Every finding on record at Lake Worth Rehabilitation Center

Based on record review and interview, the facility failed to collect a urine test to rule out a urinary tract infection (UTI) for 1 of 3 sampled residents (Resident #1). The findings included:Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, required substantial/maximum assist with activities of daily living and had been on antibiotics. A review of Resident #1's physician orders revealed an order dated 01/09/26 for urinalysis. Further review of the resident's records did not reveal the urinalysis was ever collected. Furthermore, there was no indication the physician was notified, nor a documented reason the urinalysis was not collected.An interview was conducted with Resident #1's power of attorney (POA) on 02/09/26 at 12:00 PM. The POA stated Resident #1 was prone to have UTIs. The POA further stated the resident started to exhibit familiar signs to her of developing a UTI, and she asked the facility to obtain a urinalysis. The POA stated she did not know if the urinalysis was ever obtained.An interview was conducted with Resident #1's physician on 02/09/26 at 3:00 PM. The physician stated he was aware that Resident #1 was susceptible to UTIs. The physician further stated he had ordered a urinalysis at the request of the resident's POA. The physician stated he was not aware the urinalysis was not obtained, and he should have been notified.Record review revealed Resident #1 was transferred to the hospital for altered mental status on 02/12/26. An interview was conducted with the Director of Nursing (DON) on 02/09/26 at 4:30 PM. The DON acknowledged the above.

Based on observation, interview, record and policy review; the facility failed to ensure reporting of 2 of 2 incidents involving events with major injuries both affecting 1 of 2 sampled residents (Resident #11) reviewed for accidents. The findings included: The facility's Abuse and Neglect Prohibition policy effective 10/24/22 and revised 8/2023 revealed, The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but no later than 2 hours after forming the suspicion of the events that cause the allegation involve abuse or result in serious bodily injury. The center will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. The surveyor requested a policy on falls and was told by Staff D, Registered Nurse, Regional Nurse Consultant on 06/13/25 at 2:49 PM that there is no fall policy. The surveyor then asked for a change in condition policy. The facility's policy titled Change in Condition effective 1/2023 and updated 9/2023 revealed The center will inform the resident, consult with the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification. The facility's policy titled Incident Reporting for Residents or Visitors revised 8/2023 revealed If an event involves abuse of any nature, file a complete report in accordance with the state and federal regulations. Note if abuse or bodily injury report shall not exceed 2 hours. The person discovering the event must complete the Incident/Accident report prior to completing the shift. The Administrator or Director of Nursing may assist with completion of the incident report. A review of the Electronic Health Record (EHR) revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Chronic Atrial Fibrillation, Unspecified; Unspecified dementia; and Anxiety. Her Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/24. This indicated at that time she was severely cognitively impaired. Resident #11 was readmitted to the facility on [DATE], following hospitalization for a subdural hematoma and orbital fracture post fall. Resident #11's BIMS was 0 on the Significant Change MDS with an ARD of 02/25/25. Review of the Electronic Health Record (EHR) for Resident #11 revealed a nursing medication administration note written by Staff G, a Licensed Practical Nurse (LPN) effective 06/27/24 at 2:09 AM which stated Acetaminophen tablet 325 mg Give 2 tablet by mouth every 4 hours as needed for pain scale 1-10. Not to exceed 3,000 mg per total daily dose. Resident co pain in left leg. Staff G then recorded another medication administration note at 6:43 AM on 06/27/24 which read Acetaminophen tablet 325 mg Give 2 tablet by mouth every 4 hours as needed for pain scale 1-10. Not to exceed 3,000 mg per total daily dose. PRN administration was effective. The follow up pain scale was 0. There was no progress note written by Staff G regarding any incident that may have happened which would have caused the resident pain. Record review revealed a nursing progress note written by Staff H, an LPN, effective 06/27/24 at 7:10 AM resident was in bed while the CNA made rounds she call me and said the patient stated : I am in pain and called me, patient assessed on her left leg patient can't move her leg, patient asked if a fall happened patient said no i did not fall. NP/DR (Nurse Practitioner/Doctor) . notified and place a stat Xray for the patient. vitals: BP 140/80 pulse 80 resp; (respiration)19, 02sat (saturation) 98. Record review revealed a nursing progress note written by Staff I, Registered Nurse (RN) on 06/27/24 at 9:50 AM. The note stated resident complained of pain in left leg. Upon assessing resident there were no bruises or swelling, however: resident could not flex knee and left foot was turned out. NP notified and order received from NP for stat x-ray of femur, tibia and fibula . Record reviewed revealed a subsequent nursing progress note written by Staff H on 06/27/24 at 1:37 PM Resident Xray done and results showed left femur fracture. Order given from NP to send the patient out. AMR came and transport the patient to Hospital accompanied two staff nursing for further evaluation and treatment, resident alert and oriented when left the facility. NP made aware, (family) notified. On 06/27/24 a focus Interdisciplinary Team (IDT) note was written by Staff F, LPN. The note stated Resident discuss in IDT meeting, regarding s/p fall on 6/27/24. Upon investigation nurse reported while doing rounds resident observed transferring self, unassisted from bed to wheelchair, observed sliding down on her left knee, nurse assisted back to the bed, assessed patient from head to toe, performed range of motion, patient complaint of pain on the left leg 4/10, pain medication was administered. PT. stated I am going to take a walk resident is alert x 2 with confusion. Resident's fall was witnessed, neuro check were not initiated. vital signs BP 129/78 HR 80, temp 97.8. Nephew and MD notified, received new orders for STAT X-rays to left pelvis, left Tibia and Fibula, therapy referral sent for evaluation, offered sleeping aid, x-ray was completed, results show left Femur fracture MD notified, received orders to transfer resident to the hospital for further evaluation. An interview was conducted with Staff F, an LPN, on 06/13/25 at 12:25 PM. She stated she was at the IDT meeting the next morning (06/28/24).She stated the team goes over progress notes and whatever happened overnight at the meeting. She stated the Administrator was not at that particular meeting. The Director of Nurses (DON) at the time called Staff G to find out what happened since there was no note from him in the progress notes. He stated to the IDT team while doing rounds resident observed transferring self unassisted from bed to wheel chair, observed sliding down on her left knee, nurse assisted back to the bed, assessed patient from head to toe, performed range of motion, patient complaint of pain on the left leg 4/10, pain medication was administered. Staff G wrote a statement note on 06/27/24 in the EHR which could not be accessed by the surveyor, but provided by the Regional Nurse Consultant. The note stated, observed resident transferring to wheelchair and slipped. There was no time listed as to when this happened or follow up for this statement. Record review revealed x-ray orders were put into the EHR at 8:26 AM on 06/27/24. The ordered x-rays were of the lower extremity leg and foot stat for pain and x-ray of left pelvis 2 views, left tibia and left fibula 2 views stat for pain. These orders were put in by Staff I, RN. Record review revealed no record of a call to the physician or family regarding the incident that Staff G stated happened in the phone call. An order to send Resident #11 to the hospital was put into the EHR on 06/27/24 at 9:15 AM. A review of the Job Description for an LPN was reviewed. Staff G did not have a signed job description in his personnel file according to Staff D, the Regional Nurse Consultant. An LPN job description revealed an LPN communicates with RNs and or physicians regarding pertinent resident observations and information. On 06/13/25 at 11:15 AM, an interview was conducted with the Administrator. She was asked if she was the risk manager at the time of the incident on 6/27/24. She stated that she was. She stated she was not at the Interdisciplinary Team Meeting (IDT) meeting on 06/28/24 when the incident was discussed and does not remember why at this time. She stated she is usually at the morning meetings and becomes aware of fall incidents or injury of unknown origin during those meetings. She was asked to provide the witness statements for this incident, any training done for the staff, and any training done for Staff G, a Licensed Practical Nurse (LPN), who did not write a note for this incident or call the physician and family to report this incident. There was no witness statements for this incident. There was no education in the personnel file for Staff G post incident. A telephone call was placed (by the surveyor) to Staff G on 06/13/25 at 11:37 AM with no answer. The Administrator placed a call to him immediately after and left a message to return her call as it was urgent and he never returned her call. Staff D stated she called multiple times and was not able to leave a message on his phone anymore for him to return the call. He never returned any call to the facility. The Administrator was asked if the fall was reported to the state agency and she replied that it was not. Record review revealed on 02/17/25 Resident #11 obtained another fracture. The fall investigation was reviewed with the Administrator on 06/12/25 at 11:17 AM. The Administrator stated the resident was found on the floor trying to go to the bathroom-witnessed by Staff E, an LPN. She received a laceration on the right side of her forehead and swelling and bruising on her face. She was immediately taken to a local hospital and due to head trauma was transferred to a trauma hospital. When she came back from the hospital on [DATE], her readmission diagnoses were subdural hematoma and orbital fracture. On 06/12/25 at 2:04 PM the surveyor reviewed the progress notes in the EHR of the incident. It was noted that Staff E wrote on 02/17/25 at 11:40 PM that she found the resident on the floor and did not observe the resident fall. During an interview with the Administrator on 06/12/25 at 2:15 PM, she stated she thought the fall was witnessed, therefore it did not have to be reported to the state agency, so she did not make the report.

