Every finding on record at Luxe at Lutz Rehabilitation Center (The)

Based on observations, interviews, and record review the facility failed to ensure physician orders were followed and medications were administered as ordered for two residents (#6 and #14) out of eight residents sampled. Findings included: 1. On 8/19/2026 at 8:47 a.m. a medication observation was conducted with Staff A, Licensed Practical Nurse (LPN) for Resident #14. Staff A, LPN confirmed the tablets prior to administration. Staff A dispensed the following medication: Metamucil 4 in 1 Fiber Oral Packet Duloxetine HCl Capsule 30MG (milligrams) 1 tab Metoprolol Tartrate Tablet 25 MG 1 tab Sodium chloride 1 gram 1 tab Resident #14 said her pain level was a 5. Staff A, LPN returned to the medication cart; retrieved and dispensed the following medication: Tramadol HCl Tablet 50 MG 1 tab Staff A, LPN did not record Tramadol HCl Tablet 50 MG Narcotic as given in the Medication Administration Record (MAR); Resident #14 received the narcotic medication. Staff A signed the medication out of the Narcotic log. Resident #14 refused the Sodium chloride 1 gram tab, Staff A, LPN marked the medication as given in the electronic Medication Administration Record (EMAR). Review of the admission Record showed Residents #14 was admitted on [DATE] with a diagnosis to include: chronic kidney disease, hypertension, muscle weakness, metabolic encephalopathy, seizures and depression. Review of Resident #14's Medication Administration Record (MAR), dated August 2026, revealed Sodium Chloride 1 gram tab was marked as given on 8-19-2026 and Tramadol HCl Tablet 50 MG was not marked as given on 8-19-2026. Review of Residents #14's Order Summary Report, dated 8/20/2026, revealed Sodium Chloride 1 gram tab active order with a start date 9/18/2025, and Tramadol HCl Tablet 50 MG active order with a start date 5/25/2026 Review of Residents #14's Medication Admin Audit Report, dated 8/19/2026, revealed Sodium Chloride 1 gram tab was marked given on 8/19/2026 at 8:54 a.m. by Staff A, LPN. Review of Resident #14's progress notes, dated 8/18/2026 to 8/20/2026, does not show the physician was notified for Sodium Chloride 1 gram tab, as refused by the resident. An interview and record review on 8/20/2026 at 12:33 a.m. with the Director of Nursing (DON) regarding Resident # 14's medication administration observations. The [NAME] said the nurse should have marked the narcotic medication Tramadol HCl Tablet 50 MG, as given in the Medication Administration Record (MAR). The DON said the nurse is expected to document immediately after the resident received the medication. The DON said when a resident refuses a medication the nurse is expected to document correctly as not given in the MAR; notify the physician and document in the medical record. Review of the facility's policy titled Medication Administration revised 1/2024 revealed: 3. Medications are administered in accordance with prescriber orders, including any required time limit. 7. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, 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 concern. 9. The individual administering the medication checks the label to verify the right resident, right medication, right time, and right method (route) of administration before giving the medication. 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party if indicated. 2. Review of admission record showed Resident #6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cholelithiasis, heart failure, chronic pain syndrome and osteoarthritis. Review of Resident #6's order summary report, dated, 8/20/26, revealed the following order, Morphine Sulfate ER (extended release) 30mg tablet by mouth daily for moderate to severe pain [level] 5-10. Review of Resident #6's Medication Administration Record (MAR),dated February 2026, revealed Morphine Sulfate ER 30mg was administered seven times; five of the administrations occurred when the resident reported pain level was zero. Review of Resident #6's progress notes, dated 1/16/2026 to 2/16/2026, does not show the doctor was notified when Morphine Sulfate ER 30 mg was administered for a pain level of zero. During an interview and record review on 8/20/26 at 12:37 p.m. the Director of Nursing (DON) regarding Resident #6 receiving Morphine Sulfate ER 30 mg for a reported a pain level of zero. The DON said you are right in situations where the medication does not meet the order the parameters the nurse should not administer the medication. If the medication is administered the nurse is expected to notify the physician and document in the medical record. The DON said she did not find nurses notes about notifying the doctor about the administrations that did not meet the ordered parameters.

Based on interviews and record review, the facility failed to ensure urinary catheter care was provided in accordance with standards of care for one resident (#1) out of 3 residents sampled for catheter care.Findings included: A review of Resident #1's admission record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include benign prostatic hyperplasia, malignant neoplasm of prostate, and obstructive uropathy.A review of Resident #1's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA form 3008) dated 10/3/2025 revealed in Section P. Health Status-Foley (urinary) catheter checked yes.A review of Resident #1's order summary report was absent of an order for a urinary catheter upon admission.Review of Resident #1's October 2025 Treatment Administration Record revealed the following treatment order: Indwelling urinary catheter care Q-shit [every] and PRN [as needed] with a start date of 10/20/2025.Review of Resident #1's Care Plan revealed the following:-Focus: The resident has a risk for injury/infection r/t [related to] presence of urinary catheter secondary to obstructive uropathy with a start date of 10/4/2025.- Interventions: Catheter size and balloon as per MD [Medical Doctor] orders with a start date of 10/4/2025; Monitor for s/sx [signs and symptoms] of bacteriuria [infection of the urinary system] . with a start date of 10/4/2025; Provide catheter care per orders with a start date of 10/4/2025.An interview with Staff A, Licensed Practical Nurse (LPN) was conducted on 11/6/2025 at 12:12 p.m. Staff A stated if a resident was admitted with a urinary catheter, she would call the doctor to see if they want the catheter to remain in place or the catheter to be taken out. Staff A stated she would assess the resident and refer to the physician orders. Staff A stated if the resident had no catheter orders, the admitting nurse and the nurse putting in the orders would reach out to the doctor to get the catheter orders. Staff A stated there should be orders for the catheter size and the diagnosis for the catheter, like urinary retention. Staff A stated the Certified Nursing Assistant (CNA) is responsible for catheter care, not the nurse.An interview with Staff B, CNA was conducted on 11/6/2025 at 12:58 p.m. Staff B stated Resident #1 was admitted with a urinary catheter. Staff B stated she regularly took care of the resident.An interview with Staff C, LPN Unit Manager, was conducted on 11/6/2025 at 12:58 p.m. Staff C stated Resident #1 was admitted with a urinary catheter on 10/4/2025. Staff B stated there should be orders to monitor output, diagnosis, changing catheter as needed, and catheter care every shift. Staff C stated the order for the urinary catheter started on 10/20/2025. Staff C stated she put this order in when she was performing an audit. Staff C stated the batch orders for the urinary catheter should have been put in when the resident was admitted . Staff C stated there would be no way of knowing if the catheter care was being completed because there were no orders in place.An interview with the Director of Nursing (DON) was conducted on 11/6/2025 at 1:00 p.m. The DON stated they do batch orders for residents with an indwelling urinary catheter. The orders should be the size of the catheter, the balloon, and the diagnosis for the use of the catheter. The DON stated the AHCA form 3008 on admission showed Resident #1 had an indwelling urinary catheter for obstructive uropathy. The DON stated Resident #1 should have had orders put in for a urinary catheter.The facility did not provide a policy.

Based on interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization . Findings included: 1. Review of the admission record showed Resident #18 was originally admitted to the facility 2/22/24 and readmitted on [DATE] with diagnoses of acute bronchiolitis due to respiratory syncytial virus, acute chronic respiratory failure with hypoxia, and Chronic obstructive pulmonary disease (COPD). Review of a hospital History and Physicals for Resident #18 dated 5/5/25 revealed under history of presenting complaint, This is an [AGE] year-old male resident of an extended care facility with a history of COPD, congestive heart failure, chronic kidney disease, atrial fibrillation. He was brought to the emergency room with complaints of increased shortness of breath. At the time the EMS [Emergency Medical Services] got the patient 02 [oxygen] saturation was 82% on 2 L[liters] of nasal cannula oxygen. The patient was placed on nonrebreather mask and brought to the emergency room for further evaluation. In the emergency room , the patient transitioned to BiPAP [Bilevel Positive Airway Pressure]. This morning, he is currently doing better and placed back on nasal cannula oxygen, feeling much better compared to when he came to the hospital. The consultation showed, EMS responded to a call at the patient's rehabilitation facility, where they found the patient in distress with an oxygen saturation of 82% on 2L via a non-rebreather mask.The patient reported a decreased appetite over the past few days, with occasional nausea that has since resolved. He is currently on apixaban and furosemide for anticoagulation therapy. Chest x-ray shows central pulmonary vascular congestion, as well as right-sided small pleural effusion. He was started on IV [Intravenous] antibiotics and IV diuretics in the ER [emergency room ]and was subsequently admitted to the ICU [Intensive Care Unit] for further management. Further review under medical decision making showed, the patient will be admitted for acute hypoxic respiratory distress. VBG [venous blood gas] in the ED [Emergency Department] shows hypercapnia [too much carbon dioxide (CO2) in the bloodstream]. Patient started on BiPAP to help blow off CO2. However, patient with worsening repeat measurements and becoming more sedated. Discussed with patient's power of attorney/who is his [family member]. Confirms that patient is a DNR [Do Not Resuscitate]/DNI [Do Not Intubate]. Will admit to ICU [intensive Care Unit], maximize supportive care. Started on IV antibiotics and IV diuretics. IV diuretics dosage carefully chosen due to history of hypotension requiring midodrine for Vaso [blood vessels] support. Family is not opposed to palliative care consult. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated she sent Resident #18 to the hospital on 5/5/25 because his oxygen saturations were low. She stated a CNA (Certified Nursing Assistant) was trying to transfer him from the bed when he gave out. She said, he was not himself, I called for him, he did not answer, he had a lethargic look, eyes fixed and not moving, I tried to arouse him. He was not responding. Staff D, LPN stated she asked the CNA to stay with him, and she went to get help. She stated another staff member got the DON (Director of Nursing) and the cart. Staff D, LPN stated, I continued to call him, and he did not respond, he was disoriented. Staff D, LPN stated Resident #18 was supposed to be on oxygen all the time, had compromised breathing, and had a similar episode before. Review of active physician orders for Resident #18 showed an oxygen order dated 3/28/25, O2 (oxygen) at 3L (liters) NC (nasal cannula). The order was noted verbally received. The order did not show scheduling or order administration scheduling details. Review of a Hospital Transfer Form dated 5/5/25 showed under respiratory treatments, the resident received O2 at 2L/Min (minute), Chronic. Review of an SBAR (Situation Background Assessment and Recommendation) form dated 5/5/25 showed the Change In Condition (CIC) reported on this CIC Evaluation are/were: Seems different than usual Tired, Weak, Confused, or Drowsy. Since this started it has gotten: Worse. At the time of evaluation resident/patient vital signs, weight and blood sugar were:- Blood Pressure: BP 142/60 - 5/5/2025 14:45 Position: Lying l/arm - Pulse: P 75 - 5/5/2025 14:45 Pulse Type: Regular - RR: R 19.0 - 5/5/2025 15:16 - Temp: T 98.0 - 5/5/2025 15:16 Route: Forehead (non-contact) - Pulse Oximetry: O2 88 % - 5/5/2025 14:45 Method: Oxygen via Nasal Cannula. The mental status evaluation showed increased confusion and disorientation. Functional status evaluation showed general weakness. Review of the notification section showed the Primary Care Physician (PCP) was notified with orders to send to ER (emergency room ). Review of a physician encounter progress note dated 4/7/25 showed the Reason for Appointment: Cardiac Consultation. Chief Complaint / Nature of Presenting Problem: Cardiovascular disease management during admission for rehab. History Of Present Illness: . [Resident # 18] was admitted to the facility on [DATE] for COPD exacerbation with PNA (pneumonia) 2/2 (Secondary to) RSV (Respiratory Syncytial Virus). Today, patient is lying bed. He says he is doing ok. He voiced no concerning cardiovascular complaints. His BPs (blood pressures) continue to be low at times. Since last visit, patient was discharged to ALF (Assisted Living Facility). He then developed SOB (Shortness of Breath) and was readmitted to hospital for HF (Heart Failure) and COPD exacerbation. Upon discharge he was advised to use 3L NC O2. Returned to [name of facility] as of 3/27/2025. Nursing notes, Physician/ARNP (Advanced Registered Nurse Practitioner) notes, hospital records, labs, imaging, and VS (Vital Signs) trends were reviewed. Review of a document titled Respiratory Assessment and Recommendation Form - dated 4/9/25 showed Resident #18 was assessed and his FIO2 (Fraction of inspired oxygen) was documented at 3L. Breath sounds were documented to be diminished RLL [Right Lower Lobe] and LLL [left lower lobe]. The report confirmed an oxygen concentrator was in use. Review of a physician encounter progress note dated 4/21/25 showed Resident #18 was seen for a follow -up. Under respiratory assessment, reduced NC O2 to 3L diminished bases due to poor inspiratory effort was documented. Review of a care plan for Resident #18 initiated and revised on 3/6/25 showed the resident is at risk for altered respiratory status/difficulty breathing r/t (related to) recent RSV infection and pneumonia, CHF (Congestive Heart Failure), COPD and need for supplemental oxygen. Interventions included: Encourage adequate rest periods in between tasks/activities. Encourage and assist resident to elevate head of bed to facilitate breathing as tolerated. Monitor for s/sx. (Signs and Symptoms) of respiratory distress and report to MD PRN (Medical Doctor, As needed) increased Respirations; Decreased Pulse - oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey. Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/PRN. Change tubing per MD order and PRN. Notify MD as indicated. Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Use pain management as appropriate. Monitor/document side effects and effectiveness. Review of a skilled services progress note dated 5/5/25 showed Resident #18 was redirected for anxiety. Refused alternate meal or snacks. Resident lethargic with low saturation this afternoon. MD notified. Resident became more aroused gradually with 02 and non-rebreather. Resident then asked to go to ER. MD notified. EMS and family also notified. Review of a skilled services progress note dated 5/4/25 showed [Resident #18] has complaints of SOB (shortness of breath) this afternoon, PRN (as needed) nebulizer treatment provided and are effective. Review of a medication administration progress note dated 4/27/25 showed to encourage and assist the resident to elevate HOB (head of bed) for ease of breathing/SOB (shortness of breath) while lying flat every shift related to acute bronchiolitis due to respiratory syncytial virus, acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of a summary of skilled services note dated 4/17/25 showed, New orders received for desaturation [a decrease in the amount of oxygen in the blood]. Review of progress notes dated 4/17/25 showed Resident #18 had a CIC. At the time, his oxygen was 89%. The nurse practitioner was notified of desaturation despite O2 and nebulizer treatments. New orders for STAT (without delay) CXR (Chest X-Ray) and Lasix 40mg (milligrams) p.o. (by mouth) once. Review of a physician encounter note dated 4/15/25 showed, today patient is lying in bed. BP (blood pressure) remains labile with hypotension intermittently. Denies any recent falls. States breathing is worse, O2 4L increased recently. Under respiratory assessment it was noted, congestion and attempting to cough but cannot, increased NC 4L, diminished bases due to poor inspiratory effort. Review of physician orders for Resident #18 did not show the orders to increase oxygen to NC 4L as ordered on 4/15/25. On 5/7/25 at 12:23 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff, LPN denied knowing of the order to increase oxygen to 4L on 4/15/25 stating, he has always been on oxygen. I don't remember new orders. She stated it was a nursing expectation to monitor his oxygen with a pulse oximeter and document. She stated she could not speak of the MAR/TAR (Medication Administration Record /Treatment Administration Record) documentation that was missing. She stated to ask the DON. Review of a nursing note dated 4/9/25 showed Resident #18 exhibited sob and wheezing this morning. Upon assessment, resident's lung sounds are diminished both lower lobes. Writer gave resident his scheduled inhaler. Notified [staff member] with Respiratory therapy. Resident already has DuoNeb (a combination of two medicines) scheduled q6 (every 6 hours), we will continue that order and add PRN DuoNeb q4 (every 4 hours) for sob/wheezing. MD was notified. Review of a skilled services progress note for Resident #18 dated 4/7/25 showed Resident is A/O (alert and oriented) x3 is able to make needs known, Resident has HX (history) of Respiratory issues. Oxygen on at O2 3L via N/C, NEB TX (nebulizer treatment) in place Q6. Review of a nursing readmission evaluation dated 3/27/25 showed O2 94% on 3/27/2025 21:16 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabored. The resident does not exhibit or report current respiratory issues. No respiratory issues noted/observed. On the question if the resident utilizes the following respiratory devices or equipment, it is noted None. Under notifications the assessment showed physician order treatment plan of care, medications discharge planning reviewed with resident and/responsible party. Medication reconciliation completed with medical provider. All orders confirmed and verified. Review of a progress note dated 3/23/25 showed patient complained of SOB, checked pulse Ox stating at 86%. Patient stated he wanted to go to the hospital. Notified MD of change, Per orders the patient will be sent out. Review of a Social Services progress note dated 3/14/25 showed, resident stated he has oxygen at ALF. He would like a portable one and resident has a wheelchair at facility. Review of an IDT(Interdisciplinary Team) progress note dated 3/6/25 showed resident is on supplemental oxygen and states he becomes short of breath of lying flat. Care plan was updated. Review of a general admission progress note for Resident #18 dated 3/5/25 showed upon arrival the resident's O2 was 90% - - 3/5/2025 18:04 Method: Oxygen via Nasal Cannula. Resident respirations appear even and unlabeled. The resident current exhibits or has reported the following respiratory symptoms: cough short of breath while lying flat short of breath at all times. The resident utilizes the following respiratory devices or equipment: oxygen. The residents along sounds are adventitious: right upper lobe has audible wheezes, right lower lobe has audible wheezes, and the left lower lobe has audible wheezes. Review of all progress note types for Resident #18 effective 3/7/25 to 5/8/25 did not show documentation related to on-going assessment of the resident's respiratory status and response to oxygen therapy. On 5/6/25 at 3:33 p.m. an interview was conducted with the DON. The DON stated Resident #18 went out to the hospital yesterday (5/5/25) because of low oxygen. She said, He has had a history of it, he was out of it. We called the doctor. He was able to stabilized with the O2 we administered. The DON stated Resident #18 came around before the EMS arrived. The DON stated he wanted to go the ER, so they sent him out due to shortness of breath. The DON stated she could not comment on the lack of oxygen monitoring documentation in the MAR/TAR. She said, I will look at it and get back with you. On 5/7/25 at 12:41 p.m. an interview was conducted with the DON, Nursing Home Administrator (NHA) and the Regional Nurse Consultant (RNC). The RNC stated Resident #18 was sent out due to hypoxia (low levels of oxygen in the body tissues). Reviewing the residents electronic medical record (EMR), the RNC stated the resident had an oxygen order dated 3/7/25 -3/14/25 which was discontinued when he was sent out to the hospital. The RNC stated Resident #18 returned on 3/28/25. The DON, RNC, and NHA reviewed the residents record and confirmed the oxygen order was not transcribed completely. The RNC said, The nurse should have clarified the level of oxygen and how often it should be administered. They confirmed the order was put in wrong. The RNC stated the nurses were not able to document in the MAR/TAR because it was transcribed wrong. They all reviewed the MAR/TAR and confirmed the resident was not being monitored for oxygen use from 3/28/25 to 5/5/25 when the resident was sent out for emergency care. The DON said, I see, it was entered incorrectly. The RNC and DON could not speak of the order to increase oxygen on 4/15/25 and why the administration orders were not documented. 2. Resident #12 was originally admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. The resident was admitted with diagnoses to include chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of progress notes dated 1/19/25 showed Resident #12's family member came to the facility and was upset the resident was not on oxygen . Resident with a history of COPD. All orders checked, and resident has no orders for oxygen at this time. Hospital discharge paperwork reviewed, and oxygen was discontinued upon discharge from the hospital patient readmitted on [DATE]. The family member called 911 and the resident was transferred to the hospital stating, [Resident #12] needed to be on oxygen. Review of the TAR for Resident #12 dated 1/1/25 - 1/31/25 showed Oxygen: NC/mask continuous. Encourage and assist resident to use O2 at 2 liters. The TAR showed oxygen was administered on 1/1/25 and 1/2/25. It was discontinued on 1/3/25 when Resident #12 went to the hospital. The TAR did not show the oxygen order was reinstated upon returning from the hospital on 1/19/25. Review of the TAR for Resident #12 dated 12/1/24 - 12/31/24 revealed documentation of continuous oxygen administered at 2 liters, documented on day, evening, and night shift. Review of Resident #12's care plan initiated on 11/11/24 showed the resident had difficulty breathing related to diagnosis of chronic respiratory failure, COPD, and dependent on supplemental oxygen. Interventions included to administer oxygen as ordered. Monitor O2 saturations as ordered/change tubing per facility protocol/MD order. Notify MD as indicated. Review of physician orders summary report for Resident #12 showed the history of oxygen orders as follows: On 12/7/24: Oxygen 2L/min via nasal cannula at continuing as needed for (left blank) On 12/7/24: Oxygen 2L/min via nasal cannula at continuing. The review showed the most recent oxygen orders dated 12/7/24, were not discontinued. Review of an admission/readmission nursing evaluation dated 1/9/25, showed Resident #12 was readmitted from the hospital. Under notifications the evaluation showed: Physician order treatment of care medications discharge planning reviewed with Resident and/resident responsible party, medications reconciliation completed with medical provider. All orders confirmed and verified. This evaluation did not indicate discontinuing of oxygen orders for a resident with a known COPD diagnosis and historical use of oxygen. On 5/7/25 at 2:13 p.m. an interview was conducted with the DON and the RNC. The DON stated she had reviewed Resident #12's orders and said, He had no orders at the time. The DON reviewed the EMR and could not show physician orders to discontinue oxygen use for Resident #12 who was dependent on oxygen. The RNC reviewed the hospital discharge record for Resident #12 and stated he was admitted for cardiac issues. He confirmed the oxygen orders were not discontinued by the hospital. The RNC stated he would have expected the nurse to call the doctor and re-instate the oxygen orders. Requested and did not receive the facility's policy on oxygen administration.

