Every finding on record at Manatee Springs Rehabilitation and Nursing Center

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect by failing to respond to an exit door alarm and provide supervision to prevent an elopement for one resident (#2) out of residents sampled. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. Resident #2 sustained a left forehead laceration and left elbow skin tear as a result of a fall. The resident was taken to the local hospital for treatment by Emergency Medical Services (EMS). Resident #2 was missing from the facility for approximately two hours without staff knowledge. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #2 and resulted in the determination of Immediate Jeopardy on 1/15/26. The findings of Immediate Jeopardy were determined to be removed on 2/4/26 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F689 and F726. Findings included: A review of Resident #2's admission Record revealed an admission date of 12/18/25 with diagnoses to include dementia, falls, muscle weakness, lack of coordination, psychotic disorder with hallucinations, depression, and delusional disorder. A review of Resident #2's Minimum Data Set (MDS) assessment, dated 1/7/26, under section C - cognitive patterns, revealed a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A review of Resident #2's Physician orders revealed the following:- Olanzapine oral tablet 7.5 MG [milligram] (Olanzapine) Give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with psychotic disturbance, with an order date of 1/14/26. A review of Resident #2's Care Plan revealed the following:- Resident is at risk for elopement related to Cognitive Impairment. see dxs. [diagnoses] Date Initiated: 12/19/2025., with interventions to include, Consult psychiatric and/ or psychology services as needed. Date Initiated: 12/19/2025, Maintain current phone and demographics information of the resident in the appropriate designated areas per protocol/ policy. Date Initiated: 12/19/2025, Notify other departments of resident's risk for elopement and wandering behavior. Date Initiated: 12/19/2025, Use verbal cues and distraction techniques to minimize exit seeking behavior. Date Initiated: 12/19/2025. - COGNITION: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Short term memory problem, Impaired decision making, see dxs. Date Initiated: 01/08/2026. A review of Resident #2's elopement risk assessments showed on 12/19/25 a score of 19 (a score of 12 or more means at risk for exit seeking, elopement, wandering), on 1/5/26 the assessment score was 10. A review of Resident #2's progress notes revealed the following:- 1/2/26, A BIMS assessment was completed for [Resident #2] with a score of 6.0 indicating resident is Severe Impairment . Refer to assessment for more information.- 1/8/26, Staff reports resident continues to wander, impulsive and agitated, concern for safety. Currently taking olanzapine 5mg [milligram] at bedtime, start Olanzapine 2.5mg in AM [morning] and monitor for effectiveness.- 1/13/26, .Resident continues to wander and become agitated, difficult to redirect . [PHI] seen today for staff reports that since return from the hospital he continues to be impulsive in his actions, becomes agitated and wanders aimlessly in the halls even with his Olanzapine. Staff states he is difficult to redirect and concerned about his safety. Resident unable to provide information due to cognition. unspecified dementia, unspecified severity, with psychotic disturbance Start Olanzapine 2.5mg in the morning and monitor for effectiveness Continue Olanzapine 5mg h.s [bed time]. unsteadiness on feet will continue with therapy as ordered and staff will assist resident with transfers and mobility . A review of Resident #2's emergency room records from 1/15/26 revealed the following:- .Reg Dt/Tm [registration date/time] 01/15/2026 05:29 [5:29 a.m.] . Disch [discharge] Dt/Tm: 01/15/2026 11:39 [11:39 a.m.] . Admit Reason: fall . History source: Patient, EMS [emergency medical services]. Arrival mode: Ambulance. Chief Complaint from Nursing Triage Note: 1/15/2026 5:46 EST [eastern standard time][5:46 a.m.] Chief Complaint EMS from outside of [facility name] due to a ground level fall with head injury. Patient missing from facility approx. [approximately] 2hours before being found. [Local law enforcement] has been called and is investigating. The patient presents following fall. The onset was unknown. The occurrence was unknown. Location: Left head. Associated symptoms: none. Patient brought in after a fall. Unknown details but reportedly fall within past two hours. Patient was from memory care unit andapparently was missing for period of time and had a fall. EMS brought him in with injury to left forehead/eyebrow. Patient unable to give any additional history. No known vomiting. No other complaints . Head: Normocephalic, Left eyebrow contusion superficial abrasion;. Neurological: No focal neurological deficit observed, normal motor observed, normal speech observed, Aware he is in [county name] and alert, but otherwise confused - knows this is January, but thought 1966. Further review of the emergency room records showed an EMS run report with the following: .Clinical Impression . Onset Time 03:00:00 [3:00 a.m.] 01/15/2026 . Chief Complaint Laceration to Left Eyebrow Duration 2 Hours . Injury Falls . Assessment Time: 01/15/2026 04:57:44 [4:57 a.m.] Narrative [NAME] [moderate priority, non-life-threatening, but serious illness or injury] [medic unit] dispatched emergency response to private residence via 911 system for a fall . Crew was rerouted to [facility name] . upon arrival on scene EMS crew found a [PHI] sitting upright in the back of a [local law enforcement] cruisier. Per [local law enforcement] patient is a resident of [facility name], the patient was found walking outside and called in by a nearby resident, it is unknown how long patient has been eloped from facility. Nursing staff present, history was provided by nursing staff. Per nursing staff this is patients baseline secondary to a history of dementia, patient states he tripped and fell hitting his head on the sidewalk. Patient denies LOC [loss of consciousness]. Patient has a laceration, approximately 1 inch, to left eyebrow, bleeding controlled without intervention. Patient was transferred from cruisier to stretcher via [by] stand and pivot with assistance of x2 [two individuals] EMS crew. Patient was transported to ambulance and loaded without incident. Patient was transported to [hospital name]. Incident times . Call Received 01/15/2026 04:34:51 [4:34 a.m.] . En Route 01/15/2026 04:51:13 [4:51 a.m.] . On Scene 01/15/2026 04:52:56 [4:52 a.m.] . Depart Scene 01/15/2026 05:16:01 [5:16 a.m.] At Destination 01/15/2026 05:26:58 [5:26 a.m.] Pt. [patient] transferred 01/15/2026 05:42:29 [5:42 a.m.] . A review of the local law enforcement incident sheet revealed the following: Incident Information . Reported Date: 01/15/2026 05:16 [5:16 a.m.] . Narrative: At 01/15/2026 at approximately 0448hrs [hours] [4:48 a.m.] I was dispatched to the [neighborhood address] reference an elderly male with an injury to his head knocking on doors asking for help. Upon arrival and through investigation gathering personal details it was established that [Resident #2] was a patient of the memory care unit at [facility name] . while talking with the supervisor at [facility name] [Staff A, Licensed Practical Nurse] stated that they received an open door alarm at approximately 0300hrs [3:00 a.m.] telling them that one of their doors had been opened but thought nothing of it, almost ignoring it. [Resident #2] when he was found had been outside for over an hour, was soaking wet as it had been raining and shivering cold because of the rapidly dropping temperatures outside and also had a gash on his left eyebrow which he was transported to [hospital name] for reference because it possibly needs stitches. [Staff A, LPN] informed when I asked if there was anyone supposed to be on watch she stated yes but that person was on break and he was not replaced with anybody during that time. It should be noted that the memory care unit at [facility name] is on the second floor of the building and [Resident #2] would have to walk past several nurses stations to exit the building. An internet search was conducted to determine the weather on the night and early morning of 1/15/26. Based on information from World Weather, the temperature was 55 to 63 degrees Fahrenheit with light rain and 90% humidity, (reference: https://world-weather.info). On 2/2/26 at 12:06 p.m., an interview was conducted with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The DON said she was notified by phone on 1/15/26 at 7:45 a.m., by Staff A, Licensed Practical Nurse (LPN), Resident #2 eloped and was found outside in front of the facility. The DON was told Resident #2 was taken to the hospital. The DON said having one missed call at approximately 5:00 a.m., from Staff A, LPN. The DON said Resident #2 was last seen on 1/15/26 at 2:30 a.m. in his room, in bed sleeping, by Staff D, Certified Nursing Assistant (CNA). The DON said shortly after 2:30 a.m., an emergency stairwell exit door by the therapy department had alarmed. Staff A, LPN initially went to the wrong door by the wound care nurse's office because she thought it was that door alarming. The DON said Staff A, LPN attempted to silence the alarm, but she could not recall the code. She said Staff A, LPN, was working on the first floor that shift, but at the time of the door alarming she was on the second floor. The DON confirmed Staff A, LPN was the supervisor that night. The DON said Staff A, LPN assumed the alarm was not functioning and called maintenance. The NHA said about a week prior to 1/15/26, Staff A, LPN had set off an exit door alarm herself and could not shut it off. The NHA said the Director of Plant Operations had reminded Staff A about the code during that time. The NHA said when you push on the door, it released after 15 seconds, and once it opened says, Exit now, exit now. The DON said between 2:30 a.m. to 2:35 a.m., Staff A, LPN called Staff G, Maintenance Assistant. Staff E, LPN who was assigned to Resident #2, confirmed she heard the alarm on the second floor but was told by Staff A, LPN it was malfunctioning. The DON said the two nurses did not follow the elopement policy/procedure to immediately search, check outside, and complete a head count. The DON stated, The staff failed to do that at that time. The DON said Staff G, Maintenance Assistant arrived at the facility at approximately 3:00 a.m. At approximately 4:45 a.m., the Sherrif's department arrived at the facility. The DON said the Sherrif's department called EMS. She said Staff A, LPN went outside to identify Resident #2, then he was taken to the hospital. The DON said the resident had a laceration above his left eyebrow. The DON said Resident #2 crossed the street, was knocking on windows and was found lying in a residence yard. One of the people who lived in one of the homes across the street called the police. The DON stated it was raining that morning. The RNC confirmed she checked the weather and it was 68 degrees Fahrenheit. The DON said Resident #2 returned to the facility at approximately 11:30 a.m. after being evaluated at the hospital. The NHA stated Resident #2 was supposed to discharge to an assisted living facility (ALF) with a secured unit, Because of his elopement potential. The DON said Staff D, CNA, was interviewed and said he heard the exit door alarm but was told by Staff A, LPN it was a malfunction. The DON said the supervisor, Staff A, LPN, should have called code purple to notify the staff to initiate a head account. On 2/2/26 at 1:24 p.m., an interview was conducted with the Director of Plant Operations (DPO). The DPO said the video footage cannot be rolled back, and it cleared after 24 hours. He said he viewed the video footage as soon as he was made aware of the event. He said Staff G, Maintenance Assistant was called to the facility because of the alarm that was activated by the therapy hall exit door. He said Staff G, Maintenance Assistant told him Staff A, LPN did not know how to reset the alarm, and she thought it was another door alarming. The DPO confirmed he spoke to Staff A, LPN on Monday, 1/12/26 about the code for the doors. The DPO said he showed Staff A, LPN that Monday the door flashes when opened, as well as the speaker he installed which faced the therapy hall. The DPO said when he heard a resident eloped, he reviewed the video footage. He stated he observed an older gentleman walking down the therapy hallway, Wearing parachute pants and he had a limp. The DPO confirmed the resident did not have a walker or wheelchair. He said Resident #2 was holding on to the railing as he walked down the hall. The DPO observed Resident #2 lean on the door and the alarm went off at approximately 2:32 a.m. He stated he heard, Exit now exit now, then the door opened and closed. The DPO stated, Anything can happen at that stairwell. The DPO stated he could hear staff talking and a resident was heard saying, Shut that off, and a door slammed. He said he heard both the first and second floor alarms. The DPO said he observed Staff A, LPN go to the elevator, pushed the button, and go inside the elevator. He confirmed there are no cameras outside or in the stairwell. He said as he watched the footage he did not see any staff respond to the door alarm. The DPO said he stopped watching the footage about 20 minutes after the alarm sounded. On 2/3/26 at 9:24 a.m., a telephone interview was conducted with Staff D, CNA. Staff D, CNA said on 1/15/26 he informed Staff E, LPN, he was going