Every finding on record at Courtyards of Orlando Care Center and Rehab

Based on interview, and record review, the facility failed to follow physician orders for medication administration for 5 of 5 residents reviewed for medication administration, of a total sample of 45 residents, (#112, #3, #94, #5, and #67).Findings:1. Resident #112 was admitted to the facility on [DATE] with diagnoses including esophagitis (inflammation of the esophagus) without bleeding, other psychoactive substance dependence, hypertension, nicotine dependence, chronic pain syndrome, opioid dependency, and anxiety. Review of the resident's care plan initiated 6/26/25 revealed a focus related to antianxiety medication use with an intervention to administer medication as prescribed. During a phone interview with the resident on 8/13/25 at 11:17 AM, he stated he had missed medications while at the facility. Review of resident #112's physician orders revealed an order for Xanax 1 milligram (mg) to be given twice a day for anxiety with a start date of 6/26/25 and end date of 7/10/25. Review of the Electronic Medical Record (EMAR) revealed the following:On 7/07/25 at 9:00 AM, the resident did not receive the morning dose of medications with no progress note documentation as to the reason.On 7/07/25 at 5:00 PM, the resident did not receive the afternoon dose of medications with a progress note which read, ‘pharmacy' as the reason documented.On 7/08/25 at 9:00 AM, the resident did not receive the morning dose of medications with no progress note documentation for the reason the medication was not given.On 7/08/25 at 5:00 PM, the resident did not receive the afternoon dose of medications with no progress note documentation for the reason the medication was not given. On 8/13/25 at 12:24 PM, the DON explained the investigation of resident #112's missed medication was initiated on 7/16/25 when the Department of Children and Families investigator came to the facility in regard to allegations of neglect due to the resident's concerns over not receiving his Xanax. The facility acknowledged at the time the resident missed four doses of the medication due to it needing a new prescription for it to be refilled. Further review of the medical record revealed a physician order for Xanax 1 mg by mouth now to be given three times day for anxiety starting on 7/10/25. Review of the EMAR revealed the following:On 7/16/25 at 9:00 AM, the resident did not receive the medications with no progress note documentation for the reason it was not given.On 7/26/25 at 2:00 PM, the resident did not receive the afternoon dose of medication with no progress note documenting the reason it was not given.On 7/26/25 at 9:00 PM, the resident did not receive the medication, but contained a note that documented, on order for the reason it was not given. A progress note written on 7/26/25 at 10:00 PM, revealed resident #112's Xanax was not available to be administered. The note indicated the pharmacy notified the facility that a new prescription was needed in order for the medication to be refilled. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, polyneuropathy (nerve pain), hypertension, and stroke complications. Resident #3's care plan initiated 3/07/25 revealed a focus for the risk of abnormal bleeding related to the use of anticoagulants with an intervention to administer medications as ordered. The resident also had care plan focus for the potential for adverse side effects related to use of psychotropic medications, potential of complications related to alteration in cardiac function due to diagnosis of hypertension and potential for alteration in comfort related to stroke, generalized discomfort and impaired mobility. The interventions listed included administering medications as ordered. On 8/12/25 at 1:20 PM, resident #3 stated it seemed she had a problem with availability of medication every month, but not always with the same medication being unavailable. The resident reported yesterday she was told the facility was out of her Lyrica medication. Lyrica is a prescription medication used to treat nerve pain for neuropathy and other disorders. Take exactly as prescribed by your physician, at the same time each day, Do not stop using Lyrica suddenly, (retrieved on 8/27/25 from www.drugs.com). A self-reported grievance filed on 6/09/25 by resident #3 revealed a concern that Xarelto was not available to be given. Review of the grievance revealed the investigation found the resident was out of the medication which was to be delivered that day. The resolution indicated the medication arrived the next day on 6/10/25 and education was provided to staff, that nurses were to reorder medications within five days of stock depletion, and if the medication was not present, nurses were to call the provider to either place the medication on hold or obtain a substitute. Although this education was noted on the grievance, resident #3 continued to miss doses of her medication due to it not being available per the EMAR. Xarelto is a prescription medication used mainly to prevent blood clots. It blocks the action of substances in the blood to prevent formation of blood clots. Do not stop taking Xarelto without your doctor's advice, it can increase your risk for blood clots or stroke, (retrieved on 8/27/25 from www.drugs.com). Review of the medical record revealed resident #3 had physician orders including Duloxetine HCl delayed release (DR) 20 mg daily for anxiety, Nifedipine extended release (ER) 30 mg daily for hypertension, Rivaroxaban (Xarelto) 10 mg daily for anticoagulation, and Lyrica 75 mg two times a day for neuropathy pain. Review of EMAR for June 2025 revealed the following:On 6/06/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/07/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/08/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/09/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given.On 6/20/25 at 9:00 AM, the resident did not receive her Xarelto 10 mg. There was no progress note documentation for the reason it was not given. Review of the EMAR for August 2025 revealed the following:On 8/02/25 at 9:00 AM, the resident did not receive her Tizanidine 2 mg, Xarelto 10 mg, Duloxetine DR 30 mg nor her Nifedipine ER 30 mg. A progress note for these medications indicated the medications were, on delivery.On 8/02/25 at 2:00 PM, the resident did not receive her Tizanidine 2 mg. A progress note indicated, on delivery.On 8/11/25 at 9:00 AM, the resident did not receive her Lyrica 75 mg. A progress note was documented by the nurse, pharmacy was called, and order will be delivered evening. On 8/11/25 at 2:00 PM, resident #3 did not receive her Lyrica 75 mg. A progress note indicated, medication is a new order, medication will arrive at 4. 3. Resident #94 was admitted to the facility on [DATE] with diagnoses including hypertension, stage 2 chronic kidney disease, hyperlipidemia, osteoarthritis, anxiety, atrial fibrillation, peripheral vascular disease and atherosclerotic heart disease. Review of the resident's care plan initiated 2/06/25 revealed a focus for the potential of complications related to an alteration in cardiac function due to a diagnosis history of hypertension, atrial fibrillation and hyperlipidemia. One of the interventions was to administer medications as ordered and observe for effectiveness. Review of the medical record revealed physician orders for Labetalol HCL 100 mg two times a day for hypertension. Labetalol HCL is a prescription medication used to treat high blood pressure. Use this medication as directed by the physician, do not stop taking Labetalol suddenly, it may make your condition worse, (retrieved on 8/27/25 from www.drugs.com). Review of the EMAR for August 2025 showed the following:On 8/05/25 at 6:00 PM, Labetalol HCL 100 mg was not administered as ordered. There was no progress note documentation for the reason it was not given.On 8/06/25 at 6:00 AM, Labetalol HCL 100 mg was not administered as ordered. A progress note by the nurse indicated, ran out of medication. On 8/07/25 at 6:00 AM, Labetalol HCL 100 mg was not administered as ordered. A progress note by the nurse indicated, ran out of medication. On 8/07/25 at 6:00 PM, Labetalol HCL 100 mg was not administered as ordered. A progress note documented by the nurse read, waiting for delivery. On 8/08/25 at 6:00 AM, the Labetalol HCL 100 mg was not administered, and a progress note was documented by the nurse, waiting for delivery, e-kit did not have it. 4. Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors, hypothyroidism, paranoid schizophrenia and bipolar disorder. Review of the medical record revealed physician orders for Synthroid 50 micrograms (mcg) daily for hypothyroidism. Synthroid is a prescription medication used to replace the hormone normally produced by the thyroid gland to regulate energy and metabolism. Take this medication exactly as prescribed, (retrieved on 8/27/25 from www.drugs.com). Review of the EMAR for August 2025 showed the following:On 8/02/25 at 6:30 AM, the medication was not administered and a progress note indicated, patient ran out of medication.On 8/03/25 at 6:30 AM, the Synthroid was not administered as ordered. A progress note documented by the nurse indicated, ran out of medication. 5. Resident #67 was admitted to the facility on [DATE] with diagnoses including anxiety, schizoaffective disorder, psychosis not due to substances, Gastro-esophageal Reflux disease (GERD), dementia, seizures, hypertension and depression. Review of resident #67's care plan initiated 8/19/20 revealed foci including potential for complications related to alteration in cardiac function due to diagnosis of hypertension, potential for adverse side effects related to the use of psychiatric medications, potential for injury or complications related to seizures and actual behaviors including combativeness, yelling and being verbally inappropriate. The interventions included administer medications as ordered. Review of the medical record revealed physician orders for Iron 325 mg daily for supplementation; Amlodipine 10 mg daily for hypertension; Cholecalciferol 1000 units (give 2 tabs) daily for bone health; Cyanocobalamin 1000 mcg daily for macrocytic anemia; Pepcid 20mg daily for GERD; Lidocaine patch 4% daily for low back pain; Valproic acid 250 mg/ml, give 10 milliliters (ml) twice daily for mood stabilization; Ativan gel 2 mg/ml three times a day for anxiety and Tylenol 650 mg daily for pain . Review of the EMAR for August 2025 revealed the following:On 8/03/25 at 8:00 AM, resident #67 did not receive her Iron 325 mg. There was no documentation to indicate why it was not administered as ordered.On 8/03/25 at 9:00 AM, resident #67 did not receive her Amlodipine 10mg, Cholecalciferol 2000 units, Cyanocobalamin 1000mcg, Pepcid 20mg, Lidocaine external patch 4%, Valproic acid 10ml, nor her Ativan gel 2 mg/ml. There was no documentation to indicate why the medications were not administered as ordered.On 8/03/25 at 10:00 AM, resident #67 did not receive her Tylenol 650 mg. There was no documentation to indicate why the medication was not administered as ordered.On 8/03/25 at 2:00 PM, resident #67 did not receive her Ativan gel 2 mg/ml. There was no documentation to indicate why it was not administered as ordered. On 8/14/25 at 12:57 PM, the DON said she was unaware residents #3, #5, #67, #94 and #112 had missed doses of medications since the time they became aware of resident #112's neglect allegation for missed medications this past July. She stated regular reordering of medications and audits were the actions initiated following that investigation. She was unable to say why residents missed multiple medication doses due to the drugs not being available, but confirmed she never verified the nurses were reordering and auditing as planned. The DON stated the expectation for staff when a medication was unavailable was to check the emergency medication kit, call the pharmacy and call the physician to ask for a hold order for the medication or an alternative. The facility's policy entitled Medication Administration dated 4/01/22 indicated that medications should be administered in a timely manner and in accordance with the physician's orders. If medications are unavailable at the time of medication administration, the nurse should check the Emergency Drug Kit (EDK) system for availability. If the medication is not available the nurse should notify the physician for new orders and contact the pharmacy, as needed.

Based on observation, interview, and facility policy review, the facility failed to ensure proper handling and food safety practices when staff failed to sanitize a food thermometer between checking food items, and ice bath calibration. The deficient practice had the potential to affect all residents who received a regular or puree diet by increasing the risk of cross-contamination and foodborne illness. Findings: On 8/13/25 at 11:10 AM, kitchen preparation for the lunch service began with cook G and Dietitian F present. At 11:37 AM, cook G used a food thermometer to check food temperatures of the prepared foods held on the steam table line prior to plating the food for service. The cook did not sanitize the food thermometer prior to placing the tip of the thermometer inside the pureed garlic bread, the regular garlic bread, and then the ziti bake. The cook said she cleans the thermometer between each food items. She acknowledged she did not sanitize the thermometer prior to checking the food items, nor had she cleaned it between the food items. The cook explained it was her practice to clean the thermometer between food items but said, We run out of them [the alcohol wipes] so fast, I'm constantly using them. On 8/13/25 at 11:47 AM, Dietitian F explained the process for checking the temperature of foods on the steam table. She stated, All foods are checked for their temperature before service is started. They are supposed to clean the thermometer with a sanitizing wipe in between each food item, that's the proper way. The Dietitian acknowledged she did not notice when cook G did not sanitize the thermometer between the food items in preparation for the lunch service. On 8/13/2025 at 11:50 AM, Kitchen Supervisor E explained the facility process for checking the temperature of foods on the steam table. She confirmed staff should check each food item, record the reading of the thermometer, and then clean the thermometer with an alcohol wipe between each food item.On 8/13/25 at 5:00 PM, in the kitchen, preparation for the dinner service commenced. Kitchen Supervisor E checked the temperature of a tray of turkey ranch wraps (a cold sandwich item) with a food thermometer. She then calibrated the food thermometer in an ice bath but did not sanitize the thermometer between checking the temperature of the wraps and inserting the thermometer in the ice bath. Kitchen Supervisor E proceeded to use the same un-sanitized thermometer to check the puree turkey wrap (a hot item) temperature without sanitizing the thermometer. On 8/13/25 at 5:15 PM, Kitchen Supervisor E acknowledged she had not sanitized the thermometer between checking the temperature of the cold turkey ranch wrap and the ice bath calibration, then again between the ice bath and checking the temperature of the (hot) puree turkey wrap. Kitchen Supervisor E stated, Oh I thought I did, and acknowledged she did not sanitize the thermometer between the food items and the ice bath calibration. Review of the facility policy, Final Cooking Temperatures, revised 10/01/23, revealed food was to be cooked to specific temperatures and times to mitigate the presence of dangerous microorganisms. The policy continued that food thermometers used to check food temperatures should be clean, sanitized, and calibrated for accuracy.

Based on observation, interview, and record review, the facility failed to develop an individualized care plan with interventions to address the resident's preference and needs for administration of oxygen for a resident who smokes, for 1 of 1 resident reviewed for respiratory care, of a total sample of 45 residents, (#40).Findings: Resident #40 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), tachycardia (fast heartbeat), and mood disorder. Review of the quarterly Minimum Data Det, (MDS) assessment dated [DATE], revealed the resident was assessed to be cognitively intact. On 8/11/25 at 10:54 AM, resident #40 was sitting in bed wearing a nasal cannula connected to an oxygen concentrator set to deliver oxygen at 5 liters per minute (LPM). Resident# 40 explained he liked to go out to smoke and felt he was comfortable without oxygen during that time. He continued that he had been on 5 LPM of oxygen for a few weeks, but explained he needed it more when he exerted himself. On 8/11/25 at 1:30 PM, resident #40 was sitting comfortably outside on the smoking patio, not wearing his oxygen while he smoked. The next day, on 8/12/25 at 1:54 PM, resident #40 was in his wheelchair comfortably wheeling down the 200 Hallway without oxygen. He was at ease and not in any distress without the oxygen. Review of the medical record revealed physician's orders for resident #40's oxygen was for 3 LPM, continuously via nasal cannula. Resident #40 had a care plan for smoking dated 4/23/25 that included, the resident was assessed as able to smoke with supervision, resident/responsible party informed of the facility smoking policy. Further review revealed no care plan focus or interventions related to resident #40's use of oxygen including his preference to not use oxygen so he could go outside to smoke, nor a care plan for any behaviors for rejection of care or non-compliance. On 8/14/2025 at 10:22 AM, assigned Licensed Practical Nurse (LPN) J verified resident #40's oxygen concentrator was set at 5 LPM. LPN J confirmed the resident's order was always for 5 LPM of oxygen since admission but said he adjusted the flow rate himself. The nurse explained to the resident that the physician's order was for 3 LPM, not 5 LPM and that the facility would have to inform the physician if they desired to change the order. She conveyed she was aware the resident went outside to smoke without the use of oxygen; therefore, he did not use the oxygen continuously as it was ordered by the physician. In interviews on 8/14/25 at 10:30 AM, and on 8/14/25 at 12:49 PM, the Director of Nursing (DON) in regard to resident #40's oxygen usage said that the resident often adjusted the amount by himself therefore he was noncompliant with the oxygen order. She was unable to show documentation of the noncompliance in the medical record. The DON explained the staff who was responsible to update care plans was no longer here, but that everyone helps with them. She said the expectation was for nurses to assess resident #40 and update the care plan as needed. The DON acknowledged resident #40's care plan was not personalized regarding his preference to smoke and not use oxygen as the physician had ordered it. The Facility's Policy on Comprehensive Assessments and Care Plans dated 4/01/22 indicated the standard of the facility was to make an accurate and comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, which would be reviewed and revised by the interdisciplinary team regularly.

Based on observation, interview, medical record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) for one of three residents reviewed for ADL care, of a total sample of 45 residents, (#75). This failure resulted in resident #75 not receiving timely and adequate support for personal grooming and hygiene, which could contribute to a decline in the resident's physical and psychosocial well-being. Findings: On 8/11/25 at 11:40 AM, resident #75 was awake, lying in his bed. His fingernails on both hands were elongated with brown debris visible under the nails. The resident stated he spoke Creole. He was able to answer yes/no questions appropriately, and able to gesture. Resident #75 indicated he preferred to keep his fingernails long by shaking his head to gesture no and showing his elongated fingernails. On 8/12/25 at 9:25 AM, resident #75's fingernails on both hands continued to be elongated with brown debris visible under the fingernails. The resident permitted photos to be taken of his fingernails. (Photographic evidence obtained) On 8/13/25 at 1:00 PM, resident #75 was in bed, and awake. The fingernails on both hands were elongated with visible brown debris under the nails. On 8/14/25 at 10:00 AM, resident #75 was awake and in bed. His fingernails on both hands remained elongated with brown debris visible under the nails. On 8/14/25 at 10:05 AM, Certified Nurse's Assistant (CNA) B, stated activities personnel provided fingernail care including cleaning and trimming for residents. She conveyed all CNAs including herself could provide fingernail care to residents. CNA B confirmed she was assigned to resident #75 that day but had not ever provided fingernail care to the resident. She said she used assistance from other staff to communicate with the resident in his preferred language (Creole). The CNA explained she provided fingernail care weekly. At that time CNA D entered the resident's room and asked the resident if he'd like to have his fingernails cleaned and trimmed in his preferred language. CNA D stated the resident replied, Yes, I am here for you to help me. I cannot do that myself. On 8/14/25 at 10:15 AM, Licensed Practical Nurse (LPN) C, confirmed she was assigned to care for resident #75 today. She stated the CNAs provided fingernail care including cleaning and trimming to residents, unless they were diabetic then a podiatrist would do it. She denied the podiatrist trimmed residents' fingernails and explained the nurses trimmed the fingernails for diabetic residents. LPN C stated a schedule for when the care would be provided was kept in the chart, but explained if the nails were long or dirty, staff should just provide the care, regardless of the schedule. Review of resident #75's medical record revealed her diagnoses included diabetes mellitus type 2, Alzheimer's Disease, and seizures. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed moderately impaired cognitive function, and no behavioral symptoms present including refusals of care. Review of resident #75's progress notes from 7/22/25 thru 8/14/25 did not reveal any notations of refusal of care of any type. Review of the person-centered care plan initiated 1/30/19 and revised 2/28/22, for resident #75 revealed a focus for risk for self-care deficit in ADLs related to need for assistance with daily care. The care plan indicated resident #75 required some assistance with dressing and bathing due to weakness and cognition and impaired communication (Creole speaking) and he was at risk for decline in functional status. The care plan interventions detailed the resident required assistance of one staff with dressing, hygiene and bathing. On 8/14/25 at 10:52 AM, the Administrator stated the expectation was for fingernails to be cleaned and trimmed per the resident's preference, with care provided by direct care CNAs and Activities staff. The Administrator explained each resident was assessed at admission to determine if they need assistance with the task, and whether the resident allowed it. She expressed staff should try to reapproach at a different time, or with different staff, if a resident refused care, and the behavior should be documented in the medical record. The Administrator stated it would be part of the resident's care plan, and refusals of care should also be documented in the Minimum Data Set assessments. A review of the facility policy titled ADL Care and Assistance dated 4/01/22 revealed, the facility's policy was to provide the resident with ADL care and assistance while attempting to maintain the highest practicable level of function for the resident.

Based on interview, and record review, the facility failed to assist in making transportation arrangements to diagnostic and physician's appointments for 1 out of 1 resident reviewed for choices, of a total sample of 45 residents, (#97).Findings: A review of the electronic medical record revealed resident # 97 was admitted to the facility on [DATE] with diagnoses which included acute embolism and thrombosis (blood clot) of other specified deep vein of the right lower extremity, paraplegia (partial paralysis), hyperlipidemia, and unspecified heart transplant status. Resident #97 's quarterly Minimum Data Set with an assessment reference date of 7/12/25 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated he was cognitively intact. A review of resident #97 's plan of care revealed he had the potential for complications related to an alteration in cardiac function due to his diagnoses, heart transplant status initiated on 4/23/25. Interventions included labs and diagnostic tests as ordered; update physician of results initiated 4/23/25. On 8/11/25 at 11:48 AM, resident #97 was in bed, alert and oriented to person, place and time. He stated he had missed several doctor's appointments and an echocardiogram (cardiac test) due to transportation not being arranged. The resident continued that he had appointment cancellations due to the lack of communication between facility staff and the transport coordinator. Review of the medical record progress notes from the B Wing Unit Manager (UM) revealed the following: On 6/11/25 the UM documented, Called resident transplant coordinator on last week, received message of (coordinator), being out on vacation. Attempted to reach on 6/10 to received appointment updated information for resident. Unable to reach. Left voice mail. Called this am 6/11, and was able to reach coordinator, informed to call for updated scheduling information. Unable to get receptionist online. Left message will reattempt call in 1 hour.On 8/01/25 the UM documented, resident states he received call for appointment cancellation of ECHO [echocardiogram]. Nurse attempted to call office to receive follow up time and date for makeup appointment. Message left with answering service. Awaiting response from [name of hospital] transplant office. Transplant coordinator. A review of the medical record progress notes and documents written by the Advance Practice Registered Nurse (APRN) revealed the following excerpts: On 6/21/25 and 7/19/25, the APRN documented, NO acute issues. Per resident, he went to have a bone scan last month and was told by ID [infectious disease] doctor that, everything looks good for Echo/transplant f/u [follow up] on 7/31/25. On 8/12/25 the APRN wrote, Wound care rendered by nurse, r/o [rule out] cellulitis/infection. I called the transplant center to schedule a follow up appointment. Apparently, he had missed 3 f/u visits due to dates not entered to PCC. I left a message to the answering service, Awaiting return call. On 8/13/25 at 3:31 PM, in a joint interview with the Social Worker (SW) and Director of Nursing (DON) they explained the team including the UMs, and Staffing and Transportation Coordinator had an app (application) they used to coordinate the facility's van and arrange transportation. This app was used to manage arrangements to transport residents to and from doctor's appointments or for any other transport within the community. The SW and DON described that residents who relied solely on their insurance for transportation, still had access to the facility's van because sometimes those services were unreliable. The DON and SW acknowledged resident #97 had missed some appointments with his physician at his heart transplant center as well as an echocardiogram appointment that was cancelled because no transportation was arranged. The DON explained she believed the resident had an outside coordinator to arrange transportation; however, she acknowledged the UM, and nurses were responsible for following up to ensure the arrangements were made. The DON stated they dropped the ball on this one. The DON was unsure if resident #97's echocardiogram was ever rescheduled. On 8/13/25 at 4:10 PM, in a joint interview with the SW and the Transportation Coordinator, the Transportation Coordinator explained she would get the appointment paperwork from nurses or on the resident's return from an appointment. She would then place it in the transport book, and the nurses would log the appointment in the computer. She said she would call the physician's offices and make appointments for residents who were unable to. The Transportation Coordinator described that for residents who made their own appointments but did not have transportation the facility would set transportation up through her. She explained for resident #97, she believed he made his own appointments, and the facility had never taken him anywhere. The SW said that even though the resident made the appointments himself, he communicated to nurse, and the nurse would have to put the appointment into the computer. The SW was unable to find any information that the missed echocardiogram was rescheduled. On 8/13/25 at 4:22 PM, the B Wing UM acknowledged she was aware resident #97 missed his appointments for heart transplant follow up and of the echocardiogram cancellation because transportation was not arranged. The UM stated, he mentioned missing appointments due to transportation and that the transplant center sent him a message that he missed an appointment. She continued to explain that she tried to get in touch with the transplant scheduler but had not rescheduled yet at that time. The UM said the facility's process was to put the appointment in the computer and acknowledged she never followed up with rescheduling the missed appointment after the note written on 6/11/25. On 8/13/2025 at 4:57 PM, resident #97 clarified the only time he went out for an appointment was for a scan on 5/21/25, but not with the heart transplant center nor for the echocardiogram. He continued to explain that at the end of April or May it was the facility's fault he missed his appointment. Resident #97 said he did not arrange transportation to the appointments himself, instead the facility was supposed to arrange them. He explained he got a paper with the information and gave it to facility staff, and they made the arrangements. Resident #97 said the only time he called to reschedule an appointment was the time the nurse could not do it. He said he was able to reschedule the appointment, so he wrote the information on a piece of paper and gave it to the nurse, who told him she would put it in the system, but she never did. The resident recalled he spoke to the SW about his frustration but did not hear anything back from the facility regarding his concerns. Review of the Treatment Administration Record (TAR) for May, June, July and August 2025 revealed no appointments were scheduled except on 5/06/25 for the unrelated scan and follow-up appointments for the scan which took place on 5/12/25 and 5/21/25. The TAR was reviewed for June, July and August 2025 which showed no scheduled appointments for the heart transplant center nor for the echocardiogram. On 8/13/25 at 5:13 PM, the SW confirmed the resident previously reached out to her about his frustrations on 6/15/25 and that he was waiting on the B Wing UM to reschedule the appointment. On 8/14/25 at 11:27 AM, the APRN stated that on 7/31/25 someone called the facility and told them to cancel resident #97's appointment, but she confirmed this was not documented anywhere. She continued to explain she wrote the note on 8/11/25 because the resident told her he missed all of his appointments which is why she felt she had to reach out to the transplant center herself to make the appointment. The APRN confirmed nurses were not entering the appointments into the computer which contributed to resident #97 missing his appointments. On 8/14/25 at 12:44 PM, the DON said there was a breakdown in communication when staff did not enter the dates of appointments as given by the resident. She confirmed staff should have kept calling the transplant center and followed up on rescheduling resident #97's appointments. The Regional Nurse Consultant stated the facility had a Transportation Policy (which was not provided) but explained the policy did not have anything that spoke specifically to scheduling appointments.

Based on interview and record review, the facility failed to provide a refund, and a final accounting of the resident's funds deposited with the facility within 30 days of the resident's discharge, for 1 of 3 residents sampled for personal funds, (#1). Resident #1 was admitted to the facility on [DATE] and discharged from the facility to the community on 6/27/24. Review of the facility's Admission Agreement signed by resident #1's financial power of attorney on 1/13/22 revealed the facility would refund any deposits held by them within thirty days from the resident's date of discharge. Review of the facility's Policy and Procedure Manual in the section regarding Resident Personal Funds, issued 4/01/22 and revised 1/01/24, under the Procedure section item 6. Within thirty (30) days of a resident's discharge or death, the facility will refund the resident's personal funds and provide a final accounting of those funds to the resident, the resident's representative or to the resident's estate, as applicable. In a telephone interview on 8/19/24 at 8:31 AM, resident #1's financial power of attorney said she had received one refund check for $3,266 from the facility since resident #1's discharge over 30 days after resident #1's discharge. She said she was told the facility held funds and there was still an outstanding refund of $813.00 due. The financial power of attorney said she had requested an itemized statement of how resident #1's funds had been disbursed since resident #1's original admission on 1/13/22 but had yet to receive the statement. On 08/19/24 at 12:41 PM, the Business Office Manager she said she believed resident #1's financial power of attorney was still owed $813.00. She verified the resident was discharged from the facility 06/27/2024. The Business Office Manager explained the money was overdue by 23 days beyond the 30 days from Resident #1's facility discharge. In a telephone interview on 8/19/24 at approximately 12:45 PM, the Accounts Receivable Specialist of the facility's contracted Accounting Group verified Resident #1 was discharged on [DATE]. She verified the facility owed Resident #1's financial power of attorney a refund from Resident #1's facility held account related to July 2024 and August 2024. She said it usually took about 30 days to provide a refund from a resident's date of discharge. She verified the refund was currently late over 30 days since resident #1's discharge and a full refund had not yet been issued to resident #1's financial power of attorney. She said she would contact her colleague in Accounts Payable who had the authority and ability to issue checks to have a refund check cut that day and mailed to resident #1's financial power of attorney. On 8/19/24 at 1:20 PM, the Business Office Manager, with the Director of Nursing and Administrator present, provided a document titled Resident Statement Landscape related to the facility held bank account and pointed to the line dated 7/01/24 that showed a balance of $818.02. The next line dated 7/03/24 indicated resident #1's Social Security funds of $1,212.00 had been credited to the account. The total was then $2,030.02. Also, on 7/03/24 a line item indicated, CARE COST AUTO WDL (withdrawal), with a debit of $813.00 which the Business Office Manager said indicated what the facility charged to provide care. She verified resident #1 was no longer at the facility at that time, but the facility still received resident #1's Social Security money on 7/03/24 and had an automated withdrawal regarding facility care that was not provided. The total was $1, 217.02. There was a credit adjustment on 07/25/2024 of $2,049.55 which the Business Office Manager said related to a bank account balance that had been transferred from one bank to another when a change in resident fund banks had been made earlier in the year. The total of $3,266.60 was provided by check to resident #1's financial power of attorney later than 30 days after resident #1 was discharged . The Business Office Manager could not explain why she could only see that $813.00 from July 2024 was still due to Resident's #1's financial power of attorney which was less than the refund amount confirmed by the facility's contracted Accounts Receivable Specialist. On 8/19/24 at 3:12 PM, the facility's contracted Accounts Receivable Specialist said resident #1's facility held account did not get closed soon enough after Resident #1's discharge which caused resident #1's July 2024 Social Security funds to be deposited into the account. She explained there was a further delay by the facility in closing resident #1's facility held account, and resident #1's Social Security funds related to August 2024 were also received. The Accounts Receivable Specialist said these deposits should not have happened.

Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the Ombudsman for 4 of 6 residents reviewed for hospitalization s, out of a total sample of 45 residents, (#42, #79, #18, and #21). Findings: 1. Resident #42 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, major depressive disorder, end stage renal disease and hypertension. The Minimum Data Set Annual Assessment noted resident #42 scored 3 on the Brief Interview for Mental Status evaluation which indicated the resident's cognition was severely impaired. A Nursing Home to Hospital Transfer Form dated 07/07/2023 revealed resident #42 had generalized weakness, and had a fall. Review of the medical record revealed resident #42 was in the hospital from 7/07/23 and returned to the facility on [DATE]. On 3/21/2024 at 10:18 AM, the Social Service Director (SSD) was unable to provide documentation of notice to the state Ombudsman of resident #42's emergent transfer to the hospital. The facility was unable to provide documentation of written notice made to the state Ombudsman. 2. Resident # 79 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia- unspecified severity without behavioral disturbance and hypertension. A progress note dated 01/12/23 revealed resident #79 had swelling on the right side the forehead. The resident had projectile vomiting, abdominal pain and dizziness and was transferred to the hospital. The resident returned to the facility five days later, on 1/17/23. Review of resident #79's medical record revealed a written Notification of Transfer or Discharge form for hospitalization dated 01/12/23 signed by the Nursing Home Administrator/Designee. The notice was not signed as received by the resident or representative nor was there indication of notification to the state Ombudsman's office. On 3/21/2024 at 10:18 AM, the SSD was unable to provide documentation of notice to the state Ombudsman of resident #79's emergent transfer to the hospital. The facility was unable to provide documentation of written notice made to the state Ombudsman. 45646 3. Resident #18 was admitted to the facility on [DATE] with diagnoses including muscle weakness, primary osteoarthritis, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, dementia, other sequelae of cerebral infarction, and Alzheimer's disease. Review of resident #18's medical record revealed she was hospitalized on [DATE] and readmitted to the facility on [DATE] as a result of a displaced fracture of the right femur. The medical record did not contain a copy of the Nursing Home Notice of Transfer and Discharge Notice or evidence of Ombudsman notification of the transfer. On 3/20/24 at 4:13 PM, the SSD stated social services was responsible for notifying the Ombudsman of transfers and discharges. She explained the forms were faxed to the Ombudsman office and a copy of the fax confirmation was kept in the social services office. On 3/21/24 at 10:15 AM, the SSD provided a copy of the Nursing Home Transfer and Discharge Notice. She stated she had missed sending the notice to the Ombudsman. 32131 4. Resident #121 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, dementia, atrial fibrillation, and heart failure. A physician's order dated 6/06/23, read, send the resident to the emergency room for evaluation due to altered mental status. On 3/20/24 at 4:14 PM, the SSD stated the Social Service Department was responsible to submit notification of transfer/discharges to the Ombudsman. She explained the forms were submitted weekly to the Ombudsman, and a copy of the form was placed in a binder at the facility. Clinical record review revealed no documentation or evidence that the transfer/discharge notification of the hospital transfer was submitted to the Ombudsman. On 3/21/24 at 2:42 PM, the SSD stated she was unable to locate any documents to confirm the discharge/transfer notification for resident #121 was submitted to the Ombudsman. The facility's policy Transfer and Discharge issued 4/01/2022 read, If the facility initiates the discharge, a copy of the Notice of intent to Transfer or Discharge should be sent to the Office of the State Long-Term Care Ombudsman In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of the discharge notice to a representative of the Office of the State LTC Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident was evaluated for safe self-administration of medications and failed to obtain a physician order for self-administration of medication for 1 of 1 resident reviewed for choices, of a total sample of 45 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, obstructive sleep apnea, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. The resident's quarterly Minimum Data Set assessment with Assessment Reference Date of 12/12/23 revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 14 out of 15. Observations on 3/18/24 at 11:52 AM, and on 3/19/24 at 10:04 AM showed resident # 47 lying in bed on her back. On the resident's tray table in a graduated container was Medi-honey wound gel, two vials of Deep Sea nasal spray, and a bottle of Bio Freeze. The resident stated she did most of the administration of the nasal spray herself because she tried not to cause any problems for the staff. Medi-honey gel is used to treat open wounds, to prevent gangrene and infection, (retrieved on 3/22/24 from www.carewell.com). Bio Freeze is used to provide temporary relief of muscle or joint pain caused by strains, arthritis, bruising, or backaches in adults, (retrieved on 3/22/24 from www.drugs. com). Review of the resident's clinical records revealed no documentation to indicate a self-administration evaluation was conducted for the resident, and a physician order for self-administration of medication was not identified. On 3/19/24 at 10:04 AM, observation of the resident's tray table was conducted with Licensed Practical Nurse (LPN) A. She acknowledged the findings, and stated the resident should not have any medications in her room. LPN A removed the medications from the resident's room, and stated she would inform the B Wing Unit Manager (UM), so that a physician's order for self-administration of medications could be obtained for the resident. On 3/19/24 at 10:12 AM, the Director of Nursing (DON) stated residents should not have medications in their rooms. She acknowledged that a self-administration evaluation was not conducted for resident #47, and the resident did not have a physician order for self-administration of medications. On 3/19/24 at 10:14 AM, the B Wing Unit Manager (UM) explained medications should not be in a resident's room, unless there was a physician order for self-administration of medications, and an order to keep the medications at the resident's bedside. The B Wing UM stated that nurses were aware of the process. On 3/20/24 at 6:00 PM, the DON explained if a resident wanted to self-administer medications, a self- administration evaluation needed to be completed, and a physician's order for self-administration of medications obtained. The facility's policy, Self-Administration of Medications issued on 4/01/22 read, As part of the overall evaluation, the staff and practitioner will assess or evaluate resident's mental and physical abilities to determine whether a resident is capable of self-administering medications . Self-administered medications should be stored in a safe and secure place, which is not accessible by other residents.