Based on observation, staff interview and policy and procedure review, the facility did not ensure resident medical records and confidential medical information were safeguarded in a confidential manner that would prevent unauthorized access on two (100 and 200) of two halls toured. Findings included: A tour of the 200 hall was conducted on 5/5/25 at 9: 32 a.m. A two-tiered rack was observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway to include residents, family members, vendors and visitors. Subsequent tours of the 200 hall were conducted on 5/5/25 at 4: 45 p.m. and 5/6/25 at 10: 44 a.m. The two-tiered rack containing white binders with room numbers and resident specific information and the DNR book were observed to remain in the hallway during these times,easily accessible to anyone walking down the hallway. Upon opening one of the white binders it was observed to contain a Resident Face Sheet and an AHCA (Agency for Healthcare Administration) form 3008, containing resident specific information including but not limited to resident name, date of birth,. diagnoses and insurance information. During a facility tour on 5/5/25 at 4: 46 p.m., residents paperwork was observed on top the nursing station counter which contained resident specific medical information, this medical information was observed to be easily accessible to anyone who walked up to the nursing station counter. There were no staff observed at the nursing stations during these observations. A tour of 100 hall was conducted at approximately 9:32 a.m. to 10: 00 a.m. revealing a two-tiered rack observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway including residents, family members, vendors and visitors. Subsequent tours of the 100 hall were conducted on 5/5/25 between 4: 45 p.m. and 5 p.m. and 5/6/25 at 10 :31 a.m. The two-tiered rack containing white binders with room numbers and resident specific information and the DNR book were observed to remain in the hallway during these times easily accessible to anyone walking down the hallway. Upon opening one of the white binders it was observed to contain a resident face sheet and an AHCA form 3008 containing resident specific information including but not limited to resident names, date of birth, diagnoses and insurance information. On 5/6/25 at 10:31 a.m. and at 3:43 p.m., a book containing resident's specific laboratory (lab) information was observed on the nursing station counter, easily accessible to anyone who walked up to the nursing station counter. There were no staff observed at the nursing stations during these observations. An interview was conducted with the DON (Director of Nursing) on 5/6/25 at 4: 00 p.m. The DON stated the resident records have always been out in the hall on the cart, and not secured behind the nurse's stations. She stated papers should not be left on the medication carts or counters without being turned over. The DON observed the photographic evidence of the paperwork left on top of the 200-hall nursing station and stated it was a weight sheet and belonged to a CNA (Certified Nursing Assistant). She stated it should not have been left out to be seen by anyone walking by. An interview was conducted with the Nursing Home Administrator (NHA) on 5/6/25 at 4:00 p.m. The NHA stated the resident records have been in the hallway since she got here. She agreed they are easily accessible by all residents and visitors or anyone in the halls and there was no barrier to prevent anyone from accessing the resident's records. The NHA stated staff should not leave papers with resident information out on the counters or medication carts. Review of a facility policy titled, Resident Rights, issued 9/2021 Revised 01/2024 showed- Resident Rights Standards and Guidelines: Standard - A facility must treat each resident with respect and dignity and care for each resident in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality. The facility must protect and promote the rights of the residents. Guideline: Employees stall treat all residents with kindness, respect, and dignity. Procedure: 3. The unauthorized release, access, or disclosure of resident information is prohibited, All release, access or disclosure or resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer. A facility policy titled, Administration Standards and Guidelines: Medical Records, Issued 3/2018, Revised 01/2024 showed - Standard: Medical Records will be maintained within the facility per federal requirements. ( Photographic Evidence Obtained )

Based on observations interviews and policy review, the facility failed to ensure proper infection control practices were in place for two (100 and 200) out of two halls related to use and availability of personal protective equipment (PPE) and performing hand hygiene. Findings included: On 05/05/25 at 9:33 a.m. an empty PPE supply cart was observed located outside of room [ROOM NUMBER]. room [ROOM NUMBER] was observed with a contact isolation sign present. The observation revealed the facility staff did not have readily available PPE to provide care for a resident on contact isolation. 52564 An observation of lunch service on 5/5/2025 at 12:36 p.m., room [ROOM NUMBER] revealed a contact precautionsign hanging above door. Staff A, Certified Nursing Assitant (CNA), was observed entering the room without performing hand hygiene prior to entering the room. Staff A, CNA was observed putting on the gown at bedside. Staff A, CNA proceeded to touch the resident with bare hands, positioned the resident for meal and proceeded to feed the resident. Staff A,CNA did not don gloves, or wash hands or apply sanitizer during the care process. An interview was condcuted with Staff A, CNA on 5/6/2025 at 1:31 p.m. She stated she knew the resident was on contact precautions and she would normally wear the Personal Protective Equipment (PPE). Staff A, CNA stated she knew how to put on PPE. Staff A, CNA stated any staff can restock the supplies if the supply carts were empty. During a tour of Facility on 5/6/2025 at 10:35 a.m. the following was observed. An observation of room [ROOM NUMBER] revealed a Contact Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns or gloves. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns or gloves. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed a Contact Precautions sign posted at the doorway. The supply cart outside of the room did not have gloves. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed an Enhanced Barrier Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns. An observation of room [ROOM NUMBER] revealed a Droplet Precautions sign posted at the doorway. The supply cart outside of the room did not have masks or eyewear. An observation of room [ROOM NUMBER] revealed a Droplet Precautions sign posted at the doorway. The supply cart outside of the room did not have gowns or eyewear. The observations revealed the facility staff did not have readily available PPE to provide care for a residents who were on isolation. An observation of Staff B, Housekeeper, in room [ROOM NUMBER] revealed she was in the room mopping the floor near the resident. Staff B had a surgical mask placed below her nose, no gloves, gown, or eyewear. The Droplet Precautions sign posted at the doorway indicated that staff must always wear a facemask (N-95 or higher), wear eye protection, a gown, and gloves. An interview was conducted with Staff B, Housekeeper, on 5/6/2025 at 1:55 p.m. Staff B, Housekeeper, stated she did know the resident in room [ROOM NUMBER] was on droplet precautions. Staff B, Housekeeper stated she does know how to put on PPE. Staff B, Housekeeper stated she does not know where to obtain supplies or who restocks the supply carts outside the doorway. An observation was made of Staff C, Activities Assistant entering room [ROOM NUMBER] at 1:34 p.m. There was a Droplet Precautions sign posted at the doorway, which indicated staff must always clean hands when entering and leaving the room, wear a facemask (N-95 or higher), wear eye protection, a gown, and gloves. An observation of Staff C, Activities Assistant revealed the staff member did not perform hand hygiene before entering the room. She had a surgical mask on but not an N-95 or higher. Staff C, Activities Assistant was observed writing on a clip board that was resting on the resident's dresser Staff C, Activities Assistant was observed leaving room [ROOM NUMBER] at 1:45 p.m. performed hand hygiene with Alcohol Based Hand Rub (ABHR). Staff C did not sanitize the clipboard or pen and did not wear an N-95 mask, gloves, gown, or eyewear. An interview was conducted with Staff C, Activities Assistant on 5/6/2025 at 1:47 p.m. Staff C, Activities Assistant said, a mask is required for Droplet Precautions . Staff C, Activities Assistant, stated she knows how to put on PPE and she knows where PPE is located and stored within the facility. Staff C did not explain why she did not wear proper PPE. An observation on 5/7/2025 at 1:03 p.m. revelaed room [ROOM NUMBER] had a droplet precaution signage. An unidentified therapy staff member was observed in the room not wearing eye wear.The unidentified staff member was assessing the resident for safe transfer into a wheelchair. The resident had a visitor in the room and the visitor was not wearing any PPE. A request was made to the Director of Nursing (DON) to provide information about PPE staff education. As of 5/7/2025 at 5:30 p.m., the education was not provided. An interview was condcuted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 5/7/2025 at 1:40 p.m. said No, it would not be appropriate for staff to be in the room without PPE. The DON said, We encourage visitors to wear the right PPE, but we can't make them. We educate them on admission to the facility. 46234 3- An observation was conducted on 5/5/25 at 4:46 p.m. of Staff C, Activities Assistant, who entered room [ROOM NUMBER] with no PPE on. The room had a Contact Isolation sign posted on the door and a PPE cart outside the door. The staff member was observed standing at the resident's bedside with a cart of supplies. She was then observed shaving the resident's face with no gown or gloves on. At 4:47 p.m. a second staff member, Staff G, Certified Nursing Assistant (CNA), walked into room [ROOM NUMBER] with no PPE on, went to the resident's bedside to talk to Staff C, then exited the room without performing hand hygiene. An interview was conducted on 5/5/25 at 4:48 p.m. with Staff G, CNA. She confirmed room [ROOM NUMBER] had a contact isolation sign and she did not wear PPE. She said she had been trained on the signs and PPE, but she did not see the sign. An interview was conducted on 5/5/25 at 4:57 p.m. with Staff C, Activities Assistant. Staff C exited room [ROOM NUMBER] with her supply cart and confirmed there was a contact isolation sign on the door. She said she saw the sign, but these are the ones if you are doing care with urine or stool you put on PPE. Staff C said she didn't know she had to wear PPE to go in the room and didn't know she shouldn't have taken her cart in the room. She said room [ROOM NUMBER] was her last room for one-to-one activities and she was going to wipe the cart down anyway. Staff C said she had training on PPE and isolation precautions. On 5/5/25 at 4:49 p.m. an observation was conducted on the 200 unit of a clean linen cart in the hall. There were additional items such as toothpaste, plastic bags, lotion, body wash, and gloves being stored on the shelf with clean linen inside the cart. An interview was conducted on 5/6/25 at 3:23 p.m. with the Director of Nursing (DON). She said all staff are trained in infection control and PPE use. She said her expectation if a Contact Isolation sign is on a door is for anyone that entered the room to have on a gown, glove, and mask. The DON said she would not be surprised to hear staff were in a contact room with no PPE on. She said they constantly educate but a lot of staff don't care or become so lackadaisical. She confirmed an activities cart should not have been in a contact isolation room either. The DON also confirmed no items should be stored in the clean linen cart except clean linen. A follow-up interview was conducted on 5/7/25 at 3:26 p.m. with the DON. The DON was asked why the facility had three different versions of Droplet Precaution signs with different instructions on different rooms. She said she was unaware there were different droplet precaution signs. She reviewed pictures of different droplet precaution signs and agreed it could cause confusion. The DON said she would look at the signs, but her expectation would be for anyone entering the room to have on a gown, gloves, eyewear, and masks. Review of a facility policy titled Transmission Based Precautions, revised 2/24, showed: Guideline: All staff received training on transmission-based precautions upon hire and at least annually. Procedure: 2. Contact Precautions a. Intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. 3. Droplet Precautions a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) c. Healthcare personnel wear a surgical mask for close contact with infectious resident. Photographic evidence obtained.

Based on observation interview and record review, the facility failed to ensure a post fall care plan was updated and interventions were implemented in a timely manner for one (#21) of two residents reviewed for falls. Findings included: On 5/7/25 at 12:02 p.m. Resident #21 was observed sitting in his wheelchair outside his room. He stated he fell in his room a few days ago. He said, I stumbled and fell in my room. I was trying to get to the bed. The resident stated the bed was high and he could not sit on it. He stated he was hurt and went to the hospital. The resident was observed with an open area on his right arm close to the elbow and stiches to his forehead. The resident stated at the moment he was not in pain. Resident #21 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, unspecified dementia, other secondary Parkinsonism, muscle weakness and difficulty in walking. Review of a progress note for Resident #21 dated 5/5/25 at 2:45 p.m. showed pt (patient) found on the floor post fall with an open head lack and right arm skin tear. MD (Medical Doctor) made aware and ordered to have pt sent out, POA (Power of Attorney), DON (Director of Nursing) notified. Review of a Change in Condition (CIC) evaluation on 5/6/25 at 4:27 p.m. revealed the evaluation initiated on 5/5/25 at 9:03 p.m., had not been completed to document the resident/patient's evaluation and review of notifications. Review of a Change in Condition (CIC) evaluation on 5/7/25 at 11:44 a.m. revealed the evaluation initiated on 5/5/25 at 9:03 p.m., had not been completed to document the resident/patient's evaluation and review of notifications. Review of a progress note dated 5/6/25 at 2:45 p.m. showed the pt. (patient) was received back from [Name of Hospital]. Pt. received stitches and CT (Computed Tomography) unremarkable. Pt. was placed in [a specialized chair designed for individuals with limited mobility] upon arrival and has already attempted to get up two times. Review of a care plan for Resident #21 on 5/07/25 at 11:20 a.m. showed a focus, the resident is at risk for falls R/T (related to) weakness, assistance required for mobility and transfers, pain and pain meds, psychotropic medication, incontinence and comorbidities Date Initiated 4/29/2025 and revised on 4/29/2025 . The goal showed the resident's potential for sustaining a fall-related injury will be minimized by utilizing fall precautions/interventions though next review date. Date Initiated: 4/29/2025 and Target Date: 7/28/2025. Interventions initiated on 4/29/25 included - Encourage and assist resident to use bed in the lowest position as tolerated. Encourage and remind resident to use call bell and to wait for staff assistance with transfers, ambulation, toileting, etc. as indicated. Encourage and assist the resident to wear appropriate footwear such as rubber-soled shoes, non-slip bedroom slippers, non-skid socks, etc. when ambulating, transferring, or mobilizing in w/c. Physical and Occupational therapy consult as needed. The review showed the resident's care plan was not updated/revised following the fall with injury on 5/5/25. On 5/7/25 at 12:06 p.m. an interview was conducted with Staff F, Certified Nursing Assistant (CNA). She stated the resident was positioned outside his room so she can easily monitor him and four other residents observed nearby. She stated the resident was normally confused but he can be aware of his surroundings sometimes. She stated he fell 2 days ago, had some skin tears and stated he must have hit his head. She stated he was taken out to the hospital. Staff F stated Resident #21 was slowly getting back to self. Staff F, CNA stated the resident was assisted with all ADLs, and all transfers and was dependent on staff. On 5/7/25 at 12:10 p.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN) assigned to the resident. She stated she was not at the facility when the resident fell . She stated they were supposed to be monitoring him closely. She stated most of the time this resident was confused and did not know where he was or what the time was. She stated he required close supervision all the time. Staff E stated when a resident falls, the nurse completes the Change in Condition evaluation and a post fall assessment. She stated the care plan should be updated if there were new interventions. During an interview on 5/7/25 at 11:29 a.m. with the DON and the Regional Nurse Consultant (RNC), the RNC stated Resident #21 was observed on the right side of the bed on the floor. He stated the resident had a forehead laceration and skin tear. He stated the fall was not witnessed. He said, He was found on the floor, there was blood from a laceration on his forehead. He was sent out. During this interview and record review, the DON confirmed the resident fell on [DATE] and a CIC was initiated and not completed. She reviewed the resident's record and stated, It should have been completed fully. She stated the resident had an injury, a hematoma to the face, and was found on the floor. Review of the care plan with the DON and the RNC revealed there were no post fall interventions. The DON stated she just updated the care plan. She stated it should have been updated in timely manner. Review of a facility policy titled, Standards and guidelines: Falls - Managing, preventing and documentation, dated 1/2024 showed, a standard - based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Guideline - The residents plan of care will be developed and followed accordingly to prevent or minimize the risk of falls or fall related injuries Under Resident-Centered Approaches to Managing Falls and Fall Risk, the policy showed: - The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. - If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). - Examples of initial approaches might include bed in lowest position, call light in reach, improving footwear, changing the lighting, etc. - If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. - If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or until the reason for the continuation of the falling is identified as unavoidable. - Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. - The facility is a restraint free environment. Meaning, bed alarms, chair alarms, side rails solely for fall prevention, and chemical interventions for fall prevention are not utilized.

Based on observations, interviews, and record review the facility did not ensure wound care orders were put in place and completed timely for one resident (#1) and did not ensure medications were administered appropriately for two residents (#10 and #22) out of twenty-two sampled residents. Findings included: 1. Review of Admission Record showed Resident #1 was admitted on [DATE] with diagnoses including hereditary and idiopathic neuropathy, chronic pain syndrome, morbid obesity, and primary generalized (osteo)arthritis. Review of Resident #1's Weekly Skin checks showed resident had clear skin on 4/9/25. The Weekly Skin check on 4/16/25 documented Left toe-open ulcer with current treatment in place. Review of Resident #1's physician orders showed an order for Mupirocin External Ointment 2%. Apply to left 2nd toe topically every day shift for rash. Start date 2/19/25. Discontinued 4/29/25. Review of Resident #1's provider notes showed the resident went to an outside foot specialist on 4/8/25. The Assessment/Plan showed Ulcer of left foot- Dressing changes daily, Dakin's moist/dry dressing left 2nd toe and Cellulitis of left food-Dakins solution 0.25%. 1 application every day by miscell. For 30 days. The doctor noted Dakin's Solution 0.25% 1 application every day by miscell for 30 days as prescribed. Review of Resident #1's physician orders showed the orders from the outside foot specialist were not put in place. Further review of Resident #1's provider notes showed the resident returned to the outside foot specialist on 4/22/25. The Assessment/Plan showed Ulcer of left foot- Dressing changes daily, Dakin's moist/dry dressing left 2nd toe. MRI of foot without contract. Review of Resident #1's physician orders showed the order for Apply Dakins moist/dry dressing to left 2nd toe daily. Every day shift for ulcer left 2nd toe. Started 4/23/25. Discontinued 4/28/25 Review of Resident #1's April 2025 Treatment Administration Record (TAR) showed this order was not completed on 4/23, 4/25, and 4/28/25. On 4/26 and 4/27/25 it was documented as 9, Other/See Nurse Notes. The progress notes for those day showed cleansed documented. Review of Resident #1's physician orders showed the wound care order was changed on 4/28/25 to Cleanse left 2nd toe with normal saline, gently pat dry, soak gauze with Dakins (1/4) strength solution, apply soaked gauze to toe wound, cover with dry gauze, wrap with rolled gauze, secure with tape. Change daily on 7-3 shift and PRN (as needed) if dressing becomes soiled or dislodged. May use normal saline for wet-to-dry dressing if Dakins is not available. An interview was conducted on 5/6/25 at 10:40 a.m. with the Minimum Data Set (MDS) Director who was observed on the 200 unit and stated she helped with nursing tasks when needed. She reviewed Resident #1's medical record and confirmed there were no wound care orders put into place until 4/23/25 for the 2nd left toe. She said the doctor should have been notified when the skin check was completed on 4/9/25 showing the open ulcer because no treatment orders were in place. An interview was conducted on 5/6/25 at 11:20 a.m. with the Director of Nursing (DON). She reviewed Resident #1's weekly skin checks, progress notes, and orders. She confirmed the order for Mupirocin External Ointment 2%. Apply to left 2nd toe topically every day shift for rash would not be considered wound care orders for an open ulcer on the left 2nd toe. The DON said she did not see any progress notes documenting a provider was notified. An interview was conducted on 5/7/25 at 12:48 p.m. with Staff D, Licensed Practical Nurse (LPN). She said when a resident goes to an outside provider, they sometimes come back with paperwork and the nurse will put new orders in. She said if the resident does not have paperwork, they will ask any family that may have accompanied the resident or they will call the provider to get orders and the nurse will enter them into he medical record. A follow-up interview was conducted on 5/7/25 at 1:00 p.m. with the DON. She said when a resident goes to an outside provider they typically come back with paperwork with new orders. She said if they do not, medical records will call and follow-up. The DON reviewed the provider's notes for Resident #1's visit to the foot specialist on 4/8/25. She said she had not seen the notes until 5/6/25. The DON stated someone must not have followed up. She confirmed the wound care orders were not put in place until 4/23/25 after the resident had a second visit to the foot specialist. An interview was conducted on 5/7/25 at 11:17 p.m. with the Nursing Home Administration (NHA). The NHA said she was the risk manager and looked at concerns related to Resident #1's wound care. She said on the weekend of 4/26-4/27/25 the nurse did not use Dakins solution because it was locked in the wound care office. She said she was under the impression a provider was called to change the order. The NHA reviewed Resident #1's medical record and confirmed the call and change in orders was not completed until 4/29/25. The NHA was unaware of the outside foot specialist orders from 4/9/25. Review of a facility policy titled Clean Dressing Changes, revised 1/2024, showed: Standard: the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Procedure: 1. Verify that there is a physician's order for this procedure period (Note: this may be generated from a facility protocol.) 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. . 9. Document completion of procedure in the resident record. 10. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Reporting: Notify the supervisor if the resident refuses the dressing change. Report other information in accordance with facility policy and professional standards of practice. 51097 2. Review of Resident #10's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include insomnia, aftercare following joint replacement surgery, and anxiety disorder. Review of the Resident #10's January 2025 Medication Administration Record (MAR) revealed the following orders: Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate), Give 1 tablet by mouth at bedtime for Insomnia. oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl), Give 1 tablet by mouth every 4 hours as needed for Pain Review of the January 2025 MAR revealed the sleep medication Zolpidem Tartrate was marked with a chart code of 9 on 01/18/25, 01/19/25, 01/20/25 and 01/21/25; marked as given on 01/22/25; marked with the cart code 5 on 01/23/25. The chart code 9 is defined as Other/See nurses notes. And 5 is defined as Hold/see nurses notes. Review of resident #10's MAR for January 2025 revelaed there were no nurses notes related to this medication, indicating the medication was not given. Further review of the January 2025 MAR revealed the pain medication oxycodone was not given on 01/18/25 or on 01/20/25 3 An observation and interview was conducted with Resident #22 on 05/07/25 at 12:35 p.m. Resident #22 was observed lying in bed dressed in day clothes. Resident stated she almost left this morning because she could not get her pain medications, and this is not the first time. She stated it has been going on since she got here on 05/02/25. She stated they do not give her pain medications when she requests them. She requests them every day. She stated I was in so much pain I was sick to my stomach; I get a different excuse each time I ask for pain medication. She stated it is something different each time such as we don't have it, or it's on order, the pharmacy has to bring it, and we're still waiting for it She stated it has been horrible since she got here and she has gotten her pain medication so sporadically that her pain is not controlled. She stated pain management was in this morning, and she has now gotten her medications, so she feels okay currently but is very upset. She went on to state she chose to come here for recovery and feels like she can't because she is in so much pain. She stated she just wishes she could get her pain medications on time. A review of Resident #22's Admission Record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses to include infection and inflammatory reaction due to internal right hip prosthesis, abscess of bursa, right hip, unspecified mononeuropathy of bilateral lower limbs, generalized anxiety disorder. A review of Resident #22's most recent Brief Interview of Mental Status (BIMS) showed a score of 15 indicating she is cognitively intact. A Review of Resident #22's Order Summary Report revealed the following orders: - OxyCODONE HCl Tablet 15 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain - Lyrica Capsule 150 MG (Pregabalin) Give 1 capsule by mouth two times a day for Neuropathy A Review of the May 2025 MAR revealed the medication Lyrica was not given twice on 05/03/25, twice on 05/04/25, and once on 05/05/25. On 05/03/25 it was marked with 12 indicating the medication was on order from the pharmacy/MD [Medical Doctor] aware. On 05/04/25 it was marked with 5 indicating hold/see nurses notes Review of resident #22's MAR for MAY 2025 revelaed there were notes were found in the medical record to indicate the medical doctor was aware. Further review of of the May 2025 MAR showed the medication oxycodone was not given on 05/02/25, and 05/04/25. On 05/07/25 at 12:43 p.m. an interview with Staff E, Licensed Practical Nurse (LPN) was conducted. She stated when a resident is admitted , once we reconcile the medications the pharmacy will bring them. It depends on when the resident arrives. She went on to state if there is a medication such as pain medication like oxycodone, we have an Emergency Drug Kit (EDK) that we can pull from if we have the order or prescription for the medication. If we cannot get a medication for a resident such as a medication prescribed for pain, we would call the doctor. On 05/07/25 at 3:40 p.m. an interview with the Director of Nursing (DON) was conducted. She stated if a resident is prescribed pain medication it would not be appropriate for the resident to not get the medication. A review of policy titled Standards and Guidelines: Medication Administration with a revision date of 01/2024 revealed the following: Policy: Standard: Medications are ordered and administered safely and as prescribed. Procedure: 3. Medications are administered in accordance with prescriber orders . 16. If a drug is withheld .the individual administering the medication shall document the rational in the resident's medical record and notify the physician.