on break. He confirmed Resident #2 was assigned to him that night. Staff D, CNA checked on Resident #2 before going on break and said he was asleep in bed. He said about 10 to 15 minutes into his break, he received a call from Staff A, LPN, who asked him if he knew how to turn off the door alarm. Staff D, CNA said Staff A, LPN assumed it was a malfunctioning alarm. Staff D, CNA stated he felt like she was calling in a Nonchalant way. He said he did not recall the approximate time he received a call from Staff A, LPN or when he returned, but he was on break for about 30 to 35 minutes. He said he returned from his break, answered multiple call lights, and recalled the alarm was still sounding. Staff D, CNA stated, I don't remember checking [Resident #2's] room, when he returned from his break. Staff D, CNA said later on in his shift he sat at the nurse's station and watched the hallway. Staff A, LPN called again and told him Resident #2 was found by the police. He said he told Staff E, LPN and went downstairs. Staff D, CNA said he observed the resident who had bruises around his eye and was cold and wet. He stated, It was raining that night. Staff D, CNA said he recalled the alarm door malfunctioning a week prior to Resident #2's elopement. He said the supervisor did not initiate the elopement protocol at that time and Staff D, CNA did not check on his residents. Staff D, CNA said he recalled the DON and the maintenance staff being called when the alarm malfunctioned a week before. He said Staff A, LPN did not know the code at that time. He stated, Everyone was like, how do you turn it off? He said Resident #2 was able to get in his wheelchair and walk a little. Staff D, CNA stated, He should have been 1:1, as he would get out of the bed and his wheelchair. He said he would have to re-direct him to the chair or the bed. Staff D, CNA said when they had a resident like that, the person was typically 1:1 (one to one). He stated, Administration knew this, workers knew this, we all kept an eye on him as best we could. When asked why he did not respond to the alarm on 1/15/26, he said he thought it was another malfunctioning door. On 2/2/26 at 4:27 p.m., a telephone interview was conducted with Staff E, LPN. Staff E, LPN said on 1/15/26 at approximately 3:00 a.m. being in a resident's room. Staff E, said Staff D, CNA, Resident #2's assigned CNA, was taking a 30-minute break when the resident exited the facility. She stated, Nobody saw him [Resident #2] leave. She said she was not sure if another CNA was supposed to take over when the assigned CNA was on a break. Staff E, LPN stated, I did not check that and [Staff D, CNA] did let me know he was going on break. Staff E, LPN said she heard an alarm; it was a noise she did not recognize and did not know where it was coming from. She recalled the alarm sounding for a few minutes. She stated, I didn't know what was going on. She said she received a call from Staff A, LPN, who was on the first floor, that a resident exited through a door. Staff E, LPN said she thought the police were called by Staff A, LPN. Staff E, LPN thinks Resident #2 hurt his face or head but confirmed not observing him when he returned to the facility. Staff E, LPN said she last saw Resident #2 at 2:00 a.m. on 1/15/26. She said when she heard a resident was missing, she completed a count of the residents and called Staff A, LPN. Staff E, LPN stated she heard, He got out of a kitchen door that was not secure. She said Staff D, CNA went downstairs when Resident #2 returned. She said Staff A, LPN immediately sent Resident #2 to the hospital as he had an abrasion on his face. Staff E, LPN stated she was panicking and, Everything went really fast. She said she never completed elopement drills, was not aware of the sound of the alarmed door, and felt she was not provided the proper training. Staff E, LPN stated, He should have been on precautions,15-minute checks, and 1:1. Staff E, LPN said she had constant issues with him and was worried about keeping him safe. She stated, He was a major fall risk, he constantly tried to get up, was extremely confused and wandered. Staff E, LPN said Resident #2 could stand and walk around but was not steady on his feet. She said he did not express he wanted to leave. Staff E, LPN said she did not inform the DON of her concerns, but spoke to Staff A, LPN who was aware of his behaviors before the elopement. She said Staff D, CNA, was also aware of Resident #2's behaviors. On 2/3/26 at 10:59 a.m., a telephone interview was conducted with Staff F, CNA. She said on 1/15/26 at 4:30 a.m., she walked up to the nurse's station on the first floor and saw law enforcement knocking on the door. Staff F, CNA said they told her they found a man wandering across the street and asked if he was a resident at the facility. Staff F, CNA said she took the law enforcement officer to the supervisor who was Staff A, LPN. Staff F stated it was, Storming really bad that night. She said shortly after that, the paramedics arrived at the facility with Resident #2. She said she went outside with Staff A, LPN and another CNA to see if they could bring Resident #2 into the facility. Staff F, CNA observed a cut on the resident's eye and said Staff A, LPN thought it was best he went to the hospital to be evaluated. Staff F, CNA said she worked on the first floor and did not hear any door alarms that morning. She said she recalled maintenance staff was there at approximately 3:30 a.m., to turn off the door alarm. Staff F, CNA said she asked Staff A, LPN, if everything was okay after seeing the maintenance staff. Staff F, CNA said Staff A, LPN told her the door alarm had malfunctioned. She said where she was assigned, she did not hear the door alarm by the therapy hallway exit stairwell. She said she did not know Resident #2 eloped until law enforcement came to the facility. On 2/3/26 at 11:13 a.m., an interview was conducted with Staff G, Maintenance Assistant (MA). Staff G, MA said on 1/15/16 at approximately 2:30 a.m., he received a call from Staff A, LPN who told him she could not get the door to reset, and it malfunctioned. Staff G, MA said Staff A, LPN had the code, tried the code, but the door was still alarming. He confirmed he could hear the alarm over the phone. He said at approximately 2:45 to 2:50 a.m. he arrived at the facility. He said he went directly to the alarming door which was by the therapy gym. Staff G, MA confirmed that was the only door alarming when he arrived. Staff G, MA confirmed there were no issues with the door, and it was not malfunctioning. He stated the alarm was, Pretty loud, and could be heard by the nurse's station on the second floor. He stated, If you were standing there on the first floor by that door [by the therapy hall stairwell], you could hear that alarm. On 2/3/26 at 2:12 p.m., a telephone interview was conducted with Staff H, Registered Nurse (RN). Staff H, RN said she worked on the first floor on 1/15/26 and went on a break around 3:00 a.m. Staff H, RN said while on her break, a CNA came in and appeared frantic. Staff H, RN asked the CNA what was going on; the CNA told her an alarm was going off and thought a resident had exited the facility. Staff H, RN said they both checked outside, did not see anyone, then went back inside. She said she completed a head count of her residents. She said she recalled a CNA told her a maintenance staff was there to turn the alarm off. Staff H, RN said Staff A, LPN told her there was an alarm going off, a resident pushed against the door and exited the facility. Staff H, RN said the police and EMS were involved. She said she initiated assisting with finding the resident but first communicated with the resident's assigned nurse. Staff H, RN said she called Staff E, LPN and told her the person missing might be her resident. During the phone call, Staff E, LPN told Staff H, RN, she was headed to the first floor. Staff H, RN said she never heard the door alarm at any point. She was familiar with Resident #2 as she worked on the second floor sometimes. She said Resident #2 was confused, he would walk out of his room without assistance, and at times remove his clothes. Staff H, RN said there were many times that staff needed to escort and re-direct him. On 2/3/26 at 4:27 p.m., a telephone interview was conducted with Staff J, Medical Doctor (MD). Staff J, MD said he had not met Resident #2 in-person until after the elopement. He said Staff I, Nurse Practitioner (NP) was the resident's main medical provider. He said Resident #2 had advanced dementia. Staff J, MD said Resident #2 was ambulatory but his awareness around him, ability to communicate, and insight into situations was compromised. He said the resident's baseline cognition made him a high risk for elopement and falls. Staff J, MD stated Resident #2 was, Probably appropriate for a memory care center. He said 1:1 supervision prior to the incident would have been appropriate based on what he knows about Resident #2. On 2/3/26 at 4:36 p.m., a telephone interview was conducted with Staff I, NP. She said Resident #2 had advanced dementia, confusion, and cognition dysfunction. She said he expressed he wanted to go home, was very impulsive, restless, and difficult to re-direct in certain areas. Staff I, NP said the staff tried to keep him focused on tasks and often had to re-direct him. Staff I, NP said Resident #2's family was trying to place him in a facility with memory care. She confirmed he was at risk of falls because of his cognition and muscle weakness. Staff I, NP said she reviewed in previous records/history that Resident #2 developed a shuffling gait and muscle weakness. She stated, He is an elopement risk because of cognition. A memory type unit is the safest environment for people with his level of dementia. Staff I, NP said the resident normally ambulated with someone, always assisted by staff, and used a walker. On 2/4/26 at 10:49 a.m., an interview and review of the facility's investigation was conducted with the Assistant Director of Nursing (ADON). She provided information from Staff A, LPN's witness statement provided on 1/15/26. Staff A, LPN was upstairs getting paperwork off the printer when the door alarm sounded on the stairwell. She attempted to turn the alarm off but was unsuccessful. Staff A, LPN called Staff G, Maintenance Assistant who provided the codes, but they did not work. She went back to the medication cart on the first floor to pass medications and completed other tasks. The local Sherrif's office went to the facility and initially asked if they had a resident by a certain last name. The name provided was incorrect, and the law enforcement officer clarified it was Resident #2. The law enforcement officer asked Staff A, LPN to go outside to see Resident #2 as he had a cut to his left eyebrow. Staff A, LPN asked EMS to transport the resident to the hospital for treatment and evaluation. Staff A, LPN asked all staff 11 p.m. -7 a.m. to write witness statements. A review of the facility policy titled Abuse Policy - Prevention and Management, with a revised date of 9/8/22, revealed the following: POLICYThe Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse., PROTOCOL . The Shift Supervisor is identified as responsible for immediate initiation of the reporting process . Neglect Failure of the Facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the 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. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Training - Continued . Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to, the following:Aggressive and/or catastrophic reactions of residents;Wandering or elopement-type behaviors;Resistance to care;Outbursts or yelling out; andDifficulty in adjusting to new routines or staff. The facility's immediate actions to remove the Immediate Jeopardy included: A review of Resident #2's Physician orders revealed the following:- 1:1 [one to one] supervision with staff at all times due to elopement risk. every shift for safety, with an order date of 1/15/26.- May only go out on LOA [leave of absence] with responsible party, with an order date of 1/15/26.- Resident #2's care plan was updated: Family assisting with resident placement to secured unit. Date Initiated: 01/15/2026, Provide resident with 1:1 companion as needed to decrease risk of achieving exit. Date Initiated: 01/15/2026- On 1/15/26, assigned nursing supervisor and assigned nurse received immediate education, by ADON, related to responding to alarming doors and searching immediate surroundings, doing a head count with alarming doors, notifying the DON timely of elopement of residents. Same nurse supervisor and assigned CNA was suspended pending investigation.- Ad hoc quality assurance (QA) regarding elopement with Administrator, DON, ADON, [NAME] President (VP) of Clinical Operations, and Medical Director held via conference call on 1/15/26. Quality assurance performance improvement (QAPI) continued daily, on weekdays, through 1/30/26 discussing with the IDT-current audit tools and compliance, evaluation of performance indicators in care and service areas specifically related to response to alarming doors, elopement drills, performing a head count and prevention of neglect related to elopement.- On 1/15/26, the DON, ADON, and Administrator received education, via telephone, from the VP of Clinical Operations related to the elopement, policies affected, alarming doors, head count, assessments, care plans, head count, risk management reports, reporting to the agency for healthcare administration (AHCA), elopement drills, elopement audits, QAPI, hourly head count, investigation advisement, and ongoing education and monitoring required.