Based on interview and record review, the facility failed to send quarterly personal fund account balance statements to resident's responsible party for 1 of 7 sampled residents reviewed for personal funds, out of a total sample of 45 residents, (#71). Findings: Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] for long term care. Her diagnoses included cerebral infarction, attention to gastrostomy, pressure ulcer- sacral region, dementia, epilepsy, seizures, sepsis, hypertensive heart, and chronic kidney disease. A review of the census information revealed resident #71's payor source was Medicaid as of 8/28/23. A review of the medical record revealed admission Minimum Data Set (MDS) assessment dated [DATE] which showed her Brief Interview for Mental Status score of 00 which meant she was severely cognitively impaired. Her quarterly MDS assessments dated 11/15/23 and 2/15/24 showed she was rarely/never understood, had both long term and short-term memory problems, and had severely impaired cognitive skills for daily decision making. On 3/19/24 at 11:35 AM, a phone interview was conducted with resident #71's designated responsible party and Durable Power of Attorney (POA). She acknowledged the resident was a Medicaid recipient. She said she had a trust fund account with the facility's business office but had not received statements of her account balance from the facility business office for greater than 6 months. Review of the electronic medical record (EMR) showed the Durable POA form signed and dated 7/3/2008 in resident #71's chart. The form included the resident representative's mailing address. On 3/19/23 at 3:55 PM, an interview with the Business Office Manager (BOM) revealed she had been working at the facility for 5 years and was in the role of BOM for 3 years. She explained that the resident's trust fund accounts were set up when they became Long Term Care residents, and they got an allowance of $160 per month. She stated, we don't regularly send out statements and only give them out if the balance is over $2000 so the family would know that they need to spend down the money. She added, the statements did not come from me, and she would have to find out if the Medicaid Specialist was sending them out because they were not being generated by the business office over the 3 years that she had been in that role. Review of the Resident Fund Statements dated 9/29/23 and 12/29/23 for resident #71 showed they were addressed to the resident and included the facility address and not the DPOA/resident's representative address. On 3/21/24 at 9:48 AM, a telephone interview was conducted with the [NAME] President of Finance and the Medicaid Specialist was present in person. The staff verified that they did assist resident #71's daughter with the Medicaid application process which became the payer source as of 8/28/23. They acknowledged the Durable POA paperwork with the daughter's address was contained in the EMR scanned items since August 2023 as well. They acknowledged that resident #71 had a personal trust fund account with the facility. They also acknowledged the resident had severe cognitive impairment and had a responsible party/financial and medical POA family member. The facility directly received the resident's monthly Social Security checks for direct payment. They acknowledged that because the resident was not her own decision maker that the quarterly statements should have gone to her responsible party and not the resident. The staff explained they would have to manually go into the Resident Trust management account to edit the address to ensure that it would be mailed to the resident representative at the correct address. Review of the facility's Admission paperwork regarding Personal Funds, Trust Account read, The resident may choose to deposit personal funds with Center in a resident trust fund account pursuant to trust fund agreement and beneficiary designation form in accordance with applicable state and federal laws. The Center will not charge additional fees for trust account services .The resident may see records of his/her account through quarterly statements .

Based on interview, and record review, the facility failed to ensure documentation for code status Do Not Resuscitate (DNR) matched the clinical records for 1 of 1 resident reviewed for Advance Directives, of a total sample of 45 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, obstructive sleep apnea, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Review of the resident's clinical records revealed a physician order dated 3/16/24 for Full Code status. The Electronic Medical Record (EMR) banner noted full code status. Scanned documents revealed a canary yellow form State of Florida Do Not Resuscitate Order dated 9/11/23, signed by the resident, and physician on 9/11/23. Review of the DNR Binder located at the nurses' station on the B Wing revealed a State of Florida DNR order for resident #47. On 3/18/24 at 5:43 PM, the Director of Nursing (DON) explained that if a resident was found unresponsive, the nurse would review the resident's code status in the facility's electronic medical record. The resident's clinical records, and the DNR binder were reviewed with the DON. She acknowledged that the documentation was conflicting, since there was an order for full code, and a DNR order in place. The DON stated, if a resident changed his/her mind regarding their code status, an order would be obtained to revoke the DNR order, and the information would be documented in the resident's clinical record. Clinical record review revealed no documentation to indicate the resident revoked her DNR order. This was confirmed by the DON. On 3/18/24 at 5:52 PM, resident # 47 stated she had a DNR order in her clinical records, which would remain in place. On 3/18/24 at 5:53 PM, the B Wing Unit Manager (UM) stated if a resident was found unresponsive, nurses would confirm the resident's code status by checking the electronic medical record, and the DNR binder. She acknowledged that the information in the EMR and the DNR binder were conflicting. The UM stated that when the resident was readmitted to the facility on [DATE], she placed the order for full code status in the resident's EMR based on her review of the Medical Certification For Medicaid Long Term Care Services And Patient Transfer Form (3008) dated 3/16/24. She said she did not clarify the code status with the resident, and stated it was an error on her part. An Advance Directive Note documented by the Social Service Assistant dated 3/18/24 at 5:56 PM indicated the resident's code status was discussed, and the resident wish to stay a DNR. The resident's care plan for advance directives initiated 11/07/23 noted the resident had a DNR in place and could make informed consent regarding her health care decisions. An intervention was to honor the resident's wishes regarding Advanced Directives/Code status. The facility's policy Determination of Code Status issued 4/01/2022 read, The resident's Code Status will be determined by a physician's order and/or validly executed State of Florida DNR order form .and/or documented evidence of the resident wishes being in place .Upon admission the nurse completing the admission assessment will ascertain resident's desired code status (Full Code or DNR) .The electronic record (including electronic chart, point of care kiosk or eMAR (electronic medication administration record)) will serve as the primary source of validation of code status should a resident be found unresponsive.

Based on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected vision and edentulous (without teeth) status for 1 of 3 residents reviewed for vision and dental services, of a total sample of 45 residents, (#69). Findings: Review of resident #69's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/07/22. His diagnoses included legal blindness and type 2 diabetes. Review of resident #69's MDS Annual assessment with Assessment Reference Date (ARD) of 3/05/24 revealed a Brief Interview for Mental Status score of 14 out of 15 which indicated intact cognition. On 3/18/24 at 4:25 PM, resident #69 stated he previously had upper and lower dentures, but he lost them approximately 2 years ago. He stated he was recently measured and was still waiting for his new dentures. During the conversation, his mouth opened to reveal he had no upper or lower teeth. Resident #69 stated he was also waiting for cataract surgery and mentioned he could not see well. Review of resident #69's medical record revealed an Admission Nursing Comprehensive Evaluation dated 2/26/22. It showed his visual acuity was severely impaired/blind: can only see shapes/lights or NO vision. It indicated glasses were used. The dental evaluation section included questions about the condition of the natural teeth and if the resident used dentures/partials. These were answered as, All teeth intact, no dental issues. Does not have dentures/partials. Review of resident #69's medical record revealed a Social Services Admission Evaluation date 2/28/22. The summary included, Resident reports adequate vision without the use of glasses. Resident has natural teeth with no reports of pain while chewing. Review of resident #69's medical record revealed care plans initiated on 3/07/22 for self-care deficit related to visual limitation, which read legally blind and risk for falls related to alteration in visual function as evidence by legally blind. Review of the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form signed by the hospital's physician on 4/04/22 revealed resident #69 was blind legally. Review of resident #69's medical record revealed an Admission Nursing Comprehensive Evaluation dated 4/07/22. It showed his visual acuity was severely impaired/blind: can only see shapes/lights or NO vision. It indicated no corrective devices were used. The dental evaluation section included questions about the condition of the natural teeth and if the resident used dentures/partials. These were answered as, All teeth intact, no dental issues. Does not have dentures/partials. Review of a hospital Bedside Swallow Assessment note dated 4/05/22 revealed resident #69 was observed eating a turkey sandwich with little difficulty without dentures. The note included the patient was edentulous and he reported eating meals without dentures in place. Review of a dental Screening Report dated 8/04/22 for resident #69 read, Upper and lower edentulous. Patient interested in dentures. Review of a Nutrition Risk Evaluation dated 3/07/23 read, Independent diner, edentulous and interested in dentures - dental following. Review of a dental Screening Report dated 11/16/23 for resident #69 read, Patient has upper and lower edentulous. Patient states he doesn't have dentures . Review of resident #69's MDS Annual assessments with ARD of 3/05/23 and 3/05/24 revealed his dental status was incorrectly assessed. Section L - Oral/Dental Status, Subsection L0200B, was not coded or check-marked to indicate the resident was edentulous. The MDS assessments indicated resident #69 did not have any problems with his teeth. Review of resident #69's care plan for nutrition and hydration initiated on 3/05/22 with target review date of 3/29/24 did not include the resident's edentulous status. Review of resident #69's MDS Annual assessment with ARD of 3/05/23, Quarterly assessment with ARD of 6/05/23 and Quarterly assessment with ARD of 9/05/23 revealed his vision status was incorrectly assessed. Section B - Hearing, Speech, and Vision, Subsection B1000, was coded as adequate. The MDS assessments indicated resident #69 did not have any problems with his vision. On 3/21/24 at 2:23 PM, MDS Coordinator C explained she was responsible for completing sections A, B, GG, H, I, J, L, M, N, O, and P of the MDS assessments and creating or updating residents' care plans. She stated she spoke with residents, collaborated with therapy and other departments such as dietary, activities, and reviewed the admission documents to complete the MDS assessment accurately. She stated all admissions were discussed during clinical meetings and the documentation received was reviewed during that meeting. She explained the Social Services Director also spoke with residents and found out if they needed dental and vision services. She mentioned she reviewed dental evaluation notes for long-term residents to determine if they had any loose teeth or dental issues. She acknowledged during the assessment and conversation with a resident, she would notice if the resident was edentulous. She reviewed resident #69's care plan and said there was no dental care plan, and the nutrition care plan did not mention he was edentulous. She reflected if a resident was edentulous, it would be included in the care plan because that was pertinent information for his care. She stated this was information the staff needed to know although Staff would not go in there; it (the care plan) does not do anything because the Certified Nursing Assistants or nurses do not utilize it at all. She then reviewed section B of the Annual MDS dated [DATE], the Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] and confirmed they showed resident #69's vision was adequate. She acknowledged this was incorrectly coded on the 3 mentioned MDS assessments because there was documentation that indicated he was legally blind. She also acknowledged Section L of the Annual MDS assessments dated 3/05/23 and 3/05/24 were answered incorrectly when no dental issues was selected. She confirmed she completed the MDS assessment dated [DATE] and could not offer an explanation why section L was incorrectly coded. She validated when the assessment was submitted, she attested the information was accurate. On 3/21/24 at 5:13 PM, the Director of Nursing stated she was aware of the incorrect documentation in resident #69's MDS assessments and stated the dental status was not updated because there were no concerns with his eating. She acknowledged the vision and dental sections were inaccurately coded and did not reflect the resident's vision impairment and edentulous status. She stated the assessment and care plan should be accurate and resident centered. Review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual Section B: Hearing, Speech, and Vision directed the user to code 1 if vision was impaired, code 2 if moderately impaired and code 4 if severely impaired. Review of the CMS RAI Manual revealed coding instructions for Section L: Oral/Dental Status which directed the user to place a check mark by Subsection L0200B if the resident was edentulous. Review of the facility's policy and procedure titled, Comprehensive Assessments and Care Plans dated 4/01/2022 revealed the intent to compile a comprehensive assessment by obtaining the resident's needs, goals, life history and preferences, using the RAI specified by CMS. It provided a list of areas for the assessment which included vision and dental. The Guidelines read, The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Review of the facility's policy and procedure titled MDS Assessments dated 4/01/2022 read, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines.

Based on observation, interview, and record review, the facility failed to ensure a midline dressing was changed as per professional guidelines to prevent the potential for infection, and failed to obtain physician's order for a midline dressing for 1 of 1 resident of a total sample of 45 residents, (#107). A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm .can stay in place for up to 30 days. (Retrieved on 3/22/24 from drugs.com) Findings: Resident #107 was admitted to the facility on [DATE] with diagnoses which included diabetes type II, anemia in chronic kidney disease, hypertension, Alzheimer's Disease, major depressive disorder, generalized anxiety disorders, and bipolar disorder. Observations on 3/18/24 at 4:17 PM, 3/19/24 at 9:44 AM, and on 3/20/24 at 9:38 AM, showed resident #107 reclining in her bed watching television. A midline was noted to the resident's left upper arm, and the dressing was dated 3/13/24. Resident #107 stated she was no longer receiving any medication via the midline, and shared that staff flushed the midline. On 3/21/24 at 9:56 AM, resident #107 was lying in bed positioned to her left side. The midline dressing to her left upper arm was dated 3/13/24, and the area below the midline was swollen/infiltrated. Review of the resident's physician orders revealed an order for the insertion of the midline on 2/28/24, and orders dated 3/07/24 for staff to check the midline site for signs/symptoms of infection or bleeding, and to flush the midline with 10 milliliters of normal saline every shift. A physician order for dressing change of the midline was not identified. On 3/21/24 at 9:59 AM, the resident's midline was observed with the resident's assigned nurse, Registered Nurse (RN) E. She acknowledged that the date on the midline dressing was 3/13/24, and that the area below the midline was swollen/infiltrated. RN B stated the midline dressing was to be changed every week and as needed. The resident's physician orders were reviewed with the RN, and she verbalized that an order for the midline dressing could not be identified. She stated if an order for the midline dressing was not in place, the nurse should notify the physician, and obtain an order. On 3/21/24 at 10:09 AM, the B Wing Unit Manager (UM) stated a dressing for a midline should be changed every seven (7) days. Observations of the midline dressing dated 3/13/24 was shared with the B Wing UM, she stated the midline dressing should have been changed by the resident's assigned nurse, or the wound care nurse on 3/20/24. The resident's physician orders were reviewed with the UM, who acknowledged that an order for the resident's midline dressing change could not be identified. The resident's midline was observed with the UM, and she confirmed that the date on the dressing was 3/13/24 and acknowledged that the area below the midline was swollen/infiltrated. The UM said nurses knew the resident had a midline, and if there was no order for dressing changes, nurses should notify the physician, and obtain an order. On 3/21/24 at 10:18 AM, the Assistant Director of Nursing/Infection Preventionist stated midline dressings should be changed every 7 days for prevention of infection, and the UMs were supposed to ensure that midline dressings were changed on a weekly basis. On 3/21/24 at 12:59 PM, the Registered Nurse (RN)/Wound Care Nurse recalled he completed the dressing for resident #107's midline on 3/13/24 and stated the dressing should have been changed on 3/20/24. The Wound Care nurse stated he was not aware the resident did not have an order for the dressing change. He said he should have verified the order and if an order was not in place, he should have called the physician to obtain an order. The policy PICC (Peripherally inserted central catheter)/Midline IV (Intravenous) Line issued on 4/01/22 read, Sterile dressing change using transparent dressing is performed: . at least weekly.

Based on observation, interview, and record review, the facility failed to obtain a physician order for Oxygen (O2) therapy for 1 of 1 resident reviewed for respiratory care, of a total sample of 45 residents, (#47). Findings: Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, obstructive sleep apnea, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Review of the resident's quarterly Minimum Data Set assessment dated [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The assessment indicated the resident was on oxygen therapy. Observations on 3/18/24 at 11:52 AM, and on 3/19/24 at 9:50 AM showed resident #47 reclining in bed, with O2 infusing via nasal cannula at 6 liters per minute (LPM). The resident stated she was on 4 to 6 LPM of O2 continuously. In a review of the resident's physician orders, an order for O2 therapy was not identified. On 3/19/24 at 9:57 AM, Licensed Practical Nurse (LPN) A stated she was the resident's assigned nurse. She recalled that during the shift to shift report she received, she was told that resident #47 was on O2, but she was not told the LPM. Observation of the O2 flow rate was conducted with the LPN, she acknowledged the O2 therapy was infusing at 6 LPM. A review of the resident's physician orders conducted with LPN A revealed an order for O2 therapy could not be identified. This was acknowledged by the LPN, and she verbalized she had not reviewed the resident's physician orders, or checked the O2 therapy the resident was receiving. On 3/19/24 at 10:14 AM, and at 10:20 AM, the B Wing Unit Manager (UM) stated resident #47 was readmitted to the facility on [DATE]. The UM explained she completed the readmission process, and entered the resident's orders in the resident's electronic medical record after they were reviewed and verified with the physician. The resident's physician's orders were reviewed with the B Wing UM. She acknowledged that an order for O2 therapy could not be identified for the resident and said, I missed it. The B Wing UM said the expectation was that residents would receive the correct O2 therapy/setting, and if an order for O2 therapy was not identified, nurses should call the physician and obtain orders. On 3/19/24 at 10:22 AM, the Director of Nursing (DON) stated that the Interdisciplinary team (IDT) reviewed the clinical records of all new admissions to the facility on the day following the resident's admission/readmission. She explained if the admission was on a weekend, the clinical records would be reviewed by the Supervisor, or by the IDT on the following Monday. She said the resident's readmission was completed and reviewed by the B Wing UM who was the supervisor on 3/16/24. The DON stated the expectation for O2 therapy, was that nurses should be checking and ensuring that O2 was infusing at the right LPM and follow up with maintenance of the O2 tubing. She said O2 was considered a medication, administered by physician orders, and if the resident did not have an order for the O2 therapy, nurses should notify the physician, and obtain orders. A care plan for oxygen therapy initiated on 9/06/23 with revision on 11/07/23 indicated the resident needed oxygen constantly or intermittently to aid breathing, and an intervention was for oxygen at 6 LPM. The policy Respiratory Care issued on 4/01/2022 read, Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration.

Based on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 45 residents, (#47). Findings Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Pharmacy recommendations for resident #47 on 9/18/23 indicated the resident was currently taking Digoxin and recommended that an apical pulse be obtained prior to administration of the medication. The physician/prescriber agreed to the recommendation on 10/16/23. A second pharmacy recommendation dated 12/15/23 addressed the same concern and read, Obtain an apical pulse prior to administration of the medication. The physician/prescriber response dated 1/17/24 was agree. Digoxin is used to treat heart failure and abnormal heart rhythms (arrhythmias). It helps the heart work better and helps control your heart rate (Retrieved 3/27/24 from www.medlineplus.gov). Review of the resident's physician orders revealed an order for Digoxin 125 microgram (mcg) in the morning for heart failure. There was no directive to monitor apical pulse prior to the administration of the medication as recommended by the Consultant Pharmacist on 9/18/23, and on 12/15/23. On 3/20/24 at 1:30 PM, and on 3/21/24 at 9:00 AM, the Director of Nursing (DON) stated pharmacy recommendations were received by her via mail, hand delivered or email. She explained that pharmacy recommendations regarding labs, diagnosis, and apical pulse would be entered in the identified resident's electronic medical record by the Advanced Practice Registered Nurse, DON, or the Unit Managers. The DON said the facility's protocol was that pharmacy recommendations would be addressed and responded to prior to the next monthly pharmacy recommendation. The resident's pharmacy recommendations dated 9/18/23 and 12/15/23, the physician/prescriber's responses to the recommendations dated 10/16/23, and 1/17/24, and the resident's physician orders were reviewed with the DON. She acknowledged the pharmacy recommendations, and physician's responses, and acknowledged there was no documentation for staff to obtain an apical pulse prior to administration of the resident's Digoxin. She stated she was not sure if the directive would be placed on the physician order sheet but would be on the Medication Administration Record (MAR). However, review of the resident's MAR for the period January 2024 through March 2024 revealed no documentation to indicate the resident's apical pulse was monitored prior to administration of the Digoxin, this was acknowledged by the DON. She stated apical pulse should be monitored for the resident prior to administering the Digoxin, because if the apical pulse was below 60 beats per minute, the medication should be held. On 3/21/24 at 11:58 AM, the Medical Director stated resident #47 was recently hospitalized , and was discharged to the facility on the Digoxin. The pharmacy recommendations regarding the Digoxin was shared with the Medical Director. He stated he was not sure about the nursing protocol but had placed some parameters for the Digoxin until the medication could be discussed with the resident's cardiologist. The policy Pharmacist Recommendations issued 4/01/22, read It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines . The pharmacist must report any irregularities to the attending physician .and the facility's medical director and director of nursing, and these reports must be acted upon as soon as reasonably able, but prior to the following month's MRR.

Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect by failing to verify the identity, credentials, and licensure of individual prior to employment as a Licensed Practical Nurse, (LPN) providing care to 68 residents using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A to worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (relating to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to verify the education, training, and validation of nursing licensure for Employee A which allowed Employee A to perform the duties of a nurse without the assurance of safe, professional and ethical practice and accountability of a nursing license, which placed 68 residents under her care at likelihood of serious injury, harm or death due to possible medication and treatment errors and incorrect interpretation of laboratory tests. This resulted in Immediate Jeopardy starting on 02/07/2023. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F600 was corrected on 05/08/2023 and determined to be past noncompliance. Findings: Cross reference F607, and F835 Review of Employee A's Employment Application form revealed an application for employment at the facility was completed on 12/22/22. A professional license was verified by the facility via the Florida Department of Health License Verification website, using the license number provided by Employee A on her application. Data as of 12/22/2022 indicated the license was for a LPN, and was originally issued on 10/24/14, with expiration date of 7/31/23. The license status was documented to be clear and active. The Agency for Health Care Administration Care Provider Background Screening Clearinghouse (the state agency process for background screening results for health care providers in Florida currently licensed by the Agency for Health Care Administration) website page Person Profile showed employee A was determined to be eligible for employment on, 12/22/22, and on 1/26/23. The name on the Background Screening Clearinghouse reslts webpage was spelled differently from the name on the professional license, and the middle initial/names were different. A job description for LPN was signed by Employee A and dated 2/07/23. Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility's staff schedules for the period 2/07/23 to 3/07/23, revealed employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in teh capacity of a licensed nurse while not having a valid Florida nursing license. Review of clinical records revealed the following residents were provided with care and services from Employee A. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included sprain of anterior cruciate ligament of right knee, unilateral primary osteoarthritis, diabetes mellitus type II, psychosis, dementia, hyperlipidemia (high blood cholesterol), and peripheral vascular disease (a slow and progressive circulation disorder). Review of the Medication Administration Record (MAR) showed resident #1's administered medications on 2/09/23 at 5:00 PM included Loratadine 10 milligram (mg) by mouth for allergies, Fluticasone Propionate suspension 50 microgram (mcg)/Act 1 spray in each nostril for rhinitis, at 6:00 PM, Namenda 10 mg for dementia, Insulin Glargine injection 15 units for diabetes, at 9:00 PM, Latanoprost solution 1 drop in both eyes for glaucoma, Atorvastatin 40 mg by mouth for high cholesterol, and at 10:00 PM, Hydralazine 50 mg by mouth for high blood pressure, and Gabapentin 100 mg by mouth for neuropathy (damage to the peripheral nerves, and signs may include a prickling, burning or numb sensation). Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including, Alzheimer's disease, dementia, major depressive disorder, and malignant carcinoid tumor. Resident #2's administered medications on the MAR dated 2/25/23 at 6:00 PM included Divalproex 125 mg by mouth for seizures, at 6:30 PM, Aricept 5 mg by mouth for Alzheimer's, and at 9:00 PM, Trazadone 50 mg by mouth for depression. Resident #3 was admitted to the facility on [DATE]. His diagnoses included diabetes, major depressive disorder, anxiety disorder, Parkinson's disease, hypertension (HTN), and hyperlipidemia. The resident's MAR showed he received the following medications on 2/09/23, and 2/26/23 at 6:00 PM, Insulin Glargine injection 20 units, and at 9:00 PM Mirtazapine 30 mg by mouth for depression, and Topiramate 50 mg by mouth for mood disorder. Resident #4 was admitted to the facility on [DATE]. His diagnoses included high blood pressure, DM type II, atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and hyperlipidemia. The MAR noted resident #4's administered oral medications on 2/09/23 at 5:00 PM included, Memantine 10 mg, Metformin 1000 mg for diabetes, Gabapentin 500 mg, at 9:00 PM, Atorvastatin 20 mg, and Ropinirole 0.5 mg for Parkinson's. Employee A performed blood glucose monitoring for the resident at 4:30 PM, and 9:00 PM. Resident #5 was admitted to the facility on [DATE] with diagnoses that included heart failure, HTN, colostomy, chronic respiratory failure with hypoxia (a below normal level of oxygen in the blood), hyperlipidemia, quadriplegia, and chronic obstructive pulmonary disease (COPD). Resident #5's administered medications noted on the MAR dated 2/09/23 at 6:00 PM included Baclofen 20 mg by mouth for pain, at 9:00 PM Carvedilol 3.125 mg by mouth for heart failure, Acetylcysteine inhalation 20% for shortness of breath, and the resident's midline intravenous catheter (a samll tube used to give treatments and to take blood samples) was flushed with 10 milliliters (ml) of normal saline. Resident #6 was admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, aphasia (a disorder that results from damage to portions of the brain that are responsible for language), dysphagia (difficulty swallowing), HTN, and hyperlipidemia. The MAR showed the resident's administered medication on 2/09/23, and on 2/26/23 at 9:00 PM, included Atorvastatin 80 mg by mouth. Resident #7 was admitted to the facility on [DATE], with diagnoses which included HTN, dementia, COPD, and stroke. Resident #7's administered medications as per the MAR on 2/09/23, and on 2/26/23 at 6:00 PM included oral medications, Amlodipine 5 mg for high blood pressure, and Memantine 10 mg. Resident #8 was admitted to the facility on [DATE], with diagnoses that included depression HTN, seizures, DM type II, cerebrovascular disease, and hemiplegia (paralysis of one side of the body). The MAR showed the resident's administered medications on 2/09/23, and on 2/26/23 at 5:00 PM included oral medications, Levetiracetam 1000 mg for seizures, Metformin 500 mg, at 9:00 PM, Atorvastatin 80 mg, Baclofen 10 mg for muscle pain, Mirtazapine 30 mg, Gabapentin 600 mg, and at 10:00 PM Clindamycin 600 mg for infection. Blood glucose monitoring was documented as completed at 6:00 AM on 2/25/23 and 3/05/23. Resident #9 was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, HTN, dementia, anxiety disorder, major depressive disorder, and bone cancer. Resident #9's administered medications on 2/09/23, and 2/26/23 at 5:00 PM included Docusate 100 mg by mouth for constipation, at 6:30 PM, Tamsulosin 0.4 mg by mouth for enlarged prostate, at 9:00 PM, Latanoprost 0.005% 1 drop in both eyes, and at 10:00 PM Brimonidine Tart 0.2% 1 drop in both eyes for glaucoma. Resident #10, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms such as depression or mania), delusional disorders, anxiety disorder, major depressive disorder, HTN, COPD, dementia, and traumatic brain injury. Resident #10's administered medications on 2/09/23, and 2/26/23 at 5:00 PM included Valproate Sodium 15 ml by mouth for mood disorder, 9:00 PM Latanoprost 0.005% 1 drop in both eyes, Mirtazapine 7.5 mg by mouth, Quetiapine 400 mg by mouth for schizoaffective disorder, and at 10:00 PM Baclofen 10 mg by mouth for muscle spasm. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute osteomyelitis (infection of bone), DM type II, hemiplegia/hemiparesis affecting left non-dominant side, long term use of anticoagulants (blood thinners), HTN, atrial fibrillation, and hyperlipidemia. Resident #11's administered medications on the MAR on 2/09/23, and 2/26/23 at 9:00 PM included oral medications, Atorvastatin 10 mg, Apixaban 5 mg for blood clot prevention, and Glimepiride 4 mg for diabetes. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included aphasia, frontal lobe and executive function deficit, metabolic encephalopathy (metabolism problems that cause brain dysfunction), DM type II, HTN, and peripheral vascular disease. Resident #12's administered medications on the MAR dated 2/09/23, and 2/26/23 at 5:00 PM included Carvedilol 12.5 mg by mouth, at 9:00 PM Insulin Glargine 10 units injection, Lisinopril 20 mg by mouth for high blood pressure, Gabapentin 100 mg, and Hydralazine 100 mg, both by mouth. Resident #13, an [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included DM type II, major depressive disorder, Alzheimer's disease, and dementia. Resident #13's administered medications on 2/09/23, and 2/26/23 at 9 PM included oral medications, Atorvastatin 20 mg, and Norvasc 5 mg for high blood pressure. Resident #14 was admitted to the facility on [DATE], with diagnoses which included HTN, aphasia, depression, hemiplegia, and hyperlipidemia. Resident #14's administered oral medications on 2/09/23, and 2/26/23 at 5 PM included, Loratadine 10 mg for rhinitis, and at 9 PM, Lipitor 20 mg for high cholesterol, Mirtazapine 15 mg, Levetiracetam 1000 mg, Lisinopril 20 mg, and Gabapentin 300 mg. Resident #15, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included hyperlipidemia, hypothyroidism (low thyroid hormones), dementia, psychosis, convulsions, bipolar disorder, major depressive disorder, and schizoaffective disorder. Resident #15's oral administered medications on 2/18/23, and 2/19/23 at 4:30 PM included Keppra 1000 mg for seizures, at 5 PM Depakote 500 mg, and at 6 PM Potassium Chloride 20 milliequivalents (MEQ). On 2/19/23, 2/20/23, and 2/26/23, at 6 AM employee A administered Levothyroxine 150 microgram (mcg) for hypothyroidism, at 6:30 AM Keppra 1000 mg, at 6 PM Lasix 40 mg, Lasix 20 mg for edema, at 6:30 PM Aptiom 400 mg for convulsions, at 9 PM, Seroquel 150 mg for schizoaffective disorder, Simvastatin 20 mg. On 3/04/23, 3/05/23, and 3/06/23 at 4:30 PM Keppra 1000 mg, 6 PM Lasix 20 mg, Lasix 40 mg, Potassium Chloride 20 milliequivalents (MEQ), at 6:30 PM Aptiom 400 mg, and at 9 PM Seroquel 150 mg, Simvastatin 20 mg for high cholesterol, Carvedilol 12.5 mg, and Depakote 500 mg for bipolar disorder. Resident #16, a 59- year-old female was admitted on [DATE]. Her diagnoses included hemiplegia/hemiparesis, anxiety disorder, insomnia, major depressive disorder, hypercholesterolemia, and epilepsy. Resident #16's oral administered medications on 2/09/23, and 2/26/23 at 5 PM included Keppra 1000 mg, Ciprofloxacin 500 mg for abscess, and at 9 PM Pravastatin 20 mg for cholesterol, Clonazepam 2 mg for anxiety, and Temazepam 7.5 mg for insomnia. Resident #17, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included aphasia, atrial fibrillation, Alzheimer's disease, hyperlipidemia, insomnia, HTN, and Parkinson's disease. Resident #17's oral administered medications on 2/09/23, and 2/26/23 at 6 PM included Coumadin 5 mg for blood clot prevention, and at 9 PM Atorvastatin 10 mg. Resident #18, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia, DM type II, tachycardia (fast heart rate over 100 beats/minute), HTN, cerebral infarction, and hyperglycemia (high blood sugar). Resident #18's administered medications on 2/09/23, and 2/26/23 at 5 PM included, Humalog insulin injection 3 units, at 9 PM Atorvastatin 40 mg by mouth, Insulin Glargine 15 units injection, Metoprolol 25 mg by mouth for high blood pressure, Baclofen 10 mg by mouth, and Gabapentin 300 mg by mouth. Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included DM type II, HTN, hyperlipidemia, and gastroesophageal reflux disease (GERD). Resident #19's administered medications on 2/09/23, and 2/26/23 at 5 PM included Humalog insulin injection 20 units, at 6 PM Losartan Potassium 50 mg for high blood pressure by mouth, Metformin 500 mg by mouth, and at 9 PM, Atorvastatin 40 mg by mouth, Lantus insulin injection 73 units, and Hydralazine 100 mg by mouth. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE], with diagnoses which included heart failure, hyperlipidemia, hypokalemia, atrial fibrillation, DM type II, and HTN. Resident #20's administered oral medications on 2/09/23, and 2/26/23 at 9 PM included, Apixaban 5 mg, and Metoprolol 50 mg. Resident #21, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included major depressive disorder, chronic kidney disease, hyperlipidemia, HTN, gastrostomy, and dementia. Resident #21's administered medications by gastrostomy tube on 2/09/23 at 6 PM included Carvedilol 3.125 mg, at 4 PM and 8 PM Employee A's signature on the Medication Administration Record indicated the resident's gastrostomy tube was flushed with 150 ml of water. Documentation indicated the gastrostomy tube was checked for placement (in the digestive tract), patency (tube being blocked) residual (volume of feeding remaining in the stomach), the site was observed for signs and symptoms of infection and the tube was flushed with 30 ml of water before and after medication administration through the tube. Resident #22, a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included COPD, hemiplegia/hemiparesis, anxiety disorder, HTN, major depressive disorder, and hyperlipidemia. Resident #22's administered oral medications on 2/09/23 at 9 PM included Atorvastatin 40 mg, Levothyroxine 150 mg, Melatonin 6 mg for insomnia, and Ciprofloxacin 500 mg for infection. Resident #23, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included bipolar disorder, anxiety disorder, and pneumonia. Resident #23's oral administered medications on 2/14/23, and 2/25/23 at 9 PM included, Seroquel 100 mg, Trazadone 50 mg, Alprazolam mg for anxiety, and at 10 PM Gabapentin 300 mg. Resident #24, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included DM type II, Alzheimer's disease, HTN, and COPD. Resident #24's administered oral medications on 2/25/23, and on 2/26/23 at 6 AM included, Eliquis 2.5 mg for clot prevention, at 6 PM Eliquis 2.5 mg (for blood clot prevention), and at 9 PM Atorvastatin 20 mg. Resident #25, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction, major depressive disorder, atrial fibrillation, heart failure, paranoid schizophrenia, hyperlipidemia, hemiplegia/hemiparesis, DM type II, and HTN, PVD. Resident #25's administered medications on 2/09/23, and 2/26/23 at 6 PM included digoxin 125 mcg by mouth for atrial fibrillation, Apixaban 5 mg by mouth, Baclofen 5 mg by mouth, Carvedilol 25 mg by mouth, Valproate Sodium 200 mg by mouth, at 9 PM Lantus insulin injection 50 units, Diltiazem 90 mg by mouth for high blood pressure, and at 10 PM Keppra 500 mg by mouth, and Hydralazine 100 mg by mouth. Resident #26, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, anxiety disorder, HTN, and hyperlipidemia. Resident #26's administered medications on 2/09/23, and on 2/26/23 at 10 PM included, Atorvastatin 40 mg by mouth. Resident #27, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal disease (ESRD), major depressive disorder, insomnia, hypokalemia, and convulsion. Resident #27's oral administered medications on 2/09/23, and 2/26/23 at 9 PM included, Trazadone 50 mg, Pregabalin 50 mg for neuropathy, Melatonin 3 mg, and Valproic Acid 15 ml for tremors. Resident #28, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy, dementia, HTN, and dysphagia. Resident #28's administered medications on 2/14/23 at 2 PM included Medrol 4 mg by mouth for cellulitis, at 6:30 PM Medrol 4 mg by mouth, at 9 PM, Clonazepam 0.5 mg by mouth for anxiety, Atorvastatin 20 mg by mouth, Medrol 4 mg by mouth, Risperidone 0.25 mg by mouth for mood, and Trazadone 50 mg by mouth. At 2:58 PM documentation on the resident's Medication Administration Record indicated Employee A interpreted tuberculosis skin test for the resident and administered the Pneumovax vaccine (vaccine helps protect against pneumonia) by injection at 3:02 PM. Resident #29, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included DM type II, cancer of the pancreas, dementia, hypothyroidism, hyperlipidemia, and HTN. Resident #29's administered medications on 2/14/23 at 9 AM included Amlodipine 2.5 mg by mouth, Latanoprost solution 0.005% 1 drop in both eyes, Toprol 50 mg by mouth for high blood pressure, at 5 PM Rivaroxaban 20 mg by mouth for atrial fibrillation, and at 9 PM Simvastatin 20 mg by mouth. Resident #30, a [AGE] year-old female was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included major depressive disorder, hyperlipidemia, DM type II, HTN, heart disease, ventricular tachycardia, and dementia. Resident #30's administered medications via gastrostomy tube on 2/14/23, and 2/25/23 at 10 AM included, Amlodipine 5 mg, Furosemide 20 mg for heart disease, at 9 PM Atorvastatin 20 mg, Metoprolol 25 mg, and on 2/25/23 at 5 PM Doxycycline 100 mg for wound infection. Brimonidine-Timolol ophthalmic solution 0.5% 1 drop in both eyes for glaucoma was adminstered at 9 PM. Employee A's signature on the resident's Medication Administration Record indicated the resident's gastrostomy tube was flushed with 150 ml of water, and the tube feed formula Osmolite 1.5 was administered at 45 ml per hour. Documentation indicated the gastrostomy tube was checked for placement, patency, residual, observed for signs and symptoms of infection and the tube was flushed with 30 ml of water before and after medication administration through the tube. On 5/10/23 at 10:26 AM, the Director of Nursing (DON) stated that on 5/03/23 at approximately 2:30 PM the Human Resource (HR) Director was notified via telephone by a Law Enforcement Officer, from the criminal investigation division, that they had initiated an investigation related to identity theft, and were questioning the accuracy of nursing license for Employee A. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the DON. She explained that if the applicant was approved, HR would do a license verification through the Florida Department of Health (the Florida state agency responsible for regualtion of licensed health care practitioners) and the Agency For Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to see if the prospective employee was eligible to work. The Business Office Manager/ HR Director stated Employee A applied to the facility on 12/ 22/22 via, Indeed .com (an American worldwide employment website for job listings) and an interview was conducted by the DON on 12/22/22. References were obtained for Employee A from a skilled nursing facility, and from a past coworker whom she worked with on a Rapid Response team, and the professional license was verified, and pulled from the Department of Health website. The Business Office Manager/HR Director recalled she contacted both references, and received positive feedback regarding Employee A. The Business Office Manager/HR Director stated Employee A needed fingerprints done, so she was sent out to a company contracted by the facility to have her fingerprints done. She stated Employee A's information was submitted to the company on 12/22/22, and she was determined to be eligible to work on 12/28/22. The Business Office Manager/ HR Director recalled that Employee A stated she could not start at that time since she had another job, and her background was run again on 1/17/23. She explained that it was the practice of the facility to resubmit the request for background screen, so that if something comes up, AHCA (Background Screening Clearinghouse) would catch it. The Business Office Manager/HR Director stated Employee A was eligible to work on 1/26/23, and her first day of work at the facility was on 2/07/23. The Business Office Manager/HR Director stated that when she ran the professional license, using the license number provided by Employee A nothing flagged indicating the license was clear and active. She recalled she also checked employee A's Social Security (SS) card and driver's license. The Business Office Manager/ HR Director recalled the name on the professional license and Employee A's driver's license were different, the first names were spelt differently, and there were different middle names. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy at that time. She stated she did not line up all the documents and review them thoroughly for accuracy On 5/25/23 at 11:02 AM, the DON recalled she interviewed Employee A on 12/22/22, and verbalized the employee had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON stated she reviewed Employee A's application, discussed her schooling, but never reviewed her license/certificate or asked for a transcript. She stated her level II background screen had to be cleared before she could start working, and she started orientation on 2/07/23 with mostly observation. On 2/09/23 she had an assignment with oversight from a preceptor, and on 2/14/23, Employee A was on a medication cart by herself. The DON verbalized that no one picked up the discrepancy with the names on Employee A's driver's license, SS card, and the LPN license. She confirmed employee A administered medications via gastrostomy tube, maintained gastrostomy tube feeding, administered insulin injections and other oral and optic medications. On 5/25/23 at 11:24 AM, the Administrator stated Employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the Employee's license when the detective notified the facility on 5/03/23. The Administrator said Employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A. On 5/25/23 at 11:28 AM, the Medical Director explained he was made aware of the employee working at the facility as a LPN without a license when he attended a meeting with the Administrator, Regional Consultant Nurse, and the DON on 05/03/2023. He stated he was shocked, and was concerned if any resident was harmed. He said he was pleased the facility had assessed the residents by doing clinical reviews of records and interviews and also reviewing all transfers to the hospital that identified there was no harm done to the residents. The Medical Director stated he attended the Ad Hoc Quality Assurance Performance Improvement (QAPI) and agreed with steps taken to address the issue. He stated nurses usually paged him on his paging service, but he had no recollection of having any interaction with Employee A. 5/26/23 at 3:50 PM, the Administrator, and the Regional Nurse Consultant stated the facility did not have a policy regarding the hiring process, but followed the State guidelines, and the facility's policy and procedure for Abuse, Neglect, Exploitation (ANE). Review of the facility's policy and procedure ANE and Investigations issued 4/01/2022, revealed the screening process for potential employees included a Level II FBI (Federal Bureau of Investigation) finger printing if they have not had one conducted in the previous 5 years. The document read, All health care providers that require licensure or certification will be verified prior to provision of care of residents. The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, the job duties and responsibilities included recommendation of the number and level of nursing personnel to be employed .Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs . qualified to perform the procedure .Assist the Administrator and/or the HR Director in the recruitment and selection of nursing service personnel . Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure. The job description for Licensed Practical Nurse/Registered Nurse with revision date of 1/01/2015 read, The primary purpose of your position is to provide direct nursing care to the residents, . Ensure that direct nursing care be provided by a licensed nurse .Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings and bandages, packs, colostomy, and drainage bags . as required . Take and record TPRs, blood pressures, .Monitor seriously ill residents as necessary . Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN program. Must possess a current, unencumbered, active license to practice as an .LPN/LVN (Licensed Vocational Nurse) in this state. Review of the Facility Assessment 2023 updated 4/12/23, reviewed on 4/17/23 indicated that resources needed to provide competent support and care for our resident population every day and during emergencies, included Nursing services-LPN Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated education- Abuse, Neglect, Exploitation 138/139 staff educated, 100% completed o

