Every finding on record at Indian River Center

Based on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 2 residents reviewed for dental, of a total sample of 44 residents, (#56).Findings:Review of the medical record revealed resident #56, a [AGE] year-old male was admitted to the facility from another nursing home on 5/28/25. The resident's active diagnoses included chronic subdural hemorrhage (slow blood collection/leakage between brain and outer covering), history of traumatic brain injury, cerebral ischemia (insufficient brain blood/oxygen), persistent mood disorders, atherosclerosis (narrowing of arteries), and major depressive disorder.Review of resident #56's most recent Annual Minimum Data Set Comprehensive Assessment with an Assessment Reference Date of 5/31/26 showed the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The Functional Abilities for Self-Care noted staff supervision was required to complete his Activities of Daily Living.The Care Plan Report included foci for alteration in nutrition/hydration and risk for malnutrition related to cognitive deficits, history of alcohol abuse, limited mobility, and history of weight changes (5/25/26). The resident had a care plan for potential for oral health concerns related to missing, broken/chipped natural teeth noted on admission to the facility (6/02/25), with interventions to coordinate arrangements for dental consultation and transportation as needed/ordered, and to monitor, document, and report any teeth/oral mucosa concerns (5/30/25).Review of the medical record revealed resident #56 was incapacitated for decision making and had a court-appointed guardian.On 7/28/26 at 9:46 AM, resident #56 had a strong oral malodor consistent with poor oral hygiene and/or unmet dental care needs. On 7/30/26 at approximately 10:30 AM, the resident relayed he had not been offered routine preventive dental hygiene services since his admission to the facility over a year ago. He reported that prior to admission, he routinely received professional dental cleanings twice a year. The resident stated he wished to maintain his natural teeth and avoid the need for dentures. During the observation/interview, a pronounced oral malodor was noted.On 7/30/26 at approximately 2:00 PM, Certified Nursing Assistant (CNA) C said resident #56 was regularly included in her assignment and she knew him well. She explained that dental providers regularly visited the unit, and she recalled seeing them twice in the previous two weeks. She relayed resident #56 had to be reminded to brush his teeth, he always had strong oral malodor, and to her knowledge, he had not received dental services.On 7/30/26 at 11:32 AM, the Caring Way Unit Manager explained a third party provided on-site dental care/hygiene monthly, and as needed. She said staff notified the Social Services department to add residents to the dental services list. The Registered Nurse (RN) said oral hygiene was important, she relied upon CNAs to alert her of concerns and stated, to keep your oral health well, you need to take care of your teeth.Review of the facility's on-site dental provider's list of current residents did not include resident #56.In a telephone interview on 7/29/26 at 9:54 AM, resident #56's court appointed guardian said the facility had not contacted her about providing the resident dental or any other ancillary services.On 7/30/26 at 8:10 AM, the Social Services Assistant explained her department coordinated resident's dental services. She said nursing services let the department know what residents need. She relayed every long-term care resident who had natural teeth received regular cleanings every six months and stated, the payer source doesn't matter, they all get cleanings. At 3:10 PM, the Social Services Assistant checked resident #56's medical record and was unable to locate a dental services referral and stated, I can send a referral for him; he came after I started working here, and I don't know why he's not on the list.On 7/30/26 at 3:30 PM, the Nursing Home Administrator (NHA) explained all residents were eligible to receive dental services regardless of the payer and she expected staff to at least try and let someone know when service was needed. The NHA stated, if not qualified, we will set it up and the facility may have to pay for it.Review of the Facility Assessment Tool dated 1/16/26 noted the facility's provided services which included contracted on-site dental services.The facility's standards and guidelines dated January 2024 and titled, Dental Consults, noted the facility contracted with external providers to provide resident dental services, as indicated to provide services related to dental matters.

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 residents reviewed for Choices received requested on-site hair salon services, of a total sample of 44 residents, (#104).Findings:Review of the medical record revealed resident #104, a [AGE] year-old female was admitted to the facility from an acute care hospital on 4/25/24. The resident's active diagnoses included moderate bipolar disorder, undifferentiated schizophrenia, major depressive disorder, mood disorder, and seborrheic dermatitis (itchy/flaky dandruff).The most recent Annual Minimum Data Set Assessment with an Assessment Reference Date of 5/06/25 indicated resident #104 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15, and her Functional Activities for Daily Living abilities required staff supervision.The Care Plan report noted resident #104 required an escort for any leave of absence outside the facility, and she resided in the secured/locked unit for safety, (4/25/25).On 7/30/26 at 11:18 AM, resident #104 was said she was irritated when she explained she was unable to leave the locked unit. The resident explained she had requested staff assistance on multiple occasions to obtain a haircut but had not been accommodated. Resident 104's hair was observed to be long with overgrown ends. The resident recalled asking her regular nurse, Licensed Practical Nurse (LPN) A many times over previous months for assistance obtaining a haircut and stated, I can't even get a haircut; I know they come here.On 7/30/26 at 11:16 AM, the Caring Way Unit Manager stated LPN A was unavailable and not working that day. She said when residents requested a haircut, staff called the Receptionist to add them to the list. On 7/29/26 at 1:39 PM, the Business Office Manager (BOM) provided a copy of resident #104's most recent quarterly personal funds statement. Review of the statement showed a deposit was posted from a personal check on 7/13/26 in the amount of $40.00. The BOM stated the funds were received from the resident's appointed guardian for a haircut.On 7/30/26 at 9:04 AM, the Receptionist explained she was responsible for adding residents to the on-site hair salon list for the service provider who visited once or twice weekly. She said she added residents when anyone requested services that included residents in the locked unit and those staff would normally just call her.On 7/30/26 at 2:10 PM, Certified Nursing Assistant (CNA) D who regularly worked on the secured unit explained there was a simple process for residents to receive a haircut on-site, and CNAs were not allowed to cut hair. She said CNAs informed the nurse or Unit Manager at the desk to add residents to the list for the hair salon.Review of July 2026's Hair Salon Schedules from 9:00 AM to 3:00 PM showed between five and eight residents had scheduled appointments and received services each week. There was availability open for every service day in July. Resident #104's name was not on any of the schedules.In an interview on 7/30/26 at 3:21 PM, the Nursing Home Administrator explained on-site Hair Salon services were available to all residents. She said she expected staff to add residents to the appointment list upon their request and stated, the facility will pay for the services even if they don't have money; they should have put her on the list, the beautician was here yesterday, and it could have been done.Review of the admission Packet included undated facility ancillary services titled, Hair Salon Open Tuesdays & Thursdays, 10:00 AM to 3:00 PM and listed Women's Cut for $20.00.Review of the Facility Assessment Tool dated 1/16/26 outlined the facility provided person-centered/directed care: Psycho/social/spiritual/support that included obtaining what the resident's preferences and routines were; what makes a good day for the resident; what upsets him/her and incorporate the information into the care planning process, support emotional and mental well-being; support helpful coping mechanisms. On-site services included Barber/Beauty.

Based on observation, interview, and record review, the facility failed to include 3 of 3 residents reviewed for care planning in their care plan meetings, (#56, #104, #108), and failed to develop an elopement risk care plan for 1 of 6 residents reviewed for accidents, (#142), of a total sample of 44 residents. Findings: 1. Review of the medical record revealed resident #56, a [AGE] year-old male was admitted to the facility from another nursing home on 5/28/25. The resident's active diagnoses included chronic subdural hemorrhage (slow blood collection/leakage between brain and outer covering), history of traumatic brain injury, cerebral ischemia (insufficient brain blood/oxygen), sequelae of cerebral infarction (effects of stroke), persistent mood disorders, atherosclerosis (narrowing of arteries), repeated falls, wedge compression fracture of thoracic vertebra, sequela (effects of), diverticulosis (colon inflammation), and major depressive disorder. Review of resident #56's most recent Annual Minimum Data Set (MDS) Comprehensive Assessment with an Assessment Reference Date (ARD) of 5/31/26 showed the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The Functional Abilities for Self-Care noted staff supervision was required to complete his Activities of Daily Living (ADLs). Resident #56's Care Plan Report revealed an active Comprehensive Care Plan addressing multiple identified needs including nutrition/hydration, cognitive impairment, mobility and fall risk, oral health, pain, cardiovascular status, skin integrity, impaired vision, mood/behavioral concerns, ADLs, chronic medical conditions, and medication management. On 7/28/26 at 9:46 AM, resident #56 was walking in the hallway outside his room on the locked unit, visibly anxious and frustrated. The resident expressed he had concerns regarding his continued placement on the locked unit and stated he wanted to leave the unit. He stated his condition had significantly improved since admission following a head injury and he had voiced his concerns to the Caring Way Unit Manager on multiple occasions, stating, she won't let me go. Resident #56 stated he had never been invited to participate in his care plan meetings. Review of resident #56's Interdisciplinary Plan of Care Meetings (IPOC) and invitations documentation dated 12/16/25, 3/17/25, and 7/14/26 revealed the participation sections did not document that the resident was offered the opportunity to participate in the care plan meetings, attended the meetings, declined participation, or was unable to participate. Documentation for the 12/16/25 meeting indicated the resident representative participated by telephone; however, there was no documentation that resident #56 was offered the opportunity to participate. The 3/17/26 and 7/14/26 care plan meeting records contained documentation related to attempts to contact and/or invite a resident representative; however, the records did not demonstrate that resident #56 was offered the opportunity to participate in either care plan meeting. 2. Review of the medical record revealed resident #104, a [AGE] year-old female was admitted to the facility from an acute care hospital on 4/25/24. The resident's active diagnoses included moderate bipolar disorder, undifferentiated schizophrenia, major depressive disorder, mood disorder, anxiety disorder, insomnia, coronary artery disease, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, fibromyalgia, difficulty in walking, osteoporosis, pain, old myocardial infarction (heart attack), presence of cardiac pacemaker, lack of coordination, repeated falls, and presence of coronary (heart) implant/graft. The most recent Annual MDS Comprehensive Assessment with an ARD of 5/06/26 indicated resident #104 was cognitively intact with a BIMS score of 15 out of 15, and her Functional Activities for ADL Abilities required staff supervision. Resident #104's Care Plan Report revealed an active Comprehensive Care Plan addressing multiple identified needs including nutrition/hydration, fluid imbalance, gastro-intestinal conditions, hematology conditions, cognitive impairment, mobility and fall risk, oral health, pain, cardiovascular status, skin integrity, incontinence, mental health/mood/behavioral concerns, ADLs, chronic medical conditions, preferences, and medication management. On 7/28/26 at 11:11 AM, resident #104 was sitting in a wheelchair in her room on the locked unit. The resident was visibly frustrated while discussing her placement on the unit. She stated she did not want to remain on the locked unit and expressed that staff did not listen to her concerns or preferences. Resident #104 stated she had not been invited to participate in care plan reviews or meetings for over a year and a half. Review of resident #104's IPOCs and invitations documentation dated 12/02/25, 2/17/26, and 5/19/26 revealed the resident participation fields were left unchecked, and the documentation did not verify the resident was offered the opportunity to participate in care plan meetings. The records reflected attempts to contact the guardian, with the guardian participating by telephone on 5/19/26. 3. Review of the medical record revealed resident #108, a [AGE] year-old male was admitted to the facility from an acute care hospital on [DATE]. The resident's active diagnoses included cervical spondylosis (degenerative arthritis), encephalopathy (brain dysfunction), COPD, cardiomyopathy (enlarged heart), lack of coordination, cirrhosis of liver, repeated falls, dysphagia (difficulty swallowing), hypermobility syndrome (joint instability/pain), psychotic disorder, persistent mood disorders, and recurrent major depressive disorder. The most recent Quarterly MDS Assessment with an ARD of 6/02/26 indicated resident #108 was moderately cognitively impaired with a BIMS score of 11 out of 15, and his Functional Activities for ADL Abilities required staff supervision. Resident #108's Care Plan Report revealed an active Comprehensive Care Plan addressing multiple identified needs including nutrition/hydration, impaired visual function, fluid imbalance, neurological conditions, hematology conditions, cognitive impairment, musculoskeletal conditions, mobility and fall risk, oral health, pain, cardiovascular status, respiratory complications, skin integrity, mental health/mood/behavioral concerns, ADLs, chronic medical conditions, preferences, adjustment difficulties, leave of absence concerns, and medication management. On 7/27/26 at 3:33 PM, resident #108 was observed lying in bed in his room on the locked unit. The resident was visibly distressed as he described a specialty mattress on his bed that prevented him from getting out of bed independently. He said he didn't need any help getting out of bed and didn't understand why the mattress was there. Resident #108 said he had never been invited to participate in his care plan development or reviews. Review of resident #108's IPOCs and invitations dated 12/16/25, 3/04/26, and 6/16/26 revealed the resident's representative attended in person on 3/04/26 and 6/16/26 and was contacted without response on 12/16/25. The 3/04/26 IPOC identified the resident as unable to attend; however, the 12/16/25 and 6/16/25 IPOCs did not document whether the resident was offered or participated in the care plan meeting. Review of corresponding care plan invitations noted they were undated and did not contain documentation verifying that resident #108 was invited to participate. In a joint interview with MDS Coordinator E, MDS Coordinator F, the MDS Lead, and the Regional MDS Consultant on 7/30/26 at 9:49 AM, MDS Coordinator E stated he was responsible for arranging care plan meetings. Upon review of the care plan meeting records for residents #56, #104, and #108, the MDS Coordinator acknowledged the documentation did not verify when or how the invitations were provided to the residents and did not otherwise verify the residents were afforded the opportunity to participate. MDS Coordinator E stated care plan meetings could be conducted in a resident's room when necessary to facilitate resident participation and conveyed it was important to afford residents, when practicable, the opportunity to participate in the development and review of their care plans. The Regional MDS Consultant relayed her expectations for resident care plan meetings included encouragement of resident participation as it was important, so they were updated and given an opportunity to relay concerns or questions about their care. Review of the facility's standards and guidelines dated February 2024 and titled, Comprehensive MDS Assessment and Care Plan noted the development of residents' care plans was prepared by the Interdisciplinary Team (IDT) with the participation of the resident and the resident's representative(s). The document indicated the plan of care was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments. Review of the undated Resident Rights included in the Admissions Packet provided to all residents included that residents had the right to take part in developing their care plan and the care planning process, and to take part in all decisions that affected their care. 4. Resident #142 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease, type 2 diabetes mellitus, paranoid schizophrenia, anxiety disorder and dementia. Review of the MDS admission assessment with ARD of 5/20/26 showed the resident had a BIMS score of 2 out of 15 which indicated her cognition was severely impaired. Review of the physician's orders showed that nurses were instructed to verify right leg electronic wander prevention device placement every shift and to check the device for function every night shift. On 7/27/26 at 12:30 PM, resident #142 was seen pushing on the exit door between rooms [ROOM NUMBERS] in the facility's locked unit (Caring Way). On 7/27/26 at 12:45 PM, resident #142 was observed trying to exit the double door near room [ROOM NUMBER]. Two staff members tried to coerce her back to the dining room so that other staff members could enter the locked unit. An electronic wander prevention device bracelet was seen on resident #142's right lower leg. A review of resident #142's care plan did not include elopement risk. In a joint interview on 7/30/26 at 11:48 AM, with the Social Services Director (SSD), MDS Coordinator and Assistant MDS Coordinator, they acknowledged there was no elopement care plan for resident #142. The SSD, and Assistant and MDS Coordinator confirmed resident #142 should have a care plan for risk for elopement. They explained care plans were generated by physicians' orders and acknowledged the order for the electronic wander prevention bracelet was placed on 7/20/26 which should have triggered the need for an associated care plan. They continued to explain their process of updating care plans included a review of physician's orders and ensuring that care plans were updated and accurate but did not say why resident #142's elopement risk care plan was missed. In a joint interview on 7/30/26 at 3:31 PM, the Nursing Home Administrator, Assistant Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing and the Caring Way Unit Manager acknowledged resident #142 did not have an elopement risk care plan. They confirmed it should have been done but was probably missed. The Caring Way Unit Manager said it was important to have an accurate cate plan because resident #142 was currently exit seeking and all staff needed to be aware of the care plan and interventions to reduce the risk for elopement. The facility's Standards and Guidelines for Comprehensive MDS Assessment and Care Plan issued October 2020 and revised February 2024 indicated The facility in collaboration with the resident and the resident representative, will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure safe administration of enteral feedings by failing to properly verify function of percutaneous endoscopic gastrostomy (PEG) tube prior to administration of tube feeding, and by failure to ensure accurate administration of water bolus and tube feeding formula as ordered by the physician for 1 of 2 residents reviewed for enteral feeding management, of a total sample of 44 residents, (#8). Findings:Resident # 8 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, delayed development following protein-calorie malnutrition, dysphagia (trouble swallowing), gastrostomy status and dementia. Review of the physician's orders showed the prescribed diet for resident #8 was regular pureed texture, thin consistency, in addition to the following:Enteral Tube: Verify Tube Placement before each use, if unable to verify placement notify the physician.Enteral Tube: Check residual every shift. If greater than 60 milliliters (ml) hold feeding for one hour. If residual remains greater than 60 ml continue to hold feeding and notify physician.Enteral Tube Feeding Order: Bolus feeding with Jevity 1.5, 360 ml via gastrostomy tube (G-tube) three times daily for protein-calorie malnutrition. Flush the G-tube with 120 ml of water before and 120 ml of water after each feeding, three times a day. Enteral feeding (also referred to as tube feeding) is the delivery of nutrients through a feeding tube directly into the stomach, duodenum (first part of small intestine), or jejunum (middle part of small intestine). A G-tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube. Bolus feeding is the administration of a limited volume of enteral formula over brief periods of time, (retrieved from State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities on 8/07/26). Staff should verify the G-tube's correct position within the stomach or small intestine as a safety measure to prevent serious complications before administering anything through it. G-tube residual is the volume of formula or other liquid that remains in the stomach from a previous feeding. Checking this residual volume helps to monitor the digestive process and stomach emptying and helps prevent complications like aspiration. To check the residual, attach a 60 ml syringe to the G-tube port then slowly and gently pull back on the plunger to aspirate stomach contents. Continue drawing back until no more fluid can be easily withdrawn, avoiding excessive force that could irritate the stomach lining. Injecting air repeatedly can cause air trapping in the stomach, leading to discomfort, bloating or even aspiration risk if tube is not properly secured. Measure the collected fluid volume by reading the syringe markings, (retrieved from www.biologyinsights.com on 8/11/26). On 7/29/26 at 8:33 AM, resident #8 was observed in the dining room of the memory care unit assisted by staff for breakfast. Resident #8 refused her breakfast. The assigned Licensed Practical Nurse (LPN) B said she would administer resident #8's enteral feeding at 9:30 AM. On 7/29/26 at 9:30 AM, LPN B gathered her supplies and was joined by the Caring Way Unit Manager (UM), who requested to observe and assist LPN B. During the assessment for tube placement LPN B flushed a full 60 ml syringe of air into resident #8's G-tube. She flushed the tube two more times with air until the Caring Way UM intervened and stopped the nurse from flushing the tube with air again. LPN B told the UM she knew what she was doing and this was the way she had always done it. The LPN proceeded to flush the resident's tube with a syringe of water. She did not flush the 120 ml of water before the administration of the Jevity 1.5 per the physician order. LPN B then administered one container of Jevity 1.5 which the label indicated contained 237 ml. LPN B then filled the 60 ml syringe with water three times and flushed them each into the tube for a total amount of 180 ml after the feeding. Upon completion, both the Caring Way UM and LPN B acknowledged LPN B did not check for residual per procedure, nor did she flush the G-tube with the appropriate amount of water both before and after feeding. The Caring Way UM said LPN B required immediate education. On 7/30/26 at 1:35 PM, the Assistant Director of Nursing (ADON)/Staff Educator said she was not aware of what had happened during resident #8's tube feeding on 7/29/26. She said her expectation was for the nurse to aspirate for residual and push air only if auscultating. The ADON explained the procedure was to check for placement by aspirating residual and not by auscultation. The ADON said she was also not aware LPN B flushed with the incorrect amount of water before and after the feeding. On 7/30/26 at 2:50 PM, LPN B was in the hallway returning from lunch and verbally confirmed she administered only one container of Jevity 1.5 which was 237 ml. The nurse verified the physician's order was for administration of 360 ml. On 7/30/26 at 3:20 PM, the Director of Nursing (DON), Nursing Home Administrator (NHA), the ADON and the Caring Way UM said they were not aware the amount of Jevity 1.5 that was administered was incorrect. The Caring Way UM, ADON, DON and NHA all acknowledged the amount of tube feeding administered by LPN B was not as ordered by the physician. The facility's Standards and Guidelines on Enteral Nutrition revised September 2024 indicated, adequate nutritional support through enteral nutrition would be provided to residents as ordered.