- Department heads were in-serviced on responding to alarming doors and checking the surrounding areas to visually ensure area is secure by the Maintenance Director on 1/15/26. 100% completed.- Abuse and neglect policy education initiated with all current staff, especially pertaining to neglect and the facility's responsibility to maintain a safe environment, prevention and specifically what action should be taken when a door alarm sounds, searching surrounding area and performing a head count. Initiated on 1/15/26 by the DON to department heads.- On 1/15/26, designated department heads in-serviced assigned staff on responding to alarming doors and checking the surrounding areas to visually ensure area is secure and performing a head count; neglect and elopement policy related to prevention and response: 100% all staff. 70% all roster received in-service and completed competency on 1/15/26 (education/competency daily and every shift education to all staff in facility, and those not scheduled, on 1/15-1/23/26 until 100% of all roster staff completed).- Elopement drills on every shift 1/16/26-1/18/26 and then random weekly drills performed by the DON/ADON/Designee.- Elopement education audits started 1/17/26, continued daily, then continue to be done on random shift, daily by DON/ADON/Designee.- Elopement risk reassessment completed for all residents on 1/15/26 by ADON, clinical unit managers and DON. No additional elopement risks were identified.- Care plans for residents at risk for elopement were reviewed on 1/15/26 by DON. No concerns were identified for current care plan focus or interventions for those identified to be at risk for elopement.- Elopement binder was reviewed for accuracy on 1/15/26 by DON. No concerns were identified with the elopement binder.- Audit of all current residents' leave of absence (LOA) orders in electronic health system performed on 1/15/26 by DON, ADON and unit managers. No concerns with LOA orders identified.- On 1/15/26 and daily through 1/22/26- routine operation of door monitors for alarming function check was performed for alarm functioning at all exit doors, by the Director of Maintenance.- On 1/27/26, exit alarms tested by third party independent contractor. No concerns identified.- On 2/3/26, CE-4 (policy number) Elopement Prevention Policy was updated by the Regional Clinical Consultant. Policy reviewed with IDT on 2/3/26 in ad hoc QAPI governed by Regional Clinical Consultant and re-issued to all departments, education provisions provided to all staff.- On 2/3/26, In-servicing related to the updated CE-4 Elopement Prevention Policy began with current staff in the facility. 100% in-house staff in-serviced.- Emergency in-servicing education related to responding to all alarming doors and treating as potential resident elopement and performing a head count. Only maintenance can identify a malfunctioning door alarm, and maintenance will

Based on observations, interviews, and record review, the facility failed to respond to two exit door alarms and provide adequate supervision to prevent one resident (#2), who was severely cognitively impaired and identified as a fall and elopement risk, from exiting the facility out of four residents sampled for risk of elopement. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. Resident #2 sustained a left forehead laceration and left elbow skin tear as a result of a fall. The resident was taken to the local hospital for treatment by Emergency Medical Services (EMS). Resident #2 was missing from the facility for approximately two hours without staff knowledge. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #2 and resulted in the determination of Immediate Jeopardy on 1/15/26. The findings of Immediate Jeopardy were determined to be removed on 2/4/26 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F600 and F726.Findings included: Findings included: A review of Resident #2's admission Record revealed an admission date of 12/18/25 with diagnoses to include dementia, falls, muscle weakness, lack of coordination, psychotic disorder with hallucinations, depression, and delusional disorder. A review of Resident #2's Minimum Data Set (MDS) assessment, dated 1/7/26, under section C - cognitive patterns, revealed a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A review of Resident #2's Physician orders revealed the following:- Duloxetine HCl [hydrochloric acid] Oral Capsule Delayed Release Particles 20 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to depression, unspecified, with an order date of 1/1/26.- Meclizine HCl Oral Tablet 25 MG (Meclizine HCl) Give 1 tablet by mouth every 12 hours as needed for dizziness, with an order date of 12/31/25.- Olanzapine oral tablet 2.5 MG (Olanzapine) Give 1 tablet by mouth in the morning related to unspecified dementia, unspecified severity, with other behavioral disturbance, with an order date of 1/8/26. - Olanzapine oral tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with psychotic disturbance, with an order date of 1/14/26. A review of Resident #2's Care Plan revealed the following:- MY FALLS: I am at risk for falls related to impaired cognition/ poor safety awareness, Afib [atrial fibrillation]/pacemaker, myasthenia gravis, h/o [history of] fall, use of psychotropic meds [medications], hydrocephalus. Date Initiated: 12/18/2025.- Resident is at risk for elopement related to Cognitive Impairment. see dxs. [diagnoses] Date Initiated: 12/19/2025., with interventions to include, Consult psychiatric and/ or psychology services as needed.Date Initiated: 12/19/2025, Maintain current phone and demographics information of the resident in the appropriate designated areas per protocol/ policy. Date Initiated: 12/19/2025, Notify other departments of resident's risk for elopement and wandering behavior. Date Initiated: 12/19/2025, Use verbal cues and distraction techniques to minimize exit seeking behavior. Date Initiated: 12/19/2025.- MY MOOD DISORDER: I have a diagnosis of depression, dementia with psychotic features/delusions. I take daily medications to help me feel better and stabilize my mood. Date Initiated: 01/01/2026.- Resident takes an anticoagulant medication secondary to Atrial Fibrillation Date Initiated: 01/01/2026.- COGNITION: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Short term memory problem, Impaired decision making, see dxs. Date Initiated: 01/08/2026. A review of Resident #2's Fall Risk Assessments, dated 12/19/25, 12/31/25, and 1/13/26, showed six or more questions were answered, Yes, which indicated Resident #2 was at high risk for falls based on the scoring criteria. A review of Resident #2's Elopement Risk Assessments showed on 12/19/25 a score of 19 (a score of 12 or more means at risk for exit seeking, elopement, wandering), on 1/5/26 the assessment score was 10. A review of Resident #2's Progress Notes revealed the following:- 1/2/26, A BIMS assessment was completed for [Resident #2] with a score of 6.0 indicating resident is Severe Impairment. Refer to assessment for more information.- 1/6/26 . [Resident #2] is an [personal health information (PHI)] who was admitted to [hospital name] from 12/19/2025 through 12/30/2025 following a witnessed mechanical fall at [facility name]. The patient reportedly fell while attempting to sit in a chair, which moved, resulting in a fall with impact to the left elbow and head, without loss of consciousness. He sustained a small skin tear to the left elbow. He was recently discharged on December 18 after hospitalization for self-harm concerns, during which he was treated with Olanzapine 5 mg nightly and Duloxetine, and subsequently discharged to skilled nursing care. On evaluation, he remained confused and disoriented x3, consistent with baseline dementia, and unable to provide a reliable history . He was independent with functional mobility and gait using a single-point cane (SPC) and managed indoor mobility without difficulty. Prior to his hospital re-admission, the patient was on the physical therapy caseload at this facility on 12/19/25,during which he required contact guard assistance for bed mobility, transfers, and gait using a rolling walker. His friend reported that his [family member] plans to transition him to an assisted living facility with memory care . History of: Dementia with Paranoid Delusions- Behavioral medications, redirection,rehabilitation nursing. Acute Interventions as warranted. Monitor closely for medication side effects and safety. 8. Precautions/Barriers: Confusion, fall risk, and elopement risk.- 1/8/26, Staff reports resident continues to wander, impulsive and agitated, concern for safety. Currently taking Olanzapine 5mg at bedtime, start Olanzapine 2.5mg in AM [morning] and monitor for effectiveness.- 1/8/26 . Readmission, sent to ER [emergency room] after fall and hitting head History of Present Illness: [PHI] seen for readmission to the facility after being sent to the hospital for a falling and hitting head while on blood thinners. Per hospital records CT [computed tomography] of brain normal but WBC [white blood cells] were elevated and treated for a UTI [urinary tract infection]. Resident has dementia and unable to provide any information but denies pain, headache or dizziness. unspecified dementia, unspecified severity, with psychotic disturbance Continue olanzapine 5mg h.s [every night at bedtime] Staff will continue to redirect resident and re-orient as needed . unspecified fall, subsequent encounter Staff will perform frequent checks for safety, resident unable to remember to call for help due to dementia.- 1/13/26, Resident alert with confusion, but able to make needs known. Vital signs WNL [within normal limits]. The resident has tried to get up multiple times but is very unstable, resident redirected multiple times to sit down and not get up by himself.- 1/13/26, .Resident continues to wander and become agitated, difficult to redirect . [PHI] seen today for staff reports that since return from the hospital he continues to be impulsive in his actions, becomes agitated and wanders aimlessly in the halls even with his Olanzapine. Staff states he is difficult to redirect and concerned about his safety. Resident unable to provide information due to cognition. unspecified dementia, unspecified severity, with psychotic disturbance Start Olanzapine 2.5mg in the morning and monitor for effectiveness Continue Olanzapine 5mg h.s . unsteadiness on feet will continue with therapy as ordered and staff will assist resident with transfers and mobility .- 1/14/26, Resident alert with confusion, but able to make needs known. The resident has tried to get up multiple times but is very unstable, resident redirected multiple times to sit down and not get up by himself. A review of Resident #2's miscellaneous documents revealed the following:- Determination of incapacitation, dated 12/19/25, with a physician signature, showed the following documentation, . Lacks the capacity to give informed consent and make medical decisions on his/her own behalf.- Neurobehavioral status exam report, dated 1/20/26, showed the following, . Psychotic disorder with hallucinations due to known physiological condition . Dementia in other diseases classified elsewhere without behavioral disturbance . Rationale(s) for Testing: Because impairment is suspected, assessment of patient capacity for: managing finances medical decision-making . Pertinent Medications: Duloxetine 20mg Olanzapine 8 mg Pertinent Medical Conditions: Unspecified dementia, delusional disorder, atrial fibrillation, Reflux. Dizziness, Chronic kidney disease, Myasthenia gravis,edema, Anesthesia. Behavioral Concerns/Observations: Patient is fairly incoherent. He is confused and speech is garbled and slurred. Dementia is increasing. Implications/Recommendations based on testing rationale(s): In my professional opinion, patient remains incapacitated. He is unable to make decisions regarding his finances and medical condition. A review of Resident #2's emergency room records from 1/15/26 revealed the following:- .Reg Dt/Tm [registration date/time] 01/15/2026 05:29 [5:29 a.m.] . Disch [discharge] Dt/Tm: 01/15/2026 11:39 [11:39 a.m.] . Admit Reason: fall . History source: Patient, EMS [emergency medical services]. Arrival mode: Ambulance. Chief Complaint from Nursing Triage Note: 1/15/2026 5:46 EST [eastern standard time] [5:46 a.m.] Chief Complaint EMS from outside of [facility name] due to a ground level fall with head injury. Patient missing from facility approx. [approximately] 2 hours before being found. [Local law enforcement] has been called and is investigating. The patient presents following fall. The onset was unknown. The occurrence was unknown. Location: Left head. Associated symptoms: none. Patient brought in after a fall. Unknown details but reportedly fall within past two hours. Patient was from memory care unit and apparently was missing for period of time and had a fall. EMS brought him in with injury to left forehead/eyebrow. Patient unable to give any additional history. No known vomiting. No other complaints . Head: Normocephalic, Left eyebrow contusion superficial abrasion;. Neurological: No focal neurological deficit observed, normal motor observed, normal speech observed, Aware he is in [county name] and alert, but otherwise confused - knows this is January, but thought 1966. Review of the emergency room records showed an EMS run report with the following: .Clinical Impression . Onset Time 03:00:00 [3:00 a.m.] 01/15/2026 . Chief Complaint Laceration to Left Eyebrow Duration 2 Hours . Injury Falls . Assessment Time: 01/15/2026 04:57:44 [4:57 a.m.] Narrative [NAME] [moderate priority, non-life-threatening, but