Every finding on record at Aviata at Oakfield

Based on observations, record review and interviews, the facility failed to ensure resident accessible water temperatures were maintained at safe and comfortable levels, not to exceed the required temperature of 105 - 115 degrees Fahrenheit (F) in two units (100,300) of three units, affecting three rooms (204, 315 and 113). Findings included: On 4/13/2026 at 9:10 a.m. during an initial tour of resident rooms revealed water flow temperatures too hot to hold the back of the hand under in the resident bathroom sinks in rooms [ROOM NUMBER].On 4/13/2026 at 11:00 a.m. during an interview with the Director of Maintenance (DOM), he stated he had been the DOM at the facility for four months and did not have an audit plan to include water temperature testing at individual resident room sinks. He stated he sets the facility's water heaters at a certain temperature and will read the flow temperature from that specific heater. The DOM stated the water heaters are set at around 110 - 115 degrees. He was not sure how many water heaters there were in the building but confirmed there were at least three for the resident rooms and shower rooms as well as separate water heater booster for the kitchen and laundry room. The DOM was not sure what those water heaters/booster temperature were set at. The DOM confirmed he did not have any documented evidence of testing hot water temperatures in each resident rooms and stated he did not know that was something he needed to do. During the tour and interview, the DOM conducted water temperature tests for several resident rooms that were in question. He used a digital thermal infrared thermometer and revealed he did not need to calibrate it, as it was battery powered. He said he was not sure there were ways to calibrate the device, but clarified it reads correctly, when in use. On 4/13/2026 at 11:09 a.m. the DOM tested the water temperature in resident room [ROOM NUMBER]'s bathroom sink. After he turned on the hot water and let it run for approximately two minutes, he was observed to cup his hand and let the water flow run through it. The DOM then pointed the thermometer at his cupped hand and began the reading. The thermometer read out screen reached 121 degrees F. On 4/13/2026 at 11:11 a.m. the DOM went into resident room [ROOM NUMBER] and tested the hot water. He turned on the hot water and let it flow for approximately two minutes and then cupped his hand to let the water flow in it. The thermometer read out screen read 121 degrees F. On 4/13/2026 at 11:13 a.m. the DOM went into resident room [ROOM NUMBER] and did the same water temperature demonstration and he was not able to hold his hand under the water flow for a short period of time. He pointed the thermometer at the water flow, and the read-out screen read 124 degrees F. On 4/13/2026 at 12:33 p.m. the DOM went into resident room [ROOM NUMBER] and did the same water temperature demonstration. The hot water temperature reached 121 degrees F. On 4/13/2026 at the DOM stated he was not sure why the temperatures were so high as the water heaters were set at 111 - 115 degrees F. He confirmed the temperatures should not be that high if the water heater is not even set that high. The DOM revealed an outside plumbing service has been out at the facility recently to do some plumbing work but was not sure exactly what they were doing or did. The DOM stated he would have to get with the Nursing Home Administrator to see what type of work they did. On 4/13/2026 at11:19 a.m. the DOM provided a tour of where the water heaters were stored, which was in the back and side of the facility. The DOM opened a door out on the side of the building, which housed a bank of large water heaters. The water heater on the left side of the room was observed with an external water temperature thermometer gauge. It read 111 degrees F. The second water heater on the right side of the room thermometer gauge read 112 degrees F. The DOM confirmed where the water heater temperatures were reading, that it was the normal setting. He was asked if there were any other water heaters and he expressed there was one water heater and booster that was dedicated for laundry room and kitchen. He confirmed the water from that heater does not go to resident rooms or resident spaces. On 4/13/2026 at 3:00 p.m. the DOM followed up to state he forgot about another bank of water heater tanks, which were in a locked space in the facility's main enclosed courtyard. He stated he had just looked at the thermometer gauge, and it read 127 degrees F. He did not remember this water heater before and had just remembered it. The water heater was then confirmed to read water temperature held at 127 degrees F. The DOM confirmed the water from this heater does flow to resident spaces to include community shower rooms and resident room bathroom sinks. He did not have a temperature log for this specific water heater. The DOM did not know why it was set to 127 degrees F. and needed to be set at around 111 - 115 degrees F. On 4/14/2026 at 11:00 a.m. an interview with the Nursing Home Administrator (NHA) revealed the facility has been having plumbing issues and needed parts to help regulate the temperature in one of the water heaters. The NHA provided a plumbing service work order dated 4/13/2026, which was after errant water temperatures were identified by the surveyor. The NHA did not have any plumbing services work orders for review, prior to 4/13/2026. The NHA was not sure why there were water heaters set at 127 degrees F. and confirmed they should not have been set that high. The NHA confirmed she did have a newer director of maintenance and was currently short on maintenance staff. The NHA said individual resident room bathroom sink and shower room water temperatures should have been audited and documented. The NHA was not able to provide any type of evidence this had been conducted for the last three months as requested. The NHA stated the facility had not had any complaints from residents, nor have they had any events of residents being burned by hot water. On 4/16/2026 at 4:00 p.m. the Nursing Home Administrator provided the facility's policy and procedure titled, Monitoring and Recording Facility Hot Water Temperatures for Resident Rooms, Common Areas, and Shower Rooms effective date 11/30/2014.The policy showed; To maintain and control hot water temperatures within the facility to federal and state standards. Hot water temperatures will be maintained to an acceptable level for the safety of the resident and staff.The Procedure section of the policy revealed;1. Hot Water temperatures will be checked daily within the facility by the Maintenance and/or management staff and document on the Facility Water Temperature log. Resident rooms, Shower rooms, and Common areas must be below state requirements.2. The following procedures will be utilized when monitoring hot water temperatures. a. All temperature checks for hot water temperatures must be done utilizing a Dial Stem Thermometer. Infrared and digital thermometers are not to be used. b. Prior to monitoring [NAME] water temperature, all Dial Stem Thermometers must be calibrated. The preferred method to calibrate is the use of ice water in a cup, but placing the thermometer into the ice water and adjusting the needle to 32 degrees F. or 0 degrees C.c. Once the thermometer has been calibrated, select a resident room at the beginning of each corridor.1. Let the hot water run from the faucet for 3 to 5 minutes. 2 . Insert the stem at an angle, about 2 inches into the stream of running water where as much of the stem is in the water flow as possible. 3 . The temperature should register on the thermometer in about 10 to 15 seconds. Record temperature onto temperature log.1. The following procedures will be implemented, by the Maintenance staff, if a hot water temperature is found to be above 110 degrees F., the acceptable level for resident rooms, showers, and common areas: (If high temperature is found on the weekend or holidays, immediately call maintenance staff).a. If water temperatures are above maximum degree requirements in resident rooms, common areas, or shower rooms, immediately turn off the hot water to these areas and adjust the hot water mixing valve. Immediately notify the E.D., DCS, and staff of effected area where hot water is turned off. Follow Lock Out/Tag Out procedure for turning off hot water at the source.

Based on observations, interviews and record review the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and 16 errors were identified for three resident (#6, 138 and 95) out of seven residents observed. These errors constituted a 38.1% medication error rate.Findings included: On 4/15/2026 at 8:26 a.m., during medication administration for Resident #95, an observation was made of Staff D, Registered Nurse (RN) who pulled the following medications: Ipratropium bromide and albuterol 0.5mg/3 ml (milligrams /milliliters ) and Budesonide 0.25mg/2 ml. Staff D, RN stated for Resident #95 she normally saves her for last because she has at times refused her medications and stated she had two nebulizer medications to give. Resident #95 was amiable for her medications. An observation was made of Staff D, RN opening both plastic tubes each containing the two separate nebulizer medications, pour the medications into the nebulizer vial, connect the vial containing both nebulizer medications to a face mask, hooked the tube to the nebulizer machine, turn the machine on and placed the mask over the resident's face to begin the administration of the medications. An interview was conducted with Staff D, RN, regarding the administration of both medications at once. Staff D, RN stated she combined the two medications to save time and did not think there was a policy or contraindication not to combine the medications. An observation was made of the Staff D, RN removing the facemask, washing the mask and nebulizer and left to air dry. Resident D, RN did not rinse Resident #95's mouth with water after the treatment. On 4/15/2026 at 9:31 a.m., during medication administration for Resident #138 an observation was made of Staff E, Licensed Practical Nurse (LPN) who pulled the following medications: Venlafaxine ER 150 mg one tablet, Empagliflozin 25 mg one tablet, and acetaminophen 325 mg two tablets. An observation was made of Staff E, LPN crushing all three medications together and pouring the crushed pills together in one medicine cup. An observation was made of Staff E, LPN adding water to the medicine cup to dissolve the medications. Staff E, LPN paused Resident #138's enteral pump, disconnected enteral tube connected to Resident #138, checked for residual, connected a large syringe to the gastrostomy tube and added water as an initial flush. Staff E, LPN was observed pouring the medication cup with the crushed dissolved medications into the syringe connected to the gastrostomy tube. Staff E, LPN allowed the medication to flow via gravity with an observation made of a large number of remaining medications in the medicine cup. Staff, E, LPN added more water and repeated the cycle four to five times until the medicine cup was empty. An interview was conducted with Staff E, LPN regarding adding all crushed medication at once. Staff E stated she was told it was okay to crush all medications together. Staff E, LPN, stated she did not administer Resident #138's prescribed medication Nerlynx yesterday or today because it was not available. She stated she called the pharmacy yesterday for a delivery and she will call today. Staff E called over Staff C, LPN/Unit Manager (UM), to inform him of the missing medication Nerlynx. Staff E was instructed by Staff C LPN/UM to notify the physician and said he would follow up with pharmacy.On 4/16/2026 at 9:35 a.m., an interview was conducted with Staff G, RN who stated she did not realize Resident #6 was on an antibiotic because it was never discussed in morning report with the off coming nurse. On 4/16/2026 at 9:39 a.m., an observation was made of the Assistant Director of Nursing (ADON) providing an unidentified antibiotic to Staff G,RN while she was at her 100-hallway medication cart. Staff G paused administration to the 100 hallway and walked over to the 300-hallway medication cart to provide Resident #6 his medications, including his antibiotic. On 4/16/2026 at 9:41 a.m., during medication administration for Resident #6, an observation was made of Staff G, RN who pulled the following medications:Zince 50 mg one tablet, Senna 8.6 mg one tablet, Tamsulosin hydrochloride 0.4 mg two tablets, Potassium chloride 20 mEq (milliequivalents) one tablet, Folic acid one milligram one tablet, Gabapentin 300 mg two tablets, Buspirone hydrochloride 30 mg one tablet, Pantoprazole 40 mg one tablet, Metoprolol tartrate 25 mg one tablet, Lisinopril 5 mg one tablet, Ceftriaxone one gram in 100 ml of normal saline and Clopidogrel 75 mg one tablet.On 4/16/2026 at 9:48 a.m., Staff G, RN had requested an unidentified Certified Nurse Assistant (CNA) to assist her with obtaining a blood pressure for Resident #6. On 4/16/2026 at 9:53 a.m., an observation was made of an unidentified CNA wearing a gown and gloves in Resident #6's room and stated the blood pressure was 89/58. An observation was made of Staff G, RN requesting a manual cuff from the unidentified CNA. The CNA exited the room and Staff G, RN was observed flushing Resident #6's left midline with normal saline. Staff G, RN hung the bag of Ceftriaxone on an IV (intravenous) pole and flushed the IV tubing with the antibiotic. Staff G exited the room and requested another unidentified CNA to locate the unit manager to assist in locating a manual cuff. On 4/16/2026 at 10:08 a.m., an observation was made of Staff G, RN cleaning a manual cuff with a three-minute kill time antiseptic commercial wipe. At 10:11 a.m., Staff G, RN obtained a manual cuff blood pressure reading of 90/60 and informed the resident she would be holding his blood pressure medications this morning and she would inform his physician. An observation was made of Staff G, RN, informing the resident she would be back with his Plavix. At 10:14 a.m., Staff G, RN provided Resident #6 his medications and began his infusion of his antibiotic. At 10:20 a.m., blood pressure medication was wasted and Clopidogrel (Plavix )75 mg was pulled from the electronic medication dispenser machine. At 10:25 a.m., Clopidogrel 75 mg was administered.On 4/16/2026 at 10:30 a.m., an interview was conducted with Staff F, RN and Staff G, RN. Both nurses were assigned half the 300 hallway, and both admitted they had not started their medication administration for the 300 hallway. On 4/15/2026 at 11:41 a.m., a telephone interview was conducted with the facility's pharmacy consultant. The pharmacist stated Resident #138's Venlafaxine ER (extended release) should not have been crushed. The pharmacist stated for Resident #95, it is not best practice to combine the two medications for her nebulizer treatments. The pharmacist stated it is best to provide one at a time with a three-to-five-minute interval in between the medications. The pharmacist stated it is best to provide the medication first like the Albuterol followed by the medication with the steroid in it. On 4/16/2026 at 10:56 a.m., an interview was conducted with the Medical Director (MD) for the facility. The MD stated it would be best practice to separate the two medications for Resident #95's breathing treatments. The MD stated the Budesonide will get foamy in the chamber during the aerosolization of the medication, thus, the Albuterol may not get absorbed as it should. The MD stated best practice is to separate the two medications. The MD stated although Resident #138 was not her resident, the facility knows they can come to her for assistance with obtaining specialty medications. The MD stated she was unaware of assistance needed for Resident #138's Nerlynx and will have this issue of obtaining her medication, Nerlynx, resolved. The MD stated she was not sure if the medication could be crush but she will follow up with the specialty pharmacy to resolve the delayed medication. Review of a website literature search for the medication of Budesonide accessed on 4/16/2026 showed the following: https://www.drugs.com/pro/budesonide-inhalationsuspension.html#s-43685-7 5.1 In clinical trials with budesonide inhalation suspension, localized infections with Candida albicans occurred in the mouth and pharynx in some patients. The incidences of localized infections of Candida albicans were similar between the placebo and budesonide inhalation suspension treatment groups. If these infections develop, they may require treatment with appropriate local or systemic antifungal therapy and/or discontinuance of treatment with budesonide inhalation suspension. Patients should rinse the mouth after inhalation of budesonide inhalation suspension. 2.2 The effects of mixing budesonide inhalation suspension with other nebulizable medications have not been adequately assessed. Budesonide inhalation suspension should be administered separately in the nebulizer.On 4/16/2026 at 11:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON had stated the two medications to be delivered via nebulizer for Resident #95 should have been separated. The DON stated medications should not be crushed if they are an extended-release medication and medications crushed should be delivered separately unless there was an order to combine the crushed medications. The DON stated medications delivered at 10:00 a.m. would be considered late. The DON stated there is a window for medications, an hour before and/or one hour after the scheduled medication time would be acceptable. The DON was aware of the 300-hallways delay in medications.A review of the facility's policy and procedure titled, Medication-Oral Administration of, revision date 8/15/2019, showed the following procedure: Review physician's orders Review the MAR (Medication Administration Record) or EMAR (electronic Medication Administration Record) should there be any uncertainties verifying the MAR or EMAR with the physician's order sheets and seek clarification as indicated. Refer to pharmacist if unsure if a medication should be crushed.A review of the facility's policy and procedure titled, Medication-Administration Via Enteral Tube, revision date 3/06/2019, showed the following procedure: If not a liquid medication, and if able to be crushed, finally crush each medication with pill crusher or open capsules and pour powder into a medication cup with 5 to 15 cc (milliliters) of water and dissolve. If liquid, pour the correct amount per the physician order into a medication cup. There should be one medication per cup. DO NOT MIX MEDICATIONS unless there is a specific physician order to do so. Consistency of solution should be able to pass easily through a tube. NOTE: if medication cannot be crushed and is unavailable in liquid, notify physician. Pour one, individual liquefied medication in the syringe, and allow gravity to drain medication into the stomach. Followed by at least 15 cc (or physician order if different) of water in between each medication. NOTE: Keep the syringe partially filled to prevent excess air from entering the stomach.