Based on interview, and record review, the facility failed to prevent physical abuse of a vulnerable resident by another resident on the memory care unit, (#1), and failed to prevent neglect of a cognitively impaired resident exhibiting worsening behavior, (#2), for 2 of 6 residents reviewed for abuse/neglect, of a total sample of 6 residents. This failure contributed to resident #1 sustaining a fractured jaw which led to his transfer to an acute care hospital where he died 6 days later. On [DATE] at 9:40 PM, Certified Nursing Assistant (CNA) A witnessed resident #2 enter resident #1's room. Shortly after, resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. CNA A said when he got to resident #1's room, resident #2 was coming out with resident #1's sheets in his hands. CNA A explained he saw resident #1 lying on the bed in the dark with his feet hanging off the bed. The next morning, on [DATE] at approximately 7:30 AM, Registered Nurse (RN) F was notified by CNA E that she had observed discoloration to resident #1's face. The Advanced Practice Registered Nurse (APRN) was at the facility and assessed the resident at 11:40 AM. The APRN ordered x-rays of resident #1's face as well as labs. Mobile x-rays were done and the results revealed resident #1 had suffered an acute fracture of the left and right lower jaw with soft tissue swelling. The APRN ordered resident #1's transfer to an acute care hospital at approximately 7:00 PM on [DATE]. The hospital Emergency Department (ED) physician assessment dated [DATE] indicated resident #1's injuries were suspicious for non-accidental trauma, physical abuse or neglect. Resident #1 was not a candidate for surgery due to his advanced age and complex medical history. The resident was transferred to an inpatient hospice unit for comfort care on [DATE] and passed away five days later on [DATE]. The facility failed to prevent resident-to-resident physical abuse for a vulnerable, cognitively impaired resident, (#1), failed to ensure medical care was provided in a timely manner for an emergent injury, failed to ensure incidents of abuse were accurately documented in the medical record, and failed to ensure a cognitively impaired resident, (#2) with history of aggressive behaviors was appropriately monitored and supervised to help him attain his highest practicable level of mental health. These failures contributed to an unsafe environment and put all residents that resided in the memory care unit at risk for physical abuse, and neglect. These failures resulted in Immediate Jeopardy starting on [DATE]. There were a total of 60 residents residing in the facility's memory care unit. Findings: Cross Reference F610 and F835 1. Resident #1, an [AGE] year-old male, was initially admitted to the facility from an acute care hospital on [DATE] with diagnoses that included repeated falls, and adult failure to thrive. He was transferred to the hospital from the facility on [DATE] due to unresponsiveness and was treated for pneumonia and admitted to hospice services for senile degeneration of the brain. He was readmitted to the facility on [DATE] with additional diagnoses including palliative care, congestive heart failure, dementia, pain, and long-term use of anticoagulants. Review of the Discharge Minimum Data Set (MDS) dated [DATE], revealed resident #1 had severe cognitive impairment, required supervision for eating, and substantial to maximum assistance for all activities of daily living (ADLs). For bed mobility he required partial to moderate assistance. The physician order summary for [DATE] revealed physician orders including: Apixaban (blood thinner), 5 milligrams (mg) twice a day for clot prevention; Donepezil 5 mg, once a day, and 10 mg at bedtime, for dementia; Haloperidol tablet, 2 mg three times a day for brief psychosis; Lorazepam (Ativan) gel, 1 mg every 6 hours as needed for anxiety; Mirtazapine 15 mg for depression daily; Quetiapine Fumarate 25 mg at bedtime for brief psychotic disorder; and Trazodone, 100 mg every 8 hours for depression with restlessness. Review of a psychiatric note dated [DATE] revealed resident #1 suffered with anxiety but denied depressive symptoms. The note indicated he slept well, ate well, had no manic symptoms, no agitation, and his moods were better. He was noted to be confused and restless, but no other behaviors were noted by the provider. In a telephone interview on [DATE] at 4:38 PM, resident #1's wife stated her husband was admitted to the facility because she was unable to care for him at home due to his dementia. She explained he was initially admitted to the facility on [DATE] but was hospitalized again shortly afterwards. Resident #1's wife explained she requested the hospital not return him to the facility, but he had to return on [DATE], as they were unable to find a suitable bed elsewhere. She said she and the resident's brother would visit him almost daily. Resident #1's wife recalled on [DATE] she received a call from an unknown nurse at approximately 8:30 AM, informing her of discoloration found on her husband's face. She was told at that time they did not know what might have happened but believed it might have been caused by the bedrail. She recalled she had not seen her husband's injuries yet so did not argue with their explanation at that time. Resident #1's wife said she arrived at the facility around noon on [DATE] and he was sitting in his chair in the dining room. She remembered she was surprised when she saw the extent of the bruising on her husband's face and neck because it was worse than she imagined. She said the APRN, his nurse, and another female staff member whose name she could not recall were there when she saw him and the APRN said she would order an X-ray of his face and lab work. She said she told them at that time she did not believe this was caused by the bed rails because of how bad his face looked. Resident #1's wife explained she was told they did not know what happened to him, but they would investigate. She stated at approximately 1:00 PM, she tried to feed her husband his lunch, but he could not even open his mouth to chew, so he did not eat. She said she left the facility around 4:00 PM, and received a phone call at approximately 8:30 PM informing her the x-ray showed he had a broken jaw and lab work indicated he had an elevated white blood count (WBC) so he would be transferred to the hospital by non-emergency transport. She recalled the nurse told her it seemed another resident might have attacked him. Resident #1's wife recalled she went right away to the hospital and when she arrived, he was unresponsive, and he never opened his eyes to look at her again. She said she was unable to talk to him again and he passed away six days later on [DATE]. Resident #1's wife recalled the hospital physician told her that surgery and recovery could be complicated, so the best option for him was hospice to keep him comfortable, so he was transferred to inpatient hospice. She conveyed his death certificate said his death was undetermined and per the law enforcement detective she spoke with a few weeks ago, the autopsy report was still not released as it was still an active investigation. Review of a federal report filed by the facility on [DATE] at 8:24 PM, revealed the facility's Assistant Nursing Home Administrator (NHA). reported an incident that resulted in an allegation of serious bodily injury (fracture of left and right mandibular bone). The report contained information submitted by the facility which indicated the incident occurred the previous day on [DATE] at 9:40 PM, but staff became aware of the incident on [DATE] at 7:00 PM. The description of the incident/allegation included resident #1's roommate reported to the CNA that resident #2 was in the resident's room and had made contact with resident #1. The report described the CNA went to the room and observed resident #2 leaving the room with sheets from resident #1's bed. The document detailed that resident #1 was observed with skin discoloration the following morning, an x-ray was completed, and head-to-toe assessments were completed on both residents. Resident #2 was placed on one to one supervision and a psychiatric consult was ordered as well as lab work. Resident #1 was sent to the hospital by the physician for further evaluation and treatment. The summary of relevant records was added to the report on [DATE] at 11:39 AM, which revealed per review of the relevant resident records related to the incident, that resident #2 had behavior of wandering in and out of other residents' rooms. The facility noted both residents were cognitively impaired, and they did not verify the allegation as the facility reported there were no signs of mental anguish from either resident and no signs of pain upon assessment. The facility reported resident #2 lacked cognitive capacity so therefore could not have willful intent. On [DATE] at 5:06 PM, CNA A confirmed he was assigned to care for resident #1 on [DATE] on the 3 PM to 11 PM shift. He recalled on [DATE] he was sitting at the nurses' station on the locked Caring Way unit (400 hall) and LPN B was sitting near him. He conveyed that at approximately 9:40 PM, he observed resident #2 enter resident #1's room and shortly after that resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. CNA A said when he got to the room resident #2 was coming out with resident #1's sheets in his hands and kept walking towards his own room. CNA A explained he saw resident #1 lying on the bed with his feet hanging off, and he remembered the room was dark, so he had to use his phone light to see resident #1's face because the room lights were not working. He said he reported what happened to LPN B and asked her to go check on the residents. CNA A stated the nurse did not go to check on the residents, she scoffed and, kept doing what she was doing. He said he did not report this to anyone else such as a supervisor because he thought the LPN would report it. CNA A said he left the facility at the end of his shift around 11:00 PM that evening. He acknowledged he did not report the incident to anyone until his shift the next day on [DATE], when he was asked to provide a statement to the Director of Nursing (DON) and Assistant NHA. CNA A recalled he did not see resident #1 again on [DATE], but he noticed resident #2 had a swollen hand and was not on one to one supervision. CNA A said he wanted to make sure the true details of what happened to resident #1 were known. He said he believed some staff members disliked him for telling the truth and because he, actually did his job and cared for the residents. Review of resident #1's medical record revealed there were no progress notes, or nursing assessments documenting the incident on [DATE] or [DATE], in either resident #1 or resident #2's medical record. A change in condition note was completed on [DATE] at 7:55 AM, by RN F and the Assistant Director of Nursing (ADON) which noted a change in skin color or condition, notification to APRN, and an order for STAT (without delay) labs and x-ray of face and cervical spine. A skin check with an effective date [DATE] at 8:12 AM, noted the resident had discoloration on both sides of his jaw, right side of his neck, and multiple discolorations in different stages on both arms. A pain assessment was also documented by late entry by the ADON and RN F with an effective date of [DATE] at 8:10 AM, which revealed the resident was, cognitively intact and has reported their acceptable or baseline level of pain, on a scale of ,d+[DATE], was a 0. The nurses documented resident #1 was unable to specify or could not answer the questions regarding his pain. A hospital transfer form was completed by RN F on [DATE] at approximately 6:31 PM, (almost 24 hours after resident #1 was sent to the hospital). The form noted he was transferred to the hospital on [DATE] at around 8:53 PM, due to abnormal x-ray, he required a proxy, was non ambulatory, had no active infections, and incorrectly noted no wounds or bruises present. An undated SBAR (Situation, Background, Appearance, and Review/Notify) Communication Form completed by RN F inaccurately noted the physician was notified of the transfer on [DATE] at 12:00 AM. On [DATE] at 10:17 AM, LPN B said in a phone interview that on [DATE] she worked a double shift from 7 AM to 11 PM, on the locked Caring Way unit with resident #1 and resident #2. She said she was familiar with both residents. LPN B recalled resident #2 was known to walk into other residents' rooms and caused problems with the other residents. LPN B said resident #2 was known to become aggressive, get into people's faces and grab things from other residents, especially after his family left from visiting. She explained between herself and the other nursing staff they would have to distract him when they saw him going into other resident rooms, but he was not easily redirected. They had to constantly watch him. LPN B recounted on [DATE] at about 9:40 PM, she was passing medications on the unit and was not at the nurses' station. She said she did not witness resident #2 enter or exit resident #1's room nor did she see resident #1's roommate come to the nursing station. LPN B denied that CNA A reported any incidents to her at any time during the shift. LPN B said she saw resident #1 a few times that night and he received medications sometime around 10 PM with no issues. She said she did not notice any injuries and he did not appear to be in any discomfort. LPN B confirmed she did not know of the incident until she received a call from the Assistant NHA asking for her statement sometime later on [DATE]. She stated for any incident suspicious for abuse, staff were supposed to follow the process and report it to the on-call supervisor, perform a head-to-toe assessment and document the findings. LPN B acknowledged she worked with one other nurse to cover the memory care unit that night, and did not explain how she could see everything that happened on the unit if she was passing medications or working on the other side of the Caring Way unit. Review of resident #1's Medication Audit Report for [DATE] and according to LPN B's documentation, he received Trazadone 100 mg at 9:47 PM. No other medications were given to resident #1 by LPN B that evening. On [DATE] at 10:58 AM, RN F, in an interview conducted in Spanish per RN F's request, she stated that on [DATE] she worked a double shift from 7 AM to 11 PM on the locked memory care unit. RN F stated she felt it was difficult to perform her job safely because they were not able to provide enough supervision of the residents. She explained they typically had five CNAs working on the unit for 60 confused residents and when residents had behaviors like entering other residents' rooms they tried to offer them snacks or food to distract them but many of them were not redirectable. RN F recalled at the start of her shift that morning she was informed by CNA E of the bruise on resident #1's face. She remembered she assessed the resident along with CNA E and the overnight nurse, LPN D and noticed he had bruising around his face and on his neck. RN F said she notified the APRN at approximately 7:30 AM of the bruises but acknowledged at that time she was not aware of CNA A's observation and allegation of possible resident-to-resident abuse. She said she began to complete her usual assessments and documentation and was unsure what time she called resident #1's wife to tell her about the bruise on his face. RN F stated the resident's wife arrived around the same time as the APRN, and x-rays were ordered. She said she believed this occurred because there was not enough staff working on that unit to provide supervision for the residents who were constantly wandering. On [DATE] at 11:18 AM, CNA E recalled that on [DATE] resident #1 had difficulty eating and opening his mouth during morning care that day. She remembered when she started doing room rounds at approximately 7:15 AM, she went to resident #1's room, which was the last room at the end of the hall. She recalled resident #1's bed was by the window, but she could see the bruise on his cheek from the doorway. She said she did not recall seeing the bruise when she left the previous day on [DATE]. She informed RN F and the night shift nurse, LPN D, and they went to see him. CNA E recalled the resident had bruises on both sides of his face, by his chin area and on his neck, (see photo evidence obtained). LPN D told them she had not witnessed any incidents during her shift and had not seen any bruising on his face previously. CNA E said she was unable to put resident #1's dentures in his mouth that morning because he could not open his mouth, and he did not want to eat all day. She recalled that on [DATE], resident #1's brother was at the facility during lunch time and resident #1 did not want to eat and was very tired. His brother asked for him to be put to bed so she brought his lunch tray into the room and his brother offered to try to feed him. She said when the brother left, the tray was still untouched. Review of the Documentation Survey Report for [DATE], revealed that on [DATE] the assigned CNA documented resident #1 was not available for breakfast and lunch but for dinner he had 0% intake of food and refused fluids. On [DATE] at 12:50 PM, LPN D said she was the assigned nurse for resident #1 on [DATE] on the 11 PM to 7 AM shift. She said she received report from the nurse that resident #2 was doing his usual wandering in and out of rooms all night, but was not told of any incidents. She did not recall any issues with resident #1's face and said she did not give him any medications during her shift. LPN D said she became aware of the bruising to the resident's face at the end of her shift by CNA E. She recalled at approximately 7:30 AM she went to see him with CNA E and RN F, and he had bruises on both sides of his face and neck. She acknowledged resident #2 was not placed on one to one supervision until the late afternoon of [DATE] after the facility was made aware of the allegation by CNA A of resident-to-resident assault towards resident #1. LPN D recalled resident #2 continued to be on one to one supervision until [DATE] when he was transferred to the hospital. LPN D acknowledged if she had been told of the incident during report that night she would have known to provide closer supervision for resident #2 to prevent any further incidents. On [DATE] at 12:39 PM, the APRN said in a phone interview that she received a call sometime in the morning of [DATE] from RN F saying that she found a bruise on resident #1's cheek. She said she evaluated resident #1 at approximately 11:40 AM and his wife was at the bedside. The APRN recalled he had a small bruise to the left cheek and another to the right cheek and neck, but said he did not appear to be in distress. She ordered an x-ray of his face, blood work, and UA to rule out infection. She said she called the East Coast UM to inform her of resident #1's bruising and x-ray order but was not aware of any reported incident of abuse at that time. She did not recall having any other conversations about resident #1, until she received a call later that day from the nurse reporting the fractured jaw and elevated WBCs. The APRN said she gave orders to transfer him to the hospital for further evaluation due to elevated WBCs, but she knew they would not be able to do anything about his broken jaw. Review of resident #1's radiology report dated [DATE] at 3:53 PM, reviewed on [DATE] at 9:44 PM, revealed an x-ray of the facial bones and cervical spine had been done at around 2:45 PM and results were reported at around 3:53 PM. The reason for the exam was due to swollen cheek and neck. The cervical spine showed scoliosis, mild degenerative osteoarthritic changes but no acute fractures. The face showed an acute fracture of the right and left mandible (lower jaw) at the junction of the body and symphysis with mild distraction but without significant angulation, accompanied by soft tissue swelling and possible acute bilateral frontal sinusitis. Review of the hospital radiology report dated [DATE] for a computed tomography (CT) of the facial bones revealed the reason for the exam was unknown trauma and jaw bruising. The findings included moderately displaced bilateral (both sides) anterior (towards the back) mandibular ramus fracture which appeared acute, without evidence of underlying lesion or callus. A CT of the head performed the same day included findings of no lytic (localized loss of bone tissue) or blastic (new bone growth) abnormalities were demonstrated. The hospital Emergency Department (ED) physician assessment dated [DATE] indicated resident #1's injuries were suspicious for non-accidental trauma, physical abuse or neglect. The ED physician's note indicated he was told by the resident's wife on [DATE] that she was informed that another facility resident physically assaulted her husband last night in bed. The mandible is the largest and strongest bone of the face, which forms the lower jawline. Mandibular fractures typically occur in two places, the parasymphysis (front of the jaw) and the condylar neck (the portion of the jaw that connect to the joint of the jaw). A mandibular ramus fracture is a fracture to the flat part of the jaw bone located at the back portion on each side of the face. This type of fracture is usually due to trauma including interpersonal violence/assault, motor vehicle accident, falls, and sports activities. A mandibular ramus fracture is rare, and a pathological (due to underlying disease) mandibular fracture is even more rare, accounting for less than 2% of all mandibular fractures. Pathological fractures usually follow surgical interventions such as third molar removal, infection of the jaw bones, tumors or severe bone loss due to certain medications called bisphosphonates or radiation. External signs of a fracture in this area include a displaced or elongated mandible and the skin may show hematoma or ecchymosis (bruising). A two-dimensional x-ray may not give an accurate picture of the fracture, but a CT scan is better at identifying fractures and provided a better image quality to decrease the chance of an interpretation error. The most common complication of this type of fracture was infection, especially if there was a prolonged time prior to treatment, (retrieved on [DATE] from www.ncbi.nlm.nih.gov). Broken lower jawbones are painful and may affect your breathing. You need immediate medical care if you break your jaw, and you may need surgery if it is a severe fracture. A broken jawbone is a medical emergency regardless of what part of your jawbone is broken. You may notice your jaw or cheek are bruised, or swollen, and you may not be able to close your mouth or open it wide. It would be painful when you chew food or talk, it may look like you have swelling or bruising to the jaw or cheek. A broken jaw may affect your ability to eat, speak or breathe, and may take weeks to heal even if surgery is not required (retrieved on [DATE] from www.myclevelandclinic.org). On [DATE] at 2:46 PM, the facility's reportable log for [DATE] was reviewed with the NHA, Assistant NHA, and DON. The NHA stated she was the facility's Risk Manager but at the time of the reportable incident, on [DATE], the Assistant NHA performed the role, and the DON was the Abuse Coordinator. The Assistant NHA said she first learned of the incident on [DATE] at about 3:30 PM, when she was notified by staff that an x-ray result for resident #1 showed he had sustained a fractured jaw. She said she alerted the DON, who was not at the facility that day, but arrived at approximately 4:00 PM. The Assistant NHA said although she was the Risk Manager, she was not made aware of the discoloration found on resident #1's face that morning by CNA E and RN F. The DON and Assistant NHA said they became involved in the investigation at that point, when the DON arrived and started gathering witness statements from the previous night's staff. They said CNA A worked the 3 PM to 11 PM shift on [DATE] and was interviewed in person by the DON and Assistant NHA on [DATE]. They said at that time they learned of his allegation of a possible resident-to-resident incident that occurred the previous evening of [DATE]. They said, CNA A's statement indicated he, ran down the hallway to escort [resident #2 name] personally. When I arrived to the room [resident #1's name] legs were halfway off the bed and I proceeded to fix him and ask if he was ok because [resident #2 name] took his blankets and dragged them, which he also put me in a headlock where I had to receive help from a co-worker to get him off of me which I reported to the nurse. The Assistant NHA said that LPN B assessed resident #1 that evening and did not notice any injuries. The Assistant NHA was unable to provide documentation of any assessment completed by LPN B that evening. The DON acknowledged there was no documentation of the incident, or report of the allegations made by the CNA, nor any head-to-toe assessment documented by the nurse. The DON said the nurse did not document because she did not notice any injuries to resident #1, and resident #2 was at his baseline always going in and out of other resident rooms. She explained it was normal for residents in the locked unit to wander in and out of other residents' rooms because they had dementia. The DON said, Because the fracture was not treatable there was no need to send the resident out [to the hospital] but because of his elevated blood count he was sent out and the wife agreed. They were unable to provide documentation to show any assessments completed that night for resident #1 or #2. They said they interviewed LPN B by phone, who had worked a double shift on [DATE] from 7 AM to 11 PM. LPN B told them that on the morning of [DATE] there had been no issues with resident #1 except he was sleepy during lunch and his family asked for him to be put in bed. She said his family stayed until early to mid-evening and she gave him medication at approximately 10:00 PM. He did not complain of pain, was not in any distress, and fell back to sleep. They explained LPN B checked on him again at around 10:30 PM and he was still sleeping comfortably. The Assistant NHA said the 11 PM to 7 AM staff were interviewed and both the CNA and LPN gave the same statement. CNA C and LPN D said they provided incontinence care for resident #1 at approximately 1:00 AM to 2:00 AM on [DATE] and they did not notice any injuries to the resident at that time. LPN D told them resident #1 did not receive any medications during her shift, and she first became aware of the discoloration prior to leaving on [DATE] when she was asked to go to his room by the morning nurse and CNA. She said she noticed that he had a discoloration to the left side of his jaw. The Assistant NHA said that resident #1's roommate was interviewed on [DATE] but he did not recall the incident or what he reported to CNA A. Both the DON and Assistant NHA confirmed they had not been notified on [DATE] regarding CNA A's allegations of a possible resident-to-resident incident. They confirmed LPN B said she did not witness or receive report from CNA A regarding resident #2 coming out of resident #1's room, the roommate's allegation about the attack, nor of him being put in a headlock by resident #2. The Assistant NHA explained CNA E was the first one who noticed resident #1's injuries on [DATE] during her morning rounds at approximately 7:30 AM. She told them in her statement she saw the discoloration to one side of his face and notified RN F and LPN D. They stated RN F called the APRN who was already at the facility doing rounds that morning and called resident #1's wife at approximately 8:30 AM to notify her of the bruises. They said a head-to-toe assessment was done and they started completing the incident report. The Assistant NHA and DON explained at around 11:40 AM (four hours after the bruises were first noticed and reported) the APRN evaluated resident #1 with his wife at the bedside. They said at that time the APRN ordered an x-ray of the resident's face, labs, and a UA to rule out a UTI. The x-ray and labs results were obtained at approximately 3:30 PM which confirmed he had a broken jaw and elevated WBCs. The Assistant NHA and DON said the APRN was notified shortly after that time, and an order was given for him to be transferred to the hospital via non-emergency transport for further evaluation. The Assistant NHA and DON said they notified DCF, who did not accept the case, and law enforcement at approximately 8:00 PM and completed their immediate reporting to the State Agency. They said resident #1 was transported to the hospital at approximately 8:30 PM and his wife was notified. The DON said resident #2 was placed on one to one supervision at that time on [DATE] as a preventative measure during the investigation to keep other residents safe. They confirmed resident #2 had behaviors such as wandering into other resident rooms and he could become aggressive after family visited but said he had never attacked another resident. They stated staff education on abuse/neglect was initiated on [DATE] in an abundance of caution. The Assistant NHA said they were unable to verify the allegations made by CNA A because no other staff could corroborate the story and resident #1's roommate could not recall making the allegations. They explained LPN B said she did not witness or receive report from CNA A that night regarding the incident and there were no injuries noted on resident #1. The Assistant NHA said the investigation was concluded on [DATE] with no conclusive explanation for resident #1's injuries. Review of the lab results of [DATE] revealed resident #1's WBCs were 13.49 out of a range of 3.90 (low) to 11.20 (high). Review of resident #1's mobile radiology report revealed the x ray results were reported to the facility on [DATE] at 3:53 PM. On [DATE] at 6:40 PM, a standard phone order was given by the APRN to send resident #1 to the hospital for evaluation and treatment, almost three hours after the jaw fractures were reported to the facility. Review of the hospital's inpatient hospice unit notes dated [DATE] revealed resident #1 was sent to the hospital due to being abused by another resident with cognitive issues. He had two fractures to his jaw and bruising as a result of the abuse and there was an open investigation regarding the lack of supervision to keep him safe. The note indicated his wife was very upset and angry as a result of his injuries because she had been reluctant to send him back to the facility after his last hospital admission but there was no other place that would offer him placement. A hospice note dated [DATE] revealed resident #1 was laying on his left side and had oral secretions draining. His breathing was slightly labored, and his tongue obstructed his airway along with the secretions. The note indicated resident #1 was actively dying and his wife was emotionally distraught by the attack on her husband at the facility by another resident. 2. Review of the medical record revealed resident #2, a [AGE] year-old male was admitted to the facility on [DATE] from an in-patient psychiatric hospital with diagnoses that included Alzheimer's Disease, major depressive disorder, recurrent severe, anxiety disorder, cognitive impairment, mild neurocognitive disorder, hypermobility syndrome, and affective mood disorder with other behavioral disturbance. The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) of [DATE] noted resident #2 was rarely/never understood and unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed the resident had short-term and long-term memory problems, his cognitive skills for daily decision making were severely impaired, and no acute mental status changes occurred. For 4 to 6 days, the resident had physical and verbal behaviors directed towards others, other behaviors not directed towards others, rejection [TRUNCATED]