Based on observation, record review and interview, the facility failed to ensure it had an effective infection control program related to hand hygiene on 2 of 4 units (TCU, Lakeview) , sharps containers, and use of Personal Protective Equipment (PPE) for one of one residents on Transmission Based Precautions (room [ROOM NUMBER]). Findings included: 1. Observations of meal distributions on TCU unit from 04/15/24 at 12:48 PM revealed that the meal cart arrived on the unit. Continued observations at this time revealed that that Staff I entered random rooms to deliver meal trays. Staff I was not observed to sanitize or wash his hands. Additional observations revealed the following: -04/15/24 at 12:52 PM Staff I entered room [ROOM NUMBER] (enhanced barrier room) and delivered a meal tray. No hand sanitizing or washing noted before entering the room or after exiting the room. -04/15/24 at 12:48 PM Staff I delivered meal tray to room [ROOM NUMBER]. No hand sanitizing or hand washing noted before entering the room or after exiting the room. -04/15/24 at 12:55 PM Staff I took two trays into room [ROOM NUMBER], adjusted resident in the window bed, and then set up the resident's tray. Staff I then proceeded to set up the meal tray for the resident in the door bed with no hand sanitizing or handwashing noted. -04/15/24 at 12:57 PM Staff I entered room [ROOM NUMBER], set up the meal tray for the resident in the door bed, after physically interacting with the resident in the window bed. Staff I was not observed to sanitize or wash his hands before entering the room or after exiting the room. Interview on 04/15/24 at 1:05 PM with Staff I, CNA revealed that he is a CNA on the TCU unit and loves working with the residents and helping them. Staff I said he was not aware that he did not sanitize his hands at any time during meal distribution. Review of the facility policy titled Hand Hygiene Infection Control with an issue date of 10.2014 and a revised date of 6.2023 revealed the following: -This facility shall require facility personnel used accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. -Situations that require hand hygiene include, but are not limited to: Before and after direct contact (for which hand hygiene is indicated by acceptable professional practice) Before and after assisting a resident with meals 2. Observations of the Lakeview nurses station on 04/15/24 at 11:03 AM revealed a medication cart parked in close vicinity of the nurses station. The medication cart was locked with no staff person present in the area. Closer observation of the medication cart revealed that it had a sharps container attached to the right side of the cart directly above the mounted trash can. The sharps container was noted to be full of items visible and reachable and the flap was unable to be closed due to the container being full. Observations of the Lakeview nurses station on 04/15/24 at 12:44 PM revealed that a medication cart was still parked in close vicinity to the nurses station, and that the sharps container was still full and open with sharps accessible to all. An interview at this time with the Director of Nursing (DON) revealed that the sharps container was full, that nothing should be reachable in the container, and that the flap on the container should be closed. Review of the facility policy titled Sharp Disposal with an issue date of 02/2019 and a revised date of 01/2024 revealed the following: -Guideline: To provide storage of potentially hazardous supplies and to minimize the potential risk of sticks caused by used needles. 48441 3. On 4/15/24 at 9:45 a.m., an observation and interview were conducted with the resident in room [ROOM NUMBER], who was on Contact Isolation. The outside of the resident's room had a sign indicating the following instructions: wash hands, wear gown and glove prior to entering room with an additional instruction for visitors to ask the staff if there were any questions or concerns. Upon entering the room, the resident stated the staff does not wear personal protective equipment (PPE) when entering her room. Upon doffing PPE there was no proper size garbage pail located in the resident's room and subsequently utilized a small waste pail basket located in the resident's bathroom. On 4/17/24 at 10:09 a.m., an observation and interview were conducted during medication administration for the resident on Contact Isolation. Staff K, Licensed Practical Nurse entered the resident's room without wearing appropriate PPE indicated on the Contact Isolation sign outside of the resident's room. When Staff K, LPN was asked about the instructions for isolation and what should be worn, Staff K, LPN read the sign and stated this is for family and visitors only. Staff K, LPN administered medication to resident without wearing the stated PPE on the sign. On 4/17/24 at 10:28 a.m., an interview was conducted with the Infection Control Preventionist/Assistant Director of Nursing (ICP/ADON). The ICP/ADON stated all entering the resident's room must wash their hands and don a gown and gloves. The ICP/ADON stated this is the only resident in the facility to be in contact isolation and education is needed for the entire facility. On 4/15/24 at 12:03 p.m., an observation was made of lunch in the main dining room. Observations of hand hygiene among staff in between passing and setting up lunch for residents were sporadic. Three unidentified residents refused the main entry and Staff N, Certified Nursing Assistant/Activities offered peanut butter and jelly sandwiches to these residents. One unidentified resident required assistance with the sandwich. Staff N, CNA/Activities unwrapped the sandwich and proceeded to cut the sandwich into bite size pieces, using her bare left hand to hold down the sandwich. 50434 4. Observation on 04/15/2024 at 12:53p Staff C, Certified Nursing Assistant (CNA) was observed entering residents' rooms passing lunch trays. Staff C, CNA was observed entering a resident's room raising the bed, moving the bedside table, she exited the room, went to the cart where the lunch trays were being held, grabbed another tray, and continued to the next resident's room. She continued this pattern down hall passing lunch trays without performing hand hygiene in between residents.

Based on observations, record review and interview, the facility failed to ensure the resident's right to privacy was upheld related to staff and visitors knocking at resident doors prior to entering for 3 of 36 (#51, #38 #55) sampled residents and 6 of 12 (Rooms 122, 123, 124, 127, 129, 130) random resident rooms on TCU unit. Findings included: 1. During an interview with Resident #51 in her room on 04/16/24 at 09:01 AM Staff G, Certified Nursing Assistant (CNA) was observed to enter the resident's room without knocking. During an interview with Staff G at this time she reported that she usually knocks but because the room door was open, and she knows the resident is in the room she thought that it was ok. Review of Resident #51's electronic record revealed that she was admitted to the facility on [DATE] for orthopedic aftercare. Review of the residents Minimum Data Set (MDS) Brief Interview For Mental Status (BIMS) dated 3/19/24 revealed a score of 14 (Cognitively intact). 2. During an interview with Resident#38 on 04/16/24 at 10:20 AM Staff E, Physical Therapist Assistant (PTA) entered the residents room without knocking and waiting to be invited in. During an interview with Staff E at this time she reported that she was sorry for entering the room without knocking, and that she should have knocked on the door. Review of Resident #38's electronic record revealed that she was admitted to the facility on [DATE]. Review of the residents MDS BIMS dated 3/22/24 revealed a score of 15 (Cognitively intact). 3. Observations on 04/16/24 at 10:28 AM of the TCU hallways revealed a visitor with a dog going from room to room entering the rooms without first knocking. The visitor with the dog was observed to rooms 122, 124, 123, 127, 130, and 129 without knocking and waiting to be invited in by the residents. During the observation the visitor with the dog entered Resident #55's room without knocking and the resident was in the door bed told the visitor No, no I don't want dogs. Review of Resident #55's electronic record revealed that she was admitted to the facility on [DATE] for Hereditary and Idiopathic Neuropathy. Review of the residents MDS BIMS dated 4/11/24 revealed a score of 15 (Cognitively intact). 4. Interview on 04/16/24 at 10:32 AM with Staff A, Licensed Practical Nurse (LPN), Unit Manager revealed that visitors and staff should be knocking at doors. She reported that everyone should knock on residents doors and wait to be invited in, and that this rule applies to all staff and all visitors. She reported that Pet Therapy should definitely knock on doors and wait to be invited in. Interview on 04/16/24 10:38 AM with Acting Activities Director revealed that dog therapy volunteers should be knocking on doors and waiting to be invited into the resident rooms. She reported that staff typically will walk around the facility with the dog therapy volunteers to ensure that they are not going into isolation rooms and to make sure that they do not go into rooms that resident do not like dogs. 5. Review of the facility policy titled Resident Rights with an issued date of 09/2021 and a revised date of 01/2024 revealed the following: -A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: b. be treated with respect, kindness, and dignity; t. privacy and confidentiality;

Based on interview and record review, the facility failed to ensure the physician and resident representative was informed of medications not given as well as weights not performed for one of 40 sampled residents (#56). Findings included: Resident #56 was admitted on [DATE] and discharged to the hospital on 04/02/2024. Review of the admission record showed diagnoses included but were not limited to acute respiratory failure, pneumonitis due to inhalation of food and vomit, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertensive heart disease with heart failure, malignant neoplasm of thyroid gland, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of lymph node, obesity, muscle weakness, and anxiety disorder. Record review of the admission Minimum Data Set, dated dated dated [DATE] showed Section C, Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the physician orders and Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March and April of 2024 showed: -Weigh resident daily x [times] 3 days then weekly x 4 months. -Acetazolamide 375 mg [milligrams] twice a day for elevated bicarbonate was ordered as of 03/27/2024. The MARs showed the medication was given on 03/27/24 p.m. and 03/28/24 both a.m. and p.m. Both of the 03/29/24 doses as well as the a.m. dose on 03/30/24 were shown as not given. The 03/30/24 p.m. dose as well as both doses on 04/01/24 and the a.m. dose on 04/02/24 were shown as given. Review of the Weights and Vitals Summary showed a weight on 03/19/2024 of 251.6 pounds. Review of Progress notes: -On 03/19/24 at 19:13, weigh resident daily x 3, weekly x 4 months; unable to obtain weight -On 03/20/24 at 20:10, weigh resident daily x 3, weekly x 4 months, unable to obtain weight -On 03/29/24 at 08:16: Acetazolamide 375 mg by mouth two times a day for elevated bicarb, medication on order (from pharmacy) -On 03/29/24 at 16:48 Acetazolamide 375 mg by mouth two times a day for elevated bicarbonate, on order (from pharmacy) -On 03/30/24 at 08:26 Acetazolamide 375 mg by mouth two times a day for elevated bicarbonate, awaiting pharmacy Review of Resident #56's care plans showed he had altered cardiovascular status related to Congestive Heart Failure (CHF), Hypertension, pneumonia and obesity. The Care plan was initiated on 03/18/2024. The goal was for the resident to be free from complications of cardiac problems. Interventions included but were not limited to Monitor vital signs / weights as ordered/ PRN (as needed). Notify MD of significant abnormalities/changes as ordered/indicated. Administer medications per MD order. Monitor/document/report PRN any changes in lung sounds on auscultation, edema and changes in weight. During an interview on 04/16/2024 at 12:12 p.m. Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM), stated the resident came in with respiratory failure. He had been intubated and extubated while at the hospital. He was on oxygen at 4 liters per minute. She stated he was having some edema. The nurse was supposed to create a nursing note, if unable to obtain the weight, notify the physician and get a new order, if needed. Staff A, LPN, UM verified the weights were not performed on the 03/16/24, 03/17/24, 03/18/24 per the order. She stated the assigned nurse did not acknowledge or check off that the weight had been performed. The UM stated she walked the resident to the scale on 03/19/24 and weighed him herself. The resident was able to walk. She reviewed the TAR for 03/20/24, and verified it showed cannot obtain weight. She stated again he could walk to the scale. She stated she would expect to see the weights per the physician orders. The weights should have been performed on the March 16th, 17th, 18th, 20th, and 27th, and scheduled for April 3rd. The negative outcomes for not performing his weights included he had a diagnosis of CHF, fluid overload and respiratory failure with CHF. The medication Acetazolamide. was not in the Emergency Drug Kit (EDK), Lasix was. The LPN, UM stated for any medications not given, the physician should have been notified. She stated she would check the pharmacy slips as to why no more than two days of Acetazolamide was delivered. The LPN, UM provided a pharmacy slip which showed Acetazolamide 250 mg and 125 mg was delivered on 03/29/2024. Review of the facility's policy, Medication Administration, revised on 01/2024 showed 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the resident's medical record and notify the physician and responsible party, if indicated. Review of the facility's policy, Physician Orders, revised 01/2024 showed 1. Medication shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable. 9. Physician orders should be followed as prescribed, and if not followed, the reason should be recorded on the resident's medical record during the shift. The physician should be notified and responsible party if indicated.

Based on record reviews, and interviews, the facility failed to confirm the accuracy of the Pre-Admission Screening and Resident Review (PASRR) and to correct the document for six (#2, #24, #43, #49, #238, and #388) out of twenty-four residents sampled. Findings Included: 1. An interview with the Assistant Director of Nursing (ADON) was conducted on 4/18/2024 at 12:30 PM. The ADON stated that the facility does not have a policy and procedure for completing the PASRR. Review of the clinical record for Resident #24 revealed: -Review of the electronic medical record/admission record dated 4/18/2024 showed that Resident #24 was originally admitted on [DATE] and most current admission on 11/20/2023. -Review of the electronic medical record/admission record dated 4/18/2024 revealed the following diagnoses for Resident #24: Traumatic hemorrhage of the cerebrum, dementia, Schizoaffective disorder, major depressive disorder, anxiety disorder. -Review of the electronic medical record/physician orders dated 4/18/2024 for Resident #24 revealed: monitor side effects of anti-depressant medications, monitor behaviors, consult psych services and or psychology as needed, monitor effects of psychotropic medications, pain management monitoring, trazodone for depressive disorder, Review of electronic medical record/Minimum Data Set (MDS) dated [DATE] for Resident #24 revealed. -Section A - Identification information - entry date 11/20/2023, observation date 2/15/2024 -Section C - Cognitive Patterns - Brief Interview for Mental Status (BIMS) score of 15 -Section I - Active Diagnoses - non-Alzheimer's dementia, traumatic brain injury (TBI), anxiety disorder, depression, schizophrenia, -Section N - medications - antidepressant is taking, and indication noted, Review of electronic medical record/PASRR Level I dated 4/3/2024 for Resident #24 revealed: -Section I - A anxiety disorder and depressive disorder checked. B. finding based on documented history and medications checked. Section IV - no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. Review of electronic medical record/care plan focus for Resident #24 revealed: discharge planning, pain management, advanced directive, Compliance with medications related to diagnoses of schizoaffective disorder, dementia, and anxiety disorder, impaired cognitive functioning/impaired thought processes related to diagnoses of dementia, anxiety disorder, and schizoaffective disorder, mood management related to diagnoses of depression, anxiety, and schizoaffective disorder and medication use. Review of electronic medical record/psychoactive medication consent dated 3/12/2024 for Resident #24 for the medication trazodone. An interview was conducted with the ADON on 4/18/2024 at 12:30 PM. The ADON stated that the Level I PASRR did not have the correct information documented and the diagnoses of schizoaffective disorder was absent, and level II should be completed. 39438 2. A review of the Admission Record showed Resident #2 was initially admitted to the facility on [DATE] with diagnoses of anxiety disorder and bipolar disorder. The Admission Record revealed a new diagnoses of adjustment disorder with anxiety on 06/22/20, major depressive disorder on 01/04/21, and persistent mood disorder on 06/01/21. Review of Resident #2's PASRR Level I Screen dated 04/03/24 and completed by the Assistant Director of Nursing (ADON) only showed a qualifying diagnosis of anxiety disorder and indicated no PASRR Level II was required. On 04/18/24 at 11:42 a.m., the ADON reported they started doing audits on PASRRs because there were a lot of diagnoses not listed on the PASRRs. She confirmed she completed the PASRR for Resident #2 during the audit. She confirmed that all her current diagnoses were not listed on the PASRR. She stated she only looked at physician orders to complete the PASRR and not the list of diagnoses. On 04/18/24 at 1:30 p.m., the Director of Nursing (DON) reported that PASRRs were not complete and accurate, so they started doing audits. They started the audits on 03/08 and they were reviewed by the clinical team. The concern with Resident #2's PASRR was reported, and he stated he would have to readjust the audits to look at all diagnoses as well. 48441 3. A review of the admission face sheet for Resident #43 revealed an admitted [DATE] with a primary diagnosis of osteomyelitis of vertebra lumbar region. Secondary diagnosis included but not limited to alcoholic cirrhosis of liver without ascites, generalized anxiety disorder, and unspecified depression. A review of the care plan dated 4/09/24 has focus of uses anti-anxiety medications related to anxiety disorder, at risk for complications associated with long term use at risk for falls with sedative effects of medications. Resident # 43 was care planned with the following focus: at risk for alteration in mood and /or behavior related to diagnosis of depression and anxiety and the goal to have a stable mood without signs of symptoms of depression, anxiety, or sadness. A review of physician orders includes the following but not limited to: Citalopram Hydrobromide oral tablet 40 milligrams (mg) to give one tablet by mouth one time a day for depression; Mirtazapine oral tablet 15 mg to give one tablet my mouth at bedtime for depression; Alprazolam oral tablet 0.5 mg to give one tablet by mouth every twelve hours related to generalized anxiety disorder. A review of the Preadmission Screening and Resident Review (PASRR) dated 3/13/2024 Section I: PASRR Screen Decision -Making Section A. Mental Illness or suspected Mental Illness does not have anxiety, depression nor alcohol dependency checked. A review of the admission face sheet for Resident #49 revealed an admitted [DATE] with a primary diagnosis of osteomyelitis of vertebra lumbar region. Secondary diagnosis included but not limited to unspecified depression and generalized anxiety disorder. A review of the admission care plan has a focus on mood problems related to mood disorder, depression, and anxiety, with the goal to have a stable mood without signs of symptoms of depression, anxiety, or sadness. A review of the Preadmission Screening and Resident Review (PASRR) dated 4/03/2024 Section I: PASRR Screen Decision -Making Section A. Mental Illness or suspected Mental Illness does not have depression checked. A review of the admission face sheet for Resident # 238 revealed an admitted [DATE] with a primary diagnosis of Parkinson's disease without dyskinesia without mention of fluctuations. Secondary diagnosis include but are not limited to neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, unspecified depression, and post-traumatic stress disorder (PTSD). A review of the admission care plan initiated 4/09/24, has a focus for at risk for alteration in his mood and/or behavior related to diagnosis of depression, Lewy Body dementia, Parkinson's disease, PTSD, and insomnia. A review of the Preadmission Screening and Resident Review (PASRR) dated 3/25/2024 Section I: PASRR Screen Decision -Making Section A. Mental Illness or suspected Mental Illness does not have depression, anxiety, PTSD checked. 50434 4. Review of Resident #388's admission record showed Resident #388 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance, and depression, unspecified. The level I PASRR dated 04/05/2024 showed in Section I-part A MI (Mental Illness) or suspected MI (Mental Illness) check all that apply was blank. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. Registered Nurse (RN) from St Joseph's Hospital North signed and completed the PASRR on 04/05/2024. Interview on 04/18/2024 at 11:50 a.m. with ADON stated she just started handling the PASRR. The ADON reviewed resident #388's PASRR and confirmed the PASRR was not completed and should have been corrected at admission of resident #388.