Based on observation, interview, record review and policy review; the facility failed to thoroughly identify and investigate the alleged witnessed fall and unwitnessed fall for 1 of 2 sampled residents reviewed for accidents (Resident #11). The findings included: The facility's policy titled Change in Condition effective 1/2023 and updated 9/2023 revealed All completed incident reports must be forwarded to the Director of Nursing and Administrator for review within 24 hours of the event. The facility's Abuse and Neglect Prohibition policy effective 10/24/22 and revised 8/2023 revealed The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. A review of the Electronic Health Record (EHR) revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Chronic Atrial Fibrillation, Unspecified; Unspecified dementia; and Anxiety. Her Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/24. This indicated at that time she was severely cognitively impaired. Resident #11 was readmitted to the facility on [DATE], following hospitalization for a subdural hematoma and orbital fracture post fall. Resident #11's BIMS was 0 on the Significant Change MDS with an ARD of 02/25/25. On 06/27/24 a focus Interdisciplinary Team (IDT) note was written by Staff F, a Licensed Practical Nurse (LPN). The note stated Resident discuss in IDT meeting, regarding s/p fall on 6/27/24. Upon investigation nurse reported while doing rounds resident observed transferring self unassisted from bed to wheelchair, observed sliding down on her left knee, nurse assisted back to the bed, assessed patient from head to toe, performed range of motion, patient complaint of pain on the left leg 4/10, pain medication was administered. PT. stated I am going to take a walk resident is alert x 2 with confusion. resident's fall was witnessed, neuro checks were not initiated. vital signs BP 129/78 HR 80, temp 97.8. Nephew and MD notified, received new orders for STAT X-rays to left pelvis, left Tibia and Fibula, therapy referral sent for evaluation, offered sleeping aid, x-ray was completed, results show left Femur fracture MD notified, received orders to transfer resident to the hospital for further evaluation. An interview was conducted with Staff F, an LPN, on 06/13/25 at 12:25 PM. She stated she was at the IDT meeting the next morning (06/28/24). She stated the team goes over progress notes and whatever happened overnight at the meeting. She stated the Administrator was not at that particular meeting. The Director of Nurses (DON) at the time called Staff G, the 11-7 AM LPN, to find out what happened since there was no note from him in the progress notes. He stated to the IDT team while doing rounds resident observed transferring self unassisted from bed to wheelchair, observed sliding down on her left knee, nurse assisted back to the bed, assessed patient from head to toe, performed range of motion, patient complaint of pain on the left leg 4/10, pain medication was administered. Staff G wrote a statement note on 06/27/24 in the EHR which could not be accessed by the surveyor but provided by the Regional Nurse Consultant. The note stated, observed resident transferring to wheelchair and slipped. There was no time listed as to when this happened or follow up for this statement. On 06/13/25 at 11:15 an interview was conducted with the Administrator. She was asked if she was the risk manager at the time of the incident on 6/27/24. She stated that she was. She stated she was not at the Interdisciplinary Team Meeting (IDT) meeting on 06/28/24 when the incident was discussed and does not remember why at this time. She stated she is usually at the morning meetings and becomes aware of fall incidents or injury of unknown origin during those meetings. She was asked to provide the witness statements for this incident, any training done for the staff, and any training done for Staff G, LPN, who did not write a note for this incident or call the physician and family to report this incident. There was no witness statements for this incident. There was no education in the personnel file for Staff G post incident. A telephone call was placed to Staff G on 06/13/25 at 11:37 AM by the surveyor with no answer. The Administrator placed a call to him immediately after and left a message to return her call as it was urgent and he never returned her call. Record review revealed on 02/17/25 Resident #11 obtained another fracture. The fall investigation was reviewed with the Administrator on 06/12/25 at 11:17 AM. The Administrator stated the resident was found on the floor trying to go to the bathroom-witnessed by Staff E, an LPN. She received a laceration on the right side of her forehead and swelling and bruising on her face. She was immediately taken to a local hospital and due to head trauma was transferred to a trauma hospital. On 06/12/25 at 2:04 PM the surveyor reviewed the progress notes in the EHR of the incident. It was noted that Staff E wrote on 02/17/25 at 11:40 PM that she found the resident on the floor and did not observe the resident fall. An interview was conducted with the Administrator at 2:15 PM on 06/12/25. The Administrator stated that she thought the fall was witnessed. A thorough investigation was not done at the time of the incident.

Based on observation, interview and record review, the facility failed to ensure the resident had a current order for a nebulizer treatment medication, failed to secure that medication observed at the bedside for 1 of 16 sampled residents receiving nebulizer treatments (Resident #85), and failed to ensure the resident received a psychotropic medication at the prescribed time for 1 of 4 sampled residents observed for medication administration (Resident #85). The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Anxiety Disorder. Her Brief Interview for Mental Status (BIMS) score on a quarterly Minimum Data Set with a target date of 05/01/25 was 15. This indicated she was cognitively intact. On 06/10/25 at 10:19 AM, an interview was conducted with Resident #85. The resident stated she is supposed to get a medication for anxiety early in the morning and she never gets it early. She stated she feels very anxious right now. An observation was made of a vial of medication located next to her nebulizer on a bedside table. The surveyor asked the resident if she knew what this was and she said it was Albuterol for her nebulizer treatment, they leave it there for me. On 06/10/25 the surveyor observed Staff J, a Registered Nurse (RN) administering medications for Resident #85. The medications included Clonazepam Tablet 0.5 MG (milligrams) were administered at 10:49 AM. On 06/10/25 at 1:00 PM, a review of the Medication Administration Record (MAR) was done. The MAR revealed an order for Clonazepam Tablet 0.5 MG *Controlled Drug* Give 1 tablet by mouth two times a day for anxiety HOLD FOR LETHARGY OR DROWSINESS. PLEASE SCHEDULE AT 9 AM AND 6 PM. The order was created on 04/21/25. The psychotropic medication was ordered for upon rising which could be given anywhere between 6:00 AM and 11:00 AM. Further review of the MAR revealed no current order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. (milliliter). The previous order had a start date of 01/25/25 and a discontinued date of 05/23/25. The only current order was to administer a nebulizer treatment. On 06/10/25 at 1:20 PM the surveyor asked Staff J what medication she was putting in the nebulizer for Resident #85. She stated that she was putting in Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML and she showed this surveyor the box that was in the respiratory cart. When asked to show the surveyor where the order was for the medication, she stated it was not there. A review of the MAR on 06/11/25 at 8:30 AM for Resident #85 revealed the order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML was re-entered on 06/10/25 at 6:00 PM. There was no order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML from 05/23/25 at 5:59 PM until 06/10/25 at 6:00 PM and it was being administered every 6 hours for shortness of breath. This was discussed with the Director of Nurses on 06/11/25 at 10:47 AM, who acknowledged the findings.

