Every finding on record at Lotus Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to promote dignity during mealtime assistance for 2 of 2 residents reviewed for dining support, of a total sample of 14 residents, (#3, and #5). Findings: 1. Review of resident #3's medical record revealed she was admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/14/25. Her diagnoses included dysphagia (difficulty swallowing), vascular dementia, and contracture of the right and left hands. Review of the Minimum Data Set (MDS) annual assessment with an Assessment Reference Date of 5/18/25 revealed resident #3's Brief Interview for Mental Status was not obtained as she was rarely or never understood. Instead, a Staff Assessment for Mental Status was conducted, with memory impairment noted for both short- and long-term memory. The MDS assessment indicated resident #3 was severely impaired in cognitive skills for daily decision-making. Review of Certified Nursing Assistants (CNAs) Tasks documentation revealed resident #3 was totally dependent on staff for all activities of daily living (ADLs), including eating. 2. Review of resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dysphagia (difficulty swallowing), and glaucoma. Review of the CNA's documentation for the eating task revealed resident #5's ability to eat fluctuated between independence and total dependence. Review of resident #5's baseline ADLs care plan, initiated on 6/21/25, did not identify his specific mealtime assistance needs. On 6/25/25 at 1:04 PM, resident #5 was observed in bed with a lunch tray on his bedside table. A couple of minutes later, CNA C walked into resident #5's room and stated she tried feeding the resident twice previously, but both times he refused. CNA C asked resident #5 if he wanted his lunch and he agreed. CNA C began feeding resident #5 while standing at his right side. Three chairs were available in his room. At 1:09 PM, the Central Supply Coordinator walked into resident #5's room and took one of the chairs and placed it near where CNA C was standing. After moving the bed and setting the chair to resident #5's right side, CNA repositioned the resident sitting down next to him. On 6/26/25 at 5:32 PM, the Central Supply Coordinator explained she helped during meals because she was also a CNA. She confirmed she had observed CNA C feeding resident #5 while standing and stated staff should be seated at eye level with residents during feeding for dignity and proper support. On 6/25/25 at 1:43 PM, CNA A shared she had two residents who needed assistance with their meals. She stated the [NAME] Wing was the hardest because sometimes you have a lot of feeders. She said, The nurse already knows if we have a lot of feeders, one assignment has five. On 6/25/25 at 3:08 PM, while CNA B explained the care she provided to resident #3, she referred to the resident as a feeder. The Director of Nursing (DON), present during the interview, corrected CNA B and said it was assisted diners. CNA B reiterated staff referred to resident #3 as a feeder. She explained she said feeder because she had written the word on her notes. The DON confirmed referring to residents as feeders was a dignity concern and staff should refer to them as assisted diners. On 6/26/25 at 11:12 AM, CNA D identified residents in her assignment who required assistance with meals and said, they are my feeders. When asked what she meant by feeders, she explained they were the ones needed to be fed. CNA D shared after she dropped all the trays to the residents who were able to eat by themselves, she indicated she then got the trays for her feeders. On 6/26/25 at 12:07 PM, CNA E explained her assignment had between two and four residents who needed assistance with their meals. She shared there were feeders in the day room too. The DON was present during the interview. On 6/26/25 at 12:55 PM, the DON validated CNA E referred to residents as feeders during the interview. Later at 2:54 PM, the DON indicated she expected CNAs to sit at resident's eye level when ready to assist with his or her meal. The DON indicated the facility did not have a policy, procedure, or formal competency in place regarding CNA mealtime assistance. She shared it should be in the education the CNAs received when they became CNAs. She stated they had 32 residents who were dependent on staff for eating. Review of the facility's Resident Rights policy and procedure dated 3/01/21 read, It is the policy of the facility to provide Resident Rights in accordance to State and Federal regulations. The list of procedures included, The resident has a right to a dignified existence, . A facility must protect and promote the rights of each resident . The facility will promote care for residents in a manner and an environment that maintains or enhances dignity and respect in full recognition of his or her individuality. Examples include: . Respecting resident social status, speaking respectfully, listening, and addressing the resident with a name of their choice. Review of the Facility Assessment Tool updated on 6/02/25 read, Every staff member has knowledge competency in . resident rights . Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed for the resident population.

Based on interview, and record review, the facility failed to follow its grievance process for 1 of 2 residents reviewed for grievances, of a total sample of 14 residents, (#12). Findings: Review of resident #12's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke affecting her right dominant side, contracture of the right hand, congestive heart failure, and type 2 diabetes. Review of the Minimum Data Set quarterly assessment, with an Assessment Reference Date of 6/11/25, revealed resident #12 had a Brief Interview for Mental Status score of 15 out of 15 indicating she was cognitively intact. Review of the Grievance Log from March 2025 through 6/26/25 revealed two grievances were submitted by resident #12: The first was a grievance dated 5/08/25 concerning the demeanor of the Certified Nursing Assistant (CNA), including a delay in response to the call light, and failure to identify herself due to absence of a name badge. The Summary of Findings/Conclusion section indicated the CNA was re-educated on call light response, customer service, and was instructed to wear a name badge at all times. Documentation showed the outcome was communicated to the resident on 5/13/25. The second grievance was dated 6/11/25 related to her repeated voiced concerns regarding the CNA's demeanor and response time to the call light. The Summary of Findings/Conclusion section indicated the CNA was removed from resident #12's assignment and corrective action was taken. However, the Grievance Outcome section was left blank. The complainant's satisfaction question was not answered. The form was signed by the Social Services Director and the Administrator (NHA) on 6/13/25. On 6/26/25 at 1:55 PM, the Social Services Assistant confirmed receipt of resident #12's 6/11/25 grievance. When asked if she clarified with the resident what she meant by the CNA's demeanor, she stated she did, and the resident did not like the CNA's tone of voice and raised her voice at her. The Social Services Assistant confirmed the CNA in question was the same referenced in the 5/08/25 grievance. The Social Services Assistant stated she asked the resident if she felt abused or neglected and the resident replied, No. The NHA was present during this interview. On 6/26/25 at 1:59 PM, the NHA stated she was the Abuse Coordinator for the facility. She explained abuse investigations involved interviewing the resident and assessing how they felt, including physical and emotional effects. She noted grievances were discussed during daily meetings. She validated resident #12's grievance form on 6/11/25 lacked documentation of any follow up with the resident. The NHA acknowledged clarification should have been sought to determine where this grievance met criteria for a reportable event, Review of the facility's Grievances policy and procedure dated 3/01/21 read, It is the policy of the facility to have a Grievance Process in accordance to State and Federal regulations. The policy further indicated, Each facility must respond to the grievance within a reasonable time after its submission.

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) therapy was administered as per physician orders for 1 resident reviewed for oxygen, of a total sample of 7 residents, (#5). Findings: Resident #5, a 75- year-old female was admitted to the facility on [DATE]. Her diagnoses included sequelae of cerebral infarction (stroke complications), major depressive disorder, and chronic diastolic (congestive) heart failure. Review of the resident's quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. The assessment also revealed resident #5 received oxygen. The resident's care plan for oxygen therapy initiated on 3/01/21, indicated interventions which directed staff to, give medications as ordered by the physician, and, oxygen as ordered. Observations on 2/24/25 at 10:17 AM, at 12:31 PM, and at 12:45 PM, showed the resident sitting up in bed awake, alert, and oriented. She had an O2 nasal cannula (NC) connected to an oxygen concentrator set at 4.5 liters per minute (LPM). The resident could not say how many LPM the flow rate for her O2 should be set at. Clinical record review of the resident's physician orders revealed an order dated 10/01/24 for Oxygen 2 LPM via NC as needed for congested heart failure (CHF). On 2/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) A stated O2 therapy should be checked every shift, unless there was a change in the resident's status. The LPN stated that when care was provided care, and medications given, the nurse was supposed to check the resident's O2 therapy, to ensure the O2 was flowing at the ordered rate. LPN A confirmed resident #5 had physician's orders for O2 at 2 LPM as needed. On 2/24/25 at 12:45 PM, observation of the flow rate of the resident's O2 therapy was conducted with LPN A. She acknowledged that the O2 was infusing at 4.5 LPM, and said the rate should be at 2 LPM. On 2/24/25 at 12:48 PM, the [NAME] Wing Unit Manager (UM) stated O2 therapy should be checked by nurses when giving medications, and throughout the day to ensure that O2 was going at the right flow rate. The resident's physician orders were reviewed by the UM, and she confirmed that the O2 order for the resident was for 2 LPM, not 4.5 LPM as observed. On 2/24/25 at 1:39 PM, the Director of Nursing (DON) stated nurses should check that the O2 flow rate was administered as per the physician's order. The DON explained that whenever nurses went into the resident's room, the O2 flow rate should be checked for the resident's safety, and to ensure physician orders were followed, since O2 was considered a medication. The facility's policy Oxygen Administration copyright 2024, read Oxygen is administered to residents who need it, consistent with professional standards of practice .oxygen is administered under orders of a physician.

Based on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to pre-admission screening and resident review (PASARR) and Quality of Care. Findings: Review of the facility's survey history revealed repeated concerns for accuracy of Level I PASARRs, referral for Level II PASARRs, obtaining of non-pressure wound care orders and application of dressings per professional practice during the last annual recertification survey from March 2023 and again during the current recertification survey. On 10/02/24 at 4:00 PM, the Administrator stated he had been working at the facility since April 2024 and was unaware of the previous recertification survey deficiencies due to the change of ownership. He confirmed the facility did not currently have any Performance Improvement Plans at that time for the areas of concerns regarding PASARRs and Quality of Care. The Administrator conveyed the QAPI process should address and or prevent the facility from having repeated deficiency concerns by instituting a plan of correction and ensuring it was followed consistently throughout the year. On 10/03/24 at 3:50 PM, a white notebook accessible to all visitors was located in the main lobby of the facility. Inside the notebook were the nursing home guide and the 2567 Statement of Deficiencies with the plan of corrections from the March 2023 recertification survey. Review of the facility Quality Assurance and Performance Improvement Plan date 6/10/21 read, The QA committee shall be interdisciplinary and shall develop and implement appropriate plans of action to correct identified quality deficiencies .and act on available data to make improvement .monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Record Review (PASARR) was correct upon admission, corrected after admission, and/or referred for Level II PASARR if indicated for 3 of 5 residents reviewed for PASARR, of a total sample of 54 residents, (#19, #7 and #30). Findings: 1. Resident #19 was originally admitted to this facility on 9/15/11 with admission diagnoses of type 2 diabetes mellitus, Alzheimer's disease, anxiety disorder, hypertension, and alcoholic cirrhosis of liver. The medical record revealed resident #19's Level I PASARR dated 8/10/09 indicated the resident had no mental illness nor did it include the diagnoses of Alzheimer's disease or dementia. The resident face sheet, revealed additional diagnoses of other seizures dated 4/12/21, major depressive disorder dated 2/21/14, and unspecified psychosis dated 2/21/14 for this resident. No other Level I PASARR was found in the medical record to include these significant diagnoses. On 10/03/24 at 3:13 PM, the Director of Nursing (DON) verified the only PASARR in resident #19's medical record was dated 8/10/09 and its information did not accurately reflect the resident's diagnoses at the time of admission, nor had it been updated to reflect the added diagnoses. She stated the process for Level I PASARR is the hospital who sent the resident to the facility completed the PASARR and the facility's Admission Department uploaded it into the system and the clinical staff member who completed the admission reviewed the PASARR for completion and accuracy. The DON continued, if during the stay at the facility there was a change, for example a new diagnosis, the Minimum Data Set (MDS) Department staff would put any new diagnosis into the charting system and the PASARR should then be reviewed by the DON for any necessary changes. 45646 2. Resident #7 was admitted to the facility on [DATE] with diagnoses including displaced fracture of second cervical vertebra, fracture of right pubis, type 2 diabetes, dementia and seizures. Review of the MDS modified admission assessment with assessment reference date (ARD) of 7/17/24 revealed resident #7 had a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated she had moderate cognitive impairment. The document indicated her active diagnoses included depression and schizophrenia. Review of resident #21's electronic medical record (EMR) revealed a diagnosis of other schizophrenia and major depressive disorder with an onset date of 7/10/24. The record contained a Level I PASARR screening form dated 6/30/24 which did not indicate resident #7 had a mental illness (MI) or suspected MI diagnosis. The record did not contain a Level II PASARR screening form. 3. Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, cerebrovascular disease, other seizures and unspecified dementia. Review of the MDS quarterly assessment with ARD of 9/08/24 revealed resident #30 had a BIMS score of 8/15 which indicated he had moderate cognitive impairment. The document indicated his active diagnoses included anxiety disorder, depression and psychotic disorder. Review of resident #30's EMR revealed a diagnosis of major depressive disorder with an onset date of 12/07/22, generalized anxiety disorder with an onset date of 4/01/23 and psychotic disorder with delusions with an onset date of 6/06/23. The record contained a Level I PASARR screening form dated 10/18/22 which did not indicate resident #30 had a mental illness (MI) or suspected MI diagnosis. The record did not contain a Level II PASARR screening form. On 10/03/24 at 3:12 PM, the DON stated she was responsible for completing PASARRs. She clarified the hospital provided the initial PASARR upon resident admission to the facility. She explained the clinical team then reviewed the PASARR for completion and accuracy. The DON stated the PASARR was reviewed again if there were a change in the resident's status such as a new diagnosis. She reviewed the Level I PASARR and current diagnoses for residents #19, #7 and #30. The DON verified an updated Level I PASARR had not been completed for any of the identified residents nor were they referred for a Level II PASARR screening if indicated. The facility's policy and procedure for PASARR dated March 2021 indicated the facility would refer all residents with a newly evident or possible serious mental disorder, intellectual disability or a related condition for Level II resident review.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level II was completed and failed to provide a complete PASARR Level I for 2 of 5 residents reviewed for PASARR, of a total sample of 54 residents, (#71 and #86). Findings A PASARR is a federally mandated evaluation process per the Nursing Home Reform Act . A Level I Pre-Admission Screening is required for all applicants to Medicaid certified nursing facilities, regardless of payor. A Level II Evaluation and Determination must be completed prior to admission if a serious mental illness and /or intellectual disability or related condition is identified through the Level I screening. A Level II evaluation must also be completed when there is a significant change in the resident's physical or mental condition. (Retrieved on 10/07/24, from www.myflfamilies.com). 1. Review of resident #71's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses include paranoid schizophrenia, schizoaffective disorder, bipolar type, dementia, depression, and mood disorder. The resident's Level I PASARR form was dated 9/25/18, with diagnoses that included schizophrenia, and anxiety. Page five of the document indicated the resident could not be admitted to a nursing facility and should have a Level II completed because there was a diagnosis or suspicion of a serious mental illness. There was no Level II PASARR in the record and the facility was unable to provide a copy of the Level II PASARR. On 10/03/24 at 3:14 PM, the Director of Nursing (DON) stated the PASARR was completed by the hospital prior to the resident being admitted to the facility. She stated it should be present before the resident was admitted to the facility. The DON stated after admission to the facility she would only review the PASARR if the resident had a diagnosis change. She stated that the Minimum data Set (MDS) nurse input the new diagnosis into the record. She was not able to explain why resident #71 did not have a Level II PASARR. On 10/03/24 at 3:55 PM, the Director of MDS stated that in the morning meeting she discussed any resident who had a new diagnosis. The DON, Social Worker, Unit Managers and MDS staff attended the meeting, so they would all be aware of the new diagnosis. She stated the MDS department also looked at the PASARR when the resident was admitted . She was unable to explain why resident #71 did not have a Level II PASARR. 49840 2. Resident #86 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizophrenia, and psychosis. Review of the Quarterly MDS with assessment reference date of 8/22/24, revealed that resident #86 had a Brief Interview for Mental Status score of 11 out of 15, which indicated moderate cognitive impairment. He had diagnoses of psychotic disorder and schizophrenia that were being treated with antipsychotics. Review of resident #86's medical record, revealed a Level I PASARR dated 12/02/21 that was missing the diagnosis page and therefore was incomplete. Further review of the care plan for resident #86 showed he had behaviors such as hoarding and was being monitored for antipsychotic therapy. On 10/03/24 at 03:21 PM, the DON verified the Level I PASARR was incomplete in the electronic medical record, and she was unable to find the completed paper copy of the PASARR. She stated she was the person responsible for completing PASARRs and confirmed a new Level I PASARR should have been completed due to the resident's serious mental health conditions. Review of the Policy and Procedure for PASARR issued 3/21 read it was the policy of the facility to assure all residents admitted to the facility received a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. The procedure included staff to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. The procedure described staff should refer all Level II residents and all residents with newly evident or possible serious mental disorders, intellectual disability, or a related conditions for Level II resident review upon a significant change in status assessment.

Based on observation, interview and record review, the facility failed to obtain a physician's order to provide treatment to a non-pressure wound and failed to apply non-pressure wound treatments per professional standards for 1 of 1 resident reviewed for non pressure wounds, of a total sample of 54 residents, (#19). Findings: On 9/30/24 at 1:36 PM, resident #19 was observed being assisted with his lunch. There was an undated bandage on the resident's left arm near his elbow. On 9/30/24 at 2:10 PM, the Memory Lane Unit Manager (UM) verified the resident had an undated bandage and confirmed nurses should always date a wound dressing to allow staff to know when the dressing was applied. Review of the medical record on 9/30/24 revealed no physician orders for a wound treatment to resident #19's left arm. Review of the medical record on 10/01/24, revealed a new physician order was placed at 1:13 PM, for treatment to the skin tear to resident #19's left elbow. The order indicated staff should cleanse with normal saline, pat dry, apply triple antibiotic ointment and cover with non-adherent dressing every day shift. On 10/01/24 at 3:45 PM, the resident was observed in the day room wheeling his wheelchair to a table to work on a puzzle. On his left arm near the elbow, an undated white bandage was again observed. In interviews on 10/01/24 at 5:01 PM, and on 10/03/24 at 2:10 PM, the Director of Nursing (DON) was informed an undated dressing was observed on resident #19's left arm on 9/30/24 and again on 10/01/24. She acknowledged she was aware the resident's skin tear on his left arm did not have a physician's order for the treatment when it was initially observed and verified with the UM on 9/30/24. She confirmed the physician's order for treatment was not obtained until after it was observed by the surveyor. The DON stated she expected nurses who saw a skin tear or wound on a resident, would assess the wound and notify the physician for any treatment orders. She stated it was her expectation for nurses to follow physician's orders for wound care, and confirmed all dressings were to be dated when they were applied. The facility's Wound Care policy dated 4/20/20 described wound care procedures and treatments should be performed according to physician orders using proper wound care technique. The document detailed that nurses should then document in the clinical record when treatments were performed.

Based on observation, interview, and record review the facility failed to provide wound care to heel pressure ulcers/injuries per physician order and plan of care for 1 of 3 residents reviewed for pressure ulcers/injuries, of a total sample of 54 residents, (#48). Findings: Review of the medical record indicated resident #48 was admitted to the facility on [DATE] from acute care hospital with diagnoses including unstageable pressure wounds bilateral heels, dementia, muscle weakness, muscle wasting and atrophy. Unstageable pressure injuries are widely understood to be full-thickness pressure injuries in which the base is obscured by slough and/or eschar. Correct identification of these pressure injuries can be challenging among health care professionals and, although treatments vary .(Retrieved on 10/04/24 from www.pubmed.ncbi.nlm.nih.gov). The resident's five-day modification minimum data set assessment dated [DATE] indicated resident was moderately cognitively impaired, required partial to moderate assistance from staff with his toileting, bathing, dressing, bed mobility and he was always incontinent of urine and bowel. The resident was at risk for developing pressure ulcers and had a stage three pressure ulcer/injury present on admission as well as 4 unstageable facility acquired pressure wounds/injuries. The assessment indicated the skin and ulcer treatments that applied were pressure reducing device for bed/chair, nutrition or hydration intervention to manage skin problems and pressure ulcer care. A wound care observation was conducted on 10/02/24 at 2:25 PM, with the wound care nurse. The resident was pleasantly confused and lying in bed with his lower extremities elevated on pillows with his heels off the bed. The nurse explained to resident what he was doing regarding changing the dressings on his heel wounds. The nurse removed the soiled dressings from both heels and exposed wounds which were as per the wound physician documentation dated 10/01/24. The right heel measured 0.7 centimeters (cm) by 1.3 cm by unknown depth, wound appearance with 60% granulation (pink/red tissue), 40% slough (yellow dead tissue), and moderate amount of serous (clear, watery) drainage. The left heel measured 1.3 cm by 1 cm by unknown depth and had 50% granulation 30% slough, 20% connective tissue and moderate amount of serous drainage. The wound nurse performed hand hygiene and proceeded to clean the left heel wound with dermal wound cleanser, applied skin prep peri-wound, then a pea sized amount of Santyl (debriding wound ointment) to the wound bed and covered with border dressing. He performed hand hygiene, then proceeded to do the same procedure to the right heel. Review of the physician orders dated 8/27/24 for the right heel wound and 9/25/24 for the left heel wound read, Cleanse with NS [normal saline], pat dry, skin prep peri wound, apply Santyl-moist gauze to wound bed and cover with gauze and Abd [abdominal pad], wrap with Kerlix and secure with tape every day shift for wound and as needed for soiled/dislodges. The medical record contained a care plan for pressure injury wounds to bilateral heels dated 8/21/24 and listed an intervention for wound care as ordered. On 10/2/24 at 4:18 PM, an interview was conducted with the Director of Nursing (DON) and wound care nurse. The wound care nurse acknowledged he cleaned the heel wounds with dermal wound cleanser instead of normal saline and failed to apply Santyl moist gauze to wound bed or cover with gauze, Abd pad, and wrap with Kerlix as ordered by the physician. The wound nurse confirmed he did not check the physician orders prior to doing the resident's wound care and the DON said, the nurse must follow the orders when providing wound care. The DON verified it was best practice for nurses to bring a copy of the physician order for wound care into the room when performing wound care to ensure it was done as per the physician orders. Review of the facility policy and procedures for Wound Care issued 4/20 read, Wound care procedures and treatments should be performed according to physician orders .

Based on observation, interview, and record review, the facility failed to administer oxygen (O2) therapy as ordered by the physician for 2 of 4 residents reviewed for respiratory care, of a total sample of 54 residents, (#36, #152). Findings: 1. Resident #36 was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included metabolic encephalopathy, acute and chronic respiratory failure, pneumonia, heart failure and chronic obstructive pulmonary disease (COPD). Review of the medical record for resident #36 revealed (AHCA) Agency for Health Care Administration Form 5000-3008 form dated 9/06/24 with Treatment Devices for O2 2 L [liters] NC [nasal cannula] and a physician order dated 9/07/24 that read, Respiratory: Oxygen 2 L via NC continuous. On 10/01/24 at 9:55 AM, and later at 2:10 PM, resident #36 was observed lying in bed wearing a NC attached to the O2 concentrator set at 3.5 liters per minute (LPM). Review of resident #36's care plan initiated on 9/24/24 for altered respiratory status and difficulty breathing related to shortness of breath, obesity, congestive heart failure, sleep apnea, COPD, history of respiratory failure and pneumonia had goals that he would have no signs or symptoms of poor oxygen absorption, maintain normal breathing pattern and no complications related to shortness of breath. The interventions included to administer medications as ordered. Oxygen is a medication that requires a prescription from a healthcare provider. You should only use oxygen therapy as a medical treatment. If you take in more oxygen than your body needs, it can slow your breathing and heart rate to dangerous levels. Too much oxygen can lead to oxygen toxicity or oxygen poisoning .(Retrieved on 10/04/24 from https://my.clevelandclinic.org). On 10/01/24 at 2:12 PM, resident #36's nurse was at lunch and the [NAME] Unit Manager (UM) checked the medical record for the resident and confirmed he was supposed to get O2 at 2 LPM continuously. The unit manager then went into the resident's room and verified the oxygen concentrator was currently set at 3.5 LPM via NC. The UM then adjusted the O2 concentrator setting to 2 LPM. The UM verbalized the assigned nurse should check the settings every time they went into the resident's room to ensure they were getting the oxygen as ordered. On 10/01/24 at 5:03 PM, the Director of Nursing (DON) said the nurses were supposed to check the residents' oxygen settings at least once per shift and it was best practice to check it every time they went into the room. 50875 2. Resident #152 was admitted to the facility on [DATE]. His diagnoses included pulmonary fibrosis, COPD, asthma, respiratory failure with hypoxia, dependence on supplemental oxygen, type 2 diabetes mellitus and glaucoma. Review of the quarterly Minimum Data Set assessment with reference date 8/20/24, revealed resident #152 was cognitively intact, had no behaviors, nor refused care, and required the use of O2. The assessment indicated resident #152 required supervision with activities of daily living and used a wheelchair for mobility. Review of resident #152's physician orders for continuous O2 was 2 LPM via nasal cannula. Resident #152 had a baseline care plan for required use of O2 therapy and an ineffective breathing pattern care plan related to COPD, shortness of breath and wheezing. Interventions included Licensed Nurse to administer O2 as ordered. On 9/30/24 at 11:57 AM, resident #152 was observed in bed, alert and oriented. He wore a nasal cannula connected to an oxygen concentrator. Observation of the oxygen concentrator showed it was set at 5 liters of oxygen per minute. Resident #152 stated he did not know how many liters of oxygen he needed nor the number the concentrator was set at. Resident #152 stated the machine did not work all the time and he thought it was set at 3 LPM. He explained he did not change the setting on the concentrator himself. On 9/30/24 at 1:41 PM, assigned Registered Nurse (RN) A, stated she verified the physician orders at the beginning of her shift but did not remember the amount of oxygen resident #152 received. RN A was accompanied to resident #152's room where she confirmed the flow rate on the oxygen concentrator was currently set at 5 LPM. A few minutes later, RN A was asked to verify the physician orders in the electronic record. She stated the physician's order was for 2 LPM of continuous O2. RN A confirmed resident #152 was not on the physician ordered flow rate of O2 and proceeded to resident #152's room to correct it. Upon exit of resident #152's room to the nurse's station, Licensed Practical Nurse (LPN) B, the UM for Sunflower, was informed of the situation and stated physician orders were verified per shift by the nurses to ensure residents received the correct amount of oxygen. On 10/01/24 at 5:06 PM, the DON stated for residents on oxygen, it was the responsibility of nurses to verify the orders and adjust the oxygen flow rates according to the physician orders at least once per shift. She confirmed resident #152's nurses should have validated the amount of O2 given per the physician order. She stated resident #152 monitored his O2 status and would have changed the flow rate, however, it was the responsibility of the nurses to have reeducated the resident and checked the concentrator more often than once per shift. On 10/02/24 at 9:40 AM, resident #152 was observed with O2 at 2 LPM with a nebulizer treatment running and stated he needed more air. LPN C assigned to resident #152, was made aware of the resident's statement of not getting enough air. The O2 tubing was connected to a new oxygen concentrator. On 10/02/24 at 12:14 PM, assigned LPN C stated she was aware the resident did not receive oxygen as prescribed on 9/30/24 and explained she always checked the concentrator and verified the flow rate with the physician order. She confirmed the resident felt as though he was not getting enough oxygen and spoke with the Nurse Practitioner about the resident's condition who said there was no need to increase the flow rate because resident #152's oxygen saturation was within normal limits. Review of the Oxygen Administration Policy not dated revealed oxygen was administered to residents who need it consistent with professional standards of practice, the resident's care plan and the resident's choice. It also stated as part of the compliance guidelines that oxygen was administered under orders of a physician except in emergencies and once the situation was under control, orders for oxygen were obtained as soon as practicable.

Based on observation, interview, and record review, the facility failed to follow Contact Precautions for 1 of 3 residents reviewed for Transmission Based precautions, (#17), and failed to ensure use of a clean nasal canula for 1 of 4 residents reviewed for oxygen use, (#117), of a total sample of 54 residents. Findings: 1. On 10/01/24 at 2:10 PM, Certified Nursing Assistant (CNA) I was observed entering resident #17's room without performing hand hygiene and without the required personal protective equipment (PPE) . CNA I was then observed as he placed a food item on this resident's tray and left the room, going straight back to food cart to continue passing meals, again without performing hand hygiene. A sign on resident #17's door indicated the resident was on Contact Isolation and anyone entering the room should wear a gown and gloves and should perform hand hygiene. A few minutes later in the hallway CNA I stated he donned a gown and gloves earlier when he entered the room but acknowledged during three separate other trips into resident #17's room he had not worn the required PPE. CNA I explained he didn't have time to don gown and gloves for each visit and was unaware of why the resident was on Contact Precautions. He stated he got report when he started his shift but was not told about why the resident was on isolation. He stated he understood the importance of wearing the appropriate PPE with residents on Contact Isolation to prevent the spread of infection to other residents. On 10/01/24 at 5:17 PM, the Director of Nursing (DON) stated she expected staff to follow the Contact Precaution instructions listed on the residents' door. She added the CNA's were supposed to get report from the prior shift's CNA and the shift nurse regarding the needs of the residents for which they are caring for. She confirmed the CNAs had received education regarding infection control requirements and the wearing of PPE. 2. On 9/30/24 at 2:30 PM, resident #117's oxygen tubing and nasal canula were observed on the ground in his room with the Memory Lane Unit Manager (UM). The UM asked the resident why his oxygen tubing was on the ground, and the resident replied staff had left it there. The UM then asked the resident if he needed the oxygen on right now and he stated, No Ma'am, so the UM turned off the oxygen concentrator and left the dirty nasal canula and tubing on top of the oxygen concentrator machine, and left the room. On 10/01/24 at 5:17 PM, the DON confirmed oxygen tubing that had been on the floor should be promptly disposed of. She explained she expected staff who observed a nasal canula on the floor to throw it away so it would not be picked up and placed on the resident. The policy entitled, Transmission-Based (Isolation) precautions dated 2024 by The Compliance Store, LLC, revealed a facility who implemented the policy would provide signage with instructions and personal protective equipment (PPE) near the entrance of the resident's room.