Based on interview and record review, the facility failed to implement the Comprehensive Resident-Centered Care Plan related to administering medications and performing weights for one of 40 sampled residents (#56). Findings included: Review of Resident #56's care plans showed he had altered cardiovascular status related to Congestive Heart Failure (CHF), Hypertension, pneumonia and obesity. The Care plan was initiated on 03/18/2024. The goal was for the resident to be free from complications of cardiac problems. Interventions included but were not limited to Monitor vital signs / weights as ordered/ PRN (as needed). Notify MD [medical doctor] of significant abnormalities/changes as ordered/indicated. Administer medications per MD order. Monitor/document/report PRN any changes in lung sounds on auscultation, edema and changes in weight. Resident #56 was admitted on [DATE] and discharged to the hospital on 04/02/2024. Review of the admission record showed diagnoses included but were not limited to acute respiratory failure, pneumonitis due to inhalation of food and vomit, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertensive heart disease with heart failure, malignant neoplasm of thyroid gland, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of lymph node, obesity, muscle weakness, and anxiety disorder. Record review of the admission Minimum Data Set, dated dated dated [DATE] showed Section C, Cognitive Patterns a Brief Interview for Mental Status score of 15 of cognitively intact. Review of the physician orders and Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March and April of 2024 showed: -Weigh resident daily x [times] 3 days then weekly x 4 months. -Acetazolamide 375 mg [milligrams] twice a day for elevated bicarbonate (diuretic) was ordered as of 03/27/2024. The MARs showed the medication was given on 03/27/24 p.m. and 03/28/24 both a.m. and p.m. Both of the 03/29/24 doses as well as the a.m. dose on 03/30/24 were shown as not given. The 03/30/24 p.m. dose as well as both doses on 04/01/24 and the a.m. dose on 04/02/24 were shown as given. Review of the Weights and Vitals Summary showed a weight on 03/19/2024 of 251.6 pounds. Review of Progress notes: -On 03/19/24 at 19:13, weigh resident daily x 3, weekly x 4 months; unable to obtain weight -On 03/20/24 at 20:10, weigh resident daily x 3, weekly x 4 months, unable to obtain weight -On 03/29/24 at 08:16: Acetazolamide 375 mg by mouth two times a day for elevated bicarb, medication on order (from pharmacy) -On 03/29/24 at 16:48 Acetazolamide 375 mg by mouth two times a day for elevated bicarbonate, on order (from pharmacy) -On 03/30/24 at 08:26 Acetazolamide 375 mg by mouth two times a day for elevated bicarbonate, awaiting pharmacy During an interview on 04/16/2024 at 12:12 p.m. Staff A, Licensed Practical Nurse (LPN) Unit Manager (UM), stated the resident came in with respiratory failure. He had been intubated and extubated while at the hospital. He was on oxygen at 4 liters per minute. She stated he was having some edema. The nurse was supposed to create a nursing note, if unable to obtain the weight, notify the physician and get a new order, if needed. Staff A, LPN, UM verified the weights were not performed on the 03/16/24, 03/17/24, 03/18/24 per the order. She stated the assigned nurse did not acknowledge or check off that the weight had been performed. The UM stated she walked the resident to the scale on 03/19/24 and weighed him herself. The resident was able to walk. She reviewed the TAR for 03/20/24, and verified it showed cannot obtain weight. She stated again he could walk to the scale. She stated she would expect to see the weights per the physician orders. The weights should have been performed on the March 16th, 17th, 18th, 20th, and 27th, and scheduled for April 3rd. The negative outcomes for not performing his weights included he had a diagnosis of CHF, fluid overload and respiratory failure with CHF. The medication Acetazolamide. was not in the Emergency Drug Kit (EDK), Lasix was. The LPN, UM stated for any medications not given, the physician should have been notified. She stated she would check the pharmacy slips as to why no more than two days of Acetazolamide was delivered. The LPN, UM provided a pharmacy slip which showed Acetazolamide 250 mg and 125 mg was delivered on 03/29/2024. Review of the facility's policy, Weight Assessment, revised 08/2023 showed that the guideline is to determine a baseline and an ongoing record of the resident's body weight. Weight Assessment: 1. With the resident's permission the nursing staff will measure the resident's weight within 72 hours of admission, weekly for three weeks and monthly thereafter or as determined by the physician or per the resident's preference. Review of the facility's policy, Medication Administration, revised on 01/2024 showed 16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rationale in the resident's medical record and notify the physician and responsible party, if indicated. Review of the facility's policy, Physician Orders, revised 01/2024 showed 1. Medication shall be administered upon the written order of a person duly licensed and authorized to prescribe such medications in this state as soon as practicable. 9. Physician orders should be followed as prescribed, and if not followed, the reason should be recorded on the resident's medical record during the shift. The physician should be notified and responsible party if indicated.

Based on observations, record review and interview, the facility failed to provide Activities Of Daily Living (ADL) for 2 of 3 (#10, #55) residents sampled for ADL care related to personal hygiene. Findings included: 1. Observations of Resident #55 on 04/16/24 at 12:52 PM the resident was observed sitting up in her bed eating her midday meal. The resident was noted with gray facial hair on her chin. Interview with Resident #55 at this time revealed that she does not like having the hair on her face and that no one has offered to assist her with removing the facial hair. Observations on 04/17/24 at 09:08 AM revealed Resident #55 sitting up in her bed. The resident indicated that it's still there! as she wiped her hand over her chin. The resident reported that they still have not shaved her. Review of Resident #55's electronic record revealed that she was admitted to the facility on [DATE] with diagnosis that included muscle weakness, Osteoarthritis, and Spinal stenosis. Review of the residents Minimum Data Set (MDS) Brief Interview For Mental Status (BIMS) dated 4/11/24 revealed a score of 15 (Cognitively intact). Review of the residents Admission Nursing Evaluation dated 3/22/2024 revealed that the resident had an Occupational Therapy referral with interventions that included a. ADL training hygiene/grooming Review of the Minimum Data Set (MDS) dated [DATE] revealed that the resident has impairment on both sides of her upper extremities. the MDS indicated that the resident is dependent for shower/bathing self Review of resident #55's care plan revealed a care plan dated 3/22/24 related to ADL self-care deficit r/t weakness d/t dx: neuropathy, lumbar stenosis, obesity. The care plan included interventions to: Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal hygiene, etc. ADL care: Assist Resident #55 x1 or x2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status. Interview on 04/17/24 at 09:14 AM with Staff H, CNA revealed that she is assigned to this resident. She reported that she assists residents with bathing, grooming, and transferring. Staff H reported that residents have scheduled showers 2 times a week and can request a shower at any time. She reported that she will shave men as part of their grooming if needed and that sometimes shave women if it is needed. Interview with Staff A Licensed Practical Nurse (LPN), Unit Manager on 04/17/24 at 09:17 AM revealed that residents get scheduled showers twice weekly. She reported that there is no set time to shave residents but for female residents when you see the hair they should be assisted with shaving if they want it. Interview on 04/17/24 at 09:35 AM with the Director of Nursing (DON), revealed that his expectation related to grooming that residents receive at least 2 showers a week, that they can ask for more. He reported that he expects that as tolerated staff will wash hands and face, comb their hair, and would expect that on those days the resident would get a shave based on their preference. The DON reported that this applies to everyone. The DON reported that the CNA would identify the need for a shave, and it would be reasonable for staff to ask the resident if they would like to be shaved. He reported that staff should know to refer to the Kardex. The DON reported that nurses should identify that something needs to be done and direct the CNA's to do it, if the resident declines then the CNA should make the nurse aware. 50434 2. Observation and Interview on 4/15/2024 at 11:05 am resident #10 was observed in her bed dressed in a gown. The resident was observed to have strands of white facial hair on her chin. Resident #10 at this time revealed that she does not like the hair on her chin and that she would like the facial hair to be gone. Otherwise, she is happy and feels like she is well taken care of, and she has no concerns. Observation and Interview on 4/16/2024 at 9:45 am resident #10 was observed in bed in a gown watching tv. Resident was happy in nature. She was observed to have strands of white facial hair on her chin. The resident reported that the staff have helped her get washed up, but that no one has asked or offered her assistance with the hair on her chin. Review of Resident #10's record revealed that the resident was admitted to the facility on [DATE] and had diagnosis that included muscle weakness, morbid (severe) obesity due to excess calories, dysphagia, oropharyngeal phase. Review of the residents 5-day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 (Moderate Cognitive Impairment). Continued review of the MDS revealed that the Resident is dependent with substantial/maximal assist with Shower bath self. During an Interview on 04/17/2024 at 9:45a staff B, Certified Nursing Assistant (CNA) stated she helps residents with their daily living activities such as brushing teeth, changing clothing, taking showers, and combing hair. She stated if a resident would like to be shaved, they just must ask her so that she is aware of their preferences. During an interview on 04/17/2024 at 2:15p with staff A, Licensed Practical Nurse (LPN) stated that CNA's provide care for the residents on the floor. They assist residents with dressing, bathing, shaving, brushing teeth and combing hair. She stated that if residents need to be shaved, they will help them upon the request of the resident.

Based on observations, record reviews, and interviews, the facility failed to ensure 2 of 39 (#340, #389) sampled residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings. Findings included: Review of the facility policy titled Wound Care and Treatment with an issue date of 03/2020 and a revised date of 01/2024 revealed the following: 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initial, time, and date and apply to dressing. 1. Review of Resident #340's record revealed that this resident was admitted to the facility on [DATE] with diagnosis that included: hemiplegia and hemiparesis following cerebral infraction affecting right side. Review of the residents physician orders revealed orders with a start date of 4/15/24 and an end date of 4/16/24 for [bloodwork/labdraws]in AM every night shift for 1 day Observations of Resident #340 on 04/16/24 at 09:12 AM revealed the resident lying in bed. Attempt to communicate with the resident was unsuccessful. During the observation the resident was noted with a dressing to his left hand which was unlabeled/undated. (Photographic evidence obtained). Interview on 04/16/24 at 10:40 AM with the resident's spouse in person and resident's son on phone revealed the resident was admitted to the facility yesterday and was very confused about his surroundings. They reported that he did not arrive to the facility with a dressing to his left hand that it must have been put on after he was admitted . Interview with Staff A, Licensed Practical Nurse (LPN), Unit Manager revealed that she is not sure about the dressing the resident is a new admission and may have received bloodwork. 50434 2. During Observation and Interview on 4/15/2024 at 11:00 am, resident #389 was observed sitting in his wheelchair dressed for the day. The resident was observed with bandages on his right leg and right arm which he states they are taking care of but not as well as he would hope. He states the bandages just fall off. The bandages to his right elbow and right arm were not dated. The bandages to his right and left lower legs were labeled with a date of 4/12. During Observation and Interview on 04/16/2024 at 9:30 am, resident #389 was observed lying in bed. He stated it was a little loud the previous night, so he was still resting. The resident had 3 Bandages to his right upper arm, on his right elbow and on his right forearm. All three of the bandages were white and were not dated. He also had bandages on his right and left lower legs that were not dated. A review of Resident #389's active physician orders showed a physician order dated 04/02/2024 for, cleanse right knee, left Knee, posterior left ankle, and right elbow with NS [normal saline], pat dry, apply xeroform, cover with border dressing QOD [every other day] and PRN [as needed] every day shift every other day for skin tear and as needed for skin tear. A review of the Treatment Administration Record (TAR) for April showed the same orders of cleanse right knee, left Knee, posterior left ankle, and right elbow with NS, pat dry, apply xeroform, cover with border dressing QOD and PRN every day shift every other day for skin tear and as needed for skin tear. The TAR showed the treatment was completed for 7 out of the 8 instances. During an Interview on 04/18/2024 at 9:45 AM, with Staff B, Registered Nurse (RN) states nurses are responsible for bandage changes; she says they use the orders in [name of electronic medical record] to know how often to change the bandages and what type of dressing and cleaning solution to use. She stated bandages are to be labeled with the date the bandage was applied to the resident. Interview on 04/18/2024 at 2:00p with Director of Nursing (DON) states he expects the nurses to follow the orders for the patient that are in [name of electronic medical record]. He stated it is expected of the nurses to label bandages with the correct date when they are changed. Interview on 04/18/2024 at 2:40p with Staff A, Unit Manager (UM) states she expects the nurses to follow the orders and their facility protocols for each resident. She stated their facility protocol is to label bandages each time they are changed.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Forty-four medication administration opportunities were observed and fourteen errors were identified for three residents (#42, #241, #24) of eight residents observed. These errors constituted a 25% medication error rate. Findings include: On 4/17/24 at 8:45 a.m., medication administration observations were made with Staff J, Licensed Practical Nurse (LPN) for Resident # 42. The staff member dispensed the following medications: -Amiodarone 200 milligram (mg) one tablet -Plavix 75 mg one tablet -Lasix 20 mg one tablet -Potassium chloride 10 milliequivalent (mEq) one tablet -Ferrous Sulfate 325 mg one tablet During observation and interview, Staff J, LPN stated the resident has Metoprolol 12.5 mg and Eliquis 2.5 mg due but there were none available in the medication cart. Staff J, LPN wrote on a notepad the two missing medications and administered the medication pulled above to the resident and informed the resident two medications are not available currently. Staff J, LPN stated because she is agency, she does not have the key to the locked medication room to obtain missing medications and she will let the Unit Manager know whenever she sees her. Staff J, LPN stated the notepad is her way of keeping a list of missing medications. On 4/17/24 at 10:40 a.m., an interview was conducted with Staff J, LPN regarding medication for Resident #42. Staff J, LPN stated she was complete with her medication administration for her hallway. Staff J, LPN admitted to not administering or following up with Resident #42's medication. Staff J, LPN stated the medications should be requested electronically through the electronic Medication Administration Record. Staff J, LPN stated the Eliquis was ordered on 4/14/24 but could not state why the medication had not been in the medication cart. Staff J, LPN ordered the Metoprolol as a demonstration on how to send a message to the pharmacy team. The Metoprolol was not requested until Staff J, LPN stated she forgot to put the request in earlier and forgot to inform the Unit Manager to inform of the missing medication for Resident #42 but will do this now. On 4/17/24 at 10:50 a.m., an interview was conducted with Staff L, Registered Nurse/Unit Manager (RN/UM). Staff L, RN/UM was not aware of Resident #42 missing two medications. Staff L, RN/UM stated if Staff J, LPN had informed her of the missing medications, she would have assisted the nurse to access the medication emergency supply and contact the physician of the delayed administration. A review of Resident #42's April Medication Administration Record (MAR) identified the resident was to be administered Metoprolol Succinate ER Oral Tablet extended Release 24 hour, give 12.5 mg by mouth in the morning for hypertension hold if systolic blood pressure is less than 110 or heart rate less than 60, swallow whole due at 0900, and Eliquis Oral Tablet (Apixaban) Give 2.5 mg by mouth every morning and at bedtime related to paroxysmal atrial fibrillation scheduled for 0900 and 2100. On 4/17/24 at 10:09 a.m., medication administration observation was made with Staff K, LPN for Resident # 241. The staff member dispensed the following medications: -Levemir 30 units SQ -Tylenol 325 mg two tablets -ASA 81 mg enteric coated one tablet -Pepcid 10 mg two tablets -Amiodarone 2.5 mg one tablet -Eliquis 2.5 mg one tablet -Lasix 40 mg- one tablet -Lisinopril 20 mg one tablet -Metoprolol 50 mg one tablet Staff K, LPN stated Calcium Carbonate or TUMS was due as well but stated she does not have any in her cart. After administration of currently pulled medication and insulin, Staff K, LPN returned to her cart and began to talk to the Nurse Practitioner waiting for Staff K regarding Resident #241. Staff K, LPN took a verbal order for new medications for Resident #241 and started to move the medication cart to the next resident for administration. When asked if the medication was complete for Resident #241, Staff K, LPN stated yes. A review of Resident #241's April (MAR) has Vitamin D3 capsule 400 unit give one capsule by mouth two times a day for supplement and Calcium Carbonate tablet 600 mg give one tablet by mouth two times a day for supplementation both to be administered by 0900. All the medications administered had a 09:00 administration time. On 4/18/24 at 9:25 a.m., medication administration observation was made with Staff M, RN for Resident # 24. The staff member dispensed the following medications: -Acidophilus 500 million- one tablet -Caltrate 600 mg -one tablet -Ferrous Sulfate 325 mg -one tablet -Hydroxychloroquine sulfate 200 mg one tablet -Thera -M one tablet -Colace 100 mg one tablet -Minocycline HCL 100 mg - one tablet -AREDS -one tablet -Norvasc 10 mg gave 4 tablets of 2.5 mg A review of Resident #24's April (MAR) has Sodium Chloride (NaCl) Tablet Give 2 gram by mouth every morning and at bedtime for Hyponatremia. Staff M, RN did not have NaCl tablets in medication cart and a request was made to the UM, Staff L. Staff L returned with Sodium Bicarbonate as the only medication available throughout the facility. Staff M, RN refused stating the medications are not the same. Staff L, RN/UM stated the medication was eventually purchased by their Regional Nurse Consultant at a local pharmacy down the street. On 4/17/24 at 11:05 a.m., an interview was conducted with the Director of Nursing regarding the missing medications, over the counter medications' availability and the timeliness of medication administration. The DON agreed agency nurses do not have access to the emergency administration cart for safety reasons and accountability. The DON agreed multiple factors contribute to timeliness and is working on educating staff to focus solely on medication administration and to avoid distractions. A review of the facility's policy entitled, Standards and Guidelines: Medication Administration, revised January 2024 state the following standard: medications are ordered and administered safely and as prescribed. . 3. Medications are administered in accordance with prescribed orders, including any required time limit. . 6. Medications are administered within one hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, at bedtime). . 19. Staff follows established facility infection control procedures hand washing, aseptic technique, gloves, isolation precautions, for the administration of medications, as applicable. . 22. Medications will be reordered as needed with practitioner approval unless otherwise indicated, for example, auto refill from pharmacy, emergency medication supply use, etcetera.

Based on interviews, and record reviews the facility failed to implement policies and procedures for ensuring the reporting of resident neglect related to an elopement for one resident (#4) out of three residents sampled for elopement risk. Findings included: An interview was conducted on 11/13/23 at 1:40 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN stated around 5:00 a.m. on 10/20/2023 she was in a resident room with the door shut and she heard an alarm going off for about a minute and a half. She stated, when she was able, she stopped what she was doing and walked into the hall. She said Staff E, Certified Nursing Assistant (CNA) also came into the hall from another resident room. Staff D, LPN said she did not see any residents and Staff E, CNA told her she did not see any either. She stated they shut an alarm off, at a door to the service hall, because they thought a staff member may not have shut the door all the way. She stated once the alarm was shut off, another alarm was still beeping. She said the two of them (Staff D and Staff E) went to the exit door and looked outside. She stated Resident #4 was observed outside on the sidewalk. Staff D, LPN said once she opened the door Resident #4 started walking towards her. She stated she asked the resident why he was in the parking lot, and he said he was waiting for his family member to come pick him up. She said the resident agreed to come wait inside and she and Staff E, CNA were able to get him back inside easily. Staff D, LPN said she believed Resident #4 was outside for 1 1/2 to 2 minutes. Staff D, LPN said she did not see the resident walk out the door, the resident was already outside with the door shut when she saw him. She said the resident had not attempted to get out of the facility throughout the night and had not voiced concern about wanting to go home. Staff D, LPN said when she found the resident outside, he was alert and oriented times two but was confused. Staff D, LPN said she reported this information to the Director of Nursing (DON) and the resident's family member. A review of the Admission Record showed Resident #4 was admitted on [DATE] with diagnoses including urinary tract infection, unspecified dementia, difficulty in walking and repeated falls. A review of Resident #4's care plan showed a focus area in place for Elopement Risk, dated 10/13/23. Interventions included distract resident from exit seeking by offering pleasant diversions, activities, food, conversation, encourage family to visit as able, identify pattern of wandering, provide structured activities, toileting, walking inside and outside, reorientation strategies, psychological services as ordered/indicated, and electronic monitoring device alert system. A review of Resident #4's physician orders showed an active order for an electronic monitoring device, dated 10/13/23. A review of the facility's Abuse Log 2023 did not show any reports had been filed related to Resident #4. On 10/13/23 at 9:30 a.m. the Nursing Home Administrator (NHA) confirmed the list of reported incidents was accurate. A review of Resident #4's progress notes showed the following note dated 10/20/23 at 8:23 a.m. written by Staff D, LPN: [Electronic monitoring system] alarm activated @ emergency exit door outside of room [ROOM NUMBER] (to back parking lot 5:35 a.m.), resident observed near tiled patio ambulating toward back parking lot. Writer and staff CNA introduced selves, approached resident. Resident stated, I'm waiting for my [family name], she's coming to get me. Writer, and CNA encouraged resident to wait for [family member] inside in his room. Resident in agreement. Writer, and CNA escorted resident back inside building, and to bed. DON & [family member] advised. Resident placed on Q [every]15 min safety checks. 7-3 nurse advised of above. Resident remains as per baseline. [Electronic monitoring device] intact and functioning wnl [within normal limits] LT [left] wrist. A review of Resident #4's progress notes showed the following IDT (Interdisciplinary Team) note dated 10/20/23 at 9:05 a.m. written by the DON: IDT met to review incident this morning. Based on interview with staff members, [Resident #4] was found in the hallway by his room, walking towards the emergency exit. The Nurse rushed to get to him, however, the resident had pushed on the door activating alarm. Another staff member who was in the room adjacent to the door responded to the alarm approached the resident who stated, I am waiting for my [family member]. The two staff members were able to easily direct resident back to his room by approximately 5:45 a.m. Resident was placed on Q15 minute checks. A staff member was assigned to sit in the hallway with line of sight to the resident's room at 6:40 a.m. At approximately 8:35 a.m., resident's [family member] who was informed about the incident arrived and assumed responsibility for the safety of the resident. IDT met with the resident's [family members] and explained that the resident is expressing wishes to go home. Explained the resident's functional levels; which is supervision for all ADLs [activities of daily living] including ambulating indoors. Resident's [family members] agreed that he would do better at home and can provide the required supervision for him. Psychiatric consult was initiated and completed. Resident to DC [discharge] home with HH [home health]. An interview was conducted on 11/13/23 at 3:06 p.m. with the DON and the NHA. The NHA stated an elopement is when a confused resident goes out the door without anyone knowing about it. He said on 10/20/23 the DON spoke with the staff members regarding the situation with Resident #4. He said he did speak with Resident #4's family that morning. The NHA said the family told him the resident gets anxious when he doesn't see his family members and it was best if they took the resident home. The DON said an elopement is when someone leaves a safe area unsupervised to an area that could be potentially unsafe. The DON said on 10/20/23 she got statements via phone from Staff D, LPN and Staff E, CNA, since they were the only two staff members who responded to the alarm. The DON said the nurse called her and said Resident #4 exited one of the side doors. The DON said the nurse told her she was in a resident room when she heard an alarm and responded. She said the nurse told her she saw the resident at the door and the door opened and the resident went out. The DON said the CNA came out of a room and both the LPN and CNA could visualize the resident outside. The DON provided a typed statement from Staff D, LPN for review. The statement showed the following: On 10/20/23 at approximately 5:35 a.m. I was outside of room [ROOM NUMBER] preparing medications when I heard the alarm for the emergency exit by room [ROOM NUMBER]. I saw [Resident #4] at the door. I walked down the hallway toward him when the door released and opened and closed behind him before I could get to the door. [Staff E, CNA] came out of room [ROOM NUMBER], she and I were both at the door and could see [Resident #4] just outside the door approximately 5 feet away from the door still on the sidewalk. I never lost sight of him from the hallway. I just could not get to the door before it closed. I opened the door and went outside, upon approach I introduced myself and asked him to come back in the building. He told me he was waiting for his [family member]. I was able to redirect him back into the building and to his room where he would wait for her to arrive. He was placed on 15-minute safety checks. He remained in his room for the remainder of my shift. The statement was signed by the DON and the Assistant Director of Nursing (ADON.) Staff D, LPN did not sign the statement. An interview was conducted on 11/13/23 at 3:50 p.m. with Staff E, CNA. Staff E, CNA said on 10/20/23 she was changing a resident. She said she heard an alarm but didn't know which alarm it was. She said she went ahead and finished changing the resident then hurried out the door. She said the alarm was going off for probably 1-2 minutes at that point. She said when she came out of the resident room Staff D, LPN was walking to the back door. Staff E, CNA said when they opened the door, they could see Resident #4 outside. She said he turned and started walking towards them and they got him back inside easily. She said Resident #4 wanted to see his family member. An interview was conducted on 11/13/23 at 2:52 p.m. with the ADON. The ADON said she does staff training, and she teaches staff, As soon as they [residents] cross the outside door that is an elopement. She added if the resident opens an exit door and does not tell any staff then it is an elopement. The ADON said she didn't know exactly what happened with Resident #4 on 10/20/23. She said the DON did the investigating and statements. She said she thinks she was in the office when the DON talked to Staff D, LPN on the phone about Resident #4. She said she does not remember Staff D, LPN saying anything about being in the hallway and seeing the resident. The ADON said she thought the resident was already outside, but she doesn't remember the details. When asked if she signed the statement made by Staff D, LPN, she said I sign so many papers I don't know. A follow-up interview was conducted on 11/14/23 at 8:56 a.m. with Staff D, LPN. Staff D, LPN said she had just gotten off work and while she was there, she reviewed her note about Resident #4's elopement to make sure she had remembered the details correctly. She said while reviewing she also read the IDT note that was entered by the DON on 10/20/23 at 9:05 a.m. She stated the IDT note Is not what happened. Staff D, LPN said she never reported she was in the hall and saw the resident go to the door. She said she told the DON she was in the resident room when she heard the alarm going off. She said she never told anyone she was in the hall and saw the resident walking out. A follow-up interview was conducted on 11/14/23 at 12:45 p.m. with the NHA and the DON. The DON said she would normally get the person to sign their statement on an incident but I didn't follow back up with them to get them signed. The NHA said he noticed the note IDT wrote contradicted the note Staff D, LPN wrote on 10/20/23. He said he talked to the DON about following up with Staff D, LPN because what the IDT note said was not how the nurse explained the incident. The NHA said he never spoke with Staff D, LPN about what happened, the DON told him what the nurse said. He said he did not report the elopement because the DON said Staff D, LPN never lost sight of the resident. Review of a facility policy titled Elopement Risk & Missing Resident, undated, showed the following: Policy statement: The facility will implement measures to monitor residents at high risk for elopement while providing the most homelike environment possible. Review of a facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI), reviewed 10/2022, showed the following: Standard: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property and mistreatment, collectively known and referred to as ANEMMI and hereafter defined, will not be tolerated by anyone, including staff, residents, volunteers, family members, legal guardians, resident representatives, friends, or any other individuals. The Health Center Administrator is responsible for assuring that Resident's Rights of personal privacy, confidentiality and dignity will be respected for all aspects of care and services and that resident safety, including freedom from risk of ANEMMI, holds the highest priority. Definitions: 2. NEGLECT: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when the facility is aware of or should have been aware of goods or service that a resident(s) requires but a facility fails to provide them, to the resident (s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Reporting and Response Policy: All allegations of possible ANEMMI will be immediately reported to the Abuse Hotline by the Administrator or Designee and will be evaluated to determine the direction of the investigation. Procedure: Any and all staff observing or hearing about such events must report the event immediately to the Administrator, Immediate Supervisor, AND one of the following: Directors of Nursing, ANEMMI Prevention Coordinator, or Risk Manager, so that appropriate reporting and investigation procedures take place immediately. It will also be reported to other officials in accordance with State and Federal Regulations. A. IMMEDIATE REPORT Ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. The ANEMMI Prevention Coordinator will also submit to The Agency for Health Care Administration (AHCA) Federal Immediate/5-day Report.