Based on interview and record review the facility failed to conduct an accurate and thorough investigation related to an allegation of resident to resident physical abuse of a vulnerable, cognitively impaired resident, (#1), failed to investigate an injury of unknown origin for the same event when abuse was not substantiated, including completely and thoroughly documenting investigative findings, to ensure the safety of all vulnerable residents on the memory care unit. This failure contributed to resident #1's injury, transfer to a higher level of care where he died 6 days later. Per the facility's 5-Day report to the state agency, on [DATE] at approximately 4:00 PM, Certified Nursing Assistant (CNA) A reported to administrative staff that during his shift, the previous day, on [DATE] at approximately 9:40 PM, resident #1's roommate reported to him he had seen resident #2 in their room, making contact with resident #1. CNA A went to the room and observed resident #2 exiting with resident #1's bed sheets. The next morning on [DATE] staff reported discoloration to resident #1's face to the provider so an x-ray and lab work were ordered. The x-ray revealed fractures of the left and right jaw. Head-to-toe assessments and pain evaluations were reported to be completed on both residents. Resident #2 was put on one-to-one observation, and psychiatry was consulted. Notification to the physician, resident representatives, law enforcement, and Department of Children and Families (DCF) were completed. The facility concluded the allegations were not verified because there was no, mental anguish for either of the residents. The facility reported resident #2 lacked the cognitive capacity for willful intent. The facility's failure to complete a thorough investigation, maintain accurate records of investigative findings, and ensure appropriate corrective actions were implemented, placed resident #1 and other cognitively impaired residents that resided in the memory care unit at risk for physical abuse and neglect. Resident #1 passed away on [DATE] of unknown causes and death is under investigation with DCF and law enforcement at the time of this survey. This failure resulted in Immediate Jeopardy starting on [DATE]. There were a total of 60 current residents that resided in the memory care unit. Findings: Cross Reference F600 and F835 Resident #1, an [AGE] year-old male, was initially admitted to the facility from an acute care hospital on [DATE] with diagnoses that included repeated falls, and adult failure to thrive. He was transferred to the hospital from the facility on [DATE] due to unresponsiveness and was treated for pneumonia and admitted to hospice services for senile degeneration of the brain. He was readmitted to the facility on [DATE] with additional diagnoses including palliative care, congestive heart failure, dementia, pain, and long-term use of anticoagulants. Review of the Discharge Minimum Data Set (MDS) dated [DATE], revealed he had severe cognitive impairment, required supervision for eating, and substantial to maximum assistance for all activities of daily living (ADLs). He exhibited behaviors such as physical and verbal aggression towards others, and rejection of care. Review of the facility's Reportable Incidents Log from [DATE] to [DATE] revealed there was a physical abuse allegation that involved resident #1 and #2 on [DATE]. On [DATE] at 2:46 PM, the facility's reportable log for [DATE] was reviewed with the Nursing Home Administrator (NHA), Assistant NHA, and the Director of Nursing (DON). The NHA stated she was the facility's Risk Manager but at the time of the reportable incident, on [DATE], the Assistant NHA performed the role, and the DON was the Abuse Coordinator. The Assistant NHA said she first learned of the incident on [DATE] at about 3:30 PM, when she was notified by staff that an x-ray result for resident #1 showed he had sustained a fractured jaw. She said she alerted the DON, who was not at the facility that day, but arrived at approximately 4:00 PM. The Assistant NHA said although she was the Risk Manager, she was not made aware of the discoloration found on resident #1's face that morning by CNA E and Registered Nurse (RN) F. The DON and Assistant NHA said they became involved in the investigation at that point, when the DON arrived and started gathering witness statements from the previous night's staff. They said CNA A worked the 3 PM -11 PM shift on [DATE] and was interviewed in person by the DON and Assistant NHA on [DATE]. They said at that time they learned of his allegation of a possible resident-to-resident incident that occurred the previous evening of [DATE]. They said, CNA A's statement indicated he, ran down the hallway to escort [resident #2 name] personally. When I arrived to the room [resident #1's name] legs were halfway off the bed and I proceeded to fix him and ask if he was ok because [resident #2 name] took his blankets and dragged them, which (when) he also put me in a headlock where I had to receive help from a co-worker to get him off of me which I reported to the nurse. The Assistant NHA said that Licensed Practical Nurse (LPN) B assessed resident #1 that evening and did not notice any injuries. The Assistant NHA was unable to provide documentation of any assessment completed by LPN B that evening. The DON acknowledged there was no documentation of the incident in the medical record, or report of the allegations made by the CNA, nor any head-to-toe assessment documented by the nurse. The DON explained the nurse did not document an assessment because she did not notice any injuries to resident #1 and resident #2 was at his baseline always going in and out of other resident rooms. She did not answer how anyone would know resident #1's assessment was within normal limits or even performed as the nurse alleged, if there was not an assessment documented at all. The DON explained it was normal for residents in the locked unit to wander in and out of other residents' rooms because they had dementia. In regard to why resident #1 was not sent out to the hospital immediately when the fractures were known, the DON explained, Because the fracture was not treatable there was no need to send the resident out [to the hospital] but because of his elevated blood count he was sent out and the wife agreed. The DON, and Adminstrator were unable to provide documentation to show any assessments completed that night on resident #1 or #2. They said they interviewed LPN B by phone, who had worked a double shift on [DATE] from 7 AM to 11 PM. LPN B told them that on the morning of [DATE] there had been no issues with resident #1 except he was sleepy during lunch and his family asked for him to be put in bed. She said his family stayed until early to mid-evening and she gave him medication at approximately 10:00 PM. He did not complain of pain, was not in any distress, and fell back to sleep. They explained LPN B checked on him again at around 10:30 PM and he was still sleeping comfortably. The Assistant NHA said the 11 PM-7 AM staff were interviewed and both the CNA and LPN gave the same statement. CNA C and LPN D said they provided incontinence care for resident #1 at approximately 1:00 AM to 2:00 AM on [DATE] and said they did not notice any injuries to the resident at that time. LPN D told them resident #1 did not receive any medications during her shift, and she first became aware of the discoloration prior to leaving on [DATE] when she was asked to go to his room by the morning nurse and CNA. She said she noticed that he had a discoloration to the left side of his jaw. The Assistant NHA said that resident #1's roommate was interviewed on [DATE] but he did not recall the incident or what he reported to CNA A. Both the DON and Assistant NHA confirmed they had not been notified on [DATE] regarding CNA A's allegations of a possible resident-to-resident incident. They confirmed LPN B said she did not witness or receive report from CNA A regarding resident #2 coming out of resident #1's room, the roommate's allegation about the attack, nor of him being put in a headlock by resident #2. The Assistant NHA explained CNA E was the first one who noticed resident #1's injuries on [DATE] during her morning rounds at approximately 7:30 AM. She told them in her statement she saw the discoloration to one side of his face and notified RN F and LPN D. They stated RN F called the Advance Practice Registered Nurse (APRN) who was already at the facility doing rounds that morning and called resident #1's wife at approximately 8:30 AM to notify her of the bruises. They said a head-to-toe assessment was done and they started completing the incident report. The Assistant NHA and DON explained at around 11:40 AM (four hours after the bruises were first noticed and reported) the APRN evaluated resident #1 with his wife at the bedside. They said at that time the APRN ordered an x-ray of the resident's face, labs, and a UA to rule out a UTI. The x-ray and labs results were obtained at approximately 3:30 PM which confirmed he had a broken jaw and elevated white blood count (WBC)s. The Assistant NHA and DON said the APRN was notified shortly after that time, and an order was given for him to be transferred to the hospital via non-emergency transport for further evaluation. The Assistant NHA and DON said they notified DCF, who did not accept the case, and law enforcement then completed their immediate reporting to the State Agency at approximately 8:00 PM, almost 24 hours after CNA A alleged the resident-to-resident abuse occurred, approximately 13 hours after resident #1's injuries were first reported by CNA E, and almost four and a half hours after the fractures were identified. The Assistant NHA and DON said resident #1's wife was notified, and he was transported to the hospital at approximately 8:30 PM, approximately 5 hours after the fractures were first identified. The DON said resident #2 was placed on one-to-one supervision at that time on [DATE] as a preventative measure during the investigation to keep other residents safe. They confirmed resident #2 had behaviors such as wandering into other resident rooms and he could become aggressive after family visited but said he had never attacked another resident. The Assistant NHA said they were unable to verify the allegations made by CNA A because no other staff could corroborate the story and resident #1's roommate could not recall making the allegations. They explained LPN B said she did not witness or receive report from CNA A that night regarding the incident and per her statement there were no injuries noted on resident #1. The Assistant NHA said the investigation was concluded on [DATE] with no conclusive explanation for resident #1's injuries. She did not say why they did not investigate to determine the cause of resident #1's injuries at that time if they did not find a likely reason for resident #1's injuries. Review of the lab results of [DATE] revealed resident #1's WBCs were 13.49 out of a range of 3.90 (low) to 11.20 (high). Review of resident #1's mobile radiology report revealed the x ray results were reported to the facility on [DATE] at 3:53 PM. On [DATE] at 6:40 PM, a standard phone order was given by the APRN to send resident #1 to the hospital for evaluation and treatment, almost three hours after the jaw fractures were reported to the facility. In a progress note dated [DATE] at 8:53 PM, RN G documented APRN notified of lab results, resident transferred to the local hospital. Another progress note by RN G dated [DATE] at 9:43 PM, indicated the x-ray results were reviewed with the APRN, and the resident was at the hospital. Broken lower jawbones are painful and may affect your breathing. You need immediate medical care if you break your jaw, and you may need surgery if it is a severe fracture. A broken jawbone is a medical emergency regardless of what part of your jawbone is broken. You may notice your jaw or cheek are bruised, or swollen, and you may not be able to close your mouth or open it wide, (retrieved on [DATE] from www.myclevelandclinic.org). In a telephone interview on [DATE] at 4:38 PM, resident #1's wife stated her husband was admitted to the facility because she was unable to care for him at home due to his dementia. She explained he was initially admitted to the facility on [DATE] but was hospitalized again shortly afterwards. Resident #1's wife explained she requested the hospital not return him to the facility, but he had to return on [DATE], as the hospital was unable to find a suitable bed elsewhere. She said she and the resident's brother would visit him almost daily. Resident #1's wife stated she felt there was a safety issue at the facility. She said in the lunchroom several family members saw a man and a woman fight while two staff members sat on the floor, each looking at their phones instead of observing the residents. She explained she mentioned to staff at least three times to put their phones down and pay attention to the residents before something happened. Resident #1's wife relayed this was why she was trying to transfer her husband to another facility in the area. She recalled on [DATE] she received a call from the facility at approximately 8:30 AM, informing her of discoloration found on her husband's face. She was told at that time they did not know what had happened but believed it might have been caused by the bedrail. She recalled she had not seen her husband's injuries yet, so she did not argue with their explanation at that time. Resident #1's wife said she remembered when she arrived at the facility she was surprised at the extent of the bruising on her husband's face and neck because it was worse than she imagined. She said the APRN, the nurse, and another staff member whose name she could not recall were there and the APRN said she would order an X-ray of his face and lab work. She said she told them at that time she did not believe this was caused by the bed rails because of how bad his face looked. Resident #1's wife explained she was told they did not know what happened to him, but they would investigate. She said she left the facility around 4:00 PM, and received a phone call at approximately 8:30 PM letting her know the x-ray showed he had a broken jaw and lab work indicated he had elevated WBC so he would be transferred to the hospital by non-emergency transport. She recalled the nurse told her it seemed another resident might have attacked him. Resident #1's wife recalled she went right away to the hospital and when she arrived, he was unresponsive, and he never opened his eyes to look at her again. She said she was unable to talk to him again and he passed away six days later on [DATE]. Resident #1's wife recalled the hospital physician told her that surgery and recovery could be complicated due to his age and medical history, so the best option for him was hospice to keep him comfortable. He was transferred to inpatient hospice. She recalled she told the staff present; this was not the bedrails that caused this because of the extent of his wounds. She said she was upset and left the facility but took pictures of his face to keep as proof. On [DATE] at 5:06 PM, CNA A said that on [DATE] he was sitting at the nurses' station on the Caring Way unit (400 hall locked unit) and LPN B was sitting with him. At around 9:40 PM he observed resident #2 enter resident #1's room and shortly after that resident #1's roommate went to the nurses' station and said he saw resident #2 in his room on top of resident #1. CNA A said when he got to the room resident #2 was coming out with resident #1's sheets in his hands and kept walking towards his room. Resident #1 was lying with his feet hanging off the bed and he had to use his phone light to see resident #1's face because the room lights were not working. He said he reported what he saw to the nurse and told her to go check on both residents, but she scoffed and just kept doing what she was doing. He did not go above the nurse and report to a supervisor because he expected her to do it. He reported the incident to the DON and ANHA on [DATE] sometime in the evening. CNA A said he did not recall seeing resident #1 when he returned for his shift on [DATE], but he saw resident #2 had a swollen hand and was not on 1:1 supervision. He recalled other incidents involving resident #2 including him exiting the facility during the ,d+[DATE] PM shift and CNA A and another staff member attempting to get him back, and resident #2 punching a pregnant CNA in the stomach. He said he was not sure if these incidents had been reported but staff had been reporting his aggressive behaviors to administration, but nothing was done. On [DATE] at 5:06 PM, CNA A confirmed he was assigned to care for resident #1 on [DATE] on the 3 PM to 11 PM shift. He recalled on [DATE] he was sitting at the nurses' station on the locked Caring Way unit (400 hall) and LPN B was sitting near him. He conveyed that at approximately 9:40 PM, he observed resident #2 enter resident #1's room and shortly after that resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. CNA A said when he got to the room resident #2 was coming out with resident #1's sheets in his hands and kept walking towards his own room. CNA A explained he saw resident #1 lying on the bed with his feet hanging off, and he remembered the room was dark, so he had to use his phone light to see resident #1's face because the room lights were not working. He said he reported what happened to LPN B and asked her to go check on the residents. CNA A stated the nurse did not go to check on the residents, she scoffed and, kept doing what she was doing. He said he did not report this to anyone else such as a supervisor because he thought the LPN would report it. CNA A said he left the facility at the end of his shift around 11:00 PM that evening. He acknowledged he did not report the incident to anyone until during his shift the next day on [DATE], when he was asked to provide a statement to the Director of Nursing (DON) and Assistant Nursing Home Administrator (NHA). CNA A recalled he did not see resident #1 again on [DATE], but he noticed resident #2 had a swollen hand and was not on 1:1 supervision. CNA A said he wanted to make sure the true details of what happened to resident #1 were known. He said he believed some staff members disliked him for telling the truth and because he actually did his job and cared for the residents. On [DATE] at 10:17 AM, LPN B said in a phone interview that on [DATE] she worked a double shift from 7 AM to 11 PM, on the locked Caring Way unit with resident #1 and resident #2. She said she was familiar with both residents. LPN B recalled resident #2 was known to walk into other residents' rooms and caused problems with the other residents. LPN B said resident #2 was known to become aggressive, get into people's faces and grab things from other residents, especially after his family left from visiting. She explained between herself and the other nursing staff they would have to distract him when they saw him going into other resident rooms, but he was not easily redirected. They had to constantly watch him. LPN B recounted on [DATE] at about 9:40 PM, she was passing medications on the unit and was not at the nurses' station. She said she did not witness resident #2 enter or exit resident #1's room nor did she see resident #1's roommate come to the nursing station. LPN B denied that CNA A reported any incidents to her at any time during the shift. LPN B said she saw resident #1 a few times that night and he received medications sometime around 10 PM with no issues. She said she did not notice any injuries and he did not appear to be in any discomfort, but acknowledged she did not document these findings. LPN B confirmed she did not know of the incident until she received a call from the Assistant NHA asking for her statement sometime later on [DATE]. She stated for any incident of suspicious abuse, staff were supposed to follow the process and report it to the on-call supervisor, perform a head-to-toe assessment and document the findings. LPN B acknowledged she worked with one other nurse to cover the memory care unit that night, and did not explain how she could see everything that happened on the unit if she was passing medications or working on the other side of the Caring Way unit. Review of resident #1's Medication Audit Report for [DATE] and per LPN B's documentation he received Trazadone 100 milligrams for depression at or around 9:47 PM. On [DATE] at 12:50 PM, LPN D said she was the assigned nurse for resident #1 on [DATE] on the 11 PM to 7 AM shift. She said she received report from the nurse that resident #2 was doing his usual wandering in and out of rooms all night, but was not told of any incidents. LPN D acknowledged resident #2 was not placed on one-to-one supervision, until the late afternoon of [DATE] after the facility was made aware of the fracture and allegation by CNA A of resident-to-resident assault towards resident #1. LPN D recalled resident #2 continued to be on one-to-one supervision until [DATE] when he was transferred to the hospital. The nurse acknowledged if she had been told of the incident during report that night she would have known to provide closer supervision for resident #2 to ensure there were no further incidents. In telephone interviews on [DATE] at 8:57 AM and again on [DATE] at 7:50 PM, resident #2's son recalled he was told by a nurse while visiting his father on Christmas day that his father had attacked another resident. He explained he had spoken with other nurses at the facility after that, and they were all aware of the incident between his father and the other resident (#1), but no one would say they had witnessed anything. He said his father was eventually transferred to the hospital on [DATE]. At the hospital they found bruises on both of his arms and a cut on the elbow that looked infected, which he did not know the origin of. The son recalled other incidents including when his father being attacked after he wandered into another resident's room and took some cookies. Another incident his mother witnessed when his father was grabbed by another resident and choked, and another incident with that same resident, his father was bitten on the hand, which he said he had pictures of. Resident #2's son stated he was not aware of any reports or investigations by the facility related to those incidents even though staff were present. On [DATE] at 11:18 AM, CNA E stated she worked the 7 AM to 3 PM shift on [DATE] and was the first person to see and report the discoloration to resident #1's face. She reported it to RN F at approximately 7:30 AM. During morning care on [DATE], resident #1 was unable to open his mouth for his dentures. He did not want to eat his meals that day but also remembered that he did not want to eat the previous day, [DATE] when his brother and wife visited. In a second phone interview on [DATE] at 12:20 PM, resident #1's wife recalled she had been at the facility Christmas day, [DATE] at approximately 11:15 AM and her brother-in-law arrived a little later. She conveyed that when she arrived, they had her husband sitting up in the dining room of the Caring Way unit and were getting ready to serve him lunch. His lunch tray arrived but he did not want to eat it. She said he did not have any noticeable injuries on his face at that time and was not complaining of any pain but was very sleepy. In a phone interview on [DATE] at 8:41 AM, resident #1's brother explained he visited the facility Christmas day, [DATE] with his brother's wife. He did not notice any injuries on his brother's face at that time. He was sitting in his wheelchair in the dining room of Caring Way unit with lunch tray in front of him. The brother explained the resident usually required only prompting to eat but was able to feed himself. They attempted to feed the resident, but he would not eat the food. They told the assigned CNA to lay him down since he was very sleepy, and she brought the tray to the room to see if he would eat his Christmas lunch at some point. The CNA left the tray at the bedside, but he said his brother was not interested in eating. He said he left the facility at around 5:00 PM. Review of the Documentation Survey Report for [DATE], revealed that on [DATE] the assigned CNA erroneously documented resident #1 was not available for breakfast and lunch but for dinner he had 0% intake of food and refused fluids. On [DATE] the CNA documented that he ate 25% of his breakfast, 50% of his lunch, and 25 % of his dinner, in conflict with resident #1's wife's statement that he did not eat that day. On [DATE] at 10:58 AM, RN F in an interview conducted in Spanish per RN F's request, she stated on [DATE] she worked a double shift from 7 AM to 11 PM on the locked memory care unit. RN F recalled at the start of her shift that morning she was informed by CNA E of the bruise on resident #1's face. She remembered she went to his room and assessed the resident along with CNA E and the overnight nurse, LPN D, and noticed he had bruising around his face and on his neck. RN F said she notified the APRN at approximately 7:30 AM, of the bruises but acknowledged at that time she was not aware of CNA A's observation and allegation of possible resident-to-resident abuse. RN F stated the resident's wife arrived at the facility after she was notified, around the same time as the APRN, and an x-ray was ordered. On [DATE] at 12:39 PM, the APRN said in a phone interview that she received a call sometime in the morning of [DATE] from RN F to report a bruise on resident #1's cheek. She said she evaluated resident #1 at approximately 11:40 AM and his wife was at the bedside. The APRN recalled he had a small bruise to the left cheek and another to the right cheek and neck, but said he did not appear to be in any distress. She ordered an x-ray of his face, blood work, and urinalysis (UA) to rule out infection. She said she called the East Coast Unit Manager (UM) to inform her of resident #1's bruising and x-ray order but was not aware of any reported incident of abuse at that time. She did not recall having any other conversations about resident #1, until she received a call later that day from the nurse reporting the fractured jaw and elevated WBC. The APRN said she gave orders to transfer him to the hospital for further evaluation due to the elevated WBCs, but she knew they would not be able to do anything about his broken jaw. On [DATE] at 4:02 PM, in a second interview with the Assistant NHA, DON, [NAME] President of Operations, and Regional Nurse Consultant (RNC), the Assistant NHA stated that CNA A's allegations were not corroborated by any other staff member. She explained they did not have an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting in person but held a phone conference with the Medical Director to inform him of what they knew at that time. The Assistant NHA said during the scheduled monthly QAPI meeting in January they discussed what happened in December. She explained the Medical Director was made aware of the fracture once they received the results of the x-ray sometime after 3:00 PM on [DATE]. The Assistant NHA stated they concluded the allegations that resident #1 was injured by resident #2 were not verified. She verified no call was made to resident #2's representative to report a change in condition on [DATE] when he was placed on one to one supervision and psychiatry was consulted nor of the allegation resident #2 was the aggressor in the incident with resident #1. On [DATE] at 10:36 AM, in another interview with the DON, Assistant NHA, NHA, RNC, East Coast UM, and the Assistant DON, the DON stated she was unable to give a timeline of when the events happened because she was not made aware of the allegations until after the x-ray results had resulted. The DON stated that the UM was the first person notified by the nurse of the discoloration on the morning of [DATE]. The UM said that she did not speak with the nurse on [DATE] about the incident because she had spoken to the APRN. The UM recalled she received a call from the APRN at approximately 11:40 AM to inform her of resident #1's discoloration and x-ray order. The UM then called the Assistant DON, who was not at work and the Assistant NHA about the discoloration to resident #1's cheek. The DON explained CNA E, the day shift CNA was not interviewed right away, and she was the first person to see the discoloration. The DON explained the expectation was for all staff to report all incidents to their supervisor in a timely manner. The ADON said she did not remember receiving a call from UM about resident #1's bruises. The UM stated she called the ADON and spoke with her but could not recall the details of the conversation as it had not been documented. The ADON said she was unsure when she learned about the incident and had no documentation about it. The UM stated that RN F started writing the incident report at approximately 7:31 AM, but a resident assessment was not started until 9:00 AM. The UM said she started interviews at approximately 11:40 AM, (approximately 4 hours after the bruising was reported), starting with RN F. The Assistant NHA said they submitted their immediate report after speaking with CNA A, but corrected herself and said they should have just filed immediately for injury of unknown origin. Although the facility was unable to provide a root cause, accurate documentation of the events or a timeline of events, the RNC stated she felt they had done a thorough investigation. On [DATE] at 2:20 PM, in a joint interview with the Assistant NHA and DON, the Assistant NHA explained the APRN spoke to the UM for Key [NAME] Unit and reported the incident to her not to the ADON or the East Coast UM. Her expectation was for staff to notify the Nurse Manager or Staff Coordinator immediately when there were allegations of abuse/neglect or when there was an unknown injury of a resident. The Assistant NHA acknowledged the incident was not reported in a timely manner. She verified resident #2's family was not notified of the allegations. The Assistant NHA stated they unsubstantiated resident-to-resident abuse but acknowledged there was no follow up investigation to explain how resident #1 was injured. The DON verified that looking back the facility should have done another reportable as an injury on unknown origin and said it should have been re-opened. On [DATE] at 4:48 PM, in a joint interview with the facility's corporate staff including the Director of Compliance and [NAME] President of Risk and Regulatory they stated the investigation into resident #1's injuries would be re-opened (almost three months after the incident occurred) based on inconsistencies with CNA A's statements. They acknowledged the facility submitted a new Federal Immediate Report almost three months after the incident occurred. The Director of Compliance and [NAME] President of Risk and Regulatory did not say why they would re-open an investigation into an event that occurred in December of last year, if as they said, the original investigation was accurate. The Director of Compliance said he was not with the company in [DATE] and the [NAME] President was in a different position. They acknowledged that mandatory Federal one- and five-day reports were reviewed by corporate staff before they were sent to the State Agency. When asked why they would re-open this case when their predecessors approved the original investigations and Federal reports, they said they re-interviewed CNA A and found inconsistencies with his statement. The statements were regarding resident #2 having punched a pregnant staff and put CNA A in a headlock. However, neither of the corporate staff had concerns with CNA A's allegation that he saw resident #2 coming out of resident #1's room with the bedding. The Director of Compliance said the new investigation would focus on the injury of unknown origin. He could not say why the facility did not investigate resident #1's jaw fractures as an injury of unknown origin when