Based on observation, record review and interview, the facility failed to ensure infection control policies and procedures were followed related to the use of PPE (Personal Protective Equipment) and Hand Hygiene (HH), for three residents (#16, #85 and #6) out of three residents sampled for contact precautions.Findings included: On 04/15/2026 at 11:07 AM, Staff M, Licensed Practical Nurse (LPN)/ Unit Manager (UM), was observed entering the room of Resident #16 without wearing any personal protection equipment (PPE). Staff M walked about three feet into Resident #16's room, assisted Resident #16 out of her room via wheelchair, and positioned the resident on the outside of the room door, across from the nurse's station. Staff M then went back into Resident #16's room to remove the bedside table and positioned the bedside table next to Resident #16 outside of the room. Staff M was observed not wearing any PPE. Staff M was not observed to perform hand hygiene prior to or after making contact with Resident #16's person or personal belongings. Record review for Resident #16 revealed an admission date of 3/3/2026 with medical diagnoses to include extended spectrum beta lactamase (ESBL), unspecified, resistance to multiple antibiotics, and unspecified Escherichia coli (E. Coli). Review of the summary report for Resident #16 dated 4/16/2026 revealed active orders for isolation type- enhancer barrier precautions for history of ESBL, wounds. Review of the care plan report for Resident #16 initiated on 2/16/2026, revealed a focus - Resident #16 required enhanced barrier precautions related to known Center for Disease Control (CDC) Multidrug-Resistant Organisms (MDROs) infection/colonization as evidence by ESBL/urine Clostridioides difficile (C. diff), wounds. Interventions included staff to wear enhanced barrier precaution personal protective equipment (PPE) when providing high contact direct care activities. The care plan report for Resident #16 also revealed a focus of having C. diff. Interventions included contact isolation: wear gowns and masks when changing contaminated linens. Place soiled linens in bags tightly before taking to laundry and disinfect equipment before it leaves the room. An interview was conducted with Staff M, LPN/UM, on 04/16/2026 at 4:02 PM. The interview revealed that Resident #16 was under contact precautions due to a diagnosis of C. diff. Staff M said staff should wash hands with soap and water prior to entering Resident #16's room and upon exiting the room. Staff M said this hand hygiene protocol should be followed any time staff enters the room because they may not be aware of what the resident has touched within the room. Staff M reported providing education to staff on infection control and prevention on 04/15/2026. Staff M reported monitoring infection prevention and control practices while staff is on the floor providing resident care, if protocol is observed not being followed appropriately, verbal education is provided to staff immediately. If there are further instances of not following appropriate infection prevention and control practices, then written education is provided to staff. An interview was conducted with Staff O, Certified Nursing Assistant (CNA), on 04/16/2026 at 2:51 PM. Staff O who was assigned to Resident #16 reported receiving education on infection prevention and infection control every other day. Staff O said the education included appropriate hand hygiene protocol, enhanced barrier precaution protocol, and contact precaution protocol. Education provided by facility management informed staff to perform hand hygiene prior to and after providing resident care in addition to putting on gloves and a gown before entering or leaving a resident's room when they are under contact precautions. An interview was conducted with Staff N, CNA on 04/16/026 at 3:01 PM. The interview revealed that Staff N received education during the previous week about infection prevention and control. Staff N said the education included appropriate hand hygiene protocol, enhanced barrier precaution protocol, and contact precaution protocol. Education provided by facility management informed staff to perform hand hygiene prior to and after providing resident care in addition to putting on gloves and a gown before entering or leaving a resident's room when they are under contact precautions. Staff N reported providing toileting and incontinence care for Resident #16 during previous shifts. On 4/13/2026 at 10:17 AM an observation was made of an unidentified Certified Nursing Assistant (CNA) entering Resident #85's room without a gown or gloves on. A Contact Precautions sign was observed outside of Resident #85's door. The unidentified CNA asked another CNA in the hallway for assistance with Resident #85. The other unidentified CNA was observed donning a gown and gloves prior to entering the room. An interview was conducted with the CNA entering the room who stated the CNA in the room should have donned a gown and gloves on. On 4/14/2026 at 12:55 PM an observation was made of an unidentified CNA entering Resident #85's room without a gown or gloves. The Director of Nursing (DON) observed the same observation and stated the CNA should be gowned and wear gloved upon entering the resident's room. The DON stated Resident #85 was new to Contact Isolation. On 4/16/2026 at 10:11 AM an observation was made of Staff G, Registered Nurse (RN) during medication administration. Staff G, RN entered Resident #6's room without donning a gown and gloves to administer the resident's intravenous medication on two separate occasions. Resident #6 had an Enhanced Barrier Precaution sign on his door. On 4/16/2026 at 1:20 PM an interview was conducted with Staff G, RN who agreed she should have worn a gown when administering Resident #6's intravenous antibiotic. A record review of Resident #85 's physician orders showed an order for Isolation type-Contact precautions for ESBL (Extended-Spectrum Beta Lactamase) /Urine, ordered 4/10/2026. A record review of Resident #6's physician orders showed an order for Isolation type-Enhanced Barrier Precautions for MRSA, foley catheter, Wound, every shift, ordered 4/03/2026, and an order for Enhanced Barrier Precautions- Midline every shift, ordered 4/16/2026. Review of a facility policy titled, Infection Prevention and Control Program, revised October 2018, revealed the elements of the invention prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. According to the policy, important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination (3) educating staff and enduring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and cough etiquette to visitors and family member; (5) enhancing screening for possible significant pathogens; (6) immunizing residents and staff to try to prevent illness; (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the CDC. Review of a facility policy titled, Policies and Procedure Subject: Enhanced Barrier Precautions, with an effective date of 09/01/2022 revealed enhanced barrier precautions (EBP) is used to reduce the spread of MDROs among residents by utilizing gloves and gowns for high contact resident care activities.

Based on observations, record reviews, and interviews, the facility failed to accommodate a resident's right to communicate in the language of their choice for one resident (#18) of one observed, and failed to provide a resident with a bed that met his height,comfort and furnishings requirements for one resident (#5) of one resident observed.Findings included: During a facility tour 04/14/2026 at 10:51 a.m., Resident #18 was observed in bed. The resident did not respond to the interview and was observed pointing and using hand gestures in an attempt to express themselves. A family member who was in the room stated the resident does not speak English and that they spoke Arabic language. During this observation, there were no signs posted to direct anyone on this resident's preferred communication method. Review of the admission Record revealed Resident #18 was admitted to the facility on date 4/26/2025, with diagnoses to include cerebral infarction due to thrombosis of right anterior cerebral artery, hemiparesis following cerebral infarction affecting left non-dominant side and difficulty in walking. Review of Resident #18's care plan date initiated 04/28/2025 and revised on 01/28/2026 showed he had an interpretation need related to primary language Arabic. The care plan goals showed Resident #18 will communicate via an interpreter, date initiated 04/28/2025, target date 05/27/2026. The care plan interventions showed Resident #18 has translation needs, (needs an interpreter), Dated initiated 04/28/2025. On 4/15/2026 at 11:15 a.m. an interview was conducted with Staff K, Certified Nursing Assistant, (CNA). Staff K said Resident #18 spoke Arabic. Staff K stated if a resident spoke a different language they try to understand them. Staff K said Resident #18 communicates through hand gestures because he did not understand English. Staff K stated he tried using a translation App (application), but it was not helping. On 4/15/2026 at 2:13 p.m. an interview was conducted with Staff E, Licensed Practical Nurse, (LPN/ Unit Manager. Staff E stated Resident #18 speaks Egyptian Arabic. The staff member said Resident #18, is a pointer and he uses gestures to express what he needs. The staff member said the resident understood English, but if it got to the point where he did not understand English, Staff E said they would call the language line. On 4/15/2026 at 10:29 a.m. an interview was conducted with Staff Q, CNA. This staff member said Resident #18 spoke Hindi. The staff member said there was no one at the facility who spoke his language. The Staff member did not identify how they could effectively communicate with Resident #18.On 4/15/2026 at 1:30 p.m. an interview with Staff H, LPN, was conducted. She stated the facility uses the communication line to communicate with residents who spoke a different language. During this observation and interview, the nurse was observed trying to call the communication line, but it was out of service. The nurse did not know how else to interpret for the resident. On 04/15/2026 at 1:42 p.m. an interview was conducted with Staff E, LPN/Unit manager. He stated they had two people that spoke a different language. He stated they use the [Name of communication company] line to communicate with the residents. Staff E stated that communication line was what the facility uses. Staff E confirmed the line was not operable at the time. On 04/15/2026 at 1:30 p.m. an interview was conducted with Staff E, LPN. She stated the facility uses a communication line. She stated she never had to use it because Resident #18 uses gestures when she communicates with him. On 04/15/2026 at 1:58 p.m. an interview was conducted with the Director of Nursing (DON). She stated usually they would coordinate with therapy to get a communication board to assist residents who spoke a different language. The DON said in addition, they had a translation line for staff to use to communicate with the residents who spoke a language other than English. The DON said their main source of communication was the communication line. She stated she was not aware the phone numbers to the communication line were not working. The DON said, This is the first time it has been brought to my attention that the communication language line in the facility is not working. Review of the facility policy titled, Language Access Plan, revised date 9/1/2023 showed Purpose, section 1557 is the nondiscrimination provision of the Affordable Care Act (ACA). The Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age, disability. Procedure: 4. Effective communication with Limited English Proficiency [LEP] individuals requires the Care Center to have language assistances services in place. The Care Center offers communication in the following forms: a. Oral communication: assistance service may come in the form of in-language communication (bilingual staff member communicating directly in an LEP person's language), or interpreting. 2. On 4/13/2026 at 8:50 a.m., 1:00 p.m., 4/14/2026 at 8:30 a.m., 2:00 p.m., 4/15/2026 at 8:50 a.m., 12:45 p.m., and on 4/16/2026 at 8:15 a.m. and 3:45 p.m., Resident #5 was observed in his room, lying in bed with his bed elevated approximately 25 – 35 degrees. He was noted during each observation covered with sheets and blanket, but with both of his legs and feet exposed and uncovered. Resident #5 was observed utilizing a large and wide bariatric bed. Resident #5 was observed tall in height and with both of his feet pressed up against the inside surface of the foot board. The foot board was extended out from the foot end of the mattress approximately six to seven inches, not leaving enough room for the resident to have his feet not pressing against the foot board. During an interview and observation with Resident #5 on 4/13/2026 at 8:50 a.m., he stated he was receiving Hospice services and that Hospice had provided him with this bed upon his request for a larger bed. Resident #5 stated he was in need for a longer mattress not a wider mattress. Resident #5 revealed he had spoken to various staff to include aides, nurses, social worker, and dietary staff that he needed another bed and the one he used was not long enough. Resident #5 was observed with wounds on both of his feet and ankles that were wrapped with dressings. On 4/15/2026 at 1:45 p.m. during an observation and interview, Resident #5 was in his room and lying visiting with a family member who stated they did not believe the bed was long enough. Resident #5's family member said she did not know why they provided him with such a wide bed, but not long enough. Resident #5's foot board was observed extended out from the end of the foot of the bed around one and half to two feet. the residents feet were pressed up against the surface of the foot board and turned towards the right side of the bed. Resident #5's head was positioned approximately less than eight inches from the end of the head of the bed. Resident #5 stated he did not feel right in such a wide bed and did not feel right with the bed not being long enough for his height. Resident #5 and the family member both felt the facility did not maintain his dignity as far as his bed size was concerned. On 4/14/2026 at 10:00 a.m. an interview with Staff A, LPN and Staff B, LPN who both had Resident #5 on their assignment, confirmed he had a large wide bed which was not long enough to meet his height comfort. Staff A stated confirmed both of his feet were pressing up against the foot board surface and stated he should have a longer bed. Staff A and B did not remember if Resident #5 and or the family member had asked for a longer bed. Staff A stated even though she did not remember Resident #5 complaining about the bed, this should have been something direct care staff should have caught and brought it up to the Director of Nursing (DON), or Nursing Home Administrator's (NHA) attention. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was his own decision maker. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Orthopedic aftercare, Low back pain, DMII (Diabetes Mellitus, II), Muscle wasting, Abnormalities of gait, and Anxiety. Review of the most current significant change Minimum Data Set (MDS) assessment dated [DATE] revealed; (Cognition/Brief Interview Mental Status (BIMS) score of 13 out of 15, which indicated Resident #5 was able to make his medical and daily decisions. On 4/16/2026 at 1:00 p.m. an interview with the NHA and the DON confirmed Resident #5 received Hospice services and when he was admitted to the facility, he had requested a larger bed. The NHA stated Hospice services replaced his bed with a bed from their agency, which was a much larger bed for him. She confirmed after observing this past week, Resident #5 had a wide bariatric bed. The NHA said they did not have a longer bed to meet his height and comfort needs. The DON confirmed they should have caught this and reached out to Hospice for a longer bed not a wider bed. The Nursing Home Administrator was requested to provide a policy and procedure related to bed size accommodation. A policy was not provided for review.

Based on observations, interviews and record review, the facility failed to notify the physician and family of a change in condition after a new skin condition was identified for one resident (#2) out of one resident observed.Findings included: Review of a Weekly Skin Integrity Assessment on 3/13/2026 and 3/19/2026 showed Resident #2 had bilateral lower arm bruises.Review of Progress Notes for Resident #2 did not show notification to family, physician, or the administration about the bilateral lower arm bruises found during the skin assessments on 3/13/2026 and 3/19/2026. Review of the Resident #2 information record dated 4/17/2026 showed Resident #2 was originally admitted [DATE] and readmitted on [DATE] with the diagnoses including Non-ST Elevation (NSTEMI) Myocardial Infarction, dementia, depression, post-traumatic stress disorder and chronic kidney disease.On 4/15/2026 at 2:41 p.m. an observation and interview were conducted with Staff E, Licensed Nurse Practitioner (LPN) about the discoloration on Resident #2's right forearm. Staff E stated they were not aware of this as they had been gone for the past month and it was their second day back. Staff E observed the discoloration and stated they did not know what the discoloration was, but they would review the facility's health information system. Staff E reviewed the record and upon becoming aware of the documented skin assessments completed on 3/13/2026 and 3/19/2026, Staff E, LPN stated they did not complete that assessment. On 04/16/2026 at 5:48 p.m. an interview was conducted with Staff C, LPN/ Unit manager. Staff C stated they did not hear or know about the discoloration on the Resident #2's arm until yesterday (04/15/2026). Staff C stated normally when a discoloration occurs, Staff C will note this in the system and the wound care nurse would examine it. Staff C stated discoloration was to be reported to the physician and family, and then enter the information into the health system, which would have triggered a change in condition. Staff C stated this would then be followed up by the unit manager to ensure treatments were put in place. Staff C stated Resident #2 tended to rub his arm on the bed rails often as this was a common behavior caused by frequent itchiness. Staff C could not find the documentation of this behavior in the care plan.On 4/16/2026 at approximately 10:00 a.m., an interview was conducted with the facility administration staff. They said the red discoloration on Resident #2's arms were from his behavior of rubbing his arms on the bed rail as the resident has chronic itchy skin and tends to self-inflict scratches. The administration did not provide a copy of the care plan with the stated behavior.Review of a facility policy and procedures titled Notification of Change in Condition, Revised 12/16/2020 showed a policy: The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition.Procedure:The nurse to notify the attending physician and Resident Representative when there is a(n):- Accidents- Significant change in the patient/resident's physical, mental, or psychosocial status- Notify the patient/resident and the resident representative of the change in condition.- Document notification in the medical record.- Document resident/patient change in condition on 24-Hour Report- Complete SBAR as indicated

Based on observation, interview and review of the facility's housekeeping procedures, the facility failed to ensure shower rooms were maintained in a sanitary manner in one shower room (Zone One East) out of two shower rooms observed.Findings included: On 04/16/2026 at 2:48 p.m., the shower room in zone one East wing was observed to have black biological growth on the grout in between the tiles on the shower walls in addition to the grout in between the tiles on the shower floors. The black biological grown observed was observed on the shower walls and the floor upon entrance into the shower in addition to the floor perpendicular to the wall afore mentioned. An interview was conducted on 04/16/2026 at 3:53 p.m. with the housekeeping/laundry manager. The interview revealed the housekeeping staff was responsible for maintaining the cleanliness and sanitization of the shower rooms throughout the facility. The housekeeping/laundry manager stated housekeeping staff disinfects shower equipment, maintains the cleanliness of the shower room walls and floors, and removes trash from the shower rooms. The housekeeping/ laundry manager described the process of cleaning shower rooms as follows: Housekeeping staff sweeps the floors of shower room, sprays disinfectant on the shower room walls, floors, and equipment, allows the disinfectant chemical to remain on all surfaces for a minimum of five minutes, and then removes the chemical from equipment and walls with a cloth. The manager stated the disinfectant is mopped from the floors of the shower room using the same disinfecting chemical. The housekeeping manager stated they were responsible for verifying the cleanliness and sanitization of each shower room every morning. The manager stated if errors were observed, housekeeping staff would be notified to remedy the errors. During a tour on 04/16/2026 at 3:56 p.m. the shower room in zone one east wing was observed with the housekeeping manager who confirmed the observation of black biological growth on the walls and floor of the shower room. The housekeeping manager was uncertain of the department responsible for ensuring there was no biological growth in the shower room but believed it may have been the responsibility of the maintenance department.On 04/16/2026 at 4:10 p.m. an interview and observation was conducted with the Director of Maintenance (DOM) revealing housekeeping staff were responsible for maintaining the cleanliness and sanitization of the shower rooms. The DOM observed the black biological growth in the shower room and said the growth should be cleaned and removed by housekeeping.Review of a facility policy titled, Restroom Cleaning, revised 2/1/2025 revealed [name of contracted provider] is committed to Providing a safe clean and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry-based practices. Walls are generally considered low touch surfaces. Wall washing frequency will vary depending on the location (common areas, residents/patient care areas, isolation rooms). Between scheduled cleanings, walls will be spot cleaned when they are visibly soiledReview of a facility document revised 1/2/2026, titled, Job classification - Housekeeping -1, revealed a daily work assignment showing the following expectations:Clean the soiled/Clean Utility Linen & Shower Room following the 5-step method of cleaning. The 5 Step Method of cleaning showed:1) empty trash, 2) disinfect horizontal surfaces, 3) spot clean vertical surfaces 4) dust mop floor, 5) damp mop floor. (Photographic Evidence Obtained)

Based on interview, records and policy review, the facility failed to ensure the level I Preadmission Screening and Resident Reviews (PASRRs) were completed accurately for two residents (#17 and #18) out of eight residents sampled.Findings included:Review of an admission Record dated 4/16/2026 revealed Resident #17 was admitted to the facility originally on 12/18/2025 with diagnoses to include but not limited to bipolar disorder, unspecified, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode manic without psychotic features, and Parkinson's disease.Review of Resident #17's level I PASRR dated 12/17/2025, showed under screening decision making in section A only bipolar disorder was checked and no other mental illnesses were checked. The review showed the level I PASRR was incomplete, and a level II was not submitted for consideration.Review of an admission Record dated 04/15/2026 revealed Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, other specified anxiety disorders, and primary insomnia.Review of Resident #18's level I PASRR with no date showed in section A, a blank PASRR and there were no mental illnesses checked. The review showed the level I PASRR was incomplete, and a level II was not submitted for consideration.On 04/15/2026 at 5:45 p.m. an interview was conducted with the Social Services Director (SSD). She stated she had worked at the facility since June of 2025. She stated she does not complete Preadmission Screening and Resident Reviews (PASRRs), because she does not have a master's degree in social work. The SSD stated the PASRRs are completed by a Registered Nurse. She stated when the new admissions comes, their PASRRs are evaluated by the admission team. The PASRR is placed on the chart. She stated she looks at the PASRR to see what diagnoses the resident have at the time, then if there is any discrepancy, she would notify the Interdisciplinary team (IDT) that the PASRR need to be updated. She stated Resident #17's and #18's Level I PASRRs were incorrect and should have been updated to reflect their mental health diagnoses. She stated she did not review the two resident's PASRRs and had not notified the IDT team that their PASRR's needed to be updated. On 04/16/2025 at 10:00 a.m. an interview was conducted with the Director of Nurses, DON. The DON stated she expects all level I PASRR to be reviewed, updated and completed accurately by the Interdisciplinary team. Review of a policy titled Preadmission Screening and Resident Review (PASRR) revision date 11/08/2021 showed - Policy: The center will assure that all Serious Mental ( SMI) and intellectually Disable ( ID) residents receive appropriate pre-admission screening according to Federal/ State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 7. Social Services will be responsible for coordinating significant change updates of these screenings conducted by the appropriate agency. These results, along with the results from previous years will be kept in the appropriate sections of the resident's records.