Based on interview, and record review, the facility failed to implement policies and procedures to prevent medical neglect by failing to verify identification, and licensure of Employee A prior to employment as a Licensed Practical Nurse (LPN)providing care and services to 68 residents during 16 shifts using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (related to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to implement policies and procedures for verification of identification, and licensure for nursing staff prior to performing nursing duties which allowed Employee A to perform the duties of a nurse without the assurance of safe, professional and ethical practice and accountability of a nursing license, and placed 68 residents under her care at a likelihood of serious, injury, harm or death due to possible medication and treatment errors and incorrect interpretation of laboratory tests. This resulted in Immediate Jeopardy starting on 2/07/23. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F607 was corrected on 05/08/2023 and determined to be past noncompliance. Findings Cross reference F600 and F835 Review of Employee A's Employment Application form revealed an application for employment at the facility was completed on 12/22/22. A professional license was verified by the facility via the Florida Department of Health License Verification website, using the license number provided by Employee A on her application. Data as of 12/22/2022 indicated the license was for an LPN, and was originally issued on 10/24/14, with an expiration date of 7/31/23. The license status was documented to be clear and active. The Agency for Health Care Administration Care Provider Background Screening Clearing House (the state agency process for background screening results for health care providers in Florida currently licensed by the Agency for Health Care Administration) website page) Person Profile showed Employee A was determined to be eligible for employment on, 12/22/22, and on 1/26/23. The name on the Background Screening Clearinghouse results webpage was spelled differently from the name on the professional license, and the middle initial/names were different. Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility's staff schedules for the period 2/07/23 to 3/07/23, revealed Employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in the capacity of a licensed nurse while not having a valid Florida nursing license. Review of thirty sampled residents' clinical records revealed they were provided with care and service from Employee A including administering oral, optic, inhalation, subcutaneous, and gastrostomy tube medications. Employee A provided insulin injections, blood glucose monitoring, monitored midline IV catheter, interpreted tuberculin test, provided pneumococcal vaccine, wound care, respiratory care and completed nursing assessments, with the likelihood of serious harm or death due to lack of credentials and competency. On 5/10/23 at 10:26 AM, the Director of Nursing (DON) stated that on 5/03/23 at approximately 2:30 PM, the Human Resource (HR) Director was notified via telephone by Law Enforcement Officer, from the criminal investigation division, that they had initiated an investigation related to identity theft, and were questioning the accuracy of nursing license for Employee A. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the DON. She stated that if the applicant was approved, HR would do a license verification through the Florida Department of Health, (the Florida state agency responsible for regulation of licensed health care practitioners) and the Agency for Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to ensure the prospective employee was eligible to work. The Business Office Manager/HR Director stated Employee A completed her application to the facility on [DATE]. She noted the results of her fingerprint and background screening were received on 12/28/22, and Employee A started orientation at the facility on 2/07/23. The Business Office Manager/HR Director explained that when she verified the professional license, using the license number provided by Employee A, nothing flagged, which indicated the license was clear and active. She recalled she also checked Employee A's Social Security (SS) card and recalled the name on the professional license and Employee A's driver's license were different. The first names were spelled differently, and there were different middle names. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy at that time, and did not review all the required documents thoroughly prior to the hiring of Employee A. On 5/25/23 at 11:02 AM, the DON recalled she interviewed Employee A on 12/22/22. She stated Employee A had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON stated she reviewed Employee A's application, discussed her schooling, but never reviewed her license/ certificate or asked for a transcript. She stated no one picked up on the discrepancy with the names on Employee A's driver's license, SS card, and the LPN's license. She acknowledged Employee A administered medications via gastrostomy tube, maintained gastrostomy tube feedings, and administered insulin injections and other oral and optic medications during the period she worked at the facility. On 5/25/23 at 11:24 AM, the Administrator stated Employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the employee's license when the detective notified the facility on 5/03/23. The Administrator said Employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A prior to her hire. On 5/26/23 at 3:50 PM, the Administrator, and the Regional Nurse Consultant stated the facility did not have a policy regarding the hiring process, but followed the State guidelines, and the facility's policy and procedure for Abuse, Neglect, Exploitation (ANE). Review of the facility's policy and procedure ANE and Investigations issued 4/01/2022, revealed the screening process for potential employees included a Level II Federal Bureau of Investigation (FBI) finger prints if one was not done in the previous 5 years. The document read, All health care providers that require licensure or certification will be verified prior to provision of care of residents. The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, part of the job duties and responsibilities was to Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure. Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated education- Abuse, Neglect, Exploitation 138/139 staff educated, 100% completed on 5/05/23. *On 5/03/23 Abuse, Neglect, Exploitation (ANE) completed for residents in Employee A's assignment on 2/09/23, 2/14/23, 2/18/23, 2/19/23, 2/20/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 3/04/23, 3/05/23, and 3/06/23 indicated no concerns, interviewed families of residents with BIMS below 10. *Conducted full house audit for ANE: to ensure no care concerns. Questions included: Do you have any safety concerns? Do you have any care concerns? Do you have any concerns or feel that you may have been neglected, abused, mistreated, exploited and/or misappropriation. *On 5/03/23 4 of 4 persons responsible for obtaining initial verification and ongoing monitoring of licensure and certification status re-educated on facility process for: validating License/Certification status/obtaining BGS and license verification with validation of demographics by two staff members for accuracy. Licensed nurse verification of demographic accuracy to be validated with (HR and administrator) for all active licensed nurses. *Licensed Nurse verification report validation with driver's license and level II BGS for validation of demographic accuracy to be validated with (HR and Administrator) for all active licensed nurses. *Systemic Changes: The facility initiated a cross-check process to include Onboarding- facility will determine and validate proper education, certification, licensing for positions applying for- by HR and director of hiring department. Obtain copy of driver's license/government issued ID, verify license through FL DOH Medical Quality Assurance (MQA) site and validate demographics accuracy on level II AHCA background clearing house, to be reviewed/validated by HR and Administrator and/or DON. *Beginning 5/03/23 the facility Administrator/designee reviewed concern/grievance log, 24/72 -hour report, resident/family council meetings, facility compliance /complaint line, risk management portal, electronic health record, alert reporting during the stand up/stand down administrative/clinical morning meetings. *On 5/04/23 an Immediate ACHA report was submitted. * SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note for RNs/LPN/LVNs for all residents in Employee A's assignment evaluated by Licensed nurse, medical records reviewed with the Medical Director, plan of care reviewed- no changes in condition noted. Responsible parties made aware of unlicensed staff activity. * On 5/08/23 an additional Ad Hoc QAPI was held to review actions implemented. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown origin, and the importance of licensure/certification rules and regulations for applicable employees such as nursing/CNA/Therapist. Review of the audit titled, Licensed Nurse/Agency/Student/volunteer Log revealed the log would be utilized by the Human Resources Director/designee and Director of Nursing/designee to review photo identification, licensure/certification (if applicable) and Level II Background Screening/State specific background screening. The log indicated audits were conducted on 5/05/23 and 5/08/23, and all components were identified, and in compliance with required regulations and facility's policy and procedures. On 5/10/23, and 5/26/23, interviews were conducted with three Registered Nurses, five LPNs, three CNAs, three Rehab staff, one Receptionist, and one housekeeping staff, All verbalized understanding of the education provided. On 5/26/23, interviews were conducted with four of four people responsible for obtaining initial verification and ongoing monitoring of licensure and certification status. They verbalized understanding of the education provided. The surveyor determined based on the facility's corrective actions, the facility was in substantial compliance.

Based on interview, and record review, the facility's administration failed to use its resources effectively to ensure policies and procedures were implemented to prevent medical neglect placing 68 residents in the facility at risk by not verifying identification and licensure of an individual prior to employment as a Licensed Practical Nurse (Employee A) assigned to provide nursing care and services for 68 residents on 16 shifts while working in the capacity of a LPN without a valid license. The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse, worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (relating to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to verify the education, training, and validation of nursing licensure for Employee A, which allowed Employee A to perform the duties of a nurse, without the assurance of safe, professional and ethical practice and accountability of a nursing license, which placed the 68 residents under her care at a likelihood of serious injury, harm, or death. The facility administration's failure to use its resources effectively to ensure policies and procedures were implemented to prevent medical neglect resulted in Immediate Jeopardy starting on 2/07/23. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F835 was corrected on 05/08/2023 and determined to be past noncompliance. Findings Cross reference F600, F607 Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility staff schedule for the period 2/07/23 to 3/07/23, revealed Employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in the capacity of a licensed nurse while not having a valid Florida nursing license. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the Director of Nursing (DON). She stated that if the applicant was approved, HR would do a license verification through the Florida Department of Health (the Florida state agency responsible for regulation of licensed health care practitioners), and the Agency For Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to ensure the prospective employee was eligible to work. The Business Office Manager/HR Director stated Employee A completed her application to the facility on [DATE]. She said the results of her fingerprint and background screening were received on 12/28/22, and Employee A started orientation at the facility on 2/07/23. The Business Office Manager/HR Director explained that when she verified the professional license, using the license number provided by Employee A, nothing flagged, which indicated the license was clear and active. She recalled she also checked Employee A's Social Security (SS) card and recalled the name on the professional license and Employee A's driver's license were spelled differently, and the middle names/initials were different. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy then, and did not review all the required documents thoroughly prior to the hiring of Employee A. On 5/25/23 at 11:02 AM, the Director of Nursing (DON) stated she interviewed Employee A on 12/22/22. She said Employee A had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON recalled she reviewed Employee A's application, discussed where she went to school, but never reviewed her license/certificate. She said no one picked up on the discrepancy regarding the names on her driver's license, Social Security card, and the professional license. The DON noted Employee A had two days of orientation, beginning on 2/07/23 with shadowing and on 2/09/23 she was given an assignment with oversight from a preceptor. She said on 2/14/23, Employee A was on a medication cart by herself. The DON confirmed Employee A administered medications via gastrostomy tube, maintained gastrostomy tube feedings, and administered insulin injections and other oral and optic medications during the period she worked at the facility. On 5/25/23 at 11:24 AM, the Administrator stated employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the employee's license when the detective notified the facility on 5/03/23. The Administrator said employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A. On 5/25/23 at 11:28 AM, the Medical Director explained he was made aware of the Employee working at the facility as a LPN without a license when he attended a meeting with the Administrator, Regional Consultant Nurse, and the DON on 05/03/2023. He stated he was shocked, and was concerned if any resident was harmed. He said he was pleased the facility had assessed the residents by doing clinical reviews of records and interviews and also reviewing all transfers to the hospital that identified there was no harm done to the residents. The Medical Director stated he attended the Ad Hoc Quality Assurance Performance Improvement (QAPI) and agreed with steps taken to address the issue. He stated nurses usually paged him on his paging service, but he had no recollection of having any interaction with Employee A. Review of the job description for Administrator with revision date of 1/1/2015 revealed, the primary purpose of the Administrator was to direct the day-to-day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The duties and responsibilities were to, Ensure that appropriate employment identification and work documents are presented prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, a part of the job duties and responsibilities was to Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated education- Abuse, Neglect, Exploitation 138/139 staff educated, 100% completed on 5/05/23. *On 5/03/23 Abuse, Neglect, Exploitation (ANE) completed for residents in Employee A's assignment on 2/09/23, 2/14/23, 2/18/23, 2/19/23, 2/20/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 3/04/23, 3/05/23, and 3/06/23 indicated no concerns, interviewed families of residents with BIMS below 10. *Conducted full house audit for ANE: to ensure no care concerns. Questions included: Do you have any safety concerns? Do you have any care concerns? Do you have any concerns or feel that you may have been neglected, abused, mistreated, exploited and/or misappropriation. *On 5/03/23 4 of 4 persons responsible for obtaining initial verification and ongoing monitoring of licensure and certification status re-educated on facility process for: validating License/Certification status/obtaining BGS and license verification with validation of demographics by two staff members for accuracy. Licensed nurse verification of demographic accuracy to be validated with (HR and administrator) for all active licensed nurses. *Licensed Nurse verification report validation with driver's license and level II BGS for validation of demographic accuracy to be validated with (HR and Administrator) for all active licensed nurses. *Systemic Changes: The facility initiated a cross-check process to include Onboarding- facility will determine and validate proper education, certification, licensing for positions applying for- by HR and director of hiring department. Obtain copy of driver's license/government issued ID, verify license through FL DOH Medical Quality Assurance (MQA) site and validate demographics accuracy on level II AHCA background clearing house, to be reviewed/validated by HR and Administrator and/or DON. *Beginning 5/03/23 the facility Administrator/designee reviewed concern/grievance log, 24/72 -hour report, resident/family council meetings, facility compliance /complaint line, risk management portal, electronic health record, alert reporting during the stand up/stand down administrative/clinical morning meetings. *On 5/04/23 an Immediate AHCA report was submitted. * SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note for RNs/LPN/LVNs (Licensed Vocational Nurse) for all residents in Employee A's assignment evaluated by Licensed nurse, medical records reviewed with the Medical Director, plan of care reviewed- no changes in condition noted. Responsible parties made aware of unlicensed staff activity. * On 5/08/23 an additional Ad Hoc QAPI was held to review actions implemented. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown origin, and the importance of licensure/certification rules and regulations for applicable employees such as nursing/CNA/Therapist. Review of the audit titled, Licensed Nurse/Agency/Student/volunteer Log revealed the log would be utilized by the Human Resources Director/designee and Director of Nursing/designee to review photo identification, licensure/certification (if applicable) and Level II Background Screening/State specific background screening. The log indicated audits were conducted on 5/05/23 and 5/08/23, and all components were identified, and in compliance with required regulations and facility's policy and procedures. On 5/10/23, and 5/26/23, interviews were conducted with three Registered Nurses, five LPNs, three CNAs, three Rehab staff, one Receptionist, and one housekeeping staff, All verbalized understanding of the education provided. On 5/26/23, interviews were conducted with four of four people responsible for obtaining initial verification and ongoing monitoring of licensure and certification status. They verbalized understanding of the education provided. The surveyor determined based on the facility's corrective actions, the facility was in substantial compliance.

Based on interview, and record review, the facility failed to ensure care plan meeting was scheduled in a timely manner to ensure participation in the plan of care for 1 of 1 resident of a total sample of 8 residents, (#6). Findings: Review of resident #6's clinical records revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date 10/01/22 revealed the resident's cognition was intact, with a Brief Interview For Mental Status score of 15/15. On 11/15/22 at 10:08 AM, resident #6 stated he was admitted to the facility on [DATE], and his first care plan meeting was held in August 2022. He said he was never invited to a care plan meeting before, and this one happened because he requested the meeting. On 11/15/22 at 3:49 PM and 4:06 PM, the Registered Nurse (RN) MDS Coordinator explained care plan meetings were arranged by MDS staff, and sometimes by the Social Services Director at the resident's request. She stated a care plan meeting would be held within a week to fourteen days after the resident's admission. Documentation of the resident's care plan meeting was requested from the RN MDS Coordinator. A form dated 8/04/22 was provided, which indicated that MDS, activities, dietary, social services, Unit Manager, and the resident attended this meeting. The RN MDS coordinator stated she could not find any documented evidence to indicate a care plan meeting was held with the resident prior to 8/04/22. She verbalized the process to have a sign in sheet to capture persons present at the meeting was not a new process and was in place prior to her being at the facility. The RN MDS Coordinator said she believed at the time the facility was between MDS coordinator. On 11/15/22 at 4:41 PM, the Director of Nursing (DON) said the MDS department had not been stable, and a new MDS coordinator was hired in June 2022. She stated that in review, concerns with care plans were identified and placed in the facility's Quality Assurance Performance Improvement (QAPI). The DON provided documentation of the problem identified and placed in QAPI as of October 2022. However, the problem identified was for missing Care Plans and did not address care plan meetings. The DON confirmed the resident was admitted to the facility on [DATE], and a care plan meeting was not held with the resident until 8 months later, on 8/02/22. The facility's care plan Care Plans, Comprehensive Person-Centered revised December 2016 read, Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: Participate in the planning process .The care planning process will: Facilitate resident and/or representative involvement.

Based on interview, and record review, the facility failed to complete and resolve a grievance as per protocols and guidelines for 1 of 3 residents reviewed for grievances, of a total of 8 sampled resident (#6). Findings: Review of resident #6's clinical records showed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) 10/01/22 revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 15/15. On 11/15/22 at 10:08 AM, resident #6 stated that on 8/28/22 while he was in bed, his nurse on the 3-11 PM shift kicked his door open. He verbalized he pulled back his privacy curtain, got to the door, closed it, and went back to rest. Resident #6 said that fifteen seconds later, the door was pushed back, and the only person in the hallway was the nurse. He said the nurse kept looking at him, and mean mugging him. He said he finally asked her why she was was looking at him and she said something like, I got eyes. The resident explained the nurse, Licensed Practical Nurse (LPN) A had been his nurse before, and on two occasions while she was in his room, residents came into his room to talk to her. He said he told LPN A he did not feel comfortable with residents coming into his room. He indicated he was not aware the nurse was so upset, that she would karate kick in his door. Resident #6 stated he spoke to the lady in Human Resources, who told him she would write a grievance on his behalf and give it to the Social Services Director (SSD). He noted the SSD was aware and was supposed to have done some investigation. The resident stated when he spoke to the SSD on 9/28/22 she said the incident did not happen on her watch, so she would not know how to go about it. He said she told him she was told the nurse was fired. The resident did not know what was documented in the grievance, and he did not know the outcome. On 11/15/22 at 1:07 PM, the Director of Nursing (DON) stated a grievance was documented on the resident's behalf, by the Business Office Manager/Human Resources staff who was the resident's assigned Guardian Angel. She verbalized the SSD saw the resident, and he wanted to be left alone. The DON stated she spoke to the resident, and he did not voice any concerns regarding resolution of his grievance. The Grievance-Complaint Report for resident #6 was reviewed with the DON. The form revealed the grievance was made on 8/29/22 with the date of the grievance on 8/28/22. It read, Resident stated the nurse did not give him any medications, and the nurse kicked the door. Resident did not specify which nurse. Documentation on the form revealed the Coordinator received the grievance on 9/01/22, and indicated the SSD spoke with the resident to get additional information, and he denied he made a grievance, and stated that most likely a staff member wrote it on his behalf. On 11/15/22 at 2:16 PM, the SSD stated 8/29/22 was her first day working at the facility, and the grievance for resident #6 was brought to her at the morning meeting. She stated she went to speak with the resident, and he denied anything had taken place with the nurse. The SSD verbalized that when she read the progress note documented by LPN A on 8/28/22, she went back to the resident, read the progress note to him, and he denied the actions documented by the LPN. Nothing further was done about the incident. She said the incident took place before her time, and she was not aware of the involvement of law enforcement. The SSD said she dealt with the grievance regarding the resident not getting his medications. The SSD stated that since the incident between LPN A and the resident was not a resident-to-resident issue, but a resident to staff issue, she could not speak to the process for investigation. She stated she was not aware if any witness statements were obtained from the Certified Nursing Assistant (CNA), or the other residents mentioned in the progress note documented by LPN A. The Grievance- Complaint Report for resident #6 was reviewed with the SSD and the DON. They confirmed there was no documentation to indicate the steps taken to investigate and resolve the resident's grievance. On 11/15/22 at 1:41 PM, the Business Office Manager/Human Resources staff stated during room rounds on 8/29/22, resident #6 said the nurse did not give him his medications and the nurse kicked his door. She indicated she told the resident she would write a grievance and give it to the SSD for follow-up. The Business Office Manager/Human Resources staff said at stand down meeting that day, the SSD said the resident denied anything happened. She noted she thought it was strange, stating the resident was very verbal. She said she did not go back to see the resident to follow up on his grievance. On 11/16/22 at 10:09 AM, resident #6 denied he told the facility the nurse did not kick his door. He said, why should I tell them that, she called the police on me, I didn't call the police. He said a statement was not taken from him, and when he spoke to the SSD sometime around 9/28/22 she said from her understanding they had fired the nurse. The facility's policy Grievances issued 4/01/22 read, Facility will ensure all written grievance decisions include: the date the grievance was received: a summary statement of the resident's grievance; the steps taken to investigate the grievance; a summary of the pertinent findings or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed or not confirmed; any corrective action taken or to be taken by the facility as a result of the grievance; and the date the written decision was issued.

Based on interview, and record review, the facility failed to thoroughly investigate an incident of alleged abuse for 1 of 1 resident of a total sample of 8 residents, (#6). Findings: Review of resident #6's clinical records revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) 10/01/22 revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 15/15. A progress note documented by Licensed Practical Nurse (LPN) A dated 8/28/22 at 5:15 PM read, This writer went in room (#) to give 5:00 pm medications and to obtain blood sugars, the resident starting yelling and cursing at this writer about other residents conversations to me outside of his room door. Resident was verbally abusive towards this writer with cursed words and gesturing when he hit this writer in the face, a few minutes later resident came to his door with his walker being verbally abusive with curse words while chasing this writer down the hall. I was in fear for my safety since he had already struck my face and threatened to physically harm me. I backed away and called my ADON (Assistant Director of Nursing) who instructed me to call the police. On 11/15/22 at 10:08 AM, resident #6 stated that on 8/28/22 while he was in bed, his nurse on the 3-11 PM shift banged in his door. He verbalized he used his grabber to pull back his privacy curtain, got to the door, closed it, and went back to rest. Resident #6 stated that fifteen seconds later the door was pushed back, and the only person in the hallway was the nurse. He said he could not understand why his door was pushed back, and he verbalized that the nurse kept looking at him, stating she was mean mugging him. He stated he asked the nurse why she was looking at him and said he could not recall specifically what the nurse said, but think it was something about having eyes. Resident #6 stated LPN A had been his nurse before, and on two occasions while she was in his room, residents came into his room to talk to the nurse. The resident said he told LPN A that he did not feel comfortable with the residents coming into his room. He said he did not know the nurse was so upset, that she would karate kick in his door. Resident #6 stated the nurse ended up calling the police, they came to him, read him his rights, which to him was a precursor to be arrested. He said he was not prepared to answer any questions the police asked, and he was told the nurse told the police that he walked up to her, kicked her, and slapped her. The resident said he walked with a walker, and that would be hard for him to do. He stated he never went beyond the entrance of his room door. The resident said it was mind boggling to him, that the nurse kicked in his door, and the police read him his rights. He said the facility started an investigation and spoke to two residents who were witnesses, but the facility did not speak with him. On 11/15/22 at 1:07 PM, the Director of Nursing (DON) stated she was the facility's Abuse Coordinator. She said LPN A had stated resident #6 got in her face, and started yelling at her, and to protect herself she called the police. The DON noted the Law Enforcement Officer ([NAME]) was called by LPN A, who no longer worked at the facility. She explained the officer spoke with resident #6. She said she spoke with the resident also, but it was not that serious. The DON could not provide evidence the facility did a thorough investigation of the incident. There were no witness statement from LPN A, resident #6, the Certified Nursing Assistant (CNA), or the residents mentioned in the progress note documented by LPN A. The DON stated the facility did not speak with the officer, and noted the Department of Children and Families (DCF) and the Agency For Health Care Administration (AHCA) were not notified. On 11/15/22 at 1:54 PM, the ADON stated that on 8/28/22 she was at home, when LPN A called to report she was in resident #6's room to give him medications, when he yelled at her about other residents talking outside his door. The ADON said LPN A verbalized she tried to calm the resident down, and the resident got up in her face acting as if he was going to hit her. The ADON stated LPN A told her she was going to call the police, and she told her if she felt threatened, she should go ahead and call the police. She said LPN A did not report being hit by the resident, and she was made aware of that when she read the progress note documented by the LPN. The ADON indicated she provided a written statement dated 8/29/22, and after that day, she heard nothing more about the incident. On 11/15/22 at 2:38 PM, the DON stated if there was an altercation between a resident toward a staff, the process included completing an employee incident report. She said they would speak to the resident, and document a grievance if the resident had any concern. The DON said LPN A did not inform her about being hit by resident #6. She said the facility took everything seriously and reported everything. However, documentation could not be identified to indicate the incident was investigated or reported to the relevant agencies. On 11/16/22 at 10:09 AM, resident #6 denied he told the facility the nurse did not kick his door. He said, why should I tell them that, she called the police on me, I didn't call the police. The resident stated he spoke to the lady in Human Resources, and she said she wrote a grievance on his behalf and gave it to the Social Services Director (SSD) for follow-up. The resident verbalized the facility did not obtain a statement from him, or the two residents who were witnesses and were no longer at the facility. On 11/16/22 at 11:10 AM, the DON explained that a thorough investigation included speaking with the involved parties, the resident, LPN A, the Certified Nursing Assistant (CNA) mentioned in the progress note, and completing a skin check. The DON stated LPN A did not report to her that she was hit by the resident. She confirmed with the ADON who took the call from LPN A on 8/28/22, and the ADON verbalized that LPN A did not report that she was hit by the resident. The DON stated that when she read the progress note documented by LPN A, she asked the CNA mentioned in the note, and the CNA said the resident did not hit LPN A. However, a statement was not obtained from the CNA, or any witnesses. The DON stated she spoke to resident #6, and the two residents LPN A mentioned, but they did not want to be involved. She said she asked LPN A for a statement, and she said it was documented in her progress note. The DON verbalized she failed to obtain witness statements and did not do her due diligence to thoroughly investigate the incident and report to the appropriate agencies. The facility's policy ANE (Abuse, Neglect, Exploitation) and Investigations issued on 10/11/22 read, The facility will conduct their own internal investigation including but not limited to staff .resident The facility must take all necessary corrective actions depending on the results of their investigation and must notify the proper agencies.