Based on interview and record review, the facility failed to ensure care and treatment was provided according to professional standards of practice to meet the resident's need, and prevent the potential decline in the residents' physical, mental, and/or psychosocial well-being for 1 of 4 residents reviewed for change in condition of a total sample of 10 residents, (#1). Findings: Resident #1, was admitted to the facility on [DATE] and resided on the Memory Care Unit. Her diagnoses included dementia with agitation, diabetes type II, cerebral infarction, mood affective disorder, major depressive disorder, and chronic kidney disease stage 2. Review of the resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/09/23 revealed the resident's cognition was severely impaired, with a Brief Interview for Mental Status (BIMS) score of 02 out of 15. The assessment revealed the resident required substantial to maximal assistance for toileting hygiene, required partial to moderate assistance with personal hygiene, and set up assistance for eating. Review of the physician's orders for resident #1 revealed an order dated 12/24/23 at 12:10 PM for Dextrose intravenous fluid 5% at 80 milliliters per hour for abnormal labs x 3 liters. A physician's order dated 12/24/23 at 12:31 PM read IV (Intravenous) services to start peripheral line. A nursing progress note documented by Licensed Practical Nurse (LPN) A dated 12/24/23 at 11:43 AM read, Rt (resident) lethargic refusing to eat or drink, Dr. (name) is made aware new orders received. Daughter (name) called and made aware consent given to start IV. 3 PM Dr (name) on call; made aware of abnormal lab results and previous IV order . no new orders at this time, will call back if needed. Awaiting IV services to start line. A nursing progress note on 12/24/23 at 7:52 PM read, Resident continually refused juice, milk and water that was offered throughout shift . attempted to insert a peripheral IV, pt (patient) tried to hit staff. Oncoming shift nurse notified during report. An Administration Note dated 12/25/23 at 7:36 AM, read, Dextrose 5% medication was not given because IV line has not been initiated, awaiting for nurse to come. Report given to the incoming nurse to watch out for the nurse. On 1/10/24 at 2:01 PM, Licensed Practical Nurse (LPN) B confirmed she was assigned to resident #1 on 12/25/23 on the 7 AM to 3 PM shift. She recalled the resident was confused, in pain, agitated, and was moving from side to side in the bed. LPN B said this behavior was a change from the last time she worked with the resident. She recalled the resident had an order for an intravenous line, and they were about to start antibiotic therapy, because her labs were abnormal. LPN B stated the resident's family visited and requested the resident be transferred to the hospital, as they did not want to wait for the treatment to start. LPN B acknowledged the resident was having pain but said she did not recall if any pain medication was given to the resident prior to her transfer to the hospital. On 1/10/24 at 2:14 PM, LPN A recalled the resident's condition started possibly on 12/24/23. She verbalized the resident was not drinking or eating and was lethargic and she notified the physician. She explained stat labs were done, and IV fluids were ordered. LPN A stated she spoke with the resident's daughter and received consent to start the IV line. LPN A said IV services had not come to the facility to insert the IV line, and IV fluids ordered by the physician was not started before her shift was completed at 3 PM. She indicated she gave report to the oncoming nurse and she did not work the next day, on 12/25/23. She reported she was unsure when the IV services responded. LPN A explained the process for IV services, included physician orders, obtaining consent for the insertion, calling the IV Services to place the order, and placing original order in the IV services binder kept at the nurse's station. On 1/10/24 at 2:44 PM, the Director of Nursing (DON) confirmed the process for IV services explained by LPN A. The DON stated that before the IV Services came out, nurses were told to at least attempt to insert a peripheral line. The DON noted that if the first two attempts to insert the IV line were unsuccessful, then they should call IV services. The DON stated that a Registered Nurse (RN) attempted once and was unsuccessful. She verbalized she was unsure of the time IV services was called, but as per the nurse, it was immediately after she could not get the IV line inserted. The DON stated resident #1 started to refuse fluids and food on 12/23/24. On 12/24/23, the physician was notified again as the resident continued to refuse fluids and food. She explained physician orders were obtained for labs, and to start IV fluids. She stated the resident was admitted to the facility on [DATE], and was already in acute renal failure, and her labs were worsening. She explained that when the lab results were reviewed, the physician changed the IV fluids, and also ordered an antibiotic for possible sepsis. The DON recalled that on 12/25/23 she was informed the resident's daughter was upset and she spoke with the daughter. She indicated the daughter wanted the resident transferred to the hospital, as the resident was in pain. The DON stated the resident was hitting her head against the side rail, smacking her forehead with her hands, and looked uncomfortable. She said the resident was sent to the hospital via 911. The DON recalled she was told IV services came and could not get the IV line started and they had to send another nurse. She said If she had been made aware of this, she would have directed staff to send the resident to the hospital. She said she did not expect to get a call regarding a new order for IV fluids but expected to be informed of the unsuccessful attempt to insert the IV line and the delay of IV services. She stated she was not aware of the situation, until she was told the resident's daughter wanted to talk with her. The DON verbalized that record review revealed the IV line was inserted on 12/25/23 at 12:18 PM, approximately 24 hours after the order was obtained. She stated her expectation was that nurses would have treated the order with urgency and expected a quick response time from the IV services. She verbalized that a resident could decompensate quickly, and nurses needed to notify the physician of any change in condition. The DON confirmed that there was no documentation in the resident's clinical record to indicate the physician was made aware of the delay by IV services, and delay in implementing orders for IV fluids. On 1/11/24 at 12:01 PM, the Medical Director stated resident #1 was admitted to the Memory Care Unit with history of dementia. He recalled during the Christmas weekend, the facility placed a call to the on-call service, and reported the resident was not eating or drinking but was taking her medications. He stated that based on the on-call report, labs, and reports showed worsening chronic kidney disease. He recalled an IV midline placement was ordered on 12/24/23 but when he rounded in the facility on 12/25/23, the resident did not have an IV midline, and had not received IV fluids. He said he was informed there was an issue with the IV team coming to the facility on [DATE]. He verbalized the resident's behavior was out of her baseline, but her heart rate was stable. He recalled he was very concerned because of her altered mental status, and abnormal labs. The Medical Director explained his expectation was that orders would be carried out, and for nurses to notify the physician of the IV services delay, so the provider could triage appropriately. He said resident #1's vital signs were stable, her labs were severe, and his decision would have been to send the resident to the hospital. He stated it is a disservice if interventions were not implemented. He said the goal was to take care of what can be taken care of in a safe manner in their setting and educating nursing staff that as a clinician he can feel comfortable in adhering to that goal. He explained his expectation was that within 4 hours, the IV team would respond to the order/request. If an order for IV fluids was given, he would want that order carried out within 4 to 12 hours, not 24 hours. Review of the hospital records dated 12/25/23 revealed the Emergency Department (ED) diagnosis for resident #1 was urinary tract infection, dehydration, acute kidney injury, and hypernatremia. Review of the Patient Care Timeline revealed the resident arrived in the ED on 12/25/23 at 4:40 PM, via Emergency Medical Services with a complaint of altered mental status. Assessment revealed the resident was confused, crying, oriented to person, and restless. Pain assessment using the Wong-Baker FACES pain rating revealed the resident Hurts whole lot, and the pain was described as acute, and location was the head. The Emergency Department Physician Note with date of service of 12/25/23 at 5:16 PM revealed the resident's chief complaint was altered mental status. Physical exam showed hematoma to her forehead, and the resident was disoriented, confused, and uncooperative. Documentation revealed the resident appeared thin with dry mucous membranes and altered mental status .noted to have a hematoma to her forehead .CT head obtained showing no acute process. Labs obtained showing hypernatremia, hyperglycemia, elevated creatinine, leukocytosis and elevated troponin. The patient was given fluid .Urinalysis obtained showing pyuria .she was started on Cefepime and Vancomycin and given additional fluid . Patient will be admitted to PCU (Progressive Care Unit) .Diagnosis urinary tract infection, dehydration, acute kidney injury, hypernatremia, atrial fibrillation. Hypernatremia is the medical term to describe too much sodium in your blood (Retrieved on 1/17/24 from webmd.com) Hyperglycemia is when there's too much glucose (sugar) in your bloodstream. (Retrieved on 1/17/24 from webmd.com) Leukocytosis refers to an increase in the total number of white blood cells .can be caused by infection, inflammation .or other miscellaneous causes. (Retrieved on 1/17/24 from emedicine.medscape.com) Pyuria is the presence of an excess of white blood cells in your urine. (Retrieved on 1/17/24 from webmd.com) Cefepime and Vancomycin are antibiotics The Hospital History and Physical documentation read, In the ER, patient was noted to be severely dehydrated .also noted to have UTI (Urinary Tract Infection) admitted for further management Patient blood sugar continued to trend up .Patient noted to be in DKA .consulted ICU for upgrade. Diabetic Ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. (Retrieved on 1/17/24 from www.cdc.gov) Additional hospital record review revealed the resident was admitted to ICU on 12/26/23 at 3:55 AM. The facility's policy Notification of Change in Condition with effective date of 11/30/2014, and revision date of 12/16/2020 directs staff to promptly notify the attending physician when there is a change in the resident's status or condition. The document read, The nurse to notify the attending physician .when there is a(n) . significant change in the patient/resident's physical, mental or psychosocial status. Need to alter treatment significantly .Discontinuation of a current treatment due to but not limited to: . acute condition.

Based on interview, observation, record review, review of the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker website, and review of the facility's policy titled Employee COVID 19 Vaccinations, the facility failed to implement their COVID 19 vaccination policy creating the potential for the spread of COVID-19 to all 169 residents, staff, or visitors. The facility failed to implement their policy process that ensured two (2) of 11 unvaccinated staff Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #4 followed required precautions for unvaccinated staff which included application of personal protective equipment (PPE) and COVID 19 testing. The findings include: Review of the facility's policy titled Employee COVID 19 Vaccinations, revised on 05/23/22 revealed, The Company requires that all eligible staff be fully vaccinated against COVID-19 in compliance with applicable laws, rules, and regulations . Exempt: An individual whose request for a religious or medical exemption has been approved . Religious Exemptions: Personnel with sincerely held religious beliefs may request a religious exemption . Exempted Employees and Reasonable Accommodation: a. Individuals who request and are granted a medical or religious exemption through the company's exemption review process or who need to delay vaccination due to CDC [Center for Disease Control] recommendations, will receive reasonable accommodations. b. These accommodations will include the need for additional precautions to mitigate the transmission and spread of COVID-19, in compliance with CDC, CMS [Center for Medicare and Medicaid Services], and other applicable regulatory guidance. c. Current guidance, which is subject to change, requires the use of Universal Source Control depending on Community Transmission rates and regular testing for all unvaccinated personnel working in Care Centers. i. Testing will occur at least weekly unless community transmission dictates more frequent testing. ii. Staff will use Respirators as source control. d. Accommodations will be updated as new guidance is published. Per the CDC COVID-19 Data Tracker website, the facility's community transmission rate of COVID-19 was low. Review of an untitled and undated document provided by the facility on 04/11/23 revealed the most recent cases of COVID-19 occurred on 03/28/23. On 03/28/23, two staff members and one resident tested positive for COVID-19. At the time of the survey on 04/11/23, there were no positive cases of COVID-19. 1.Review of the Employee Information List dated 04/11/23, revealed LPN #3 was hired on 04/23/12. During an interview on 04/11/23 at 2:27 PM, LPN #3 stated she was not vaccinated for COVID-19 and had filled out a form and been granted an exemption. LPN #3 stated she was not tested regularly for COVID-19 and was only tested when there were new resident or staff positive cases. LPN #3 stated she was not aware of any additional precautions she had to take based on being unvaccinated. Review of the COVID-19 Consent Form and Waiver revealed for the past 90 days, LPN #3 was tested for COVID-19 on 01/17/23, 01/24/23, on 01/31/23, and there was one undated form. During an interview on 04/11/23 at 4:56 PM, the Director of Nursing (DON) stated within the past 90 days there were COVID-19 outbreaks in January 2023 and on 03/28/23 and staff were tested for COVID in response to the outbreaks. The DON stated the undated form for LPN #3 was for the March 2023 COVID outbreak. 2. Review of the Employee Information List dated 04/11/23, revealed CNA #4 was hired on 01/14/23. During an interview on 04/11/23 at 2:38 PM,CNA #4 stated she had not been vaccinated for COVID-19 and had been granted an exemption. CNA #4 was not wearing a face mask. CNA #4 stated when COVID-19 rates were low, staff did not have to wear face masks. CNA #4 stated she had been tested for COVID-19 the previous week due to residents being positive for COVID; however, she stated she was not otherwise tested for COVID-19 on a regular basis. CNA #4 stated she was unaware of any additional precautions required for staff who had not been vaccinated for COVID-19. During an interview on 04/11/23 at 4:56 PM, the Director of Nursing (DON) stated she could not locate any testing records for CNA4. During an interview on 04/11/23 at 3:02 PM, the Administrator stated staff wore face masks depending on COVID-19 rates in the county. The Administrator stated the rate was currently low so staff were not required to wear masks. The Administrator stated if the facility was in a COVID-19 outbreak, staff had to wear masks. If the facility was in outbreak, staff were also tested for COVID-19 twice a week. The Administrator stated he was not aware the facility policy indicated weekly testing for COVID would be done and the use of respirators for unvaccinated staff was required. During an interview on 04/11/23 PM at 3:14 PM, the Infection Preventionist (IP) stated she was new in her role and had been employed by the facility for two and a half months. The Regional Nurse/Registered Nurse (RN) was also interviewed at this time. The Regional Nurse stated since October 2022, there was no longer a requirement for regular COVID-19 testing of exempt or unvaccinated staff or a requirement to wear a respirator, which was considered an N-95 mask. The Regional Nurse stated if COVID-19 rates were high, staff were required to wear masks. The Regional Nurse stated they had updated their COVID-19 Pandemic Plan after the last revision of the COVID-19 Vaccination policy and the Pandemic Plan reflected their current practice. The Regional Nurse stated their current Pandemic Plan did not require any staff (vaccinated, exempt, or unvaccinated) to wear face masks unless the COVID-19 rate was as high. The IP stated she was not aware of additional precautions for staff who were not vaccinated or had exemptions granted. The IP and Regional Nurse verified the staff were only required to wear face masks when the county transmission rate was high. During an interview on 04/11/23 at 4:56 PM, the Director of Nursing (DON) stated the same precautions were in effect for unvaccinated staff as were in place for vaccinated staff. The DON stated there were no additional measures in place for unvaccinated staff and was not aware of the requirement for additional precautions. The DON stated the only testing being conducted in the facility for COVID-19 was in response to COVID-19 outbreaks. The DON stated there were two staff and a resident who recently tested positive for COVID-19, all on 03/28/23. The facility had conducted COVID-19 testing in response to the positive cases on 03/28/23 and prior to that there had been positive cases in January 2023 and testing was also conducted at that time. The DON reviewed the COVID-19 Vaccination policy and she verified the policy indicated weekly testing should be completed for unvaccinated/exempt staff and that unvaccinated/exempt staff should wear a respirator (N 95 mask).

Based on observation, interview, and record review, the facility's nursing staff failed to adhere to standards of professional practice to promote skin integrity, obtain and implement appropriate wound care orders, and apply treatments and dressings as ordered for 2 of 2 residents reviewed for non-pressure skin conditions, of a total sample of 66 residents, (#61 & #30). The facility's failure to implement adequate preventative interventions and follow policies and procedures for skin and wound care resulted in actual harm for resident #61, preventable injuries during activities of daily living (ADLs) care and development of a skin infection. Findings: 1. Review of resident #61's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, heart disease, hypertension, depression, anxiety, and insomnia. The Quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 1/23/23 revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. The document noted she had no mood or behavioral issues and did not reject care that was necessary to achieve the resident's goals for health and well-being. Resident #61 required limited assistance for bed mobility, and extensive assistance for transfers, dressing, and personal hygiene. The MDS assessment showed the resident had no impairments in functional range of motion of her extremities. On 2/27/23 at 10:30 AM, a large purple-brown discoloration was noted on resident #61's right arm. The area extended from above the elbow, around the joint, and faded towards her forearm. Certified Nursing Assistant (CNA) AA stated she last worked with resident #61 three days ago, on Friday 2/24/23, and there might have been a small bruise on her right arm, but definitely not as large as it was today. CNA AA lifted the resident's sheet to expose the left elbow which had a large dark purple bruise around the elbow, which extended from her upper arm to her forearm. Beneath the left elbow there was a large, dark red, pendulous area which had the appearance of a blood blister. A dressing dated 2/26/23 on the resident's forearm indicated the probable presence of a wound. CNA AA said, The left arm bruise was not there on Friday. It must have happened over the weekend. I already told the nurse this morning. The resident grimaced and guarded her left arm as CNA AA repositioned and supported the extremity on a rolled towel. The resident stated she had requested pain medication since the incident. Resident #61 said, The CNAs are very rough when they do things with me. She explained the injury and bruising occurred when a CNA took her clothes off. Review of the medical record revealed resident #61 had a care plan for ADL self-care performance deficit initiated on 7/02/19. The interventions directed nursing staff to conduct weekly skin inspections and observe for redness, cuts, and bruises. A care plan for actual skin impairment related to fragile skin, initiated on 7/02/19, had interventions that included avoid scratching, keep skin clean and dry, and use caution during transfers and bed mobility to prevent striking the resident's extremities. Resident #61 had a physician order dated 1/16/23 to check for bleeding and bruising every shift related to use of blood thinner medication, Clopidogrel 75 milligrams once daily. An order dated 2/15/23 directed staff to apply and moisturizing ointment to the resident's extremities for dry skin. A physician order dated 2/17/23 indicated weekly skin evaluations were scheduled on Tuesdays for the 3:00 PM to 11:00 PM shift. Review of resident #61's medical record revealed no Change in Condition forms regarding a recent wound or other skin injury. A Change in Condition form dated 2/15/23 indicated the physician was notified of the resident's decreased appetite and signs of depression. The document revealed the nurse completed a skin evaluation and noted no issues on that date. A Weekly Skin Integrity Review dated 2/21/23 showed resident #61's skin was intact, with no bruises, discolorations, or skin tears noted. The Treatment Administration Record (TAR) for February 2023 revealed nurses' initials to verify they monitored resident #61 for signs and symptoms of bleeding and bruising every shift from Friday 2/24/23 to Monday 2/27/23. However, review of nursing progress notes revealed no documentation to indicate if, when or how the resident suffered the bruises and skin tear. The TAR did not reflect any treatment order for the dressing dated 2/26/23 that was observed on resident #61's left arm. On 2/27/23 at 3:21 PM, during a meeting with the Interim Director of Nursing (DON) and the Administrator, they were informed resident #61 reported rough treatment by a CNA and showed evidence of significant bruising on both arms, neither of which was documented anywhere in the medical record. The DON stated her expectation was staff would report skin injuries immediately, and the Administrator stated nurses should have completed an incident report. On 2/27/23 at 3:52 PM, the Interim DON stated she assessed resident #61's left arm and confirmed the resident had a skin tear and a puffy area below her elbow where a large amount of blood seemed to have pooled. She acknowledged there was also a discolored area to the resident's right arm around the elbow. The Interim DON validated a nurse applied a dressing to the skin tear without making physician notification or obtaining an order. Review of the medical record revealed the Regional Director of Clinical Services (RDCS) completed a Change in Condition form effective 2/27/23 at 5:12 PM. The document indicated resident #61 had a skin tear left elbow and discoloration to bilateral elbows.Resident states CNA from 3-11 shift was rough while removing her shirt causing a skin tear. The physician was notified on 2/27/23 at 4:55 PM and gave an order to apply triple antibiotic ointment, wrap with gauze and apply geri-sleeves. The resident's son was notified a few minutes later at 5:10 PM. On 2/28/23 at 9:44 AM, Registered Nurse (RN) R stated she was resident #61's regularly assigned day shift nurse on Tuesdays, Wednesdays, and Thursdays. She stated she was sure the resident did not have any bruises or discolorations on her arms on the past Thursday, 2/23/23. RN R stated when she checked the electronic medical record this morning she discovered resident #61 had suffered a skin tear at some point over the weekend and had a new treatment order. RN R confirmed resident #61's skin had always been very fragile but she never had an order for a geri-sleeve, a protective stocking sleeve, for her arms. She confirmed once made aware of bruises and skin tears, any nurse assigned to resident #61 should have completed change in condition and incident report forms, informed the physician and family, and done a thorough skin assessment. RN R explained the resident received a daily blood thinner and was at high risk for bleeding and bruising. She confirmed resident #61's left arm showed signs of significant bleeding under the skin. RN R measured the discolored area on the resident's right arm as approximately 15 centimeters (cm) x 17 cm. She stated the bruised area on the left arm was even larger. On 3/01/23 at 5:22 PM, a meeting was held with the Administrator, the RDCS, and the DON. The DON stated she interviewed resident #61 and determined she was alert and oriented and displayed good recall ability. She stated the resident reported an evening shift CNA on the past weekend injured her arm when she removed her shirt which was tight. The DON and RDCS acknowledged it was the CNA's responsibility to recognize the resident's shirt was tight, and remove it with the appropriate level of care and caution to avoid skin injuries. The RDCS verified the assigned nurse should have notified the physician to obtain an immediate treatment order, informed the family, and then contacted the DON regarding the incident. She stated nursing staff assigned to the resident over the weekend and on Monday morning should all have reported the issue to ensure the resident received appropriate care. The RDCS stated resident #61's day shift nurse on Monday received information on the skin tear in change of shift report and applied a treatment although there was no treatment order on the TAR. The RDCS explained the day shift nurse simply followed the treatment applied by a previous nurse without clarifying the absence of a physician order. The RDCS said, We are not calling this a bruise. The resident said the issue with her elbows comes and goes. As far as I see, it does not seem those are bruises. Her skin is thin and there's like a pocket. We are calling them discolorations. She already has something going on and she had orders for an ointment for her skin. We are waiting for [name of the Medical Director] or the Nurse Practitioner to see resident and she needs a dermatologist to diagnose her condition. The RDCS validated there was no nursing documentation in the medical record of bruises on the resident's elbow during the past four weeks. She confirmed she had not yet done additional research to see if resident #61 had a known dermatological condition that was never diagnosed or treated during her time in the facility. Review of a Progress Note dated 2/08/23 revealed resident #61 was assessed by an Advanced Practice Nurse practitioner (APRN) during a long-term care follow up visit. The note indicated nursing staff did not report any acute changes, and the resident was alert and oriented to person, place, and time, and had no complaints. The APRN's Physical Examination read, The elbows/forearms are normal in appearance, mobility, and are nontender. An integumentary or skin examination revealed the resident's skin was pale, but the texture was normal and there were no rashes, eruptions, or skin ulcers observed. On 3/02/23 at 10:41 AM, resident #61's attending physician, the facility's Medical Director, assessed her left arm. He removed the geri sleeve which had been applied only after the facility was informed of the resident's skin injuries. The geri-sleeve was soiled with a moderate amount of drainage from the wound. The Interim DON validated the dressing on resident #61's left arm was dated 2/28 which indicated daily wound care was not performed and a clean treatment not applied on 3/01/23 as ordered by the physician. The Medical Director used normal saline solution to loosen the dressing which was stuck to the wound to reveal the treatment in place was a petrolatum dressing and not the triple antibiotic ointment with gauze that was ordered. After removal of the dressing, resident #61's skin tear actively bled and the Medical Director had to hold pressure on the area with a gauze pad until the bleeding was controlled. The Interim DON confirmed it was not acceptable for a nurse to substitute a dressing without a physician's order. The Medical Director stated the skin tear measured 4 cm x 2 cm and nurses should have called him and/or the Wound Care specialist physician in a timely manner to report the injury and obtain treatment orders. He explained the resident's skin was fragile and thin, and could be bruised or torn during regular ADL care. The Medical Director acknowledged preventative skin protection measures such as geri-sleeves and staff taking precautions during care were important. He said, This is an opportunity for CNA education. When informed the RDCS suggested a dermatological consult was necessary for a possible untreated skin condition, the Medical Director disagreed. He stated he was very familiar with resident #61 and explained she sometimes developed clear, fluid-filled blisters on her bilateral arms as a result of low albumin levels, despite supplementation. The Medical Director informed the Interim DON he recommended a collagen or hydrogel type dressing to promote healing, and consultation with the Wound Care specialist physician for evaluation and treatment. He assessed the skin surrounding the wound and resident #61's left elbow and said, She has developed a cellulitis. The Medical Director explained he would also order an oral antibiotic to treat the resident's skin infection. Cellulitis is a bacterial skin infection that causes redness, swelling, and pain in the infected area. If untreated, cellulitis can spread and cause serious health problems. Good wound care and hygiene are important for preventing cellulitis (retrieved on 3/14/23 from www.cdc.gov). 2. Review of the medical record revealed resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes, hypertension, obesity, and insomnia. Review of the Annual MDS assessment with ARD of 1/28/23 revealed resident #30 had a BIMS score of 15 which indicated he was cognitively intact. He required extensive assistance for ADLs including bed mobility. transfers, dressing, and personal hygiene. The MDS assessment showed the resident had no skin issues. Resident #30 had a care plan for ADL self-care performance deficit initiated on 8/15/22. The interventions included weekly skin inspections to observe for issues such as redness and open areas, and report changes as indicated. A care plan for potential for skin impairment related to fragile skin, incontinence, and decreased mobility was initiated on 8/15/22. The interventions directed nursing staff to keep the resident's skin clean and dry, apply lotion on dry skin, and use caution during transfers and bed mobility. On 2/27/23 at 2:43 PM, resident #30 stated he had an unknown type of wound on his bottom, possibly even an infection. CNA AA stated the resident still had a dressing on his sacrum, but the area was now completely healed and the dressing was in place for protection of the skin. Resident #30's Weekly Skin Integrity Review forms revealed on 2/15/23 his skin was intact. A skin evaluation dated 2/20/23 indicated the resident had a pressure ulcer to his left buttock with an intact, clean, dry dressing. The document read, no other open areas, bruising, or redness noted. On 2/28/23 at 9:34 AM, CNA AA prepared to provide ADL care for resident #30. She stated she usually informed nurses when she was ready to start morning care as it was a convenient time for her to assist nurses to turn and reposition the resident for wound care and application of the dressing to his sacrum. CNA AA recalled yesterday, Monday 2/27/23, when she asked the day shift nurse if she was ready to do the dressing change, the nurse informed her there was no order for a dressing in the electronic medical record. With resident #30's permission, CNA AA repositioned him to his right side to expose a bordered dressing on his sacrum which was soiled with feces and slightly lifted around the right side edges. The dressing was dated Sunday 2/26/23 on the 7:00 AM to 3:00 PM shift. Resident #30's sacrum was slightly pink and no open areas were noted. Review of the TAR for February and March 2023 revealed resident #30 had an active physician treatment order initiated on 2/08/23. The order read, Clean Left buttock area with normal saline, apply skin prep to peri wound. Apply Calcium Alginate to wound bed. Cover with Foam dressing. Secure with tape, every day shift for open blister. Review of the TARs revealed nurses' initials to verify the daily treatment was done as ordered except on 3/01/23. On 3/02/23 at 12:33 PM, the Interim DON was informed resident #30 had a two-day-old dressing in place on his sacrum that did not reflect the physician order, and there was no blister as noted on the TAR. She validated nurses were expected to follow physician orders, and if there was a discrepancy, they should seek clarification from the provider. On 3/03/23 at 12:22 PM, the Interim DON stated she assessed resident #30 with the West Wing Unit Manager and they found his skin was intact and he no longer had a dressing to his sacrum. She explained the facility had a Wound Care specialist and a nurse who rounded with him, and nurses should have alerted either provider or any member of nursing management that the area was healed. The Interim DON could not explain why nurses continued to apply a dressing without appropriate orders or documentation. Review of the facility's policy and procedure for Dressing Change revised on 12/06/17 revealed clean dressings would be applied to wounds to promote healing. The procedure directed nurses to apply treatments as ordered and then document in the medical record.

Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement processes to identify and address deficient practices, and failed to provide adequate oversight of staff to ensure the provision of necessary care and services to maintain the highest practicable well-being for all residents. Findings: Review of the Facility Assessment updated on 2/24/23 revealed the facility was a 180-bed skilled nursing facility that could meet the needs of residents with common diseases and special conditions. The document indicated residents would receive care and services as determined by their needs and plans of care to include assistance with activities of daily living (ADL) care, prevention of falls, promotion of skin integrity, medication management and administration, and infection control and prevention. The Facility Assessment revealed the facility's intent to offer person-centered care such as build relationship with resident/get to know him/her; engage resident in conversation.prevent abuse and neglect, identify hazards and risks for residents. The document noted the necessary resources to provide competent care for residents included adequate Administration, Nursing, Food and Nutrition, Pharmacy and Support staff. In order to promote coordination and continuity of care, the facility would strive to arrange consistent and routine assignments, and ensure staff were trained and were competent to meet residents' needs. The document listed training topics and competencies such as Resident Rights, Abuse / Neglect / Exploitation, Infection Control, Medication Administration, Resident Assessment and other Specialized Care. Nursing staff competencies would be reviewed on hire, annually, and as needed. In addition to facility staff, contracted staff for Dietary, Housekeeping, and Laundry services were expected to provide necessary services to meet residents' needs and ensure the facility's operational success. On 3/01/23 at 10:00 AM, the Short Term Social Services Director (SSD) was informed of concerns identified related to addressing residents' concerns, specifically for residents who were bedbound and/or cognitively impaired, and not able to adequately make their needs and desires known to staff or actively pursue resolution themselves. She stated in addition to the facility's official grievance process, issues that affected vulnerable residents could be identified during Angel Rounds. The Short Term SSD explained the program involved members of management rounding on assigned rooms every morning. She showed a checklist titled Mock Survey (Quality Assurance) that instructed management staff on required observations and to ensure resident is without grievances/concerns. When asked about a specific resident, the Short Term SSD checked the Angel Rounds assignment sheet and explained the resident was in one of five rooms assigned to the Assistant Business Office Manager (BOM). The Short Term SSD stated the facility no longer had an Assistant BOM and said, That person left a while ago. We have a back up person, the Business Office Manager. On 3/01/23 at 10:24 AM, the BOM stated she had been on staff for approximately three months and there was no Assistant BOM during that period. She said, I have never been told to Angel Rounds. She was shown the Mock Survey (Quality Assurance) form which indicated she was assigned to to daily rounds of five rooms and serve as back up for the Assistant BOM in another five rooms. The BOM stated she had never seen the checklist. She acknowledged if daily Angel Rounds were completed, the concerns of residents in those rooms would probably have been noticed and addressed. On 3/01/23 at 11:00 AM and 3/02/23 at 9:47 AM, the Administrator confirmed the facility no longer had a functional Angel Rounds program in which management staff were assigned to daily room and resident rounds. He said, I stopped the program. because we have changed so many staff members and have all new management staff. The Administrator acknowledged the program would be an effective method of identifying important issues that affected residents' comfort and well-being. On 3/03/23 at 1:06 PM, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator T explained issues identified related to obtaining and implementing physician orders, following interdisciplinary team recommendations, and ensuring continuity of care for residents through the chart review process were in large part attributable to lack of adequate oversight from nursing management. She explained the facility had not been staffed with consistent Unit Managers or a Director of Nursing for several months. LPN MDS Coordinator T stated as a result, the daily clinical meeting had not been as effective as required. She stated concerns identified related to grievances and advance directives were the responsibility of the Social Services department which had also been short-staffed for a while. On 3/03/23 at 3:34 PM, a meeting was held with the facility's Administrator and the Regional Director of Clinical Services (RDCS). They confirmed a resident successfully eloped from the facility on 12/19/22. The Administrator and RDCS were informed the resident and facility staff reported a previous elopement attempt approximately five days before the actual elopement. They denied knowledge of any previous elopement attempts by the resident and could not explain why the incident investigation did not reflect the previous attempt and increased risk. The RDCS confirmed the facility did not define increased or enhanced supervision to ensure direct care staff could provide appropriate care and supervision to prevent additional elopements. The Administrator acknowledged although the facility had recently decreased use of Certified Nursing Assistants from staffing agencies, they continued to rely heavily on nurses from staffing agencies. The RDCS validated reliance on agency nurses who were not familiar with residents and the facility's policies and procedures, in conjunction with lack of general oversight of nursing staff were contributing factors to the breakdowns noted in resident care and services. She explained experienced nurses had been filling in for open Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Manager (UM) positions, but the facility experienced the outcomes of overall lack of stability in Nursing department leadership. The Administrator recalled since November 2022, the facility had gone through two DONs, two Interim ADONs, and two UMs who lasted no more than one month. He acknowledged daily clinical and department head meetings were still conducted but might not be as productive as they should be. He stated the facility never considered a moratorium on admissions despite the known concerns in the Nursing department. The Administrator and RDCS were informed of a staff CNA who did not know how to locate the Kardex or CNA care plan in his assigned resident's medical record, an LPN on staff for one year who verbalized he never received education or showed competency in medication administration and wound care, a repeated medication error 24 hours after the the initial error was brought to the attention of nursing management, and multiple residents who received crushed, controlled release medications despite contraindication. The RDCS acknowledged all nursing staff should receive education on hire to ensure they met the facility's standards. She stated the identified medication error was repeated due to lack of communication between nursing management staff. Review of the job description for Director of Clinical Services or DON (undated) revealed the purpose of the position included ensuring .the highest degree of quality care is maintained at all times. The DON's duties and responsibilities included hiring a sufficient number of staff and directing the Nursing and care plan team. Review of the job description for Executive Director I or Administrator (undated) revealed duties and responsibilities were to recruit, hire and provide adequate orientation and training to ensure the facility had a sufficient number of qualified staff, and to ensure a safe, clean and comfortable environment. The functions of the Administrator's position included .provide leadership to all facility staff in meeting the goal of providing quality resident care.