Based on observations, record review and interviews, the facility failed to implement the care plan related to fall interventions for one residents (#16) of two observed and failed to follow the resident's care plan for protective heel boots for one resident (#108) of one observed. Findings included: 1. On 4/13/2026 at 10:37 a.m. Resident #16 was observed in her room lying flat in bed. She was noted with fall floor mats on either side of her bed. The fall floor mat on the right side of the bed was observed in a folded position and positioned against the wall, away from the bed. Further observations revealed the call light was placed on the back left side of the pillow, out from her reach. Resident #16 confirmed she would not be able to reach her call light should she need it. The same observations were made on 4/14/2026 at 1:24 p.m. and on 4/16/2026 at 9:03 a.m. On 4/13/2026 at 10:40 a.m. an interview and observation with Staff B, Certified Nursing Assistant (CNA) confirmed Resident #16 was in bed and lying on her side and with the call light placed on her upper pillow, and above her head. Staff B confirmed Resident #16 would not be able to reach the call light if she needed to use it. Resident #16 was asked if she knew where her call light was and she attempted to reach around for it and then gave up. She said, don't know. Staff B stated all residents are to have call lights placed within their reach while in bed no matter if they were able to use them or not. Staff B, CNA confirmed the fall floor mat on the right side of the bed was folded and not placed appropriately at bedside. She was not sure what the resident's needs were with relation to the fall floor mats. Staff B stated she believed if a resident had fall floor mats in the room, they needed to be placed on the floor at bedside and not off to the side of the room. On 4/14/2026 at 10:00 a.m. an interview was conducted with a Licensed Practical Nurse (LPN), Staff A, who confirmed Resident #16 was in her room and lying in bed. Staff A observed and confirmed Resident #16 could not reach her call light/call light cord, as it was out from her reach and hanging over the back of her bed. Staff A revealed as far as she knew, Resident #16 used the call light and stated even if she did not, the call light is to be placed within her reach, while in bed. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to age related Osteoporosis, Unspecified fracture of the lower end of right radius, Muscle wasting, Abnormalities of gait, Cognitive communication deficit, History of falls, Anxiety, Major depression.Review of the most current Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed; (Cognition/Brief Interview Mental Status (BIMS) score of 9 out of 15, meaning the resident was moderately impaired. Review of the current care plans with a next review date 6/2/2026 revealed the following but not limited to: Resident has had multiple falls and an actual fall with a fracture, with interventions to include but not limited to: Keep the bed in low position, Bilateral floor mats. Resident is at risk related to confusion, gait/balance problems, unaware of safety need, with interventions to include but not limited to: Be sure the resident's call light is within reach and encourage the resident to use it. On 4/16/2026 at 1:00 p.m. an interview with both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed Resident #16 is able to use her call light and should always have her call light placed within her reach while she is in bed. Both were not aware of her having any behaviors in the past of her removing the light/cord from her reach. They also confirmed she does utilize fall floor mats on both sides of the bed and when she is in bed and stated the mats should be appropriately placed on either side of the bed. 2. On 04/13/2026 at 11:13 a.m., and 12:49 p.m., and on 04/14/2026 at 11:07 a.m., and 4:14 p.m., and on 04/15/2026 at 11:23 a.m., Resident #108 was observed in bed with no heel boots on. Resident #108 heel boots were inside the closet. Review of Resident #108's medical record revealed an admission date of 8/23/2015 with diagnoses to include adjustment disorder with mixed anxiety and depressed mood, muscle weakness (Generalized), foot drop - left foot, right foot. Review of Resident #108's Care Plan Report, date initiated: 11/17/2018, Revision dated 01/08/2025 showed the focus Resident #108 ADL (Activity of living) self-care performance deficit r/t (related to) previous CVA (cerebrovascular accident) with left sided weakness, impaired cognition, impaired communication and foot drop. Assistance needed with all ADL's. The goal showed Resident #108 will maintain current level of function through the review date. Interventions included: -Don/Doff bilateral ankle flexion boots for contracture management as ordered, Date initiated: 09/06/2023 On 04/15/2026 at 1:01 p.m., an interview was conducted with Staff P, CNA. She stated Resident #108 was to have boots on for two to three hours a day. Staff P stated the physical therapist (PT) said the resident was not on caseload and needed to check with the PT director. Staff P revealed Resident #108's boots were in the closet. On 04/15/2026 at 1:30 p.m., an interview was conducted with Staff H, LPN. She stated she was not aware the heel boots were not being put on Resident #108. She said that the whole time the resident is in bed, the expectation would be to have the heel boots on the whole time. She stated it is the nurse's and certified nurses assistants responsibility to ensure a resident's care plan are followed and someone should have noticed the boots were not on while cleaning and repositioning Resident #108. On 04/15/2026 at 1:45 p.m., an interview was conducted with Staff C, LPN/Unit manager (UM). He stated when a resident has a care plan to have heel boots, the expectation was for the heel boots to be on at all times while the resident is in bed. Staff C said if the heel boots are not available, then the staff should make sure the resident heels are offloaded using pillows. Staff C said if a resident is refusing, then it should be documented in the progress notes and that they respect residents' wishes. On 04/14/2026 at 1:58 p.m., an interview was conducted with the DON. The DON stated if a resident is care planned to have heel boots/protective boots, her expectation are the heel boots should be put on as ordered. She stated if a resident is refusing, it is to be documented daily in charts. Review of the facility policy titled, Plans of Care effective date 11/30/2014, revealed, Policy - An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements.The procedure section of the policy showed:Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Develop and implement an individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician's orders, dietary orders, therapy services, social services, PASAR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Develop and implement an individualized Person-Centered comprehensive plan of care by the interdisciplinary team that includes but not limited to – the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS).

Based on record review and interviews, the facility failed to review, revise and update interventions for a fall care plan to ensure safety and prevent accidents for one Resident (#18) out of five residents sampled. Findings included: Review of an admission Record dated 04/15/2026 revealed Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to cerebral infarction due to thrombosis of right anterior cerebral artery, muscle wasting and atrophy, not elsewhere classified, unspecified, difficulty in walking, not elsewhere classified, and generalized muscle weakness.Review of a Situation, Background, Assessment, and Recommendation, (SBAR) Communication Form, and Progress Note for Registered Nurses, RN's/ License Practical Nurses, LPN/ License Vocational Nurses, LVN, dated 3/8/2026 showed a change in condition due to a fall. At 8 p.m., resident observed lying on the floor near his bed and wheelchair. Review of an SBAR Communication Form, and Progress Note dated 2/2/2026 showed a change in condition due to a fall. The recommendations for the primary clinician showed: neuro checks, medication for anxiety. Review of a focus care plan showed, (Resident #18) has had an actual fall with no injury, laying on floor next to bed wrapped in covers, lying on floor next to bed, Fall (Resident #18) attempted to ambulate while [family member] in room, 4:15 AM fall. Resident laying on floor next to bed, non-sitting on floor head resting on bed, fall observed next to bed no injury, fall, no injury noted unwitnessed, fall from Wheel Chair, fall no injury noted witnessed fall from wheel chair, fall observed next to bed no injury, slid out of wheel chair at nurses station, slid out of Wheel chair in his room. is noted to attempt to get up out of chair on multiple occasions thus resulting in falls. Dated initiated 07/15/2025 revised on 02/03/2026. This care plan included a goal showing Resident #18 will resume usual activities and minimize the risk of further incidents through next review date, initiated 07/15/2025, revised date 5/27/2026. This care plan included interventions that showed frequent rounding while in bed, date initiated 12/17/2025. Frequent rounding when resident is in the wheel chair in his room, Date initiated 02/03/2026, revised on 4/15/2026 and Medication review, date initiated 03/09/2026. On 04/15/2026 at 12:12 PM, an interview was conducted with Staff I, License Practical Nurse (LPN) /Minimum Data Set (MDS) coordinator. Staff I stated she started at the facility in mid-to-late September. She stated everyday she updates the care plans. A report is ran every day to see if there have been any changes to residents' orders, behaviors, or if a resident is placed on oxygen. From that information, she updates the care plan in the electronic medical record (EMR). Staff I stated the reports she runs also show whenever a resident has a fall. The Interdisciplinary Team (IDT) meets if a resident had a fall over night. They discussed the fall. Then the team would come up with an intervention for the resident's fall. Staff I stated the care plan would have an intervention for every fall a resident has had. Staff I stated she did not know why the IDT put frequent round when Resident #18 was in the wheelchair in his room for his fall on 2/2/2026 and they already had an intervention put in place on 12/17/2025 to frequently round when Resident #18 is in bed. Staff I stated she did not know why the IDT put to review Resident #18 medication for an intervention for his fall on 3/8/2026, when the facility already reviews his medications. Staff I stated, Maybe it was a specific medication they wanted to review, Staff I stated she was not sure about the medication because the record doesn't show which medications were reviewed. On 04/15/2026 at 1:58 PM, an interview was conducted with the Director of Nurses (DON). The DON stated Resident #18 had two different interventions to frequently round in his room because those were the intervention the facility used when she first started working at the facility. The DON stated her expectation was her staff should conduct frequent rounds every day as part of their assignment. The DON stated the interdisciplinary team had a meeting on 02/9/2026, and they discussed Resident #18. The intervention they put in place was that they made changes to his chair, but she did not know why that information was not updated on his care plan. The DON stated Resident #18 had a fall on 03/8/2026 and they discussed his anxiety medications, but she was not able to see what changes were made to his medication. The DON stated her expectation was when there is an IDT meeting, a progress note is documented in the electronic medical records to show what changes were made, and the care plan should be updated accurately. The DON stated when she reviewed Resident #18's medications, she did not see any information that showed Resident #18 medication was reviewed and adjusted after their fall meeting on 3/8/2026. Review of a policy titled, Fall Management Revision date, 07/29/2019 showed, overview, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall (s) and minimize the potential for a resulting injury. Process: C. Post Fall Strategies 5. Update care plan and nurse aide Kardex (a nursing quick reference guide for patient information and care needs) with intervention(s) 8. Update plan of care with new interventions as appropriate Review of a policy titled, Plan of Care, Revision date, 09/25/2017 showed under policy, 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.Procedure: 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 intervention after the completion of each Omnibus Budget Reconciliation Act (OBRA) Minimum Data Set (MDS) assessment (except discharge assessment), and as needed.

Based on record review, interviews, and policy review, the facility failed to document and plan the discharge process, for one of three residents sampled (Resident #1).Findings Included:During an interview on 01/05/26 at 12:47 PM, Resident #1's representative stated the resident was discharged home without supplies and the home health care company did not show up. During an interview on 01/05/26 at 01:22 PM, with Staff B, Social Services Worker (SSW), and the Social Services Director, SSD. Staff B, SSW stated the home health care provider had not been confirmed for Resident #1, prior to discharge on [DATE]. Staff B, stated no supplies were provided to Resident #1 at discharge. Staff B, stated Resident #1 was not reached out to post discharge from the facility. Staff B, stated being made aware the home health care provider had declined to admit Resident #1. Resident #1 had to ascertain a different home health care provider. Review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] and discharged [DATE] with the following diagnosis: sepsis, osteomyelitis of the femur, chronic obstructive pulmonary disease, muscle weakness, malignant neoplasm of rectum, colostomy, chronic kidney disease and female genital tract fistula. Review of Resident #1's care plan did not reveal a plan for discharge. Review of Resident #1's orders dated 12/15/25 revealed wound care treatment orders for daily dressing changes to the coccyx. Review of Resident #1's progress notes revealed: a nursing progress note dated 12/19/25 at 2:26 PM, revealed Resident #1 went home via a stretcher with one driver.Review of Resident #1's social service discharge note dated 12/19/25 at 3:31 PM, revealed Resident #1 was to receive home health.Review of Resident #1's physician progress note dated 12/22/25 at 9:27 AM, revealed Resident #1 was ready for discharge. The note revealed a social worker arranged home health care.Review of Resident #1's progress notes lacked documentation of discharge planning with Resident #1 and/or Resident #1's representative. Review of Resident #1's social service progress note dated 12/23/25 at 1:34 PM, revealed a post discharge note which showed social services spoke with Resident #1's family member and was informed home health had not shown up. Social services called the initial home health company and confirmed the company had not agreed to care for Resident #1.During an interview on 01/05/26 at 2:16 PM, the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Nursing Home Administrator (NHA), stated Resident #1 had a stage three pressure injury on the coccyx. The DON stated Resident #1 had physician orders for daily wound care. The DON stated there was no information documented for the nurse's role in Resident #1's discharge. The DON confirmed there should be documentation regarding education, and any supplies given to the resident at time of discharge. Review of the facility policy titled Discharge Planning, dated 11/30/14 revealed: Policy: To evaluate the resident's health status and formulate the best plan of discharge for each resident. Discharge Planning begins the day of admission. The process involves the resident and family, Care Management/Social Services and other members of the clinical team. 1. An initial evaluation of resident is completed upon admission. A discharge goal and length of stay will be established upon admission and reviewed/revised at plan of care conferences. The goal is based upon clinical findings, availability of community and family resources and resident/family goals. 2. Discharge planning record will be completed within seven days after admission. Discharge planning is adjusted as appropriate. 4. At the time of discharge, a discharge summary and home-going instructions are provided to the resident or the resident's caregiver which will include the following: current diagnosis, rehabilitation potential, summary of prior treatment, physician orders for immediate care, pertinent social information, community referrals as needed (e.g., home health, mental health, adult daycare, etc.) 5. Residents discharged to home will be made aware of, understand and agree with the proposed discharge plan, discharge date and other home care needs. 6. Within twenty-four (24) to forty-eight (48) hours (or next day) after discharge to home, another nursing facility or to another type of residential facility such as a board-and-care home, a follow-up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided according to the discharge plan. 7. Documentation of the after discharge contact will be made on the social service progress note and labeled Post-Discharge Note. 8. Should pre-scheduled services not be provided or arranged, the social worker will make every attempt to coordinate service and follow-up again.

Based on interviews and record review the facility failed to ensure treatment and care in accordance with professional standards of practice by failing to implement post fall evaluations, for one (Resident #1) of three residents reviewed for falls. Findings included: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include: sepsis, unspecified organism, muscle weakness, and other abnormalities of gait and mobility. Review of the Minimum Data Set revealed Resident #1had a Brief Interview Mental Status of 15, which indicated cognition was intact. Review of the functional abilities and goals section revealed the resident used a walker or wheelchair, required substantial or maximal assistance for showering, bathing, toileting hygiene, personal hygiene, and upper body dressing, and required assistance from two or more helpers to roll left and right, go from sitting to lying, lying to sitting on side of bed, and from sitting to standing. Review of Resident #1's fall assessment dated [DATE], revealed Resident #1 had not experienced a fall within six months prior to admission and Resident #1 had impaired mobility and cognitively intact. The assessment revealed Resident #1 was a low fall risk. Review of Resident #1's progress note dated 12/18/2025 at 01:05 PM, revealed: upon doing room checks nurse observed resident on the floor beside her bed. nurse asked resident what happened. resident stated she tried to push herself back in the and slipped into the floor. resident assessed head to toe red mark on forehead, skin tear left elbow. CNA and nurse used [mechanical] lift used to place resident back in bed. Review of Resident #1's medical chart did not reveal a neurological check post incident, or other fall related assessments. During an interview on 01/05/2026 at 02:16 PM, the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Nursing Home Administrator (NHA) stated Resident #1 had an unwitnessed fall. The DON read a progress note from Resident #1's medical record, which revealed the resident had been observed on the floor on 12/18/2025, related to an unwitnessed fall. The ADON stated Resident #1 had an unwitnessed fall on 12/17/2025. The ADON stated the facility did not ask Resident 1 if the red mark on Resident #1's forehead was due to a head injury. The ADON stated not knowing what the red mark on Resident #1's forehead was. The ADON stated the facility took the residents' words on it. The ADON stated Resident #1 did not incur an injury as a result of the fall. The DON read a progress note dated 12/18/2025 at 01:05 AM, which revealed Resident #1 had a red mark on the forehead and a skin tear to the left elbow. The DON stated unwitnessed falls require monitoring, neuro checks, complete skin assessments, treatment for possible skin care, frequent monitoring, and a range of motion assessments. The DON stated the required steps for post fall care had not been completed for Resident #1, after the fall. The DON stated the ADON had reviewed the resident's files and was unable to find neuro checks for Resident #1. Review of a policy titled Fall Management, revised 07/29/2019, revealed: Policies and ProceduresResidents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Purpose:Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall (s) and minimize the potential for a resulting injury.C. Post Fall Strategies:1. Resident will be evaluated and post fall care provided2. Initiate Neurological checks as per policy or directed by physician order3. Notify the Physician and resident representative4. Re-evaluate fall risk utilizing the Post Fall Evaluation5. Update Care plan and Nurse Aide Kardex with intervention(s)6. Initiate post fall documentation every shift for 72 hours7. Interdisciplinary Team to review fall documentation and complete root cause analysis8. Update plan of care with new interventions as appropriate9. Review resident weekly times 4.