Based on record review, and interview, the facility failed to promote a culture of safety on the locked memory care unit to ensure residents' dementia and/or behaviors were free of abuse/neglect. The facility Administration's lack of active involvement and their deficient behavioral monitoring, reporting and investigative standards contributed to negative resident-to-resident interactions, which ended, at times, with physical fights, battery, and/or life altering injuries for 2 of 6 residents reviewed for abuse, neglect and behaviors of a total sample of 6 residents, (#1, and #2). On 12/25/24 at 9:40 PM, Certified Nursing Assistant (CNA) A witnessed resident #2 enter resident #1's room. Shortly after, resident #1's roommate approached the nurses' station and said resident #2 was in his room on top of resident #1. CNA A said when he got to resident #1's room, resident #2 was coming out with resident #1's sheets in his hands. CNA A explained he saw resident #1 lying on the bed in the dark with his feet hanging off the bed. The next morning, on 12/26/24 at approximately 7:30 AM, Registered Nurse (RN) F was notified by CNA E that she had observed discoloration to resident #1's face. The Advanced Practice Registered Nurse (APRN) was at the facility and assessed the resident at 11:40 AM. The APRN ordered x-rays of resident #1's face as well as labs. Mobile x-rays were done and the results revealed resident #1 had suffered an acute fracture of the left and right lower jaw with soft tissue swelling. The APRN ordered resident #1's transfer to an acute care hospital at approximately 7:00 PM on 12/26/24. The hospital Emergency Department (ED) physician assessment dated [DATE] indicated resident #1's injuries were suspicious for non-accidental trauma, physical abuse or neglect. Resident #1 was not a candidate for surgery due to his advanced age and complex medical history. The resident was transferred to an inpatient hospice unit for comfort care on 12/27/24 and passed away five days later on 1/01/25. The facility Administration failed to prevent physical abuse for a vulnerable, cognitively impaired resident (#1), failed to ensure medical care was provided in a timely manner for an emergent injury to ensure minimal pain and suffering, failed to ensure incidents and allegations of abuse were accurately documented in the medical record, and failed to ensure a cognitively impaired resident, (#2) with known aggressive behaviors received needed mental health services; was appropriately monitored and supervised; and had a comprehensive person-centered care plan with appropriate behavioral interventions. These failures contributed to an unsafe environment and put all residents residing in the memory care unit at risk for physical abuse and delays in care. These failures resulted in Immediate Jeopardy starting on 12/26/24. There were a total of 60 residents residing in the facility's memory care unit. Findings: 1. Resident #1, an [AGE] year-old male, was initially admitted to the facility from an acute care hospital on 10/26/24 with diagnoses that included hypertensive chronic kidney disease stage 3, repeated falls, and adult failure to thrive. He was transferred to the hospital from the facility on 11/16/24 due to unresponsiveness after his wife witnessed him slump over on his chair during dinner. He was treated for community acquired pneumonia and admitted to hospice for senile degeneration of the brain. He was readmitted to the facility on [DATE] with additional diagnoses including encounter for palliative care, congestive heart failure, syncope and collapse, dementia with behavioral disturbances, anxiety, major depressive disorder, pain, and long-term use of anticoagulants. In a telephone interview on 3/10/25 at 4:38 PM, resident #1's wife stated her husband was admitted to the facility because she was unable to care for him at home due to his dementia. She explained he was initially admitted to the facility on [DATE] but was hospitalized again shortly afterwards. Resident #1's wife explained she requested the hospital not return him to the facility, but he had to return on 11/27/24, as the hospital was unable to find a suitable bed elsewhere. She said she and the resident's brother would visit him almost daily. Resident #1's wife stated she felt there was a safety issue at the facility. She said in the lunchroom several family members saw a man and a woman fight while two staff members sat on the floor, each looking at their phones instead of observing the residents. She explained she mentioned to staff at least three times to put their phones down and pay attention to the residents before something happened. Resident #1's wife relayed this was why she was trying to transfer her husband to another facility in the area. She recalled on 12/26/24 she received a call from the facility at approximately 8:30 AM, informing her of discoloration found on her husband's face. She was told at that time they did not know what had happened but believed it might have been caused by the bedrails. She recalled she had not seen her husband's injuries yet, so she did not argue with their explanation. Resident #1's wife said she remembered when she arrived at the facility she was surprised at the extent of the bruising on her husband's face and neck because it was worse than she imagined. She said the APRN, the nurse, and another staff member whose name she could not recall were there and the APRN said she would order an x-ray of his face and lab work. She said she told them at that time she did not believe this was caused by the bed rails because of how bad his face looked. Resident #1's wife explained she was told they did not know what happened to him, but they would investigate. She stated at approximately 1:00 PM, she tried to feed her husband his lunch, but he could not even open his mouth to chew, so he did not eat. She said she left the facility around 4:00 PM, and received a phone call at approximately 8:30 PM letting her know the x-ray showed he had a broken jaw and lab work indicated he had elevated white blood count (WBC) so he would be transferred to the hospital by non-emergency transport. She recalled the nurse told her it seemed another resident might have attacked him. Resident #1's wife recalled she went right away to the hospital and when she arrived, he was unresponsive, and he never opened his eyes to look at her again. She said she was unable to talk to him again and he passed away six days later on 1/01/25. Resident #1's wife recalled the hospital physician told her that surgery and recovery could be complicated due to his age and medical history, so the best option for him was hospice to keep him comfortable. He was transferred to inpatient hospice. She recalled she told the staff this was not the bedrails that caused this because of the extent of his wounds. She said she was upset and left the facility but took pictures of his face to keep as proof. On 3/10/25 at 2:46 PM, the facility's reportable log for December 2024 was reviewed with the Nursing Home Administrator (NHA), Assistant NHA, and Director of Nursing (DON). The NHA stated she was the facility's Risk Manager but at the time of the reportable incident, on 12/26/24, the Assistant NHA performed the role, and the DON was the Abuse Coordinator. The Assistant NHA said she first learned of the incident on 12/26/24 at about 3:30 PM, when she was notified by staff that an x-ray result for resident #1 showed he had sustained a fractured jaw. She said she alerted the DON, who was not at the facility that day, but arrived at approximately 4:00 PM. The Assistant NHA said although she was the Risk Manager, she was not made aware of the discoloration found on resident #1's face that morning by CNA E and RN F. The DON and Assistant NHA said they became involved in the investigation at that point, when the DON arrived and started gathering witness statements from the previous night's staff. They said CNA A worked the 3 -11 PM shift on 12/25/24 and was interviewed in person by the DON and Assistant NHA on 12/26/24. They said at that time they learned of his allegation of a possible resident-to-resident incident that occurred the previous evening of 12/25/24. They said, CNA A's statement indicated he, ran down the hallway to escort [resident #2 name] personally. When I arrived to the room [resident #1's name] legs were halfway off the bed and I proceeded to fix him and ask if he was ok because [resident #2 name] took his blankets and dragged them, which he also put me in a headlock where I had to receive help from a co-worker to get him off of me which I reported to the nurse. The Assistant NHA said that Licensed Practical Nurse (LPN) B assessed resident #1 that evening and did not notice any injuries. The Assistant NHA was unable to provide documentation of any assessment completed by LPN B that evening. The DON acknowledged there was no documentation of the incident, or report of the allegations made by the CNA, nor any head-to-toe assessment documented by the nurse. The DON said the nurse did not document because she did not notice any injuries to resident #1 and resident #2 was at his baseline always going in and out of other resident rooms. She explained it was normal for residents in the locked unit to wander in and out of other residents' rooms because they had dementia. The DON said, Because the fracture was not treatable there was no need to send the resident out [to the hospital] but because of his elevated blood count he was sent out and the wife agreed. They were unable to provide documentation to show any assessments completed that night on resident #1 or #2. They said they interviewed LPN B by phone, who had worked a double shift on 12/25/24 from 7 AM to 11 PM. LPN B told them that on the morning of 12/25/24 there had been no issues with resident #1 except he was sleepy during lunch and his family asked for him to be put in bed. She said his family stayed until early to mid-evening and she gave him medication at approximately 10:00 PM. He did not complain of pain, was not in any distress, and fell back to sleep. They explained LPN B checked on him again at around 10:30 PM and he was still sleeping comfortably. The Assistant NHA said the 11 PM-7 AM staff were interviewed and both the CNA and LPN gave the same statement. CNA C and LPN D said they provided incontinence care for resident #1 at approximately 1:00 AM to 2:00 AM on 12/26/24 and said they did not notice any injuries to the resident at that time. LPN D told them resident #1 did not receive any medications during her shift, and she first became aware of the discoloration prior to leaving on 12/26/24 when she was asked to go to his room by the morning nurse and CNA. She said she noticed that he had a discoloration to the left side of his jaw. The Assistant NHA said that resident #1's roommate was interviewed on 12/26/24 but he did not recall the incident or what he reported to CNA A. Both the DON and Assistant NHA confirmed they had not been notified on 12/25/24 regarding CNA A's allegations of a possible resident-to-resident incident. They confirmed LPN B said she did not witness or receive report from CNA A regarding resident #2 coming out of resident #1's room, the roommate's allegation about the attack, nor of him being put in a headlock by resident #2. The Assistant NHA explained CNA E was the first one who noticed resident #1's injuries on 12/26/24 during her morning rounds at approximately 7:30 AM. She told them in her statement she saw the discoloration to one side of his face and notified RN F and LPN D. They stated RN F called the APRN who was already at the facility doing rounds that morning and called resident #1's wife at approximately 8:30 AM to notify her of the bruises. They said a head-to-toe assessment was done and they started completing the incident report. The Assistant NHA and DON explained at around 11:40 AM (four hours after the bruises were first noticed and reported) the APRN evaluated resident #1 with his wife at the bedside. They said at that time the APRN ordered an x-ray of the resident's face, and labs. The x-ray and labs results were obtained at approximately 3:30 PM which confirmed he had a broken jaw and elevated WBCs. The Assistant NHA and DON said the APRN was notified shortly after that time, and an order was given for him to be transferred to the hospital via non-emergency transport for further evaluation. The Assistant NHA and DON said they notified DCF, who did not accept the case, and law enforcement then completed their immediate reporting to the State Agency at approximately 8:00 PM, almost 24 hours after CNA A alleged the resident-to-resident abuse occurred, approximately 13 hours after resident #1's injuries were first reported by CNA E, and almost four and a half hours after the fractures were identified. The Assistant NHA and DON said resident #1's wife was notified, and he was transported to the hospital at approximately 8:30 PM, approximately 5 hours after the fractures were first identified. The DON said resident #2 was placed on one-to-one supervision at that time on 12/26/24 as a preventative measure during the investigation to keep other residents safe. They confirmed resident #2 had behaviors such as wandering into other resident rooms and he could become aggressive after family visited but said he had never attacked another resident. They stated staff education on abuse/neglect was initiated on 12/26/24 in an abundance of caution. The Assistant NHA said they were unable to verify the allegations made by CNA A because no other staff could corroborate the story and resident #1's roommate could not recall making the allegations. They explained LPN B said she did not witness or receive report from CNA A that night regarding the incident and per her statement there were no injuries noted on resident #1. The Assistant NHA said the investigation was concluded on 12/31/24 with no conclusive explanation for resident #1's injuries. She did not say why they did not investigate the cause of resident #1's injuries at that time if they did not find a likely reason for resident #1's injuries. On 3/14/25 at 2:07 PM, the facility's investigation was again reviewed, with the Assistant NHA. She said the Key [NAME] Unit Manager notified her of the resident #1's x-ray results. The Assistant NHA said she did not observe resident #1 on 12/26/25 and therefore would not be able to speak about the resident's discoloration/bruising except what was conveyed to her by other staff and their documentation or lack thereof. The facility's investigation showed that CNA A, as the lone staff, observed resident #2 leaving resident #1's room with a blanket on the evening of 2/25/25 at approximately 9:40 PM. The Assistant NHA could not say where the other staff who were working on the unit were at the time of the incident. She did not explain if the other staff were assisting other residents, at lunch or even on a break per the facility investigation. Review of staff statements that were provided by the Assistant NHA lacked dates, time stamps and objective descriptions such as the location of the staff member when the alleged altercation between resident #1 and resident #2 occurred. There was no evidence that the Administrative staff that led the investigation made any effort to determine why CNA A was the only witness, or why he did not report the incident to other staff or a supervisor when he did not receive an appropriate response from the nurse he informed. The Assistant NHA acknowledged CNA A's statement did not include the observation of resident #2 coming out of resident #1's room, she added that information was only obtained verbally. The Assistant NHA explained, going into other resident rooms was just part of the behaviors, for resident #2 in regard to whether resident #2's unwanted entry to resident #1's room, removing resident #1's bedding or entering any other resident's room was a concern that should have been documented or reported to the nurse or a manager. The Assistant NHA said the resident-to-resident abuse was not substantiated in the facility 's Federal 5-day report because CNA A was the only witness. The Assistant NHA relayed the facility had opened a new investigation related to resident #1's fractured jaw since the start of the complaint survey. She explained the new investigation was to focus on injury of an unknown origin. The Assistant NHA did not provide an answer if the allegation should have been considered an injury of unknown origin since the facility did not substantiate the Federal 5 Day Report for resident-to-resident abuse. The Assistant NHA did not provide an explanation or a Root Cause Analysis (RCA) as to why resident #1's jaw was fractured. On 3/14/25 at 4:48 PM, the facility's corporate staff including the Director of Compliance and [NAME] President of Risk and Regulatory discussed why they re-opened the investigation into the incident of resident #1's bilateral fractured jaw almost three months after the incident occurred. They acknowledged the facility submitted a new Federal Immediate Report almost three months after the incident occurred as well. The Director of Compliance and [NAME] President of Risk and Regulatory did not say why they would re-opened an investigation into an event that occurred in December of last year if as they said, the original investigation was accurate. The Director of Compliance said he was not with the company in December 2024 and the [NAME] President was in a different position. They acknowledged that mandatory Federal one- and five-day reports were reviewed by corporate staff before they were sent into the State Agency. When asked why they would re-open this case when their predecessor approved the original investigations and Federal reports, they said they re-interviewed CNA A and found inconsistencies with his statement. The concerned statements noted resident #2 punched a pregnant staff and put CNA A in a headlock. However, neither of the cooperate staff had concern with CNA A's allegation that he saw resident #2 coming out of resident #1's room with the bedding. The Director of Compliance said the new investigation would focus on the injury of unknown origin. The Director of Compliance introduced a new theory at that time, that resident #1's injury was the result of a pathological fracture due to osteoporosis. The Director of Compliance said on 3/12/25 the facility requested a review of resident #1's x-ray results and osteoporosis was now added to the report. He agreed osteoporosis was not on the original x-ray reading report. Corporate staff voiced statements indicating the facility wanted to re-litigate the facts of the incident but still maintain their original investigation was complete and thorough. The facility's Administration and Corporation's lack of involvement of the locked unit led to the acceptance/culture of demented residents' inappropriate and often unsafe behaviors such as fighting and wandering into other resident's rooms/space was normal and accepted versus implementing appropriate interventions for staff to utilize to maintain the safety of residents on the locked unit. The facility Administration and Corporate staff did not say why they had not placed the same urgency into their original investigation of resident #1's injuries from the onset, as they were now with the re-opening of a new investigation. 2. Resident #2 was admitted to the facility on [DATE] from a psychiatric hospital. His diagnoses included Alzheimer's disease, dementia with behaviors, anxiety, major depression and unspecified mood disorder. Medical record review revealed a Level I, Preadmission Screening and Resident Assessment (PASARR) dated 10/01/24 was completed at the hospital and a Level II PASARR was required. There was not any evidence in the medical record that a Level II PASARR was completed on or about the time of admission for resident #2, or that one had been requested by the facility. The State of Florida Agency for Health Care Administration (AHCA Med/Serv Form 004 Part A, March 2017) form completed by the in-patient psychiatric facility on 9/09/24 prior to resident #2's admission to the facility read, . Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASARR (Pre-admission Screening and Resident Review) because there is a diagnosis of or suspicion of Serious Mental Illness. The medical record contained progress notes which provided some insight to the resident's past behaviors prior to the alleged physical abuse of resident #1. A progress note dated 10/03/24 indicated resident #2 was admitted to the facility after having been previously Involuntarily admitted (Florida [NAME] Act) to a psychiatric facility for attacking his own family. Progress notes dated 10/10/24, 10/14/24, 10/18/24 and 11/09/24 respectively depicted a resident that was excessively exit seeking, setting off door alarms, restless, wandering in and out of other residents' rooms, and waking other residents up. The notes indicated the resident was often resistive to redirection. One particular progress note dated 11/24/24, which was struck out but still in the medical record for review, revealed resident #2 wandered into the room of a resident he did not get along with, got into the bed which upset the other resident, and ultimately lead to a fight between the two residents. The facility staff noted on several occasions that redirection of resident #2 was ineffective. The Situation Background Assessment and Recommendation (SBAR) note dated the next day, 11/25/24, indicated a nurse noticed two minor skin openings and discoloration to the back of resident #2's left hand. The next day, 11/26/24, an Interdisciplinary Team (IDT) note revealed the resident wandered in and out of other residents' rooms, refused care and at times was resistant to redirection. This note indicated the resident continued to be anxious/restless and attributed the discoloration to the back of the resident's hand, to a lab draw that was earlier in the week. The author of the IDT note did not provide any insights as how a resident-to-resident altercation was ruled out as the etiology for the wound/discoloration since the resident was noted to freely wander into other resident's rooms. On 3/11/25 at 10:17 AM, LPN B said in a phone interview that on 12/25/24 she worked a double shift from 7 AM to 11 PM on the locked Caring Way unit with resident #1 and resident #2. She said they were assigned to her previously and she was familiar with both residents. LPN B recalled resident #2 was known to walk into other resident's rooms and caused problems with the other residents. LPN B said resident #2 was known to become aggressive, get into people's faces and grab things from other residents, especially after his family left from visiting. She explained between herself and the other nursing staff they would have to distract him when they saw him going into other resident's rooms, but he was not easily redirected. They had to constantly watch him. Resident #2 had behaviors care plan initiated on 10/05/24. The interventions included administer medications, encourage/assist resident to develop appropriate coping methods, encourage resident to express feelings, explain procedures prior to doing them, and intervene or redirect resident as necessary. The care plan interventions were never updated despite the staff's frequent inability to redirect him, monitor him and/or prevent him from wandering into other resident's rooms, in conflict with other residents on the locked unit, until after the alleged incident on 12/25/24. The care plan was not updated until the reported incident on 12/26/24, after the alleged assault of resident #1, who sustained a bilateral jawbone fracture. Nursing home Administration did not intervene to identify and attempt to prevent resident #2's inappropriate behaviors until the life altering injury of resident #1 was identified. On 3/11/24 at 10:58 AM, RN F in an interview conducted in Spanish per RN F's request, she stated she often worked on the memory care unit. RN F stated she felt it was difficult to perform her job safely because they were not able to provide enough supervision of the residents there. She explained they typically had five CNAs working on the unit for 60 confused residents and when residents had behaviors like entering other residents rooms they tried to offer them snacks or food to distract them but many of them were not redirectable. In a joint interview on 3/11/25 at 10:40 AM, with the Nursing Home Administrator (NHA) and Assistant NHA, the Assistant NHA stated they had requested a level II PASARR) from the psychiatric hospital but never received it. They were not able to provide documentation they had attempted to obtain the level II screening prior to 3/11/25, when it was brought to their attention during the survey. The NHA and the Assistant NHA said they never submitted their own level II screening because they expected to receive it from the psychiatric hospital. They continued, resident #2 already received all of the services he needed to manage his mental health, such as visits with the Psychiatrist who provided medication management. The Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date of 12/29/24 noted during the look-back period, resident #2 was rarely/never understood and unable to complete the Brief Interview for Mental Status. Staff assessed the resident had short-term and long-term memory problems, his cognitive skills for daily decision making were severely impaired, and he had no acute mental status changes. The assessment indicated that for four to six days, the resident had physical and verbal behaviors directed towards others, other behaviors not directed towards others, rejection of evaluation or care, and he wandered. The MDS detailed the resident received three medications by injection, received high-risk anti-psychotic, anti-anxiety, anti-depressant, hypnotic, and anti-convulsant medications. The assessment indicated resident #2 received no psychological therapy and no active discharge planning had occurred. Resident #2's Order Summary Report for December 2024, included the physician ordered medications: Citalopram (an anti-depressant) 20 Milligrams (MG) each day at bedtime for depression; Depakote (anti-convulsant) 875 MG every 8 hours for affective mood disorder; Dextromethorphan (anti-tussive) 15 MG twice daily for behaviors; Haldol Decanoate (anti-psychotic) 75 MG injection every 21 days for dementia psychosis; one-time Haldol injections for agitation received on 12/04/24, 12/17/24, 12/26/24, 12/27/24, 12/28/24, and 12/29/24; Lorazepam (anti-anxiety) both 0.5 MG twice daily for anxiety and wandering, and 1 MG once on 12/13/24 for anxiety and insomnia; Mirtazapine (anti-depressant) 7.5 MG once daily at bedtime for sadness/depression; Paroxetine (anti-depressant) 20 MG once daily at bedtime for depression; and Temazepam (sedative-hypnotic) 15 MG once daily at bedtime for insomnia. On 3/11/25 at 8:57 AM, in a telephone interview resident #2's son stated the family was not happy with how the facility handled many situations with his father. He recalled when his father was at the psychiatric hospital, they stabilized his mental health with medications and treatment, so there were not any issues. Resident #2's son said when he came to the nursing home, the facility changed his father's medications constantly, without discussing it with his family, and they did not understand why. He said he believed the facility did not have enough staff to supervise the residents on the locked unit and gave examples. He recalled an incident when his father was attacked after he wandered into another resident's room and took some cookies. Another time last November his mother witnessed his father being grabbed by another resident on the unit and choked until his father was able to push the other resident off of him. In another incident with that same resident, he recalled his father was bitten on the hand, which he had pictures of. Resident #2's son stated he was not aware of any reports or investigations by the facility related to those incidents even though staff were present. He said he had recordings of care plan meetings he attended, where the staff promised to do different things to ensure his father's safety, but they never followed through with any of the interventions. The son recalled he was told by a nurse at the facility that his father attacked another resident on or about 12/25/24. He explained he had spoken with other nurses at the facility, and they were all aware of the incident, but no one would say they had witnessed anything. He said his father was eventually transferred to the hospital on 12/29/24. At the hospital they found bruises on both of his arms and a cut on the elbow that looked infected. The son said they took his father out of the nursing home for no reason, and he was never given a reason why his father needed to go to the hospital. In interviews on 3/14/25 at 11:52 AM and 1:25 PM, the Social Service Director stated she was responsible for creating and updating care plans for any behaviors exhibited by the residents. She said she did this by attending clinical meetings and speaking to the psychiatric provider when residents had issues. The Social Services Director did not say why resident #2 had no new interventions in his care plan after the behaviors noted by nurses and by the psychiatric provider. She stated she did not recall any incidents with resident #2 and denied knowledge of any incidents between resident #2 and any other residents. She acknowledged care plans should be revised when issues occurred but said there was no policy for it. The Social Services Director said they looked at what worked and would continue to use that intervention. Review of a progress note completed by the Psychiatric Mental Health Nurse Practitioner dated 12/26/24 revealed resident #2 had paranoid thoughts and read, . staff documented assaultive and aggressive behaviors . Review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy revised 10/2022 noted, All events reported as possible ANEMMI will be investigated to determine whether ANEMMi occurred. The policy included, Residents who are suspected of initiating abusive behavior toward other residents will be immediately separated from the suspected victim. The immediate actions to remove the Immediate Jeopardy by the facility were reviewed and revealed the following which was verified by the survey team: *12/26/24 resident #1 no longer resides in the facility, discharged on [DATE]. *12/29/24 resident #2 no longer resides in the facility, discharged on [DATE]. *12/26/24 at 7:30 AM staff noticed discoloration to resident #1's jaw/neck and notified APRN per orders for anticoagulant monitoring. Upon examination APRN ordered a facial x-ray at 12:44 PM. Resident #1 transferred to hospital at 8:09 PM for evaluation related to lab results. *12/26/24-12/27/24- 200 of 200 current staff across all departments were provided education on abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown source. *12/26/24 at 3:53 PM x-ray results received by facility. The Unit Manager notified the APRN and the facility Risk Manager of the x-ray results. An internal investigation was initiated, and a federal immediate report was submitted. *3/14/25, the NHA and DON were re-educated by the Registered Nurse Consultant (RNC) on the components of F835 with an emphasis on taking immediate action on ensuring person centered care and interventions are in place for residents with a history of dementia and behaviors for effectiveness, thoroughly investigating and reporting allegations in a timely manner and appropriate interventions for behavioral dementia residents and timely medical treatment. *3/14/25, a quality review was conducted by the RNC/designee of 57 current residents who reside on the memory care unit to ensure appropriate interventions for behavioral dementia residents are in place and timely medical treatment is rendered within the previous 30 days. No like residents were identified. *3/14/25, a quality review was conducted by the RNC/ [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II Evaluation was completed for 2 of 3 residents, (#2, #4); and failed to complete Level I screen after significant change in condition for 1 of 3 residents, (#2) reviewed for PASARR, of a total sample of 6 residents. Findings: 1. Review of the medical record revealed resident #2, a [AGE] year-old male was admitted to the facility on [DATE] from an in-patient psychiatric hospital with diagnoses that included Alzheimer's Disease, major depressive disorder, recurrent severe, anxiety disorder, cognitive impairment, mild neurocognitive disorder, hypermobility syndrome, and affective mood disorder with other behavioral disturbance. The Minimum Data Set (MDS) Quarterly Assessment with Assessment Reference Date (ARD) of 12/29/24 noted during the look-back periods, resident #2 was rarely/never understood and unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed the resident had short-term and long-term memory problems, his cognitive skills for daily decision making were severely impaired, and no acute mental status changes occurred. For 4 to 6 days, the resident had physical and verbal behaviors directed towards others, other behaviors not directed towards others, rejection of evaluation or care, and he wandered. The assessment showed the resident required staff supervision/moderate assistance to complete Activities of Daily Living (ADL), and for Functional Mobility. The resident received 3 injections, high-risk anti-psychotic, anti-anxiety, anti-depressant, hypnotic, and anti-convulsant medications, and no psychological therapy or active discharge planning occurred. The Physician's Determination of Resident's Capacity to Make Medical Decisions Based on Informed Consent dated 12/10/24 noted the physician determined resident #2 was unable to make his own decisions. The Care Plan Report initiated on 10/05/24 noted the resident required secure dementia unit with new surrounding adjustment difficulties and impaired safety awareness, cognitive deficits, high fall risk, nurse monitoring of adverse medication effects, history of non-compliance/refusal of care, behaviors including impulsivity, combativeness with staff, wandering in/out of other resident's rooms, getting into other resident's beds, exit-seeking, and re-direction resistance/difficulty with an intervention initiated on 12/26/24 for 1:1 staff observation/re-direction of resident's behaviors including going into other resident's rooms. The Order Summary Report included physician ordered medications for Citalopram (anti-depressant) 20 Milligrams (MG) each day at bedtime for depression, Depakote (anti-convulsant) 875 MG every 8 hours for affective mood disorder, Dextromethorphan (anti-tussive) 15 MG twice daily for behaviors, Haldol Decanoate (anti-psychotic) 75 MG injection every 21 days for dementia psychosis, one time Haldol injections for agitation on 12/04/24, 12/17/24, 12/26/24, 12/27/24, 12/28/24, and 12/29/24, Lorazepam (anti-anxiety) 0.5 MG twice daily for anxiety and wandering and 1 MG once on 12/13/24 for anxiety and insomnia, Mirtazepine (anti-depressant) 7.5 MG once daily at bedtime for sadness/depression, Paroxetine (anti-depressant) 20 MG once daily at bedtime for depression, and Temazepam (sedative-hypnotic) 15 MG once daily at bedtime for insomnia. The State of Florida Agency for Health Care Administration (AHCA Med/Serv Form 004 Part A, March 2017) completed by the in-patient psychiatric facility on 9/09/24 prior to resident #2's admission to the facility read, . Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASRR (Pre-admission Screening and Resident Review) because there is a diagnosis of or suspicion of Serious Mental Illness. In a joint interview with the Nursing Home Administrator (NHA) and Assistant NHA on 3/11/25 at 10:40 AM, the NHA conveyed the facility was not aware of resident #2's Level II evaluation results until after they obtained a copy the same day from the in-patient psychiatric facility. Review of a progress note completed by the Psychiatric Mental Health Nurse Practitioner on 12/26/24 noted resident #2 had paranoid thoughts and read, . staff documented assaultive and aggressive behaviors. On 3/15/25 at 12:45 PM, the Director of Nursing (DON) said there were discussions in clinical meetings to determine if new PASARR screens or evaluations were needed, and she was responsible for ensuring they were completed. She did not explain why a new screen was not completed for resident #2 after he showed assaultive behaviors. 2. Review of the medical records revealed resident #4, a [AGE] year old male was admitted to the facility on [DATE] from Hospice with diagnoses including chronic pancreatitis, dementia with other behavioral and psychotic disturbance, brief psychotic disorder, major depressive disorder, moderate, primary insomnia, generalized anxiety disorder, affective mood disorder, Post-Traumatic Stress Disorder (PTSD), alcohol abuse, and persistent mood disorder. The MDS Quarterly Assessment with ARD of 2/20/25 noted resident #4 scored 4 out of 10 on the BIMS that indicated he was severely cognitively impaired. The assessment showed the resident had physical, verbal, behavioral symptoms directed towards others, other behavioral symptoms towards himself, rejection of evaluation or care for 4 to 6 days, and for 1 to 3 days, he wandered. The Care Plan Report initiated on 5/30/23 included secured dementia unit placement to meet individual needs for ADL care, impaired safety awareness, dementia, impaired cognitive function/thought processes, Long Term Care services, Hospice Services, nurse adverse medication effects monitoring, ADL self-care deficits, behaviors including nutritional supplement and medication declinations, and read, (Does not want nurse to touch any part of arm/shoulder/fingers). Care Plans initiated on 6/07/24 included: PTSD, resistive/refusals of care, anxiety, depression, and Paranoid Schizophrenia like behaviors and initiated 7/07/24: Incapacity. The Physician's Determination of Resident's Capacity to Make Medical Decisions Based on Informed Consent dated 12/23/24 noted the physician determined resident #4 was unable to make his own decisions. A progress note completed by the Psychiatric Mental Health Nurse Practitioner on 1/02/25 noted resident #4 reported he had been in a physical altercation with a peer who entered his room and took his property. In a telephone interview on 3/13/25 at 1:40 PM, the Psychiatric Mental Health Nurse Practitioner said he knew resident #4 well and recalled evaluating him on 1/02/25. He checked the medical record and explained the assessment occurred after the resident was moved to a new room and with a new roommate. He said he believed the resident confabulated the story and the resident's memory was very impaired and unreliable. He stated he was not aware of resident #2's involvement in any resident to resident physical altercations that were verified. On 3/13/25 at 12:30 PM, resident #4 was observed sitting on the bed in his room. The resident said, I had no fights or arguments with anybody. On 3/15/25 at 1:43 PM, resident #4 was observed sitting in a wheelchair in his room. He said he did not recall telling the Psychiatric Mental Health Nurse Practitioner that he hit someone and said, they pissed me off taking all my clothes; I just stood there and watched them. On 3/13/25 at 2:18 PM, the East Coast Unit Manager checked resident #4's medical record and said she completed a new PASARR screen on 1/06/25 that indicated a Level II Evaluation was required. She was unable to locate a completed evaluation. Review of the State Agency PASARR vendor records noted on 1/13/25, resident #4's case was administratively closed when the additional medical records required from the facility to process the Level II Evaluation were not received. The record showed on 3/13/25, the facility submitted a new request. On 3/15/25 at 12:45 PM, the DON said resident #4's Level II evaluation wasn't completed due to lack of consent. The DON explained she was not aware additional medical records were required and conveyed the facility missed conducting follow-up measures to ensure the Level II evaluation was completed. On 3/15/25 at 1:26 PM, the Regional Director of Operations said the facility did not have company policy for PASARR and they followed regulatory guidelines.