Based on observation, interview, and record review, the facility failed to honor the right to be treated with dignity and respect while receiving assistance with meals, (#53, #115 & #105), during personal care, (#61), and for all residents in and near a common area (West Wing Day Room), of a total sample of 66 residents. Findings: 1. Review of resident #53's medical record revealed she had dementia and moderate cognitive impairment. Her care plan for activities of daily living (ADLs) self-care performance deficit was initiated on 12/22/22, and read, The resident requires extensive assistance by staff to eat. On 3/01/23 at 1:00 PM, resident #53 was seated at a table in the middle of the West Wing Day Room. Certified Nursing Assistant (CNA) O stood in front of resident #53 as she fed her. There were twelve additional residents seated in the room and the clear glass windows around the perimeter of the room allowed residents, staff, and visitors to visualize the activities in the room. Licensed Practical Nurse (LPN) M stood outside the West Wing Day Room and observed CNA O's method of assisting resident #53 with her lunch meal. He confirmed it was a dignity issue as CNAs should be seated at eye level when they assisted residents with meals. CNA O continued to feed the resident, whose face was at the level of the CNA's waist. CNA O looked across at LPN M but continued to stand and feed resident #53 until the meal was finished. She then walked towards another resident seated at a table nearby, stood beside her and fed that resident one spoonful of her lunch. When CNA O looked up and realized she was still being watched, she walked across the room and retrieved a chair. On 3/01/23 at 1:05 PM, CNA O confirmed she stood while she assisted resident #53 with lunch. She acknowledged she should have been seated. 2. Review of resident #105's medical record indicated he had moderate cognitive impairment and a diagnosis of Parkinson's Disease. His care plan for ADL self-care performance deficit related to disease process was initiated on 12/15/21, and read, The resident requires extensive assistance by staff to eat. On 3/01/23 at 1:09 PM, the loud clanging of utensils against a plate was heard from the West Wing nurses' station. A short distance down the hallway, CNA X was observed standing to feed resident #105 who was seated on the side of his bed. She explained the resident required assistance with his meal as the shaking of his arms made it difficult for him to feed himself at times. CNA X continued to feed the resident while loudly hitting the utensil against the plate between scoops of food. She was prompted about standing and feeding the resident and acknowledged the correct procedure involved being seated. 3. Review of resident #115's Quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 12/10/22 revealed he had a diagnosis of quadriplegia and was totally dependent on staff for eating. On 3/01/23 at 1:29 PM, CNA D stood at resident #115's bedside as she assisted him with his lunch meal. When prompted regarding standing to feed the resident, CNA D said, I'm not going to lie. They told me we should be sitting. CNA D looked around the room and explained she chose to stand as there were no chairs in the room. On 3/02/23 at 3:29 PM, the West Wing Unit Manager (UM) stated her expectation was CNAs would find and use chairs of appropriate height to allow them to sit at residents' eye level while they assisted with meals. She stated on hire, nursing staff received education in orientation regarding properly assisting with residents' meals. The UM validated CNAs were to be seated while they assisted with meals to ensure residents were treated with dignity. 4. Review of resident #61's medical record revealed a Quarterly MDS assessment with ARD of 1/23/23 with a Brief Interview for Mental Status score was 15, which indicated she was cognitively intact. The MDS assessment showed resident #61 required extensive assistance from staff for toilet use and personal hygiene. On 2/27/23 at 10:30 AM, resident #61 complained that CNAs spoke on their cell phones while they cared for her. The resident pointed to her ears and explained CNAs used cell phones with earphones when they changed her brief and completed personal hygiene tasks. She stated CNAs also stood in her bathroom and continued to speak on their phones. On 3/01/23 at 5:22 PM, the Interim Director of Nursing (DON) stated after the facility was made aware of resident #61's concerns, she interviewed the resident and determined CNA S was the staff member who recently cared for the resident while on the phone. The Interim DON stated CNA S acknowledged she used her cell phone in resident #61's bathroom. 5. On 3/01/23 at 4:11 PM, CNA N was seated in the doorway of the West Wing Day Room as she spoke on a cell phone speakerphone. Both sides of the conversation were audible from the hallway, and when asked if she was on her personal cell phone, CNA N paused her conversation and said, Yes. She then said goodbye to the other party on the cell phone, hung up, and placed the device in her pocket. CNA N validated she was aware she should not use a personal cell phone while she worked. On 3/01/23 at 4:14 PM, the Interim West Wing UM confirmed CNA N's actions were not respectful of the residents in the Day Room, and did not reflect dignified treatment. She emphasized it was against the facility's policy for staff to use personal cell phones in patient care areas. On 3/02/23 at 3:29 PM, the West Wing UM explained the Day Room was used to monitor residents at risk for falls. She stated her expectation was the assigned CNA would not just sit by the door and talk on the phone while she watched the residents. The West Wing UM stated CNA N's duties included interacting with the residents in the Day Room by offering snacks, water, and juice, and helping them to participate in activities and games. She validated it was not acceptable for any staff member to use a personal cell phone anywhere on the unit during working hours, especially while performing personal care tasks, as it was not professional behavior and created a dignity issue for residents. Review of the facility's Information Handbook dated December 2021, revealed residents had .the right to be treated with consideration, respect, and full recognition of [their] dignity and individuality. Review of the facility's employee handbook dated December 2022 revealed requirements regarding Use of Personal Cellular Telephones and Electronic Devices. The policy indicated use of personal cellular devices during working hours, while on duty, was prohibited. The document read, Employees are permitted use of personal electronic devices while on their break or meal period as long as the equipment is used in designated outside areas of the care center.

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopements for 1 of 3 residents reviewed for elopement, in a total sample of 66 residents, (#134). Findings: Review of the medical record revealed resident #134 was admitted to the facility's secure Memory Care Unit on 3/01/22. Her diagnoses included Schizophrenia, Delusional Disorder, Hypertension, and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated she was cognitively intact. The MDS assessment revealed resident #134 was able to walk independently in her room, but she required supervision of one staff member to person for locomotion both on and off the Memory Care Unit. An Elopement Risk Evaluation dated 7/14/22 indicated resident #134 was at risk for elopement. Review of resident #134's medical record was being seen by a psychiatric provider and there were several notes regarding her delusional thinking. A progress note dated 6/09/22 read, Patient is currently taking Risperidone for schizophrenia disorder.Per staff patient has been delusional, she thinks the family killed her baby. She has been very paranoid. A progress note dated 11/14/22 read, .patient has been exhibiting delusional thinking and refusing medications. On 2/28/23 at 11:37 AM, resident #134 was in her room and there was Certified Nursing Assistant (CNA) seated in the hallway just outside the resident's room door to provide one-to-one supervision. Resident #134 explained she was admitted to the facility from the hospital about a month ago and said, I became very aggressive because I've been kidnapped and held against my will. When I checked in here they told me I could never leave. However, resident #134 stated she had been able to get out of the facility on two occasions. She recalled she went out through an exit door at the end of the hall. Resident #134 stated at about 4:00 PM one afternoon she pushed the exit door an alarm sounded. The resident said, You have to really shove it, the door, real hard, and it breaks the lock. It's an insecure lock. They have it set up this way so people can do this. She recalled two staff members apprehended her and brought her back into the facility. Resident #134 stated the second time she eloped from the facility successfully was one morning at approximately 5:00 AM, when all the staff on the Memory Care Unit were busy in residents' rooms. The resident stated she figured out the best time to leave was either nighttime or early in the morning. She explained, Because they were not going out in the dark to come after you. It's not the CNAs' job duties to come after you in the dark. It's a legal thing. She stated the second time she left the facility, she hid in the woods for two and a half hours. She recalled the facility sent three ladies and four Deputy Sheriffs to search for her. Resident #134 stated when she was found, she told the Deputy Sheriffs she had been kidnapped but they took her back to the facility anyway. She said, The Deputies don't care because they are going to get a big payoff. On 2/28/23 at 12:00PM, resident #134 left her room, walked to the Memory Care Unit nurses' station, and pointed to the the exit door at the end of the hallway. The confirmed she got out twice through that exit door. Upon returning to her room, resident #134 pointed to CNA G and stated that she was one of the staff members who apprehended her. On 2/8/23 at 12:11 PM, CNA G recalled the events of resident #134's first elopement attempt on 12/14/22. She stated it was prior to the Big Elopement that occurred in the early morning hours of 12/19/22. CNA G stated she was working during the 3:00 PM to 11:00 PM shift and at around dinner time as staff passed out the meal trays, she saw resident #134 at the exit door. She confirmed it was the same exit door that resident #134 had pointed out. CNA G stated the resident had a bag in her hand and she pushed the door once and the alarm went off. CNA G stated she called out, Stop! However, instead of stopping, the resident made a big push and the exit door opened. CNA G explained she ran after the resident and caught up with her halfway towards the front of the facility. She stated resident #134 was swung the bag at her and the former Assistant Executive Director and other staff helped to bring the resident back to the facility. On 3/1/23 at 10:42 AM, CNA D recalled the events of resident #134's second elopement, on 12/19/22. She said she arrived at the facility at approximately 6:45 AM that morning, and as she entered the facility, the Medical Records Staff was handing out pictures of the missing resident. She stated she joined a nurse and a CNA from a staffing agency in the search for the resident. CNA D recalled they checked the empty field behind the facility and walked along the wooded area on the east side of the facility. She stated as they walked towards the front of the facility towards the main highway, they spotted resident #134 in a construction site on the adjacent property. She stated as they approached the resident, she raised her arm and swung a large piece of wood, probably debris from the construction site, at the three staff members. CNA D said the nurse got close enough to hug the resident while the other two staff disarmed her. CNA D stated she waved over to the Deputy Sheriff's car as they were also searching for the resident. She explained the resident told the Deputy she had been kidnapped and that her family paid eight million dollars to keep her at the facility. CNA D recalled resident #134 said, Take me to jail. I attacked y'all. Take me to jail. Didn't I? Didn't I attack y'all. It was assault and battery and this is eight to ten years in jail. CNA D stated the Deputy Sheriffs were able to convince the resident to return to the facility by telling her she would have to sign papers and retrieve her personal items before she went to jail. On 3/01/23 at 4:30 PM, the resident most likely elopement route was retraced and measured. The resident left her room and exited the facility through South-East Door #4. The resident walked 701.7 feet until she reached the entrance to the construction site where she was only 261.5 feet from a busy 4-lane divided highway. The resident walked another 80.8 feet over rough,uneven ground towards the center of the construction site. On 3/01/23 at 4:58 PM, the Project Superintendent of the construction site recalled the morning an elderly women got out of the nursing home and staff were seen chasing her. He stated she was swinging a piece of lumber at staff that was either 2 inches x 2 inches or 2 inches x 1 inch. The Project Superintendent stated his work crews were there and they usually arrived at about 6:30 AM. He recalled the sun was already up, but it was a cold morning. On 3/01/23 at 5:21 PM, the Regional Nurse Consultant (RNC), Director of Nursing (DON), and the Administrator discussed resident #134's elopement on 12/19/22. They explained the facility obtained statements from staff that showed on the morning of 12/19/22 at approximately 5:45 AM, a nurse on the unit adjacent to the Memory Care Unit heard an exit door alarm while she was passing medication. They stated the investigation indicated that nurse entered the Memory Care Unit, went out the exit door and looked around for a resident. The nurse did not find a resident so she returned to the building and informed the night shift nursing supervisor. The elopement code was paged overhead and staff conducted a head count on all nursing units and discovered resident #134 was missing. They stated staff continued to search for the missing resident and law enforcement was notified. The facility staff found resident #134 in the construction site on the adjacent property and the Deputy Sheriffs brought her back to the facility. Resident #134 was then placed on one-to-one supervision. The RNC stated that incident was the first time resident #134 had eloped from the facility and the facility's Root Cause Analysis of the elopement was that the resident did not want to be in the facility. On 3/02/23 at 10:27 AM, the Maintenance Director verified resident #134 exited the facility through the South-East Door #4 on the Memory Care Unit. He explained the exit door had a 15-second delayed egress function, and if someone depressed the crash bar, an alarm would sound, and after 15 seconds the magnetic lock would release to unlock the door. However, he stated if someone pushed on the crash bar and/or door with significant force, it was possible to bypass the 15-second delay and open the door. The Maintenance Director stated the exit door was set up that way as a safety feature, so if there was an emergency, staff and residents would not have to wait 15 seconds to get out of the facility. On 3/02/23 at 1:30 PM, the receptionist stated she sometimes worked on the nursing units as a CNA, and she was very familiar with resident #134. She stated she believed she worked on 12/14/22 during the 3:00 PM to 11:00 PM and recalled resident #134 got out of the facility in the afternoon or early evening. The receptionist stated staff were about to pass out dinner trays and resident #134 gave the South-East Door #4 a big push, and the exit door opened. The receptionist stated the person who was the receptionist that day, the Assistant Administrator and a nurse from a staffing agency retrieved the resident and brought her back inside. The receptionist validated resident #134 also got out on 12/19/22. She stated the resident was very smart and she always peeked out from her doorway see if regular staff worked or if there were new staff. On 3/02/23 at 2:53 PM, the Administrator stated that he had just interviewed facility staff and he found out that resident #134 had indeed eloped twice from the facility, on 12/14/22 and 12/19/22. He stated that neither he nor the RNC had been made aware of the first elopement on 12/14/22, until they were informed today. On 3/03/23 at 3:33 PM, resident #134's two elopements were discussed with the Administrator and the RNC. They acknowledged the resident had been at risk for elopement since July 2022, but she refused to wear a electronic monitoring device on her person. The resident elopement care plan was reviewed and the approach, Frequent Monitoring was added on 7/22/22 since the resident refused to wear a electronic monitoring device. The Administrator and the RNC were not able to define the term Frequent Monitoring. They were informed staff were not able to describe the frequency or intervals of safety checks and observations that were necessary to prevent resident #134 from leaving the facility again. They acknowledged the facility needed to determine the Root Cause Analysis of each elopement, to include the ease with which the the exit door was breeched, so the appropriate amount of supervision could had been determined.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services related to safe administration of controlled release medications, and accurate and/or timely acquisition of medication to meet the needs of 12 residents who received controlled release medications, of a total sample of 66 residents, (#8, #40, #49, #50, #69, #110, #112, #125, #126, #131, #141 & #146). Findings: 1. Review of resident #112's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease, hypertension, and mini-strokes. Review of resident #112's active Order Summary Report revealed a physician order dated 2/05/23 for Isosorbide Mononitrate ER 24 hour 30 milligrams (mg) once daily for hypertension. Controlled release drugs which include those with the suffixes ER (Extended Release) and DR (Delayed Release) are designed to release medicine over an extended period of time to promote smooth release and a longer duration of action. Crushing may mean a fatal dose is released (retrieved on 3/10/23 from www.drugs.com). On 2/27/23 at 7:49 AM, Licensed Practical Nurse (LPN) M crushed the resident's Isosorbide Mononitrate ER 30 mg tablet. On 2/27/23 at 7:57 AM, LPN M was prompted not to administer the crushed medication. He was asked to retrieve and read the blister pack for resident #112's Isosorbide Mononitrate ER. He discovered printed instructions that read, Do NOT CHEW or CRUSH before swallowing. May cause DIZZINESS. Medication affects blood pressure. He stated he was familiar with his assigned residents and knew resident #112 would spit out his pills if they were not crushed. When asked why ER medication should not be crushed, LPN M explained the medication would be released at a faster rate than intended. Review of the Memory Lane Report Sheets revealed the instruction for nurses to crush resident #112's medication. On 2/27/23 at 8:09 AM, the Interim Director of Nursing (DON) was informed that LPN M crushed an ER tablet contrary to instructions on the blister pack. She stated her expectation was prior to medication administration, all nurses would follow professional standards related to medication administration. The Interim DON explained nurses should check medication lists and containers to ensure medications could be crushed safely. She stated the decision to crush medications should be based on recommendations by the manufacturer and/or pharmacy. The Interim DON stated there should be a physician's order transcribed to the Medication Administration Record (MAR) regarding crushing medication if not contraindicated. She acknowledged LPN M should have notified the physician resident #112 was no longer able to swallow his medication whole. On 2/28/23 at 4:25 PM, LPN DD was asked to check the medication cart to ensure resident #112's Isosorbide Mononitrate ER 30 mg tablets had been replaced with an alternative form of the medication. She retrieved the same blister pack utilized by LPN M during medication administration the previous day and confirmed the instruction was not to crush the tablet. LPN DD checked her nursing report sheet and confirmed it indicated his medication had to be crushed. She checked the MAR for 2/28/23 and validated resident #112 received the ER tablet again despite the medication error identified on the previous day. On 2/28/23 at 4:42 PM, the Interim West Wing Unit Manager (UM) was informed neither the assigned nurses nor nursing management removed resident #112's Isosorbide Mononitrate ER tablets after the facility was made aware of the concern related to crushing the tablet. She acknowledged the physician should have been notified immediately and a new order obtained to ensure the resident's medications were administered in an appropriate form. Order Summary Report forms for all residents in the facility who had physicians' orders for medication with the suffix ER were reconciled with nursing report sheets from all medication carts. 2. Resident #8 had physician orders dated 3/22/22 for Namzaric capsule ER 24 hour 21-10 mg once daily for Alzheimer's disease, and Pantoprazole Sodium DR 40 mg once daily for gastroesophageal reflux disease. The blister pack for Namzaric ER ,d+[DATE] mg capsules read, Swallow whole - Don't chew/crush. Review of the Memory Lane Report Sheets revealed the instruction for nurses to crush resident #8's medication. 3. Resident #40 had a physician order dated 3/17/22 for four capsules Zonisamide 100 mg once daily for seizures and an order dated 1/11/19 for Potassium Chloride ER 20 milliequivalents (meq) once daily for hypokalemia. Zonisamide is a drug used to treat seizures. The manufacturer's instructions directed, Swallow the capsule whole and do not crush, chew, break, or open it (retrieved on 3/13/22 from www.drugscom).The Potassium Chloride ER blister pack read, Do NOT CHEW or CRUSH before swallowing. Review of the East Wing Cart 3 nursing report sheet revealed the instruction for nurses to crush resident #40's medication. 4. Resident #49 had a physician order dated 3/29/17 for Tylenol 8 hour Arthritis ER 650 mg every eight hours as needed for pain. Review of the West Wing Cart 2 nursing report sheet revealed the instruction for nurses to crush resident #49's medication. On 2/28/23 at 4:52 PM, LPN EE stated she worked for a staffing agency and was not familiar with residents on her assignment. She explained she utilized the nursing report sheets to determine which residents' pills had to be crushed. She checked the medication cart and confirmed there was no container of the ordered drug Tylenol Arthritis ER 650 mg for resident #49. LPN EE explained if the resident complained of pain she would instead administer two tablets of the available stock medication, Tylenol 325 mg. When prompted regarding following physician orders and best nursing practice, LPN EE acknowledged the physician should be notified that the ordered medication was not available. 5. Resident #50 had a physician order dated 2/21/23 for Metoprolol Succinate ER 24 hour 100 mg at bedtime for hypertension. The medication blister pack read, Not to be chewed or crushed. Review of the East Wing Cart 3 nursing report sheet revealed the instruction for nurses to crush resident #50's medication. 6. Resident #69 had a physician order dated 12/17/22 for Namenda XR Extended Release 24 hour 14 mg via G-tube once daily for dementia. A gastrostomy tube or G-tube is a feeding tube that is inserted directly into the stomach through a surgical incision in the abdominal wall (retrieved on 3/10/23 from www.my.clevelandclinic.org). Review of the MAR for February 2023 revealed the resident received the medication daily as ordered, which indicated it was crushed and dissolved in order to be administered via the tube. 7. Resident #110 had physician orders dated 1/09/23 for Aspirin Enteric Coated DR 81 mg once daily for clot prevention and Diltiazem HCl ER 12 hour 60 mg twice daily for hypertension. Review of the West Wing Cart 1 nursing report sheet revealed the instruction for nurses to crush resident #110's medication. 8. Resident #125 had a physician order dated 7/12/22 for Desvenlaxafine Succinate ER 24 hour 50 mg once daily for major depressive disorder, and an order dated 1/07/22 for Alendronate Sodium 70 mg every Monday morning for osteoporosis. The manufacturer's instructions for administration of Alendronate read, Do not crush, chew, or suck on an Alendronate regular tablet. Swallow it whole (retrieved on 3/13/23 from www.drugs.com). Review of the West Wing Cart 1 nursing report sheet revealed the instruction for nurses to crush resident #125's medication. 9. Resident #126 had a physician order dated 7/30/21 for Potassium Chloride ER 10 meq once daily for edema. Review of the West Wing Cart 2 nursing report sheet revealed the instruction for nurses to crush resident #126's medication. On 3/02/23 at 12:06 PM, LPN FF walked by the West Wing nurses' station. He held a plastic cup with pills and informed the West Wing UM resident #126 refused to take her medication. The West Wing UM checked the nursing report sheet and informed LPN FF that the resident required her medication crushed. LPN FF returned to the medication cart to crush the tablets and when asked to pull the blister packs to verify if the pills should be crushed, he verified the Potassium Chloride ER pack read, Not to be chewed or crushed. Take with plenty of water. 10. Resident #131 had a physician order dated 1/14/22 for Procardia XL ER 24 hour 30 mg once daily for hypertension. The medication blister pack read, Do NOT CHEW or CRUSH before swallowing. Review of the Memory Lane Report Sheets revealed the instruction for nurses to crush resident #131's medication. 11. Resident #141 had a physician order dated 7/10/22 for Vitamin B12 oral tablet ER 1000 micrograms (mcg) for Vitamin B12 deficiency. Review of the Memory Lane Report Sheets revealed the instruction to crush resident #8's medication. On 2/28/23 at 4:25 PM, LPN DD reviewed resident #141's MAR and noted the resident had an ER medication although she needed her medications crushed. LPN DD checked the medication cart for the Vitamin B12 ER tablet and stated no such medication was in the cart. She explained there was a bottle of Vitamin B12 500 mcg tablets and nurses probably gave two of those tablets instead. The Interim West Wing UM stated she was not familiar with the ER form of Vitamin B12, and it was not a formulary stock medication. She confirmed resident #141 could not have received the medication as ordered since the facility did not stock it and it was not sent from the pharmacy. The Interim West Wing UM stated all assigned nurses over the previous six months should have clarified the physician's order to ensure the resident received the correct medication in the appropriate form. 12. Resident #146 had a physician order dated 1/14/23 for two tablets Metoprolol Succinate ER 25 mg once daily for hypertension. The medication blister pack read, Not to be chewed or crushed. Review of the Memory Lane Report Sheets revealed the instruction for nurses to crush resident #146's medication. On 2/27/23 at 1:48 PM, LPN BB stated she worked for a staffing agency and this shift was her second shift in the facility. LPN BB explained she was not familiar with the residents as yesterday she was assigned to another unit. She stated she relied on the nursing report sheet and verbal report from the offgoing nurse. LPN BB showed the report sheet with her handwritten notes and pointed to the indicators beside each resident's name, C for crushed pills or W for whole pills. On 2/28/23 at 4:17 PM, Registered Nurse (RN) CC stated he was on staff and had a regular assignment so he knew which residents took their pills whole and which ones needed their pills to be crushed. During review of the nursing report sheet for RN CC's assignment, he indicated there were inaccuracies on the form related to whether or not to crush pills. He acknowledged it was a concern as nurses from a staffing agency would simply follow the printed instructions. On 2/28/23 at 4:25 PM, LPN DD stated she worked for a staffing agency and this was her first shift on the Memory Care unit. She explained she received a verbal report from the day shift nurse and also had a report sheet with her assigned residents' names, room numbers and other important information such as whether medication were to be crushed. She showed her pre-printed report sheet which had some residents' names with the letter W struck out and replaced with the letter C. LPN DD confirmed the offgoing nurse told her those residents now needed their medications crushed. She reviewed the list of residents who received controlled release drugs and confirmed some of her assigned residents who required crushed medications were on that list. LPN DD validated it was concerning that nurses followed information on a report sheet rather than physician orders, pharmacy instructions, and drug manufacturers' warnings. She acknowledged nurses were responsible for identifying contraindications and informing the ordering physician. On 2/28/23 at 5:03 PM, LPN FF stated he worked for a staffing agency and relied on nursing the report sheet to determine whether or not to crush his assigned residents' medications. He was asked to review the list of residents on controlled release medications and pull the blister packs to check instructions. He searched for resident #69's Namenda XR Extended Release 24 hour 14 mg tablets and confirmed it was not in the medication cart and the MAR indicated it was not administered as ordered during the day shift. He then searched for resident #110's Diltiazem HCl ER 12 hour 60 mg and stated that medication was not in the cart either. He checked the MAR and discovered the drug was not administered during the day shift and was not available for this evening's dose. He explained the nursing report sheet indicated resident #110 required crushed medications, but based on change of shift report, I scratched out crush. He acknowledged he had not verified whether or not the resident had difficulty swallowing. LPN FF randomly selected blister packs with controlled release medications from the cart and was not able to identify instructions regarding not crushing or chewing. He was shown the instructions and prompted to read the card carefully. He stated he would not have noticed the instructions due to the fine print and said, It would be much safer if the pharmacy put warnings in another color like red. On 3/02/23 at 10:59 AM, the facility's Medical Director was informed of significant concerns related to nurses crushing controlled release medications although contraindicated. He stated his expectation was nurses would follow physicians' orders as written, and immediately notify the provider if any change in status including difficulty swallowing suggested an alternate medication was necessary. The Medical Director confirmed nurses should not select substitutions for medications that were not available. On 3/03/23 at 10:24 AM, in a telephone interview, the facility's Consultant Pharmacist confirmed she conducted Monthly Medication Reviews for all residents of the facility to identify any irregularities in medication regimens. She was informed of concerns identified related to residents who required medications to be crushed due to swallowing issues receiving controlled release medications despite contraindication. The Consultant Pharmacist said, I am sure there is a policy and procedure to call the physician. If the instructions say do not crush they should call the physician to substitute. The Consultant Pharmacist stated she was able to answer only general questions regarding medication action, not resident-specific concerns. When given the example of nurses crushing Metoprolol Succinate ER, she repeated that facility would have to follow its policy. The Consultant Pharmacist was asked how the medication action was affected by being crushed. She said. Obviously it would not be Extended Release then. The facility's policy and procedure for Administering Medications revised in April 2019 read, Medications are administered in a safe and timely manner, and as prescribed. The policy read, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) prior to giving the medication. The document indicated if nurses believed a medication dosage was inappropriate or if a potential adverse consequence was identities, the nurse would contact a physician to address the concern. Review of the Facility assessment dated [DATE] revealed the facility could care for residents with common diagnoses and conditions, and offered services to meet residents' needs including medication administration via G-tube and oral routes. The document indicated all nursing staff would demonstrate competency in medication administration on hire, annually, and as needed.

Based on observation, record review, and interview, the facility failed to label stored foods in the walk-in refrigerator and defrost frozen foods under running water. Findings: Review of the facility menu revealed broccoli florets would be served at the lunch meal on 2/27/23. During an initial kitchen inspection on 2/27/23 at 6:16 AM, the facility's walk-in refrigerator was observed. There were two half-pans covered with foil paper. One of the pans had lima beans and the other pan contained cooked rice. The pans were not labeled with the date or the contents. The prep sink was filled with water and there were eight bags floating in the water. The water faucet was not running and the sink was not draining. At 6:34 AM, a Dietary Aide drained the prep sink, removed the bags of broccoli and placed them in a steam table pan. The bags of broccoli were warm to the touch and some of the bags of broccoli were full of water. The prep sink did not have a drain stop and the Dietary Aide explained she used one of the bags of broccoli as a drain stop. On 2/27/23 at 6:54 AM, the walk-in refrigerator was observed with the Certified Dietary Manager (CDM). She confirmed the pans of lima beans and rice were not dated or labeled. A large metal bowl on the shelf covered with foil was also not dated or labeled. The CDM removed the foil and said there was pudding in the bowl. A plastic bowl covered with clear wrap was not labeled or dated. The CDM said the plastic container contained tomato sauce. She explained food and leftovers that were stored in the walk-in refrigerator must be labeled and dated. She indicated kitchen staff had been educated on dating and labeling of stored foods. When informed of the bags of broccoli that were soaking in the prep sink, the CDM stated the bags of broccoli should have been defrosted under running water with the drain open. Chapter 3 of the Food and Drug Administration's (FDA) 2022 Food Code noted labeling of foods and the thawing of foods that are completely submerged under running water.

Based on observation, interview,and record review, the facility failed to determine if self-administration of medication was clinically appropriate and safe for 1 of 8 residents reviewed for choices and resident rights, of a total sample of 66 residents, (#132). Findings: Review of resident #132's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Anemia, Anxiety, and Mood Disorder. Review of the physician orders revealed resident #132 received two inhalation medications: Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-225 micrograms per inhalation (mcg/INH), one puff every day, and Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg per actuation, two puffs every four hours as needed. On 2/27/23 at 9:36 AM, resident #132 was in bed with cough drops, one Breo Ellipta inhaler, and one Albuterol Sulfate inhaler to the left of her pillow. When asked about the inhalers, the resident explained she had COPD and administered the inhaled medications herself. The assigned nurse, nurse GG, was asked to come to the resident's room and when she arrived at 10:10 AM, she observed the resident's inhalers on the bed and stated resident #132 did not self-administer medications. Approximately one to two minutes later, the Assistant Director of Nursing (DON) entered the room and nurse GG explained the situation. Both staff attempted to convince resident #132 to relinquish the inhalers, but the resident adamantly refused to hand them over. Resident #132 slid the inhalers underneath her pillow as she said, Don't take my inhalers. I need them. The ADON stated she would inform the DON, and nurse GG said she would check the physician orders. Medical record review revealed the resident had a Brief Interview for Mental Status score of 13/15 which indicated her cognition was intact. However, the medical record did not contain any evidence that resident #132 had been assessed by facility staff to verify she could self-administer medication safely. On 3/03/23 at 10:07 AM, the ADON stated although resident #132 initially refused to hand over the inhalers, the DON was able to retrieve the medications from her later that afternoon. The ADON added she reviewed resident #132's medical record and did not see a physician's order for the resident to self-administer medications.

Based on interview and record review, the facility failed to honor the right to refuse treatment related to a Do Not Resuscitate Order (DNRO), for 1 of 1 resident reviewed for advance directives, of a total sample of 66 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE], and readmitted on [DATE] after a hospital stay. His diagnoses included cerebrovascular disease, seizures, hypertension, Alzheimer's disease, and protein-calorie malnutrition. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #44's primary diagnosis in the hospital was septic shock. Septic shock is the final and most severe stage of sepsis, which is the body's extreme reaction to an infection. The inflammation throughout the body can cause dangerously low blood pressure and is life-threatening (retrieved on [DATE] from www.my.clevelandclinic.org). The transfer form indicated resident #44 was not alert and required a surrogate to make healthcare decisions. The Advance Care Planning section of the document read, DO NOT Resuscitate (DNR). The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date of [DATE] revealed resident #44 had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. The resident required extensive assistance for bed mobility and personal hygiene, and was totally dependent on staff for dressing, eating, and toilet use. The MDS assessment showed resident #44 had functional limitations in range of motion in one arm and both legs and required a wheelchair for mobility. He experienced shortness of breath with exertion and when lying flat. The document indicated resident #44 relied on a feeding tube inserted directly into his stomach for nutrition, and he had four unhealed pressure injuries of different stages. Review of the Order Summary Report dated [DATE] revealed a physician's order dated [DATE] that read, Prognosis: Poor. An active physician's order for Full Code status was entered on [DATE], the day after resident #44 was readmitted from the hospital. Full Code means all resuscitation procedures would be provided to keep someone alive if the person's heart stopped beating and/or he/she stopped breathing, Full resuscitation measures include Cardiopulmonary Resuscitation (CPR) with chest compressions, intubation or insertion of a breathing tube into the airway, and defibrillation, an electric shock to the heart (retrieved on [DATE] from www.webmd.com). Resident #44 had a care plan for advance directives initiated on [DATE] and revised on [DATE]. The document indicated the resident had a Certificate of Incapacity, a Health Care Proxy, and Full Code status. The goal read, Resident will have advanced directives followed. An intervention dated [DATE] directed staff to discuss advance directives with the resident and/or his representative. On [DATE] at 4:55 PM, in a telephone interview with resident #44's daughter, one of his emergency contacts, she clarified that her father should have a DNR code status. She explained during his last hospitalization in [DATE], the physicians spoke with her and her sisters about the severity of their father's condition. She stated based on the conversation, the family selected DNR status. The daughter explained if their father died naturally and peacefully at his advanced age, they wanted to prevent aggressive attempts to bring him back. She stated the DNR paperwork was supposed to be included in the hospital transfer documents when he returned to the facility in September. The daughter recalled a telephone call from the facility's Long Term Social Services Director (SSD) regarding her father's code status. She stated she informed him it was supposed to be DNR, and the Long Term SSD suggested she go to the hospital to retrieve the document. The daughter explained she had not yet been able to do so due to her work schedule. Review of the facility's policy and procedure for Advanced Directives revised on [DATE] revealed upon admission, the SSD or Business Development Coordinator would determine if the resident had an advance directive, and if one existed, either person would .obtain a copy and place it in the resident's medical record. The policy indicated advance directives would be reviewed quarterly and as needed, with a purpose of identifying and clarifying current instructions and determining if changes were desired. On [DATE] at 5:00 PM and 5:39 PM, the Long Term SSD stated he discussed resident #44's code status with the daughter but could not recall when. He reviewed the electronic medical record and confirmed there was no documentation regarding the discussion. The Long Term SSD denied knowledge of an existing DNRO and stated he did not tell the daughter to get the document from the hospital. He explained nurses were responsible for reviewing physician orders including advance directives on admission and readmission, and in addition, charts were reviewed in the daily interdisciplinary team clinical meeting. The Long Term SSD acknowledged if the hospital transfer form indicated resident #44 had DNR status but there was no attached DNRO form, the facility should have sought clarification from the family, attempted to obtain the form from the hospital, or initiated a new DNRO form in the facility. He explained the Social Services Department conducted quarterly reviews to update residents' code statuses; however, he stated he was recently hired and had only checked that all residents assigned to him had a code status selected, but he had not verified the information was accurate. On [DATE] at 5:14 PM, the Medical Records staff checked resident #44's paper chart and discovered a hospital Palliative Care Division Progress Note dated [DATE] that read, Goals of Care: Stabilization, no further aggressive invasive treatments. CODE STATUS: Full DNR. The Medical Records staff acknowledged the resident's code status was circled by an unknown person for emphasis, but there was no DNRO form in the chart. Review of the facility's Admission Audit checklist revised on [DATE] revealed a chart audit should be conducted within 24 hours for each newly admitted or readmitted resident. This audit included review of the hospital transfer form, hospital discharge summary and history and physical, and advance directives status. On [DATE] at 5:41 PM, the Director of Nursing (DON) stated the charts of all new admissions were reviewed by staff from all departments to ensure pertinent data was complete. The DON said, It is the responsibility of Nursing and Social Services to ensure advance directive information is there and correct. The facility should have called the daughter for verification. She confirmed without the DNRO form, resident #44's code status defaulted to Full Code. On [DATE] at 2:34 PM, the Long Term SSD provided a Care Conference Record that showed meetings held on [DATE] and [DATE] to discuss resident #44's plan of care were attended only by facility staff. The form indicated the daughter who was designated Health Care Proxy did not respond to invitations but there was no documentation of attempts to involve the other daughters who were listed as emergency contacts. The Long Term SSD presented a DNRO form dated [DATE], signed by a physician, that showed verbal consent was obtained from the resident's daughter who was his Health Care Proxy. When asked how the facility obtained the DNRO form, the Long Term SSD explained the facility's Admissions staff contacted the hospital. He said, We got it this morning within about an hour.

