Every finding on record at Aviata at Kissimmee Gardens

Based on observation, interview, and record review, the facility failed to honor a resident's preference and did not respond timely to resident's request for a Coronavirus Disease 2019 (COVID-19) booster vaccine for 1 of 4 residents reviewed for choices, of a total sample of 40 residents, (#113).Findings: Review of the medical record revealed resident #113, a [AGE] year-old female, was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. Her diagnoses included cerebra ischemia (stroke), type 2 diabetes, insomnia, and anxiety disorder. Review of resident #113's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 10/13/25 revealed a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. The MDS assessment noted no behavioral symptoms and no rejection of care or treatment during the look-back period. On 1/12/26 at 9:51 AM, resident #113 stated she requested a COVID-19 booster vaccine in October 2025 and was still waiting to receive it. She reported she was told the vaccine was not available. On 1/14/26 at 9:50 AM, Registered Nurse (RN) F stated resident #113 mentioned she wanted to receive the COVID-19 booster vaccine. RN F indicated she spoke with the Infection Preventionist (IP), who told her the vaccine had already been administered. RN F explained nursing staff provided education regarding vaccines and, at times, obtained consent, while the IP was responsible for follow up and administration of the vaccines. Review of resident #113's medical record revealed an Informed Consent for COVID-19 Vaccine form dated 11/04/25. The form showed resident #113 consented to receive the COVID-19 vaccine. The form was signed by the IP and documented the verbal consent from resident #113. Review of resident #113's November 2025 Medication Administration Record (MAR) revealed COVID-19 vaccine order was entered on 11/12/25 but was not administered. The MAR showed a COVID-19 order was again entered on 11/17/25 with code 9 documented, indicating Other / See Nurse Notes. Review of resident #113's Progress Notes revealed a note dated 11/17/25 indicating the facility was waiting on the pharmacy for the COVID-19 vaccine booster. On 1/14/26 at 11:39 AM, the IP stated approximately 15 residents wanted to receive the COVID-19 booster vaccine. She indicated physician orders were obtained; however, the vaccines were not acquired due to insurance-related issues and cost concerns. She stated the issue was being handled by the finance department and the Director of Nursing (DON). The IP acknowledged resident #113 wanted the COVID-19 vaccine and stated the resident was upset with her for not administering it. On 1/15/26 at 11:00 AM, the IP further stated that on 12/16/25, she and the DON received a list from the Finance Manager identifying residents with Medicare Part B coverage that may pay for the vaccine. She acknowledged she did not follow up regarding resident #113's request for the COVID-19 vaccine. She also stated she did not have access to the pharmacy online system and indicated that during her nearly three years at the facility, she had not ordered or administered COVID-19 vaccines. On 1/15/26 at 11:34 AM, the DON explained once consent was obtained and a physician order was issued, an order should be entered into the system to obtain the vaccine from the pharmacy. She stated influenza and pneumonia vaccines typically arrived within three to five days once ordered, but COVID-19 vaccines could take longer, due to authorization requirements through Medicare Part B or other insurance. She indicated she needed to verify timeframes with the IP. On 1/15/26 at 1:23 PM, during a telephone interview, the Pharmacy Representative stated COVID-19 vaccine orders were submitted using an electronic form, the same process used for influenza vaccines. Upon review of her system, she indicated she did not see any COVID-19 vaccine orders submitted by the facility. She stated if the vaccine was not ordered electronically with the correct form, the pharmacy would not dispense it, and the facility would need to follow up. She further stated COVID-19 and influenza vaccines were ordered as bulk vaccines and were not resident-specific. On 1/15/26 at 2:15 PM, in a joint interview with the Administrator (NHA) and the DON, both stated they were not aware of any issues related to obtaining or administering COVID-19 vaccines. The NHA shared the IP attended daily stand-up and Quality Assurance and Performance Improvement meetings and had not raised any concerns. The NHA stated she expected the IP to manage all aspects of the immunization process. Later, at 2:55 PM, the NHA stated she spoke with the Pharmacy General Account Manager, who confirmed the IP had access to place vaccine orders electronically. The NHA indicated Pharmacy General Account Manager was unable to identify the last date COVID-19 vaccines were ordered. The NHA stated the IP had received the same pharmacy training as other nursing management staff when the facility contracted with the pharmacy provider approximately one year earlier. Review of the facility's policy titled COVID-19 Vaccine - Resident, revised 11/17/21, revealed the vaccine was to be offered to residents and ordered through the pharmacy partner, local or state public health agency, or through arrangements with a vaccine provider to administer the vaccine. Review of the facility's policy titled Resident Rights, dated 11/30/24, revealed the facility's intent to ensure resident rights were known to staff.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation for application and removal of Thromboembolic Deterrent (TED) hose for 1 out of 1 residents sampled for application of TED hose, of a total sample of 40 residents, (#45).Findings: TED hose are stockings that help prevent blood clots and swelling in your legs, (retrieved from www.drugs.com on 1/16/26).Resident #45 was admitted to the facility on [DATE] with diagnoses that included partial weakness and paralysis after a stroke affecting the right dominant side, heart disease, altered mental status and major depressive disorder. A review of the Annual Minimum Data Set (MDS) assessment with reference date 10/19/25 revealed resident #45 had a Brief Interview for Mental Status Score of 13 out of 15, which indicated normal cognition.A review of the medical record revealed on 12/10/25 change in condition documentation of pitting edema in the right lower leg for resident #45 and physician's orders initiated on 12/10/25 directing nursing staff to apply TED stocking on in the morning and off at night for venous stasis. The Medication Administration Record (MAR) revealed that nurses checked off that TED hose stockings were applied and removed from 12/10/25 to 1/13/26 with the exception of the date 12/28/25. There was no corresponding documentation in the nurses' progress notes about resident # 45's refusal to wear the TED hose, nor was there an issue with supply nor size of resident #45's TED hose.On 1/12/26 at 10:31 AM, resident #45 was in his wheelchair in the hallway and was not wearing the TED hose. The MAR for that day indicated documentation that showed the hose was applied.On 1/13/26 at 2:49 PM, resident #45 was in bed and was not wearing the TED hose stockings. He stated he did not wear the TED hose but did not give a reason why. The MAR for 1/13/26 contained documentation the hose was applied.On 1/13/26 at 4:00 PM, in a joint interview with assigned RN B and the Sunflower Way Unit Manager (UM), the RN acknowledged resident #45 did not have the physician ordered TED hose on. The nurse stated he was not aware of the order for the TED hose and explained possibly it was a new order. He confirmed the MAR with his documentation that the TED hose had been applied on 1/12/26 and for that day, 1/13/26. He was unable to say why he had checked off that the hose was applied and said he may have checked it off in error. RN B confirmed the documentation in the record was incorrect and should not show the TED hose was applied to the resident on 1/12/26 and 1/13/26. At that time, the UM verified together with RN B confirmed the physician order was not new and was placed on 12/10/25. The UM verified another mistake in the medical record, when the nurse on the night shift had incorrectly documented she removed the stockings on 1/12/26 even though they were never applied. On 1/13/26 at 4:10 PM, RN E in a telephone call, did not recall what happened but explained she must have documented in error.On 1/13/26 at 4:17 PM, the Sunflower Way UM acknowledged the documentation on the MAR was incorrect for 1/12/26 and 1/13/26. With the resident's permission to look into his drawers, the UM found the TED hose. Resident #45 stated he had never worn them, and he did not wish to wear them. The UM verified the physician should be notified the resident did not wish to wear the ordered TED hose.On 1/14/26 at 11:30 AM, the assigned Certified Nursing Assistant (CNA) C said that resident #45 often refused care, would refuse to wear his brace, and did not wear the TED hose. The CNA said she did not recall putting the hose on him. 1/14/26 at 12:47 PM, resident #45's sister and his POA stated she visited once or twice a week and had never seen resident #45 with the TED hose on.On 1/15/26 at 2:45 PM, the Director of Nursing and the Nursing Home Administrator acknowledged nurses were expected to accurately document whether orders were implemented in the medical record and not simply check off boxes.The facility's policy on Clinical/Medical Records revised on 8/25/17 indicated that clinical records were maintained in accordance with professional practice standards to provide complete and accurate information on every resident for continuity of care.

Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene during medication administration and failed to sanitize equipment between residents per infection control standards to prevent cross-contamination and the spread of infection, for 1 of 4 nurses reviewed for medication administration.Findings: On 1/13/26 at 9:00 AM, Licensed Practical Nurse (LPN) A was observed for a medication pass on resident #128. She took resident #128's blood pressure, set the used cuff on top of her cart, but did not clean or sanitize it. The nurse made two trips to the medication room, touched the medication machine, handled the medications, but did not perform any hand hygiene. She entered the resident's room three different instances passing the hand sanitizer dispenser located to the right of the doorway each time. There was also a full bottle of alcohol-based hand sanitizing solution on her cart, which she did not use. On 1/13/26 at 9:18 AM, LPN A confirmed she was aware she should sanitize her hands with alcohol-based hand sanitizing solution each time she entered or exited a room. She said, I forgot, I'm so sorry. On 1/14/26 at 11:42 AM, the Infection Preventionist confirmed all staff had regular training on infection prevention including hand hygiene. She said staff were expected to perform hand hygiene before they handled medications, before and after they put on gloves, between residents, before they go into the medication room, and after they come out of any room, to avoid contamination. The Infection Preventionist explained that sometimes staff got busy and forgot but stressed that handwashing was important to prevent germ transmission. Review of the 2025 education log revealed all staff were educated on infection control once a month for the last year, excluding the month of September. On 1/15/26 at 10:45 AM, the Director of Nursing explained the best way to control infection, We have educated our staff since the day they were hired on hand hygiene, personal protective equipment, and to clean equipment before and after use. Review of the Hand Hygiene policy dated 2/05/21 read, Hand hygiene should be performed before and after patient care, after contact with inanimate objects (including medical equipment), and antiseptic hand wash or rub may be used. Review of the Medication - Oral Administration policy and procedure, dated 8/15/19 directed staff to, Perform hand hygiene prior to [when] administration begins.

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available on 2 of 3 units to meet residents' needs related to timely administration of scheduled medications, (Cliffstone and Pebblestone). Findings: Observations on 4/15/24 at 10:53 AM, and at 12:43 PM, showed Registered Nurse (RN) O at her medication cart still administering 9:00 AM medications. On 4/15/24 at 6:02 PM, RN O stated she completed the scheduled 9:00 AM medications at approximately 12:00 PM to 12:30 PM. She stated medications were supposed to be given either one hour before or one hour after the scheduled medication times. On 4/16/24 at 10:07 AM, and at 10:47 AM, RN M was observed in the process of medication administration on Cliffstone unit. On 4/16/24 at 10:50 AM, RN M stated he had three additional residents who had not received their 9:00 AM medications. He explained he was delayed because he had to explain each medication to another resident. On 4/16/24 at 11:12 AM, RN M was again observed at his medication cart. He stated he had one more resident to give 9:00 AM medications to. On 4/16/24, resident #90 was observed on the Pebblestone Unit receiving his scheduled 9:00 AM medications from Licensed Practical Nurse (LPN) J over 2 hours late at 12:08 PM. On 4/17/24 at 10:38 AM, LPN C, was observed at her medication cart on the Cliffstone unit. She stated she had twelve residents left to give 9:00 AM medications to. On 4/17/24 at 12:47 PM, LPN C stated she started working at the facility two months ago and had not worked on the Cliffstone unit in over a month. She explained she was not stationed on a specific unit, and every time she worked, she was assigned to a different unit, so she tried to familiarize herself with the new residents and their medication routines. LPN C acknowledged she completed the scheduled 9:00 AM medications about 2 hours late, at approximately 12 PM. She said it was, unrealistic to safely pass medications for 30 residents in a 2-hour window, and complete other tasks that needed her attention. She acknowledged late medications were considered a medication error if they were given after the 1 hour before or after window. The LPN explained she took her time during medication administration, to ensure she did not make a mistake. She stated she had received education from Administration that medications should be given within one hour before or one hour after the scheduled time. On 4/17/24 at 2:57 PM, late medication administration observations were discussed with the Director of Clinical Services (DCS), and the Regional DCS. The Regional DCS stated the facility had an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting on 3/19/24 after on-time completion of medication administration was identified as a concern. The DCS and Regional DCS explained the facility had an opportunity to go to liberalized medication administration times in response to the identified concerns about late administration of medications. They described this action would take some time to put into place as processes and education to staff needed to be worked out. They shared other actions put into place including audits which included observations, helping staff with technique, cleaning up medication carts, and reducing unnecessary medications with assistance from the Medical Director. These audits were reviewed in another QAPI meeting held on 3/28/24. The DCS and Regional DCS confirmed audits, and QAPI meetings did not address staffing concerns, nor did they address actions needed to address timely administration of medications in the interim, while the facility waited to transition to liberalized medication administration times.

Based on observation and interview, the facility failed to ensure beverages and dishware were stored and served in a safe and sanitary manner to prevent foodborne illness. Findings: 1. On 4/15/24 at 9:58 AM, during the initial observation of kitchen with the Certified Dietary Manager (CDM), it was noted plate bases were placed on the drying rack stacked together without room to allow air flow for drying. Wet trays were stacked on top of each other in a pile, not allowing air flow for drying. Additionally, wet drinking glasses were placed on a tray upside down with no room between lip of glass and tray for air flow for drying. The CDM stated a tray liner was supposed to get placed between the lip of the glasses and the tray for air flow when drying. On 4/18/24 at 1:51 PM, during a follow-up kitchen observation with the CDM, plate bases were again seen placed on drying rack stacked together without room for air flow for drying and wet drinking glasses were placed on a tray upside down with no room between lip of glass and tray for air flow for drying. Tray liners the CDM had cut during the initial kitchen observation were seen piled on a cart in the corner of the kitchen away from the working area, unused. 2. On 4/15/24 at 12:40 PM, during meal observation in the dining room, a container of thickened lemon water dated 3/01 was open on the beverage cart. The Activities Director stated he provided beverages for residents at the lunch meal and the container of thickened lemon water was not present on the beverage cart when he poured the drinks. He explained if he had seen the container with the date 3/01, he would have taken it back to the kitchen to get a fresh one. The Activities Director removed the container from the dining room. A few minutes later, the CDM, the District Manager for the contracted food service management company, and the Dietary cook, came to the dining room with the aforementioned thickened liquid beverage container. They stated the 3/01 date on the container indicated when the container was received into the facility. They explained, the beverage container provided to the dining room was opened that day but acknowledged staff failed to appropriately label the container with the opened date. On 4/18/24 at 2:05 PM, the nourishment pantry on the 300 unit was observed and found to have an opened container of thickened lemon water dated 3/10. The Executive Director (ED) was present and read the directions on the container which indicated the product was to be disposed of within 7 days after opening. The ED confirmed the date on the thickened lemon water container was well past the 7 days the product could be safely kept as directed by the label. The ED disposed of the container.

Based on observation, interview, and record review, the facility failed to promote dignity in dining for 3 of 3 residents reviewed for dignity, of a total sample of 46 residents, (#77, #86, and #265). Findings: 1. Review of resident #77's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, mild protein-calorie malnutrition, and dysphagia. Review of resident #77's Minimum Data Set (MDS) annual assessment with Assessment Reference Date (ARD) of 3/18/24 revealed a Brief Interview for Mental Status (BIMS) score was not obtained because she was rarely/never understood. The MDS assessment noted resident #77 was totally dependent on staff for all activities of daily living (ADLs), including eating. Review of resident #77's care plan, initiated on 7/12/22, revealed she had an ADL self-care performance deficit related to Alzheimer's disease, generalized weakness, gait/balance problems, and incontinence. On 4/15/24 at 12:32 PM, Certified Nursing Assistant (CNA) E was observed feeding resident #77 while standing by her bed. At 12:36 PM, CNA E continued feeding resident #77 while standing. Later at 12:47 PM, CNA E stated she had 3 residents who needed eating assistance on today's assignment. She indicated she, Sometimes sits, otherwise remains standing while helping the resident, whatever is more comfortable, to her. She explained she received her training in CNA school and was oriented by another CNA when hired by the facility. She stated she never had any issues standing up to feed residents before. On 4/15/24 at 12:58 PM, and 1:11 PM, Unit Manager (UM) G was also observed feeding resident #77 while standing next to her bed. 2. Review of resident #86's medical record revealed he was admitted to the facility on [DATE] with diagnoses including stroke, aphasia (inability to speak), dysphagia (difficulty swallowing), Alzheimer's disease, dementia, and failure to thrive. Review of resident #86's MDS quarterly assessment with ARD of 3/06/24 revealed a BIMS score was not obtained because he was rarely/never understood. The MDS assessment noted resident #86 was totally dependent on staff for all ADLs, including eating. Review of resident #86's care plan, initiated on 1/09/23, revealed he had an ADL self-care performance deficit related to previous stroke, aphasia, lack of coordination, and dementia. On 4/15/24 at 12:28 PM, resident #86 was seated in bed eating lunch assisted by UM G who was standing next to him. On 4/15/24 at approximately 5:35 PM, CNA F was observed assisting resident #86 to eat while she stood next to his bed. At 5:47 PM, CNA F stated she did not have much space to place a chair next to the bed, so she stood and fed him. She confirmed she was supposed to be seated while assisting residents to eat. 3. Review of resident #265's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including Parkinsonism, anxiety, and contractures of the left elbow, left wrist, and left and right hands. Review of resident #265's MDS quarterly assessment with ARD of 1/22/24 showed a BIMS score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment revealed resident #265 was totally dependent on staff for ADLs, including eating. Review of resident #265's ADL self-care performance care plan initiated on 4/15/24 revealed she was totally dependent on staff for eating. On 4/15/24 at 12:25 PM, and 12:33 PM, CNA D was observed standing next to resident #265 assisting the resident to eat lunch while she sat in a recliner chair. On 4/15/24 at 1:02 PM, CNA D stated she preferred to stand while assisting residents to eat because she was busy. CNA D referred to resident #86 as a, Feeder, who ate well during the conversation about other residents who required eating assistance. She asked, How can I be seated to assist them? She indicated in Florida it was up to the CNA if they wanted to sit or not while assisting residents to eat. CNA D stated she did not recall if this was discussed during her facility orientation. On 4/16/24 at 11:14 AM, UM G stated staff usually stood up next to the residents when they assisted them to eat. She explained there were not always chairs available in the rooms. She mentioned it was important to be at eye level with residents to observe their eating, and therefore she preferred to be, Up and ready to go. She stated she was not aware of any specific requirements about assisting residents to eat. She said she guessed, It all depends. She noted she had previously seen CNAs standing while assisting residents to eat and had not had an issue with it. On 4/17/24 at 11:10 AM, the Director of Nursing stated he provided education to all new staff upon hire. He explained a Skills Competency Assessment: Eating Support form was conducted for all CNAs upon hire and annually. He reviewed the form and stated it did not specify staff should be seated versus standing because of the resident's right to dignity, only that CNAs needed to sit to be at the same level as the resident. Review of the Skills Competency Assessment: Eating Support revealed CNA D, E, and F met the competency by direct observation or return demonstration and fully met standards on 9/08/23, 1/10/24, and 11/15/23 respectively. Review of the Roadmap / New Hire Orientation: All Staff Mandatory Education/Information to be Provided form revealed UM G received education on Understanding Resident Rights on 11/07/23. Review of the policy and procedures titled Resident Rights dated 11/30/14 read, It is the policy of The Company to. Ensure that resident' rights are known to staff. The policy included ongoing resident rights training would be given to staff members.

Based on observation, interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was conducted and failed to obtain a physician's order for self-administration of medication for 1 of 10 residents reviewed for choices, of a total sample of 46 residents, (#30). Findings: Resident #30 was admitted to the facility on [DATE], with diagnoses which included poly-osteoarthritis, hypertension, adjustment disorder with mixed anxiety and depressive mood, bilateral artificial knee joint, and hyperlipidemia. Review of the resident's quarterly Minimum Data Set assessment with Assessment Reference Date of 2/05/24, revealed the resident's cognition was intact, with a Brief Interview For Mental Status score of 13 out of 15. Observations on 4/15/24 at approximately 12:04 PM, and on 4/16/24 at 5:14 PM, showed a container of Biofreeze gel on resident #30's tray table. The resident stated she used the medication on her shoulders and neck for pain approximately three to four times daily. Biofreeze (for use on the skin) is used to treat adults .to provide temporary relief of muscle or joint pain caused by strains, arthritis, bruising, or backaches (retrieved on 4/29/24 from drugs.com). On 4/16/24 at 5:16 PM, observation of the resident's tray table was conducted with Registered Nurse (RN) M. He acknowledged the Biofreeze gel on the resident's tray table, and resident #30 verbalized she used the medication on her neck, shoulders, and knees. On 4/16/24 at 5:31 PM, RN M stated residents needed a physician's order to self-administer medications, and medications were not to be kept at the resident's bedside. Resident #30's physician's orders were reviewed with RN M. He stated the resident had an order for nurses to apply Biofreeze to her bilateral knees as needed but did not have an order for the medication to be applied to her shoulders and neck. RN M confirmed a physician's order for the resident to self-administer the medication was not found. On 4/18/24 at 6:20 PM, the Director of Clinical Services stated residents needed an evaluation, and a physician's order for self-administration of medication before they were allowed to self-medicate. The facility's policy, Self-Administration of Medication at Bedside with effective date of 11/30/2014, and revision date of 8/22/2017 read, Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. The procedure indicated staff should, Verify physician's order in the resident's chart for self-administration of specific medications . Complete self-administration of Medications Evaluation, and read, The MAR (Medication Administration Record) must identify meds (medications) that are self-administered .if kept at bedside, the medication must be kept in a locked drawer.

Based on observation, interview and record review, the facility failed to revise care plans to reflect accurate, appropriate, and individualized interventions related to showers/bathing and eating needs for 3 of 8 residents reviewed for activities of daily living (ADLs), of a total sample of 46 residents, (#31, #77 and #86). Findings: 1. Review of resident #31's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes and mood disorder. Review of resident #31's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) of 2/09/24 revealed he was totally dependent on staff for showers/bathing, lower body dressing and putting on/taking off footwear. Review of resident #31's care plan, revised on 8/30/22, revealed a focus on ADL self-care performance deficit related to hemiplegia, limited mobility, difficulty walking and poor communication. The interventions incorrectly noted he was able to bathe/shower with maximum assistance from staff and required moderate to maximum assistance by staff to dress. 2. Review of resident #77's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, mild protein-calorie malnutrition, and dysphagia (difficulty swallowing). Review of resident #77's MDS annual assessment with ARD of 3/18/24 revealed she was totally dependent on staff for all activities of daily living (ADLs). Review of resident #77's MDS quarterly assessment with ARD of 12/18/23 revealed she was totally dependent on staff for all ADLs. Review of resident #77's care plan, initiated on 7/12/22, revealed a focus on ADL self-care performance deficit related to Alzheimer's disease, generalized weakness, gait/balance problems, and incontinence. The interventions incorrectly noted resident #77 was able to perform eating and personal hygiene/oral care tasks with extensive assistance from staff. 3. Review of resident #86's medical record revealed he was admitted to the facility on [DATE] with diagnoses including stroke, aphasia (inability to talk), dysphagia, Alzheimer's disease, dementia, and failure to thrive. Review of resident #86's MDS quarterly assessment with ARD of 3/06/24 revealed he was totally dependent on staff for all ADLs. Review of resident #86's care plan, initiated on 1/09/23, revealed a focus on ADL self-care performance deficit related to cerebral infarction, aphasia, lack of coordination, and dementia. The interventions incorrectly noted resident #86 was able to perform dressing and personal hygiene with extensive assistance from staff. It also noted he was able to eat with moderate assistance from staff. On 4/18/24 at 3:47 PM, the MDS Lead explained the MDS assessment captured how residents performed at the time of the assessment. She noted the functional assessment was completed in collaboration with therapy. She stated the care plan should reflect the results of the MDS assessment. On 4/18/24 at 4:03 PM, the MDS Coordinator stated she was responsible for participation of care plan meetings, completing MDS assessments and updating care plans. She explained care plan updates correlated with the findings of the MDS assessments. She indicated the care plan was reviewed and updated at least quarterly or sooner if needed. She stated updating the care plan was important to ensure staff provided care of residents' personal needs appropriately. She validated the care plan should have read dependent on the noted ADLs for residents #77, #86, and #31. Review of the facility's policy titled, Plans of Care revised on 9/25/17 read, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The procedure included review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each . MDS assessment.

Based on observation, interview, and record review, the facility failed to identify, and obtain physician orders for treatment of non-pressure related skin conditions for 2 of 2 residents reviewed for non-pressure related skin conditions, of a total sample of 46 residents, (#42, & #56). Findings: 1. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Chronic Obstructive Pulmonary Disease, dementia, peripheral vascular disease, edema, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/11/24, revealed the resident's cognition was severely impaired, with a Brief Interview For Mental Status (BIMS) score of 00 of 15. The assessment indicated the resident was dependent on staff for toileting hygiene, chair/bed-to-chair transfers, and required substantial/maximum assistance to roll left/right, and for personal hygiene. On 4/18/24 at 10:00 AM, resident #42 was lying in bed on his back, Certified Nursing Assistant (CNA) N was at the resident's bedside. A gauze dressing was noted to the resident's lower left leg dated 4/05/24. On 4/18/24 at 10:26 AM, the [NAME] Hall/Sunflower Way Unit Manager (UM)-Licensed Practical Nurse (LPN) stated the resident did not have a pressure injury, and she was not aware of any wound/dressing to the resident's lower left leg. On 4/18/24 at 10:29 AM, observation of the dressing to the resident's left lower leg was conducted with the UM. She acknowledged the dressing to the resident's left lower leg dated 4/05/24, and stated she would have to change the dressing, to see what was under it. Review of the resident's physician orders conducted with the UM revealed no orders for treatment of a wound on the resident's left lower leg. Review of skin checks completed on 3/30/24, and 4/06/24 identified a wound to the front of the resident's left lower leg. However, there was no documentation to indicate the physician was made aware, nor any orders for wound care were obtained. The UM stated wound care/dressings required a physician's order, and verbalized she could not identify any orders for wound care/treatments for the resident's left lower leg. 2. Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included metabolic encephalopathy (brain dysfunction related to metabolism), fracture of nasal bones, diabetes type II, major depressive disorder, contracture of the right and left shoulder, atrial fibrillation, hypertension, and malignant neoplasm (cancer) of the prostate. Review of the resident's quarterly MDS with ARD of 1/15/24 revealed the resident's cognition was moderately impaired, with a BIMS score of 08 of 15. The resident required substantial/maximal assistance with personal hygiene, and partial/moderate assistance with chair to bed-to chair transfer. Observations on 4/15/24 at 1:02 PM, 4/16/24 at 9:55 AM, and 5:26 PM, and on 4/17/24 at 10:42 AM, revealed resident #56 in bed with an undated gauze dressing on his left arm extending from his elbow to his wrist. A dried, dark rust-colored stain was noted on the dressing close to the resident's elbow. On 4/17/24 at 4:56 PM, LPN C stated the dressing to the resident's left arm was, probably, from his recent fall on 4/07/24. The resident's physician's orders were reviewed with the LPN, and she could not identify a physician's order for dressings/treatment to the resident's left arm. On 4/17/24 at 5:20 PM, the Director of Clinical Services stated he did not know what was under the dressing on the resident's left arm. The Director of Clinical Services stated review of the resident's admission assessment revealed the resident had bruises and a skin tear to his right hand, and his right antecubital. He reviewed the resident's physician orders and could not identify any order for dressing/treatment to the resident's left arm. He explained staff must have a physician order for dressings/wound care. On 4/17/24 at 5:33 PM, observation of the resident's left arm dressing was conducted with the Director of Clinical Services. He acknowledged the gauze dressing to the resident's left arm was undated and had a dried, dark rust-colored-stain near the elbow. On 4/17/24 at 5:36 PM, the Registered Nurse/Wound Care Nurse, reviewed the resident's clinical records, and shared she could not identify any documentation regarding the gauze dressing/wound care to the resident's left arm, and confirmed there were no notes by the wound care Advanced Practice Registered Nurse (APRN) to address the wound/treatment to the resident's left arm. On 4/18/24 at 9:12 AM, the Director of Clinical Services (DCS) stated the gauze dressing was removed from the resident's left arm, and skin tears to the resident's forearm, knuckles, and hand were noted. He stated the observations were identified after the resident's fall on 4/07/24, but treatment orders were not obtained and in place until 4/17/24. The DCS stated that upon readmission on 4/10/24, a nurse provided a dressing to the resident's left arm, but an order was not obtained as required. Progress note documented by the Wound Care Nurse on 4/17/23 at 7:54 PM, read, Resident with skin tear to left hand and arm. A care plan for potential for skin impairment initiated on 5/03/21 with revision on 3/22/24 revealed that staff should, Follow facility protocols for treatment of injury.

Based on observation, interview, and record review, the facility failed to ensure Occupational Therapy (OT) recommendation for Restorative Nurse Program (RNP) for Range of Motion (ROM) was initiated and maintained for 1 of 1 resident reviewed for limited ROM, of a total sample of 46 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, fibromyalgia, contracture of the left hand, left elbow, and left shoulder, pseudobulbar affect, schizoaffective disorder-Bipolar type, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 3/15/24 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status BIMS score of 12 out of 15. The assessment indicated the resident had impairment in functional limitation in ROM to one side of her upper and lower extremities and was dependent on staff assistance with toileting and personal hygiene. On 4/15/24 at 1:29 PM, resident #47 was lying in bed on her back. The resident's left hand was contracted, and a splint was not noted. The resident stated she did not have a splint, and she was not receiving therapy. On 4/17/24 at 10:31 AM, Restorative Certified Nursing Assistant (CNA) L stated resident #47 was not on the RNP and did not have a splint. On 4/17/24 at 11:28 AM, the Director of Rehabilitation stated the resident had contractures to her left hand and wrist, and since November 2023, the resident had not been seen by therapy. She stated the resident refused splints, and after three refusals, the splint program was stopped. The Director of Rehabilitation stated the facility's Rehabilitation company changed on 11/01/24, and resident #47 was not in therapy when the transition from one company to the other company occurred. The Director of Rehabilitation explained that when residents were discharged from therapy with a splint, the resident would be referred to the RNP. She said, if the resident refused or disliked the splint, therapy would review, and transition the resident to the RNP to continue with ROM. The Director of Rehabilitation stated the resident was not on therapy's caseload and she could not identify any documentation to indicate the resident was discharged to RNP for ROM exercises. She stated the resident's contractures had not been managed since November 2023, and acknowledged since the resident had not been on therapy caseload or the RNP, her contractures could have worsened, and a new screen would have to be done for comparison/determination. Review of the Occupational Therapy Discharge Summary with dates of service from 12/28/22 to 2/17/23 revealed resident #47 was discharged from OT and referred to RNP. Documentation for the discharge recommendations read, Restorative program for positioning and Left upper extremity ROM established and educated to Nursing and restorative staff. Prognosis to maintain CLOF (current level of function) excellent with consistent staff support, excellent with participation in RNP. On 4/17/24 at 12:00 PM, the Licensed Practical Nurse/MDS Coordinator shared that she assisted with the facility's RNP. She explained she received the communication form from therapy, coordinated data, and placed therapy's recommendation(s) as a task in the facility's electronic medical records for the Restorative CNA. A review of the resident's clinical records by the Licensed Practical Nurse/MDS Coordinator revealed no indication that resident #47 was on the RNP. On 4/18/24 at 2:36 PM, the resident's recommendation from OT was reviewed with the Director of Rehabilitation. She acknowledged the resident's discharge recommendation was for left upper extremity ROM by the RNP, and documentation indicated the task was established and education was provided to the. Nursing and restorative staff. The Rehabilitation Director stated no documentation was identified to indicate therapy recommendation for RNP was followed for the resident. The Director of Rehabilitation stated the facility did not have a policy for contracture management, but had documentation to assist with contracture management which included ROM.

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered per physician orders for 2 of 2 residents reviewed for oxygen therapy, of a total sample of 46 residents, (#14 and #58). Findings: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), and cerebral infarction (stroke). The Minimum Data Set (MDS) modification of the quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status, (BIMS) of 15 which indicated the resident was cognitively intact. The assessment also reflected resident #14 received oxygen. Observations on 4/15/24 at 3:17 PM, and 4/16/24 at 10:28 AM, revealed resident #14 wearing a nasal cannula attached to an oxygen concentrator set at 6 liters per minute (LPM) of oxygen. Review of the Order Summary Report dated 3/15/23 revealed a physician's order for oxygen at 10 LPM by nasal cannula, every shift. On 4/16/24, the order was changed to oxygen at 6 LPM by nasal cannula every shift. Review of the COPD care plan indicated an intervention dated 3/15/24 and revised on 3/18/24 which described staff should follow physician orders for oxygen settings. On 4/16/24 at 10:30 AM, Unit Manager (UM) A checked her computer and stated resident #14's oxygen concentrator should be set to 10 LPM. UM A observed resident #14's oxygen concentrator in his room, and confirmed it was set at 6 LPM, not the 10 LPM ordered by the physician. The UM adjusted the oxygen flow rate of the concentrator to 10 LPM. The UM described the protocol for ensuring oxygen was delivered as ordered was the nurse should check the concentrator flow rate at the beginning of the shift. 2. Resident #58 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, heart failure, mood disorder, and anxiety. The MDS modification of the significant change assessment dated [DATE], revealed he was rarely or never understood, was severely, cognitively impaired, and received oxygen therapy. Observations on 4/15/24 at 2:00 PM and 4/16/24 at 10:27 AM, revealed resident #58 in his room wearing a nasal cannula connected to an oxygen concentrator set at 1.5 LPM. Review of the Order Summary Report dated 3/26/24 revealed an order for continuous oxygen at 2 LPM by nasal cannula. Review of the cardiovascular care plan indicated an intervention dated 2/09/23 and revised on 10/10/23 for oxygen settings, give oxygen as needed. The oxygen therapy care plan had an intervention dated 11/07/23, revised on 4/04/24 for staff to administer oxygen by nasal cannula per physician orders. On 4/16/24 at 10:32 AM, UM A checked her computer and stated resident #58's oxygen concentrator should be set to 2 LPM. A short time later, UM A observed resident #58's oxygen concentrator in his room, and confirmed it was set at 1.5 LPM, not the 2 LPM ordered by the physician. UM A adjusted the oxygen concentrator flow rate to 2 LPM. The UM reiterated that the nurse should check the oxygen flow rate at the beginning of the shift to ensure it was given as ordered by the physician. On 4/18/24 at 6:00 PM, the Director of Nursing stated his expectation was the nurse would follow the physician orders for oxygen settings and check the concentrator at the beginning of the shift and also with each medication administration. He explained it was important for the resident to receive the correct amount of oxygen especially for a resident with a diagnosis of COPD.

Based on observation, interview, and record review the facility failed to ensure medications were administered within the designated guidelines, and per professional standard and practices, for 2 of 7 residents observed during medication administration, of a total sample of 46 residents, (#30, & #90). Findings: 1. Resident #30 was admitted to the facility on [DATE], with diagnoses which included poly-osteoarthritis, hypertension, adjustment disorder with mixed anxiety and depressive mood, bilateral artificial knee joint, and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/05/24, revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 13 out of 15. On 4/17/24 at 5:10 PM, resident #30 said she received her scheduled 9:00 AM medications sometime around 10:30 AM depending on what the nurse was doing. Review of the resident's Medication Administration Audit Report for the period 4/15/24 to 4/17/24 revealed on 4/15/24 resident #30 received her scheduled 9:00 AM medications between 11:06 AM and 11:24 AM, which included Bupropion 300 milligram (mg) daily (QD) for depression, Metoprolol 25 mg QD for high blood pressure, and Tizanidine 2 mg twice daily for muscle spasms, a second dose of Tizanidine was administered at 5:58 PM. On 4/17/24, resident #30 received her scheduled 9:00 AM medications at 12:21 PM, which included Levofloxacin 750 mg QD for pneumonia. On 4/17/24 at 12:47 PM, Licensed Practical Nurse (LPN) C stated she knew it was a medication error if medications were given after a specific time and verbalized she took her time when administering medications, because she did not want to make a mistake. LPN C stated she was told by the Administration that medications should be given one hour before or one hour after the scheduled time. She explained it was not realistic to safely complete the medication administration in the allotted time. On 4/17/24 at 2:57 PM, the late medication administration observations were discussed with the Director of Clinical Services (DCS), and the Regional DCS. They acknowledged resident #30's scheduled 9:00 AM medications were given outside of the parameters. 43192 2. Review of resident #90's medical record revealed he was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, atrial fibrillation, anemia, and osteoarthritis. Review of resident #90's MDS quarterly assessment with ARD of 3/08/24 revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. On 4/16/24 at 12:08 PM, LPN J entered resident #90's room and told him she was there to give him his medications. She indicated she was helping his assigned nurse to pass medications. She did not tell resident #90 which medications she was giving to him. When she left the room, resident #90 asked, What was that medicine for? Review of the physician orders revealed the following medications were scheduled for administration at 9:00 AM: Aspirin 81 mg, Mirtazapine 7.5 mg, Tamsulosin 0.4 milligrams (mg), Vitamin C 500 mg, Eliquis 5 mg, Furosemide 40 mg and Metoprolol 37.5 mg. A second dose for Eliquis and Furosemide were scheduled for 10:00 PM. A second dose for Metoprolol was scheduled for 9:00 PM. Review of resident #90's Medication Administration Audit Report revealed 9:00 AM medications on 4/16/24 were actually administered at 12:08 PM. The policy Administering Medications revised April 2019 read, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained for self administration of medications. Findings: Review of the facility's QAPI Plan revealed the QAPI team would identify, collect and analyze data from different departments reflecting performance and establish benchmarks for each area. The form indicated the team would analyze the problem area by conducting a root cause analysis, identify solutions and develop a Performance Improvement Plan (PIP) to address the identified area. The PIP would include goals, actions responsible party, target dates and status/outcome with results reported monthly to the QAPI committee. Completed PIPs would be filed and monitored periodically to assure achievements were being sustained. Concerns with self-administration of medication was identified and cited at F554 on the previous recertification survey conducted 10/23/23 through 10/26/23. During this survey, concerns with self-administration of medications were again identified and the facility was found to be in noncompliance with F554. Insufficient auditing and oversight by the QAPI committee to prevent the citation was identified as a result of the repeat concerns regarding self-administration of medications. On 4/18/24 at 6:25 PM, the Administrator stated the facility constantly educated staff on medications at bedside and department heads conducted daily room rounds. She explained medications at bedside was a challenge because residents purchased them on outings or family members brought them in. She stated the department heads were supposed to look at bedside areas to identify medications during their rounds. She could not explain why medications were still found at bedside without resident assessments for self-administration of medications when facility improvement actions were in place. The Administrator acknowledged a change to the room rounds process should be addressed to identify issues found by the survey team.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment while handling linens to prevent cross-contamination and spread of infection and failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards. Findings: 1. On 4/17/24 at 3:06 PM, Laundry Attendant K was stocking a linen cart with clean bed sheets, blankets, and pads on the [NAME] unit. One sheet fell on the floor, and she picked it up, flapped it, folded it and placed it back in the cart on top of clean linens. On 4/17/24 at 3:07 PM, Laundry Attendant K acknowledged she picked up the bed sheet from the floor and placed it back with the clean linens. She stated she was not supposed to pick up items from the floor and put them with clean supplies because the floor was considered dirty. On 4/17/24 at 5:30 PM, the Housekeeping/Laundry Manager stated Laundry Attendant K told her she made a mistake and placed a dirty sheet she had picked up from the floor with the clean sheets. She explained if linens fell on the floor, the employee needed to put them in a plastic bag and leave the bag in the soiled utility room. She indicated the sheet on the floor was considered contaminated and could not be placed with the clean linens. 2. On 4/18/24 at 9:44 AM, Certified Nursing Assistant (CNA) I walked out of room [ROOM NUMBER] wearing gloves and walked into room [ROOM NUMBER] with the same gloves on. She touched the mattress, linens, and a pillow. She removed the gloves, stepped outside room [ROOM NUMBER] but did not perform hand hygiene. On 4/18/24 at 9:46 AM, CNA I stated she was a new employee who had started at the facility on 3/28/24. She acknowledged she received Infection Control education during her new hire orientation. CNA I indicated she went into room [ROOM NUMBER], checked the resident in bed B then went into the bathroom to look for a missing wallet for the resident in room [ROOM NUMBER]. She stated she was not supposed to move between rooms wearing gloves. CNA I said, That is wrong, and I should not have done it, my bad. A few minutes later, she noticed another staff sanitizing his hands, and acknowledged she should have sanitized her hands when she exited the resident's room to prevent the spread of infection. On 4/18/24 at 10:34 AM, the Infection Preventionist (IP) and the Director of Nursing acknowledged picking up linen from the floor and placing them with clean linens, wearing the same gloves from room to room, and not sanitizing hands could lead to cross-contamination and the spread of germs. The IP validated staff did not follow their Infection Control Standards. Review of the Skills Competency Assessment: Hand Hygiene revealed CNA I met the competency by direct observation or return demonstration and fully met standards on 3/26/24. Review of the Infection Control Policies and Procedures revised in October 2018 read, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the policy and procedure titled Handwashing/Hand Hygiene revised in August 2019 read, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy included hand hygiene was the final step after removing and disposing of PPE.

