the pathway, and the pavement ended abruptly with a 6-inch drop to an area of uneven grass and dirt. Resident #1 walked around the side of the facility, crossed another wide uneven grassy area, passing thick scrub and bushes on his right side and arrived near the generator and dumpster at the back of the facility, a distance of approximately 353 feet from the front parking lot. From there, resident #1 walked past a tree stump and stepped up onto a concrete pathway which sloped towards the middle of the narrow driveway that led to the back door of the kitchen. When resident #1 was retrieved by the DM, he had walked more than 600 feet without an assistive device, over dangerously uneven and unsafe terrain. On 3/02/21 at 12:28 PM, CNA A stated she was assigned to resident #1 on the day he eloped. She stated she was on the way to relieve CNA C for her lunch break and resident #1's roommate called to her as she passed by the room. The roommate pointed to resident #1 who was attempting to stand up from his wheelchair and walk. CNA A explained resident #1 was not supposed to walk without assistance because he could fall. She said, I asked where he was going, and he didn't answer. He is very confused. He is very shaky in his movements sometimes. I sat him back down in the wheelchair because I didn't want him to fall. I pulled the wheelchair out to the hallway just beside the door so everyone could keep an eye on him. CNA A stated resident #1's lunch had not yet been served and she left him in the hallway. She stated when she returned to the unit, she was informed resident #1 got outside. CNA A stated she felt resident #1 would be in danger outside the facility as he was not capable of crossing the road safely and would have easily gotten lost or badly hurt. In interviews conducted on 3/01/21 at 12:25 PM and 1:31 PM, the Administrator reviewed the facility's investigation of the elopement incident. She stated the facility's timeline indicated the last time resident #1 was seen before he eloped was on 1/22/21 at approximately 12:45 PM, by his roommate. The administrator confirmed resident #1 was next seen at approximately 1:30 PM by the hospice CNA in the front parking lot. She stated she obtained a statement from the hospice CNA but never asked her to show exactly where she saw resident #1. The timeline showed the hospice CNA waited a while to complete the facility's check in process during a busy period at the front door, went to the restroom and then mentioned seeing an elderly gentleman in the parking lot when she returned the restroom key to the reception desk. The Administrator stated that by the time the hospice CNA reported this to staff, cook D had already located resident #1 at approximately 1:30 PM. When asked about the accuracy of the timeline as it showed resident #1 was in the front parking lot and also at the rear of the facility at approximately 1:30 PM, the Administrator acknowledged she did not have exact times. She stated she determined resident #1 was outside the facility for approximately 10 to 15 minutes. The Administrator did not respond when informed the timeline appeared to indicate resident #1 was outside the facility unsupervised for at least 45 minutes. The Administrator acknowledged the facility's investigative documentation referred to the distance resident #1 was found from the building itself, not the distance he had traveled to get there. The Administrator stated although all exit doors were tested and determined to be functional on the day of resident #1's elopement, an outside contractor was hired to check all doors again on 2/04/21. She explained the contractor discovered the B Wing C hall exit door near the courtyard door was not functioning properly as it alarmed intermittently. On 3/02/21 at 1:27 PM, the Administrator stated the facility's investigation showed resident #1's assigned caregiver, CNA A relieved CNA C who was on lunch break from her 1:1 supervision assignment. The administrator said, I can't say that the door failed for sure. However, we determined it was the most likely point of exit as interviews with residents by that door showed they heard the alarm. The Administrator stated interviews with staff indicated no staff members on the A or B Wings either heard or responded to door alarms at the time resident #1 exited the facility. She explained all staff were probably assisting residents with personal hygiene, incontinence care and toileting after lunch. The Administrator was asked if there was adequate staffing on the day resident #1 eloped to ensure appropriate supervision of all residents during busy periods. She said, I cannot pay a staff member to sit and listen for