Based on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing care was completed as per professional standards, and physician order for 1 of 1 resident of a total sample of 7 residents, (#7). Findings: Resident #7, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included acute cystitis with hematuria, urinary tract infection, and chronic systolic (congestive) heart failure. The resident's hospital Discharge Worksheet dated 1/24/25 read, Your PICC/Midline dressing should be changed routinely every 7 days or sooner if becomes wet, soiled or loose. Review of the resident's Admission Readmission Nursing Evaluation dated 1/29/25 revealed he was admitted from the hospital on 1/29/25. The resident was alert and oriented to person, place, time and event, and had an intravenous (IV) access via a PICC. A PICC is a catheter (small tube) used to give treatments and to take blood. The catheter is inserted into an arm vein . guided through the peripheral vein into a central vein near your heart. (retrieved on 2/14/2025 from www.drugs.com). On 2/05/25 at 12:56 PM, resident #7 was sitting on the side of his bed. A PICC line was noted to the resident's right upper arm, and the dressing was dated 1/24. The resident stated the IV access was placed in the hospital, and he received IV antibiotic via the access for 30 minutes per/dose. He stated the dressing had not been changed since he was admitted to the facility. On 2/05/25 at 1:00 PM, Registered Nurse (RN) A confirmed she was resident #7's assigned nurse. She stated the resident had a right upper arm PICC line and was getting antibiotics every 8 hours for acute cystitis. She verbalized the PICC should be flushed before and after medication administration, and the end should be capped when not in use. RN A said the PICC line dressing should be changed within 24 hours of the resident's admission, and then every 7 days and as needed (PRN) for any soilage. On 2/05/25 at 1:05 PM, an observation of the resident's PICC line dressing was conducted with RN A. She acknowledged the date on the dressing was 1/24. A review of the resident's physician orders was conducted by RN A. She verbalized that an order was in place for the PICC line dressing to be changed every 7 days and PRN. She said the resident's PICC line dressing was not changed as ordered, since the date noted on the dressing was 1/24. RN A said it should have been changed on 1/31/25 but was not done. Review of the resident's physician orders showed orders dated 1/29/25 for PICC line care that read, PICC line Right arm: Monitor for s/s (signs/symptoms) of infection, swelling, color change, pain, drainage etc. If abnormalities observed, stop use of IV site and notify physician Q (every) shift until 2/19/2025 23:59 (11:59 PM) and as needed. Change dressing within 24 hours of admission, insertion, or reinsertion and Q 7 days and PRN thereafter using sterile technique. Measure arm circumference and external length of catheter. Physician order dated 1/31/25 was for Piperacillin 3.0-375 gm IV Q 8 hrs for cystitis until 2/19/2025. Piperacillin/tazobactam is used to treat a wide variety of bacterial infections. It is a penicillin antibiotic. It works by stopping the growth of bacteria. (retrieved on 2/14/2025 from webmd.com). Review of the resident's Physician/Practitioner progress notes dated 1/30/25 revealed the physician's plan included Routine PICC care. Review of the resident's Medication Administration Record (MAR) revealed documentation on 1/30/25 that indicated the PICC line dressing was changed at 9:40 AM. The date observed on the PICC line dressing was 1/24, not 1/30/25. On 2/05/25 at 1:16 PM, observation of the resident's PICC line dressing was conducted with the East Coast Registered Nurse (RN) Unit Manager (UM). She acknowledged the dressing was dated 1/24 and stated that by protocol the PICC line dressing was to be changed weekly. The RN/UM stated a resident admitted with a Midline/PICC would have batch orders for the care of the Midline/PICC placed in the residents' Electronic Medical Records (EMR). She stated the Midline/PICC line dressing changes should be done by the resident's assigned nurse and explained the PICC dressing for resident #7 should have been changed 24 hours after his admission, and then every 7 days thereafter. On 2/05/25 at 2:20 PM, the Director of Nursing (DON) stated PICC line dressings should be changed if soiled or wet then every 7 days after admission. The resident's MAR was reviewed, and the DON confirmed that signature on 1/30/25 indicated the PICC dressing was changed. The date noted on the resident's PICC dressing was 1/24. She acknowledged the order signed off by Licensed Practical Nurse (LPN) B was for dressing change within 24 hours of admission and every 7 days and as needed thereafter. On 2/05/25 at 2:33 PM, LPN B stated the protocol was to change the PICC dressing if dirty or within 24 hours of admission. The resident's MAR was reviewed with the LPN. She acknowledged she signed the order on 1/31/24 to indicate she had checked the resident's IV access, and not that a dressing change was done. She stated a dressing change was not needed at that point, and noted the PICC dressing was normally changed by an RN not an LPN. LPN B acknowledged th the physician order she signed off on was for dressing change, and stated she should have signed off on the order that instructed staff to monitor the PICC. On 2/05/25 at 3:25 PM, the DON provided a revised policy for Central Lines. She acknowledged that since the date noted on the resident's PICC line dressing was 1/24, the dressing was not changed in the facility since the resident was admitted on [DATE]. A care plan developed for a midline located in the right arm related to infection was initiated on 1/30/25. An intervention was, IV access site maintenance: perform dressing changes, flushes, etc. as ordered. The facility's policy Central Lines issued 10/2020, and revised 02/2025 read, Change dressing routinely and per physician orders.

Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents on admission and/or failed to make referrals for newly evident or possible mental disorders/diagnoses to evaluate the need for specialized services or alternative placement for 6 of 7 residents reviewed for PASARRs, of a total sample of 57 residents, (#30, #34, #1, #41, #94, and #84). Findings: 1. Review of the medical record revealed resident #30, a [AGE] year old female was admitted to the facility from an acute care hospital on 6/26/24 with diagnoses that included history of stroke, metabolic encephalopathy (brain dysfunction), epilepsy, dementia, insomnia, major depressive disorder, generalized anxiety disorder, and psychotic disorder. The Minimum Data Set (MDS) Admission assessment with an Assessment Reference Date (ARD) 7/03/24 indicated during the look-back period, resident #30 was rarely/never understood and staff assessed her cognition as severely impaired. The assessment noted the resident had continuous signs of delirium and sometimes had social isolation. The Functional Abilities and Goals noted the resident required moderate assistance from staff to complete Activities of Daily Living (ADL). She was frequently incontinent of bladder and bowel functions, had a history of falling, and received high-risk anti-psychotic, anti-anxiety, anti-depressant, antibiotic, and anti-platelet medications. The overall goal for discharge showed the resident was to remain in the facility. The Order Summary Report showed active physician's orders that included: behavior and psychotropic medication side effect monitoring every shift, and psychiatric consultation. Medications included: Keppra 750 Milligrams (MG) twice daily for seizures, Lacosamide 200 MG every twelve hours for epilepsy, Depakote 250 MG three times daily for mood disorder, Lorazepam 0.5 MG tablet every eight hours as needed for anxiety, Sertraline 100 MG once daily for depression, Trazodone 50 MG three times daily for depression, and Lorazepam gel 1 MG applied to skin every 8 hours as needed for restlessness, agitation, and trying to stand. The Comprehensive Care Plan's focuses included: anticonvulsant anti-psychotic, anti-anxiety, and anti-depressant medications, seizure disorder, staff assisted ADL care, staff dependency for emotional, intellectual, physical, and social stimulation, impaired cognitive functions and thought processes, and dementia with secured unit placement. The Preadmission Screening and Resident Review Level I Screen Form (AHCA MedServ Form 004 Part A, March 2017) (PASARR) Section I completed by the hospital on 6/25/2024 documented resident #30 did not have any possible MI or SMI. On 9/13/24 at 9:16 AM, the Social Services Director said she did not complete the PASARR screens. She explained, the Admissions Coordinator ensured a form was received for all new admissions and the Interdisciplinary Team (IDT) discussed any required changes or revisions every morning during clinical meetings. On 9/13/24 at 9:26 AM, the East Coast Unit Manager (UM) said she had recently assisted with PASARR Level I Screen revisions and updates. The Registered Nurse (RN) explained, she understood a new screen was required if the form was incorrect, or if new psychiatric diagnoses were later added. She checked resident #30's medical record and confirmed the Level I PASARR from her admission in June was not marked, so she needed a new one because it didn't list the diagnoses. On 9/13/24 at 10:30 AM, the Director of Nursing (DON) explained there was not a policy for the facility's PASARR process and, .it keeps going back and forth for who is responsible. 2. Review of the medical record revealed resident #34, a [AGE] year old female was admitted to the facility from another nursing home on 4/25/23. The resident's active diagnoses included: nervous system degeneration, dementia, cerebrovascular (brain vessels) disease, pain, anxiety disorder, major depressive disorder, repeated falls, and schizoaffective disorder. The MDS Quarterly Assessment with ARD 8/29/24 showed during the look-back periods, resident #34 scored 2 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she was severely cognitively impaired. The assessment noted the resident had continuous inattention and disorganized thinking that did not fluctuate. The Functional Abilities and Goals noted the resident required substantial/maximal assistance from staff to complete ADLs. The resident was always incontinent of bladder and bowel functions, and received high-risk opioid medications. No active discharge planning was in place, and the resident was not expected to return to the community. The Comprehensive Care Plan's focuses included: behaviors, refusals of care/treatment, anti-anxiety medications for restlessness, impaired cognitive function/impaired thought processes, mood disorder, insomnia, depression, staff assisted ADL care, staff dependency for emotional, intellectual, physical, and social stimulation, impaired cognitive functions and thought processes, and dementia with secured unit placement. The Order Summary Report showed active physician's orders that included: resident may not go on LOA (Leave of Absence) from the facility, mechanical lift transfer, and psychotropic medication side effect monitoring. Medications included: Lorazepam 0.5 MG every eight hours as needed for restlessness, and Tramadol (opiate) 50 MG every eight hours as needed for chronic pain. The PASARR's Section I completed by the hospital on 3/27/23 documented resident #34 did not have any possible MI or SMI. The Admission Record noted MI or SMI diagnoses were added after the resident's facility admission that included: major depressive disorder, recurrent mild (5/02/23), other specified anxiety disorders (8/10/23), and schizoaffective disorder (11/02/23). On 9/13/24 at 2:24 PM, the East Coast UM checked resident #34's medical record and said the only PASARR that was completed was by the hospital on 3/27/23 and no MI or SMI diagnoses were marked. She checked the diagnosis record and confirmed they were added after she was admitted to the facility. On 9/13/24 at 9:37 AM, the DON said she could not answer why or how the PASARR revisions/corrections were missed. She stated, We do a really detailed discussion in psych (psychiatric) meetings; it includes the psychiatric providers, social services, and nursing; we do discuss diagnoses in the meetings. 50401 3. Resident #41 was admitted on [DATE] with diagnoses that included speech and language deficits following cerebral vascular accident, dementia moderate with mood disturbance, major depressive disorder, mood disorder, history of falling, and insomnia. The PASARR dated 5/19/23, indicated diagnoses of anxiety and depression but did not include the admission diagnoses of mood disorder nor dementia from 8/16/23. Per the medical record on 8/13/24, a psychiatry consult was ordered to address the resident's mood and cognitive status. The Psychiatry note dated 8/28/24 indicated the resident reported she had been feeling down, had anhedonia (the inability to feel joy or pleasure), low energy, poor sleep and irritability. The Psychiatry Subsequent Note dated 8/30/24 indicated the resident had a diagnosis of bipolar disorder which was not indicated on the admission diagnoses nor on the Level I PASARR. On 9/10/24 at 9:15 AM, the resident stated she had been having horrible dreams that were like torture but could not describe them in detail without emotional distress. She explained she had not told anyone about the dreams but did talk to the Psychiatric Nurse. She said it was very frightening and made her feel like she didn't know if it was real or not. On 9/11/24 at 4:00 PM, the Key [NAME] UM, reviewed the resident's care plan and stated she was unsure why the diagnoses of dementia and mood disorder were not recorded on her PASARR. She was not sure if there was an updated PASARR in Medical Records that had not been uploaded into the computer yet. On 9/12/24 at 10:15 AM, the Medical Record Coordinator stated she was unsure if there were any updated PASARR's not yet downloaded into the resident's medical record. On 9/12/24 at 1:02 PM, the Assistant Director of Nursing (ADON) submitted a Psychiatric consult for a new symptom of nightmares and said the provider would see her tomorrow. On 9/12/24 at 2:42 PM, the facility provided an updated PASARR performed that day, 9/12/24. The newly updated PASARR still indicated the resident did not have a primary diagnosis of dementia even though the medical record indicated she did have the diagnosis of dementia. 4. Resident #1 was admitted on [DATE] with diagnoses that included multiple sclerosis, depression, bipolar I disorder, and anxiety disorder. The Level I PASARR in the medical record, dated 4/01/22 , indicated a diagnosis of depression only but did not include the diagnoses of bipolar or anxiety disorders as her records indicated. A Psychiatry Consult note dated 4/10/23 revealed the consult was ordered because the resident was, Acting bipolar. This consult note also indicated the resident had a past medical history of bipolar disorder. An updated PASARR that included this diagnosis was not found. On 9/11/24 at 4:00 PM the Key [NAME] UM, stated she was unsure why bipolar and anxiety disorders were not recorded on the resident's PASARR. She was not sure if there was an updated PASARR had been completed since the diagnoses was discovered. On 9/12/24 at 10:15 AM, the medical records coordinator stated she did not know if there were any updated PASARR's since the original one dated 4/01/22 and she would look amongst her documents that had not been downloaded into resident records yet. On 9/13/24 at 10:52 AM, the DON confirmed they were not aware the Level I PASARR was incorrect/incomplete when they provided a new, updated PASARR to the surveyor. 40892 5. Resident # 94 was admitted to the facility on [DATE] with diagnoses including mood disorder and post-traumatic stress disorder. Review of the MDS significant change assessment with ARD of 6/10/24 revealed resident #94 had a BIMS score of 15/15, which indicated she was cognitively intact. The assessment revealed her active diagnoses included bipolar disorder and post-traumatic stress disorder. A review of the resident #94's EMR revealed the diagnoses of mood disorder with an onset date of 4/09/23 and bipolar disorder with an onset date of 4/09/23. The medical record contained a level I PASARR screening form dated 2/28/23 which did not indicate resident #94 had a MI or suspected MI. The record did not contain a Level II PASARR screening form. On 9/12/24 at 10:47 AM, the DON stated the PASARR dated 2/28/23 was incomplete. She confirmed there were no diagnoses listed on the form though the resident had diagnosis of bipolar disorder. The DON indicated the PASARR should have listed the MI or suspected MI diagnoses and was therefore incorrect. On 9/13/24 at 10:52 AM, the DON stated the company did not have a policy for which staff was responsible for updating the PASARRs. 48878 6. Review of the medical record revealed resident #84 was admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia, dementia with behavioral and psychotic disturbance, brief psychotic disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and alcohol abuse. Resident #84's Quarterly MDS with an ARD of 8/20/24 revealed the resident scored 10 out of 15 on the BIMS exam which indicated he had moderate cognitive impairment. Resident #84's Order Summary Report and the Medication Administration Record showed the resident had an order for Oxcarbazepine 300 MG by mouth two times a day for mood, Quetiapine 50 MG by mouth one time a day for paranoid schizophrenia, and Trazodone 25 MG by mouth, three times a day for depression with agitation. Review of resident # 84's medical record revealed behaviors, post-traumatic stress disorder, schizophrenia, and antipsychotic medication care plans that indicated the resident refused care and to monitor and report changes in behavior to the physician. On 9/11/24 at 1:15 PM, the DON stated it was her and Social Service's responsibility to ensure the residents' Level I and Level II PASARRs were completed and submitted timely. She also stated the residents were to have Level I PASARRs submitted prior to admission, or a new one completed if a resident was diagnosed with a new mental illness, or if there was a change in condition. She verified resident #84 was diagnosed with paranoid schizophrenia, dementia with behavioral and psychotic disturbances, brief psychotics disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and alcohol abuse on 5/17/23, however, only the anxiety disorder, depressive disorder, and substance abuse was listed on the Level I PASARR submitted prior to admission on 6/30/22. The DON acknowledged the resident's paranoid schizophrenia, dementia with behavioral and psychotic disturbance, brief psychotic disorder, and post-traumatic stress disorder should have been included on the Level I PASARR. She confirmed the Level I PASARR was inaccurate and another Level I PASARR should have been submitted with the correct diagnoses upon admission and did not know how it was missed. On 9/13/24 at 10:51 AM, the DON stated the facility did not have a PASARR policy or any guidelines to follow regarding the PASARRs. She stated she was told to follow the regulations but did not know what the regulations were.