Based on observation, interview and record review, the facility failed to ensure a resident's bathroom was adequately equipped to allow residents to call for staff assistance through a communication system in 1 of 6 resident rooms reviewed for environmental status, (room [ROOM NUMBER]). Findings: On 4/15/24 at 12:12 PM and 4/16/24 at 5:16 PM, no call light system was noted in the bathroom shared by rooms #125 and #127. On 4/16/24 at 5:28 PM, resident #19 stated she used the bathroom by herself. She indicated she had been in the same room a few months and had not needed staff assistance while in the bathroom. She stated a resident in the other room who could not talk also used the same bathroom. Review of the Maintenance Work Orders binder in the [NAME] Hall Unit revealed there were 2 work orders for room [ROOM NUMBER] in March 2024. One of the work orders for room [ROOM NUMBER] was dated 3/26/24 for a broken toilet which was repaired on 4/01/24. On 4/16/24 at 5:49 PM, the Director of Maintenance explained his assistant worked on painting, repairing and renovating rooms. He indicated all department managers were assigned residents' rooms to inspect on a daily basis. He stated they used a mock survey sheet where they documented issues to be addressed and those were discussed during morning meetings. He explained the work orders on the nursing units were checked every day by himself or his assistant and addressed the same day. He stated call lights were located in each room by the bed and in the bathroom, some of them were next to the toilet and the showers. He indicated call lights were important in case someone fell so they could easily reach the call light and call for assistance. He explained the call lights next to the beds lit up outside the resident's room in a yellowish light color and red if the bathroom call light was activated so staff could differentiate when someone was in the bathroom. At 6:01 PM, a tour of the bathroom in room [ROOM NUMBER] with the Director of Maintenance was conducted. He stated a plate was covering the location where the call light would have been located. He mentioned that was, Probably like that for a long time. He stated he did not remember anyone mentioning to him there was no call light in that bathroom. On 4/16/24 at 6:06 PM, the Administrator stated all department managers inspected their assigned residents' room at a minimum of 3 times a day, and sometimes more often. She explained if they found something out of compliance they checked that room more often. She indicated the results of the inspections were documented in room round sheets and included checking call lights. She stated call lights should be within residents' reach near the toilet and their bed. She explained if a call light was non-functional, the resident received a call bell to use in the meantime. On 4/16/24 at 6:14 PM, an inspection of room [ROOM NUMBER] was conducted with the Maintenance Director and Administrator. Residents #19 and #97 confirmed they did not have call bells to use in the bathroom and the call lights they had were next to their beds. Administrator acknowledged there was no call system in the bathroom used by rooms #125 and #127. On 4/17/24 at 10:18 AM, the Assistant to the Maintenance Director recalled fixing the toilet in room [ROOM NUMBER] on 3/26/24. He explained the toilet caused a flood in the rooms and it was fixed immediately. He stated his focused was on fixing the toilet and he did not notice there was no call light system or cord in that bathroom. He indicated it was very important for the residents to have a way to call staff in case of an emergency. On 4/17/24 at 11:46 AM, the Maintenance Director stated he was unable to show evidence of call light audits. He indicated he checked the Work History Report in TELS (maintenance electronic records system) but it yielded no results. He explained some tasks were missing from his list and he had informed his Regional Director. He said regular audits of call lights were not part of his monthly inspection because it was not showing on TELS. He stated he learned of any call light issues from the mock survey observations. He indicated staff did not report it missing and his assistant did not notice it when he went to that room to fix the bathroom. Review of the policy and procedure titled Call Bell System - Inoperable reviewed on 8/22/17 read, Resident must have, at all times, a system to notify staff when assistance is needed. The call bell system is to be inspected on a regularly scheduled basis by Maintenance. If the call bell system is inoperable, in one room, one hall, or the entire unit the following procedure must be followed: Maintenance, the ED (Executive Director), and the DCS (Director of Clinical Services) must be notified immediately if any call bell or system is inoperable.

Based on interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was conducted for 1 of 1 resident of a total sample of 44 residents, (#151). Findings: Resident #151 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), generalized weakness, major depressive disorder, Myasthenia Gravis without acute exacerbation, nonrheumatic mitral (valve) prolapse, heart failure, and convulsions. Review of the Admission/Readmission Data Collection form with effective date of 8/16/23, revealed the resident was alert, and oriented. Review of the resident's Medication Administration Record (MAR) for the period 8/17/23 to 8/21/23, revealed code entries of 2 indicating drug refused for the resident's medications including, Prednisone 20 milligram (mg) for COPD on 8/18/23, Rosuvastatin 40 mg for elevated lipids on 8/17/23, and 8/18/23, Spironolactone 12.5 mg for heart failure on 8/18/23, and 8/19/23, Trazadone 50 mg 2 tablets every evening and bedtime for depression on 8/18/23, Cellcept 500 mg two times daily, for mitral valve prolapse on 8/17/23, 8/18/23, and 8/19/23, Eliquis 5 mg every 12 hours for blood thinner, on 8/17/23, and 8/18/23, Topamax 25 mg morning and bedtime for convulsions, on 8/17/23, and 8/18/23, Toprol 50 mg every 12 hours for high blood pressure on 8/17/23, and 8/18/23. The MAR code 9 indicated other/See nurses notes was documented for medications including, Levothyroxine 75 microgram (mcg) for low thyroid on 8/18/23, and 8/19/23, Mestinon 60 mg (Pyridostigmine Bromide) every 8 hours for Myasthenia Gravis, on 8/17/23, 8/18/23, 8/19/23, and 8/20/23, Trazadone 50 mg 2 tablets every evening on 8/17/23, and Topamax 25 mg morning and bedtime, on 8/17/23, and 8/19/23. A progress note dated 8/17/23 at 2:44 PM, read resident take her own medication and at 5:40 PM resident refused and said that take her own medication. Progress note dated 8/18/23 at 5:02 AM, read Patient refused all night and morning medications . Patient indicates that she will only take the medications she has in the room. Review of the resident's physician orders/order summary from 8/16/23 to 8/25/23 revealed no physician's order for self-administration of medications. On 10/24/23 at 4:09 PM, the Director of Nursing (DON) recalled resident #151 had all her medications at her bedside and insisted to administer the medications herself. The DON stated the resident's daughter was approached, and she verbalized the resident's cognition was intact, and she could manage her own medications. The DON stated the Medical Director who was the resident's primary physician was made aware. The DON explained the Medical Director was not in agreement with the resident self administering her medication and did not give an order to self-administer her medications. The DON verbalized the resident self-administered her medications despite not having a physician's order for self- administration. Review of the resident's clinical records with the DON revealed no documentation to indicate what medications were self-administered. He stated documentation was the resident refused the facility's medications and preferred to take her own. On 10/24/23 at 5:37 PM, the Medical Director recalled nursing staff told him at admission that resident #151 refused the facility's medications and wanted to take her medications herself. He stated he reviewed and verified the resident's medications, and discussed with her that she had an extensive medication list with over ten medications. He noted the medications included some muscle relaxer, Trazadone, medications with the potential to be abused, and potential for overdose. He stated he discussed with the resident that it was a huge liability, and would potentially put her at risk. He explained to her the nursing staff was trained and knew what medications to give her. The Medical Director stated he did not place an order for self-administration of medications for the resident due to her extensive medication list, and the potential for medication overdose/abuse. He stated he had a 'bit of conflict as the resident refused to let the facility hold her medications, and it would be an impingement of the resident rights if the facility confiscated her medications. He recalled he had a conversation with resident #151, informing her that she was not allowed to take her medications without a self-administration order, and he left with the understanding the resident would allow the facility to give her the medications. He verbalized the resident was consistently saying she knew what her pills looked like and did not like her pills brought to her in a cup. He said the resident told him she would feel more comfortable, if pills were taken from package, and placed in the medication cup in front of her. The Medical Director stated his recommendation was that nursing staff prepared medications in front of the resident, to make her more comfortable/compliant in taking her medications. He acknowledged he could not say for sure if this was being done. On 10/25/23 at 11:00 AM, the DON stated he reviewed the documentation and could not be positive what medications the resident self-administered. On 10/26/23 at 1:35 PM, Registered Nurse (RN) A recalled having resident #151 in her assignment for one shift. She remembered she prepared the resident's medications but when she went to the resident's room, the resident told her she would take her own medications. RN A stated she asked the resident if she knew what medications she was taking, and the resident said she had a list of her medications and showed her the medication bottles. RN A stated she could not recall which medications resident #151 took. She conveyed the facility's protocol was to order residents' medications from the pharmacy. She explained that a physician order was required for self-administration of medications. She said she notified the physician that the resident insisted on taking her own medications and the physician said the resident was not supposed to self-administer her medications. The facility's policy Self-Administration of Medications at Bedside with effective date 11/30/2014, and revision date of 8/22/2017, read, Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. The procedure steps included, Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete Self-administration of Medication Evaluation .The MAR must identify meds that are self-administered.

Based on observation, interview, and record review, the facility failed to ensure an individualized activity program based on preferences and plan of care was provided for 1 of 2 dependent residents reviewed for Activities, of a total sample of 44 residents, (#73). Findings: Resident #73 was admitted to the facility on [DATE], with her most recent readmission on 9/11/23. Her diagnoses included Alzheimer's disease, generalized muscle weakness, symptoms and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/18/23, revealed the resident was rarely/never understood. The assessment noted daily and activity preferences indicated the resident liked listening to music, doing things with groups of people, and participating in favorite activities. Review of the Psychosocial Evaluation conducted on 4/01/22, revealed the resident preferred one on one, and small group activities. Her current interest included animals/pet, music, and television on Spanish channels. Documentation read, will receive 1:1 visits as tolerated. She enjoys watching Spanish TV channels, nail spa, listen to Spanish music, and hand massage. Observations on 10/23/23 at 11:24 AM, at 12:40 PM, at 3:49 PM, and on 10/25/23 at 10:15 AM, resident #73 was lying in bed on her back. She did not respond when spoken to, and no form of activities was noted. The television was not on, and no music was being played. On 10/25/23 at 10:22 AM, the Director of Activities stated that bird therapy, and room visits were provided by the Activity Department for dependent residents. He stated resident #73 did not do much but liked to listen to music. The Director of Activities stated the Activities Assistant documented on the Activity Log when room visits were made. Review of the Activity log for the period 9/15/23 to current revealed no documentation to indicate room visits or any form of activities were provided for resident #73. This was confirmed by the Director of Activities. On 10/25/23 at 10:30 AM, the Activities Assistant stated that in the morning, she went room to room, provided ice, and friendly visits to residents, and documented the interaction on the activity log. She stated she had done room visits with resident #73 but forgot to document the visits in the Activity Log. On 10/25/23 at 10:43 AM, Certified Nursing Assistant (CNA) B, stated resident #73 required total care for all her activities of daily living, and was on hospice services. CNA B stated the resident was confused, and activities were not provided for her. On 10/25/23 at 3:37 PM, the resident's Psychosocial evaluation, assessment of Section F of the resident's MDS, and interventions documented in the resident's care plan for activities was shared with the Activities Director. He stated he did not know what the resident required and had not reviewed the resident's Psychosocial evaluation or care plan. He verbalized he focused on residents admitted to the facility since he was hired. The Activities Director confirmed the resident's name was not on the activity log for 1 on 1 visits, and said he needed to work on understanding what each resident needed for their day-to-day activities. The resident's care plan noted she was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, and physical limitations was initiated on 4/11/22, and revised on 10/11/22. The goal noted the resident was to receive 1 on 1 visits as tolerated through the next review date. Interventions included, 1 on 1 visits as tolerated, enjoys watching Spanish TV channels, listen to Spanish music, hand massage, and needs bedside/in room visits and activities if unable to attend out of room events. The facility's policy Community Life Overview with effective date of 11/01/2021 read, Activity programs are developed and implemented to meet the individualized physical, mental, and psychosocial/emotional needs of the resident. The procedure indicated the facility should identify activities and programming of interest to the resident, and Document resident participation.

Based on observation, interview, and record review, the facility failed to ensure a Midline intravenous dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed of a total sample of 44 residents, (#152). Findings: Resident #152, an 84- year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included aphasia, occlusion and stenosis of unspecified cerebral artery, [NAME] fever, chronic obstructive pulmonary disease, heart failure, gastrostomy, and atrial fibrillation. Review of the Medical Certification for Medicaid Long-Term Care Services And Patient Transfer Form (3008) dated 10/16/23 revealed the resident's primary diagnosis was sepsis, and acute kidney injury. Documentation indicated the resident was alert, disoriented, could not follow simple instructions, and had a Midline that was inserted on 10/12/23. A midline . is a long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to safely administer medication into the bloodstream. (retrieved on 11/02/23 from www.uhs.nhs.uk). On 10/24/23 at 3:25 PM, resident #152 was lying in bed on his back. He was unable to answer questions. A Midline was noted to the resident's left upper arm. The midline dressing was lifting at the edges, and the dressing was dated 10/14/23. On 10/24/23 at 3:28 PM, observation of the resident's midline was conducted with the Director of Nursing (DON). He confirmed the date on the dressing was 10/14/23 and stated midline dressings should be changed every seven days, and resident #152's dressing should have been changed on 10/21/23. Review of the resident's physician orders revealed no order for dressing changes, or flushes for the resident's midline. The DON verbalized the resident was admitted to the facility from an acute care hospital on 10/16/23 with a midline that was inserted on 10/12/23. He stated the protocol was for the nurse to review the admitting orders with the physician, make the physician aware of the midline, and obtain an order for the midline dressing to be changed, flushed, or discontinued if not in use. The DON said the midline dressing was to be changed on admission, and then every seven days. On 10/24/23 at 3:32 PM, the resident's primary nurse, Registered Nurse (RN) C stated he observed the midline to the resident's left upper arm this morning but did not note the date on the dressing. He stated he was aware midline dressings should be changed every seven days. He reviewed the resident's clinical records and confirmed that a physician's order for the midline was not identified. The facility's policy for Midline Catheter Dressing Change with revision date of 2/2018 read, The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection . Sterile dressing change using transparent dressings is performed upon admission. if transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label.

Based on interview, and record review, the facility failed to ensure binding arbitration agreements explicitly granted the resident or their representative the right to rescind the contract within 30 calendar days of signing for 2 of 3 residents reviewed for arbitration agreements, (#202, #250). Findings: 1. Resident #202 was admitted to the facility on [DATE] and signed the Optional Arbitration Agreement (form revised 4/17) on 10/18/23. The agreement read, It is understood by Resident that he or she is not required to use this Facility .It is further understood that the Agreement to Arbitrate is a separate and stand-alone contract from the Admission Agreement The agreement did not include option to rescind the agreement within 30 calendar days of signing. 2. Resident #250 was admitted to the facility on [DATE] and signed the Optional Arbitration Agreement (form revised 4/17) on 10/17/23 which did not include option to rescind the agreement. On 10/26/23 at 1:18 PM, the Admissions Director said she was responsible for getting the new admission paperwork signed by the resident or their representative which included the Optional Arbitration Agreement. The Admission Director acknowledged she was not aware of the federal regulatory requirement of giving residents or their representative 30 days to rescind the agreement.

Based on observation and interview, the facility failed to ensure the dumpster and the immediate area was maintained in a safe, functional, and sanitary manner. Findings: On 4/03/23 at 8 AM, a tour of the garbage storage area was conducted with the Certified Dietary Manager (CDM). Observation of the area revealed there was a box dumpster on the left and a regular dumpster on the right. The following concerns were identified around the immediate perimeter of the regular dumpster: a pill pack with 6 tablets, 2 plastic food lids, plastic spoons and fork, broken up wood pallets, broken up cardboard boxes, cigarette butts, 2 twin size mattresses, 2 wheelchairs, a clothes hanger, broken glass, a chili spice package and a surgical mask. The CDM stated the mess has not been cleaned up since the last hurricane. She informed the Maintenance Director approximately 1-2 months ago that it needed to be cleaned up. She added that it was the maintenance staff's responsibility to clean up the construction debris and kitchen staff needed to put other items in the dumpster as well. She acknowledged that dumpsters were not maintained in a sanitary fashion and could attract rodents and pests. On 4/06/23 at 11:32 AM, the Maintenance Director stated he has been the only person in the maintenance department for 3 1/2 months. He added that the kitchen staff are responsible for any food related trash and ensuring the garbage is picked up around the dumpster and the maintenance staff should pick up construction debris. Review of the facility policy and procedure dated 8/2017, Dispose of Garbage and Refuse read, All garbage and refuse will be collected and disposed of in a safe and efficient manner. The Dining Services Director coordinate with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish and other debris .

Based on interview, and record review, the facility's nursing staff neglected to address escalating exit seeking behaviors for a cognitively impaired resident, failed to provide adequate supervision, and failed to secure an exit door to prevent a vulnerable, cognitively impaired resident from exiting the facility for 1 of 3 residents reviewed for neglect, out of a total sample of 7 residents, (#2). These failures contributed to the elopement of resident #2 and placed him at risk for serious injury/harm/death. While resident #2 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. On 1/14/23 at approximately 5:40 PM, resident #2, a physically and cognitively impaired resident, walked away from the nurses' station on the Pebble Stone Unit, through an occupied unit and exited through a fire egress door that was deactivated and unlocked near the therapy gym. The alarm was deactivated, and staff members were not alerted and unaware resident #2 had left the facility. Resident #2 crossed a 7-lane, high traffic highway and walked approximately 700 feet until he was found near a convenience store by facility staff. At the time the resident was out of the facility, the weather at 5:56 PM on 1/14/23 was 49 degrees ( ) Fahrenheit (F) with winds of 14 miles per hour and the sunset occurred at 5:50 PM. (Retrieved from www.timeanddate.com on 2/18/23). Resident #2 wore a short-sleeve shirt, long pants, hospital gown and was barefoot. The facility was unaware of the resident's whereabouts until approximately 6:10 AM, when facility staff located him across the highway near a convenience store. The facility's failure to provide adequate supervision, address escalating exit seeking behaviors and failure to maintain a secure environment placed all residents who wandered at risk. These failures resulted in Immediate Jeopardy starting on 1/14/23. The Immediate Jeopardy was removed on 1/20/23. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F689 Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included dementia, fracture of left pubis, absence of left great toe, psychosis, anxiety, traumatic brain injury, type 2 diabetes, abnormal posture, difficulty walking, and abnormalities of gait and balance. The admission Minimum Data Set (MDS) with Assessment Reference Date of 1/10/23 revealed resident #2's Brief Interview for Mental Status (BIMS) was not obtained because the resident was rarely or never understood. Instead, a Staff Assessment for Mental Status was conducted, and memory problem was selected for both short and long-term memory. The MDS assessment indicated resident #2 was severely impaired on his cognitive skills for daily decision making. He did not exhibit wandering behaviors in the lookback period. He required limited assistance with transfers and walking in his room and in the corridor or unit. Resident #2 required supervision for locomotion and extensive assistance for dressing. He had unsteady balance during transitions and walking and was only able to stabilize himself with staff assistance. He used a wheelchair for mobility and had one fall with injury since admission. Review of a social services Progress Notes dated 1/11/23 revealed resident #2's room was changed to another unit which provided increased supervision. On 2/05/23 at 12:52 PM, Registered Nurse (RN) Q explained resident #2 was moved to Pebble Stone Unit on 1/11/23, because of his exit seeking behaviors. She stated he tried to open doors, setting the alarm off an exit door by the MDS staff office. She recalled the MDS Coordinator had to assist the resident from the area twice before. RN Q said she placed an electronic wandering device on resident #2 that day. She stated she did not understand why he was moved to Pebble Stone unit and felt he was moved to a less secure area as there were not as many staff on the weekend on this unit. On 2/06/23 at 3:27 PM, RN B recalled she saw resident #2 near the exit door on 1/11/23 when she was performing wound care in a resident's room. She explained the alarm went off, and staff responded and redirected him. She was unable to say what interventions were implemented after resident #2's attempts to exit the facility. She stated she was not aware of any increased supervision interventions for the resident after he tried to exit the facility. Review of resident #2's medical record revealed a care plan for elopement related to impaired safety awareness, created on 1/11/23, that read, Resident wanders aimlessly. The goal listed the resident's safety would be maintained through the review date of 2/02/23. The interventions directed staff to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book and offer him coffee and a snack. Additional interventions included to place an electronic monitoring device to his right wrist, and to identify patterns of wandering. The care plan did not address any changes to the level of supervision required after resident #2 made attempts to exit the facility. The resident had a psychiatry consult on the day he was exit seeking and was moved to the Pebble Stone unit. The psychiatry note dated 1/11/23 showed, Staff reports that pt (patient) wanders throughout the facility and is at times exit seeking. The note indicated resident #2 was alert and oriented times one, confused, thought association was not intact, insight and judgment was inadequate and thought process non-linear. The note included he was not on any psychotropic medications, had a negative psychiatric history, and no medication changes were needed. Review of resident #2's medical record revealed no evidence of a Change of Condition evaluation, progress notes or an Elopement Risk Evaluation noting the changes in behavior he exhibited which resulted in a change of room from one unit to another on 1/11/23. Review of a Physical Therapy Treatment Encounter Note dated 1/13/23, 2 days after the resident was transferred to Pebble Stone unit read, During gait training, patient frequently tried to elope through emergency doors. On 1/14/23 at 8:06 PM, a Change in Condition form documented the resident had eloped from the facility. Resident #2 .opened the therapy door and went out in the parking lot. When assessed, the resident was noted to exhibit increased confusion or disorientation. The report indicated the physician was notified and no new orders were recommended. An Elopement Risk Evaluation dated 1/14/23 at 7:30 PM, revealed resident #2 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, was not aware of to safety needs, and had the ability to exit the facility. The assessment done post elopement inaccurately noted no history of elopement. On 2/04/23 at 5:13 PM, Registered Nurse (RN) B stated she was in a resident's room on 1/14/23 when RN A came to the room and told her resident #2 was missing. She said they quickly headed outside through the therapy door, which was unlocked and wide open. She recalled RN A thought she saw the resident walking south but soon realized there was no one walking in that direction. She said they went back inside the facility where the Manager on Duty organized the search inside the facility. She stated she then returned to her car and left the facility in search of the resident. She entered the a gas station parking lot near the facility and saw the resident walking slowly by the sidewalk close to a convenience store. She remembered he wore red pants, a shirt and a hospital gown on top because it was cold that night. She reported she parked her car and approached resident #2 and he asked if she could take him to his daughter-in-law's house. RN B stated she told the resident to get in her car and she drove back to the facility. She recalled before he left the facility, he was sitting in a chair near the Pebble Stone nurses' station because he needed supervision. She described the road the resident crossed as heavily trafficked and said it was cold and dark that evening. She said, I give thanks to God that nothing happened to him. God protected him. She explained when they returned to the facility, they placed blankets on the resident to warm him up because it was so cold that night. She recalled he was barefoot and his left toe wound was covered by dry, dark scab. She said she had applied skin prep to resident #2's surgical left great toe wound at 1:00 PM that day. She explained the wound did not require a dressing because it was not draining, but he had 2 or 3 staples left, mostly scab. She indicated his family came shortly after he was found, and she completed a written statement. She said she learned after he returned to the facility that he had previously wandered away from his family's home and been hit by a car. On 2/04/23 at 5:37 PM, RN A explained she was resident #2's assigned nurse on 1/14/23. She recalled during report on 1/12/23, she was told to be careful with him because he needed close attention. She said the resident was confused but responded to his name and recognized his family when they visited. RN A stated he always stayed near the exit doors and verbalized he wanted to leave the facility routinely. She stated all day long he was restless and did not want to stay in one place. She explained other times he was redirectable, and she gave him coffee and snacks and he was content but not that day. RN A acknowledged she did not alert the resident's assigned Certified Nursing Assistant (CNA) to observe him more frequently especially when she was in other resident rooms passing medications. She could not explain why she did not call the physician, his family or talk to his assigned CNA or other staff about his behavior. She said, With the running back and forth that day, I was more focused on getting him back to this room. She explained on the day he eloped, he headed to the door at the end of the hallway each time he walked outside his room but she was able to redirect him back to his room. She noted he would only remain in his room for 15 to 20 minutes. She explained he was a Spanish speaking resident, and she could communicate with him in Spanish. RN A stated on her last medication pass, she noticed resident #2 was very restless, so she had him sit in front of the nurses' station so she could observe him while preparing medications. She recalled she came out of a resident's room after administering medications and resident #2 was no longer sitting at the nursing station. She checked the lobby, then walked to the end of a hallway, turned left towards the therapy gym where she noticed the exit door was opened. She indicated no alarms sounded despite the door being wide open and the resident had a wander guard device. She indicated she informed RN B that resident #2 had left the facility and they proceeded to go outside to look for him. She said shortly after, she received a call from RN B informing she had found the resident. She explained once the resident was returned to the facility, he was shivering as he only wore a short sleeve shirt and was barefoot. She recalled he had a great toe amputation and they covered him with blankets, put socks on, inspected his skin and found no injuries. She said he was placed on one to one supervision. She stated he crossed an 8-lane highway and was found by the convenience store. Thank God he was not hit by a car. He did not know where he was or what he was doing. It was dangerous. On 2/06/23 at 1:38 PM, CNA K stated 1/14/23 was the first time she was assigned to resident #2 and received report at change of shift of no issues. She stated she saw him in his bed and later walking by the nurses' station, limping on one leg, not holding onto anything. She explained he sat in a chair by the nurses' station, would get up and walk back and forth to his room. She stated she did not know she had to pay close attention to him and had no knowledge the resident had tried to leave the facility. She said she did not hear any door alarms but was told the resident was missing and started searching. She noted the last time she saw resident #2 was around 5:45 PM to 5:50 PM and he was sitting by the nurses station. She stated the search lasted approximately 10-15 minutes and when she returned to the unit, she saw resident #2 was returned to the facility and he was shivering. She said she asked herself, how did he make it there? She stated that was a big street and it was very cold outside. On 2/06/23 at 2:24 PM, CNA I stated resident #2 was on her assignment during her 7:00 AM to 3:00 PM shift on 1/14/23. She stated she worked a double shift until 11:00 PM that day. She indicated she had not had resident #2 assigned to her before. She stated he walked around limping, and tried to open an exit door in the morning and was caught by a CNA in time, so the alarm did not go off. She indicated the nurse gave him medication to calm him down and it helped a little. She said he rested for a few hours and then she noticed he went with the nurse everywhere she went. She indicated she saw him sitting down in a chair across the nurses station at around 5:30 PM and not long after that, she heard the overhead page calling resident #2 to return to his room. She said he left the facility between 5:40-5:45 PM and was found around 6:05 or 6:10 PM. She mentioned everyone was thanking Jesus they found him. She recalled thinking how he could have crossed a big road with 6 lanes. She stated it was not safe for him to be out there and that was the reason they panicked when they learned he was missing. She indicated she only heard the overhead announcement, but not a door alarm. She indicated no alarm was activated and she did not know how he was able to open the door. On 2/06/23 at 9:49 AM, the Director of Maintenance indicated he tested and checked all the exit doors every morning. He stated he pushed the doors for 15 seconds to ensure all magnets were working properly and tested the wander electronic system by each door. He explained the Manager on Duty was responsible to check the doors and test the wander system on the weekends. The Director of Maintenance stated he was out of state the weekend of January 14th but he was informed by the Administrator about the elopement. He indicated on the day of the incident, every nurses station had a key to all screamer alarms. He explained the Friday before the elopement, the door the resident exited from was inspected in the morning and afternoon by his assistant, and no issues were noted. He stated the morning of the incident, the Manager on Duty checked the door, and no issues were reported. He explained there was an electronic monitoring system alarm and a red screamer alarm on the door. He stated he was not sure how resident #2 got out without activating the alarm. The Director of Maintenance stated he did not talk to any staff to understand what exactly happened and he had not participated in the investigation. He stated he was asked to check the doors multiple times and to audit the doors every day which was the same process he completed before the incident. He stated checking the doors was something that was always done and was documented daily in his maintenance electronic system which he printed daily and provided to the Administrator. He stated someone who had the red screamer key must have opened the door. He said, Someone did it on purpose. He explained a year and a half ago staff used the key to get out and return through that door for smoke breaks. He indicated they did not have cameras in the facility and had requested cameras for resident safety but the request was denied. He noted the nurses had keys to unlock the red box screamer alarms, and all the screamers used the same key. He explained for the alarm not to activate, it had to be disabled using the key and code entered on keypad, there was no other explanation. A report to show time keypad was deactivated was requested but the Director of Maintenance stated they did not have that service and could not show a time log for the door. On 2/07/23 at 10:53 AM, the Medical Director indicated he was not the attending physician for resident #2 but he was informed of resident #2's elopement by the Administrator. He said he did not receive any calls from nurses that day regarding resident #2 behavior issues but resident #2 was mentioned during a stand down meeting before that day with intervention to contact psych. He said he expected nurses to contact the physician if a resident had a change in condition or could be harm to themselves or others. He explained walking barefoot outside after a great toe amputation could pose risk for sutures to open leading to worsening of the wound and infection. He indicated traffic posed a threat of an accident and noted the facility understood the seriousness of what occurred. He stated he learned someone deactivated the alarm, but they did not find who or how exactly. He explained because they did not know how it happened, putting a tamper proof system was required so no human aspect could tamper with it. On 2/05/23 at 3:59 PM, in a telephone interview, resident #2's son stated his father was victim of a hit and run accident in November 2022. He said his father worked as a janitor for [AGE] years, smoked a lot, liked to be outdoors, and used to walk 2 to 4 miles around town before he was struck by a car. He explained after the accident, his father's confusion increased, and he became aggressive, and was incoherent. He indicated no one from the facility asked him anything about his dad after he was admitted . He recalled on 1/14/23 at approximately 7:00 PM, they went to the facility for a regular visit and when they arrived, no one opened the front door right away after they rang the bell. He said they were asked to wait outside and it was a crazy cold night. He stated when they were let in, they were taken to an office and informed that his father had left the facility, crossed the highway and was found by the convenience store. He explained after learning of the incident, he saw his dad and he had 2 blankets over him and shivered and shivered, non-stop. He explained someone told them his dad had a wander bracelet but he was not informed about the device placement. He stated he could not understand how his dad got out because every time they visited, someone had to unlock the door and allow them to enter. He indicated he was frustrated, afraid, nervous and could not comprehend how this had happened in a place that had locked doors. He stated his father was transferred to the hospital from the facility on January 22, 2023 to rule out a stroke but was informed by the hospital that his father had infection to the left great toe wound. He explained his father was still in the hospital at this time. On 2/07/23 at 6:20 PM, the Director of Nursing (DON) explained the elopement assessment was not completed accurately and acknowledged resident #2's history was not considered when completing the evaluation. He explained a review of the hospital records would have provided the whole story. He explained resident #2's family could had been contacted for additional information and acknowledged the facility did not conduct a welcome meeting because they had a high turnover. He recalled resident #2 was moved to a different room because of his exit seeking behavior and the decision to transfer him to the Pebble Stone Unit was made as it was a more visible area and had 2 nurses instead of one. He stated there was always people in that unit and anyone could see and redirect him. When asked about less staff working on the weekends, the DON stated they were more people around on the weekends, including visitors and church members. The DON did not explain why increased supervision was not implemented to ensure the resident did not exit the facility unsupervised. On 2/06/23 at 4:03 PM, a meeting was held to discuss resident #2's elopement with the Administrator, Director of Nursing and the Regional Director of Clinical Services (RDCS). The Administrator stated on 1/14/23 she received a call from the Manager on Duty at approximately 6:11 PM informing her they were unable to locate resident #2. She asked the Manager on Duty if they had initiated the missing resident search, meaning page overhead, and was told it was done. The Administrator stated she arrived at the facility within 12 minutes of the call and before she arrived she received a second call from the Manager on Duty that the resident had been found and had exited by the therapy door. She explained she checked the affected door and it was completely disarmed. She explained she instructed staff to perform a head count of all their residents and check on residents with electronic wandering devices. She stated she noticed the red screamer alarm was on the off position. She explained whoever opened the door had to enter a code to disarm the door and then used a key to turn the screamer alarm off. She indicated all nurses had the key for the screamer alarms but they had not identified who disarmed the alarms and unlocked the door. The Administrator noted she was the facility's Abuse Coordinator and Risk Manager. She explained neglect occurred when goods and services were withheld for a resident and could potentially cause harm. She mentioned examples of neglect included not providing the level of supervision required. She stated the facility was responsible to control residents' environment to ensure their safety. She explained neglect could be prevented by educating staff, ensuring residents' centered care plan were in place, following policies and procedures and performing checks. Review of the Clinical Nurse I (RN) job description dated September 2018 revealed the primary purpose of the position was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. The job function read, As Clinical Nurse I-RN, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. The duties and responsibilities included, Provide regular resident status updates to appropriate personnel. Maintain ongoing communications with physicians concerning resident care. Facilitate problem solving and open communications with the unit nursing staff. Review of the policy and procedure titled Abuse, Neglect, Exploitation & Misappropriation revised on 11/16/22 read, Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. The policy defined neglect as . the failure of the center, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Examples include but are not limited to; . Failure to take precautionary measures to protect the health and safety of the resident. Failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental, or emotional condition that a prudent person would recognize. Failure to adequately supervise a resident known to wander from the facility without the staff knowledge. The document revealed a list of Prevention systems including, Monitoring of residents who may be at risk is the responsibility of all facility staff. Review of the Facility Assessment Tool updated on 1/09/23 read, If a resident develops a new condition while residing in the center the resident will receive a change in condition assessment by nursing team and the provider is notified. The document revealed the facility had an average of 10-15 residents with behavioral health needs. Factors of the resident population taken into account when the facility determined staffing and resources needed included history of trauma impacting care and resident preferences. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On 1/14/23, RN B located resident #2 outside the facility across the street on a sidewalk and escorted back to the facility unharmed. RN A completed head-to-toe assessment and found no injuries. Physician and responsibly party were notified. *On 1/14/23, was placed on 1:1 supervision with electronic wandering device in place until discharge on [DATE]. *On 1/14/23, the facility wide head count was conducted including residents at risk for elopement and all residents were accounted for. *On 1/14/23, the Administrator rounded the facility and validated all exit doors were secure, alarms were functioning properly, and screamers were placed to on position. *On 1/14/23, the DON reviewed and updated an elopement evaluation and care plan to include 1:1 supervision. *Beginning on 1/14/23, facility staff, including contracted staff, was educated by clinical leadership and Administrator on elopement process, identifying residents at risk for elopement, process to participate in elopement drills, and process to implement appropriate safety interventions and supervision for residents identified at risk for elopement. Staff also educated on importance of maintaining door security. Education validated with post testing on elopement and elopement drill participation. New hires will receive education in orientation. Certified letters were mailed to staff unable to attend education. As of 1/26/23 a total of 103 of 108 staff, including contracted staff, received elopement education, and participated in elopement drills. *On 1/15/23, resident #2 received a psychiatric telehealth visit. Medications recommendations included Ativan 1 mg every 4 hours PRN for 14 days and Gabapentin 300 mg 3 times a day. *On 1/15/23, current facility residents' elopement evaluations were completed by the DON and staff RN on the current census of 96 with 8 residents identified as at risk for elopement. *On 1/15/23, the Divisional Nurse Consultant (DNC) completed quality review of residents at risk for elopement and validated the following: wander guard equipment in place and functional, physician orders in place for electronic wandering device and care plans reviewed with appropriate level of supervision in place. Any identified issues were addressed. *On 1/15/23, the [NAME] President of Facility Management conducted assessment of all facility doors. *On 1/15/23, the Administrator removed red screamer box door alarm keys from the nursing staff to prevent disabling of the red box alarm. *On 1/16/23, the Clinical Quality Specialist onsite and conducted secondary review of residents at risk for elopement. Facility elopement list was verified again and elopement books at front desk and on nursing units were audited for completion and accuracy. *Beginning on 1/18/23, facility nurses were educated by the DON regarding accuracy of elopement evaluations and importance of providing supervision to residents with wandering or exit seeking behaviors. Education included review of completing accurate elopement evaluation, physician notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking and the importance of implementing the appropriate level of supervision at the time of the residents change in behavior. As of 1/26/23, 23 out of 23 nurses received education from DCS. *Facility staff and contracted staff educated by SSD regarding policy and procedure for abuse and neglect. As of 1/26/23 a total of 107 of 108 staff members, including contracted staff, received education. *On 1/18/23, DON and Administrator were educated by the DNC regarding the process to review admission and readmission charts for accuracy of elopement evaluation and responsibility to provide appropriate interventions and supervision for residents with wandering and exit seeking behaviors. Section added to morning clinical meeting checklist to verify accuracy of elopement evaluation. *On 1/18/23, Ad Hoc Quality Improvement Performance Committee meeting held to review the recommendations from the Root Cause Analysis. Members in attendance included the Medical Director (via telephone), Administrator, DCS, DNC, Regional [NAME] President, SSD, MDS Director, Business Office Manager (BOM), Dietary Manager (CDM), Business Development Liaison, Director of Therapy, Staffing Coordinator, Community Life Coordinator, and Central Supply Coordinator. The committee approved the recommendations. *On 1/19/23, facility held monthly QAPI meeting. Members in attendance included the Medical Director, Administrator, DON, Business Office Manager, SSD, MDS Coordinators, Admission Director, Activities Director, Director of Therapy, Staffing Coordinator, Central Supply Coordinator and Dietary Manager. The IDT reviewed the facility elopement performance plan and the Ad Hoc QAPI meeting minutes from 1/18/23. *On 1/20/23, quality review of new admissions/readmissions since 01/01/23 conducted by DON and DNC to ensure admission elopement evaluations were accurate. *On 1/20/23, the facility door upgrades and functional tests were completed by the contracted vendor. All doors have annunciation on the new installed keypad, a strobe light with alarm on each corridor to indicate if the exit door on that corridor has been breached. There is also an annunciator panel at each nurses station that indicate and sound if a door alarmed. These features along with the mag lock on each door and a secondary screamer was tested . Doors equipped with a Secure Care wandering device are A1, B, C, E. *On 1/20/23, Ad Hoc QAPI meeting held. Members in attendance included the Medical Director, Administrator (via telephone), DON, Business Office Manager, DNC, SSD, MDS Coordinators, Medical Records Coordinator, Customer Service Liaison, Activities Director, Director of Therapy, Staffing Coordinator, Central Supply Coordinator and Clinical Dietary Manager. The team reviewed the final upgrades for the facility doors. *Concierge and/or Manager on Duty to complete quality audits of residents with electronic wandering devices to check for placement and function. Any issues identified to be reported to the Administrator. *Administrator initiated education with Admissions team and Social Services team to contact resident/responsible party to determine history of wandering and/or elopement from other locations at the time of admission. *On 1/24/23, Director of Maintenance was educated by the Administrator regarding newly installed door alarm system. *DON/designee will continue weekly quality review times 3 months of residents at risk for elopement to ensure policy and procedures in place. New admissions audited by DCS/designee to ensure accurate elopement risk identification, appropriate interventions in place as required and care plan in place as necessary. *Director of Maintenance/designee will continue door and security checks to ensure a secure resident environment. Issues identified will be discussed in the monthly QAPI meeting. Interviews were conducted with 17 facility staff including 11 CNAs, 4 licensed nurses, 1 dietary aide, 1 therapist, and 1 Activities staff between 2/04/23 and 2/08/23. Interviews revealed some therapists did not receive abuse and neglect education after the elopement and not all direct care staff had participated in elopement drills. On 2/04/23 at 11:37 PM, CNA L stated she had not participated in elopement drills after incident. On 2/04/23 at 11:57 PM, CNA M stated she did not work the night incident occurred and learned about elopement the following night. She stated she was not familiar with resident #2 as he was a new resident. She stated the facility sent a registered letter which she signed and returned. She stated she called the facility to inquiry ab [TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility unsupervised, failed to conduct assessments to identify risk for elopement and implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision and secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 7 residents, (#2). On 1/14/23 at approximately 5:40 PM, resident #2, a physically and cognitively impaired resident, walked away from the nurses' station on the Pebble Stone Unit, through an occupied unit and exited through a fire egress door that was deactivated and unlocked near the therapy gym. The alarm was deactivated, and staff members were not alerted and unaware resident #2 had left the facility. Resident #2 crossed a 7-lane, high traffic highway and walked approximately 700 feet until he was found near a convenience store by facility staff. At the time the resident was out of the facility, the weather at 5:56 PM on 1/14/23 was 49 degrees ( ) Fahrenheit (F) with winds of 14 miles per hour and the sunset occurred at 5:50 PM. (Retrieved from www.timeanddate.com on 2/18/23). Resident #2 wore a short-sleeve shirt, long pants, hospital gown and was barefoot. The facility was unaware of resident's whereabouts until approximately 6:10 AM, when facility staff located him across the highway near a convenience store. These failures contributed to the elopement of resident #2 and placed all residents who wandered at risk for serious injury/serious harm/death and resulted in Immediate Jeopardy starting on 1/14/23 and was removed 1/20/23. Findings: Cross Reference F600 Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included dementia, fracture of left pubis, absence of left great toe, psychosis, traumatic brain injury, type 2 diabetes, abnormal posture, difficulty walking, and abnormalities of gait and balance. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 1/03/23 revealed resident #2 was not ambulatory and required assistance of one staff person for transfers. The document indicated the resident was alert, disoriented but could follow simple instructions. The Admission/Readmission Data Collection evaluation dated 1/03/23 revealed resident #2 was oriented to person only, did not use an assistive device for mobility, had left great toe amputation, and was not at risk for elopement. Review of an admission Elopement Risk Evaluation dated 1/03/23 inaccurately noted the resident was not cognitively impaired, independently mobile, had no poor decision-making skills and did not have the ability to exit the facility. Review of an Elopement Risk Evaluation dated 1/10/23 revealed resident #2 was cognitively impaired, independently mobile and exhibited poor decision-making skills. The document indicated resident #2 had not demonstrated exit seeking behaviors, was aware of safety needs, had no history of elopement and did not have the ability to exit the facility. Based on these answers, the resident was not determined to be at risk for elopement. The document directed staff to complete form quarterly and with a significant change. The evaluation form indicated if the resident was deemed at risk, a prevention protocol should be initiated immediately and documented in the care plan. Review of a social service Progress Notes dated 1/11/23 revealed resident #2's room was changed to another unit which provided increased supervision. A psychiatry New evaluation note dated 1/11/23 revealed Staff reports that pt (patient) wanders throughout the facility and is at times exit seeking. The note indicated resident #2 was alert and oriented times one, confused, thought association was not intact, insight and judgment was inadequate and thought process non-linear. The note included he was not on any psychotropic medications, had a negative psychiatric history, and no medication changes were needed. Review of resident #2's medical record revealed no evidence of a Change of Condition evaluation, progress notes or an Elopement Risk Evaluation noting the changes in behavior he exhibited which resulted in a change of room from one unit to another on 1/11/23. A care plan for elopement related to impaired safety awareness, created on 1/11/23, read, Resident wanders aimlessly. The goal listed the resident's safety would be maintained through the review date of 2/02/23. The interventions directed staff to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books and offer him coffee and a snack. Additional interventions included to place an electronic monitoring device to his right wrist, to identify patterns of wandering. The document read, Is wandering purposeful, aimless, or escapist? Is resident looking for something? The care plan directed staff to intervene as appropriate. There were no interventions noted for increased supervision. A care plan for risk for falls related to deconditioning, weakness, recent trauma, left pelvic fracture, head injury and toe amputation, was initiated on 1/05/23 and read, Actual fall with skin tear, poor communication/comprehension, unsteady gait, confusion- never asks for help, low BIMS (Brief Interview for Mental Status). An intervention dated 1/07/23 directed staff to place resident in clear/observation area near nurse station. The admission Minimum Data Set (MDS) with Assessment Reference Date of 1/10/23 revealed resident #2 BIMS was not obtained because the resident was rarely or never understood. Instead, a Staff Assessment for Mental Status was conducted, and memory problem was selected for both short and long-term memory. The MDS assessment indicated resident #2 had severely impaired cognitive skills for daily decision making, did not exhibit wandering behaviors in the lookback period, required limited assistance with transfers and walking in his room/unit, and required supervision for locomotion. The assessment noted the resident had unsteady balance and walking and was only able to stabilize himself with staff assistance. He used a wheelchair for mobility and had one fall with injury since admission. He did not receive antipsychotic, antidepressant or antianxiety medications during the 7-day lookback period. Review of resident #2's medical record revealed an incomplete Psychosocial Evaluation dated 1/10/23 at 9:10 PM. Section A. Community Life was completed but not section B. Social Services which included questions such as Have you ever been through anything life threatening or traumatic? or any social/behavioral/emotional concerns. Review of a Physical Therapy Treatment Encounter Note dated 1/13/23 read, Patient demonstrated partial carryover due to new learning abilities. During gait training, patient frequently tried to elope through emergency doors. Review of resident #2's medical record revealed a Change in Condition form dated 1/14/23 at 8:06 PM, that read, Disoriented patient opened the therapy door and went out in the parking lot. When assessed, the resident was noted to exhibit increased confusion or disorientation. The report indicated the physician was notified and no new orders were recommended. An Elopement Risk Evaluation dated 1/14/23 at 7:30 PM, revealed resident #2 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors, was oblivious to safety needs, and had the ability to exit the facility. The assessment done post elopement inaccurately noted no history of elopement. On 2/04/23 at 5:13 PM, Registered Nurse (RN) stated she applied skin prep to resident #2's surgical left great toe wound on the day he eloped at 1:00 PM. She explained the wound did not require a dressing because it was not draining, but he had 2 or 3 staples left, mostly scab. She noted she was in another resident's room when RN A came to the room and told her resident #2 had left the facility. She said they quickly headed outside through the therapy door, the same door resident #2 had exited which unlocked and wide open. She recalled RN A thought she saw the resident walking south but soon realized there was no one walking in that direction. She said they went back inside the facility where the Manager on Duty organized the search inside the facility. She stated she then returned to her car and left the facility in search of the resident. She entered the a gas station parking lot near the facility and saw the resident walking slowly by the sidewalk close to a convenience store. She remembered he wore red pants, a shirt and a hospital gown on top because that night was a bit cold. She reported she parked her car and asked resident #2, What are you doing? She said he asked her if she could take him to his daughter-in-law's house. RN B stated she told the resident to get in her car and she drove back to the facility. She recalled before he left the facility, he was sitting in a chair near the Pebble Stone nurses' station because he needed supervision. She described the road the resident crossed as heavily trafficked and said it was cold and dark that evening. She said, I give thanks to God that nothing happened to him. God protected him; He protected all of us. She explained when they returned to the facility, they placed blankets on the resident to warm him up because it was so cold that night. She recalled he was barefoot and his left toe wound was covered by eschar. She indicated his family came shortly after he was found, and she completed a written witness statement. She said she learned after he returned to the facility that he had previously wandered away from his family's home and been hit by a car. On 2/04/23 at 5:37 PM, RN A explained she was resident #2's assigned nurse on 1/14/23 and had taken care of him two times before the incident. She recalled during report on 1/12/23, she was told to be careful with him because he needed close attention. She said the resident was confused but responded to his name and recognized his son and daughter in law when they visited. RN A stated he always stayed near the exit doors and verbalized he wanted to leave the facility routinely. She stated all day long he was restless and did not want to stay in once place. She explained other times she was assigned to his care, he was redirectable, and she gave him coffee and snacks and he was content but not that day. RN A acknowledged she did not alert the resident's assigned Certified Nursing Assistant (CNA) to observe him more frequently especially when she was in other resident rooms passing medications. She said, With the running back and forth that day, I was more focused on getting him back to this room. She explained on the day he eloped, he headed to the door at the end of the hallway each time he walked outside his room but she was able to redirect him back to his room. She explained he was a Spanish speaking resident, and she could communicate with him in Spanish. She explained when redirecting resident #2 away from the exit doors she would tell him he needed to raise his legs and rest and he complied but only stayed in his room for 15 to 20 minutes. RN A stated on her last medication pass, she noticed resident #2 was very restless, so she had him sit in front of the nurses' station so she could observe him while preparing medications. She recalled she came out of a resident's room after administering medications and resident #2 was no longer sitting at the nursing station. She checked the lobby, then walked to the end of a hallway, turned left towards the therapy gym where she noticed the exit door was opened. She indicated no alarms sounded despite the door being wide open and the resident had a wander guard device. RN A stated she walked outside, looked in the parking lot and returned back inside and found RN B in a resident's room. She indicated she informed RN B that resident #2 had left the facility and they proceeded to go outside to look for him. She explained they looked for him in the near vicinity then came back to the facility and RN B got in her car and she went in another staff person's car to search for the resident. She said shortly after, she received a call from RN B informing she had found the resident. She explained once the resident was returned to the facility, he was shivering as he only wore a short sleeve shirt and was barefoot. She recalled he had a great toe amputation and they covered him with blankets, put socks on, inspected his skin and found no injuries. She said he was placed on one to one supervision. She stated he crossed an 8-lane highway and was found by the convenience store. Thank God no one hit him. He did not know where he was or what he was doing. It was dangerous. On 2/04/23 at 8:57 PM, CNA D explained she worked on 1/14/23, the evening the resident eloped. She heard the missing resident announcement and began search of rooms, and closets. She explained after resident #2 returned, she was assigned to provide one to one supervision. She described the elopement and said, it could have been worse. On 2/04/23 at 10:26 PM, the Activities Director stated she was the Manager-on-Duty on 1/14/23. She recalled before the elopement, resident #2 participated in activities such as coffee social and listening to Hispanic music. She stated he was initially brought to activities by wheelchair but a few days after admission, he walked to activities. She recalled on 1/14/23, resident #2 participated in Bingo, from 2:30 to 4 PM, and towards the end, he stood up by himself and said he wanted to go to the bathroom and left the room. She explained at about 6:10 PM, she heard noise outside her office and thought she heard the nurse say she was worried. She said she did not see anyone outside the office and quickly walked toward the therapy gym and saw the exit door open. She explained staff were aware of his wandering because he was transferred from River Rock Unit to Pebble Stone Unit to be closer to the nurses' station. She stated he had tried to open exit doors before and had an electronic wandering device. She stated she panicked, walked down the ramp to the parking lot, looked around but did not see anyone. She then went back into the facility and had to pull the exit door to close it. She recalled she went to resident #2's room, did not find him there and did not see his assigned nurse. She said she put the pieces together, picked up the phone and paged the elopement code announcement. She remembered she called the resident's name and for him to return to room number and mentioned his room, 3 times. She explained this alerted staff he was missing. She noted even though she had not confirmed he was missing, she assumed this was the situation. She stated she called the Administrator from her cell phone after she paged the elopement code and informed she thought resident #2 had left the facility. She explained a few minutes after she spoke with the Administrator, RN B returned with resident #2. She recalled he was shivering and had a blue gown covering his shoulders. She explained resident #2's family came in a few minutes after the incident to visit him and the Administrator met with them in her office. She indicated she, along with RN A, were present when the Administrator explained what had just happened to his family. She recalled the resident's daughter in law told them he had been hit by a car before when he had wandered away from the family home. She acknowledged the elopement process was not followed on 1/14/23 even though they had elopement drills before the incident happened. On 2/05/23 at 12:12 PM, resident #2's elopement route was retraced by the state agency surveyors. Resident #2 left the nurses' station area at approximately 5:40 PM, walked through west side of the Pebble Stone Unit hallway, turned left and walked towards the therapy gym. He arrived at an exterior exit door, approximately 170 feet away from the nurses' station and exited the unalarmed and unlocked door onto a ramp which led to the parking lot. Resident #2 walked an additional 110 feet as he crossed the parking lot, and through a grassy area to reach the sidewalk next to a heavily traveled highway. He traveled along the sidewalk approximately 91 feet and crossed a busy 7-lane highway with a median road, and walked 118 feet to the other side. It is unknown if the resident crossed at the traffic lights. He walked an additional 202 feet to reach the location he was found near the convenience store and gas station at approximately 6:20 PM. Photographic evidence was obtained of the hazards outside the facility including a ditch with a steep embankment near the sidewalk, broken glass, broken benches with sharp edges, uneven pavement, and homeless peddlers. On 2/05/23 at 12:52 PM, RN Q explained she worked half a day with resident #2 on 1/11/23, the day he was transferred to the Pebblestone unit because of exit seeking behaviors. She stated he tried to open doors, setting the alarm off an exit door by the MDS office. She recalled the MDS Coordinator had to assist the resident from the area twice before. She explained she placed an electronic wandering device on resident #2 that day. She stated she did not understand why he was moved to Pebble Stone unit and felt he was moved from a safer to a more dangerous location. When asked if she brought her question to management she said, Management had already made the decision. On 2/05/23 at 3:59 PM, in a telephone interview, resident #2's son stated his father was victim of a hit and run accident in November 2022. He said his father worked as a janitor for [AGE] years, smoked a lot, liked to be outdoors, and used to walk 2 to 4 miles around town before he was struck by a car. He explained after the accident, his father's confusion increased, and he became aggressive, and was incoherent. He indicated no one from the facility asked him anything about his dad after he was admitted . He recalled on 1/14/23 at approximately 7:00 PM, they went to the facility for a regular visit and when they arrived, no one opened the front door right away after they rang the bell. He said they were asked to wait outside and it was a crazy cold night. He stated when they were let in, they were taken to an office and informed that his father had left the facility, crossed the highway and was found by the convenience store. He explained after learning of the incident, he saw his dad and he had 2 blankets over him and shivered and shivered, non-stop. He explained someone told them his dad had a bracelet but seemed something was wrong, and a nurse came to change it. He stated he was not informed about the electronic wandering device placement prior to that night. He explained they were told they would have to find him another place because of what he did. He stated he could not understand how his dad got out because every time they visited, someone had to unlock the door and allow them to enter. He indicated he was frustrated, afraid, nervous and could not comprehend how this had happened in a place that had locked doors. He explained after the incident the family was told his father did not qualify for the services at the facility because of what he did and was now considered a high risk individual requiring the services of a locked unit. He stated they were informed the facility was looking for a locked facility but the closest one was in [NAME], which was too far and a burden considering the heavy traffic to [NAME]. He stated his father was transferred to the hospital from the facility on January 22, 2023 to rule out a stroke but was informed by the hospital that his father had infection to the left great toe wound. He explained his father was still in the hospital at this time. On 2/06/23 at 9:49 AM, the Director of Maintenance stated his responsibilities included resident safety, repairs to the building, fire drills, and testing of exit doors. He indicated he tested and checked all the exit doors every morning. He stated he pushed the doors for 15 seconds to ensure all magnets were working properly and tested the wander electronic system by each door. He explained the Manager on Duty was responsible to check the doors and test the wander system on the weekends. The Director of Maintenance stated he was out of state the weekend of January 14th but he was informed by the Administrator about the elopement. He stated the facility had a prior elopement through the same door resident #2 exited but the alarm activated that time. He indicated on the day of the incident, every nurses station had a key to all screamers. He explained the Friday before the elopement, the door the resident exited from was inspected in the morning and afternoon by his assistant, and no issues were noted. He stated the morning of the incident, the Manager on Duty checked the door, and no issues were reported. He explained there was an electronic monitoring system alarm and a red screamer alarm on the door. He stated he was not sure how resident #2 got out without activating the alarm. The Director of Maintenance stated he did not talk to any staff to understand what exactly happened and he had not participated in the investigation. He stated he was asked to check the doors multiple times and to audit the doors every day which was the same process he completed before the incident. He stated checking the doors was something that was always done and was documented daily in his maintenance electronic system which he printed daily and provided to the Administrator. He stated someone who had the red screamer key must have opened the door. He said, Someone did it on purpose. He explained a year and a half ago staff used the key to get out and return through that door for smoke breaks. He indicated they did not have cameras in the facility and had requested cameras for resident safety but the request was denied. He noted the nurses had keys to unlock the red box screamer alarms, and all the screamers used the same key. He explained for the alarm not to activate, it had to be disabled using the key and code entered on keypad, there was no other explanation. A report to show time keypad was deactivated was requested but the Director of Maintenance stated they did not have that service and could not show a time log for the door. On 2/06/23 at 10:38 AM, the Director of Therapy stated resident #2 was confused and wandered but was redirectable during therapy. She explained he needed maximum cues to get things done but did them. She noted he was doing well and showed improvement in strengthening but not cognitively. She indicated during an Interdisciplinary Team (IDT) meeting they discussed the resident wandered but had not tried to exit. She shared the facility was supposed to have a Journey Home meeting for newly admitted residents but they did not always happen. She indicated resident #2 was ambulatory when he was admitted but his balance was off. She indicated resident #2 was absolutely not safe to be outside unsupervised. She explained resident #2 limped because of his amputated left great toe which affected his balance. She indicated he was supposed to be partial weight bearing on his left side, but he did not comply. She said, God was looking after him; his cognition was so bad he wouldn't even know a car if it came at him. He was probably roaming. She indicated he did not have shoes on at the time of the event which could have led to a fall or infection. She responded, I was pretty mad about that because I had told several CNAs to keep his shoes on. She stated they had a phone meeting with his family the Monday after he eloped to discuss his discharge plan, which was tentatively set for the following Tuesday. She stated she felt the facility was trying to get him out of there. On 2/06/23 at 1:38 PM, CNA K stated 1/14/23 was the first time she was assigned to resident #2 and received report at change of shift of no issues. She stated she saw him in his bed and later walking by the nurses' station, limping on one leg, not holding onto anything. She explained he sat in a chair by the nurses' station, would get up and walked back and forth to his room. She stated she did not know she had to pay close attention to him and had no knowledge the resident tried to leave the facility earlier that day. She recalled she assisted a resident with her dinner meal with the door closed and when she opened the door, she saw 2 nurses running down the hallway. She remembered CNA I told her resident #2 was missing. She said she did not hear any door alarms and started searching for the resident. She stated she walked outside and searched the entire parking lot with CNA T, then walked to the front of the facility but did not see the resident. She stated the last time she saw resident #2 was around 5:45 to 5:50 PM and he was sitting by the nurses station. She stated the search lasted approximately 10-15 minutes and when she returned to the unit, she saw resident #2 was returned to the facility and he was shivering. She said she asked herself, how did he make it there? She stated that was a big street and it was very cold outside. On 2/06/23 at 2:24 PM, CNA I stated resident #2 was on her assignment during her 7:00 AM to 3:00 PM shift on 1/14/23. She stated she worked a double shift until 11:00 PM that day. She indicated she had not had resident #2 assigned to her before. She stated he walked around limping, and tried to open an exit door in the morning and was caught by a CNA in time, so the alarm did not go off. She indicated the nurse gave him medication to calm him down and it helped a little. She said he rested for a few hours and then she noticed he went with the nurse everywhere she went. She indicated she saw him sitting down in a chair across the nurses station at around 5:30 PM and not long after that, she heard the overhead page calling resident #2 to return to his room. She said he left the facility between 5:40-5:45 PM and was found around 6:05 or 6:10 PM. She mentioned everyone was thanking Jesus they found him. She recalled thinking how he could have crossed a big road with 6 lanes. She stated it was not safe for him to be out there and that was the reason they panicked when they learned he was missing. She indicated she only heard the overhead announcement, but not a door alarm. She indicated no alarm was activated and she did not know how he was able to open the door. On 2/06/23 at 4:03 PM, a meeting was held to discuss resident #2's elopement with the Administrator, Director of Nursing and the Regional Director of Clinical Services (RDCS). The Administrator stated on 1/14/23 she received a call from the Manager on Duty at approximately 6:11 PM informing her they were unable to locate resident #2. She asked the Manager on Duty if they had initiated the missing resident search, meaning page overhead, and was told it was done. The Administrator stated she arrived at the facility within 12 minutes of the call and before she arrived she received a second call from the Manager on Duty that the resident had been found and had exited by the therapy door. She explained she checked the affected door and it was completely disarmed. She explained she instructed staff to perform a head count of all their residents and check on residents with electronic wandering devices. She the door had been checked that day by the Manager on Duty and the door was locked and alarms were armed. She stated she noticed the red screamer alarm was on the off position. She explained whoever opened the door had to enter a code to disarm the door and then used a key to turn the screamer alarm off. She indicated all nurses had the key for the screamer alarms. She stated she checked all exterior exit doors in the facility at that time. She stated when she returned to her office, the resident's family had arrived for their usual evening visit. She said she met with the family and informed them the resident had exited the facility unsupervised, had an electronic wandering device and was found by facility staff. She indicated she told them they would find a secure location for him and he would be placed on one to one supervision. She explained that same night, she collected statements from all staff present at the time of the elopement. She explained they initiated an investigation and reported to the appropriate authorities. She provided copy of the timeline they created based on the findings of their investigation. Discrepancies were noted between their timeline and the witness statements she collected from their staff. She stated the outcome of their investigation was substantiated because the facility door was under the facility's control. The RDCS stated resident #2's assigned nurse kept him under closer supervision and acknowledged the supervision provided by the staff did not work that evening. She stated she truly believed the supervision would have been effective if the door alarm had not been disabled. The Administrator acknowledged the potential and actual hazards resident #2 could have encountered along the path he walked such as broken glass, uneven pavement, ditch by the parking lot, busy road, and cold temperature. On 2/07/23 at 10:53 AM, the Medical Director indicated he was not the attending physician for resident #2 but he was informed of resident #2's elopement by the Administrator. He said he did not receive any calls from nurses that day regarding resident #2 behavior issues but resident #2 was mentioned during a stand down meeting before that day with intervention to contact psych. He said he expected nurses to contact the physician if a resident had a change in condition or could be harm to themselves or others. He explained walking barefoot outside after a great toe amputation could pose risk for sutures to open leading to worsening of the wound and infection. He indicated traffic posed a threat of an accident and noted the facility understood the seriousness of what occurred. He stated he learned someone deactivated the alarm, but they did not find who or how exactly. He explained because they did not know how it happened, putting a tamper proof system was required so no human aspect could tamper with it. On 2/07/23 at 6:20 PM, the Director of Nursing (DON) explained the admitting nurse did not understand how to properly compete the admission assessment. He stated he noted the initial assessment for resident #2 was completed incorrectly, and he was not assessed correctly. He explained a review of the hospital records would have provided the whole story. He explained resident #2's family could had been contacted for additional information and acknowledged the facility did not conduct a welcome meeting because they had a high turnover. He recalled resident #2 was moved to a different room because of his exit seeking behavior and the decision to transfer him to the Pebble Stone Unit was made as it was a more visible area and had 2 nurses instead of one. He stated there was always people in that unit and anyone could see and redirect him. When asked about less staff working on the weekends, the DON stated they were more people around on the weekends, including visitors and church members. On 2/08/23 at 10:20 AM, the Social Services Director stated they had initial meetings called Journey to Home attended by Department Heads to learn about newly admitted residents. She noted it took them a while to talk to resident #2's family as they were not able to reach his son. She indicated she spoke with resident #2's son and learned he wanted to take him home after therapy was completed and found out his dad liked to walk around but he never mentioned he left his house or wandered. She said she did not know he was hit by a car before the elopement. and recalled during clinical meeting it was mentioned he had an accident but not he was struck by a car. She indicated it was a cold night and busy intersection where he crossed. She stated she did not foresee or thought something like this was going to happen. Review of the policy and procedure Elopement/Wandering Risk Guideline revised on 8/01/ [TRUNCATED]