Based on interview and record review, the facility failed to implement an effective discharge planning process for discharge to home with Home Health Care services as ordered by the physician for 2 of 3 discharged residents, (#4, #8). Failure to implement an effective discharge plan for Home Health Care (HHC) services resulted in resident #4 and #8 not receiving required therapy services, Home Health Aide (HHA) services and Durable Medical Equipment (DME) to facilitate a smooth and safe transition from the facility to home. As a result, residents #4 and #8 experienced difficulties with daily routine, mobility, and excessive hardship for family members caring for the residents. Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Discharge Return Not Anticipated assessment with reference date 09/16/22 revealed resident #4 required supervision with bed mobility, transfers, walking in room, locomotion on unit, dressing, personal hygiene and physical assistance of one person with locomotion off the unit. Review of resident #4's individualized plan of care documented activity of daily living (ADL) self-care performance deficit related to impaired balance and pain in his right foot. Resident #4's discharge plan initiated on 08/10/22 noted he wished to return home with caregiver after rehabilitation. The intervention included to make arrangements with required community resources to support independence post-discharge. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physical therapy evaluation dated 08/10/22, revealed a treatment plan with goals for safe transfers to standing position, achieve and maintain balance, safe ambulation and safety with ascending and descending stairs. Review of the occupational evaluation dated 08/10/22, revealed a treatment plan with goals for functional activity for daily living tasks (toileting, dressing, bathing, hygiene), activity tolerance, strengthening and balance in order to return to prior level of living. On 10/18/22 at 2 PM, the Therapy Manager stated resident #4 had received PT and OT services which started on 08/09/22 and had ended on 09/15/22. She explained he actively participated in his therapy every day and in the beginning he was non-weight bearing on his right foot due to amputations of several toes. His therapy included transfers, toileting, dressing on the lower foot, setup for ADLs, strengthening of his upper body, and balance on his non-effected foot. The Therapy Manager stated, he needed Home Heath Services, PT and OT upon discharge. Review of the Notice of Medicare Non-Coverage (NOMNC) dated 09/13/22 indicated his Skilled Nursing Facility services ended on 09/15/22. Review of the Discharge Plan and Instructions dated 09/16/22 documented resident #4 will return home with family and Home Health Services. Review of the Social Service progress note on the day of discharge, 09/16/22 at 8:19 PM, showed the Admissions Director communicated with Home Health Care agency representative and agency had not received resident #4's referral for services. The progress note indicated the Home Health Care agency could not provide services as resident #4's insurance was not in the company's network. There was no documentation to indicate the physician was informed the HHC agency could not provide required services for the resident post discharge so changes could be made to the resident's discharge plan. On 10/17/22 at 8:23 PM, 31 days after discharge, the Admissions Director documented she telephoned resident #4 and he explained he had not received home health services and he needed the services. On 10/18/22 at 3:08 PM, the Admission Director documented she had spoken to another Home Health Care agency and they required an order from the resident's PCP in order to provide home health services. On 10/19/22 at 2:00 PM, the Admissions Director stated the Social Services Director who had arranged the home health services for resident #4 was no longer employed at the facility. She explained she called resident #4's PCP on 10/18/22 without success so she called resident #4 to inform him of the need for a physician order. She noted the resident did not have a scheduled appointment with his PCP. On 10/19/22 at 12 PM, during a telephone interview, resident #4 said he had not received any home health services, including PT, OT, Home Health Aide, Skilled Nursing, nor rollator walker since the day he was discharged from the facility. He stated he had left several messages for the SSD at the facility but no one called him back. He said he was told that home health services would start a day or 2 days after he came home but no one came and no one contacted him. He explained it was difficult to care for himself after he came home and his [AGE] year old family member was helping him but it was a hardship. He said, She helps me but then her back starts to hurt. He explained his mobility was very limited and he could not put a shoe on his right foot because of the swelling. I am afraid of getting an infection in my foot so I purchased a knee scooter which keeps my foot off the floor but the scooter cost me $119.00. He explained he had not had a shower since he came home. I really need some help and would like someone to help me to shower safely. On 10/19/22 at 1 PM, a phone interview was conducted with Home Health Care agency representative. She stated they had not received a referral for resident #4 from the facility and even if they had, they did not have a contract with the resident's insurance company to provide services. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS Discharge Return Not Anticipated assessment with reference date 09/26/22 revealed resident #8 required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She needed supervision with eating and she had been independent with walking in room and corridor. She was occasionally incontinent of bladder and frequently incontinent of bowel. Review of resident #8's individualized plan of care documented an ADL self-care performance deficit related to [CONDITION(S)], fatigue, impaired balance, and pain from muscle spasms. The resident had falls on 07/22/22 and on 10/07/22 related to poor balance, history of falls and incontinence. The discharge plan initiated on 07/26/22 noted the resident wished to return home with interventions to make arrangements with required community resources to support independence post-discharge. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge on 09/26/22 with Home Health, Home Health Aide, bedside commode, rolling walker, and PT. Review of the Physical Therapy Evaluation dated 08/30/22 included goals to improve bed mobility, safe transfers, safe ambulation with 2-wheeled walker for independence and to reduce risk for falls. Review of the Occupational Therapy Evaluation dated 08/30/22 showed goals to improve ability and safety with dressing, toileting, and to increase strengthening with upper body strength to improve ADLs. On 10/18/22 at 2:30 PM, the Therapy Manager stated resident #8's husband was her with her most of the time and she received PT/OT/ST services starting on 08/30/22 through 09/26/22. The Therapy Manager explained PT was for bed mobility, transfers, and ambulation, OT was for upper and lower body dressing, toileting, transfers, upper body strengthening and hygiene and ST worked on swallowing. She really needs Home Health Care services, home exercise program, and a rolling walker for ambulation. Review of the Notice of Medicare Non-Coverage (NOMNC) dated 09/23/22 indicated her Skilled Nursing services ended on 09/26/22. Review of the Progress Note dated 09/26/22 at 11:30 AM, documented resident discharged home with medications and belongings. Discharge instructions given to resident and husband and they are aware of need to follow-up with PCP. Review of the Discharge Plan and Instructions dated 09/26/22 at 10:23 AM documented the resident would receive home care services and therapy at home. Review of the Social Service Progress Notes dated 09/26/22 at 4:42 PM, revealed the Admissions Director had spoken to HHC agency representative to follow-up on services. The agency representative explained she spoke to the resident and informed her she needed to see her PCP as the insurance required an authorization from her PCP to start HHA services on October 19, 2022, 23 days after discharge. There was no documentation to indicate the physician were informed the HHC agency could not provide services so changes could be made to the resident's discharge plan. On 10/19/22 at 1 PM, during a telephone interview, the HHC agency representative stated the facility had sent the incorrect information for resident #8. The facility had sent the wrong name of the resident, the same last name but not the right resident. The representative explained they did not have any Home Health Aides to send for resident #8 and they had a difficult time hiring staff. On 10/19/22 at 1:30 PM, during a telephone interview, resident #8's husband explained his wife's PT, OT and nurse had started today, 23 days post discharge. He said that an aide had not been to the house to provide any care for his wife. I have been doing the laundry and I make all the meals but it has been difficult as I have a cardiac problem and I lost my leg in 2013. He explained he had to help his wife wash in the shower and, this is very difficult for me. He added his wife was able to use the toilet but she also wore a brief for incontinence. We never received a rolling walker so she used a walker I used in 2013. PT was in today and they told me the walker was not appropriate for her to use. It has been very hard for me but she is my wife and I am responsible for helping her. The facility told us that we would have Home Health Care services, PT, Home Health Aide and rolling walker when she was discharged home but no one came for weeks. On 10/18/22 at 11:20 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said HHC agency services and DME should be arranged prior to the resident's discharge home. She explained the Social Worker was responsible for the resident's referral to the HHC agency and noted currently, the facility did not have a Social Worker to facilitate and follow up with discharged residents. She said a telephone call should be made to residents two days post discharge to ensure they received the services ordered. The resident should have home health services and DME in place upon or very soon after their discharge home. The DON acknowledged this did not happen for residents #4 and #8. Review of the Facility's Discharge Planning Policy and Procedures, dated 11/30/2014, read, 4. At the time of discharge, a discharge summary and home-going instructions are provided to the resident or the resident's caregiver which will include . Community referrals as needed (e.g., home health. 6. Within twenty-four (24) hours to forty-eight (48) hours (or next day) after discharge to home . a follow-up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided according to discharge plan . 8. Should pre-scheduled services not be provided or arranged, the social worker will make every attempt to coordinate service and follow-up again.

Based on observation, interview, and record review, the facility failed to provide adequate staff supervision and a safe environment to prevent a cognitively impaired, vulnerable resident from exiting the facility unsupervised for 1 of 5 residents reviewed for elopement, of a total sample of 8 residents, (#1). On 7/22/22 at approximately 3:30 PM to 3:45 PM, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised. Resident #1 walked past the receptionist's desk and exited the facility's front doors when they opened automatically. He walked approximately 300 steps to the end of the driveway and then proceeded to walk across a 4 lane heavily trafficked divided highway. The facility was not aware of resident #1's whereabouts for approximately 15 minutes until he was observed by facility staff member, Certified Occupation Therapist Assistant (COTA) A as she was leaving the facility. This failure contributed to resident #'s elopement and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. The facility's failure to provide a safe environment and adequate staff supervision for a vulnerable, cognitively impaired resident contributed to resident #1's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 7/22/22 and was removed on 7/25/22. The facility was in substantial compliance as of 8/3/22. Findings: Resident #1 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic [CONDITION(S)], intestinal obstruction, dementia, muscle weakness and unsteadiness on feet. Metabolic [CONDITION(S)] or toxic metabolic [CONDITION(S)] is a condition in which brain function is disturbed either temporarily or permanently due to (Retrieved on 8/29/2022 from www.MedicineNet.com). The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/14/22 revealed resident #1 ambulated with the assistance of 1 person, used a walker, was at risk for falls and was transferred from the hospital to the facility for therapy services. Review of the nurses Admission/Readmission Data Collection dated 7/14/22 revealed the resident used a walker, and was occasionally incontinent of bladder. Although the resident was cognitively impaired, elopement risk did not trigger as the resident did not have the ability to exit the facility when he was admitted to the facility. Resident #1's baseline care plans dated 7/14/22 included potential problems regarding self-care deficit ADL (activities of daily living) function and altered communication which included interventions to ask simple yes/no questions, allow ample response time and orient/re-orient to surroundings as needed. A care plan was initiated on 7/15/22 for impaired cognitive function or impaired thought process related to impaired decision-making with goal the resident would be able to communicate his basic needs daily and interventions were to cue, reorient and supervise as needed. A psychosocial evaluation dated 7/15/22, indicated resident #1 had hearing and vision limitations, was only oriented to person and his short-term memory was not intact. Review of the medical record revealed resident #1 had physician orders dated 7/14/22 for Occupational (OT) therapy five times a week for four weeks and Physical (PT) therapy orders dated 7/15/22 for five times a week for five weeks included therapeutic exercises, activities, and neuromuscular re-education. The Minimum Data Set (MDS) admission assessment with assessment reference date of 7/19/22 revealed resident #1 was sometimes able to make self-understood and understand others. The assessment indicated he had disorganized thinking and a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated severely impaired cognition. The admission assessment indicated resident #1 required limited assistance of one staff to walk in room and corridor and was only able to stabilize with staff assistance when walking with assistive device. A skilled nurses' note dated 7/20/22, indicated resident #1 was only oriented to person, had vision and hearing limitations, wore glasses, had periods of forgetfulness and his mobility was limited but he was able to walk with a walker. A review of the resident's clinical record noted a Situational Background Assessment Recommendation (SBAR) form dated 7/22/22 that read, the resident was observed by the rehab staff standing at the end of the facility's driveway. The form noted the resident was last observed at approximately 3:30 PM in the dining room watching a movie with a group of residents accompanied by the Activity Staff. The form showed he was brought back to his room by the Executive Director and the resident was assessed with no injuries and the resident's family and physician were notified of the elopement incident. On 8/24/22 at 9:55 AM, the Director of Nursing (DON) and Executive Director (ED) verified they were informed of resident #1's elopement from the facility on 7/22/22 at 3:57 PM by the Rehabilitation Office Coordinator. The ED acknowledged the resident exited the facility on 7/22/22 and said an investigation was initiated upon the residents' return to the facility. They spoke about their timeline of the elopement and reported resident #1 was watching a movie in the facility's main dining room on 7/22/22 at 2 PM and was last seen by the activity staff at approximately 3:35 PM. When the movie ended, activity staff assumed he had returned to his room but the resident had exited the building. He was observed by COTA A at 3:50 PM as she was leaving work for the day and driving out the facility driveway. In a telephone interview on 8/22/22 at 2:25 PM, COTA A stated, I saw resident #1 on 7/22/22 at 3:50 PM when leaving work. I was driving down facility driveway and saw him at end of the driveway by the stop sign. She said she did not identify him as a resident until she started to drive down the road then realized she saw him in therapy that morning. She recalled she made a U-turn and pulled into the convenience store on the corner of the highway and phoned her supervisor. She said she told her supervisor she was 99% sure the man near the highway was one of their residents. She remembered she came out of her car and saw the resident had already crossed 2 lanes of traffic to the median directly across from where she saw him at the stop sign. She indicated the resident stopped in the median, looked both ways prior to crossing the other 2 lanes to the other side of the road. COTA A explained she ran down the sidewalk toward resident #1 and upon approaching him, checked his wrist band and confirmed he was a resident. She reported her supervisor called her back and verified the resident was missing from the facility. She stated the resident told her he had just watched a movie and was going to his son's house. COTA A then assisted him across the 4-lane divided highway toward the facility. She recalled the resident was fully dressed, wore a face mask and looked like any other person on the street. She recounted the ED met them with a wheelchair in the facility's driveway. On 8/22/22 at 4:09 PM, the Rehabilitation Office Coordinator said, COTA A called her between 3:50 PM and 3:55 PM on 7/22/22 and told her, there was a man walking down the street and I think I saw him in the therapy department this morning. She said by the time she called COTA A back, she confirmed his arm bracelet identified he was from the facility. The ROC indicated she ran out to meet them at the end of the facility driveway and the resident was obviously confused stating he wanted to see his family. The Rehabilitation Office Coordinator reported the highway in front of the facility was heavily trafficked and very dangerous to cross. On 8/23/22 at 3:07 PM, a telephone interview was conducted with the receptionist who no longer worked at the facility. She stated, I did not get any training, they threw me into that position. I was only told to answer the phone and transfer calls to the nurses' stations or overhead page the person. When asked how resident #1 was able to walk past the reception desk and exit the facility on 7/22/22, she said she saw him walking out the door at 2:45 PM when she returned from lunch. She then contradicted herself and stated, the ED asked me to write a statement and I did not feel comfortable because I did not see anything and did not see resident walk out the door. She said she was sent home that day and on 7/26/22, she was informed she was no longer employed as she let a resident get out of the building. On 8/23/22 at 4:05 PM, the Business Office Manager recalled the receptionist had just moved from working in activities to the reception desk. She said the receptionist was provided with training which consisted of use of phones and screening visitors. She said she felt comfortable with the receptionist's knowledge of the proper procedures, and the receptionist never indicated unfamiliarity with the job. On 8/22/22 at 4:38 PM, Activities Assistant C stated on Friday, 7/22/22 at 2 PM, there were approximately 10-15 residents that participated in movie activity in the main dining room. She said she did not know resident #1 well as he was new but recalled he sat against the wall near the kitchen. She noted the movie finished between 3:30 to 3:45 PM and resident #1 left sometime when she brought other residents back to their rooms. I honestly do not know if he needed assistance to go back to his room and was not sure if he came on his own or if the other Activities Assistant invited him. The Activity Director was present at the time of interview and indicated another Activities Assistant (M) invited resident #1 to the movie and one of the Certified Nursing Assistants (CNA)s brought him to the activity. The Activity Director stated, it would have been the responsibility of the activity staff to bring residents back to their unit/rooms after the activity finished. She noted that having a crowd of people at the activity would have added to residents' confusion and it was important for activity staff to ensure residents returned to their rooms safely. A review of the facility's investigation did not show any witness statements for Activities Assistant M and the Activity Director indicated she was not available for interview. On 8/23/22 at 2:30 PM, Licensed Practical Nurse (LPN) H said he worked for an agency and was assigned to resident #1 for the first time on 7/22/22 day shift, from 7 AM to 3 PM. He recalled activities staff came to get the resident for the 2 PM movie. He said he did not know the activity staff person's name. On 7/22/22 at 11 AM the 3-11 PM, Registered Nurse (RN) E verified she was familiar with resident #1 and had him regularly on her assignment. RN E said he was a confused, quiet, and gentle person. He was bedbound initially and then he began to get out of bed and walk about. She stated he could voice his needs in short sentences and would let staff know if he needed to go to the bathroom. At the beginning of her shift on 7/22/22, after getting report, she did not see the resident in his room, the day room or therapy area. She recalled she told the CNA and they went together and saw him in the dining room watching a movie. She remembered he sat near the kitchen and there were quite a few other residents at the movie as well as activity staff. RN E explained later in her shift, the ED brought the resident back to the floor and informed her the resident had eloped. She said she assessed the resident and he was transferred to the facility's secure unit. The RN reported, it would not be safe for this resident to be outside by himself as he is confused and could get lost, or anything could happen to him. On 8/23/22 at 10:38 AM, CNA D who worked the 3 PM-11 PM shift on 7/22/22 said this was her first time resident #1 was assigned to her. She verbalized the resident was confused and needed frequent checks. She explained at the start of her shift, he was not in his room. She said she looked for him in the bathroom, patio and then found the resident watching a movie in the dining room sitting near the back wall by the kitchen at 3:30 PM. She recalled she checked on him 2 more times while he was watching the movie and later heard he was wandering outside. When he came back to his room, he was confused, and the nurse checked him from head to toe. On 8/23/22 at 2:52 PM, CNA I said she worked for an agency. She indicated familiarity with the resident as she was assigned to his care 3 to 4 times. The CNA recalled on 7/22/22, the activity staff came and brought resident #1 to the movie in the dining room. CNA I stated, he would not be safe outside by himself due to traffic and construction site next to the facility. On 8/23/22 at 12:53 PM, the Social Services Director (SSD) said she saw resident #1 on 7/15/22 and had a brief conversation with him. The SSD conveyed, with a BIMS of 5 he would be safe in the facility courtyard with supervision, but he required supervision if outside the building. Because of his cognitive deficits, anything could happen outside, he could potentially get lost, hit by a car, or fall. On 8/23/22 at 2:04 PM, COTA F explained initially the resident was in a wheelchair and progressed to not needing assistive devices. She said he could get up on his own from a chair with assistance of arm rests. She did a therapy session with resident #1 on 7/21/22 and noted he needed cuing due to confusion. She added he required supervision if outside for safety so he wouldn't get hurt. She said although he needed stand by assistance during therapy on 7/21/22 and 7/22/22, he did not walk like a normal person, he walked side to side. She stated she had to stay right next to him to support and steady him to help prevent a fall. On 8/22/22 at 3:30 PM, residents #1's probable elopement route was retraced. The resident walked approximately 50 steps from the main dining room toward the hall through the double doors to the lobby. He would have then walked past the reception desk and out the automated double sliding glass doors. From there he headed approximately 300 steps on the facility's driveway to the stop sign. Resident #1 then crossed the 4 lane divided highway with grassy median to the North/ hospital side of road. The heavily trafficked and continuously noisy road was observed noted by the surveyors as unsafe to cross at the location resident #1 crossed. Resident #1's approximate 0.1-to-0.2-mile trek from the facility to the other side of the 4 lane busy divided highway showed he passed hazards such as curbs ranging from 6 to 8 inches, and construction site to the East side of the facility's driveway. The ED verified the area was not safe and was frequented by homeless persons. On 8/22/22 at 4:27 PM, Physical Therapy Assistant B said he was working with resident #1 on strengthening, walking, balance, and transfers. Initially he was in bed, and we worked on walking around his room from 20 feet then progressed to 75 feet in with stand by contact guard for safety just prior to his elopement on 7/22/22. The Physical Therapy Assistant explained the resident was confused and it was not safe for him to be outside unsupervised. He added it was dangerous for him to cross the road even if he had crossed at the cross walk. The Physical Therapy Assistant stated, no one would be safe to cross the road in front of facility and no resident would be safe to cross at any point unsupervised. He verified the construction site adjacent to the facility posed safety hazard for resident #1. On 8/23/22 at 10:15 AM, a telephone interview with resident #1's son verified he was informed by the facility of the elopement incident on 7/22/22. I was not thrilled about it and glad they found him, and he was back quick. He stated his dad would not be safe walking outside the building by himself and said they did not allow him to do this when he was at home. On 8/24/22 from 9:55 AM to 11 AM, the elopement incident was reviewed with the Executive Director and DON. The ED confirmed he was notified by Rehabilitation Office Coordinator at 3:57 PM on 7/22/22, that resident #1 was missing from the facility. He said once the resident was found, he immediately took a wheelchair and met the resident and COTA A on the driveway. The ED recalled the resident told them, the movie was over, so I'm going home. He said the resident was fully dressed and wore a face mask. Once we got him back into the facility, we brought him to RN E who did a head to toe assessment and vital signs. The DON added, the staff stayed with him until he was transferred to the facility's secure memory care unit. The ED explained they immediately started their investigation and identified the root cause was the front lobby doors opened automatically as did the doors leading from the lobby into the hallway. They also identified the receptionist's story was inconsistent as she had left her post to get snack and hot water without ensuring coverage. The policy is that staff do not leave their post without getting coverage. In a telephone interview on 8/24/22 at 4:14 PM, the Medical Director stated she was informed of resident #1's elopement on 7/22/22. She explained that sometimes with dementia, residents can become disoriented and often want to go home wherever that may be. She said she felt worried about resident #1's safety when he got out of the facility as we are close to the highway, and he could get lost and not find his way back. The missing/patient/resident Policy and Procedure (P&P) revised 8/1/20 read, An elopement occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury The Receptionist Competency signed by reception staff G on 7/21/22 read, It is the responsibility of the staff member at the front desk to monitor all resident activity .Residents that come to the lobby get priority attention over visitors and phone calls until all residents are safe and then they can resume call or discussion with visitors Review of the facility assessment updated 5/2/2022 read, the facility could meet the needs for residents with neurological system diagnosis including dementia .Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as .care of someone with cognitive impairment .identify hazards and risk for residents Review of immediate actions implemented by the facility to remove the Immediate Jeopardy revealed the following, which were verified by the survey team: * On 7/22/22, resident #1 was safely brought back inside the facility, assigned nurse assessed resident for any injuries or signs and symptoms of distress, he was place on 1:1 supervision until transferred to secure unit. A wander guard device was placed on the resident and the resident was started on 15 minute safety checks for 24 hours. Family and attending physician were notified of the elopement and the resident's plan of care was updated to reflect the new interventions and orders. The resident remained on the secure unit until he was discharged to home with family on 7/27/22. * On 7/22/22, the facility completed a facility wide head count to ensure all residents were accounted for and safe, completed a new elopement assessment on current residents in the facility to ensure they did not have a change in risk since their last assessment, audited the elopement books in the facility to ensure all residents that were at risk for elopement were included in all books. * On 7/22/22, the Maintenance Director completed a system check on all exit doors to ensure locks and alarms were working correctly. * On 7/22/22 MDS Coordinator completed comprehensive audit to ensure care plans for residents at risk for elopement had appropriate interventions. * On 7/22/22, the Maintenance Director and/or designee locked the front lobby door to the facility and turned off the automatic opening function to the door, so it was secure and required facility staff to manually open or close the lobby door for entry or exit. * On 7/22/22, a facility employee was placed at the front entrance door to unlock the doors when an authorized person (staff or visitor) required entrance or exit from facility. * On 7/22/22, the facility conducted an ad hoc QAPI (Quality Assurance Performance Improvement) meeting with the management staff including the Administrator, the Director of Nursing, and the Medical Director to review the facility's events and discuss the plan of correction. The following measures were put in place: * From 7/22/22 through 7/27/22, the Director of Nursing, Administrator and/or designee educated current staff in the facility on the elopement policies and procedures with a post competency test, until 100% of facility staff were educated with a posttest competency. * From 7/22/22 through 7/27/22, the Administrator and or designee completed elopement drills with education daily on each shift with facility staff. * On 7/23/22 an outside vendor checked all exit doors for function and completed an assessment of entrance doors and developed a plan to secure the front door and doors leading to lobby. * On 7/27/22 an outside vendor installed a new keypad lock system to the front entrance doors along with a keypad lock system to the lobby doors, at this point no one can enter or exit the facility without a staff member entering the security code to unlock these doors. * The Director of Nursing and/or designee will assess residents on admission and/or re-admission, then 7 days after admission/readmission, quarterly, significant change for exit seeking behavior for elopement risk. * The Maintenance Director and/or designee audit/check all facility exit doors for function and security every day. * Any newly hired employees or any agency staff new to the facility is educated on the facility's elopement policies and procedures with a post-test competency before they will be able to work in the facility. The facility's further corrective actions after the Immediate Jeopardy removal included the following: * From 7/22/22 and 7/25/22, the facility reviewed the plan of correction in an ad hoc QAPI meeting that included the Administrator, the Director of Nursing, Medical Director, and other facility management staff. * The Director of Nursing and/or designee will audit daily five times a week to ensure new admissions and/or re-admissions will be assessed for risk of elopement. * The Director of Nursing and/or designee will audit five times a week that residents are re-assessed for elopement risk 7 days after admission/readmission, quarterly, significant change or after an exit seeking event. * The Maintenance Director and/or designee will audit the exit doors daily to ensure that they are locked and functioning. * Visitor will receive a bright green visitor badge upon entrance to the facility so that staff have a visual reminder who is a visitor. * Residents that leave the facility on a leave of absence will sign out on the LOA form at the nurse's station and receive a LOA pass that will be presented to the receptionist prior to leaving the facility. The LOA pass will be secured front desk area until the resident returns. Interviews conducted by survey team from 8/22/23 to 8/26/22 with 25 staff members representing all shifts included 3 Certified Nursing Assistants, 4 Licensed Practical Nurses, 3 Registered Nurse, 3 Therapy staff, 4 House Keeping/Laundry, 2 Dietary, and 2 Activities, 3 business Office/Reception, and 1 Maintenance indicated they were knowledgeable of the elopement policy and procedures, door security, alarm procedures and the visitation processes. The surveyors validated the education with attendance sheets for elopement drills and in-services. Review of QAPI audits revealed daily door monitoring was conducted per performance improvement plan. The sample was expanded to include 4 additional residents who were at risk for elopement. Observations, interviews, and/or record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #2, #3, #4, and #5. The survey team determined based on the facility's corrective actions; the facility was in substantial compliance on 8/3/23.