Based on observation, interview, and record review, the facility failed to maintain a secure environment in the locked memory care unit and failed to provide adequate supervision to prevent a physically and cognitively impaired resident from exiting the facility, for 1 of 6 residents reviewed for elopement, of a total sample of 16 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility at night, unsupervised, there was high likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. On 5/26/22 at 9:03 PM, resident #1 pushed open an unlocked, alarmed fire exit door on the secure memory care unit. As he exited the door, an alarm sounded but staff failed to respond accordingly to the alarm to determine if a resident had left. Upon leaving the facility, the resident headed toward the northwest corner of the facility's back parking lot in the dark. It is unknown which way he went or what he did until someone at a neighboring apartment complex observed the resident and called 911 at 9:12 PM for a well- being check. Police officers found the resident sitting in the apartment complex parking lot at 9:42 PM. The facility was unaware resident #1 was missing from the building until approximately 9:45 PM when his assigned Certified Nursing Assistant (CNA) recognized she had not seen him for some time. The facility was unaware of the resident's whereabouts until approximately 9:53 PM when police called the facility to inquire of a possible missing resident. There were 16 facility residents identified at risk for elopement. The facility's failure to ensure the fire exit door was secure, failure to respond to the door alarm when resident #1 left the building and failure to ensure frequent supervision per his care plan contributed to resident #1's elopement and placed all residents identified with wandering/exit seeking behaviors at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 5/26/22 and was removed on 6/03/22. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], depression, type 2 diabetes, and altered mental status. [CONDITION(S)] is a brain disorder that can lead to problems with thinking, movement, behavior, and mood. Visual hallucinations, or seeing things that are not there, are a common symptom, and tend to happen early on (retrieved on 6/07/22 from the U.S. Department of Health and Human Services. www.alzheimers.gov). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/01/22 revealed resident #1 required a surrogate for decision making, was at risk for falls and used insulin. The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/07/22 revealed resident #1 had moderate difficulty hearing and was sometimes understood by others. The assessment indicated he had disorganized thinking and a Brief Interview for Mental Status (BIMS) score of 08/15 which indicated moderately impaired cognition. The admission assessment indicated resident #1 required extensive assistance of one staff to walk in room and corridor and was only able to stabilize with staff assistance when walking with assistive device. During the 7-day look back period, resident #1 was given insulin and anti-depressant medications 6 of 7 days and received scheduled pain medications. Review of the resident's medical record revealed a physician's order dated 5/13/22 for application of an electronic wandering device to his right ankle. Physician orders also included insulin injections twice a day for diabetes, [MEDICATION(S)] delayed release twice a day for depression, [MEDICATION(S)] at bedtime for anorexia and [MEDICATION(S)] once a day for depression. A nurse's progress note dated 4/20/22, indicated resident #1 was agitated at frequent intervals through the night, and exhibited exit seeking behaviors. The note indicated resident #1 yelled and was combative towards staff when they attempted to redirect him. A care plan was initiated on 5/13/22 for potential for elopement due to cognitive impairment, periods of increased confusion, exit seeking behaviors, wandering by exit doors and resident's verbalization to leave the facility. The care plan goal indicated the resident would remain safe and not leave the facility unsupervised. The interventions included enhanced supervision and redirection from staff when observed going near exit doors. Resident #1's care plan dated 4/29/22 for inappropriate physical, verbal behaviors and hallucinations directed staff to check resident every (Q) 15 minutes for impulsive behavior. A care plan for risk for falls and actual falls related to impaired balance, unsteady gait, poor safety awareness and use of [CONDITION(S)] medications was initiated 4/04/22 and noted interventions for staff to remind resident to request assistance and supervise resident during ambulation and transfers as needed. Review of a social service note dated 5/19/22, revealed resident #1 stated he would rather die if he had to stay in the facility and the psychiatrist was notified. The resident was seen by psychiatry one week before the elopement incident and the consult note dated 5/19/22 detailed the resident's exit seeking behaviors. The note read the resident was agitated and restless, but was locked in the unit. The note described resident #1's depressive symptoms and sadness due to placement in the unit. The mental status examination revealed the resident's insight and judgement were poor, short- and long-term memory was impaired, attention span was fair and he was orientated to person only. The plan of action included medication changes, psychotherapy for depressed mood and Q 15 minute frequent monitoring until symptoms further reduce. On 6/03/22 at 6:17 PM, the Assistant Director of Nursing (ADON) stated the Administrator, Director of Nursing (DON) and Maintenance Director initiated the investigation into resident #1's elopement from the facility on 5/26/22 after he was returned to the facility by police. She stated she did not watch the video recording of the incident, but she had helped with the investigation. The ADON said the resident's assigned CNA B last saw him at about 9:30 PM and his nurse gave him medications at approximately the same time. The ADON noted the investigation found resident #1 had left the facility at approximately 9:45 PM. Review of the Q15-minute monitoring documentation provided by the facility on 6/03/22 at 6:35 PM, revealed CNA B documented Q 15-minute checks 18 times between 6:04 PM and 6:16 PM. CNA B also documented Q 15-minute checks an additional 10 times from 9:25 PM and 9:26 PM. The Medication Admin Audit Report provided on 6/03/22 at 6:40 PM by the ADON dated for the night of the elopement on 5/26/22 indicated medications were administered to resident #1 at 9:26 and 9:27 PM. On 6/03/22 at 7:49 PM, the reports for the electronic wander monitoring system were reviewed with the Maintenance Director. He confirmed the report showed the alarmed fire exit door on the secure memory care unit was opened by the floor technician on 5/26/22 at 7:01 PM and the door locked again. The report indicated the resident #1 exited the door at 9:03 PM on 5/26/22 and the alarm sounded. The report noted the event lasted 31 minutes and 52 seconds before the alarm was cleared at 9:34 PM. The [NAME] Police Department Citizen Connect website revealed a Check the Well Being call was reported by an unnamed person on 5/26/22 at 9:12 PM, from the neighboring property (retrieved from www.[NAME].gov on 6/04/22 at 12:59 PM). In interviews on 6/03/22 at 11:09 AM and 11:47 AM, the Maintenance Director stated he watched video recording from the door camera positioned on the southwest hallway across from memory care unit door where the resident exited. He stated the video was no longer available to view. The Maintenance Director described watching the floor technician unlock the fire exit door of the memory care unit at approximately 7:30 PM on 5/26/22 to take trash out. He stated the door closed behind the floor technician, and he did not re-enter the building nor did anyone follow him out. He said the video then showed resident #1 exited through the door, walked out toward the maintenance shed, then disappeared out of camera view. He reported staff did not come to check the door immediately after resident #1 exited the building. The Maintenance Director reported the door sometimes did not close completely, but the alarm for the electronic wander system was still engaged. When surveyors stated they would retrace resident #1's probable elopement route, the Maintenance Director said he would accompany the team because, the whole area is not safe. On 6/03/22 at 11:14 AM, resident #1's probable elopement route was retraced. The resident exited the locked memory care unit and walked toward the maintenance shed located on the northwest corner of the property. From there he turned right toward the front of the building, and walked onto the sidewalk in front of the facility. He then headed south towards the neighboring property where he was found. He would have crossed the facility's two driveways, then crossed the two-lane divided entrance road of a large Behavioral Health intake and inpatient facility next door. If resident #1 continued approximately 0.1 to 0.2 miles to the entrance road toward the Behavioral Health facility, he would have come to a large, unfenced lake at the edge of the facility's parking lot. Instead, he walked to the apartments located on the front of their property. Resident #1's 0.3-mile trek from the back door of the facility to the apartment's parking lot passed hazards such as uneven pavement, large potholes, drainage ditches, and a bus stop frequented by homeless individuals. The sidewalk ran parallel to a moderately busy street, and a dense, unlit wooded area directly across the street from the facility. On 6/03/22 at 10:25 AM and 2:59 PM, and 6/04/22 at 3:38 PM, Licensed Practical Nurse (LPN) D stated he watched the video recording of resident #1 as he exited the facility through the memory care exit door. He stated between 8:30 to 9:00 PM, resident #1 walked down the long hallway and through the fire exit door on the memory unit. He pushed it right open, no 15 second delay and walked right out. LPN D stated he was at the nurse's station on the evening of 5/26/22 and recalled hearing the door alarm. He said he initially thought it was the door alarm to the smoking area on the B wing which, goes off frequently. LPN D stated when the door alarm continued, he called the Maintenance Director's cell phone to ask how to switch the alarm off. He said the Maintenance Director asked if a resident went out the door. LPN D said he replied no and a short time later someone turned the alarm off. He said he later recalled hearing a CNA said she couldn't find resident #1, but he didn't pay attention until the CNA came by again and repeated in an alarmed voice that she couldn't find resident #1. LPN D stated everyone started looking for the resident inside the facility and then expanded the search to outside. On 6/03/22 at 4:38 PM, and 6/05/22 at 3:59 PM, CNA B stated she worked the 3-11 PM shift on 5/26/22 the day of the elopement. She recalled seeing resident #1 fully dressed with his tennis shoes on, pacing up and down the long hallway of the memory care unit like he often did. CNA B recounted resident #1 stated he wanted to go home and when she saw him wandering the hallway around 8:30 PM, she re-directed him to sit in a chair outside the shower room. She explained she was busy with another resident until about 9:45 PM when she realized she hadn't seen resident #1 for some time. She described going to resident #1's room and saw assigned Registered Nurse (RN) A in the hall by the medication cart. She said she alerted RN A and other staff and they started searching for resident #1. CNA B explained another CNA (H) was specifically assigned to do Q 15-minute checks on resident #1 and two other residents as they had behaviors and were elopement risk. She said she realized he had left the facility earlier in the evening and was not watching resident #1 as assigned. CNA B stated if she had known CNA H was not there to do 15 minute checks on resident #1, she would have checked on him more frequently. She explained if CNA H was doing the 15 minute monitoring, the resident would not have eloped from the facility because he frequently re-directed the residents away from doors. In telephone interviews on 6/03/22 at 6:49 PM and on 6/05/22 at 12:20 PM, RN A stated the 3:00 PM to 11:00 PM shift on 5/26/22 started out crazy. She recalled it was her first time working the evening shift and she had several medication passes to her assigned residents over the course of the 8-hour shift. She stated the last medication pass was between 8:00 PM to 9:00 PM and recalled resident #1 paced up and down the long hallway of the memory care unit. RN A explained CNA H was assigned to monitor resident #1 every 15 minutes because of his elopement risk and other behaviors. She recalled she frequently told staff doing the Q 15-minute checks to position themselves by the main door of the unit to easily visualize the exit doors. She explained she was not aware CNA H had left the facility that evening until after resident #1 was returned by the police. RN A recalled sometime after 9:00 PM, CNA B notified her she could not find resident #1 and they initiated a search. She stated no one announced the elopement code overhead to notify staff nor did anyone call police to help with the search for resident #1 when he was not found in the facility as per facility protocol. RN A was not able to give an exact time when events occurred but thought she gave resident #1 his 9:00 PM dose of medications sometime between 8:00 and 9:00 PM. She stated she did not always chart the time medications were administered and acknowledged the times on the medication administration record were not accurate. The Individualized Monitoring Quick Reference Tool undated document described the purpose of individualized monitoring (every 15 minute/30 minute/hourly) is necessary for resident safety when other interventions have proven to be unsuccessful. The process included a specific staff member assigned to that resident for the shift and the supervisor will designate relief staff to cover breaks and mealtimes to ensure increased monitoring observation of the resident. Ensure shift to shift reporting takes place related to need for increased monitoring to prevent breaks in appropriate monitoring. On 6/03/22 at 5:17 PM, CNA F recalled while they searched for resident #1 on the evening of 5/26/22, the facility received a phone call from the police asking whether the facility was missing a resident. She stated she and another CNA went outside and saw police lights down the road. They headed towards the lights to the apartments located south of the facility. CNA F recounted when she approached the parking lot, she saw resident #1 in the police car and identified him. She said the police brought him back to the facility. On 6/04/22 at 12:09 PM, the Administrator stated he spoke to the police officers who had responded to the 911 call for resident #1. He said the officer reported he arrived at the apartments complex at 9:42 PM. He indicated when police were unable to determine resident #1's identity, they called the facility at 9:53 PM to inquire if they had a missing resident. On 6/04/22 at 5:00 PM, the elopement incident was reviewed with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC). The Administrator confirmed the DON was notified by Licensed Practical Nurse (LPN) D at 9:53 PM on 5/26/22, that resident #1 was missing from the facility. He stated LPN D called back a few minutes later to say resident #1 was brought back to the facility by the police and was assessed by nursing staff. The Administrator stated through their investigation, they found the root cause of resident #1's elopement was a faulty door that did not close properly as it was warped. The DON and Administrator stated they started investigation of the incident once they arrived at the facility that night. The DON said the investigation found staff heard the door alarm when resident #1 exited the facility. She stated LPN D responded to the door alarm but he did not look outside as per protocol to determine if a resident had exited. The DON noted LPN's failure to assess for elopement of a resident when the door alarm sounded contributed to the cause of resident #1's elopement. The Administrator then re-affirmed the finding of the faulty door being the root cause of resident #1's elopement and stated, ultimately, it's the faulty door, because it did not engage. He explained, If it was working properly, it would not alarm, and he would have been here. The Administrator stated a door check had been done by the Maintenance Director the day of the elopement and he did not find a problem with the door. He confirmed two vendors had evaluated the door after the elopement and did not make any recommendation to replace the door due to it being warped. He stated on the night of the elopement, the electronic wander system worked properly when tested and the weekly door checks performed by the Maintenance Director did not show any previous problems with the door closing. The Administrator confirmed the protocol for staff if a door alarm sounded was to respond to the alarm as soon as possible. The DON acknowledged resident #1 was on Q 15-minute checks assigned to CNA H that evening from 3:00 PM until 11:00 PM. She stated CNA H was not at the facility when they arrived after the elopement, and they were still not able to get a statement from him for the investigation. The DON stated CNA H had clocked out at 7:05 PM on 5/26/22, 4 hours before the end of his shift. She added staff were not aware he had left early from his shift. The DON and Administrator had not considered lack of supervision for resident #1 after CNA H left his assignment at 7:05 PM as part of the root cause of the elopement, and the Administrator again emphasized the door was the main problem. The DON discussed the timeline they developed as part of their investigation. She stated RN A gave resident #1 his medications at approximately 9:00 PM contrary to the ADON's statement. She said they identified on 6/03/22 that the Q 15-minute documentation performed by CNAs did not accurately reflect the actual times residents were checked and confirmed there was no record of when Q 15-minute checks were actually done for resident #1 on 5/26/22. In a telephone interview on 6/05/22 at 6:02 PM, the Medical Director stated he was informed of resident #1's elopement on 5/26/22. He explained residents with dementia were unpredictable, and said he expressed his concerns to the facility of how they should prevent this from happening again. He conveyed if a resident was at high risk for elopement they should be monitored more closely. He explained the door was the last line of defense to prevent elopement and the CNAs were first responders at the facility. The Medical Director explained most residents with dementia eloped because of their impairment but they would not know how to get back. He noted appropriate preventive measures must be in place such as staff to monitor those at risk. He acknowledged staff should respond to door alarms timely and appropriately and said it was a very unpleasant surprise when he heard of resident #1's elopement. The elopement Policy and Procedure (P&P) revised 4/01/22 revealed interventions to provide safety to the resident as needed included Increased supervision- at times residents may require more frequent rounding and supervision to ensure location of a resident. Additionally, the policy provided direction that staff are to, . respond to alarms sounding promptly to identify purpose of alarm sounding or overhead announcements. The P&P Elopement issued 4/02/22 in the Elopement Triggers section listed residents who seek exit from the center, were cognitively impaired and could walk, verbalized desire to go home or to work, and stayed near or tries to open doors. Proactive interventions for residents at risk of elopement included, staff to react to trigger statements like, I want to go home and increase frequency of resident observation rounds. Review of the facility assessment dated [DATE] revealed the facility could meet the mental health and behavior needs of residents with diagnoses that included [CONDITION(S)], impaired cognition, depression, and behaviors that need interventions. The document indicated the facility would provide care that included implementation of interventions to help give care to residents with cognitive impairment and provide a secure unit to assist with some residents with exit seeking behavior. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 5/26/22 the resident was re-evaluated by licensed nurse with full body assessment including skin, pain, vital signs and updated BIMS. No skin impairments noted. *On 5/26/22 resident #1's electronic wander system bracelet was checked for proper functioning and placement. An immediate visual head count was taken with no concerns. The Q 15 minute visual safety observation for resident #1 was validated and plan of care was reviewed. *On 5/26/22 a 24-hour door monitor was assigned on the southwest fire exit door until door repaired/replaced. *On 5/26/22 the Maintenance Director checked all exit doors to verify proper functioning of doors including transponder for electronic wander system, and completed daily since. The southwest exit door closer was adjusted to increase tension. *On 5/26/22 the internal electronic wander system door override ability was removed on the southwest fire exit door, and ability to enter the door from the outside by code was removed. *On 5/26/22 the Executive Director checked staffing ratios for day of event. *On 5/27/22 all residents were re-evaluated for elopement risk with no additional residents identified. *On 5/27/22 residents at risk for elopement were re-evaluated for physician orders, electronic wander system placement and function, enhanced supervision, plans of care, CNA tasks/Kardex documentation for increased supervision validated and updated as appropriate. *On 5/27/22 elopement binders were reviewed and revised post re-evaluations and placed at each nursing station and front desk which was verified. *On 5/26/22 the facility initiated education on elopement standards and guidelines, the 4-point action plan, 1:1 supervision, alarm response (respond to door panel to identify -expand search exterior timely), daily door checks, 24/7 door watch for southwest fire exit door until vendor has approved proper functioning order and/or door replaced, Q 15-minute visual safety observations documented timely, electronic wander system placement and function, and proper and timely notification to supervisor if staff member leaves work at any time, leave and/or shift abandonment and follow up and timely adjustment to floor assignment with acknowledgments, and abuse and neglect. Newly hired staff to be educated on these components during orientation. As of 5/30/22 134 of 134 staff educated. *On 5/26/22, elopement drills were initiated. Additional drills to be performed randomly 3 times a week on different shifts. Elopement drills were performed 9 times from 5/26/22 -6/3/22 on different shifts. * On 5/26/22 an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. The committee conducted a Root Cause Analysis, accepted plans, and discussed recommendations. Audits and progress presented monthly to QAPI to ensure compliance. Monitoring included function of doors, electronic wander system monitoring function, daily clinical review of new admits, re-admits and changes in condition requiring increased supervision and/or elopement evaluation, elopement interventions for elopement risk-residents during morning clinical meetings, elopement binders, validation of elopement skills checklist with return demonstration, enhanced supervision/visual safety observations validation, 24 hour door watch for southwest fire exit door, and alarm response by staff daily. *On 5/27/22, the southwest fire exit door was evaluated by 2 vendors for good working order and recommendations were made. Awaiting 3rd vendor for recommendation to replace and/or repair. *On 6/03/22, ad hoc QAPI meeting held to improve process for documentation of Q 15-minute visual safety observations including implementation of a timer for the checks. Review of in-service and drill attendance sheets and reconciliation with staff roster validated education was completed according to the facility's plan. From 6/03/22 to 6/06/22 interviews conducted with 31 staff representing all shifts including 4 RNs, 7 LPNs, 13 CNAs, and 4 housekeeping staff revealed staff participated in elopement drills and were knowledgeable of the facility's elopement standards and guidelines. Staff verbalized the importance of notifying supervisor if leaving assignment, monitoring wandering residents, and responding to door alarms. The sample was expanded to include 5 additional residents at risk for wandering, and elopement. Observations, interviews and record reviews revealed residents #2, #3, #4, and #5 residents had elopement risk assessments, appropriate care plans, and demographic information placed in the elopement binders. Resident #7 was a newly admitted resident reviewed for elopement risk assessment and supervision.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of 1 of 9 residents reviewed for elopement risk, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised for 7 hours, there was high likelihood she could have fallen, become lost or been hit by a car. On [DATE] at 6:45 PM, resident #1 exited the facility unsupervised without staff knowledge. She walked past the secure memory care exit door by following the Receptionist D and through the front exit door which Receptionist D opened, not realizing she was a resident. The resident's assigned Certified Nursing Assistant (CNA) C could not find her at approximately 8:30 PM. Facility staff were unaware of resident #1's whereabouts until she was found by Law enforcement on [DATE] at 1:30 AM. She was found 5.2 miles from the facility, walking against traffic on highway State Road (SR) 408 ramp which leads to Interstate(I)-4. Both SR 408 and I-4 are elevated highways in the busy Orlando Metro area. The facility's failure to provide adequate supervision and a secure environment resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] and was removed on [DATE]. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted [DATE]. Her [DIAGNOSES REDACTED]. The Admission Nursing Comprehensive Evaluation dated [DATE] revealed the resident's elopement risk score was 13. A score of ,[DATE] indicated At risk for elopement and directive noted to place picture in elopement book and apply wander guard (an alerting bracelet). Resident #1's physician's orders [REDACTED]. The resident's daily medications included: Eliquis a blood thinner, Donepezil for dementia, [MEDICATION NAME] for depression and [MEDICATION NAME] and Quetiapine for anxiety. The Minimum Data Set (MDS) discharge assessment with assessment reference date [DATE], revealed the resident had short-term memory problems and her cognition skills for daily decision making were moderately impaired. The resident did not exhibit behaviors of wandering during the seven day look back period. She required supervision for transfers, walk in room/corridor, and locomotion off unit. Resident #1 did not require a walker, or any mobility device and her vision was not impaired. A social service note dated [DATE] read, .Writer contacted resident's daughter and she reported having POA (Power of Attorney). Daughter states she previously had resident at home with her, and resident would wander off from the home. The eInteract Change in Condition Evaluation dated [DATE] at 10:15 PM, read Elopement . Resident ate supper in the hallway by the nursing station and after eating the CNA got her ready for bed. Approx. 8:15 assigned CNA went to check on the resident in the room and observed her bed made that she had pulled for the resident. Seconds after we initiated a code for all staff to assist with search. Physician note dated [DATE] read, RN (Registered Nurse) notified me last night that pt. (patient) went missing-she was subsequently found wandering and brought back in safe condition to facility. Today her mental status is at her baseline pleasantly confused. The resident's Baseline Care Plan for elopement created on [DATE] included the goal that, Resident will remain safe and not leave facility unsupervised. Interventions included to Redirect resident prn (as needed) if observed near exit doors. Frequent observation of whereabouts. On [DATE] at 5:37 PM, Licensed Practical Nurse (LPN) A stated that on [DATE] at 8:30 PM, resident #1's assigned CNA told her she did not know where the resident was. LPN A stated the last time she saw resident #1, she was sitting close to the nurses' station. She said she informed the evening Nursing Supervisor at 8:45 PM, a Code Yellow (code for missing resident) was called and a search was started to locate the resident. LPN A noted she searched the secure unit, notified the A Wing, and also searched the lunchroom. She added that some staff searched outside the facility, while other staff began search in the neighboring area in their cars. LPN A said the evening Supervisor informed the Director of Nursing (DON) at about 9 PM, and the DON directed her to call Law Enforcement (LE). LPN A stated LE arrived at the facility at approximately 9:30 PM. They viewed the facility's video recording that showed the resident went through the secure unit's double doors, into the lobby, and went through the front door. LPN A stated that when she left work between 12:30 AM to 1:00 AM, resident #1 had not been found. On [DATE] at 5:59 PM, CNA C stated that on [DATE] she started work at 3 PM. She did rounds on the residents in her assignment. She said resident #1 was in her room. CNA C said the dinner meal cart arrived on the unit at 5 PM, and resident #1 ate at the nurse's station. After eating, the resident walked up and down the hallway. CNA C stated she provided care for other residents in her assignment and charted at 8 PM. She said at 8:30 PM to 8:45 PM, she checked on the resident in her room, but she was not there. She said LPN A was at the medication cart in and she told her that she did not see the resident. The evening Supervisor was also made aware, and they looked in all the rooms, and a Code Yellow was called. CNA C stated she was not sure of the time the DON arrived, because she was frightened, and scared. She added the police came, searched, and viewed the facility's video recording. She verbalized they saw the resident left the building around 6 PM. CNA C stated she did not leave the facility but stayed until the resident came back to the facility at approximately 2 AM. Review of the Police Department Case Report dated [DATE] at 6:30 PM revealed that at approx. 10:09 PM the police responded to the facility in reference to a missing person. Documentation read, I reviewed the facility's camera system and was able to observe (name of resident) leaving the facility at approximately 1640 hours, heading northbound . Units from across the city responded in order to conduct an area check . Helicopter unit as well as .Bloodhound unit assisted. On [DATE] at 7:07 PM, a telephone interview was conducted with the Law Enforcement Officer (LEO) who found the resident. He stated he was working off duty when he received the call regarding the missing resident. The LEO stated the resident was found at the I-4 and SR 408 interchange, on the highest ramp walking against traffic. The LEO stated he spotted resident #1 at 1:28 AM on [DATE]. He called out to her, and she responded to him, and answered all his questions. He identified the resident spoke about trying to get to Apopka to see family and said something about her feet and her side hurt due to the long walk. LEO stated the resident declined medical attention and the Service Unit brought her back to the nursing home. He described the interchange ramp as one of the highest in the Orlando area, and said, a fall from that ramp would not be good and identified it would be catastrophic. On [DATE] at 7:22 PM, the Administrator stated he was out of State when the incident happened. He said he got a telephone call from the DON at 9:30 PM on [DATE] and was told the staff had already searched for the resident before they called him. The Administrator stated the Maintenance Director, DON, the Regional Nurse Consultant, the Vice President of Operations, and the Vice President of Clinical Services came to the facility on the night of the incident and remained until the resident was found. The Administrator noted that resident #1 left the facility around 6:45 PM, as per facility video recording. The facility became aware the resident was missing around 8:30 PM to 9:00 PM. He said he understood the resident was approximately seven miles away from the facility and was headed toward her cousin's house. She was returned to the facility shortly after 1:20 AM on [DATE]. The Administrator stated he came to the facility on Friday [DATE] at 7:30 PM and focused on education of staff. He said the Root Cause Analysis (RCA) identified the resident was newly admitted and did not look like a resident. She wore blue scrub pants with a jacket, carried a water bottle, and had a packed lunch when she exited. He said she tailgated the front desk Receptionist D when he entered the door code to exit the secure unit. He added the secure door alarmed as the resident had an alerting bracelet but Receptionist D thought the door alarmed because it was held open too long. The Receptionist then over-rode the keypad at the nurses' station and allowed the resident to exit the secure unit. Then the Receptionist walked to the front lobby and the resident walked to the front door. The resident asked the Receptionist if she needed a code to exit and the Receptionist answered, no. He entered the code to disarm the front door and the resident left the facility. When the front door alarmed, Receptionist D again thought the door was held opened too long. On [DATE] at 7:55 PM, the Maintenance Director stated he was called by the DON on [DATE] at approximately 9:45 PM. He came to the facility sometime after 10 PM and LE were already in the building. The Maintenance Director stated he viewed the facility's video recording with two LEOs at 10:30 PM at the A wing (Secured unit) nursing station. The video revealed that resident #1 was allowed out of the secure unit, and the front door by the Receptionist. He stated the camera showed 7:40 PM, but the time was actually 6:40 PM, since the camera was off by one hour due to Daylight Saving Time. He said the resident exited the secure unit at 6:30 PM, and left the facility out the front door at 6:40 PM. He identified the outside video surveillance showed her heading north of the facility. The Maintenance Director verbalized he joined the search by driving north of the facility toward major highway, US 441 but did not find the resident. He said he came back to the facility to get an update, then went back out, in the opposite direction, South. He added that by that time, Law Enforcement had deployed a helicopter unit to aid in search for the resident. The Maintenance Director said he was back in the facility when it was reported at 1:50 AM on [DATE], the resident had been located. He said he spoke to Receptionist D who had also viewed the video recording, and the Receptionist told him that he thought the resident was a visiting nurse. On [DATE] at 8:14 PM, the DON said on [DATE] at 9 PM, the evening Supervisor called her to inform they could not find resident #1. The DON stated she immediately came to the facility and started searching. She said she was not very familiar with the area but checked at gas stations for the resident. She noted the evening Supervisor called the resident's family, but the resident was not with them. The DON identified that Receptionist D went to the secure unit to deliver a message to the nurse. He left the message near the telephone at the nurse's station. He then walked to the exit door, pressed the code to disarm the door and did not see resident #1 was behind him. He noted her in the front lobby reception area, when the resident asked, do I need a code to get out? He told her no, then disarmed the door to allow her to exit not realizing she was a resident. The DON stated that based on the video recording, resident #1 left the secure unit at approximately 6:30 PM. She verbalized that she watched the video recording along with law enforcement, and the Maintenance Director. She said they saw Receptionist D arrived on the secure unit and when he left the unit, the resident was behind him. The DON expressed the resident had on a face mask, and carried a water bottle and a bag with fruits. She added the resident wore clothing that resembled a nurse's uniform and the Receptionist allowed her to exit the facility as he thought she was a visiting nurse. She said Law Enforcement was called and they brought the Canine unit to smell the resident's pillowcase. She said she received a call from the facility while she was out searching that LE found the resident at 1:30 AM on [DATE]. She said the resident was found on I-4. The DON noted the resident was last seen by CNA C at approximately 5:30 PM when the dinner trays were picked up. She added that CNA C escorted the resident to her room, pulled the resident's bed covers down, and then took care of the roommate. On [DATE] at 12:10 AM, CNA E stated that she came to work on [DATE] at 10:30 PM, saw police, and discovered a resident was missing. CNA E said she joined the search in the street, and in the back courtyard of the facility. CNA E revealed that when the resident was brought back to the facility, her body was cold. She did not have any bruises. I gave the resident something to eat and drink and she went to bed. CNA E said the resident was tired, and as soon as she ate the snack and was readied for bed, she went to sleep. She said she tried to talk to the resident in the morning, but the resident went to bathroom and went back to sleep. On [DATE] at 10:44 AM, a telephone interview was conducted with LPN B, the resident's primary assigned nurse on the day of elopement. The LPN stated the last time she saw resident #1 was on [DATE] at about 6:,[DATE]:20 PM. LPN B said that earlier in the shift, the resident was her usual. She walked around, stood by the door, and went into different resident rooms. At approximately 5:55 PM- 6 PM, she said she administered the resident's medication, [MEDICATION NAME], a blood pressure medication. LPN B stated the resident's CNA realized the resident was missing when she went to settle the resident into bed at about 8:30 PM. She verbalized the evening Supervisor was informed, and a search for the resident ensued. The Supervisor notified the DON, and LE. She said the police came and viewed the facility's video recording. The video surveillance showed that an employee let the resident out of the secure unit, and out the front door, as he thought the resident was a visitor. LPN B stated the video recording identified the resident left the facility at 6:40 PM. She said it was an honest mistake. On [DATE] at 11:50 AM, during a telephone interview with the evening Nursing Supervisor, she stated that on [DATE], she was on the B wing until dinner time at 5:30 PM to 6 PM. She added she did periodic checks on the A Wing, the secure unit. She said when she went to the secure unit at 8:30 PM, she was informed that CNA C could not locate resident #1. The Supervisor said she was told the resident ate dinner, and at approximately 6 PM, the CNA took her to her room to get her ready for bed. She said CNA C went back to resident #1's room at 8:30 PM, but did not see the resident and her bed was made. The Supervisor said she called the code for missing resident, Dr. Find. She noted staff responded, and she directed some to search the all rooms on both units, including bathrooms, and outside the building. After 10 to 15 minutes, staff were deployed to drive along the street the facility was located. She revealed she drove north of the facility and another staff drove south of the facility in hopes of locating the resident but the resident was not located. She said after they searched for one hour, she returned to the facility and notified the DON at 9:30 PM, then called LE between 9:30 PM to 9:45 PM. She verbalized the police responded within 10 to 15 minutes, took her statement, and reviewed the facility's video recording. The video recording showed Receptionist D entered the door code and the resident exited the secure unit, and then exited the facility. The Supervisor stated she was notified by the resident's daughter, that the resident was located at 1:40 AM on [DATE]. She said resident #1 was returned to the facility by LEOs at 1:50 AM. The resident was exhausted, and she was given fluids. After the resident was assessed for injuries and a complete skin check was done, she went to sleep. The Supervisor said the police reported the resident was found at the intersection of SR 408 and I-4. On [DATE] at 11:10 AM, resident #1's daughter was contacted by telephone. She stated the facility told her that her mother left the facility around 6 PM, however she was not called until 10 PM. The daughter said that when she arrived at the facility, she was told that someone from the hospital, a volunteer, let the resident out, because he thought she was a patient who came for treatment or something. She acknowledged the police and staff were searching for the resident. She said she was told the resident was last seen heading north, so she and her husband drove that way and went all the way to Apopka. The daughter stated that her mother was bought back to the facility almost 3 o'clock in the morning. The Police said they found her by I -4, and SR 408. I don't even know where that is. The police said she walked 5 ½ miles, and when they found her, she said she was so tired. The resident's daughter stated, that when she first placed her mother at the nursing home, she told staff that she would try to leave the facility so she had to be watched closely. She added, from day one I told them. The daughter said she did not know what the facility was doing to make sure an elopement did not happen again. On [DATE] at 3:19 PM, Receptionist D stated that on [DATE] he came to work at approximately 4:30 PM. At about 6:30 PM, he went to the secure unit with a message for the nurse. Receptionist D said he could not find the nurse, so he left the message at the nurses' station. He said he exited the unit shortly after and had not realized that a resident had followed him out. He acknowledged he did not know the resident. He saw her at the front door and she wore blue pants, black shoes, a bonnet on her head, and asked if she could leave. Receptionist D said he assumed the resident was a visiting nurse. He said she wore long sleeves so her wrists were covered. He did not see anything to identify her as a resident. He stated he went to the front door, entered the code and let her out. He acknowledged the alarm activated but he thought it was because the door was open for too long. Receptionist D noted that nurses informed him at about 8:00 PM that a resident was missing and the DON and police were called. He noted that video recording showed he allowed the resident to exit the facility. He said he assisted with the search, and the resident was finally found at about 2 AM on [DATE]. On [DATE] at 10:45 AM, the resident's baseline care plan for elopement dated [DATE] was reviewed with the MDS Coordinator. The MDS Coordinator noted the purpose of the elopement baseline care plan was to make staff aware the resident was at risk for elopement, and to prevent elopement. The MDS Coordinator acknowledged the interventions to redirect the resident from exit doors was ineffective as the resident was let out of the unit. She said that everyone was responsible to redirect the resident, and this was not implemented on the night of the elopement. The MDS Coordinator stated the resident's care plan was reviewed after the elopement incident in the morning clinical meeting. She said the Interdisciplinary team (IDT) reviewed the timeline of the incident and questioned why no one redirected the resident away from the secure unit door when she followed the Receptionist out. She stated that since the resident was on a locked unit, all staff on the unit were responsible to redirect residents, and if resident #1 had been redirected, the elopement would not have occurred. On [DATE] at 6:31 PM, a discussion with the Administrator, and DON revealed that an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was conducted on [DATE], [DATE], and on [DATE]. The Administrator said the Medical Director was involved via phone and in person. He noted that facility video recording was available and utilized to identify the events that led up to the resident's elopement. The resident's elopement care plan was also reviewed with the Administrator, who verbalized the care plan had not been followed regarding supervision of the resident. Based on the resident's final location, the surveyors retraced by car, the resident's most likely route following her exit from the facility. The resident would have [MEDICATION NAME] two major thoroughfares and intersections that were heavily trafficked. One of the thoroughfares ran north and south and the other, east and west. The first being Princeton Street and John Young Parkway, was a major thoroughfare in the Metro Orlando area. Princeton Street ran East and West, and John Young Parkway ran North and South. John Young Parkway was a busy six- lane divided highway. At the intersection, it expanded to include multiple turn lanes. Within the intersection were multiple businesses and wooded areas. The second major intersection the resident would have walked was Princeton Street and Orange Blossom Trail (US 441), a four to six lane divided highway. Princeton Street continued to I-4. The resident's actual route could not be determined due to various secondary streets she could have walked to arrive at the location where she was found. It was not known how the resident walked on to the highway as both I-4 and SR 408, were elevated highways, still under construction in the Orlando Metro area. The resident was located approximately 5.2 miles South-East of the facility. It would have taken the resident a minimum of 1 hour and fifty minutes to walk to the location she was found, if she had used the most direct route. Documentation indicated the resident was out of the facility from [DATE] at 6:45 PM to [DATE] at 1:28 AM, approximately seven hours. As per the Orlando Sentinel a major news publication in Florida dated [DATE], Title: 14, S.R 408 link major upgrade for Orlando noted, . The interchange was decades in the making. It's an enormous upgrade for drivers, removing them from weaving through congested pinch points and now has them fly at expressway speeds on elevated ramp laves varying from four stories to 12 stories high .ramps curve as they rise or descend, diverge or converge with other ramps and otherwise visually affirm what they are called: Flyover ramps. As per the Orlando Sentinel dated [DATE], the Orlando area is still the nation's most dangerous for pedestrians. The temperature in Orlando on [DATE] at 6 PM was a high of 66 degrees Fahrenheit (F) and a low of 59 degrees F. On [DATE] at 12 AM, the temperature was a high of 57 degrees F, and a low of 54 degrees F. (Retrieved from Time & Date. com [DATE]) The Facility Assessment 2021 tool last dated [DATE] and last reviewed on [DATE] indicated that services and care offered were based on the resident's needs and included a secure unit to assist with some residents with exit seeking behavior. Staff training/education and competencies included Care/management for persons with dementia. Review of the immediate corrective measures implemented by the facility revealed the following: *On [DATE] at 8:30 PM, head count began for all residents. * On [DATE] the secure unit door checked and secured by Evening Supervisor *On [DATE] at 12:05 AM, all doors checked and exit doors checked with alerting bracelet, and transponder system by the Maintenance Director to verify proper functioning of doors. * On [DATE] at 12:05 AM, residents on unit assessed by the DON/designee to validate placement of alerting bracelets. *On [DATE] at 1:45 AM, upon return to the facility, a full body assessment was conducted on resident #1. There were no changes. The resident was placed on 1:1 observation, and her elopement assessment was updated. *On [DATE] at 2 AM, head count of residents completed by DON and staff with no concerns * On [DATE] Ad Hoc QA meeting to review elopement/wandering residents, review actions completed, assess other residents at risk for elopement, review education, and the facility's audit plan. The Medical director participated via telephone * On [DATE] residents on unit assessed to validate alerting bracelet in place, current picture in the electronic Medication Administration Record [REDACTED]. * On [DATE] staff member at the door will check visitors in and out with identification. * On [DATE] staff education by Executive Director/designee re: wandering, elopement procedure. * On [DATE] education on wandering and elopement completed with involved receptionist and other staff * On [DATE] elopement drills initiated on all shifts until facility staff have participated 100% for 3 weeks * On [DATE] residents interviewed regarding Abuse and Neglect by Social Services Director/designee. Skin assessment completed for residents who could not be interviewed. * On [DATE] ID bracelet audit and bracelets placed * On [DATE] elopement risk added to nursing report sheet * On [DATE] second Ad Hoc QA (Quality Assurance) meeting held * On [DATE] front door locked; door ring cameras installed by company representative. * On [DATE] audit for ongoing staff competency on wandering/elopement initiated. * On [DATE] audit of residents' elopement scores upon admission and with change in condition, and to validate appropriate physician orders [REDACTED]. * On [DATE] audit of elopement books daily x 12 weeks initiated, to be reviewed during morning meeting. Results to be brought to QAPI (Quality Assurance and Performance Improvement) committee monthly for 3 months or until compliance. * On [DATE] initiated Audit of visitor sign in and out process. * On [DATE] third QA meeting- regarding follow-up questions and education. Staff interviews conducted with 25 staff (3 RNs, 7 LPNs, 12 CNAs, 3 Receptionists) from [DATE] at 5:02 PM to [DATE] at 5:35 PM, revealed the facility had provided education on elopement, and that elopement drills were being conducted. Although the facility initiated in-service on elopement, and conducted elopement drills, interviews conducted with LPN A and CNA C on [DATE] at 5:37 PM, and 5:59 PM respectively, revealed that both staff members referred to the Code for missing resident as code yellow and not Dr. Find the code used by the facility. Clinical record reviews were conducted for eight current residents. The resident's elopement risk evaluations were current, physician's orders [REDACTED].