Based on interview and record review, the facility failed to honor advanced directives for a Do Not Resuscitate Order (DNRO) for 1 of 5 residents sampled for DNROs of a total of 17 residents residing in the facility with DNROs, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) despite her explicit wish for a natural, dignified death and placed her at risk for serious injury / impairment / prolonged death. While resident #1 suffered resuscitation attempts including chest compressions, there was likelihood she experienced pain, broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 6:00 AM, resident #1 suddenly became unresponsive at the Pebblestone unit nurses' station. Registered Nurse (RN) A transferred resident #1 to her bed while RN D went to request assistance from the Director of Nursing (DON). RN A applied oxygen to resident #1 for slow and shallow respirations and left resident #1 alone and returned to the nurses' station. When the DON arrived at the nurses' station, he was informed by RN A that resident #1 was a full code. The DON assessed resident #1 and when she stopped breathing and had no pulse, the DON instructed RN B to start CPR. A few minutes later, RN C informed the DON and RN B that the resident had a DNRO. The facility's failure to honor advance directives put all residents with a DNROs at risk. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. 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 an Immediate Jeopardy after verification of the facility's immediate actions. Findings: Resident #1 was a [AGE] year-old, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) quarterly assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 9 which indicated moderately impaired cognition. The assessment revealed resident #1 received hospice services, was independently ambulatory and able to express her preferences. Resident #1 had a care plan initiated on [DATE] for advance directives related to a DNRO. The care plan goal read, Resident will have advanced directive followed. Review of resident #1's electronic medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's progress note dated [DATE] included, Patient is DNR. Review of resident #1's electronic medical record revealed two copies of the form titled, State of Florida DO NOT RESUSCITATE ORDER that noted, Based upon informed consent, I the undersigned, hereby direct that CPR be withheld or withdrawn. The physician's statement read, I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation . from the patient in the event of the patient's cardiac or respiratory arrest. The document dated [DATE] was signed by resident #1's granddaughter and the physician. The updated DNRO dated [DATE] was signed by resident #1 and the physician. A Change in Condition form, dated [DATE] at 6:40 AM, read, Resident complaint of having a small discomfort in the back area and lost consciousness, did not respond. RN A noted interventions provided were oxygen and notification to 911. On [DATE] at 12:13 PM, RN A recalled on the morning of [DATE], resident #1 walked to the nurses' station using a walker and asked for coffee. RN A stated he noticed resident #1 did not look good and appeared to lose her balance. RN A said, She complained of back pain and passed out. I grabbed her. RN A explained he yelled to RN D that he needed help while he placed resident #1 in a nearby wheelchair and transported her to her room. RN A stated RN D did not accompany him to the room but rather ran from the unit to get assistance. On assessment, RN A stated the resident's respiratory rate was decreasing and her breathing was becoming shallow. RN A indicated he attempted to obtain vital signs but could not get a reading for either blood pressure or identify a pulse. He said he placed resident #1 on oxygen. RN A explained when the DON arrived on the Pebblestone unit he asked if anyone had checked the resident's medical record for code status. RN A recalled he told the DON he had not yet checked the resident's code status. He explained the DON and RN B stayed in the resident's room while he went to review the chart. He said that shortly after, Emergency Medical Services (EMS) personnel arrived, assessed the resident and cardiac monitor showed no heart activity. RN A explained he was not aware resident #1 received CPR while he was at the nurses' station reviewing the chart. On [DATE] at 1:20 PM, during a telephone interview, RN D stated she was passing medications on the Pebblestone unit when RN A yelled, Hey, I have a Code here. RN D stated RN A placed resident #1 in a wheelchair and took her to her room. RN D recalled she ran to the DON's office and told him there was a Code Blue on Pebblestone unit. RN D said she informed RN B, the Cliffstone unit nurse, that there was a Code on Pebblestone unit. RN D acknowledged she was supposed to check the medical record for code status, and use the overhead paging system to announce Code Blue. She explained she was very nervous and ran to the DON's office instead. She said she followed RN B and the DON into resident #1's room and when the resident stopped breathing, RN B asked the DON if she needed to initiate CPR. RN D noted she observed RN B perform chest compressions while the DON gave supported respirations using a bag-valve-mask (BVM) device. RN D indicated she left the resident's room at that time and went to the nurses' station to verify resident #1's code status in the medical chart. She said during review of the medical record with RN A, the assigned nurse, and RN C, the oncoming dayshift nurse, they discovered resident #1's yellow DNRO form. She explained the DNRO form should have been at the front of the chart and it wasn't. She reported that when the DNRO was found, they realized the resident was not to be resuscitated. She explained RN C took the chart with the yellow DNRO form to resident #1's room and informed the DON and RN B about the code status. RN D acknowledged the DNRO represented resident #1's wishes. On [DATE] at 1:56 PM, RN C stated she arrived on the Pebblestone unit on the morning of [DATE], and Code Blue was in progress. RN C recalled RN A and RN D were at the nurses' station and EMS was on the telephone. RN C acknowledged after verification of DNR status with RNs A and D, she took the chart to resident #1's room. RN C explained that the resident's code status should be checked first thing and nursing staff should follow this direction. On [DATE] at 2:18 PM, during a telephone interview, RN B confirmed RN D alerted her to a Code Blue on the Pebblestone unit. RN B recalled when she entered resident #1's room, the DON, RN A and D were already at the bedside. RN B recalled the DON asked for the BVM, and she knew a Code Blue meant CPR would be needed. RN B said she asked the DON if she should initiate CPR, to which he responded yes. She said she began performing chest compressions and acknowledged she should not have without verification of code status. RN B stated when she heard RN D yell, Code Blue, she assumed resident #1 was full code, but did not ask. She said she was not familiar with the facility's process as she had not received orientation about advance directives protocols. She acknowledged RN C entered the room with resident #1's chart a few minutes after they initiated CPR and told them the resident had a DNRO. She reported she performed compressions for approximately 2 minutes while the DON handled the BVM. On [DATE] at 2:52 PM, the DON recalled early in the morning of [DATE] he was in his office when RN D ran in and yelled, Code Blue, Code Blue, Code Blue. He said he asked RN D if the resident was a full code and she answered, Yes. The DON explained he headed towards the resident's room while RN D continued yelling Code Blue as she ran towards RN B who was in the Cliffstone unit. He said when he arrived at the Pebblestone unit nurses' station, he saw RN A with a chart. The DON asked RN A if the resident was a full code and RN A answered, Yes. He explained he acted on verbal confirmation of code status by 2 RNs. He recalled when he arrived at resident #1's bedside, he assessed her and noted a bounding pulse but she was gasping for air. He then asked staff to provide a BVM and directed staff to call 911. The DON stated he shook resident #1 and called her name and she opened her eyes, looked up at him, and her head fell to the left. He said he then told RN B, We need to start CPR. The DON stated they probably performed 2 cycles of CPR before RN C entered room with EMS personnel and informed resident #1 had a DNRO. According to American Heart Association, one cycle of CPR consists of 30 compressions and 2 breaths (Retrieved from www.heart.org on [DATE]). He remembered EMS personnel placed cardiac monitor on resident and pronounced her dead. The DON explained he trusted the RNs and took their word regarding the resident's code status. In hindsight, I knew as a DON I should have checked. He explained the facility process was for nurses to verify code status with the yellow DNRO in the chart, and not the electronic medical record. The DON explained the Code Blue procedure directed staff to use the intercom and page the phrase Code Blue. On [DATE] at 3:52 PM, the Administrator stated he received a call from the DON on [DATE] at 7:08 AM explaining they performed CPR on a resident who had a DNRO. The Administrator noted he conducted an investigation and the Root Cause Analysis showed nurses did not follow the facility's procedures related to verification of code status prior to initiating CPR. He explained the procedure required verification by 2 nurses of the actual yellow DNRO form. On [DATE] at 2:43 PM, the Clinical Quality Specialist explained the facility had not conducted a Code Blue mock drill in the previous 9 months, since [DATE]. She said this factor likely contributed to the incident and acknowledged nursing staff did not honor resident #1's wishes. She explained the facility's policy directed staff to check the medical record and have 2 licensed nurses verify the code status and noted this was not done. She stated her expectation was one staff member would stay with the resident while another one checked the chart. On [DATE] at 9:08 AM, during a telephone interview, resident #'s 1 granddaughter stated she was not aware her grandmother had received CPR until a few days after she died when an anonymous staff member called to inform her of the incident. She explained a DNRO was her grandmother's decision as she often expressed that she had already lived a long life. The granddaughter stated she was saddened, angry and disappointed the facility did not honor her grandmother's wishes. She expressed concerns that other residents' wishes for DNR would not be honored. On [DATE] at 1:00 PM, during a telephone interview, the facility's Medical Director stated she was resident #1's attending physician. She explained resident #1 was admitted to the facility with a DNRO and that every DNRO yellow form must be easily accessible, in the front of the residents' chart. She could not explain why this breakdown in process occurred. She said, Knowing who is DNR at the beginning of their shift would be a good way to start for all nurses. The problem was they reacted before they verified. Review of the undated job description for the Director of Clinical Services (or DON) revealed he/she would ensure all nursing staff were knowledgeable of the residents' rights including honoring the right to refuse treatment. The Facility Assessment reviewed by the Quality Assurance and Performance Improvement (QAPI) committee on [DATE] revealed every staff member would show competency in resident rights and changes of condition. The facility's policy and procedure titled Advanced Directives revised on [DATE] read, The center will abide by state and federal laws regarding advance directives. The center will honor all properly executed advance directives that have been provided by the resident and/or resident representative. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] to [DATE], the Clinical Quality Specialist provided individualized training on determining resident code status to the five licensed nurses involved in the incident. *On [DATE] and [DATE], RNs A and B and the DON were suspended pending investigation. *On [DATE], the Director of Social Services (SSD) conducted a whole house audit of 79 medical records, 100% of all residents. The SSD verified all residents with DNROs had yellow forms placed as the first item in the chart. *On [DATE], ad hoc Quality Assessment Performance Improvement committee meeting was held to conduct a root cause analysis and develop a Performance Improvement Plan. The root cause analysis identified lack of consistent staff training in orientation and failure to conduct ongoing monthly Code Blue mock drills as contributing factors. The meeting was attended by Medical Doctor (via telephone), Executive Director, Clinical Quality Specialist, MDS Coordinator, Case Manager, Unit Manager, Human Resource Coordinator, Business Development Coordinator, Central Supply, Business Office Manager, Maintenance Director, Activities Director, and Director of Rehab Services. *On ,d+[DATE] to [DATE], licensed nurses received education to include CPR Policy & Procedure (P&P), Advanced Directives Policy & Procedure (P&P), Nurse Practice Act, Resident Rights, Following Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Post tests were used to validate comprehension and all nurses obtained a passing score. In-service attendance sheets were used to validate participation by all facility staff. *On [DATE] to [DATE], the facility conducted five Code Blue mock drills and staff participation validated understanding and competency. Review of Code Blue drill forms revealed signature of responders and a drill critique with opportunities for improvement as indicated. *Newly hired licensed nurses and any agency staff will receive education upon hire or accepting a shift, to include CPR P&P, Advanced Directives P&P, Nurse Practice Act, Resident Rights, Following Physician Orders, Abuse/Neglect/Exploitation/Misappropriation and participation in Code Blue drills. *Interviews were conducted from [DATE] to [DATE] with 10 staff members including 7 RNs, 1 Licensed Practical Nurse, 1 Certified Nursing Assistant and 1 Personal Care Attendant. Staff were knowledgeable of CPR and advance directives and Abuse and Neglect P&P. *The sample was expanded to include six additional residents, #2, #3, #4, #5, #6, and #7. Interviews and/or record reviews revealed no concerns with advance directives including DNROs.

Based on interview and record review, the facility neglected to perform neurological assessments after falls to monitor for and identify signs and symptoms of serious injury for 1 of 5 residents reviewed for falls, (#3). On 08/10/21 at 8:00 PM, resident #3 fell and was found sitting in his bathtub incontinent of urine. Facility staff returned the resident to his wheelchair but did not initiate neurological assessments to assess for any head injury the resident may have sustained after he fell in the bathtub. Three hours later, at 11:00 PM, resident #3 fell a second time in his room. He was found on the floor with his head on the metal base of the over bed table, bleeding from a laceration to the back of his head. The facility's failure to initiate neurological assessments for a resident after an unwitnessed fall and subsequent second fall resulted in transfer to the hospital for a severe head injury with bleeding in the brain, seizures and respiratory failure that required mechanical ventilation. This failure resulted in Substandard Quality of Care at Immediate Jeopardy starting on 08/10/21. The Immediate Jeopardy was removed on 08/14/21. 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: Cross reference F689 Resident #3 was a [AGE] year-old cognitively impaired male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #3's hospital records revealed an Emergency Provider Report dated 08/11/21. The report noted a CAT (Computed Tomography) Scan of the head/brain completed on 08/11/21 at 12:40 AM, showed an acute subdural hemorrhage left temporal parietal lobe measuring up to 0.3 cm (centimeters) in width. Review of the Neurosurgical Progress Note dated 08/12/21, revealed a second CAT Scan of head/brain was completed on 08/11/21 at 6:14 PM, showed resident #3's hemorrhage had worsened and extended from the left side of his brain to affect both sides. The note read, bilateral subacute subdural hematomas, right 0.9 cm and left 0.8 cm in width. The quarterly Minimum Data Set assessment with assessment reference of 07/05/21 revealed a Brief Interview for Mental Status score of 6/15 which indicated the resident had severe cognitive impairment. The assessment noted he required limited assistance with all transfers, his balance and walking were not steady, but he was able to stabilize without staff assistance when moving from seated to standing position, moving on and off the toilet and with surface to surface transfers. Resident #3 used a wheelchair for mobility and was always continent of bladder and bowel. The assessment documented 2 previous falls with no injury. Review of the resident #3's most recent fall risk evaluations documented a score of 65 on 03/19/21 and a score of 80 on 04/14/21. Scores above 51 deemed a resident to be at high risk for falls. Review of the resident's care plan for actual falls initiated on 07/18/2019 and revised on 08/11/21 documented interventions on 03/19/21 to educate the resident to call for assistance with transfers and to ensure the resident wore appropriate shoes when out of bed. On 04/15/21 the care plan was updated to indicate labs were ordered. There were no interventions to address the level of supervision the resident required to prevent further falls nor specific post-fall actions/approaches to identify injuries and prevent complications. On 08/10/21 at 8:00 PM, a nursing progress note completed by Registered Nurse (RN) A documented resident #3 was wandering around unit hallways in his wheelchair, entered other residents' rooms and attempted to open exit doors on five occasions. The resident was placed in his room and soon after was found by Certified Nursing Assistant (CNA) B in the bathtub of his room, incontinent of urine. He was provided incontinence care and placed back in his wheelchair. An assessment was completed by RN A which included vital signs with no obvious injury noted. RN A documented, Continue observation for any neurological signs and symptoms or complications. The progress note did not include any evidence of any neurological assessments done, or actions implemented by facility staff to provide an appropriate level of staff supervision for resident #3 after he fell at 8:00 PM. On 08/10/21 at 11:00 PM, a second nursing progress note completed by RN A documented, Resident was found in his room lying on the floor next to the over bed table with bleeding head injury. The progress note indicated there was an open laceration to the back of his head that measured 3 to 4 cm long. RN A provided wound care and 911 called to transfer resident #3 to the emergency department (ED) for evaluation and treatment. Review of resident #3's medical record revealed two Change in Condition forms dated 08/10/21 at 11:00 PM. Both forms were completed by RN A. The first Change in Condition form revealed resident #3 was found inside his bathtub. He said he wanted to go to the bathroom to urinate. The second Change in Condition form documented the resident was found on the floor next to the over bed table with a 3 to 4 cm long open wound to his head. On 08/14/21 at 9:56 AM, during telephone interview, RN A stated on 08/10/21 at 8:00 PM, resident #3 was found by CNA B sitting in the bathtub in his bathroom, incontinent of urine. She said she assessed the resident, and he was placed back in bed where incontinence care was provided. She recalled that at 11:00 PM, CNA B informed her the resident fell again in his room. She said she entered the resident's room, and his head was on the metal base of the over bed table. He had a laceration to the back of his head and there was blood on the floor. RN A stated, I did vital signs and neuro checks every 15 minutes and documented the neuro checks on the Change in Condition form from 8:00 PM until 11:30 PM when resident #3 was sent to the hospital. RN A recalled that after the resident's first fall he was observed in the hallway falling asleep in his wheelchair. She said, I asked CNA B to put him back in his bed and to watch him. RN A stated she did not implement one to one supervision or instruct staff to provide an increased level of supervision for the resident to prevent further falls. Neuro checks are used to assess an individual's neurological functions and level of consciousness to determine whether the individual is functioning properly and react appropriately to the test . The test assesses the visual, verbal, audible, physical, mental, and emotional response of the individual being assessed (Retrieved from www.nursetheory.com on 08/23/21). Contrary to RN A's statement that she conducted neurological checks every 15 minutes per facility policy, there was no documentation found in the medical record to support her statement. Review of the facility's Neurological Evaluation Policy and Procedure, revised on 11/30/14, read, Procedure: . Perform neurological checks as follows unless otherwise ordered by the physician. Every 15 minutes for 1 hour. Every hour for the next 4 hours. Every 4 hours for the next 19 hours. Document neurological checks, vital signs and observations on the appropriate form. Place in the medical record. Notify the physician of any changes in condition. Review of resident #3's medical record revealed no neurological assessments were completed by RN A after the 2 unwitnessed falls that occurred at 8:00 PM and 11:00 PM on 08/10/21. Per the facility policy, RN A should have performed neurological assessments after resident #3's first fall on 08/10/21 at 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:00 PM, and 10:00 PM. After his second fall on 08/10/21 at 11:00 PM, 11:14 PM and 11:30 PM. The facility failed to check the resident 7 times between the first fall and second unwitnessed fall with severe head injury. On 08/12/21 at 1:35 PM, the Director of Clinical Services (DCS) stated if a resident had an unwitnessed fall, the nurse was required to complete neurological checks for 72 hours to determine if the resident had sustained a head injury. She indicated neurological assessments are completed to identify changes in a resident's mental status which may indicate signs and symptoms of serious head injury. On 08/14/21 at 10:48 AM, the Regional Nurse Consultant and DCS acknowledged resident #3's medical record did not contain any nursing progress notes or neurological assessments for his two unwitnessed falls on 08/10/21. The DCS stated neurological checks should have been initiated immediately after the resident's first unwitnessed fall. She said resident #3 should have received a total of 9 neurological assessments, but these were not done according to the facility's policy for Neurological Evaluation. On 08/14/21 at 2:37 PM, the DCS stated RN A came into the facility on [DATE], 3 days after the resident's falls, to complete documentation on the Neurological Assessment Flow Sheets. The DCS stated RN A explained she had a notebook which contained information related to resident #3. She added, The page did not contain any neurological check information, it only had the resident's vital signs. The DCS could not explain why RN A did not document the resident's assessments at the time of the falls and why she brought the handwritten piece of paper to the facility 3 days after the resident was transferred to the hospital. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policy and Procedure, revision date 11/28/2017, read, Policy: . Employees of the center are charged with continuing obligation to treat residents so they are free from . neglect . No employee may at any time commit an act of . neglect . Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident Review of the Facility Assessment, dated 08/17/2017, read, . Part 2: Services and care we offer based on our residents' needs . for mobility and fall/fall with injury prevention . Every staff member has knowledge competency in: . neglect . identification of condition change . dementia management Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team. *On 8/13/21-8/15/21, 102 in house residents were evaluated for fall risk. Care plans for residents identified at high risk for falls were updated for supervision. *On 8/13/21 the Vice President of Operations educated the Executive Director, Director of Clinical Services and the Assistant Director of Clinical Services regarding Abuse, Neglect and Exploitation. *On 8/13/21 the Director of Clinical Services educated the Unit Manager regarding Abuse, Neglect and Exploitation. * 8/13/21-8/15/21 the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services or Unit Manager educated current facility staff including all departments regarding Abuse, Neglect, Exploitation, with a post test to validate competency. 119/127 staff members were educated as of 8/15/21. Staff members that had not received the education would receive education prior to their next scheduled shift. Any staff not receiving education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. *8/14/21-8/15/21 the Director of Clinical services, Assistant Director of Clinical Services and Unit Manager educated licensed nurses regarding how to conduct Neuro checks which included competency checks to validate skills for performing neuro checks. 20/24 licensed nurses were educated as of 8/15/21. Licensed nurses that had not been educated would receive education on performing neuro checks prior to their next scheduled shift. Any licensed nurse that had not received education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. * The Interdisciplinary Team (IDT) would review all residents who had a fall during the morning clinical meeting, and in the afternoon at stand down meeting, to ensure neuro checks were completed for residents with unwitnessed falls. The nursing home supervisor and manager on duty, would review residents who had falls during weekend, and prior to manager on duty leaving, to ensure neuro checks were completed for residents with unwitnessed falls and the Director of Clinical Services had been informed of any falls. * The Director of Clinical Services or designee would review clinical records of all falls on a weekly basis to validate that neuro checks were completed of all unwitnessed falls. * On 8/14/21-8/15/21, the Director of Clinical Services and other nurse management team members educated licensed nursing staff regarding provision of supervision of residents to reduce risk for falls. This included notification of the DCS of all unwitnessed falls. 20/24 licensed nursing staff educated as of 8/15/21. Licensed nursing staff members that had not been educated would receive education prior to their next scheduled shift. Any licensed nursing staff that had not received education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. * On 8/14/21 an Ad Hoc Quality Assurance Performance Improvement meeting was held to discuss the Immediate Jeopardy, and education provided to staff. Additional Ad Hoc QAPI meetings would be held weekly, until it was determined that substantial compliance was met. * The Interdisciplinary Team (IDT) would review newly admitted residents during the morning clinical meeting to identify fall risk, and review care plans to ensure appropriate interventions were in place, to include appropriate level of supervision based on resident assessment and behaviors. *The DCS or designee would review clinical records weekly of all residents who had falls to validate that supervision was provided as needed based on the resident's assessment. Findings would be submitted to the QAPI committee for review and determination of further action to be taken. Staff interviews conducted with 17 staff ( including 5 RNs, and 7 CNAs,) on 8/15/21 between 12:20 PM to 3:33 PM, revealed the facility had provided education on Fall Management, Neuro Checks, and Abuse, Neglect and Exploitation.