alarms. They were giving care as they should. The Administrator did not respond when asked if non-clinical staff could monitor the unit during periods when nursing staff were very busy. On 3/02/21 at 2:34 PM, the B Wing Unit Manager (UM) described resident #1 as a little disoriented but always pleasant. She stated he usually propelled himself in a wheelchair throughout the B Wing and often tried to stand and walk on his own. She explained resident #1 was a fall risk and had fallen a few times. The B Wing UM said, It was not safe for him to be outside. This man was not a stable walker. I still can't fathom how he got out and ended up where he did . I have no idea how he got out. The B Wing UM explained nurses were responsible for completing elopement risk evaluations on admission. The B Wing UM stated prior to the elopement she was not sure who, if anyone, ever checked the elopement evaluations for accuracy. She reviewed resident #1's Elopement Evaluation form dated 12/19/21, confirmed it was inaccurate and stated the score did not accurately reflect his elopement risk. The B Wing UM was asked to review resident #1's Elopement Evaluation completed on 1/22/21 after he eloped. She validated the score of 10 indicating At risk to wander was incorrect. The form noted resident #1 had not wandered in the past month although he eloped that day. She acknowledged a correct response to that question would have given a score of 11 indicating High Risk to Wander. Review of the policy and procedure for Elopements and Wandering Residents implemented on 4/01/20 revealed residents at risk for elopement would receive adequate supervision, care, and services to ensure their safety. The document indicated the facility had locks and alarms on doors to prevent elopements. It read, Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The policy's compliance guidelines supported the importance of identifying and assessing risk and implementing appropriate interventions. The Facility Assessment Tool updated on 10/01/20 revealed the facility was able to care for residents with [MEDICAL CONDITIONS] and behaviors that required interventions. The document indicated the facility would provide person-centered care by identifying hazards and risks, and ensuring staff were aware of care plan interventions that reflected a resident's preferences and routines. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: * Resident #1 was re-assessed after being returned to the facility and deemed to be at risk for elopement on 1/22/2021. * Resident #1 received skin and pain assessments, vital signs were checked, a new BIMS score was obtained, and he was immediately placed on 1:1 supervision. The required notifications were made including the physician, family, and law enforcement in a timely manner on 1/22/2021. * A head count was conducted to ensure the safety of all residents, and proper function of all doors was verified on 1/22/2021. Daily door checks were being conducted and are on-going. * All residents in the facility were re-assessed for elopement risk and their care plans were reviewed and updated as indicated. All (3 of 3) elopement binders were reviewed and updated on 1/22/2021. * On 1/22/21, re-education of staff was initiated. The topics included the elopement policy and procedures, locations and contents of elopement risk binders, and elopement drill procedures. A post-test was assigned to measure understanding of the material presented. On-going monthly elopement education will continue for current employees and remains mandatory for newly hired employees. * On 1/25/21, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held, and a Root Cause Analysis completed. A Performance Improvement Plan (PIP) was developed, and audit sheets were created for weekly elopement drills x 4 weeks, then monthly x 3 months. * On 2/03/21, screamer door alarms were installed on all exterior exit doors except the door to the laundry on the A Wing. This exit door had a keypad code, restricted to staff who needed the code to perform their job function including housekeeping, laundry, maintenance and the Administrator and DON. Ongoing daily door checks and audits were expanded to include the function of screamer alarms. Keys to silence the screamers alarms were kept by maintenance staff and the UMs / charge nurses on the A and B Wings. * On 2/04/21, an outside contractor tested the functionality of all doors. * On 2/05/21, the facility achieved 100% compliance with staff education on elopement. Attendance was verified by reconciliation with the active staff roster. * On 2/18/21 in the scheduled QAPI committee meeting, resident #1's elopement, the PIP and results