Based on interview and record review, and observation, the facility failed to keep residents free from neglect on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents (#1, 2, 6 & 7) had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at 4 separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and staff neglected to provide adequate care and services, including adequate supervision, to prevent resident #3 from touching 4 residents in an inappropriate sexual manner, even after the resident exhibited previous sexually inappropriate behaviors. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the sexually inappropriate behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility staff neglected to identify and implement procedures to protect residents from repeated occurrences of sexually inappropriate behavior even after they were aware of and documented resident #3's sexual behaviors starting on 1/10/13. The facility failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms. As of the exit date of the survey, 2/16/13, the facility had no system in place to keep residents free from mistreatment and neglect, including identification of residents whose behaviors render them at risk for touching other residents or being touched in an inappropriate manner, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger the behavior, and reassessment of the interventions on a regular basis. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: Cross Reference to F225, F226, F323, F203. Review of resident #3's record indicated the resident was admitted to the facility from the hospital on [DATE]. The history and physical from the hospital admission indicated the resident was brought to the emergency roiagnom on [DATE] by ambulance for altered mental status. He was also in the hospital on [DATE] for change in mental status and was found wandering in a shopping mall. He had uncontrolled diabetes on both admissions. His diagnoses as listed on the nursing home admission record face sheet were: diabetes, altered mental status, late effect cerebral vascular disease, hypertension, muscle weakness, and difficulty walking. The cumulative [DIAGNOSES REDACTED]. The resident did not have a [DIAGNOSES REDACTED]. Review of the Pre-Admission Screen and Resident Review indicated it was not completed prior to admission. It was completed on 2/12/13. The screen indicated resident #3 did not have a [DIAGNOSES REDACTED]. It also indicated the resident had a [DIAGNOSES REDACTED]. Review of the nurses' notes for resident #3 indicated he became agitated and verbally abusive to staff after the nurse spoke to the him about continuing to urinate in the hallway, inside the room on the floor, and on the curtain on 12/31/12 at 5 a.m. On 1/03/13, nurses' notes documented the resident was hostile to staff and continued to urinate on the floor, by the roommate, the bed, the curtain, and the hallway. Review of Social Service Director's (SSD) notes dated 1/03/13 indicated the resident was "observed trying to touch females. Requires redirect. Will monitor." Upon interview with the SSD on 2/15/13 at 1:40 p.m. and on 2/16/13 at 10 a.m., he discussed his documentation of the resident touching females. He stated his documentation meant resident #3 was touching females on the arm, not inappropriately. When asked why he would document that type of behavior if it was not inappropriate, he stated some individuals may not like to be touched on their arm. When asked if he documents every resident who touches a resident on their arm and he replied, "No". When asked for explanation of documentation for his note from 1/03/13 of "will monitor" he was unable to provide it. The minimum data set (MDS) assessment for resident #3 had an observation end date of 1/03/13. The section for cognitive patterns indicated the resident's "Brief Interview for Mental Status" (BIMS) score was 04. The BIMS total score is highly correlated with the Mini-Mental State Exam (Folstein, Folstein, & McHugh 1975) scores. A score of 0-7=severe impairment. The assessment indicated the resident had no mood indicators. Behavioral symptoms indicated the resident had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and the behavior occurred 1 to 3 days during the observation period of 12/27/13 to 1/03/13. It also indicated the resident rejected care 1 to 3 days, and did not wander. The resident required limited assistance to move between locations in his room and adjacent corridor on the same floor. The resident was not receiving any psychoactive medications as of 1/03/13. The care assessment summary indicated the care areas triggered in the following areas and the triggered areas were addressed in the care plan: cognitive loss/dementia, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, and pressure ulcers. On 1/08/13 at 11 a.m., the documentation in the nurses' notes indicated the resident continues to urinate in the hallway and floor of his room, gets very aggravated when redirected, curses as staff, and says he is being accused of something he did not do. The interdisciplinary care plan team meeting was held on 1/08/13. The resident or family did not attend. The care plan for psychosocial and behavioral impairment was initiated on 1/04/13. The focus section of the care plan lists: He has been verbally abusive with staff and refused assistance with care. He does not like to be redirected at times, and will make inappropriate remarks to some of the female staff. A handwritten remark is written in the focus section of 1/25/13 reviewed. The goals for the care plan are: resident will accept assistance from staff without being verbally abusive thru next review, target date 4/04/13; resident will have fewer episodes of inappropriate behavior toward female staff thru next review, target date 4/04/13. The interventions listed: introduce staff with each interaction, monitor mood and behavior problems, provide calm environment, psych eval as needed. The plan of care did not indicate the frequency or how the mood and behavior problems would be monitored, only that they would be completed by "all." The care plan for impaired cognition related to short term memory problems, long term memory problems, decisions poorly, mental function varies over the course of the day was initiated on 1/04/13. A hand written remark was in the focus section, "readm" 1/25/13. The goal was resident will be able to make needs known thru next review date, target date 4/04/13. Interventions included: Allow resident to make choices. Allow time for responses, anticipate resident's need for toileting, comfort, clothing, room temperature, entertainment, personal care and bathing, and grooming. Face resident when talking. Give simple, clear responses to resident's questions when asking questions. Introduce self with each interaction. Listen attentively and watch for non-verbal responses or clues. Provide a calm environment. Take time to listen and respond to resident. Talk to resident as if he/she is expected to understand. Explain details slowly. Give time to comprehend. The other care plans observed in the record were: Nutrition, Activities, Self Care Deficit for activities of daily living, Risk for skin breakdown, Alteration in comfort, At risk for Cardiac Alteration, At risk for complications from diabetes. A care plan for trying to touch females was not developed. A care plan for wandering was not developed. Review of the physician's progress notes revealed an admission note dated 1/09/13. The note did not include the resident's behaviors as documented in the nurse's notes and social service notes as of that date. On 1/10/13 at 10:15 p.m., the documentation in the nurses' notes read, "Resident keeps asking for sexual favors from female staffs. Also, keeps urinating in the hallway." On 1/12/13 at 10 p.m., nurses' notes indicated, "Resident won't stay in bed. Kept asking same question over and over. Confused his room with other resident room." On 1/13/13 at 5:15 a.m., the notes indicated the resident was very aggressive with staff. Cursing and abusive language was verbalized by the resident. On 1/16/13 at 11 p.m., the notes indicated the resident kept going into other residents' rooms and refused to allow vital signs to be taken. On 1/18/13 at 12 p.m., LPN #D documented in the nurse's notes, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager (UM) and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room." In an interview with abuse coordinator on 2/15/13 at approximately 10:25 a.m., he reported the female resident was resident #6. Record review for resident #6 revealed the last annual MDS assessment was completed 8/02/12 and the resident's cognition was severely impaired. The resident had a [DIAGNOSES REDACTED]. She was sitting in her wheelchair in the activity room at the time resident #3 put his hand in her pants on 1/18/13. Observation of resident #6 on 2/15/13 at 11:15 a.m. revealed she was sitting in a wheelchair at a table in the dining/activity room. She was not speaking to anyone was not involved in any activity at that moment. Nurse #L documented in the nurses' notes on 1/18/13 at 9:20 p.m., "....Wanders/ambulates in hallway with wide stance. Wandered into a female's room this shift and made a pass at a female resident sitting in the hallway." A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." The plan/recommendation was for [MEDICATION NAME] Patch 4.6 milligrams (mg) every 24 hours and [MEDICATION NAME] 250 mg twice a day, and follow up in one month. Review of the physician's orders [REDACTED]. Review of resident #3's care plans revealed no interventions to address the risk of him being hurt due to him touching female residents inappropriately and no care plans were developed regarding medications ordered by the psychiatrist or possible nonpharmacologic interventions. Review of the physician orders [REDACTED]. The next entry for SSD notes on 1/23/13 documented, "nursing reports resident as being aggressively inappropriate to female residents. Was seen by psych and given meds on 1/18/13. Will monitor. Also, his room was changed from 124 A to 103 so he could be in a cluster of male rooms instead of females. Room change occurred on 1/17/13." Review of the resident rooms for the section of the hallway for room [ROOM NUMBER] revealed 10 resident rooms and 5 rooms were male rooms. Review of the resident rooms for the section of the hallway for room [ROOM NUMBER], after the room change, revealed 10 resident rooms and only 3 were male rooms. On 1/24/13, no time documented in the nurses' notes, LPN #I documented the resident was alert with confusion, "up ad lib." At 2:40 p.m. the documentation was as follows: "CNA observed resident in room [ROOM NUMBER]B with his hand inside female resident pants and rubbing his hand inside of pant as she was lying on the edge of bed 105B. As the CNA was trying to redirect him, he drew back his hand at the CNA." The notes indicated the resident was sent via Baker Act to the hospital at 5:30 p.m. Previous review of an abuse report submitted by the abuse coordinator indicated the female resident was resident #1. Neither resident #3, nor resident #1 resided in room [ROOM NUMBER]. Record review for resident #1 revealed a [DIAGNOSES REDACTED]. She exhibited physical and verbal behavioral symptoms toward others daily and wandered daily. She could walk in corridor with supervision. Resident #1 had a care plan reviewed on 11/20/12 for: Frequently wanders in and out of activities due to: impaired cognition, decreased safety awareness, dementia. The goal was for resident #1 to remain in activity for at least 10 minutes. An intervention was to redirect resident as needed. The care plan did not address the risk to the resident or any interventions to prevent potential abuse or inappropriate touching from other residents. The resident had a care plan for wandering in and out of other resident's rooms and the goal was that the resident will wander safely within the secured unit thru the next review date. The care plan for wandering was not reviewed after resident #3 was observed with his hand in her pants on 1/24/13 after both her and resident #3 wandered into another resident's room (#4). Resident #1 was observed on 2/14/13 at 10 a.m. She was standing at a table in the activity room, playing with a doll and a stuffed animal. She was attempting to offer her teddy bear to the resident sitting next to her. At 12:30 p.m. that day she was observed eating lunch in the activity/dining room and she was feeding herself. At 12:50 p.m. CNA #B was observed feeding her the rest of her lunch. The CNA stated resident #1 starts feeding herself, but then she will just play with her food and forgets to finish eating, so staff feed her the rest of her meal. The next Physician's note for resident #3 was from 1/24/13. It revealed the physician documented the reported inappropriate sexual behavior. He noted "unable to control pt's (patients) behavior" and "....Baker Act and transfer to psych hospital." The SSD documentation entry on 1/24/13 read, "Baker Act was utilized as resident became increasingly inappropriate with females and he became difficult to redirect." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility from 1/24/13 indicated the resident had a mental illness [DIAGNOSES REDACTED]. It was completed by the licensed social worker. The supporting evidence section documented, "Despite psych meds(resident #3) is a danger to other female residents as he is sexually inappropriate with his touching and increasingly aggressive." The Other Information section included, "Nursing has witnessed (resident #3) become very aggressive towards female residents whom are unable to defend themselves-he presents a danger." An Approval for Release of Person on Involuntary Status From a Receiving Facility was signed and dated by the examiner at the hospital receiving facility on 1/25/13 at 9:43 a.m. It indicated the patient does not meet criteria for involuntary outpatient placement pursuant to 394.4655 based upon one or more of the following reasons: Person is likely to survive safely in the community without supervision and there are available less restrictive treatment alternatives offering an opportunity for improvement of his/her condition. The handwritten documentation was as follows: (resident #3) is exhibiting advancement of his dementia. He is not currently suicidal or homicidal and is not aggressive or psychotic. There are less restrictive environment for caring for the patient. The Florida Mental Health Act of 1971, commonly known as the "Baker Act" per Florida Statute 394.451, allows for involuntary examination of an individual with evidence of: 1) mental illness, and 2) evidence of harm to self, harm to others, or is self neglectful. Per the Baker Act Handbook and User Reference Guide-2011, The primary role of a Baker Act receiving facility is to perform psychiatric evaluations and provide short term psychiatric treatment. If a person has behavioral conditions that are not psychiatric in nature they should not be sent to a psychiatric facility. The Baker Act requires a patient have a documented mental illness and to be able to participate in a psychiatric treatment plan. Resident #3 had no [DIAGNOSES REDACTED]. On 1/25/13, upon return to the facility after the incident of sexual inappropriate behavior with resident #1, resident #3 had physician telephone orders for [MEDICATION NAME] 500 mg. twice a day for [MEDICAL CONDITION] and [MEDICATION NAME] 20 mg. every morning for depression and decrease libido. The record did not contain any other information regarding how the [DIAGNOSES REDACTED]. Behavior monitoring records were not initiated until 1/29/13 for the [MEDICATION NAME], despite the fact that the resident was started on the medication 11 days earlier. The behavior listed on the Behavior/intervention Monthly Flow Record for [MEDICATION NAME] was inappropriate sexual behavior. The intervention codes noted (see care plan) however a care plan for inappropriate sexual behavior was not developed. The flow record did not list any individualized interventions for inappropriate sexual behavior. When the resident returned to the facility on [DATE] at 4:45 p.m., the nurses notes were written as follows: "Resident was brought to facility via stretcher + 2 attendants. Resident alert + responsive. Mucous membrane moist, pink, + intact. Denies having any pain. Lungs clear. Active ROM (range of motion) in upper extremities. Skin warm, dry, + intact. + bowel sounds. Abdomen soft + non tender. Old scar above umbilicus. Active ROM lower extremities. Feet very dry. Toe nails overgrown. MD notified of return. VS (vital signs) B/P (blood pressure) 137/78. P (pulse) =74, R (respirations) = 18, T (temperature) = 98.4 resident made comfortable. Will monitor." The nurses' notes did not indicate what would be monitored. Another MDS assessment was completed for resident #3 upon return to the facility on [DATE] with the observation end date of 2/09/13. The assessment changed from the initial assessment from 1/03/13. For Hearing, Speech, and Vision, it indicated the resident usually understands-misses some part/intent of message, but comprehends most conversation. Cognitive score remained the same. The resident's mood had changed to feeling down, depressed or hopeless 2-6 days, and trouble concentrating on things 2-6 days. Behavioral Symptoms indicated the resident now had physical and verbal behavioral symptoms directed toward others that occurred 1-3 days, had delusions, rejected care 1 to 3 days, and did not wander. Functional status remained the same for required limited assistance to move between locations in his room and adjacent corridor on the same floor, but walk in corridor improved from limited assistance to supervision. An antidepressant was coded as given 7 of the last 7 days. On 1/26/13, no time written LPN #D documented in the nurses' notes as follows, "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m., he reported the male resident was resident #7. Record review for resident #7 revealed the resident has [MEDICAL CONDITION]. The last annual MDS assessment was completed on 7/11/12 and it indicated the resident's vision was highly impaired and the resident's cognition was severely impaired. His ability to understand others was assessed as, sometimes understands. The resident is dependent upon staff for all activities of daily living. Resident #7 was sitting in a wheelchair in the activity room at the time resident #3 put his hand on his penis. Observation of resident #7 on 2/15/13 at 11:45 a.m. revealed he was sitting in his room in a wheelchair. He opened his eyes when spoken to, but he did not respond to questions as he was hard of hearing. The nurse's note written by LPN #I on 1/29/13 at 3:35 p.m. indicated resident #3 was up "ad lib." The SSD notes on 1/28/13 included documentation regarding the resident #3's return to the nursing home indicating the Baker Act was not warranted as such behaviors were related to dementia. His documentation indicated resident was a danger to other females on the dementia unit and noted concern regarding the resident's sexual acting out. The notes indicate the SSD was attempting to find alternative placement for the resident, but no notation of any intervention planned for resident #3 or for protection of the other residents. The SSD notes from 2/04/13 indicate he met with the psychiatrist who changed medications started previously related to resident #3's behaviors. Review of the care plans revealed no indication of psychiatrist visits, initial orders, or changes to orders. The notes did not contain information regarding type of behaviors, assessment for possible causes of behaviors, and any nonpharmalogical interventions attempted prior to the use of medications. The Psychiatric progress note dated 2/04/13 documented, "Pt. states he is doing better." The psychiatrist also noted the resident was still sexually preoccupied. Input from staff/family was less sexual, less angry. The psychiatrist increased the [MEDICATION NAME] to 9.5 mg daily. The nurses' notes from 1/26/13 to 2/11/13 indicated resident #3 did not exhibit inappropriate sexual behavior, however the resident was observed in the hallway pulling out his penis and urinating in the hallway on 2/09/13 at 2:40 p.m. On 2/08/13 at 8:40 p.m., documentation indicated the resident urinated in the hallway again. On 2/10/13, the resident was out of bed ambulating in dining room/activities, but the notes did not include documentation of how the resident was supervised or monitored. On 2/12/13 at 12:20 p.m. the nurses' notes documented by the UM were as follows, " ....a CNA informed me resident was standing in hallway close to his room putting his finger in resident's vagina. On visiting the area I saw female resident standing in hallway with her diaper in her hand and the male resident standing close beside her with his fingers in the vagina. I asked him what he is doing and told him to leave the lady alone, he just looked at me and did not move, so I attempted to take him to his room and he attempted to hit me." "....Resident was left in his room by family members who left without notifying staff they were leaving." Review of the Federal abuse report submitted by the abuse coordinator indicated the female resident was resident #2. Although the documentation indicated staff members were not aware resident #3 was alone, the UM indicated in an interview on 2/14/13 at 2:50 p.m. and in her documentation in the nurses' notes on 2/12/13 at 12:20 p.m., the daughter had approached her at the nursing station, so the daughter was not in resident #3's room at that time. Record review for resident #2 revealed a [DIAGNOSES REDACTED]. Her assessment documented she exhibited no wandering although she had a plan of care for frequent wandering in and out of activities due to dementia that was initiated on 8/20/13 and was reviewed to continue with the plan of care on 11/22/12. The care plan for wandering was not reviewed after the resident was subjected to sexually inappropriate behavior by resident #3 on 2/12/13. She walks in the corridor with limited assistance, however observation of the resident on 2/14/13 at 12:45 p.m., revealed she walked without assistance, using a walker. She had no physical or verbal behavioral symptoms directed toward others. On 2/14/13 at 12:45 p.m. an interview was attempted with resident #3. She was unable to complete one thought or reply appropriately to simple questions. She was later observed at 12:45 p.m. ambulating without staff assistance in the hallway with a walker. The SSD notes from 2/12/13 indicated resident #3 touched a demented female resident inappropriately and the resident required hospitalization . The resident was not arrested "probably based on the fact that he is demented." The SSD notes continued, "It is unknown whether the visitation by the resident's family caused the resident to react in a sexually inappropriate way towards another female resident because resident's behavior had improved since his meds were changed by the psychiatrist. However, the resident's family visited the resident regularly, and the daughter visited at twice a week. The SSD did not document any relationship between the family visits and the resident's sexual behaviors previously, even though the family had been visiting regularly since admission on 12/27/12 and the start of resident behaviors were documented as early as 12/31/12 by nursing staff and 1/03/13 by the SSD. The Physician's note was on 2/12/13 which read, "....Pt had inappropriate sexual encounter with another female patient who required medical attention for vaginal bleeding." "....I made decision that this patient is inappropriate to be in nursing facility at this time due to danger to other patient's safety. I am going to Baker Act this patient." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility for 2/12/13 indicated it was completed by resident #3's physician. The criteria for reason to believe the person has a mental illness documented, "[MEDICAL CONDITION]." The supporting evidence included, "Resident has been observed being constantly sexually inappropriate with elderly females and exercises poor judgment and has caused physical harm to a female resident who was hospitalized ." The section for Other Information was blank. Review of the CNA Care Tracker notes revealed no documentation of level of supervision for resident #3. The "Resident Behavior by Day Chart Report " did not document any physically abusive or verbally abusive behaviors from the day of admission on 12/27/12 to discharge on 2/12/13 with the exception of 1/22/13, verbally abusive behaviors. The census and condition report completed by the DON indicated the facility had 68 residents out of 109 that had dementia and 60 residents with behavioral symptoms. During an interview with the UM registered nurse, on 2/14/13 at 9:30 a.m., she explained the residents on the A-wing all had mild to severe dementia and were mostly long-term residents. She indicated there were 56 residents on the unit because one resident was sent to the hospital. She indicated resident #3 was sent to the hospital via Baker Act on 2/12/13. In an interview with Licensed Practical Nurse (LPN) #D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. She said she does not take anything they (residents) say or do personally because she understands that it's an illness and they cannot help it. She said, "You have to be patient and if they don't want to cooperate, come back and try again later." She said most residents stay in the activity/dining room. When LPN #D was asked how she deals with residents with behaviors toward other residents, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the her pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN #D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She explained, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room [ROOM NUMBER] because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say "what am I doing? I don't speak English." When asked if the resident had ever touched her, she said no, but he would make comments like "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA-A she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in room [ROOM NUMBER], so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step back and he said, 'what the hell' and pushed the table and showed his fist." Resident #1 "was just lying there. I asked the nurse to come." She explained that he was sent out of the facility the same day. She said when he returned, he was on 1 to 1 supervision for about a day and ?. She said he could walk independently. "He was a smart mouth, very alert. I would take him to bathroom and he would say, 'I don't understand English,' but he did." She also said that she did not know if it was investigated, but the day she found resident #3 in room [ROOM NUMBER] with resident #1, the other resident in the room, resident #4, was lying on the bed and her pants were "dropped." This incident occurred on 1/24/13. On 2/15/13 at 11 a.m. during an interview with Activity CNA-K, she said that she had worked in Activities since last May. She explained that she had reported an incident that had occurred between resident