Based on observations, record review, and interviews, the facility failed to prevent complications for a resident who received enteral feeding. This affected 1 of 1 sampled resident, (Resident #300), who was reveiwed for enteral feeding (tube feeding). This had the potential to affect 4 residents who were dependent on enteral feeding for nutrition at that time. The findings include: A review of the facility's Procedural Guidelines for Enteral Nutrition effective 01/2023 stated that the nurse must administer the enteral feeding regimen according to the formula, the system type, and the method of delivery ordered by the physician. It also stated that feeding tube orders must include the following information: the product to be used, the rate and/or timing of administration, the total volume to be given per 24-hour period, the total calories provided per 24-hour period, the route of delivery (i.e. via gastrostomy tube, jejunostomy tube), the method of administration (i.e. pump, bolus), and the volume of water given as water flush and before and after medications. A record review of the enteral feeding order for Resident #300 with a start date of 05/22/25 stated: two times a day for Enteral Feeding Osmolite 1.5 @65 mls/hr over 20 hrs (off at 10 am, on at 2 pm). This feeding tube order failed to include the total volume of Osmolite that was to be given per 24-hour period, the total calories provided per 24-hour period, the route of delivery, and the method of administration. The water flush was contained in a separate order. In addition, the order said to administer the enteral feeding for a duration of 20 hours two times a day. This is not possible. A review of current professional standards of practice to promote the safe provision of enteral feeding recommends that the components of the feeding be included in the doctor's order. These include the following: the kind of feeding and its caloric value, the volume of the formula, the mechanism of administration (e.g., gravity or pump), and the volume and frequency of water flushes. Nurse driven enteral nutrition protocols for volume-based feedings are recommended. The reference for these protocols is the American Society for Parenteral and Enteral Nutrition (ASPEN) 2016: ASPEN Safe Practices for Enteral Nutrition Therapy. Resident #300 was admitted to the facility on [DATE]. The resident's medical history included acquired absence of other specified parts of the digestive tract, Gastrointestinal Hemorrhage, Unspecified Severe Protein-Calorie Malnutrition, Cerebral Palsy, Gastrostomy Status, and Perforation of Intestine. Resident #300 had a Gastrojejunostomy tube inserted on 03/09/25. The MDS assessment dated [DATE] revealed that Resident #300 had severe cognitive impairment and he was totally dependent on enteral feeding for nutrition. A record review of Resident #300 showed his most recent weight was 86.2 pounds on 06/08/25. His Body Mass Index (BMI) was 15.8. This indicated that he was severely underweight. According to the Nutrition Comprehensive Evaluation/Risk Screen on 03/19/25, the resident's guardian requested that the dietitian increase the amount of enteral feeding because Resident #300 had recently lost 25-30 pounds. The RD complied with her request and increased the volume of the feeding two times. Resident #300's weight upon admission was 87 lbs. He did not gain weight after the feedings were increased from 800 milliliters per day to 1100 milliliters per day, and on 05/09/25 the volume was increased to1300 milliliters per day. The three different enteral feeding orders since admission provided 1200 Calories, 1650 Calories, and 1949 Calories respectively. During an observation of Resident #300's enteral feeding formula on 06/10/25 at 4:20 PM, the surveyor saw the nurse connect the tube from the pump that was set-up to administer the Osmolite 1.5 Cal Nutrition formula. She started the pump. The bottle of Osmolite 1.5 contained 1000 ml. It was a full bottle and the graduated measurements of milliliters were marked, from the top of the plastic bottle 1000 milliliters, then below it about 1 inch 900 milliliters, down to 200 milliliters with black lines. The label had the date 06/10/25, and the start time 15:00 handwritten on it. The pump was set to deliver 65 milliliters per hour. This rate agreed with the doctor's order. Approximately 24 hours later, on 06/11/25 at 4:26 PM, the same bottle that was hung the prior day, dated 6/10/24 with the time 15:00, showed 200 milliliters remaining. Photographic evidence obtained. That indicated that 800 milliliters was administered, instead of the 1300 milliliters that was recommended by the Registered Dietitian in his Nutrition Assessment. The resident received 500 milliliters less than he was supposed to receive. During an observation on 06/12/25 at 9:39 AM, Resident #300 was in bed watching television, and his enteral feeding was in progress. The pump was set to administer Osmolite 1.5 Cal at 65 milliliters per hour. The label had the date 06/11/25, and the start time 9 PM handwritten on the label. Approximately 350 milliliters remained in the 1000 milliliter bottle. This means that 650 milliliters was administered from the bottle with the date 06/11/25, and time 9 PM. Seventeen hours and 11 minutes elapsed in the time period from 06/10/24 at 4:26 PM when there was 200 milliliters remaining in the bottle, until 06/12/25 at 9:37 AM when 650 milliliters was administered from the bottle. Seventeen hours of administration of formula at 65 milliliters per hour should have provided Resident #300, 1105 milliliters, not 850 milliliters that was administered (200 milliliters plus 650 milliliters). The DON entered Resident #300's room at 9:45 AM. The DON told the Home Health Aide (HHA) that she could take Resident #300 outside for a stroll. The DON said she would ask the nurse to disconnect the pump 15 minutes earlier, and then to reconnect the pump to the Resident at 1:45 PM (15 minutes earlier), so that he would get the complete feeding. The nurse, Staff K, disconnected the resident's feeding tube from the pump at 9:45 AM. During an interview with the DON at 9:50 AM in Resident #300's room, when asked how she knew that the resident would receive the amount of Osmolite 1.5 Cal that he was supposed to receive, the DON explained that the pump should be off at 10:00 AM and then turned back on at 2:00 PM. On that day she said the nurse would start up the pump again at 1:45 PM. During an observation in Resident #300's room on 06/12/25 at 2:11 PM, the resident was in bed and his enteral feeding was being administered. A new bottle of Osmolite 1.5 Cal hung from the pole attached to the pump. The label on the Osmolite 1.5 Cal had the date, 06/12/25, and a start time 1:54 PM, handwritten on the label. On 06/12/25 at 2:11 PM, the surveyor observed the bottle of Osmolite 1.5 Cal dated 06/11/25, with start time handwritten, 9:00 PM, in the garbage bin located in Resident #300's bathroom. Two hundred and fifty milliliters remained in the plastic bottle in the garbage bin. (Photographic evidence obtained). During an observation on 06/12/25 at 4:31 PM, the bottle of Osmolite 1.5 that was loaded onto the pump connected to Resident #300 had approximately 940 milliliters remaining. That means that approximately 60 milliliters was administered from the bottle of Osmolite 1.5 Cal that was dated 06/12/25. The start time was handwritten and said 1:54 PM. During the time period from 06/11/25 at 4:26 PM to 06/12/25 at 4:32 PM, approximately 1010 milliliters of Osmolite 1.5 Cal was administered. Resident #300 should have received 1300 milliliters of formula during the 24 hour period. During an interview with Staff A, on 06/12/25 at 5:39 PM, when asked how she knew how much Osmolite 1.5 Cal to give to Resident #300, she said she needed to open and check the order in the electronic medical records. She said he received 65 milliliters per hour. When asked if she could tell the surveyor how much he received in a day, the RN calculated 65 milliliters, times 20 hours, and she said it totaled 1300 milliliters per day. When asked how she knew if Resident #300 received that amount from the feeding, Staff A said that she looked at the time written on the bottle to see when they started it. If the bottle was empty on her shift, then she changed it. Staff A was asked how she knew when a bag of formula ran out. Staff A responded that the machine showed the bag was empty. Staff A added that if there was less than 50 ml then you can throw it out and start a new bottle. She said she usually left at 11:00 PM. Staff A said if the bottle wasn't empty on her shift, then maybe the next morning someone would hang a new bottle. Staff A said that the pump had to stop at 10:00 AM and then it was started at 2:00 PM. Staff A said that in the back of her head she knew how much Resident #300 was getting every day. During the interview, the surveyor showed Staff A a photo that was taken at 4:20 PM on 06/10/25 at the moment that the nurse connected Resident #300 to the pump and started the feeding. The handwritten time on the bottle said 15:00 (3:00 PM), not 16:20 (4:20 PM). When asked why she thought the time written on the label wasn't accurate, Staff A said that the nurse most likely wrote it in advance so that she could do her work more quickly. The surveyor told Staff A that based on observations, Resident #300 received approximately 500 milliliters less than he should have in a 24-hour period of time. Since 500 milliliters at 65 milliliters per hour yields 7.69 hours, this meant that the resident didn't receive Osmolite 1.5 Cal for 7.69 hours when he should have received the feeding. When Staff A was asked how she thought this could happen, she said that even though the CNAs aren't supposed to turn the pump on or off, a CNA may have turned it off to provide care, and then the CNA may have forgotten to turn the pump back on. When Staff A was asked if it was important for the resident to get the full amount of the prescribed feeding, she said of course. The resident had to get what he was supposed to get. When Staff A was asked about possible complications related to not getting enough of the enteral feedings, Staff A said that the resident was at increased risk for malnutrition, being underweight, having a heart problem, and becoming dehydrated. During an interview on 06/12/25 at 6:34 PM, Staff B was asked why she threw out 250 milliliters of Osmolite 1.5 Cal earlier that day prior to the 2:00 feeding. She said that she threw it out because it may have been thick. She said that when the formula got thick, the pump beeped a lot. Staff B added that the nurse who worked on the same unit before her that day advised her to throw out the used bottle of formula and to start a new bottle. During an interview with the RD and Staff C (the Dietetic Technician, Registered (NDTR) ) on 06/12/25 at 6:30 PM, when asked who changed the enteral feeding order on 06/12/25 to include the total volume of 1300 milliliters of Osmolite 1.5 Cal to be administered daily, the RD said that he changed the order. When asked why he changed the order and added in the volume, he said that the Clinical Nurse Manager advised him to do that. When asked how much Osmolite 1.5 Cal Resident #300 was supposed to receive daily, the RD said 1300 milliliters. Photos of the dated bottles of Osmolite 1.5 Cal, and observations of the amount of Osmolite in the plastic bottles at 24 hour intervals were shared with the RD. The photo of the Osmolite 1.5 Cal that showed 250 milliliters was thrown into the garbage was shared. The RD said that he saw a problem and that there was room for improvement. When the RD was asked if he was familiar with ASPEN's Safe Practices for Enteral Nutrition Therapy, he said that he knew about ASPEN and learned about it in school. During the interview with the RD and Staff C (the Dietetic Technician, Registered (NDTR) ) on 06/12/25 at 6:30 PM, the NDTR was asked if she received education in writing enteral feeding orders. The NDTR said that she was educated about writing enteral feeding orders when she was in college. When asked if that practice included writing the total volume of formula to be administered daily, the NDTR said honestly, she couldn't remember.

Based on observation, interview and record review, the Administrator failed to carry out her duties as outlined in her job description which included risk management and overall management of the facility which affected 1 of 2 sampled resisdents reviewed for accidents (Resident #11). The findings included: A review of the signed job description for the Administrator revealed the Administrator serves as risk manager for the facility and is responsible for the overall management of the facility. The Administrator ensures all required records are maintained and submitted, as appropriate, in an accurate and timely manner. A review of the Electronic Health Record (EHR) revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Chronic Atrial Fibrillation, Unspecified; Unspecified dementia; and Anxiety. Her Brief Interview for Mental Status (BIMS) score was 7 on the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/24. This indicated at that time she was severely cognitively impaired. Per record review of a nursing progress note dated 06/27/24 the resident was observed in bed with her left foot turned outwards. An x-ray was done which showed a left femur fracture. She was transferred to the hospital. On 06/13/25, the surveyor asked Staff D, a Registered Nurse (RN) Regional Nursing Consultant, for a review of the investigation for this incident. On 06/13/25 at 11:15 an interview was conducted with the Administrator. She was asked if she was the risk manager at the time of the incident on 6/27/24. She stated that she was. She stated she was not at the Interdisciplinary Team Meeting (IDT) meeting on 06/28/24 when the incident was discussed and does not remember why at this time. She stated she is usually at the morning meetings and becomes aware of fall incidents or injury of unknown origin during those meetings. She was asked to provide the witness statements for this incident, any training done for the staff, and any training done for Staff G, a Licensed Practical Nurse (LPN), who did not write a note for this incident or call the physician and family to report this incident. There was no witness statements for this incident. There was no education in the personnel file for Staff G post incident. His job description also was not in his personnel file. A telephone call was placed to Staff G on 06/13/25 at 11:37 AM with no answer. The Administrator placed a call to him immediately after and left a message to return her call as it was urgent and he never returned her call. Staff D stated she called multiple times and was not able to leave a message. He never returned any call to the facility. The Administrator was asked if the fall was reported to the state agency and she replied that it was not. An interview was conducted with Staff F, an LPN, on 06/13/25 at 12:25 PM. She stated she was at the IDT meeting the next morning (06/28/24). She stated the team goes over progress notes and whatever happened overnight at the meeting. She stated the Administrator was not at that particular meeting. The Director of Nurses (DON) at the time called Staff G to find out what happened since there was no note from him in the progress notes. He stated to the IDT team while doing rounds resident observed transferring self unassisted from bed to wheelchair, observed sliding down on her left knee, nurse assisted back to the bed, assessed patient from head to toe, performed range of motion, patient complaint of pain on the left leg 4/10, pain medication was administered. Staff G wrote a statement note which could not be accessed by the surveyor in the EHR. The note stated, observed resident transferring to wheelchair and slipped. There was no time listed as to when this happened or follow up for this statement. Record review revealed on 02/17/25 Resident #11 obtained another fracture. The fall investigation was reviewed with the Administrator on 06/12/25 at 11:17 AM. The Administrator stated the resident was found on the floor trying to go to the bathroom-witnessed by Staff E, an LPN. She received a laceration on the right side of her forehead and swelling and bruising on her face. She was immediately taken to a local hospital and due to head trauma was transferred to a trauma hospital. When she came back from the hospital on [DATE], her admission diagnoses were subdural hematoma and orbital fracture. On 06/12/25 at 2:04 PM the surveyor reviewed the progress notes in the EHR of the incident. It was noted that Staff E wrote that she found the resident on the floor and did not observe the resident's fall. The Administrator was then called into the conference room to discuss this. The Administrator acknowledged this. She stated she was mistaken and thought this was witnessed by the nurse. She stated she thought a witnessed fall was when a person saw the resident on the floor. She stated the interim DON was doing the investigation and the investigation was not all together in one place. It was discussed with the Administrator that this was an unwitnessed event and since the resident had a low BIMS this should have been thoroughly investigated and reported since the resident also had an orbital fracture. Resident #11's BIMS was 0 on the Significant Change MDS with an ARD of 02/25/25. Since no one saw the resident fall, it was assumed that the resident fell. The surveyor requested to see the witness' statements. There was a statement from the nurse who found the resident on the floor. Other statements were received in the afternoon of 06/12/25 since a thorough investigation was not done. A telephone call was placed to Staff E, LPN, on 6/13/25 at 12:00 PM. She stated that she found the resident on the floor while doing rounds at 11:40 PM on 02/17/25. She was found on the side of the bed, actively bleeding. She put pressure on the wound and called the doctor. She stated a CNA saw Resident #11 at 10:30 PM and she saw her at 10:50 PM during her rounds. The resident was found on the floor at 11:40 PM. When asked about her cognitive status, Staff E stated she was confused as usual.