of elopement drills and door checks were reviewed. Ongoing monthly QAPI committee review to continue. * On 2/22/21, the facility relocated the annunciator panel for B Wing exit doors from the A Wing nurses' station to the B Wing nurses' station. * Elopement drills were completed successfully on 1/22/21, 1/23/21, 1/24/21, 1/25/21, 1/29/21, 2/01/21, 2/06/21 and 2/10/21. * Nursing administration including the DON and UMs will continue to review elopement evaluations for accuracy in daily clinical meetings. * Interviews conducted from 3/01/21 to 3/02/21 with 10 staff members (7 CNAs representing all shifts, 1 housekeeper, 1 central supply staff and 1 maintenance assistant) indicated they were knowledgeable of the elopement policy and procedures, supervision of residents at risk for elopement and restrictions related to door code access. The sample was expanded to include 2 additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #4 & #5.

Based on observation, interview and record review, the facility failed to provide adequate supervision and appropriate interventions to prevent falls for 1 of 3 residents, (#1). Findings: Resident #1 was an [AGE] year-old male who was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a brief interview for mental status (BIMS) score of 0 indicating severe cognitive impairment. The assessment revealed the resident had memory problems, severely impaired cognitive skills, no behaviors, and multiple falls. He required extensive assistance of 2 staff for transfers, and required extensive assistance of 1 staff for locomotion on and off the unit. He was frequently incontinent of bowel and bladder and needed extensive assistance of 1 staff for dressing, eating, toileting and personal hygiene. On 8/12/19 at 11:46 AM, resident #1 was resting in bed and appeared to be sleeping. His family was at the bedside. The resident was receiving hospice crisis care. On 8/12/19 at 2:03 PM, a review of the resident's fall incidents were reviewed with the MDS coordinator G. The MDS coordinator G stated that, resident #1 was the only resident in the building that used chair and bed alarms. It was noted that the resident had 11 falls in the facility since (MONTH) 2019. The falls occurred on 4/28/19, 5/01/19, 5/21/19, 5/24/19, 6/11/19, 6/14/19, 6/21/19, 6/28/19, 7/02/19, 7/05/16, and on 8/03/19. A review of the fall that occurred on 4/28/19 at 6:00 AM showed that the resident was found on the floor next to his bed. He had been in bed prior to the fall. An intervention on the care plan dated 4/28/19 read, 3-day bowel and bladder for patterning. The fall on 5/01/19 at 3:00 PM noted that while in the dining room, the resident tried to stand from his wheelchair and fell . The care plan intervention dated 5/1/19 read, place at table when in dining room. On 5/21/19 at 12:30 AM, the resident was found on the floor next to his bed. He had been in bed prior to the fall. The care plan intervention dated 5/21/19 read, keep frequently used items in reach. On 5/24/19 at 5:30 AM, the resident was found sitting on the floor in the hallway next to his wheelchair. The care plan intervention dated 5/24/19 read, Encourage to remain in supervised areas. On 6/11/19 at 4:45 AM, the resident was found on the floor next to his bed. He fell while attempting to get out of bed. The care plan intervention dated 6/11/19 read, encourage resident to get out of bed when awake. On 6/14/19 at 9:00 PM, the resident was found on the floor in the hallway. He had attempted to stand up from his wheelchair. The care plan intervention dated 6/14/19 read, Provide diversionary activities when restless. On 6/21/19 at 6:30 PM, the resident was found sitting on the floor next to his wheelchair. The care plan intervention dated 6/21/19 read, Reposition frequently as needed (PRN) in wheelchair. On 6/28/19 at 4:20 AM, the resident was found on the floor next to his bed lying on his back with laceration to the right side of his forehead. The incident documented that the Certified Nursing Assistant, (CNA) turned her back to the resident to grab washcloths and towels for care when resident fell on the floor. The resident was wearing a soft helmet during the fall. He was transferred to the hospital and returned the same day at 9:00 AM with sutures to the right forehead. There were no care plan interventions added to the plan of care after this incident resulting in injury and transfer to the hospital. On 7/02/19 at 1:15 AM, the resident was found in the hallway lying on the floor. The care plan intervention dated 7/02/19 read, chair alarm. On 7/05/19 at 8:40 PM, the resident was again found sitting on the floor next to his wheelchair in the hallway. The care