Based on interview and record review, and observation, the facility failed to keep residents free from neglect on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents (#1, 2, 6 & 7) had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at 4 separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and staff neglected to provide adequate care and services, including adequate supervision, to prevent resident #3 from touching 4 residents in an inappropriate sexual manner, even after the resident exhibited previous sexually inappropriate behaviors. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the sexually inappropriate behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility staff neglected to identify and implement procedures to protect residents from repeated occurrences of sexually inappropriate behavior even after they were aware of and documented resident #3's sexual behaviors starting on 1/10/13. The facility failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms. As of the exit date of the survey, 2/16/13, the facility had no system in place to keep residents free from mistreatment and neglect, including identification of residents whose behaviors render them at risk for touching other residents or being touched in an inappropriate manner, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger the behavior, and reassessment of the interventions on a regular basis. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F224. Findings: Cross Reference to F225, F226, F323, F203. Review of resident #3's record indicated the resident was admitted to the facility from the hospital on [DATE]. The history and physical from the hospital admission indicated the resident was brought to the emergency roiagnom on [DATE] by ambulance for altered mental status. He was also in the hospital on [DATE] for change in mental status and was found wandering in a shopping mall. He had uncontrolled diabetes on both admissions. His diagnoses as listed on the nursing home admission record face sheet were: diabetes, altered mental status, late effect cerebral vascular disease, hypertension, muscle weakness, and difficulty walking. The cumulative [DIAGNOSES REDACTED]. The resident did not have a [DIAGNOSES REDACTED]. Review of the Pre-Admission Screen and Resident Review indicated it was not completed prior to admission. It was completed on 2/12/13. The screen indicated resident #3 did not have a [DIAGNOSES REDACTED]. It also indicated the resident had a [DIAGNOSES REDACTED]. Review of the nurses' notes for resident #3 indicated he became agitated and verbally abusive to staff after the nurse spoke to the him about continuing to urinate in the hallway, inside the room on the floor, and on the curtain on 12/31/12 at 5 a.m. On 1/03/13, nurses' notes documented the resident was hostile to staff and continued to urinate on the floor, by the roommate, the bed, the curtain, and the hallway. Review of Social Service Director's (SSD) notes dated 1/03/13 indicated the resident was "observed trying to touch females. Requires redirect. Will monitor." Upon interview with the SSD on 2/15/13 at 1:40 p.m. and on 2/16/13 at 10 a.m., he discussed his documentation of the resident touching females. He stated his documentation meant resident #3 was touching females on the arm, not inappropriately. When asked why he would document that type of behavior if it was not inappropriate, he stated some individuals may not like to be touched on their arm. When asked if he documents every resident who touches a resident on their arm and he replied, "No". When asked for explanation of documentation for his note from 1/03/13 of "will monitor" he was unable to provide it. The minimum data set (MDS) assessment for resident #3 had an observation end date of 1/03/13. The section for cognitive patterns indicated the resident's "Brief Interview for Mental Status" (BIMS) score was 04. The BIMS total score is highly correlated with the Mini-Mental State Exam (Folstein, Folstein, & McHugh 1975) scores. A score of 0-7=severe impairment. The assessment indicated the resident had no mood indicators. Behavioral symptoms indicated the resident had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and the behavior occurred 1 to 3 days during the observation period of 12/27/13 to 1/03/13. It also indicated the resident rejected care 1 to 3 days, and did not wander. The resident required limited assistance to move between locations in his room and adjacent corridor on the same floor. The resident was not receiving any psychoactive medications as of 1/03/13. The care assessment summary indicated the care areas triggered in the following areas and the triggered areas were addressed in the care plan: cognitive loss/dementia, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, and pressure ulcers. On 1/08/13 at 11 a.m., the documentation in the nurses' notes indicated the resident continues to urinate in the hallway and floor of his room, gets very aggravated when redirected, curses as staff, and says he is being accused of something he did not do. The interdisciplinary care plan team meeting was held on 1/08/13. The resident or family did not attend. The care plan for psychosocial and behavioral impairment was initiated on 1/04/13. The focus section of the care plan lists: He has been verbally abusive with staff and refused assistance with care. He does not like to be redirected at times, and will make inappropriate remarks to some of the female staff. A handwritten remark is written in the focus section of 1/25/13 reviewed. The goals for the care plan are: resident will accept assistance from staff without being verbally abusive thru next review, target date 4/04/13; resident will have fewer episodes of inappropriate behavior toward female staff thru next review, target date 4/04/13. The interventions listed: introduce staff with each interaction, monitor mood and behavior problems, provide calm environment, psych eval as needed. The plan of care did not indicate the frequency or how the mood and behavior problems would be monitored, only that they would be completed by "all." The care plan for impaired cognition related to short term memory problems, long term memory problems, decisions poorly, mental function varies over the course of the day was initiated on 1/04/13. A hand written remark was in the focus section, "readm" 1/25/13. The goal was resident will be able to make needs known thru next review date, target date 4/04/13. Interventions included: Allow resident to make choices. Allow time for responses, anticipate resident's need for toileting, comfort, clothing, room temperature, entertainment, personal care and bathing, and grooming. Face resident when talking. Give simple, clear responses to resident's questions when asking questions. Introduce self with each interaction. Listen attentively and watch for non-verbal responses or clues. Provide a calm environment. Take time to listen and respond to resident. Talk to resident as if he/she is expected to understand. Explain details slowly. Give time to comprehend. The other care plans observed in the record were: Nutrition, Activities, Self Care Deficit for activities of daily living, Risk for skin breakdown, Alteration in comfort, At risk for Cardiac Alteration, At risk for complications from diabetes. A care plan for trying to touch females was not developed. A care plan for wandering was not developed. Review of the physician's progress notes revealed an admission note dated 1/09/13. The note did not include the resident's behaviors as documented in the nurse's notes and social service notes as of that date. On 1/10/13 at 10:15 p.m., the documentation in the nurses' notes read, "Resident keeps asking for sexual favors from female staffs. Also, keeps urinating in the hallway." On 1/12/13 at 10 p.m., nurses' notes indicated, "Resident won't stay in bed. Kept asking same question over and over. Confused his room with other resident room." On 1/13/13 at 5:15 a.m., the notes indicated the resident was very aggressive with staff. Cursing and abusive language was verbalized by the resident. On 1/16/13 at 11 p.m., the notes indicated the resident kept going into other residents' rooms and refused to allow vital signs to be taken. On 1/18/13 at 12 p.m., LPN #D documented in the nurse's notes, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager (UM) and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room." In an interview with abuse coordinator on 2/15/13 at approximately 10:25 a.m., he reported the female resident was resident #6. Record review for resident #6 revealed the last annual MDS assessment was completed 8/02/12 and the resident's cognition was severely impaired. The resident had a [DIAGNOSES REDACTED]. She was sitting in her wheelchair in the activity room at the time resident #3 put his hand in her pants on 1/18/13. Observation of resident #6 on 2/15/13 at 11:15 a.m. revealed she was sitting in a wheelchair at a table in the dining/activity room. She was not speaking to anyone was not involved in any activity at that moment. Nurse #L documented in the nurses' notes on 1/18/13 at 9:20 p.m., "....Wanders/ambulates in hallway with wide stance. Wandered into a female's room this shift and made a pass at a female resident sitting in the hallway." A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." The plan/recommendation was for [MEDICATION NAME] Patch 4.6 milligrams (mg) every 24 hours and [MEDICATION NAME] 250 mg twice a day, and follow up in one month. Review of the physician's orders [REDACTED]. Review of resident #3's care plans revealed no interventions to address the risk of him being hurt due to him touching female residents inappropriately and no care plans were developed regarding medications ordered by the psychiatrist or possible nonpharmacologic interventions. Review of the physician orders [REDACTED]. The next entry for SSD notes on 1/23/13 documented, "nursing reports resident as being aggressively inappropriate to female residents. Was seen by psych and given meds on 1/18/13. Will monitor. Also, his room was changed from 124 A to 103 so he could be in a cluster of male rooms instead of females. Room change occurred on 1/17/13." Review of the resident rooms for the section of the hallway for room [ROOM NUMBER] revealed 10 resident rooms and 5 rooms were male rooms. Review of the resident rooms for the section of the hallway for room [ROOM NUMBER], after the room change, revealed 10 resident rooms and only 3 were male rooms. On 1/24/13, no time documented in the nurses' notes, LPN #I documented the resident was alert with confusion, "up ad lib." At 2:40 p.m. the documentation was as follows: "CNA observed resident in room [ROOM NUMBER]B with his hand inside female resident pants and rubbing his hand inside of pant as she was lying on the edge of bed 105B. As the CNA was trying to redirect him, he drew back his hand at the CNA." The notes indicated the resident was sent via Baker Act to the hospital at 5:30 p.m. Previous review of an abuse report submitted by the abuse coordinator indicated the female resident was resident #1. Neither resident #3, nor resident #1 resided in room [ROOM NUMBER]. Record review for resident #1 revealed a [DIAGNOSES REDACTED]. She exhibited physical and verbal behavioral symptoms toward others daily and wandered daily. She could walk in corridor with supervision. Resident #1 had a care plan reviewed on 11/20/12 for: Frequently wanders in and out of activities due to: impaired cognition, decreased safety awareness, dementia. The goal was for resident #1 to remain in activity for at least 10 minutes. An intervention was to redirect resident as needed. The care plan did not address the risk to the resident or any interventions to prevent potential abuse or inappropriate touching from other residents. The resident had a care plan for wandering in and out of other resident's rooms and the goal was that the resident will wander safely within the secured unit thru the next review date. The care plan for wandering was not reviewed after resident #3 was observed with his hand in her pants on 1/24/13 after both her and resident #3 wandered into another resident's room (#4). Resident #1 was observed on 2/14/13 at 10 a.m. She was standing at a table in the activity room, playing with a doll and a stuffed animal. She was attempting to offer her teddy bear to the resident sitting next to her. At 12:30 p.m. that day she was observed eating lunch in the activity/dining room and she was feeding herself. At 12:50 p.m. CNA #B was observed feeding her the rest of her lunch. The CNA stated resident #1 starts feeding herself, but then she will just play with her food and forgets to finish eating, so staff feed her the rest of her meal. The next Physician's note for resident #3 was from 1/24/13. It revealed the physician documented the reported inappropriate sexual behavior. He noted "unable to control pt's (patients) behavior" and "....Baker Act and transfer to psych hospital." The SSD documentation entry on 1/24/13 read, "Baker Act was utilized as resident became increasingly inappropriate with females and he became difficult to redirect." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility from 1/24/13 indicated the resident had a mental illness [DIAGNOSES REDACTED]. The supporting evidence section documented, "Despite psych meds(resident #3) is a danger to other female residents as he is sexually inappropriate with his touching and increasingly aggressive." The Other Information section included, "Nursing has witnessed (resident #3) become very aggressive towards female residents whom are unable to defend themselves-he presents a danger." An Approval for Release of Person on Involuntary Status From a Receiving Facility was signed and dated by the examiner at the hospital receiving facility on 1/25/13 at 9:43 a.m. It indicated the patient does not meet criteria for involuntary outpatient placement pursuant to 394.4655 based upon one or more of the following reasons: Person is likely to survive safely in the community without supervision and there are available less restrictive treatment alternatives offering an opportunity for improvement of his/her condition. The handwritten documentation was as follows: (resident #3) is exhibiting advancement of his dementia. He is not currently suicidal or homicidal and is not aggressive or psychotic. There are less restrictive environment for caring for the patient. The Florida Mental Health Act of 1971, commonly known as the "Baker Act" per Florida Statute 394.451, allows for involuntary examination of an individual with evidence of: 1) mental illness, and 2) evidence of harm to self, harm to others, or is self neglectful. Per the Baker Act Handbook and User Reference Guide-2011, The primary role of a Baker Act receiving facility is to perform psychiatric evaluations and provide short term psychiatric treatment. If a person has behavioral conditions that are not psychiatric in nature they should not be sent to a psychiatric facility. The Baker Act requires a patient have a documented mental illness and to be able to participate in a psychiatric treatment plan. Resident #3 had no [DIAGNOSES REDACTED]. On 1/25/13, upon return to the facility after the incident of sexual inappropriate behavior with resident #1, resident #3 had physician telephone orders for [MEDICATION NAME] 500 mg. twice a day for [MEDICAL CONDITION] and [MEDICATION NAME] 20 mg. every morning for depression and decrease libido. The record did not contain any other information regarding how the [DIAGNOSES REDACTED]. Behavior monitoring records were not initiated until 1/29/13 for the [MEDICATION NAME], despite the fact that the resident was started on the medication 11 days earlier. The behavior listed on the Behavior/intervention Monthly Flow Record for [MEDICATION NAME] was inappropriate sexual behavior. The intervention codes noted (see care plan) however a care plan for inappropriate sexual behavior was not developed. The flow record did not list any individualized interventions for inappropriate sexual behavior. When the resident returned to the facility on [DATE] at 4:45 p.m., the nurses notes were written as follows: "Resident was brought to facility via stretcher + 2 attendants. Resident alert + responsive. Mucous membrane moist, pink, + intact. Denies having any pain. Lungs clear. Active ROM (range of motion) in upper extremities. Skin warm, dry, + intact. + bowel sounds. Abdomen soft + non tender. Old scar above umbilicus. Active ROM lower extremities. Feet very dry. Toe nails overgrown. MD notified of return. VS (vital signs) B/P (blood pressure) 137/78. P (pulse) =74, R (respirations) = 18, T (temperature) = 98.4 resident made comfortable. Will monitor." The nurses' notes did not indicate what would be monitored. Another MDS assessment was completed for resident #3 upon return to the facility on [DATE] with the observation end date of 2/09/13. The assessment changed from the initial assessment from 1/03/13. For Hearing, Speech, and Vision, it indicated the resident usually understands-misses some part/intent of message, but comprehends most conversation. Cognitive score remained the same. The resident's mood had changed to feeling down, depressed or hopeless 2-6 days, and trouble concentrating on things 2-6 days. Behavioral Symptoms indicated the resident now had physical and verbal behavioral symptoms directed toward others that occurred 1-3 days, had [MEDICAL CONDITION], rejected care 1 to 3 days, and did not wander. Functional status remained the same for required limited assistance to move between locations in his room and adjacent corridor on the same floor, but walk in corridor improved from limited assistance to supervision. An antidepressant was coded as given 7 of the last 7 days. On 1/26/13, no time written LPN #D documented in the nurses' notes as follows, "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m., he reported the male resident was resident #7. Record review for resident #7 revealed the resident has [MEDICAL CONDITION]. The last annual MDS assessment was completed on 7/11/12 and it indicated the resident's vision was highly impaired and the resident's cognition was severely impaired. His ability to understand others was assessed as, sometimes understands. The resident is dependent upon staff for all activities of daily living. Resident #7 was sitting in a wheelchair in the activity room at the time resident #3 put his hand on his penis. Observation of resident #7 on 2/15/13 at 11:45 a.m. revealed he was sitting in his room in a wheelchair. He opened his eyes when spoken to, but he did not respond to questions as he was hard of hearing. The nurse's note written by LPN #I on 1/29/13 at 3:35 p.m. indicated resident #3 was up "ad lib." The SSD notes on 1/28/13 included documentation regarding the resident #3's return to the nursing home indicating the Baker Act was not warranted as such behaviors were related to dementia. His documentation indicated resident was a danger to other females on the dementia unit and noted concern regarding the resident's sexual acting out. The notes indicate the SSD was attempting to find alternative placement for the resident, but no notation of any intervention planned for resident #3 or for protection of the other residents. The SSD notes from 2/04/13 indicate he met with the psychiatrist who changed medications started previously related to resident #3's behaviors. Review of the care plans revealed no indication of psychiatrist visits, initial orders, or changes to orders. The notes did not contain information regarding type of behaviors, assessment for possible causes of behaviors, and any nonpharmalogical interventions attempted prior to the use of medications. The Psychiatric progress note dated 2/04/13 documented, "Pt. states he is doing better." The psychiatrist also noted the resident was still sexually preoccupied. Input from staff/family was less sexual, less angry. The psychiatrist increased the [MEDICATION NAME] to 9.5 mg daily. The nurses' notes from 1/26/13 to 2/11/13 indicated resident #3 did not exhibit inappropriate sexual behavior, however the resident was observed in the hallway pulling out his penis and urinating in the hallway on 2/09/13 at 2:40 p.m. On 2/08/13 at 8:40 p.m., documentation indicated the resident urinated in the hallway again. On 2/10/13, the resident was out of bed ambulating in dining room/activities, but the notes did not include documentation of how the resident was supervised or monitored. On 2/12/13 at 12:20 p.m. the nurses' notes documented by the UM were as follows, " ....a CNA informed me resident was standing in hallway close to his room putting his finger in resident's vagina. On visiting the area I saw female resident standing in hallway with her diaper in her hand and the male resident standing close beside her with his fingers in the vagina. I asked him what he is doing and told him to leave the lady alone, he just looked at me and did not move, so I attempted to take him to his room and he attempted to hit me." "....Resident was left in his room by family members who left without notifying staff they were leaving." Review of the Federal abuse report submitted by the abuse coordinator indicated the female resident was resident #2. Although the documentation indicated staff members were not aware resident #3 was alone, the UM indicated in an interview on 2/14/13 at 2:50 p.m. and in her documentation in the nurses' notes on 2/12/13 at 12:20 p.m., the daughter had approached her at the nursing station, so the daughter was not in resident #3's room at that time. Record review for resident #2 revealed a [DIAGNOSES REDACTED]. Her assessment documented she exhibited no wandering although she had a plan of care for frequent wandering in and out of activities due to dementia that was initiated on 8/20/13 and was reviewed to continue with the plan of care on 11/22/12. The care plan for wandering was not reviewed after the resident was subjected to sexually inappropriate behavior by resident #3 on 2/12/13. She walks in the corridor with limited assistance, however observation of the resident on 2/14/13 at 12:45 p.m., revealed she walked without assistance, using a walker. She had no physical or verbal behavioral symptoms directed toward others. On 2/14/13 at 12:45 p.m. an interview was attempted with resident #3. She was unable to complete one thought or reply appropriately to simple questions. She was later observed at 12:45 p.m. ambulating without staff assistance in the hallway with a walker. The SSD notes from 2/12/13 indicated resident #3 touched a demented female resident inappropriately and the resident required hospitalization . The resident was not arrested "probably based on the fact that he is demented." The SSD notes continued, "It is unknown whether the visitation by the resident's family caused the resident to react in a sexually inappropriate way towards another female resident because resident's behavior had improved since his meds were changed by the psychiatrist. However, the resident's family visited the resident regularly, and the daughter visited at twice a week. The SSD did not document any relationship between the family visits and the resident's sexual behaviors previously, even though the family had been visiting regularly since admission on 12/27/12 and the start of resident behaviors were documented as early as 12/31/12 by nursing staff and 1/03/13 by the SSD. The Physician's note was on 2/12/13 which read, "....Pt had inappropriate sexual encounter with another female patient who required medical attention for vaginal bleeding." "....I made decision that this patient is inappropriate to be in nursing facility at this time due to danger to other patient's safety. I am going to Baker Act this patient." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility for 2/12/13 indicated it was completed by resident #3's physician. The criteria for reason to believe the person has a mental illness documented, "[MEDICAL CONDITION]." The supporting evidence included, "Resident has been observed being constantly sexually inappropriate with elderly females and exercises poor judgment and has caused physical harm to a female resident who was hospitalized ." The section for Other Information was blank. Review of the CNA Care Tracker notes revealed no documentation of level of supervision for resident #3. The "Resident Behavior by Day Chart Report " did not document any physically abusive or verbally abusive behaviors from the day of admission on 12/27/12 to discharge on 2/12/13 with the exception of 1/22/13, verbally abusive behaviors. The census and condition report completed by the DON indicated the facility had 68 residents out of 109 that had dementia and 60 residents with behavioral symptoms. During an interview with the UM registered nurse, on 2/14/13 at 9:30 a.m., she explained the residents on the A-wing all had mild to severe dementia and were mostly long-term residents. She indicated there were 56 residents on the unit because one resident was sent to the hospital. She indicated resident #3 was sent to the hospital via Baker Act on 2/12/13. In an interview with Licensed Practical Nurse (LPN) #D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. She said she does not take anything they (residents) say or do personally because she understands that it's an illness and they cannot help it. She said, "You have to be patient and if they don't want to cooperate, come back and try again later." She said most residents stay in the activity/dining room. When LPN #D was asked how she deals with residents with behaviors toward other residents, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the her pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN #D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She explained, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room [ROOM NUMBER] because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say "what am I doing? I don't speak English." When asked if the resident had ever touched her, she said no, but he would make comments like "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA-A she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in room [ROOM NUMBER], so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step back and he said, 'what the hell' and pushed the table and showed his fist." Resident #1 "was just lying there. I asked the nurse to come." She explained that he was sent out of the facility the same day. She said when he returned, he was on 1 to 1 supervision for about a day and ?. She said he could walk independently. "He was a smart mouth, very alert. I would take him to bathroom and he would say, 'I don't understand English,' but he did." She also said that she did not know if it was investigated, but the day she found resident #3 in room [ROOM NUMBER] with resident #1, the other resident in the room, resident #4, was lying on the bed and her pants were "dropped." This incident occurred on 1/24/13. On 2/15/13 at 11 a.m. during an interview with Activi

Based on interview and record review, the facility failed to thoroughly investigate and report allegations of neglect on one of two wings for 3 of 9 sampled residents on the A-wing (#4, 6 & 7). The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. The Abuse Coordinator also stated he was unaware of information regarding resident #4 for possible inappropriate sexual behavior that occurred in her room when resident #3 had his hand in the pants of another resident, #1, on 1/24/13. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated on the 5-day Federal report the and did not consider neglect, despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. As of the exit date of the survey on 2/16/13, the facility had not identified neglect to provide adequate interventions and supervision or implemented corrective measures to prevent further potential neglect. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: Cross Reference to F224. On 2/14/13 at 5:40 p.m. during an interview with the Abuse Coordinator (AC), he stated he is also the Risk Manager and the Staff Development Coordinator. He explained that he monitors the staff by conducting background screening on all new hires related to screening for abuse. Training is offered to new employees at orientation and on an annual basis. He was not sure when he conducted his last annual in-service for abuse. Staff-to-resident interactions are reported to him along with unknown injuries and bruises. He said he investigates all incidents and allegations of abuse, neglect, or exploitation. He said in morning meeting, the management staff discuss all incidents on the floor reported by nurses. He explained that he teaches staff about reporting abuse. He stated also he did not consider neglect or lack of supervision when he submitted the Federal reports to the agency for abuse for resident #1 and 2. Review of federal reports submitted since the last recertification survey in July revealed 2 other resident-to-resident issues, one in August and one in September. Both incidents indicated the allegation was abuse, not neglect regarding supervision, and involved residents with dementia in the activity room/dining room on the A-wing. Corrective action included: staff members will be re-educated on monitoring residents that indicate increased anxiety and agitation. It did not indicate any level of increased supervision or details for monitoring residents. During the interview with the AC at that time, he discussed resident #3. He said, "I had discussions on resident #3 and on behaviors that need to be reported. I provided education to CNAs to report to nurses when they had any observations." When asked to provide documentation of the discussions, he indicated he did not have any documentation of discussions or education relating to resident #3. The AC was asked why his report from 1/24/13 did not include information regarding resident #4. The interview with conducted earlier in the day with CNA-A was discussed, and he stated that he was not aware of any incident concerning resident #4 and was not told that her pants were also pulled down during the incident on 1/24/13. He stated, "I don't know anything about resident #4 on 1/24/13 other than she was taking a nap." The AC was asked why incidents of inappropriate sexual behavior that occurred in the activity room on 1/18/13 between resident #3 and resident #6 and on 1/26/13 between resident #3 and resident #7 were not reported. He said he was not aware of the incidents. The AC said that when resident #3 was in the activity room, they moved him to another table by himself. He denied having any knowledge of the 1/26/13 incident involving the resident groping another male resident and touching his penis under the table. He stated, "Nothing was reported to me concerning inappropriate touching in the activity room." He said that he was only aware of the resident "touching other residents on the arm and face." He stated that he had "no knowledge of the resident (#3) touching anyone's penis" and there was no incident report documenting the incident. He stated that he was also unaware of the incident on 1/18/12 when resident #3 had his hand under the table in the pants of resident #6, attempting to reach her vagina. He denied that it was reported to him. During the interview with the AC, he confirmed a resident spoke with a CNA when resident #3 was involved inappropriate sexual behavior with resident #2 on 2/12/13 and he confirmed a resident was yelling to alert staff when resident #3 was involved with sexually inappropriate behavior with resident #1 on 1/24/13. He verified it was residents, and not staff, who identified the inappropriate behavior. The AC also stated he did not consider neglect for lack of supervision when he submitted the reports to the agency for abuse for resident #1 and 2. When he submitted the required reports to the agency for resident #6 and #7 on 2/15/13, the reports indicated the type of incident was abuse, not neglect. In an interview with Licensed Practical Nurse (LPN) #D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. When LPN #D was asked how she deals with residents with behaviors toward another resident, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the resident's pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN#D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She said, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room [ROOM NUMBER] because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say, "what am I doing? I don't speak English." When asked if the resident had ever touched her, she said no, but he would make comments like, "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA #A, she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in room [ROOM NUMBER], so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step back and he said, 'what the hell' and pushed the table and showed his fist." She said resident #1 "was just lying there. I asked the nurse to come." She explained that he was sent out of the facility the same day. She said when he returned, he was on 1 to 1 supervision for about a day and ?. She said he could walk independently. "He was a smart mouth, very alert. I would take him to bathroom and he would say, 'I don't understand English,' but he did." She also said that she did not know if it was investigated, but the day she found resident #3 in room [ROOM NUMBER] with resident #1, the other resident in the room, resident #4, was lying on the bed and her pants were "dropped". This incident occurred on 1/24/13. On 1/18/13 at 12 p.m., LPN #D documented, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room. " On 1/26/13, no time, LPN #D documented as follows: "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." Review of the 5 Day report for resident #6 revealed the type of incident was listed as abuse and it occurred on 1/18/13. The immediate report was not submitted until 27 days later, on 2/14/13 at 8:43 p.m. The 5 Day report was submitted less than 24 hours later, on 2/15/13 at 6:33 p.m. The summary of the investigative findings revealed at approximately 12 p.m., resident #3 had his left hand in the resident's pants and was attempting to reach resident #6's vagina. The report indicated staff members were present and prevented him from doing it. The report does not include exactly what was prevented. The report indicated the allegation of abuse was not substantiated even though the AC's investigation findings indicated resident #3 had his hand in resident #6's pants. The corrective actions indicated resident #3 was transferred to another table by himself and was no longer in the facility. He was sent to the hospital by Baker Act. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the 5 Day report for abuse for resident #7 revealed the type of incident was listed as abuse and it occurred on 1/26/13. The immediate report was not submitted until 19 days later, on 2/14/13 at 9:05 p.m. The 5 Day report was submitted less than 24 hours later, on 2/15/13 at 6:39 p.m. The summary of the investigative findings revealed at approximately 10 a.m., the nurse observed resident #3's left hand on top of resident #7's pants in his penile area. The report indicated the allegation of abuse was not substantiated even though the AC's investigation findings indicated resident #3's hand was on the penile area of resident #7. The corrective actions indicated resident #3 was relocated to another area in the activity room and at the time of the report, he was no longer in the facility. He was sent to the hospital by Baker Act. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the 5-day report for resident #1 revealed the type of incident was listed as abuse and it occurred on 1/24/13. The immediate report was submitted on 1/24/13 at 5:40 p.m. The 5-day report was submitted on 1/29/13 at 3:31 p.m. The summary of the investigative findings revealed at approximately 2:40 p.m. resident #1 wandered into another resident's room. A staff member heard another resident, #5, yelling "get him out of here." Another staff member responded and saw resident #3's hand underneath resident #1's clothing. Both residents have a [DIAGNOSES REDACTED].#4 being in bed in the same room with her pants "dropped". The report indicated the allegation of abuse was not substantiated even though CNA #A witnessed resident #3's hand in resident #1's underwear and "he was really pushing his hand up there." The corrective actions indicated resident #3 was sent to the hospital for evaluation and management of his behaviors. His medications were evaluated and adjusted by the psychiatrist. He is involved in activities with staff supervision. He is escorted by staff when he goes to the bathroom or goes to his room. We will continue hourly check of resident's whereabouts and will re-direct as needed. The corrective actions did not indicate measures the facility took to prevent reoccurrence regarding both residents wandering or resident #3 wandering at times when he was not in activities. The report did not indicate how resident #3 would be monitored when he was in his room. It did not indicate the degree of supervision, nor the frequency, except to say hourly checks. It did not indicate how they would protect the other residents. In a telephone interview with resident #1's son on 2/16/13 at 11:20 a.m., he stated he was informed of an incident involving his mother and a male resident on 1/24/13. He stated he was informed the male resident had fondled his mother's breasts over her clothes. He stated the nurse told him her clothes were not removed. When asked if he was told the male resident had his hand in his mother's pants and was rubbing his hand inside her pants, he replied, "no". He said he also spoke with the Social Services Director (SSD) and he did not tell him the male resident had his hand in her pants. The SSD told him the male resident was sent out of the facility, but was returning and they were keep him sedated. He stated she doesn't always remember who they are when they visit. During an interview with the SSD on 2/16/13 at 12 p.m., the SSD stated when he spoke with resident #1's son about the events on 1/24/13, he did not know the details of the incident because the "abuse coordinator takes care of that." He stated he only knew that inappropriate sexual behavior occurred. When asked if he thought he should be aware of those details since he talks with the family members and is responsible for the residents psychosocial well-being, he said the abuse coordinator handles the specific details. Review of the 5 Day report for resident #2 revealed the type of incident was listed as abuse and it occurred on 2/12/13. The immediate report was submitted on 2/12/13 at 3:35 p.m. The 5-day report was submitted on 2/15/13 at 5:53 p.m. The description of incident indicated the incident occurred on 2/11/13 at approximately 12:40 p.m. In an interview with the AC on 2/14/13 at 5:40 p.m., he indicated the date (2/11/13) was an error and that the incident occurred on 2/12/13. Corrective actions were that the Orlando Police Department was notified and investigated the case. The resident was on 1 to 1 supervision until the physician came to Baker Act the resident again to the same hospital the resident was sent on 1/24/13 when the receiving facility informed the nursing home the resident was not appropriate for Baker Act due to his dementia. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the Federal 5 Day reports for abuse, submitted by the AC for residents #1, #2, #6 and #7 all revealed the corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the facility Abuse and Neglect Prevention Plan and Policy revealed, "Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals." The policy included definitions of abuse and neglect. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish." "Neglect is defined as failure to provide goods and services needed to prevent physical harm, mental anguish, or mental illness. The term neglect also means the failure of a caregiver to make reasonable effort to protect a resident from abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychosocial injury or a substantial risk of death." "Neglect occurs on an individual basis when a resident does not receive necessary care in one or more areas." ".... Courtyards of Orlando prohibits mistreatment, neglect, an abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." "Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." The policy and procedure did not include a date. The Procedure indicated all alleged violations involving mistreatment, neglect, or abuse are to be reported immediately to the Administrator or designated representative. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse while the investigation is in progress. Under Prevention and Protection the policy indicated, "Encourage families, staff, and residents to report concerns, incident and grievances without fear of reprisal and provide feedback regarding these concerns." The policy also directed the facility identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. The facility will analyze and a. Identify features in the environment that could make abuse or neglect more likely to occur. b. Deploy sufficient staff on each shift to meet the needs of the residents, and assuring that staff has knowledge of residents' needs. c. Supervise staff to identify inappropriate behaviors. d. Identify and care plan staff interventions to prevent occurrences regarding residents with needs and behaviors which might lead to conflict or neglect, such as residents who have a history of aggressive behavior, wander into resident rooms, have self-injurious behavior, have communication problems, require heavy nursing, are totally dependent upon the staff. e. Staff are to monitor residents daily for changes which might trigger abusive behavior and the residents are to be reassessed routinely by the interdisciplinary team. The Identification and Investigation section of the policy indicated the facility was to identify events and report to agencies listed and supervisors or designees. The facility is to begin the investigation after notifying the administrator and appropriate agencies: Document statements or interviews of resident, suspect, any eyewitness and any circumstantial witnesses, Preserve as evidence any relevant material/documentation pertaining to the allegation, Examine the alleged victim promptly and document findings, Protect the alleged victim from further abuse identifying and removing the cause of danger, and the administrator will oversee all necessary corrective actions depending on the results of the investigation. The Director of Nursing (DON) is to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The policy identified the Abuse Coordinator by name and indicated all reporting will be made to the coordinator.

Based on interview and record review, the facility failed to thoroughly investigate and report allegations of neglect on one of two wings for 3 of 9 sampled residents on the A-wing (#4, 6 & 7). The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. The Abuse Coordinator also stated he was unaware of information regarding resident #4 for possible inappropriate sexual behavior that occurred in her room when resident #3 had his hand in the pants of another resident, #1, on 1/24/13. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated on the 5-day Federal report the and did not consider neglect, despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. As of the exit date of the survey on 2/16/13, the facility had not identified neglect to provide adequate interventions and supervision or implemented corrective measures to prevent further potential neglect. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F225. Findings: Cross Reference to F224. On 2/14/13 at 5:40 p.m. during an interview with the Abuse Coordinator (AC), he stated he is also the Risk Manager and the Staff Development Coordinator. He explained that he monitors the staff by conducting background screening on all new hires related to screening for abuse. Training is offered to new employees at orientation and on an annual basis. He was not sure when he conducted his last annual in-service for abuse. Staff-to-resident interactions are reported to him along with unknown injuries and bruises. He said he investigates all incidents and allegations of abuse, neglect, or exploitation. He said in morning meeting, the management staff discuss all incidents on the floor reported by nurses. He explained that he teaches staff about reporting abuse. He stated also he did not consider neglect or lack of supervision when he submitted the Federal reports to the agency for abuse for resident #1 and 2. Review of federal reports submitted since the last recertification survey in July revealed 2 other resident-to-resident issues, one in August and one in September. Both incidents indicated the allegation was abuse, not neglect regarding supervision, and involved residents with dementia in the activity room/dining room on the A-wing. Corrective action included: staff members will be re-educated on monitoring residents that indicate increased anxiety and agitation. It did not indicate any level of increased supervision or details for monitoring residents. During the interview with the AC at that time, he discussed resident #3. He said, "I had discussions on resident #3 and on behaviors that need to be reported. I provided education to CNAs to report to nurses when they had any observations." When asked to provide documentation of the discussions, he indicated he did not have any documentation of discussions or education relating to resident #3. The AC was asked why his report from 1/24/13 did not include information regarding resident #4. The interview with conducted earlier in the day with CNA-A was discussed, and he stated that he was not aware of any incident concerning resident #4 and was not told that her pants were also pulled down during the incident on 1/24/13. He stated, "I don't know anything about resident #4 on 1/24/13 other than she was taking a nap." The AC was asked why incidents of inappropriate sexual behavior that occurred in the activity room on 1/18/13 between resident #3 and resident #6 and on 1/26/13 between resident #3 and resident #7 were not reported. He said he was not aware of the incidents. The AC said that when resident #3 was in the activity room, they moved him to another table by himself. He denied having any knowledge of the 1/26/13 incident involving the resident groping another male resident and touching his penis under the table. He stated, "Nothing was reported to me concerning inappropriate touching in the activity room." He said that he was only aware of the resident "touching other residents on the arm and face." He stated that he had "no knowledge of the resident (#3) touching anyone's penis" and there was no incident report documenting the incident. He stated that he was also unaware of the incident on 1/18/12 when resident #3 had his hand under the table in the pants of resident #6, attempting to reach her vagina. He denied that it was reported to him. During the interview with the AC, he confirmed a resident spoke with a CNA when resident #3 was involved inappropriate sexual behavior with resident #2 on 2/12/13 and he confirmed a resident was yelling to alert staff when resident #3 was involved with sexually inappropriate behavior with resident #1 on 1/24/13. He verified it was residents, and not staff, who identified the inappropriate behavior. The AC also stated he did not consider neglect for lack of supervision when he submitted the reports to the agency for abuse for resident #1 and 2. When he submitted the required reports to the agency for resident #6 and #7 on 2/15/13, the reports indicated the type of incident was abuse, not neglect. In an interview with Licensed Practical Nurse (LPN) #D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. When LPN #D was asked how she deals with residents with behaviors toward another resident, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the resident's pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN#D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She said, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room [ROOM NUMBER] because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say, "what am I doing? I don't speak English." When asked if the resident had ever touched her, she said no, but he would make comments like, "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA #A, she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in room [ROOM NUMBER], so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step back and he said, 'what the hell' and pushed the table and showed his fist." She said resident #1 "was just lying there. I asked the nurse to come." She explained that he was sent out of the facility the same day. She said when he returned, he was on 1 to 1 supervision for about a day and ?. She said he could walk independently. "He was a smart mouth, very alert. I would take him to bathroom and he would say, 'I don't understand English,' but he did." She also said that she did not know if it was investigated, but the day she found resident #3 in room [ROOM NUMBER] with resident #1, the other resident in the room, resident #4, was lying on the bed and her pants were "dropped". This incident occurred on 1/24/13. On 1/18/13 at 12 p.m., LPN #D documented, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room. " On 1/26/13, no time, LPN #D documented as follows: "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." Review of the 5 Day report for resident #6 revealed the type of incident was listed as abuse and it occurred on 1/18/13. The immediate report was not submitted until 27 days later, on 2/14/13 at 8:43 p.m. The 5 Day report was submitted less than 24 hours later, on 2/15/13 at 6:33 p.m. The summary of the investigative findings revealed at approximately 12 p.m., resident #3 had his left hand in the resident's pants and was attempting to reach resident #6's vagina. The report indicated staff members were present and prevented him from doing it. The report does not include exactly what was prevented. The report indicated the allegation of abuse was not substantiated even though the AC's investigation findings indicated resident #3 had his hand in resident #6's pants. The corrective actions indicated resident #3 was transferred to another table by himself and was no longer in the facility. He was sent to the hospital by Baker Act. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the 5 Day report for abuse for resident #7 revealed the type of incident was listed as abuse and it occurred on 1/26/13. The immediate report was not submitted until 19 days later, on 2/14/13 at 9:05 p.m. The 5 Day report was submitted less than 24 hours later, on 2/15/13 at 6:39 p.m. The summary of the investigative findings revealed at approximately 10 a.m., the nurse observed resident #3's left hand on top of resident #7's pants in his penile area. The report indicated the allegation of abuse was not substantiated even though the AC's investigation findings indicated resident #3's hand was on the penile area of resident #7. The corrective actions indicated resident #3 was relocated to another area in the activity room and at the time of the report, he was no longer in the facility. He was sent to the hospital by Baker Act. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the 5-day report for resident #1 revealed the type of incident was listed as abuse and it occurred on 1/24/13. The immediate report was submitted on 1/24/13 at 5:40 p.m. The 5-day report was submitted on 1/29/13 at 3:31 p.m. The summary of the investigative findings revealed at approximately 2:40 p.m. resident #1 wandered into another resident's room. A staff member heard another resident, #5, yelling "get him out of here." Another staff member responded and saw resident #3's hand underneath resident #1's clothing. Both residents have a [DIAGNOSES REDACTED].#4 being in bed in the same room with her pants "dropped". The report indicated the allegation of abuse was not substantiated even though CNA #A witnessed resident #3's hand in resident #1's underwear and "he was really pushing his hand up there." The corrective actions indicated resident #3 was sent to the hospital for evaluation and management of his behaviors. His medications were evaluated and adjusted by the psychiatrist. He is involved in activities with staff supervision. He is escorted by staff when he goes to the bathroom or goes to his room. We will continue hourly check of resident's whereabouts and will re-direct as needed. The corrective actions did not indicate measures the facility took to prevent reoccurrence regarding both residents wandering or resident #3 wandering at times when he was not in activities. The report did not indicate how resident #3 would be monitored when he was in his room. It did not indicate the degree of supervision, nor the frequency, except to say hourly checks. It did not indicate how they would protect the other residents. In a telephone interview with resident #1's son on 2/16/13 at 11:20 a.m., he stated he was informed of an incident involving his mother and a male resident on 1/24/13. He stated he was informed the male resident had fondled his mother's breasts over her clothes. He stated the nurse told him her clothes were not removed. When asked if he was told the male resident had his hand in his mother's pants and was rubbing his hand inside her pants, he replied, "no". He said he also spoke with the Social Services Director (SSD) and he did not tell him the male resident had his hand in her pants. The SSD told him the male resident was sent out of the facility, but was returning and they were keep him sedated. He stated she doesn't always remember who they are when they visit. During an interview with the SSD on 2/16/13 at 12 p.m., the SSD stated when he spoke with resident #1's son about the events on 1/24/13, he did not know the details of the incident because the "abuse coordinator takes care of that." He stated he only knew that inappropriate sexual behavior occurred. When asked if he thought he should be aware of those details since he talks with the family members and is responsible for the residents psychosocial well-being, he said the abuse coordinator handles the specific details. Review of the 5 Day report for resident #2 revealed the type of incident was listed as abuse and it occurred on 2/12/13. The immediate report was submitted on 2/12/13 at 3:35 p.m. The 5-day report was submitted on 2/15/13 at 5:53 p.m. The description of incident indicated the incident occurred on 2/11/13 at approximately 12:40 p.m. In an interview with the AC on 2/14/13 at 5:40 p.m., he indicated the date (2/11/13) was an error and that the incident occurred on 2/12/13. Corrective actions were that the Orlando Police Department was notified and investigated the case. The resident was on 1 to 1 supervision until the physician came to Baker Act the resident again to the same hospital the resident was sent on 1/24/13 when the receiving facility informed the nursing home the resident was not appropriate for Baker Act due to his dementia. The corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the Federal 5 Day reports for abuse, submitted by the AC for residents #1, #2, #6 and #7 all revealed the corrective actions did not indicate any measures the facility took to prevent reoccurrence or how they would protect the other residents. Review of the facility Abuse and Neglect Prevention Plan and Policy revealed, "Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals." The policy included definitions of abuse and neglect. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm or pain or mental anguish." "Neglect is defined as failure to provide goods and services needed to prevent physical harm, mental anguish, or mental illness. The term neglect also means the failure of a caregiver to make reasonable effort to protect a resident from abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychosocial injury or a substantial risk of death." "Neglect occurs on an individual basis when a resident does not receive necessary care in one or more areas." ".... Courtyards of Orlando prohibits mistreatment, neglect, an abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." "Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." The policy and procedure did not include a date. The Procedure indicated all alleged violations involving mistreatment, neglect, or abuse are to be reported immediately to the Administrator or designated representative. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse while the investigation is in progress. Under Prevention and Protection the policy indicated, "Encourage families, staff, and residents to report concerns, incident and grievances without fear of reprisal and provide feedback regarding these concerns." The policy also directed the facility identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. The facility will analyze and a. Identify features in the environment that could make abuse or neglect more likely to occur. b. Deploy sufficient staff on each shift to meet the needs of the residents, and assuring that staff has knowledge of residents' needs. c. Supervise staff to identify inappropriate behaviors. d. Identify and care plan staff interventions to prevent occurrences regarding residents with needs and behaviors which might lead to conflict or neglect, such as residents who have a history of aggressive behavior, wander into resident rooms, have self-injurious behavior, have communication problems, require heavy nursing, are totally dependent upon the staff. e. Staff are to monitor residents daily for changes which might trigger abusive behavior and the residents are to be reassessed routinely by the interdisciplinary team. The Identification and Investigation section of the policy indicated the facility was to identify events and report to agencies listed and supervisors or designees. The facility is to begin the investigation after notifying the administrator and appropriate agencies: Document statements or interviews of resident, suspect, any eyewitness and any circumstantial witnesses, Preserve as evidence any relevant material/documentation pertaining to the allegation, Examine the alleged victim promptly and document findings, Protect the alleged victim from further abuse identifying and removing the cause of danger, and the administrator will oversee all necessary corrective actions depending on the results of the investigation. The Director of Nursing (DON) is to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The policy identified the Abuse Coordinator by name and indicated all reporting will be made to the coordinator.