serious illness or injury] [medic unit] dispatched emergency response to private residence via 911 system for a fall . Crew was rerouted to [facility name] . upon arrival on scene EMS crew found a [PHI] sitting upright in the back of a [local law enforcement] cruisier. Per [local law enforcement] patient is a resident of [facility name], the patient was found walking outside and called in by a nearby resident, it is unknown how long patient has been eloped from facility. Nursing staff present, history was provided by nursing staff. Per nursing staff this is patients baseline secondary to a history of dementia, patient states he tripped and fell hitting his head on the sidewalk. Patient denies LOC [loss of consciousness]. Patient has a laceration, approximately 1 inch, to left eyebrow, bleeding controlled without intervention. Patient was transferred from cruisier to stretcher via [by] stand and pivot with assistance of x2 [two individuals] EMS crew. Patient was transported to ambulance and loaded without incident. Patient was transported to [hospital name]. Incident times . Call Received 01/15/2026 04:34:51 [4:34 a.m.] . En Route 01/15/2026 04:51:13 [4:51 a.m.] . On Scene 01/15/2026 04:52:56 [4:52 a.m.] . Depart Scene 01/15/2026 05:16:01 [5:16 a.m.] At Destination 01/15/2026 05:26:58 [5:26 a.m.] Pt. [patient] transferred 01/15/2026 05:42:29 [5:42 a.m.] . A review of the local Law Enforcement incident sheet revealed the following: Incident Information . Reported Date: 01/15/2026 05:16 [5:16 a.m.] . Narrative: At 01/15/2026 at approximately 0448hrs [hours] [4:48 a.m.] I was dispatched to the [neighborhood address] reference an elderly male with an injury to his head knocking on doors asking for help. Upon arrival and through investigation gathering personal details it was established that [Resident #2] was a patient of the memory care unit at [facility name] . while talking with the supervisor at [facility name] [Staff A, Licensed Practical Nurse] stated that they received an open door alarm at approximately 0300hrs [3:00 a.m.] telling them that one of their doors had been opened but thought nothing of it, almost ignoring it. [Resident #2] when he was found had been outside for over an hour, was soaking wet as it had been raining and shivering cold because of the rapidly dropping temperatures outside and also had a gash on his left eyebrow which he was transported to [hospital name] for reference because it possibly needs stitches. [Staff A, LPN] informed when I asked if there was anyone supposed to be on watch she stated yes but that person was on break and he was not replaced with anybody during that time. It should be noted that the memory care unit at [facility name] is on the second floor of the building and [Resident #2] would have to walk past several nurses' stations to exit the building. A review of Resident #2's Physical Therapy notes revealed the following: DOS 1/1/26 - 1/26/26 . Diagnoses Myasthenia gravis without (acute) exacerbation onset 12/19/2025 . Unsteadiness on feet 12/31/25 . Lying to sitting on side of bed baseline 1/1/26 supervision or touching assistance . discharge 1/26/2026 supervision or touching assistance . Chair/bed-to-chair transfer baseline 1/1/26 supervision or touching assistance . discharge 1/26/2026 supervision or touching assistance Comments: . SBA [stand by assistance] for safety due to poor safety awareness, lacks insight regarding unsafe situation, verbal and tactile cues for correct hand placement, recognizing hazard and safety while turning . Patient will improve physical mobility performance to reduce risk for falls . baseline 1/1/2026 Physical Mobility Scale: 27/45 [goal is 35/45 on physical mobility scale] to indicate 49-50% impairment in physical mobility performance, high risk for falls . Discharge 1/26/2026 Physical Mobility Scale: 31/45 to indicate 20-39% impairment in physical mobility performance, high risk for falls. Gait - Level Surfaces . Baseline 1/1/2026 supervision or touching assistance . discharge 1/26/2026 supervision or touching assistance . Comments: Pt [patient] cont [continues] to require CGA [contact guard assist] for balance and safety in gait using RW [rolling walker], or HHA [home health aide], amb [ambulation] distance improved to 150 ft [feet]. Gait is notable for narrow BOS [base of support], continuous steps, forward lean on trunk and decreased trunk rotation. Assessment and Summary of Skilled Services . Prior Medical PMHx [past medical history]: Pt was at [hospital name] on 12/09/25 under [NAME] Act [involuntary evaluation and treatment for severe mental health crisis] for paranoid delusions and concerns for safety. Functional Mobility Assessment . W/C [wheelchair] mobility Does the resident use a wheelchair and/or scooter = Yes . Wheel 150 feet = Dependent . Cognition/Communication Assessment . Functional Daily Decision Making = Severely Impaired . An internet search was conducted to determine the weather on the night and early morning of 1/15/26. Based on information from World Weather, the temperature was 55 to 63 degrees Fahrenheit with light rain and 90% humidity. https://world-weather.info On 2/2/26 at 9:32 a.m., an interview was conducted with Staff B, Registered Nurse (RN). She confirmed she was Resident #2's assigned nurse, but he was currently hospitalized for pneumonia. She said the exit door alarms are very loud and are heard throughout the second floor. She said when the exit door was pushed, after 15 seconds it would unlock. Staff B, RN said some doors needed a key and others needed a code to turn the alarm off. She said she was not working when Resident #2 eloped. Staff B, RN said she worked on 1/15/26, the morning he returned from the hospital. She stated she was told, He went to the hospital, he tried to escape, and the police were called to find him. She said Resident #2 was able to walk with assistance and he used a wheelchair. She stated, His major concern was falls. She said when he first came to the facility, he was weak and falling all the time. On 2/2/26 at 9:53 a.m., an interview was conducted with Staff C, RN. He said the protocol was always to call a code purple (resident suspected missing) when the exit alarm sounded. Staff C, RN said he heard a resident exited a few weeks ago but did not know who the resident was. He said he would not be able to hear the therapy hall door alarm from where he is assigned to the back hall. Staff C, RN said there was a specific, high-pitched sound on the exit doors and confirmed they are loud. He said the first-floor staff could hear the second-floor alarm if they were by that area. On 2/2/26 at 12:06 p.m., an interview was conducted with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The DON said she was notified by phone on 1/15/26 at 7:45 a.m., by Staff A, LPN, that Resident #2 eloped and was found outside in front of the facility. The DON was told Resident #2 was taken to the hospital. She said she had one missed call at approximately 5:00 a.m., from Staff A, LPN. The DON said Resident #2 was last seen on 1/15/26 at 2:30 a.m. in his room, in bed sleeping, by Staff D, CNA. She said shortly after 2:30 a.m., an emergency stairwell exit door by the therapy department had alarmed. She said Staff A, LPN initially went to the wrong door by the wound care nurse's office because she thought it was that door alarming. The DON said Staff A, LPN attempted to silence the alarm, but she could not recall the code. She said Staff A, LPN, was working on the first floor that shift, but at the time of the door alarming she was on the second floor. The DON stated Staff A, LPN was the supervisor that night. She said Staff A, LPN assumed the alarm was not functioning and called maintenance. The NHA said about a week prior to 1/15/26, Staff A, LPN had set off an exit door alarm herself and could not shut it off. He said the Director of Plant Operations had reminded her about the code during that time. The NHA said when you push on the door, it released after 15 seconds, and once it opened says, Exit now, exit now. The DON said between 2:30 a.m. to 2:35 a.m., Staff A, LPN called Staff G, Maintenance Assistant. She said another nurse, Staff E, LPN who was assigned to Resident #2, confirmed she heard the alarm on the second floor but was told by Staff A, LPN it was malfunctioning. The DON said the two nurses did not follow the elopement policy/procedure to immediately search, check outside, and complete a head count. She stated, The staff failed to do that at that time. She said Staff G, Maintenance Assistant arrived at the facility at approximately 3:00 a.m. The DON said at approximately 4:45 a.m., the Sherrif's department arrived at the facility. The DON said the Sherrif's department called EMS. She said Staff A, LPN went outside to identify Resident #2, and the resident was taken to the hospital. The DON said the resident had a laceration above his left eyebrow. She said Resident #2 crossed the street, was knocking on windows of homes, and was found lying in a residential yard. She stated that one of the people who lived in one of the homes across the street called the police. The DON stated it was raining that morning. The RNC confirmed she checked the weather and it was 68 degrees Fahrenheit. The DON said Resident #2 returned to the facility at approximately 11:30 a.m. after he was evaluated at the hospital. She said Resident #2 had discharge plans prior to the elopement. The NHA stated Resident #2 was supposed to discharge to an Assisted Living Facility (ALF) with a secured unit, Because of his elopement potential. The DON said Staff D, CNA, was interviewed and said he heard the exit door alarm but was told by Staff A, LPN it was a malfunction. The DON said she asked Staff A, LPN to gather witness statements from whoever was left that worked the 11:00 p.m. to 7:00 a.m. shift. She said staff statements showed they did not hear the alarm. She said the staff on the first floor said they did not hear or see anything. The NHA said the second-floor alarm could not be heard on the first floor. The DON said the supervisor, Staff A, LPN, should have called code purple to notify the staff to initiate a head account. The DON said on 1/15/26 the Director of Plant Operations checked every exit door for malfunction and did not find any concerns. The NHA said before Resident #2 eloped, the doors were checked weekly and documentation supported the door had not malfunctioned in the weeks prior to the elopement. On 2/2/26 from 1:02 p.m. to 1:17 p.m., a re-enactment of Resident #2 exiting the facility was conducted with the DON, RNC, and the Director of Plant Operations. The RNC was observed at Resident #2's room on the second floor. She said his room is five doors away from the nurse's station. The Director of Plant Operations showed a camera pointed at the exit door by the nurse's station. He confirmed the camera did not point towards the resident hallways. The RNC and DON said Resident #2 did not exit the door next to the wound care nurse's office, which was closest to the resident's room. The Director of Plant Operations pointed out a speaker on the ceiling in front of the wound care nurse's office and facing the elevator towards the therapy gym. He said it was installed prior to Resident #2's elopement and it was loud. The RNC said Resident #2 walked past the elevator in front of the therapy gym to the exit door in Zone 6 by the therapy hall. A, Do not enter, sign was observed hanging to the right side of the exit door. The Director of Plant Operations said the sign is typically across the door. He confirmed there are flashing lights on the exit doors, which indicated what door was alarming. The RNC and Director of Plant Operations said the resident walked down two flights of stairs to the first floor exit door towards the back of the facility. The Director of Plant Operations said there was a red screamer on the first floor exit door when Resident #2 eloped. He said the red screamer was louder, but after approximately 10 to 15 minutes it self-terminated. He said the first-floor staff would have heard the alarm on 1/15/26 if they were by that door. The RNC said Resident #1 exited towards the back of the facility that faced the back parking lot. A paved path was observed from the back to the front of the building. The DON and RNC said Resident #2 crossed a four-lane street and walked to one of the homes where he knocked on the window. An observation of the four-lane street revealed a sign showing a speed limit of 40 mph. The DON stated Resident #2 told her he, Went through a jungle, and thought it was one of the houses with many trees. The house observed had multiple overgrown trees with debris and furniture items on the ground. Photographic evidence obtained during the tour. On 2/2/26 at 1:24 p.m., an interview was conducted with the Director of Plant Operations. He said the video footage cannot be rolled back, and it cleared after 24 hours. He said he viewed the video footage as soon as he was made aware of the event. The Director of Plant Operations said he arrived at the facility on 1/15/26 at 4:00 a.m., which was his typical schedule. He stated that morning, Nobody said a word to me, including Staff A, LPN who he saw when he arrived. He said Staff G, Maintenance Assistant was called to the facility because of the alarm that was activated by the therapy hall exit door. He said Staff G, Maintenance Assistant told him Staff A, LPN did not know how to reset the alarm, and she thought it was another door alarming. He stated he spoke to Staff A, LPN on Monday, 1/12/26 about the code for the doors. The Director of Plant Operations said he showed her on Monday the door flashes when opened, as well