Based on interview and record review, the facility failed to permit a resident under bed hold to return to the facility after a hospitalization for 1 of 3 residents reviewed for discharge out of a total sample of 8 residents, (#20). Due to resident #20's dementia, the reasonable person concept would be applied to determine the psychosocial outcome severity in this situation, since the resident was not able to express his feelings. A reasonable person would have been very angry and depressed as a result of not being allowed to return to the nursing home, which was considered his home for the past few years. The facility made the decision to not allow the resident to return to his home without his knowledge and consent, and because the facility chose to not provide the necessary care and services for a resident with dementia, which is the type of care the facility was able to provide according to their facility assessment. Findings: Cross reference to F582, F623 Resident #20 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of 5/10/22 revealed resident #20 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making. The document indicated no active discharge plan in place for resident #20 to return to the community. The MDS discharge assessment dated [DATE] indicated the resident was expected to return to the facility. Review of resident #20's electronic medical record revealed a Change of Condition form dated 7/05/22 which indicated resident #20 was a long-term resident and was sent to the emergency room (ER) 7/05/22 due to altered mental status (AMS). The Nursing Home Transfer and Discharge Notice dated 7/05/22 was scanned into the electronic medical record as well as the Bed Hold Authorization which showed the guardian had consented to holding a bed. Review of the Order Summary Report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #20's care plans revealed a care plan for physically aggressive behavior initiated 10/01/18 which recorded an altercation with another resident on 3/25/19 and 5/31/22. Interventions included initiation of one-to-one monitoring which was still in effect when the resident went to the hospital 7/05/22. A care plan for wandering and risk of elopement was initiated 12/13/18. Interventions included placement of electronic monitoring device. Review of resident's census line revealed he was placed on the secured memory care unit 1/01/2019. A discharge care plan initiated 10/12/18 indicated resident wished to remain at the facility under long-term care. In a phone interview on 8/22/23 at 5:45 PM, resident #20's guardian stated he was admitted to the facility in 2018 and was to remain long-term care. She explained resident #20 was sent to the hospital on 7/05/22. She recalled the hospital care manager notified her the facility refused to re-admit him. She reported he was still in the hospital. Resident #20's guardian stated she attended care plan conferences and was never informed there was a problem. She conveyed she attempted to reach out to the facility, but no one had called her back. On 8/23/22 at 12:07 PM, the Social Services Director (SSD) reviewed resident #20's medical record and reported he was admitted to the facility in September 2018. She explained he was on the secured unit and the plan was to remain long-term care. The SSD stated resident #20 went to the hospital and she did not know why he had not returned. She verbalized he could return to the secured unit as long as he was appropriate for the unit. She clarified a resident was appropriate for the unit if they had a risk for elopement. She acknowledged resident #20 was considered to be at risk for elopement and was on the secured unit prior to his hospitalization . On 8/23/22 at 1:23 PM, the Business Office Manager (BOM) reviewed resident #20's financial records and stated he had Medicaid as the primary payor source when he went to the hospital on 7/05/22. She confirmed he was a long-term resident in the facility and was expected to return. On 08/24/22 at approximately 12:15 PM, the hospital Director of Care Management stated resident #20 was admitted to the hospital on 7/05/22. She reported care management had contacted the facility by electronic communication on 7/11/22, 7/15/22, 7/16/22, 7/17/22 and 7/18/22 regarding readmission of resident #20 to the facility. She explained the facility had initially denied admission on 7/11/22 and again on 7/21/22 in the electronic communication system. She stated the hospital Care Manager contacted the facility by phone on 7/14/22 and spoke to the previous Admission Director who stated the facility could not accept the resident back. The hospital Director of Care Management recalled she also placed a call to the facility on [DATE] and spoke to the previous Admission Director. She reported the previous Admission Director informed her she spoke to the Administrator and Director of Nursing and the facility would not be readmitting resident #20. A review of the electronic communication between the hospital and facility revealed on 7/11/22, the hospital's care management sent a message to the facility to notify them resident #20 was ready for discharge. On 7/11/22 the facility's previous Admission Director replied that resident #20 was on one-to-one supervision at the facility prior to hospitalization and the facility could not meet his needs. On 7/15/22, the hospital's care management sent a message asking if resident #20 was welcome back as the hospital understood he was a long-term care resident at the facility. On 7/16/22, the hospital's care management sent a message which stated they had an active discharge order and inquired if the facility was willing to accept resident #20. On 7/17/22, the hospital care management sent another message asking if the facility was able to accept resident #20. On 7/18/22, the hospital care management inquired if there was an update on accepting resident #20 back to the facility. On 7/21/22, the facility's Admission Coordinator declined the referral and responded the resident did not meet the criteria for re-admission and required a behavioral unit. On 8/24/22 at 1:15 PM, the Regional Director of Business Development reviewed the electronic communication between the hospital and the facility. She acknowledged on 7/11/22, the previous Admission Director denied readmission for resident #20 and on 7/21/22 the Admission Coordinator denied readmission for resident #20. On 8/24/22 at 1:35 PM, the Director of Nursing stated she had not received a hospital referral for resident #20. She denied having any conversation with admissions about resident #20 or his return to the facility. She explained she was unaware of any communication between admissions and the hospital. On 8/24/22 at approximately 2:20 PM, the Administrator stated he did not recall a hospital referral for resident #20 and was unaware he was still in the hospital. He explained he assumed the resident had gone to another facility. The Administrator denied having a conversation with admissions or the Ombudsman regarding resident #20. He verbalized the Ombudsman may have spoken with admissions about the resident and just did not share it with him. In a phone interview on 8/25/22 at 8:09 AM, the Long-Term Care (LTC) Ombudsman stated resident #20's guardian informed him the facility had refused to accept the resident back into the facility. The LTC Ombudsman recalled he spoke with the facility Administrator by phone on 7/22/22 at 9:05 AM and the Administrator informed him the facility would not be taking the resident back as he was too violent and was on one-to-one supervision. The LTC Ombudsman conveyed he tried to explain the appropriate process for issuing a discharge notice but the administrator remained adamant he was not taking the resident back. Review of resident #20's medical record revealed no documentation for the resident not returning to the facility. There was no documentation to reflect any discussions between facility staff and the resident's guardian regarding the facility's inability to meet the needs of the resident or the facility's inability to re-admit the resident. The facility was unable to provide a physician's note to validate the facility could not provide the care and services necessary to meet resident #20's needs according to his plan of care. The facility was also unable to provide evidence that a 30-day discharge notice was provided to the resident or resident's representative at the time the facility denied readmission or the resident's right to appeal. Review of the facility assessment updated 5/2/2022 read, the facility could meet the needs for residents with neurological system diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as .care of someone with cognitive impairment .identify hazards and risk for residents

Based on interview and record review the facility failed to ensure nursing staff had appropriate competencies and skill sets to prevent significant medication errors for 1 of 3 residents who received [MEDICATION(S)] patch, (#1). On [DATE] at 1:41 PM, and 1:42 PM, the resident received 100 micrograms (MCG) of [MEDICATION(S)] instead of 50 MCG, double the prescribed dose. On [DATE] at approximately 12:00 PM, the resident fell from his wheelchair, and sustained a head injury with a laceration to his forehead. The resident was unresponsive with fixed pupils. He was transferred to the Emergency Department (ED) where two patches of [MEDICATION(S)] were noted on his chest. The patches were removed and [MEDICATION(S)] was administered to revive the resident. [MEDICATION(S)] is a powerful synthetic opioid that is similar to [MEDICATION(S)] but is 50 to 100 times more potent .it is typically used to treat patients with severe pain or to manage pain after surgery. (Retrieved from https://www.drugabuse.gov/drug-topics/[MEDICATION(S)], the National Institutes of Health, National Institute on Drug website, on [DATE]). [MEDICATION(S)] is a medication used to treat known or suspected opioid overdose. Serious overdose symptoms may include unusual sleepiness .or breathing problems (ranging from slow/shallow breathing to no breathing.) (Retrieved from WebMDwebsite, https://www.webmd.com/drugs/2/drug- 4/[MEDICATION(S)]-nasal/details on [DATE]). The facility's failure to ensure nursing staff had appropriate competencies and skill sets to prevent significant medication error resulted in Immediate Jeopardy starting on [DATE]. There was likelihood the resident could have suffered more serious injury and/or died when he became confused, had difficulty breathing, became unresponsive and fell from his wheelchair after he received double the prescribed dose of [MEDICATION(S)]. The Immediate Jeopardy was removed on [DATE] after validation of the implementation of the facility's removal plan and the scope and severity of F726 was reduced to a D. Findings: Cross Reference F760 Resident #1 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 received a double dose of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received two patches of 50 MCG/HR, a total dose of 100 MCG/HR instead of one patch of 50 MCG/HR as ordered by the physician. Review of the Change in Condition form dated [DATE] at 2:13 PM, indicated resident #1 fell . Documentation revealed the resident became non coherent, non-responsive, pupils fixed. He had increased confusion or disorientation was unresponsive had labored or rapid breathing and irregular pulse. Documentation read, Called 911 for pick up due to low oxygen of 77 and pulse 128. The ED Physician Sheet dated [DATE] at 1:14 PM read, Patient was noted to have multiple [MEDICATION(S)] patches on his body that may be contributing to his decreasing respiratory status. Once removed and administered [MEDICATION(S)] patient returned to baseline mental status .However .has unknown amount of [MEDICATION(S)] in his system. The resident's history and physical (H&P) dated [DATE] revealed the resident's chief complaint was fall. The document read, fell out of his chair, hitting his forehead on the floor The nurse told me that he had 2 [MEDICATION(S)] patches on. He is supposed to have 1 on, and that his pupils were pinpoint when he came in. On [DATE] at 2:05 PM, an interview was conducted with the Administrator, Assistant Administrator, and the Director of Nursing (DON). The DON explained on review of additional Controlled Medication Utilization forms, he discovered that on [DATE], two doses of [MEDICATION(S)] 50 MCG/HR were retrieved and given to resident #1. He stated he called LPN A, and she explained that she was confused by the electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He explained LPN A said she applied [MEDICATION(S)] 50 MCG/HR to the resident's left arm, and another patch to his right arm. Review of the email statement provided by LPN A dated [DATE] at 1:27 PM revealed she cared for resident #1 on [DATE] and [DATE]. Documentation read, On [DATE] .He did ask for his [MEDICATION(S)] patch. I went and saw that he gets 2. So applied them. On [DATE] at 2:18 PM, in a telephone interview, LPN A stated on [DATE] when she reviewed resident #1's orders in preparation for medication administration, she saw 2 orders for [MEDICATION(S)] 50 MCG/HR. LPN A explained she retrieved 2 [MEDICATION(S)] patches from the narcotic drawer and applied 1 patch to the resident's left chest and applied a second patch to his right chest. LPN A stated she did not clarify the orders with another nurse or the physician, because she thought she did the right thing, and the resident was rushing her. LPN A verbalized she worked with the resident again on [DATE]. She recalled the resident was awake, alert, and oriented, and she administered his scheduled medications, along with PRN Oxycodone 15 mg. LPN A recalled the resident was quiet after medication administration, and she observed him leaning forward in his wheelchair. LPN A stated approximately 2 hours after medication administration she went to check on the resident and found him on the floor, face down, bleeding from his head. LPN A remembered the resident was foggy. She said she obtained orders from the physician for the resident to be transferred to the ED for evaluation and treatment. On [DATE] at 4:25 PM, the DON explained the facility assessed nursing staff competencies during orientation and the onboarding process. He provided a blank Section C Skills Competency Assessments for Nurse staff used by the facility. He said a completed skills competency assessment should be in LPN A's personnel file, but he was not able to locate it. The DON confirmed the form was misplaced or was not completed. He said LPN A participated in general orientation and onboarding which included the topic of Medication Management. Review of LPN A's Roadmap Onboarding Action items checklist dated ,d+[DATE]-,d+[DATE] showed she had completed day one, and day two activities. Day 3 of orientation noted Topics to be educated on required tell, show, do, practice, review and competency. The competency assessment for medication administration was not checked to show this competency skill was completed by LPN A. In an interview conducted with the DON on [DATE] at 2:02 PM, he stated competency assessments were conducted in the first week of education during orientation. He explained new nurses were paired with another nurse for 1 week. He explained the Consultant Pharmacist did monthly medication administration observations for competency and was asked to observe newly hired nurses. He recalled LPN A worked only on the weekends and was not observed by the Consultant Pharmacist for competency check as he conducted visits on the weekdays. The DON stated clarification of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the facility did not have a written policy and procedure regarding clarification of orders. He stated the expectation was if nurses were unsure or confused about a particular order, they should stop and ask. On [DATE] at 5:35 PM, a second telephone interview was conducted with LPN A. She remembered she was confused when she reviewed the resident's medications on the computer screen. She explained that all the resident's medications were listed, and on the right of the screen she saw the [MEDICATION(S)] order and saw the exact same order beneath the first one. LPN A stated she did not pay much attention to the small print on the MAR, she saw [MEDICATION(S)] twice and could not say why she did not think to check/clarify the order. LPN A stated she had been a nurse for five months, and [DATE] was the first time she applied a [MEDICATION(S)] patch. She explained that in nursing school she was trained to wear gloves to apply patches, but she could not recall any further education on [MEDICATION(S)]. She said she was not familiar with the medication but researched it after the incident. She stated she should have known about the medication as [MEDICATION(S)] overdoses had been on the news recently. LPN A noted she could have asked another nurse for clarification of the resident's order, but did not, because she thought it was what the physician ordered, and it was the resident's normal dose. LPN A explained she had a weeklong orientation when she started working at the facility. She recalled the first day was orientation to the facility, then she was paired with a nurse for four days and worked independently on the fifth day. On [DATE] at 10:35 AM, the DON stated LPN A had completed facility orientation. He explained the second day of orientation included education of the facility's Electronic Medical Record, how to document the MAR, alerts from pharmacy, and medication interactions. He added the new nurse was paired with another nurse on the third day to observe medication administration, including patches, the seven rights of medication administration, and how to read orders. The DON explained competencies continued on day four, and once checked for competencies the new nurse was assigned a resident with observation by a mentor. He stated LPN A received two weeks of orientation, but failed to follow protocols related to reading, verifying, comparing, and asking. He verbalized LPN A did not utilize her available support system. The facility's policy Administering Medications revised [DATE] read, If a dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The Job description for Clinical Nurse (LPN) indicated the LPN was, Responsible for providing direct resident care in accordance with established plans. The duties and responsibilities included, Perform routine nursing services for residents as directed. The following immediate measures implemented by the facility to remove Immediate Jeopardy were verified by the survey team: * [DATE] resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No issues identified *[DATE] current residents with orders for pain patches, to include [MEDICATION(S)] were reviewed by the DON to ensure orders were written correctly and without ambiguity. Any issues identified were reviewed with the physician and corrected at that time. * [DATE] LPN A was removed from the staffing schedule and suspended pending investigation. * [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the plan and the results of the facility wide reviews. The Medical Director reviewed and approved the plan. The Ad Hoc QAPI Committee approved the recommendations. * [DATE] a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis as determined by the QAPI committee. *[DATE] facility nursing administration, including the DON began education of Licensed Nurses and Contract Agency Nurses regarding following physician orders, policy for administration of transdermal medication and process to address orders with ambiguity. Education validated with med pass competency. Currently 11 out of 38 licensed nursing staff had competency reviewed. Certified letters were sent out to staff members that were unable to obtain the education and competency. Staff will be required to complete in-servicing with competency prior to working their next shift. * Newly hired staff will receive education and competency verified in orientation regarding following physician orders, policy for administration of transdermal medication and process to address orders with ambiguity. * Newly written physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] * The QAPI Committee will hold weekly meetings to review and discuss the results of the ongoing quality monitoring to include competencies. The findings will be reported to the QAPI Committee weekly. The review schedule will be modified based on findings and recommendations of the committee. Interviews conducted with staff including 6 Registered Nurses (RN), 7 LPNs on [DATE] between 11:22 AM to 4:40 PM, and on [DATE] between 12:47 PM and 1:00 PM, revealed the facility had provided education on following physician orders, policy for administration of transdermal medication, and process to address orders with ambiguity.

Based on interview and record review the facility failed to ensure a [MEDICATION(S)] patch was administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:41 PM, and 1:42 PM, the resident received 100 micrograms (MCG) of [MEDICATION(S)] instead of 50 MCG, double the prescribed dose. On [DATE] at approximately 12:00 PM, the resident fell from his wheelchair, and sustained a head injury with a laceration to his forehead. The resident was unresponsive with fixed pupils. He was transferred to the Emergency Department (ED) where two patches of [MEDICATION(S)] were noted on his chest. The patches were removed and [MEDICATION(S)] was administered to revive the resident. [MEDICATION(S)] is a powerful synthetic opioid that is similar to [MEDICATION(S)] but is 50 to 100 times more potent .it is typically used to treat patients with severe pain or to manage pain after surgery. (Retrieved from https://www.drugabuse.gov/drug-topics/[MEDICATION(S)], the National Institutes of Health, National Institute on Drug website, on [DATE]). [MEDICATION(S)] is a medication used to treat known or suspected opioid overdose. Serious overdose symptoms may include unusual sleepiness .or breathing problems (ranging from slow/shallow breathing to no breathing.). (Retrieved from WebMDwebsite, https://www.webmd.com/drugs/2/drug- 4/[MEDICATION(S)]-nasal/details on [DATE]). The facility's failure to prevent a significant medication error resulted in Immediate Jeopardy starting on [DATE]. There was likelihood the resident could have suffered more serious injury and/or death when he became confused, had difficulty breathing, became unresponsive and fell from his wheelchair after he received double the prescribed dose of [MEDICATION(S)]. The Immediate Jeopardy was removed on [DATE] after validation of the implementation of the facility's removal plan and the scope and severity was reduced to a D. Findings: Cross Reference F726 Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment with Assessment Reference Date of [DATE], revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE]. The assessment revealed the resident received scheduled and as needed (PRN) opioid pain medications in all 7 days of the look back assessment period. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 received a double dose of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received two patches of 50 MCG/HR, a total dose of 100 MCG/HR instead of one patch of 50 MCG/HR as ordered by the physician. Review of the Change in Condition form dated [DATE] at 2:13 PM, indicated resident #1 fell . Documentation revealed the resident became non coherent, non-responsive, pupils fixed. He had increased confusion or disorientation was unresponsive had labored or rapid breathing and irregular pulse. Documentation read, Called 911 for pick up due to low oxygen of 77 and pulse 128. The ED Physician Sheet dated [DATE] at 1:14 PM read, Patient was noted to have multiple [MEDICATION(S)] patches on his body that may be contributing to his decreasing respiratory status. Once removed and administered [MEDICATION(S)] patient returned to baseline mental status .However .has unknown amount of [MEDICATION(S)] in his system. The resident's history and physical (H&P) dated [DATE] revealed the resident's chief complaint was fall. The document read, fell out of his chair, hitting his forehead on the floor The nurse told me that he had 2 [MEDICATION(S)] patches on. He is supposed to have 1 on, and that his pupils were pinpoint when he came in. On [DATE] at 2:50 PM, the Director of Nursing (DON) said the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He recalled that when he reviewed the hospital's H&P, he noted documentation of two [MEDICATION(S)] patches on the resident's body. He said he reviewed the resident's orders and spoke to Licensed Practical Nurse (LPN) A who administered the medication on [DATE] and transferred the resident to the hospital on [DATE]. The DON stated LPN A said she had no recollection of noticing two [MEDICATION(S)] patches on the resident. The DON verbalized he reviewed the resident's Controlled Medication Utilization Record, and only one patch was administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated no further investigation was done. On [DATE] at 2:05 PM, an interview was conducted with the Administrator, Assistant Administrator, and the DON. The DON explained on review of additional Controlled Medication Utilization forms, he discovered that on [DATE], two doses of [MEDICATION(S)] 50 MCG/HR were retrieved and given to resident #1. He stated he called LPN A, and she explained that she was confused by the electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He explained LPN A said she applied [MEDICATION(S)] 50 MCG/HR to the resident's left arm, and another patch to his right arm. Review of the resident's Controlled Medication Utilization Record revealed 5 patches of [MEDICATION(S)] 50 MCG/HR were obtained from the pharmacy on [DATE]. On [DATE] at 1:41 PM 2 doses of [MEDICATION(S)] 50 MCG/HR were retrieved and administered to resident #1, leaving a balance of 3 patches. Review of the Medication Admin Audit Report revealed 2 doses of [MEDICATION(S)] 50 MCG/HR were applied transdermally on [DATE] at 1:41 PM and 1:42 PM. This was confirmed by the DON. Review of the email statement provided by LPN A dated [DATE] at 1:27 PM revealed she cared for resident #1 on [DATE] and [DATE]. Documentation read, On [DATE] .He did ask for his [MEDICATION(S)] patch. I went and saw that he gets 2. So applied them. On [DATE] at 2:18 PM, in a telephone interview, LPN A stated on [DATE] when she reviewed resident #1's orders in preparation for medication administration, she saw 2 orders for [MEDICATION(S)] 50 MCG/HR. LPN A explained she retrieved 2 [MEDICATION(S)] patches from the narcotic drawer and applied 1 patch to the resident's left chest above his nipple and applied a second patch to his right chest above his nipple. LPN A stated she did not clarify the orders with another nurse or the physician, because she thought she did the right thing, and the resident was rushing her. LPN A verbalized she worked with the resident again on [DATE]. She recalled the resident was awake, alert, and oriented, and she administered his scheduled medications, along with PRN Oxycodone 15 mg. LPN A recalled the resident was quiet after medication administration, and she observed him leaning forward in his wheelchair. She offered to assist him back to bed, but the resident said he wanted to remain in his wheelchair. LPN A stated approximately 2 hours after medication administration she went to check on the resident and found him on the floor, face down, bleeding from his head. LPN A remembered the resident was foggy. She said she obtained orders from the physician for the resident to be transferred to the ED for evaluation and treatment. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 received Oxycodone 15 mg tablet on [DATE] at 5:08 AM, 1:32 PM, and at 7:30 PM. On [DATE] he received Oxycodone 15 mg at 5:08 AM and 9:12 AM. On [DATE] at 1:40 PM, the Advanced Practice Registered Nurse (APRN) recalled when resident #1 was initially admitted to the facility he was on Oxycodone tablets every 6 hours. She changed the frequency to every 4 hours PRN and increased his [MEDICATION(S)] patch from 25 MCG to 50 MCG every 72 hours The APRN said if the resident received more medication than was ordered, it would make him more lethargic, confused, and could contribute to a fall. She said if an order was ambiguous, the expectation was that staff would call her for clarification of the order, prior to administration of the medication. On [DATE] at 5:35 PM, a second telephone interview was conducted with LPN A. The LPN explained she was confused when she reviewed the resident's medications on the computer screen. She explained that all the resident's medications were listed, and on the right of the screen she saw the [MEDICATION(S)] order and saw a similar order beneath the first order. LPN A stated she did not pay much attention to the small print on the MAR, she saw [MEDICATION(S)] twice and did not know why she did not think to check/clarify the order. The LPN said she felt the physician ordered the medication twice. She recalled that when the resident fell on [DATE], she did not link his fall was related to the [MEDICATION(S)] patches but attributed the resident passing out and fall to his Oxycodone medication. She stated she should have known about the medication as [MEDICATION(S)] overdoses had been on the news recently. LPN A stated she had been a nurse for five months, and [DATE] was the first time she applied a [MEDICATION(S)] patch. She did not realize she had administered a large dose of [MEDICATION(S)]. LPN A verbalized she did not ask for clarification of the medication prior to administration. She said she thought it was what the physician ordered, and it was the resident's normal dose. She said, I was just following the orders. Review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A stated she applied two patches to the resident's chest and initialed the boxes for removal and apply thinking they were 2 orders for [MEDICATION(S)]. She said she did not pay attention to the remove and apply. The resident's care plan revealed he had Potential for pain related to depression, disease process The care plan was initiated on [DATE] and revised on [DATE]. Interventions included to Administer [MEDICATION(S)] as per orders. The facility's policy Administering Medications revised [DATE] read, If a dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The Job description for Clinical Nurse (LPN) indicated the LPN was, Responsible for providing direct resident care in accordance with established plans. The duties and responsibilities included, Perform routine nursing services for residents as directed. The Facility assessment dated [DATE] and reviewed on [DATE], indicated nurses received education/in-services/ competencies regarding medication administration on hire, annually, PRN, and on demand. The following immediate measures implemented by the facility to remove the Immediate Jeopardy were verified by the survey team: * [DATE] resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No issues identified *[DATE] current residents with orders for pain patches, to include [MEDICATION(S)] were reviewed by the DON to ensure orders were written correctly and without ambiguity. Any issues identified were reviewed with the physician and corrected at that time. * [DATE] LPN A was removed from the staffing schedule and suspended pending investigation. * [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the plan and the results of the facility wide reviews. The Medical Director reviewed and approved the plan. The Ad Hoc QAPI Committee approved the recommendations. * [DATE] a Performance Improvement Plan was developed and initiated based upon Root Cause Analysis as determined by the QAPI committee. *[DATE] facility nursing administration, including the DON began education of Licensed Nurses and Contract Agency Nurses regarding following physician orders, policy for administration of transdermal medication and process to address orders with ambiguity. Education validated with med pass competency. Currently 11 out of 38 licensed nursing staff had competency reviewed. Certified letters were sent out to staff members that were unable to obtain the education and competency. Staff will be required to complete in-servicing with competency prior to working their next shift. * Newly hired staff will receive education and competency verified in orientation regarding following physician orders, policy for administration of transdermal medication and process to address orders with ambiguity. * Newly written physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] * The QAPI Committee will hold weekly meetings to review and discuss the results of the ongoing quality monitoring to include competencies. The findings will be reported to the QAPI Committee weekly. The review schedule will be modified based on findings and recommendations of the committee. Interviews conducted with staff including 6 Registered Nurses (RN), 7 LPNs on [DATE] between 11:22 AM to 4:40 PM, and on [DATE] between 12:47 PM and 1:00 PM, revealed the facility had provided education on following physician orders, policy for administration of transdermal medication, and process to address orders with ambiguity.

Based on record review and interview, the facility failed to ensure the resident's right to be free from abuse for 1 of 9 sampled residents when a CNA slapped resident #9 on the face/neck after the resident resisted care and exhibited behavioral expressions of distress, (#9). The failure to keep resident #9 free from a willful infliction of injury as he was experiencing behavioral distress resulted in a finding of Immediate Jeopardy starting on 9/11/18. The facility implemented actions to correct the immediate jeopardy which was removed on 9/22/18. Findings: Resident #9 was a [AGE] year-old male initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment with reference date 6/26/18 identified the resident's ability to express ideas and wants was sometimes understood and his ability to understand others was by simple direct communication only. He had a cognitive deficit assessment using the Brief Interview for Mental Status score of 03. A score of 03 to 07 indicated severe cognitive impairment. The resident had behaviors that significantly interfered with his care and put others at significant risk for physical injury. He required extensive assistance of two staff for activities of daily living including bed mobility, transfers between surfaces, dressing, toilet use and personal hygiene. Review of the resident's plan of care for behaviors developed at admission on 6/6/18 focused on the resident exhibiting signs and symptoms of BPSD (behavioral and psychological symptoms of dementia), mood affective disorder, anxiety and [MEDICAL CONDITION] drug use. The care plan noted that the resident exhibited combative behavior, resisted care, attempted to hit, kick, bite staff during care. The interventions included to assess behaviors for underlying medical causes, assess for changes in psychosocial status and/or environment. Explain procedures to resident before providing care. Introduce self when providing care. Provide positive feedback when resident was compliant and/or appropriate. Redirect inappropriate behaviors as needed. Wait and reattempt when resident was refusing care. There were three episodes of resident's aggressive /combative behavior documented in (MONTH) (YEAR). The care plan noted that the behaviors continued in (MONTH) (YEAR) including attempting to bite, kick and hit staff. On 9/11/18 at 9:45 AM, certified nursing assistant (CNA) A was providing morning care to resident #9 by himself. This contradicted directions on the plan of care which documented 2-person assist with personal hygiene. The CNA A called for assistance from registered nurse (RN) B to assist with transferring resident to his wheelchair. Approximately 10 minutes later, the RN B came to the resident's room. The resident was sitting at the foot of the bed and was distressed and agitated. The RN stood by the resident's side and tried to calm him by rubbing the resident's back. The CNA A was standing directly in front of the resident as the resident was becoming increasingly more distressed. The resident was shouting out for help. At this time, CNA C was walking by the resident's room and heard the resident's calls of, help me. When CNA C walked in the resident's room, she witnessed CNA A slap the resident on the left side of the face/neck. An interview on 11/02/18 at 10:25 AM with CNA C revealed that she was resident #9's primary CNA. She explained that the resident showed signs of distress if he was hungry or if he was not explained what was being done. She said on the day of the incident (9/11/18), they had an extra CNA on staff. I did not have resident #9 that day. I felt the assignment was not good. This was the first time I did not take care of resident #9 when I worked. I am the only one to keep him calm. RN B was the nurse that day. I thought that CNA A being a man, might be able to take care of resident #9. I was helping other CNAs down the hall with residents that needed total care. As I was going to the bathroom, I walked past resident #9's room and heard him scream, please help, stop beating me. He kept yelling help, help. I pushed the door open and saw CNA A slap resident #9 on the neck/face. CNA A had his back to the door so he did not see me come in. I told CNA A to get out of the room, now. RN B was standing by resident #9 holding his shoulders from the back and CNA A was in front of the resident. After CNA A left the room CNA C and RN B transferred the resident to his wheelchair and took him out of the room. CNA C then went to the administrator's office and reported the incident. An interview on 11/2/18 at 11:05 AM with RN B revealed that he was asked by CNA A for assistance with transferring resident #9 to his wheelchair. He stated that the CNA A told him that the resident was trying to bite him while doing care. He informed the CNA that he would come to assist as soon as he finished medication pass with another resident. He went to the room after approximately 10 minutes. When he entered the room, the resident was sitting sideways at the foot of the bed. The resident was distressed and shouting out. The CNA was getting frustrated with the resident and was being a little rough with the resident. The RN B stated that he tried to calm the resident by rubbing his back and as he was doing so, CNA A slapped the resident to the left side of the face/neck. He said that at the same time, CNA C walked in the room, witnessed the slap and told CNA A to leave the room. He said that he told CNA A that this was not the action we take in situations like this. He said that he did not expect the CNA to slap the resident. When asked how often he worked with resident, RN B stated, often. He was very aware of the resident's behaviors. The RN B did not provide an answer as to why he allowed CNA A to stay with the resident when the resident was clearly distressed and CNA A was getting frustrated. He did not answer when asked why they did not wait and reattempt care later when the resident was calmer as per plan of care. When asked why resident #9's primary CNA C was not assigned to his care, he said the assignment was already done when he arrived on the unit. He did not have a concern with CNA A caring for resident #9 as the resident was calm in the morning. He stated that he should have changed the resident's caregiver to CNA C as she knew how to care for him. An interview with the desk nurse licensed practical nurse, LPN D on 11/2/18 at 5:27 PM revealed that she was responsible for scheduling CNA assignments on 9/11/18. She stated that they had an extra CNA on 9/11/18 on 7:00 AM to 3:00 PM shift. She adjusted the room assignments not taking into considerations, primary assignments or resident needs. She was aware that CNA A worked on the other unit, west wing and was not very familiar with resident #9. She did not provide an answer as to why she did not assign resident #9 to his primary caregiver who was working that day. An interview with the Director of Nursing (DON) on 11/03/18 at 11:30 AM revealed that the facility had investigated this incident of abuse. Their root cause was that CNA A did not ask for assistance when caring for resident #9. She said the CNA A completed resident #9's morning care by himself when he should have asked for assistance. He then sat the resident at the end of the bed and asked RN B for assistance to transfer the resident to his wheelchair. The CNA A became impatient waiting for RN B and attempted to transfer the resident by himself. The resident attempted to bite the CNA and began to shout out, help. When RN B came into the room, the resident was clearly agitated and the CNA was frustrated. At this time, CNA C was walking past the room and heard the resident's cries for help. She stepped into the room just as CNA A slapped the resident's face/neck. At 10:15 AM on 9/11/18, CNA C reported the incident to the administrator and DON. The DON completed an upper body assessment of the resident. The DON confirmed that CNA A was not familiar with resident #9's behaviors during care. Although an investigation was completed, the DON did not provide an answer as to why the resident's primary CNA was not assigned to resident #9. She did not provide an answer as to why CNA A did not follow the plan of care and wait and reattempt care when the resident was calmer. When asked why CNA A did not request another CNA for assistance when providing care to the resident thus becoming frustrated and slapping the resident, she stated he should have asked for assistance. Interview with the medical director on 11/02/8 at 11:40 AM confirmed that he was aware of the incident of abuse. He immediately called the nurse practitioner after the incident to evaluate the resident and no injury was noted. He said he was informed that the CNA (A) was terminated. He stated that it should not matter which CNA cared for the resident as all employees have been educated on how to care for residents with behaviors. He was not able to explain what the facility trained staff to do for residents with behavioral expressions of distress. All incidents were reviewed at morning meeting. If staff education was needed, it was done right away. I need to make sure we address incidents in a timely manner. If needed, psych services are available to assess residents and give recommendations. We utilize the tools we have. If I disagree with the solution, I make my opinion known. The facility did not provide a resident with known behaviors with consistent caregivers who were able to de-escalate his behaviors. The facility assigned a CNA who was unfamiliar with the resident even though the primary caregiver was on duty. The CNA did not follow the plan of care, and worked alone to provide care to the resident. The CNA exacerbated the resident's distress. Instead of following the care plan techniques for caring for the resident with severe dementia and behavioral expressions, he slapped the resident. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 9/11/18 and removed as of 9/22/18. The facility implemented the following measures to correct the deficient practice: *Staff received education on Abuse starting on 9/11/18. The education consisted of definitions of abuse, identification of abuse, how to work with cognitively impaired residents, role play of residents with behaviors and how to de-escalate the behaviors. A return demonstration of the role play was done as well as a written post test. The education included assisting the resident with cognitive impairment to complete ADLs, and strategies to use for resident with active physical behaviors. The facility had completed education of all staff by 9/22/18. There was one staff who received education upon return to work on 10/27/18. *Certified letters were sent to employees on leave informing them that education must be completed prior to working on the units when they returned to work. *An Ad Hoc QAPI meeting was held on 9/11/18. The policy for Abuse and Neglect was reviewed. The Certified nursing assistant was immediately suspended pending investigation and terminated on 9/18/18 *Law Enforcement and the Abuse Registry were contacted on 9/11/18. *An improvement plan was developed - educate all staff 100%, report to government agencies. *Quality Improvement Monitoring was conducted 1 time a week and will continue for 8 weeks, then 1 time a month for 4 months using a sample size of 5 interviewable residents, 5 staff members and interviewing family members of cognitively impaired residents. The cognitively impaired residents had more frequent skin checks weekly. Observed for injuries of unknown origin, none had been identified.