Based on interviews and record review the facility failed to implement an effective discharge planning process by not ensuring medical follow-up related to home health care was initiated for one resident (#1) of two residents sampled for discharge. Findings included: A review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included fracture of right femur, history of falling, need for assistance with personal care, muscle weakness, and difficulty in walking. The record revealed Resident #1 was discharged from the facility on 10/07/2023. A review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview For Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of Resident #1's progress notes revealed the following: -9/25/2023 1:10 p.m. Discharge planning, SSD (Social Service Director) spoke with resident and [family member] to discuss discharge plan. Resident will return home alone. Resident will remain a FULL CODE. -10/3/2023 3:46 p.m. Communication with family, [Family member] and resident have appealed discharge, appeal packet sent to insurance vendor, Case ID [number]. -10/4/2023 10:24 a.m. Discharge Planning/Summary, Resident appealed discharge, if appeal not in her favor; Discharge plan is resident scheduled to be discharged home on Friday 10/06. Home Health Services will be set up through Home Health Vendor for PT(physical therapy)/OT (occupational therapy). DME (durable medical equipment) is a Wheelchair ordered via DME vendor. Resident informed to follow up with PCP (primary care provider). Resident's [Family member] will pick up. -10/5/2023 2:53 p.m. Care plan note, Care plan meeting held with IDT (interdisciplinary team) and [Family member]. Resident declined to attend. SSD: Resident remain a FULL CODE and discharge home with family. Family refused to sign care plan paperwork. She stated she has no concerns. -10/6/2023 3:44 p.m. Discharge planning/summary, SSD spoke with resident's [Family member] at her request, [family member] states she has decided to not wait the 14 days for the appeal process and will take resident home on 10/07/2023. SSD informed her that Home Health vendor will be providing home health, and I will have to notify them that resident will be discharging on 10/07/2023. Explained to [family member] that home health will not begin on tomorrow and will have to notify DME coming, and wheelchair will be delivered to residents home upon authorization from insurance vendor, [family member] expressed understanding. -10/6/2023 3:51 p.m. Skin/Wound, SSD contacted Home Health Vendor regarding, resident discharge, message left for Home Health to contact resident's [Family member]. -10/6/2023 3:56 p.m. Communication with family, SSD called DME vendor and spoke with Representative, states wheelchair will be scheduled for delivery on Monday 10/9/23 and will contact [family member] to inform her on delivery. An interview was conducted on 11/13/2023 at 4:19 p.m. with Staff A, Social Worker and Staff B, Social Worker. Staff B reported the resident was discharged home with a home health vendor. She reported she was unsure if the resident received home health services after discharge. She reported she typically does not call families after discharge to ensure that discharge was appropriate. Staff B reported the receptionist typically sends out a survey, but she does not see them. Staff B reported she contacted the Home Health Agency and set up care for discharge. Staff B confirmed she wrote the progress note dated 10/6/2023 at 3:51 p.m. and she contacted the Home Health vendor and left a message. She was unable to verbalize if the Home Health vendor received the message. Staff B reported she typically would not follow up if she does not hear back from the Home Health agency and if there is a problem the vendor will contact her. She reported the resident would also contact the vendor because they get the contact information at the time of discharge. A phone interview was conducted on 11/13/2023 at 4:29 p.m. with Staff C, Home Health Community Liaison. Staff A, and Staff B were present in conference room. Staff C stated they receive referrals by email or fax and once they get the referral, they run the resident's insurance. She stated on 10/4/2023 she received a fax to her office for anticipated services for Resident #1. Staff C reported the resident's insurance was run on 10/4/2023 and identified the resident's insurance was out of network and they could not accept the resident. She stated she communicated with [Staff B] on 10/4/2023 via email that the insurance was out of network, and they would be unable to accept the resident. An interview was conducted on 11/13/2023 at 4:34 p.m. with Staff B. She stated she did not remember or have documentation of an email from the Home Health vendor declining resident. An interview was conducted on 11/14/2023 at 1:45 p.m. with the Nursing Home Administrator (NHA). The NHA stated they did not have a discharge summary for Resident #1. He stated the discharge summary is the paperwork the resident signs at discharge. A review of the facility policy titled Transfer or Discharge, Preparing a Resident for, undated, revealed the following: Policy Statement: Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: 1-Nursing services is responsible for: -a. Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment; -b. Preparing the discharge summary and post-discharge plan; -d. Providing the resident or representative (sponsor) with required documents (i.e., Discharge Summary and Plan); . A review of the Social Worker job description revealed the following: Overview: The social worker will work with residents in the nursing home by identifying their psychosocial, mental, and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs. Responsibilities: . -Coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident's return to the community. --Social Services Director must maintain monthly resident discharge log of residents for the purpose of follow-up calls.

Based on interview and record review, the facility failed to inform residents or their representatives of a room change for three (Resident #2, #3 and #4) of three sampled residents. Findings included: A medical record review was conducted for Resident #2 which revealed he was admitted to the facility on [DATE] to [room number]. He was transferred to a different room [room number] on the same day, 3/11/23. The resident was admitted at 4:58 p.m. and changed rooms at 10:47 p.m. The facility failed to inform the resident or his representative of the room change. Resident #3 was admitted to the facility on [DATE] with a re-admitted [DATE]. Resident #3 was admitted to [room number] and moved to a different room without notification of the room change to the resident or their representative. Resident #4 was admitted to the facility on [DATE] to [room number]. On 3/23/23, the resident was moved to a different room. The facility failed to inform the resident or their representative of the room change. In a review, the medical records for Resident #2, #3 and #4 were silent to the reason for the move or any type of notification to the resident or their representative. On 3/27/2023 at 2:34 p.m., the Director Nursing reported she did not see any progress notes for the room changes and would ask the Social Service Director (SSD). On 3/27/2023 at 3:00 p.m., the SSD provided Room Change forms for the three residents without the resident or representative signatures to verify if they had agreed to or were notified of the move. The form was submitted incomplete and not part of the medical record. Policy was reviewed titled: Room Change/Roommate Assignment indicates under #2; Prior to changing a room or roommate assignment all parties involved in the change/assignments (e.g., residents and their representatives (sponsors) will be given a ____ hour/day advanced notice of such change. #8. Documentation of a room change is recorded in the resident;s medical record.

Based on observations, interviews, and policy review the facility failed to maintain an infection prevention and control program related to failing to process linens to prevent the spread of infection for 99 out of 102 residents by not ensuring proper washing temperature or sanitizing solution was utilized. Findings included: During the initial facility tour on 5/24/22 at 9:20 a.m. eleven (#280, #122, #129, #131, #165, #166, #169, #172, #174, #175 and #179) resident rooms were posted with Enhanced Barrier Precaution signs and one resident room (#171) was posted with a Contact Precaution sign. An observation and interviews were conducted during a tour of the facility's laundry area on 5/24/22 at 11:20 a.m. Two commercial washing machines were being used as well as one non-commercial washing machine. The non-commercial machine only had standard laundry detergent connected to it. (Photographic Evidence Obtained) Staff A, laundry/housekeeper stated they use the non-commercial machine because they do not bleach the personal laundry. She did confirm the commercial machines are able to wash clothes without bleach. Staff B, Environmental Services (EVS) Manager, stated resident's personal laundry is also washed in the non-commercial machine due to each resident's clothes being washed individually. Staff B added, they aren't going to run those (commercial machines) for five pieces of clothes. Staff A and Staff B confirmed the non-commercial washer is only using detergent and no sanitizer. A load of resident clothing protectors was observed being washed during tour in the non-commercial machine. The washing machine was set to normal wash, warm water, heavy soil level, two rinses, and presoak was off. The facility's policy titled, Department (Environmental Services)-Laundry and Linen, dated January 2014, was reviewed. The policy stated: Sorting Soiled Linen 5. Pre-wash briefs, underpads, and any other items soiled with feces, using the maximum setting of bleach/EPA (Environmental Protection Agency) registered germicidal, and then process through a regular cycle. Washing linen and other soiled items 1. Laundry may be processed in either low-temp or high-temp (temperature) cycles. a. for high-temp processing, wash linen in water that is at least 160 F (Fahrenheit) for a minimum of twenty-five mins. (minutes) b. for low-temp processing, wash linen in water that is at least 71-77 F and use 125 ppm (parts per million) chlorine bleach rinse if the material being washed can withstand bleach and remain intact. On 5/24/22 at 12:25 p.m. an interview was conducted with Staff A. She stated for residents on any kind of precautions, their laundry comes into the dirty laundry area in a yellow bag or double bagged. She stated, this is how they know it is contaminated. She stated laundry staff wear protective equipment to sort the laundry and it is washed by itself. She confirmed the personal laundry for residents on precautions is still washed in the non-commercial washing machine. Staff B, EVS Manager joined the interview and stated dark color clothes, even from precaution rooms are washed in warm water because if you put it on hot it gets very wrinkled. She confirmed all resident clothing protectors and colored clothes, even those from precaution rooms, get washed in warm water on a normal cycle in the non-commercial machine. She confirmed this also included incontinent resident's personal clothes that could be soiled. She stated only light-colored clothes get washed in hot water. Staff A stated sometimes they set the machine to do two rinses if the clothes are dirty. They both confirmed all other laundry, such as sheets, towels, and gowns are washed in the commercial washing machines. Staff B stated they do not have a book or manual for the non-commercial machine, and she does not know what the temperatures are for each cycle. On 5/24/22 at 12:59 p.m. an interview was conducted with Staff C, Maintenance Assistant. He stated the water heater for the laundry room was outside. The temperature of the water heater for the laundry room was observed to be set at 140 degrees Fahrenheit. (Photographic Evidence Obtained) The water heater is an insta-hot water heater. He stated he did not know what temperature the water got up to for the non-commercial washing machine, but said, I would say 140 since it is on that hot water line. On 5/24/22 at 2:10 p.m. a call was placed to the manufacturer of the liquid laundry detergent being used by the facility in the non-commercial washing machine. The Specialty Product Advisory representative indicated this product was not specifically EPA rated to kill bacteria such as clostridioides difficile (c. diff.) She stated they do have products EPA rated for c-diff and other organisms. On 5/24/22 at 2:58 p.m. a call was placed to the customer service department for the non-commercial washing machine. The company was provided with the model number of the non-commercial washing machine in the facility. They stated the temperature of the cycle is based on what the water heater is set at. It can only get as hot as the temperature is set. According to the non-commercial washing machine's Cycle Guide for the washing machine model used at the facility, the wash temperature of hot's description was some cold water is added to save energy. This will be cooler than your hot water heater setting. For the description for warm wash temperatures it read as some cold water may be added, so this will be cooler than what your previous washer provided. An interview was conducted with Staff E, Maintenance Assistant on 5/25/22 at 11:40 p.m. He stated the water temperature is tested in three random resident rooms every day. Those temperatures are compiled weekly in the facility's maintenance system. He stated the water temperature is tested in the laundry sinks weekly, but not in the machines. An interview was conducted with Staff D, Infection Preventionist on 5/25/22 at 12:32 p.m. She reviewed the facility's laundry policy. She stated this policy does not specifically mention resident's personal laundry but should cover everything laundered in the facility. She was notified of the non-commercial washing machine's temperature. She stated it could definitely be a problem if the temperature should be at 160 and is 140. She said it certainly looks like some bacteria could spread this way due to not being washed in hot enough water. She stated she will look into it. An interview was conducted on 5/25/22 at 1:15 p.m. with the Maintenance Director. He stated he was able to test the water temperature coming from the pressure release valve of the insta-hot water heater that flows to the washing machine. He stated the temperature tested at 138 degrees Fahrenheit. He stated it is not a high temperature machine. He stated they either must wash at a high temperature with laundry soap or a medium temperature with a product that will sanitize or not use the non-commercial washing machine. On 5/25/22 at 1:22 p.m. an interview was conducted with Staff B, EVS Manager in the presence of the Nursing Home Administrator. She stated the non-commercial machine has been used for about a year. She then stated personal laundry for residents on precautions is done in the commercial machines, contradicting her stated from the previous day. A review of a list of residents, provided by the Director of Nursing (DON), showed three residents who do not have their personal laundry washed in the facility, their family takes it home to wash it. The Centers for Disease Control and Prevention's (CDC) Appendix D- Linen and Laundry Management, under the heading Healthcare-Associated Infections, lists the following guidance. Best practices for laundering soiled linen: -Follow instructions from the washer/dryer manufacturer. -Use hot water (70-80°C x 10 minutes [158-176°]) and an approved laundry detergent. -Disinfectants are generally not needed when soiling is at low levels. -Use disinfectant on a case-by-case basis, depending on the origin of the soiled linen (e.g., linens from an area on contact precautions.) -Dry linens completely in a commercial dryer. (https://www.cdc.gov/hai/prevent/resource-limited/laundry.html) The CDC's Background G. Laundry and Bedding, under the heading Infection Control, states the following: 4. Parameters of the Laundry Process Fabrics, textiles, and clothing used in health-care settings are disinfected during laundering and generally rendered free of vegetative pathogens (i.e., hygienically clean,) but they are not sterile. Laundering cycles consist of flush, main wash, bleaching, rinsing, and souring. Cleaned wet textiles, fabrics, and clothing are then dried, pressed as needed, and prepared for distribution back to the facility. The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Low-temperature laundry cycles rely heavily on the presence of chlorine or oxygen-activated bleach to reduce the levels of microbial contamination. (https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html) The facility's policy titled, Policies and Practices-Infection Control, dated October 2018, was reviewed. The policy stated: The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 2.The objective of our infection control policies and practices are to: a. Prevent, detect, investigate and control infections in the facility b. Maintain a safe, sanitary, and comfortable environment . 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall establish, review, and revise infection control policies and practices, and help department heads and manages ensure that they are implemented and followed.

Based on observation, interview and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring equipment is maintained in a clean manner and free from debris, related to 3 of 4 (Kitchen, Fern Unit, TCU Unit) ice machines, dish machine, and kitchen walls. Findings included: During an initial tour of the kitchen on 02/01/22 at 10:40 a.m. revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. -Debris was noted on top of the dish machine and its surrounding area. -Black substance was noted on backsplash behind the dish machine table. Observation of the kitchen 02/03/22 at 08:06 a.m. of the morning meal tray line revealed the following: -The kitchen housed a large free standing Ice machine. Inspection of the the interior of the ice machine revealed there was a black substance noted on the plastic dispensing rim. (Photographic Evidence Obtained) -Debris was noted on top of the dish machine and its surrounding area. (Photographic Evidence Obtained) -Black substance was noted on backsplash behind the dish machine table.(Photographic Evidence Obtained) Tour of the kitchen 02/03/22 at 11:15 AM with the Certified Dietary Manager confirmed there was debris on top of the dish machine and its surroundings, there was a black substance on the backsplash behind the dish machine, and a black substance was noted on the interior of the ice machine on the plastic dispenser. Tour of the nourishment rooms on 02/03/22 at 11:30 AM revealed the ice/water dispensers located on Lake Fern Unit and TCU Unit were noted to have a white substance coating ice/water dispensing spouts and the catch trays. (Photographic Evidence Obtained) Interview with the CDM revealed she will address the issues right away and include maintenance in the areas that they address. Review of the facility policy titled Sanitization with an effective date of 1/15/2021 revealed the following: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.