as the speaker he installed which faced the therapy hall. He stated, Staff A, LPN knew how to reset the doors. He said when he heard a resident eloped, after he completed his rounds that morning, he reviewed the video footage. He stated he observed an older gentleman walking down the therapy hallway, Wearing parachute pants and he had a limp. He stated the resident did not have a walker or wheelchair. He said Resident #2 was holding on to the railing as he walked down the hall. The Director of Plant Operations observed Resident #2 lean on the door and the alarm went off at approximately 2:32 a.m. according to the tape time. He stated he heard, Exit now exit now, then the door opened and closed. He stated, Anything can happen at that stairwell. The Director of Plant Operations stated he could hear staff talking and a resident was heard saying, Shut that off, and a door slammed. He said he heard both the first and second floor alarms. The Director of Plant Operations said he observed Staff A, LPN go to the elevator, push the button, and go inside the elevator. He stated there were no cameras outside or in the stairwell. He said as he watched the footage, he hoped staff would go to door, but he did not see any staff respond. The Director of Operations said he stopped watching the footage about 20 minutes after the alarm sounded. A review of the facility's Logbook documentation with task name check operation of door monitors and patient wandering system, showed for the week of 1/11/26 to 1/15/26 all the doors on the second floor passed. On 2/3/26 at 9:24 a.m., a phone interview was conducted with Staff D, CNA. He said on 1/15/26 he informed Staff E, LPN, he was going on break. He confirmed Resident #2 was assigned to him that night. Staff D, CNA checked on Resident #2 before going on break and said he was asleep in bed. He said about 10 to 15 minutes into his break, he received a call from Staff A, LPN, who asked him if he knew how to turn off the alarm. Staff D, CNA said Staff A, LPN assumed it was a malfunctioning alarm. He stated he felt like she was calling in a Nonchalant way. He said he did not recall the approximate time he received a call from Staff A, LPN or when he returned, but he was on break for about 30 to 35 minutes. He said he returned from his break, answered multiple call lights, and recalled the alarm was still sounding. Staff D, CNA stated, I don't remember checking [Resident #2's] room when he returned from his break. He said later on in his shift he sat at the nurse's station and watched the hallway. Staff A, LPN called again and told him Resident #2 was found by the police. He said he told Staff E, LPN and went downstairs. Staff D, CNA said he observed the resident who had bruises around his eye and was cold and wet. He stated, It was raining that night. Staff D, CNA said he recalled the alarm door malfunctioning a week prior to Resident #2's elopement. He said the supervisor did not initiate the elopement protocol at that time and Staff D, CNA did not check on his residents. Staff D, CNA said he recalled the DON and the Maintenance staff being called when the alarm malfunctioned a week before. He said Staff A, LPN did not know the code at that time. He stated, Everyone was like, how do you turn it off? He said Resident #2 was able to get in his wheelchair and walk a little. Staff D, CNA stated, He should have been 1:1, as he would get out of the bed and his wheelchair. He said he would have to re-direct him to the chair or the bed. He said when they had a resident like that, the person was typically 1:1. He stated, Administration knew this, workers knew this, we all kept an eye on him as best as we could. When asked why he did not respond to the alarm on 1/15/26, he said he thought it was another malfunctioning door. On 2/2/26 at 4:27 p.m., a telephone interview was conducted with Staff E, LPN. She said on 1/15/26 at approximately 3:00 a.m. she was in a resident's room. She said Staff D, CNA, Resident #2's assigned CNA, was taking a 30-minute break when the resident exited the facility. She stated, Nobody saw him [Resident #2] leave. She said she was not sure if another CNA was supposed to take over when the assigned CNA was on a break. Staff E, LPN stated, I did not check that and [Staff D, CNA] did let me know he was going on break. She said she heard an alarm; it was a noise she did not recognize and did not know where it was coming from. She recalled the alarm sounding for a few minutes. She stated, I didn't know what was going on. She said she received a call from Staff A, LPN, who was on the first floor, that a resident exited through a door. Staff E, LPN said she thought the police were called by Staff A, LPN. She thinks Resident #2 hurt his face or head but confirmed she did not observe him when he returned to the facility. Staff E, LPN said she last saw Resident #2 at 2:00 a.m. on 1/15/26. She said when she heard a resident was missing, she completed a count of the residents and called Staff A, LPN. Staff E, LPN stated she heard, He got out of a kitchen door that was not secure. She said Staff D, CNA went downstairs when Resident #2 returned. She said Staff A, LPN immediately sent Resident #2 to the hospital as he had an abrasion on his face. Staff E, LPN stated she was panicking and, Everything went really fast. She said she never completed elopement drills, was not aware of the sound of the alarmed door, and felt she was not provided the proper training. She stated, He should have been on precautions,15-minute checks, and 1:1. Staff E, LPN said she had constant issues with him and was worried about keeping him safe. She stated, He was a major fall risk, he constantly tried to get up, was extremely confused and wandered. Staff E, LPN said Resident #2 could stand and walk around but was not steady on his feet. Staff E, LPN said she did not inform the DON of her concerns, but spoke to Staff A, LPN who was aware of his behaviors before the elopement. She said Staff D, CNA, was also aware of Resident #2's behaviors. On 2/3/26 at 10:55 a.m., a follow-up interview was conducted with the Director of Plant Operations. He said the door that goes out to the smoking patio and a door, used only by staff, have had some issues. The Director of Plant Operations confirmed he came to the facility on Monday, 1/12/26, before Resident #2 eloped to assist/re-educate Staff A, LPN on how to turn the door alarm off. He said he did not document when he gets called to the facility. He said he documented in the electronic system that showed tasks where maintenance is needed/completed. He said there have been no recent door malfunctions documented in the electronic system. On 2/3/2

Based on observations, interviews, and record review, the facility failed to ensure nursing staff were knowledgeable and competent to provide care and services to prevent an elopement for one resident (#2) out of four sampled residents when they failed to respond to exit door alarms. On 1/15/26 at approximately 2:30 a.m., Resident #2 exited the facility, unwitnessed by staff, through a second-floor stairwell door with an audible alarm sounding. The resident walked down two flights of stairs and exited to the back of the facility through a second alarmed door sounding. Resident #2 walked approximately 170 yards through a parking lot, across a four-lane road with a 40 mile per hour (mph) speed limit, and into a neighborhood where he was found by local police. Resident #2 sustained a left forehead laceration and left elbow skin tear as a result of a fall. The resident was taken to the local hospital for treatment by Emergency Medical Services (EMS). Resident #2 was missing from the facility for approximately two hours without staff knowledge. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #2 and resulted in the determination of Immediate Jeopardy on 1/15/26. The findings of Immediate Jeopardy were determined to be removed on 2/4/26 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Cross reference to F600 and F689.Findings included: A review of Resident #2's admission Record revealed an admission date of 12/18/25 with diagnoses to include dementia, falls, muscle weakness, lack of coordination, psychotic disorder with hallucinations, depression, and delusional disorder. A review of Resident #2's Minimum Data Set (MDS) assessment, dated 1/7/26, under section C - cognitive patterns, revealed a Brief Interview of Mental Status (BIMS) score of 6, indicating severe cognitive impairment. A review of Resident #2's Physician orders revealed the following:- 1:1 [one to one] supervision with staff at all times due to elopement risk. every shift for safety, with an order date of 1/15/26.- May only go out on LOA [leave of absence] with responsible party, with an order date of 1/15/26. A review of Resident #2's Care Plan revealed the following:- Resident is at risk for elopement related to Cognitive Impairment. see dxs. [diagnoses] Date Initiated: 12/19/2025., with interventions to include, Consult psychiatric and/ or psychology services as needed.Date Initiated: 12/19/2025 Family assisting with resident placement to secured unit. Date Initiated: 01/15/2026 Maintain current phone and demographics information of the resident in the appropriate designated areas per protocol/ policy. Date Initiated: 12/19/2025 Notify other departments of resident's risk for elopement and wandering behavior. Date Initiated: 12/19/2025 Provide resident with 1:1 companion as needed to decrease risk of achieving exit. Date Initiated: 01/15/2026 Use verbal cues and distraction techniques to minimize exit seeking behavior. Date Initiated: 12/19/2025.- COGNITION: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Short term memory problem, Impaired decision making, see dxs. Date Initiated: 01/08/2026. A review of Resident #2's elopement risk assessments showed on 12/19/25 a score of 19 (a score of 12 or more means at risk for exit seeking, elopement, wandering), on 1/5/26 the assessment score was 10, and on 1/15/26 the assessment score was 26. A review of Resident #2's progress notes revealed the following:- 1/2/26, A BIMS assessment was completed for [Resident #2] with a score of 6.0 indicating resident is Severe Impairment . Refer to assessment for more information.- 1/6/26 . [Resident #2] is an [personal health information (PHI)] who was admitted to [hospital name] from 12/19/2025 through 12/30/2025 following a witnessed mechanical fall at [facility name]. The patient reportedly fell while attempting to sit in a chair, which moved, resulting in a fall with impact to the left elbow and head, without loss of consciousness. He sustained a small skin tear to the left elbow. He was recently discharged on December 18 after hospitalization for self-harm concerns, during which he was treated with olanzapine 5 mg nightly and duloxetine, and subsequently discharged to skilled nursing care. On evaluation, he remained confused and disoriented 3, consistent with baseline dementia, and unable to provide a reliable history . He was independent with functional mobility and gait using a single-point cane (SPC) and managed indoor mobility without difficulty. Prior to his hospital readmission, the patient was on the physical therapy caseload at this facility on 12/19/25,during which he required contact guard assistance for bed mobility, transfers, and gait using a rolling walker. His friend reported that his [family member] plans to transition him to an assisted living facility with memory care . History of: Dementia with Paranoid Delusions- Behavioral medications, redirection,rehabilitation nursing. Acute Interventions as warranted. Monitor closely for medication side effects and safety. 8. Precautions/Barriers: Confusion, fall risk, and elopement risk.- 1/8/26, Staff reports resident continues to wander, impulsive and agitated, concern for safety. Currently taking olanzapine 5mg at bedtime, start Olanzapine 2.5mg in AM [morning] and monitor for effectiveness.