Based on interview and record review, the facility failed to provide appropriate supervision for a cognitively impaired resident identified at high risk for falls, to prevent a fall with head injury and transfer to a higher level of care for 1 of 5 residents reviewed for falls, (#3). On 8/10/21 at 8:00 PM, resident #3 fell and was found sitting in his bathtub, incontinent of urine. Facility staff returned the resident to his wheelchair but did not implement increased supervision or additional fall prevention interventions. Subsequently, 3 hours later at 11:00 PM, the resident suffered a second fall in his room. He was found on the floor with his head on the metal base of the over bed table, bleeding from a laceration to the back of his head. The facility's failure to provide appropriate supervision for a resident assessed to be at high risk for falls resulted in transfer to the hospital for a severe head injury with bleeding in the brain, seizures and respiratory failure that required mechanical ventilation. This failure resulted in substandard quality of care and Immediate Jeopardy starting on 8/10/21. The Immediate Jeopardy was removed on 8/14/21. The scope and severity of the deficiency was decreased to D, no actual harm with potential for more that minimal harm that is not Immediate Jeopardy, after verification of the facility's corrective actions. Findings: Cross Reference F600 Resident # 3 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, generalized muscle weakness, abnormalities of gait and mobility, heart failure, dementia, and cognitive communication deficit. The quarterly Minimum Data Set with Assessment Reference Date of 7/05/21 showed the resident's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of 6/15. Resident #3 was assessed as being independent with bed mobility, toilet use, and personal hygiene, and required limited assistance of one-person with transfers, locomotion on the unit, and dressing. He had unsteady balance during transition and walking, moving from seated to standing position, moving on and off toilet, and surface-surface transfer, but he was able to stabilize without staff assistance. His mobility device was a wheelchair. Review of resident #3's medical record revealed a fall risk evaluation dated 3/19/21 with a score of 65. The form indicated scores above 51 deemed residents to be at high risk for falls. The resident's care plan for actual falls, created on 7/18/19, included an intervention dated 3/19/21 regarding educating the resident to call for assistance with transfers. Resident #3's next fall risk evaluation, completed after a fall on 4/14/21 revealed his score had increased to 80. The care plan was updated on 4/15/21 to reflect diagnostic labs were ordered and staff were instructed to determine and address causative factors of falls. Review of Change in Condition forms dated 8/10/21 revealed the resident had two falls. The first form noted he fell into the bathtub with no documented injury. The second form showed he was found on the floor with an open head wound approximately 3 to 4 centimeters (cm) in length. A progress note dated 8/10/21 at 8:00 PM read, resident wandering around unit hallways, in his wheelchair entering other residents' rooms and trying to open exits doors 5 times. Resident was placed in his room and was oriented. The progress note revealed during rounds, the resident was found in the bathroom tub by Certified Nursing Assistant (CNA) B and was assisted to his bed by Licensed Practical Nurse (LPN) D and CNA B. A nursing assessment was performed, and no trauma or skin lacerations were noted. The progress note did not include documentation to indicate any actions taken by nursing staff to provide an appropriate level of supervision for resident #3 after he fall at 8:00 PM. A progress note dated 8/10/21 at 11:00 PM, revealed the resident suffered another fall. Documentation revealed resident #3 was found lying on the floor next to his overbed table, bleeding from a head injury. An open wound of approximately 3 to 4 cm long was observed, and a physician's order was obtained to send resident #3 to the hospital for evaluation and treatment. On 8/12/21 at 11:29 AM, the River Rock Unit Manager (UM) stated residents were assessed for fall risk on admission, quarterly, after a fall, and as needed. The UM stated if a resident fell , the nurse should assess the resident, monitor vital signs, evaluate Range of Motion (ROM), and initiate appropriate and immediate fall interventions based on the assessment findings. The UM stated nurses should initiate and conduct neurological checks or neuro checks at regular intervals for a 24-hour period after any resident had an unwitnessed fall. Neuro checks are used to assess an individual's neurological functions and level of consciousness to determine whether the individual is functioning properly and react appropriately to the test .The test assesses the visual, verbal, audible, physical, mental, and emotional response of the individual being assessed. (Retrieved from www.nursetheory.com 8/23/21) On 8/12/21 at 2:10 PM, resident #3's fall incidents on 8/10/21 were reviewed with the Director of Clinical Services (DCS), and the Assistant Director of Clinical Services (ADCS). The DCS stated the resident was alert to person, confused, and at high risk for falls. Review of the resident's medical records showed neurological checks were not initiated after the resident's first unwitnessed fall on 8/10/21 at 8:00 PM, nor after his second fall at 11:00 PM prior to his transfer to the Emergency Department (ED). There was no documentation to indicate any increased level of supervision was provided for the resident after his fall, nor any interventions to prevent additional falls. The DCS verified there was no documentation or evidence of interventions to ensure the safety of the resident. On 8/14/21 at 9:56 AM, in a telephone interview, Registered Nurse (RN) A stated resident #3 had Alzheimer's disease, and dementia, and did not follow simple commands. RN A stated on 8/10/21 the resident was walking around without his wheelchair. He was assisted to his wheelchair and placed in the hallway. When CNA B saw the resident was falling asleep, she placed him in his bed. RN A stated fifteen minutes after the resident was placed in bed, he was found in the bathtub in his bathroom. She said the resident told her he wanted to pee. RN A stated the resident, was confused, and sometimes urinated on the floor. RN A recalled the resident was sitting in the bathtub in urine and denied pain. RN A stated she assessed the resident, checked his body, his head, did range of motion, and noted no signs of trauma. She stated LPN D lifted the resident out of the bathtub, transferred him to his bed, and he was returned to his wheelchair in the hallway after staff provided incontinence care. The RN stated she checked the resident's vital signs at 8:00 PM, at the time of the fall and did neuro checks every fifteen minutes until 11:00 PM when he suffered another fall. RN A explained she recorded neuro checks on the Change in Condition form. Review of the resident's Change in Condition forms dated 8/10/21 revealed Neurological Evaluation documentation that read, No changes observed. There were no entries related to scheduled neuro checks found on the forms. RN A stated when the resident was again falling asleep in his wheelchair, she told CNA B to place him in bed, and told her to watch him. When asked if the resident was placed on 1 to 1 supervision or had increased frequency of observations, the RN acknowledged she did not implement those measures. RN A stated CNA B sat in the hallway close to the resident's door. She said that at approximately 11:00 PM, she was informed by CNA B the resident was on the floor. RN A stated when she entered the resident's room, his head was on the base of his overbed table, and she noted a laceration to the back of the resident's head, and blood on the floor. She recalled resident #3 was lifted into his wheelchair and transferred back to bed with assistance from another staff member. RN A stated she asked the resident what happened, and he said he wanted to pee. She said she rendered first aid, called 911, and returned resident #3 to his wheelchair in the hallway to await the arrival of Emergency Medical Services (EMS) personnel. On 8/14/21 at 1:24 PM, CNA B stated on 8/10/21 between 5 PM-6 PM while picking up supper trays, she observed resident #3 in his bed. CNA B said the resident was able to go to the bathroom by himself. She said she did not see him in his bed during her rounds at about 8:00 PM. She then checked the bathroom, and discovered him in the bathtub. CNA B stated she asked the resident what happened, and he said he wanted to pee. She notified RN A, who asked LPN D to help lift resident #3 from the tub to his wheelchair, and to his bed. CNA B verbalized that later that night she was seated at the nurses' station, not in the hallway outside the resident's door when she heard a noise. When she went into the resident's room, she saw him on the floor with blood at the back of his head. She again notified RN A, who transferred resident #3 back to bed with help from other nurses. CNA B stated she had approximately 11 residents on her assignment that shift, and she never provided one to one observation for resident #3 at any time during the shift. On 8/13/14 at 4:18 PM, resident #3's care plan for an actual fall was reviewed with the DCS. The care plan read, lost his balance while standing at bedside table 8/10/21, unwitnessed fall with injury. The DCS acknowledged that interventions on the care plan such as education regarding calling for assistance were not appropriate and individualized for this cognitively impaired resident. She confirmed the care plan did not address how often the resident was to be observed or supervised, nor was it revised or updated on 8/10/21 to address the cause of the first fall, and to prevent further falls. Review of the Emergency Provider Report dated 8/11/21 revealed the resident's chief complaint was fall, head injury. The document read, .presents by EMS as a trauma alert secondary to fall .Patient had some obvious head trauma. Computed Tomography (CAT) Scan of the head/brain completed on 8/11/21 at 12:40 AM showed an acute subdural hemorrhage left temporal parietal lobe measuring up to 0.3 cm in width. A follow up CAT Scan completed later that day, on 8/11/21 at 6:14 PM revealed resident #3's brain bleed had worsened and expanded to, Bilateral subacute subdural hematomas, right 0.9 cm and left 0.8 cm. The hospital history and physical dated 8/11/21 showed the resident had a posterior scalp laceration approximately 4 cm with bleeding and hematoma noted. The provisional diagnoses included: Subdural hematoma, status post fall and the document read, The patient had [CONDITION(S)] after the head injury, with respiratory failure. He is intubated. He is seen by Neurosurgery for acute subdural hematoma Continue vent (ventilator) support. The Trauma Progress note on 8/13/21 revealed the patient remained intubated and on mechanical ventilation. The facility's policy Fall Management with effective date 11/30/2014 and revision date 7/29/2019 read, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk .Post Fall Strategies: 1. Resident will be evaluated, and post fall care provided. 2. Initiate Neurological checks as per policy or directed by the physician order. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team. *On 8/13/21-8/15/21, 102 in house residents were evaluated for fall risk. Care plans for residents identified at high risk for falls were updated for supervision. *On 8/13/21 the Vice President of Operations educated the Executive Director, Director of Clinical Services and the Assistant Director of Clinical Services regarding Abuse, Neglect and Exploitation. *On 8/13/21 the Director of Clinical Services educated the Unit Manager regarding Abuse, Neglect and Exploitation. * 8/13/21-8/15/21 the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services or Unit Manager educated current facility staff including all departments regarding Abuse, Neglect, Exploitation, with a post test to validate competency. 119/127 staff members were educated as of 8/15/21. Staff members that had not received the education would receive education prior to their next scheduled shift. Any staff not receiving education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. *8/14/21-8/15/21 the Director of Clinical services, Assistant Director of Clinical Services and Unit Manager educated licensed nurses regarding how to conduct Neuro checks which included competency checks to validate skills for performing neuro checks. 20/24 licensed nurses were educated as of 8/15/21. Licensed nurses that had not been educated would receive education on performing neuro checks prior to their next scheduled shift. Any licensed nurse that had not received education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. * The Interdisciplinary Team (IDT) would review all residents who had a fall during the morning clinical meeting, and in the afternoon at stand down meeting, to ensure neuro checks were completed for residents with unwitnessed falls. The nursing home supervisor and manager on duty, would review residents who had falls during weekend, and prior to manager on duty leaving, to ensure neuro checks were completed for residents with unwitnessed falls and the Director of Clinical Services had been informed of any falls. * The Director of Clinical Services or designee would review clinical records of all falls on a weekly basis to validate that neuro checks were completed of all unwitnessed falls. * On 8/14/21-8/15/21, the Director of Clinical Services and other nurse management team members educated licensed nursing staff regarding provision of supervision of residents to reduce risk for falls. This included notification of the DCS of all unwitnessed falls. 20/24 licensed nursing staff educated as of 8/15/21. Licensed nursing staff members that had not been educated would receive education prior to their next scheduled shift. Any licensed nursing staff that had not received education would not be permitted to work until education was completed and validated by the Director of Clinical Services or designee. * On 8/14/21 an Ad Hoc Quality Assurance Performance Improvement meeting was held to discuss the Immediate Jeopardy, and education provided to staff. Additional Ad Hoc QAPI meetings would be held weekly, until it was determined that substantial compliance was met. * The Interdisciplinary Team (IDT) would review newly admitted residents during the morning clinical meeting to identify fall risk, and review care plans to ensure appropriate interventions were in place, to include appropriate level of supervision based on resident assessment and behaviors. *The DCS or designee would review clinical records weekly of all residents who had falls to validate that supervision was provided as needed based on the resident's assessment. Findings would be submitted to the QAPI committee for review and determination of further action to be taken. Staff interviews conducted with 17 staff ( including 5 RNs, and 7 CNAs,) on 8/15/21 between 12:20 PM to 3:33 PM, revealed the facility had provided education on Fall Management, Neuro Checks, and Abuse, Neglect and Exploitation.

Based on observation, interview and record review, the facility failed to prevent residents with severe cognitive impairment from exiting the facility, failed to implement appropriate interventions to address escalating anxiety and behavioral symptoms and failed to respond to door alarms in a timely manner, for 2 of 6 residents reviewed for elopement, out of a total sample of 7 residents, (#1 and #2). These failures contributed to the elopement of two residents and placed them at risk for serious injury/impairment/death. While both residents were out of the facility unsupervised, there was reasonable likelihood they could have fallen, become lost or been hit by a car. On 04/13/21 at approximately 4:15 PM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. Resident #1 was observed by a staff member outside the therapy exit door approximately 8 feet away on a downward sloping ramp that ended at a parking lot. The facility was not aware of resident #1's whereabouts and due to her dementia, anxiety disorder and cognitive impairment, the elopement placed her at risk for injuries from falling, getting lost or getting hit by a car. On 5/2/21 at approximately 1:45 PM, 19 days after the above mentioned event on 04/13/21, the facility failed to prevent a resident with known exit seeking behaviors and severe cognitive impairment from exiting the facility unsupervised and failed to respond to alarms in a timely manner. Resident #2 was found by a staff member approximately 77 feet away from the facility, close to the edge of the parking lot near a grassy area that had a ditch. The resident was in close proximity to a heavily trafficked highway. Resident #2 was wearing an electronic monitoring device when she left the facility. She had history of exit-seeking behaviors and regularly pushed on exit doors. The facility's failure to provide adequate supervision and ensure safe and secure environment placed all residents who wandered at risk. This resulted in Substandard Quality of Care and Immediate Jeopardy starting on 4/13/2021. The Immediate Jeopardy was removed on 05/03/21. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more then minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: 1. Resident #1, a [AGE] year old female, was initially admitted to the facility on [DATE]. She was discharged home and then readmitted on [DATE] as she was not able to care for herself. Her diagnoses included dementia with behavioral disturbance, [CONDITION(S)], [CONDITION(S)], anxiety disorder, generalized muscle weakness, difficulty in walking and unsteadiness on her feet. [CONDITION(S)] is defined as damage or disease that affects the brain. It occurs when there is a change in the way the brain works or a change in the body that affects the brain. Those changes can lead to an altered mental state and confusion (retrieved on 05/19/21 from the WebMD website at www.webmd.com). [CONDITION(S)] describes conditions that affect the mind, where there has been some loss of contact with reality. Individuals may have difficulty understanding what is real and what is not (retrieved on 05/19/21 from the National Institute of Mental Health website at www.nimh.gov). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 03/23/21 revealed resident #1 was alert and disoriented but could follow simple instructions. The Admission/Readmission Data Collection form dated 03/25/21 revealed resident #1 was alert and oriented to person and place but had memory problems. Section N2 of the form, Elopement Risk Evaluation, indicated she was cognitively impaired and independently mobile. The form inaccurately indicated she did not have poor decision-making skills and deemed her not at risk for elopement. A Nursing Progress Note dated 03/29/21 revealed resident #1 refused treatment and walked the hallway with her husband while carrying a suitcase. Both residents said they were leaving the facility and returning to their home. The note revealed nursing staff informed resident #1 and her husband they could not leave the facility. The Elopement Risk Evaluation form dated 03/30/21 indicated resident #1 was cognitively impaired, independently mobile, had poor decision-making skills, demonstrated exit seeking behaviors and had the ability to exit the facility. She was determined to be at risk for elopement. The Change in Condition form dated 03/30/21 revealed resident #1 was verbally aggressive, hallucinating and threatened to harm others with utensils. The Advanced Practice Registered Nurse (APRN) was notified and gave orders for Lorazepam, an antianxiety medication via injection. An electronic monitoring device was placed on the resident #1's wrist as she was at risk for elopement. Review of the medical record revealed a physician's order dated 03/31/21 for Lorazepam solution 2 milligrams (mg)/milliliter (ml) to be given via intramuscular injection every 12 hours as needed (PRN) for anxiety disorder. Resident #1 also received an order for Lorazepam 0.5 mg by mouth at bedtime. Resident #1's care plan for elopement created on 03/31/21 revealed she was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The care plan interventions included to assess for elopement risk, place an electronic monitoring device and identify patterns of wandering. The document read, Is wandering purposeful, aimless, or escapist? Is resident looking for something? The care plan directed staff to intervene as appropriate, but it did not include PRN antianxiety medication. The Minimum Data Set (MDS) admission assessment with assessment reference date of 04/01/21 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 03/15 indicating severe cognitive impairment. She had continuously exhibited inattention and disorganized thinking and had verbal behavioral symptoms directed towards others on 1 to 3 days in the lookback period. She required supervision for transfers and walking. Resident #1 did not use a wheelchair or cane for mobility. She had unsteady balance but was able to stabilize without staff assistance. She received antipsychotic and antianxiety medications during the 7 day lookback period. A Nursing Progress Note dated 04/10/21 at 1:45 PM, revealed resident #1 was wandering around the unit throughout the shift and constantly asked for her husband. The notes indicated resident #1 had an unwitnessed fall in the hallway and was discovered on the floor by a nurse when she exited a nearby room. The Nursing Progress Note dated 04/11/21 at 11:45 PM, revealed resident #1 again wandered around the unit throughout the shift, repeatedly asking for her husband. The notes indicated staff encouraged the resident to return to bed to prevent her from falling again but she became verbally aggressive. he nurse's note revealed non-pharmacological interventions were ineffective and the assigned nurse administered 1 mg Lorazepam solution via intramuscular injection as ordered. A Nursing Progress Note dated 04/12/21 at 10:38 AM, revealed resident #1 continued to show behavior and poor safety. On 05/16/21 at 1:40 PM, Registered Nurse (RN) A stated that on 04/13/21 at about 3:15 PM, resident #1 came to the nurses' station and started looking for her husband. RN A said Certified Nursing Assistant (CNA) E redirected resident #1 to her room. RN A stated she last saw resident #1 in her room at about 3:30 PM, before she left the unit to get something from the central supply room. RN A recalled that when she was returned to the unit around 4:00 PM she saw Licensed Practical Nurse (LPN) D pushing resident #1 in a wheelchair down the hallway towards her. She recalled LPN D said, Well, your patient got out by the therapy area and she had to be brought back in. RN A explained she was not familiar with resident #1 as that was the first time she was assigned to care for her. In interviews conducted on 05/16/21 at 3:34 PM, and 05/17/21 at 8:49 AM, CNA E stated she was not assigned to resident #1 on the day she exited the building. She said she interacted with her in her room at the start of the 7:00 AM shift when she offered her coffee before breakfast. CNA E recalled resident #1 verbalized she was waiting for her husband at that time. She stated after breakfast, resident #1 continued to talk about waiting for her husband. CNA E said by lunch time resident #1 not only kept talking about waiting for her husband but she began to walk back and forth between her room and the nurses' station. CNA E stated she informed RN A that resident #1 needed to be watched closely as she was fixated on finding her husband. When asked about interventions used to distract resident #1, CNA E stated at around 1:30 PM, she told resident #1 her husband went to work but it was not effective and resident #1 kept on looking for her husband. She said after shift change at 3:00 PM, resident #1 exited her room and was still worried about her husband. CNA E added she attempted to stop the Pebble Stone Unit Manager (UM) as he walked by, but he shook his hand instead as if signaling that he did not want to be involved in the conversation. CNA E explained she persisted and the Pebble Stone UM paused to speak with resident #1 and told her that her husband might be in her room. CNA E stated she and the Pebble Stone UM redirected resident #1 to her empty room. She said she left the area soon afterwards to provide care for another resident. She stated about 20 to 30 minutes later, RN A informed her resident #1 had been found outside the facility. On 05/17/21 at 9:11 AM, CNA H stated she was assigned to resident #1 from 7 AM to 3 PM and 3 PM to 11 PM shifts on the day she exited the facility. CNA H acknowledged resident #1 searched for her husband all day, from the start of the day shift, and gradually got worse as the day progressed. She noted CNA E assisted her with monitoring resident #1 and described how they had to babysit her. She said that both she and CNA E informed the assigned nurse, RN A about resident #1's increasingly anxious behavior related to not being able to find her husband. She said she was not sure if RN A attempted to do anything to calm resident #1. CNA H stated that when she last observed resident #1 that afternoon at around 3:30 PM, she was seated at the edge of her bed still asking for her husband. She said that she did not hear any door alarm when resident #1 exited the building as she was with another resident in a room behind a closed door. CNA H acknowledged resident #1 would not be safe outside the facility and she would be in danger if she got to the busy road by herself. On 05/17/21 at 9:42 AM, the Occupational Therapy Assistant (OTA) stated on 04/13/21, she was in the bathroom near the therapy gym when she heard exterior door alarms. She recalled she initially heard a beeping sound that indicated that someone was attempting to open the door followed by a loud continuous screamer alarm that meant the exterior door had been breached. She said she ran from the bathroom towards the exterior door by the therapy gym where she noted an empty wheelchair by the door. The OTA explained she looked outside and saw resident #1 a few feet away, standing on the ramp that led to the facility's parking lot. She said she exited the building to retrieve resident #1 while trying to call a coworker for assistance with her personal cell phone. The OTA stated she was able to convince resident #1 to go back inside and recalled no other staff responded to the alarm. She said she assisted resident #1 into the wheelchair and pushed her back to the unit through the therapy lobby, passed the vending machines and along Pebble Stone 2 hallway until they arrived at the nurses' station at the center of the unit. The OTA acknowledged she did not encounter any other staff along the way. She said she returned resident #1 to LPN D who was by the nurses' station and told him what happened. She explained that resident #1 was able to ambulate without a device but was not not completely safe because her balance was unsteady. In addition, the OTA explained resident #1 had poor safety awareness. She added, it was luck that I was in the bathroom because if she reached the road, it would be unfortunate because she would have crossed the road or gotten lost. On 5/17/21 at 9:56 AM, a tour of the area outside the facility where resident #1 was found was conducted with the OTA. She showed the ramp where the resident was found. The ramp led to the parking lot and faced a busy 6-lane highway. The OTA demonstrated that resident #1 was in the middle of the ramp and not holding onto the rails approximately 8 feet from the door. She recalled resident #1 kept repeating that she wanted to go home. On 05/17/21 at 1:23 PM, the Pebble Stone UM stated he started work at the facility on 04/12/21, the day before resident #1 got out of the building. He explained that on 04/13/21, resident #1's husband was in the hospital and she was very anxious to find him. The Pebble Stone UM acknowledged he continuously redirected resident #1 back to her room between 8 AM and 10 AM and promised her they would call the hospital later that afternoon to inquire about her husband. He said he did not recall any further conversation regarding resident #1 that afternoon prior to leaving at the end of his shift at 4:00 PM. The Pebble Stone UM stated his expectation was staff should provide increased monitoring and supervision during resident #1's periods of heightened anxiety. He stated that nurses should check the medical record and administer appropriate PRN medication if available and monitor for about an hour after it was given to evaluate for effectiveness. He added that if the PRN medication was not effective, the physician should be notified. He said, even 1 hour was too long not to address the behavior, much less for 9 hours. On 05/17/21 at 2:11 PM, the Director of Maintenance (DOM) explained if a resident with monitoring device approached an exterior door, it would automatically lock but not alarm. He noted that exterior doors were fire egress doors and would unlatch if continuous pressure was held on the bar for 15 seconds. He said during that 15 second period there would be a beeping alarm that would be followed by a shrill sound of the screamer alarm once the door opened. The DOM stated the screamer alarm could be heard by staff who were far away and would alarm continuously until turned off with a key by either a nurse or maintenance staff. On 05/17/21 at 2:47 PM, the DOM demonstrated the function of the door alarms at the therapy gym exit door. He triggered the 15 second egress alarm and the screamer alarm and only 1 staff member responded, the same OTA who retrieved resident #1 when she exited the building. The DOM acknowledged that facility staff had poor response to alarms when he conducted drills. On 5/18/21 at 4:34 PM, CNA M stated he could not hear the alarm if he was in a room at the end of the hallway. On 05/17/21 at 3:10 PM, the Director of Nursing (DON) said on the day resident #1 exited the building, staff had been informed there was a problem with the alarm system. She said the staff needed to reset the alarm at the nurses' station. She explained the malfunctioning system was possibly the reason staff did not respond to the alarm. When asked about resident #1's anxious behavior, the DON stated that assigned nurse should have notified the physician so her anxiety could have been addressed in a timely manner. She said RN A could have administered PRN medication if available, or initiated 1:1 supervision. The DON acknowledged redirection was an appropriate intervention but the resident should not have been told that her husband was at work or in their room. On 5/17/21 at 3:44 PM, the Executive Director (ED) stated the alarm system might have malfunctioned because there was a power outage on 04/13/21. She said, when the power came back, it affected things. The Regional Director of Clinical Services added there was a thunderstorm on the day of the incident that affected the function of the door alarm system. Review of historical weather data from 04/12/21 at 8:56 AM to 04/13/21 at 3:56 PM, revealed there was not any thunderstorm activity in the vicinity of the facility. (retrieved on 05/17/21 from Time and Date website at www.timeanddate.com). On 05/17/21 at 4:43 PM, the DOM stated on the morning of 04/13/21, there was weekly scheduled testing of the facility's generators. He said there was a brief power outage and the door alarms had to be reset manually by himself and his assistant. He confirmed the alarms were reset by 8:45 AM, 6 hours before resident #1 exited the building. He noted he checked the doors throughout the day and all alarms were functional. He acknowledged the alarm panel boards at the nurses' station beeped randomly every 2 hours for the past 2 weeks. He said nurses had to reset the button on the panel. He explained this beeping was not a door alarm and the proper thing to do was for staff to check doors when an alarm sounded. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Alzheimer's disease, delusional disorder, depression and anxiety. Elopement Risk Evaluations completed 7/23/20, 12/29/20, 4/13/21 and 5/2/21 showed the resident was at risk for elopement. Resident #2's annual Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's Brief Interview for Mental Status (BIM) score was 99 which indicated the resident's cognitive skills for daily decision making were severely impaired. Resident #2's elopement/wandering care plan initiated 12/7/18 included approaches to 1. assess for fall risk, 2. distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, 3. electronic monitoring device to the right wrist, check placement and functioning as ordered. Medical record review revealed resident #2 had 4 falls in the facility prior to her elopement. On 3 of the 4 falls, the resident was transferred to the hospital due to hitting her head on the floor. A psychiatric evaluation dated 1/25/21 noted, .wandering and paranoia is worse mostly in the evening, responds with redirection and manageable per staff. The note added that the resident also had occasional exit seeking behaviors and agitation and at times can be redirected. Another psychiatric evaluation dated 2/22/21 noted, .continues with wandering, going to different rooms, confabulation, delusions, but manageable with current regimen and redirection A nursing progress note dated 4/26/21 at 1:34 PM, read Weekend nurse reports patient was wandering the halls and pushing at doors throughout shift but was easily redirected. Patient increasingly agitated A nursing progress note dated 4/26/21 at 2:24 PM, noted Psych evaluated today, gradual dose reduction done on 4/19/21 to decrease [MEDICATION(S)] from 50 mg to 25 mg at bedtime was unsuccessful due to resident wandering constantly thru to the hall and trying to exit seek. New orders for [MEDICATION(S)] 50 mg daily at 5 pm [MEDICATION(S)] is an antipsychotic medication used to treat psychotic and delusional disorders by changing the actions of chemicals in the brain. (Retrieved on 5/26/21 from www.drugs.com). On 5/16/21 at 2:01 PM, RN A said resident #2 left the Pebblestone Unit on 5/2/21 and went out the fire exit doors on the west side of the facility. RN A explained resident #2 continuously wandered throughout the hallway and pushed on the fire exit doors. RN A recalled on 5/2/21 she was coming out of resident's room and she heard the door alarm. She said she looked at the east fire exit doors and did not see anything going on there. She went to the nurses' station and looked at the door indicator panel at the nurses' station. RN A recalled she looked towards the front entrance but realized the receptionist was there. She then headed towards the west and saw an empty wheelchair at the exit door. She said she went to the door and saw resident #2, near the end of the parking lot facing the main street. She went outside toward the resident who was near the intersection of heavily trafficked 2 lane road and 6 lane divided highway. RN A indicated the six lane highway was always very busy. She said resident #1 eloped from the facility first then a few days later, resident #2 left the facility. At this time, LPN C stated more staff would help with the overall supervision of residents. LPN C added, having more eyes on the residents is always better. She pointed to the dry erase board attached to the wall with staff assignments. Both LPN C and RN A said they originally had 6 CNAs but 1 CNA was pulled to another unit to do 1:1 supervision of a resident. They said they divided up that CNA's assignment to the remaining CNAs. This meant that each of the CNA on the Pebblestone Nursing Wing had more residents to supervise than what was originally intended. RN A recalled the same thing happened on 5/2/21 when there were only 5 aides on the wing, and resident #2 eloped. The area outside the facility where resident #2 was found was observed. There was a ditch, approximately 28 feet to the resident's left, that had a steep embankment. The resident was found in close proximity to a six lane divided highway with heavy traffic. On 5/17/21 at 10:14 AM, CNA E stated she was assigned to resident #2 on 5/2/21 as her regularly assigned CNA was off that day. She said she was on break when resident #2 exited the building. She was informed by RN A that the resident got out of the facility. She recalled that the resident wandered around the unit that day. CNA E indicated on some days the resident could walk by herself and then on other days she was not steady on her feet. That's when we put her in a wheelchair. CNA E recalled, resident #2 wandered around the unit and pushed on the west fire exit door. When she would push on the door, the alarm would go off and we would have go and get her and redirect. CNA E added that resident #2 could get agitated when redirected. On 5/17/21 at 10:49 AM, CNA H stated she had worked a the facility for about [AGE] years and was not at work when the resident eloped. She was aware resident #2 was confused and liked to wander/walk around the unit. She was exit seeking, and tried to open the exit doors especially in the afternoon. She said the resident could be willful, there is no way to have her sit, when she wants to walk. CNA H said a helpful approach to redirect the resident was to tell the resident that she was the boss. She would explain to the resident that the resident needed to supervise her. CNA H explained that when she went into a resident room, she would tell resident #2 to wait outside so she could supervise CNA H. She said this approach was not part of the care plan, that's my thing I do with her. CNA H said she had used this approach for the past 2 years but there was no indication this technique was shared with other staff. CNA H explained that when the resident was exit seeking, staff had to be more alert and provide increased supervision. On 5/17/21 at 12:36 PM, CNA I said she worked part time on weekends and was resident #2's direct care aide on 5/2/21. She indicated she was unaware the resident got out of the building that day until housekeeping staff told her. CNA I recalled that on 5/2/21 around 1:30 PM, she was providing care to another resident and did not hear any alarms. She said the resident had an electronic monitoring device on her ankle as she was an elopement risk. She acknowledged the resident would not be safe outside the facility, without supervision. She added that she did not understand how the resident got out as she had an electronic wandering device. There was no indication that CNA I understood how the electronic wander system worked, in concert with fire exit doors. CNA I said she personally thought resident #2 needed 1 to 1 supervision. On 5/17/21 at 2:11 PM, the DOM stated he had worked at the facility for 2 months. He explained how the fire exit doors and the electronic wandering device system worked. He said the facility had a total of 8 exterior exit doors. Seven of the 8 exit doors had a magnetic lock (Maglock) except the door that led to the courtyard. He stated if a resident, with a wander guard device was near an exit door, the door would lock. If the resident pushed on the door an alarm would sound. If the resident continuously pushed on the door, the door would open after 15 seconds. He said there was an extra alarm on the door called a screamer. When the exit door opened, the screamer would alarm. He stated with the current wander guard system, the door that resident #2 exited from the facility only alarmed when the resident #2 pushed on the door and the door opened. On 5/17/21 at 3:10 PM, a meeting was held to discuss resident #1 and #2's elopement with the Administrator, DON and Regional Director of Clinical Services. They acknowledged both elopements. The DON could not provide any information regarding which staff were on the unit, and what they were doing at the time resident #2 exited the facility. The DON did not have any information on which staff were at lunch or on break when the resident left. The DON stated they were still investigating to determine which staff were at lunch/break and where the staff were on the unit. On 5/18/21 at 11:05 AM, RN A was recalled on 5/2/21, the second nurse on the Pebblestone Nursing Unit, was an agency nurse. She said he was not in the hallways and she did not know where he was. She could not recall if he informed her that he was going on break. She indicated when she called the bosses to tell them about the elopement, the agency nurse came back into the building. I don't know where he was coming from. She said if the agency nurse was a staff nurse, resident #2 would not have exited the facility. RN A noted that she usually could not hear the door alarms when she was in a resident room. She said if she was assisting a fall risk resident in the bathroom, she would not be able to leave and respond to an alarm. On 5/18/21 at 11:04 AM, CNA E and CNA K acknowledged that they could not hear the exit door alarm if they were in resident rooms with the doors closed. On 5/18/21 at 4:28 PM, CNA L stated that in some resident rooms, it was harder to hear the exit door alarms when the room doors were closed. Review of the policy and procedure for Elopement/Wandering Risk Guide revised on 08/02/20 indicated the facility would initiate individualized interventions to prevent elopement based on a resident's risk. The document Best Practices-Elopement/Wandering Risk dated 08/01/20 indicated elopement triggers included patient is cognitively impaired and can ambulate or independently propel in a wheelchair, patient repeatedly asking for spouse or family, patient verbalizes wanting to go home, observe for aimless wandering fear or anxiety about the surroundings . Interventions for elopement and/or wandering including reacting to trigger statements like I want to go home and increase frequency of monitoring. The Facility Assessment Tool updated on 12/15/20 revealed the facility was able to care for residents with [CONDITION(S)], anxiety disorder and behaviors that required interventions. The document indicated the facility would identify and implement interventions to help support individuals with issues such as dealing with anxiety and care of someone with cognitive impairment. Care and services were individualized and personalized to each resident preference. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: *Resident #1 was assessed and did not reveal any signs of injury or distress on 04/13/21. *Resident #1 was immediately placed on 1:1 supervision on 04/13/21. *Resident #1's electronic monitoring device was checked and noted to be in place and functioning properly on 04/13/21. *The Executive Director (ED) led a Quality Assurance and Performance Improvement (QAPI) meeting on 04/13/21 with the Medical Director (MD), Director of Clinical Services (DCS), Social Services Director (SSD), MDS Coordinator, Medical Records (MR) Director and unit managers. Elopement policy and procedures were reviewed, root cause of elopement was discussed. *Resident #1 was moved to a room in River Rock unit with her husband on 04/13/21. *Resident #1 was evaluated by psychiatric services on 04/14/21 with recommendation for changes in medication and continue with 1:1 supervision. *Resident #2 was assessed and noted to to have no alterations in skin integrity or apparent injuries on 05/02/21. *Resident #2 was placed on 1:1 supervision on 05/02/21. *Resident #2's electronic monitoring device was checked and noted to be in place and functioning properly on 05/02/21. *Resident #2 was moved to the River Rock unit, away from frequent pedestrian traffic and frequently used entrance/exit doors on 05/02/21. *An Ad hoc QAPI meeting was held on 05/03/21 led by the ED with DCS, MD, MDS Coordinator, DOM, Human Resources Director, SSD, MR coordinator, Admissions Coordinator and unit managers. Elopement policy and procedures were reviewed, root cause analysis completed as well as systemic changes to prevent further risks. * ED and DCS rounded in the facility to validate all exit doors were secure and alarms functioning properly on 04/13/21. *During rounds it was discovered that electronic monitoring system had not reset following a generator test on 04/13/21, staff were placed to monitor doors until the system was reset. *The DCS and designees completed elopement risk assessments on all current residents to identify others that may be at risk, no new residents were identified at risk on 04/13/21. *Staff were assigned to complete hourly door monitoring from 04/13/21 until 04/20/21. *Staff were assigned to monitor doors every 4 hours from 04/21/21 to 04/27/21. *Staff were assigned to monitor doors every 6 hours from 04/27/21 to 05/02/21. *Staff were assigned to monitor doors hourly from 05/02/21 until 05/10/21. *The ED and DOM rounded the facility on 05/02/21 to validate all exit doors were secured and alarms were functioning. *The DCS and designees re-evaluated all residents for elopement risk, no new residents were identified. * On 05/03/21, 6 residents who were identified as high risk for elopement with current exit seeking behaviors were moved to River Rock unit where there was less foot traffic and entrance/exit doors not frequently used or outdoor distraction or stimulations. *On 04/13/21 the DCS and designees initiated education for all staff on elopement risk identification to include identification of behaviors that may be indicative of exit seeking. This education consisted of post tests to validate knowledge. Education was completed on 04/27/21. *The DCS and designees conducted elopement drills daily for 3 days which started on 04/13/21 then weekly through 04/30/21. This included post-drill education based on staff response. *On 05/02/21 the DCS and designees initiated education for all staff on elopement risk identification to include identification of behaviors that may be indicative of exit seeking. *A new door security system was ordered on 04/16/21 and was pending installation. *QAPI meeting was held on 04/20/21. Elopement was reviewed at this time. The MD, ED, DCS, SSD, DOM, and unit managers were present. *QAPI meeting was also held on 04/27/21 in which elopement was reviewed with the MD, ED, DCS, SSD, MDS coordinator, unit managers and Medical Records coordinator were present. *Ad hoc QAPI was held on 05/03/21 with the MD, ED, DCS, SSD, MR, MDS, D [TRUNCATED]