Based on observations, interviews and record reviews, the facility failed to provide an environment free of pests in 4 of 15 rooms on the 2 South Unit (room [ROOM NUMBER], #241, #250 and #251). The findings included: Review of the second floor Maintenance Report Logbook, located at the nurse's station, revealed the following: - Concern regarding roaches in room [ROOM NUMBER]-A on 06/12/24, documented as 'fixed' on the same day. - Infestation of roaches in room [ROOM NUMBER] and 241 on 07/28/24 reported by staff. During a room-by-room tour on 08/12/24 at 10:05 AM, the following observations were made: In room [ROOM NUMBER], 2 (two) live juvenile roaches and multiple dead roaches were observed behind the [NAME]. There was also one dead juvenile roach observed on the resident's bed, while the resident was sleeping. In room [ROOM NUMBER], 2 (two) live and mature roaches were observed on the wall and floor behind vacant bed-A. In room [ROOM NUMBER], 2 (two) live juvenile roaches were observed on the floor in the shared bathroom, live and dead roaches in all stages of life were observed behind a nightstand to the left of the air conditioning unit, and dead roaches were observed by the window bed. In room [ROOM NUMBER], numerous live mature and juvenile roaches were observed behind a closet to the left of the air conditioning unit. Two (2) dead roaches were observed on the floor by the window bed. During a room-by-room tour, on 08/12/24 at 10:43 AM, accompanied by the Maintenance Supervisor and the Director of Nursing (DON), the concerns regarding pests were acknowledged and observed by both the Maintenance Supervisor and the DON. On 08/12/24 at 11:20 AM, the Administrator and the Social Services Manager were made aware of the concerns. During an interview, on 08/12/24 at 11:23 AM, with Staff B, when asked of the presence of roaches, Staff B stated, most of the time it is in the hallway, they have been treating the rooms. During an interview, on 08/12/24 at 11:59 AM, with Staff D, when asked of the presence of pests and roaches, Staff D replied, I have not seen them, but families have reported to me. I haven't heard any since maybe about a month ago. During a review of pest control invoices, dated from 05/09/24 to 08/06/24, it was noted that all the invoices documented no pest activity on the following dates: 05/09/24, 06/12/24, 07/10/24, 07/24/24 and 08/06/24. During an interview, on 08/12/24 at 12:28 PM, with the Pest Control Technician who treats the facility, when asked regarding the presence of pests and roaches, the Pest Control Technician replied, I have seen roach droppings, but they were dry. I have seen signs, but no live activity. The Pest Control Technician acknowledged that he was aware of the current infestation identified by the Surveyor and stated, I requested for them to empty out the resident's nightstands and move the residents so that I can do some extra treatments. The plan will be twice a week.

32078 Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on 1 of 2 units/floors in the facility (2nd floor secured unit). This affected Residents #67, #24, #85, #51, #79, #57, #58, #68, #40, #31, #59, #32, #91, #28). The findings included: The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained): room [ROOM NUMBER]B - overbed light string was off; Resident's daughter stated the string pulls off very easily. The daughter must pull on the short little string to turn the light on or off. The toilet in bathroom has debris. room [ROOM NUMBER]A - Stained privacy curtains, bedside chairs, and linens. room [ROOM NUMBER]B - Rust on bottom rail of bed; light string missing from over-bed light and lying over bedside nightstand. room [ROOM NUMBER]B - Over-the-bed table with corner in disrepair. When asked how long it had been like that, Resident # 51 stated, Oh about 3 months or so. My previous roommate broke it. The table was also very wobbly. room [ROOM NUMBER] - Red splattering on window air conditioning unit; the over-the-bed table had one corner in disrepair; privacy curtain was stained. room [ROOM NUMBER]A - IV pole and bed rail near the tube feeding pole were soiled with tube feeding contents; the mattress near the tube feeding pole was splattered with residue from tube feeding contents. room [ROOM NUMBER] - Bed A's nightstand was missing strip along top edge. The bottom cabinet door was missing its knob, and the door was hanging crooked on its hinge. The bathroom toilet tank was missing its cover. room [ROOM NUMBER]A - Over-bed table's edge is separating from the table. The bathroom wall by handrail next to toilet had brown smudge which resembled feces. room [ROOM NUMBER]A - The over-bed table is starting to bubble and separate around edges. room [ROOM NUMBER]A - Over-bed table's corner is coming apart. Toilet brush was left lying on back of toilet tank lid. room [ROOM NUMBER]B - Over-bed table is separating around edges; The bathroom has strong urine smell. The floor around the toilet was soiled. room [ROOM NUMBER]A - Over-bed table is coming apart at the corner; the top drawer's bottom edging on the nightstand is starting to come off along the left side corner. room [ROOM NUMBER]B - The side chair's seat is stained/dirty; The over-bed table is separated around edges and the bathroom toilet seat was soiled with feces. room [ROOM NUMBER]B - Over-bed table edges are separating, with some edges missing; The side chair was soiled/stained. An interview was conducted with Maintenance Director on 02/28/24 at 3:12 PM, he stated that Angel rounds are completed each morning and if there are any environmental concerns, they are put in the maintenance logbook at the nurse's station and maintenance staff will check the logbook periodically (every 1-2 hours). Concerns will also be brought up at the morning meetings. On 02/29/24 at 2:36 PM, a tour was conducted with the Maintenance Director. He acknowledged the concerns presented to him during the tour of the above resident rooms.