Based on observations, interviews, and record review, the facility failed to ensure urostomy and nephrostomy tubes care was provided and was consistent with professional standards of practice for one (Resident #1) out of three residents reviewed.Findings included: Review of Resident #1's medical certification for Medicaid long-term care services and patient transfer form (3008), dated 11/26/25 Section P-Patient Health Status showed the following urostomy, bilateral [nephrostomy] tubes and colostomy. During an interview on 1/5/26 at 12:33 pm. the Director of Nursing (DON) said at the time of admission to the facility batch orders (standing orders) are ordered based on the hospital discharge orders. The DON stated at the time of Resident #1's admission the orders should have addressed the care of the urostomy and nephrostomy tubes. When asked about Resident #1 missing orders for the care of the urostomy and nephrostomy tubes, the DON stated, I can't speak to that; I have no information. A review of Resident #'1's admission record revealed admission to the facility on [DATE], with diagnoses including sepsis, acute osteomyelitis, Chronic Obstructive Pulmonary Disease (COPD), chronic kidney disease (CKD), artificial openings of urinary tract, female genital tract fistula, history malignant neoplasm of large intestine, colostomy status and deep vein thrombosis (DVT). A review of admission/readmission data collection revealed Resident #1 was admitted to the facility on [DATE] at 8:00 p.m. Section J, gastrointestinal, showed presence of a colostomy. Section K, genitourinary, does not show the presence of urostomy tube and or nephrostomy tube. A review of Resident #1's Minimum Data Set (MDS), admission assessment dated [DATE] Section H-Bowel and Bladder revealed Resident #1 has nephrostomy tube and ostomy (include urostomy . colostomy). A review of physician orders, as of 12/19/25 revealed the following:An order dated 12/5/25, Procedure: Colostomy appliance change order: change colostomy bag and wafer now. Skin Care: clean peristomal skin with water only; pat dry. Apply skin barrier wipe and ensure full drying before wafer placement.Supplies: Use patient specific colostomy supplies per formulary.Monitoring: Notify provider for peristomal skin breakdown, persistent leakage, bleeding, or concern for infection. A review of Resident #1's care plan, dated 12/10/25, revealed a focus area as follows: [Resident #1] has skin excoriation on the sacrum and coccyx .related to (r/t) . [ileal conduit], ostomy and nephrostomy tubes. A review of Resident 1's Nurse Practitioner (NP) follow-up note, dated 12/12/2025 revealed, physical exam: incontinent of bowel and bladder colostomy, urostomy and nephrostomy tubes [bilaterally] .all appliances intact at today's exam. Continue daily assessment for leakage, obstruction, decreased output, skin breakdown or signs of infection at infection sites. Maintain meticulous stoma and nephrostomy care. Monitor urine color and output; report hematuria (blood in urine), foul odor, or catheter-related pain. High Risk statement: multiple ostomies and nephrectomy tubes significantly increase risk for urinary obstruction, pyelonephritis, skin breakdown, electrolyte imbalance, and sepsis. Report any change . The plan of care was discussed and collaborated with [nursing] staff. Clinical documentation was available to Unit Manager (UM)/Director of Nursing (DON), as well as physician . A review of Resident #1's physician progress note, dated 12/18/25 revealed the following: the patient has a permanent Colostomy, ileal conduit urostomy, and bilateral nephrostomy tubes. All appliances are intact on today's exam. Daily monitoring will continue for leakage, obstruction, decreased output, skin breakdown, hematuria, foul odor, or insertion site infection. High Risk statement: multiple ostomies and nephrectomy tubes significantly increase risk for urinary obstruction, pyelonephritis, skin breakdown, electrolyte imbalance, sepsis and hospitalization . Clinical documentation was available to Unit Manager (UM)/Director of Nursing (DON), as well as physician . During an interview on 1/5/26 at 12:33 p.m. Staff A, Licensed Practical Nurse (LPN) said when caring for a resident with ostomies the nurses follow physician orders. During a follow-up interview on 1/5/26 at 4:33 p.m. the DON said nurses are expected to reconcile hospital discharge orders with the physician upon admission. All orders must be entered into the electronic medical record system. For residents with a colostomy or nephrostomy, care is provided every shift and as needed. Care orders are reflected in the Treatment Administration Record (TAR). The frequency of changing colostomy bags is resident-specific and depends on stool consistency, physician orders, and PRN needs. The physician's order specifies how often the colostomy bag should be changed. Ostomy care is documented on the TAR. The Minimum Data Set (MDS) nurse is responsible for making sure this information is incorporated into the resident's care plan. Review of facility's policy and procedure titled, Clinical Guideline Skin & Wound Document, effective date 4/1/2017 revealed the following:Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/ prevention of pressure injury.Process . Develop individualized goals and interventions and document on the care plan and the CNA Kardex . Monitor residents' response to treatment and modify treatment as indicated. Evaluate the effectiveness of interventions, and progress towards goals during the care management meeting and as needed. Review of facility's policy and procedure tiled, Plans of Care, revised 9/25/2017 revealed the following:Policy: 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.Procedure:-Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .-Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to-the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident, and, to the extent practicable, .The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.-The Individualized Person-Centered plan of care may include but is not limited to the following: Resident's strengths and needs-Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements .Note: The resident's plan of care encompasses many documents that are part of the resident's clinical record including, but not limited to, structured care plan documents, MARS, TARS, physician orders, flow records, and/or legal documents that would drive the plan of care for the individual resident.

Based on observations, record reviews, and interviews the facility failed to notify the physician of a non-functioning wound vac and neglected to provide wound care per physician orders for one (#1) of three residents sampled for surgical wounds. Findings included: Review of Resident #1's clinical record showed the resident was admitted to the facility on [DATE] with diagnoses not limited to right knee arthritis due to other bacteria, type 2 diabetes mellitus with other circulatory complications, right knee rheumatoid arthritis without rheumatoid factor, and acquired absence of other right toe(s). Review of Resident #1's operative report dated 4/17/25 showed the resident was 6 weeks post right total knee arthroplasty with 3 weeks of increasing right knee pain and swelling. The postoperative diagnosis was prosthetic joint infection of the right knee. The operation conducted on 4/17/25 was a second stage revision right total knee arthroplasty with removal of antibiotic spacer and the surgeon's application of an incisional wound vac. The postoperative (postop) instructions included: - Follow up in 2 weeks after surgery. - (Manufacturer name) VAC for 2 weeks which will be removed in the office. - Weight bear as tolerated, lower extremity in the immobilizer to allow for soft tissue rest. Review of Resident #1's April Medication Administration Record (MAR) showed a follow-up appointment was scheduled on 4/29/25 with the surgeon for 5/7/25 at 1:30 p.m. The MAR showed an order for the resident to receive the antibiotic Daptomycin Intravenous solution reconstituted - 500 milligram (mg) intravenously in the morning for bacterial infection for 4 weeks and 500 mgs of Ciprofloxacin twice daily for 7 days for a bacterial infection. Review of Resident #1's April Treatment Administration Record (TAR) showed staff were to: Monitor wound vac and cast to the right foot for signs/symptoms (s/s) of infection every shift. The documentation showed staff monitored the area during the 12-hour shifts of day and night from 4/24/25 to 4/30/25. Review of Resident #1's Admission/readmission Data Collection, effective 4/23/25 at 6:08 p.m. revealed the resident was alert and oriented (A&O) to person, place, and time, had a Peripherally Inserted Central Catheter (PICC) inserted in the right upper arm, and a left leg surgical site. The staff noted the resident arrived at the facility on 4/23/25 at approximately 5:50 p.m., was A&O x4, a wound vac noted to right leg with a cast in place, per order cast is not to be removed until f/u (follow up) with surgeon, and a PICC in right upper arm. The evaluation did not describe the drainage in the wound vac tubing or canister, or the amount seen. Review of a late entry Physician Progress Note, effective 4/24/25 at 10:37 p.m. revealed Resident #1 had been admitted at the Skilled Nursing Facility (SNF) after hospitalization for right knee issues. The history showed the resident had underwent a second-stage revision of the right total knee arthroplasty which included the removal of an antibiotic spacer, application of a wound VAC, and insertion of antibiotic beads. The resident was weight-bearing as tolerated, wound VAC was to remain in place for 2 weeks and due to deconditioning and need for long-term antibiotics the resident had been admitted for further rehabilitation. The plan was for the resident to continue current antibiotic regimen, follow up with Orthopedics in 2 weeks, and to Maintain wound VAC for 2 weeks. Review of Resident #1's skilled notes dated 4/24, 4/25, 4/26, 4/28, and 4/30/25 revealed staff did not comment on the presence of the wound vac or if the resident had a surgical incision. The notes showed the vascular access was not present on 4/24, 4/25, and 4/28 but was present on 4/26 and 4/30/25. The record revealed staff did not document a skilled note on 4/27 or 4/29/25. An interview was conducted on 5/20/25 at 12:32 p.m. with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member reported Resident #1 was admitted with a wound, believed it was either a pressure or surgical wound, had a wound vac which the resident was admitted with, and an immobilizer which kept leg straight. Staff A stated a wound vac dressing was to be changed on Monday-Wednesday-Friday and if the wound vac was inoperable staff were to apply a wet-to-dry dressing, contact the surgeon. The staff member stated the wound vac and wet-to-dry dressing orders were standard. Staff A stated the resident came in close to the weekend, on Wednesday 4/23/25. The staff member reported working Monday through Friday and was notified by the Nurse Practitioner the following Monday the resident's wound vac was not working and stated need to reach out to the surgical team. Staff A stated the weekend supervisor had initiated the wet-to-dry dressing on Sunday (4/27/25). Staff A stated the expectation for staff was to write a note describing the drainage and the amount, pain or discomfort, and if it had a foul smell. Staff A said, All that goes into your progress note. The staff member reviewed the April 2025 MAR and TAR confirming it did not include information related to the amount of drainage. The wound vac was to be on for 2 weeks and the vac would have been set to run for 2 weeks. Staff A did not know the preset, and the assumption was it stopped working due to the preset. Staff A reported directing the floor nurse to apply the wet-to-dry dressing, once a day. The original wet-to-dry dressing was done on 4/26 at 10:19 a.m. Staff A, LPN reviewing the record stated the dressing was also done on 4/27 at 11:16 a.m., and on 4/28 before the resident left. Staff A confirmed there was no documentation related to the application of the dressing on 4/25/25. An interview was conducted on 5/20/25 at 2:05 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA reported Resident #1 had been admitted on [DATE] with a wound vac to the post-surgical wound on right knee. The facility was notified by the surgeon's office (4/30/25) that Resident #1's wound was not progressing, and they suggested the resident be transferred to hospital for evaluation. The NHA clarified the surgeon's office had notified the facility the resident was going to the hospital from the appointment. The NHA reported the following staff interviews: - Staff B, the resident's primary nurse on (Sunday) 4/27/25, had identified the wound vac cord was not providing power to the device and had notified the weekend supervisor. - Staff C, Registered Nurse (RN) was the evening nurse on 4/26 and had stated the wound vac was plugged in and very little drainage was in tubing and canister. - Staff D, Registered Nurse/Weekend Supervisor (RN/WS) reported being made aware on 4/27 the wound vac cord was not providing power and had looked in central supply (CS) for another cord before reaching out to the CS coordinator. - Staff E, Central Supply (CS) Coordinator confirmed Staff D had reached out for an alternative cord and the coordinator had attempted placement of another cord which was not compatible. - Staff A had been notified by the Nurse Practitioner (NP) on 4/28/25 that Resident #1's wound vac was not functioning. Staff A had contacted the surgeon's wound care office and had initiated a wet-to-dry dressing change. - Staff F, RN was the assigned nurse (for Resident #1) for the 4/28-day shift reported . the wound vac was not powered on, and the area did not have any edema or redness. - Staff G, RN was the assigned nurse on 4/29 and had reported not being aware of any concerns with the wound vac. - Staff H, Certified Nursing Assistant (CNA) . reported the machine was not turning on. During the on-going interview, The NHA reported an order was placed on 4/28 with a start date on 4/29 for a wet-to-dry dressing. The DON stated if a wound vac was not working staff were to get hold of surgeon and get orders. The DON was unaware of the surgeon's on-call. The NHA reported reviewing the TAR which had shown on 4/29 the wet-to-dry dressing was not applied. The NHA stated the primary nurse had notified the weekend supervisor of non-functioning wound vac. The primary nurse should know to call the physician. The staff members stated education had been provided to nurses that if a wound vac enters the facility or was applied, they have an order to notify physician to obtain a wet-to-dry dressing and to check vac functioning and placement every shift. The DON stated the expectation was for the wound to be assessed and documented in the daily skilled charting. The DON confirmed the resident did have a PICC and staff should be documenting the existence, location, and any signs or symptoms of infection. The DON stated the expectation was for staff to document if the wound vac was functioning, location, description of drainage and the amount if able to see it. Review of Resident #1's progress notes revealed a late entry note, effective 4/28/25 at 5:28 p.m., created on 4/30/25 at 11:32 a.m., written by Staff A showing the writer had received a call from the Orthopedic office with orders to place a wet to dry dressing on the patient's wound and they would like to see the resident on 4/30 instead of next month, the writer placed new orders in the electronic record and the facility would continue with the plan of care at this time. Review of Resident #1's April 2025 Treatment Administration Record (TAR) revealed the following order: - Treatment as follows: Cleanse left knee with wound cleanser and pat dry. Apply saline gauze to wound bed and cover with abdominal (abd) pad every day and as needed for soiling or dislodgement every day shift for wound care. Start date 4/29/25 at 7:00 a.m., held from 4/30 12:44 p.m. to 5/1 at 12:00 a.m., and discontinued on 5/2/25 at 12:28 p.m. The April 2025 TAR revealed the dressing had been applied on 4/29/25. The corresponding as needed (prn) order revealed the dressing had not been applied on 4/28, 4/29, or 4/30/25. An interview was conducted on 5/21/25 at 1:37 p.m. with Staff D, RN/WS (Weekend Supervisor). The staff member reported being notified on Sunday (4/27/25) morning that the wound vac was not working and had sent a message to CS that the battery was not charging. Staff D stated the primary nurse would have been the one to contact the physician and the policy was if a wound vac was not working, the expectation was to keep the dressing clean, dry, and intact. Staff D stated not knowing what Resident #1's orders were, and the policy was to have either wet-to-dry (dressing) or to keep the wound vac's sponges clean, dry, and intact, whatever the order says. A request was made on 5/20/25 for policies regarding nursing documentation and for wound vac care/maintenance. The facility showed they did not have those policies. Review of the policy - Abuse, Neglect, Exploitation, & Misappropriation, revised 11/16/22, revealed it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. 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. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/ or misappropriation of property against any resident. Violation of the standard subject employees to disciplinary action, including dismissal, provided herein. The policy defined neglect as: the failure of the center, its employees or service providers provide goods 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. - Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. - Failure to provide services that result in harm to the resident, such as not turning a bed fast resident or leaving a resident in a soiled bed. Review of the policy - Daily Skilled Nursing Progress Note, revised 9/29/17, revealed Residents receiving skilled care have progress documented daily in the medical record by the nurse. The procedure included: - Use the daily skilled note to document resident's progress daily on skilled care. - May document a narrative note in the additional note section for any items not addressed in the note. - Incidental or by exception documentation may also be included in the narrative note. -Sign, save and lock assessment in electronic record.

Based on interviews and record review, the facility failed to provide necessary treatment to promote healing and prevent infection for an identified pressure ulcer for one (#5) of three residents reviewed. Findings included: Review of Resident # 5's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated 10/21/24, showed on 10/6/24, a surgical procedure was performed on the left hip. Review of Resident #5's admission record showed admission to the facility on [DATE] and transferred to the hospital on 11/23/24, with diagnoses to include left femur fracture, muscle weakness, muscle wasting, dementia and on 11/19/24 the onset of stage 3 pressure ulcer of the sacrum on 11/19/24. Review of Resident #5's Order Summary Report showed orders to include consult wound care as needed (PRN), order dated 11/19/24 low air loss mattress for Stage 3 pressure area to coccyx. An order date 11/19/24, start date, 11/20/24 to cleanse sacrum area with wound cleanser and pat dry, apply nickel thick layer of Santyl to wound bed, cover with calcium (CA) alginate and secure with bordered gauze change daily and as needed (PRN) for soiling and dislodgement every day shift for wound care. Review of Resident #5's Admission/ Readmission Data Collection record, dated 10/22/24, Section M: Skin showed right hip surgical incision. Review of Resident #5's Admission Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. In Section GG: Functional Abilities revealed Resident #5 required substantial/maximal assistance to roll from lying on back to the left and right sides. In Section M: Skin Conditions revealed Resident #5 is at risk for developing pressures ulcers and does not have one or more unhealed pressure ulcers. Review of Resident #5's Treatment Administration Record, dated November 2024 showed an order to cleanse sacrum area with wound cleanser and pat dry, apply nickel thick layer of Santyl to wound bed, cover with calcium (CA) alginate and secure with bordered gauze change daily and as needed (PRN) for soiling and dislodgement every day shift for wound care, start date 11/22/24. Treatment was documented as completed on 11/23/24 only. An order for weekly skin sweeps every night shift every Tuesday for Resident #5 showed skin was checked on 11/5, 11/12 and 11/19. The checks did not reveal concerns with new or worsening of skin conditions. Review of Resident # 5's Nursing Progress Note, dated 10/23/24 at 2:22 A.M. showed .redness to sacrum . Review of Resident #5's Weekly Skin Integrity Review, effective date 10/30/24, showed surgical wound to hip side of thigh and side of left outer knee. Review of Resident #5's Skilled Note, dated 11/4/24, showed skin is moist warm abnormal turgor pale. Review of Resident #5's Weekly Skin Integrity Review, effective date 11/06/24, at 6:31 A.M. showed sacrum wound and mid-back skin breakdown. Review of Resident # 5's Situation, Background, Appearance and Review and Notify (SBAR) form, dated 11/6/24, showed Summoned to room by assigned CNA, resident has two open areas to sacrum and mid back respectively, dry dressing applied, resident repositioned to the left side. The section titled Review and Notify showed the primary care clinician was notified on 11/6/24 at 7:08 A.M. Review of Resident #5's Weekly Skin Integrity Review, effective date 11/06/24, at 2:27 P.M. showed sacrum open area and treatment (Tx) in place. Review of Resident #5's Weekly Skin Integrity Review, effective date 11/13/24, showed sacrum, wound on admission. Review of Resident #5's Weekly Skin Integrity Review, effective date 11/17/24, showed bedsore in her sacrum. Review of Resident #5's Wound Assessment Report, dated 11/19/24, authored by the facility's wound care physician, showed a wound on the sacrum with the following measurements length 6.0 cm (centimeters), width 3.5 cm and depth 0.1 cm. The etiology was a pressure injury, a new stage 3 wound. Additional wound assessment showed 40% granulation, 30% slough and 30% eschar. There was a moderate amount of serous [clear to yellow fluid] exudate [drainage]. The treatment ordered was dressing change daily, clean wound with normal saline, primary treatment Santyl and bordered gauze dressing. Review of Resident #5's Weekly Skin Integrity Review, effective date 11/20/24, showed sacrum wound Review of Resident #5's care plan focused on impaired skin integrity related to immobility and incontinence. The care plan goal was pressure injury will show signs of healing without complications by review date. The care plan interventions include administer treatments as ordered and monitor for effectiveness, assess/ record/monitor wound healing at least weekly, monitor nutritional status. Served diet as ordered. Monitor intake and record. Notify medical doctor (MD) if any deterioration in wound status. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, initiated on 11/19/24. On 1/13/25 at 2:50 P.M. during an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), the DON said at the time of Resident #5's admission to the facility, Zinc Oxide ointment was applied to the buttocks. She verified there was not an order for this medication. The DON said on 11/6/24 when the wounds were identified, there should have been pressure wound care orders and verified no orders were documented. She said on 11/19/24 when the pressure ulcer was documented by the wound care physician, she expected wound care orders, and documentation the treatment was completed as ordered. After reviewing Resident #5's TAR (Treatment Adminsitration Record) the DON confirmed between 11/19/24 and 11/23/24 wound care was documented only on 11/23/24. Review of a facility policy titled, Pressure Injury Record, revision date 4/1/17 showed a policy to document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. The procedure showed: 1. Residents will have a pressure injury record completed for each skin impairment that is related to pressure. Review of a facility policy titled, Skin Evaluation, revised on 4/1/17 showed under policy, A licensed nurse will complete a total body evaluation on each resident weekly . paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas and skin problems. Under procedure - 1. A licensed nurse will complete a total body evaluation on each resident weekly and document the observation on the skin evaluation form. 2. The evaluated nurse must date & each review. 3. If a resident is assessed as having a skin problem, the evaluating nurse will initiate the appropriate form. For pressure areas complete the Pressure Injury Record. 5. The licensed nurse will document the observations on the skin evaluation form. Review of a facility's policy subject, Physician Orders, revision date 3/3/21 showed: policy - The center will ensure that physician orders are appropriately and timely documented in the medical record. Procedure-routine orders a nurse may accept a telephone order from the physician, physician assistant or nurse practitioner (as permitted by state law). The order will be repeated back to the physician, PA or ARNP for his /her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMAR (Electronic Medication Administration Record)/eTAR (Electronic Treatment Administration Record ). Review of a facility policy titled, Clinical Guideline Skin and Wound, effective date 4/1/17 revealed: Overview to provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/ prevention of pressure injury. Process- on admission/ readmission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Braden Risk Evaluation to be completed on admission /readmission, weekly for four weeks from admission, quarterly and with significant change in condition. Licensed nurse to complete skin evaluation weekly and prior to transfer/ discharge and document in the medical record. CNA (certified Nursing Assistant) to complete skin observations and report changes to licensed nurse. Licensed nurse to document presence of skin impairment/ new skin impairment when observed and weekly until resolved. Licensed nurse to report changes in skin integrity to the physician/practitioner and the resident/ responsible party and document in the medical record . Evaluate the effectiveness of interventions, and progress towards goals during the care management meeting and as needed.