Based on observation, record review and interview, the facility failed to ensure assistance and supervision were provided to prevent an avoidable accidents for 1 of 5 sampled residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing progress note dated 9/13/20 at 6:28 PM read, at approximately dinner time resident #1 asked her Certified Nursing Assistant (CNA A) to warm her soup for her. By trying to feed herself the soup fell on her thigh and the resident was burnt on two different places, assessment was done, MD made aware, treatment given, resident is alert and oriented request that she prefer to talk to her guardian herself. The CNA was removed from the assignment, safety measures in place, will continue to observe resident. A physician's progress note dated 9/16/20 indicated that resident #1 had [MEDICAL CONDITION] to spilt hot soup. Two burned areas were identified on the right anterior thigh and the right lateral thigh. The two burnt areas measured 5 cm (centimeters) x 7 cm x 0.1 cm and 3 cm x 2 cm x 0.1 cm, respectively. On 9/17/20 at 2:15 PM, resident #1 stated her family brought in food/soup to the facility and it was stored in the refrigerator that was located in the unit's pantry. She stated that on 9/13/20 at dinner time, she asked CNA A to warm up her soup that was in the refrigerator. Resident #1 said CNA A brought her the soup in a Styrofoam cup with a lid. She said she could see steam coming up from the straw. The resident explained that CNA A told her the soup was hot and she set it on the table to cool. The resident stated that her hands were shaky that day and she picked up the soup and it spilled on her leg. She stated the soup had never been that hot before even after I had let it sit. Resident #1 said her pants were covered with hot soup. She said she pressed her call light and a nurse arrived but she left to get another staff to help. The resident recalled that CNA A came into her room after she had been burnt. She said the CNA told her, 'this is all your fault.' The resident stated, It's painful, even now. When I stretch, I can feel that my skin is ripping apart. Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/3/19 noted the resident scored 14 out of 15 on the Brief Interview for Metal Status which indicated she was cognitively intact. Section G of the MDS assessment for Activities of Daily Living (ADLs) assessed resident #1 as 2/2 for eating which indicated assistance by 1 staff person was required to eat safely. Review of the Occupational Therapy (OT) progress notes indicated resident #1 was certified for therapy from 8/26/20 to 9/8/20. The OT progress note dated 9/8/20 indicated the resident required supervision for eating/feeding. The resident's ADL Care Plan was initiated on 12/5/19 and was last reviewed on 7/10/20. The eating section of the ADL Care Plan remained the same since 12/5/20. It noted, 'The resident requires assistance from staff to eat as necessary. After the resident was burnt by the hot soup the physician gave orders dated 9/14/20 that read the resident, is assist to feed with all meals. Although the physician ordered the resident to be assisted with her meals to ensure resident safety, the resident's ADL Care Plan was not updated to reflect the physician's new order. Further medical record review noted that the resident was cared planned for resistive/refusing care. This Care Plan noted, 'If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. However, the resident's care plan did not instruct staff on how to re-heat food/soup and to ensure she would not be scalded or burned. On 9/17/20 at 2:45 PM, CNA A confirmed she was working when resident #1 was burnt by the hot soup. CNA A stated she was passing out dinner trays when the resident asked her to heat up her soup. CNA A stated she put the soup in a Styrofoam cup and placed it in the microwave for 2 minutes. She said the soup was still cold so she continued heating it for 1 more minute. There was no indication that CNA A was aware or had been trained that food needed to be rapidly re-heated to 165 degrees and served at a palatable temperature while minimizing the risk of scalding or burns. CNA A stated there was no thermometer in the pantry to measure the temperature of the re-heated soup. CNA A stated that the resident needed total assistance with some things and assist with other. CNA A stated after she delivered the soup, she instructed the resident to call her if she needed help. Then CNA said she left resident #1's room and assisted another resident with eating. There was no indication that CNA A assisted resident #1 with eating or provided supervision during the meal. CNA A stated, it's not my fault, because resident #1 did not wait. CNA gave no time frame as to how long the resident should have waited for assistance or why she left hot soup with the resident even though she did not provide any supervision or assistance as per the resident's plan of care. On 9/17/20 at 3:12 PM, Licensed Practical Nurse (LPN) B confirmed she responded to the resident's call light when she spilled the soup. LPN B stated when she entered the room, she saw the spilled soup on the resident's lap. She said there was a red mark on the resident's upper thigh. She stated the resident's meal tray was in the room with the white Styrofoam cup. The resident told her that she was burned by the soup. LPN B explained that the CNAs were responsible for re-heating the residents' personal food that family brought in. LPN B stated there had been no prior training for re-heating food. LPN B stated that resident #1 was sometimes able to feed herself and sometimes needed assistance to feed. LPN B did not explain who or how they assessed whether resident #1 was able to feed herself at each meal. LPN B did not provide an answer when asked if resident #1 was assessed to be able to eat the hot soup independently on 9/13/20 at dinner time. When asked if there was a process to ensure residents were not burned from hot food or soup, LPN B stated, it should be at the normal temperature. LPN B was not able to define 'normal temperature' so that residents were not burned or scalded from hot food. On 9/17/20 at 3:34 PM, the contracted Certified Dietary Manager (CDM) stated that facility staff, not the contracted dietary staff, were responsible for re-heating residents' food. He stated the kitchen staff do not allow food from the outside to be brought into the kitchen. He explained that food that was brought in by family was stored in the refrigerator in the pantry. The CDM stated he had instructed the kitchen staff on how to re-heat food but had not provided training to the CNAs. Observation of the pantry with the CDM noted a sign on the wall that instructed staff to re-heat coffee and food to 135 degrees Fahrenheit. The CDM stated he did not post the sign. He stated the correct way to re-heat food was to rapidly re-heat it to 165 degrees Fahrenheit. When asked what could be done to prevent residents being burned by hot food, the CDM said at his last job, they used 'thermal sticks' which turn a certain color depending on the temperature of the food. He stated thermal sticks were not used at this facility. On 9/17/20 at 4:18 PM, a meeting was conducted with the Administrator and Director Of Nursing (DON). The DON stated that after resident was burned, the staff were in-serviced on re-heating food. The DON did not provide a reason as to why signs in the pantries instructed staff to re-heat food to 135 degrees Fahrenheit. She reviewed the Policy and Procedure provided by the CDM. She stated that food needed to be rapidly reheated to 165 degrees Fahrenheit. When asked about the Root Cause of why resident #1 was burned, the DON stated that she did not have a Root Cause Analysis as they were still investigating and working on staff in-services. The DON added that the CNA should not have left the resident alone with the hot soup. The DON did not explain why resident #1 was not given assistance and supervision during meals as noted in the plan of care and therapy notes.

Based on observation, record review and interview, the facility failed to use its resources effectively and efficiently to ensure the highest practicable physical, psychosocial well-being and safety needs were met for 1 of 3 residents reviewed for elopement out of a total sample of 12 residents, (#2). On 7/22/20 at approximately 9:10 pm, a newly admitted resident, #2 removed the thumb screw on the window slide lock, and exited the facility through the window, in the dark, unsupervised. The facility was located on the corner of a busy thoroughfare. Resident #2 walked approximately 528 feet, in the dark, to a local convenience store. The resident crossed a heavily trafficked 6-lane divided highway to the convenience store on the other side of the highway. The resident was was found by a family member who observed him standing in the parking lot of the convenience store. The facility was unaware the resident was outside, in the dark, unsupervised, until they were informed by the resident's family. The facility's failure to ensure window locks were installed with securing screws as directed on 7/23/2020, failure to follow up to ensure completion of window securing screws and failure to provide adequate supervision resulted in Immediate Jeopardy starting on 7/22/20. The Immediate Jeopardy was removed on 10/27/20. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN) C noted the resident was alert, oriented to person but not place or time. LPN C noted the resident had memory problems. The resident spoke English and sometimes made himself understood and sometimes had the ability to understand others. LPN C noted the resident did not have any obvious behavior problems and the resident was a non-smoker. In the elopement section, the resident was noted to have impaired cognition, poor decision-making skills and had the ability to exit the facility. LPN C determined the resident was not an elopement risk, based on the evaluation tool which noted he did not wander, did not have exit seeking behavior or a history of elopement. The nursing progress notes demonstrated resident #2's behaviors escalated since admission. A nursing progress note dated 7/18/20 at 9:30 pm, revealed the attending physician was called related to the resident's behaviors. The resident refused to stay in bed or in his room. Resident had difficulty walking due to weak lower limbs and confusion. The Advanced Practice Registered Nurse (APRN) gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/19/20 at 7:13 pm, nursing progress note read, .resident's spouse in room [ROOM NUMBER]. When she approached him, he yelled and screamed at her because he doesn't remember that she is wife . Nursing progress note dated 7/21/20 at 5:30 pm read, Resident was agitated screaming yelling at his wife for money. When the nurse tried to intervene resident pushed the nurse out of the room and slam the door .Administrator, DON (Director of Nursing) and social worker and unit manager came to escort him .after many attempts he finally decided to leave .Police was called, officer came and talked to him to stay away from his wife, as she wished . On 10/27/20 at 12:46 pm, resident #2's eldest daughter was contacted by phone. She stated her mother was admitted to the facility first, followed by her father. She said they had been together for over [AGE] years and that her mother took care of her father. The daughter was aware that her father constantly went into her mother's room at the facility. She said her father did not like to be cooped up, he would hang out with friends and that he liked to smoke. The daughter stated on the day when her mother's room was changed, her father eloped from the facility, that evening. She stated her cousin found her father at the convenience store and was able to get him into the car. The cousin then drove the resident to the daughter's apartment, nearby, and they both brought him back to the facility. On 10/28/20 at 11:13 am, the Social Worker (SW) stated resident #2's wife was admitted to the facility first and within a week, resident #2 arrived at the facility. She said the next day he started going into his wife's room, asking her for money. The SW stated the resident wanted money to buy marijuana. The SW recalled the resident wanted to smoke his weed. The SW added the resident continued to go into the wife's room, despite being told that his wife needed to rest. She stated that on 7/22/20 at 4:23 pm, the wife was moved to a different nursing unit, which was on the opposite end of the facility. She verbalized that she did not inform resident #2 about his wife's room change and was not aware if resident #2 had known that his wife had been moved. The SW said she believed that it was important for resident #2, to see his wife. She noted that it was important for resident #2 to be outside and that he had never been in a nursing home. The SW did not provide an answer when asked what measures the facility implemented to ensure the resident's need to see his wife, after she was moved to a different unit. The SW provided no indication that the facility had set up visiting times, for resident #2 to see his wife. The SW expressed that she understood that when a couple had been together for [AGE] years, a spouse could have felt lost, when he did not find her in her usual room. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] noted resident #2 had been transferred to another nursing home. The MDS indicated the resident's Brief Interview for Mental Status (BIMs) was 9, which indicated the resident's cognition was moderately impaired. The MDS noted the resident's Inattention and Disorganized thinking. The MDS also noted that resident #2 had verbal behaviors and wandering, that had occurred 1 to 3 days. Even though the resident behaviors had increased along with his wandering, there was no evidence the facility had re-evaluated resident #2 for elopement until after he eloped on 7/22/20. On 10/26/20 at 4:49 pm, an interview was conducted with the Administrator, Director of Nursing and the Regional Nurse Consultant. The Administrator said resident #2's wife had a room change on the afternoon of 7/22/20. He added that at approximately 9:10 pm on 7/22/20, resident #2 eloped from the facility. He stated that resident #2 went out the window of his wife's previous room that was across the hallway from his. The staff spoke about their 4-point corrective action plan that included staff re-education, elopement drills and changing the hardware fasteners on the window slide locks. The administrator stated all the windows in the rooms now had slide locks, which prevented the windows from fully opening. He stated that during the investigation, they could not find the window slide lock the resident would have opened to leave the facility. The Administrator described the screw/bolt on the slide lock as wing nut that could be loosened by hand. It was noted that this particular bolt was known as a thumb screw, which could be tightened/untightened by hand. The Administrator believed the resident untightened the thumb screw and was able to remove the sliding window lock. The Administrator stated that part of their corrective action plan was to change all the thumb screws and replace them with a hex head screw, on every window in the facility. The hex head screw required the use of a wrench or screwdriver to tighten or untighten. On 10/27/20 at 9:25 am, the windows in rooms 101, 102, 103, 104, 105, 107, 108, 119, 123, 125, 127, 128, 129 and 204 were observed. All the windows still had the thumb screw which could be untightened by hand. Later that morning at 9:55 am, the Administrator provided audits completed by Maintenance Staff of all the window slide locks. The audits indicated the window slide locks had been replaced with the new hex head screws. The Administrator was informed that windows in 14 rooms still had the thumb screws that could be untightened by hand. He could not explain why the audit was inaccurate and could not explain what processes had been in place, to ensure accuracy of the window slide lock audits. There was not any indication that Administration had verified whether the thumb screws had been replaced to prevent residents from fully opening the windows. On 10/27/20 at 5:40 pm, the fourteen room windows were re-checked. Each of the window slide locks either had a hex head screw or a [NAME] head screw. The window in room [ROOM NUMBER] had a slide lock with a hex head screw. When the slide lock was lightly touched with one finger, the entire slide lock fell to the floor. The Administrator placed the window slide lock back on the window frame and tightened the hex head screw with a wrench. On 10/26/20 at 4:45 PM, the Administrator and DON noted that resident #2 had exited the facility 4 hours after his wife's room change. There was no indication the facility had considered telling the resident that his wife had not left the facility but only had a room change. The facility had not planned for increased supervision, security of the environment and/or considered supervised scheduled visits in anticipation of the resident's reaction to his wife not being in the room where he routinely visited her. Review of the corrective measures implemented by the facility on 7/22/20 revealed the following: On 07/22/20 at 9:55 PM, the resident was returned to the facility. He was assessed by the nurse and there were no signs of injury. A wander device was placed on his right arm, he was placed on 1:1 staff supervision and a consult was ordered for psychiatric evaluation. He was evaluated by psychiatric services on 07/23/20 with recommendations for changes in his medications and transfer to a secure unit in another nursing facility. Resident #2 was transferred to another nursing facility on 07/23/20. The facility reviewed the medical records for all residents and elopement risk evaluations were completed with no new resident identified at risk for elopement. The elopement binders were reviewed on 07/22/20 and 10/27/20 to validate if residents at risk for elopement were included in the binders. The Administrator rounded in the facility on 07/22/20 to identify if other windows were missing the window locks. The Maintenance Director conducted daily rounds starting on 07/23/20 to 07/30/20 to validate the window securing devices (thumbscrew) were in place. The Administrator ensured that all window locks and hardware were in place as of 10/27/20. Staff interviews were conducted for staff involved on 07/22/20 3 PM-11 PM shift regarding resident #2's behaviors and location leading up to the event. A root cause analysis was completed based on medical record review and staff interviews on 07/23/20. On 07/22/20 education and elopement drills were initiated and completed daily on various shifts until 07/28/20 and then monthly. Staff were educated on identifying elopement risk based on resident behaviors and residents verbalizing desire to leave the facility. Newly hired staff will receive education on elopement risk and participate in elopement drills during their orientation process. Education will include a post test. On 07/23/20 the facility had an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director to discuss the root cause analysis and corrective action plan. Review of the corrective measures implemented on 10/27/20 by the facility to remove Immediate Jeopardy revealed the following: All 4 Elopement Risk Binders contained a face sheet and resident pictures of all 12 residents at risk for wandering/elopement. Observation of all 14 resident room windows and the River Rock sitting room window revealed they were corrected and now had the hex head screws securely in place so the windows could not be opened. Sign in sheets for education on elopement policy and procedures with posttest were reviewed and revealed that 100% of active staff attended. Sign in sheets for staff participation in elopement drills were reviewed and revealed 100% of active staff had completed elopement drills. An audit of all resident windows to ensure that a hex head screw was in place and secure was conducted by the Administrator on 10/28/20 with no issues found. New employee orientation contained elopement education and requirement to participate in an elopement drill. On 10/28/20 the Maintenance Assistant was educated by the Administrator on the use of the hex head screw for securing the windows and checking to ensure that the windows were secure. Audits will be completed daily. On 10/28/20 the Administrator was educated by the Regional Vice President of Operations on elopement policy and procedure, window security and the need to check and follow up to ensure maintenance staff had completed projects as directed. The resident sample was expanded to include 2 additional residents (#4, #6) who were assessed at being wander/elopement risk and having a Wander Guard device in place. Record reviews, observations and interviews with staff revealed no issues. Interviews with 3 Registered Nurses, 1 Licensed Practical Nurse and 4 Certified Nursing Assistants on 10/28/20 from 1:00 PM-4:30 PM revealed they were knowledgeable regarding the facility's elopement 8 staff members on 10/28/20 revealed they were knowledgeable regarding the facility's elopement policy and procedure, wander guard placement, supervision and missing resident process. The Maintenance Assistant was interviewed and knowledgeable regarding the use of the hex head screws to secure all windows, to test the screws for security and audits to be conducted daily.

Based on observation, interview and record review, the facility failed to provide necessary care and services to prevent falls and ensure appropriate and timely post-fall medical care for 1 of 3 residents reviewed for falls (#22), and failed to protect residents from physical/sexual abuse for 1 of 3 residents reviewed for abuse (#1), from a total sample of 18 residents. These failures led to major injuries and contributed to the risk of serious impairment or death for resident #22, and caused psychosocial harm for resident #1. On [DATE] at approximately 7:30 AM, resident #22 fell in her room and hit her head. She was sent to the hospital for evaluation and returned later that afternoon. On [DATE] at approximately 3:30 AM, within 24 hours of the first fall, resident #22 had another unwitnessed fall and again hit her head. The physician was not notified, and nursing staff returned resident #22 to bed, where she remained until she was sent to the hospital more than 6 hours later. Resident #22 was diagnosed with [REDACTED]. Resident #22's neurological status was not assessed appropriately after her fall and while she was left in bed without adequate supervision and monitoring, there was a high likelihood she could have fallen again or suffered [MEDICAL CONDITION], coma or death from her head injuries. On [DATE] at 6:00 PM, resident #1 was observed crying. He informed Certified Nursing Assistant (CNA) T that when the day shift CNA QQ was washing him, she pulled his testicles and penis and when she turned him over she put her finger in his rectum. The Administrator interviewed resident #1, felt the resident was confused and concluded that the incident did not happen in the facility. The Administrator did not investigate the incident thoroughly and compromised the safety of all the residents in the facility. Findings: 1. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of [DATE] revealed resident #22 had adequate hearing and vision, clear speech and no comprehension deficits. Her Brief Interview for Mental Status (BIMS) score of 14 on a 0 to 15 scale indicated she was cognitively intact. Resident #22 had no behavioral issues such as rejection of care or wandering. She required extensive assistance of 1 staff member for bed mobility, walking, transfers on/off the toilet and personal hygiene. The MDS assessment showed resident #22 required extensive assistance of 2 staff members for other transfers . between surfaces including to or from: bed, chair, wheelchair, standing position. Resident #22's balance during transitions and walking was unsteady, and she was only able to stabilize with the assistance of staff. She used a wheelchair for mobility. Resident #22 had frequent urinary and bowel incontinence. The MDS assessment revealed resident #22 had 1 fall with major injury, defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. Review of resident #22's medical record revealed a care plan for activities of daily living (ADL) self-care performance deficit related to [MEDICAL CONDITION] and a stroke. The care plan, initiated on [DATE], indicated resident #22 required assistance from 1 staff member with transfers and toilet use. A care plan for risk for falls, initiated on [DATE], had a goal of minimizing the risk of a serious injury. The interventions included call light within reach, bed in low position and appropriate footwear. Resident #22 had a care plan for [MEDICAL CONDITION] that affected ADLs, mobility and safety, initiated on [DATE], that directed nursing staff to Monitor for risk of falls. Review of a nursing progress note and a Change in Condition Evaluation form dated [DATE] revealed resident #22 was found on the floor in her room, between the beds and beside her wheelchair. She fell during an attempt to transfer herself back to bed. Resident #22 was lying on her right side and had a bruise to the center of forehead. She complained of pain to her right elbow and forehead, and the assigned nurse initiated neurological checks. The physician was notified of the unwitnessed fall and gave an order to send resident #22 to the hospital emergency room (ER) for evaluation. Neurological checks or neurochecks are usually done after an unwitnessed fall to identify signs of a head injury. The evaluation includes checking level of consciousness, vital signs, pupil size and reactivity to light and hand grip strength. Standard clinical nursing practice suggests this evaluation should be done immediately after the fall, at regular intervals, with gradually decreasing frequency over 72 hours. (www.hcpro.com) The facility's policy and procedure for Neurological Evaluation revised on [DATE], indicated neurological checks should be performed Every 15 minutes for 1 hour. Every hour for the next 4 hours. Every 4 hours for the next 19 hours. The document revealed the results of the neurological checks, vital signs and observations would be noted on the appropriate form, and the physician notified of any changes in condition. Resident #22 returned from the hospital that afternoon, on [DATE] at 2:20 PM and was re-evaluated for risk for falls. The Fall Risk Evaluation form revealed inaccurate data. The document indicated resident #22 had no falls in the previous 3 months instead of 2 actual falls on [DATE] and [DATE], as noted in the medical record. Review of the medical record revealed a care plan for actual falls was initiated on [DATE], with a goal to minimize the risk of further incidents. The interventions initiated on [DATE], included observe for 72 hours and report pain, bruises, change in mental status, new onset confusion or sleepiness, and Determine and address causative factors of the fall. The care plan interventions were not revised or updated after the falls on [DATE] and [DATE] to reflect appropriate and individualized interventions to prevent further falls and injuries. Review of resident #22's medical record revealed neurological checks were conducted after she returned from the hospital on [DATE] at 2:20 PM, 2:35 PM, 2:50 PM, 3:00 PM and 4:00 PM by the day shift nurse. The day shift nurse's progress note read, Endorsed to oncoming nurse to do neurological checks and monitor for pain. The evening nurse's flow sheets showed neurochecks continued, and were done at 5:00 PM, 6:00 PM and 11:00 PM. A Neurological Assessment Flow Sheet indicated resident #22's next neurochecks were done on [DATE] at 5:17 AM, at a 6-hour rather than 4-hour interval, by the night shift nurse Registered Nurse (RN) I. The flow sheet was incomplete and inaccurate as RN I did not assess resident #22's pupil response nor check and record current vital signs. RN I noted resident #22 had no response to painful stimulus, a finding that would indicate a lack of consciousness. The flow sheet revealed Resident fell during morning shift, bruise on left eye and forehead she was sent to the ER. Resident had a re-fall during night shift no changes observed, no other observations. Review of resident #22's medical record revealed no nursing progress notes or change in condition evaluation form related to the fall during the night shift. There was no documentation of notification of the physician and family, nor initiation of post-fall neurochecks after the second fall. A nursing progress note dated [DATE] at 11:48 AM revealed resident #22 was sent to the hospital via 911 due to the fall which occurred at or about 3:00 AM. Later that evening at 8:51 PM the evening shift nurse's note indicated she called the hospital and was told resident #22 remained in the ER and was being closely monitored. On [DATE] at 9:56 PM a nursing progress note revealed the facility was informed resident #22 was admitted for a subdural hematoma. A subdural hematoma is a collection of blood between the layers of tissue that surround the brain. Subdural hematomas are usually caused by severe head injuries. The bleeding and increased pressure on the brain from this injury can lead to unconsciousness and death. (www.webmd.com) Review of a hospital progress note dated [DATE] at 11:55 AM revealed This is the 2nd fall and the facial swelling increased and came to the emergency room . The note indicated resident #22 visited the ER the day before, after the first fall. She had a negative computed tomography or CT Scan of her head and was discharged back to the facility. Resident #22's medication list included aspirin 81 milligrams (mg) once daily and [MEDICATION NAME] 75 mg once daily, which are platelet aggregation inhibitor drugs that can cause increased bleeding. (www.drugs .com) CT scans of the head/brain and face done on [DATE] at 12:00 PM, after the second fall, showed Critical Results. Resident #22 was diagnosed with [REDACTED]. A hospital progress note completed on [DATE] at 12:54 PM revealed resident #22 was admitted to the trauma intensive care unit (ICU) for monitoring. On [DATE] at 8:19 AM, the hospital physician's documentation indicated resident #22 had no acute changes overnight and she was transferred from trauma ICU to a lower level of care with fall precautions. Resident #22 was discharged back to the facility on [DATE]. On [DATE] at 5:59 AM and 6:27 AM, resident #22 confirmed she fell a few times since admission to the facility. She recalled 2 recent falls that resulted in 2 trips to the hospital in a 24-hour period. She said, They did a lot of scans. I had bleeding in my brain . Resident #22 explained on the night she fell in the bathroom, she fell forward out of her wheelchair onto the floor and landed on her face. Resident #22 stated after the fall, she called out for help, but nobody heard. She said, It was a long time. Resident #22 explained sometimes staff did not check on her or respond to the call light, especially at night, so she often chose to go to the bathroom by herself. On [DATE] at 8:47 AM, RN I explained she was assigned to the Cliff Stone unit on [DATE] for the 11:00 PM to 7:00 AM shift. She stated she was not aware she had 10 additional residents on the Pebble Stone unit, including resident #22, until later that night. RN I stated she never received report on the 10 residents on the Pebble Stone unit, and explained she was therefore not aware resident #22 fell the morning before, nor that neurochecks should have been continued on her shift. RN I said, It's not convenient to have some residents on one unit and then more residents on another . I feel uncomfortable working like that. The distance between the Cliff Stone nurses' station and resident #22's room was measured to be greater than 164 feet. RN I stated at about 4:00 AM on [DATE], CNA X came to the Cliff Stone unit from the Pebble Stone unit to alert her that resident #22 was on the floor. She explained they assisted resident #22 back to bed and the other nurse on the Pebble Stone unit, licensed practical nurse (LPN) K, instructed her to complete neurological, fall risk and pain assessments. RN I stated she was not aware regular neurological assessments should have been initiated after the fall and did not know the required frequency at that time. She stated she tried to call the physician twice, but did not leave a message, and did not notify resident #22's family. RN I explained there was no supervisor in the facility during the night shift and she eventually notified a unit manager and the assistant director of nursing (ADON) at about 7:00 AM before she left work. RN I acknowledged neurological checks should have been continued after the first fall, and re-started after resident #22's second fall to monitor for complications from hitting her head in both unwitnessed falls. RN I validated resident #22 could have died from her head injury. Review of the policy and procedure (P&P) Fall Management revised on [DATE] revealed resident-centered fall prevention interventions would be initiated based on the resident's fall risk. The purpose was to identify residents at risk for falls and develop and revise interventions to decrease the risk of further falls and injuries. The process included post-fall strategies such as evaluation, neurochecks according to policy or as ordered, notification of the physician and resident's representative, re-evaluation of fall risk, updating the care plan and Kardex with new interventions, initiation of post-fall documentation for 72 hours, Interdisciplinary Team (IDT) review of fall documentation, completion of a root cause analysis, updating the plan of care and weekly review of resident status for 4 weeks. The P&P Abuse, Neglect, Exploitation & Misappropriation revised on [DATE], defined Neglect as the failure of the facility to provide services to a resident that are necessary to avoid physical harm. The document indicated Neglect included Failure to take precautionary measures to protect the health and safety of the resident and failure to notify a resident's legal representative of an incident such as a fall with possible injury. On [DATE] at 9:35 AM, LPN A stated she worked on [DATE] and was aware resident #22 fell , went to the hospital and returned to the facility. Although she was not assigned to resident #22 on [DATE], she recalled seeing a lump in the middle of her forehead and minor bruising. LPN A stated she arrived at the facility the following morning on [DATE] after 9:00 AM for her first shift as weekend nursing supervisor. She explained the night nurse LPN K was still on the Pebble Stone unit as no relief nurse showed up. LPN A stated LPN K was not actually assigned to resident #22, but as of 7:00 AM when RN I's night shift ended, the units were no longer split and resident #22 was to be assigned to a nurse on the Pebble Stone unit. LPN A recalled as she stood at the medication cart, she observed resident #22 in bed. She said, I was shocked when I saw her face because she did not look like that yesterday. She looked like she got beat up. She had a big forehead, it was double the normal size. She looked like a different person. Around her eyes were very bruised. She looked like a racoon. Under her eyes she had significant facial swelling. Forehead was easily twice the size. LPN A mentioned to LPN K that resident #22 looked worse than she looked the day before. She stated LPN K then informed her resident #22 fell again during the night shift. LPN A stated she asked LPN K if the physician and family were notified and LPN K said, It's not my patient. LPN A stated she immediately left a message for the on-call physician and notified the family. She explained the physician did not return her call in a timely manner and said, She looked very bad and I was worried about trauma and bleeding. I called the family to notify them and used my judgement and called 911 . She was alert and responsive, but since I couldn't figure out what happened on ,[DATE] (night shift) and got no report, I sent her out. LPN A validated RN I did not follow the facility's policies and procedures for falls and neurological assessment. She acknowledged essential notifications were not made to the physician or the family. LPN A stated RN I should have continued resident #22's neurochecks throughout the night shift following her first fall and initiated the protocol again after the second fall. On [DATE] at 2:56 PM, CNA X stated she was assigned to resident #22 during the 11:00 PM to 7:00 AM shift on the night she fell . CNA X confirmed she received verbal report from the off-going CNA but was not informed resident #22 fell and went to the hospital earlier that day. She recalled at about 12:30 AM she walked over to the Cliff Stone unit to inform RN I that one of the residents on Pebble Stone unit asked for his nurse. CNA X stated RN I was very surprised because she was not aware she had additional residents on the other unit. CNA X explained she returned to the Pebble Stone unit and continued her rounds. She explained she was extremely busy because the facility was short-staffed on the previous shift and she had to give several bed baths and change all the bedding for residents who had not received care. She said, It took me a long time because I had to do so much to make sure everybody was clean. CNA X explained it was about 3:30 AM when she finally reached resident #22's room and noted she was not in bed. CNA X stated she saw light in the bathroom, so she knocked at the door, asked if resident #22 was alright and heard, Help me. CNA X stated she opened the bathroom door and found resident #22 face down on the floor. She stated she went to the Cliff Stone unit to get RN I. CNA X stated they both picked resident #22 up off the floor and assisted her back to bed. CNA X said, She was in pain . I saw bruising on her face and a bump on her forehead. CNA X recalled RN I assessed resident #22, asked her a few questions and returned to the Cliff Stone unit. She stated RN I was busy on the Cliff Stone unit after the incident and returned to Pebble Stone unit briefly to administer medication to other residents, but not for resident #22. When asked about the level of assistance resident #22 required for ADLs, CNA X said, Supervision. She goes to the bathroom by herself in the wheelchair and uses the grab bars to transfer to the toilet. CNA X confirmed she documented on residents' ADL flowsheets on a tablet but acknowledged she did not know how to access residents' care instructions or Kardex. Review of resident #22's Kardex with CNA X revealed the instruction for 1 staff member to assist resident #22 with transfers, toilet use and personal hygiene. CNA X was surprised and said, I thought she needed only supervision. When asked about fall prevention, CNA X said, I treated her like normal that night because I never knew she fell . Otherwise I would have checked on her more often. It is not possible to watch and give proper care to 20 patients at night. On [DATE] at 11:17 AM, in a telephone interview, LPN K stated she received report on all Pebble Stone unit residents during change of shift report on [DATE] and was told resident #22 fell . She acknowledged she never passed this information on to RN I. When she was informed RN I did not know she had a partial assignment on the Pebble Stone unit that night, LPN K stated RN I should have received that information in orientation. LPN K stated her expectation was the nurses from the other units who had residents on the Pebble Stone unit would come to her for report on their assigned residents. On [DATE] at 12:54 PM, the MDS Coordinator explained she was responsible for developing and reviewing care plans and revising interventions to promote individualized approaches to resident care. She explained in the past, the interdisciplinary team (IDT) met every morning and discussed incidents that occurred in the previous 24 hours, including falls. She stated the IDT no longer met regularly. The MDS Coordinator explained the IDT used to discuss the circumstances of residents' fall, identify possible causes and develop specific interventions to prevent further falls. She confirmed resident #22's care plans for falls were not reviewed and updated with appropriate interventions to prevent falls and injuries. She validated after the creation of an actual fall care plan on [DATE], the fall prevention interventions for resident #22 were not revised after falls on [DATE], [DATE] and [DATE]. The MDS Coordinator stated the fall care plan was never discussed after (MONTH) 2019, even when resident #22 had a fall with major injuries. She explained the lack of IDT discussion did not support good nursing practice. The MDS Coordinator said, Nothing was done differently even after the major injury. A toileting schedule might help, but I think staff supervision is the main thing. The MDS Coordinator stated the Kardex was also developed and revised in the care planning process and CNAs needed access to accurate, updated information to provide appropriate care. She explained the standard approach of rounds every 2 hours was not individualized, and after a fall it would have been appropriate to implement more frequent monitoring for resident #22. Review of the P&P Plans of Care revised on [DATE] revealed an individualized person-centered plan of care would be established for each resident by the IDT. The P&P indicated the comprehensive plan of care would be reviewed, updated and/or revised . based on changing goals, preferences and needs . with a goal of attaining a resident's highest practicable well-being. On [DATE] at 12:43 PM, the Staffing Coordinator (SC) stated CNAs often told her they were short-staffed and could not complete their assigned tasks. She said, I tell them I have to stay in the guidelines. It is not right for the residents. The SC confirmed administration was aware that CNAs sometimes had more than the maximum allowed 20 residents on the night shift. The SC said, I get complaints from residents regarding short staff on night shift, call lights not being answered timely and incontinence care not being done. They say they are not getting proper treatment. I believe residents can be harmed or neglected by improper care if there is not enough staff. On [DATE] at 1:22 PM, the administrator stated he was aware sometimes nurses had assignments that included residents on 2 separate units. When asked if he felt nurses were able to adequately care for all assigned residents in that situation, he said, It doesn't sound suitable to me. The administrator acknowledged it would be difficult for CNAs to closely monitor 20 or more assigned residents whether on one or more units. He validated staffing issues could have contributed to resident #22's fall. During a telephone interview on [DATE] at 12:18 PM, resident #22's daughter stated a nurse from the facility called her on [DATE] at about 10:40 AM and reported her mother fell during the night shift, the second fall in 24 hours. The daughter stated she was not notified at the time her mother fell and facility staff could not explain why her mother was not sent to the hospital during the night. She explained her mother was diagnosed with [REDACTED]. She said, I can't understand why the nurses waited to send her to the hospital. It was so upsetting when we got to the hospital and found her that way. On [DATE] at 3:06 PM, the interim director of nursing (DON) acknowledged it was not prudent to assign a nurse to 2 separate units because he/she might not be able to adequately monitor residents in both areas, especially if residents had complex needs or if acute situations developed on different units. She validated the previous nursing management team should have reviewed resident #22's fall risk evaluations and care plans after each fall in order to determine effective interventions to prevent further falls and injuries. The interim DON acknowledged in this situation, resident #22's assigned nurse did not follow facility policies and procedures or accepted professional standards. The interim DON stated all CNAs were expected to use the Kardex to determine the level of assistance each resident needed for ADLs and to obtain information on safety precautions. On [DATE] at 5:30 PM, in a telephone interview, the Medical Director stated her expectation was she would be informed of incidents that occurred in the facility. She was not aware resident #22 suffered severe head injuries from a recent fall. She explained the protocol for unwitnessed falls or possible head injuries included immediately notifying the physician, doing a comprehensive nursing assessment, obtaining vital signs, initiating neurological checks and completing an incident report. The Medical Director confirmed she should have been notified if staff were not able to contact the attending physician. She validated a head injury that was not treated in a timely manner could result in severe impairment or death. 2. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Medicare 14 day Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of ,[DATE], indicating moderate cognitive impairment. The assessment showed he required extensive assist of two persons for bed mobility, transfers, personal hygiene, and extensive assist of 1 person for toileting. He was frequently incontinent of urine and always incontinent of bowel. A review of the resident's care plan noted that he was to be discharged home. On [DATE] at 11:00AM, the resident was resting in bed. The resident was Spanish speaking. He stated on the day after he returned from the hospital, a certified nursing assistant (CNA) QQ came into his room to provide incontinence care. He said he knew something was wrong right away as she was cleaning him differently. She went right for my penis and testicles. She put her finger in my rectum. He stated he told her to stop and get out, and she did. He stated he cried after she left the room as he felt abused. This happened in the morning after breakfast but before lunch. He stated he did not report this to anyone on that shift. He did however, report it to the 3 PM-11 PM CNA T who spoke Spanish. The resident said that when CNA T came into his room she noticed he was upset and asked what happened. He reported to CNA T what the morning CNA QQ did to him on the previous shift. After he told CNA T about the incident, she brought the registered nurse, (RN) FF and asked him to tell her what happened. He stated he did not tell his family all the details because he was too embarrassed. He called the police that night to report the incident. On [DATE] at 9:25 AM, the resident stated that it was okay to ask him about the incident as it helped to ensure that it did not happen to anyone else. On [DATE] at 9:45 AM, the resident stated his name, his date of birth and explained that he was at the facility to receive physical therapy. He stated that the alleged abuse incident happened the day after he returned from the hospital. It definitely happened here and not in the hospital. He described the CNA QQ involved in the incident as an older female, who was tall with short hair. During the interviews on 3 separate days, the resident consistently described the abuse incident and was able to describe the staff member involved. During a telephone interview on [DATE] at 11:35 AM, CNA T stated, It was about 6:00 PM when I went to resident #1's room. His eyes were red and he looked very upset. I asked him what was wrong and he started to cry saying he was very embarrassed to tell me. He said the CNA QQ who was taking care of him during the day pulled his testicles and penis while she was cleaning him and then put her finger in his rectum. He told her to stop doing that and stop abusing him. He said she was tall with short hair and was round. On [DATE] at 11:10 AM, during a telephone interview, registered nurse, (RN) FF stated that on [DATE] during the 3 PM-11 PM shift, CNA T told me that resident #1 had a complaint. The resident informed me that the day shift CNA QQ had treated him very aggressively with his intimate parts. He said CNA QQ pulled his scrotum and put her finger in his rectum. I immediately reported this to licensed practical nurse, (LPN) EE, the 3 PM-11 PM supervisor. During a telephone interview on [DATE] at 11:25 AM, RN L stated, When I came to work on [DATE] for the 11 PM-7 AM shift, RN FF and CNA T from 3 PM-11 PM shift informed me the resident complained about the morning CNA QQ. They informed me that CNA QQ yanked on the resident's penis and put her finger in his rectum and told him she was tired of cleaning him up and if he didn't stop the diarrhea, she was going to put something up his rectum. She stated she went to see the resident but he covered his face and did not want to talk about it. He told her he was going to call the police. I immediately checked him from head to toe. I left the room and called the Administrator, who stated he was coming to the facility. I informed him of the incident and he went to see the resident along with the 11 PM-7 AM supervisor. On [DATE] at 9:23 AM, the Administrator stated that he received a telephone call from the facility on [DATE] at about midnight. I was told that law enforcement was in the building as resident #1 alleged that a staff member was rough with him. I immediately came to the facility and spoke to law enforcement. I interviewed the resident who stated the staff member treated him roughly when she cleaned his private areas. He was unable to provide the name of the staff member and told me the incident happened on Monday ([DATE]) or Tuesday ([DATE]). The resident was in the hospital on those days and did not return to the facility until Wednesday, (MONTH) 25th. For any allegation of abuse, I start my investigation right away. After I get basic information of the incident from the resident, I call law enforcement and the state agencies. I then submit the state immediate report. I did an abuse inservice with the staff that were present. I did not do an abuse investigation or suspend any CNAs. The administrator stated that he met with the resident on [DATE] along with the Human Resources Coordinator. I showed him pictures of 3 different CNAs including CNA QQ. The resident was not able to identify anyone from the photographs. The Administrator did not consider that the resident may have been distressed as a result of the incident and unable to clearly recount the details. On [DATE] at 2:30 PM, the staffing coordinator described each of the CNA's who worked on the 7 AM-3 PM shift on [DATE]. When she described CNA QQ, it was the same description given by resident #1 when he described the person who abused him. A telephone interview on [DATE] at 3:25 PM with CNA QQ revealed, I have already spoke to the facility about the allegation of abuse. I have no idea what the resident is talking about because I come to work to help people. I talked to him while I was washing him and when I was finished, I went and told the nurse that he had a dressing that needed to be changed. CNA QQ did not explain why the resident felt he was treated in a rough manner and wanted her to leave the room. She did not explain why the resident was upset and crying after she provided care to him. On [DATE] at 10:00 AM, the Director of Nursing (DON) stated, I was not made aware of the abuse allegation on Friday [DATE] which was my first day here. I do not recall anyone saying anything to me about an abuse allegation.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of physical/sexual abuse for 1 of 3 residents reviewed for abuse (#1), and failed to conduct an investigation to ensure necessary care and services were provided for fall management, and report investigative findings within 5 days for 1 of 3 residents reviewed for falls (#22), from a sample of 18 residents. The failure to complete thorough investigations led to inaccurate and incomplete incident reports, implementation of inadequate corrective actions, and contributed to the risk for serious psychosocial harm for resident #1, and serious injury/impairment/death for residents #22. On 8/24/19 at approximately 7:30 AM, resident #22 fell in her room and hit her head. She was sent to the hospital for evaluation and returned later that afternoon. On 8/25/19 at approximately 3:30 AM, within 24 hours of the first fall, resident #22 had another unwitnessed fall and again hit her head. The physician was not notified, and nursing staff returned resident #22 to bed, where she remained until she was sent to the hospital more than 6 hours later. Resident #22 was diagnosed with [REDACTED]. Resident #22's neurological status was not assessed appropriately after her fall and while she was left in bed without adequate supervision and monitoring, there was a high likelihood she could have fallen again or suffered [MEDICAL CONDITION], coma or death from her head injuries. On 9/26/19 at 6:00 PM, resident #1 was observed crying. He informed Certified Nursing Assistant (CNA) T that when the day shift CNA QQ was washing him, she pulled his testicles and penis and when she turned him over she put her finger in his rectum. The Administrator interviewed resident #1, felt the resident was confused and concluded that the incident did not happen in the facility. The Administrator did not investigate the incident thoroughly and compromised the safety of all the residents in the facility. Findings: Cross reference F600, F835 1. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #22 had adequate hearing and vision, clear speech and no comprehension deficits. Her Brief Interview for Mental Status (BIMS) score of 14 on a 0 to 15 scale indicated she was cognitively intact. She required extensive assistance of 1 staff member for bed mobility, walking, transfers on/off the toilet and personal hygiene. The MDS assessment showed resident #22 required extensive assistance of 2 staff members for other transfers . between surfaces including to or from: bed, chair, wheelchair, standing position. Resident #22's balance during transitions and walking was unsteady and she was only able to stabilize with the assistance of staff and used a wheelchair for mobility. The MDS assessment revealed resident #22 had 1 fall with major injury, defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. Review of the Event Facility Report or incident log for 7/01/19 to 9/30/19 revealed resident #22 fell twice during that period. An incident report for the first fall indicated on 8/24/19 at 7:30 AM, resident #22 was found on the floor in her room. The document indicated she fell during an attempt to self-transfer between the wheelchair and bed without assistance. The fall resulted in a minor injury, a bruise to the center of her forehead and resident #22 was transferred to the hospital emergency room (ER) for treatment. The incident report's Investigation/Action Plan indicated the causative factor for the fall was resident #22's wheelchair was not locked. The document read, A new Plan of Care/Intervention has been completed to prevent further events . new changes communicated to staff. Immediate actions have been taken for this event. An inadequate investigation led to inaccuracy in determination of the causative factor for the fall. The finding of the wheelchair not being locked, and the intervention to Educate resident to lock wheelchair brakes when transferring were inappropriate as resident #22 required staff assistance for transfers. The status of the incident was listed as Ready for review but the section for management review showed the administrator had not reviewed the document as of 9/30/19, more than 1 month after the incident. Review of resident #22's care plan for falls, initiated on 5/02/19, revealed no revisions or updates with immediate actions or appropriate interventions as indicated on the incident report. The incident log revealed resident #22 had a second fall on 8/25/19 at 4:20 AM, less than 24 hours after the first fall. The 7-page incident report was blank, and except for the date and time of the fall, there was no description of the event, no information on resident #22's condition or preventative measures / interventions in use at the time of the fall. There were no investigative findings including possible causative factors, and no evidence of an immediate action or revised interventions to prevent further falls. The incident log summary indicated the report was still In progress as of 9/30/19. On 9/29/19 at 5:59 AM and 6:27 AM, resident #22 confirmed she fell a few times since admission to the facility. She was alert and oriented to person, place and time, and recalled 2 recent falls resulted in 2 trips to the hospital in a 24-hour period. Resident #22 explained on the night she fell in the bathroom, she fell forward out of her wheelchair onto the floor and landed on her face. Resident #22 stated after the fall, she called out for help, but nobody heard. She said, It was a long time. Resident #22 stated sometimes staff did not check on her or respond to the call light, especially at night, so she often chose to go to the bathroom by herself. On 10/01/19 at 8:47 AM, a telephone interview was conducted with Registered Nurse (RN) I. She stated on 8/24/19 she was assigned to all residents on the Cliff Stone unit for the 11:00 PM to 7:00 AM shift. RN I explained that during that shift she discovered she was also responsible for 10 residents on the Pebble Stone unit, including resident #22. She stated she never received a change of shift report on the 10 residents on the Pebble Stone unit, and was not aware resident #22 fell earlier that day or required neurological checks. RN I stated at about 4:00 AM certified nursing assistant (CNA) X informed her resident #22 was on the floor. She stated she accompanied CNA X to the Pebble Stone unit and observed resident #22 face down on the bathroom floor. RN I stated resident #22 informed her she fell and went to the hospital the previous morning. RN I explained she completed pain, neurological and fall assessment forms as directed by the Pebble Stone nurse, licensed practical nurse (LPN) K. RN I stated she tried to call the physician but did not leave a message regarding resident #22's second unwitnessed fall with a head injury. She explained she was new to the facility and did not know what to do. RN I confirmed she did not notify resident #22's family. Furthermore, she was not aware she was supposed to initiate regular neurological assessments to monitor resident #22's status. On 10/01/19 at 9:35 AM, LPN A explained she arrived at work on 8/25/19 after 9:00 AM and received report from LPN K. LPN A stated at about 10:00 AM, she observed resident #22 in bed and was shocked at her appearance. LPN A said, She looked like she got beat up. She had a big forehead, it was double the normal size. She looked like a different person, around her eyes were very bruised. She looked like a racoon. Under her eyes she had significant facial swelling. Forehead was easily twice the size. LPN A stated LPN K then informed her resident #22 fell during the night shift. She stated she called the physician and left a message, then notified resident #22's family. LPN A explained the physician did not return her call in a timely manner and said, She looked very bad and I was worried about trauma and bleeding. I called the family to notify them and used my judgement and called 911 . She was alert and responsive, but since I couldn't figure out what happened on 11-7 and got no report, I sent her out. Review of hospital progress notes dated 8/25/19 and 8/26/19 revealed resident #22 was admitted to the hospital's trauma intensive care unit (ICU) for monitoring due to [DIAGNOSES REDACTED]. (www.webmd.com) On 10/01/19 at 2:02 PM, the administrator said, I had a conversation with (resident #22's) daughter and she wanted reassurance that her mom would be ok and that we had things in place to make sure that she did not fall again. He stated he never received any information about resident #22's fall from the Director of Nursing (DON) nor in the daily department heads' meeting. The administrator acknowledged he was the facility's Risk Manager (RM) and his responsibilities included investigation of incidents to prevent reoccurrences. He validated he did not investigate resident #22's fall and said, If they had reported to me I would have investigated and submitted a report . On 10/02/19 at 12:18 PM, in a telephone interview with resident #22's daughter, she stated a nurse notified her on 8/25/19 at about 10:40 AM that her mother fell during the night and asked if she should be sent to the hospital. Resident #22's daughter said, It was so upsetting when we got to the hospital and found her that way. It was so bad she needed to be in ICU overnight. The daughter explained she and her sister went to the facility later that day after seeing her mother's condition in the hospital to discuss the delay in notification and treatment. She said, We tried to find out exactly what happened, how (she) fell and why she wasn't sent to the hospital. The daughter stated the DON came to the facility, told them there would be an internal investigation and asked them to leave her office. The daughter stated she and her sister were so upset about the incident and the way they were treated by the DON they returned the following day to speak with the administrator. She said, He told us, me and my sister, that he would do an investigation and get back to us. He never did. The daughter explained she waited approximately 2 weeks and met with the Social Services Director about her mother's fall and injuries. She said, I asked about the fall again because I wanted to get an answer, and she said it was an internal investigation, just like what the DON told me. If they investigated they might be able to tell me what happened. I want to know why she fell . On 10/02/19 at 1:22 PM, the administrator described the incident investigation procedure. He confirmed all falls required an investigation. He stated the DON usually led fall investigations, gathered information, completed the incident report and provided the document for his review. The Administrator stated he tried to review incident reports and grievances once monthly. He acknowledged he did not have a system to regularly monitor and track open investigations and said, If they did not investigate I wouldn't know. The administrator did not respond when asked how he ensured adherence to reporting deadlines if he did not monitor investigations daily. The Administrator could not explain why an incident investigation was not initiated based on the information he obtained in the meeting with resident #22's daughter, even though he was not notified by the DON. The administrator validated the facility did not investigate resident #22's fall and therefore did not determine if it was an adverse event. He explained the purpose of an investigation was to prevent further incidents not only for resident #22 but for others. Review of the job description for the Administrator, signed on 1/28/19, revealed his duties and responsibilities included scheduling regular meetings with direct report staff to monitor facility operations, guiding the implementation of and adhering to facility policies and procedures. The job description for Risk Manager, a role assigned to the administrator, revealed duties and responsibilities included meeting monthly with the Quality Assurance and Performance Improvement committee, and investigating and analyzing actual and potential risks related to Fall resulting in injury or multiple falls . Incident(s) requiring transfer to hospital. The job description indicated the RM was Responsible for timely and accurate State / Federal reporting of all mandatory events to required agencies and law enforcement. The document indicated the RM would review documentation tools and assess compliance with policy and procedure The policy and procedure Abuse, Neglect, Exploitation & Misappropriation revised on 11/28/17, revealed all reported events, including falls would be investigated by the DON and the information obtained would be forwarded to the administrator. The document indicated the resident and all possible witnesses would be interviewed and a detailed report would be prepared. The policy and procedure indicated the results of the investigation would be reported to the State survey agency within 5 working days of the incident, and if substantiated, appropriate corrective action implemented. On 10/02/19 at 12:54 PM, the MDS Coordinator stated she was responsible for reviewing charts and updating residents' care plans with appropriate and individualized interventions. She said, (Resident #22's) fall has been a big thing with me. I got her chart and saw that she had a subdural hematoma. The MDS Coordinator stated she informed the Regional Nurse Consultant, the DON and Assistant Director of Nursing (ADON) that resident #22's fall needed to be reported due to the circumstances and severity of her injuries. She explained the facility used to conduct a clinical team meeting every day at 8:30 AM, but the new DON and ADON rarely conducted the meetings. The MDS Coordinator explained investigations of all falls in the previous 24 hours used to be conducted in those clinical meetings. She stated the process involved interdisciplinary team (IDT) review of possible causes of the fall and development of appropriate interventions for each resident. The MDS Coordinator explained overall resident care in the facility was negatively impacted by the absence of IDT discussion, including thorough review of incidents. She stated resident #22's first fall on 5/01/19 was reviewed and investigated appropriately, but falls on 6/09/19, 8/24/19 and 8/25/19 were never reviewed with the IDT, even after major injuries. The policy and procedure Fall Management revised 7/29/19, revealed post-fall strategies including Interdisciplinary Team to review fall documentation and complete root cause analysis. Review of the policy and procedure Resident Incident/Accident Reports revised on 8/24/17 revealed Residents incidents/accidents are recorded, reviewed, and trended through a Quality Assurance and Performance Improvement process . to promote resident safety. The procedure included the direction to complete an incident report for any occurrence that was not consistent with routine resident care, notify the physician of any actual or suspected injury after doing a nursing assessment and implement appropriate preventative interventions. The document indicated the event and assessment findings would be documented in the clinical record and on the 24-hour report, and the resident's family would be notified. The policy and procedure read, Incident reports shall be reviewed by the Director of Nursing for completion and follow up and then reviewed by the IDT and administrator. The document revealed Certain accidents or incidents may require further investigation. On 10/02/19 at 5:30 PM, during a telephone interview, the Medical Director explained she attended Quality Assessment and Assurance committee meetings with the administrator and other members of the IDT. The Medical Director stated her expectation was the facility would notify her of serious incidents. However, she acknowledged she was not aware of resident #22's fall with major injuries. The Medical Director explained the protocol for a head injury included nursing assessment, neurological assessments, physician and family notification and completion of an incident report. She validated that investigation of incidents was necessary to ensure the safety of all residents. 2. Resident #1 was readmitted to the facility on [DATE] after being hospitalized for [REDACTED]. His [DIAGNOSES REDACTED]. The Medicare 14-day Minimum Data Set Assessment ((MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) score of 11/15, indicating moderate cognitive impairment. The assessment also noted that the resident required extensive assist of 2 persons for bed mobility, transfers, personal hygiene, extensive assist of 1 person for toileting, total dependence with assist of 2 persons for dressing and bathing. He was frequently incontinent of urine and always incontinent of bowel. On 9/29/19 at 11:00AM, resident #1 was resting in bed. The resident was Spanish speaking. He stated on the day after he returned from the hospital, a Certified Nursing Assistant (CNA) came into his room to provide incontinence care. He said he knew something was wrong right away as she was cleaning him differently. She went right for my penis and testicles. She put her finger in my rectum. He stated he told her to stop and get out, and she did. He stated he cried after she left the room as he felt abused. This happened in the morning after breakfast but before lunch. He stated he did not report this to anyone on that shift. He did report it to the 3 PM-11 PM CNA T who spoke Spanish. The resident said that when CNA T came into his room she noticed he was upset and asked what happened. He reported to CNA T what the morning CNA did to him on the previous shift. After he told CNA T about the incident, she brought the registered nurse, (RN) FF and asked him to tell her what happened. He stated he did not tell his family all the details because he was too embarrassed. He called the police that night to report the incident. On 10/1/19 at 9:25 AM, the resident stated that it was okay to ask him about the incident as it can help to ensure that it does not happen to anyone else. On 10/2/19 at 9:45 AM, the resident stated his name, his date of birth and explained that he was at the facility to receive physical therapy. He stated that the alleged abuse incident happened the day after he returned from the hospital. It definitely happened here and not in the hospital. He described the CNA involved in the incident as an older female, who was tall with short hair. During these 3 interviews the resident consistently described the abuse incident and was able to describe the staff member involved. During a telephone interview on 10/01/19 at 11:35 AM, CNA T stated, It was about 6:00 PM when I went to resident #1's room. His eyes were red and he looked very upset. I asked him what was wrong and he started to cry saying he was very embarrassed to tell me. He said that CNA QQ, who was taking care of him during the day pulled his testicles and penis while she was cleaning him and then put her finger in his rectum. He told her to stop doing that and stop abusing him. He said she was tall with short hair and round. CNA T stated that she informed the nurse on duty, registered nurse, (RN) FF. On 10/1/19 at 11:25 AM, RN L stated, When I came to work on 9/26/19 on the 11 PM-7 AM shift, RN FF from 3 PM-11 PM and CNA T told me that resident#1 complained about the morning CNA QQ. They informed me that CNA QQ yanked on the resident's penis and put her finger in his rectum and told him she was tired of cleaning him up and if he didn't stop the diarrhea, she was going to put something up his rectum. I went in to talk to the resident but he did not want to talk about it. He covered up his face with a blanket. I immediately assessed him from head to toe. When the Administrator arrived, I told him exactly what RN FF told me. On 10/02/19 at 3:32 PM, licensed practical nurse, (LPN) EE stated that on the evening of 9/26/19, she went to resident #1's room but he would not talk to me. She said CNA T told her that resident #1 reported to her that CNA QQ on day shift was rough and aggressive with him. LPN EE stated she called the Social Services Director, (SSD) as she was the Abuse Coordinator. The SSD informed me that she should come to the facility and talk to the resident, but she was at home with her 2-year-old baby. She told me she could not come back to the facility but would follow up. On 9/30/19 at 9:23 AM, the Administrator stated that he received a telephone call from the facility on 9/27/19 at about midnight. I was told that law enforcement was in the building as resident #1 alleged that a staff member was rough with him. I immediately came to the facility and spoke to law enforcement. I interviewed the resident who stated the staff member treated him roughly when she cleaned his private areas. He was unable to provide the name of the staff member and told me the incident happened on Monday (September 23) or Tuesday (September 24). The resident was in the hospital on those days and did not return to the facility until Wednesday, (MONTH) 25th. For any allegation of abuse, I start my investigation right away. After I get basic information of the incident from the resident, I call law enforcement and the state agencies. I then submit the state immediate report. The Administrator stated that he interviewed the unit manager and CNA QQ. I concentrated on CNA QQ as she worked the day shift. The administrator stated that he met with the resident on 9/27/19 along with the Human Resources Coordinator. I showed him pictures of 3 different CNAs including CNA QQ, who was involved in the incident. The resident was not able to identify anyone from the photographs. After I spoke to the resident, I did an abuse in-service with the staff that were present. I did not do an abuse investigation. I have not determined anything yet. I did not suspend any CNAs. The Administrator did not consider that the resident may have been distressed as a result of the incident and unable to clearly recount the incident. On 9/30/19 at 4:45 PM, the Social Services Director (SSD) stated that she was the abuse coordinator and responsible for investigating, analyzing and reporting any abuse allegations to the administrator. On Friday morning (9/27/19) I was told by the administrator that there was an incident involving abuse with resident #1. She stated that she conducted a BIMS interview with resident #1 as there were reports that he was confused. The SSD stated that the resident was saying different things to different people but she was unable to explain what the different things were. I asked the resident general questions but nothing specific about the abuse. I did jot down his mood and made a referral to psych because of a change in BIMS score and he stated he was sad because he wanted to go home. Usually after an allegation of abuse, I first interview the resident and re-interview them again later. I then interview other residents that may have been affected by the alleged abuser and I also interview staff. She stated that she did not interview any other residents or staff this time. She said, this allegation of abuse was not investigated like others. There was miscommunication between staff. The SSD stated that she did not receive any calls from staff that evening regarding the resident's allegation of abuse. This was in contradiction to the statement from LPN EE who stated she notified the SSD at home regarding the abuse allegation and the SSD told her she could not come back to the facility but would follow up. On 9/30/19 at 4:25 PM, an interview was conducted with the administrator and the Social Services Director (SSD) regarding resident #1's allegation of physical/sexual abuse. They acknowledged they did not follow the facility's established policy and procedure for abuse prohibition related to protection of the victim and investigation of the incident. When asked who led investigations into allegations of abuse as Abuse Coordinator, the administrator and SSD looked questioningly at each other and could not immediately verbalize who was assigned to that role. Review of the facility Policy: Abuse, Neglect, Exploitation & Misappropriation, revision date 11/28/2017 read: 5. Investigation: The Abuse Coordinator or his/her designee shall investigate all reports or allegations of abuse, neglect, misappropriation and exploitation. Social Service representative may be offered in the role of resident advocate during any question of or interviewing of residents. The abuse Coordinator and /or Director of Clinical Services shall take statements from the victim, the suspect(s), an all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared.