Based on observation, record review, interview, and policy review, the facility failed to provide an ongoing activity program based upon assessments, care plans, and personal preferences, for 2 of 2 residents who voiced concerns related to the lack of activities (Resident #51 and #9), and for 5 of 5 residents observed only in their rooms, with a lack of sensory stimulation, and or assessed as needing either one-to-one activities or friendly visits (Residents #79, #91, #37, #43, and #40). The findings included: Review of the Activities Policy implemented 10/16/23 and revised 02/07/24 documented, 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: . (The policy then describes multiple different types of activities provided by the facility.) This policy lacked any information for one-to-one or sensory type activities for the cognitively impaired residents. At the time of the survey, the facility lacked any written policy or procedure for one to one activities or friendly visits as documented in resident care plans. 1) Review of the record revealed Resident #51 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Annual MDS assessment dated [DATE] documented it was very important for Resident #51 to participate in his favorite activities and to go outside. Review of a Quarterly Activity Evaluation dated 12/07/23 documented current interests for Resident #51 included books/newspapers/magazines, TV/movies, going outside, and sports. Review of the current care plan initiated on 06/02/22 and revised on 02/25/24 documented Resident #51 preferred to stay in his room watching TV/movies/news and socializing with peers/staff, and enjoys going outside when he chooses. Interventions included to provide the resident with the activity calendar, and to invite, escort, and encourage to attend activities. An additional intervention dated 06/05/23 included for staff to provide friendly visits daily for added socialization. During an interview on 02/27/24 at 11:09 AM, when asked if he participates in any of the activities at the facility, Resident #51 stated, What activities? When asked what he would like to do, the resident stated he enjoyed card games with a group. When asked if there were any card games or card groups at the facility, the resident stated he was not aware of any. An observation of the February 2024 Activity Calendar in the resident's room lacked any scheduled card games (Photographic Evidence Obtained). An observation of the February 2024 activity calendar posted in the common area of the second floor documented card games were scheduled for 02/10/24 at 11:00 AM (Photographic Evidence Obtained). During an interview on 02/29/24 at 2:10 PM, Staff E, Activity Assist assigned to the second floor, explained she had been a Certified Nursing Assistant (CNA) at the facility for about a year, and had joined the activity department about two weeks prior to the survey. Staff E confirmed she worked every other weekend, including the weekend of 02/10/24. When asked if the facility had the Card Games activity on 02/10/24, Staff E stated she was not aware of any card games and had not organized any such activity. When asked what she had been doing in activities, Staff E explained she was assigned to the second floor and she had been doing the group activities. When asked if she had done any one to one activities for the residents in their rooms, Staff E stated only that she goes around and turns on the TVs about 2 PM each day. When asked specifically about Resident #51, Staff E stated when she was a CNA, she would sometimes take him outside after he ate lunch in the downstairs dining room. Staff E stated she hadn't done that for awhile. On 02/29/24 at 2:40 PM, the Activity Director, who had stated she was fairly new to the facility and was still learning the resident's names, and that she worked Monday through Friday, and her activity assistants would rotate weekends. The Activity Director was taken into the room of Resident #51. Upon arrival, Resident #51 stated he had seen that staff down in the dining room, but did not know she was part of the activity program. Resident #51 stated he only knew she was a lady who makes rounds in the dining room. When told she was the new Activity Director, Resident #51 became visibly upset and stated, If it says on that calendar that it's time for a walk or something, when I go to do it, they tell me it's canceled for whatever reason. Resident #51 stated they used to offer to take him outside after lunch, but they don't do that anymore. Resident #51 stated the new director would have to prove herself as he had lost confidence in the program. Review of the documented activities in the Tasks section of the electronic medical record (EMR) lacked any documented activities for the past 30 days, expect for four days of documented Television in Room. 2) Review of the record revealed Resident #79 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident was rarely understood and severely cognitively impaired. Review of the most current Activity assessment dated [DATE] documented Resident #79 was dependent upon staff to manage the television or radio, and would receive one to one staff visits for mental and social stimulation. Review of the current care plan initiated on 10/17/23 documented Resident #79 enjoyed watching the television, listening to music, and getting activities and family visits. An intervention included daily friendly visits for added socialization. Review of the Tasks section of the EMR for the past 30 days documented the television as the only activity on four days. Multiple observations throughout the survey and specifically on 02/26/24 at 4:23 PM, 02/28/24 at 9:42 AM, and on 03/01/24 at 10:12 AM, all revealed Resident #79 in her darkened and quiet room, in bed, with no television, radio, or any other type of sensory stimulation. 3) Review of the record revealed Resident #91 was admitted to the facility on [DATE]. Review of the current care plan initiated on 01/03/24 documented the resident was new to the facility, and enjoyed staying in room at times watching television/movies/news, going outside, enjoyed reading the Bible, surfing the web on his phone, and enjoyed attending group activities. This same care plan documented the resident preferred to pursue Independent activities and visits from family members. An additional intervention documented to provide with friendly visits daily for added socialization. Multiple observations throughout the survey from 02/26/24 through 03/01/24 revealed Resident #91 in his room, always in bed, with no television or music playing. The resident was never observed doing anything but lying in bed with his eyes closed, except for during meals. The EMR lacked any documented evidence of any type of activity. During an interview on 02/29/24 at 10:54 AM, the Activity Director explained she had looked through all the information in the activity department, but had not found any type of one to one resident list or book. The Activity Director stated there was documentation in the EMR for activities, but that she and her staff had not been doing any documentation. The Activity Director stated there were currently two activity aides, one assigned upstairs and one downstairs, who were responsible for both the group and individual activities. The Activity Director explained she had just made a list of residents who she had assessed as needing one to one activities for conversation or sensory stimulation, but again stated she had not been documenting the provision of activities. The Activity Director provided her one to one resident list, which did not include Resident #91. The list did include Resident #79 (example #2). During an interview on 02/29/24 at about 4:00 PM, the Medical Records person, who was the previous Activity Director, stated she did not have any type of one to one resident list or book, but stated she was told just to document the provision of activities in the EMR. The Medical Records person stated she left the activity department on 02/23/24. 36734 4) Resident #37 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent on activities of daily living. Resident #37 was care planned for memory problems due to Dementia. The resident enjoys staying in her room at times or in the lounge area watching TV/movies/news/listening to music/socializing with peers/staff, attending Ice cream socials, going outside with peers and during family visits, getting her nails done by her daughter or staff, and BINGO/Word games/Game shows especially Jeopardy. Her Representative brought her a stuffed animal, her bunny, which she loves to hold and play with throughout the day when she chooses to. Interventions included: Provide materials to utilize in room when requested, and Provide with activity calendar, invite and encourage to attend activities daily, respect wishes to decline participation. Resident #37 was observed throughout the survey 02/26/24 and 03/01/24 in bed without any activities provided. 5) Resident #43 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and was dependent on activities of daily living. Resident #43 was care planned for none verbal and stay in his room watching TV and getting daily chronicle read to him. Interventions included: Provide with activity calendar, also get room visits 3-5 per week from activities. Resident #37 was observed throughout the survey 02/26/24 and 03/01/24 in bed without any activities provided. 38902 6) On 2/26/24 at 11:00 AM, a review of the resident Electonic medical records revealed that Resident #9's Brief Interview for Mental Status (BIMS) was 08 out of 15. She was admitted to the facility on [DATE]. On 02/26/24 at 4:16 PM, the resident was observed in her room. The resident had been seen in her room most of the day. During an interview with Resident #9, she stated that she needed someone to transport her to Activities, and she was bored. The Resident's Care Plan Interventions documented: Provide materials to utilize in room when requested. The resident will be assisted to activities of choice, and verbalize satisfaction with activity plan and social interaction. On 02/28/24 at 9:20 AM, the Activities Director was asked about the activities for Resident #9. The Activities Director stated that she did not have any knowledge or documentation regarding Resident #9's participation in any specific activities. 32078 7) Resident #40 was admitted to the facility on [DATE], and she is currently in Hospice. On 02/26/24 at 11:02 AM, Resident #40 was seen lying in bed on her right side. The Resident's eyes were open, but she was unresponsive to my Good Morning greeting or attempts to engage her in conversation. No music was playing in the room at this time. The television was not on. On 02/27/24 at 9:02 AM, Resident is seen with her eyes closed. She appears to be in some discomfort, showing restlessness. The nurse was notified by the surveyor of this observation. The Nurse later documented in her progress notes that the resident was very agitated and restless, and unable to verbalize needs .Orders given by hospice nurse to administer Buspar 5 mg PO [by mouth] twice a day, Lorazepam 1 mg PO every 6 hours PRN [as needed] for agitation [Name] made aware and gave consent to administer. Orders transcribed. No music was playing in the room, and the television was not on. On 02/28/24 at 9:55 AM, Resident was lying in bed on right side. Resident was resting peacefully. No music playing in her room. The television is not on. On 02/29/24 at 2:31 PM, Resident appears to be restless; she is laying uncovered in the bed. No music is playing in her room. Television is not on. A review of Resident #40's latest comprehensive Minimum Data Set (MDS) after a Significant Change (Hospice) on 06/08/23, the MDS documents under section for Activity Preferences that it very important to listen to music I like; and Somewhat important to keep up on news and have newspapers, books and magazines, and do things with groups of people. A review of the Care Plan completed on 12/28/23 documents for Activities: Resident prefers independent activities. Resident to receive friendly visits 3-5 times a week for added socialization. On 02/29/24 at 10:50 AM, an interview was conducted with the Activities Director, she stated, I just started this job on the 6th of this month. My aide started on the 8th. We have been doing just basic activities to get to know the residents since starting. We have just started the 1:1 visits. There are 3 activities personnel; 2 upstairs and 1 downstairs. On 02/29/24 at 1:15 PM, the Activities Director stated, I have done some 1:1 activities with this resident. We are trying to do hand massages with her as a calming activity. Activity Director confirmed that there was no documentation recording the days, times, and type of 1:1 activities being done with the residents requiring 1:1 visits. Interview with the previous Activity Director on 02/29/24, who is now working in Medical Records, confirmed that any documented 1:1 activity should have been documented in the electronic record under Tasks. Review of the electronic Activity Task Sheet shows no group, independent or 1:1 activities done with Resident #40 from 02/06/24 to 02/29/24, except for television on 02/15/24, 02/17/24, 02/20/24 and 02/21/24.

Based on observation and interview, the facility failed to maintain resident care equipment in a safe and sanitary condition related to specialized mattress and wheelchairs for 7 of 32 sampled residents (#24, #68, #40, #32, #91, #21, #28). The findings included: 1) Review of the record revealed Resident #28 was admitted to the facility on [DATE] with a large pressure injury to his sacrum. This wound healed and re-opened in June 2023. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was totally dependent on staff for all activities of daily living and had two pressure injuries. Review of the orders documented the initiation of a low airloss specialty mattress as of 10/14/22. This order documented to check for placement and settings every shift. During an observation on 02/26/24 at 11:28 AM, Resident #28 was noted in bed, lying on a specialty air mattress. Observation of the specialty air mattress pump control unit revealed clear packing-type tape wrapped around the cord where it attached to the machine, and the tape continued around the entire machine (Photographic Evidence Obtained). On 02/28/24 at 2:36 PM, the specialty air mattress pump control unit remained the same, with the clear tape wrapped around the machine in the same manner. Staff B, the assigned Certified Nursing Assistant (CNA), who had also worked on Monday 02/26/24, was asked to come to the resident's room, and stated she had not noticed the tape wrapped around the air mattress control unit. The CNA stated she would now report it to a supervisor. Staff F, assigned Licensed Practical Nurse (LPN) on Tuesday 02/27/24 and 02/28/24, was unaware of the tape wrapped around the control unit. The Assistant Director of Nursing (ADON)/second floor supervisor was unaware of the tape wrapped around the control unit. The Administrator arrived at the resident's room and stated she was unaware of the situation. The Administrator explained that any needed maintenance would be logged into the maintenance book at the nurses' station. Review of the maintenance book from December 2023 to the present lacked any documented maintenance concerns for Resident #28. When asked about any type of rounds by the managerial staff, the ADON stated they do daily Angel Rounds for each resident. During an interview on 02/28/24 at 3:12 PM, the Maintenance Director stated he was unaware of the need for a new mattress or control unit for Resident #28 until today, after surveyor intervention. When asked the process for maintenance concerns identified by staff, the Maintenance Director explained all concerns should be documented in the maintenance books located at each nurses' station, and he or his staff will check the books every 1 to 2 hours throughout the day. The Maintenance Director confirmed they do Angel Rounds each morning, and again any concerns would need to be logged in the maintenance books. The director also stated the staff report concerns during the morning meetings. Review of the documented Angel Rounds for Resident #28 revealed they were completed daily by the Director of Rehab (DOR), with the last one completed on Friday 02/23/24. There were no documented concerns for Resident #28. The Director of Rehab was asked to go into the resident's room with the surveyor on 02/29/24 at approximately 3:00 PM. When asked what he observes during his Angel Rounds, the Director of Rehab explained he looks at both the resident and the room to identify any potential needs. The DOR confirmed an observation of the bed, mattress, and specialty air mattress control unit would be part of his routine. The DOR stated he did not see any tape on the specialty air mattress control unit during his rounds on 02/23/24. 32078 2) The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained):. room [ROOM NUMBER]B - Wheelchair stained; rust on bottom rail of bed; room [ROOM NUMBER]A - IV pole contained much rust. room [ROOM NUMBER]A - IV pole and bed rail near the tube feeding pole were soiled with tube feeding contents; the mattress near the tube feeding pole was splattered with residue from tube feeding contents. room [ROOM NUMBER]A - The resident's reclining wheelchair's footrest is observed to be lopsided, tilting downward on the left side. room [ROOM NUMBER]B - The vinyl on the resident's wheelchair arms is partially missing. room [ROOM NUMBER]B - The vinyl on the wheelchair arms is cracked and coming off. An interview was conducted with Maintenance Director on 02/28/24 at 3:12 PM, he stated that Angel rounds are completed each morning and if there are any environmental concerns, they are put in the maintenance logbook at the nurse's station and maintenance staff will check the logbook periodically (every 1-2 hours). Concerns will also be brought up at the morning meetings. On 02/29/24 at 2:36 PM, a tour was conducted with the Maintenance Director. He acknowledged the concerns identified and presented to him during this tour.