Based on observations, interviews, and record review the facility failed to protect the resident's right to be free from neglect by not providing supervision for one resident (#1) out of four residents sampled for elopement. At approximately 12:15 p.m. on 12/20/23, Resident #1 was able to exit the facility through a door with a wander monitoring device alarm, walk into the facility lobby area, and speak with two facility staff members. One staff member held the door open for Resident #1 to enter the lobby, and the other staff member asked Resident #1 to sign out on the visitor log. Resident #1 signed the visitor log and exited out another door with a wander monitoring device alarm. Resident #1 walked approximately 0.2 miles down a heavily trafficked road, he crossed four lanes of traffic, and called his family member to pick him up. The facility staff were not aware Resident #1 was missing until Resident #1's family member called the facility inquiring if he was there. Resident #1 was absent for approximately 32 minutes before facility staff located him and brought him back to the facility where he was identified to not have a wander monitoring device in place. Resident #1 was assessed to be at high risk for elopement with a physician's order to have a wander monitoring device in place. Review of Resident #1's medical record revealed Resident #1 did not have a wander monitoring device in place on 12/12/23, 12/13/23, 12/16/23, and 12/19/23. A wander monitoring device could not be located by nursing staff to place on Resident #1 and there was no evidence of an increase in supervision for Resident #1. The likelihood of serious physical harm or death to Resident #1 as a result of the facility's failure to provide adequate supervision to prevent the elopement resulted in findings of Ongoing Immediate Jeopardy starting 12/12/23. Findings included: Review of the facility's policy titled Abuse, Neglect, Exploitation & Misappropriation with an effective date of 11/30/2014 revealed the following: Policy: It is inherent in the nature and dignity of each resident at the center he/she be afforded basic human rights, including that right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and hereby establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. 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. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions: .Neglect is the failure of the center, its employees or service providers to provide goods 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 adequately supervise a resident known to wander from the facility without the staff knowledge . An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00p.m. she relieved the receptionist. Around 12:20 p.m. to 12:30p.m. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45p.m. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had an [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had an [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just confused because he was supposed to leave the next day. A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed . An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's Admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on 12/21/23. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/Readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to adon [Assistant Director of Nursing], but she couldnt [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00a.m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. Review of Resident #1's care plans revealed no elopement risk care plan and no interventions related to the monitoring or supervision of Resident #1. There was a care plan with a revision date of 10/20/23 and revealed At risk for leaving the center against medical advice R/T [related to] alcohol use due to substance disorder. The goal included Resident will understand the risk of leaving the center against medical advice. Interventions included the following. Discuss concerns and attempt to resolve issues. Educate residents of risk of leaving against medical advice. Review of the visitor log for December 20, 2023, titled Welcome To Our Center revealed the following. Name: a signature which was not legible. Person/Room Visiting: [Resident #1] Relationship: not legible writing Time In: 12/ the rest of the writing was not legible. Time Out was blank On 12/20/23 it was partly cloudy with a temperature high of 67 degrees Fahrenheit and a temperature low of 47 degrees Fahrenheit. https://www.wunderground.com/calendar/us/fl/[NAME]/KTPA/date/2023-12 According to Maps, from the facility to the Beauty Salon it is approximately a 0.2-mile walk. An observation was made on 1/16/23 at 5:03 p.m. of Resident #1's walking route. It was a heavily trafficked 4-lane road with a posted speed limit sign of 40 miles per hour (MPH). Sections of the sidewalk were blocked off by construction cones with uneven ground and missing concrete. (Photographic evidence obtained) Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . An interview was conducted on 1/17/24 at 1:32 p.m. with the [NAME] Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20p.m. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30p.m. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47p.m. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on .

Based on observations, interviews, and record review the facility failed to provide supervision to prevent an unwitnessed exit from the facility for one resident (#1) out of four residents sampled for elopement. Resident #1 had diagnoses to include metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, and a history of falling. Resident #1 was assessed to be at high risk for elopement with a physician's order to have a wander monitoring device in place. Review of Resident #1's medical record revealed Resident #1 did not have a wander monitoring device in place on 12/12/23, 12/13/23, 12/16/23, and 12/19/23. A wander monitoring device could not be located by nursing staff to place on Resident #1 and there was no evidence of an increase in supervision for Resident #1. At approximately 12:15 p.m. on 12/20/23, Resident #1 was able to exit the facility through a door with a wander monitoring device alarm, walk into the facility lobby area, and speak with two facility staff members. One staff member held the door open for Resident #1 to enter the lobby, and the other staff member asked Resident #1 to sign out on the visitor log. Resident #1 signed the visitor log and exited out another door with a wander monitoring device alarm on it. Resident #1 walked approximately 0.2 miles down a heavily trafficked road, he crossed four lanes of traffic, and called his family member to pick him up. The facility staff were not aware Resident #1 was missing until Resident #1's family member called the facility inquiring if he was there. Resident #1 was absent for approximately 32 minutes before facility staff located him and brought him back to the facility where he was identified to not have a wander monitoring device in place. The likelihood of serious physical harm or death to Resident #1 as a result of the facility's failure to provide adequate supervision to prevent the elopement resulted in findings of Ongoing Immediate Jeopardy starting 12/12/23. Findings included: Review of Resident #1's Admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on 12/21/23. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/Readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to ADON [Assistant Director of Nursing], but she couldn't [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00a.m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00p.m. she relieved the receptionist. Around 12:20 p.m. to 12:30pm. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45p.m. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had a [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had a [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just confused because he was supposed to leave the next day. A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed . An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's care plans revealed no elopement risk care plan and no interventions related to the monitoring or supervision of Resident #1. There was a care plan with a revision date of 10/20/23 and revealed At risk for leaving the center against medical advice R/T [related to] alcohol use due to substance disorder. The goal included Resident will understand the risk of leaving the center against medical advice. Interventions included the following. Discuss concerns and attempt to resolve issues. Educate residents of risk of leaving against medical advice. Review of the visitor log for December 20, 2023, titled Welcome To Our Center revealed the following. Name: a signature which was not legible. Person/Room Visiting: [Resident #1] Relationship: not legible writing Time In: 12/ the rest of the writing was not legible. Time Out was blank On 12/20/23 it was partly cloudy with a temperature high of 67 degrees Fahrenheit and a temperature low of 47 degrees Fahrenheit. https://www.wunderground.com/calendar/us/fl/[NAME]/KTPA/date/2023-12 According to Maps, from the facility to the Beauty Salon it is approximately a 0.2-mile walk. An observation was made on 1/16/23 at 5:03 p.m. of Resident #1's walking route. It was a heavily trafficked 4-lane road with a posted speed limit sign of 40 miles per hour (MPH). Sections of the sidewalk were blocked off by construction cones with uneven ground and missing concrete. (Photographic evidence obtained) Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated, I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert and still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20pm. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47pm. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on . Review of the facility's Elopement/Wandering Risk Guideline policy with an effective date of 9/21/2016 revealed the following. Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, readmission, 7 days post admission, quarterly, with significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain photograph. Initiate individualized interventions based on Patient/Resident's risk. Document individualized interventions in the patient/resident Care Plan and Kardex. If utilizing a wander monitoring system device check placement of the device every shift and functionality every day. Maintain the Elopement Risk Alerts in an easily accessible location. Complete routine elopement drills monthly and review in QAPI [quality assurance performance improvement] meeting. Review of the facility's Missing Patient/Resident policy with an effective date of 11/30/24 revealed the following. Overview: Staff will investigate cases of missing patient/resident and possible elopement. An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. Procedure: Check Leave of Absence (LOA) book and Medical Record to ensure patient/resident is not on an authorized leave or medical appointment. Announce (resident name) please return to your room, over PA system. Repeat three times to alert staff of a missing patient/resident. Assign staff to search the Center and grounds. If the patient/resident is not located after an initial search the point person will notify the Director and/or Director of Nurses, Resident Representative, and Physician. The Executive Director and/or Director of Nursing or designee to notify Law Enforcement. Upon return to the Center a physical evaluation will be completed to determine if further treatment is needed. Document in the Medical Record. Notify Physician, Resident Representative, Executive Director, Director of Nurses, and Law enforcement (If applicable) of patient's/resident's return. Review and revise the interventions as indicated related to elopement and wandering risk and update the Care Plan and Kardex

Based on interviews and record review the facility failed to implement and develop a comprehensive care plan for one resident (#1) out of 4 residents reviewed who were at high risk for elopement. Findings included: Review of Resident #1's Admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on 12/21/23. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes B. Elopement Risk Evaluation If it is determined that the resident has eloped, implement care plan immediately to ensure resident's safety. Report all residents AT RISK to the Director of Clinical Services and on the 24-hour report. Review of Resident #1's comprehensive care plan, as of 1/2024, revealed an elopement risk care plan was not developed with individualized interventions prior to his elopement on 12/20/2023. Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20p.m. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47pm. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done . The NHA said It was the fault of the Activities Director letting him out of the doors and the resident not having his [Wander Monitoring Device] on . An interview was conducted on 1/19/24 at 2:30 p.m. with Staff J, LPN, MDS Coordinator. She said, I float between two buildings. I started on 12/25/23. I work at this building about 20 hours a week. They also have contracted traveling MDS coordinators . Upon admission all the residents need to be assessed for elopement risk and if they are an elopement risk a care plan with appropriate interventions needs to be put in place immediately. Review of the facility's Plans of Care policy and procedures with an effective date of 11/30/2014, revealed the following: Policy: 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. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASRR recommendations., if applicable and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility of the resident .the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS) . Review of the facility's Elopement/Wandering Risk Guideline policy with an effective date of 9/21/2016 revealed the following. Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. Process: Patient/Residents to be evaluated on admission, readmission, 7 days post admission, quarterly, with significant change in condition, and elopement event using the risk tool. If a patient/resident is identified as being at risk complete an Elopement Risk Alert and obtain photograph. Initiate individualized interventions based on Patient/Resident's risk. Document individualized interventions in the patient/resident Care Plan and Kardex .