Based on observation, interview and record review, the facility failed to ensure nursing staff were competent in providing care and services to prevent falls and implement appropriate post-fall interventions for 1 of 3 residents reviewed for falls (#22). This failure led to a fall with major injuries and contributed to the risk of serious impairment or death for resident #22. On [DATE] at approximately 7:30 AM, resident #22 fell in her room and hit her head. She was sent to the hospital for evaluation and returned later that afternoon. On [DATE] at approximately 3:30 AM, within 24 hours of the first fall, resident #22 had another unwitnessed fall and again hit her head. The physician was not notified, and nursing staff returned resident #22 to bed, where she remained until she was sent to the hospital more than 6 hours later. Resident #22 was diagnosed with [REDACTED]. Resident #22's neurological status was not assessed appropriately after her fall and while she was left in bed without adequate supervision and monitoring, there was a high likelihood she could have fallen again or suffered [MEDICAL CONDITION], coma or death from her head injuries. The facility's failure to ensure nursing staff competency resulted in substandard quality of care at the Immediate Jeopardy level, starting on [DATE]. Cross reference F600. Findings: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #22 had adequate hearing and vision, clear speech and no comprehension deficits. Her Brief Interview for Mental Status (BIMS) score of 14 on a 0 to 15 scale indicated she was cognitively intact. Resident #22 required extensive assistance of 1 staff member for bed mobility, walking, transfers on/off the toilet and personal hygiene. The MDS assessment showed resident #22 required extensive assistance of 2 staff members for other transfers . between surfaces including to or from: bed, chair, wheelchair, standing position. Resident #22's balance during transitions and walking was unsteady and she was only able to stabilize with the assistance of staff. She used a wheelchair for mobility. Resident #22 had frequent urinary and bowel incontinence. The MDS assessment revealed she had 1 fall with major injury, defined as bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. Review of the medical record revealed resident #22 had a care plan for activities of daily living (ADL) self-care performance deficit related to [MEDICAL CONDITION] and history of a stroke, initiated on [DATE]. The interventions for nurses and certified nursing assistants (CNAs) included assistance of 1 staff member for transfers, toilet use and personal hygiene The care plan for risk for falls, initiated on [DATE], had a goal to minimize the risk of serious injury. The interventions directed staff to ensure the call light was within reach, bed in low position, ensure resident wore appropriate footwear and remove items from wheelchair seat for proper positioning. The care plan for actual falls, initiated on [DATE], had interventions including determine and address causative factors, lock wheelchair brakes for transfers and observe/report for 72 hours signs and symptoms of pain, bruises or change in mental status. Review of a Change in Condition Evaluation form and a nursing progress note dated [DATE] revealed at about 7:30 AM resident #22 had an unwitnessed fall in her room when she attempted to self-transfer between the bed and wheelchair. She was noted with a bruise on her forehead and the physician gave an order to send her to the hospital emergency room (ER) for evaluation. Nursing progress notes indicated resident #22 returned to the facility that afternoon at about 2:20 PM and was re-evaluated for fall risk. Review of the Fall Risk Evaluation form dated [DATE] at 3:11 PM revealed the section for history of falls in the previous 3 months read, No falls . instead of 2 falls as noted in the medical record. This error impacted resident #22's fall risk score, and as a result she was not deemed to be at risk for falls. Nursing staff did not make revisions to resident #22's care plans to ensure appropriate interventions to prevent further falls and injuries. Review of Neurological Assessment Flow Sheet forms and nursing progress notes revealed resident #22's neurological status was monitored regularly until [DATE] at 11:00 PM. After a 6-hour interval, resident #22's neurological status was next assessed on [DATE] at 5:17 AM. The flow sheet, completed by Registered Nurse (RN) I, was incomplete and inaccurate as she did not assess pupil response, check current vital signs or record pain response correctly. The assessment indicated resident #22 was alert but had no response to pain, a sign of unconsciousness. An attached progress note read, resident fell during morning shift, bruise on left eye and forehead she was sent to the ER. Resident had a re-fall during night shift no changes observed, no other observations. RN I did not complete a Change in Condition Evaluation form or neurological assessment flow sheets related to the second fall. There were no progress notes regarding the circumstances of the fall, physician and family notification of the incident or immediate interventions such as basic first aid, increased monitoring or frequent toileting to prevent further falls. Neurological checks or neurochecks are usually done after an unwitnessed fall to identify signs of a head injury. The evaluation includes checking level of consciousness, vital signs, pupil size and reactivity to light and hand grip strength. Standard clinical nursing practice suggests this evaluation should be done immediately after the fall, at regular intervals, with gradually decreasing frequency over 72 hours. (www.hcpro.com) The facility's policy and procedure for Neurological Evaluation revised on [DATE], indicated neurological checks should be performed Every 15 minutes for 1 hour. Every hour for the next 4 hours. Every 4 hours for the next 19 hours. The document revealed the results of the neurological checks, vital signs and observations would be noted on the appropriate form, and the physician notified of any changes in condition. Review of the policy and procedure Fall Management revised on [DATE], revealed a purpose to develop of revise interventions .to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. The document directed nurses to perform specific Post Fall Strategies including evaluation of the resident, post fall care, neurological checks, notification of the physician and resident's representative, documentation of fall risk evaluation, updating the nursing and CNA care plans with new intervention(s) and initiation of post-fall documentation for 72 hours. On [DATE] at 11:36 PM, a telephone call was made to the facility to contact RN I. Licensed practical nurse (LPN) H answered the call. He confirmed RN I was at work and he was asked to transfer the call to her. LPN H returned to the phone a few minutes later and stated RN I was available, but said, You need to take your time. She should be able to manage if you speak slowly because her English is not very good. RN I confirmed she was assigned to the Cliff Stone unit on the night resident #22 had her second fall. She recalled on [DATE] at about 4:00 AM, certified nursing assistant (CNA) X came from the Pebble Stone unit and told her resident #22 fell . RN I explained she accompanied CNA X back to the Pebble Stone unit and they assisted resident #22 back to bed. RN I stated she called the physician, but said, I did not know to leave a message in the call center . I was new and nobody told me what to do. RN I acknowledged English was her second language, and explained on the night of resident #22's fall she had been on staff for only 1 week and had not yet been oriented to clinical policies and procedures. RN I stated on her first shift in the facility, the unit manager told her she would be working with another nurse, but when she arrived at the facility she found out she would be working alone. RN I reiterated, I didn't have any training yet. On [DATE] at 8:47 AM, the telephone interview with RN I was continued with translation assistance from the Admissions Coordinator. RN I stated she was hired on [DATE] and assigned her first shift on [DATE]. She said, They put me on the unit without training, without computer access and gave me narcotic keys. RN I stated on the night shift resident #22 fell , she was assigned to the Cliff Stone unit for the 11:00 PM to 7:00 AM shift and was not aware she had 10 additional residents on the Pebble Stone unit, including resident #22. She stated she did not receive report on the 10 residents and therefore did not know resident #22 fell earlier that day, nor that she was expected to continue neurological checks related to the first fall. RN I stated after CNA X informed her resident #22 was on the floor at about 4:00 AM, she walked over to the Pebble Stone unit and they found resident #22 on the floor in the bathroom, boca abajo. The Admissions Coordinator translated the phrase to English, explaining resident #22 was face-down on the floor. She stated they assisted resident #22 into her wheelchair and then back to bed. RN I recalled resident #22 informed her she went to the hospital the previous morning after a fall with a head injury. RN I stated she completed physical, neurological, fall risk and pain assessment forms at that time and left resident #22 in bed. She verified she attempted to contact the physician but did not leave a message. RN I said, I did not know anything about who to contact. There was no supervisor in the building. RN I acknowledged she did not re-assess resident #22, attempt to contact the physician again or notify the family prior to leaving the facility. She confirmed she did not give a change of shift report on resident #22's status to the nurse on the Pebble Stone unit because . she knew about it. RN I stated she notified the unit manager and the Assistant Director of Nursing (ADON) of the incident at about 7:00 AM, just before she left work. RN I said, By that date I was working for 1 week without an orientation. I told them I would not work anymore because I was not comfortable working without training or orientation. I was going to quit. They convinced me to stay and put me with another nurse for 3 days. She acknowledged resident #22 could have died from her head injury and stated during the clinical orientation provided after the incident, she learned neurochecks should have been done according to the facility's protocol. Review of the job description for Clinical Nurse I (RN) revealed duties and responsibilities included 2. Provide regular resident status updates to appropriate personnel. 7. Maintain ongoing communications with physicians concerning resident care. 8. Complete required documentation in an accurate and timely manner. 32. Provide routine nursing services for residents as directed. Specific requirements for an RN indicated he/she Must be able to read, write, speak, and understand the English language. On [DATE] at 9:35 AM, licensed practical nurse (LPN) A stated she was assigned to resident #22 on [DATE] and observed her in bed at about 10:00 AM. She said, I was shocked when I saw her face because she did not look like that yesterday. She looked like she got beat up. LPN A described resident #22's forehead as swollen to twice the normal size, with raccoon-type bruising around her eyes and significant facial swelling. LPN A stated the Pebble Stone night nurse, LPN K, told her resident #22 fell during the night. LPN A recalled she asked LPN K if the physician and family were notified and LPN K said, It's not my patient. LPN A explained she left a message for the on-call physician and notified resident #22's family. She said, I used nurses' judgement since I knew it was her second fall. She looked very bad and I was worried about trauma and bleeding . She was alert and responsive, but since I couldn't figure out what happened on ,[DATE] and got no report, I sent her out. LPN A validated RN I did not follow the policy and procedure for neurochecks or falls. LPN A stated she called the hospital later that day to inquire about resident #22 and was told she was being monitored closely for a subdural hematoma. LPN A expressed concern regarding some nurses from other countries who had a language barrier. She said, If they don't know how to speak English properly they can't communicate with the doctor and family. In this situation, (RN I) wasn't properly oriented or spoke enough English. LPN A explained RN I often appeared frustrated and overwhelmed because of the language barrier. On [DATE] at 11:17 AM, LPN K confirmed she received report on all residents on the Pebble Stone unit at the start of the 11:00 PM shift on [DATE]. She explained she did not give report to RN I who was assigned to 10 residents on the Pebble Stone unit in addition to all resident s on the Cliff Stone unit. LPN K stated her expectation was RN I would come to her for information. She was informed RN I did not know she had residents on the Pebble Stone unit and LPN K said, All nurses on the other units should know they have patients around the corner on (Pebble Stone. RN I) should have gotten that information in orientation. During a telephone interview on [DATE] at 3:36 PM, RN L stated she was assigned to the River Rock unit on the night resident #22 fell . RN L stated RN I was new to the facility and was not aware she had residents on 2 units. RN L recalled after resident #22 fell , CNA X told RN I .not to worry, she falls all the time. RN L stated she gave RN I the book with physicians' contact numbers, but did not follow up to verify she called the physician regarding resident #22's fall. RN L said, I don't think she had the proper orientation. Review of hospital progress notes dated [DATE] and [DATE] revealed resident #22 was admitted to the hospital's trauma intensive care unit (ICU) for monitoring due to [DIAGNOSES REDACTED]. (www.webmd.com) On [DATE] at 2:56 PM, CNA X stated she was assigned to resident #22 during the 11:00 PM - 7:00 AM shift on [DATE]. Translation assistance was again provided by the Admissions Coordinator. CNA X stated she had to inform RN I she had additional residents on the Pebble Stone unit that night. CNA X said, Nobody told her she had other residents and she was surprised. She stated after she informed RN I resident #22 was on the floor they both assisted her back to bed. She stated RN I did an assessment and then returned to the Cliff Stone unit. When asked about the level of assistance resident #22 required for activities of daily living (ADLs), CNA X said, Supervision. She goes to the bathroom by herself in the wheelchair and uses the grab bars to transfer to the toilet. CNA X explained she was familiar with resident #22 as she had worked with her in the restorative nursing program in the past. She stated she did not know how to access residents' care instructions on the CNA care plan or Kardex and relied only on verbal report from other staff. CNA X was guided to access resident #22's Kardex. She validated the Kardex revealed resident #22 required assistance of 1 staff member with transfers, toilet use and personal hygiene. CNA X expressed surprise and said, I thought she needed only supervision. When asked whether she felt the Kardex would be useful in caring for residents, CNA X said, That's very good. We need to give an in-service for that. I have been here 4 years and never knew. CNA X stated she was not informed of resident #22's first fall in report and said, I treated her like normal that night because I never knew she fell . Otherwise I would have checked on her more often. Interviews conducted with 10 additional CNAs who were on staff between 2 weeks and [AGE] years revealed none were aware the tablets they used for electronic documentation of ADL care also provided access to the Kardex for all residents. On [DATE] at 5:31 PM, CNA J said, I have never seen a Kardex. She stated she got report on her assigned residents verbally and in walking rounds. She explained the tablet was only used for documentation of ADLs. On [DATE] at 9:15 AM, CNA U stated the facility used a paper Kardex book. She searched the racks with residents' charts but was not able to provide a Kardex. A nurse seated at the nurses' station informed CNA U there was no such book. CNA U acknowledged she got information in verbal report only and said, I don't have a Kardex for my patients. On [DATE] at 9:19 AM, CNA V stated there was no Kardex for residents in the facility. She was not aware of how to find written care instructions on her assigned residents. On [DATE] at 9:22 AM, CNA D stated she always received verbal report on her residents and was not aware written directions for resident care existed. On [DATE] at 9:23 AM, CNA O searched the tablet but was not able to access the Kardex. She stated she either asked the nurse or another CNA for verbal report but said, It is easier to ask the nurse. We used to have a book. When showed where the Kardex was located, CNA O said, They did not show me that. She acknowledged depending on memory was not reliable because CNAs could forget to report important issues and it was difficult to remember all instructions on 20 residents. On [DATE] at 9:30 AM, CNA W stated the Kardex was located on the tablet. However, when asked to pull up a Kardex she showed the screen for ADL documentation. CNA W did not know a Kardex was a CNA care plan with instructions for patient care. CNA W said, Sometimes we get bad information. It is better to have it written down too so we can check it back. On [DATE] at 9:32 AM, CNA Y said, They don't have a Kardex book here. When I give report, I tell them to take a pencil and piece of paper. I get report from the nurse. CNA Y was not aware of any area on the tablet that was linked to a Kardex. On [DATE] at 9:35 AM, CNA trainee Z stated she was always assigned to work with another CNA who would tell her what to do. She said, They know all the residents. She confirmed she received information on residents in a verbal format only. On [DATE] at 9:40 AM, CNA AA stated the facility did not use either electronic or paper Kardexes so she relied on information provided by other staff members. On [DATE] at 9:50 AM, CNA BB stated she relied on the accuracy of verbal reports. She was not aware there was written care plan information for CNAs. On [DATE] at 12:54 PM, the MDS Coordinator stated fall care plans should be reviewed and updated with individualized interventions after every fall. She confirmed all nurses had access to update care plans with new and appropriate interventions after fall, . but they do not do it. The MDS Coordinator explained the care instructions on the CNAs' Kardex were derived from the nursing care plan and addition of CNA-specific tasks by unit managers. She acknowledged use of the Kardex was essential for obtaining accurate information on the care needs of each resident. She was informed 11 CNAs were interviewed regarding use of the Kardex and none knew how to access the essential tool. The MDS Coordinator said, It should be taught in orientation. On [DATE] at 12:30 PM, the Staffing Coordinator said, There are several nurses especially at night that are almost totally Spanish speaking . If I call, they text me back in Spanish and I put I don't understand Spanish. The SC reviewed a list of all facility staff and identified 9 RNs and 2 CNAs who had minimal fluency in English. She explained she had difficulty communicating with them, and said, I have to repeat myself often and I've needed to get another person to translate. The unit manager who used to be here was my main translator. On [DATE] at 5:35 PM, the Human Resources Coordinator (HRC) confirmed RN I was hired on [DATE] and completed the human resources portion of her orientation from 9:00 AM to 4:00 PM that day. She stated RN I was instructed on general facility policy and procedures applicable to all new employees. The HRC validated RN I's time sheet showed she started her first shift the following night, [DATE] at 10:30 PM. The HRC reviewed RN I's personnel file and was not able to provide evidence of clinical orientation or competency evaluations prior to being assigned to care for residents. The following afternoon at 3:29 PM, the HRC explained the usual process for orientation of licensed nurses was general employee HR orientation on day 1, followed by a clinical orientation on day 2. She stated on the second day nurses would be educated on the electronic health record and have competency evaluations based on policies and procedures. The HRC stated after the 2-day classroom orientation, she collaborated with the SC for newly hired nurses to be paired with other nurses for 4 days of orientation to the floor. The HRC was asked why RN I was scheduled to work unsupervised with residents without completing the orientation and competency evaluation process. She said, It should not have happened that way. On [DATE] at 4:10 PM, the SC stated the ADON scheduled RN I for her first shift on [DATE], the day after she was hired. The SC said, I always thought we would still have to train them before we sent them out on the floor. The SC validated RN I did not receive an appropriate orientation before she was assigned to care for residents. On [DATE] at 3:06 PM, the interim Director of Nursing (DON) stated in her experience, newly hired nurses required 1 day of general HR orientation and 3 days of classroom education with clinical policies and procedures, competencies and training on the electronic medical record. She said, I believe 2 weeks with another nurse is an appropriate amount of time for orientation to the floor. The interim DON explained her expectation was a newly hired nurse would start with the day shift and be assigned to a specific, strong nurse as a mentor. She stated feedback from both nurses would be used to individualize the length orientation process. However, she explained a minimum of 3 days should be required. The interim DON validated at least moderate fluency in English was necessary to ensure accuracy in communicating with providers and relaying assessment findings. She acknowledged RN I did not follow policies and procedures or accepted professional standards for fall management. She confirmed all CNAs should have access to and use the Kardex to obtain current care and safety interventions because verbal reports were not always reliable. Review of the Facility Assessment Tool reviewed on [DATE], revealed the facility required every staff member to have knowledge competency on topics including abuse/neglect, identification of condition change and hand hygiene. The document indicated additional competencies were determined based on job title, skills and abilities. The assessment read, Competencies are verified upon orientation . and are based on the care and services needed by residents. During a telephone interview on [DATE] at 5:30 PM, the Medical Director stated she was not aware of resident #22's fall with major injuries. She acknowledged the facility's policies and procedures for fall management and neurological checks were not followed. The Medical Director said, I should have been notified if they could not contact the attending physician. The medical director explained a head injury that was not treated in a timely manner could cause severe injury or death. She stated she was aware the facility had experienced recent changes in nursing management and acknowledged resident care and outcomes have been impacted. The Medical Director stated the possible root cause of resident #22's falls and injuries was related to lack of staffing competency and coordination of care.

Based on observation, interview and record review, the facility failed to use its resources effectively to conduct investigations to prevent abuse and neglect, and failed to ensure nursing staff competency in the provision of necessary care and services to maintain the highest practicable level of well-being of residents. These failures caused psychosocial harm for resident #1 and contributed to resident #22's serious injury and risk for impairment/death. On 9/26/19 at 6:00 PM, resident #1 was observed crying. He informed Certified Nursing Assistant (CNA) T that when the day shift CNA QQ was washing him, she pulled his testicles and penis and when she turned him over she put her finger in his rectum. The Administrator interviewed resident #1, felt the resident was confused and concluded that the incident did not happen in the facility. The Administrator did not investigate the incident thoroughly and compromised the safety of all the residents in the facility. Resident #22 had a fall with injury on 8/24/19 at 7:30 AM, then suffered a second fall with major head and facial injuries within 24 hours, on 8/25/19 at about 3:30 AM. After the second fall, she was left in bed for over 6 hours before she was sent to the hospital for treatment. Resident #22 did not receive adequate post-fall monitoring and supervision from nursing staff, and there was a high likelihood she could have fallen again or suffered [MEDICAL CONDITION], coma or death from her head injuries. Findings: Cross reference F600, F610, F726. The Facility Assessment Tool reviewed on 4/19/19, revealed a purpose of determining the necessary resources to provide competent care for the facility's residents in everyday situations and emergencies. The document indicated the facility would provide care and services based on individual needs such as Mobility and fall/fall with injury prevention (and) Person-centered/directed care. The assessment revealed specific care and practices would include transfers, timely assistance for toileting, support to promote emotional well-being and prevention of abuse and neglect. The document indicated the facility's necessary resources included sufficient and competent staff, updated policies and procedures, and a Medical Director. On 10/02/19 at 12:54 PM, the Minimum Data Set (MDS) Coordinator stated the facility no longer conducted daily interdisciplinary team (IDT) clinical meetings. She explained the meetings used to be held 5 days weekly, Monday through Friday at 8:30 AM. However, they were not held regularly in the past few months. The MDS Coordinator said, We might have had 3 meetings in 3 months. She stated nursing administration, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), simply did not show up. The MDS Coordinator explained during the daily IDT meetings, members of the clinical team including representatives from nursing administration, therapy, care planning, dietary and social services used to review the charts of newly admitted residents, check all new orders and discuss all incidents that occurred in the previous 24 hours. The MDS Coordinator stated there was currently no coordination between MDS/care planning and nursing staff, therefore care plans lacked appropriate interventions. She said, There is really no IDT care planning process at this time. I think it hurts resident care because nobody knows what is going on. On 10/01/19 at 2:02 PM, the administrator stated there was a daily clinical meeting in the mornings, followed by a department heads meeting attended by himself and all managers. He confirmed incidents such as falls and allegations of abuse and neglect should be discussed in both meetings. However, he did not recall a review of resident #22's fall with major injuries, and said, I never heard anything about this incident from the DON. The administrator confirmed as the facility's Risk Manager, he had the responsibility of investigating and reviewing all incidents. On 10/02/19 at 1:22 PM, the administrator confirmed staff informed him the daily clinical IDT meetings were not being held. He said, I heard they were not doing it regularly and I addressed it with the DON and ADON. However, the administrator acknowledged he never followed up to ensure the daily IDT meetings were re-implemented. The administrator was asked how he was informed about incidents and conducted thorough investigations without regular input from the IDT. He explained the DON usually completed investigations and he reviewed the completed incident reports. He said, To be honest I do try to look at the incidents, but not every day . I try to get to them once a month and review them all. The administrator validated since he did not monitor the progress of investigations regularly, he would not know if an incident was investigated in a timely manner nor guarantee reporting occurred within the required timeframe. The administrator acknowledged he was aware nurses had concerns regarding assignments that spanned 2 units. He said, It doesn't sound suitable to me. He was not able to verbalize any actions taken by the facility's administration to address this staffing concern. The administrator stated he reviewed staffing calculations every day to ensure the facility remained within its budget. He denied knowledge of concerns related to insufficient staff. When the administrator was informed staffing calculations for the previous 6 weeks showed repeated instances of failure to meet minimum State staffing requirements, he explained he was not aware because he did not review all areas of the forms. Review of the job description for Executive Director I (Administrator) signed on 1/28/19, revealed the administrator was Responsible for the day-to-day clinical and administrative activities of the facility . and ensures compliance with all state and federal regulations. The job description indicated the administrator's duties and responsibilities included 5. Recruit, hire, and provide orientation/training for a sufficient number of qualified staff to carry out facility programs and services . 7. Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations. 9. Maintain and guide the implementation of facility policies and procedures . 13.Maintain a file for and monitor incident reports. 14. Attend and/or conduct facility meetings, as required, to carry out responsibilities. On 10/02/19 at 3:06 PM, the interim DON explained daily IDT review of incidents, grievances and clinical issues was essential to ensure residents received appropriate care and services. She acknowledged the facility was responsible for providing orientation, competency evaluations and on-going education for nursing staff. She confirmed this was not done for Registered Nurse (RN) I who received no clinical orientation prior to her first assigned shift, or the CNAs who did not know how to access instructions for residents' care needs. The interim DON validated it was important for nursing administration to ensure staff assignments promoted safe and efficient care according to residents' needs. She explained assigning 1 nurse to residents on 2 separate units could lead to inadequate monitoring and supervision. On 9/30/19 at 4:25 PM, an interview was conducted with the administrator and the Social Services Director (SSD) regarding resident #1's allegation of physical/sexual abuse. They acknowledged they did not follow the facility's established policy and procedure for abuse prohibition related to protection of the victim and investigation of the incident. When asked who led investigations into allegations of abuse as Abuse Coordinator, the administrator and SSD looked questioningly at each other and could not immediately verbalize who was assigned to that role. During a telephone interview on 10/02/19 at 5:30 PM, the Medical Director stated she was not aware of resident #22's fall with major injuries or of resident #1's allegation of physical/sexual abuse. She confirmed her expectation was the facility would inform her of serious incidents. The Medical Director acknowledged she was not asked to participate in investigations to ensure the safety of residents #1 and #22, and the well-being of all residents. She explained since (MONTH) 2019 when she started as Medical Director, there have been 3 DONs and general staffing issues. The Medical Director stated staffing concerns and lack of coordination of care had most likely impacted resident care and outcomes.