Based on interview and record review, the facility failed to adequately supervise a cognitively impaired resident with known exit seeking behaviors and implement approaches to ensure safety for 1 of 3 sampled residents out of 42 total residents with wander bracelets. These factors contributed to the elopement of resident #1, placing him at high at risk for serious injury/impairment/ death. On 9/21/18, the actions/inactions of the facility staff compounded the situation in which resident #1 eloped from the facility between 9:30 AM and 10:15 AM via an alarmed/coded locked door on the northwest side of the building. The resident was missing for approximately 2 hours and his whereabouts were unknown by staff. The resident was found 10 miles from the facility walking on uneven, grassy area of a busy two lane road between the car dealership and the entrance to an elementary school. The resident did not have a walker/wheelchair with him. The failure to provide the needed supervision resulted in the resident's elopement and subsequent past non-compliance at the Immediate Jeopardy level, Identified as occurring on 9/21//18 and removed as of 10/11/18 Findings: Resident #1 was an [AGE] year old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Upon admission, the facility interviewed the resident and assessed that he was cognitively impaired as evidenced by the Minimum Data Set ((MDS) dated [DATE]. The Brief Interview for Mental Status (BIMS) identified that the resident had a score of 6 which indicated severe cognitive impairment. The quarterly MDS assessment dated [DATE] again identified the resident with severe cognitive impairment. His functional status assessment identified that he required supervision to move around the facility. His behaviors included wandering occurring daily. His primary source of movement was walking with his wheelchair. The nursing progress notes read that on the morning of 7/22/18, resident #1 was anxious, wanting to leave and tried to exit the facility. The care plan noted that he had packed his belongings and tried to exit via the front door. He had increased confusion and a wander bracelet was initiated. On 7/27/18 the care plan noted that the resident had removed his wander bracelet. An interview with the director of nursing (DON) on 10/31/18 at 4:08 PM revealed that the facility was not able to locate the wander bracelet and suspected that the resident had cut it off with a dinner knife. Another wander bracelet was applied. A nursing progress note on 8/5/18 at 9:07 PM, documented that the resident tried to go out the front door of the facility stating that he had received a phone call of an emergency at home. He wanted a taxi called to take him home (the resident was homeless). The resident was redirected and monitored closely by staff. On 8/7/18 the plan of care documented that he removed his wander bracelet again (second bracelet). The facility attempted to transfer the resident to the secure memory care unit due to his exit seeking behaviors, with agreement from the resident's brother. The resident refused to go and remained on the original unit, which was not locked. Another bracelet was applied. A nursing progress note dated 8/21/18 at 3:54 PM revealed that the resident was observed agitated, anxious and combative. He was observed seeking a door and wanted to go to home. The resident continued exit seeking behavior and removed his wander bracelet (3rd time). Another wander bracelet was applied. On 8/27/18 the interdisciplinary team met for the weekly behavioral meeting. They noted that resident #1 was non-compliant with smoking, was exiting seeking and refusing care at times. He was referred for a psych consult. A nursing progress note on 8/28/18 at 3:36 PM documented that resident #1 was very insistent to go home. The resident was observed walking with his wheelchair with his belongings. His whereabouts were monitored. A nursing progress note on 9/12/18 at 11:54 AM read that the resident was exit seeking and attempted to get a taxi. He was placed on 1:1 monitoring until 9/13/18. A nursing progress note On 9/14/18 at 3:33 PM identified him as an elopement risk with every 15 minute monitoring There was no further documentation until 9/17 and 9/18 which again noted elopement risk and whereabouts monitored every 15 minutes. An initial psychiatric evaluation dated 9/7/18 showed that the resident was a veteran, and homeless, prior to admission. He was oriented to self, vaguely aware to the place at the time, not aware to time, and a poor historian. He wanted to go home but could not say where home was. His long-term memory was better than short-term. The psychiatrist's recommendations included monitoring mood/behavior and elopement precautions. A nursing progress note dated 9/21/18 at 11:40 AM read that at 10:30 AM the resident was paged to his room three times. The resident's responsible party was called. He stated that the resident was not with him. On 9/21/18 the resident eloped from the facility while he was being monitored for exit seeking behaviors with fifteen minute checks. The resident had attempted to leave the facility four times prior to the actual elopement on 9/21/18. During the 15 minute checks between 9:00 AM and 10:00 AM certified nursing assistant (CNA) B informed Registered nurse (RN) A that she could not find the resident. The RN stated that she last saw the resident between 9:30 AM and 10:00 AM and began to search for the resident. The staff initiated the elopement protocol, which included searching inside all areas of the facility. Staff were sent outside to search the grounds and nearby shopping strip malls and gas station. The resident was not located. The social services assistant (SSA) who was familiar with the resident started searching for the resident by car. She contacted the resident's family member, cab companies and the police. The family member was not aware of the resident's whereabouts. The cab company confirmed picking the resident up from the facility's side entrance and delivered him to his friend's house. Upon arrival to the friend's house, the friend stated that he had dropped resident #1 off at a car dealership. The SSA drove to the car dealership and found the resident walking on the uneven grassy area of a busy 2 way road near the dealership and the entrance of an elementary school. The resident had walked approximately 0.3 miles from the dealership with no walker or wheel chair. The SSA attempted to get the resident into her car but he refused. The police arrived and escorted the resident back to the facility at approximately 12:30 PM. The facility's investigation of the incident revealed that the resident was last seen between 9:30 AM and 10:00 AM by CNA B and RN A. An interview on 10/30/18 at 2:05 PM with Registered Nurse (RN) A revealed that she was informed by CNA B at approximately 10:00 AM that she could not locate resident #1. We immediately paged for the resident to return to his room and began room checks. I searched the entire building and did not find him. We were all aware that the resident was an elopement risk as he repeatedly requested to go home. He was capable of removing his wander bracelet. We don't know if he removed the wander bracelet again or how he exited the building. On 10/31/18 at 10:00 AM Certified nursing assistant (CNA) B stated that she was caring for the resident #1 when he eloped on 9/21/18. She had only been assigned to the resident a few times. She was aware that the resident was an elopement risk and tried to watch him closely. She said she provided morning care to the resident between 9:00 AM and 10:00 AM and his wander bracelet was present at that time. He was able to walk with a walker or by pushing his wheelchair. She discovered him missing between 9:30 AM and 10:00 AM but could not provide a specific time. Although she stated she checked on the resident every 15 minutes, CNA B could not provide any documentation of the 15 minute checks. A review of the CNA assignments showed that each CNA had 8-12 residents assigned to their care. They did not have a specific CNA that was solely responsible for checking at risk residents every 15 minutes. When asked how the safety of resident #1 could have been ensured, CNA B stated that if the door codes had been changed more frequently, the elopement may have been prevented. An interview with the social services assistant on 10/30/18 at 3:20 PM revealed that the resident would constantly ask to go home but he was homeless. He used his wheelchair like a walker. He would walk while pushing the wheelchair. He smoked and would occasionally smoke in non-designated areas. She stated that resident #1 was close friends with another resident in the facility who was alert and oriented. Both residents would go out to the courtyard and would smoke together. This friend knew the code to press on the key pad to unlock the door to go outside to the courtyard. The access codes for all doors were the same. She believed that resident #1 learned the code from the friend. Resident #1 left the facility by the laundry/maintenance door (northwest corner door) as his wheelchair was found by the door. When he left I knew exactly where he was going. He went home. He lived with a friend down the street from his home. I called the brother, asked for the friend's number, called the cab company that dropped him home. The locked unit was not appropriate at the time. He refused to go to the secure unit. The only thing that was effective was 1:1. The SSA could not explain why the resident was discontinued from 1:1 observations within 24 hours. She stated the decision was made at morning meeting but did not provide rationale. An interview with the director of nursing (DON) on 10/30/18 at 2:14 PM revealed that resident #1 knew the code to go into the courtyard. She said he probably learned it from observing staff/visitors/residents going out. He was a smoker and went out to the courtyard. The code was the same exit code on all doors in the facility. He left by the laundry/maintenance door which unlocked by pressing a 4 digit code, the same as the courtyard smoking door. She did not explain how the resident was able to call a cab company and have them pick him up from the side laundry/maintenance door. She speculated that the resident may have used a visitor/another resident's phone or had them call the cab company. The DON identified that the uniform codes throughout the facility contributed to the resident's elopement. She said the resident was known to sit by the laundry/maintenance door. The DON did not provide an answer when asked how the resident was monitored every 15 minutes when he sat by the laundry/maintenance door which was more than 200 feet away from his unit. She did not provide any documentation of the 15 minute checks. An interview with the maintenance director on 11/1/18 at 10:30 AM noted that he changed the door codes every 6 months and as needed. If the security of the door code had been compromised, he was required to change the code. He stated that he was unaware that residents knew the door code. He said the door codes were different for entry and exit but that all doors in the facility had the same codes. The entry codes were the same at all doors and the exit codes were the same for all the doors. An interview with the administrator on 11/1/18 at 1:00 PM revealed that they suspected the resident had cut the wander bracelet off. He demonstrated cutting the bracelet with a dinner knife. Although it took a few minutes, the strap of the bracelet could be cut with a dinner knife. He stated that the facility had never found the wander bracelets to determine how the bracelets were removed. He explained that the door codes were changed every 6 months and as needed. He did not explain why the codes were not changed when the facility became aware that other residents had the codes to exit onto the courtyard smoking area which was the same code for all exit doors in the facility. An interview with the medical director on 11/2/18 at 11:30 PM revealed that he was aware of resident #1's elopement from the facility. He stated that they ensured that the resident's mental status was appropriately assessed. They used wander bracelets, redirection and psych services if a resident was exit seeking. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 9/21/18 and removed as of 10/11/18. *The facility's corrective Actions revealed that an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 9/21/18 and required education to all staff. They identified that the resident had obtained the door code to exit the facility. It was the same code for the smoking area. They changed the code to the smoking area to make it different than the entrance and exit codes. *Policies for missing residents and potential elopement assessments were reviewed. *All residents at risk for elopement had care plan orders, CNA Kardex and elopement books reviewed and completed with level of supervision for each resident identified. All potential elopement residents were placed on 15-minute visual contact/checks. *The Federal 5 day Abuse report was submitted timely. *An adverse incident report was submitted to the State agency on 10/05/18. *Facility Process changes included a different code for entering and exiting the building doors. The codes were to be changed at a minimum of every three months and as needed. A key pad to the front entrance was added. Codes were not to be shared with non- facility affiliated employees or visitors. Manager on Duty was assigned to check all doors on shift. *After the Elopement in the first 72 hours education and 3 drills for 3 days. *All staff, per diem and contracted staff received education on 9/21/18 -9/25/18. Education including role playing. A total of 239 staff were educated. The education consisted of best practices for missing resident which defined, elopement, search techniques, responding to door alarms, search grids for elopement, and a review of indicators that a resident may be planning to leave. The facility defined who was allowed access to the door codes. Certified letters were sent to all staff not present during the initial education and were not allowed to return to the units until education was completed. Post tests were completed on the education provided. *A mock elopement drill was conducted with a resident on 10/11/18

Based on interview and record review, the facility failed to administer its resources effectively to ensure the supervision and safety of 1 of 3 sampled residents, (#1). The administration failed to use their resources effectively and efficiently to ensure that resident #1, at risk for elopement was provided with adequate supervision to ensure a safe and secure environment. This failure resulted in the elopement and potential serious injury/impairment/death of resident #1. Administration failed to assess the level of supervision needed for resident with known attempted elopements and failed to ensure the security of door access codes. This was identified as past non-compliance at the Immediate Jeopardy level occurring on 9/21/18 and removed as of 10/11/18. Findings: Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident with severe cognitive impairment. His functional status assessment identified that he required supervision to move around the facility. His behaviors included wandering occurring daily. His primary source of movement was walking with his wheelchair. On 9/21/18, the resident eloped from the facility between 9:30 AM and 10:15 AM via an alarmed/coded locked door on the northwest side of the building. The resident was missing for approximately 2 hours and his whereabouts were unknown by staff. The facility's investigation revealed that the resident called a cab and exited the facility from the side door. He was found 10 miles from the facility walking on uneven, grassy area of a busy two-lane road between a car dealership and the entrance to an elementary school. The resident did not have his walker/wheelchair with him. A review of the nursing progress notes documented that the resident had attempted to elope on 7/22/18, 8/05/18, 8/21/18 and on 9/12/18. A wander bracelet was initiated on 7/22/18 when the resident first tried to elope. The resident removed the wander bracelet and another one was applied on 7/27/18. The facility suspected that the resident had removed the bracelet by cutting it with a dinner knife. On 8/07/18, the resident again removed his wander bracelet and another one was applied. He removed the bracelet for the third time on 8/21/18 and another bracelet was applied. An interview with the administrator on 11/01/18 at 1:00 PM revealed that they suspected that the resident had cut the wander bracelet off. The administrator demonstrated cutting the bracelet with a dinner knife. Although it took a few minutes, the strap of the bracelet could be cut with a dinner knife. He stated that the facility had never found the wander bracelets to determine how the bracelets were removed. Even with this assumption of cutting the bracelets with a knife, the facility administration continued to use the wander bracelet to prevent the resident from exiting the facility with full knowledge that the resident knew how to remove them. On 10/31/18 at 10:00 AM Certified Nursing Assistant (CNA) B stated that she was caring for the resident #1 when he eloped on 9/21/18. She said she provided morning care to the resident between 9:00 AM and 10:00 AM. She discovered him missing between 9:30 AM and 10:00 AM but could not provide a specific time. Although she stated she checked on the resident every 15 minutes, CNA B could not account for his whereabouts between 9:30 AM and 10:00 AM consisting of two 15 minute checks. The CNA did not provide any documentation of the 15 minute checks. A review of the CNA assignments showed that each CNA had 8-12 residents assigned to their care. They did not have a specific CNA that was solely responsible for checking at risk residents every 15 minutes. When asked how the safety of resident #1 could have been ensured, CNA B stated that if the door codes had been changed more frequently, the elopement may have been prevented. An interview with the social services assistant, (SSA) on 10/30/18 at 3:20 PM revealed that the resident would constantly ask to go home but he was homeless. She stated that resident #1 was close friends with another resident in the facility who was alert and oriented. Both residents would go out to the courtyard and would smoke together. This resident (friend) knew the code to press on the key pad to unlock the door to go outside to the courtyard. The access codes for all doors were the same. The SSA believed that resident #1 learned the code from his friend. She stated that the resident had attempted to elope on 9/12/18 and was placed on 1:1 monitoring. She said that the only measure that was effective in preventing elopement was, 1:1 supervision. The SSA could not explain why the resident was discontinued from 1:1 supervision within 24 hours, on 9/13/18. An interview with the director of nursing (DON) on 10/30/18 at 2:14 PM revealed that resident #1 was discontinued from 1:1 supervision after 24 hours as he did not like the constant monitoring. However, the administration did not utilize distant monitoring where the supervising staff was not within the resident's personal space but still able to maintain a line of sight of the resident. The DON stated that the resident knew the 4-digit code to go into the courtyard. She said he probably learned it from observing staff/visitors/residents going out. An interview with the maintenance director on 11/01/18 at 10:30 AM noted that he changed the door codes every 6 months and as needed. If the security of the door code had been compromised, he was required to change the code. He stated that he was unaware that residents knew the door code. The administrator on 11/01/18 at 1:00 PM did not explain why the codes were not changed when the facility became aware that other residents had the codes to exit onto the courtyard smoking area that was the same code for all exit doors in the facility. The administrator's job description read, To ensure that the highest degree of quality care can be provided to our residents at all times. The ED is entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concept that continually improve systems and processes to achieve superior results Although resident #1 had attempted to exit the facility 4 times in a two-month period, administration failed to gain an overall awareness of the serious threat for the resident posed by elopement. They failed to reassess the potential of successful elopement for a resident with multiple attempts of exit seeking and attempting to leave the facility. The facility mainly relied on the wander bracelet for supervision however, the resident repeatedly removed the bracelet thus rendering it ineffective. Interviews with administrative staff revealed that the resident was aware of the door code to exit the facility yet failed to change the codes on the doors. Administration then implemented 15 minute checks of the resident but they could not provide evidence that these checks were being done. Consequently, the only measure that was identified as being effective to prevent elopement by the SSA was 1:1 monitoring. The administration however did not utilize resources for the 1:1 supervision and/or provide innovative ways to prevent the successful elopement of resident #1. Past non-compliance at the Immediate Jeopardy level was identified as occurring on 9/21/18 and removed as of 10/11/18. *The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 9/21/18. Reeducated all facility staff, contracted staff and per diem staff of elopement/missing persons procedures. The committee reviewed 100% of residents at risk for elopement, reviewed and updated as needed care plans, physician orders, certified nursing assistant Kardex and elopement books. Level of supervision for each resident was identified. *The facility had morning meetings to review all new admissions, discharges and elopement risks. *All staff, per diem and contracted staff received reeducation on 9/21/18 -9/25/18. A total of 239 staff were educated. The education consisted of Best Practices for missing resident, which defined, elopement, search techniques, responding to door alarms and search grid for elopement. A review of indicators that a resident may be planning to leave. Education including role playing, defining who was allowed access to door codes and post-test. Certified letters were sent to all staff not present during the initial education and staff were not allowed to return to the units until education was completed. * A mock elopement drill was conducted with a resident as the subject as missing on 10/11/18 with 100% compliance. * The door codes were immediately changed. The codes were changed so that they were not the same for smoking area, entry and exits. The frequency was changed from every 6 months to every 3 months and as needed. The security of the doors a check at a minimum of two times a day. A key pad was installed to the main front lobby door. *As of the exit date on 11/03/18, observations were made of the staff opening doors via the key pads, observing for anyone that was not authorized access were present in the area. Visitor interview to determine if they had access to the codes. A tour of the facility noted all doors were secure.

Based on observation, interview, and record review, the facility staff failed to render first aid to a chocking resident (#46) in the Secure Dining Room. The staff's failure to respond appropriately and timely to resident #46, created an environment that was not safe for 11 cognitively impaired residents during dining (#6, 22, 40, 46, 65, 94, 134, 151, 153, 157 & 204). Staff interviews revealed that the Certified Nursing Assistants (CNAs) were not competent in performing the Heimlich Maneuver and the facility failed to identify the CNAs' incompetencies in Life Saving/First Aid procedures. The Immediate Jeopardy started on [DATE] and the Immediacy was removed as of the exit date of [DATE] and the severity level lowered to potential for harm. Cross refer: F353, F490 and F498. Findings: 1. Medical e-record review revealed resident #46 was first admitted into the facility on [DATE] with some of her [DIAGNOSES REDACTED]. She had mental health [DIAGNOSES REDACTED]. According to the Resident Review Evaluation Request, completed on [DATE] by the licensed social worker (LSW), the resident had a decline status had an increase in behavioral, psychiatric or mood related symptoms. On [DATE] at 12:20 PM as the surveyor entered the Memory Lane main dining room (DR), resident #46 was making choking movements. She was reaching up with both hands towards her neck. She had a large amount of that day's lunch meal in her mouth, which was chicken Alfredo spaghetti noodles. She had a large portion of the spaghetti noodles hanging out of her mouth down to below her jaw line, which measured approximately 4.5 inches in length. The surveyor shouted out loud to the only Certified Nursing Assistant (CNA) M that was in the Memory Lane's larger dining room (DR), She's choking! Is somebody going to help her? There was a smaller DR that was for residents needing assistance with eating. There was one nurse assigned to watch both dining rooms. There was not a nurse in the larger DR. By then, certified nursing assistant (CNA) B came into the dining room and was getting ready to pass more trays to other residents when the surveyor said, Is somebody going to help her? Both of the CNAs just stood there. Then CNA M went over to the resident. She lightly patted on her right shoulder and asked her if she was alright. When the resident did not answer her because she was choking, she just stood there and said are you alright? She asked her one more time if she was alright. At that point the surveyor said she is choking, do something. The surveyor then said Somebody get the nurse. At this time resident #46 tried several attempts at pulling out the strands of spaghetti that was hanging from her mouth. She tried 3 times to pull out the pasta and on the 3rd attempt she was able to pull the pasta out of her mouth. She then made a noise like clearing her throat and she spat out what was in her throat. After this occurred, CNA B went out of the DR to get the Licensed Practical Nurse, LPN N. LPN N was in the hallway in between Memory Lane 2 dining rooms. She was not in either dining room while residents were eating. When LPN N came into the DR she bent over to the residents eye level and asked her if she was ok. The resident said yes and she wanted something to eat. LPN N asked resident #46 if she wanted something else other than the chicken alfredo and she said no. LPN N asked her if she want the same thing and she said yes. LPN N said she would cut the pasta into smaller pieces. CNA M and the surveyor went out of the DR while LPN N brought another meal tray, set it down for her, and cut it up. When the surveyor returned to the DR where resident #46 was, she was eating same type of food she choked on earlier. There was one CNA, M, in the dining room on Memory Lane. While resident #46 was choking, the CNA had her back to the resident while taking meal trays from the meal cart. CNA was delivering meal trays to the other residents who were sitting in the dining room at that time. The other residents in the DR with the potential for choking were at Table 1: #157, #22; Table 2: #46, #40, #65; Table 3: #204, #94; and Table 4: #134, #6, #151, and #153. The residents' diets and any type of precautions for these residents were: #157: Regular Pureed with fortified foods; #22: Regular Mechanical soft, fortified foods; #46: Regular mechanical soft, Nectar; #40: Carb Control Diet (CCD), No added salt (NAS); #65: #204: Regular; #94: Regular mechanical soft fortified foods; #134: NAS-Pureed fortified; #6: Regular; #151: CCD, NAS large portions; and #153: CCD mechanical soft, lactose intolerant. Resident #46 had an ADL (activities of daily living) care plan for self care performance deficit as related to dementia, aggressive behavior, and disease process-psychosis and confusion, refusal to participate and refusal of care with an implementation date of [DATE]. The goal with a target date of [DATE] was the resident will receive appropriate staff support through the next review date, specify the ADL. Eating was marked with a checkmark. The approaches and interventions for eating were to keep needed items within easy reach, and open and set up items. Another approach indicated the resident requires supervision by regarding eating and speech therapy screen and treatment as needed. The care plan for nutrition and dehydration with an implementation date of [DATE] listed an approach and intervention to assist with feeding as needed. With one CNA in the DR who is passing trays while all the residents are at various stages of eating, residents are not supervised during the meal and are at greater risk for possible choking or aspiration. On [DATE] 1:45 PM during an observation with CNA M, she just gave resident #46 a large piece of cake. She then went back to serving the rest of the cake to other residents. Resident #46 started eating the cake. The resident was feeding herself rapidly taking a large bites of cake with her fork. The surveyor stood there to observe if she were to choke again. CNA M was asked if resident #46 ever had a history of [REDACTED]. She was asked how long has resident #46 had been eating rapidly and placing large amounts of food in her mouth. Her response was for a long time. She was asked if she had any training on choking and how often does she get the training. She said yes when she does the cardiopulmonary resuscitation (CPR) training and that's about every 2 years. She was then asked if she did any other type of choking training other than that which was done with CPR. She replied No. On the same day, [DATE] at 1:50 PM, resident #46 was asked if she had ever choked before and she said yes, however, she related what happened earlier in the day today. She was cognitively aware enough to remember the incident and relate it to choking. Interviews were attempted with residents #134, #6, #65, and #40. Due to their advanced decline in cognition, they were not interviewable. On [DATE] at 2:00 PM and interview was conducted with LPN N who said one nurse was assigned to work in the secured unit. She said she worked at the facility for [AGE] years and [AGE] years in the secured unit. She was asked if resident #46 had ever choked before to which she replied No. She was asked if any resident ever choked in the unit during all of those years. She stated never when she was on duty. The locked unit has 2 dining rooms; the larger one is the Day Room/dining room; the smaller room is called the Plus room which the aides assist the residents in eating. She stated she is always assigned to both DRs. She was asked if she ever received training on choking. She replied that she gets inservices, but didn't remember when. She said she has CPR training every 2 years and choking is part of the training. At 2:08 PM Unit Manager (UM) for the secured unit and part of the southeast unit, which was on the other side of the locked doors, joined the conversation. She was asked how many aides should their be in each DR? They both said 2 and there is one that walks the hallways helping out. They were asked if the aides knew what to do when someone is choking. They both said they should have known what to do. When asked why do you think CNA M just stood there? LPN N said it's probably because they saw you standing there and was afraid to do anything. On [DATE] 3:34 PM a post choking assessment progress note was written by LPN N: Pt, alert No further choking episodes Temp 97.3. No other assessment was done by the nursing staff. At 5:45 PM on the same day, [DATE], in the Main DR on Memory Lane resident #46 had already finished eating. She was observed coughing really hard. It was the type of cough as if there was something in the throat area. She was coughing so hard her face was turning red. The UM was in the DR watching her while she was coughing. There were 2 aides in that DR and one nurse split between the Main DR and the assisted DR. On [DATE] at 9:35 AM resident #46 was observed out in the Courtyard Patio eating a peanut butter cracker. When asked how she was doing she said she didn't feel good. She was asked her if her throat or chest hurt and she said No. On [DATE] at 11:45 AM #resident 46 was back on the unit. She and the other residents were in the Main DR on Memory Lane. Resident #46 was asked if she was feeling better now to which she replied yes. CNA M was the only aide in that room. There were 12 residents in the DR a that time. At 11:55 AM CNA B came into the room. CNA M was asked what would you do for someone who was choking, like resident #46 was yesterday. She said she would do the Heimlich maneuver. She was asked to verbally explain how she would perform it. She explained it correctly. She was then asked to physically show how it would be performed, which she also did correctly. She was asked what would you do if someone was choking and had food hanging from their mouth, like resident #46 At that time she validated that she should have put gloves on and pulled out the food that was hanging from resident #46's mouth On [DATE] at 11:49 AM the UM was asked if anyone from nursing did an assessment of resident #46 after the choking incident. She stated she called the doctor and asked for a chest xray. She was asked if it was for her coughing or choking and she said, both. She said the physician ordered a speech therapy evaluation and treat. The chest Xray (CXR) was completed later during the day. On [DATE] at 12:24 PM review of the CXR report revealed: Dense consolidation detected in the Right lower lobe. The costophrenic angles are sharp. No pneumothorax. The heart and mediastinal structures are within normal limits. Osseous structures show no acute abnormality. Conclusion: Dense Right lower lobe consolidation. Follow up recommended. Electronically signed by the MD on [DATE] at 10:29 PM. This Xray was compared to a chest Xray done on [DATE], due to a Cough. Findings revealed . the lungs were clear. No pleural effusions. Impression: No acute disease. On [DATE] at 12:30 PM review of the Speech therapist (ST) evaluation and recommendations revealed a previous ST was done on [DATE] for cognitive communication skills. For start of care, dated [DATE], it revealed, in part, the following: Under reason for referral: Patient presented with s/s (signs/symptoms) of penetration/aspiration during dysphagia screening. referred d/t (due to) patient choking during meal. Sensory Responses = present but delayed (Patient presented with overt s/s that were consistent with delayed swallow response.) : Swallowing = Moderate impairment. PLOF= WFL. (Prior level of function-within functional limitations). Clinical Impressions/Recommendations: swallowing completed resulting in a moderate oropharyngeal phase dysphagia (difficulty swallowing) characterized by reduced mastication (chewing), fast rate of ingestion, large bites, and throat clearing and coughing before and after the swallow. Coughing occurred x 1 during consumption of thin liquids and x1 during consumption of mixed consistencies (e.g., grapes). Current recommended diet is pureed texture with nectar thick liquids. ST to continue to assess for patient's safest least restrictive diet over the course of skilled ST treatment period. She couldn't handled a mix between liquid and solid. ( she created her bolus the liquid would go down the throat into the trachea instead of the esophagus, causing a silent aspiration). An interview was conducted with the ST- W, on [DATE] at approximately 12:10 PM, regarding the evaluation he did. He stated she seems to be aspirating some liquid that is ahead of the bolus before it is swallowed. ST screening may have indicated the resident was having changes in swallowing which precipitated the aspiration during dysphagia screening. This may have prevented the build up in her lungs, from the silent aspirations, causing the dense consolidation in her right lung. If her aspirating episodes were caught earlier, she may not have had the amount of aspiration that caused that dense consolidation in her right lung. A review of the hard copy chart revealed a Nutritional Review, completed on [DATE], indicated resident #46's diet was Mech Soft. Under Ability to Chew/Swallow: tolerating diet. No new recommendations. On [DATE] at 5:15 PM interview with resident #46 revealed upon questioning her is she ever had any other times when she was choking on her food. She very clearly said yes, but could not give any specifics dates or times. A meeting was held with the administrative team on [DATE] at 11:00 AM and they were informed that Immediate Jeopardy had been identified. As a result of the meeting, the administrator provided the following corrective action plan on [DATE] at 8:10 PM. The facility conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on [DATE] with the medical director and all management staff. The team identified all residents as potential risk for choking. The affected resident, #46 was assessed by the nurse and the physician with orders for chest x-ray which showed right lower lobe consolidation. Orders were obtained for antibiotics, speech therapy and infectious disease consult. The resident's care plan and CNA kardex were reviewed and updated by the interdisciplinary team on [DATE]. All other residents (minus those that refused) were screened by speech therapy on [DATE] and evaluated by the licensed nurses to determine if their diets were suitable and if there were any concerns with eating. Of the 169 residents that were screened, 11 were identified with need for follow up with speech screening which was being conducted. On [DATE], nursing staff were educated on supervision of meals to ensure that residents were observed during meals for signs and symptoms of choking. Education included appropriate placement of hands to render emergency intervention in the event of a choking event using the Heimlich maneuver with return demonstration. On [DATE], licensed nurses were educated that diets could be downgraded if the resident experienced difficulty managing their diet such as coughing. The nurse should downgrade the diet texture until speech therapy evaluated the resident. Education was provided with return demonstration on the use of a suction machine to remove items which may obstruct a resident's airway. Suction machines were now placed in all dining rooms. On [DATE], beginning with dinner meal, a licensed nurse was assigned for supervision in each dining area as per staff schedule. The name of the CPR certified licensed nurse was also noted on the staff schedule. As of [DATE], 27 of 52 nurses and 77 of 102 CNAs had completed their education and return demonstration. No staff had or will be permitted to work until they had received education. A nurse manager/educator was assigned to meet, educate and perform required competencies to staff needing training prior to working their shift. An employee roster was kept of staff who had not received training for tracking purposes. Newly hired nursing staff would receive education and training with return demonstration upon hire during orientation. The facility contacted all resident families via telephone to inform them to check with the nurse regarding food consistency before giving their loved ones any food. The CPR policy and the Heimlich policy were reviewed and no revisions were required. QAPI will meet weekly or as required until substantial compliance was met with the 5 citations identified at Immediate Jeopardy. As of the exit time on [DATE], on-going in-services were continuing until all staff were educated prior to start of their shift. Observations, interviews and record reviews verified the removal of immediate jeopardy. The facility implemented sufficient measures to remove the immediacy and decrease the severity/scope as of [DATE], but the facility remains out of compliance with F323. The severity and scope of the deficiency was lowered to D-isolated, no actual harm with potential for no more than minimal harm to residents. As of [DATE], the plan of correction was not submitted to include the facility's plans to fully implement, monitor performance, and evaluate the effectiveness of their action plans to ensure sustained compliance.