Based on interview, and record review of facility documentation, the facility failed to effectively implement Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring of previously identified areas of concern and adequately track performance to ensure prior improvement measures were realized and sustained. Findings: Review of the facility's policy, Quality Assurance/Performance Improvement Plan revealed the following, All employees will participate in ongoing quality assurance and performance improvement efforts which support our mission by striving to provide excellent service for residents. The document indicated the QAPI committee was ultimately responsible to ensure compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. In addition the QAPI committee would implement any Performance Improvement Projects (PIP) topics indicated by data analysis. PIPs were, Implemented in accordance with CMS' protocol for conducting PIPs. On 9/11/24 at 1:35 PM, the Nursing Home Administrator revealed the facility had identified a concern related to Preadmission Screening and Resident Review (PASARR) and created a PIP. Review of the PIP revealed it was started on 5/08/24. The first step of the plan was for an audit to be completed on current residents to ensure each had a Level I PASARR completed. When asked for the audit, the Administrator provided a paper with a handwritten list of resident's names. The words, waiver or no waiver, was hand written next to the names. The audit did not include a date to indicate when it was completed, nor did it include what the audit consisted of. Review of the PIP section entitled Monitoring revealed the action step that the Director of Nursing/Designee would conduct audits on new admissions weekly x four weeks, then every two weeks x two months to ensure compliance. Review of the PIP document presented by the facility revealed no documentation under the heading, Status for the new admission audits. The Administrator then provided audits for newly admitted residents starting on 5/11/24. The Administrator was asked about resident #5 who was admitted on [DATE] and did not have a PASARR in their medical record. The Administrator explained as he was not in the facility that week the audit was not done for new residents admitted during that time. Review of the next weeks audit revealed Resident #5 was not added to those audit sheets either. The Administrator did not answer why the facility did not go back and review the new admissions on the off weeks for compliance, nor why 5 additional residents were found during the survey to have concerns with their PASARRs that had not been corrected by the facility. The Five Elements of QAPI include Governance and Leadership, in which the facility designates one or more persons be accountable for QAPI. Another element, the PIP is a concentrated focus on a particular problem and involves gathering information systematically to clarify issues or problems and intervene for improvement, (retrieved on 9/26/24 from www.cms.gov).

Based on observation, interview and record review, the facility failed to treat residents courteously, fairly and with dignity by using labels such as feedersto identify them, by standing over residents while assisting with their meals, and by leaving their meal at the bedside for an extended time before they were to be assisted with dining for 2 of 7 residents reviewed for dependent dining, of a total sample of 57 residents, (#130 and #54). Findings: 1. On 9/09/24 at 1:15 PM, Certified Nursing Assistant (CNA) A was observed bringing a meal tray into resident #130's room. She then fed the resident lunch while standing up, leaning over the resident's meal and bedside tray, while she spooned food items into the resident's mouth. CNA A was observed going in and out of several resident's rooms and at 1:26 PM, another resident asked her for assistance to get back to bed. CNA A replied, she had two feeders she needed to help, and she would help him when she finished. CNA A was then observed entering resident #130's room to assist the roommate, resident #54, with their lunch. CNA A also stood over this resident while feeding them. A few minutes later, the Key [NAME] Unit Manager (UM) came into the room and walked over to resident #54 and CNA A. She whispered into CNA A's ear, and CNA A then took a seat in a chair and continued assisting resident #54 with their lunch. On 9/09/24 at 1:40 PM, CNA A stated the UM whispered to her to sit down and be comfortable as she assisted the resident with her meal, and she realized she had used the word, feeders when she referred to these 2 residents previously. She stated it was important for aides to sit while assisting residents because it made them both more comfortable and it was important to not use labels when referring to residents to maintain their dignity as an individual. On 9/09/24 at 1:48 PM, the Key [NAME] UM, stated CNA A was a newer CNA and she advised her to sit down while assisting residents to eat. She stated it was important to sit while assisting residents with their meals to maintain good eye contact and ensure the resident did not feel rushed. The Key [NAME] UM confirmed staff should not identify residents by labels such as feeders, because it was a dignity issue. She explained staff should call residents who required assistance to eat, assisted diners. 2. On 9/11/24 at 12:55 PM, a lunch tray was brought to resident #54's room and left at her bedside while the resident slept. Almost an hour later, at 1:45 PM ,CNA B indicated resident #54 was a feeder and she would feed her in a minute. CNA B stated she was not aware residents should not be called feeders and stated, I just call them that. On 9/11/24 at 2:29 PM, the Key [NAME] UM, stated residents who needed assistance with dining, were supposed to receive their meals after the residents who could feed themselves, when the staff were able to assist them. She stated staff should be educated not to leave trays next to the bedside to get cold and instead should bring the tray with them when they were ready to assist the resident. When she learned of CNA B calling resident #54 a feeder, she stated, Not again! She stated, I'm going to have to do some education. On 9/12/24 at 1:02 PM, the Assistant Director of Nursing (ADON) stated residents were not to be labeled, feeders and were to be treated with dignity. The facility's policy on Activities of Daily Living (ADL) Care and Services dated April 2020 and revised on January 2024, indicated appropriate care and services would be provided for residents who were unable to carry out ADL's independently including appropriate support and assistance with dining. The policy on Residents Rights dated September 2021 and revised on January 2024 stated Federal and State law guaranteed certain basic rights to all residents of this facility including being treated with respect, kindness, and dignity. CNA training documents including competency questionnaires for CNAs provided by the facility both undated and from October and November 2023, indicated education to ensure staff were aware it was inappropriate to use labels when referring to residents, such as feeders. The training program documents also indicated when staff assisted a resident with meals, they should be seated next to the resident.

Based on interview, and record review, the facility failed to obtain a Level I Preadmission Screening and Resident Review (PASARR) for 1 of 6 residents reviewed for PASARRs, of a total sample of 57 residents, (#5). Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinsonism, dementia, bipolar disorder, depression, insomnia, and dysphagia. Review of the resident's clinical record revealed no Level I or Level II PASARR. Review of resident #5's physician orders revealed Quetiapine Fumarate 600 milligrams (mg) at bedtime for bipolar disorder with a start date of 7/16/24, Donepezil 10 mg at bedtime for dementia on 7/16/24, Mirtazapine Tablet 30 mg at bedtime for depression with a start date of 7/16/24, Lamotrigine 200 mg at bedtime for bipolar disease with a start date of 8/01/24, Lamotrigine 200 mg in the morning for bipolar disease with a start date of 8/1/24 and Aripiprazole 25mg in the morning for bipolar disorder with a start date of 9/03/24. Review of the resident's care plan from 7/18/24 revealed focuses which included the use of antidepressant medication related to depression, the use of antipsychotic medications related to bipolar disorder, the resident having a mood problem related to a mood disorder listed as bipolar disorder and the resident having impaired cognitive function and impaired thought processes related to a diagnosis of dementia. On 9/11/24 at 1:35 PM, the Nursing Home Administrator confirmed a Level I PASARR should have been completed for resident #5 but they could not no provide one. On 9/12/24 at 2:31 PM, the [NAME] President of Operations stated there was no facility policy or procedure for PASARR.

Based on observation, interview, and record review, the facility failed to honor choice of morning routines and schedules significant to support autonomy for 1 of 6 residents reviewed for choices from a total sample of 55 residents, (#66). Findings: A review the medical record revealed resident #66 was admitted to the facility 7/26/2019 with diagnoses including stroke and hemiplegia. Resident #66's Minimum Data Set (MDS) quarterly assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated the resident was cognitively intact. Activities of daily living (ADL) showed the resident required assistance with transfers from the bed and getting dressed. The MDS admission comprehensive assessment with Assessment Reference Date of 7/28/2022 noted it was very important to the resident to choose what clothes to wear while in the facility. Resident #66's lifestyle and activity assessment evaluation dated 7/27/2022 indicated the resident formerly worked as a fashion advisor. Resident #66's care plan showed the resident was dependent on staff for emotional, intellectual, physical, and social stimulation related to physical limitations including weakness/decreased mobility, with a history of cerebral vascular accident (CVA) and hemiplegia/hemiparesis. On 1/23/2023 at 1:32 PM, resident #66 said it was very important for her to get out of bed and get dressed between 7:00 AM and 7:30 AM. The resident explained she was frequently required to wait for 2 hours or longer after requesting staff's assistance to get out of bed and dressed in the morning. She said she was regularly prevented from her customary routine which upset her and caused distress because she could not, start her day. Resident #66's current Visual/Bedside Kardex Report for Certified Nursing Assistant (CNA) use showed the resident required transfer and dressing assistance. The report did not include person-centered customary routines or preferences. On 1/25/2023 at 12:25 PM, the Director of Nursing (DON) said resident preferences were discussed with care plan updates during clinical meetings. The DON explained customary routines were important because a resident may be negatively affected when they were not honored. On 1/25/2023 at 12:28 PM, the Caring Way Unit Manager said the DON and Unit Managers ensured preference documentation was completed so CNAs were aware of the resident's care choices. The Unit Manager stated care plan updates were imported to the CNA Kardex where everything about the resident was noted. She explained the Kardex was important, especially when an agency CNA wasn't familiar with the resident and had been assigned. The Unit Manager acknowledged resident #66's preferred schedule and routines were not included in the Kardex for CNAs to see. She explained it was important for a resident to have choices as the facility was their home, and not accommodating them negatively affected mood and energy. On 1/26/2023 at 9:43 AM, CNA M said not all CNAs knew resident #66 wanted to get up and dressed early. On 1/26/2023 at 10:01 AM, Licensed Practical Nurse (LPN) I stated she was aware resident #66 liked to get out of bed and wanted to be up and dressed early. LPN I said CNAs only knew of residents preferences as indicated in their software documentation, familiarity with the resident, or by receiving verbal communication from other staff. On 1/26/23 at 10:26 AM, the MDS Coordinator said residents were interviewed for specific preferences and they were discussed at care plan meetings. She stated resident #66's last care plan meeting was 11/1/2022. The MDS Coordinator explained the Interdisciplinary Team (IDT) updated care plans and MDS was ultimately responsible. On 1/26/23 at 10:45 AM, the Social Services Assistant said nurses were responsible for entering resident preferences to the medical record software for CNAs to be aware. She explained resident #66 was an early riser, and it was important for the resident to, be up and dressed as early as 7:30 AM. The facility's welcome packet, pages 20-21, titled Attachment 3 read, (a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident, and (c) (3) (iii) Incorporate the resident's personal and cultural preferences in developing goals of care. The Facility assessment dated [DATE], page 6, titled, Other 1.7, read, The Facility's Lifestyles Director meets with the resident upon admission to obtain the individualized daily living preferences to ensure they can continue life on their own schedule while residing in the facility as much as the facility can . we are flexible with resident schedules. , page 8, Part 2, Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information. Record and discuss treatment and care preferences.

Based on observation, interview and record review, the facility failed to provide adequate personal hygiene related to nail care for 1 of 4 dependent residents reviewed for Activities of Daily Living (ADLs) of a total sample of 55 residents, (#91). Findings: Review of resident #91's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, congestive heart failure, atrial fibrillation, glaucoma, hearing loss, and dementia. Review of resident #91's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/22 revealed he had a Brief Interview for Mental Status score of 12 which indicated he had moderate cognitive impairment. The MDS showed resident #91 required extensive assistance on staff for dressing, and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. Review of the Admission Readmission Nursing Packet dated 8/9/22 included a Skin Assessment. The assessment revealed thickening and extremely long fingernails. On 1/23/23 at 11:53 AM, during a medication pass observation with Licensed Practical Nurse (LPN) H, resident #91 showed his fingernails and asked the nurse when his nails were going to be trimmed. All fingernails were long, thick, and curved with light brown substance underneath the nails. She responded by informing the resident that the podiatrist had to trim his fingernails. On 1/24/23 at 5:36 PM, resident #91 showed his long fingernails and stated the podiatrist saw him today. He explained the podiatrist cut his toenails and told him he could not touch him from the knees up. He indicated the facility had not found anyone who could trim his fingernails. On 1/25/23 at 5:48 PM, Certified Nursing Assistant (CNA) G stated most of her assigned residents needed assistance with their ADLs. She indicated resident #91 refused showers occasionally but she provided a head-to-toe bed bath. She stated she was aware his fingernails were long, and this had been addressed with management. On 1/25/23 at 5:55 PM, the Unit Manager (UM) for the East Coast Unit explained shortly after resident #91 was admitted to the facility, a podiatrist trimmed his fingernails. She stated a second podiatrist examined resident #91 yesterday and said he could not trim his fingernails. She stated CNAs had tried to file them, but tissue was growing under them, and they did not want to cause bleeding. On 1/26/23 at 10:03 AM, the UM explained she spent time interacting with the residents in her unit to better know them and their needs. She stated they had discussed resident #91 fingernails issue multiple times during the Interdisciplinary Team (IDT) meetings and the facility was seeking a referral to address it. She shared there were many discussions about the nail care he required. She indicated a podiatrist had seen resident #91 on 8/27/22 and provided nail care. She stated his fingernails had looked the same ever since he was admitted to the facility. She indicated this had been a continuous concern for this resident. The UM could not provide any evidence of the IDT discussions or contacts made for outside resources. She reviewed his medical record for progress notes and could not find any regarding nail care. She indicated CNAs could provide nail care but not if the resident was diabetic. The UM stated it was within the CNAs' scope of practice to keep resident #91's nails cleaned. She stated CNAs could not trim them because his fingernails were very thick. The UM stated she and her staff were aware of his need, but unaware which physician could provide the services resident #91 needed. On 1/26/23 at 4:14 PM, the Director of Nursing (DON) stated she spoke with the podiatrist on Tuesday 1/24/23 after he saw resident #91. She explained the physician told her resident #91 had a medical condition called onychomycosis with onychogryphosis and it was not safe for anyone in the facility to trim his nails. She mentioned the physician told her resident #91 needed to see a hand specialist. She indicated the previous podiatrist who had seen resident #91 back in August 2022 filed them. The DON stated this was the first time she had encountered a situation like this one. She explained they did not pursue anything in August because the physician made no recommendations and the long fingernails did not affect the resident in any way, and he continued getting his ADLs. Review of resident #91's nursing care plan for ADLs initiated on 8/09/22 revealed he required assistance with ADL functions due to chronic conditions which included history of stroke, diabetes, and risk for injury. The care plan interventions listed grooming: someone must assist the resident to groom himself. Review of the Certified Nursing Assistant job description, dated 8/15/19, responsibilities included, Attend the individual needs of residents which may include assistance with grooming, bathing . or other needs in keeping with the individuals' care requirement, and scope of practice. Review of the Activities of Daily Support, Support policy and procedure not dated read, Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy revealed, Appropriate care and services will be provided for resident who are unable to carry out ADLs independently . including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, nail care and oral care).

Based on observation, interview, and record review, the facility failed to provide services and treatments to prevent further decrease in range of motion for 1 of 5 residents reviewed for positioning and mobility of a total sample of 55 residents, (#112). Findings: Resident #112 was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction, contracture of right ankle, contracture of left ankle and contracture of muscles of left hand. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/16/22 revealed resident #112 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. She required extensive to total assistance with Activities of Daily Living (ADLs) and did not resist care. The assessment revealed she had limited range of motion (ROM) to one side of her body for upper extremities and both sides of her body for lower extremities. A care plan for ADL assistance required was initiated 9/19/22 and revised on 9/21/22. The care plan revealed resident #112 required assistance due to multiple factors which included contractures of both legs, right knee and left hand. Interventions included left hand splint as ordered. Review of resident #112's medical record revealed a physician order dated 12/06/22 for left wrist splint to be applied in the morning and removed in the afternoon as tolerated. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2022 and January 2023 revealed no nursing documentation to validate resident #112's left hand splint was applied as ordered. Review of the progress notes revealed no documentation related to resident #112's left hand splint. On 1/23/23 at 11:06 AM, 1/24/23 at 9:25 AM, 1/25/23 at 10:14 AM and 1/25/23 at 2:59 PM, resident #112 was observed in bed. She did not have a splint on her left hand. A left-hand splint was noted to be on the nightstand next to resident #112's bed during the observations. On 1/25/23 at 10:27 AM, Certified Nursing Assistant (CNA) C stated she was familiar with resident #112. She reported the resident required assistance with ADLs. She explained she provided ROM as part of ADL care but did not apply the splint. CNA C clarified therapy applied splints. On 1/25/23 at 2:54 PM, the Therapy Director reported resident #112 was not currently on caseload. She clarified therapy did not don and doff the splint once the resident was discharged from therapy. She stated if a resident discharged from therapy with a splint, therapy educated the CNA on how to don and doff the splint and when it should be worn. She explained the resident would also be referred to restorative nursing therapy. The Therapy Director reviewed the record for resident #112 and confirmed she should have a left wrist splint put on in the morning and removed in the afternoon. On 1/25/23 at 3:01 PM, the Restorative Nurse stated she had just started in the position recently. She explained she had a meeting with the Director of Nursing (DON) and Therapy Director on 1/19/23 about getting the restorative program up and running again. She was unable to identify who performed ROM or application of splints. On 1/25/23 at 3:03 PM, the MDS Coordinator stated she and the Restorative Nurse were new to the facility and had started recently. She recalled the DON approached her after the Restorative Nurse started. The DON informed her she wanted to get the whole restorative program up and running. The MDS Coordinator stated she did not know whether or not part of the program was in place. She reviewed the physician orders for resident #112 and confirmed the order for a left wrist splint. The MDS Coordinator was unable to provide documentation showing application of the splint. On 1/25/23 at 3:26 PM, the Regional Nurse Consultant (RNC) confirmed a meeting was held on 1/19/23 to discuss the restorative program. She stated she was unsure how long the restorative program had not been functional but believed that some residents received ROM and splinting by CNAs. She stated the nurses documented on the MAR if the splint was applied. On 1/25/23 at 4:25 PM, Licensed Practical Nurse (LPN) A confirmed resident #112 was on her assignment. She stated she was familiar with the resident and had worked with her previously. She explained she had never put on or removed resident #112's splint. LPN A clarified therapy took care of the splints. She stated splint applications were signed on either the MAR or TAR. On 1/25/23 at 4:42 PM, the LPN Nurse Supervisor reviewed the physician orders for resident #112 and confirmed the order for a left wrist splint dated 12/06/22. She reviewed the MAR and TAR for January 2023 and acknowledged the order was not on either. The LPN Nurse Supervisor then checked the order type on the physician order and explained the order was coded as Other orders (no documentation required). She stated each physician order entered into the electronic record would be placed into an order type which would determine whether the order appeared on the MAR or TAR for documentation. She then reviewed the CNA tasks and Kardex for resident #112 and confirmed the application of the splint was not located on either. The LPN Nurse Supervisor acknowledged there was no documentation to show the splint had been applied as ordered.

Based on observation, interview and record review, the facility failed to provide appropriate care and services for oxygen therapy for 1 of 1 resident reviewed for respiratory care of a total sample of 55 residents, (#105). Findings: Resident #105 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Her diagnoses included cerebrovascular disease, diabetes mellitus type 2, hypertension, coronary artery disease and congestive heart failure. Review of the Admission Minimum Data Set (MDS) assessment with assessment reference date 11/23/22 revealed resident #105 was cognitively intact, and had physical or verbal behaviors towards herself or others. Resident #105 was assessed as needing extensive assistance from at least two staff for bed mobility, transfers from surface to surface and dressing. She required extensive assistance from one staff for eating and personal hygiene. Resident #105 was noted to require use of oxygen and received hospice care. Resident #105 had a care plan for altered cardiovascular status related to diagnoses of anemia, arrythmia, heart failure and other heart related diagnoses. Interventions included staff to administer oxygen (O2) per physician's orders. Review of resident #105's medical record revealed no other care plans related to oxygen use. On 1/24/23 at 10:05 AM, resident #105 was observed in her room, alert and oriented to person, place and time. She was wearing a nasal cannula connected to an oxygen concentrator with an attached humidifier operating. The oxygen concentrator was set at 3 liters of oxygen per minute (LPM). Resident #105 stated she was not sure who was supposed to fill the humidifier with water, but said her husband did it when the water would get low, usually every other day. Review of the Medication Review Report dated 01/24/23 revealed a physician's order for Respiratory-Oxygen nasal cannula/mask continuous. Encourage and assist resident to use O2 at 2 LPM via nasal cannula continuously for hypoxemia every shift dated 11/16/22. Additional orders were in place to change O2 tubing/mask/bag every week on Sundays and as needed dated 11/16/22. There were no orders for oxygen humidification found. On 1/24/23 at approximately 5:30 PM, Licensed Practical Nurse (LPN) A observed resident #105 in her room and confirmed resident #105's O2 concentrator was set at 3 LPM with the humidifier in place. LPN A returned to the nurse's station and reviewed the physician orders. She confirmed resident #105 did not have orders for the humidification and acknowledged the order was for 2 LPM not 3. When asked why she had not noticed resident #105's oxygen was set on 3 LPM or why there was no order for the humidification she stated resident #105 came over from the rehabilitation unit with the humidification and O2 concentrator set at 3 LPM. On 1/24/23 at approximately 5:35 PM, the Key West Unit Manager explained the resident needed to have an order for oxygen with humidity, and the nurse was responsible to change or refill the water in the canister. She was unable to say why resident #105 did not have an order for the humidified oxygen nor why the concentrator was set at 3 LPM instead of the ordered 2 LPM. She stated she would clarify the order with the physician and Hospice. On 1/26/23 at 9:58 AM, the Director of Nursing stated if the physician determined the resident needed oxygen she expected the staff to follow those orders. She stated she did not believe the facility had a protocol for the humidification of oxygen, but stated she thought if there was no order the staff should follow the care plan instead. Review of the Oxygen Administration policy with revision date October 2010 revealed the purpose to provide guidelines for oxygen administration. The guidelines indicated oxygen therapy was administered per physician's orders and/or facility protocol.