Based on interviews with facility nursing and administrative staff , Resident #6's family member, Witness #1, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), review of the resident's medical record and facility policies, and observation of the facility layout including the location of Resident #6's room, hallways, exit doors and parking areas, it was determined facility staff failed to recognize the need for and provide necessary interventions for one Resident, (#6) of four residents sampled for risk of elopement, related to a change in condition, beginning on 01/15/2021 in which she displayed agitation, medication refusals, aggression, and subsequent exit seeking behavior. Resident #6 was a [AGE] year old retired Nurse, initially admitted to the facility on [DATE] and known to socialize with other residents and staff. She was discharged to the care of family on 11/20/2020, a request made frequently by the resident. On 11/23/2020, three days before the Thanksgiving Holiday, the family requested that the facility take Resident #6 back as they were unable to care for her at home. A review of Resident #6's nursing notes and physician progress notes [REDACTED]. Resident #6 was able to exit the facility at approximately 9:15 p.m. on Martin L. King Jr. holiday, Monday, 01/18/2021. With exhibited increasing behaviors and concern by nursing that the resident would be able to exit the facility, which was not secured for exit seeking residents, and concern by the resident's PCP that she was at risk of hurting herself or others, the primary oversight for Resident #6 was 15 minute monitoring. During the late evening of 1/18/2021, Witness #2 knocked on the front door of the facility to notify them that Resident #6 was in a wheelchair in the bike lane, attempting to throw herself in front of a car, on the four lane highway in front of the facility, with a 55 mile per hour speed limit. This resulted in findings of on-going Immediate Jeopardy occurring on 01/18/2021 when Resident #6, who had been exhibiting aggressive exit seeking behaviors, since 1/15/21, was able to successfully locate an unlocked exit door and self-propel herself through the facility parking lot and into the bike lane of a busy four lane highway unbeknownst to facility staff charged with her oversight. Findings included: 1. A review was conducted of the facility's Abuse Investigation and Reporting policy, (revision date of July 2017). The Policy Statement read: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local , state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Interpretation and Implementation of the policy included responsibilities of the Administrator and the Investigator. The Administrator's role was to assign the investigation to an appropriate individual, provide supporting documents relative to the alleged incident to the individual responsible for the investigation, and to keep the resident and her representative informed of the progress of the investigation. The Role of the Investigator was to review completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person(s) reporting the incident; any witnesses to the incident; the resident; the resident's attending Physician as to the resident's current level of cognitive function and medical condition; all staff members, on all shifts, who had contact with the resident during the period of the alleged incident; the roommate, family members and visitors ; and review all events leading up to the alleged incident. Reporting the alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator or her designee to the following persons or agencies: the State licensing/certification agency ; the local / State ombudsman; the resident's representative; Adult Protective Services, Law enforcement officials, the resident's Attending Physician and the Facility Medical Director. The alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported immediately, but not later than: a) two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b) twenty-four hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. The Administrator, or her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 2. An interview was conducted with the Administrator on 01/22/2021 beginning at 5:00 p.m. The Administrator was asked to explain what happened to Resident #6 as there were no nurses' notes the evening of 01/18/21 when it had been reported by facility staff that the resident was able to leave the facility without escort or staff knowledge. The Administrator reported that the resident was seen at 9:00 p.m. on 01/18/2021 by the nurse and when he went to look for her 15 minutes later, due to 15 minute checks, she was not on the nursing unit. She reported that she had been told that about that same time, a loud knocking was heard on an outside door. Staff reported that there was someone at the door notifying them that one of their residents was outside. The Administrator reported that staff found the resident in her wheelchair in the parking lot of the facility. She reported that by 9:30 p.m. the resident had been brought back into the facility. She confirmed that it had been determined that the resident hadn't left the parking lot of the facility, but had been observed sitting under the streetlight, just inside the entrance lanes from the main highway. The Administrator reported, on 01/22/2021 in the interview that began at 5:00 p.m., that she thought Resident #6 had been able to exit the building by pulling the door open. She was not able to say whether the door was wide open when the resident was brought back, but had reported that the staff were notified of the resident being out of the building by loud knocking on the front, or North entrance. The Administrator reported that a witness had assisted the resident back to the building, but when staff approached the resident, the witness left. She reported that no one got the name or phone number of the witness. The Administrator confirmed that the resident had been sent to the hospital for involuntary examination on 01/19/2021. The Administrator had no explanation for why there were no nurses' notes detailing the resident's exit from the building and return. The note and form for the involuntary examination on 01/19/2021 and the Psychiatric Nurse Practitioner's note, written on 01/19/2021, were not available in the resident's medical record and the Administrator agreed to provide the note and the involuntary hospitalization paperwork. During the interview that began on 01/22/2021 at 5:00 p.m., the Administrator referred to the facility's 4 Point Plan, documented on 01/22/2021, that was developed to address the elopement by Resident #6. The Administrator confirmed that she had not submitted an immediate report to the state agency as the resident hadn't left the facility property, she was returned inside within 15 minutes and she was safe with no injury. She thought the incident had resolved and didn't feel the facility had control over the situation. In a follow up interview with the Administrator on 02/11/2021 beginning at 10:00 a.m., it was confirmed that the Administrator took the lead on this investigation. The Administrator revealed that the timeline of when the resident had exited the building had been based on the interviews conducted on 01/20/2021. She reported that they had not spoken with the resident's daughter in relation to the investigation and did not know the identity of the witness that remained with the resident and sat by the bedside of the resident until she fell asleep. She confirmed all of the facility doors had been checked by the facility's Maintenance Director and they had not had an outside company or a representative from the door's manufacturer come out to check the functionality of the exit doors. On 02/12/2021 at approximately 9:30 a.m., the Administrator reported that she had submitted an Adverse Event Report to the state agency on 02/11/2021 at 4:30 p.m. She reported that the findings from the initial investigation conducted on 01/20/2021 had not changed and there had not been any revision to the plan or to the policies on wandering and elopements or the Abuse policy. She confirmed that the trainings conducted with staff were based on the policies that had been in place when the resident had eloped. At 5:40 p.m. on 01/22/2021, the Administrator had the Maintenance Director explain and demonstrate how they believe the resident was able to exit the building. It was explained with a demonstration while standing in front of the South exit door, that, even if the scanning device that activated the doors was turned off, the door could still be pulled open. In a second interview with the Maintenance Director on 02/11/2021 beginning at 1:45 p.m., he confirmed that on 01/19/2021 when he heard of the elopement the night before, he went to the South exit door and found it unlocked. He confirmed that it had been set to de-activate the sensor so the door wouldn't open if someone walked up to the door. But he hadn't realized the door was not locked and could be pulled open. He confirmed, by demonstration on 02/11/2021 during the interview that began at 1:45 p.m., that the door could be pulled open and it would shut on its own. On 02/11/2021 during the interview with the Administrator that began at 10:00 a.m., facility policies on Elopement and Occurrence Reports were requested. After review of both policies, with comparison to the facility's interventions and staff interviews, it was determined that the facility had not followed their policies in providing supervision to prevent Resident #6 from eloping, and did not follow their policies related to investigating the elopement or documenting and reporting the elopement. On 02/12/2021 at 2:09 p.m., the Administrator was interviewed about the location at which Resident #6 was found on 01/18/2021. The Administrator was asked if any of the three staff members who had gone outside to assist with bringing the resident back inside had shown her where Resident #6 was found. She stated no. When asked how she determined where the resident was found, she stated it was through the investigation and the statements. She reported that one statement indicated the resident was found by the shoulder of the road. The Administrator was asked to show the surveyors the location where the resident was found. The Administrator proceeded to walk the surveyors just beyond the stop sign at the south entrance to the facility parking lot, indicating this was the shoulder of the road. The Administrator was identifying a location that was closer to the facility than the actual shoulder of the road and not in the bicycle lane, which was the location the Witness #1 reported the resident was found. The surveyors used a measuring wheel (Lufkin model PSMW28) to measure the distance from the sliding glass doors at the South entrance to the location where the Administrator said she was told the resident was found. The distance was 162 feet (photographic evidence obtained), or 54 yards. 3. A review was conducted of the Facility Assessment (completed: January 15, 2021), which included both their resident population and the resources the facility needs to care for their residents. The facility determined they would admit residents with a variety of diseases, conditions, and disabilities which included Psychiatric / Mood Disorders (page 6). The facility documented that they would provide support and care to residents with Mental health and behavior concerns that would include, Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[MEDICAL CONDITION], other psychiatric diagnoses, intellectual or developmental disabilities. (page 9) Support and care provided to residents would include Psycho/social/spiritual support such as emotional and mental well-being, helpful coping mechanisms, and identifying hazards and risks for residents, including preventing abuse and neglect. Staff training and education and competencies included the identification of resident changes in condition, how to identify medical issues appropriately, how to identify if symptoms represent problems in need of intervention and how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. Competencies needed and training provided to all staff at all levels included caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing non-pharmacological interventions. A review was conducted of the Orientation training materials provided by the facility to new employees. The agenda for the Orientation included training on Abuse, Neglect, Exploitation and Misappropriation of Resident's Property. A review of the training material revealed handouts that defined the terminology used in the training. Referenced in the definition of abuse was Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well - being. Neglect was defined as The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient/resident care and services to assure care is provided. 4. Review of Resident #6's clinical record revealed she was a long-term resident of the facility, initially admitted on [DATE]. On Friday, 11/20/2020, the resident was discharged to her son's home. By 11/23/2020 a note in the resident's medical record indicated the family was asking about the resident's re-admittance to the facility as they were not able to care for the resident at home. Notes in the resident's medical record and interviews with facility staff and the resident's PCP indicated the resident had a fall within the first few days of being home. The resident returned to the facility on Monday, 11/23/20, prior to the Thanksgiving holiday, with [DIAGNOSES REDACTED]. A review of the admission record also revealed [DIAGNOSES REDACTED]. A review of the resident's progress notes, prior to readmission on 11/23/20, revealed that the resident had been monitored by 15-minute checks, beginning on 10/05/2020 and continuing until she was discharged to her son's home on 11/20/2020. A review of progress notes in relation to the frequent monitoring revealed: On 10/05/2020 an encounter note written by the Psychiatric Nurse Practitioner (NP) documented: Visit type: crisis intervention: Unit manager called provider reporting resident verbalizing suicidal thoughts, request a stat (immediate) evaluation. Called daughter, gave verbal ok for one-time [MEDICATION NAME] IM (intramuscular), patient requested. [AGE] year old female reports she is mad at daughter, she does not have a plan to kill herself, she does not want to die, she is mad at God for not taking her. She reports all of her friends and family have passed; she is ready to move on to heaven. Patient is mad at daughter for not letting her stay at home. Patient refused her insulin this am (morning). patient agreed to try [MEDICATION NAME] IM, refused any pills, patient feels she takes enough meds. Will obtain UA (urinalysis). The Psychiatric Nurse Practitioner's note dated 10/05/2020 included a Review of Systems documenting mood symptoms as loneliness, anxious, depressed mood, and frustration. She had a fearful affect and seemed sad. Psychotic symptoms included disorganized / incoherent speech and/or behavior with impaired reality testing. She expressed passive death wishes, with disruptive/repetitive behaviors and vocalizations. She refused medications and was resistant to care. The NP's mental status examination of the resident included her lack of insight concerning matters of self and lacks judgement regarding everyday activities. Her plan included notifying the Primary Care Doctor for urinalysis orders, administering [MEDICATION NAME] one 0.5 mg intramuscular dose, encouraging the patient to verbalize her feelings and monitor for changes. She was going to follow up in one week. On 10/09/2020 at 10:10 a.m. a review of the resident's doctor's note revealed: patient has been agitated and more confused than usual since last week. She was seen by psych earlier this week after she was found crying and telling she wanted to kill herself. Unit manager came and talked to her, took her to the garden outside. Apparently, she was upset with her daughter. She denies having a plan to hurt herself. She was seen by the psychiatric ARNP who recommended [MEDICATION NAME] IM, but it was not necessary. Resident had a urinalysis that came back abnormal, so she was started on the antibiotic Cipro. Pending culture results. Today she has been calm. On 10/09/2020 at 1551 (3:51 p.m.), the nurse's note read: patient is upset following hospitalization of roommate, refusing all meds, glucose checks and insulin. Patient states she has been diabetic for [AGE] years and doesn't need anything. Will continue to attempt to monitor patient. On 10/12/2020 the NP provided a follow up evaluation for the anxiety evaluation and refusal to take medications the prior week. Her chief complaint was anxiety evaluation status [REDACTED]. History included describing the resident as a [AGE] year old female doing better this week than last, taking medications, eating well per staff and patient is on IV antibiotics for UTI. Medications included trazadone 50 mg by mouth at bedtime and [MEDICATION NAME] 150 mg by mouth twice a day. Review of systems found no mood, anxiety, psychotic, suicidal or agitation symptoms. The Plan was to maintain medication dosages, encourage the patient to verbalize her feelings, monitor for changes. She would follow up monthly and as needed. On 11/12/2020, the Social Services Director spoke with the resident's daughter who informed this writer that she would like the patient to discharge to home with her son on Friday 11/20/20. Spoke with family to address individual's needs and concerns regarding care to ensure quality care and successful transition . Family member has no questions or concerns related to the discharge at this time and is happy with the plan of care. On 11/13/20, an order was received from the resident's PCP for a urinalysis culture and sensitivity as the resident was having increased confusion and some hallucinations. On 11/13/20, the UM requested an evaluation for increased confusion and disturbing hallucinations which had been noticed the past couple of days. Resident's daughter also noticed the change and she is concerned about another UTI now that she is going home next week (11/20/20). A review of a Social Services note dated 11/23/2020, written at 12:13 p.m., revealed a conversation in which Resident #6's daughter was hoping to have her mother brought back to the facility. The plan from the insurance case manager was to have a trial of one week at home before returning the resident to the facility. The next note in the chart, dated 11/23/2020 and written at 16:33 (4:33 p.m.) indicated the resident had returned to the facility and was being screening for COVID-19. The Readmission Summary documented by the nurse on 11/23/2020 at 18:12 (6:12 p.m.) read: resident arrived from home via family transport. Readmission [DIAGNOSES REDACTED]. The resident's PCP documented a History and Physical on 11/25/2020 at 12:48. The assessment included the reason for her return as: The resident was readmitted on Monday after discharged home with family three days before. Daughter requested readmission because they were not able to take care of her. The Registered Dietitian assessed the Resident's nutritional status on 11/25/2020 at 13:03 and included the following: [AGE] year old female, returns to facility following brief d/c (discharge) home. Patient usually very friendly and talkative, today seemed very depressed. I'm not good, I'm sad. Reports poor appetite since returning. An Admission Minimum Data Set (MDS) Assessment completed on 11/30/2020 assessed Resident #6 as scoring a 10 on the Brief Interview for Mental Status indicating cognition was moderately impaired. She was assessed as having a depressed mood infrequently (once a week) and having no behaviors, including wandering. The resident required limited assistance with one staff for transferring, toileting and being mobile in her room or in the hall using either a walker or wheelchair. An elopement risk evaluation was completed on 11/23/2020 as part of the admission packet and it assessed the resident as having no indicators of being at risk of elopement. However, a care plan was developed when the resident was readmitted on [DATE] for being at risk for wandering and elopement. The Focus of the care plan was: I am an elopement risk due to my past history, wandering tendencies or cognitive decline with no regard to my safety. Interventions included: encouraging activities of the resident's choice; notifying the doctor if exit seeking behavior becomes a danger to self or others; provide redirection as required; and safety checks as indicated. An interview was conducted with the MDS Coordinator on 02/12/2021 at 12:30 p.m. in which he confirmed the care plan for elopement had been pulled forward from her past care plans, as the resident was only gone for three days. The MDS Coordinator reported that he felt it was probably relevant to keep it active. He confirmed that the nurse's elopement assessment did not reflect the resident was at risk. He said the resident had occasional wanderings, so it wasn't captured on the assessment. The care plan, dated 11/24/2020, included a Focus area for impaired cognitive skills related to the [DIAGNOSES REDACTED]. A care plan was initiated on 11/24/2020 for the Focus area of the [DIAGNOSES REDACTED]. Interventions included administering medications as ordered, emotional support as needed, medication review if needed, observing for behavioral/mood symptoms such as verbal abuse, screaming, crying, sad affect, sleeplessness, etc, observe for signs and symptoms of side effects related to medication use and report to the Doctor or Nurse Practitioner as needed, and consult Psychiatry and follow up as indicated. A care plan was initiated on 11/24/2020 for the Focus area of experiencing a traumatic event which has impacted her emotional health. The resident had a history of [REDACTED]. Interventions included avoiding triggers that may re-trigger memories of traumatic events in her past, encourage her to express her feelings/ concerns/thoughts, provide a quiet, nonthreatening environment; respect the resident's space and privacy; staff will knock and introduce themselves when entering her personal space; and alert Doctor or designee of any significant changes in behavior. A care plan was initiated on 12/03/2020 for the Focus area of the [DIAGNOSES REDACTED]. Interventions included administering medications as ordered; observe for side effects of antidepressants; provide emotional support; medication review as needed; observe for behavioral/mood symptoms: verbal abuse, screaming, crying, sad affect and sleeplessness; psychiatric consult and follow up as indicated; and report side effects of medication to the Nurse Practitioner and Doctor. These care planned areas were not reflected in the 11/23/20 elopement assessment related to questions of behaviors, medications, and diseases which would have increased the elopement risk score. The elopement assessment included a question on Emotional Status, which was answered, happy with placement. The resident scored a 2 on the elopement risk assessment identifying her as not at risk for elopement. The form included the instructions: If the total score is 10 or greater, the resident should be considered to be at risk for elopement. Expressions of feeling abandoned by family is a risk factor for suicide, in addition to voicing a lack of feeling connected or belonging to others and feeling like a burden on family, according to Thomas Joiner (Why People Die by Suicide, Joiner 2005). A review of the discussion of risk factors in the book Challenges Associated with Managing Suicide Risk in Long Term Care Facilities revealed known risk factors of suicide in community dwelling older adults apply to residents of long-term care facilities. These similar risk factors include the presence of a mood disorder, or a medical illness, social isolation and recent life stressors. The authors identified risk factors for suicide that are specifically characteristic of residents in large long-term care facilities and facilities with higher rates of staff turnover. The ability to bond with staff and feel a part of a community can be difficult if the resident census is high and staff that care for you are frequently unknown to you, or seemed rushed when they are providing care. (Riley, Nadorff, Conwell, Edelstein, 2013). On 12/01/2020, a psychiatric 60 day follow up assessment was completed upon the November admission which identified no concerns. The note included under History of Present Illness: [AGE] year-old female reports she is doing much better now that she is back in long term care. She had wanted to go home with her children but was unable to take care of herself the way she thought she could, now she is back in long-term care. Her children are unable to care for her due to their own working lives. Patient is intermittently weeping during interview as she is trying to comprehend her failing health, her failing mind and having to spend out her days in long-term care. Her medications included Trazadone 50 mg by mouth at bedtime and [MEDICATION NAME] 150 mg by mouth twice a day. During the exam the resident denied any mood symptoms, anxiety, psychotic symptoms, suicidality, or agitation. Her recommendations were to continue the [MEDICATION NAME], allow the resident to verbalize her feelings, monitor for changes, and she would follow up in three months. The resident's Primary Care Provider (PCP) saw her on 12/28/2020 and wrote that the resident had no acute changes in her condition or behavior, that she was compliant with treatment, getting along well with her roommate. Wandering around the unit self-propelling the wheelchair. Forgetful but still able to voice her needs. The plan included fall precautions to continue, therapy as needed and nursing for skin care, pain assessment, and timely medication administration. Two days later, on 12/30/2020, the 3-11 shift nurse documented, at 2135 (9:35 p.m.) that, when presented with medications, the resident told the nurse to go away. On 01/01/2021 at 1624 (4:24 p.m.), the resident complained of throbbing pain to her right ear, with an oral temperature of 98.0 F, no discharge, redness, or swelling noted. MD notified, MD on call for PCP gave instructions to administer PRN (as necessary) Tylenol as per current order for ear pain. The resident's PCP saw her on 01/04/2021 and documented the complaint of right ear pain during the weekend and the resident was started on oral antibiotics. The PCP documented that the resident was feeling better today after 48 hours of treatment, with no fever. On 01/05/2021 at 1:18 a.m., the nurse documented that the resident's pain was not being managed with Tylenol. The patient was awake and tearful from pain in the ear. The patient was at the nurse's station because she cannot sleep due to pain. The nurse documented that she reached out to the on- call physician for further orders. She documented that she offered the patient something warm to drink, a snack and to transfer the patient back into bed, but she refused. On 01/12/2021 at 18:00 (6:00 p.m.), the Nurse Unit Manager wrote: resident came to this nurse at the end of (nursing unit), she was crying and said she needed to get out of here. I asked what was the matter and she said she cannot stay with that woman in her room any longer, I asked her what happened because she was so happy to be back in that room and she said, 'her roommate thinks she is better than anyone, she said I had a nice lady give me a very nice shower and my roommate made a phone call and said she was not going to let her shower her.' This resident said she cannot live with someone who thinks she is better than everyone else and she would rather sleep outside. I explained that I was not gonna let her sleep outside and we would find her another room. She started crying, again, and said she can't afford to pay for another room and, since you are (my daughter's) friend, can you just call her to come pick me up. I consoled this resident and assured her that it was taken care of and it would not cost her any more money. I showed resident the room and she was happy to sleep there and I told her in the morning if she was happy with this room we would move her belongings. On 01/15/2021, Resident #6's PCP documented: Evaluation requested for changes in condition. Patient has been agitated, refusing meds and displaying some aggressive behavior. A urine sample was collected and came back positive. The Plan included an oral antibiotic with the note that the medication would be adjusted when the culture was available. On 01/17/2021 at 2:05 a.m., a Behavior note written by Staff L, Licensed Practical Nurse (LPN) noted: The resident was observed fully dressed, up in wheelchair at beginning of shift, no face mask in place. Resident was on enhanced contact precautions/ESBL urine. The 3-11 nurse working on 01/16/2021 reported resident wandering about unit entering other resident's rooms, continuously exit seeking, yelling, pushing on emergency exit doors, kicking glass on door. After change in shift resident evaluated for pain, discomfort, thirst, hunger, toileting needs. Diversional activity offered, refused. Resident continued to wander about unit, pressing on emergency