Based on interview, record review, and policy review, the facility failed to ensure showers as per resident preference and schedule for 1 of 2 sampled residents reviewed for choices (Resident #51). The findings included: Review of the policy Shower Policy implemented 10/10/22 documented, Procedures: 1) Administer resident shower twice weekly and/or as often as necessary as per facility protocol. 2) If reasonably practicable, try to accommodate resident's preference in the shower schedule. 3) Shower refusal by the resident shall be relayed by the assigned CNA to the charge nurse. 10) document. Review of the record revealed Resident #51 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating he was cognitively intact. Further review of this MDS documented Resident #51 needed substantial assistance for showering. Review of the Annual MDS assessment dated [DATE] documented it was very important for the resident to choose between a bath and a shower. Review of the current care plan initiated on 08/26/22 documented the resident's plan was to remain in the facility as a long-term resident. This care plan documented staff were to consider the resident's preference for care such as showering/bathing time. Review of the Certified Nursing Assistant (CNA) documentation in the Tasks section of the electronic medical record (EMR) documented the shower schedule for Resident #51 was every Tuesday, Thursday, and Saturday during the 7 AM to 3 PM shift. Review of this documentation for the past 30 days lacked any documented provision of showers. Review of the progress notes for the past 30 days lacked any documentation related to showers. During an interview on 02/27/24 at 11:08 AM, when asked if he was receiving baths and or showers as per his preference, Resident #51 stated he should get a shower two or three times a week, but is lucky to get a shower once weekly. During an interview on 02/28/24 at 9:44 AM, Resident #51 was sitting up at his bedside, shaving with an electric shaver. When asked if he got cleaned up that morning, Resident #51 stated he asked for a shower but was told he had one yesterday, so he didn't need one that day. Resident #51 stated he would really like to have a shower daily, as that was what he did prior to his admission at the facility. During an interview on 02/29/24 at 1:59 PM, when asked the process for providing resident showers, Staff A, Certified Nursing Assistant (CNA), explained there was a written shower schedule that was also documented on the large white board (pointing to the white board at the nurses' station that documented the Nurse and CNA room assignments), and that they could also provide showers if requested by a resident. When asked if she documented the provision of a shower, the CNA explained there was a shower book and they filled out a shower sheet. The CNA was asked to locate and provide the shower schedule, shower book and documented shower sheets for the month of February 2024 for Resident #51. During a side-by-side review of the three requested items, Staff A identified Resident #51 was scheduled for showers on Tuesday, Thursday, and Saturday during the 7 AM to 3 PM shift. The CNA found evidence of showers for Resident #51 dated Tuesday 02/13/24, Wednesday 02/21/24, Thursday 02/22/24, Saturday 02/24/24, Monday 02/26/24, and Tuesday 02/27/24. The weekend supervisor found documentation for three additional showers dated Thursday 02/01/24, Saturday 02/03/24, and Tuesday 02/06/24. The weekend supervisor explained the shower sheets were in the supervisor's office as they needed to be signed off by a supervisor. The weekend supervisor also stated there may be some additional shower sheets waiting to be uploaded into the EMR. During an interview on 02/29/24 at 2:32 PM, the Medical Records person stated there was no pending documentation for Resident #51. Documentation revealed Resident #51 received only 9 of the 13 scheduled showers, or of the 29 preferred daily showers.

Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 32 sampled residents related to oxygen use for Resident #91 and discharge status for Resident #57. The findings included: 1) Review of the record revealed Resident #91 was admitted to the facility on [DATE], was transferred to the hospital on 02/05/24, and returned to the facility on [DATE]. Review of the current orders documented to keep the resident's oxygen saturation at 90% or greater as of 02/07/24. Although the orders lacked a specific order for as needed oxygen, review of the oxygen saturation levels from 02/07/24 through 02/13/24 in the vital sign section of the electronic medical record (EMR) documented oxygen use on 5 of those 7 days. Review of the current MDS assessment dated [DATE] lacked any documented oxygen use for Resident #91. Review of the corresponding care plan initiated 02/25/24 documented Resident #91 was at risk for altered respiratory status and to administer oxygen as ordered and to monitor the oxygen saturation level as needed. During an interview on 03/01/24 at approximately 1:00 PM, when asked about the lack of documented oxygen use in the current MDS assessment dated [DATE], the MDS Coordinator referred to the order to maintain the oxygen levels at 90% or greater and then referred to the February 2024 Medication Administration Record (MAR) that documented all of the oxygen saturation levels taken each of the three daily shifts were at or above 90%. The MDS Coordinator stated because the oxygen levels were at or greater than 90%, oxygen was not in use by Resident #91. The MDS Coordinator agreed there was no documentation on the MAR as to whether those oxygen levels were taken with or without oxygen. When shown the oxygen saturation levels in the vital sign section of the EMR, that documented the oxygen was used on 5 of the 7 days during the MDS 7 day look-back period, the MDS Coordinator stated he thought it was a documentation error. When asked if the vital signs were taken and documented by the licensed nurses or the certified nursing assistants, the MDS Coordinator stated it was completed by the licensed nursing staff. 38902 2) On 02/28/24/ at 08:38 AM, a record review of the resident electronic medical recods revealed that Resident #96 was admitted to the facility on [DATE] and had a planned discharge home on 11/30/23. The documentation in the resident's MDS was not accurate, as it documented that Resident #96 was transfered to the hospital. On 02/29/2024 at 8:56 AM, an interview was conducted with the MDS Coordinator. During this interview, the MDS Coordinator acknowledged the error regarding where the resident was discharged .

Based on record review and interview, the facility failed to refer 1 of 1 sampled resident for a Level II resident review, as indicated by the pre-admission screening and resident review (PASRR) Level I review completed by hospital staff (Resident #67). The findings included: Review of the record revealed Resident #67 was admitted to the facility on [DATE], transferred to the hospital on 12/25/22, and returned to the facility on [DATE]. Review of the PASRR Level I screen completed by the hospital on 01/05/23 documented by checkmark that Resident #67 had depressive disorder as documented in Section 1A, and was currently receiving services for MI (mental illness). Further review of this PASRR documented in Section II.1. there was an indication the individual had or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage. Section II. 3. A. documented the resident had received recent treatment for a mental illness with an indication of psychiatric treatment more intensive than outpatient care. Section II. 3. B. documented the resident had experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a resident treatment environment, or which resulted in interventions by housing or law enforcement officials. The directions on the PASRR Level I form documented, A Level II PASRR evaluation must be completed prior to admission if any box in Section 1.A. or 1.B. is checked and there is a 'yes' checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Further review of this PASRR documented it was not a provisional admission. Section IV of this PASRR lacked documentation the resident may be admitted to the facility, as the section was left blank. Further review of the electronic medical record (EMR) lacked any documented Level II PASRR. Review of the current orders revealed Resident #67 was being administered Risperdal (an antipsychotic medication) every 12 hours for behavioral and psychological symptoms of dementia, Lorazepam (an antianxiety medication) twice daily for anxiety, and Benztropine (an anticholinergic antiparkinson medication used for tremors) at bedtime for extrapyramidal side effects (EPS/drug-induced movement disorders). Resident #67 was being monitored for psychotropic side effects and behaviors. A current care plan initiated on 07/29/22 and revised on 07/19/23 documented the resident had an aggressive history toward staff with multiple documented behaviors. During an interview on 02/28/24 at 11:08 AM, when asked if the PASRR Level I that was completed by the hospital on 01/05/23 indicated a need for a Level II, the Social Services Director (SSD) stated, I am not real familiar with the form. It is done by the Administrator or DON (Director of Nursing). During an interview on 02/29/24 at 9:43 AM, Administrator confirmed she was responsible for reviewing and completion of the PASRR forms. When asked about the Level II PASRR for Resident #67, the Administrator agreed a Level II should have been completed in January 2023, as indicated on the Level I completed by the hospital at that time. The Administrator stated it had been missed.

Based on record review and interview, the facility failed to revise the care plan for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #33). The findings included: Review of the record revealed Resident #33 was admitted to the facility on [DATE], transferred to the hospital on 07/14/23 and returned on 07/15/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked any documented use of opioids (narcotic pain medications). Review of the current physician orders lacked any opioids, and indicated Tylenol was the only medication ordered for pain. Review of the current care plan initiated on 09/04/22 and revised on 02/07/23 documented Resident #33 was at risk for pain or discomfort related to (multiple diagnosis and conditions) . and oxycodone 5 milligrams being administered every eight hours as needed. This care plan also documented an intervention to administer Naloxone (a medication to reverse an opioid overdose) as needed. Further review of the record revealed the previously ordered oxycodone had been discontinued on 07/15/23. During an interview on 03/01/24 at about 1:00 PM, upon review of the current care plan related to pain management for Resident #33, the MDS Coordinator agreed the care plan had not been revised. The MDS Coordinator also agreed that the narcotic had been discontinued on 07/15/23. The MDS Coordinator had no reason for the failure to revise the care plan.