Based on interview and record review, the facility failed to implement their policies for abuse and neglect on one of two wings for 5 of 9 sampled residents on the A-wing. (#1, 2, 3, 6 & 7) Four residents (#1, 2, 6 & 7) were touched in a sexually inappropriate manner from 1/18/13 to 2/12/13 by one resident, #3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. Staff members were aware of resident #3's behavior and did not report it to Administration. As of the exit date of the survey, 2/16/13, the facility had not implemented their policy and procedures for abuse and neglect for identification, investigation, prevention, protection, reporting, and training when documentation revealed verbal aggression on 12/31/12 and sexually inappropriate behavior occurred on 1/10/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: Review of the facility Abuse and Neglect Prevention Plan and Policy revealed, "Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals." The policy included definitions of neglect. "Neglect is defined as failure to provide goods and services needed to prevent physical harm, mental anguish, or mental illness. The term neglect also means the failure of a caregiver to make reasonable effort to protect a resident from abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychosocial injury or a substantial risk of death." "Neglect occurs on an individual basis when a resident does not receive necessary care in one or more areas." ".... Courtyards of Orlando prohibits mistreatment, neglect, an abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." "Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." The policy and procedure did not include a date. The Procedure indicated all alleged violations involving mistreatment, neglect, or abuse are to be reported immediately to the Administrator or designated representative. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse while the investigation is in progress. Screening and Training included screening employees for history of abuse, neglect or mistreatment. Staff Training indicated the facility would provide training during orientation and ongoing during each year about: Definitions of verbal abuse, physical and mental abuse, sexual abuse, corporal punishment, involuntary seclusion, misappropriation of resident belongings; The phone numbers of Adult Protective Services; How all facility staff has the legal authority to report any activity which they know or have reasonable cause to suspect is abuse, neglect, or exploitation; Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge of allegations without fear of reprisal since it is presumed he or she acted in good faith; How to recognize signs of burn-out, frustration and stress that may lead to abuse; What constitutes abuse, neglect, and exploitation; Any staff that feel threatened as a target of an investigation, has the right to be represented by counsel. Under Prevention and Protection the policy indicated, "Encourage families, staff, and residents to report concerns, incident and grievances without fear of reprisal and provide feedback regarding these concerns." The policy also directed the facility identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. The facility will analyze and a. Identify features in the environment that could make abuse or neglect more likely to occur. b. Deploy sufficient staff on each shift to meet the needs of the residents, and assuring that staff has knowledge of residents' needs. c. Supervise staff to identify inappropriate behaviors. d. Identify and care plan staff interventions to prevent occurrences regarding residents with needs and behaviors which might lead to conflict or neglect, such as residents who have a history of aggressive behavior, wander into resident rooms, have self-injurious behavior, have communication problems, require heavy nursing, are totally dependent upon the staff. e. Staff are to monitor residents daily for changes which might trigger abusive behavior and the residents are to be reassessed routinely by the interdisciplinary team. The Identification and Investigation section of the policy indicated the facility was to identify events and report to agencies listed and supervisors or designees. The facility is to begin the investigation after notifying the administrator and appropriate agencies: Document statements or interviews of resident, suspect, any eyewitness and any circumstantial witnesses, Preserve as evidence any relevant material/documentation pertaining to the allegation, Examine the alleged victim promptly and document findings, Protect the alleged victim from further abuse identifying and removing the cause of danger, and the administrator will oversee all necessary corrective actions depending on the results of the investigation. The Director of Nursing (DON) is to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The policy identified the Abuse Coordinator by name and indicated all reporting will be made to the coordinator. 1. Cross Reference to F224. "....Courtyards of Orlando prohibits mistreatment, neglect, and abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." The facility failed to implement the policy and procedure for prevention and protection and did not keep residents #1, 2, 3, 6, & 7 from being subjected to neglect. 2. Cross Reference to F225. "All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are to be reported immediately to the Administrator or designated representative." The facility failed to implement the policy and procedure for identification and reporting for alleged violations for residents #4, 6 & 7. 3. Cross Reference to F224, F225, F520. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse or neglect while the investigation is in progress. The facility failed to implement the policy and procedure for investigation and did not thoroughly investigate the alleged violations for #1, 2, 3, 4, 6, & 7 and did not have a system in place to prevent further abuse or neglect during the investigation. The facility did not review a trending analysis to prevent additional occurrences. 4. Cross reference to F224. The Staff Training section of the policy and procedure indicated the facility would provide training during orientation and ongoing during each year, however the Administrator, DON ,and AC could provide no evidence of training when resident #3 began exhibiting sexual behaviors, nor could they provide evidence of training after the incidents of sexual abuse occurred. The facility failed to implement the policy and procedure for training.

Based on interview and record review, the facility failed to implement their policies for abuse and neglect on one of two wings for 5 of 9 sampled residents on the A-wing. (#1, 2, 3, 6 & 7) Four residents (#1, 2, 6 & 7) were touched in a sexually inappropriate manner from 1/18/13 to 2/12/13 by one resident, #3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. Staff members were aware of resident #3's behavior and did not report it to Administration. As of the exit date of the survey, 2/16/13, the facility had not implemented their policy and procedures for abuse and neglect for identification, investigation, prevention, protection, reporting, and training when documentation revealed verbal aggression on 12/31/12 and sexually inappropriate behavior occurred on 1/10/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F226. Findings: Review of the facility Abuse and Neglect Prevention Plan and Policy revealed, "Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals." The policy included definitions of neglect. "Neglect is defined as failure to provide goods and services needed to prevent physical harm, mental anguish, or mental illness. The term neglect also means the failure of a caregiver to make reasonable effort to protect a resident from abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychosocial injury or a substantial risk of death." "Neglect occurs on an individual basis when a resident does not receive necessary care in one or more areas." ".... Courtyards of Orlando prohibits mistreatment, neglect, an abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." "Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." The policy and procedure did not include a date. The Procedure indicated all alleged violations involving mistreatment, neglect, or abuse are to be reported immediately to the Administrator or designated representative. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse while the investigation is in progress. Screening and Training included screening employees for history of abuse, neglect or mistreatment. Staff Training indicated the facility would provide training during orientation and ongoing during each year about: Definitions of verbal abuse, physical and mental abuse, sexual abuse, corporal punishment, involuntary seclusion, misappropriation of resident belongings; The phone numbers of Adult Protective Services; How all facility staff has the legal authority to report any activity which they know or have reasonable cause to suspect is abuse, neglect, or exploitation; Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge of allegations without fear of reprisal since it is presumed he or she acted in good faith; How to recognize signs of burn-out, frustration and stress that may lead to abuse; What constitutes abuse, neglect, and exploitation; Any staff that feel threatened as a target of an investigation, has the right to be represented by counsel. Under Prevention and Protection the policy indicated, "Encourage families, staff, and residents to report concerns, incident and grievances without fear of reprisal and provide feedback regarding these concerns." The policy also directed the facility identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. The facility will analyze and a. Identify features in the environment that could make abuse or neglect more likely to occur. b. Deploy sufficient staff on each shift to meet the needs of the residents, and assuring that staff has knowledge of residents' needs. c. Supervise staff to identify inappropriate behaviors. d. Identify and care plan staff interventions to prevent occurrences regarding residents with needs and behaviors which might lead to conflict or neglect, such as residents who have a history of aggressive behavior, wander into resident rooms, have self-injurious behavior, have communication problems, require heavy nursing, are totally dependent upon the staff. e. Staff are to monitor residents daily for changes which might trigger abusive behavior and the residents are to be reassessed routinely by the interdisciplinary team. The Identification and Investigation section of the policy indicated the facility was to identify events and report to agencies listed and supervisors or designees. The facility is to begin the investigation after notifying the administrator and appropriate agencies: Document statements or interviews of resident, suspect, any eyewitness and any circumstantial witnesses, Preserve as evidence any relevant material/documentation pertaining to the allegation, Examine the alleged victim promptly and document findings, Protect the alleged victim from further abuse identifying and removing the cause of danger, and the administrator will oversee all necessary corrective actions depending on the results of the investigation. The Director of Nursing (DON) is to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The policy identified the Abuse Coordinator by name and indicated all reporting will be made to the coordinator. 1. Cross Reference to F224. "....Courtyards of Orlando prohibits mistreatment, neglect, and abuse of the residents. All personnel are instructed to follow through on all treatments and care issues in order to assure the resident is not neglected." The facility failed to implement the policy and procedure for prevention and protection and did not keep residents #1, 2, 3, 6, & 7 from being subjected to neglect. 2. Cross Reference to F225. "All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are to be reported immediately to the Administrator or designated representative." The facility failed to implement the policy and procedure for identification and reporting for alleged violations for residents #4, 6 & 7. 3. Cross Reference to F224, F225, F520. The procedure also indicated the facility will thoroughly investigate and document each alleged violation and will have a system in place which will assist in the prevention of further potential abuse or neglect while the investigation is in progress. The facility failed to implement the policy and procedure for investigation and did not thoroughly investigate the alleged violations for #1, 2, 3, 4, 6, & 7 and did not have a system in place to prevent further abuse or neglect during the investigation. The facility did not review a trending analysis to prevent additional occurrences. 4. Cross reference to F224. The Staff Training section of the policy and procedure indicated the facility would provide training during orientation and ongoing during each year, however the Administrator, DON ,and AC could provide no evidence of training when resident #3 began exhibiting sexual behaviors, nor could they provide evidence of training after the incidents of sexual abuse occurred. The facility failed to implement the policy and procedure for training.

Based on interview and record review, and observation, the facility failed to provide adequate supervision to maintain a secure environment on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents (#1, 2, 6 & 7) had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at 4 separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and was not adequately supervised to prevent him from touching 4 residents in a sexually inappropriate manner, even after the resident exhibited previous inappropriate sexual behaviors. The facility failed to implement the appropriate level of supervision to prevent resident-to-resident incidents for residents that wander for residents #1, 2 & 3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility failed to identify and implement adequate supervision and procedures to protect residents or intervene prior to inappropriate sexual behavior occurring when they became aware of resident #3's aggressive and sexually inappropriate behaviors or even after they continued, and failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms as of the exit date of the survey on 2/16/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: Cross reference to F224, F272, F279, F280, F203. Review of resident #3's record indicated the resident was admitted to the facility from the hospital on [DATE]. The history and physical from the hospital admission indicated the resident was brought to the emergency roiagnom on [DATE] by ambulance for altered mental status. He was also in the hospital on [DATE] for change in mental status and was found wandering in a shopping mall. He had uncontrolled diabetes on both admissions. His diagnoses as listed on the nursing home admission record face sheet were: diabetes, altered mental status, late effect cerebral vascular disease, hypertension, muscle weakness, and difficulty walking. The cumulative [DIAGNOSES REDACTED]. The resident had no [DIAGNOSES REDACTED]. Review of the Pre-Admission Screen and Resident Review indicated it was not completed prior to admission. It was completed on 2/12/13, the day of discharge. The screen indicated resident #3 did not have a [DIAGNOSES REDACTED]. It also indicated the resident had a [DIAGNOSES REDACTED]. Nurses' notes dated 12/30/12 indicated resident is self-ambulatory and activities of daily living (ADLs) were provided by staff. Review of the nurses' notes for resident #3 revealed he was alert and confused. He became agitated and verbally abusive to staff after the nurse spoke to the resident about continuing to urinate in the hallway, inside the room on the floor, and on the curtain on 12/31/12 at 5:00 a.m. At 1:00 p.m. the notes indicated the resident urinated in the hallway and is very agitated. On 1/03/13 nurses' notes document the resident was hostile to staff and continued to urinate on the floor, by the roommate, the bed, the curtain, and the hallway. Review of Social Service Director (SSD) notes dated 1/03/13 indicated the resident was "observed trying to touch females. Requires redirect. Will monitor." Upon interview with the Social Service Director on 2/15/13 at 1:40 p.m. and on 2/16/13 at 10:00 a.m., discussed his documentation of resident touching females. He stated his documentation meant resident #3 was touching females on the arm, not inappropriately. When asked why he would document that type of behavior if it was not inappropriate, he stated some individuals may not like to be touched on their arm. When asked if he documents every resident who touches a resident on their arm and he replied, "No." When asked for explanation of documentation for his note from 1/03/13 of "will monitor" he was unable to provide it. The minimum data set (MDS) assessment for resident #3 had an observation end date of 1/03/13. The section for cognitive patterns indicated the resident's Brief Interview for Mental Status (BIMS) score was 04. The BIMS total score is highly correlated with the Mini-Mental State Exam (Folstein, Folstein, & McHugh 1975) scores. A score of 0-7=severe impairment. The assessment indicated the resident had no mood indicators. Behavioral symptoms indicated the resident had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and the behavior occurred 1 to 3 days during the observation period of 12/27/13 to 1/03/13. It also indicated the resident rejected care 1 to 3 days, and did not wander. The resident required limited assistance to move between locations in his room and adjacent corridor on the same floor. The resident was not receiving any psychoactive medications as of 1/03/13. The care assessment summary indicated the care areas triggered in the following areas and the triggered areas were addressed in the care plan: cognitive loss/dementia, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, and pressure ulcers. On 1/04/13 at 12:30 p.m. the documentation indicated the resident, "continues to urinate in the trash can, hallway, and room floor. Redirect, gets aggravated when being redirected." On 1/08/13 at 11:00 a.m., the documentation in the nurses' notes indicated the resident continues to urinate in the hallway and floor of his room, gets very aggravated when redirected, curses as staff, and says he is being accused of something he did not do. The interdisciplinary care plan team meeting was held on 1/08/13. The resident or family did not attend. The care plan for psychosocial and behavioral impairment was initiated on 1/04/13. The focus section of the care plan lists: He has been verbally abusive with staff and refused assistance with care. He does not like to be redirected at times, and will make inappropriate remarks to some of the female staff. A handwritten remark is written in the focus section of 1/25/13 reviewed. The goals for the care plan are: resident will accept assistance from staff without being verbally abusive thru next review, target date 4/04/13; resident will have fewer episodes of inappropriate behavior toward female staff thru next review, target date 4/04/13. The interventions listed: introduce staff with each interaction, monitor mood and behavior problems, provide calm environment, psych eval as needed. The plan of care did not indicate the frequency or how the mood and behavior problems would be monitored, only that they would be completed by "all." The care plan for impaired cognition related to short term memory problems, long term memory problems, decisions poorly, mental function varies over the course of the day was initiated on 1/04/13. A hand written remark was in the focus section, "readm" 1/25/13. The goal was resident will be able to make needs known thru next review date, target date 4/04/13. Interventions included: Allow resident to make choices. Allow time for responses, anticipate resident's need for toileting, comfort, clothing, room temperature, entertainment, personal care and bathing, and grooming. Face resident when talking. Give simple, clear responses to resident's questions when asking questions. Introduce self with each interaction. Listen attentively and watch for non-verbal responses or clues. Provide a calm environment. Take time to listen and respond to resident. Talk to resident as if he/she is expected to understand. Explain details slowly. Give time to comprehend. The other care plans observed in the record were: Nutrition, Activities, Self Care Deficit for activities of daily living, Risk for skin breakdown, Alteration in comfort, At risk for Cardiac Alteration, At risk for complications from diabetes. A care plan for wandering was not developed. a care plan to address supervision after resident #3 was trying to touch females was not developed. Review of the physician's progress notes revealed an admission note dated 1/09/13. The note did not include the resident's behaviors as documented in the nurse's notes and social service notes as of that date. On 1/10/13 at 10:15 p.m., the documentation in the nurses' notes was, "Resident keeps asking for sexual favors from female staffs. Also, keeps urinating in the hallway." 1/12/13 at 10:00 p.m. nurses' notes indicated, "Resident won't stay in bed. Kept asking same question over and over. Confused his room with other resident room." On 1/13/13 at 5:15 a.m., the notes indicated the resident was very aggressive with staff. Cursing and abusive language was verbalized by the resident. On 1/16/13 at 11:00 p.m. the notes indicated the resident kept going into other residents' rooms and refused to allow vital signs to be taken. The nurses' notes did not include documentation of any level of increased supervision. On 1/18/13 at 12:00 p.m., LPN-D documented, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m. he reported the female resident was resident #6. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #6 revealed the last annual MDS assessment was completed 8/02/12 and the resident's cognition was severely impaired. The resident had a [DIAGNOSES REDACTED]. She was sitting in her wheelchair in the activity room at the time resident #3 put his hand in her pants on 1/18/13. Observation of resident #6 on 2/15/13 at 11:15 a.m. revealed she was sitting in a wheelchair at a table in the dining/activity room. She was not speaking to anyone was not involved in any activity at that moment. Nurse -L documented on 1/18/13 at 9:20 p.m., "....Wanders/ambulates in hallway with wide stance. Wandered into a female's room this shift and made a pass at a female resident sitting in the hallway." The nurses' notes did not include documentation of any level of increased supervision A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." The plan/recommendation was for Exelon Patch 4.6 milligrams (mg) every 24 hours and Depakote 250 mg twice a day, and follow up in one month. Review of the physician's orders [REDACTED]. Review of resident #3's care plans revealed no interventions to address the risk of him bring hurt due to him touching female residents inappropriately and no care plans were developed regarding medications ordered by the psychiatrist, possible nonpharmacologic interventions, or additional supervision. Review of the physician orders [REDACTED]. The next entry for SSD notes on 1/23/13 documented, "nursing reports resident as being aggressively inappropriate to female residents. Was seen by psych and given meds on 1/18/13. Will monitor. Also, his room was changed from 124 A to 103 so he could be in a cluster of male rooms instead of females. Room change occurred on 1/17/13." Review of the resident rooms for the section of the hallway for room 124 revealed 10 resident rooms and 5 rooms were male rooms. Review of the resident rooms for the section of the hallway for room 103, after the room change, revealed 10 resident rooms and only 3 were male rooms. On 1/24/13, no time documented in the nurses' notes, LPN-I documented the resident was alert with confusion, "up ad lib." At 2:40 p.m. the documentation from the same nurse was as follows: "CNA observed resident in room 105B with his hand inside female resident pants and rubbing his hand inside of pant as she was lying on the edge of bed 105B. As the CNA was trying to redirect him, he drew back his hand at the CNA." The notes indicated the resident was sent via Baker Act to the hospital at 5:30 p.m. Previous review of an abuse report submitted by the abuse coordinator indicated the female resident was resident #1. Neither resident #3, nor resident #1 resided in room 105. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #1 revealed a [DIAGNOSES REDACTED]. She exhibited physical and verbal behavioral symptoms toward others daily and wandered daily. She could walk in corridor with supervision. Resident #1 had a care plan reviewed on 11/20/12 for: Frequently wanders in and out of activities due to: impaired cognition, decreased safety awareness, dementia. The goal was for resident #1 to remain in activity for at least 10 minutes. An intervention was to redirect resident as needed. The care plan did not address the risk to the resident or any interventions to prevent potential abuse from other residents. The resident had a care plan for wandering in and out of other resident's rooms and the goal was that the resident will wander safely within the secured unit thru the next review date. The care plan for wandering was not reviewed after resident #3 was observed with his hand in her pants on 1/24/13 after both her and resident #3 wandered into another resident's room. Resident #1 was observed on 2/14/13 at 10:00 a.m. She was standing at a table in the activity room, playing with a doll and a stuffed animal. She was attempting to offer her teddy bear to the resident sitting next to her. At 12:30 p.m. that day she was observed eating lunch in the activity/dining room and she was feeding herself. At 12:50 p.m. CNA-B was observed feeding her the rest of her lunch. The CNA stated resident #1 starts feeding herself, but then she will just play with her food and forgets to finish eating. The next Physician's note was from 1/24/13. It revealed the physician documented the reported inappropriate sexual behavior. He noted "unable to control pt's (patients) behavior." " ....Baker Act and transfer to psych hospital." The SSD documentation entry on 1/24/13 read, "Baker Act was utilized as resident became increasingly inappropriate with females and he became difficult to redirect." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility from 1/24/13 indicated the resident had a mental illness [DIAGNOSES REDACTED]. It was completed by the licensed social worker. The supporting evidence section documented, " Despite psych meds-(resident #3) is a danger to other female residents as he is sexually inappropriate with his touching and increasingly aggressive. " The Other Information section included, " Nursing has witnessed (resident #3) become very aggressive towards female residents whom are unable to defend themselves-he presents a danger." An Approval for Release of Person on Involuntary Status From a Receiving Facility was signed at dated by the examiner at the hospital receiving facility on 1/25/13 at 9:43 a.m. It indicated the patient does not meet criteria for involuntary outpatient placement pursuant to 394.4655 based upon one or more of the following reasons: Person is likely to survive safely in the community without supervision and There are available less restrictive treatment alternatives offering an opportunity for improvement of his/her condition. The handwritten documentation was as follows: (resident #3) is exhibiting advancement of his dementia. He is not currently suicidal or homicidal and is not aggressive or psychotic. There are less restrictive environment for caring for the patient. The Florida Mental Health Act of 1971, commonly known as the "Baker Act" per Florida Statute 394.451, allows for involuntary examination of an individual with evidence of: 1) mental illness, and 2) evidence of harm to self, harm to others, or is self neglectful. Per the Baker Act Handbook and User Reference Guide-2011, The primary role of a Baker Act receiving facility is to perform psychiatric evaluations and provide short term psychiatric treatment. If a person has behavioral conditions that are not psychiatric in nature they should not be sent to a psychiatric facility. The Baker Act requires a patient have a documented mental illness and to be able to participate in a psychiatric treatment plan. Resident #3 had no [DIAGNOSES REDACTED]. On 1/25/13, upon return to the facility after the incident of sexual inappropriate behavior with resident #1, the resident had physician telephone orders for Depakote 500 mg twice a day for psychosis and Paxil 20 mg every morning for depression and decrease libido. The record did not contain any other information regarding how the [DIAGNOSES REDACTED]. The record did not contain documentation of any change in the plan of care or increased supervision upon resident #3's return to the facility. Behavior monitoring records were not initiated until 1/29/13 for the Depakote, despite the fact that the resident was started on the medication 11 days earlier. The behavior listed on the Behavior/intervention Monthly Flow Record for Depakote was inappropriate sexual behavior. The intervention codes noted (see care plan) however a care plan for inappropriate sexual behavior was not developed. The flow record did not list any individualized interventions for inappropriate sexual behavior or wandering. When the resident returned to the facility on [DATE] at 4:45 p.m., the nurses notes were written as follows: "Resident was brought to facility via stretcher + 2 attendants. Resident alert + responsive. Mucous membrane moist, pink, + intact. Denies having any pain. Lungs clear. Active ROM (range of motion) in upper extremities. Skin warm, dry, + intact. + bowel sounds. Abdomen soft + non tender. Old scar above umbilicus. Active ROM lower extremities. Feet very dry. Toe nails overgrown. MD notified of return. VS (vital signs) B/P (blood pressure) 137/78. P (pulse) =74, R (respirations) = 18, T (temperature) = 98.4 resident made comfortable. Will monitor." The nurses' notes did not indicate what would be monitored or how staff would supervise resident #3. Another MDS assessment was completed for resident #3 upon return to the facility on [DATE] with the observation end date of 2/09/13. The assessment changed from the initial assessment and for Hearing, Speech, and Vision, it indicated the resident usually understands-misses some part/intent of message, but comprehends most conversation. Cognitive score remained the same. The resident's mood had changed to feeling down, depressed or hopeless 2-6 days, and trouble concentrating on things 2-6 days. Behavioral Symptoms indicated the resident now had physical and verbal behavioral symptoms directed toward others that occurred 1-3 days, had delusions, rejected care 1 to 3 days, and did not wander. Functional status remained the same foe required limited assistance to move between locations in his room and adjacent corridor on the same floor, but walk in corridor improved from limited assistance to supervision. An antidepressant was coded as given 7 of the last 7 days. On 1/26/13, no time, LPN D documented as follows: "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m., he reported the male resident was resident #7. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #7 revealed the resident has vascular dementia. The last annual MDS assessment was completed on 7/11/12 and it indicated the resident's vision was highly impaired and the resident's cognition was severely impaired. The resident is dependent upon staff for all activities of daily living. Resident #7 was sitting in a wheelchair in the activity room at the time resident #3 put his hand on his penis. Observation of resident #7 on 2/15/13 at 11:45 a.m. revealed he was sitting in his room in a wheelchair. He opened his eyes when spoken to, but he did not respond to questions. He was hard of hearing. The nurse's note written by LPN-I on 1/29/13 at 3:35 p.m. indicated resident #3 was up "ad lib." The SSD notes on 1/28/13 include documentation regarding the resident#3's return to the nursing home indicating the Baker Act was not warranted as such behaviors were related to dementia. His documentation indicated resident was a danger to other females on the dementia unit and noted concern regarding the resident's sexual acting out. The notes indicate the SSD was attempting to find alternative placement for the resident, but no notation of any intervention planned for supervision of resident #3 or for protection of the other residents. The SSD notes from 2/04/13 indicate he met with the psychiatrist who changed medications started previously related to resident's behaviors. Review of the care plans revealed no indication of psychiatrist visits, initial orders, or changes to orders. The notes did not contain information regarding type of behaviors, assessment for possible causes of behaviors, or any nonpharmalogical interventions attempted prior to the use of medications. The Psychiatric progress note dated 2/04/13 documented, "Pt. states he is doing better." The psychiatrist also noted the resident was still sexually preoccupied. Input from staff/family was less sexual, less angry. The psychiatrist increased the Exelon patch to 9.5 mg daily. The nurses' notes from 1/26/13 to 2/11/13 indicated the resident did not exhibit inappropriate sexual behavior, however the resident was observed in the hallway pulling out his penis and urinating in the hallway on 2/09/13 at 2:40 p.m. On 2/08/13 at 8:40 p.m. documentation indicated the resident urinated in the hallway again. On 2/10/13 the resident was out of bed, ambulating in dining room/activities, but the notes did not include documentation of how the resident was supervised or monitored. On 2/11/13 at 12:00 p.m. documentation indicated the resident was ambulating ad lib and was very combative at times. The nurses' notes did not include documentation of any level of increased supervision On 2/12/13 at 12:20 p.m. the nurses notes documented by the UM were as follows, "....a CNA informed me resident was standing in hallway close to his room putting his finger in resident's vagina. On visiting the area I saw female resident standing in hallway with her diaper in her hand and the male resident standing close beside her with his fingers in the vagina. I asked him what he is doing and told him to leave the lady alone, he just looked at me and did not move, so I attempted to take him to his room and he attempted to hit me." "....Resident was left in his room by family members who left without notifying staff they were leaving." Although the documentation indicated staff members were not aware the resident was alone, the UM indicated in an interview on 2/14/13 at 2:50 p.m. and in her documentation in the nurses ' notes on 2/12/13 at 12:20 p.m., the daughter had approached her at the nursing station, so the daughter was not in resident #3's room at that time. Record review for resident #2 revealed a [DIAGNOSES REDACTED]. Her assessment documented she exhibited no wandering although she had a plan of care for frequent wandering in and out of activities due to dementia that was initiated on 8/20/13 and was reviewed to continue with the plan of care on 11/22/12. The care plan for wandering was not reviewed after the resident was subjected to sexually inappropriate behavior by resident #3 on 2/12/13. She walks in the corridor with limited assistance, however observation of the resident on 2/14/13 at 12:45 p.m., revealed she walked without assistance, using a walker. She had no physical or verbal behavioral symptoms directed toward others. On 2/14/13 at 12:45 p.m. an interview was attempted with resident #3. She was unable to complete one thought or reply appropriately to simple questions. She was later observed at 12:45 p.m. ambulating without staff assistance in the hallway with a walker. The SSD notes from 2/12/13 indicated the resident touched a demented female resident inappropriately and the resident required hospitalization . The resident was not arrested "probably based on the fact that he is demented." The SSD notes continued, "It is unknown whether the visitation by the resident's family caused the resident to react in a sexually inappropriate way towards another female resident because resident's behavior had improved since his meds were changed" by the psychiatrist. However, the resident's family visited the resident regularly, and the daughter visited at twice a week. The SSD did not document any relationship between the family visits and the resident's sexual behaviors previously, even though the family had been visiting regularly since admission on 12/27/12 and the start of resident behaviors were documented as early as 12/31/12 by nursing staff and 1/03/13 by the SSD. The Physician's note was on 2/12/13 which read, "....Pt had inappropriate sexual encounter with another female patient who required medical attention for vaginal bleeding." "....I made decision that this patient is inappropriate to be in nursing facility at this time due to danger to other patient's safety. I am going to Baker Act this patient." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility for 2/12/13 indicated it was completed by resident #3's physician. The criteria for reason to believe the person has a mental illness documented, "dementia with psychosis." The supporting evidence included, "Resident has been observed being constantly sexually inappropriate with elderly females and exercises poor judgment and has caused physical harm to a female resident who was hospitalized ." The section for Other Information was blank. Review of the CNA Care Tracker notes revealed no documentation of level of supervision for resident #3. The "Resident Behavior by Day Chart Report" did not document any physically abusive or verbally abusive behaviors from the day of admission on 12/27/12 to discharge on 2/12/13 with the exception of 1/22/13, verbally abusive behaviors. The census and condition report completed by the DON indicated the facility had 68 residents out of 109 that had dementia and 60 residents with behavioral symptoms. During an interview with the unit manager (UM) registered nurse, on 2/14/13 at 9:30 a.m., she explained the residents on the A-wing all had mild to severe dementia and were mostly long-term residents. She indicated there were 56 residents on the unit because one resident was sent to the hospital. She indicated resident #3 was sent to the hospital via Baker Act on 2/12/13. In an interview with Licensed Practical Nurse (LPN)-D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. She said she does not take anything they (residents) say or do personally because she understands that it's an illness and they cannot help it. She said, "You have to be patient and if they don't want to cooperate, come back and try again later." She said most residents stay in the activity/dining room. When LPN-D was asked how she deals with residents with behaviors toward other residents, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the her pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN-D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She explained, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room 103 because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say "what am I doing? I don't speak English. "When asked if the resident had ever touched her, she said no, but he would make comments like "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA-A she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in Room 105, so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step back and he said, 'what the hell' and pushed the table and showed his fist." Resident #1 "was just lying there. I asked the nurse to come." She expl