Based on observation of the facility layout including the location of Resident #6's room, hallways, entrances, exits, and parking areas, review of resident medical records, facility policies and photographic evidence, and interviews with the facility's nursing and administrative staff, Resident #6's family member, Witness #1, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), the facility failed to thoroughly investigate how one resident of four sampled residents (Resident #6), with a previous history of verbalizing suicidal thoughts and wandering, was able to elope from the building. Facility staff failed to interview all staff and the witnesses who were present during the evening on 01/18/2021 and failed to review the resident's medical record to ensure all resident related behaviors and statements were taken into consideration, which led to an incomplete and incorrect timeline of events. Resident #6 was a [AGE] year-old retired Nurse, originally admitted to the facility on [DATE] and known to enjoy roaming the halls in her wheelchair. She was discharged to the care of family on 11/20/2020, a request made frequently by the resident. On 11/23/2020, three days before the Thanksgiving Holiday, the family drove the resident back to the facility as they were unable to care for her at home. Resident #6 was admitted , again, on that date. A review of Resident #6's nursing notes and physician progress notes [REDACTED]. Between 1/15/21 to 1/18/21, Resident #6 continued to display an increase in behaviors to include continuous exit seeking, yelling, pushing on emergency exit doors, kicking the glass on exit doors, and hitting a window with a walker in attempts to leave the facility. Resident # 6 exited the facility, unknown to staff, at approximately 9:15 p.m. on Martin Luther King Jr. Day, Monday, 01/18/2021. Despite these increasing behaviors and concern by nursing that was shared with the resident's daughter, that the resident would be able to exit the facility due to it not being a secured facility, and concern by the resident's PCP that she was at risk of hurting herself or others, the primary oversight approach for Resident #6 was that of 15 minute monitoring. This resulted in findings of on-going Immediate Jeopardy occurring on 01/18/2021 when Resident #6, who had been exhibiting aggressive, and deliberate exit seeking behaviors, was able to successfully locate an unlocked exit door and self-propel herself through the facility parking lot and into the bike lane of a busy four lane highway, unbeknownst to staff. Findings included: 1- On 01/27/2021 at 1:15 p.m. a phone interview was conducted with Witness #1. Witness #1 stated that at approximately 9:15 p.m. on 01/18/2021, she was driving north on the highway that the facility faced, when she noted the car in front of her begin to slow and drive erratically. When she got closer, she noted in her headlights that the car had pulled over to the bike lane and had parked in front of a person in a wheelchair, who was in the bike lane, in an attempt to block traffic. She said she had to drive north, use the turn lane to go back south and then back north to join the car and person in the wheelchair. She said she wasn't aware of a residential facility along that road so she couldn't figure out how someone in a wheelchair could be out alone, especially in such cold weather. She said the other driver was familiar with the facility and somehow notified them of their resident being on the side of the road. She said that a male employee came out to return the resident back inside. The resident refused and continued to try to lunge herself out of her wheelchair into the traffic lanes. The employee was able to wheel the resident back toward the facility by tilting the wheelchair and only using the back wheels. This approach prevented the resident from digging her heels in to refuse to return to the facility. Witness #1 said she held the resident's hand as they walked back to the facility which, she described, as approximately 30 yards. She said she was able to bond with the resident and get her to talk with her. She reported the resident was saying she would rather die than return to the facility and that her kids didn't love her. She said it took about an hour to get the resident back into the facility and, when she finally left about an hour after that, she left her name and phone number with the resident and with facility staff. She said she was surprised no one had called her the next day about the incident. Observation on 02/12/2021 at 8:30 p.m. revealed that the facility was located on a four lane, divided highway with a bike lane and a center median. The speed limit at the facility location was 55 miles per hour and the traffic lights were distant from each other. The South entrance to the facility parking lot was dimly lit with a streetlight illuminating the area once the turn off to the parking lot was made. South of the entrance was a wooded area and the entrance to the facility was on a curve. There was no traffic light at the entrances to the facility from the highway. On 01/18/2021 the sun had set at 5:59 p.m. (www.suntoday.org) and the temperature that night was 54 degrees Fahrenheit (www.wunderground.com). On 01/25/2021 at 2:43 p.m., a phone interview was conducted with Resident #6's daughter. The daughter stated that one of the witnesses called her while she was attempting to keep her mother away from the traffic lanes. She said it was close to 10:30 p.m. when she spoke to her mother outside. She was aware that the witness stayed with her mother for almost two hours and had accompanied her mother back into the facility and into her room. She said the witness assured her mother that she would not leave her until she was safely inside. An interview was conducted on 01/29/2021 beginning at 1:50 p.m. with the male employee who had left the facility to bring the resident back. Staff I, Certified Nursing Assistant (CNA), stated he worked for a staffing agency. He confirmed he heard banging on the front door, where the receptionist sits during the day (north entrance). When he went to see who it was, he reported there was a lady telling him, through the closed door, that there was a resident outside. He said he walked 25-50 feet south on the highway that the facility affronts before he saw the resident with another person standing next to her. He reported that the resident refused to come back in and described her as not agreeable and very feisty. He said she kept trying to slide out of her wheelchair into the road. She was saying that she wanted to die. He reported that it took at least 30 minutes to talk her into coming back in. He reported he didn't know the resident and didn't remember working with her much. He confirmed he was assigned as a one on one with her for the rest of that night following the elopement. He confirmed that one of the witnesses (#1) had stayed with her and came into the building with her. He was able to identify the witness by name. On 1/29/21 at 5:40 PM, the Night Unit Manager, Staff H, reported in a phone call that she spoke with two female witnesses who found the resident on the road, not the sidewalk, of the highway. She said the two cars were parked to protect the resident in her wheelchair from the cars that were whizzing by. She remembered that she could feel the cars speeding past them. Staff H confirmed the resident was fighting them, as she didn't want to go back inside. They had to tilt her wheelchair back to wheel her in. She said the resident was very upset even though she confirmed later that her nurse reported he had given her [MEDICATION NAME] that evening. Staff H reported that she wasn't sure how Resident #6 was able to leave the building. She confirmed it had to be one of the main doors - either the North or the South doors as the other doors were fire doors and the alarm would have gone off if the door had opened. She confirmed it took a while to get the resident back in the facility. She stated that she hadn't looked at her watch, but she had so much to do that night. She said earlier in the night she saw Resident #6 in the small therapy gym which exits to the enclosed courtyard of the building. She said she took the resident back to her side of the building, and she realized later that by taking her past the front doors, it gave her a chance to see that exit door. Staff H was informed that there were no notes in Resident #6's record documenting the elopement and course of events that happened that night. She said she didn't know that and that statements were given the next day. Staff H reported that she had not received the witnesses' contact information that night, but the witness seemed to know Resident #6. She ended the call by saying that Resident #6 just wasn't herself that night. In a phone call, on 02/11/2021 beginning at 6:00 p.m., CNA, Staff J, stated that she had gone outside to help find and bring Resident #6 back into the building. Staff J confirmed that she had answered the loud knocking on the north entrance door along with Staff I, CNA. They were told that there was a resident outside. While she was outside with Staff I, she called Staff H, Nursing Supervisor, at 9:30 p.m. to let her know they were outside with the resident. She said the resident was found right alongside the road, not in the parking lot or on the sidewalk. Staff J reported she returned inside but Staff I stayed with Resident #6. She reported that the resident didn't want to come back in, and she didn't know when they came back in the facility. She confirmed that she had been asked to write a statement and that the time that she heard the knocking and went outside would be in her statement. On 01/29/2021 beginning at 1:30 p.m., a phone interview with Staff G, Licensed Practical Nurse (LPN), revealed he was the nurse assigned to Resident #6 on 01/18/2021 during the 3 p.m. to 11 p.m. shift when the elopement occurred. He reported that he didn't know her that well as he was part time and usually assigned to a different wing. He confirmed that she was on 15-minute checks for some incident, and described the incident as probably trying to get out of the building. He reported the resident was very anxious that night and added that there were several residents on 15-minute checks that night. Staff G reported that he saw the resident at 9:00 p.m., in the hall near her room, and when he went back to check on her at 9:15 p.m. she wasn't around. He said he started to look for her and between 9:15 p.m. and 9:30 p.m., the other nurse's unit called to say they had his resident. The caller confirmed she had been out of the building. Staff G reported they didn't know any details such as how she was able to get out of the building or even how they knew she was out of the building. He reported that he felt very fortunate that nothing happened to her as the highway that the facility was on was a very busy road. He said when she was brought back, he assessed her while she was sitting in her wheelchair and found no injuries, no bruises, and even checked her knees to assure she hadn't fallen on them and they were skinned. He confirmed that there was someone with her, who he thought was family. He confirmed that person wasn't there when he assessed her, but came into the room when he was done. He thought the individual was signing something or getting the correct PPE (personal protective equipment). Staff G reported that he was not sure what to do in this situation as he had never had a resident who had eloped before. Staff G stated that the Unit Manager instructed him to assess the resident, and she would take care of the documentation. This was why there were no notes from him post elopement on 01/18/21. Staff G remembered giving Resident #6 her IM (intramuscular) antibiotic and her [MEDICATION NAME] that night. He thought she had been returned to her room by 9:30 p.m. He repeated that he didn't know how she could have exited the facility and said it must have been from the other unit as Resident #6's unit was in the back of the building and had no exit doors. He stated she must have gone through to the next unit and somehow gotten out that way. In a follow up interview with Staff G on 02/12/2021, beginning at 8:45 a.m., the nurse was asked about the resident's location on the night of 01/18/21, prior to the elopement as the safety checks that he had documented on the 15 minute monitoring form only listed that the resident was in her chair. Staff G reported that the resident remained near her room or in her room, and referred to the current COVID pandemic and residents were to remain in their rooms. He confirmed he hadn't received training on completing the 15 minute safety check logs, as the instructions were on the log. He confirmed he wrote wandering at the 9:15 p.m. check on 01/18/2021 since he didn't see her and figured she was wandering. Staff G reported that he hadn't looked at his watch when he got the call from the other nursing unit reporting that Resident #6 was back in the building, but he didn't think she was gone long. He reported that they had precautions in place - the 15 minute checks. That's how they knew she was gone, as he didn't find her at the 9:15 p.m. check. He stated it was scary at first, when they couldn't find her and then found out she was out by the side of the road, but there wasn't anything else they could have done for her. He referred to the (undocumented) assessment he had completed on Resident #6 and reported that he found nothing, not even a red spot. He said that he thought he had documented the assessment, but knew that the other nursing unit had assessed her too. He said the other nursing unit phoned the daughter to ensure she was aware of the event. Staff G confirmed he hadn't completed an incident or event report as that is something the Unit Managers do. He reported that he had never been trained in that position, he didn't know all they had to do, but he thought they would be the ones to complete the incident report. He said he hadn't ever been asked to complete one before. Staff G confirmed that he did not go outside to help find the resident as he had other residents that he couldn't leave. He added that by the time he was aware she had gotten out, she was back. Staff G confirmed he had written and submitted his statement of events, included just what he knew and saw, and didn't include what others told him. A phone interview was conducted with Resident #6's assigned Staff Q, CNA, on 02/11/2021 beginning at 5:36 p.m. The CNA confirmed she was assigned to Resident #6 on the 3-11 shift on 01/18/2021. She reported that she had 22 residents to care for that night. She said that she knew Resident #6 well as she had cared for her often. She confirmed that Resident #6 was in a mood that night and had been since that weekend. She said the resident was very agitated and would not settle. She wouldn't stay with you when you asked her. She would listen and you could redirect her, but soon she was off. She could self -propel and she was fast. She said that Resident #6 took a long nap that day and didn't eat her dinner until 7:30 p.m. She commented that she was all around the unit in her chair, throughout the weekend and on Monday, the holiday, at every door, trying to get out. She said the resident was setting off the door alarms, pushing on the doors until the alarms sounded, at both ends of her hall. Staff Q said she tried to get the resident to remain with her or remain with the nurse, but soon she would get away from them. Resident #6 was leaving her nursing unit to go to the other side (of the building). She wanted to go out. Staff Q reported that she last saw the resident between 8:15 p.m. and 8:45 p.m. on 01/18/2021 as that was a down time for the aide. She said Resident #6 was around her room, at the end near the little nursing station. Staff Q said she didn't see her after that. She said that the nurse found her in a room providing care and told her that Resident #6 had gotten out. She said the nurse told her someone went out to get her back. He didn't know how, but he had been told she exited through the South door. She didn't know when the resident came back inside but when she did return, Staff I, CNA, was with her, and a lady was walking with them. She said she put the resident to bed and the lady stayed with the resident, talking with her, and holding her hand. Staff Q reported that she hadn't asked who the lady was or what her name was. Staff Q reported that Staff I knew the lady's name. Staff Q said she didn't see Resident #6, again, before her shift was up. She confirmed that she received training on residents who had eloped and what to do the next time she worked. She denied having been asked to write a statement about the night Resident #6 got out of the building. On 02/12/2021 at approximately 9:50 a.m., the Administrator provided a copy of Staff Q's answers to questions she had asked her at approximately 12:00 p.m. on 02/11/2021. According to the documentation recorded 24 days post event, Staff Q reported that she had redirected the resident with other staff redirecting as well, that she was caring for other residents when the incident occurred, she last saw the resident at the nurses' station which was after dinner and her nurse notified her of the incident. An interview was conducted on 01/22/2021 beginning at 11:30 a.m. with the Nurse Supervisor, Staff E, who confirmed she knew Resident #6. She reported that she wasn't in the building when Resident #6 left the facility. She reported that the resident was usually a very nice pleasant woman. She knew her well and was one of her favorites. She reported that when the resident got a UTI, her behavior changed, she got nasty, teary, and expressed that she wanted to die. She reported that she felt her children didn't need her. Staff E reported that you could see the UTI coming as the resident would exhibit a slight change in behavior and attitude. In a follow up interview conducted with Staff E, on 02/12/2021 beginning at 10:40 a.m., Resident #6 was identified as usually roaming the halls, and talking with other residents. She confirmed that Resident #6 seemed a little upset that she had to come back to the facility in November after being home for only 3 days with her family. She said that she hadn't noted that Resident #6 showed any interest in the exits when she first returned. She said that her hang out location was the big nursing station or on her hall talking with others. On 01/22/2021, beginning at 11:40 a.m., the resident's PCP reported that Resident #6 was a long-term patient who had behavior changes if she got a UTI. She reported that everyone knew that. She reported that the resident had gone home with her daughter but within a few days it became apparent that the family could not care for her. She returned to the facility and began to have changes in her behavior. The Physician reported that she had been notified of the behavior change on 1/15/21 and she ordered an antibiotic for the UTI as well as [MEDICATION NAME] (oral and IM) and then [MEDICATION NAME] (oral and IM), for the behaviors. She reported that she ordered the second antibiotic as intramuscular to ensure the resident would take the medication and the infection would resolve. She reported that the facility referred the resident's behavior to the Psychiatric Nurse Practitioner but added that they were trying not to initiate an involuntary psychiatric hospitalization for the resident, which was the reason she was trying to treat the UTI with an IM antibiotic. She reported that the decision was made to admit the resident involuntarily to the hospital as the resident was trying to break the glass on the doors and she had told the staff she would go into the street to get killed. The Physician confirmed that the resident left the building with her wheelchair, as she was very mobile in her wheelchair either by walking behind it or self-propelling it. In a second interview with the resident's PCP, on 02/11/2021 beginning at 12:30 p.m., it was confirmed that she was managing the resident's UTI , having changed the medication based on the culture results and then changed the route of the medication to ensure the infection would resolve. She reported that she had been told the resident was accepting the IM injections of the antibiotic. (A review of the Medication Administration Record [REDACTED].) The PCP reported that the resident's daughter had texted her on 01/19/2021 to ask for advice on the resident's behavior, since she had left the building. The PCP reported that she had to call the Unit Manager, Staff E to ask what was going on. She said that Staff E explained what had happened the night before when Resident #6 was able to exit the building, unescorted and without facility knowledge to implement her plan to get run over by a car. The PCP reported that she then spoke with the daughter. A review of the note written by the Psychiatric ARNP on 01/19/2021(no time) documented that she had been called for a follow up stat (immediate) visit as patient was verbalizing that she wanted to wheel herself into the main road and get hit by a car. She included that the resident was verbalizing a suicidal plan. Under History of Present Illness, the ARNP wrote: female very calm sitting in her wheelchair dressed appropriately verbalizing her determination to get out any door via her wheelchair to get to the main road to get hit by a car, she wants to die, she has a flat affect. She reports she knows she has nursing staff watching her continuously. Patient reports she is not going to sleep so she can find a door to get out and get hit by a car. Patient not crying with telling her plan. Refuses to tell reason why, patient reports if she goes to hospital she will get out. The ARNP's note included that she had spoken with the resident's daughter who was aware that the patient was determined to kill herself today, to be hit by a car, and agreed to have the patient admitted to the hospital for involuntary psychiatric examination. The Psychiatric ARNP was interviewed by phone on 01/25/2021 beginning at 4:20 p.m. The ARNP confirmed she knew Resident #6 and agreed to answer questions. She confirmed that she was aware the resident had left the building, but, only after she had arrived at the facility and had begun to review the medical record prior to speaking with the resident. She said she was hearing from staff what happened, but wanted to read the documented details, rather than hearing, what she said, what he heard. She confirmed that there was no documentation in the resident's medical record related to the resident's elopement the evening of 01/18/2021. She reported that she told the facility staff that they needed to get something into the medical record about the incident. The ARNP reported that the resident usually cried when she talked with her or would say something then forget what she said shortly after. She said the resident was easy to redirect with her behavior and her speech. But this time was different, as the resident was very calm, and she seemed to have a plan. She reported that the resident's behavior scared her. The resident knew which doors had alarms, which door she could use to get out. She realized that night was cold, 40 degrees Fahrenheit, and asked her if she was cold? The resident said no, she had brought her winter coat with her. An interview was conducted on 01/22/2021 beginning at 12:49 PM with the Social Services Director (SSD) who reported he was not aware that Resident #6 had left the building when he came to work the morning of 01/19/2021. He reported there was a Risk Meeting held daily and the elopement had not been discussed at that time. He reported that he had later heard something about the resident leaving the building, but it had not been formalized as an elopement. When asked if the Social Services Coordinator was aware of the resident leaving the building, the SSD reported that he didn't know, but thought that if she had known, she would have told him and they would have discussed the incident. He confirmed that the resident had been sent to the hospital involuntarily as she had been refusing medications, and he knew she was disoriented. At 1:05 P.M. on 01/22/2021, the Social Services Coordinator was interviewed and confirmed that she knew Resident #6. She reported that she was not aware that Resident #6 was physically out of the building, until she received training on 01/21/2021 on elopement. She reported that she asked if someone had left the building and was told yes. She reported that she knew Resident #6 had behaviors, but didn't know if the resident had been sent to the hospital involuntarily. She reported that she had been asked to send a referral to a local facility that had a secured unit. She reported that she found out today (01/22/2021) how the resident left the building. She reported that she heard the front door was not secured and the resident was able to pull or push it open. An interview was conducted with the Administrator on 01/22/2021 beginning at 5:00 p.m. The Administrator was asked to explain what happened to Resident #6 as there were no nurse's notes for the evening of 01/18/21 when it had been reported by facility staff that the resident was able to leave the facility without escort or staff knowledge. The Administrator reported that the resident was seen at 9:00 p.m. on 01/18/2021 by the nurse and when he went to look for her 15 minutes later, due to 15 minute checks, she was not on the nursing unit. She reported that she had been told that about that same time, a loud knocking was heard on an outside door. Staff reported that there was someone at the door notifying them that one of their residents was outside. The Administrator reported that staff found the resident in her wheelchair in the parking lot of the facility. She reported that by 9:30 p.m. the resident had been brought back into the facility. She confirmed that it had been determined that the resident hadn't left the parking lot of the facility, but had been observed sitting under the streetlight, just inside the entrance lanes from the main highway. The Administrator reported, on 01/22/2021 in the interview that began at 5:00 p.m., that she thought Resident #6 had been able to exit the building by pulling the door open. She was not able to say whether the door was wide open when the resident was brought back, but had reported that the staff were notified of the resident being out of the building by loud knocking on the front, or North entrance. The Administrator reported that a witness had assisted the resident back to the building, but when staff approached the resident, the witness left. She reported that no one got the witness's name or phone number. The Administrator confirmed that the resident had been sent to the hospital for involuntary examination on 01/19/2021. The Administrator had no explanation for why there were no nurses' notes detailing the resident's exit from the building and return. The note and form for the involuntary examination on 01/19/2021 and the Psychiatric Nurse Practitioner's note written on 01/19/2021 were not available in the resident's medical record. During the interview that began on 01/22/2021 at 5:00 p.m., the Administrator referred to the facility's 4 Point Plan, documented on 01/22/2021, that was developed to address the elopement by Resident #6. The Administrator confirmed that she had not submitted an immediate report to the state agency as the resident hadn't left the facility property, she was returned inside within 15 minutes and she was safe with no injury. She thought the incident had resolved and didn't feel the facility had control over the situation. A follow up interview with the Administrator on 02/11/2021 beginning at 10:00 a.m. revealed that the timeline of when the resident had exited the building had been based on the interviews conducted on 01/20/2021. She reported that they had not spoken with the resident's daughter in relation to the investigation and did not know the identity of the witness that had remained with the resident and sat by the bedside of the resident until she fell asleep. She confirmed all of the facility doors had been checked by the facility's Maintenance Director and they had not had an outside company or a representative from the door's manufacturer come out to check the functionality of the exit doors. On 02/12/2021 at approximately 9:30 a.m., the Administrator reported that she had submitted an Adverse Event Report to the state agency on 02/11/2021 at 4:30 p.m. She reported that the findings from the initial investigation conducted on 01/20/2021 had not changed and there had not been any revision to the plan or to the policies on wandering and elopements or the Abuse policy. She confirmed that the trainings conducted with staff were based on the policies that had been in place when the resident had eloped. At 5:40 P.M. on 01/22/2021, the Administrator had the Maintenance Director explain and demonstrate how they believe the resident was able to exit the building. It was explained with a demonstration while standing in front of the South exit door, that even if the scanning device that activated the doors was turned off, the door could still be pulled open. In a second interview with the Maintenance Director on 02/11/2021 beginning at 1:45 p.m., he confirmed that on 01/19/2021 when he heard of the elopement the night before, he went to the South exit door and found it unlocked. He confirmed that it had been set to de-activate the sensor so the door wouldn't open if someone walked up to the door. But he hadn't realized the door was not locked and could be pulled open. He confirmed, by demonstration on 02/11/2021 during the interview that began at 1:45 p.m., that the door could be pulled open and it would shut on its own. On 02/12/2021 at 2:09 p.m., the Administrator was interviewed about the location at which Resident #6 was found on 01/18/2021. The Administrator was asked if any of the three staff members who had gone outside to assist with bringing the resident back inside had shown her where Resident #6 was found. She stated no. When asked how she determined where the resident was found, she stated it was through the investigation and the statements. She reported that one statement indicated the resident was found by the shoulder of the road. The Administrator was asked to show the surveyors the location where the resident was found. The Administrator proceeded to walk the surveyors just beyond the stop sign at the south entrance to the facility parking lot, indicating this was the shoulder of the road. The surveyors used a measuring wheel (Lufkin model PSMW28) to measure the distance from the sliding glass doors at the South entrance to the location where the Administrator said she was told the resident was found. The distance was 162 feet (photographic evidence obtained), or 54 yards. Further observation determined the Administrator was identifying a location that was closer to the facility than the actual shoulder of the road and not in the bicycle lane, which was the location the witness reported the resident was found. On 02/11/2021 during the interview with the Administrator that began at 10:00 a.m., facility policies on Elopement and Occurrence Reports were requested. After review of both policies , with comparison to the facility's interventions and staff interviews, it was apparent that the facility had not followed their policies in providing supervision to prevent Resident #6 from eloping, and did not follow their policies related to investigating the elopement or documenting and reporting the elopement. In a telephone interview with the Director of Nurses (DON), on 01/29/2021 beginning at 3:50 p.m., the DON conf (TRUNCATED)