Based on observation, interview, and record review, the facility failed to maintain the food pantry in a safe and sanitary manner for 1 of 1 pantry sampled, (Caring Way). Finding: On 3/6/22 at 12:28 PM, the pantry on the Caring Way unit was toured with the facility's Certified Dietary Manager (CDM). Upon entry, a musty like, pungent odor was noted. Certified Nursing Assistant (CNA) A, entered the pantry and stated the room had a noticeable metallic, rust like odor. The CDM acknowledged the odor and said she would inform the maintenance staff. On 3/6/22 at 3:07 PM, the CDM reported that housekeeping had cleaned the pantry. At 3:20 PM, the pantry was observed with the Administrator and Maintenance Director. The Administrator indicated he noticed the odor. Several bins were moved so the left side and back of the ice machine could be observed. There was a plastic drain pipe extending from the back of the ice machine, to a drain in the floor. The drain pipe was noted with dark, mold-like substance that covered the length of the pipe. The back of the ice machine also had black mold-like substance. The seams to the back of the ice machine had whitish material that resembled calcified hard water residue with black mold like spots. The Administrator and Maintenance Director could not explain why the ice machine was not maintained in a safe and sanitary manner. Review of Policy and Procedure #27, titled Ice Machines read, The Facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk for food hazards. The ice machine will be cleaned once quarterly or more often as needed. The scoop and storage container will be cleaned once each day The Procedure for cleaning the ice machine are as follows: 1. Unplug ice machine and remove ice. 2. Wash interior with detergent solution. 3. Rinse and drain with hot water. 4. Sanitize and air dry 5. Clean the exterior with detergent solution and rinse 6. Wash and sanitize the ice scoop at least once each day in the dishwasher and air dry. 7. Store the ice scoop in a clean non-porous container that allows water to drain off. On 3/6/22 at 3:45 PM, the CDM and Regional Dietary Director were asked how a mold-like substance was overlooked when multiple staff entered the pantry daily. The CDM explained that perhaps staff thought it was not their responsibility. It's suppose to be a collaboration, between the kitchen, maintenance and housekeeping staff to ensure the pantry is clean.

Based on observation, interview and record review, the facility failed to maintain a secure environment in an enclosed courtyard, failed to respond to exit door chimes, and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 8 residents reviewed for elopement, out of a total sample of 9 residents (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was a likelihood he could have fallen, become lost or been hit by a car. On 12/12/21 at approximately 9:11 PM, resident #1 exited the secure memory care unit and entered an enclosed courtyard. The resident wandered in and out of the facility through two doors located at opposite ends of the unit and walked back and forth across the dimly lit courtyard. Staff did not respond to the door chimes which sounded nine times in 15 minutes as resident #1 repeatedly opened the doors that led to the courtyard. While in the courtyard, he attempted to open two locked exterior exit doors in the wall surrounding the enclosed area. Resident #1 eventually retrieved a wheelchair from the unit's atrium, pushed it to the end of the courtyard and stood on it to climb over the wall. He landed approximately six feet below, on the other side of the wall, and then walked in the dark near a drainage ditch and a residential street until he arrived at a house. He rang the doorbell, and when the homeowner opened the door, the resident spoke to him in an unintelligible foreign language. The homeowner assumed the resident was from the nearby nursing facility and guided him back to the building. Staff were unaware resident #1 was missing until the homeowner returned him to the facility at 10:00 PM. The facility's failure to provide adequate supervision, ensure an appropriate response to exit door chimes, and maintain a secure courtyard placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on 12/12/21. The Immediate Jeopardy was removed on 12/16/21. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of immediate corrective actions. Findings: Cross Reference F835 and F867. Resident #1, a [AGE] year-old male, was admitted to the facility's memory care unit on 10/22/21. He was transferred from another skilled nursing facility as he required a secure environment that was appropriate for his wandering and exit-seeking behaviors. Resident #1's diagnoses included Alzheimer's disease, alcohol dependence with alcohol-induced persisting dementia, skull fracture, brain hemorrhage, and [CONDITION(S)] disorder. Resident #1's hospital record revealed a History and Physical report dated 9/30/21 that read, We use the formal Interpretation service to speak with him. The Interpreter confirms that he is not even paying attention to the questions and is not really useful to get much history from him. Review a Neuropsychological Evaluation, conducted on 10/01/21 while resident #1 was hospitalized , revealed his diagnosis of alcohol induced persisting dementia impeded his ability to recognize the consequences of his actions. The document indicated the resident was oriented to person only and lacked decision-making capacity. The evaluation read, Ongoing areas of concern will include behavioral impulsivity, lack of insight and judgement, which is not expected to improve with time or treatment. Review of the medical record revealed an admission Elopement Risk Evaluation, dated 10/22/21, that deemed resident #1 to be at high risk for elopement. He had an electronic monitoring device placed on his left ankle. Review of the Progress Notes revealed resident #1 was seen by a physician on 10/23/21 at 3:39 PM. The History and Physical assessment note indicated the resident was confused, oriented to himself only, and exhibited intermittent agitation. A nurse's note, dated 10/24/21 at 1:27 PM, described resident #1 continuously banging on the doors for over one hour. A note dated 10/27/21 at 12:36 AM revealed resident #1 was actively exit-seeking by . attempting to open every coded door on the unit . redirection has failed. A few hours later at 5:45 AM, a note indicated resident #1 continued his efforts to exit the unit by . attempting to go out of windows in dining room and all other doors. Redirection failed. The Minimum Data Set (MDS) Admission assessment with assessment reference date of 10/28/21 revealed resident #1 was admitted from another skilled nursing facility. The MDS assessment indicated staff were unable to determine if the resident needed an interpreter for communication. He had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision-making. The MDS assessment showed resident #1 wandered on 1 to 3 days in the 7-day lookback period but wandering did not place him at risk of going to a dangerous place. He required limited assistance to walk in his room, extensive assistance to walk on the unit, and limited assistance for locomotion. Resident #1's balance was unsteady, but he was able to stabilize without staff assistance, and he used a walker and wheelchair for mobility. He had falls and a fracture in the six months prior to admission and one fall without injury after admission. His height was 6 feet 2 inches. Resident #1 used an electronic monitoring device daily. An electronic monitoring device is used for those who wander. The device sets off a sound alarm when the resident attempts to open a door to the outside. Review of the medical record revealed resident #1 had a care plan initiated on 10/29/21 regarding the need for a secure dementia unit due to a diagnosis of dementia and wandering and exit-seeking behaviors. A care plan for behavioral tendencies related to alcohol induced persisting dementia, traumatic brain injury and [CONDITION(S)] disorder was initiated on 10/29/21. The goal was staff would attempt to re-direct the resident as behaviors occurred. The interventions included staff awareness of the resident's tendency to wander; anticipate and meet his needs; check placement and function of his monitoring device; monitor behavior episodes and attempt to determine underlying cause; and prevent him from leaving the facility unsupervised. Resident #1's care plan for alteration in memory, decision-making and communication was initiated on 10/29/21. The document indicated the resident primarily spoke Polish and had a Brief Interview for Mental Status score of 0, which indicated severe cognitive impairment. The interventions directed staff to cue, reorient and supervise the resident. A care plan for altered mood and psychosocial well-being, initiated on 10/29/21, had interventions including behavioral health consultations as indicated, implementation of non-pharmacological approaches such as a regular bedtime routine, and monitoring, recording and reporting signs and symptoms of mood issues or anxiety to the physician. The Medication Administration Record (MAR) for December 2021 revealed on 12/11/21, the day before resident #1 eloped, the day shift nurse noted he had 2 episodes of exit-seeking behavior. During the next shift, resident #1's exit-seeking behavior escalated, and Registered Nurse (RN) E noted many occurrences. On 12/12/21, the day the resident eloped, RN E again noted he had many occurrences of exit-seeking behavior during the day shift. The medical record did not show the escalating behaviors were reported to the physician or nursing administration, and there were no nurses' progress notes to indicate oncoming nurses were made aware of the need for increased monitoring and supervision. The medical record revealed an Event Note dated 12/13/21 at 3:49 AM, written by RN A. The progress note provided a timeline for resident #1's elopement. The document indicated the resident was observed inside the facility between 9:00 PM and 9:30 PM, seated in the atrium, walking the hallways, and occasionally went out to the courtyard. RN A noted at 10:00 PM, a staff member notified him a neighbor brought resident #1 back to the facility. The timeline showed at 10:10 PM, RN A went to the facility's front lobby door, confirmed the person outside was indeed a resident of the facility, and thanked the homeowner for returning resident #1. On 12/15/21 at 12:42 PM, in a telephone interview, RN A confirmed resident #1 was under his care in the secure memory care unit on the night he eloped. He recalled he last saw the resident seated in the unit's atrium near the nurses' station sometime between 9:00 PM and 9:30 PM, but he could not provide an exact time. RN A stated this was resident #1's usual location at that time of the evening. RN A stated he passed medication while the two Certified Nursing Assistants (CNAs) on the unit helped residents to bed. He stated at some point there was only one CNA on the unit while the other one was on break. RN A stated resident #1 did not speak or understand much English and his gait varied from unstable and wobbly in the morning to slow and steadier in the evening. He described the chimes that sounded when the two doors that led from the unit to the courtyard were opened. RN A said, The purpose is to alert staff that a resident went out. We might not be able to hear it if we are in a room. The doors stay open all night. It would be nice if it could be locked at a certain time . Residents should not be outside at night. I discourage it but I cannot be always watching them at night. The chime is loud, but we need enough staff if we keep the door open, otherwise the door should be locked. RN A stated staffing needs for the secure unit could change quickly depending on incidents or residents' behaviors on any given day. RN A was informed RN E documented resident #1 had exit-seeking behaviors on 12/11/21 during the evening shift and on 12/12/21 during the day shift. Although he assumed RN E's assignment on both days, RN A stated he was not given that information in change of shift report, and he was not aware of the resident's escalating exit-seeking behaviors. On 12/15/21 at 2:08 PM, the Maintenance Director recalled past attempts by residents to get over the walls of the secure unit's enclosed courtyard. He stated he removed items that could be used as leverage to breach the walls, such as flowerpots and picnic tables. He confirmed resident #1 placed a wheelchair to the right of exterior exit door B and stood on it to climb over the wall. He explained the courtyard wall was about six feet high and the two exterior exit doors in the wall that led outside the facility required a code to release the doors' magnetic locks. The Maintenance Director stated the two inner doors that led from the secure unit to the enclosed courtyard, one in the atrium and the other at the end of the 400 hallway doors, were never locked as they were not equipped with magnetic locks that automatically released if the fire alarm was activated. He explained these doors did not have alarms, instead they had chimes similar to those used in stores. Review of video footage from the facility's security cameras showed on 12/12/21 at 9:11 PM, resident #1 left the secure unit through the 400-hallway exit door and entered the enclosed courtyard. He walked along the pathway, crossed the dimly lit courtyard, and tried to unlock exterior exit door B in the wall. The resident then walked across the grass and stepped back onto the pathway. He retraced his steps to again cross the courtyard and attempted to unlock exterior exit door A in the outside wall. Next, resident #1 re-entered the secure unit through the 400-hallway door. A few minutes later, he appeared at the other end of the secure unit as he opened the door that led from the atrium to the courtyard. The resident looked around and then walked back into the atrium. A short time later, he exited through the atrium door, followed the pathway, and again tried to unlock exterior exit door B in the wall. He then returned to the atrium door and entered the unit. Soon after, resident #1 exited through the 400-hallway door at the opposite end of the unit and crossed the courtyard. He re-entered the facility through the atrium door and then seconds later opened the door again, stuck his head outside to look around the courtyard and returned to the atrium. The video showed resident #1 as he retrieved a wheelchair and pushed it through the atrium door. He followed the path that led to exterior exit door B and disappeared out of camera range when he stepped off the pathway to the right of the door at 9:26 PM. The video footage showed no staff responded to the door chimes that sounded nine times in 15 minutes to alert them a resident had accessed the dark courtyard. Resident #1 wandered in the courtyard without supervision and no staff member intervened during the period he actively sought to exit the facility. Resident #1's elopement route was traced by the surveyors on 12/15/21 at 2:24 PM. The resident had placed a wheelchair against the courtyard wall to the right of exterior exit door B. Due to mounded dirt and mulch, the height of the wall from ground level was approximately 5 feet 5 inches in that area, lower than the resident's height of over 6 feet. He stood on the wheelchair, climbed over the wall, and landed on the other side, 5 feet 9 inches below. The resident stood in the grassy area outside the enclosed courtyard facing a drainage ditch, a culvert, and a residential street. He turned left and walked over uneven terrain in the dark, beside the ditch, past a wooded area and a large manhole cover. Resident #1 arrived at a driveway, walked towards the front door of the house, and rang the doorbell. He traveled approximately 460 feet from the facility to the house, and then walked approximately 0.3 miles back to the facility's front lobby door with the homeowner, a Good Samaritan. On 12/15/21 at 2:47 PM, in a telephone interview, the homeowner recalled the night an elderly man rang his doorbell. He stated he could not understand anything the man said but realized he spoke an Eastern European language. The homeowner said, I figured he was a patient from the nursing home because this is not the first time I heard of people getting out. He stated he slowly guided the man towards the facility. He recalled as they walked along the street, the man headed towards the dark grassy area between his home and the facility. The homeowner stated he was able to convince him to remain on the street, and they continued to walk to the facility's back parking lot. When he knocked at the back door, staff directed him to go to the front lobby door where he informed staff the resident showed up at his house. Review of time-stamped video footage from the homeowner's doorbell camera revealed on 12/12/21 at 9:40 PM, resident #1 appeared at the front door. The homeowner opened the door and was unsuccessful in attempts to determine the resident's situation as he did not speak English. On 12/15/21 at 9:21 AM, resident #1 stood at the nurses' station in the secure unit. His conversation was incoherent with only one recognizable word heard, passport. A few minutes later at 9:33 AM, the resident was unable to answer simple questions such as providing his name. CNA F was seated nearby and explained she was assigned to do 1:1 supervision with the resident as he eloped recently. She said, They told me he got over the wall. On 12/15/21 at 4:28 PM, Licensed Practical Nurse (LPN) C, stated resident #1 exhibited exit-seeking behaviors including knocking and pushing on the double doors that connected the secure unit to the rest of the facility. LPN C stated he felt the doors to the enclosed courtyard should be locked at night as the darkness and uneven surfaces made the area an unsafe environment. He explained residents occasionally fell in the courtyard during the day, and it was even more dangerous at night due to vision and balance issues. LPN C was informed on the night resident #1 eloped, he opened the courtyard doors nine times in 15 minutes. LPN C said, I would respond to the chime even for one time, much less nine times. I don't want my residents to get hurt. It is possible for me not to see resident for an hour if I am busy, but I rely on the CNAs to monitor them as well during that time. LPN C explained resident #1 usually sat quietly in the atrium after dinner until a CNA took him to bed. He stated it was possible the resident behaved differently on the weekends if regular staff were not present. On 12/15/21 at 4:53 PM, CNA D stated she was regularly assigned to care for resident #1 on the 3:00 PM to 11:00 PM shift. She explained the resident usually sat in the atrium and occasionally went to the courtyard. CNA D said, Most of the time we don't let him go outside alone . There are two doors in the courtyard wall, and he goes to both and tries to open them. CNA D explained she did not allow her assigned residents to go to the courtyard by themselves at night because it was not safe. She stated all residents in the secure unit needed to be monitored closely, and when the door chime sounded, staff were to monitor the activity at the door. CNA D stated she was shocked that resident #1 eloped, and even more shocked that staff did not realize he was missing. On 12/15/21 at 5:12 PM, the secure unit's Unit Manager (UM) confirmed verbal descriptions and documentation by staff of resident #1 trying door handles, punching in codes at the keypads, and attempting to leave the secured area through doors and windows deemed him to be exit-seeking and at high risk for elopement. She stated she was never made aware of these behaviors and could have initiated 1:1 supervision or rotating staff monitoring for 15-to-30-minute intervals. The UM explained when door chimes sound, staff should check the courtyard. She explained it was not safe for any resident to be outside at night. The UM acknowledged if resident #1 had been adequately supervised, he would never have gotten over the wall. On 12/16/21 at 12:57 PM, in a telephone interview, RN E confirmed she documented resident #1 had many episodes of exit-seeking behavior on 12/11/21 and 12/12/21. She recalled multiple occasions on both days when the resident punched the double doors and the keypad in an effort to leave the unit. She explained the MAR directed nurses to document the actual number of episodes of exit-seeking behavior, but resident #1's behavior was continuous, and she was not able to quantify the occurrences. RN E confirmed staff were required to monitor exit-seeking or agitated residents closely, but neither 1:1 supervision nor increased monitoring by rotating staff was implemented as her immediate interventions appeared to be effective. She stated during the day, residents opened doors to the courtyard regularly and staff had to check the courtyard as it was impossible to see the entire courtyard from inside the unit. RN E said, If staff do not respond, there is no point to the chime. I am not sure of the purpose of the chime. She stated the courtyard wall was lower in the section breached by resident #1 and it was concerning as other residents were also aware of this weakness. RN E stated it would be very difficult for any of the residents on the secure unit to manage outside the facility, on a street, and in the dark as all were physically or cognitively impaired. She stated if the courtyard doors were to remain unlocked, the unit's staffing needed to change to provide additional monitoring for residents with exit-seeking behaviors in the courtyard. On 12/16/21 at 3:38 PM, in a telephone interview, resident #1's son stated since his father suffered a severe head injury a few months before, he required constant supervision as he made poor decisions and did not communicate well in either English or Polish. The son explained it was very dangerous for his father to be outside the facility alone, especially at night, as he would be lost immediately and unable to provide his contact information. On 12/15/21 at 3:29 PM, resident #1's elopement incident was discussed with the facility's leadership team including administration and corporate staff. The Director of Nursing (DON) stated she conducted interviews with staff, and no one recalled hearing the exit door chimes or knew the resident was outside in the courtyard that night. The DON stated her expectation was staff would do regular rounds to ensure residents were accounted for and safe, but she could not provide a recommendation for frequency of rounds. The DON explained the door chimes were not alarms and staff did not have to respond immediately. The leadership team was informed one of the two CNAs on the secure unit was on break at the time of the incident, which resulted in fewer staff to monitor and supervise residents. The Administrator stated a staff member from the 300-hallway outside the secure unit should have been assigned to cover the CNA's assignment while she was on break. On 12/15/21 at approximately 3:29 PM, the Regional Nurse Consultant (RNC) stated it was not necessary for staff to check the courtyard if they were aware resident #1 was wandering around. The RNC said, I have been on the nurses' station before and heard the door chimes sounding as residents went in and out. If I knew a patient liked to wander and liked to hear the chimes, I would not necessarily go outside to look. She did not respond when asked if she felt cognitively and physically impaired residents were adequately supervised when alone in the courtyard at night. On 12/15/21 at approximately 3:29 PM, the Vice President of Operations (VPO) could not explain how resident #1 eloped and why his absence was unnoticed if there was sufficient staff to monitor and supervise him. The policy and procedure for Elopement and Wandering effective 11/09/21, revealed the facility would provide adequate supervision for residents identified to be at risk for unsafe wandering or elopement. The policy directed staff to redirect and distract residents who wandered and notify nurse management. The document indicated residents would be . adequately supervised to mitigate any risks likely to occur. The policy defined adequate supervision as an individualized intervention based on the number and level of staff required to meet a resident's assessed needs and identified environmental hazards. The document read, Adequate supervision may vary from resident to resident and from time to time for the same resident. The Facility Risk Assessment 2021, approved on 12/17/20, revealed the facility could care for residents with dementia, Alzheimer's disease, and traumatic brain injury. The document included a description of a secured park atmosphere outside the memory care unit. The assessment indicated the facility's staffing was stable and based on expected care needs determined by a detailed prescreening process. The document read, In other words, we do not vary staffing levels according to a prospective customer's acuity or care needs. Basic services provided for residents include risk assessments and implementation of systems and interventions to maximize safety. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On 12/12/21 at approximately 10:00 PM, a neighbor arrived at the facility's front door with resident #1. He explained the resident showed up at his front door. The resident was returned to the secure unit, assessed by the nurse, and noted to have a superficial abrasion on his left knee. Notifications were made to the physician and family. The resident's electronic monitoring device was checked for function and placement, and he was placed on 1:1 supervision. *On 12/12/21, door alarms were checked, and proper function validated. *On 12/13/21, an elopement re-assessment was completed for resident #1, and the interdisciplinary team (IDT) conducted a care plan meeting. *On 12/13/21, the facility initiated a Courtyard Monitor position to provide 24/7 monitoring of the enclosed courtyard area. *On 12/13/21, all current residents' elopement assessments were reviewed and updated with 100% compliance achieved. The facility's elopement list was updated and elopement books at the front desk and on nursing units were audited to ensure completion and accuracy. The IDT reviewed residents identified as at risk for elopement to validate the following items: electronic monitoring equipment was in place in accordance with manufacturer's guidelines, associated physician orders, appropriate care plans included individualized interventions and checking placement of electronic monitoring device every shift. *On 12/13/21, maintenance staff continued daily door checks including function of electronic monitoring device. Logbook Documentation, dated 12/12/21 to 12/16/21, validated all exit doors including the electronic monitoring system were functional. *On 12/13/21, the corporate office was contacted regarding expanding wall height to prevent any other incidents. Contractors are scheduled to review fence build up on 12/27/21. *On 12/13/21, the Regional Director of Clinical Services educated nursing leadership regarding completion of elopement evaluations. *On 12/13/21, staff education on the facility's elopement policy and procedure and in-servicing on Code Orange for missing person was initiated, with a goal of 100% set. As of 12/16/21, 107 out of 189 employees have been educated. All remaining employees will be educated at the start of next shift working. A total of 4 elopement drills were completed as of 12/16/21. Review of in-service and drill attendance sheets and reconciliation with staff roster validated education was completed according to the facility's elopement policy. *On 12/16/21, an Ad Hoc Quality Improvement Performance Committee meeting was held. Attendees included the Medical Director, Administrator, Clinical Nurse Consultant, Director of Nursing, Assistant Director of Nursing, Social Service Director, Clinical Reimbursement Coordinator, Business Office Manager, Therapy Director, Business Development Liaison and Unit Managers, Medical Records, Director of Dietary, Director of Maintenance, Director of Recreation, and Care Plan Coordinator. Results of the facility's investigation were reviewed and plans discussed. Contractors are scheduled to install magnetic locks on courtyard doors on 12/17/21. Once installed, doors to the courtyard will be locked at 8:00 PM daily. Staff will be assigned to cover assignments in the absence of coworkers during breaks. Maintenance Director/designee will continue daily door and security checks to ensure a secure resident environment. Any issues identified will be discussed in monthly meetings. *On 12/16/21, interviews conducted with 14 facility staff including 10 CNAs and 4 LPNs revealed 9 of 10 CNAs and 3 of 4 LPNs were knowledgeable of the elopement policy and procedure and verbalized the importance of monitoring wandering residents and reporting behavior changes. *The sample was expanded to include 8 additional residents at risk for wandering, exit-seeking and elopement. Record review revealed these residents had elopement risk re-assessments, care plans reviewed, and demographic information placed in the elopement binders.