Based on interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP), when the facility staff failed to prevent accidents and hazards related to the supervision of residents at risk for elopement for one resident (#1) out of four residents reviewed for elopement. Ongoing non-compliance was identified during the complaint survey on 1/16/24 through 1/19/24 related to the supervision of residents and a process to ensure staff have the necessary wander monitoring devices and wander monitoring device checkers accessible and available to them. Findings included: Review of the facility's Ad Hoc Quality Assurance & Performance Improvement Meeting, dated 12/20/23, revealed the reason for the Ad Hoc meeting was for the Facility Elopement on 12/20/23. The goal was To Ensure elopement risk residents are properly identified. . What did you do to ensure it would not happen again? Education provided to facility staff on the facility policy for Elopement. Education provided to the facility staff on Abuse Neglect and Misappropriation to include Supervision of facility residents. Who will check the system? Who will check the checker? Unit Managers and or designee to review facility residents who are at risk for elopement to ensure the facility is following the policy for elopement. DON [Director of Nursing] and or designee to review the facility elopement books to ensure they are updated as necessary. Maintenance Dept [department] and or designee will review facility [Wander Monitoring Device] system to ensure proper functioning. Findings will be reviewed monthly by the facility QAPI committee for recommendation, updates and until substantial compliance has been met. An interview was conducted on 1/17/24 at 1:32 p.m. with the Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The RNC said Resident #1 went out the front door to the left. The NHA said the Activities Director was covering the front desk ringing people in and signing residents out and so forth and the resident approached the front door and apparently, he appears like a visitor and the Activities Director let him out of both doors, the door into the lobby and the door to exit the building. The RNC said Our assumption is that he [Resident #1] left around 12:15 to 12:20pm. because the receptionist left for lunch at 12:00 p.m. and the Activities Director took over for the Receptionist. We do not have cameras that record. We have a camera at the door between the resident hallway and the lobby. The camera was functional at the time of the event, but it does not record. The [Family Member] called at 12:30pm. and spoke with the Activities Director. She contacted knowing that [Resident #1] was on [Street Name], sitting on a bench waiting for her to pick him up. The Receptionist called the elopement drill overhead and then [Staff B, AD] called the [Family Member] back at 12:35 p.m. and said hey do you know exactly where he is at and the [Family Member] said he was on a bench on the corner of [Street Name] and [Street Name]. [Staff D, Human Resources] got him and he was in the car at 12:47 p.m. and he said he was waiting for his [Family Member] to get him. They came back here [the facility] and he was reassessed with a skin sweep with no injuries, he had a [Wander Monitoring Device] placed on him, he did not have a [Wander Monitoring Device] on, had his BIMS redone and it was a 12 out of 15, [indicating moderate cognitive impairment] prior to that on 12/5/23 his BIMS was 99 because he was refusing to have a BIMS done. The NHA and the RNC said the immediate response was a new elopement risk assessment on everyone in facility completed on 12/20/23 and then new admissions were completed to make sure they had their seven-day elopement assessment. The RNC said, Once residents come in, we do an elopement assessment and then seven days later we do another elopement assessment to make sure we are capturing any changes after admission. We audited everyone who was at elopement risk and ensured the care plans were in place with appropriate interventions. We made sure they had physician's orders for expiration date, placement, function, and where it [wander monitor device] was placed. All the doors and the wander guard system in itself were inspected by the former Maintence and the Maintence Assistant. No issues were found with the doors or the wander guard system The NHA said It was the fault of the Activities Director letting him [Resident #1] out of the doors and the resident not having his [Wander Monitoring Device] on. The RNC said, The elopement books were updated to update the current residents at risk for elopement. The NHA said, We have them at the receptionist area, therapy, and all the nursing stations. In the books should be a colored copy of the patient, a description of the resident, and the Facesheet of the resident. The RNC said, There is also the process of what the staff need to do if an elopement occurs in the binder. The DON [Director of Nursing] is responsible for the books. The NHA said it's the clinical teams responsibility to ensure the elopement book are up to date. The RNC said, Every week day when they have the clinical meeting they [Interdisciplinary team] looks through each binder to remove discharges and add admitted residents who are at risk. The DON or designee will update the elopement books. The NHA said they are in the books every day. the NHA clarified they as the clinical team or designee. The NHA said we would do an overhead page and we would hide an actual resident and observe the staff response. We would also do door alarms to see how the staff are responding. After the drill, would be reminders on what to do. Another discussion would be if you cannot find the resident inside then you go outside and contact responsible parties and law enforcement. The RNC said, The drills were pretty heavy because we were doing them every shift multiple times a day and now we are doing all shifts once a week. The NHA said, The drills are going good. There seemed to be questions between one wing and the other on closing the door after it has already been searched. The NHA said, When the overhead page is called the staff are supposed to search their assigned areas. The RNC said, The staff are supposed to first respond to the area where the person is missing and receive their assignment on where they need to search. As they are walking to the area of the missing resident they can look around as they are headed to the area. The RNC said there was an ad hoc QAPI meeting held with the IDT team on 12/20/23, and she attended via phone. She also said there was a follow up QAPI meeting on 1/9/24. Review of Resident #1's Admission Record revealed he was initially admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] from an acute care hospital and discharged home on 12/21/23. His medical diagnoses included metabolic encephalopathy, altered mental status, difficulty in walking, muscle weakness, lack of coordination, history of falling severe sepsis with septic shock, anemia, alcoholic liver disease, and acute kidney failure. Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. Review of Resident #1's Admission/Readmission Data Collection dated 11/28/23 revealed he was alert, oriented to person only, and his memory was OK. He was assessed to be pleasant with no obvious behavior problems and uses a walker for an assistive device. Review of Resident #1's Elopement Risk Evaluation dated 11/28/23 revealed the following. 1. Is the resident cognitively impaired? Yes 2. Is the resident independently mobile (Ambulatory or wheelchair)? Yes 3. Does the resident have poor-decision-making skills? Yes 4. Has the resident demonstrated exit seeking behavior? No 5. Does the resident wander oblivious to safety needs? Yes 6. Does the resident have a history of elopement? No 7. Does the resident have the ability to exit the facility? Yes YES to questions 4,5, or 6 automatically place the resident AT RISK. 8. Based on potential risk factors above, resident is determined to be at risk for elopement. Yes Review of Resident #1's Functional Abilities and Goals-Admission, dated 12/1/23, revealed he was independent with chair/bed to chair transfers, walked 150 feet, walked 10 feet on uneven surfaces, and independent with 12 steps: The ability to go up and down 12 steps with or without a rail. The resident does not use a wheelchair and/or scooter. Review of Resident #1's December Treatment Administration Record (TAR) revealed the following physician orders: [Wander Monitoring Device]- to left ankle check for function each day every night shift for monitoring. start date of 11/30/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q[every] Shift for Placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 [Wander Monitoring Device] Check Q shift for placement every shift for wandering. start date of 11/29/23 and an end date of 12/22/23 For the three above physician orders there was no documentation on 12/1/23 through 12/4/23. On 12/19/23 and 12/16/23 the orders were signed off as 9. Review of Chart Codes/ Follow Up Codes revealed 9=Other/ See Nurses Note. Review of Resident #1's eMAR [electronic Medication Administration Record]-Medication Administration Note dated 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. 12/16/23 at 7:23 p.m. revealed no [Wander Monitoring Device]. On 12/20/23 at 2:59 a.m. revealed not present. Review of Resident #1's Nursing Progress Note dated 12/12/23 at 7:40 p.m. written by Staff A, Registered Nurse (RN) revealed resident dont [sic] have the [Wander Monitoring Device] on his both ankles, informed this to ADON [Assistant Director of Nursing], but she couldn't [sic] new [Wander Monitoring Device] now. Review of Resident #1's Nursing Progress Note, dated 12/13/23 at 7:00 a. m., written by Staff A, RN revealed informed the morning nurse resident need the [Wander Monitoring Device], dont[sic] have one now. Review of Resident #1's medical record revealed no evidence Resident #1 had an increase in supervision when he did not have his wander monitoring device in place. An interview was conducted on 1/16/24 at 10:08 a.m. with Staff B, Activities Director (AD) she said on 12/20/23 around 12:00pm. she relieved the receptionist. Around 12:20 p.m. to 12:30pm. the Kitchen Manager entered the lobby from the resident hallways and Resident #1 followed behind her into the lobby. I saw him, and I thought he was a family member because he looked so much better than he did when he first came to us. His hair was combed, he was shaved, he was walking very well and confidently. I thought he was a family member, so I asked him to sign out and he wrote his name down on a blank line, he looked at the clock and signed out. It was about 5 minutes later, and his [Family Member] called me and said my husband is calling me asking me to pick him up on [Street Name] and she wanted me to make sure he was in his room. I called down to the nurse's station and the ADON answered the phone, and I asked her to look to see if he was in his room and he wasn't, so they immediately started searching for him inside and outside of the building. The [Family Member] was on hold at this time, so I told her he was not in his room, and we were looking for him. I gave her my personnel number and told her to call me on that so I could go and look for him. While I was on the phone with her [Resident #1] kept calling her and she said he was on [Street Name]. I think it was Human Resources and a nurse who found him, I'm not sure exactly where they found him, but they put him in their car and brought him back around 12:45pm. When I got back to the facility, I saw [Resident #1] and it was at that point that I realized oh man I was the one who let him out. I couldn't believe I did that. I told the [Family Member] that we found him, and he was back, and she was a little upset and said if she didn't call me would the staff have known he was even gone? And I told her I would have the DON [Director of Nursing] call her. [Resident #1] was not injured but he did not have his [Wander Monitoring Device] on, so they put one back on him. When he walked through both doors neither alarm went off to let me know that he had a [Wander Monitoring Device] on. That's why I just thought he was a family member. When he first got here, he was door seeking and he had a [Wander Monitoring Device] on but after that I had not seen him in the hallways as often. The day he eloped it was sunny and breezy out; it was a nice day. He was wearing long sleeves, pants, loafer slippers with a rubber soul. He did not have any assistive devices when he left, and he was walking very well and confidently. He was not injured. An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 1/16/24 at 10:50 a.m. she said she was Resident #1's CNA on 12/20/23, the day he eloped. She said around 11:30 a.m. she was working with his roommate getting him ready and at the time Resident #1 was sitting on his bed. When I left the room . [Resident #1] was still sitting on his bed around 11:45 a.m. I went to help another resident and while I was doing that the therapist came in and said that someone else needed to use the bathroom. I told her to tell the resident's family that I will be there in a minute I just need to finish up with this resident. When I came out of the room the family was in the hallway screaming and yelling that his dad needed to use the bathroom right now. I told him I would go put my dirty linens away and be right there and he would not accept that. The ADON came over to diffuse the family member and she had asked me to step off the unit, so I went outside for about 15 minutes and the other CNA assisted the resident to the bathroom. I'm not sure where the nurse was at that time but I'm sure she was busy with a resident because this unit is the rehab [rehabilitation] unit, and it is always very busy. When I came back about 15 minutes later, I started to pass meal trays but before I could even pass one tray the ADON said [Resident #1] was missing and immediately everyone in the building started searching for him inside, outside, everywhere .When he came back, he did not have on his [Wander Monitoring Device] and he did not have any injuries thank god because that could have been really bad and he could've gotten really hurt. He walked well without any assistive devices, but he would get tired and would rest against the wall or sit down . Before he eloped, we would have to redirect him at least six or seven times a shift. When his [family] would visit and leave he would get more anxious and want to go home. He was definitely exit seeking and he did have a [Wander Monitoring Device] on his leg at one point because I would see it when he sat down and crossed his legs. He was alert but he was confused and easily redirected. The day he eloped I did not see a [Wander Monitoring Device] on him, but I also did not look. His [family] gave him a bath, shaved him, and got him dressed the night before so I did not have to do any of that in the morning and I usually check the [Wander Monitoring Device] when I do my baths . An interview was conducted with Staff C, CNA on 1/16/24 at 11:12 a.m. she said she was working the day Resident #1 eloped and she was not his CNA, but she was the other CNA on the hall. She confirmed Resident #1 was exit seeking and would need a lot of redirecting back to his room. He always wanted to go home. She said he walked well without any assistive devices he would just need to take breaks because he would get tired, and he would rest against the wall and just keep an eye on everything. An interview was conducted on 1/16/24 at 3:46 p.m. with Staff D, Human Resource (HR) she said on the day Resident #1 eloped there was an overhead page about a missing resident. She reported to the lobby and received a face sheet of the resident. As she was getting her search location Staff E, RN asked if he could drive with her. Staff D, HR said she drove out of the facility, went left, and after approximately 30 seconds she turned into a beauty salon. She said the beauty salon was located across the street from the facility. She said the resident was found sitting on a bench in front of the beauty salon and Staff E, RN got out of the car, talked to the resident for a minute, the resident walked independently with a steady gait back to the car. She said the resident got into the back seat and said I'm fine. and You're going to take me back. She drove Resident #1 and Staff E, RN back to the facility and dropped them off at the front door and went to park her car. She said she did not notice [Wander Monitoring Device], but she did not look for one. She said he did not have any injuries that she noticed. An interview was conducted on 1/16/24 at 4:00 p.m. with Staff F, Receptionist. She said on the day Resident #1 eloped she went on lunch break at 12:00 p.m. and Staff B, AD covered the receptionist desk. Staff F, Receptionist returned at 12:30 p.m. and she said when she came back everyone was a mess looking around for Resident #1 because the family member had called and said he was on the street waiting for her to pick him up. She said she asked if anyone had done an overhead page and they said they didn't, so she overhead paged for the resident to return to his room and when he didn't, she called a code silver. She said everyone continued to search for him. She was not sure where he was found. She said early the same morning between 9:00 a.m. and 10:00 a.m. the family member called her to have the nurse check on him because Resident #1 had called her and said he was leaving today and needed to be picked up. She paged the nurse and the nurse said he was in his room, and he was alright just confused because he was supposed to leave the next day. A phone interview was conducted on 1/17/24 at 8:44 a.m. with Staff E, RN. He said he heard the overhead page Resident #1 was missing. He said he had worked with him when he was first admitted and he was unable to walk but he knew the resident went to the hospital, came back, received rehabilitation, and saw him walking the halls without assistive devices and walked well. He said Resident #1 was confused. He said since he knew what the resident looked like, and he knew he could walk he went to check outside. When he went outside, he saw people were starting to get in their car and look, so he asked Staff D, HR if he could ride with her and she said yes, and they got into her car and went left out of the building, and he was looking for Resident #1. At the beauty salon he saw the resident sitting on the bench in front of their door. He [Resident #1] was confused, so I introduced myself to him, he did not recognize me, but he came right with me and got into the car. Staff E, RN said he brought the resident back inside the building and he heard the resident cut his wander monitoring device off. He said he spoke with the family, and they were not happy to the point they took him out of the facility right after that. He said after the elopement they did elopement education, supervision education, and did elopement drills but as of last week there is still confusion on exactly how the drills are supposed to be run. At first everyone was meeting in one area to get their assignments. Then everyone was staying in their areas to look but that did not get told to everyone so there was confusion. A phone interview was conducted on 1/17/24 at 10:28 a.m. with Resident #1's family member she said I was at my work, in my office it was close to noon time, 11:00-11:30 a.m., and he [Resident #1] called me and told me to go and pick him up. I thought he was just calling me from the facility but then he told me that he was on the street, and he told me [Street Name]. I was shocked because that was the name of the street the facility was on, and I thought how would he know that? I told him to wait right there. I called the facility to see if [Resident #1] was there in his room. So, everyone ran to his room, and he wasn't there, and they looked all around the facility and people were starting to drive around. I called my husband back and I said what is the name of the business you are in front of. I googled that business and I saw that it was all the way on the corner of the street .he said there are stairs and I told him to sit on the stairs I'm going to have someone pick you up. One person at the facility gave me their number so I called her, and she said she was driving in the opposite direction of where he said he was but someone else was going in that direction and the male nurse found him and brought him back to the facility and he was okay. Fortunately, [Resident #1] had his phone and he decided to call me, and I don't know what would have happened to [Resident #1] if he did not call me. I asked him how he got out, but he has memory problems and he said he hopped a fence, but the facility has security footage and he walked out of the front door, and he even signed himself out like he was a visitor. [Resident #1] is [AGE] years old, and he doesn't use a wheelchair or a walker. He did not need anything to walk at that point, so he looks like a visitor, but his mind is not right he has hallucinations and makes up stories. When he first got to the facility, he could not walk so he had a wheelchair, then he was able to use a walker, then he was able to walk on his own but still a little off balance. I was panicking because he has no memory and no sense of direction of where he was going to go .He probably just walked straight, then he got to the intersection and saw the street sign and probably did not know if he should go right or left so that is why he called me. Even if he had turned around, the road curves and you're not able to see the facility from where he was so he wouldn't know to go back there. Fortunately, I gave him his cell phone and it had enough charge on it, and he thought to call me. If those things did not happen, I don't know what would have happened to [Resident #1] if he did not think to call me. I make an effort to visit him every day, so I stay on his mind, so his mind does not forget me. He was definitely not safe to be outside by himself. When he came back to the facility for the second time after going to the hospital, they put a bracelet [Wander Monitoring Device] on him because he walked out of his room but that was probably on for only 3 or 4 days then I did not see it again. I just thought the facility took it off because he wasn't walking out of his room anymore because when I would visit him, he was always in his room but when they brought him back, they told me he took off the bracelet and they put a new one on him right away. I didn't feel comfortable with him there after this happened. Resident #1's family member said she took him home the day after he eloped. A phone interview was conducted on 1/17/24 at 12:10 p.m. with Resident #1's Physician. She said she was aware Resident #1 had eloped. She said He is a patient who looks pretty good, very well dressed, talks well, but he has encephalopathy and some dementia. He was let out by activities and the staff found him a little bit after. He looks like a visitor but if you didn't know him and you didn't talk with him for a while you would think he was a visitor. It was critical for him when he got out but when he was in the building, he was fine, he was always in his room sitting next to his bed. I was involved with their plan of correction to prevent this from happening again and I signed off on everything. An interview was conducted on 1/18/24 at 11:29 a.m. with Staff G, RN. She said, she was the nurse for Resident #1 on the day he eloped. She said she did not get anything in report about Residents #1's wander monitoring device and she did not check to see if his wander monitoring device was in place before he eloped. She said she gave Resident #1 his morning medications around 10:30 a.m. and 11:00 a.m. and he was sitting next to his bed. She said she had no concerns. She said Resident #1 would walk around the hallways and was an elopement risk. She said when Resident #1 returned from the elopement he did not have any injuries and he did not have a wander monitoring device on. She said he had a wander monitoring device put on when he returned. An interview was conducted with Staff I, Kitchen Manager, on 1/17/24 at 2:41 p.m. She said, it was around lunch time. I don't know what I was doing up here [the lobby]. I was going into the facility from the lobby. I was speaking to [Staff B, AD] at the desk and the gentleman [Resident #1] was coming out and I held the door for him to enter the lobby, he said hello, I said hello. He was moving slowly but steady and he had a brown bag in his hand so that is why I held the door for him. His pajama pants caught my eye to the point where I turned and watched him enter the lobby and I heard [Staff B, AD] say to him can you sign out, so I just thought he was a visitor, and she knew that. When he came back, I asked was he wearing pajama pants and they said yes, and I said oh no why didn't the alarm go off and that's when they realized he didn't have a [Wander Monitoring Device] on. In the kitchen not all the overhead pages could be heard during service. That has since been adjusted. The day of the elopement I just heard all the commotion, so I asked what is going on and that's how I found out he was missing. A phone interview was conducted with Staff H, RN on 1/17/24 at 3:08 p.m. She said she works the 7:00 p.m. to 7:00 a.m. shift. She said at the beginning of her shift, the night before Resident #1 eloped, she checked to see if he had his wander monitoring device on and it wasn't. She looked for another wander monitoring device but could not find one, so she did not put one on him. She said she did not increase supervision for the resident, and she only told the day shift nurse that he did not have his wander monitoring device on, and she could not find another one. She said the nurse charted on 12/20/23 the wander monitoring device was on the resident and when I came back after he eloped and found out about it, I asked her why she didn't put a [Wander Monitoring Device] on him, and she told me she was not really paying attention to what I was saying. Staff H, RN said 12/19/23 was the third time the resident did not have on his wander monitoring device and the second time she could not find a wander monitoring device to put back on him. The first time she realized he did not have on a wander monitoring device she told the Unit Manager and the Unit Manager said she needed one for another resident who was worse than him. So, I told the ADON I needed one and she told me she couldn't find one either. I told the day shift nurse, and she must have found one and put it on him because people were charting one was on him. After he eloped the Nursing Home Administrator told me I needed to call her and put the resident on 1 to 1 [supervision] if I can't find a [Wander Monitoring Device] but I did not know that. When I told my ADON and the Unit Manager they did not tell me I needed to do that. I asked around to other staff and some of them didn't know we had to put residents on 1 to 1 if there isn't a [Wander Monitoring Device] on the resident. I'm not sure if that education was just to me or to everyone but everyone should have gotten that education because not everyone knows about that. Review of Resident #1's IDT [interdisciplinary team] note dated 12/20/23 at 1:30 p.m. revealed, spoke to [Family Member] aware he is back in facility new [Wander Monitoring Device] applied to left ankle. IDT note dated 12/20/23 at 1:39 p.m. revealed Note Text: review elopement. [Family Member] called stated [Resident #1] was on [Street Name] waiting for her to pick him up staff went immediately found him sitting on a bench waiting for his [Family Member] assisted back to facility without difficulty stated I was going home. Full assessment done no obvious injury noted skin sweep done negative denied pain or discomfort [Resident #1's Physician] aware [Family Member] called aware he is back in facility found with no [Wander Monitoring Device] on ankle. New [Wander Monitoring Device] placed on left ankle. IDT note dated 12/20/23 at 4:00 p.m. revealed [Hospital] Social Worker notified Social Worker is aware of resident's behavior. stating the resident should be in a memory care unit where his needs could be met. Resident's [Family Member] will be driving [Resident #1] to the [Hospital] for further assistance. Review of Resident #1's Physician Progress Note dated 12/21/23 at 12:44 p.m. revealed Note Text: Progress Note . [Resident #1] is a pt [patient] with chronic ETOH [alcohol] use, dementia, hallucinations, his [Family Member] wants to take him to the [Hospital] for more assistance, psychologist evaluation, pt was found wandering in the street yesterday. He called his [Family Member] to give his location, and staff from the facility found him. Today I examined him, he is alert still confused. [Resident #1] was ready for discharge, physical therapy evaluated him. He was walking more than 300 feet, but his [family member] says she works, and the pt will be alone the all day [sic], she wants to transfer to the [Hospital] for more resource.Recommendations/Plan: .will transfer the pt to the [Hospital], following family wishes . An interview was conducted on 1/17/24 at 4:25 p.m. with the NHA, he said when he came to the facility on [DATE] he has just been doing the elopement drills with the post drill education. The RNC said audits are completed weekly. The RNC said she participated in the investigation via phone calls. The NHA said since I have been here, we ordered [Wander Monitoring Devices]. The RNC said, The NHA approves the order, and when they arrive, they are dispersed between all of the nurse's medication carts. The NHA said About two weeks ago a sister facility asked if we had an extra [Wander Monitoring Device], we gave them one and we noticed we did not have enough extra to make us feel comfortable, so we ordered more. The RNC said she told the old Assistant Director of Nursing (ADON) to distribute all the wander monitoring devices between the medication carts. An interview was conducted with the Director of Nursing (DON) on 1/17/24 at 5:00 p.m. she said we are not doing audits on the medication to ensure extra wander monitoring devices are stored in them. I have seen [Wander Monitoring Devices] laying around. I know I have seen one in my office and one in the old ADON's office. I have been doing medication cart audits for medication storage and I don't remember seeing any [Wander Monitoring Devices] but I was not looking for it. An interview was conducted on 01/17/2024 at 5:02 p.m. with the DON. She stated the facility had six medication carts, three on the west side of the building and three on the east side of the building. The six medication carts and nurse interviews were conducted in the presence of the DON. West Side: On 01/17/2024 at 5:06 p.m. an interview was conducted with Staff G, RN. She reported she had no residents on her assignment who had a wander monitor device present. A review of her medication cart revealed no presence of an extra wander monitoring device in the cart. Staff G, RN confirmed she did not have a wander monitoring device checker in her medication cart. On 01/17/2024 at 5:09 p.m. an interview was conducted with Staff K, Licensed Practical Nurse (LPN). A review of her medication cart revealed the presence of one extra wander monitoring device. Staff K, LPN, confirmed her medication cart did not have a wander monitoring device checker in it, but, she stated, Rehab has the checker, or she would take the resident to the door to [TRUNCATED]