Based on observation of the facility layout including the location of Resident #6's room, hallways, entrances, exits, and parking areas, review of resident medical records, facility policies and photographic evidence, and interviews with the facility's nursing and administrative staff, Resident #6's family member, a witness, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), it was determined that the facility failed to provide the level of supervision needed to prevent an elopement for one (Resident #6) of four residents sampled for elopement. Additionally, the facility failed to provide adequate supervision and services necessary to prevent falls for three (Resident #4, #8, and #9) of three residents sampled for falls. Resident #6 was a [AGE] year-old retired Nurse, initially admitted to the facility on [DATE] and known to enjoy roaming the halls in her wheelchair and talking with other residents. She was discharged to the care of family on Friday, 11/20/2020, a request made frequently by the resident. On Monday, 11/23/2020, three days before the Thanksgiving holiday, the family decided to have Resident #6 admitted , again, to the facility as they were unable to care for her at home. A review of Resident #6's nursing notes and physician progress notes [REDACTED]. Between 1/15 - 1/18/21, Resident #6 continued to display, a severe increase in behaviors to include continuous exit seeking, yelling, pushing on emergency exit doors, kicking the glass on exit doors, and hitting a window with a walker in attempts to leave the facility. Resident #6 was able to exit the facility at approximately 9:15 p.m. on Martin L. King Jr. holiday Monday, 01/18/2021. Despite these increasing behaviors and concern by nursing that was shared with the resident's daughter, that the resident would be able to exit the facility due to it not being a secured facility, and concern by the resident's PCP that she was at risk of hurting herself or others, the resident was only placed on 15 minute monitoring. On 1/18/2021 at approximately 9:15 p.m., Witness #2 was heard by staff knocking on the front door of the facility informing them that Resident #6 was in her wheelchair in the bike lane of four lane highway, with a 55 mile per hour speed limit, in front of the facility attempting to throw herself in front of a car. The facility's failure to adequately assess the potential for self-harm/injury and provide the needed oversight to keep Resident #6 safe, allowed her to elope from the building, in an attempt, to self-propel into traffic and get run over. This resulted in findings of on-going Immediate Jeopardy occurring on 01/18/2021 when Resident #6, who had been exhibiting aggressive, exit seeking behaviors, was able to successfully locate an unlocked exit door, during the evening hours, and self-propel herself through the facility parking lot and into the bike lane of a busy four lane highway, unbeknownst to staff. Findings included: 1. Review of Resident #6's clinical record revealed she was a long-term resident of the facility, initially admitted on [DATE]. On Friday, 11/20/2020, the resident was discharged to her son's home. By 11/23/2020 a note in the resident's medical record indicated the family was asking about the resident's re-admittance to the facility as they were not able to care for the resident at home. Notes in the resident's medical record and interviews with facility staff and the resident's PCP indicated the resident had had a fall within the first few days of being home, and the son and daughter felt they were not able to care for the resident at home. The resident returned to the facility on Monday, 11/23/20, prior to the Thanksgiving holiday, with [DIAGNOSES REDACTED]. A review of the admission record also revealed [DIAGNOSES REDACTED]. A review of the resident's progress notes, prior to readmission on 11/23/20, revealed that the resident had been monitored by 15-minute checks, beginning on 10/05/2020 and continuing until she was discharged to her son's home on 11/20/2020. A review of progress notes in relation to the frequent monitoring revealed: On 10/05/2020 an encounter note written by the Psychiatric Nurse Practitioner documented: Visit type: crisis intervention: Unit manager called provider reporting resident verbalizing suicidal thoughts, request a stat (immediate) evaluation. Called daughter, gave verbal ok for one-time [MEDICATION NAME] IM (intramuscular), patient requested. [AGE] year old female reports she is mad at daughter, she does not have a plan to kill herself, she does not want to die, she is mad at God for not taking her. She reports all of her friends and family have passed; she is ready to move on to heaven. Patient is mad at daughter for not letting her stay at home. Patient refused her insulin this am (morning). patient agreed to try [MEDICATION NAME] IM, refused any pills, patient feels she takes enough meds. Will obtain UA (urinalysis). On 10/09/2020 at 10:10 a.m. a review of the resident's doctor's note revealed: patient has been agitated and more confused than usual since last week. She was seen by psych earlier this week after she was found crying and telling she wanted to kill herself. Unit manager came and talked to her, took her to the garden outside. Apparently, she was upset with her daughter. She denies having a plan to hurt herself. She was seen by the psychiatric ARNP who recommended [MEDICATION NAME] IM but it was not necessary. Resident had a urinalysis that came back abnormal, so she was started on the antibiotic Cipro. Pending culture results. Today she has been calm. On 10/09/2020 at 1551 (3:51 p.m.), the nurse's note read: patient is upset following hospitalization of roommate, refusing all meds, glucose checks and insulin. Patient states she has been diabetic for [AGE] years and doesn't need anything. Will continue to attempt to monitor patient. On 10/12/2020, a follow up note was written by the Psychiatric Nurse (PN) for the concern of the resident refusing medications. The PN documented, doing better this week, taking meds eating well per staff. Patient on IV antibiotics for Urinary Tract Infection. On 11/12/2020, the Social Services Director spoke with the resident's daughter who informed this writer that she would like the patient to discharge to home with her son on Friday 11/20/20. Spoke with family to address individual's needs and concerns regarding care to ensure quality care and successful transition . Family member has no questions or concerns related to the discharge at this time and is happy with the plan of care. On 11/13/20, an order was received from the resident's PCP for a urinalysis culture and sensitivity as the resident was having increased confusion and some hallucinations. On 11/13/20, the UM requested an evaluation for increased confusion and disturbing hallucinations which had been noticed the past couple of days. Resident's daughter also noticed the change and she is concerned about another UTI now that she is going home next week (11/20/20). A review of a Social Services note dated 11/23/2020, written at 12:13 p.m., revealed a conversation in which Resident #6's daughter was hoping to have her mother brought back to the facility. The next note in the chart, dated 11/23/2020 and written at 16:33 (4:33 p.m.) indicated the resident had returned to the facility and was being screening for COVID-19. The Readmission Summary documented by the nurse on 11/23/2020 at 18:12 (6:12 p.m.) read: resident arrived from home via family transport. Readmission [DIAGNOSES REDACTED]. The resident's PCP documented a History and Physical on 11/25/2020 at 12:48. The assessment included the reason for her return as: Resident readmitted on Monday after discharged home with family three days before. Daughter requested readmission because they were not able to take care of her. The Registered Dietitian assessed the Resident's nutritional status on 11/25/2020 at 13:03 and included the following: [AGE] year old female , returns to facility following brief d/c (discharge) home. Patient usually very friendly and talkative, today seemed very depressed. I'm not good, I'm sad. Reports poor appetite since returning. An Admission Minimum Data Set (MDS) Assessment completed on 11/30/2020 assessed Resident #6 as scoring a 10 on the Brief Interview for Mental Status indicating cognition was moderately impaired. She was assessed as having a depressed mood infrequently (once a week) and having no behaviors, including wandering. The resident required limited assistance with one staff for transferring, toileting and being mobile in her room or in the hall using either a walker or wheelchair. An elopement risk evaluation was completed on 11/23/2020 as part of the admission packet and assessed the resident as having no indicators of being at risk of elopement. However, a care plan was developed when the resident was readmitted on [DATE] for being at risk for wandering and elopement. The Focus of the care plan was: I am an elopement risk due to my past history, wandering tendencies or cognitive decline with no regard to my safety. Interventions included: encouraging activities of the resident's choice; notifying the doctor if exit seeking behavior becomes a danger to self or others; provide redirection as required; and safety checks as indicated. An interview was conducted with the MDS Coordinator on 02/12/2021 at 12:30 p.m. in which he confirmed the care plan for elopement had been pulled forward from her past care plans, as the resident was only gone for three days. The MDS Coordinator reported that he felt it was probably relevant to keep it active. He confirmed that the nurse's elopement assessment did not reflect the resident was at risk. The resident had occasional wanderings, so it wasn't captured on the assessment, but the MDS Coordinator felt it was relevant. The care plan, dated 11/24/2020, included focus areas for impaired cognitive skills related to the [DIAGNOSES REDACTED]. On 12/03/2020, the focus area of [DIAGNOSES REDACTED]. These care planned areas were not reflected in the 11/23/20 elopement assessment related to questions of behaviors, medications, and diseases which would have increased the elopement risk score. The elopement assessment included a question on Emotional Status, which was answered, happy with placement. 2. On 12/01/2020, a psychiatric 60 day follow up assessment was completed upon readmission which identified no concerns. The note included under History of Present Illness: [AGE] year old female reports she is doing much better now that she is back in long term care. She had wanted to go home with her children but was unable to take care of herself the way she thought she could, now she is back in long-term care. Patient is intermittently weeping during interview as she is trying to comprehend her failing health, her failing mind and having to spend out her days in long-term care. The resident's Primary Care Provider (PCP) saw her on 12/28/2020 and wrote that the resident had no acute changes in her condition or behavior, that she was compliant with treatment, getting along well with her roommate. Wandering around the unit self propelling the wheelchair. Forgetful but still able to voice her needs. The plan included fall precautions to continue, therapy as needed and nursing for skin care, pain assessment, and timely medication administration. On 12/30/2020, the 3-11 shift nurse documented, at 2135 (9:35 p.m.) that when presented with medications, the resident told the nurse to go away. On 01/01/2021 at 1624 (4:24 p.m.), the resident complained of throbbing pain to her right ear, with an oral temperature of 98.0 F, no discharge, redness, or swelling noted. MD notified, MD on call for PCP gave instructions to administer PRN (as necessary) tylenol as per current order for ear pain. The resident's PCP saw her on 01/04/2021 and documented the complaint of right ear pain during the weekend and the resident was started on oral antibiotics. The PCP documented that the resident was feeling better today after 48 hours of treatment, with no fever. On 01/05/2021 at 1:18 a.m., the nurse documented that the resident's pain was not being managed with Tylenol. The patient was awake and tearful from pain in the ear. The patient was at the nurse's station because she cannot sleep due to pain. The nurse documented that she reached out to the on-call physician for further orders. She documented that she offered the patient something warm to drink, a snack and to transfer the patient back into bed, but she refused. On 01/12/2021 at 18:00 (6:00 p.m.), the Nurse Unit Manager wrote: resident came to this nurse at the end of (nursing unit), she was crying and said she needed to get out of here. I asked what was the matter and she said she can not stay with that woman in her room any longer, I asked her what happened because she was so happy to be back in that room and she said, 'her roommate thinks she is better than anyone, she said I had a nice lady give me a very nice shower and my roommate made a phone call and said she was not going to let her shower her.' This resident said she cannot live with someone who thinks she is better than everyone else and she would rather sleep outside. I explained that I was not gonna let her sleep outside and we would find her another room. She started crying again and said she can't afford to pay for another room and since you are (my daughter's) friend, can you just call her to come pick me up. I consoled this resident and assured her that it was taken care of and it would not cost her anymore money. I showed resident the room and she was happy to sleep there and I told her in the morning if she was happy with this room we would move her belongings. On 01/15/2021, Resident #6's PCP documented: Evaluation requested for changes in condition. Patient has been agitated, refusing meds and displaying some aggressive behavior. A urine sample was collected and came back positive. On 01/17/2021 at 2:05 a.m., a Behavior note written by Staff L, Licensed Practical Nurse (LPN) noted: The resident was observed fully dressed, up in wheelchair at beginning of shift, no face mask in place. Resident was on enhanced contact precautions/ESBL urine. The 3-11 nurse working on 01/16/2021 reported resident wandering about unit entering other resident's rooms, continuously exit seeking, yelling, pushing on emergency exit doors, kicking glass on door. After change in shift resident evaluated for pain, discomfort, thirst, hunger, toileting needs. Diversional activity offered, refused. Resident continued to wander about unit, pressing on emergency exit doors, strike doors with aluminum reaching device. Resident approached by staff CNA, attempted to strike CNA, kick glass on door. Call placed to resident's daughter to advise of above. Daughter spoke with resident, resident stated, They are trying to kidnap me. I'm trying to get the police here or an ambulance to take me to (the hospital). Writer assured resident she is safe here, this is her home, she is with friends. Resident put phone on counter stated, she's not my daughter anymore, wandered off unit to day room. Writer advised daughter of safety concerns, as this is not a locked unit, after 15 seconds emergency door will open, resident could potentially exit building. Resident is in room at bedside sitting in wheelchair at this time. Above behaviors are noted when resident has a UTI (urinary tract infection), however resident is known to wander, exit seek when no UTI is evident at times. Writer initiated q (every) 15-minute rounding/safety checks. On 01/17/21 at 23:48 (11:48 p.m.), a Behavior Note written by Staff S, Registered Nurse (RN) read: Patient had episodes of being combative. Patient went to the front lobby and grabbed the rolling walker then started hitting the front door. Staff was able to pacify patient and able to take her back to the nurse's station. Staff called her daughter, but when she spoke to her daughter, she hanged (sic) up the phone. Patient's daughter was aware that patient is being combative. Patient went inside the activity room and with the rolling walker that she is holding, she started slamming the window. (Physician) was notified and order given for PRN (as necessary) [MEDICATION NAME] PO (by mouth) and IM (intramuscular). Staff spoke to patient and able to calm her down without giving the medication. Patient after a few hours came back to nurse's station stating that she feels better now and more calm. On 01/18/2021 at 1:13 a.m., a Skilled Infectious Process Note indicated the resident's antibiotic for the UTI had been changed to another medication which would be administered intramuscularly. On 01/18/2021 at 11:00 a.m., a Progress Note by the resident's PCP read: Patient had aggressive and exit seeking behavior during the day but worse since yesterday. She went to the front door and was kicking and pushing the emergency button trying to open it. Then she was hitting a window with her walker. We have orders for oral and IM [MEDICATION NAME] to use as needed. Urine culture came back positive for Multi drug resistant ESBL positive E coli. Treatment was changed to [MEDICATION NAME] 1 gram IM daily. She received one dose on Saturday and one yesterday but is refusing it today. The Plan included: [MEDICATION NAME] 20 mg IM today and repeat tomorrow. I have concerns for her safety. She is at risk of hurting herself or staff and if we can not treat her UTI she is not going to get better so I am using it as an emergency measure. On 01/18/2021 at 1558 (3:58 p.m.), the nursing progress note revealed Pt (patient) agitated, kicking doors, throwing objects; all medications held due to her refusal of them. On 01/18/2021 at 2029 (8:29 p.m.), the resident accepted an IM dose of [MEDICATION NAME] which the nurse documented as 'effective'. This was the last note recorded in Resident #6's clinical record on 01/18/2021. 3. A review was conducted of the Facility Assessment (completed: January 15, 2021) a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. The facility determined they would admit residents with a variety of diseases, conditions, and disabilities which included Psychiatric / Mood Disorders (page 6). The facility documented that they would provide support and care to residents with Mental health and behavior concerns that would include, Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment , care of individuals with depression, trauma/[MEDICAL CONDITIONS], other psychiatric diagnoses, intellectual or developmental disabilities. (page 9) Support and care provided to residents would include Psycho/social/spiritual support such as emotional and mental well-being, helpful coping mechanisms, and identifying hazards and risks for residents, including preventing abuse and neglect. Staff training and education and competencies included the identification of resident changes in condition, how to identify medical issues appropriately, how to identify if symptoms represent problems in need of intervention and how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. Competencies needed and training provided to all staff at all levels included caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder and implementing non-pharmacological interventions. 4. On 01/27/2021 at 1:15 p.m. a phone interview was conducted with Witness #1. Witness #1 stated that at approximately 9:15 p.m. on 01/18/2021, she was driving north on the highway that the facility faced, when she noted the car in front of her begin to slow and drive erratically. When she got closer, she noted in her headlights that the car had pulled over to the bike lane and had parked in front of a person in a wheelchair, who was in the bike lane, in an attempt to block traffic. She said she had to drive north, use the turn lane to go back south and then back north to join the car and person in the wheelchair. She said she wasn't aware of a residential facility along that road so she couldn't figure out how someone in a wheelchair could be out alone, especially in such cold weather. She said the other driver was familiar with the facility and somehow notified them of their resident being on the side of the road. She said that a male employee came out to return the resident back inside. The resident refused and continued to try to lunge herself out of her wheelchair into the traffic lanes. The employee was able to wheel the resident back toward the facility by tilting the wheelchair and only using the back wheels. This approach prevented the resident from digging her heels in to refuse to return to the facility. Witness #1 said she held the resident's hand as they walked back to the facility which, she described, as approximately 30 yards. She said she was able to bond with the resident and get her to talk with her and even to giggle at the things she was saying. She reported the resident was saying she would rather die than return to the facility and that her kids didn't love her. She said it took about an hour to get the resident back into the facility and when she finally left about an hour after that, she left her name and phone number with the resident and with facility staff. She said she was surprised no one had called her the next day about the incident. Observation on 02/12/2021 at 8:30 p.m. revealed that the facility was located on a four lane, divided highway with a bike lane and a center median. The speed limit at the facility location was 55 miles per hour and the traffic lights were distant from each other. The South entrance to the facility parking lot was dimly lit with a streetlight illuminating the area once the turn off to the parking lot was made. South of the entrance was a wooded area and the entrance to the facility was on a curve. There was no traffic light at the entrances to the facility from the highway. On 01/18/2021 the sun had set at 5:59 p.m. (www.suntoday.org) and the temperature that night was 54 degrees Fahrenheit (www.wunderground.com). On 01/25/2021 at 2:43 p.m., a phone interview with Resident #6's daughter revealed that one of the people that stopped to help her mother remain out of the traffic lanes when she eloped from the facility on 01/18/2021, had called her to let her mother talk with her while her mother was still outside. She said it was close to 10:30 p.m. when she spoke to her mother outside. She was aware that Witness #1 stayed with her mother for almost two hours and had accompanied her mother back into the facility and into her room. She said Witness #1 assured her mother that she would not leave her until she was safely inside. An interview was conducted on 01/29/2021 beginning at 1:50 p.m. with the male employee who had left the facility to bring the resident back. Staff I, Certified Nursing Assistant (CNA) stated he worked for a staffing agency. He confirmed he heard banging on the front door, where the receptionist sits during the day (north entrance). When he went to see who it was, he reported there was a lady telling him, through the closed door, that there was a resident outside. He said he walked 25-50 feet south on the highway that the facility affronts before he saw the resident with another person standing next to her. He reported that the resident refused to come back in and described her as not agreeable and very feisty. He said she kept trying to slide out of her wheelchair into the road. She was saying that she wanted to die. He reported that it took at least 30 minutes to talk her into coming back in. He reported he didn't know the resident and didn't remember working with her much. He confirmed he was assigned as a one on one with her for the rest of that night following the elopement. He confirmed that one of the witnesses had stayed with her and came into the building with her. He was able to identify the witness by name. Review of Resident #6's medical record did not reveal an order for [REDACTED]. There was no documentation of the aide's one on one monitoring and no documentation on the staffing schedule that an aide was assigned to provide one on one monitoring on the 11 to 7 and 7 to 3 shifts that began on 01/18/2021 and continued into 01/19/2021 until the resident was discharged to the hospital. On 1/29/21 at 5:40 PM, the Night Unit Manager, Staff H, reported in a phone call that she spoke with two female Witnesses (#1 and #2) that found the resident on the road, not the sidewalk, of the highway. She said the two cars were parked to protect the resident in her wheelchair from the cars that were whizzing by. She remembered that she could feel the cars speeding past them. Staff H confirmed the resident was fighting them, as she didn't want to go back inside. They had to tilt her wheelchair back to wheel her in. She said the resident was very upset even though she confirmed later that her nurse reported he had given her [MEDICATION NAME] that evening. Staff H reported that she wasn't sure how Resident #6 was able to leave the building. She confirmed it had to be one of the main doors - either the North or the South doors as the other doors were fire doors and the alarm would have gone off if the door had opened. She confirmed it took a while to get the resident back in the facility. She stated that she hadn't looked at her watch, but she had so much to do that night. She said earlier in the night she saw Resident #6 in the small therapy gym which exits to the enclosed courtyard of the building. She said she took the resident back to her side of the building, and she realized later that by taking her past the front doors, it gave her a chance to see that exit door. Staff H was informed that there were no notes in Resident #6's record documenting the elopement and course of events that happened that night. She said she didn't know that and that statements were given the next day. Staff H reported that she had not received Witness #1's contact information that night, but Witness #1 seemed to know Resident #6. She ended the call by saying that Resident #6 just wasn't herself that night. In a phone call, on 02/11/2021 beginning at 6:00 p.m., the CNA, Staff J, revealed that she had gone outside to help find and bring Resident #6 back into the building. Staff J confirmed that she had answered the loud knocking on the north entrance door along with Staff I, CNA. They were told that there was a resident outside. While she was outside with Staff I, she called Staff H, Nursing Supervisor, at 9:30 p.m. to let her know they were outside with the resident. She said the resident was found right alongside the road, not in the parking lot or on the sidewalk. Staff J reported she returned inside but Staff I stayed with Resident #6. She reported that the resident didn't want to come back in, and she didn't know when they came back in the facility. She confirmed that she had been asked to write a statement and that the time that she heard the knocking and went outside would be in her statement. On 01/29/2021 beginning at 1:30 p.m., a phone interview with Staff G, Licensed Practical Nurse (LPN), revealed he was the nurse assigned to Resident #6 on 01/18/2021 during the 3 p.m. to 11 p.m. shift when the elopement occurred. He reported that he didn't know her that well as he was part time and usually assigned to a different wing. He confirmed that she was on 15-minute checks for some incident, and described the incident as probably trying to get out of the building. He reported the resident was very anxious that night and added that there were several residents on 15-minute checks that night. Staff G reported that he saw the resident at 9:00 p.m., in the hall near her room, and when he went back to check on her at 9:15 p.m. she wasn't around. He said he started to look for her and between 9:15 p.m. and 9:30 p.m., the other nurse's unit called to say they had his resident. The caller confirmed she had been out of the building. Staff G reported they didn't know any details such as how she was able to get out of the building or even how they knew she was out of the building. He reported that he felt very fortunate that nothing happened to her as the highway that the facility was on was a very busy road. He said when she was brought back, he assessed her while she was sitting in her wheelchair and found no injuries, no bruises, and even checked her knees to assure she hadn't fallen on them and they were skinned. He confirmed that there was someone with her, who he thought was family. He confirmed that person wasn't there when he assessed her, but came into the room when he was done. He thought the individual was signing something or getting the correct PPE (personal protective equipment). Staff G reported that he was not sure what to do in this situation as he had never had a resident who had eloped before. Staff G stated that the Unit Manager instructed him to assess the resident, and she would take care of the documentation. This was why there were no notes from him post elopement on 01/18/21. Staff G remembered giving Resident #6 her IM antibiotic and her [MEDICATION NAME] that night. He thought she had been returned to her room by 9:30 p.m. He repeated that he didn't know how she could have exited the facility and said it must have been from the other unit as Resident #6's unit was in the back of the building and had no exit doors. He stated she must have gone through to the next unit and somehow gotten out that way. In a follow up interview with Staff G on 02/12/2021 beginning at 8:45 a.m., the nurse was asked about the resident's location on the night of 01/18/21 prior to the elopement as the safety checks that he had documented on the 15 minute monitoring form only listed that the resident was in her chair. Staff G reported that the resident remained near her room or in her room and referred to the current COVID pandemic and residents were to remain in their rooms. He confirmed he hadn't received training on completing the 15-minute safety check logs, as the instructions were on the log. He confirmed he wrote wandering at the 9:15 p.m. check on 01/18/2021 since he didn't see her and figured she was wandering. Staff G reported that he hadn't looked at his watch when he got the call from the other nursing unit reporting that Resident #6 was back in the building, but he didn't think she was gone long. He reported that they had precautions in place - the 15-minute checks. That's how they knew she was gone, as he didn't find her at the 9:15 p.m. check. He stated it was scary at first, when they couldn't find her and then found out she was out by the side of the road, but there wasn't anything else they could have done for her. He referred to the (undocumented) assessment he had completed on Resident #6 and reported that he found nothing, not even a red spot. He said that he thought he had documented the assessment but knew (TRUNCATED)