plan intervention dated 7/05/19 read, Encourage to attend activities. A fall on 8/03/19 at 2:00 PM showed the resident was found on the floor next to his bed. The care plan intervention dated 8/03/19 read, redirect as tolerated. On 8/12/19 at 3:21 PM, the fall interventions from 7/5/19 were reviewed with the Director of Activities. She stated that she did not know why the intervention to attend activities was added as there are no group activities in the evenings at 8:40 PM. The group activities start at 9:45 AM each day and end at 3:30 PM. On Tuesday evenings there is bingo from 6:45 PM to 8:00 PM. On 8/12/19 at 3:13 PM, the resident's 11 falls were reviewed with the Director of Nursing (DON). She stated that although the intervention after the fall on 4/28/19 noted bowel and bladder patterning, she could not find any documentation of the patterning. She stated that the intervention was initiated by the weekend supervisor, who was no longer employed at the facility. She could not explain the other interventions that were added after the fall incidents. She did not explain what item the resident was reaching for post fall on 5/21/19, keep frequently used items in reach. When asked about the intervention post fall on 6/11/19, encourage resident to get out of bed when awake, she did not provide an answer. The DON could not say what diversional activities could be used after the fall on 6/14/19. She also did not provide an answer when asked what strategies were implemented after the resident sustained [REDACTED]. She verified that multiple interventions in the plan of care for resident #1's falls were not appropriate or individualized to his care. When it was pointed out that all of these falls occurred as a result of the resident trying to get out of bed or out of his wheelchair, she stated, the MDS nurses update the care plans during the week and the weekend supervisor on the weekends. We have a daily morning clinical meeting, and discuss interventions after each fall. She did not address if the facility attempted to assess why the resident repeatedly attempted to get out of bed or his wheelchair. On 8/12/19 at 2:57 PM, Registered Nurse (RN) B stated, we keep residents safe by using low beds, keeping residents by the nurse's station if they're in their wheelchairs, using floor mats next to their beds, and checking them every 15 minutes. They each have a plan of care that gets updated as needed. We don't use alarms in the building. She could not provide any documentation of the 15 minute checks and was not sure if that was policy. On 8/12/19 at 11:39 AM, CNA F said the facility did not use bed or chair alarms in the facility. She made sure that residents did not fall by checking on them every 2 hours. She did not know if the 2 hour checks were policy. On 8/12/19 at 11:35 AM, CNA [NAME] said she kept the residents from falling by checking to see if they were dry and asking if they had to go to the bathroom. She made sure of proper placement of bed and chair alarms, and made sure bed was in low position. She stated the facility used bed and chair alarms. On 8/12/19 at 5:04 PM, CNA H stated she usually worked the 11:00 AM to 7:30 PM shift and also worked some night shift when needed. When resident #1 is awake in bed he will try to get out of the bed, so we put him in his wheelchair. He has strong upper body strength and will stand up from his wheelchair by grabbing the railings, so we try to keep him away from railings. I check on the residents who are at risk for falls as often as I can. She stated that resident #1, required 1:1 supervision to keep him from falling. I'm surprised they didn't provide a 1:1 staff person during the night hours when he is most active. It was noted that more than half of the falls the resident sustained [REDACTED]. On 8/12/19 at 4:38 PM, the DON was not aware if the facility had a falls prevention program. She stated I don't think we have a falls program that I'm aware of, like a falling star program. We have huddle team meetings two times per day to discuss residents with recent fall incidents that have new interventions put in place. When asked about supervision for residents identified at high risk for falls, the DON did not provide any documentation. She did not provide any policy on accidents/falls. The facility failed to evaluate the effectiveness of interventions to prevent resident #1 from repeated falls and failed to modify the strategies to prevent further falls with input from direct care staff. The resident sustained [REDACTED]. The fall on 6/28/19 resulted in head injury and transfer to the hospital for sutures to his right forehead. Although the resident sustained [REDACTED].