Based on interview and record review, and observation, the facility failed to provide adequate supervision to maintain a secure environment on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents (#1, 2, 6 & 7) had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at 4 separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and was not adequately supervised to prevent him from touching 4 residents in a sexually inappropriate manner, even after the resident exhibited previous inappropriate sexual behaviors. The facility failed to implement the appropriate level of supervision to prevent resident-to-resident incidents for residents that wander for residents #1, 2 & 3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility failed to identify and implement adequate supervision and procedures to protect residents or intervene prior to inappropriate sexual behavior occurring when they became aware of resident #3's aggressive and sexually inappropriate behaviors or even after they continued, and failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms as of the exit date of the survey on 2/16/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F323. Findings: Cross reference to F224, F272, F279, F280, F203. Review of resident #3's record indicated the resident was admitted to the facility from the hospital on [DATE]. The history and physical from the hospital admission indicated the resident was brought to the emergency roiagnom on [DATE] by ambulance for altered mental status. He was also in the hospital on [DATE] for change in mental status and was found wandering in a shopping mall. He had uncontrolled diabetes on both admissions. His diagnoses as listed on the nursing home admission record face sheet were: diabetes, altered mental status, late effect cerebral vascular disease, hypertension, muscle weakness, and difficulty walking. The cumulative [DIAGNOSES REDACTED]. The resident had no [DIAGNOSES REDACTED]. Review of the Pre-Admission Screen and Resident Review indicated it was not completed prior to admission. It was completed on 2/12/13, the day of discharge. The screen indicated resident #3 did not have a [DIAGNOSES REDACTED]. It also indicated the resident had a [DIAGNOSES REDACTED]. Nurses' notes dated 12/30/12 indicated resident is self-ambulatory and activities of daily living (ADLs) were provided by staff. Review of the nurses' notes for resident #3 revealed he was alert and confused. He became agitated and verbally abusive to staff after the nurse spoke to the resident about continuing to urinate in the hallway, inside the room on the floor, and on the curtain on 12/31/12 at 5:00 a.m. At 1:00 p.m. the notes indicated the resident urinated in the hallway and is very agitated. On 1/03/13 nurses' notes document the resident was hostile to staff and continued to urinate on the floor, by the roommate, the bed, the curtain, and the hallway. Review of Social Service Director (SSD) notes dated 1/03/13 indicated the resident was "observed trying to touch females. Requires redirect. Will monitor." Upon interview with the Social Service Director on 2/15/13 at 1:40 p.m. and on 2/16/13 at 10:00 a.m., discussed his documentation of resident touching females. He stated his documentation meant resident #3 was touching females on the arm, not inappropriately. When asked why he would document that type of behavior if it was not inappropriate, he stated some individuals may not like to be touched on their arm. When asked if he documents every resident who touches a resident on their arm and he replied, "No." When asked for explanation of documentation for his note from 1/03/13 of "will monitor" he was unable to provide it. The minimum data set (MDS) assessment for resident #3 had an observation end date of 1/03/13. The section for cognitive patterns indicated the resident's Brief Interview for Mental Status (BIMS) score was 04. The BIMS total score is highly correlated with the Mini-Mental State Exam (Folstein, Folstein, & McHugh 1975) scores. A score of 0-7=severe impairment. The assessment indicated the resident had no mood indicators. Behavioral symptoms indicated the resident had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and the behavior occurred 1 to 3 days during the observation period of 12/27/13 to 1/03/13. It also indicated the resident rejected care 1 to 3 days, and did not wander. The resident required limited assistance to move between locations in his room and adjacent corridor on the same floor. The resident was not receiving any psychoactive medications as of 1/03/13. The care assessment summary indicated the care areas triggered in the following areas and the triggered areas were addressed in the care plan: cognitive loss/dementia, urinary incontinence, psychosocial well-being, behavioral symptoms, falls, nutritional status, and pressure ulcers. On 1/04/13 at 12:30 p.m. the documentation indicated the resident, "continues to urinate in the trash can, hallway, and room floor. Redirect, gets aggravated when being redirected." On 1/08/13 at 11:00 a.m., the documentation in the nurses' notes indicated the resident continues to urinate in the hallway and floor of his room, gets very aggravated when redirected, curses as staff, and says he is being accused of something he did not do. The interdisciplinary care plan team meeting was held on 1/08/13. The resident or family did not attend. The care plan for psychosocial and behavioral impairment was initiated on 1/04/13. The focus section of the care plan lists: He has been verbally abusive with staff and refused assistance with care. He does not like to be redirected at times, and will make inappropriate remarks to some of the female staff. A handwritten remark is written in the focus section of 1/25/13 reviewed. The goals for the care plan are: resident will accept assistance from staff without being verbally abusive thru next review, target date 4/04/13; resident will have fewer episodes of inappropriate behavior toward female staff thru next review, target date 4/04/13. The interventions listed: introduce staff with each interaction, monitor mood and behavior problems, provide calm environment, psych eval as needed. The plan of care did not indicate the frequency or how the mood and behavior problems would be monitored, only that they would be completed by "all." The care plan for impaired cognition related to short term memory problems, long term memory problems, decisions poorly, mental function varies over the course of the day was initiated on 1/04/13. A hand written remark was in the focus section, "readm" 1/25/13. The goal was resident will be able to make needs known thru next review date, target date 4/04/13. Interventions included: Allow resident to make choices. Allow time for responses, anticipate resident's need for toileting, comfort, clothing, room temperature, entertainment, personal care and bathing, and grooming. Face resident when talking. Give simple, clear responses to resident's questions when asking questions. Introduce self with each interaction. Listen attentively and watch for non-verbal responses or clues. Provide a calm environment. Take time to listen and respond to resident. Talk to resident as if he/she is expected to understand. Explain details slowly. Give time to comprehend. The other care plans observed in the record were: Nutrition, Activities, Self Care Deficit for activities of daily living, Risk for skin breakdown, Alteration in comfort, At risk for Cardiac Alteration, At risk for complications from diabetes. A care plan for wandering was not developed. a care plan to address supervision after resident #3 was trying to touch females was not developed. Review of the physician's progress notes revealed an admission note dated 1/09/13. The note did not include the resident's behaviors as documented in the nurse's notes and social service notes as of that date. On 1/10/13 at 10:15 p.m., the documentation in the nurses' notes was, "Resident keeps asking for sexual favors from female staffs. Also, keeps urinating in the hallway." 1/12/13 at 10:00 p.m. nurses' notes indicated, "Resident won't stay in bed. Kept asking same question over and over. Confused his room with other resident room." On 1/13/13 at 5:15 a.m., the notes indicated the resident was very aggressive with staff. Cursing and abusive language was verbalized by the resident. On 1/16/13 at 11:00 p.m. the notes indicated the resident kept going into other residents' rooms and refused to allow vital signs to be taken. The nurses' notes did not include documentation of any level of increased supervision. On 1/18/13 at 12:00 p.m., LPN-D documented, "Resident observed with his hand under the table in the pants of another female resident attempting to reach her vagina. Resident was then moved from that table to another table with males. DON and unit manager and risk management was notified regarding the resident inappropriate behavior. ARNP (Advanced Registered Nurse Practitioner) was notified ....Resident continues to wander the halls and wander into other female resident room." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m. he reported the female resident was resident #6. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #6 revealed the last annual MDS assessment was completed 8/02/12 and the resident's cognition was severely impaired. The resident had a [DIAGNOSES REDACTED]. She was sitting in her wheelchair in the activity room at the time resident #3 put his hand in her pants on 1/18/13. Observation of resident #6 on 2/15/13 at 11:15 a.m. revealed she was sitting in a wheelchair at a table in the dining/activity room. She was not speaking to anyone was not involved in any activity at that moment. Nurse -L documented on 1/18/13 at 9:20 p.m., "....Wanders/ambulates in hallway with wide stance. Wandered into a female's room this shift and made a pass at a female resident sitting in the hallway." The nurses' notes did not include documentation of any level of increased supervision A psychiatric report of consultation was dated 1/18/13 and it indicated Report Requesting Regarding: psych eval ordered d/t impulsivity. The findings documented, "....has been impulse and having diff. being redirected. Pt. had been touching female residents inappropriately which puts him at risk for being hurt. Pt. is also dx (diagnosed ) with dementia. Upon interview, pt. tried to answer questions, but he is very confused." The plan/recommendation was for Exelon Patch 4.6 milligrams (mg) every 24 hours and Depakote 250 mg twice a day, and follow up in one month. Review of the physician's orders [REDACTED]. Review of resident #3's care plans revealed no interventions to address the risk of him bring hurt due to him touching female residents inappropriately and no care plans were developed regarding medications ordered by the psychiatrist, possible nonpharmacologic interventions, or additional supervision. Review of the physician orders [REDACTED]. The next entry for SSD notes on 1/23/13 documented, "nursing reports resident as being aggressively inappropriate to female residents. Was seen by psych and given meds on 1/18/13. Will monitor. Also, his room was changed from 124 A to 103 so he could be in a cluster of male rooms instead of females. Room change occurred on 1/17/13." Review of the resident rooms for the section of the hallway for room 124 revealed 10 resident rooms and 5 rooms were male rooms. Review of the resident rooms for the section of the hallway for room 103, after the room change, revealed 10 resident rooms and only 3 were male rooms. On 1/24/13, no time documented in the nurses' notes, LPN-I documented the resident was alert with confusion, "up ad lib." At 2:40 p.m. the documentation from the same nurse was as follows: "CNA observed resident in room 105B with his hand inside female resident pants and rubbing his hand inside of pant as she was lying on the edge of bed 105B. As the CNA was trying to redirect him, he drew back his hand at the CNA." The notes indicated the resident was sent via Baker Act to the hospital at 5:30 p.m. Previous review of an abuse report submitted by the abuse coordinator indicated the female resident was resident #1. Neither resident #3, nor resident #1 resided in room 105. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #1 revealed a [DIAGNOSES REDACTED]. She exhibited physical and verbal behavioral symptoms toward others daily and wandered daily. She could walk in corridor with supervision. Resident #1 had a care plan reviewed on 11/20/12 for: Frequently wanders in and out of activities due to: impaired cognition, decreased safety awareness, dementia. The goal was for resident #1 to remain in activity for at least 10 minutes. An intervention was to redirect resident as needed. The care plan did not address the risk to the resident or any interventions to prevent potential abuse from other residents. The resident had a care plan for wandering in and out of other resident's rooms and the goal was that the resident will wander safely within the secured unit thru the next review date. The care plan for wandering was not reviewed after resident #3 was observed with his hand in her pants on 1/24/13 after both her and resident #3 wandered into another resident's room. Resident #1 was observed on 2/14/13 at 10:00 a.m. She was standing at a table in the activity room, playing with a doll and a stuffed animal. She was attempting to offer her teddy bear to the resident sitting next to her. At 12:30 p.m. that day she was observed eating lunch in the activity/dining room and she was feeding herself. At 12:50 p.m. CNA-B was observed feeding her the rest of her lunch. The CNA stated resident #1 starts feeding herself, but then she will just play with her food and forgets to finish eating. The next Physician's note was from 1/24/13. It revealed the physician documented the reported inappropriate sexual behavior. He noted "unable to control pt's (patients) behavior." " ....Baker Act and transfer to psych hospital." The SSD documentation entry on 1/24/13 read, "Baker Act was utilized as resident became increasingly inappropriate with females and he became difficult to redirect." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility from 1/24/13 indicated the resident had a mental illness [DIAGNOSES REDACTED]. The supporting evidence section documented, " Despite psych meds-(resident #3) is a danger to other female residents as he is sexually inappropriate with his touching and increasingly aggressive. " The Other Information section included, " Nursing has witnessed (resident #3) become very aggressive towards female residents whom are unable to defend themselves-he presents a danger." An Approval for Release of Person on Involuntary Status From a Receiving Facility was signed at dated by the examiner at the hospital receiving facility on 1/25/13 at 9:43 a.m. It indicated the patient does not meet criteria for involuntary outpatient placement pursuant to 394.4655 based upon one or more of the following reasons: Person is likely to survive safely in the community without supervision and There are available less restrictive treatment alternatives offering an opportunity for improvement of his/her condition. The handwritten documentation was as follows: (resident #3) is exhibiting advancement of his dementia. He is not currently suicidal or homicidal and is not aggressive or psychotic. There are less restrictive environment for caring for the patient. The Florida Mental Health Act of 1971, commonly known as the "Baker Act" per Florida Statute 394.451, allows for involuntary examination of an individual with evidence of: 1) mental illness, and 2) evidence of harm to self, harm to others, or is self neglectful. Per the Baker Act Handbook and User Reference Guide-2011, The primary role of a Baker Act receiving facility is to perform psychiatric evaluations and provide short term psychiatric treatment. If a person has behavioral conditions that are not psychiatric in nature they should not be sent to a psychiatric facility. The Baker Act requires a patient have a documented mental illness and to be able to participate in a psychiatric treatment plan. Resident #3 had no [DIAGNOSES REDACTED]. On 1/25/13, upon return to the facility after the incident of sexual inappropriate behavior with resident #1, the resident had physician telephone orders for Depakote 500 mg twice a day for psychosis and Paxil 20 mg every morning for depression and decrease libido. The record did not contain any other information regarding how the [DIAGNOSES REDACTED]. The record did not contain documentation of any change in the plan of care or increased supervision upon resident #3's return to the facility. Behavior monitoring records were not initiated until 1/29/13 for the Depakote, despite the fact that the resident was started on the medication 11 days earlier. The behavior listed on the Behavior/intervention Monthly Flow Record for Depakote was inappropriate sexual behavior. The intervention codes noted (see care plan) however a care plan for inappropriate sexual behavior was not developed. The flow record did not list any individualized interventions for inappropriate sexual behavior or wandering. When the resident returned to the facility on [DATE] at 4:45 p.m., the nurses notes were written as follows: "Resident was brought to facility via stretcher + 2 attendants. Resident alert + responsive. Mucous membrane moist, pink, + intact. Denies having any pain. Lungs clear. Active ROM (range of motion) in upper extremities. Skin warm, dry, + intact. + bowel sounds. Abdomen soft + non tender. Old scar above umbilicus. Active ROM lower extremities. Feet very dry. Toe nails overgrown. MD notified of return. VS (vital signs) B/P (blood pressure) 137/78. P (pulse) =74, R (respirations) = 18, T (temperature) = 98.4 resident made comfortable. Will monitor." The nurses' notes did not indicate what would be monitored or how staff would supervise resident #3. Another MDS assessment was completed for resident #3 upon return to the facility on [DATE] with the observation end date of 2/09/13. The assessment changed from the initial assessment and for Hearing, Speech, and Vision, it indicated the resident usually understands-misses some part/intent of message, but comprehends most conversation. Cognitive score remained the same. The resident's mood had changed to feeling down, depressed or hopeless 2-6 days, and trouble concentrating on things 2-6 days. Behavioral Symptoms indicated the resident now had physical and verbal behavioral symptoms directed toward others that occurred 1-3 days, had delusions, rejected care 1 to 3 days, and did not wander. Functional status remained the same foe required limited assistance to move between locations in his room and adjacent corridor on the same floor, but walk in corridor improved from limited assistance to supervision. An antidepressant was coded as given 7 of the last 7 days. On 1/26/13, no time, LPN D documented as follows: "Resident is being observed by CNA. OOB (out of bed) in activity room, while in activity room resident was observed with his left hand on a male resident penis, when resident was confronted he said it was fine. Resident was removed and placed to another area in the room and all CNA were instructed to not place anyone next to him." In an interview with the abuse coordinator on 2/15/13 at 10:25 a.m., he reported the male resident was resident #7. The nurses' notes did not include documentation of any level of increased supervision Record review for resident #7 revealed the resident has vascular dementia. The last annual MDS assessment was completed on 7/11/12 and it indicated the resident's vision was highly impaired and the resident's cognition was severely impaired. The resident is dependent upon staff for all activities of daily living. Resident #7 was sitting in a wheelchair in the activity room at the time resident #3 put his hand on his penis. Observation of resident #7 on 2/15/13 at 11:45 a.m. revealed he was sitting in his room in a wheelchair. He opened his eyes when spoken to, but he did not respond to questions. He was hard of hearing. The nurse's note written by LPN-I on 1/29/13 at 3:35 p.m. indicated resident #3 was up "ad lib." The SSD notes on 1/28/13 include documentation regarding the resident#3's return to the nursing home indicating the Baker Act was not warranted as such behaviors were related to dementia. His documentation indicated resident was a danger to other females on the dementia unit and noted concern regarding the resident's sexual acting out. The notes indicate the SSD was attempting to find alternative placement for the resident, but no notation of any intervention planned for supervision of resident #3 or for protection of the other residents. The SSD notes from 2/04/13 indicate he met with the psychiatrist who changed medications started previously related to resident's behaviors. Review of the care plans revealed no indication of psychiatrist visits, initial orders, or changes to orders. The notes did not contain information regarding type of behaviors, assessment for possible causes of behaviors, or any nonpharmalogical interventions attempted prior to the use of medications. The Psychiatric progress note dated 2/04/13 documented, "Pt. states he is doing better." The psychiatrist also noted the resident was still sexually preoccupied. Input from staff/family was less sexual, less angry. The psychiatrist increased the Exelon patch to 9.5 mg daily. The nurses' notes from 1/26/13 to 2/11/13 indicated the resident did not exhibit inappropriate sexual behavior, however the resident was observed in the hallway pulling out his penis and urinating in the hallway on 2/09/13 at 2:40 p.m. On 2/08/13 at 8:40 p.m. documentation indicated the resident urinated in the hallway again. On 2/10/13 the resident was out of bed, ambulating in dining room/activities, but the notes did not include documentation of how the resident was supervised or monitored. On 2/11/13 at 12:00 p.m. documentation indicated the resident was ambulating ad lib and was very combative at times. The nurses' notes did not include documentation of any level of increased supervision On 2/12/13 at 12:20 p.m. the nurses notes documented by the UM were as follows, "....a CNA informed me resident was standing in hallway close to his room putting his finger in resident's vagina. On visiting the area I saw female resident standing in hallway with her diaper in her hand and the male resident standing close beside her with his fingers in the vagina. I asked him what he is doing and told him to leave the lady alone, he just looked at me and did not move, so I attempted to take him to his room and he attempted to hit me." "....Resident was left in his room by family members who left without notifying staff they were leaving." Although the documentation indicated staff members were not aware the resident was alone, the UM indicated in an interview on 2/14/13 at 2:50 p.m. and in her documentation in the nurses ' notes on 2/12/13 at 12:20 p.m., the daughter had approached her at the nursing station, so the daughter was not in resident #3's room at that time. Record review for resident #2 revealed a [DIAGNOSES REDACTED]. Her assessment documented she exhibited no wandering although she had a plan of care for frequent wandering in and out of activities due to dementia that was initiated on 8/20/13 and was reviewed to continue with the plan of care on 11/22/12. The care plan for wandering was not reviewed after the resident was subjected to sexually inappropriate behavior by resident #3 on 2/12/13. She walks in the corridor with limited assistance, however observation of the resident on 2/14/13 at 12:45 p.m., revealed she walked without assistance, using a walker. She had no physical or verbal behavioral symptoms directed toward others. On 2/14/13 at 12:45 p.m. an interview was attempted with resident #3. She was unable to complete one thought or reply appropriately to simple questions. She was later observed at 12:45 p.m. ambulating without staff assistance in the hallway with a walker. The SSD notes from 2/12/13 indicated the resident touched a demented female resident inappropriately and the resident required hospitalization . The resident was not arrested "probably based on the fact that he is demented." The SSD notes continued, "It is unknown whether the visitation by the resident's family caused the resident to react in a sexually inappropriate way towards another female resident because resident's behavior had improved since his meds were changed" by the psychiatrist. However, the resident's family visited the resident regularly, and the daughter visited at twice a week. The SSD did not document any relationship between the family visits and the resident's sexual behaviors previously, even though the family had been visiting regularly since admission on 12/27/12 and the start of resident behaviors were documented as early as 12/31/12 by nursing staff and 1/03/13 by the SSD. The Physician's note was on 2/12/13 which read, "....Pt had inappropriate sexual encounter with another female patient who required medical attention for vaginal bleeding." "....I made decision that this patient is inappropriate to be in nursing facility at this time due to danger to other patient's safety. I am going to Baker Act this patient." Review of documentation on the Certificate of Professional Initiating Involuntary Examination for the transfer to a psychiatric receiving facility for 2/12/13 indicated it was completed by resident #3's physician. The criteria for reason to believe the person has a mental illness documented, "dementia with psychosis." The supporting evidence included, "Resident has been observed being constantly sexually inappropriate with elderly females and exercises poor judgment and has caused physical harm to a female resident who was hospitalized ." The section for Other Information was blank. Review of the CNA Care Tracker notes revealed no documentation of level of supervision for resident #3. The "Resident Behavior by Day Chart Report" did not document any physically abusive or verbally abusive behaviors from the day of admission on 12/27/12 to discharge on 2/12/13 with the exception of 1/22/13, verbally abusive behaviors. The census and condition report completed by the DON indicated the facility had 68 residents out of 109 that had dementia and 60 residents with behavioral symptoms. During an interview with the unit manager (UM) registered nurse, on 2/14/13 at 9:30 a.m., she explained the residents on the A-wing all had mild to severe dementia and were mostly long-term residents. She indicated there were 56 residents on the unit because one resident was sent to the hospital. She indicated resident #3 was sent to the hospital via Baker Act on 2/12/13. In an interview with Licensed Practical Nurse (LPN)-D on 2/14/13 at 10:40 a.m., she stated most of the residents that she takes care of have dementia. She was one of 2 nurses posted on the assignment for 2/14/13 and had residents in rooms 100 to 115. She said she does not take anything they (residents) say or do personally because she understands that it's an illness and they cannot help it. She said, "You have to be patient and if they don't want to cooperate, come back and try again later." She said most residents stay in the activity/dining room. When LPN-D was asked how she deals with residents with behaviors toward other residents, she mentioned that they had to place resident #3 in the activity room away from other residents because he was touching other residents inappropriately. She said most resident to resident altercations between other residents involved fighting over dolls and she would intervene by removing the doll or toy. She stated that a couple of weeks ago on 1/18/13, she went to activity room and saw resident #3 leaning over the table towards resident #6 with his hands under the table in the her pants in her vaginal area. She said resident #6 was confused and she was just sitting at the table waiting for her meal. LPN-D said that she reported the incident to "everyone who is above me: the DON, UM, Administrator, Risk Manager, and also told the CNAs." She explained, "They moved him to a table of males, but then around a week later on, I caught him feeling resident #7's penis." She said resident #7 was confused, so he just sat there. She said they moved resident #3 from his previous room in 124 to room 103 because there were fewer women on this side. She said that he was ambulatory and could take himself to the bathroom. She explained that he understood English, but when he was "caught in the act," he would say "what am I doing? I don't speak English. "When asked if the resident had ever touched her, she said no, but he would make comments like "you can be my wife." On 2/14/13 at 2:35 p.m. during an interview with CNA-A she revealed that the CNAs rotate assignments every 2 weeks. She stated that she was familiar with resident #3 and had taken care of him in the past. She said "he used to be in another room, but they moved him because he would pee in the garbage can and on the floor." She said that "one day I was in the dining room and another staff member instructed me to look in Room 105, so I saw resident #3 on the edge of the bed and he had his hand in resident #1's underwear." She said "he was really pushing his hand up there and when he pulled it out, it smelled like her vagina. I told him to step

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and failed to maintain a quality assessment and assurance committee to address neglect. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: 1. Based on interview and record review observation, the facility failed to keep residents free from neglect on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and staff neglected to provide adequate care and services, including adequate supervision, to prevent resident #3 from touching 4 residents in an inappropriate sexual manner, even after the resident exhibited pervious sexually inappropriate behaviors. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility staff neglected to identify and implement procedures to protect residents from repeated occurrences of sexually inappropriate behavior even after they were aware of and documented resident #3's sexual behaviors on 1/10/13. The facility failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms. As of the exit date of the survey, 2/16/13, the facility had no system in place to keep residents free from mistreatment, neglect, and misappropriation of property, including identification of residents whose behaviors render them at risk for touching other residents in an inappropriate manner, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger the behavior, and reassessment of the interventions on a regular basis. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross Reference to F224. 2. Based on interview and record review, the facility failed to thoroughly investigate and report allegations of neglect on one of two wings for 3 of 9 sampled residents on the A-wing (#4, 6 & 7). The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. The Abuse Coordinator also stated he was unaware of information regarding resident #4 for possible inappropriate sexual behavior that occurred in her room when resident #3 had his hand in the pants of another resident, #1, on 1/24/13. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated for the and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. As of the exit date of the survey on 2/16/13, the facility had not identified neglect to provide adequate interventions and supervision or implemented corrective measures to prevent further potential neglect. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F225. 3. Based on interview and record review, the facility failed to implement their policies for abuse and neglect on one of two wings for 5 of 9 sampled residents on the A-wing. (#1, 2, 3, 6 & 7) Four residents (#1, 2, 6 & 7) were touched in a sexually inappropriate manner from 1/18/13 to 2/12/13 by one resident, #3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated for the and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. Staff members were aware of resident #3's behavior and did not report it to Administration. As of the exit date of the survey, 2/16/13, the facility had not implemented their policy and procedures for abuse and neglect for identification, investigation, prevention, protection, reporting, and training when documentation revealed verbal aggression on 12/31/12 and sexually inappropriate behavior occurred on 1/10/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F226. 4. Based on interview and record review, the facility failed to conduct an appropriate transfer/discharge that included an appropriate location on 2 occasions for 1 of 9 sampled residents (#3). Cross reference to F203 5. Based on interview and record review, an observation, the facility failed to provide adequate supervision to maintain a secure environment on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and was not adequately supervised to prevent him touching 4 residents in a sexually inappropriate manner, even after the resident exhibited sexual behaviors. The facility failed to implement the appropriate level of supervision to prevent resident-to-resident incidents for residents that wander. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility failed to identify and implement adequate supervision and procedures to protect residents or intervene prior to inappropriate sexual behavior occurring when they became aware of resident #3's aggressive and sexually inappropriate behaviors and failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms as of the exit date of the survey on 2/16/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F323. 6. Based on interview and record review the facility failed to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, failed to be administered in a manner that enables it to use its resources effectively and efficiently, and failed to maintain a quality assessment and assurance committee to address these issues. Four residents (#1, 2, 6, & 7) were touched in an inappropriate sexual manger by the same resident (#3) from 1/18/13 to 2/12/13. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F520. Review of the Policy for the Administrator revealed the Policy Statement was, "A licensed administrator is responsible for the day-to-day functions of the facility." Policy and Implementation indicated the administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility, Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities, Evaluation and implementing recommendations from the facility's committees (Quality Assessment and Assurance), Ensuring that the facility admits only those residents for whom it can provide adequate care.

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and failed to maintain a quality assessment and assurance committee to address neglect. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F490. Findings: 1. Based on interview and record review observation, the facility failed to keep residents free from neglect on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and staff neglected to provide adequate care and services, including adequate supervision, to prevent resident #3 from touching 4 residents in an inappropriate sexual manner, even after the resident exhibited pervious sexually inappropriate behaviors. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility staff neglected to identify and implement procedures to protect residents from repeated occurrences of sexually inappropriate behavior even after they were aware of and documented resident #3's sexual behaviors on 1/10/13. The facility failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms. As of the exit date of the survey, 2/16/13, the facility had no system in place to keep residents free from mistreatment, neglect, and misappropriation of property, including identification of residents whose behaviors render them at risk for touching other residents in an inappropriate manner, and the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger the behavior, and reassessment of the interventions on a regular basis. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross Reference to F224. 2. Based on interview and record review, the facility failed to thoroughly investigate and report allegations of neglect on one of two wings for 3 of 9 sampled residents on the A-wing (#4, 6 & 7). The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the behavior was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. The Abuse Coordinator also stated he was unaware of information regarding resident #4 for possible inappropriate sexual behavior that occurred in her room when resident #3 had his hand in the pants of another resident, #1, on 1/24/13. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated for the and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. As of the exit date of the survey on 2/16/13, the facility had not identified neglect to provide adequate interventions and supervision or implemented corrective measures to prevent further potential neglect. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F225. 3. Based on interview and record review, the facility failed to implement their policies for abuse and neglect on one of two wings for 5 of 9 sampled residents on the A-wing. (#1, 2, 3, 6 & 7) Four residents (#1, 2, 6 & 7) were touched in a sexually inappropriate manner from 1/18/13 to 2/12/13 by one resident, #3. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of the 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7. The Abuse Coordinator indicated sexual abuse for residents #1, 6 & 7 was not substantiated for the and did not consider neglect despite the fact that all 5 residents were cognitively impaired and resident #3 was observed with his hand in resident #1's pants, resident #3 was observed with his hand in resident #6's pants, resident #3 was observed with his hand on the penile area of resident #7, and resident #3 was observed in the hallway with his hand in resident #2's vagina. Staff members were aware of resident #3's behavior and did not report it to Administration. As of the exit date of the survey, 2/16/13, the facility had not implemented their policy and procedures for abuse and neglect for identification, investigation, prevention, protection, reporting, and training when documentation revealed verbal aggression on 12/31/12 and sexually inappropriate behavior occurred on 1/10/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F226. 4. Based on interview and record review, the facility failed to conduct an appropriate transfer/discharge that included an appropriate location on 2 occasions for 1 of 9 sampled residents (#3). Cross reference to F203 5. Based on interview and record review, an observation, the facility failed to provide adequate supervision to maintain a secure environment on one of two wings for 5 of 9 sampled residents on the A wing (#1, 2, 3, 6 & 7). Four residents had severe cognitive impairment and were subjected to sexually inappropriate behavior by resident #3 at separate times from 1/18/13 to 2/12/13. Resident #3 had severe cognitive impairment and was not adequately supervised to prevent him touching 4 residents in a sexually inappropriate manner, even after the resident exhibited sexual behaviors. The facility failed to implement the appropriate level of supervision to prevent resident-to-resident incidents for residents that wander. The Administrator, Director of Nursing, Social Services Director, and Abuse Coordinator/Risk Manager all indicated they were unaware of 2 incidents in which residents were touched in a sexually inappropriate manner by resident #3 on 1/18/13 for resident #6 and on 1/26/13 for resident #7, despite the fact the abuse was witnessed, documented, and reported by a nurse, and the psychiatric consult documented behavior of touching female residents inappropriately on 1/18/13 for resident #3. A resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by rubbing his hand inside resident #1's pants on 1/24/13. Another resident alerted facility staff when resident #3 exhibited sexually inappropriate behavior by having his hand in resident #2's vagina on 2/12/13. Resident #2 sustained harm and was sent to the emergency room . The facility failed to identify and implement adequate supervision and procedures to protect residents or intervene prior to inappropriate sexual behavior occurring when they became aware of resident #3's aggressive and sexually inappropriate behaviors and failed to identify the increased risk for resident #3 and 2 other residents (#1 & 2) who wander in and out of other residents' rooms as of the exit date of the survey on 2/16/13. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F323. 6. Based on interview and record review the facility failed to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, failed to be administered in a manner that enables it to use its resources effectively and efficiently, and failed to maintain a quality assessment and assurance committee to address these issues. Four residents (#1, 2, 6, & 7) were touched in an inappropriate sexual manger by the same resident (#3) from 1/18/13 to 2/12/13. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Cross reference to F520. Review of the Policy for the Administrator revealed the Policy Statement was, "A licensed administrator is responsible for the day-to-day functions of the facility." Policy and Implementation indicated the administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility, Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities, Evaluation and implementing recommendations from the facility's committees (Quality Assessment and Assurance), Ensuring that the facility admits only those residents for whom it can provide adequate care.

Based on interview and record review the facility failed to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, failed to be administered in a manner that enables it to use its resources effectively and efficiently, and failed to maintain a quality assessment and assurance committee to address these issues. Four residents (#1, 2, 6, & 7) were touched in an inappropriate sexual manger by the same resident (#3) from 1/18/13 to 2/12/13. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. Findings: Cross Reference to F224, F225, F226, F323, and F490. In an interview with the Abuse Coordinator on 2/16/13 at 2:50 p.m. he indicated he is the Quality Assessment and Assurance (QA & A) contact person. He said he is also the Risk Manager and the Staff Development Coordinator. He stated the last QA & A meeting was 1/30/13 and no issues were discussed regarding resident #3's behaviors and potential risks to him and the other residents, even though the facility staff were aware of resident #3's aggression and sexual behaviors towards staff and residents. The Medical Director is the attending physician for all residents affected by the abuse (#1, 2, 3, 6, 7) The facility Abuse and Neglect Prevention Plan and Policy directs the Director of Nursing to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The AC confirmed this was not completed for the last QA meeting on 1/30/13.

Based on interview and record review the facility failed to keep residents free from neglect, facility failed to thoroughly investigate and report allegations of neglect, failed to implement policies and procedures for neglect, failed to provide adequate supervision to maintain a secure environment, failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, failed to be administered in a manner that enables it to use its resources effectively and efficiently, and failed to maintain a quality assessment and assurance committee to address these issues. Four residents (#1, 2, 6, & 7) were touched in an inappropriate sexual manger by the same resident (#3) from 1/18/13 to 2/12/13. As of the exit date of the survey, 2/16/13, the facility had no systems in place to address these issues. These practices resulted in immediate jeopardy starting on 1/18/13 and it was determined to be ongoing as of the exit date on 2/16/13. On 3/06/13 the facility had implemented sufficient measures to decrease the severity/scope to D, but the facility remains out of compliance with F520. Findings: Cross Reference to F224, F225, F226, F323, and F490. In an interview with the Abuse Coordinator on 2/16/13 at 2:50 p.m. he indicated he is the Quality Assessment and Assurance (QA & A) contact person. He said he is also the Risk Manager and the Staff Development Coordinator. He stated the last QA & A meeting was 1/30/13 and no issues were discussed regarding resident #3's behaviors and potential risks to him and the other residents, even though the facility staff were aware of resident #3's aggression and sexual behaviors towards staff and residents. The Medical Director is the attending physician for all residents affected by the abuse (#1, 2, 3, 6, 7) The facility Abuse and Neglect Prevention Plan and Policy directs the Director of Nursing to utilize a map of the facility, a monthly Incident Tracking form to perform a trending analysis to determine what changes may be needed in order to prevent additional occurrences. This will be reviewed in monthly Quality Assurance meeting. The AC confirmed this was not completed for the last QA meeting on 1/30/13.