- 1/13/26, .Resident continues to wander and become agitated, difficult to redirect . [PHI] seen today for staff reports that since return from the hospital he continues to be impulsive in his actions, becomes agitated and wanders aimlessly in the halls even with his Olanzapine. Staff states he is difficult to redirect and concerned about his safety. Resident unable to provide information due to cognition. unspecified dementia, unspecified severity, with psychotic disturbance Start Olanzapine 2.5mg in the morning and monitor for effectiveness Continue Olanzapine 5mg qhs . unsteadiness on feet will continue with therapy as ordered and staff will assist resident with transfers and mobility . A review of Resident #2's emergency room records from 1/15/26 revealed the following:- .Reg Dt/Tm [registration date/time] 01/15/2026 05:29 . Disch [discharge] Dt/Tm: 01/15/2026 11:39 . Admit Reason: fall . History source: Patient, EMS [emergency medical services]. Arrival mode: Ambulance. Chief Complaint from Nursing Triage Note: 1/15/2026 5:46 EST [eastern standard time] Chief Complaint EMS from outside of [facility name] due to a ground level fall with head injury. Patient missing from facility approx. [approximately] 2hours before being found. [Local law enforcement] has been called and is investigating. The patient presents following fall. The onset was unknown. The occurrence was unknown. Location: Left head. Associated symptoms: none. Patient brought in after a fall. Unknown details but reportedly fall within past two hours. Patient was from memory care unit andapparently was missing for period of time and had a fall. EMS brought him in with injury to left forehead/eyebrow. Patient unable to give any additional history. No known vomiting. No other complaints . Head: Normocephalic, Left eyebrow contusion superficial abrasion;. Neurological: No focal neurological deficit observed, normal motor observed, normal speech observed, Aware he is in [county name] and alert, but otherwise confused - knows this is January, but thought 1966. Further review of the emergency room records showed an EMS run report with the following: .Clinical Impression . Onset Time 03:00:00 01/15/2026 . Chief Complaint Laceration to Left Eyebrow Duration 2 Hours . Injury Falls . Assessment Time: 01/15/2026 04:57:44 Narrative [NAME] [moderate priority, non-life-threatening, but serious illness or injury] [medic unit] dispatched emergency response to private residence via 911 system for a fall . Crew was rerouted to [facility name] . upon arrival on scene EMS crew found a [PHI] sitting upright in the back of a [local law enforcement] cruisier. Per [local law enforcement] patient is a resident of [facility name], the patient was found walking outside and called in by a nearby resident, it is unknown how long patient has been eloped from facility. Nursing staff present, history was provided by nursing staff. Per nursing staff this is patients baseline secondary to a history of dementia, patient states he tripped and fell hitting his head on the sidewalk. Patient denies LOC [loss of consciousness]. Patient has a laceration, approximately 1 inch, to left eyebrow, bleeding controlled without intervention. Patient was transferred from cruisier to stretcher via [by] stand and pivot with assistance of x2 [two individuals] EMS crew. Patient was transported to ambulance and loaded without incident. Patient was transported to [hospital name]. Incident times . Call Received 01/15/2026 04:34:51 . En Route 01/15/2026 04:51:13 . On Scene 01/15/2026 04:52:56 . Depart Scene 01/15/2026 05:16:01 At Destination 01/15/2026 05:26:58 Pt. [patient] transferred 01/15/2026 05:42:29. A review of the local law enforcement incident sheet revealed the following: Incident Information . Reported Date: 01/15/2026 05:16 . Narrative: At 01/15/2026 at approximately 0448hrs [hours] I was dispatched to the [neighborhood address] reference an elderly male with an injury to his head knocking on doors asking for help. Upon arrival and through investigation gathering personal details it was established that [Resident #2] was a patient of the memory care unit at [facility name] . while talking with the supervisor at [facility name] [Staff A, Licensed Practical Nurse] stated that they received an open door alarm at approximately 0300hrs telling them that one of their doors had been opened but thought nothing of it, almost ignoring it. [Resident #2] when he was found had been outside for over an hour, was soaking wet as it had been raining and shivering cold because of the rapidly dropping temperatures outside and also had a gash on his left eyebrow which he was transported to [hospital name] for reference because it possibly needs stitches. Staff A, LPN informed when I asked if there was anyone supposed to be on watch she stated yes but that person was on break and he was not replaced with anybody during that time. It should be noted that the memory care unit at [facility name] is on the second floor of the building and [Resident #2] would have to walk past several nurses stations to exit the building. On 2/2/26 at 9:32 a.m., an interview was conducted with Staff B, Registered Nurse (RN). She confirmed she was Resident #2's assigned nurse, but he was currently hospitalized for pneumonia. She said the exit door alarms are very loud and are heard throughout the second floor. She said when the exit door was pushed, after 15 seconds it would unlock. Staff B, RN said some doors needed a key and others needed a code to turn the alarm off. She said she was not working when Resident #2 eloped. Staff B, RN said she worked on 1/15/26, the morning he returned from the hospital. She stated she was told, He went to the hospital, he tried to escape, and the police were called to find him. She said Resident #2 was able to walk with assistance and he used a wheelchair. She stated, His major concern was falls. She said when he first came to the facility, he was weak and falling all the time. On 2/2/26 at 9:53 a.m., an interview was conducted with Staff C, RN. He said the protocol was always to call a code purple (resident suspected missing) when the exit alarm sounded. Staff C, RN said he heard a resident exited a few weeks ago but did not know who the resident was. He said he would not be able to hear the therapy hall door alarm from where he is assigned to the back hall. Staff C, RN said there was a specific, high-pitched sound on the exit doors and confirmed they are loud. He said the first-floor staff could hear the second-floor alarm if they were by that area. On 2/2/26 at 12:06 p.m., an interview was conducted with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and the Nursing Home Administrator (NHA). The DON said she was notified by phone on 1/15/26 at 7:45 a.m., by Staff A, LPN, that Resident #2 eloped, was found outside in front of the facility, and taken to the hospital. She said she had one missed call at approximately 5:00 a.m., from Staff A, LPN. The DON said Resident #2 was last seen on 1/15/26 at 2:30 a.m. in his room, in bed sleeping, by Staff D, CNA. She said shortly after 2:30 a.m., an emergency stairwell exit door by the therapy department had alarmed. She said Staff A, LPN initially went to the wrong exit door, by the wound care nurse's office, because she thought it was that door alarming. The DON said Staff A, LPN attempted to silence the alarm, but she could not recall the code. The DON confirmed Staff A, LPN was the supervisor that night. She said Staff A, LPN assumed the alarm was not functioning and called maintenance between 2:30 a.m. to 2:35 a.m. The NHA said about a week prior to 1/15/26, Staff A, LPN had set off an exit door alarm herself and could not shut it off. He said the Director of Plant Operations had reminded her about the code during that time. The NHA said when you push on the door, it released after 15 seconds, and once it opened says, Exit now, exit now. The DON said another nurse, Staff E, LPN who was assigned to Resident #2, confirmed she heard the alarm on the second floor but was told by Staff A, LPN it was malfunctioning. The DON said the two nurses did not follow the elopement policy/procedure to immediately search, check outside, and complete a head count. She stated, The staff failed to do that at that time. She said Staff G, Maintenance Assistant arrived at the facility at approximately 3:00 a.m. At approximately 4:45 a.m., the Sherrif's department arrived at the facility. The DON said the Sherrif's department called EMS. She said Staff A, LPN went outside to identify Resident #2, then he was taken to the hospital. The DON said the resident had a laceration above his left eyebrow. She said Resident #2 crossed the street, was knocking on windows and was found lying in a residence yard. One of the people who lived in one of the homes across the street called the police. The DON stated it was raining that morning. The RNC confirmed she checked the weather, when the DON called her to report the incident, and it was 68 degrees Fahrenheit. The DON said Resident #2 returned to the facility at approximately 11:30 a.m. and was immediately put on 1:1 supervision. She said he had discharge plans prior to the elopement. The NHA stated Resident #2 was supposed to discharge to an assisted living facility (ALF) with a secured unit, Because of his elopement potential. The DON said Staff D, CNA, was interviewed and said he heard the exit door alarm but was told by Staff A, LPN it was a malfunction. She said staff statements showed they did not hear the alarm and staff on the first floor said they did not hear/see anything. The NHA said the second-floor alarm could not be heard on the first floor. The DON said the supervisor, Staff A, LPN, should have called code purple to notify the staff to initiate a head account. On 2/2/26 from 1:02 p.m. to 1:17 p.m., a re-enactment of Resident #2 exiting the facility was conducted with the DON, RNC and the Director of Plant Operations. The RNC was observed at Resident #2's room on the second floor. She said his room is five doors away from the nurse's station. The Director of Plant Operations showed a camera pointed at the exit door by the nurse's station. He confirmed the camera did not point towards the resident hallways. The RNC and DON said Resident #2 did not exit the door next to the wound care nurse's office, which was closest to the resident's room. The Director of Plant Operations pointed out a speaker on the ceiling in front of the wound care nurse's office and facing the elevator towards the therapy gym. He said it was installed prior to Resident #2's elopement and it was loud. The RNC said Resident #2 walked past the elevator in front of the therapy gym to the exit door in zone 6 by the therapy hall. A, Do not enter, sign was observed hanging to the right side of the exit door. The Director of Plant Operations said that sign is typically across the door. He confirmed there are flashing lights on the exit doors, which indicated what door was alarming. The RNC and Director of Plant Operations said the resident walked down two flights of stairs to the first-floor exit door towards the back of the facility. The Director of Plant Operations said there was a red screamer on the first-floor exit door when Resident #2 eloped. He said the red screamer was louder, but after approximately 10 to 15 minutes it self-terminated. The Director of Plant Operations said he replaced the red screamer on the first-floor exit door with a screamer that required a key to turn it off. He said the first-floor staff would have heard the alarm on 1/15/26 if they were by that door. The RNC said Resident #1 exited towards the back of the facility that faced the back parking lot. A paved path was observed from the back to the front of the building. The DON and RNC said Resident #2 crossed a four-lane street and walked to one of the homes where he knocked on the window. An observation of the four-lane street revealed a sign showing a speed limit of 40 mph. The DON stated Resident #2 told her he, Went through a jungle, and thought it was one of the houses with many trees. Photographic evidence obtained. On 2/2/26 at 1:24 p.m., an interview was conducted with the Director of Plant Operations. He said the video footage cannot be rolled back, and it cleared after 24 hours. The Director of Plant Operations said he arrived at the facility on 1/15/26 at 4:00 a.m., which was his typical schedule. He stated that morning, Nobody said a word to me, including Staff A, LPN who he saw when he arrived that morning. He said Staff G, Maintenance Assistant was called to the facility because of the alarm that was activated by the therapy hall exit door. He said Staff G, Maintenance Assistant told him Staff A, LPN did not know how to reset the alarm, and she thought it was another door alarming. He confirmed he spoke to Staff A, LPN on Monday, 1/12/26 about the code for the doors. The Director of Plant Operations said he showed her that Monday the door flashes when opened, as well as the speaker he installed which faced the therapy hall. He stated, Staff A, LPN knew how to reset the doors. He said when he heard a resident eloped, he reviewed the video footage. He stated he observed an older gentleman walking down the therapy hallway, Wearing parachute pants and he had a limp. He confirmed the resident did not have a walker or wheelchair. He said Resident #2 was holding on to the railing as he walked down the hall. The Director of Plant Operations observed Resident #2 lean on the door and the alarm went off at approximately 2:32 a.m. He stated he heard, Exit now exit now, then the door opened and closed. The Director of Plant Operations stated he could hear staff talking and a resident was heard saying, Shut that off, and a door slammed. He said he heard both the first and second floor alarms. The Director of Plant Operations said he observed Staff A, LPN go to the elevator, pushed the button, and go inside the elevator. He confirmed there are no cameras outside or in the stairwell. He said as he watched the footage, he hoped staff would go to door, but he did not see any staff respond. The Director of Operations said he stopped watching the footage about 20 minutes after the alarm sounded. A review of the facility's logbook documentation with task name check operation of door monitors and patient wandering system, showed for the week of 1/11/26 to 1/15/26 all the doors on the second floor passed. On 2/3/26 at 9:24 a.m., a telephone interview was conducted with Staff D, CNA. He said on 1/15/26 he informed Staff E, LPN, he was going on break. He confirmed Resident #2 was assigned to him that night. Staff D, CNA checked on Resident #2 before going on break and said he was asleep in bed. He said about 10 to 15 minutes into his break, he received a call from Staff A, LPN, who asked him if he knew how to turn off the alarm. Staff D, CNA said Staff A, LPN assumed it was a malfunctioning alarm. He stated he felt like she was calling in a Nonchalant way. He said he did not recall the approximate time he received a call from Staff A, LPN or when he returned, but he was on break for about 30 to 35 minutes. He said he returned from his break, answered multiple call lights, and recalled the alarm was still sounding. Staff D, CNA stated, I don't remember checking [Resident #2's] room, when he returned from his break. He said later on in his shift he sat at the nurse's station