Based on record review and interview, the facility failed to identify the primary decision maker to ensure that health care decisions were consistent with the resident's wishes for 1 of 9 sampled residents, (#307). This failure resulted in the resident being denied the right to formulate advance directives. The denial of his right to formulate an advance directive began at the time of admission and continued as the resident's condition changed requiring hospice services and continued throughout the days he was receiving services as his death became imminent. The resident did not have an advance directive at the time of his death and endured cardio-pulmonary resuscitation (CPR) that did not commence until almost one hour after his respirations and heartbeat ceased. The facility was determined to be in Immediate Jeopardy beginning on [DATE] that was corrected by [DATE]. Findings: Resident #307 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Social Service Admission Evaluation dated [DATE] noted that the resident did not have any Advance Directives, Do Not Resuscitate (DNR), Legal Guardian, Power of Attorney (POA), or Healthcare Proxy. The Social Worker's (SW) notes reflected that the resident was responsible for himself and that resident rights were reviewed. A copy of Resident Rights was provided to resident #307 on [DATE]. There was no documentation presented to show that the resident was given an opportunity to formulate advance directives. Review of the facility's policy and procedure, Advance Directives-Admissions/Social Service, SS-121, read that Advance Directives will be reviewed at least quarterly as part of the Minimum Data Set review. The staff were directed to review the following: Identify and Clarify the content and intent of existing care instructions, and whether the resident wishes to change or continue these instructions: a) Identify situations where health care decision-making is needed b) Review the resident's condition and existing choices and continue or modify approaches c) Any changes to Advance Directives will require a new Advance Directives Discussion Document (CNS-036) to be completed and the previous document to be filed in the thinned record. A review of the quarterly Social Services progress note showed that the last time the facility had documented a review of the Advanced Directives with the resident was on [DATE]. The resident's BIMS score at that time was 12 indicating moderate cognitive impairment. There was no documented evidence the physician deemed resident #307 to be incapacitated to make medical decisions. The staff noted that the resident did not have any Advance Directives and that information about Advance Directives was reviewed with the resident. The staff noted that the resident was a Full Code, directing nursing staff to perform CPR during an emergency, in which the resident's breathing or heart stopped. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] noted that the resident's health had declined. The resident was extensive to total assist with all activities of daily living (ADLs), which included bed mobility, locomotion, dressing and eating. The MDS noted that the resident was receiving tube feedings along with a mechanically altered diet. When resident #307 declined, the facility staff did not identify Advance Directives decision making was needed per their policy. A review of the hospital's History & Physical, dated [DATE], noted that the resident was transferred to the Emergency Department (ED) for shortness of breath and increased cough for the past 3 days. The ED physician documented the resident's extensive past medical history of [REDACTED]. The resident was admitted to the hospital with [REDACTED]. A review of the hospice Nursing Comprehensive Admission Assessment noted that the resident was admitted to hospice care on [DATE]. The hospice nurse spoke with resident #307's female friend and obtained a brief history: A [AGE] year old male who has resided at the nursing home since (YEAR). In 2013, his now POA began to care for him at his home She is a former Attorney but became a CNA (Certified Nursing Assistant) and has cared for private patients for many years. The patient was cared for by her in his home and she eventually moved him to her home in Kissimmee when he was experiencing multiple falls. She continued to care for him at her home until sometime in (YEAR) he became incontinent. As the episodes of incontinence worsened, she could no longer care for him and took him to the veteran's hospital. From there he was transferred to the current nursing home for rehab. Per POA .his condition has deteriorated since then. He is bedbound, has multiple wounds, had a feeding tube inserted in (MONTH) (YEAR), due to failing a swallow study. Prior to the insertion of the feeding tube, he had been losing approximately ,[DATE]% of his body weight monthly. He has had multiple hospitalization s in the last 6 months-one year [MEDICAL CONDITION], respiratory infections, urinary tract infections, and possible [MEDICAL CONDITION]. The most recent hospitalization on (MONTH) 7, (YEAR) was [MEDICAL CONDITION]. He returned to the facility on (MONTH) 17, (YEAR) with intravenous antibiotics but did not succeed at any other therapy. Due to his deteriorating condition, his POA has opted for hospice care in the facility and no further hospitalization s or aggressive treatment. The hospice nurse noted on [DATE] that the female friend was the Medical POA who did not want a DNR. The nurse noted, DNR to be Signed (the next day) on [DATE] .does not want CPR. The hospice nurse assessed resident #307 and determined that the resident had a speech/language barrier. The nurse further noted that the resident was only oriented to person and that the resident was not able to understand and participate in care. The resident's principal hospice [DIAGNOSES REDACTED]. The female friend never signed the DNR form. A review of the Agent's Certification as to the Validity of Power of Attorney and Agents Authority dated [DATE] read, This Document Does Not Authorize Anyone to Make Medical and Other Health-Care Decisions for You. The Power of Attorney form that was signed by the resident and the female friend, was notarized but did not delineate the resident's Medical-POA. On [DATE], the facility staff asked the Advanced Registered Nursing Practitioner (ARNP) to see the resident due to abnormal laboratory blood values. The ARNP noted that the resident was weaker and functionally declining. The ARNP documented, More Appropriate for Hospice Care/PT (patient) is DNR Now. The ARNP indicated the resident was a DNR, but there was no supporting evidence that the physician had signed a DNR order. As the resident declined, both the facility staff and the hospice staff failed to realize that a POA/DNR was not executed. The resident's care plan for advance directives remained unchanged, indicating that he was still a Full Code, and was to receive cardio-pulmonary resuscitation. The physician order [REDACTED]. On [DATE] at 5:30 PM, the hospice physician wrote an order for [REDACTED]. On [DATE] at 10:00 AM, the hospice case manager visited the resident. A new order was written to hold the tube feedings temporarily due to aspiration. On the morning of [DATE] at 5:30 AM, the hospice nurse noted that the resident's breathing was labored with apnea up to 30 seconds. Apnea is a temporary cessation of breathing. (Oxford Dictionary). She noted that the resident's respiratory rate had decreased to 3 to 4 breaths per minute. For humans, the typical respiratory rate for a healthy adult at rest is ,[DATE] breaths per minute. (wikipedia.com). At 7:00 AM, the nurse noted the resident continued to have labored breathing, was weak and gasping for air. She documented at 7:20 AM that the resident's pulse was 0 and he had stopped breathing. At 7:30 AM, the hospice nurse informed the hospice agency and the facility's 11 PM to 7 AM nurse that the resident had passed away. Despite the resident being a Full Code, requiring cardiopulmonary resuscitation, both the hospice nurse and the facility's 11 PM-7 AM nurses failed to initiate CPR. Resident #307's death and the facility's investigation was discussed with the Administrator and Consultant Nurse on [DATE] at 2:17 PM. They confirmed that the resident was a Full Code and that CPR should have been initiated. The Administrator stated when the hospice nurse informed the 11 PM-7 AM nurse, he should have checked the medical record for Code Status and then initiated CPR immediately. The Administrator stated the nurse assumed the resident had a DNR order because he was on Crisis Care. Although the resident had been at the facility for 2 years, the facility had failed to review his advanced directives as per their own policy. The facility policy was to review advanced directives on a quarterly basis. The most recent review of advanced directives was done in (MONTH) (YEAR). The facility neglected to assess the resident's Health Care Decision-Making capacity, when he began to decline. The physician did not assess the resident's decision making capacity to determine if an incapacity to make medical decisions was warranted. The facility failed to identify the appropriate person who could make decisions for the resident, which were consistent with the resident's wishes. Resident #307 had a female friend who the facility incorrectly identified was the POA. However, there was no documentation provided to the facility that she was the legal POA for medical decisions. Review of the facility's corrective measures revealed the following: * An ad hoc Quality Assurance and Performance Improvement meeting was held on [DATE] with all department heads including the medical director via phone to discuss incident involving resident #307 and implementation of corrective actions. * All current residents' code status reviewed including DNR, Advanced Directives if the resident has either a POA, Proxy Guardian, Health Care Surrogate and if there was incapacity determination by the physician - completed [DATE] * After the incident, on [DATE] staff inserviced on Advance Directives, CPR, Resident Rights, Nurse Practice Act. Any staff that was off work were mailed certified letter to complete education prior to working. At the time of the recertification survey all facility staff had been inserviced. * Staff CPR certifications reviewed -completed [DATE] *Immediate Reports filed [DATE] * Facility Administrator called Hospice Administrator on [DATE]. On [DATE] in person meeting between Facility Administrator and Hospice Administrator. Survey Team interviewed Hospice Administrator on [DATE] at 10:46 AM. Hospice Manager confirmed initial phone call and later in person meeting with Facility Administrator. Hospice Manager admitted that there was a breakdown by the Facility and Hospice. The Hospice Manager stated the following was put in place: 1. Every Hospice Admission, Hospice & Facilty will coordinate an initial care plan meeting to outline and discuss the resident's plan of care inclusive of advanced directives. 2. Facility and Hospice will arrange monthly meetings to review any updates and changes to plan of care. 3. With admissions to crisis care, Hospice and Facility Social Services will meet to discuss advanced directives and resident's plan of care throughout crisis care. Hospice Nurse will directly communicate the need for crisis care to the Director of Nursing Service and Facility Administrator. 4. Social Service of the facility to speak with the representative of Hospice and will have weekly conversations to discuss the resident's plan of care and upcoming care plan meetings * Facility Administrator phone call to 2nd Hospice Provider Executive Director (ED) - [DATE] * In person meeting with 2nd Hospice Provider ED - [DATE] * Care plan meeting collaboration with Hospice [DATE] & [DATE] * 5 Day Report [DATE] * 15 Day Adverse Report [DATE] The survey team expanded the sample and added all 8 current hospice residents. Advance Directives were reviewed and each of the residents' code status was in the electronic medical recorded (EMR) and in the paper chart. Interviews with 7 RNs, 3 LPNs, 1 CNA, the social worker and the assistant business office manager confirmed they were inserviced. Nursing staff demonstrated knowledge of code status and where to find it in the EMR and paper chart. Staff indicated that Code Blue Drills were being conducted randomly. During a code blue one staff calls for help and stays with resident. Staff check the code status, call 911 and bring crash cart. If full code, CPR initiated until arrival of EMS. Review of the facility's code blue drills from [DATE] to [DATE] demonstrated staff participation and monitoring by quality assurance staff. During an interview with the Social Worker (SW) present on [DATE] at 1:39 PM, the Administrator stated the POA paper work was checked by the Business Office Manager (BOM). Now the BOM and SW verify POA/Guardian/Proxy/Health Care Surrogate documentation. The SW was aware the advanced directives are reviewed quarterly per facility policy.

Based on record review and interview the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) for 1 of 8 sampled residents (#307). This failure resulted in resident #307 not receiving cardiopulmonary resuscitation immediately. Cardio-pulmonary resuscitation did not commence until almost an hour after the resident's respirations and heartbeat had ceased. The facility was determined to be in Immediate Jeopardy beginning on [DATE] and corrected by [DATE]. Findings: Resident #307 was originally admitted to the nursing home on [DATE] with [DIAGNOSES REDACTED]. A Social Service Admission Evaluation dated [DATE] noted that the resident was legally responsible for himself and that he did not have any Advance Directive, Do Not Resuscitate (DNR) order, Legal Guardian, Power of Attorney (POA), or Health Care Proxy. (Note: the Legal Guardian, Power of Attorney (POA) or Healthcare Proxy have the authority to make Advance Directive decisions when the person is not capable of doing so). The resident had resided with a 'female friend'/caretaker prior to nursing home admission. A review of the POA declaration form dated [DATE] noted the resident's female friend' as his POA. A detailed review of the declaration form revealed that the 'female friend' was not the Medical-POA and could not make medical decisions such as a DNR for resident #307. The declaration form read, 'This Document Does Not Authorize Anyone to Make Medical and Other Health-Care Decisions for You (resident #307).' Review of the facilities' CPR policy last revised on [DATE] noted that all residents will be provided CPR unless the resident has a physician's orders [REDACTED]. A review of the medical record noted that the resident had two recent hospitalization s. A hospital History & Physical (H&P) dated [DATE], noted that the resident was transferred to the Emergency Department (ED) for shortness of breath and increased cough for the past 3 days. The resident was determined to have pneumonia. The physician documented the resident's extensive past medical history of [REDACTED]. Another hospital history & physical dated [DATE] noted that the resident was transferred from the nursing home to the hospital due to coffee-ground emesis. The H&P noted that the resident was drowsy and responded 'minimally' to questions and was septic. It was noted in the H&P that the resident had dementia and could only answer simple yes and no questions. The resident stayed in the hospital for nine days and returned to the facility on [DATE]. On [DATE], the resident was admitted to Hospice Care for dementia. The hospice nurse indicated that the resident was not aware of his terminal illness or prognosis. The hospice nurse spoke with the female friend/alleged POA and determined that she did not want CPR for the resident. The nurse noted that the DNR was to be signed by the female friend the next day on [DATE]. However, the DNR was never signed and there was no indication that either the hospice staff or the facility staff followed up to ensure the resident had Medical-POA/Decision Maker and/or Advanced Directives/DNR that were consistent with the resident's wishes. On [DATE], the facility staff asked the Advanced Registered Nursing Practitioner (ARNP) to see the resident due to abnormal blood lab values. The ARNP noted that the resident was weaker and functionally declining. The ARNP documented, 'More appropriate for Hospice Care/Pt (patient) is DNR now.' The resident continued to decline and on [DATE] the physician ordered that the resident start on Crisis Care due to changes in mental status. During Crisis Care hospice staff, remain continuously at the resident's bedside with death being imminent. On [DATE] at 7:20 AM, the hospice nurse noted that the resident's pulse was zero and the resident was no longer breathing. The hospice licensed practical nurse contacted the Hospice agency at 7:30 AM to inform them the resident had passed. There was no documentation the hospice or facility staff immediately initiated CPR. An interview with the hospice nurse on [DATE] at 1:08 PM, revealed that on [DATE], the resident began actively dying at 5:30 AM. She stated the resident had labored breathing with apnea up to 30 seconds. The nurse confirmed that the resident passed away at 7:20 AM and she did not initiate CPR. She stated that the resident's code status was not in the hospice care plan and she assumed he was a DNR as he was on crisis care. The nurse stated that she informed the facility's 11 PM to 7 AM nurse after the resident had passed. An interview was held on ,[DATE]//18 at 2:17 PM with the administrator and nurse consultant. They provided a timeline of events and their investigation of the resident's death. The administrator confirmed that the resident passed away on [DATE] at about 7:20 AM. The hospice nurse did not initiate CPR. The hospice nurse informed the 11 PM to 7 AM evening nurse that the resident had died . At approximately 7:40 AM, the evening nurse informed the Assistant Director of Nursing (ADON) that the resident had died . The ADON accessed the resident's medical record in attempt to contact family/responsible party. At that time, the ADON discovered that the resident was a Full Code and called 911. The administrator stated that the facility staff started CPR at about 8:15 AM, almost one hour after the resident had deceased . He stated that the hospice nurse and the facility 11 PM-7 AM nurse did not initiate CPR as they both assumed the resident was a DNR since he was on crisis care. The facility failed to identify that the resident was a Full Code and failed to immediately initiate lifesaving CPR. The staff started CPR, almost an hour after the resident had died . The staff continued CPR until Emergency Medical Services arrived and took over. The administrator confirmed that resident #307 was a Full Code and did not have a DNR in place. Review of the facility's corrective measures revealed the following: * An ad hoc Quality Assurance and Performance Improvement meeting was held on [DATE] with all department heads including the medical director via phone to discuss incident involving resident #307 and implementation of corrective actions. * All current residents' code status reviewed including DNR, Advance Directives if the resident had either a POA, Proxy Guardian, Health Care Surrogate and if there was an incapacity determination by the physician - completed [DATE] * After the incident, on [DATE] staff inserviced on Advance Directives, CPR, Resident Rights, Nurse Practice Act. Any staff that was off work were mailed certified letter to complete education prior to working. At the time of the recertification survey all facility staff had been inserviced. * Staff CPR certifications reviewed -completed [DATE] *Immediate Reports filed [DATE] * Facility Administrator called Hospice Administrator on [DATE]. On [DATE] in person meeting between Facility Administrator and Hospice Administrator. Survey Team interviewed Hospice Administrator on [DATE] at 10:46 AM. Hospice Manager confirmed initial phone call and later in person meeting with Facility Administrator. Hospice Manager admitted that there was a breakdown by the Facility and Hospice. The Hospice Manager stated the following was put in place: 1. Every Hospice Admission, Hospice & Facilty will coordinate an initial care plan meeting to outline and discuss the resident's plan of care inclusive of advance directives. 2. Facility and Hospice will arrange monthly meetings to review any updates and changes to plan of care. 3. With admissions to crisis care, Hospice and Facility Social Services will meet to discuss advance directives and resident's plan of care throughout crisis care. Hospice Nurse will directly communicate the need for crisis care to the Director of Nursing Service and Facility Administrator. 4. Social Service of the facility to speak with the representative of Hospice and will have weekly conversations to discuss the resident's plan of care and upcoming care plan meetings * Facility Administrator phone call to 2nd Hospice Provider Executive Director (ED) - [DATE] * In person meeting with 2nd Hospice Provider ED - [DATE] * Care plan meeting collaboration with Hospice [DATE] & [DATE] * 5 Day Report [DATE] * 15 Day Adverse Report [DATE] The survey team expanded the sample and added all 8 current hospice residents. Advance Directives were reviewed and each of the residents' code status was in the electronic medical recorded (EMR) and in the paper chart. Interviews with 7 RNs, 3 LPNs, 1 CNA, the social worker and the assistant business office manager confirmed that they were inserviced. Nursing staff demonstrated knowledge of code status and where to find it in the EMR and paper chart. Staff indicated that Code Blue Drills were being conducted randomly. During a code blue one staff calls for help and stays with resident. Staff check the code status, call 911 and bring crash cart. If full code, CPR initiated until arrival of EMS. Review of the facility's code blue drills from [DATE] to [DATE] demonstrated staff participation and monitoring by quality assurance staff. During an interview with the Social Worker (SW) present on [DATE] at 1:39 PM, the Administrator stated the POA paper work was checked by the Business Office Manager (BOM). Now the BOM and SW verify POA/Guardian/Proxy/Health Care Surrogate documentation. The SW was aware the advanced directives are reviewed quarterly per facility policy.

Based on record review and interview the facility failed to provide medically related social services to meet the needs to formulate advanced directives for 1 of 9 residents, (#307). The facility's non-compliance resulted in a delay in which resident #307 did not immediately receive Cardio-Pulmonary Resuscitation. Cardio-pulmonary resuscitation did not commence until about an hour after the resident's respirations and heartbeat had ceased. The facility was determined to be in Immediate Jeopardy that started on [DATE] and corrected by [DATE]. Findings: Resident #307 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure for Advance Directives Admissions/Social Service (SS-121) delineated the responsibilities of the Social Service staff concerning resident Advance Directives. Some of the responsibilities in this policy included: a) Determine whether the resident has an advance directive and, if not, determine whether the resident wishes to establish an advance directive. b) Indicate the resident's wishes to provide or withhold CPR c) Indicate names of persons that will act as a primary decision maker with position held and phone number. d) Obtain signature from resident/responsible party and facility representative e) Document Discussions f) Advance Directive will be reviewed at least quarterly g) Identify situations where health care decision making is needed. The policy noted, 'Should any of the situations described below arise, the matter will be referred to the Executive Director immediately, and no order for withholding of treatment should be entered until the problem is resolved. a) Doubts expressed by any interested person as to the resident's competence. b) Disagreement between the resident and the attending physician as to the appropriate course of action. c) Disagreement between the appropriate primary decision maker and/or next of kin and the attending physician as to the appropriate course of action. d) Refusal by a primary decision maker to honor the reliable advance directive of a resident. e) Disagreement between family member of an incompetent resident, or between family members and a conservator of the resident, duly appointed by the probate court as to the appropriate course of action f) Doubt as the appropriateness of the basis for any decision by a primary decision maker a. Appropriate primary decision maker are: b. Conservator of the resident's person, or c. Agent(s) named in health care proxy. A review of the Social Services Admission Evaluation form dated [DATE] noted that the resident was legally responsible for himself and that he did not have a Legal Guardian or Power of Attorney (POA). The Social Services Director (SSD) documented that the resident did not have any Advance Directives such as a Living Will, Durable POA for Health Care, Healthcare Proxy or a Do Not Resuscitate order. A copy of the Resident Rights form was provided to resident #307 and the SSD reviewed the form with him. The SSD noted that the resident had lived with a 'female friend' prior to nursing home placement. There was no evidence to show that the resident chose to formulate any advance directives at that time. Review of the Advance Directive Care Plan initiated [DATE] noted that the resident was a Full Code. The goal on this care plan noted, Resident will have advance directives followed. The facility had documented evidence that Advance Directives were reviewed with resident #307 on [DATE]. The Social Services Quarterly Progress Review dated [DATE] noted that the resident was oriented and that he could independently make decisions with a Brief Interview for Mental Status (BIMS) score of 12 (most recent BIMS [DATE]). A BIMS score of 8 to 12 indicated moderately impaired cognition. The Social Worker (SW) noted Resident #307 was a Full Code and the location for his Advance Directives would be in the 'chart and computer.' Review of the Agent's Certification as to the Validity of Power of Attorney and Agents Authority dated [DATE] appeared to be an attempt to make resident #307's 'female friend,' his DPOA/POA. This document noted, 'This Document Does Not Authorize Anyone to Make Medical and other Health-Care Decisions For You.' The document was not filled out correctly and did not grant any authority to the 'female friend,' to make decisions either medically or financially on behalf of the resident. There was no evidence that the facility's staff and/or the SW had reviewed this document and found it to be invalid. There was no evidence that the facility staff, including the SW, made any attempts to rectify this matter and secure a Decision Maker for the resident. The resident's health continued to decline as evidenced by the Significant Change Minimum (MDS) data set [DATE]. The resident had declined and was assessed as extensive to total assist with all activates of daily living (ADL's). The resident had two recent hospitalization s. A hospital History & Physical (H&P) dated [DATE], noted that the resident was transferred to the Emergency Department (ED) for shortness of breath and increased cough for the past 3 days. The resident was determined to have pneumonia. The physician documented the resident's extensive past medical history of [REDACTED]. Another hospital H&P dated [DATE] noted that the resident was transferred from the nursing home to the hospital due to coffee-ground emesis. The H&P noted that the resident was drowsy and responded 'minimally' to questions and was septic. It was noted in the H&P that the resident had dementia and could only answer simple yes and no questions. The resident stayed in the hospital for nine days and returned to the facility on [DATE] with a feeding tube. After multiple hospitalization s and decline the SSD and the facility staff failed to assess the resident's decision making ability. Review of the hospice Nursing Comprehensive Admission assessment dated [DATE], noted that the resident was admitted to Hospice Care. The hospice nurse spoke with resident #307's 'female friend' and obtained a brief history, 'A [AGE] year old male who has resided at the nursing home since (YEAR). In 2013, his now POA began to care for him at his home .She is a former Attorney but became a CNA (Certified Nursing Assistant) and has cared for private patients for many years. The patient was cared for by her in his home and she eventually moved him to her home when he was experiencing multiple falls. She continued to care for him at her home until sometime in (YEAR) he became incontinent. As the episodes of incontinence worsened she could no longer care for him at took him to the veteran's hospital. From there he was transferred to the current facility for rehabilitation. Per POA, (name of POA), his condition has deteriorated since then, he is bedbound, has multiple wounds, had a feeding tube inserted in (MONTH) (YEAR), due to failing a swallow study. Prior to the insertion of the feeding tube, he had been losing approximately ,[DATE]% of his body weight monthly. He has had multiple hospitalization s in the last 6 months-one year [MEDICAL CONDITION], respiratory infections, urinary tract infections and possible [MEDICAL CONDITION]. The most recent hospitalization on (MONTH) 7, (YEAR) was [MEDICAL CONDITION]. He returned to the facility on (MONTH) 17, (YEAR) with intravenous antibiotics but did not succeed at any other therapy. Due to his deteriorating condition, his POA has opted for hospice care in the facility and no further hospitalization s or aggressive treatment.' The hospice nurse noted that the 'female friend' was the Medical POA without valid evidence of such. She noted that the POA did not want a DNR. The nurse noted, 'DNR to be signed on [DATE] .does not want CPR.' The hospice nurse assessed resident #307 and determined that the resident had a speech/language barrier. The nurse further noted that the resident was only oriented to person and that the resident was not able to understand and participate in care. The resident's principal hospice [DIAGNOSES REDACTED]. making ability and failed to ensure a legitimate POA. The resident's Advance Directive Care Plan was updated to reflect that the resident was now on Hospice Care. The care plan still noted that the resident was a Full Code. On [DATE], the physician ordered the resident on Hospice Critical Care due to a mental status change and the resident's overall decline. Crisis Care means that a hospice nurse would be at the resident's bedside continuously due to imminent death. The resident deceased two days later on [DATE] at 7:20 AM. On [DATE] at about 7:30 AM, the hospice nurse informed the facility evening nurse (11 PM to 7 AM shift) that the resident had passed away. Neither, the hospice nurse or the evening nurse initiated CPR though the resident was a Full Code. Subsequently, on [DATE] at approximately 7:40 AM, the Assistant Director of Nursing (ADON) was informed of the resident's passing. The ADON obtained the resident's medical record to find the phone numbers of the resident's responsible party. In the midst of doing this, she discovered that resident #307 did not have a DNR order and that he was a Full Code. The facility called 911 and CPR was initiated at approximately 8:15 AM, almost an hour after the resident had deceased . An interview with the administrator and nurse consultant on [DATE] at 2:31 PM revealed that they could not find any documentation from the previous SSD concerning the resident's advance directives or POA status. They confirmed that the resident's advance directives were not reviewed as per facility policy. They stated that these factors lead to the assumption that the resident was a DNR. The administrator acknowledged that the hospice staff had planned to obtain a DNR but there was no follow through by the SSD. Review of the facility's corrective measures revealed the following: * An ad hoc Quality Assurance and Performance Improvement meeting was held on [DATE] with all department heads including the medical director via phone to discuss incident involving resident #307 and implementation of corrective actions. * All current residents' code status reviewed including DNR, Advanced Directives if the resident has either a POA, Proxy Guardian, Health Care Surrogate and if there was an incapacity determination by the physician - completed [DATE] * After the incident, on [DATE] staff inserviced on Advanced Directives, CPR, Resident Rights, Nurse Practice Act. Any staff that was off work were mailed certified letter to complete education prior to working. At the time of the recertification survey all facility staff had been inserviced. * Staff CPR certifications reviewed -completed [DATE] *Immediate Reports filed [DATE] * Facility Administrator called Hospice Administrator on [DATE]. On [DATE] in person meeting between Facility Administrator and Hospice Administrator. Survey Team interviewed Hospice Administrator on [DATE] at 10:46 AM. Hospice Manager confirmed initial phone call and later in person meeting with Facility Administrator. Hospice Manager admitted that there was a breakdown by the Facility and Hospice. The Hospice Manager stated the following was put in place: 1. Every Hospice Admission, Hospice & Facilty will coordinate an initial care plan meeting to outline and discuss the resident's plan of care inclusive of advanced directives. 2. Facility and Hospice will arrange monthly meetings to review any updates and changes to plan of care. 3. With admissions to crisis care, Hospice and Facility Social Services will meet to discuss advanced directives and resident's plan of care throughout crisis care. Hospice Nurse will directly communicate the need for crisis care to the Director of Nursing Service and Facility Administrator. 4. Social Service of the facility to speak with the representative of Hospice and will have weekly conversations to discuss the resident's plan of care and upcoming care plan meetings * Facility Administrator phone call to 2nd Hospice Provider Executive Director (ED) - [DATE] * In person meeting with 2nd Hospice Provider ED - [DATE] * Care plan meeting collaboration with Hospice [DATE] & [DATE] * 5 Day Report [DATE] * 15 Day Adverse Report [DATE] The survey team expanded the sample and added all 8 current hospice residents. Advance Directives were reviewed and each of the residents' code status was in the electronic medical recorded (EMR) and in the paper chart. Interviews with 7 RNs, 3 LPNs, 1 CNA, the social worker and the assistant business office manager confirmed that they were inserviced. Nursing staff demonstrated knowledge of code status and where to find it in the EMR and paper chart. Staff indicated that Code Blue Drills were being conducted randomly. During a code blue one staff calls for help and stays with resident. Staff check the code status, call 911 and bring crash cart. If full code, CPR initiated until arrival of EMS. Review of the facility's code blue drills from [DATE] to [DATE] demonstrated staff participation and monitoring by quality assurance staff. During an interview with the Social Worker (SW) present on [DATE] at 1:39 PM, the Administrator stated the POA paper work was checked by the Business Office Manager (BOM). Now the BOM and SW verify POA/Guardian/Proxy/Health Care Surrogate documentation. The SW was aware the advanced directives are reviewed quarterly per facility policy.

Based on record review and interview the facility failed to designate a member of the interdisciplinary team (IDT) who was responsible for working with the hospice representatives to mutually coordinate care & services to attain/maintain the resident's highest practicable wellbeing for 1 of 9 sampled residents, (#307). The facility's failure resulted in an Immediate Jeopardy, in which, resident #307 did not receive cardio-pulmonary resuscitation immediately after his respirations and heartbeat ceased. The facility was determined to be in Immediate Jeopardy beginning on [DATE] that was corrected by [DATE]. Findings: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been at the facility for two years and his heath declined. He was placed on hospice care on [DATE]. On [DATE], the physician ordered Hospice Crisis Care indicating the resident's death was imminent. The physician noted that the resident had a change in mental status. The resident eventually died on [DATE] at 7:20 AM. The hospice nurse noted that the resident's heartbeat was zero and that he had stopped breathing. Hospice provides palliative care which is resident/family centered care that optimizes quality of life by anticipating, preventing and alleviating suffering. In short, hospice care provides an avenue through the terminally ill disease process so that the resident may pass away with dignity and grace. This however, was not the case with resident #307. A review of the resident's medical record revealed [REDACTED]. Shortly after the resident died , the hospice nurse informed the facility's evening nurse (11 PM to 7 AM shift) that the resident had passed away. The Assistant Director of Nursing (ADON) was informed of the resident's death. When the ADON reviewed the resident's medical record to contact the resident's family/ responsible party, she discovered that the resident was a Full Code and did not have a Do Not Resuscitate (DNR) form/order. The facility contacted the hospice provider and discovered that they also did not have a DNR order. It was determined that since there was no DNR in place, the resident was a Full Code. The facility called 911 and the staff initiated CPR starting at 8:15 AM, almost one hour after the resident's respirations and heartbeat ceased. Emergency Management Services (EMS) arrived at the facility and assumed continuity of CPR. At 9:08 AM (after 53 minutes of CPR) the EMS Medical Director pronounced the resident's death. A comprehensive review of the facility's and hospice provider's process, or lack thereof, identified key elements that would have prevented this tragic end and allowed resident #307 to die peacefully, without unnecessary trauma to his body. First, when the resident was admitted to the facility, the Social Service Director (SSD) identified that the resident did not have any Advance Directives such as a Living Will, Durable Power of Attorney (DPOA/POA) for Health Care, Health Care Proxy or DNR. The SSD noted that the resident resided with a 'female friend prior to nursing home placement. There were no attempts made by the SSD to obtain advance directives. The facility had a multitude of policies and procedures for Advance Directives that instructed facility staff of their responsibilities concerning Advance Directives. The policies & procedures noted that Advance Directives were to be reviewed quarterly but this was not done for resident #307. The one and only time advance directives were reviewed was on [DATE], 9 months after admission. The resident's Advance Directive Care Plan revised on [DATE] noted that he was a Full Code. The care plan goal noted, 'Resident will have advanced directives followed. The Social Worker noted that Advanced Directives were reviewed with #307 and that he did not elect any Advance Directives. The Social Worker noted that the resident was a Full Code. The Advance Directive Policy & Procedure further noted that staff were responsible for identifying and making changes if there were concerns with the resident's competency/decision making ability or/and any concerns involving POA/Primary Decision Maker. Although the resident's condition had declined physically and cognitively, the facility failed to review his advance directives. Review of the Agent's Certification as to the Validity of Power of Attorney and Agents Authority dated [DATE] appeared to be an attempt to make resident #307's 'female friend,' his DPOA/POA. However, this document clearly noted, This Document Does Not Authorize Anyone to Make Medical and other Health-Care Decisions For You. The document was not filled out correctly and therefore did not grant any authority to the 'female friend,' to make decisions either medically or financially on behalf of the resident. There was no evidence that the facility's staff and/or the SW had reviewed this document and found it to be invalid. There was no evidence that the facility staff, including the SW, made any attempts to rectify this matter and secure a Decision Maker for the resident. When the resident was placed on Hospice Care on [DATE], the hospice nurse noted that the resident's 'female friend' was the Medical POA even though there was evidence to the contrary. The hospice nurse noted that the 'female friend' did not want CPR and that the DNR form would be signed the next day on [DATE]. However, a DNR form was never signed and there was no apparent evidence that the Hospice Team or the Facility IDT actively pursued a DNR, especially when the resident was placed on Crisis Care. Review of the contract between the Hospice Provider and the Facility noted in section 4.4 that the Hospice Provider will provide, 'Hospice election form and any advance directives specific to each Hospice Patient.' The hospice staff failed to verify the resident's advance directives and the legal POA. The facility staff in turn failed to coordinate with the hospice staff to ensure that a legal POA was in place and the resident's wishes for end of life were honored. Hospice staff initiated an interdisciplinary plan of care that included patient centered goals for pain management, communication, pressure wounds, and neurologic/cognition. The hospice staff noted that upon hospice admission, the resident's cognition was severely impaired. The resident's Advance Directives care plan was updated on [DATE] to reflect that the resident was now on hospice. However, the care plan still noted that the resident was a Full Code. On [DATE] at 1:08 PM the hospice crisis care nurse (CCN) was interviewed. She stated that she was with the resident when he passed away. She confirmed that the resident died at approximately 7:20 AM. She stated that she informed the facility's evening nurse and contacted the hospice agency to inform them of the resident's death. She confirmed that neither she or the evening nurse initiated CPR. The CCN stated that she was not aware of the resident's Code Status and assumed he was a DNR because he was on crisis care. She stated that the resident's hospice information was in a folder in the resident's room. The folder contained a list of his medications but there was nothing in the folder that indicated the resident's code status. She stated that she was not informed by the facility that the resident was a full code. The resident's code status should have been in the folder especially if he was a full code. A member of the facility's interdisciplinary team should have been aware of the inconsistencies concerning the resident #307's ability to make medical decisions and identify a legal POA, Health Surrogate or Health Care Proxy willing to make medical decisions consistent with the resident's wishes. This information should have been provided to the hospice staff. Furthermore, both the facility and the hospice staff failed to have clarity of the resident's code status. Both assumed that he was a DNR as he was on crisis care. There was no designated team member assigned by the facility to coordinate the resident's hospice care to ensure that these issues were clarified so that the resident's final wishes were respected. Review of the facility's corrective measures revealed the following: * An ad hoc Quality Assurance and Performance Improvement meeting was held on [DATE] with all department heads including the medical director via phone to discuss incident involving resident #307 and implementation of corrective actions. * All current residents' code status reviewed including DNR, Advanced Directives if the resident had either a POA, Proxy Guardian, Health Care Surrogate and if there was an incapacity determination by the physician - completed [DATE] * After the incident, on [DATE] staff inserviced on Advanced Directives, CPR, Resident Rights, Nurse Practice Act. Any staff that was off work were mailed certified letter to complete education prior to working. At the time of the recertification survey all facility staff had been inserviced. * Staff CPR certifications reviewed -completed [DATE] *Immediate Reports filed [DATE] * Facility Administrator called Hospice Administrator on [DATE]. On [DATE] in person meeting between Facility Administrator and Hospice Administrator. Survey Team interviewed Hospice Administrator on [DATE] at 10:46 AM. Hospice Manager confirmed initial phone call and later in person meeting with Facility Administrator. Hospice Manager admitted that there was a breakdown by the Facility and Hospice. The Hospice Manager stated the following was put in place: 1. Every Hospice Admission, Hospice & Facilty will coordinate an initial care plan meeting to outline and discuss the resident's plan of care inclusive of advanced directives. 2. Facility and Hospice will arrange monthly meetings to review any updates and changes to plan of care. 3. With admissions to crisis care, Hospice and Facility Social Services will meet to discuss advanced directives and resident's plan of care throughout crisis care. Hospice Nurse will directly communicate the need for crisis care to the Director of Nursing Service and Facility Administrator. 4. Social Service of the facility to speak with the representative of Hospice and will have weekly conversations to discuss the resident's plan of care and upcoming care plan meetings * Facility Administrator phone call to 2nd Hospice Provider Executive Director (ED) - [DATE] * In person meeting with 2nd Hospice Provider ED - [DATE] * Care plan meeting collaboration with Hospice [DATE] & [DATE] * 5 Day Report [DATE] * 15 Day Adverse Report [DATE] The survey team expanded the sample and added all 8 current hospice residents. Advance Directives were reviewed and each of the residents' code status was in the electronic medical recorded (EMR) and in the paper chart. Interviews with 7 RNs, 3 LPNs, 1 CNA, the social worker and the assistant business office manager confirmed that they were inserviced. Nursing staff demonstrated knowledge of code status and where to find it in the EMR and paper chart. Staff indicated that Code Blue Drills were being conducted randomly. During a code blue one staff calls for help and stays with resident. Staff check the code status, call 911 and bring crash cart. If full code, CPR initiated until arrival of EMS. Review of the facility's code blue drills from [DATE] to [DATE] demonstrated staff participation and monitoring by quality assurance staff. During an interview with the Social Worker (SW) present on [DATE] at 1:39 PM, the Administrator stated the POA paper work was checked by the Business Office Manager (BOM). Now the BOM and SW verify POA/Guardian/Proxy/Health Care Surrogate documentation. The SW was aware the advanced directives are reviewed quarterly per facility policy.