Based on observation, interview, and record review, the facility failed to coordinate care between the facility and dialysis for 1 of 2 residents reviewed for dialysis (Resident #29). The findings included: 1) Resident #29 was admitted to the facility on [DATE], with diagnoses included End Stage Renal Disease. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was receiving Hemodialysis. Resident #29 as care planned for at risk for complications related to hemodialysis. Dialysis Days: M-W-F in house. An intervention included collaborate care services with dialysis center. A review of the facility's Dialysis Resident Communication Report from 01/29/24 until 02/28/24 revealed no documentation in the Dialysis Center Staff section of the Communication Report revealed no documentation of any medicine given in dialysis, except on 02/28/24 (Wednesday), where it was documented Heparin and Micera (medicine to increase Red Blood Cells) 50 micrograms (mcg) was given. A review of Resident #29's orders revealed an order dated 02/22/24 for Micera 100 mcg at dialysis every other Wednesday. 2) Resident #29 was also care planned for at risk for alteration nutrition/hydration. Nepro 1.8 at 60ml/hr x 18 hrs (on at 6P off at 12P). This provides 1944 kcals, 87 gms pro, 785ml free H2O (plus 630ml flushes). She also receives Liquid protein supplement BID for an additional 200 kcals 30 gms pro daily for stage 4 sacrum wound. An interview was conducted with Staff Z, a Registered Nurse on 03/01/24 at 11:00 AM. Staff Z stated Resident #29 get disconnected from tube feedings prior to going to dialysis at approximately 7-8 AM on Mondays, Wednesday, and Friday. Staff Z stated the resident is not reconnected to tube feedings until 6 PM that evening. (tube feedings off for approximately 4 hours early). 3) Further record review for Resident #29 did not reveal any communication with facility Dietitian and dialysis Dietitian.

Based on observation, interview, and record review, the facility failed to follow infection control practices after wound care for 1 of 2 sampled residents observed for wound care (Resident #43); Failed to follow best practice to prevent transmission of blood-borne pathogens using the ultra-mist machine for 1 of 1 sample residents with specialized wound care (Resident #43); and failed to maintain clean oxygen tubing for 1 of 2 residents reviewed for respiratory care (Resident #91). The findings included: A review of the facility's policy Wound Cleansing and Dressing, revised on 9/25/23, documented: Cleanse the wound using normal saline or wound cleanser. Change gloves and perform hand hygiene as needed to prevent contamination. Apply new dressing after cleansing the wound. 1) A wound care observation for Resident #43 was conducted with the Wound Care Nurse (WCN) on 02/28/24 at 11:50 AM. The wound care nurse cleaned the resident's sacral wound as ordered. The WCN continued wound care with the same gloves on. The WCN dressed Resident #43's wound, and continued to reposition the resident in bed, touching tube feeding pole/pump, etc with the same gloves on and no hand hygiene. An interview was conducted with the WCN on 02/29/24 at 12:00 PM. The WCN acknowledged she did not remove her gloves and perform hand hygiene after she cleaned Resident #43's wound. 2) A review of the facility's policy Ultra Mist Therapy, revised on 02/07/24, documented under cleaning the Ultra Mist System: Do not sterilize the treatment wand including tip with steam, ETO, radiation, gas/plasma, or cold sterilant. May clean and sanitize with regular cleaning materials unless in an isolation room. Disinfect with approved disinfectant if in isolation. Wound care treatment was observed on Resident #43 on 02/28/24 at 11:40 AM. Staff Z, a Physical Therapist (PT), was observed bringing an Ultra Mist System (special wound care equipment that uses ultrasound and Normal Saline mist to aid in the healing of a pressure ulcer) in the resident's room. Along with the system, Staff Z brought in a red biohazard bag, and donned protective eye glasses and a mask. Staff Z explained sometimes the wounds treated can be bloody. Staff Z proceeded to place a disposable applicator on the treatment wand. Staff Z provided treatment with the applicator close to the wound for 4 minutes. Staff Z stated the Ultra Mist System was new to the facility, approximately 3 months, and therapy was trained on how to use it. After treatment of Resident #43's sacral wound, Staff Z stated she was going to wipe the system down with alcohol pads. Staff Z proceeded to grab a container of hand disinfective wipes, and wipe the machine down. Staff Z stated that was what she was trained to do. Further observation of the hand disinfective wipes container revealed the wipes contained 70% alcohol. An interview was conducted with the Nursing Home Administrator (NHA) on 02/28/24 at 3:00 PM. The NHA stated alcohol wipes should not be used to disinfect the Ultra Mist System. The NHA stated bleach wipes should be used to disinfect the machine. An interview was conducted with the NHA and Director of Nursing on 02/29/24 at 10:00 AM. The NHA stated she misspoke when she stated alcohol should not be used to disinfect the Ultra Mist System. The NHA stated she reached out to the company and the company stated via email that 70% alcohol wipes are approved options as indicated on our IFU (instructions for use). The use of certain chemicals can affect the plastic on the Ultra Mist System and can void the warranty of the product. The recommendation is often to use 70% alcohol wipes as they are often on hand, they have less abrasive smell and more likely to be tolerated by the patient population, it removes the variation of needing to dilute the concentration of bleach per the manufacturer's recommendations, some facilities have various types and the concentration can vary, this extra step can lend to confusion in the dilution process. Facilities and clinicians have preferred to not choose this method as the 70% alcohol wipes are equally as effective. The patient is not in contact with the ultra mist device, and there is a single use, per patient disposable component provided for the purpose of sterility. This company does not support the position that the facility should specifically be using bleach to wipe down the Ultra Mist System, and support and further recommend the 70% alcohol option due to the reasons stated above. A review of the Ultra Mist System Instructions for use manual documented to use germicidal wipes for cleaning/disinfecting. An interview was conducted with the Infection Control Preventionist (ICP) on 02/29/24 at 2:00 PM. The ICP stated the nurses clean all equipment such as glucometers (machine to measure blood sugars), as well as medicine carts with bleach wipes. The ICP further stated all nurses carts are stocked with bleach wipes only, because she did not want them to confuse them with the alcohol wipes. The ICP stated she did not know that they were using alcohol wipes to disinfect the Ultra Mist System. The ICP stated alcohol wipes were not appropriate for the facility's setting/population. The ICP stated alcohol was not effective on Multiple Drug Resistant Organism infections such as C-Diff, or any blood borne pathogens. The ICP stated she ordered some Sani -Wipes which contain some bleach, but was less caustic to disinfect/clean the Ultra Mist System. The facility had 3 residents with current orders for the Ultra Mist System. 25404 3) Review of the Oxygen Management Policy revised 05/04/23 documented, 5. Care of Concentrator: c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the record revealed Resident #91 was admitted to the facility on [DATE], was transferred to the hospital on 02/05/24, and returned to the facility on [DATE]. Current physician orders dated 02/07/24 documented to keep oxygen saturation at 90% or greater, and to administer Ipratropium-Albuterol nebulizer treatment every 6 hours. Review of the oxygen saturation levels obtained by the nurses, documented Resident #91 utilized oxygen on 13 of 22 days from 02/07/24 through 02/29/24. Review of the current care plan initiated on 02/22/24 documented to change oxygen tubing per facility protocol and or physician order, and as needed. Observations on 02/26/24 at 10:13 AM, 02/26/24 at 3:49 PM, and 02/27/24 at 10:48 AM revealed oxygen tubing that was not dated in any way (Photographic Evidence Obtained). Resident #91 was using the oxygen at 2 to 3 liters/minute. A nebulizer machine was noted on the resident's bedside night stand, with tubing running from the machine into the closed top drawer. Resident #91 gave permission to look in the top drawer. The mask was noted in a clear plastic bag and no date was noted (Photographic Evidence Obtained). An observation on 02/28/24 at 11:52 AM revealed the oxygen tubing had been removed, and the concentrator was no longer in use. The nebulizer tubing remained in the closed top drawer. During an interview on 03/01/24 at 10:11 AM, when asked the process for maintaining the oxygen and nebulizer tubing, Staff D, Licensed Practical Nurse (LPN) explained it was done weekly be the night shift. An observation with Staff D revealed the same nebulizer tubing in the top drawer of the bedside night stand of Resident #91. Upon observation, the LPN was unable to find a date on the tubing or bag. Upon closer observation, the mask was noted with small brown debris inside. The LPN confirmed she had used the mask earlier that day, did not notice the lack of any date, and agreed it needed to be changed.

Based on record review and interview, the facility failed to state in their Admission Agreement (pg. 15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 100 out of 100 residents. The findings included: A review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement' was completed on 02/28/24. The separate 'Arbitration Agreement' and 'Arbitration Program Guide' contained all required regulatory language. However, within the Admission Agreement (Agreement between the Facility and Resident/Representative) there is a paragraph on page 15 (Item #26) which states: WAIVER OF RIGHT TO JURY TRIAL. BY SIGNING THIS AGREEMENT RESIDENT AND RESPONSIBLE PARTY ARE WAIVING (A) THE RIGHT TO A JURY TRIAL FOR ANY CLAIM(S) BROUGHT HEREIN AND (B) INSOFAR AS THE ARBITRATION AGREEMENT IS EFFECTIVE ARE AGREEING TO ARBITRATE CLAIMS PROVIDED FOR THEREIN INCLUDING ANY AND ALL CLAIMS ARISING OUT OF OR RELATED TO THE FACILITY SERVICES PROVIDED HEREUNDER TO RESIDENT, INCLUDING, SPECIFICALLY, RESIDNT'S MEDICAL CARE AND TREATMENT. Even if the resident/representative chooses not to sign the separate 'Arbitration Program Guide' and 'Arbitration Agreement,' because the above paragraph is contained within the Admission Agreement (Resident Contract), each resident/representative seeking admission to the facility is being required to sign an arbitration agreement as a condition of admission and/or as a requirement to receive care and services at the facility. Nowhere in this paragraph does it inform the resident/representative that they are not required to agree to this Arbitration Agreement as a condition for admission or to receive care and services, nor does it give the resident/representative the right to rescind the agreement within 30 days of signing it. On 02/28/24, an email was sent to the Executive Director informing her of the concern with the Arbitration paragraph (Item #26) on page 15 of the Admission Agreement. It was also brought to her attention, in person, on 02/29/24 at approximately 11:30 AM. She stated she would inform the corporate office of the concern.