Based on record review, observations, and interviews the facility 1) failed to hold scheduled interdisciplinary care conferences and notify resident representatives of care conferences within a time frame adopted by the facility's policy for five residents/representatives (#9, #33, #42, #51, and #62) out of 34 sampled residents, and 2) failed to revise the care plan for one resident (#33) out of 34 sampled residents related to the discontinuation of oxygen therapy. Findings included: 1) A review of Resident #9's Admission Record indicated the resident was admitted on [DATE]. The Admission Record for the resident included diagnoses not limited to right hand, right shoulder, and right elbow contractures, unspecified peripheral vascular disease, unspecified obesity, and Type 2 Diabetes Mellitus without complications. The record identified the resident was the responsible party with emergency contacts. The Annual Minimum Data Set (MDS) assessment, dated 6/18/23, for Resident #9 identified a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognition. On 7/24/23 at 10:35 a.m., Resident #9 reported a male staff member had asked about the care plan but, I was mad at them because they weren't doing it. The Care Conference Record for Resident #9, provided by the MDS Director, indicated the last care plan meeting was held on 6/14/22 in response to the quarterly assessment and was attended by the MDS Director, one other staff member, and not by the resident. The record did not include any comments regarding what was discussed. The Care Conference Record indicated the last note for Resident #9 was dated 12/7/21. A review of Resident 9's care plan indicated goals for the resident were revised on 3/24/23 with target dates of 10/8/23, and the last care plan review was completed on 7/10/23. The care plan did include 2 focuses, initiated on 6/26/23, that identified the resident had a mood disorder and used psychotropic medications related to (r/t) mood disorder. 2) A review of Resident #33's Admission Record identified an admitted [DATE] and included diagnoses not limited to hereditary spastic paraplegia and legal blindness as defined in USA. The record identified the resident was the responsible party with two family members listed as emergency contacts. The quarterly Minimum Data Set (MDS, dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. On 7/24/23 at 11:55 a.m., Resident #33 reported not knowing anything about that (care plan meeting) but has family members (available). The Care Conference notes, indicated the admission conference dated 12/7/21, was In Progress. The latest Social Service Progress note, dated 1/20/23 did not identify a care plan meeting was held with the resident but did mention a request was made by the family for a transfer to another facility. The care plan for Resident #33 indicated goals were revised on 1/4/23 and the latest care plan review was completed on 6/29/23. The care plan did include a focus, initiated on 5/5/23 that identified the resident had oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD) . On 7/25/23 at 2:11 p.m., the MDS Director reviewed the findings in Resident #33's record related to the care conferences. 3) A review of the Admission Record indicated Resident #42 was admitted on originally admitted on [DATE] and recently on 1/11/23. The record indicated a family member was the responsible party and health care proxy. The annual MDS assessment, dated 4/23/23, for Resident #42 identified a BIMS score of 14 out of 15 indicating an intact cognition. The care plan for Resident #42 indicated the resident did have a certificate of incapacity on file. The care plan identified the last review was completed on 5/12/23. On 7/25/23 at 2:03 p.m., the MDS Director stated the last care conference was on 7/19/22 and confirmed there was no documentation of a care plan meeting since 7/19/22. The Director reported having spoken with the resident but does not remember having a meeting in the last year. 4) A review of Resident #51's Admission Record identified an admitted [DATE] and a family member was the responsible party. The quarterly MDS, dated [DATE], indicated Resident #62 had an intact cognition, with a BIMS score of 15 out of 15. A review of Resident #51's Care Conference Record indicated the last care plan conference was held 2/2/22 and did not identify which items had been discussed. The care plan for Resident #51 indicated the last review was completed on 5/19/23. The MDS Director stated, on 7/25/23 at 2:20 p.m., she probably wouldn't see any quarterly note from Social Service (related to care plan meeting). The Director stated a meeting was supposed to be done quarterly in conjunction with the MDS quarterly assessment In an ideal world, and confirmed Resident #51 should have had a meeting in November and in May. 5) A review of the Admission Record for Resident #62 identified an admitted [DATE] and that the resident was the responsible party. The Annual MDS, was dated 6/16/23, and indicated the resident had a moderate cognition impairment as evident by a BIMS score of 9 out of 15. On 7/24/23 at 12:59 p.m., Resident #62 stated not knowing about participation in care planning. A review of the hard copy chart on 7/26/23 at 6:48 a.m., revealed it did not contain any care plan meeting information. The last Social Service note in the chart was dated 12/14/22 and indicated that a missing cell phone was located in the residents bed linens. The Social Service notes, dated 7/6/22 to 2/1/23 did not indicate that a care plan meeting had been held with the resident or representative. A review of the assessments that were opened for Resident #62 indicated a Care Conference Record was not available. The review of Resident #62's care plan revealed the last review was on 7/10/23. On 7/25/23 at 2:29 p.m., the MDS Director reviewed the binder, which contained records of care conferences for the residents, and stated Resident #62 did not have a record. The Director stated if the Care Conference Record in the assessments was not available, one had not been opened for the resident. During an interview on 7/25/23 at 2:03 p.m., the MDS Director stated usual attendees of care plan meetings were Social Services, therapy if the resident was skilled, MDS, and the nursing manager. The Director stated he had been in the building for about year and half, and a letter announcing the care plan meeting was placed on the table in the residents' room if alert and oriented, otherwise they call the representative the day of the meeting, and he only documents when they attend. The MDS Director stated Social Services have been in and out (of the facility), 8 Social workers in the last year, Administrators in and out, and 10 Directors of Nursing in the last year. The MDS Director stated the facility does okay for the short-term residents due to discharge planning but not so good for the long-term residents. The Regional MDS Registered Nurse (RN) stated, 7/25/23 at 4:51 p.m., that care plans should be done on admission, reviewed quarterly with the MDS (assessment) and as needed. The attendees should include the resident, if resident is not alert and oriented whoever is responsible, if alert and oriented ask the resident if they would like to invite whoever, Social Services, Dietary, Therapy if receiving, Activities, and nursing - usually the Unit Manage or nurse who was responsible for the resident. The Regional MDS stated family should be notified 7-14 days prior to the meeting either by telephone and documented or by letter to the address (on record) and the notes should indicate what was discussed and who attended. A review of the letter announcing the resident's care plan meetings revealed the following: The team and (facility name) believe a meeting with the resident and/or resident representative is an important part of our planning process in order to provide the highest quality of Patient Centered Care. Your input is greatly appreciated and valued in this process. The policy - Plans of Care, effective 11/30/14 and revised 9/25/17, indicated the following procedure: - Develop and implement an Individualized Person-Centered comprehensive plan of care by the Interdisciplinary Team that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professional in disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable, the participation of the resident and the resident's representative(s) within seven (7) days after completion of the comprehensive assessment (MDS). The policy - Care Plan Invitation, effective 11/30/14 and revised 9/25/17, indicated the following: The resident and/or the resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conferences for the specified resident. The procedure instructed to Deliver a Care Planning Invitation to the resident 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. If resident has capacity, ask if they wish to have the resident representative at the care conference. Per resident choice or determination of capacity, mail Care Planning Invitation to the resident representative 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. Have all attendees to the Care Planning Conference, including resident and resident representatives sign the Care Plan Conference Record to verify their attendance. The policy - Care Conference, effective 11/30/14 and revised 10/1/19, indicated the following: The Center will hold regularly scheduled interdisciplinary care conferences for the purpose of planning and developing the resident's individualized plan of care, and providing communication between the Interdisciplinary Team (IDT), resident, and/or resident representative. The procedure indicated that The resident and/or the resident representative shall be invited to attend each of the Interdisciplinary Care Planning Conference for the specified resident. The procedure revealed that each discipline should be prepared to discuss the resident's problems, strengths and goals and identify strategies and/or interventions to address areas of opportunity. The Care Conference Record should be maintained in the medical record. 6) The review of Resident #33's Admission Record identified an admitted [DATE] with diagnoses that included but not limited to acute respiratory failure with hypoxia (onset date 4/7/22), unspecified chronic obstructive pulmonary disease (onset 12/4/19), and shortness of breath (onset 12/4/19). The quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #33 had shortness of breath or trouble breathing when lying flat. The quarterly assessments on 12/29/22 and 6/28/23 and the annual assessment dated [DATE] did not indicate that the resident received oxygen therapy. The Order Summary Report, active as of 7/26/23 at 5:39 p.m., did not include a physician order for Resident #33 to receive oxygen. The Weights and Vitals Summary indicated from 4/17/22 at 3:42 p.m. to 7/20/23 (the last recorded oxygen saturation) the residents oxygen saturation was valued while the resident was on room air. An observation and interview of Resident #33 at 11:51 a.m. on 7/24/23 and on 7/26/23 at 10:45 a.m. did not reveal the resident was wearing oxygen while lying mostly flat with shortness of breath. On 7/26/23 at 4:26 p.m. the resident reported not using oxygen and no oxygen equipment was observed in the room. The care plan for Resident #33 identified a focus area as: Resident has oxygen therapy related to chronic obstructive pulmonary disease (COPD), initiated and revised on 5/5/23. The interventions included Oxygen Settings: O2 per MD orders initiated and revised on 5/5/23. On 7/27/23 at 1:35 p.m., an interview was conducted with Staff P, Licensed Practical Nurse (LPN) and Staff B, Registered Nurse/Unit Manager (RN/UM). Staff P reported not thinking Resident #33 had oxygen and left the area to check. Staff B reviewed the resident's orders and stated the resident did not have an order for oxygen. Staff B reviewed the resident's care plan and stated the residents' care plan for oxygen therapy should have been resolved. Staff P returned and confirmed the resident did not have oxygen. The staff members stated Resident #33 did not utilize oxygen during their tenure (2-3 months) at the facility. The policy - Plans of Care, effective 11/30/14 and revised on 9/25/17, indicated the following: 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 identified that the facility Review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs or the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure 1) One of one Dish Washing machines were operating per final rinse requirements during two of four days observed, on 7/24/2023 and 7/25/2023; and 2) One of one rental walk in freezer unit observed with heavy ice build up inside the unit during two of four days observed, on 7/24/2023 and 7/25/2023. Findings included: 1) On 7/24/2023 at 7:24 a.m. the facility's kitchen was approached and met with the Kitchen Manager Staff A. She indicated she has not been employed at the facility long but long enough to know her kitchen, her staff, and how to operate the kitchen. Staff J. revealed they have a Registered Dietician who routinely comes to the facility on Monday's and is usually available for contact during other days of the week. Since it was still early and the kitchen staff were just starting with plating meal trays for breakfast, it was determined that the dish washing machine had not been operating as of yet. Staff A. revealed they would be operating the dish washing machine at around 8:30 a.m.--9:00 a.m. Staff J. stated the dish washing machine was operating effectively and has not had any recent repairs, and stated the machine was a High Temperature machine. At 9:00 a.m. the Kitchen was toured with Staff J. She pointed out the dish washing machine was not being used and it could be observed for operation. She said they had some temperature issues about one month ago (6/2023), and that temperatures were not reaching appropriate temps for wash and rinse. She revealed the dish machine maintenance company had come in to look at the machine and he fixed it but at the same time he installed a sanitizing option to work in conjunction with the high temperatures. Staff J. was not sure why the service person did that, as they operate with a High Temperature machine only. She was asked if she and her staff then take sanitizer reading for each meal service to see if the sanitizer is pumped out and through the machine appropriately. She revealed she was not sure. The Staff member who was operating the machine during this observation, Staff K. confirmed the dish machine was a High Temperature machine and was not sure why there was sanitizer being pumped into the machine. Staff J. and K. were asked if they document dish machine temperatures for both the Wash and Rinse cycle and if they document the Parts Per Million (PPM) levels as well. Staff J. revealed they do have a daily log sheet and log those things every meal service, every day. Staff J. pointed out the dish machine log, which was posted on the wall around the corner of the dish machine. The current 7/2023 month log revealed Breakfast service wash temperatures ranging from 170 degrees F. to 189 degrees F. dating 7/1/2023 - 7/24/2023. The final rinse for Breakfast service ranged from 177 degrees F. to 185 degrees F. during the same date time frame. Further review of the log revealed staff documented sanitizer PPM range at 200 PPM each day from 7/1/2023 - 7/24/2023. A review of the Lunch meal service wash temperatures ranged from 170 degrees F. to 185 degrees F. and rinse ranging 175 degrees F. to 190 degrees F. during the same date time frame, and also with documented PPM at 200. The Dinner meal service wash temperatures ranged from 170 degrees F. to 185 degrees F. and with the rinse temperatures ranging from 180 degrees F. to 190 degrees F., also during the same date time frame. Further, staff documented the PPM each day at 200. Staff J. was asked why staff documented the sanitizer Parts Per Million (PPM) at 200 each day, when the dish machine was noted as a High Temperature machine. She did not know exactly other than that was why the dish machine service man installed a few weeks ago. Staff J. and Staff B. could not answer as to how they determined 200 ppm on a daily basis. Further, Staff J. and K. were asked if they had any sanitizer litmus paper test strips to take sanitizer readings and they both indicated that they did not have test strips available and have not been using them to take sanitizer PPM readings. Staff J. and Staff K. were again asked how they came to the conclusion of documenting 200 PPM each day and each meal service, with relation to the sanitizer. Neither Staff J. or Staff K. had an answer as to why they documented 200 PPM each day. At this time Staff J. was asked if they could run a temperature demonstration for both the wash and rinse cycle. At 9:38 a.m. Staff K. was observed to run a plastic crate of dishes through the machine. Staff J. was present during the demonstration and it was observed: The wash cycle gauge reached around 168 - 169 degrees F., and the final rinse gauge when the rinse cycle started, only reached 145 - 146 degrees F. Staff J. and K. both indicated the machine was running fine just moments before this observation and the temperature for rinse was in the 170's. Staff J. confirmed the final rinse cycle temperature did not reach the required temperature. At 9:40 a.m. a second crate of dishes was run through and again the wash temperature reached 168 - 169 degrees F., and the rinse temperatures only reached around 145 degrees F. Both wash and rinse cycle was confirmed by Staff J., Kitchen Manager. Staff J. again indicated the final rinse was not reaching the required temperature. She stated she would immediately call the dish machine maintenance service person and get him/her out to the facility to look at the machine to see what was wrong. She also indicated until he/she comes and fixes the machine, they would now provide residents with paper and plastic eating ware only. She was then asked how the sanitizer is actually measured and she again confirmed that there is no way and that they had just thought when the dish machine maintenance company installed the sanitizer option, that it reached 200 ppm. There was no actual testing of the sanitizer during both machine cycle demonstrations. On 7/26/2023 at 9:42 a.m. the kitchen was visited to observe the dish machine operation. Once entered the dish machine area, there were two employees Staff L. and Staff K. observed operating the dish washing machine. Staff K. was observed bringing soiled dishes into the dish machine room while Staff L. was observed placing dishes into empty plastic crates and feeding the crates of dishes into the machine. An interview with Staff L. revealed she was knowledgeable of the machine's use and indicated the dish machine was a High temperature machine and wash temperatures are to reach at least 160 degrees F. and above, and rinse temperatures are to reach at least 180 degrees F. and above. Staff L. confirmed there is no need for sanitizer to run through the machine and that as of yesterday (7/25/2023), they are no longer pumping sanitizer in the machine. While interviewing Staff L., Staff J. confirmed the dish machine maintenance company came out to look at the machine yesterday 7/25/2025 and indicated there was a problem with a part that keeps the required water flow temperature through the machine. The Kitchen Manager Staff J. revealed the machine was fixed and the wash temperature now reached around 170 degrees F., and the rinse temperatures reaches around 185 - 190 degrees F. At 9:47 a.m. dietary aide Staff L. ran a plastic crate of dishes though the machine and the following was observed: The wash temperature reached 170 degrees F., and the Rinse temperature reached 190 degrees F. A second demonstration revealed a plastic crate of dishes ran through the machine at 9:48 a.m. with the wash temperature reaching 170 degrees and the rinse temperature reaching 197 degrees F. Staff J. was asked about the container of sanitizing liquid on the ground, placed under the dish machine. She revealed the dish machine maintenance company removed the tubing from the bottle and dish machine connection and indicated that sanitizer is not needed with regards to a High temperature machine. Staff J stated she inserviced her staff with regards to the proper use of the machine and they are not to document Parts Per Million (PPE) sanitizer results on the machine daily temperature log. Staff J. was still not sure why her staff were documenting 200 PPM each day and during each meal service, when they do not have any test strips to take a reading. On 7/26/2023 at 11:20 a.m. the Kitchen Manager Staff J. provided the specifications for the dish washing machine which revealed the following: (Machine is a Conveyor Drive Motor with a Wash motor and Wash heater. The specifications further revealed the machine is to be used as a Hot water Sanitizing machine to include minimum wash temperature at 160 degrees F., and minimum rinse temperature at 180 degrees F. On 7/26/2023 at 11:30 a.m., the Kitchen Manger Staff J. provided the surveyor with a dish machine maintenance service report, dated 7/25/2023. The report was dated one day after the machine had been observed with rinse temperatures not meeting requirement; which was on 7/24/2023. The report revealed; Extra Service Request, Request Description: Temperature issues. Service comments section of the report revealed; Upon arrival Machine was only reaching 140 degrees F. on the final rinse temperature gauge noticed it would only stop at 140 degrees F. and nothing higher, replaced temperature gauge on the final rinse now is reaching 180 +. Machine can be used as high temp spike with customer and told them they can remove the sanitizer off dish machine. There was no indication from the report as to why sanitizer option was utilized in the first place. The machine had not been operated as a Low Temperature dish washing machine previously, as per interview with all the kitchen staff to include the Kitchen Manager Staff J., and Kitchen aides Staff K. and L. 2) During kitchen tour on 7/24/2023 at 7:24 a.m., The Kitchen Manager Staff J. pointed out she has two reach in refrigerators and one is currently down and not working. She pointed out the see through glass door reach in and there was a note on it that indicated not working. Staff J. revealed this reach in had stopped working about three or four days ago and maintenance had been notified. She demonstrated and verbalized there was nothing stored in this reach in and there would not be any food stored in the reach in until it gets fixed and reading temps are under 40 degrees F. The tour continued to the walk in refrigerator and it appeared stocked with food items. Staff J. revealed the walk in freezer, located within the walk in refrigerator, was also out of order and that there was at this time no food stored in it. Staff J. verified there was no food stored in this unit. Staff J. revealed the walk in freezer had been out of order for about four weeks now and at this time they have a rented freezer trailer, that is located out in the back parking lot area. The outside walk in freezer (rented freezer trailer), was observed with the door completely shut. The seals to the door appeared in good working order and there were plastic flap strips used as a barrier to the elements. Upon entering the trailer freezer, there were various boxes of food items stored on shelves inside the unit. The back of the freezer was observed with an air conditioned chiller unit that was heavily caked with built up icing and ice [NAME]. There was a three shelved storage unit under the air conditioned chiller that was also heavily built up with ice. There was no food stored on any of the shelves. The floor directly to the right side of the three shelved cart was also observed with heavy ice build up with measured approximately three feet length, four feet wide, and approximately twelve inches high at the highest point of the ice build up pile. There was a bucket placed on top of the ice build up pile with a ladle inside. The bucket was heavily built up with ice. Photographic evidence was taken. An interview with the Kitchen Manger Staff J. revealed there had been leveling problems with the trailer freezer and back flow water was supposed to go through to a hose, and then outside of the unit and then to the concrete ground. She stated because of the way the trailer freezer sat, the water flowed back into the actual freezer and then the water froze, causing what was observed. She stated the freezer unit has had this problem for a week or so and have only had this unit for about four weeks. Staff J. further stated the maintenance department was aware of the situation and has made adjustments, but it seems it never got fully fixed. Staff J. stated the inside of the freezer unit should not be with ice build up. The analog temperature gauge inside the unit revealed 28 degrees F. On 7/25/2023 at 9:50 a.m. the outside walk in rental freezer was again observed. Staff J opened the door and the same heavy icing as observed. Staff J. revealed she had mentioned the problem to the Maintenance Director yesterday and she believed he, or the Administrator, had called the rental company to let them know of the heavy icing issue. She was not sure what the outcome of the communication was. The analog thermometer inside this freezer read 28 degrees F. On 7/26/2023 at 11:17 a.m. the kitchen was toured with Staff J. She stated they received another walk in freezer trailer rental during the night. The freezer was observed and the new one was stocked with food items and free from icing, free from frost build up. The inside temperature thermometer read 27 degrees F. Staff J. revealed the rental company did not have any written documentation to include instructions of use, and the company representative verbalized how to use the unit. On 7/27/2023 at 10:58 a.m. an interview with the Maintenance Director revealed the facility's main kitchen walk in freezer, which is within the walk in refrigerator has been out of commission for about three weeks and he had to await for parts to come in and then assistance with install. He confirmed the facility management had ordered a rental trailer freezer to use until the main freezer gets repaired. He revealed it was brought to his attention this past week that the rental freezer had created heavy icing, and ice frost build up and had to call the rental company to replace with another unit. The Maintenance Director revealed the rental company did not leave specific directions on its use but it was verbally gone through with him. He revealed if there are any problems, he or management will call the rental company and they will come and fix or correct the problem. The Maintenance Director did not have a policy and procedure with regards to rental freezer unit. The Maintenance Director revealed he was not made aware of the dish machine not maintaining the correct wash/rinse temperatures until 7/25/2023. He did say however, that the facility management called out the dish machine maintenance service representative and he/she came out to do the repairs and to his knowledge the machine is now working properly. On 7/27/2023 the Nursing Home Administrator (NHA) provided the following policy and procedures for review: 1. Warewashing, dated with a revision date of 9/2017, revealed; All dishware, service ware, and utensils will be cleaned and sanitized after each use. The Procedure section of the policy revealed: 1. The Dining Service staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware, 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature machines, 3. Temperature and/or sanitizer concentration logs will be completed, as appropriate, and 4. All dishware will be air dried and properly stored. The policy also indicated; Attachment 1. Dish Machine log. Review of the attached Dish Machine log revealed; template to document Wash, Rinse temperatures and sanitizer Parts Per Million (PPM), for all three meal services, and to include every day of the month. The log had a Standards section at the bottom of the page that revealed; High Temp Machine: Wash = 150 - 160 degrees F., Rinse 180 degrees F. The sheet also revealed; Always defer to manufacture's guidelines regarding temperatures and correct chemical concentration for use. Per interview with he Nursing Home Administrator, there was no equipment to include walk in freezer policy and procedure for review.