Based on observation, record review and interview the facility failed to provide sufficient staff with appropriate competencies and skills to assure resident safety to prevent choking. The facility staff also failed to provide adequate supervision to avert institutional isolation & restraints so that residents could attain or maintain the highest practicable level of well being for 2 of 32 sampled residents (#46 &166). Cross refer: F221, F323, F490 Findings: 1. On [DATE] at 12:20 PM resident #46 was eating lunch in the secure unit dining room. There were 11 residents in the room and Certified Nursing Assistant (CNA) M was the only staff in the room and she was passing out meal trays. The main entree was Chicken Alfredo Spaghetti. Resident #46 was observed choking and spaghetti noodles were hanging out of her mouth. CNA M had her back to the resident as she was removing meal trays from the cart and was not aware that the resident was choking. After being informed that resident #46 was choking, CNA M failed to implement first aide procedures to abate the choking. CNA M patted the resident lightly on the back of the shoulder and asked the resident if she was okay. At that time CNA B entered the dining room and the surveyor asked her to get the nurse. Resident #46 attempted several times to clear her throat and on the third attempt she was able to pull the noodles out of her mouth and spat up the remaining food. Several minutes after the resident had cleared her throat, Licensed Practical Nurse (LPN) N walked into the dining room. LPN N failed to assess the resident post choking incident and offered her more Chicken Alfredo Spaghetti. Later that afternoon at 1:45 PM the resident #46 was observed in the secure unit dining room with a slice of cake. The resident was feeding herself rapidly taking a large bites of cake with her fork. CNA M was in the room and she was asked how long has the resident been eating rapidly and placing large amounts of food in her mouth. CNA M indicated the resident has been eating this way for a long time. CNA #M stated that she attends First Aide Training every two years and that the training included Cardiopulmonary Resuscitation (CPR) and Choking. The CNA indicated she does not receive any other training on choking except the information she gets when she renews her CPR. However, CNA M's First Aide Training was not realized because the CNA failed to act when resident #46 was choking. Approximately fifteen minutes later at 2 PM, LPN N stated there are 2 dining rooms on the secure unit. The larger one is the Day Room/Dining room and the smaller is called the Plus Room. LPN N stated that she is assigned to both dining rooms. Resident #46 ate in the Day Room/Dining Room. At 2:08 PM the secure wing Unit Manger (SWUM) joined the both the SWUM and LPN N stated that each dining room is to have 2 CNAs during meals. They said that the CNAs know what to do if a resident is choking. When asked why CNA #M did not render first aide to resident #46 during the choking incident, LPN N said, It's probably because they saw you (surveyor) standing there and was afraid to do anything. In light of the choking incident and the lack of staff response, an attempt was made to determine if the facility's current staffing levels were meeting the residents' needs. Staff were also interviewed to determine their competency in emergency/first aide producers for chocking events. The staff members gave different responses as to their competency and/or knowledge of choking interventions such as the [MEDICATION NAME] Maneuver. The staff gave differing information for the time spent and frequency of the First Aide Training they received for choking. On ,[DATE] at 1:50 PM CNA V stated that she has worked at this facility for 8 months and the facility has not provided any training on choking. She stated she learned about choking when she received her CPR training/certification. She stated that she has never performed the [MEDICATION NAME] Maneuver. If a resident was choking she would call the nurse and try to help with the [MEDICATION NAME]. On [DATE] at 1:55 PM CNA X stated she has worked at the facility for [AGE] years. She described signs & symptoms of choking as a change in in color on the resident's face and their eye will look petrified. She stated that either the South Wing Unit Manager or another nurse gave an inservice on choking and [MEDICATION NAME] Maneuver, 4 months ago. CNA X stated she has never had to do the [MEDICATION NAME] Maneuver. She was not able to describe how to do the [MEDICATION NAME] and where her hands should be placed on a choking victim. CNA X was interviewed again on [DATE] at 1:10 PM and she tried explain the [MEDICATION NAME] Maneuver. CNA X placed her hands at breast level and indicated that you push in and up. CNA X indicated that there are not enough staff at this facility. She stated that it is difficult to provide care to the 12 residents that are on her assignment. She stated that she is stressed because she is on the go all the time and don't have time to stop. On [DATE] at 1:58 PM CNA Q stated that she has worked at the facility for [AGE] years and is usually assigned to the West Wing. During lunch that day she assigned to the West Wing Hallway where she passed out meal trays and assisted resident that ate in their rooms. She stated she was aware of the signs of choking. She motioned as she was gasping and stated you can see it in their face -turning blue. She added, you can see it in their eyes. She could not remember the name of the [MEDICATION NAME] Maneuver, but stated she would stand behind the resident. She demonstrated her hand placement, for the [MEDICATION NAME] Maneuver, on herself. She made a fist with one hand and placed her other hand on top. She placed her hands just below her sternum and stated that she push/trust inward. When questioned about her hand placement she was said that her hands would be at or just below the residents sternum/ribs. CNA Q could not recall the last time she had her First Aid training. To perform the [MEDICATION NAME] Maneuver on someone, stand behind the person with your arms around the waist. Make a fist with one hand and position it slightly above the navel. Grasp your fist with the other hand and press hard into the abdomen with a quick, upward thrust. (http://www.mayoclinic.org/first-aid/first-aid-choking/basics/art) CNA Q was not able to demonstrate/describe the [MEDICATION NAME] Maneuver. On [DATE] at 2:03 PM CNA B stated she has worked in both dining rooms on the secured unit. She stated that there are always two CNAs in the dining rooms when the residents are eating she stated that the nurse goes between both dining rooms and that the nurse will help pass trays or assist with meals. CNA B stated she would know what to do if a resident was choking. CNA B added that LPN N and her talk about emergency issues all the time. CNA B explained the discussion with LPN N are not a formal class, but just conversations between them. She added that she watches all the emergency programs on TV, so I am prepared. CNA B sated the facility offers First Aid Classes, that include CPR and Choking, every 2 years. CNA B stated that she took the class 2 years ago and the class is 45 minutes to 1 hour long. On [DATE] at 2:15 PM CNA C stated she works in both dining rooms in the secure unit. She explained normally there are two CNAs for each dining room and a nurse floats between the two dining rooms. CNA C stated that the nurse will stay in the dining room when they are really busy. She defined busy as having 2 or more residents on the unit that are acting out. On [DATE] at 3:00 PM the Director of Nursing (DON) was asked how she monitors the care and service provided by staff, especially on the Secure Dementia Unit. She stated that all the CNAs were First Aid Certified and were aware of what to do if a resident was choking. She said that having First Aid Certification was a job requirement She also said that the facility provided First Aid training on monthly basis, by an outside company. When asked if the facility conducted and simulated mock choking/code drills, to determine staff's ability to respond, the DON stated that they do not conduct such drills. The DON added that the staff are taught how to respond to resident choking during the First Aid Class that are one hour in length. The DON could not provide a syllabus of the First Aid Class and it could not be determined what the CNAs are being taught. On [DATE] at 4 PM CNA #D stated that he has worked at the facility for [AGE] years and that CNA to resident ratio is 12 to 1. He stated that Facility's Administration had told them that the State has a requirement of one CNA for 20 resident and therefore the Facility is doing better than what the State requires. CNA D explained that if you have residents who are short term and do things for themselves then 12 residents to 1 CNA is workable. He added that if you provide care for long term residents that need assistance with their Activities of Daily Living (ADLs), you cannot provide the care and supervision the residents need. On [DATE] at 1:25 PM LPN L indicated she has 31 residents on her assignment. She stated that her co-worker, the other nurse on this unit has 31 residents as well. LPN L explained that there used to be 3 nurses on this unit, but the facility downsized the nurses so that there are only 2 nurses on the unit now. She added that it was very difficult to get the work done and it was very stressful because we can't look at residents holistically. LPN L stated that during meals there is a CNA in the Dining/Day Room all the time. However, the nurse explained that she is not always available to provide supervision or assist the CNA in the dining room because she often is called away because someone needs something. She added that residents also eat in their rooms but we can't supervise them. She described the [MEDICATION NAME] Maneuver and indicated that you put your hands xyphoid process and push in and up. On [DATE] at 4:00 PM the Regional Consultant Nurse (RCN) stated that the facility did not provide the First Aid Class. She stated the facility only provides the space for the training. The outside instructor organizes the class and the staff are able to register for the class on their own time. A list of the staff that had taken the First Aid Class in the past two year was requested, but the facility did not provide the list after numerous requests. The next day, [DATE], at 4 PM the RCN explained that out of 153 staff, the facility only had documentation for 76 staff that were certified in First Aid. The RCN stated that the CNAs are not required to have First Aid Training, which is contrary to the DON's statements. The RCN added that the facility did not have a policy requiring First Aid Certification. On [DATE] at 4:10 PM CNA E stated that she works in Central Supply, but had a floor assignment as a CNA approximately 2 months ago. She stated that she assisted residents in the West Wing Dining Room. The CNA stated, CNAs do not need CPR/First Aid, it is not required. On [DATE] at 4:52 PM CNA R stated he has worked at the facility for 2 years and usually works on the ,[DATE] shift. His usual assignment is 12 to 13 resident per night. He added the sometimes the nurse will help out depending on who the nurse is that evening. He stated that he renewed his First Aide/CPR certification here at the facility. He had to pay $25.00 dollars and the class took 4 hours. CNA R stated that the facility schedules the class prior to your shift and that he get to clock in for attending the class. An interview with the Administrator on [DATE] at 4:20 PM revealed that the facility did not have a system in place to evaluate competencies of CNAs. The administrator stated that they did not conduct annual performance reviews for the CNAs. She said that the facility unionized and performance review were associated with pay increases, therefore they did not conduct annual performance appraisals. She stated that a competency skills assessment was reviewed at hire for skills such as using mechanical lifts. infection control, and documentation skills. That was the only time that competencies are assessed. She could not provide an answer when questioned as to how the facility assessed skills for CNAs that had been working for several years. The administrator could not provide any evidence that the staff have the necessary skills to perform their duties and competency to ensure resident safety. The Administrator stated that training was done via an electronic learning system (computerized self learning). The Administrator added that the facility provides training after each sentinel event. However, there no performance reviews to assess what was learned. On [DATE] at 5:36 PM the DON stated the current staff coordinator had a death in the family, therefore the DON been doing the staffing/scheduling with the assistance from the Assistant Director of Nursing. The DON stated that the daily staffing is based on the total resident census. She explained that on the 7a-3p shift there will be ,[DATE] residents per CNA and ,[DATE] residents per nurse. The 3p-11p shift will have ,[DATE] residents per CNA with ,[DATE] residents per nurse. The 11p-7a shift will have no more than 20 residents per CNA and no more that 40 residents per nurse. There was not any indication that the DON based the staffing upon the acuity of the residents their health and safety needs were being met. The DON did not explain why these staff to patient ratios were sufficient to meet the needs of the residents. There was not any indication that that the facility used staff feedback to address the staffing ratios and ensure each residents' highest practicable well being was being met. 2. On [DATE] at 5:45 PM resident #166 was observed to be restrained/isolated. The resident was in her room and the door that led out to the hallway was closed. The resident was in her wheelchair with the brakes were in the locked position. In the room there was an overbed table against the wall between the armoire and chest of drawers. The staff had wheeled the resident up against the overbed table to prevent the resident from rising out of her wheelchair. The resident was violently rocking back in attempt to free herself. The resident attempted to stand and was partially standing when she grabbed onto the sleeve of the surveyor. The surveyor attempted to redirect the resident but the resident was confused and held onto the sleeve tightly. The surveyor called for help to the Registered Nurse (RN) S who was in the hallway at the medication chart. The RN S looked into the room and did not assist the surveyor. The RN stated from outside the room that she would call the CNA. At 6 PM a CNA T came into the room and was able to free the surveyor. CNA T explained that she had positioned the resident against the over the bed table/wall and locked the resident wheelchair wheel brakes. She stated that the resident spends most of her time in the secure unit but eats in her room. The CNA stated the resident is brought back to the Secure Unit but not until all the residents in the Secure Unit Dining Room have finished eating. CNA T added that when resident #166 finished eating dinner she was placed in this position so that she would not try to get up from the wheelchair because she is at risk for falls. CNA T stated she has been working at the facility for a year and that the veteran CNAs taught her to place the resident in the room, facing the wall, with the over the bed table. CNA T stated, everybody (all staff) does it. The CNA stated that the resident can walk, but needs assistance, as she runs rather walking. CNA T described how the resident is positioned when she is in the Secure Unit's Dining/Day room. We put her at the back table in the secure unit dining/day room and put her brakes on so she can't get out. That is the only way we can keep her safe as the wall is to her back and the table is in front of her so she can't get out. At approximately 6:10 PM RN S attempted to explain why she did not assist/help surveyor when she requested help. RN S stated that she was passing out medication and had so many residents that she could not stop to help. When asked what would she do if resident #166 was in the room alone and attempting to free herself from the restraint, RN S did not provide an answer and kept on saying she did not have time. On [DATE] at 11:15 AM resident #166 was in the Secure Unit Dining/Day room in her wheelchair. The resident had her back to the wall and the resident/wheelchair was pushed up against a table. Immediately to the resident's right was an over the bed table that was up against a large trash bin so that the resident would not be able to get up/out. The resident was observed rocking her body back an forth as she sat in the wheelchair. Approximately five minutes later at 11:20 am RN Y stated that resident #166 has to be watched at all times because the resident will get up and start running and she is fast. RN Y added that at times she has the resident close to her and that the resident has to be watched all the the time. RN Y admitted that she she can not watch all the time and that the resident needs 1 to 1 supervision. On [DATE] at 12:45 PM the resident's niece sated that her father, resident #166's brother, visits the the resident every weekend and a few times during the week. The niece stated that her aunt (resident #166) needed a lot of attention. My father feels like she is a problem because find her in her room with the door closed and she is facing & scratching at the wall. He feels ruined when he sees her there by herself alone in the room. The niece stated that they find the resident in her room facing the wall every other weekend- about 50% of the time they visit. The niece added that her aunt gets frustrated when she is left in room secluded/restrained and that is why her aunt scratches the wall. She will grab onto people and not let them go as she is desperate and does not want the to leave her there. The niece stated We tell the staff and they say they will take care of it but happens again and again. Review of the job descriptions for nursing staff. Clinical Nurse I-LPN: . Department Assigned: Nursing Under Duties and Responsibilities: . 4. Conduct and document a thorough assessment of each resident's medical status upon admission and throughout the resident's course of treatment. Under Education: Graduate/Completion of approved/accredited school of nursing. Valid license as an LPN in the state of practice. Under Experience: Must have a minimum (1) year nursing experience preferred in a setting serving the dame age/type of resident population served by this facility, Under Specific Requirements: . No where in the Duties/Responsibilities; Education; Experience; or Specific Requirements does it mention that the LPN must be CPR/choking trained. Clinical Nurse I RN: (as with the LPN verbiage as mentioned above, there are no requirements that the RN's have to be CPR/choking certified. Certified Nursing Aide (CNA) : Review of the 5 page job description for the CNA revealed no requirement for the CNA to be CPR/choking certified. Review of the Policies and Procedures for Emergency Intervention- [MEDICATION NAME] Maneuver. Document Name: S-120 Effective Date: [DATE] Revision Date: blank 2. With one hand on top of the other, place the heel of the bottom hand on the abdomen slightly above the umbilicus and below the rib cage. 3. Press into the victim's abdomen with a quick upward thrust. 4. Repeat several times if necessary until food or foreign body has been removed. Review of the Orientation Checklist revealed there is under Advance Directive Education: Green light/Red light training, post test, and DNR at a glance. This deals with whether to do CPR or not to do CPR. Has nothing regarding the training of CPR. On the Licensed Nurse Skills Checklist under Performance Objectives it has Completes CPR Certification or shows proof of current certification. EXPIRATION DATE: No where in the entire Orientation packet and checklists does it indicate they would be giving CPR classes. It is the employee's responsibility to do get and do the training. A meeting was held with the administrative team on [DATE] at 11:00 AM and they were informed that Immediate Jeopardy had been identified. As a result of the meeting, the administrator provided the following corrective action plan on [DATE] at 8:10 PM. The facility conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on [DATE] with the medical director and all management staff. The team identified all residents as potential risk for choking. The affected resident, #46 was assessed by the nurse and the physician with orders for chest x-ray which showed right lower lobe consolidation. Orders were obtained for antibiotics, speech therapy and infectious disease consult. The resident's care plan and CNA kardex were reviewed and updated by the interdisciplinary team on [DATE]. All other residents (minus those that refused) were screened by speech therapy on [DATE] and evaluated by the licensed nurses to determine if their diets were suitable and if there were any concerns with eating. Of the 169 residents that were screened, 11 were identified with need for follow up with speech screening which was being conducted. On [DATE], nursing staff were educated on supervision of meals to ensure that residents were observed during meals for signs and symptoms of choking. Education included appropriate placement of hands to render emergency intervention in the event of a choking event using the [MEDICATION NAME] maneuver with return demonstration. On [DATE], licensed nurses were educated that diets could be downgraded if the resident experienced difficulty managing their diet such as coughing. The nurse should downgrade the diet texture until speech therapy evaluated the resident. Education was provided with return demonstration on the use of a suction machine to remove items which may obstruct a resident's airway. Suction machines were now placed in all dining rooms. On [DATE], beginning with dinner meal, a licensed nurse was assigned for supervision in each dining area as per staff schedule. The name of the CPR certified licensed nurse was also noted on the staff schedule. As of [DATE], 27 of 52 nurses and 77 of 102 CNAs had completed their education and return demonstration. No staff had or will be permitted to work until they had received education. A nurse manager/educator was assigned to meet, educate and perform required competencies to staff needing training prior to working their shift. An employee roster was kept of staff who had not received training for tracking purposes. Newly hired nursing staff would receive education and training with return demonstration upon hire during orientation. The facility contacted all resident families via telephone to inform them to check with the nurse regarding food consistency before giving their loved ones any food. The CPR policy and the [MEDICATION NAME] policy were reviewed and no revisions were required. QAPI will meet weekly or as required until substantial compliance was met with the 5 citations identified at Immediate Jeopardy. As of the exit time on [DATE], on-going in-services were continuing until all staff were educated prior to start of their shift. Observations, interviews and record reviews verified the removal of immediate jeopardy. The facility implemented sufficient measures to remove the immediacy and decrease the severity/scope as of [DATE], but the facility remains out of compliance with F353. The severity and scope of the deficiency was lowered to D-isolated, no actual harm with potential for no more than minimal harm to residents. As of [DATE], the plan of correction was not submitted to include the facility's plans to fully implement, monitor performance, and evaluate the effectiveness of their action plans to ensure sustained compliance.

Based on observation, interview, and record review, the facility failed to administer its resources effectively to ensure that supervision, care and services were provided to residents to prevent choking for 1 resident (#46) and 10 other residents with potential for choking, (#22, 40, 6, 65, 134, 157, 204, 94, 151 & 153) in the secure dementia unit and failed to ensure that furniture and resident equipment were not used to restrain for convenience and prevent 1 of 1 resident reviewed for restraints from being able to voluntarily move about the room (#166). Administration failed to provide a system to identify the level of supervision and staffing needed for the residents in the dementia unit during dining and did not use all resources available to provide adequate care and services. This failure resulted in substandard quality of care and Immediate Jeopardy on [DATE] and immediacy removed as of the exit date of [DATE]. Cross refer: F221 F323, F353, F498 Findings: 1. On [DATE] at 12:20 PM, resident #46 was observed eating lunch in the secure unit dining room. The secure unit is a locked area for cognitively impaired residents with potential exit seeking behaviors. There were 11 residents in the dining room and certified nursing assistant, CNA M was the only staff in the room passing out meal trays. Resident #46 was making choking movements, gagging and had spaghetti noodles hanging out of her mouth. CNA M had her back to the resident and was alerted by the surveyor that the resident needed help. After being alerted that resident #46 was choking, CNA M failed to administer first aid procedures to assist the choking resident. She patted the resident lightly on the shoulder and asked the resident if she was okay. At this time, CNA B entered the dining room and the surveyor instructed her to get the nurse. The resident attempted several times to clear her throat and by the third attempt she was able to pull the spaghetti noodles out of her mouth and spat up the remaining food. The licensed practical nurse, (LPN) N walked into the dining room several minutes after the resident had cleared her throat. She failed to assess the resident post choking incident and offered the resident more of the same food. The administrator's job description read, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. A review of the policy for meal service, (D-345) dated [DATE] read, Meals will be served to the residents in a courteous manner with supervision by the nursing staff. At least one member of the nursing staff will remain in the dining room until all residents have completed their meal. An interview with the director of nursing (DON) on [DATE] at 3:00 PM revealed that she was unaware if a licensed nurse was required in all the dining rooms during meals. She stated that she would find out the answer. She returned a few minutes later and stated that a licensed nurse was not required in all of the dining rooms. She stated that a licensed nurse was only required in the main dining room during meals as restorative dining was held there. She could not explain why a licensed nurse was not required in all the other dining rooms for supervision despite having complex residents there. She was not able to provide an answer as to why only one certified nursing assistant (CNA) was in the secure unit dining room for supervision. The secure unit was a locked unit with cognitively impaired residents with varying behaviors where the choking incident occurred. She stated that all the CNAs were first aid certified and were aware of what to do if a resident was choking. She said that having first aid training was a job requirement. She said that the facility provided first aid training monthly by an outside instructor for all staff to be certified in first aid including responding to a choking resident. When asked if any training or mock choking codes were provided by the facility, she stated no. She said the staff were taught how to respond to a choking resident during the first aid class which was an hour long. She could not provide a syllabus of the first aid class taught by the outside instructor after numerous requests. She could not provide an answer when asked how staff were trained to identify signs of choking in dementia residents as they may not exhibit typical signs of choking. She also could not provide an answer when asked how she monitored the effectiveness of the first aid training. Inconsistent to the director of nursing, the regional consultant on [DATE] at 4:00 PM, stated that the facility did not provide first aid training, they only provided the space for the training. She stated that the outside instructor organized the class and staff were able to register for the class on their own time. The facility did not pay for the staff to take the training. A list of the staff who had taken the training in the last two years was requested, but the facility did not provide the list after numerous requests. The regional consultant stated on [DATE] at 4:00 PM that out of 153 staff, they had documentation that 76 staff were certified in first aid which was half the facility staff but did not provide a list. She stated it was not a job requirement or policy for CNAs to have first aid training. An interview with the administrator on [DATE] at 4:20 PM revealed that the facility did not have a system in place to evaluate competencies of CNAs. The administrator stated that they did not conduct annual performance reviews for the CNAs. She said that the facility was unionized and performance reviews were associated with pay increases therefore they did not conduct annual performance appraisals. She stated that a competency skills assessment was conducted at hire for skills such as using mechanical lifts, infection control and documentation skills. That was the only time that competency was assessed. She could not provide an answer when questioned as to how the facility assessed skills for a CNA that had been working for several years. The administrator could not provide an answer when asked how she ensured that staff were trained and competent to perform their duties. She stated that training was done via electronic learning but could not explain how the learning was monitored for competency. She replied, after each sentinel event, we do training. However, there was no performance review to assess what was learned. Numerous interviews with CNAs, revealed that some CNAs had taken the first aid course at the facility. There were varying responses as to how long the first aid training was ranging from 45 minutes to 4 hours. Most of the CNAs were unable to identify the signs and symptoms of a cognitively impaired choking resident as these residents would not always show the typical signs of choking. The CNAs response to hand placement also varied from between the breasts to under the ribs. It was evident that the facility had failed to perform CNA competency and thus failed to identify care areas and skills needed for CNAs to respond expeditiously to meet the needs of a choking resident. The care plans of the other residents in the dining room (#6, 22, 40, 65, 94, 134, 151, 153, 157 & 204) showed that all residents had measures to assist with feeding as needed and to monitor their intake and record the percentage of meal consumed. Four of the residents had specific percentage of meal to be consumed (#65, 94, 134 & 151). In an interview conducted on [DATE] at 5:36 PM, the DON stated that staffing for the units was done according to the total census of the facility. She stated that a CNA would usually have ,[DATE] residents in her assignment on the day shift, ,[DATE] residents on the ,[DATE] shift and 20 residents on the night shift. The DON was unable to provide an answer when asked how the intake percentage of the residents was monitored when there was only one CNA in the dining room. The DON failed to account resident acuity into the staffing pattern and focused strictly on numbers to determine the facility staffing. She was not able to provide an answer as to why only one CNA was in the secure unit dining room during lunch on [DATE] when the resident choked and then 2 CNAs and a licensed nurse post choking incident on [DATE]. The facility failed to demonstrate an overall awareness of the serious threat that choking can have on residents. The facility relied on the outside instructor for CNA competency related to first aid skills for choking. The facility did not utilize their resources to staff according to acuity of residents verses number of residents therefore, did not provide care to meet the residents' highest sense of well being. 2. On [DATE] at 5:45 PM, the resident #166's room door was closed. After knocking to gain entrance, she was observed in her room. She was in her wheelchair pushed up against an overbed table with the brakes in the locked position facing the wall. The overbed table was wedged between a chest of drawers and a dresser. The resident's bed was to her back. The resident was violently rocking back and forth trying to push her wheelchair forward and backward. She attempted to stand up, but the overbed table in front of her was preventing her from getting up. On the wall within the resident's reach was a round area where the paint had been peeled off measuring 2 feet by 2 feet. There were fragments of peeling paint remaining at the edges. On [DATE] CNA T entered the room at 6:00 PM and was able to free the surveyor's sweater sleeve from the resident. She stated that she had placed the resident in the wheelchair with with the brakes locked, in front of the wall and the overbed table. She stated that she assisted the resident with her dinner and then left her there as there was no one to watch her. She stated that the resident spent her day in the secure unit dining which was supervised, but was assisted for meals in her room. After her meal, she is taken back to the secure unit dining room, but not until all the residents in that dining room have completed their meal. She said that the resident was placed in this position so that she would not try to get up from her wheelchair as she would fall. She said the resident could walk, but needed assistance as she runs rather than walking. We put her at the back table in the secure unit dining room and put her brakes on so she can't get out. That is the only way we can keep her safe as the wall is to her back and the table is in front of her so she can't get out. She stated that everyone did this as they did not have time to sit with the resident to keep her from getting out of her wheelchair. She said she was told to do this from other CNAs who care for resident #166. An interview with RN S on [DATE] at 6:10 PM revealed that she did not know resident #166 very well and did not know that the staff were restraining the resident in her room because they did not have time to sit with the resident to keep her from getting out of her wheelchair. An interview with the unit manager on [DATE] at 11:10 AM noted that she was aware of the peeling paint in the resident's room. She stated that the resident picked at the paint on the wall when they place her there for meals. She could not provide an answer as to why the staff were restraining the resident in her room after meals. She said she was aware that the CNAs were assisting resident with meals in her room, but was not aware that they kept her restrained in this manner after meals. An interview with the director of nursing and administrator on [DATE] at 2:00 PM revealed that they were both unaware that the resident #166 was restrained left in her room unable to move and with the door closed. The DON stated that the resident was to be observed closely in the secure unit dining room, but could not answer when asked if she observed the resident daily during or post meals. An interview with the maintenance director on [DATE] at 11:25 AM revealed that he was aware that the resident picked at the paint. He stated that she picked at the paint when the staff left her there, I have seen her do that. A meeting was held with the administrative team on [DATE] at 11:00 AM and they were informed that Immediate Jeopardy had been identified. As a result of the meeting, the administrator provided the following corrective action plan on [DATE] at 8:10 PM. The facility conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on [DATE] with the medical director and all management staff. The team identified all residents as potential risk for choking. The affected resident, #46 was assessed by the nurse and the physician with orders for chest x-ray which showed right lower lobe consolidation. Orders were obtained for antibiotics, speech therapy and infectious disease consult. The resident's care plan and CNA kardex were reviewed and updated by the interdisciplinary team on [DATE]. All other residents (minus those that refused) were screened by speech therapy on [DATE] and evaluated by the licensed nurses to determine if their diets were suitable and if there were any concerns with eating. Of the 169 residents that were screened, 11 were identified with need for follow up with speech screening which was being conducted. On [DATE], nursing staff were educated on supervision of meals to ensure that residents were observed during meals for signs and symptoms of choking. Education included appropriate placement of hands to render emergency intervention in the event of a choking event using the [MEDICATION NAME] maneuver with return demonstration. On [DATE], licensed nurses were educated that diets could be downgraded if the resident experienced difficulty managing their diet such as coughing. The nurse should downgrade the diet texture until speech therapy evaluated the resident. Education was provided with return demonstration on the use of a suction machine to remove items which may obstruct a resident's airway. Suction machines were now placed in all dining rooms. On [DATE], beginning with dinner meal, a licensed nurse was assigned for supervision in each dining area as per staff schedule. The name of the CPR certified licensed nurse was also noted on the staff schedule. As of [DATE], 27 of 52 nurses and 77 of 102 CNAs had completed their education and return demonstration. No staff had or will be permitted to work until they had received education. A nurse manager/educator was assigned to meet, educate and perform required competencies to staff needing training prior to working their shift. An employee roster was kept of staff who had not received training for tracking purposes. Newly hired nursing staff would receive education and training with return demonstration upon hire during orientation. The facility contacted all resident families via telephone to inform them to check with the nurse regarding food consistency before giving their loved ones any food. The CPR policy and the [MEDICATION NAME] policy were reviewed and no revisions were required. QAPI will meet weekly or as required until substantial compliance was met with the 5 citations identified at Immediate Jeopardy. As of the exit time on [DATE], on-going in-services were continuing until all staff were educated prior to start of their shift. Observations, interviews and record reviews verified the removal of immediate jeopardy. The facility implemented sufficient measures to remove the immediacy and decrease the severity/scope as of [DATE], but the facility remains out of compliance with F490. The severity and scope of the deficiency was lowered to D-isolated, no actual harm with potential for no more than minimal harm to residents. As of [DATE], the plan of correction was not submitted to include the facility's plans to fully implement, monitor performance, and evaluate the effectiveness of their action plans to ensure sustained compliance.