Based on interview, observation, and record review the facility failed to provide appropriate supervision to prevent an elopement, which resulted in a missing resident, and failed to notify 911 in a timely manner of the missing resident for 1 of 3 sampled elopement risk residents of 7 elopement risk residents in the facility (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] at 4:47AM and walk approximately 2 miles with bare feet. Resident #1 was found by the police and was transported by Emergency Services to a local hospital for evaluation. There were 109 residents in the facility at the time of the survey. The facility's Administrator was notified of Immediate Jeopardy on [DATE] at 4:54 PM. The findings included: The policy titled Missing Resident, implementation date of [DATE], under the heading Procedure, stated: 1. All personnel are responsible for reporting a resident attempting to leave the premises or suspected missing to the Charge Nurse or Director of Nursing as soon as practical. This includes any resident that did not sign out on a pass and/or did not notify a staff member of his or her leaving. Resident #1 was admitted to the facility on [DATE]. Resident #1's Quarterly Minimum Dataset (MDS) assessment, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicates a severe cognitive impairment. The resident had the following pertinent diagnoses: Metabolic Encephalopathy, Psychotic disorder with hallucinations due to known physiological condition, Unsteadiness on Feet, Cognitive Communication Deficit, Unspecified Dementia, Unspecified Severity, With Agitation, and Cortical Age-Related Cataract, Right Eye. These diagnoses contribute to the resident's inability to make appropriate decisions regarding his own safety and wellbeing. The cataract could have contributed to his vulnerability by decreasing his vision and depth perception, which could have led to falls and poor judgement regarding dangers such as distance and speed of approaching traffic. At approximately 4:30 AM on [DATE], Resident #1 left his room, exited the facility into a fenced patio area with large shrubs lining the inside perimeter of the fence, through a door that was unlocked and unalarmed. Video surveillance cameras caught the resident searching for a way to get out of the fenced space. The resident was seen, by camera, going into the shrubs several times until he found an opening that allowed him to climb the 4-foot fence. Once over the fence, the cameras recorded the resident walking off the facility's property on the sidewalk heading west. The resident was bare foot at the time of the incident. The video surveillance recording put the time that the resident left the premises at 4:47 AM. The resident walked approximately 2 miles heading west along a residential street with a speed limit of 25 mph. Approximately 1 large block prior to the street's terminus there is a railroad crossing with a pair of tracks, one heading north and the second heading south. The street terminates at a curved north-south road that parallels a park with a large lake. There is easy access to the park with a path that leads directly to the lake. The resident proceeded south on the road until the road intersected with an east-west 4 lane road, with a 45-mph speed limit, near the northbound entrance ramp to a major north-south highway, with a speed limit of 70 mph, where he was found by the police at approximately 9:40 AM, according to the police report. The resident was off facility property on his own for approximately 5 hours. On [DATE] the weather at 4:47 AM was partly cloudy with a temperature between 71- and 72-degrees Fahrenheit (F). At 9:40 AM, the approximate time the resident was located by the police, the weather was scattered clouds with a temperature between 81- and 82-degrees F. After being found by police, the resident was transported to a local hospital for evaluation, and then returned to the facility. Upon his return to the facility, Resident #1 was reassessed for his BIMS score and was found to have a reduction to a 3 out of 15. This indicated Resident #1 was more severely cognitively impaired than his prior assessment had indicated on [DATE]. While out of the facility, Resident #1 could have gotten lost, struck by a train or car and been severely injured or died , walked to the lake fallen in and drowned, or because of his bare feet, he could have suffered an injury that could have become severely infected leading to the loss of a limb. On [DATE] at 2:33 PM, an interview was conducted with Resident #1 regarding the incident. Resident #1's thought processes were disjointed. Resident #1 did remember going out of the building and out into the patio area. He remembered, with prompting, climbing the fence. When asked about being barefoot Resident #1 stated that he didn't have these, indicating his slippers. Resident #1 did not remember where he went but indicated that he walked a long way. On [DATE] at 2:55 PM, an interview was conducted with Staff A, a Registered Nurse (RN). Staff A stated that she started her shift by reviewing her assignment and organizing her care. She stated that she checked Resident #1's vital signs at around 1:15 AM. Staff A stated Resident #1 was watching TV at that time. Staff A stated she saw Resident #1 between 4:00 AM and 4:30 AM. Staff A indicated her Certified Nursing Assistant (CNA) notified her Resident #1 was missing after 6:00 AM. Staff A instructed the CNA to look in the bathroom and when Resident #1 was not found she and the CNA did a room to room search for the resident. Staff A stated it took about a half-hour to search the first floor then the nurse went to the second floor where she and the second-floor staff searched for Resident #1. When Resident #1 was not found they expanded the search to around the building and in the community. Staff A stated that another nurse took her car and headed east, Staff A took her car and headed west. Staff A stated she took an auxiliary staff member with her to search. Once Staff A returned from looking for the resident then she called the Director of Nursing (DON) to report Resident #1 was missing. Staff A stated that no alarms went off. Staff A stated that at the time of the event she did not think about calling the DON sooner than she did. Staff A stated that the facility re-educated the staff on the different protocols to follow but the facility had not yet conducted drills. On [DATE] at 3:41 PM, a telephone interview was conducted with Staff B, Certified Nursing Assistant (CNA). Staff B stated that at 1:00 AM on [DATE], she made rounds, and all residents were sleeping. Staff B explained that at 3:00 AM she made rounds and noted all of the residents were sleeping. Staff B stated that at 5:00 AM she started her morning rounds which included changing the residents and assisting with morning care. Staff B stated that at approximately 6:00 AM, Staff B went to do morning care for Resident #1, and he was missing. Staff B stated she checked the bathroom and when she did not see Resident #1, she told the nurse. Staff B stated that the nurse informed the other staff and then the nurse and Staff B started checking every room for Resident #1. On [DATE] at 11:00 AM, an interview was conducted with the Director of Nursing (DON) regarding the elopement policy. The DON admitted that when she was notified of the elopement she panicked. The DON explained that by the time the police were contacted regarding the missing resident, the police had already found the resident and informed the DON that he was being transported to the hospital to make sure there was no negative outcomes for the resident, especially since it was warm outside, between ,d+[DATE] F, and Resident #1 was bare foot.

Based on interview and record review, the facility failed to supply a resident's Health Care Surrogate (HCS) a copy of the resident's medical records in a timely manner (Resident #1). The findings included: A review of the facility's policy titled, Release of Information, revealed, in part, the resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such request will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). Facility has 30 days to give the records requested after establishing legal authority or representation. Resident #1 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment. Record review revealed a Health Care Surrogate (HCS) was designated in the event the resident was determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures signed on 09/15/22 and witnessed by the facility's former Social Services Director (SSD). Resident #1 was deemed incapacitated on 09/16/22 by the attending physician. Resident #1's HCS had signed a formal request for the resident's medical records on 01/05/23 (which was in effect until 01/01/24). A review of copies of emails from Resident #1's HCS to the facility starting with date of 01/21/23 until 04/24/23 revealed the HCS made multiple attempts to retrieve the medical records for the resident. An interview was conducted with Resident #1's HCS on 04/25/23 at 12:00 PM. The HCS confirmed she had attempted multiple times with multiple personnel to retrieve copies of Resident #1's records. An interview was conducted with Staff A, the facility's Medical Records, on 04/25/23 at 1:00 PM. Staff A acknowledged there was a signed designation of a HCS for Resident #1 on 09/15/22. Staff A further acknowledged the facility's receipt of a written request from Resident #1's HCS for the residents medical records on 01/05/23. Staff A stated corporate was handling the request from the resident's HCS, as she did not have any further details of the case. An interview was conducted with the Director of Nursing (DON) on 04/25/23 at 2:00 PM. The DON acknowledged the above.

Based on interview and record review, the facility failed to immediately inform the physician and representative when there was a significant change and life threatening condition for 1 of 2 sampled residents (Resident #2). The findings included: Review of the facility's policy titled, Change in Condition, dated 3/8/22, documented the following: Policy Interpretation: A. The Charge Nurse will notify the resident's attending physician when there has been: #4. A significant change in the resident's physical, emotional/mental condition. B. A significant change of condition is a decline or improvement in the resident's status that: #1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review revealed, review of the closed clinical record of Resident #2 noted the resident's date of admission to the facility on [DATE] with diagnoses to include; Alzheimer's Disease, Dementia, Osteoporosis, Unspecified Psychosis, and Major Depressive Disorder. Review of the Minimum Data Set annual assessment dated [DATE], documented no score for the Brief Interview for Mental status, indicating the resident was not able to complete the interview. Review of Resident #2's Nurses Note, documented the following entries: 02/08/23 (2:23 PM) - Assessment revealed resident's declining by facial grimacing, refusing both breakfast and lunch. Sip of fluids including supplements as taken. ARNP (Advanced Registered Nurse Practitioner) made aware, awaiting response. Staff will continue to monitor. 02/08/12 (11:28 PM) - Oxygen at 2 Liters in place. Appetite poor but 160 cc of supplement offered and accepted. Blood Pressure 105/51, Pulse 81, Temperature 97.5, Respirations 18. Message left for Physician regarding appetite, awaiting call back from . Staff rendered Activities of Daily Living (ADL) care. 02/09/23 (8:34 PM) - Give 650 mg Tylenol for pain or temperature greater than 100.1 administer. 650 mg = 2 tabs pain. 02/09/23 (9:09 PM) - Oxygen at 2 Liter in place, Blood Pressure 78/65, Pulse 108, Temperature 97, Oxygen Saturation 85%, Resprrations 19, Facial grimacing noted and Tylenol 650 mg administer for general pain. Appetite poor consumed 255 of dinner, MD (Medical Doctor) notified and new order received to send resident to [local hospital] for Hypoxia. Resident left facility 8:05 PM via 911. Interview with Director of Nursing on 03/09/23 at 1 PM noted that the Nurse Practitioner (ARNP) was notified of the change in condition on 02/08/23 at 2:23 PM. Assessment revealed the resident's declining by facial grimacing and refusal of food and fluid and awaiting for response. Further review and interview noted no documentation that the ARNP returned the facility's call concerning the declining condition of the resident. On 02/08/23 at 11:28 PM the attending physician was notified of the residents change in condition. It was not until 02/09/23 at 9:09 PM that the resident's condition continues to decline and the MD ordered the resident to hospital for Hypoxia via 911. It was further discussed that over 29 hours elapsed from the original 02/08/23 call to the ARNP to when the attending physician finally responded on 02/09/23 and ordered Resident #2 to the hospital via 911. It was also noted during the review of the facility's policy for Change in Condition failed to include time frames and frequency for additional notification to the attending for change of condition.