and watched the hallway. Staff A, LPN called again and told him Resident #2 was found by the police. He said he told Staff E, LPN and went downstairs. Staff D, CNA said he observed the resident who had bruises around his eye and was cold and wet. He stated, It was raining that night. Staff D, CNA said he recalled the alarm door malfunctioning a week prior to Resident #2's elopement. He said the supervisor did not initiate the elopement protocol at that time and Staff D, CNA did not check on his residents. Staff D, CNA said he recalled the DON and the maintenance staff being called when the alarm malfunctioned a week before. He said Staff A, LPN did not know the code at that time. He stated, Everyone was like, how do you turn it off? He said Resident #2 was able to get in his wheelchair and walk a little. Staff D, CNA stated, He should have been 1:1, as he would get out of the bed and his wheelchair. He said he would have to re-direct him to the chair or the bed. He said when they had a resident like that, the person was typically 1:1. He stated, Administration knew this, workers knew this, we all kept an eye on him as best as we could. When asked why he did not respond to the alarm on 1/15/26, he said he thought it was another malfunctioning door. On 2/2/26 at 4:27 p.m., a telephone interview was conducted with Staff E, LPN. She said on 1/15/26 at approximately 3:00 a.m. she was in a resident's room. She said Staff D, CNA, Resident #2's assigned CNA, was taking a 30-minute break when the resident exited the facility. She stated, Nobody saw him [Resident #2] leave. She said she was not sure if another CNA was supposed to take over when the assigned CNA was on a break. Staff E, LPN stated, I did not check that and [Staff D, CNA] did let me know he was going on break. She said she heard an alarm; it was a noise she did not recognize and did not know where it was coming from. She recalled the alarm sounding for a few minutes. She stated, I didn't know what was going on. She said she received a call from Staff A, LPN, who was on the first floor, that a resident exited through a door. Staff E, LPN said she thought the police was called by Staff A, LPN. She thinks Resident #2 hurt his face or head but confirmed she did not observe him when he returned to the facility. Staff E, LPN said she last saw Resident #2 at 2:00 a.m. on 1/15/26. She said when she heard a resident was missing, she completed a count of the residents and called Staff A, LPN. Staff E, LPN stated she heard, He got out of a kitchen door that was not secure. She said Staff D, CNA went downstairs when Resident #2 returned. She said Staff A, LPN immediately sent Resident #2 to the hospital as he had an abrasion on his face. Staff E, LPN stated she was panicking and, Everything went really fast. She said she never completed elopement drills, was not aware of the sound of the alarmed door, and felt she was not provided the proper training. She stated, He should have been on precautions,15-minute checks, and 1:1. Staff E, LPN said she had constant issues with him and was worried about keeping him safe. She stated, He was a major fall risk, he constantly tried to get up, was extremely confused and wandered. Staff E, LPN said Resident #2 could stand and walk around but was not steady on his feet. She said he did not express he wanted to leave. Staff E, LPN said she did not inform the DON of her concerns, but spoke to Staff A, LPN who was aware of his behaviors before the elopement. She said Staff D, CNA, was also aware of Resident #2's behaviors. On 2/3/26 at 10:55 a.m., a follow-up interview was conducted with the Director of Plant Operations. The Director of Plant Operations confirmed he came to the facility on Monday, 1/12/26, to assist/re-educate Staff A, LPN on how to turn the door alarm off. He said the door was not malfunctioning at that time. The Director of Plant Operations said he did not document when he gets called to the facility. He said he documented in the electronic system that showed tasks where maintenance is needed/completed. He said there have been no recent door malfunctions documented in the electronic system. On 2/3/26 at 10:59 a.m., a telephone interview was conducted with Staff F, CNA. She said on 1/15/26 at 4:30 a.m., she walked up to the nurse's station on the first floor and saw law enforcement knocking on the door. She said they told her they found a man wandering across the street and asked if he was a resident at the facility. Staff F, CNA said she took the law enforcement officer to the supervisor who was Staff A, LPN. She stated it was, Storming really bad that night. She said shortly after, the paramedics arrived at the facility with Resident #2. She said she went outside with Staff A, LPN and another CNA to see if they could bring Resident #2 into the facility. Staff F, CNA observed a cut on the resident's eye and said Staff A, LPN thought it was best he went to the hospital to be evaluated. She said she worked on the first floor and did not hear any door alarms that morning. She said she recalled maintenance staff was there at approximately 3:30 a.m., to turn off the door alarm. She said she asked Staff A, LPN, if everything was okay after seeing the maintenance staff. Staff F, CNA said Staff A, LPN told her the door alarm had malfunctioned. She said where she was assigned, she did not hear the door alarm by the therapy hallway exit stairwell. She said she did not know Resident #2 eloped until law enforcement came to the facility. She said she was not aware of any door that had malfunctioned or false alarms in the last few weeks. On 2/3/26 at 11:13 a.m., an interview was conducted with Staff G, Maintenance Assistant. He said on 1/15/16 at approximately 2:30 a.m., he received a call from Staff A, LPN who told him she could not get the door to reset, and it malfunctioned. Staff G, Maintenance Assistant said Staff A, LPN had the code, tried the code, but the door was still alarming. He confirmed he could hear the alarm over the phone. He said at approximately 2:45 to 2:50 a.m. he arrived at the facility. He said he went directly to the alarming door which was by the therapy gym. Staff G, Maintenance Assistant confirmed that was the only door alarming when he arrived. He said he reset the alarm, the door shut and the magnet locked like it was supposed to. Staff G, Maintenance Assistant confirmed there were no issues with the door, and it was not malfunctioning. He stated the alarm was, Pretty loud, and could be heard by the nurse's station on the second floor. He stated, If you were standing there on the first floor by that door [by the therapy hall stairwell], you could hear that alarm. On 2/3/26 at 2:12 p.m., a telephone interview was conducted with Staff H, RN. She said she worked on the first floor on 1/15/26. She said she went on a break around 3:00 a.m. Staff H, RN said while on her break, a CNA came in and appeared frantic. Staff H, RN asked the CNA what was going on; the CNA told her an alarm was going off and thought a resident had exited the facility. Staff H, RN said they both checked outside, did not see anyone, then went back inside. She said she completed a head count of her residents. She said she recalled a CNA told her a maintenance staff was there to turn an alarm off. Staff H, RN said Staff A, LPN told her there was an alarm going off as a resident pushed against the door and exited the facility. Staff H, RN said the police and EMS were involved. She said she initiated assisting with finding the resident but first communicated with the resident's assigned nurse. Staff H, RN said she called Staff E, LPN and told her the person missing might be her resident. Staff H, RN said she never heard the door alarm at any point. She was familiar with Resident #2 as she worked on the second floor sometimes. She said Resident #2 was confused, he would walk out of his room without assistance, and at times remove his clothes. Staff H, RN said there were many times that staff needed to escort and re-direct him. She thinks Resident #2 possibly had an infection. She confirmed she had received elopement training/in-services. Staff H, RN said they were instructed to complete a head count, make sure all residents are there, and make an announcement overhead. She stated, I think I overlooked that part of the process. I ended up calling the nurse directly. She said no one told her there was a malfunctioning alarm that morning and while she had been working at the facility all the door alarms functioned. On 2/3/26 at 4:27 p.m., a telephone interview was conducted with Staff J, Medical Doctor (MD). He said he had not met Resident #2 in-person until after the elopement. He said Staff I, Nurse Practitioner (NP) was the resident's main medical provider. He said Resident #2 had advanced dementia. Staff J, MD said Resident #2 was ambulatory but his awareness around him, ability to communicate, and insight into situations was compromised. He said the resident's baseline cognition made him a high risk for elopement and falls. Staff J, MD stated Resident #2 was, Probably appropriate for a memory care center. He said 1:1 supervision prior to the incident would have been appropriate based on what he knows about Resident #2. On 2/3/26 at 4:36 p.m., a telephone interview was conducted with Staff I, NP. She said Resident #2 had advanced dementia, confusion, and cognition dysfunction. She said he expressed he wanted to go home, was very impulsive, restless, and difficult to re-direct in certain areas. Staff I, NP said Resident #2's family was trying to place him in a facility with memory care. She confirmed he was at risk of falls because of his cognition and muscle weakness. Staff I, NP said she reviewed in previous records/history that Resident #2 developed a shuffling gait and muscle weakness. She stated, He is an elopement risk because of cognition. A memory type unit is the safest environment for people with his level of dementia. Staff I, NP said she was told Resident #2 pushed through an alarmed door, staff heard the alarm but thought the alarm stopped, and there was not a response because staff assumed someone checked. On 2/3/26 at 2:37 p.m., an interview was conducted with Staff K, Physical Therapist (PT). She confirmed therapy services were provided to Resident #2 from 1/1/26 to 1/26/26. She said the resident would go up and down mobility wise because of his cognition; at times he could be more alert and sometimes he was semi-lethargic. Staff K, PT said Resident #2 required one to two step commands and typically followed directions. She stated, I would take him in a wheelchair to the gym and use a walker to with him. She said she would support him with a gait belt when they would walk. Staff K, PT said Resident #2 could walk about 150 feet but needed a walker because he would shuffle and did not have a wide base of support. She stated, I do not think it would have been safe for him to walk just holding a handrail. She was surprised about the distance he walked, as well as going downstairs when he eloped. She said he could have fallen walking alone without a walker. She said she never tried stairs with the resident during therapy. On 2/4/26 at 10:49 a.m., an interview and review of the facility's investigation was conducted with the Assistant Director of Nursing (ADON). Sh

Based on interview and record review, the facility failed to ensure appropriate certification for Nursing Aides within four months of the dates of hire for four (Staff members A, B, C, and D) of four staff members reviewed. Findings included: On 02/27/2025 at 9: 00 a.m., the Human Resources Director brought documentation of the nursing aides hired by the facility to the conference room. Review of the documentation revealed four nursing aides had been working for the facility over four months without obtaining certified nursing assistant certification: Staff A, Nursing Aide was hired on 6/18/2024. Staff B, Nursing Aide was hired on 9/24/2024. Staff C, Nursing Aide was hired on 9/24/2024. Staff D, Nursing Aide was hired on 10/22/2024. During an interview on 2/27/2025 at 1:40 p.m. with the Human Resource Director, she confirmed Employee A, B, C, and D were not certified and were employed as nursing assistants During an interview on 2/27/2025 at 1:40 p.m. with the Director of Nurses (DON), she stated she was not aware Staff A, B, C, and D were not Certified Nursing Assistants. During an interview on 2/27/2025 at 3:00 p.m. with the Nursing Home Administrator (NHA), he stated he was told they could hire nursing assistants if they received their certification within the four months after being hired. The NHA stated he was not aware of Staff members A, B, C, and D working outside the period allowed without their certifications. He stated the expectations when it came to hiring nursing assistants, was that they follow the guidelines required for the nursing assistants to work in the building and that they were certified to maintain employment. Review of 2024 Florida Status, Titled XXIX Public Health Chapter 400 Nursing Homes and Related Health Care Facilities, No Date, showed Section 211 Persons employed as nursing assistants; certification requirement; qualified medication aids designation and requirements. 400.211 Persons employed as nursing assistants; certification requirement; qualified medication aids designation and requirements- 2. The following categories of persons who are not certified as nursing assistants under part II f chapter 464 may be employed by a nursing facility for a single consecutive period of 4 months: The certification requirements must be met within 4 months after initial employment as a nursing assistant in a licensed nursing facility.