Based on interview and record review, the facility failed to meet professional standards of Quality Nursing Care as per the Florida Nurse Practice Act for 2 (#1, #3) of 4 sampled residents related to administration of a controlled narcotics, one of which was not prescribed for the resident (#3) with a known allergy. This resulted in lethargy, hypotention and a transfer to a local hospital. The Florida Nurse Practice Act 464.003. 3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed pediatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Findings include: 1. According to the clinical record face sheet, Resident #3 was originally admitted to the facility on [DATE], and most recently on 3/3/12 after a hospitalization for a fractured arm and a [MEDICAL CONDITION]. Other medical [DIAGNOSES REDACTED]. She is listed on the face sheet and the physician's orders [REDACTED]. On 4/19/12, a review was conducted of Resident #3's clinical record. An entry in the nurse's notes that was dated 4/6/12 at 11:00 p.m. stated, " medication was given to the wrong patient. A call was placed to (the physician)-orders received to monitor patient through night due to allergy to [MEDICATION NAME] sulfate. Monitor respirations. Daughter also notified. Pt. is alert with confusion. Knew I was the nurse. Vital signs 97.7-74-18-b/p-128/70." Further review of the clinical record revealed that there was no documentation of what specific medication that Resident #3 received in error from the time that it was administered until two days later on 4/8/12, after the resident had been admitted to the hospital. Upon further review of Resident #3's clinical record, there were no subsequent vital signs or respirations documented through the night of 4/7/12. An entry timed 6:45 a.m. on 4/7/12 stated, "Resident has been stable no adverse reactions no respiratory distress," and then on 4/7/12 at 7:30 a.m. the nurses notes stated, "appears lethargic, but arousable. At breakfast fairly with assistance." The next entry in the nurse's notes was dated 4/7/12 and timed 1:00 p.m., and stated, "Daughter here. Upset. States her mom's legs are cold like ice. Daughter wheeled her in her room-put her back to bed. Resident more alert and responsive. 'I want a Dr. to check her out here right now.' Supervisor came in check her-VS 104/68-72-22-temp 98.4. Moving all extremities. Pedal pulses present both legs. Remains in no distress. Doctor called and said to send resident to ER if she wants her checked." A subsequent entry timed 3:30 p.m. stated, "Ambulance refused to take patient. She needs to be monitored. Put on the EKG monitor. They are not equipped to do so. Resident has history of heart problem. Call 911 to come and take patient." The last two entries in the nurses notes were dated 4/8/12, the day after Resident #3 was admitted to the hospital. There was no specific time documented for the entries, and they stated, "Weekend Coordinator spoke with ICU nurse providing care for resident and clarified resident received [MEDICATION NAME] 60mg ER and [MEDICATION NAME] 600mg at approximately 2330." Continued review of the clinical record revealed that Resident #3 was allergic to [MEDICATION NAME]. On 4/19/12 at 11:14 a.m., an interview was conducted with the Assistant Director or Nursing (ADON), who confirmed that Resident #3 received [MEDICATION NAME] Extended Release 60 mg by mouth at approximately 10:30 p.m. on 4/6/12 in error, as this was not a medication that was prescribed for her. She stated that she first learned of this error from the Weekend Supervisor who called her in the late morning or early afternoon on 4/7/12 to report this error. The ADON described her conversation with the weekend supervisor as, "I was basically asking what had happened, what orders the Doctor had given and how the resident was doing." She stated that she then spoke with the Licensed Practice Nurse ( LPN) Employee A, who was identified as the nurse that was assigned to Resident #3 when the medication error occurred. She stated that she confirmed that [MEDICATION NAME] 60 mg Extended Release had been given to Resident #3 in error by the LPN that was assigned to Resident #3. The ADON also confirmed that Resident #3's family had visited in the afternoon of 4/7/12 and observed a change in Resident #3, and asked the facility to have a physician evaluate Resident #3. She stated, "Well, I know that the weekend supervisor said that the family wanted the resident to be evaluated by a physician, but Doctor said that she was not able to come in, and to transfer the resident to the hospital." She also stated that the nurses had told her on the telephone that afternoon when she asked about Resident #3's condition, that she was "was just a little bit sleepy." The ADON also confirmed that Employee A had told her that in addition to the [MEDICATION NAME] Extended Release 60 mg by mouth, the resident had also received an additional dose of [MEDICATION NAME] 600 mg po (by mouth) 2230 as well. The ADON confirmed that the medications that Resident #3 had received in error on 4/6/12 were not documented anywhere in Resident #3's clinical record at the time that she was transported to the hospital. She confirmed that this was added to the clinical record on 4/8/12, one full day after Resident #3 had been admitted to the hospital, and was then in the Intensive Care Unit. She also confirmed that Resident #3 was listed in the clinical record as being allergic to [MEDICATION NAME]. In an interview on 4/19/12 at approximately 1:50 p.m., the facility's corporate consulting registered nurse confirmed that the nurses notes that were dated 4/6/11 at 11:00 p.m., stated, "monitor patient thru night due to allergy to ms ([MEDICATION NAME] sulfate). Monitor resp. (respirations.)" She also confirmed that between the time of the medication error that occurred at approximately 10:30 p.m., on 4/6/12 and approximately 18 hours later when the resident was finally transported to the hospital at approximately 4:30 p.m. on 4/7/12, with an altered level of consciousness and [MEDICAL CONDITION], that there were only two sets of vital signs including respirations that were documented in the clinical record, at 1:00 a.m., on 4/7/12, and again twelve hours later at 1:00 p.m., on 4/7/12. A review of the facility's Resident Transfer Form indicated that Resident #3 was transported by Emergency Medical Systems (EMS) ambulance on 4/7/12. A review of the EMS records revealed that the resident was transported at 4:30 p.m. An entry by the Emergency Department physician that was dated 4/7/12 at 4:51 p.m., stated that Resident #3 became hypotensive in the ambulance en route to the emergency room and her blood pressure was 60's/30's. He also indicated that Resident #3 had a medical history that included a recent [MEDICAL CONDITION] (NSTEMI) and had stents placed in three coronary arteries. A second entry timed 7:12 p.m., stated " The patient has potential for rapid decompensation because of opioid intoxication. Pt given [MEDICATION NAME] 2mg on presentation and she went from somnolent state wit [MEDICAL CONDITION] in 70's and returned to 90's with [MEDICATION NAME]. She was transferred to the Medical Intensive Care Unit." 2. According to the face sheet & the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's care plans were listed as: falls, Foley, incontinence, pressure ulcer, sad expression, pain, hospice, activities, dietary, impaired skin, mobility and mood. On 4/19/12 at 9:15 a.m. and at 1:00 p.m., the resident was located in bed resting with her eyes closed. Nursing assessment notes, dated 4/18/12, listed a steady decline. According to the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/1712 the resident was ordered [MEDICATION NAME] sulfate at 100mg/5ml solution every 4 hours while awake. The medication times of administration were: 12:30 a.m., 4:30 a.m., 8:30 a.m., 12:30 p.m., 4:30 p.m. and 8:30 p.m. On 04/02/12 at 8:00 p.m., the medication was noted as not given; however, there was no written indication (on the MAR indicated [REDACTED]. On 04/06/12 at 4:30 a.m., the medication was noted as not given as prescribed because the resident was lethargic. On 04/8/12 at 4:30 a.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/8/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/10/12 at 4:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/10/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/12/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/13/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/14/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/16/12 at 8:30 p.m., the medication was noted as not given as prescribed because the resident refused the medication. On 04/18/12 at 12:30 a.m., the medication was noted as not given as prescribed because the resident was lethargic. According to the Doctor's order sheet and the nurses' notes, there was no call, to the Doctor, explaining that Doctor's orders had not been followed. There was no call to the Doctor explaining that the medication had been withheld, at various times and dates, due to the resident being lethargic and/or refusing the medication. Notifying the doctor of a resident's frequent medication refusal and a resident's lethargy is important regarding the resident's comfort, health, safety & proper dosing regarding narcotic use for the resident who had [MEDICAL CONDITION] and was on hospice services. There was no documentation on the MAR, the nurses' notes or other as to: the reason why the resident refused the medication for the above dates; nor was there patient teaching documentation regarding consequences of refusing medications. The nurses' notes (progress notes) for this resident jumped from 3/18/12 - 4/10/12; and, then again another jump from 4/10/12 - 4/19/12. There was no charting, in the nurses' notes, for this resident for 22 days and then again for18 days; this made process difficult to follow. The corporate nurse was asked by the surveyor, "it is difficult for me to know what's going on with this resident because of the charting." The corporate nurse gave a general statement of, "this is a hospice resident." No further information was provided regarding the 22 day & 18 day lapse in charting regarding the nurses' notes. On 04/19/12 at 9:30 a.m., the surveyor asked the ADON for documentation that the Physician was called regarding the medication not being given as per physician's orders [REDACTED]. The ADON mentioned, "the nurse should have documented her information." On 04/19/12 at 11:30 a.m., the surveyor asked the corporate nurse regarding documentation that the Physician was notified of medication not given as per physician's orders [REDACTED]." No proof of Physician notification was provided by end of survey. The corporate nurse did provide a pharmacy service policy, dated 5/10/10, which stated: the facility should notify the Physician of refusal of treatment; and, the facility should notify the Physician immediately if the refused medication could affect the health & safety of the resident. Additionally the April 2012 MAR indicated [REDACTED] On 4/5/12 at 8:30 p.m., the once daily medication [MEDICATION NAME] DR 135mg for [MEDICAL CONDITION], was not marked as being given; there was no indication in the MAR, nurses' notes or other as to why the medication had not been given.

Based upon interview and clinical record review, the facility did not ensure that it was free of significant medication errors for one (#3) out of four residents concerning narcotic use. Administration of an extended release controlled narcotic that was not prescribed for resident #3, with a known allergy, resulted in lethargy, [MEDICAL CONDITION] and transfer to a local hospital. Findings include: According to the clinical record face sheet, Resident #3 was admitted to the facility most recently on 3/3/12 after a hospitalization for a fractured arm and a [MEDICAL CONDITION]. Other medical [DIAGNOSES REDACTED]. She is listed on the face sheet and the physician's orders [REDACTED]. On 4/19/12, a review was conducted of Resident #3's clinical record. An entry in the nurse's notes that was dated 4/6/12 at 11:00 p.m. stated, "medication was given to the wrong patient. A call was placed to (the physician)-orders received to monitor patient through night due to allergy to [MEDICATION NAME] sulfate. Monitor respirations. Daughter also notified. Pt. is alert with confusion. Knew I was the nurse. Vital signs-97.7-74-18-b/p-128/70." Further review of the clinical record revealed that there was no documentation of what specific medication that Resident #3 received in error from the time that it was administered until two days later on 4/8/12, after the resident had been admitted to the hospital. The last two entries in the nurses notes that were dated 4/8/12, no specific time documented, stated, "Weekend Coordinator spoke with ICU nurse providing care for resident and clarified resident received [MEDICATION NAME] 60mg ER (extended release) and [MEDICATION NAME] 600mg at approximately 2330 (10:30p.m.)." The last entry, dated 4/8/12(no time), stated that the physician was notified of the specific medications given in error. According to the Geriatric Dosage Handbook 13th Edition: [MEDICATION NAME] is listed as an [MEDICATION NAME], Narcotic with a Warning/precaution: May cause respiratory depression; use with caution in patients (particularly elderly or debilitated) ... may cause [MEDICAL CONDITION] in patients with acute [MEDICAL CONDITION] infarction ...Elderly may be particularly susceptible to CNS depression [MEDICATION NAME] is listed an Anticonvulsant with Drug interactions CNS depressant: Sedative effects may be additive with CNS depressants; includes: ...narcotic [MEDICATION NAME] and other sedative agents. Monitor for increased effect. Upon further review of Resident #3's clinical record, there were no subsequent vital signs documented through the night of 4/7/12. An entry timed 6:45 a.m., on 4/7/12, stated, "Resident has been stable no adverse reactions no respiratory distress," and then on 4/7/12 at 7:30 a.m. the nurses notes stated, "appears lethargic, but reusable. Ate breakfast fairly with assistance." The next entry in the nurse's notes was dated 4/7/12 and timed 1:00 p.m., and stated, "Daughter here. Upset. States her mom ' s legs are cold like ice. Daughter wheeled her in her room-put her back to bed. Resident more alert and responsive. 'I want a Dr. to check her out here right now.' Supervisor came in check her-VS 104/68-72-22-temp 98.4. Moving all extremities. Pedal pulses present both legs. Remains in no distress. Dr. called and said to send resident to ER if she wants her checked." A subsequent entry timed 3:30 p.m. stated, "Ambulance refused to take patient. She needs to be monitored. Put on the EKG monitor. They are not equipped to do so. Resident has history of heart problem. Call 911 to come and take patient." On 4/19/12 at 11:14 a.m., an interview was conducted with the Assistant Director or Nursing (ADON), who confirmed that Resident #3 received [MEDICATION NAME] Extended Release 60 mg by mouth at approximately 10:30 p.m. on 4/6/12 in error, as this was not a medication that was prescribed for her. She stated this error was made by Employee A, a Licensed Practical Nurse (LPN). She stated that she first learned of this error from the Weekend Supervisor who called her in the late morning or early afternoon on 4/7/12 to report this error. The ADON described her conversation with the weekend supervisor as, "I was basically asking what had happened, what orders the Dr. had given and how the resident was doing." She stated that she then spoke with the Employee A on the telephone. She stated that she confirmed that [MEDICATION NAME] 60 mg Extended Release had been given to Resident #3 in error by Employee A who had been assigned to Resident #3 for the 3:00 p.m. to 11:00 p.m. shift on 4/6/12. The ADON also confirmed that Resident #3's family had visited in the afternoon of 4/7/12 and observed a change in Resident #3, and asked the facility to have a physician evaluate Resident #3. She stated, "Well, I know that the weekend supervisor said that the family wanted the resident to be evaluated by a physician, but the Physician said that she was not able to come in, and to transfer the resident to the hospital." She also stated that the nurses had told her on the telephone that afternoon when she asked about Resident #3's condition, that she was "was just a little bit sleepy." The ADON also confirmed that the LPN had told her that in addition to the [MEDICATION NAME] Extended Release 60 mg by mouth, the resident had also received an additional dose of [MEDICATION NAME] 600 mg 2230 as well. [MEDICATION NAME] is an anticonvulsant for which the resident already had an order for [REDACTED].#3 had received in error on 4/6/12 were not documented anywhere in Resident #3's clinical record at the time that she was transported to the hospital. She confirmed that this was added to the clinical record on 4/8/12, one full day after Resident #3 had been admitted to the hospital, and was then in the Intensive Care Unit. She also confirmed that Resident #3 was listed in the clinical record as being allergic to [MEDICATION NAME]. In an interview on 4/19/12 at approximately 1:50 p.m., the facility's corporate consulting registered nurse confirmed that the nurses notes that were dated 4/6/11 at 11:00 p.m., stated, "monitor patient thru night due to allergy to ms ([MEDICATION NAME] sulfate). Monitor resp. (respirations.)" She also confirmed that between the time of the medication error that occurred at approximately 10:30 p.m., on 4/6/12 and approximately 18 hours later when the resident was finally transported to the hospital at approximately 4:30 p.m. on 4/7/12, with an altered level of consciousness and [MEDICAL CONDITION], that there were only two sets of vital signs including respirations that were documented in the clinical record, at 1:00 a.m., on 4/7/12, and again twelve hours later at 1:00 p.m., on 4/7/12. A review of the facility's Resident Transfer Form indicated that Resident #3 was transported by Emergency Medical Systems (EMS) ambulance on 4/7/12. A review of the EMS records revealed that the resident was transported at 4:30 p.m. An entry by the Emergency Department physician that was dated 4/7/12 at 4:51 p.m., stated that Resident #3 became hypotensive in the ambulance en route to the emergency room and her blood pressure was 60's/30's. He also indicated that Resident #3 had a medical history that included a recent [MEDICAL CONDITION] (NSTEMI) and had stents placed in three coronary arteries. A second entry timed 7:12 p.m., stated "The patient has potential for rapid decompensation because of opioid intoxication. Pt given [MEDICATION NAME] 2mg on presentation and she went from somnolent state with [MEDICAL CONDITION] in 70's and returned to 90's with [MEDICATION NAME]. She was transferred to the Medical Intensive Care Unit."