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 7 sampled residents who was at risk for elopement (#1) in a total of 13 at risk residents. This failure contributed to the elopement of resident #1, placing him at risk for serious injury/impairment/death. The failure to develop and implement a baseline elopement risk care plan resulted in the resident's elopement and subsequent Past Non-Compliance at the Immediate Jeopardy level, identified as occurring on 12/04/17 and removed on 1/03/18. Findings: Cross reference F689, F725, F867. Resident #1 was an [AGE] year old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was Spanish speaking only. His primary mode of locomotion was a walker, which he often forgot to use. Upon admission assessment, he was noted to walk occasionally for short distances and had balance problems while standing and walking. He was assessed as an elopement risk as he demonstrated exit seeking behavior. The admission nursing assessment noted, patient (resident) is seeking to escape. He was assessed as a fall risk as he had 3 or more falls in the past 3 months at home. Three days after admission, on 12/04/17 at approximately 6:30 PM, the resident exited the facility via the front door that was not manned or locked. The sun had set at 5:29 PM on 12/04/2017. The resident was observed near a bus stop approximately 200 feet from the nursing home at the intersection of a 6 lane busy highway by a family member of an adjacent nursing home. It was unclear which route the resident followed and if he had attempted to cross the street. The family member reported to the staff of the adjacent nursing home that an elderly man was observed looking lost near the bus stop. The staff of the adjacent nursing home went to the bus stop and brought the resident back to their nursing home. Upon realizing the man was not their resident, they telephoned the facility and informed the staff that they had their resident. The resident did not have on a wander bracelet. Upon resident #1's admission to the facility on Friday, 12/01/17 at 5:30 PM, an admission nursing assessment and data collection was conducted. A review of the assessment identified that he was at risk for elopement and at risk for falls. The elopement risk evaluation section of the admission data collection noted that he was cognitively impaired with poor decision making skills, wandered obliviously to safety needs, demonstrated exit-seeking behavior, and had the ability to exit the facility. The elopement risk evaluation deemed him to be at risk for elopement. The falls risk evaluation section of the data collection revealed that he was at risk for falls. He ambulated with a walker, had gait balance problems while standing and while waking, had three or more falls in the past three months prior to coming to the facility, and received medications that placed him at risk for falls. The admission nurse documented on the 12/01/17 admission assessment that resident had attempted to elope on the night of his admission as follows: (Resident) .trying to excape (escape) from the facility given medications in bed resting There was no documented evidence that the physician was notified of the resident's attempt to elope and no documented interventions to reduce the resident's attempt of elopement. On Saturday, 12/02/17 at 11:04 PM, a nurse's note for resident #1 revealed that he continued to have the following exit seeking behaviors: Patient alert with confusion refers wants to go out Again, there was no documented evidence that the physician was notified or any evidence that any interventions were put into place for resident #1 to reduce the risk of elopement. The 24-hour nurses' report for the same time frame, 12/02/17 on the 3-11 PM shift, continued to note concerns regarding resident #1's potential elopement risk: Need (wander bracelet) confused. There continued to be no documented evidence that the physician had been notified of the resident's attempts to elope and no documented evidence that interventions were put into place to prevent the resident from eloping from the facility. On Monday, 12/04/17 at 10:15 PM, a nurse's note read, This client (resident) eloped this shift from this facility, he was located across the street at the (adjacent nursing home). Client was escorted back to this facility by staff. Complete assessment was done of this client. No apparent injuries present, he is confused and requesting to go back to (island country of origin). He was determined to be a high elopement risk, was placed on the elopement risk assessment book, (wander bracelet) was placed on his right ankle, family, and Dr. (physician) notified. The 24-hour report, dated 12/04/17 for the 3-11 PM shift, read, Patient without (wander bracelet), escape of facility and arrived at front facility across street. Despite documented evidence that resident #1 was an elopement risk at admission on 12/01/17, and had exhibited elopement behaviors since his admission up until the day he eloped on 12/04/17, there was no documented evidence that any interventions had been put into place necessary to prevent the resident's elopement. The director of clinical services (DCS) was interviewed on 4/10/18 at 10:55 AM, regarding resident #1's elopement. She validated that the resident had eloped on 12/04/17, three (3) days after his admission. She validated that he had not been issued a wander bracelet prior to his elopement. She stated that a wander bracelet should have been placed on him the night of his admission, 12/01/17, when he was assessed to be at risk for elopement and had attempted to leave the facility. She could not give a reason as to why elopement interventions including the wander bracelet had not been implemented for the resident at that time. The DCS stated that resident #1 was discovered missing when a family member from the adjacent nursing home located across the street (three lane street) had seen an elderly male standing by the bus stop at the intersection near a six lane heavy traffic highway. The family member thought that he looked like a resident and alerted the adjacent facility staff. Their staff then went to the bus stop and brought resident #1 back to their nursing home facility. The DCS stated that the adjacent nursing home across the street discovered he was not their resident, and called us to inquire if he was our resident. She stated that the resident most likely eloped through the front door of the facility. She said that a nurse had seen him sitting in the lobby prior to the incident, so we are thinking he went out the front door. She stated that after his elopement, a cognition assessment was completed and he was given a score of 6, which indicated severely impaired cognitive abilities. Review of resident #1's Baseline Care Plan and Summary (interim care plans), dated 12/02/17 and signed by the Minimum Data Set (MDS) coordinator, noted that resident #1 had a wander bracelet on his left ankle. This contraindicated the above nursing documentation and interview with the DCS that elopement interventions including the wander bracelet were not implemented for resident #1 until after his elopement on 12/04/17. Interview with the MDS coordinator on 4/10/18 at 12:45 PM revealed that she had started her job as the MDS coordinator on 11/29/17, 2 days prior to resident #1's admission. She validated that she had initiated and completed the baseline care plan and interventions. It was noted to have been written in the same person's handwriting. She validated that it was dated as completed on 12/02/17. She stated that the date was an error, that it should have been dated 12/05/17. She said that 12/02/17 was a Saturday and she did not work that day. She could not provide an answer as to why she dated the baseline care plan on a day when she was not at the facility. She stated that she had just started her job and was at the time learning her role and expectations. She validated that the wander bracelet was not placed on resident #1 until after his elopement on 12/04/17, not on 12/02/17 as the Baseline Care Plan indicated. She validated that the Baseline Care Plan had not been done within 48 hours of admission. She validated that elopement interventions should have been put into place prior to the resident's elopement. She said that typically the admission nurse initiates and/or completes the baseline care plan. She said that the nurses had not done it, so she did it. On 4/10/18 at 11:50 AM, registered nurse (RN) A stated that she was working in the facility at the time of the elopement. She received a phone call somewhere between 7:15 PM and 7:30 PM from nursing home located across the street. She did not remember the name of the person calling, but that person asked if we had a resident by the name of resident #1 because he was at their facility. RN A said that the caller told her that a family member from the nursing home across the street had been on her way to the facility, saw him on the side of the road, and let the staff know at the nursing home across the street. RN A stated that she and RN B, who no longer worked at the facility, walked across the street and brought resident #1 back to the facility. She stated that resident #1 was calm and did not say anything. He was unsteady on his feet, and had a walker with him. She said the front door was not locked at the time of his elopement because she and RN B went out the front door to get the resident and then came back through the front door. It was not locked. On 4/10/18 at 4:20 PM, an interview was conducted with certified nursing assistant (CNA) C who had been assigned to care for resident #1 on the evening of his elopement. CNA C stated she saw the resident at approximately 6:30 PM on 12/04/17 when he was leaving the dining room. She did not see him again until the nurse informed her at approximately 7:30 PM that he had eloped. She was busy transporting and helping other residents in the dining room during that time. The CNA said that she was not aware that the resident would wander, because he did not have on a wander bracelet. Review of the facility's Clinical Guideline for Elopement, revision date of 11/23/16 included the following: The Center is to evaluate and identify residents that are at risk for elopement and develop interventions to mitigate risk. The process to identify and put interventions in place to reduce the risk of elopement included: Residents to be evaluated on admission/readmission If a resident is identified as being at risk, complete an elopement risk alert and obtain a full body photograph. Initiate interventions to mitigate risk of elopement. If utilizing wander monitoring system device, check placement of the device every shift and function every day. Document individualized intervention in the resident care plan and kardex On 4/12/18 at 4 PM, an interview with the administrator, regional director of clinical services, and clinical quality specialist was conducted. They stated that the Clinical Guideline for Elopement was the facility's elopement policy and procedure. They stated that the facility had not sufficiently followed the elopement clinical guideline to appropriately identify and plan interventions to reduce the risk and/or prevent resident #1's elopement from the facility. They validated that the Baseline Care Plan was part of the facility's process to identify and plan interventions for elopement risk residents and that it had not been done timely for resident #1. They stated appropriate initial interventions would have included one to one (1:1) supervision and/or a wander bracelet for a resident at risk for elopement. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 12/04/17 and removed as of 1/03/18. The facility had initiated a 4-point action plan beginning on 12/04/17. Upon return to the facility, the resident was placed on 1:1 supervision until assessed by the interdisciplinary team and a wander bracelet was applied. He had a Brief Interview for Mental Status completed; Psychosocial monitoring was implemented as part of the skilled charting. The physician was notified and a Psychiatric consultation was ordered. - All residents had an elopement risk evaluation completed. - Residents with wander bracelets were checked to ensure proper functioning, placement and ensured that physician orders [REDACTED]. The checks were documented on the medication and treatment administration records. - A process was in place for a restorative CNA to check all wander bracelets each morning including weekends. - Elopement binders with resident pictures and information were reviewed, updated and accessible at all nursing stations and entrances. - Care plans and Kardexes were reviewed and updated for residents identified at risk for elopement. - Elopement drills were being done on each shift once monthly. - The front door was manned by a receptionist from 8:30 AM until 5:30 PM on weekdays and from 10 AM until 2 PM on weekends. The receptionists were responsible for unlocking the front door when they arrived in the morning and for locking the door when they left work. The manager on duty was responsible for double-checking to ensure the door was locked. The receptionist monitored all persons going in and out of the facility. - The front door locked when a resident with a wander bracelet was within range. All other egress doors had 15-second delays and had alarms attached to the doors. If the doors were opened, an ear piercing sound emitted alerting the staff. The maintenance director monitored the doors daily to ensure proper functioning. - All staff were educated about the Elopement/Wandering Risk Clinical Guidelines, Elopement Risk Binders, and Elopement Drill Procedures. Staff understanding of the education was monitored using a post-test. Current staff were not allowed to work until education was provided. All staff were educated by 1/03/18. Newly hired staff were provided education regarding Elopement/Wandering and Missing Resident Guidelines at orientation. - It was noted on the 4-point plan that the Administrator and Interdisciplinary Team completed a root cause analysis and an Ad Hoc QAPI (Quality Assurance/Performance Improvement) meeting was held prior to 1/03/18 although the current administrator could not locate the documentation. - The DCS/designee monitored staff education, elopement risk evaluations, and wandering bracelet function at the morning meetings. Findings were reviewed at the monthly QAPI meetings.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent elopement for 1 of 7 sampled residents who was at risk for elopement (#1) in a total of 13 at risk residents. This failure contributed to the elopement of resident #1, placing him at risk for serious injury/impairment/death. The failure to provide adequate supervision and a safe environment resulted in the resident's elopement and subsequent Past Non-Compliance at the Immediate Jeopardy level, identified as occurring on 12/04/17 and removed on 1/03/18. Findings: Cross reference to F655, F725, and F867. Resident #1 was an [AGE] year old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was Spanish speaking only. His primary mode of locomotion was a walker, which he often forgot to use. Upon admission assessment, he was noted to walk occasionally for short distances and had balance problems while standing and walking. He was assessed as an elopement risk as he demonstrated exit seeking behavior. The admission nursing assessment noted, patient is seeking to escape. He was assessed as a fall risk as he had 3 or more falls in the past 3 months at home. Three days after admission, on 12/04/17 at approximately 6:30 PM, the resident exited the facility via the front door that was not manned or locked. The sun had set at 5:29 PM on 12/04/17, an hour before the resident eloped. The resident was observed near a bus stop approximately 200 feet from the nursing home at the intersection of a 6 lane busy highway by a family member of an adjacent nursing home. It was unclear which route the resident followed and if he had attempted to cross the street. The family member reported to the staff of the adjacent nursing home that an elderly man was observed looking lost near the bus stop. The staff of the adjacent nursing home went to the bus stop and brought the resident back to their nursing home. Upon realizing the man was not their resident, they telephoned the facility and informed the staff that they had their resident. The resident did not have on a wander bracelet. Upon resident #1's admission to the facility on Friday, 12/01/17 at 5:30 PM, an admission nursing assessment and data collection was conducted. A review of the assessment included that he was at risk for elopement and at risk for falls. The elopement risk evaluation section of the admission data collection noted that he was cognitively impaired with poor decision making skills, wandered obliviously to safety needs, demonstrated exit-seeking behavior, and had the ability to exit the facility. The elopement risk evaluation deemed him to be at risk for elopement. The falls risk evaluation section of the data collection revealed that he was at risk for falls. He ambulated with a walker, had gait balance problems while standing and while waking, had three or more falls in the past three months prior to coming to the facility, and received medications that placed him at risk for falls. The admission nurse documented in the 12/01/17 admission assessment that resident had attempted to elope on the night of his admission as follows: (Resident) trying to excape (escape) from the facility given medications in bed resting There was no documented evidence that the physician was notified of the resident's attempts to elope and no documented interventions to reduce the resident's attempts of elopement. On Saturday, 12/02/17 at 11:04 PM, a nurse's note for resident #1 revealed that he continued to have the following exit seeking behaviors: Patient alert with confusion Patient refers wants to go out There was no documented evidence that the physician was notified or any evidence that interventions were put into place for resident #1 to reduce the risk of elopement. The 24-hour nurses' report for the same time frame, 12/02/17 on the 3-11 PM shift, continued to note concerns regarding resident #1's potential elopement risk: Need (wander bracelet) confused. There continued to be no documented evidence that the physician had been notified of the residents attempts to elope and no documented evidence that interventions were put into place to prevent the resident from eloping from the facility. On Monday, 12/04/17 at 10:15 PM, a nurse's note read, This client (resident) eloped this shift from this facility, he was located across the street at the (adjacent nursing home). Client was escorted back to this facility by staff. Complete assessment was done of this client. No apparent injuries present, he is confused and requesting to go back to (island country of origin). He was determined to be a high elopement risk, was placed on the elopement risk assessment book, (wander bracelet) was placed on his right ankle, family, and Dr. (physician) notified. The 24-hour report, dated 12/04/17 for the 3-11 PM shift, read, Patient without (wander bracelet), escape of facility and arrived at front facility across street. Despite documented evidence that resident #1 was an elopement risk at admission on 12/01/17, and had exhibited elopement behaviors since his admission up until the day he eloped on 12/04/17, there was no documented evidence that any interventions had been put into place necessary to prevent the resident's elopement. The director of clinical services (DCS) was interviewed on 4/10/18 at 10:55 AM, regarding resident #1's elopement. She validated that the resident had eloped on 12/04/17, three (3) days after his admission. She validated that he had not been issued a wander bracelet prior to his elopement. She stated that a wander bracelet should have been placed on him the night of his admission, 12/1/17, when he was assessed to be at risk for elopement and had attempted to leave the facility. She could not give a reason as to why elopement interventions, including the wander bracelet, had not been implemented for the resident at that time. The DCS stated that resident #1 was discovered missing when a family member from the adjacent nursing home located across the street (three lane street) had seen an elderly male standing by the bus stop at the intersection of the three lane street and a six lane busy highway beside the nursing home. The family member thought he looked like a resident. She stated that the adjacent nursing home facility staff were alerted by the family member. They went to the bus stop and brought resident #1 back to their nursing home facility. The DCS stated that the adjacent nursing home called to inquire if he was our resident, which he was. She stated that the resident most likely eloped through the front door of the facility. She said that a nurse had seen him sitting in the lobby prior to the incident so we are thinking he went out the front door. She stated that after his elopement, a cognition assessment was conducted and he was given a score of 6 which indicated severely impaired cognitive abilities. Multiple phone calls were made in an attempt to interview the admitting nurse of 12/01/17 and the nurse of 12/02/17 for the 3-11 PM shift. Neither worked during the week of the investigation and neither returned the phone calls. The nurse who worked the 3-11 PM shift on 12/04/17, the night of resident #1's elopement, no longer worked at the facility. On 4/09/18 at 1:30 PM, an interview was conducted with resident #1's psychologist. She conducted a consultation visit after his elopement. She stated that resident #1 was confused, especially to his location, thinking he was in his home country. She stated that his cognition varied and that she performed a mini mental examination in Spanish on 12/5/17. It revealed that he had moderate cognitive impairment. Review of the cognitive examination revealed that he had a score of 16 in a range of 10-20, which indicated moderate impairment. On 4/09/18 at 2 PM, a phone interview was conducted with the daughter of resident #1. She said that when her dad was admitted to the facility, he was confused. She said he became very confused in (his island homeland) after a recent hurricane and was not able to obtain his medications. She said that he had gone missing from his home. She said after this, she had brought her mother and father to here to live with her in (MONTH) (YEAR). She said that he knew his name and general time of day, but did not know where he was. She said that when he came to the facility, she spoke to the admission's person about his confusion. On 4/10/18 at 11:10 AM, the facility receptionist stated that the front door was not locked on the evening of resident #1's elopement. She stated that at that time, the front door locked automatically later in the evening, not sure of the time. She stated that she worked from 8:30 AM to 5:30 PM and then left for the day. She stated that there was no one present at the front desk watching or supervising the door when resident #1 eloped. On 4/10/18 at 11:20 AM, the maintenance director stated that during the time of resident #1's elopement on 12/04/18, the front door automatically locked at 8:30 PM and unlocked at 7:30 AM. He stated that this process failed because there was no supervision of residents going in and out of the front door for about three hours between the time the receptionist left at 5:30 PM and the time that the electronic lock kicked in at 8:30 PM. On 4/10/18 at 11:50 AM, registered nurse (RN) A stated she worked in the facility at the time of elopement. She received a phone call somewhere between 7:15 PM and 7:30 PM from the nursing home located across the street. She did not remember the name of the person calling, but that person asked if we had a resident by the name of resident #1 because he was at their facility. RN A said that the caller told her that a family member from the nursing home across the street had been on her way to the facility, saw the resident near the bus stop and notified their staff. RN A stated that she and RN B, who no longer worked at the facility, walked across the street and brought resident #1 back. She stated that resident #1 was calm and did not say anything. He was exhausted and was unsteady on his feet, and had a walker with him. RN A stated that she knew the front door was not locked at the time of his elopement because she and RN B went out the front door to retrieve the resident and then came back through the front door which was unlocked. A review of the resident's interim care plan on 4/10/18 at 12:45 PM with the minimum data set (MDS) coordinator validated that she had done them. The Baseline Care Plans were dated 12/02/17, and noted that the resident had a wander bracelet on his left ankle. This information was contradictory with the staff interviews and medical record documentation which indicated he did not have a wander bracelet until after his elopement on 12/04/17. The MDS coordinator stated that she had signed and dated the Baseline Care Plans as having been done on 12/02/17, but the date was an error on her part. She stated that she had not started or completed the Baseline Care Plans until 12/05/17, the day after resident #1's elopement. She validated that the resident did not have a wander bracelet in place on his left ankle prior to his elopement on 12/04/17. She said that when the resident eloped, she was new to her job and was learning her role. She validated that the Baseline Care Plans had not been completed within 48 hours of the resident's admission. She stated that normally the admission nurse initiates the Baseline Care Plans, but she had not done it. She validated there were no other elopement interventions documented in theBaseline Care Plans, such as supervision or activities. On 4/10/18 at 4:20 PM, certified nursing assistant (CNA) C, who had been assigned to care for resident #1 on the evening of his elopement, stated she saw the resident at approximately 6:30 PM when he was leaving the dining room. She did not see him after 6:30 PM, but then about 7:30 PM, as she was busy transporting and helping other residents in the dining room during that time. The CNA said that she was not aware that he wandered, because he did not have a wander bracelet. On 4/11/18 at 1:50 PM, CNA E stated that it was difficult to supervise all residents' whereabouts when there was no one at reception especially on the weekends. She said when the door was not locked, anyone could come in or leave the facility. On 4/11/18 at 2:15 PM, CNA H revealed that she had 3 residents with wander bracelets. She stated that it was impossible to monitor residents at all times as the doors were not locked and no one was at the front desk to supervise. She said, We try to see all residents every half hour but you can't do it if you are busy in the shower or in the dining room. On 4/12/18 at 10:50 AM, CNA D said that on resident #1's first night in the facility, he was confused and tried to exit the building. She heard that other CNAs were rotated hourly to provide one-to-one (1:1) supervision for the resident as he was exit seeking. A review of the 24-hour nursing report and medical record did not reveal any documented evidence to support that 1:1 supervision had been provided to resident #1. On 4/12/18 at 4 PM, an interview with the administrator, regional director of clinical services, and clinical quality specialist was conducted. They stated that the Clinical Guideline for Elopement was the facility's elopement policy and procedure. They stated that the facility had not sufficiently followed the elopement clinical guideline to appropriately identify and plan interventions to reduce the risk and/or prevent resident #1's elopement from the facility. They stated appropriate initial interventions would have included 1:1 supervision and/or a wander bracelet for a resident who was at risk for elopement. On 4/12/18 at 7:15 PM, the resident's daughter stated that she was told her father did not have his walker with him when he left the facility. This was contradictory to RN A's statement. RN A stated that the resident had his walker with him. According to admission notes, dated 11/30/17, the resident would forget to use his walker. On 4/12/18 at 8 PM, resident #1's physician and facility medical director stated that he had not been made aware of the resident's elopement risks until after his elopement. Review of the facility's Clinical Guideline for Elopement, revised on 11/23/16, included the following: The Center is to evaluate and identify residents that are at risk for elopement and develop interventions to mitigate risk. The process to identify and put interventions in place to reduce the risk of elopement included: Residents to be evaluated on admission/ readmission If a resident is identified as being at risk complete an elopement risk alert and obtain a full body photograph. Initiate interventions to mitigate risk of elopement. If utilizing wander monitoring system device, check placement of the device every shift and function every day. Document individualized intervention in the resident care plan and kardex Past Non-Compliance at the Immediate Jeopardy level was identified as occurring on 12/04/17 and removed as of 1/03/18. The facility had initiated a 4-point action plan beginning on 12/04/17. Upon return to the facility the resident was placed on 1:1 supervision until assessed by the interdisciplinary team and a wander bracelet was applied. He had a Brief Interview for Mental Status completed; Psychosocial monitoring was implemented as part of the skilled charting. The physician was notified and a Psychiatric consultation was ordered. - All residents had an elopement risk evaluation completed. - Residents with wander bracelets were checked to ensure proper functioning, placement and ensured that physician orders [REDACTED]. The checks were documented on the medication and treatment administration records. - A process was in place for a restorative CNA to check all wander bracelets each morning including weekends. - Elopement binders with resident pictures and information were reviewed, updated and accessible at all nursing stations and entrances. - Care plans and kardexes were reviewed and updated for residents identified at risk for elopement. - Elopement drills were being done on each shift once monthly. - The front door was manned by a receptionist from 8:30 AM until 5:30 PM on weekdays and from 10 AM until 2 PM on weekends. The receptionists were responsible for unlocking the front door when they arrived in the morning and for locking the door when they left work. The manager on duty was responsible for double-checking to ensure the door was locked. The receptionist monitored all persons going in and out of the facility. - The front door locked when a resident with a wander bracelet was within range. All other egress doors had 15-second delays and had alarms attached to the doors. If the doors were opened, an ear piercing sound emitted alerting the staff. The maintenance director monitored the doors daily to ensure proper functioning. - All staff were educated about the Elopement/Wandering Risk Clinical Guidelines, Elopement Risk Binders, and Elopement Drill Procedures. Staff understanding of the education was monitored using a post-test. Current staff were not allowed to work until education was provided. All staff were educated by 1/03/18. Newly hired staff were provided education regarding Elopement/Wandering and Missing Resident Guidelines at orientation. - It was noted on the 4-point plan that the Administrator and Interdisciplinary Team completed a root cause analysis and an Ad Hoc QAPI (Quality Assurance/Performance Improvement) meeting was held prior to 1/03/18 although the current administrator could not locate the documentation. - The DCS/designee was monitored staff education, elopement risk evaluations, and wandering bracelet function at the morning meetings. Findings were reviewed at the monthly QAPI meetings.

Based on interview and record review, the facility failed to have sufficient staff to provide care and supervision for a resident identified as an elopement risk, allowing the resident to walk out of the facility's front door and walk to the intersection of a 6 lane busy highway. The facility staff did not have any knowledge of the resident's whereabouts until an adjacent nursing facility contacted them approximately an hour later informing them that they had found the resident at a bus stop. This failure resulted in subsequent past non-compliance at the Immediate Jeopardy level identified as occurring on 12/04/17 and removed as of 1/03/18. Findings: Cross Reference: F655, F689, F867. Resident #1 was an [AGE] year old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was Spanish speaking only. His primary mode of locomotion was a walker, which he often forgot to use. Upon admission assessment, he was noted to walk occasionally for short distances and had balance problems while standing and walking. He was assessed as an elopement risk as he demonstrated exit seeking behavior. The admission nursing assessment noted, patient is seeking to escape. He was assessed as a fall risk as he had 3 or more falls in the past 3 months at home. Three days after admission, on 12/04/17 at approximately 6:30 PM, the resident exited the facility via the front door that was not manned or locked. The sun had set at 5:29 PM on 12/04/17, an hour before the resident eloped. The resident was observed near a bus stop approximately 200 feet from the nursing home at the intersection of a 6 lane busy highway by a family member of an adjacent nursing home. It was unclear which route the resident followed and if he had attempted to cross the street. The family member reported to the staff of the adjacent nursing home that an elderly man was observed looking lost near the bus stop. The staff of the adjacent nursing home went to the bus stop and brought the resident back to their nursing home. Upon realizing the man was not their resident, they telephoned the facility and informed the staff that they had their resident. The resident did not have a wander bracelet on. Upon resident #1's admission to the facility on Friday, 12/01/17 at 5:30 PM, an admission nursing assessment and data collection showed that he was at risk for elopement and at risk for falls. The elopement risk evaluation section of the admission data collection noted that he was cognitively impaired with poor decision making skills, wandered obliviously to safety needs, demonstrated exit-seeking behavior, and had the ability to exit the facility. The falls risk evaluation section of the data collection revealed that he was at risk for falls. He ambulated with a walker, had gait balance problems while standing and while waking, had three or more falls in the past three months prior to coming to the facility, and received medications that placed him at risk for falls. On 4/10/18 at 11:10 AM, the receptionist noted that she had worked at the facility for 1.5 years. She stated that she worked weekdays from 8:30 AM until 5:30 PM. She said the front door was not locked at the time of the elopement. She stated that there was no one present at the front desk watching or supervising the door when resident #1 eloped. There is no one at the front desk before I come in or after I leave. She stated that the front door automatically locked at 8:30 PM and automatically unlocked at 7:30 AM. On weekends, the front desk was manned by a receptionist from 10 AM until 2 PM. She stated that the front door was unattended before 10 AM and after 2 PM on the weekends. On 4/10/18 at 11:20 AM, the maintenance director stated that during the time of resident #1's elopement on 12/04/17, the front door automatically locked at 8:30 PM and unlocked at 7:30 AM. He stated that this process failed because there was no supervision of residents going in and out of the front door for about three hours between the time the receptionist left at 5:30 PM and the time that the electronic lock kicked in at 8:30 PM. On 4/10/18 at 11:50 AM, registered nurse (RN) A noted that she had received the telephone call from the adjacent facility. She stated that she had stayed past her shift on 12/04/17 as she had unfinished work that she was completing. She had a busy day and stayed late when she received the telephone call between 7:15 PM and 7:30 PM from the adjacent facility informing her that they had resident #1 with them. She stated that she was not aware that he was missing. She said that she and RN B walked over to the other facility across a 3 lane highway and brought the resident back. She stated that the resident was calm, compliant and had no behaviors, was unsteady on his feet, and did not have a wander bracelet on. A statement by RN B on 12/04/17 read that he had last seen the resident at 4:50 PM when he administered medications and insulin to the resident. He did not see the resident again until almost 3 hours later, when he went to retrieve the resident from the adjacent nursing home. On 4/10/18 at 12:45 PM, the minimum data set (MDS) coordinator revealed that she had started her job as the MDS coordinator on 11/29/17, two days prior to resident #1's admission. She validated that the Baseline Care Plan which included interventions to prevent elopement, should have been done within 48 hours of the resident's admission. She said that typically the admission nurse initiated and/or completed the baseline care plan but it was not done. She did not know why the nurses did not initiate/complete the Baseline Care Plan for resident #1. On 4/10/18 at 3:45 PM, the director of clinical services (DCS) revealed that RN B was no longer employed at the facility. She did not know why assigned RN B did not observe the resident for almost 3 hours. She stated that the whereabouts of all residents should be observed every half hour. Multiple phone calls were made in an attempt to interview the admitting nurse of 12/01/17 and the nurse of 12/02/17 from the 3-11PM shift. Neither worked during the week of the investigation and neither returned the phone calls. On 4/10/18 at 4:20 PM, certified nursing assistant (CNA) C revealed that she was assigned to care for the resident during the 3-11 PM shift on the day the resident eloped. She stated that the resident was in his room at the start of the shift, and then he was escorted to the dining room for dinner at about 5:15 PM. She saw him last at approximately 6:30 PM when he left the dining room. She did not see where he went as she only saw him leave the dining room. She stated that she was not aware of his whereabouts until she was informed at 7:30 PM that he had exited the facility and had been seen at the bus stop at the 6 lane highway. She was not aware that the resident was an elopement risk as he did not have a wander bracelet on. She said she was busy with dining room duties and did not have time to ensure the resident would not exit the facility. She said, When we have dining room duty, we are in the dining room for an hour and half. She could not recall if she asked her co-worker to supervise her assigned residents while she was doing dining room duty. On 04/11/18 at 1:50 PM, CNA E stated that it was difficult to supervise all residents' whereabouts when there was no one at reception especially on the weekends. The door was not locked and anyone could come in or go out. On 4/11/18 at 2:15 PM, CNA H revealed that she had 3 residents with wander bracelets. She stated that it was impossible to monitor residents at all times as the doors were not locked and no one was at the front desk to supervise. We tried to see all residents every half hour but you couldn't do it if you were busy bathing a resident or in the dining room. On 4/12/18 at 10:50 AM, CNA D revealed that the resident had been very confused and exit seeking on the day of admission, 12/01/17. She was told that CNA staff had to be rotated hourly from their regularly assigned resident duties to provide one-to-one- (1:1) supervision for resident #1 during the night of his admission. She said they didn't have staff that could stay with the resident for 1:1 supervision so CNAs had to rotate hourly. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 12/04/17 and removed as of 1/03/18. The facility had initiated a 4-point action plan beginning on 12/04/18. Upon return to the facility the resident was placed on 1:1 supervision until assessed by the interdisciplinary team and a wander bracelet was applied. He had a Brief Interview for Mental Status completed; Psychosocial monitoring was implemented as part of the skilled charting. The physician was notified and a Psychiatric consultation was ordered. - All residents had an elopement risk evaluation completed. - Residents with wander bracelets were checked to ensure proper functioning, placement and ensured that physician orders [REDACTED]. The checks were documented on the medication and treatment administration records. - A process was in place for a restorative CNA to check all wander bracelets each morning including weekends. - Elopement binders with resident pictures and information were reviewed, updated and accessible at all nursing stations and entrances. - Care plans and kardexes were reviewed and updated for residents identified at risk for elopement. - Elopement drills were being done on each shift once monthly. - The front door was manned by a receptionist from 8:30 AM until 5:30 PM on weekdays and from 10 AM until 2 PM on weekends. The receptionists were responsible for unlocking the front door when they arrived in the morning and for locking the door when they left work. The manager on duty was responsible for double-checking to ensure the door was locked. The receptionist monitored all persons going in and out of the facility. - The front door locked when a resident with a wander bracelet was within range. All other egress doors had 15-second delays and had alarms attached to the doors. If the doors were opened, an ear piercing sound emitted alerting the staff. The maintenance director monitored the doors daily to ensure proper functioning. - All staff were educated about the Elopement/Wandering Risk Clinical Guidelines, Elopement Risk Binders, and Elopement Drill Procedures. Staff understanding of the education was monitored using a post-test. Current staff were not allowed to work until education was provided. All staff were educated by 1/03/18. Newly hired staff were provided education regarding Elopement/Wandering and Missing Resident Guidelines at orientation. - It was noted on the 4-point plan that the Administrator and Interdisciplinary Team completed a root cause analysis and an Ad Hoc QAPI (Quality Assurance/Performance Improvement) meeting was held prior to 1/03/18 although the current administrator could not locate the documentation. - The DCS/designee was monitored staff education, elopement risk evaluations, and wandering bracelet function at the morning meetings. Findings were reviewed at the monthly QAPI meetings.

Based on observation, interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for supervision of residents at risk for elopement. This resulted in the elopement of 1 of 7 residents and placed him at risk for potential serious injury/impairment/death (#1). The facility's QAA committee failed to identify quality deficiencies. They did not complete a thorough investigation to find the root cause of the elopement incident, and failed to evaluate and analyze the risk once an elopement and the potential for serious injury/impairment/death occurred. There was no system in place for the front door to be secured at all times to ensure residents at risk did not exit the facility unsupervised. The facility did not follow their process once a resident was identified at risk for elopement. The facility did not have an effective system in place to visualize and supervise all elopement risk residents throughout the shift. These failures resulted in the resident's elopement and subsequent past non-compliance at the Immediate Jeopardy level identified as occurring on 12/04/17 and removed as of 1/03/18. Findings: Cross reference to F689, F725, F655. The facility's guidelines for Resident Elopement, last revised on 11/23/2016 read, The Center to evaluate and identify residents that are at risk for elopement and develop interventions to mitigate risk. If a resident is identified as being at risk initiate interventions to mitigate risk of elopement, if utilizing wander monitoring system device check placement of the device every shift and functionality every day. Document individualized interventions in the resident care plan and kardex. Resident #1 was an [AGE] year old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was Spanish speaking only. His primary mode of locomotion was a walker, which he often forgot to use. Upon admission assessment, he was noted to walk occasionally for short distances and had balance problems while standing and walking. He was assessed as an elopement risk as he demonstrated exit seeking behavior. The admission nursing assessment noted, patient is seeking to escape. He was assessed as a fall risk as he had 3 or more falls in the past 3 months at home. Three days after admission, on 12/04/17 at approximately 6:30 PM, the resident exited the facility via the front door that was not manned or locked. The sun had set at 5:29 PM on 12/04/17. The resident was observed near a bus stop approximately 200 feet from the nursing home at the intersection of a 6 lane busy highway by a family member of an adjacent nursing home. It was unclear which route the resident followed and if he had attempted to cross the street. The family member reported to the staff of the adjacent nursing home that an elderly man was observed looking lost near the bus stop. The staff of the adjacent nursing home went to the bus stop and brought the resident back to their nursing home. Upon realizing the man was not their resident, they telephoned the facility and informed the staff that they had their resident. The resident did not have a wander bracelet on. On 4/10/18 at 10:55 AM, the director of clinical services (DCS) revealed that the resident was identified at risk for elopement as he was attempting to exit seek at admission on 12/01/17. She stated that a wander bracelet should have been applied at that time. She could not provide any insight as to why the admitting nurse did not apply the wander bracelet. She stated that the facility's front door was not manned or locked at the time of the elopement. She stated that the front door of the facility was manned by a reception from 8:30 AM until 5:30 PM during weekdays. On the weekend, the door was manned by receptionist from 10 AM until 2 PM. The front door was set to unlock at 7:30 AM and lock at 8:30 PM. She stated that the front door would lock automatically when a resident with a wander bracelet came near the door. She could not provide an answer when asked how residents, who either had not been identified as potential for elopement, who may remove their wander bracelet or had a malfunction with the wander bracelet, would be prevented from exiting the facility. When the DCS was asked how the residents at risk for elopement were supervised, she stated that every resident was to be observed every half hour as this was the facility protocol. She stated that it was not in their policy but it was the expectation of the facility. She was informed that the certified nursing assistant (CNA) who was caring for the resident during the evening of the incident was on dining room duty and had stated that she was in the dining room for 1.5 hours and had lost sight of the resident for more than an hour. The DCS stated that the expectation was for CNAs to ask their co-workers to cover for them when away from the residents during breaks and dining room duties. She stated that she was not aware if this occurred on 12/4/17 when resident A's CNA was doing dining room duties. On 4/10/18 at 11:50 AM, registered nurse (RN) A noted that she had received the telephone call from the adjacent facility. She stated that she worked on 12/04/17 when she received the telephone call between 7:15 PM and 7:30 PM from the adjacent facility informing her that they had resident #1 with them. She said that she and another nurse walked over to the other facility and brought the resident back. She said that he was unsteady when walking but had his walker with him. She said, We brought the resident back via the front door and it was not locked. A wander bracelet was applied when he returned to the facility. On 4/10/18 at 1:20 PM, the DCS and administrator revealed that although they identified the elopement incident of 12/04/17 as a serious event, they did not have an emergency QAA meeting following the incident. The monthly QAA meeting was held 10 days after the incident, on 12/14/17 but the elopement incident was not discussed. The elopement incident was first discussed 52 days later at the meeting held on 1/25/18. The administrator stated that she did not know why an emergency meeting was not held and why the incident was not discussed at the (MONTH) (YEAR) meeting. She said that she started her role as administrator only 2 days ago, 4/08/18. There were two interim administrators prior to her assuming the role but she could not find any evidence of discussions of the incident until the (MONTH) 25, (YEAR) meeting. The DCS stated that a 4-point plan had been started immediately after the incident occurred. Although a formal meeting was not held, she stated that members of the QAA committee held informal meetings. She stated that the medical director was kept abreast of the plan during his visits to the facility. She however could not provide the dates of the informal meetings. She stated that a root cause analysis of the incident had been done which included failure to implement a wander bracelet and not having a secure environment. When the DCS was questioned as to why the resident was attempting to exit the facility and where he was going, she stated that she had completed interviews with the resident and family members that she would present. On 4/11/2018 at 1:30 PM, the administrator related that the DCS was no longer working at the facility. She stated that she could not locate the root cause analysis of the incident. A telephone interview with the medical director on 4/12/18 at 8 PM indicated that he did not recall being made aware of resident #1's elopement. He stated that an emergency QAA meeting was not held and he did not recall any plans to correct the occurrence. The medical director telephoned back on 4/12/18 at 8:15 PM and stated that he had been informed of the resident's elopement. He stated that although the incident was not discussed at the (MONTH) (YEAR) QAA meeting, he did remember having conversations of the 4-point plan. He stated that the 4-point plan was discussed at the (MONTH) (YEAR) meeting. The facility had addressed all the issues related to the elopement, and had implemented all measures on the 4-point plan and was monitoring the effectiveness of the measures. Elopement is a serious issue and should be addressed as soon as possible during QAA meetings. The facility had an at risk [AGE] year old resident who exited the facility on 12/04/17 in the dark at 6:30 PM. Although his exact route was not known, he walked approximately 200 feet toward the intersection of a busy 6 lane highway. He may have potentially walked over uneven grassy areas and crossed the highways. The resident was observed by a family member of an adjacent nursing facility about 30-45 minutes later who alerted staff that an elderly man resembling a resident looked lost near the bus station at the busy 6-lane highway. The QAA committee failed to fully investigate the elopement incident. They did not identify the root cause of the elopement as they focused on the incident rather than the elopement as a whole. They did not identify the failures in their systems for preventing elopement. There was no individualized interim care plan that outlined preventative measures, supervision, or approaches to minimize elopement. The facility did not follow their protocol for supervision of residents. The facility's doors were not secure to maintain a safe environment for residents at risk or for potential risk of elopement. Past Non-Compliance at the Immediate Jeopardy level was identified as occurring on 12/04/17 and removed as of 1/03/18. The facility had initiated a 4-point action plan beginning on 12/04/17. Upon return to the facility the resident was placed on one-to-one (1:1) supervision until assessed by the interdisciplinary team and a wander bracelet was applied. He had a Brief Interview for Mental Status completed; Psychosocial monitoring was implemented as part of the skilled charting. The physician was notified and a Psychiatric consultation was ordered. - All residents had an elopement risk evaluation completed. - Residents with wander bracelets were checked to ensure proper functioning, placement and ensured that physician orders [REDACTED]. The checks were documented on the medication and treatment administration records. - A process was in place for a restorative CNA to check all wander bracelets each morning including weekends. - Elopement binders with resident pictures and information were reviewed, updated and accessible at all nursing stations and entrances. - Care plans and kardexes were reviewed and updated for residents identified at risk for elopement. - Elopement drills were being done on each shift once monthly. - The front door was manned by a receptionist from 8:30 AM until 5:30 PM on weekdays and from 10 AM until 2 PM on weekends. The receptionists were responsible for unlocking the front door when they arrived in the morning and for locking the door when they left work. The manager on duty was responsible for double-checking to ensure the door was locked. The receptionist monitored all persons going in and out of the facility. - The front door locked when a resident with a wander bracelet was within range. All other egress doors had 15-second delays and had alarms attached to the doors. If the doors were opened, an ear piercing sound emitted alerting the staff. The maintenance director monitored the doors daily to ensure proper functioning. - All staff were educated about the Elopement/Wandering Risk Clinical Guidelines, Elopement Risk Binders, and Elopement Drill Procedures. Staff understanding of the education was monitored using a post-test. Current staff were not allowed to work until education was provided. All staff were educated by 1/03/18. Newly hired staff were provided education regarding Elopement/Wandering and Missing Resident Guidelines at orientation. - It was noted on the 4-point plan that the Administrator and Interdisciplinary Team completed a root cause analysis and an Ad Hoc QAPI meeting was held prior to 1/03/18 although the current administrator could not locate the documentation. - The DCS/designee was monitored staff education, elopement risk evaluations, and wandering bracelet function at the morning meetings. Findings were reviewed at the monthly QAPI meetings.