Based on observation, interview and record review, the facility failed to use its resources effectively to provide a secure environment and adequate supervision to prevent elopement for 1 of 8 residents reviewed for elopement out of a sample of 9 residents (#1), and ensure the safety of all residents on the Caring Way secure memory care unit. Findings: Cross Reference to F689 and F867. Review of a facility investigation revealed on 12/12/21 at approximately 9:11 PM, resident #1 exited the facility's secure memory care unit and entered an enclosed courtyard. The resident wandered in and out of the facility through two doors located at opposite ends of the unit and walked back and forth across the dimly lit courtyard. Staff did not respond to the door chimes which sounded nine times in 15 minutes as resident #1 repeatedly opened the doors that led to the courtyard. While in the courtyard, he attempted to open two locked exterior exit doors in the wall surrounding the enclosed area. Resident #1 eventually retrieved a wheelchair from the unit's atrium, pushed it to the end of the courtyard and stood on it to climb over the wall. He landed approximately six feet below, on the other side of the wall, and then walked in the dark near a drainage ditch and a residential street until he arrived at a house. He rang the doorbell, and when the homeowner opened the door, the resident spoke to him in an unintelligible foreign language. The homeowner assumed the resident was from the nearby nursing facility and guided him back to the building. Staff were unaware resident #1 was missing until the homeowner returned him to the facility at 10:00 PM. On 12/15/21 at 3:29 PM, the facility's leadership team, including administration and corporate staff, discussed resident #1's elopement incident. The Director of Nursing (DON) stated staff did not hear the chimes when resident #1 opened the doors to the courtyard that night. She stated she did not feel staff had to respond to the chime as it was not an alarm, and residents were free to go outside. The leadership team was informed one of the two Certified Nursing Assistants (CNAs) on the unit was on break at the time resident #1 eloped, resulting in decreased supervision for all residents. When asked about the availability of staff and interventions to meet the unpredictable behaviors and changing needs of the residents on the secure memory care unit, Caring Way, the Administrator stated activities staff were assigned to the unit. However, he acknowledged activities staff left at 5:00 PM daily and nursing staff were responsible for distracting and entertaining residents with items left by activities staff. The leadership team did not respond when asked about the likelihood of busy nursing staff having time to conduct 1:1 activities with agitated or exit-seeking residents. On 12/15/21 at 5:12 PM, the Caring Way Unit Manager (UM) stated she was never made aware of resident #1's exit-seeking behaviors. She acknowledged if he was adequately supervised, he would never have gotten over the outside wall. The UM confirmed security cameras showed activity in the courtyard, but the monitor was on the other side of the unit outside the locked double doors. She explained the screen was not visible to staff inside the secure section of the unit. Staff were not assigned to monitor the video camera. On 12/16/21 at 5:00 PM, the Administrator recalled in early 2021, resident #9 was able to get over the Caring Way enclosed courtyard wall, and the facility installed a slatted wooden barrier to raise the height of the wall in that area. When asked how that would prevent the same problem reoccurring at another area along the extensive wall that surrounded the courtyard, the Administrator said, It is in the plan . He explained the height of the entire wall was never increased due to concerns regarding neighborhood restrictions on heights of fences and other structures. The Administrator could not provide any details on community restrictions that prohibited increasing the height of the wall. He could not provide information on any interim interventions implemented to secure the courtyard in over six months between resident #9's elopement attempt and resident #1's successful elopement. On 12/16/21 at approximately 5:00 PM, the DON acknowledged staff interviews and record reviews conducted during the survey indicated concerns regarding current residents' attempts to breach the courtyard wall. She stated staff were expected to document behaviors in progress notes or communicate in verbal report, and the interdisciplinary team (IDT) would review the information in daily clinical meetings. The DON stated the Administrator did not always attend daily meetings, but she informed him of any concerns related to safety and security of residents. The Administrator denied knowledge of any concerns and could not explain why issues related to courtyard access after dark, staffing, and the courtyard wall height were never identified, addressed, and resolved by the members of the administrative team. Review of the facility's Quality Assurance and Performance Improvement (QAPI) process with the leadership team revealed administration had not utilized the QAPI Plan to develop appropriate corrective actions. On 12/16/21 at approximately 5:00 PM, the Regional Nurse Consultant (RNC) explained the facility's secure unit provided an essential, specialized service and function as it was the only one in the county. She said, That wall has been there for sixteen years, and neither the wall height nor the doors that allow access to the courtyard were a problem before. She was informed the facility's administration was responsible for ensuring the height of the wall and level of supervision was appropriately adapted to meet the needs of the residents the facility chose to admit. The RNC acknowledged if the facility accepted residents with high-risk exit-seeking behaviors into a unit that could not ensure their safety, the facility did not provide a beneficial service. On 12/16/21 at 6:34 PM, during a tour of the enclosed courtyard with the Caring Way UM, she acknowledged sections of the wall had varying heights. She acknowledged there was a section close to the 400-hallway exit door that was approximately 5 feet high, which was lower than the area breached by resident #1. The UM was shown the slatted wooden barrier used to raise the wall height in the area climbed by resident #9. The UM stated she had never noticed the wooden structure and said, l was not aware it existed. She did not respond when asked about the effectiveness of increasing the height of a single section of the wall if other sections were much lower. The job description for Administrator, dated 8/15/19, revealed he/she would administer, direct, and coordinate all functions of the facility. Job responsibilities included continuous assessment of residents' needs and staffing requirements and maintaining a safe living environment. The job description for Director of Nursing (undated), indicated his/her responsibilities included collaborating with staff . to identify and correct problem areas and improve services. The DON was expected to ensure residents' safety, identify areas for improvement in delivery of care, promote coordination of care by the IDT, and communicate recommendations to the Administrator.

Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility and failed to ensure all staff were knowledgeable of elopement protocols to promote safety for 1 of 34 residents at risk for elopement, (#21). On 9/3/21 at 7:46 PM, the facility failed to prevent a physically and cognitively impaired resident #21, from exiting the facility unsupervised in the dark without shoes. The resident exited the facility by pushing the panic bar on the main entrance doors for 15 seconds which released the magnetic lock. Resident #21 walked along wet sloping sidewalks with grates and drainage ditches with varying depths of 3 to 6 feet. The facility staff were not aware of the resident's whereabouts for approximately 1 hour when she was found near an apartment complex. While the resident was out of the facility unsupervised, she could have fallen, been hit by a car, been accosted, slipped into a ditch or become lost. The facility's failure to provide adequate supervision and ensure a secure environment resulted in substandard quality of care at the Immediate Jeopardy level starting on 9/3/21. Findings: Resident #21 was a [AGE] year-old female, most recently admitted to the facility on [DATE]. Her diagnoses included [CONDITION(S)], [CONDITION(S)] disease of nervous system, chronic pain, metastatic [CONDITION(S)], [CONDITION(S)], anxiety, and dementia. A review of the resident's medical record revealed nursing progress notes dated 1/6/21 at 4:09 PM, 4:30 PM and 5:20 PM that showed the resident was exit seeking and pushing on exit doors. The resident had told staff she wanted to go home. The facility staff placed a wander alert bracelet on the resident. Another progress note dated 1/7/21 read the resident was again, pushing on exit doors and told staff she wanted to go home. The resident was noted to be disoriented and confused and had started on antibiotic therapy for a urinary tract infection ([CONDITION(S)]). On 6/3/21 the psychiatric Advanced Practice Registered Nurse (APRN) noted, Per nursing there is no acute change in patient behaviors, more focused, cooperative but always wants to go home . The Monthly Nursing Summary dated 6/26/21 noted the resident was at risk for elopement and had episodes of confusion in the past with exit seeking behavior. The quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident's Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The assessment showed the resident required supervision for transfers, walking in room and locomotion both on and off the unit. The resident was independent for walking in corridors. The assessment also noted the resident was not steady but was able to stabilize without staff assistance for moving from seated to standing position, walking, and turning around. A care plan for risk for falls initiated 10/6/20 and revised 9/7/21 included interventions to ensure the resident wore appropriate non-slip, well-fitting footwear, encourage resident to use wheelchair when fatigued or ambulating long distances and noted she frequently declined to use her walker and needed frequent reminders for safety. A care plan initiated on 1/7/21 related to exit seeking behaviors included approaches for staff to be aware of her tendency to wander, check wander alert placement every shift, provide diversional activities when behavior occurred, redirect resident when she attempted to leave building and, do not allow resident to leave facility. On 9/3/21 an exception note written by the resident's assigned Registered Nurse, (RN) B showed resident #21 had eloped from the facility and was found outside by administration. The resident was assessed, taken to the shower, and was provided with one to one (1:1) supervision. On 9/20/21 at 2 PM, resident #21 was in her room with Certified Nursing Assistant (CNA C) who provided 1:1 supervision. The resident sat at the edge of the bed and a wander alert bracelet was noted on her left ankle. The resident said she did not know why the device was on her ankle. She added, They just slapped it on there. She said her son told her it was for some type of containment. The resident recalled the evening she left the facility. She said she cut off her wander alert bracelet with scissors and left the building by the front entry doors. She thought she left the facility around 8 PM but throughout the interview the resident paused as she searched for words. She explained she had difficulty remembering but had not planned on leaving. She recalled, We were all settling down and I was walking by the door. I tried the door and thought that if I'm not supposed to leave, the door would be locked. I walked out and remember going through the parking lot. She could not remember if she had her walker with her. She said it was starting to get dark when she left the facility and then it started to rain shortly after. I did not realize where I was but I kept on walking. She remembered she carried a lot of stuff with her including a large bottle of vaseline which she had to drop as it was too heavy. She said after walking for some time, it became very dark and she realized she was lost. She said she was tired and sat under a tree. She explained a couple came out of the apartment complex and then emergency services arrived and then some people who were familiar. She stated, they should not allow me to be out and walk around. I'm in a nursing home because I have hallucinations and don't have the ability to make decisions. On 9/20/21 at 1:28 PM, the East Coast Unit Manager (UM) acknowledged resident #21 eloped from the facility on 9/3/21, through the front exit door. She said on 9/3/21 the resident cut off the wander alert bracelet with a pair of scissors and left the facility at approximately 7:40 PM. She stated the Director of Nursing (DON) located the resident sitting under a tree near an apartment complex. She added that First Responders were with the resident when the DON arrived. She explained the resident left the facility without her walker but noted the resident tired easily and needed her walker for stability. She acknowledged the resident had dementia with periods of confusion and received [MEDICATION(S)] for pain which made her more confused. She recalled the resident had exit seeking episodes in January 2021 but did not get out of the building. She verbalized the resident would not be safe outside the facility in the dark. On 9/20/21 at 2:26 PM, CNA D stated she was assigned to resident #21's care on the 3 PM to 11 PM shift on 9/3/21. She acknowledged the resident had a wander alert bracelet but did not consider her at risk for elopement as the resident had not mentioned leaving the facility. She noted the resident, keeps looking at the exit doors whenever she comes out of her room. CNA D said on the evening of 9/3/21, she helped resident #2 get ready for bed. She remembered she placed the resident's nightgown on the bed and the resident was in the bathroom brushing her teeth when she left the room to assist another resident. CNA D recalled RN B discovered resident #21 was missing and a Code Orange was called. She stated she looked in the parking lot for resident #21 but did not find her. CNA D stated it was dark and added it would not be safe for the resident to be outside by herself. She spoke of how scared she was for the resident. I prayed to God to find her and thankfully she was found. On 9/20/21 at 2:51 PM, RN B stated she was assigned to the resident on the evening of 9/3/21 when she heard the front door alarm at 7:30 PM. She said she asked CNA D to check and she did not see anyone. RN B said she thought that maybe kitchen staff may have set off the alarm when they exited through those doors. She indicated the annunciator panel at the East nursing station showed the front entrance doors were breached. RN B acknowledged the resident had a wander alert bracelet as she checked it on her shift. She said she took a break at approximately 7:42 PM, and went outside to move her car closer to the front entrance. She remembered the parking lot was very dark and she did not see anyone outside. She returned to the facility at 7:50 PM and started her medication pass. She recalled she went to resident #21's room at about 8 PM but the resident was not there. She checked the bathroom and asked CNA D where the resident was. She then checked the other rooms on the unit and went to the courtyard but the resident was not there. She said she called a Code Orange with a description of the resident. She continued to search for the resident on the other unit and called the DON at 8:15 PM. She then proceeded outside to search for the resident around the perimeter of the building. She recalled it was very dark, and wet as it had rained. She recalled her own shoes were drenched. She remembered feeling relieved when she saw the Administrator, DON and the resident in the front lobby at approximately 8:45 PM. She said the resident was soaked, wearing only socks, no shoes and was carrying a flowered purse. She stated the resident did not have her walker and she did not have her wander alert bracelet on her ankle. RN B stated the resident told her she had cut off the wander alert bracelet. On 9/21/21 at 6:15 PM, CNA E stated she assisted with the search for resident #21 on 9/3/21. She recalled she went outside and it was drizzling. She said the resident would not be safe outside the facility in the dark by herself. CNA E explained the resident could have met someone while she was out of the facility alone, trusted them, and gone with them. She noted the resident could have been hit by a car, anything is possible. CNA E recalled seeing resident #21 when she returned to the facility and stated the resident was wet and in need of a change of clothes. She looked confused, she was repeating her story and it changed with each version. On 9/20/21 at 4:31 PM, resident #21's elopement investigation was reviewed with the Administrator. He recalled on the evening of 9/3/21, the DON called him to inform resident #21 had eloped from the facility. He said that both he and the DON immediately headed back to the facility. He stated the resident was found at a condominium complex located 0.45 miles west of the facility. He explained that when the DON drove past the condominium complex, she saw First Responders and stopped to check and found the resident. The DON brought the resident back to the facility. The Administrator explained the facility's camera near the front entry doors captured the resident leaving the facility at 7:47 PM. He said when he reviewed the recording, he saw a fire truck pass by the facility at 8:38 PM followed by an ambulance at 8:44 PM. He identified the DON was with the resident at about 8:45 PM and brought the resident back to the facility at 8:54 PM. The Administrator explained the front entrance doors were wander alert protected but also had 15 second delayed egress. If the egress bar was continuously pushed for 15 seconds, an alarm sounded at the door. Once the door opened, the alarm sounded at the East Coast Nursing station. He stated the expectation was for staff to check the door alarm. If the source of what caused the alarm could not be identified, staff were required to call a Code Orange to do head count of all residents. He said the resident was assessed when she was brought back to the facility on [DATE] and a new wander alert bracelet was placed. He noted labs were also done which showed the resident had a [CONDITION(S)]. He explained that staff did not see the resident leaving the facility and based on staff interviews, all staff on the East Coast Nursing wing were busy caring for other residents when the resident eloped from the facility. On 9/20/21 at 6:15 PM, the facility's video recording of resident #21's elopement was observed with the Administrator and Maintenance Director. The recording showed the resident walked out the front door on 9/3/21 at 7:47 PM. The resident wore a yellow blouse and long shorts. She had socks but no shoes and carried a bag over her right shoulder with other items in her hands. On 9/20/21 at 6:54 PM, the Maintenance Director described how the double fire doors and the front entry doors functioned. There were double fire doors prior to entrance to the lobby which were alarmed. He explained these doors remained open during the day and were closed at 6:00 PM. The Administrator identified the double fire doors had been unlocked in the evening of 9/3/21 by RN A and the resident was able to get to the lobby without any alarms sounding. The Maintenance Director said the front entry doors were wander alert protected and also had a delay exit. He showed a sign near the front door which read, Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. The Administrator explained that the resident pushed the egress bar until the door unlocked and she exited the building. The Maintenance Director tested the front entry doors by pushing on the panic bar. A beeping noise sounded at the front door and at the East Coast nurses station. The light on the enunciator panel showed the front entrance door had been breached. He then pushed the panic bar for 15 seconds which allowed the doors to open and a steady beep sounded. The resident's probable elopement route was retraced on 9/20/21 at 7:30 PM, at approximately the same time the resident left the facility. There was steady rain and several puddles of pooled water prior to reaching the sidewalk. The parking lot was dark and not well lit. The resident walked through the parking lot and turned left onto the sidewalk. The sidewalks were uneven and curved and the resident would have had to negotiate several drainage grates. There were drainage ditches that continued along the sidewalk and were approximately 3 feet to 6 feet deep. The resident would have passed several residential driveways dodging cars that partially blocked the sidewalk. She would have crossed 2 intersections with light traffic in the dark. To reach the condominium complex where she was found, the resident had to cross a two lane road and grassy areas without shoes, a total of 0.45 miles. On 9/21/21 at 10:26 AM, the DON described the events of 9/3/21. She was at home when RN B called to say a Code Orange was in progress and that resident #21 was missing. The DON stated she was told that staff were searching outside the facility for the resident. She said that on her way to the facility, she drove past a fire truck and stopped to check. She turned into the condominium complex and the resident was sitting under a tree. She noted the resident had the facility's identification bracelet on and was able to tell them she lived in the area. The DON said she was informed by First Responders that a concerned citizen had called 911. She said resident #21 recognized her as the DON. She recalled the resident told her, I was looking for excitement, I must have bit off more than I can chew. She said the First Responders released the resident into her care and she brought the resident back to the facility. She then assessed the resident and gave her a shower. She recalled the resident gave her several different answers as to why she left the facility but did remember she went through 2 doors, heard the alarm and thought to herself, I might as well keep going. She said the resident told them she read the sign on the front exit doors to push the door for 15 seconds. She explained the resident was placed on 1:1 supervision and she notified the son. The DON stated the resident knew what she was doing but acknowledged she would not have been safe outside in the dark, by herself. The DON explained the staff did not follow the procedure for door alarms. She said when any door alarmed, staff were expected to check to identify who activated the alarm. If staff could not identify the source of the alarm, a Code Orange was to be called and all staff were expected to do a head count of their residents to ensure a resident did not exit the facility. She verbalized this did not happen when the resident exited the front door and activated the alarm. On 9/21/21 at 11:24 AM, the receptionist stated she had worked on 9/3/21 and left at 6:00 PM. She said she locked the fire doors before she left and that had been her practice for years. On 9/21/21 at 11:30 AM, CNA C recalled on the evening on 9/3/21, the front entry doors alarmed at approximately 7:30 PM. She remembered RN A asked her to check the doors as they were alarming. CNA C stated the fire exit doors were alarming, so she entered the code to stop/reset the alarm. She said she then went to the front exit doors, and they were not alarming. She then looked through the glass and did not see anyone but she did not go outside to check. CNA C stated she returned to her unit and saw resident #21 in her room. CNA C acknowledged she did not report back to RN A or call Code Orange. On 9/21/21 at 2:12 PM, the Administrator and DON discussed the timeline of the resident's elopement. They said they identified that RN A deactivated the inner fire doors on 9/3/21 after the receptionist had locked them at 6:00 PM. RN A's written statement noted that she answered a front door alarm sometime between 7 PM and 8 PM but they could not narrow down the exact time. They noted that it was clear that RN A did not call a Code Orange to ensure all residents were accounted for. They stated the video recording showed that resident #21 left the facility at 7:47 PM. The recording also showed RN B left the facility at 7:49 PM to move her car and returned by front entrance door at 7:58 PM. They said RN B did not hear any alarm when she went out to move her car. It was not until a few minutes after 8:00 PM that RN B went to resident #21's room to administer medications that she discovered the resident was missing. The Administrator identified the root cause of the elopement was the resident had [CONDITION(S)] that interfered with her cognition and the inner fire doors were deactivated by RN A. They acknowledged their process for doing resident head count was not done but they failed to identify the lack of resident supervision as one of the key factors in their root cause analysis and why staff did not react to the front door alarm, in a timely manner, when resident #21 eloped from the facility. On 9/21/21 at 6:32 PM, during a telephone interview, the resident's physician stated he was notified of the elopement on 9/3/21. He acknowledged the resident had periods of confusion and stated that infections, such as a [CONDITION(S)] caused changes in her cognition. He said the resident would definitely not be safe outside of the facility, alone, in the dark. In response to a call made on 9/21/21 at 2:00 PM, resident #21's son stated he was aware that his mother had eloped from the facility on the evening on 9/3/21. He spoke about her medical condition, history of falls, and her pain medication. He verbalized that she received [MEDICATION(S)] for pain which sometimes made her more confused. He said his mother could had been lost when she was outside the facility in the dark. He said he spoke to her about the elopement and she may have been trying to go to a friend's house when she left the facility. Review of the immediate corrective measures implemented by the facility revealed the following, which were reviewed by the surveyors: *9/3/21 Resident had a skin check completed. *9/3/21 Wander alert bracelet placed back on #21's ankle. *9/3/221 Elopement risk completed by DON with resident #21. *9/3/21 Interview completed by DON with resident #21. *9/3/21 Staff interviews initiated. *9/3/21 Administrator tested the door alarm that resident #21 exited through to ensure door functioning correctly. *9/3/21 Physician, Power of Attorney and Hospice notified of resident #21 elopement. *9/4/21 Maintenance Director and Administrator reviewed camera recordings to establish timeline. *9/7/21 Resident #21 evaluated by Psychologist. *9/10/21 Resident care plan meeting held with interdisciplinary team which consisted of Social Services, Director of Nursing and Unit Manager. *Current facility resident elopement evaluations were initiated on 9/4/21. Of the current census of 143 there were 32 other residents besides resident #21 identified at being at risk elopement. *On 9/8/21 the interdisciplinary team review of residents at risk for elopement to validate the following items: wander alert equipment is in place in accordance with manufacturer's guidelines, physician orders in place for wander alerts, care plans in place and resident specific, monitoring is being conducted every shift for placement of wander alerts. *Wander alert exit doors are being checked for function every day by maintenance and recorded in electronic system. *Facility elopement list was updated on 9/8/21 and elopement books at front desk and on nursing units were audited to ensure completion. *Regional Director of Clinical Services (RDCS) educated nursing leader on 9/8/21 regarding completion of elopement evaluations. *As of 9/8/21 -131 employees educated on elopement and Code Orange protocols. *On 9/4/21 in-service regarding Code Orange for missing person initiated. A goal of 100% of staff education to be completed. As of 9/21/21 152 out 196 employees have been educated. All remaining employees will be educated at the start of next shift working. A total of 4 elopement drills have been completed. *AD HOC Quality Improvement Performance Improvement (QAPI) Committee meeting was held on 9/7/21 to review the recommendations made from investigation. The following team members were in attendance: Medical Director, Administrator, Clinical Nurse Consultant, Director of Nursing, and Assistant Director of Nursing, Social Service Director, Clinical Reimbursement Coordinator, Business Office Manager, Therapy Director, Business Development Liaison and Unit Managers, Medical Records, Director of Dietary, Director of Maintenance, Director of Recreation, Care Plan Coordinator. *Maintenance Director/designee will continue daily door and security checks to ensure a secure resident environment. Any issues identified will be discussed in monthly QAPI meeting. *Quality reviews will continue as above or until QAPI determines substantial compliance. Staff interviews were conducted with 10 facility staff including 4 CNAs, 2 Licensed Practical Nurses, 1 Physical Therapy Assistant, 1 Dietary Aide, 1 Dietary Director and 1 RN on 9/21/21 between 2:00 PM to 6:00 PM. Interviews revealed the facility had provided education and training on elopement, Code Orange protocols and monitoring of residents at risk of elopement. The facility was determined to have removed the immediacy as 9/8/21.