Based on observation, interview, and record review, the facility failed to ensure that certified nursing assistants (CNA) were competent with the necessary skills and techniques to respond to a cognitively impaired choking resident, (#46) and 10 other cognitively impaired residents who were at risk for potential choking, (#22, 40, 6, 65, 134, 157, 204, 94, 151 & 153) in the secure dementia unit and to keep residents free from physical restraints for convenience (#166) The failure of the CNAs to respond appropriately to a choking resident resulted in substandard quality of care and Immediate Jeopardy starting on [DATE] and the immediacy was removed onsite on [DATE]. The severity and scope was lowered to D-no actual harm with potential for more than minimal harm that is not immediate jeopardy-isolated. Cross refer: F221, F323, F353, F490 Findings: 1. On [DATE] at 12:20 PM, resident #46 was observed eating lunch in the secure unit dining room. The secure unit is a locked area for cognitively impaired residents with potential behaviors such as exit seeking. There were 11 residents in the dining room and certified nursing assistant, CNA M was the only staff in the room passing out meal trays. Resident #46 was observed making choking movements, gagging and had spaghetti noodles hanging out of her mouth. CNA M had her back to the resident and was alerted by the surveyor that the resident needed help. After being alerted that resident #46 was choking, CNA M failed to administer first aid procedures to assist the choking resident. She patted the resident lightly on the shoulder and asked the resident if she was okay. At this time, CNA B entered the dining room and the surveyor instructed her to get the nurse. The resident attempted several times to clear her throat and by the third attempt she was able to pull the spaghetti noodles out of her mouth and spat up the remaining food. On [DATE] at 3:00 PM the director of nursing, (DON) was asked how she monitored the care and services to ensure quality especially in the dementia unit. She stated that all the CNAs were first aid certified and were aware of what to do if a resident was choking. She said that having first aid training was a job requirement. She said that the facility provided first aid training monthly by an outside company for all staff to be certified in first aid including responding to a choking resident. When asked if any training or mock choking codes was provided by the facility, she stated that the facility had not done mock choking codes or any training on choking. The staff were taught how to respond to a resident choking during the first aid class which was an hour long. She could not provide a syllabus of the first aid class taught by the outside instructor despite numerous requests. She could not provide an answer when asked how staff were trained to identify signs of choking in dementia residents as they may not exhibit typical signs of choking. Inconsistent with the director of nursing, the regional consultant on [DATE] at 4:00 PM, stated that the facility did not provide first aid training, they only provided the space for the training. She stated that the outside instructor organized the class and staff were able to register for the class on their own time. The facility did not pay for the staff to take the training. A list of the staff who had taken the training in the last two years was requested but the facility did not provide the list despite numerous request. The regional consultant stated on [DATE] at 4:00 PM that out of 153 staff, they had documentation that 76 staff were certified in first aid which was half the facility staff, but did not provide a list. She stated that CNAs are not required to have first aid training and it was not in their policy for CNAs to have first aid training. A review of the CNA job description did not include first aid certification as a job function. An interview with the administrator on [DATE] at 4:20 PM revealed that the facility did not have a system in place to evaluate competencies of CNAs. The administrator stated that they did not conduct annual performance reviews for the CNAs. She said that the facility was unionized and performance reviews were associated with pay increases therefore they did not conduct annual performance appraisals. She stated that a competency skills assessment was conducted at hire for skills such as using mechanical lifts, infection control and documentation skills. That was the only time that competency was assessed. She could not provide an answer when questioned as to how the facility assessed skills for a CNA that had been working for several years. The administrator could not provide an answer when asked how she ensured that staff were trained and competent to perform their duties. She stated that training was done via electronic learning, but could not explain how the learning was monitored for competency. She replied, after each sentinel event, we do training. However, there was no performance review to assess what was learned. Based on numerous interviews with CNAs, it was evident that the facility had failed to perform CNA competency and thus failed to identify care areas and skills needed for CNAs to respond expeditiously to meet the needs of a choking resident. An interview with CNA M on [DATE] at 1:45 PM revealed that she had training on choking when she did her first aid training every two years, but could not recall when she had the training. She stated she had not had any training on choking at the facility. She stated that she should have attempted to clear the resident's mouth first and if necessary perform an abdominal thrust. An interview with CNA A on [DATE] at 1:50 PM noted that she had worked at the facility for [AGE] years. She had never had any mock training on choking or any training in the facility. She stated she had first aid training 2 years ago which was about 45 minutes to an hour long. She stated that she would feel comfortable dealing with a resident who was choking as she watched a lot of emergency programs on television and felt she was prepared. An interview with CNA V on [DATE] at 2:00 PM revealed that she had worked at the facility for 8 months and had not received any training on choking. She had received training when she did first training prior to working at the facility. She stated that if a resident was choking, she would call the nurse, but was not able to describe proper placement to do abdominal thrust. On [DATE] at 1:55 PM CNA X stated that she had worked at the facility for [AGE] years and had not received training on choking residents. She stated that the nurse had given an informal inservice on [MEDICATION NAME] maneuver 4 months ago. She was unable to describe where the hands were to be placed on a choking victim. On [DATE] at 1:58 PM, CNA Q stated that she had worked at the facility for [AGE] years and had not had any training on choking at the facility. She stated that she was aware of the signs of choking as you can see it in the resident's eyes and that the resident is turning blue. She could not recall when she last had first aid training. She was not able to discuss the [MEDICATION NAME] maneuver properly as she was insistent that the hand placement should be below the resident's ribs. The facility must ensure that certified nursing assistants are trained and competent in skills and methods required to care for cognitively impaired residents including unexpected incidents such as choking. It is evident that the facility did not have a system in place to assess the competency of CNAs with skills necessary to provide appropriate care and services. Therefore, no training was provided to the CNAs to ensure they were able to respond efficiently to a resident that was choking. 2. On [DATE] at 5:45 PM, the resident #166's room door was closed. After knocking to gain entrance, she was observed in her room. She was in her wheelchair pushed up against an overbed table with the brakes in the locked position facing the wall. The overbed table was wedged between a chest of drawers and a dresser. The resident's bed was to her back. The resident was violently rocking back and forth trying to push her wheelchair forward and backward. She attempted to stand up, but the overbed table in front of her was preventing her from getting up. On the wall within the resident's reach was a round area where the paint had been peeled off measuring 2 feet by 2 feet. There were fragments of peeling paint remaining at the edges. On [DATE] CNA T entered the room at 6:00 PM and was able to free the surveyor's sweater sleeve from the resident. She stated that she had placed the resident in the wheelchair with with the brakes locked, in front of the wall and the overbed table. She stated that she assisted the resident with her dinner and then left her there as there was no one to watch her. She stated that the resident spent her day in the secure unit dining which was supervised, but was assisted for meals in her room. After her meal, she is taken back to the secure unit dining room, but not until all the residents in that dining room have completed their meal. She said that the resident was placed in this position so that she would not try to get up from her wheelchair as she would fall. She said the resident could walk, but needed assistance as she runs rather than walking. We put her at the back table in the secure unit dining room and put her brakes on so she can't get out. That is the only way we can keep her safe as the wall is to her back and the table is in front of her so she can't get out. She stated that everyone did this as they did not have time to sit with the resident to keep her from getting out of her wheelchair. She said she was told to do this from other CNAs who care for resident #166. An interview with the unit manager on [DATE] at 11:10 AM noted that she was aware of the peeling paint in the resident's room. She stated that the resident picked at the paint on the wall when they place her there for meals. She could not provide an answer as to why the staff were restraining the resident in her room after meals. She said she was aware that the CNAs were assisting resident with meals in her room, but was not aware that they kept her restrained in this manner after meals. An interview with the director of nursing and administrator on [DATE] at 2:00 PM revealed that they were both unaware that the resident #166 was restrained left in her room unable to move and with the door closed. The DON stated that the resident was to be observed closely in the secure unit dining room, but could not answer when asked if she observed the resident daily during or post meals. A meeting was held with the administrative team on [DATE] at 11:00 AM and they were informed that Immediate Jeopardy had been identified. As a result of the meeting, the administrator provided the following corrective action plan on [DATE] at 8:10 PM. The facility conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on [DATE] with the medical director and all management staff. The team identified all residents as potential risk for choking. The affected resident, #46 was assessed by the nurse and the physician with orders for chest x-ray which showed right lower lobe consolidation. Orders were obtained for antibiotics, speech therapy and infectious disease consult. The resident's care plan and CNA kardex were reviewed and updated by the interdisciplinary team on [DATE]. All other residents (minus those that refused) were screened by speech therapy on [DATE] and evaluated by the licensed nurses to determine if their diets were suitable and if there were any concerns with eating. Of the 169 residents that were screened, 11 were identified with need for follow up with speech screening which was being conducted. On [DATE], nursing staff were educated on supervision of meals to ensure that residents were observed during meals for signs and symptoms of choking. Education included appropriate placement of hands to render emergency intervention in the event of a choking event using the [MEDICATION NAME] maneuver with return demonstration. On [DATE], licensed nurses were educated that diets could be downgraded if the resident experienced difficulty managing their diet such as coughing. The nurse should downgrade the diet texture until speech therapy evaluated the resident. Education was provided with return demonstration on the use of a suction machine to remove items which may obstruct a resident's airway. Suction machines were now placed in all dining rooms. On [DATE], beginning with dinner meal, a licensed nurse was assigned for supervision in each dining area as per staff schedule. The name of the CPR certified licensed nurse was also noted on the staff schedule. As of [DATE], 27 of 52 nurses and 77 of 102 CNAs had completed their education and return demonstration. No staff had or will be permitted to work until they had received education. A nurse manager/educator was assigned to meet, educate and perform required competencies to staff needing training prior to working their shift. An employee roster was kept of staff who had not received training for tracking purposes. Newly hired nursing staff would receive education and training with return demonstration upon hire during orientation. The facility contacted all resident families via telephone to inform them to check with the nurse regarding food consistency before giving their loved ones any food. The CPR policy and the [MEDICATION NAME] policy were reviewed and no revisions were required. QAPI will meet weekly or as required until substantial compliance was met with the 5 citations identified at Immediate Jeopardy. As of the exit time on [DATE], on-going in-services were continuing until all staff were educated prior to start of their shift. Observations, interviews and record reviews verified the removal of immediate jeopardy. The facility implemented sufficient measures to remove the immediacy and decrease the severity/scope as of [DATE], but the facility remains out of compliance with F498. The severity and scope of the deficiency was lowered to D-isolated, no actual harm with potential for no more than minimal harm to residents. As of [DATE], the plan of correction was not submitted to include the facility's plans to fully implement, monitor performance, and evaluate the effectiveness of their action plans to ensure sustained compliance.

Based on record review and interview, the facility failed to appropriately transfer a resident who had a transfer/discharge appeal pending for 1 of 4 sampled residents (#300). The facility's failure to permit the resident to remain in the facility while the appeal was pending resulted in actual harm having a negative psychosocial impact to resident #300. Findings: Resident #300 was admitted to the facility on [DATE] for rehabilitation and medical management after a recent hospital stay. He has a history of multiple cerebral infarction with residual lower extremity weakness and right upper extremity weakness, wheelchair bound, Diabetes Mellitus Type I, Hypertension, and High Blood Sugar. On 5/03/17 the facility served resident #300 with a 30-Day Nursing Home Transfer and Discharge Notice. The notice stated Resident #300 was going to be transferred from his current location to another facility that is owned by the same company. The other facility was located approximately 60 miles away, in Lakeland Florida. The facility in Lakeland offers the same services as Resident #1's current facility, so Resident #300 would not receive any additional services than what he was already receiving. On the transfer form under, Reasons for the Transfer was, Your needs cannot be met in this facility, and the health of other individuals in this facility is endangered. The Brief explanation to support this action portion of the form read that the resident did not comply with facility rules, curses loudly, and was leaving the facility without an order. The place on the form for the resident to sign notice received by indicated the resident refused to sign the form. During an interview on 6/14/17 at 1:00 PM, with the Social Services Director (SSD), she stated, that resident #300 did not want to go to Lakeland, and so she began looking for another Nursing Home placement. She confirmed that the facility did not rescind the 30-day Notice, and at the end of 30 days she didn't know what she would have done with Resident #300. I don't know what I would have done, I guess we would have kept looking or transferred him to Lakeland. Resident #300 contacted his case manager at Sunshine Medicaid, his insurance company, and requested they file an Appeal on his behalf, contesting the transfer. On 5/09/17 a Verbal Request for Hearing was received in the Office of Appeal Hearings in Tallahassee, Florida. On 5/11/17, an Order to Produce Notice and Begin Hearing Process was entered notifying all parties involved about the upcoming hearing that will be scheduled. A copy of the Notice was sent to Resident #300, the facility, the Ombudsman, and the Agency for Healthcare Administration (AHCA). In an interview on 6/14/17 at 10:20 AM, the SSD stated that the facility received the Notice of Hearing around 5/11/17, and the facility was aware of the resident's appeal and the hearing. On 5/24/17, a Florida Ombudsman Program Investigator went to the facility to meet with Resident #300 and the facility staff in reference to the resident receiving a Notice of Transfer/Discharge, and the appeal that was currently pending. Review of the ombudsman notes revealed resident #300 stated he was born and raised in Orlando and he did not want to go to a facility in Lakeland, but he may agree to go to an Adult Family Care Home (AFCH), so he could retain his freedom. The facility Administrator was informed by the investigator that he would consider an AFCH, and she agreed to look for placement in an AFCH for him. On 6/02/17, the facility discharged Resident #300 to an Assisted Living Facility (ALF), not an AFCH. When resident #300 arrived at the facility, the receiving facility found out that he required insulin injections and needed a mechanical lift for transfers. At that point, the Administrator for the ALF stated the facility was unable to accept resident #300, as they could not meet his needs. The resident was then transferred to an Acute Care Hospital where he waited for several days, until he was transferred to another nursing home in the Orlando area. In a telephone interview on 6/14/07 at 12:35 PM with the ALF Administrator, he stated the facility was not aware of resident #300's needs. He confirmed that an onsite evaluation was completed when the resident was still in the nursing home, but not all of the resident's information was available at the time of the visit. He stated when resident #300 arrived at his facility, he found out that the resident had a prescription for insulin and used a mechanical lift for transfers. He asked the resident if he had to use a mechanical lift for transfers, because he was informed by the nursing home that the resident could transfer himself. Resident #300 stated he could not transfer without the mechanical lift. The resident also had right sided weakness, and was unable to give himself insulin injections. The ALF Administrator stated their facility cannot give insulin to a resident and they were not aware he required injections for diabetes when they accepted him. The ALF Administrator called transport and had the resident taken to the hospital because he couldn't stay at his facility. The ALF Administrator stated that the nursing home did not send completed paperwork for the resident, and did not send a medication list prior to the resident leaving their facility. He said the nursing home staff told him that Resident #300 was independent with his medications and transfers. He said if he had known that the resident needed so much care he never would of accepted him and he would not have needed to send him to the hospital. A telephone interview with resident #300 was conducted on 6/14/17 at 3:10 PM. During the interview he was very upset, and would cry on and off during the interview. He did not agree to the transfer to an ALF, and feels the nursing home facility forced him to go and ignored the appeal. He said he felt especially bad when they called the police to make him leave, even though he repeatedly told the facility he didn't want to leave. He felt the facility treated him like an animal. On the day of discharge, before Resident #300 left, he told staff, at the facility, that he did not want to leave, and wanted to stay because there was a hearing coming up. He stated that while the police and staff were in his room, he called the Ombudsman investigator, who was at the facility a few weeks prior, and told her that the facility was trying to make him leave. He then called his Case Manager at Medicaid and advised her of the situation. Resident #300 stated that they both told the facility not to transfer him at that time and they needed to wait for the resident's hearing date. A telephone interview was completed with the Ombudsman on 6/14/17 at 2:24 PM. She confirmed that she was in the facility few weeks prior to the transfer of the resident. When she arrived at the facility she met with the Administrator and the director of nursing (DON). She advised them that their office had received an appeal on a transfer/discharge for Resident #300 and then she met with Resident #300. At the conclusion of her meeting with the resident, Administrator, and DON, the Ombudsman stated the facility was aware that Resident #300 was appealing his transfer from their facility. The Ombudsman stated on 6/02/17 she received a frantic phone call from Resident #300. The resident was telling her that the facility was trying to make him leave to another facility and he didn't want to go. During this conversation the resident put the Ombudsman on speaker phone. She stated that there was a lot of yelling. A woman in the room identified herself as being in charge, but refused to give her name. The Ombudsman said that she told this person that the resident does not want to leave the facility and they should not transfer him at this time because the resident has an appeal hearing coming up. The Ombudsman stated she knew the facility heard her and at that point she thought the facility had stopped the resident's transfer. She also stated she did not receive any notification from the facility that the resident had been transferred. On 6/15/17 at 3:00 PM an interview was completed with the Assistant Director of Nursing (ADON). The ADON acknowledged that she was the only person in charge the day of Resident #300's transfer. She stated that she called Law Enforcement because when she gave the resident his transfer papers, the resident became abusive, and kept telling the facility that he didn't want to leave. She stated since the transfer/discharge was written, she called law enforcement to assist with the transfer. She confirmed that the resident called someone while she was in the room and he had his phone on the speaker during this encounter, but she didn't know who it was. A review of Resident #300's Medical Record was completed and a copy of the Nursing Home Transfer and Discharge Notice was filed inside. Under the section, Requesting An Appeal of this Decision, it states, .If you request a fair hearing within 10 days after receiving this notice, you will not be transferred or discharged until the hearing decision has been make, unless your circumstances requires an emergency transfer or discharge Resident #300 was served a copy of this notice on 5/03/17, and he filed his appeal on 5/09/17, which is 6 days after receipt, but less than 10 days, as indicated on the Transfer and Discharge Notice. His hearing was scheduled for June 20, 2017, but the facility transferred him on June 2, 2017 prior to any decision regarding his appeal.

Based on record review and interview, the facility failed to provide appropriate and accurate documentation to a transfer facility and failed to properly prepare a resident for a safe transfer for 1 of 4 sampled residents (#300). The facility's failure to provide provide appropriate and accurate documentation to prepare resident #300 for transfer resulted in actual harm having a negative psychosocial impact to resident #300 and subsequent additional unnecessary transfer to an acute care hospital. Findings: Resident #300 was admitted to the facility on [DATE] for rehabilitation and medical management after a recent hospital stay. He has a history of multiple cerebral infarction with residual lower extremity weakness and right upper extremity weakness, wheelchair bound, Diabetes Mellitus Type I, Hypertension, and High Blood Sugar. On 5/03/17 the facility served resident #300 with a 30 Day Nursing Home Transfer and Discharge Notice. The notice stated Resident #300 was going to be transferred from his current location to another facility, owned by the same company and providing him with the same services, but it was approximately 60 miles away in Lakeland Florida. Resident #300 refused to accept the transfer/discharge and filed an Appeal with the State of Florida on 5/03/17. On the 30 Day Transfer and Discharge Notice, it states that if a resident files an appeal within 10 days of receiving the notice, the facility will not transfer the resident, except in emergencies, to another facility until after the hearing. On 6/02/17 the resident was transferred to a different facility than the one listed on the transfer/discharge notice. The resident was transferred to an assisted living facility (ALF). On 5/30/17, the accepting ALF, came into the facility to evaluate the resident for placement. At the time the ALF visited the facility, resident #300's, Resident Health Assessment for Assisted Living Facilities Form 1823, required for admission to the ALF, was not yet completed and it had not been signed by the resident's physician. In an interview with the ALF's Administrator on 6/14/17 at 12:00 PM, he stated that when resident #300 was evaluated for placement, the facility had not yet completed the 1823 paperwork. He said the nursing home (NH) facility withheld information from him about the resident's current medical conditions and daily resident needs. The facility did not inform the ALF administrator that the resident needed maximum assistance with transfers and required a mechanical lift for all transfers. They also did not disclose that Resident #300 was also unable to administer his own medications. The ALF Administrator stated he requested a completed 1823 form, and the Social Services Director said she would finish the paperwork and fax it to him later. The ALF Administrator stated that when he did finally receive the 1823 form from the facility it did not state that the resident needed a mechanical lift, and under the medication section the form said see attached, but there was not a copy of the medication list sent with the faxed form. It was not until the resident arrived at his facility did he understand the extent of resident #300's needs, and he realized that his facility was unable to meet the needs of the resident. He said that when the resident arrived at his facility he did not have any of his medications with him and the resident required insulin and blood pressure mediations. A review of the 1823 form was completed and under Physical or sensory limitations, it states the resident is wheelchair-bound, but it does not state that the resident has paralysis to his bi-lateral lower extremities and has paralysis to his right arm. Under Section 1.: Health Assessment A. To what extent does the individual need supervision or assistance with the following? If S=Needs Supervision or A= Needs Assistance is indicated, please explain the extent and type of supervision or assistance needed in the comments column. Under Bathing, Dressing, Toileting, and Transferring it is checkmarked that Resident #300 needs assistance in these areas, but the comments section is blank, and does not state the extent or type of assistance needed for the resident. Under section C. Does the individual have any of the following conditions/requirement? If yes, please include an explanation in the comments column. Number 4. Pose a danger to self or others? It is marked No, but on the 30 day discharge notice given to the resident on 5/3/17, it states that the reason the resident is being discharged is related to, The health of other individuals in our facility is endangered. In Section 2-B: Self-Care and General Oversight Assessment-Medications. A. Please list all current medications prescribed below, it states, See Attached. V. Does the Individual need help with taking his or her medications (meds)? Yes/No, neither are selected. If yes, please place a checkmark in front of the appropriate box below. It is checkmarked next to the box, Needs Assistance with Self-Administration of Medications, this allows unlicensed staff to assist with orals and topical medication. Next to this box is a box that states, Needs Medication Administration, Not all ALFs have licensed staff to provide this service. This box is not selected, even though Resident #300 requires assistance with his insulin injections. Resident #300's minimum data set assessment dated , 4/10/17, showed the resident needed total assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #300's last treatment from Physical Therapy shows the resident is Maximal assist with all bed mobility and transfers. During an interview with the SSD on 6/14/17 at 1:00 PM, she stated she does not review medications or medical information to any ALF staff that come in to see a resident for possible placement. She stated it is up to the evaluating facility to retrieve that information. When an ALF representative comes into the facility she takes them to a resident's room, introduces them, and shows the representative where the nurses station is. She said it is up to the representative to ask the nurses for information regarding the resident, we do not offer it until asked. The SSD confirmed during her interview that she did not write on the 1823 that the resident required a mechanical lift, and she wasn't sure if the ALF was aware that he needed one. She also confirmed that she checked the, Needs Assistance with Self-Administration of Medications, on the resident's 1823 form, and that was correct, because ALF's can't give insulin. She said she checked that box and then arranged for Home Health Care to come in and give the resident his insulin injections multiple times per day. The 1823 was signed by the attending physician's Nurse Practitioner (NP) on 5/31/17. A review of the SSD progress note on 5/31/17, states the NP signed the 1823 for resident #300, On 6/01/17 at 10:00 AM, the SSD wrote she met with the resident and informed him he was being transferred by the NP to a lower level of care. She explained the transfer was scheduled for Friday, 6/2/17. During a telephone interview completed with resident #300 on 6/14/17 at 3:10 PM he stated he did not agree with the transfer to the ALF. He confirmed that a man did come and talk to him, but he did not agree to a transfer at any point. He said he was not asked about using a mechanical lift or his injections. He did not visit the ALF or receive any preparation for moving to the ALF. Resident #300 stated that the facility knew that he didn't want to leave, and he was appealing the 30 day transfer/discharge they had served on him. Resident # 300 said he believed that he would not be sent anywhere until after the hearing date. He stated when he arrived at the facility, the ALF Administrator told him they couldn't take care of him, and he couldn't use his mechanical lift at the facility. He was only there a few hours until he was transferred again to the hospital because they said they couldn't take care of him. After several days at the hospital, he was transferred again to another skilled nursing facility, like the facility from which he was originally discharged .

Based on observation, interview and record review, the facility failed to ensure that furniture and resident equipment were not used to restrain and prevent 1 of 1 resident reviewed for restraints from being able to voluntarily move about the room (#166). The facility's failure to ensure resident #166 was free from physical restraints used for convenience resulted in actual harm having a negative psychosocial impact. Cross reference: F353, F490, F498 Findings: Resident #166 was admitted to the facility in September 2016 with [DIAGNOSES REDACTED]. On 6/30/2017 at 5:45 PM, the resident's room door was closed. After knocking to gain entrance, she was observed in her room. She was in her wheelchair pushed up against an overbed table with the brakes in the locked position facing the wall. The overbed table was wedged between a chest of drawers and a dresser. The resident's bed was to her back. The resident was violently rocking back and forth trying to push her wheelchair forward and backward. She attempted to stand up, but the overbed table in front of her was preventing her from getting up. On the wall within the resident's reach was a round area where the paint had been peeled off measuring 2 feet by 2 feet. There were fragments of peeling paint remaining at the edges. When the surveyor approached the resident, she grabbed onto the sleeve of the surveyor's sweater tightly. The surveyor called out to the nurse who was in the hallway at the medication cart. The registered nurse, RN S looked in the room, but did not enter the room. She stated from outside the room that she would call the certified nursing assistant, (CNA). The surveyor called out to the nurse that help was needed, but the nurse, RN S walked away. She was heard calling out to the CNA to come to the resident's room to assist. The CNA T entered the room at 6:00 PM and was able to free the surveyor's sweater sleeve from the resident. She stated that she had placed the resident in the wheelchair with the brakes locked, in front of the wall and the overbed table. She stated that she assisted the resident with her dinner and then left her there as there was no one to watch her. She stated that the resident spent her day in the secure unit dining which was supervised, but was assisted for meals in her room. After her meal, she is taken back to the secure unit dining room, but not until all the residents in that dining room have completed their meal. She said that the resident was placed in this position so that she would not try to get up from her wheelchair as she would fall. She said the resident could walk, but needed assistance as she runs rather than walking. We put her at the back table in the secure unit dining room and put her brakes on so she can't get out. That is the only way we can keep her safe as the wall is to her back and the table is in front of her so she can't get out. She stated that everyone did this as they did not have time to sit with the resident to keep her from getting out of her wheelchair. She said she was told to do this from other CNAs who care for resident #166. An interview with RN S on 6/30/2017 at 6:10 PM revealed that she did not know resident #166 very well and did not know that the staff were restraining the resident in her room because they did not have time to sit with the resident to keep her from getting out of her wheelchair. An interview with the unit manager on 7/01/17 at 11:10 AM noted that she was aware of the peeling paint in the resident's room. She stated that the resident picked at the paint on the wall when they place her there for meals. She could not provide an answer as to why the staff were restraining the resident in her room after meals. She said she was aware that the CNAs were assisting resident with meals in her room, but was not aware that they kept her restrained in this manner after meals. An interview with the maintenance director on 7/01/17 at 11:25 AM revealed that he was aware that the resident picked at the paint. He stated that she picked at the paint when the staff left her there, I have seen her do that. During a telephone interview with the resident's niece on 7/01/17 at 12:45 PM, she stated that her father, the resident's brother, visited the resident every weekend and at least a few times during the week. She stated that the resident needed a lot of attention. My father feels like she is a problem because we find her in her room with the door closed and she is facing the wall and scratching at the wall. He feels ruined when he sees her there by herself alone in the room. She said they find her in her room facing the wall every second weekend, about 50% of the time of their visits. She gets frustrated when she is left there and that is why she scratches at the wall. She will grab onto people and not let them go as she is desperate and she does not want them to leave her there. We tell the staff and they said they will take care of it, but it happens again and again. An interview with the director of nursing and administrator on 7/01/17 at 2:00 PM revealed that they were both unaware that the resident #166 was restrained and left in her room unable to move and with the door closed. The DON stated that the resident was to be observed closely in the secure unit dining room, but could not answer when asked if she observed the resident daily during or post meals. A review of the resident's care plan for safety dated 5/02/17 read to keep resident in a highly visible area when out of bed, and check on the resident every 15 minutes. There was no mention of assisting the resident with meals in her room.

Based on observation, interview and record review the facility failed to treat 1 of 4 sampled residents reviewed for transfer/discharge with respect and dignity to promote the resident's quality of life (#300) and failed to treat 5 of 47 sampled residents with dignity during dining, (#118, 185, 218, 100 & 96). The facility's failure to treat resident #300 with respect and dignity during the transfer/discharge process resulted in actual harm having a negative psychosocial impact. Findings: 1. Resident #300 was admitted to the facility on [DATE] for rehabilitation and medical management after a recent hospital stay. He has a history of multiple cerebral infarction with residual lower extremity weakness and right upper extremity weakness, wheelchair bound, Diabetes Mellitus Type I, Hypertension, and High Blood Sugar. On 5/03/17 the facility served resident #300 with a 30-Day Nursing Home Transfer and Discharge Notice. The notice stated he was going to be transferred from his current location to another facility, owned by the same company and providing the same services the resident was currently receiving, but it was 60 miles away. The transfer would not improve the resident's physical or emotional well-being. On the Transfer Form under, Reasons for the transfer was, Your needs cannot be met in this facility, and the health of other individuals in this facility are endangered. Resident #300 stated in his interview on 6/14/17 at 3:10 PM, that he did not have a problem with the residents at the facility and only argued with the staff that worked there because they would not do their job. The resident stated that he felt the staff were horrible there, but he still didn't want to leave the facility because he was born and raised in the Orlando area. When resident #300 was served with the 30-day transfer/discharge notice on 5/03/17, he refused to sign the paperwork because he did not agree with the discharge. The notice included the resident had a right to appeal the decision if he disagreed with it. The notice indicated if he requested a fair hearing to appeal within 10 days of receiving the notice, he would not be transferred or discharged until the hearing decision was made, unless he required an emergency transfer or discharge. Resident #300 received the notice on 5/03/17 and his case manager at Sunshine Medicaid, his insurance company, filed the appeal on his behalf on 5/09/17. This was 6 days after he received the discharge notice. A Verbal Request for Hearing was received in the Office of Appeal Hearings in Tallahassee, Florida dated 5/09/17. On 5/11/17, an Order to Produce Notice and Begin hearing Process was entered into the system. A copy of the notice was sent to resident #300, the Facility, the Ombudsman, and the Agency for Healthcare Administration (AHCA). The notice advised all parties involved that a hearing would be scheduled in the near future, and all persons should prepare for hearing. In an interview with Resident #300 on 6/14/17 at 3:10 PM, he said that he did not agree with the 30 day transfer/discharge notice because all of his family and support live in Orlando, and if he went to the facility that was 60 miles away, they wouldn't be able to visit, and he would be alone. He stated he has been in and out of nursing homes since 2008, and he had never had an issue like this before. During the interview the resident said he was extremely mad with the facility and he began to cry. He said he was embarrassed and humiliated by everything that happened to him while he was a resident at the nursing home facility. He stated when they came into his room on 6/02/17, and told him he was going to an ALF, he immediately told the staff he did not want to transfer to another facility, and he had a hearing coming up soon. The resident stated he became very upset when the facility staff would not listen to him, and continued to say he needed to leave. The Assistant Director of Nursing (ADON) called Law Enforcement and they responded to the scene. Resident #300 stated that he called the Ombudsman who visited him on 5/04/17 on his cell phone, and told her what was going on. He put the Ombudsman on speaker phone and she told the people in the room, ADON and law enforcement, that the resident appealed the transfer and he was not to be transferred until after his hearing date when decision will be made regarding his appeal. After he hung up his cell phone, the resident stated that staff continued to tell the police that he needed to leave. Resident #300 stated the facility staff treated him like he was an animal, ignored his requests not to leave, and were very mean to him. As the resident continued to cry during the telephone interview, he said he was very upset with how he was treated. He said he told the staff that he didn't want to be transferred. He said he began to yell at staff the whole time they were packing his things, and when the police arrived, they wouldn't listen to him either because the staff kept saying he had to leave. He stated he didn't want to leave, he had a hearing coming up, and the Ombudsman and his caseworker at the insurance company told staff that he wasn't supposed to leave until after the hearing. They (the nursing home staff) just ignored us, and did what they wanted to anyway. They treated me like an animal. They did this out of spite to me. They didn't tell me I was leaving, I had no idea. They came in and said the doctor wanted me transferred today, and I told them no. The police were talking and watching while they packed up my stuff and they said I had to leave, and I told them no, but they made me go. They were just trying to get rid of me and it was against my will. It was the worst I have ever been treated. An interview was completed with the Ombudsman on 6/14/17 at 2:24 PM. She confirmed that she was in the facility a few weeks prior to the discharge of Resident #300. While in the facility she stated that she met with Resident #300, the Administrator, and the Director of Nursing. She confirmed that she advised the Administrator that she was there to investigate the Notice of Hearing their office had received in reference to the 30 day notice the facility had served on the resident, and the subsequent appeal filed by Resident #300. The Ombudsman also confirmed during her interview, that she received a frantic call from Resident #300 on 6/02/17, stating that the facility was trying to make him leave the facility to go to an ALF, and he didn't want to go. She states the resident put her on speaker phone, and there was a lot of yelling in the room. A woman in the room identified herself as being in charge, but the woman refused to give her name. The Ombudsman said that she told this person that the resident did not want to leave the facility, and they should not transfer him at this time because there is an appeal hearing scheduled. The Ombudsman said she thought that they did not discharge the resident. She thought he was still in the facility because the Ombudsman office never got notification that he had been transferred anywhere. On 6/15/17 at 3:00 PM, an interview was conducted with the Assistant Director of Nursing, ADON. The ADON acknowledged that she was the only person in charge the day Resident #300 left. She stated that she called Law Enforcement because when she gave Resident #300 his transfer/discharge papers, the resident became loud, and kept telling the facility that he didn't want to leave. She stated, He had a safe discharge, and he needed to go. The ADON confirmed that the resident had someone on his speaker phone on 6/02/17, but said she did not know who was on the phone. 2. An observation of the main dining room on 6/26/2017-6/28/2017 at 12:00 PM and 5:00 PM showed several residents with table cloths wrapped around their upper body while being assisted with meals. There were no clothing protectors or cloth napkins observed in the dining room. On 6/26/2017 at 12:15 PM, resident #118 was observed with a peach colored table cloth wrapped around her chest and upper body. The resident's daughter stated that the facility had no clothing protectors. She and her family had asked for clothing protectors for months, but the facility had not provided any, so we use towels, table cloths or whatever we can find. It looks undignified, but we have no other option. On 6/26/17 at 12:25 PM resident #185 was observed with a peach colored table cloth wrapped around her upper body. Her son was assisting with her meal and stated that he had asked for clothing protector or even a large napkin, but could not get any. He stated that he could usually find some table cloths so he had been using them. He said it looked silly, but his mother needed something as she spilled food and drinks on her clothing. An observation of resident #218 on 6/26/17 at 12:35 PM showed the resident with 5-6 small paper napkins around her neck and upper chest area. The resident's granddaughter was assisting her with lunch. She stated that her family had been asking for clothing protectors for months as her grandmother was shaky and spilled food on her clothing. She said she gave up on asking the facility. She stated they were using table cloths as a protector, but the family thought it looked childish and undignified. We had a few clothing protectors made, but they were in the wash. We gave up asking for them. She stated that she took several small napkins and placed them around the resident's neck. On 6/27 at 5:45 PM resident #100 was observed in the dining room with a table cloth wrapped around her chest up to her neck. She was being assisted with her meal by certified nursing assistant (CNA) O. The CNA stated that she was not aware if the facility had any type of clothing protectors. She could not provide an answer when asked if there was anything else she could use to protect the resident's clothing other than a table cloth. On 6/28/2017 at 5:30 PM the resident's husband was observed yelling in the main dining room. He stated that he came in twice per day to assist his wife to eat lunch and dinner and he was fed up with not having anything to cover her clothing with. He said on that day, he could not even find a table cloth to use to protect her clothing. On 06/28/17 at 12:15 PM CNA A stated she had worked at the facility for the past 3 years and had, never seen a clothing protector. If someone asked for something to cover their clothing, we just hand them a towel. An interview with the administrator on 6/29/17 at 3:20 PM revealed that the facility did not have any clothing protectors, but they had some cloth napkins that could be used to protect the resident's clothing. She stated that the cloth napkins were kept in the laundry room and if anyone requested a protector, staff should go to the laundry to get the cloth napkins. She could not provide an answer when asked if all staff were aware that cloth napkins were kept in the laundry room. She also could not provide an answer when asked if she had seen the residents in the main dining room with draped with table cloths. 3. On 06/26/17 at 1:25 PM CNA AA was referring to residents who needed assistance as feeders. CNA AA stated, I should not say feeders. I should say, residents who need assistance.' On 06/26/17 at 5:48 PM CNA Z was observed delivering trays and said, that tray is for the feeder down the hall. On 06/26/17 at 5:49, CNA Z stated, I should have said residents who need assistance. On 06/26/17 at 6:15 PM the DON stated that staff know not to refer to residents as feeders. On 06/27/17 at 12:45 PM, resident #96 was eating in her room. A staff member had placed the meal tray on the foot of resident's bed. The bedside table had personal items on it. the resident was eating her meal by sitting on bed and leaning sideways to eat. She said, I asked for another table to put my tray on, but they never brought one.