Based on observation, interview, and record review, the facility failed to thoroughly and accurately identify resident specific triggers related to Post Traumatic Stress Disorder (PTSD) and develop a resident specific plan of care to prevent re traumatization for two Residents (#32 and #56) out of two residents reviewed with diagnoses of PTSD. Findings included: 1. Review of Resident #32's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD, bipolar disorder, anxiety disorder, schizophrenia,), and major depressive disorder. An interview was conducted on 06/19/24 at 10:20 AM with Resident #32. She said she was very shaky today because she had tardive dyskinesia. Resident #32 became tearful and said she did not know if she saw a psychiatrist or a psychologist. The resident then said she was tired and wanted to lay down. During the interview Resident #32 was observed to have hand tremors. An interview was conducted on 06/17/24 at 10:50 AM with Staff A, Restorative Certified Nursing Assistant (CNA). She said Resident #32 had a behavior of being tearful regarding her diagnoses and she calmed with music or talking about the dogs and horses. She said Resident #32's behaviors could be sporadic. An observation was conducted on 06/17/24 at 10:56 AM of Resident #32. She was observed to be tearful on her way to restorative therapy with Staff A pushing her in the wheelchair. Staff A was overheard saying she would put on some music for the resident in the restorative room. An interview was conducted on 06/19/24 at 10:25 AM with Staff B, Licensed Practical Nurse (LPN). She said she had been taking care of Resident #32 for 2 years and was very familiar with her. She said the resident was very anxious in the morning and she tended to be much better by the afternoon. Staff B confirmed Resident #32 had PTSD. She said she reviewed her record, and it was not very clear as to why she had PTSD other than she was sexually assaulted and the resident said she was kidnapped. Staff B said she did not know what the resident's triggers were and confirmed there was nothing in the record to identify the resident's triggers or how to avoid the triggers to prevent re traumatization. Review of Resident #32's Social Services Admission History (Premier) dated 10/7/2020 revealed section B. Primary Care PTSD Screen. A. Sometimes things can happen to people that are unusually or especially frieghtening[sic], horrible, or traumatic. For Example: A serious accident or fire, a physical or sexual assault[sic] or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. 1. Have you ever experienced this kind of event?: Yes In the Past Month, have you: 2a. Had nightmares about the event(s) or thought about the event(s) when you did not want to? No 2b. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Yes 2c. Been constantly on guard, watchful, or easily startled? No 2d. Felt numb or detached from people, activities, or your surroundings? No 2e. Felt guilty or unablet [sic] o[sic] stop blaming yourself or others for the events(s) or any problems the event(s) may have caused? No .Outcome .2. Based on the results of the Primary Care PTSD Screener: Psychology Services consulted . Life Events Checklist .6. Physical Assault (for example being attacked, hit, slapped, kicked, beaten up) Happened to me .8. Sexual Assault (rape, attempted rape, made to perform any sexual act through force or threat of harm) Happened to me .15. Sudden, unexpected death of someone close to you. Happened to me. Based on the information from the Life event Checklist: Psychiatric Services Consulted. Review of Resident #32's psychiatry physician note dated 7/15/22 revealed .As an adult, patient states, I was placed in a sex house, where black men rape white women. She was not able to recall for how long she was held captive or who the men were, she just recall that one of the men who was involved helped her escape because .he felt bad. Patient states she never reported the incident to the police . Review of Resident #32's psychology note dated 6/7/24 revealed .Description of what the psychotherapy entailed and how it addressed the presenting problem: Pt [patient] presents with positive mood. Explored use of coping skills prior to session. Practiced reframing negative thoughts. Engaged in role play to practice reframing negatives. Review of Resident #32's psychology note dated 5/31/24 revealed .Description of what the psychotherapy entailed and how it addressed the presenting problem: Explored mood and pt expressed thoughts of death. Explored emotions and assessed for SI. No SI at this time. Discussed pt use of art as coping strategy. Explored link to purpose and self esteem [sic]. An interview was conducted on 06/19/24 at 11:42 AM with Staff C, Social Services Director (SSD). She said she was familiar with Resident #32 and confirmed she had a diagnosis of PTSD. She said when she spoke to Resident #32 about her diagnoses she became tearful and shook. She said Resident #32 received psychology and psychiatry services and when there was an acute concern the psychiatrist and the psychologist would come to her and they would talk about a plan of care. Staff C, SSD also said there was a monthly meeting and psychiatry was involved in the meeting and concerns and plans of care were discussed. Staff C, SSD reviewed the psychiatry note dated 7/15/22 and said she kind of remembers that. She said a care plan was developed to identify Resident #32 had PTSD. Staff C, SSD said an assessment was completed to identify if a resident had PTSD. Psych services were consulted if the resident did have PTSD and psych physicians would come and speak to the social services department if there were concerns. She confirmed there was no documentation related to Resident #32's triggers and how to prevent re traumatization. Review of Resident #32's mood and behavior care plan revised on 4/17/24 showed MOOD/BEHAVIOR: The resident may/may not have a mood/behavior problems r/t [related to] depressed, PTSD, see psych consult/notes. 1/18/2021 Handling and or resolving issues or concerns/thoughts making statements for not knowing how to deal with situations (easily redirected). 3/18/22 indications of financial/material need, life event(s), concerns about daughter's health. The goals revealed o Improve mood state or anxiety level by next review o Will improve/minimize sadness, crying, restlessness, anxiety o Will not harm self o Participate in activities of choice The interventions showed: o Administer psychotropic medications as ordered [Refer to POS for current order]. Report missed or refused medication to physician (Missed doses can lead to an acute event & should be reported to the physician) o Encourage resident, to express feelings. o Speak softly & clearly when communicating o Observe for changes in mood/depression and notify physician o Discuss procedures & mediations prior to administration o Psychiatry Services as needed o Psychological Services o Encourage to talk about problems o Encourage to participate in activities of choice o Diversional Activity if upset: TV o When restless or anxious, provide calm, quiet atmosphere o Assist the resident, family, caregivers) to identify strengths, positive coping skills and reinforce these. o Observe/record/report immediately to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, States that life isn't worth living, wishes for death. An interview was conducted on 06/19/24 at 1:00 PM with the Director of Nursing (DON). She said Resident #32 has had PTSD since she was admitted , and she had psychiatry and psychology services. She said she would have to review the record to know what the resident's triggers were and what the facility was doing to prevent re traumatization outside of psychiatry and psychology services. An interview was conducted with Staff D, LPN, first floor Unit Manager (UM). He said he has worked with Resident #32 since her admission and was very familiar with her. He said Resident #32 had a lot of chronic anxiety; she came from another building to be with her with her [family]. Staff D said for the most part Resident #32 had done well but she did get a little anxious at times. He said in his opinion medical things gave her anxiety such as going out to outside doctor's appointments. So, we now send someone with her for the outside doctor appointments. He said Resident #32 went out to a doctor's appointment alone and the doctor's office called the facility and let them know her anxiety got so bad she could not clearly talk. So, after the incident the facility started sending someone with her to all outside doctor appointments and he thinks that had helped her. Staff D confirmed Resident #32 had a diagnosis of PTSD and said I don't know what that is about because she has not shown any triggers. I think she was involved in some bad marital relationships, but we have not gotten into that conversation. Staff D said he did not know what her triggers were. She does like music and coloring. 2. Review of Resident #56's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses of chronic post traumatic stress disorder (PTSD), Major depressive disorder, mood disorder due to known physiological condition with mixed features, and dementia. An interview was conducted on 6/17/24 at 10:50 a.m. with Resident #56. She said PTSD? I don't have that crap. Review of Resident #56's psychology re-assessment note dated 12/13/22, revealed Resident #56 had a diagnosis of PTSD, was raped at 15-had baby. Review of Resident #56's Social Services Admission History (Premier) dated 8/1/23 revealed PTSD screen: Sometimes things can happen to people that are unusually or especially frieghtening [sic], horrible, or traumatic. For Example: A serious accident or fire, a physical or sexual assult [sic] or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. .A2. Have you ever experienced this kind of event? Yes (If Yes, please answer the questions below) The questions below were not completed. .B1. Based on the results of the PTSD Screener: No further intervention is required . Review of the Life events checklist revealed none of the life events happened to Resident #56. Outcome: 1. Based on the information from the Life Event Checklist: Resident requires no further intervention. Review of Resident #56's psychiatry note dated 3/21/24 showed, There is no known history of physical, sexual, emotional abuse, or emotional neglect. Post Traumatic Stress Disorder: Patient denies symptoms of PTSD. Denies experiencing traumatic events that involved actual or threatened death or serious injury . Review of Resident #56's quarterly Minimum Data Set (MDS), dated [DATE], 2/10/24, 11/10/23, 4/20/2023, 1/18/23, and 10/18/2022, section I, Active Diagnoses revealed a Psychiatric/Mood Disorder diagnosis of PTSD. Resident # 56's significant change MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's Medicare 5-day MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's Annual MDS, dated [DATE], section I, revealed a diagnosis of PTSD. Resident # 56's Admission MDS, dated [DATE], section I, did not reveal a diagnosis of PTSD. Resident # 56's 5-day MDS, dated [DATE], section I, did not reveal a diagnosis of PTSD. Review of Resident #56's psychosocial care plan revised on 5/2/24 revealed PSYCHOSOCIAL: The resident has,a [sic] potential/actual psychosocial well-being problem related to may/may not have post-traumatic stress, life event(s) The goals showed Will verbalize feelings related to emotional state by review date and will utilize effective coping mechanisms as through the review date. The interventions showed, Allow the resident, time to answer questions and to verbalize feelings perceptions, and fears o Support/ Encourage/ Assist to set realistic goals o Determine resident's expectations and discuss eah [sic] in realistic terms o Encourage family/friend to remain involved o Psychiatry Services as needed o Psychological Services as needed o Discuss resident's concerns or fears o Discuss with resident feelings, reminiscence, issues Review of Resident #56's mood care plan revised on 5/2/24 revealed MOOD: The resident has a mood problem r/t States with trouble falling asleep or staying asleep. 8/26/22 Depression/anxiety per consult. PTSD. The goals revealed o Participate in activites [sic] of choice o Will receive adequate sleep. The interventions revealed o Encourage resident, to express feelings. o Speak softly & clearly when communicating o Psychiatry Services as needed o Psychological Services as needed o Encourage to talk about problems o Encourage to participate in activites [sic] of choice o When restless or anxious, provide calm, quiet atmosphere o Assist the resident, family, caregivers) to identify strengths, positive coping skills and reinforce these. An interview was conducted on 06/19/24 at 1:47 PM with Staff D, LPN, first floor UM he said he was not aware that Resident #56 had a diagnosis of PTSD. He said he did not know anything about what happened or her triggers. An interview was conducted with the Director of Nursing (DON) on 06/19/24 at 1:50 PM. She said she would have to look at Resident #56's chart to know if she had PTSD and recommended talking to Staff D. An interview was conducted on 06/20/24 at 11:43 AM with the DON. She said she thought she read somewhere in the resident's medical record she had an episode during COVID isolation where she was remembering things from her past. The DON confirmed there were no documented PTSD triggers or an attempt to identify the triggers to prevent re traumatization. Review of the facility's Trauma Informed Care policy, revised on 9/8/22 revealed Policy To ensure that residents who are trauma survivors receive culturally competent trauma informed care in accordance with professional standards of practice and take in account Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility will provide the necessary behavioral health care services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the individual resident assessment and plan of care. To train and assist staff to avoid re-victimization of those residents who have survived trauma and create an environment where the resident feels safe and secure. Individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being. Guidelines: While care and services must always be person-centered and honor residents' choice and preferences, what is different about providing care and services to a trauma survivor is that theses residents may have lost the ability to trust caregivers, and to feel safe in their environment. As a result, the principles of trauma-informed care must be addressed and applied purposefully. .Collaboration-There is an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care. There is recognition that healing that healing happens in relationships and in the meaningful sharing of power and decision-making. .PTSD Post-Traumatic Stress Disorder involves the development of symptoms following exposure to one or More [sic] traumatic, life-threatening events. Symptoms usually develop within the first 3 months after The [sic] trauma occurs, although there may be a delay in months or even years. Symptoms may include, but not limited to, the re-experiencing or re-living of the stressful event . Dissociation (e.g. detachment from reality, avoidance, or social withdrawal), hyperarousal (e.g. Increased[sic] startle response or difficulty sleeping). Symptoms may be severe or long-lasting when the Stressor[sic] is interpersonal and intentional (e.g., torture or sexual violence). .Triggers Facilities must identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. While most triggers are highly individualized, some common triggers may include: Experiencing a lack of privacy or confinement in a crowded or small space; Exposure to loud noises, or bright/flashing lights; Certain sights, such as objects that are associated with those that used to abuse, and/or Sounds, smells, and even physical touch. .Procedure 1. On admission an assessment/screening tool will be completed by the Social Service staff to Identify [sic] any trauma, post life events and/or post-traumatic stress disorder that the resident has Experienced or is currently experiencing so that our understanding of their traumatic events can Be [sic] more meaningful. An IDT approach will be used to identify a resident's history of trauma as Well [sic] as his or her cultural preferences. Screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission assessment, history/physical, social service History[sic]/assessment etc will provide information regarding resident's history. Additional Information may be obtained from the medical record, family members or other additional Assessments[sic] completed. 2. Evaluation of the information received will be completed by the Interdisciplinary team and Physicians to identify those risk factors/areas that may need to be included in the resident's plan of care to Mitigate[sic]/eliminate triggers. .4. Facility staff will have education/training in caring for residents identified with mental and Psychological [sic] disorders, as well as residents with a history of trauma and/or post traumatic stress Disorder [sic], including non-pharmacological interventions when appropriate. Trauma informed care Trainings [sic] will be conducted at least annually and will be included in orientation for all new Employees [sic]. .6. Trauma Specific interventions will be placed in their individualized person-centered care plan Upon [sic] admission and revised as necessary. Care plans will be reviewed quarterly and more often If [sic] necessary based on any change in their physician and psychosocial well-being. The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, Mental [sic] health professionals) to develop and implement individualized interventions. Facility/Social Services might consider establishing a support group, run by a qualified Professional [sic], or allowing a support group to meet in the facility. If a trauma survivor is reluctant to share his/her history, facility must still try to identify Triggers which may re-traumatize the resident; care plan interventions will be added Which [sic] minimize or eliminate the effect of the trigger on the resident. Trigger-specific interventions should identify ways to decrease the resident's exposure to Triggers [sic] which re-traumatize the resident, as well as identifying ways to mitigate or Decrease [sic] the effect of the trigger on the resident. Staff must understand the cultural preferences of the individual and how it impacts Delivery [sic] of care; .Trauma-specific interventions should recognize the interrelation between trauma and Symptoms [sic] of trauma such as substance abuse, eating disorder, depressions, anxiety; .

Based on observation, interview and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for four (#24, #111, #58 and #34) of 58 residents sampled, and in one of five medication carts left unlocked on one (1st) of two floors. Findings included: 1. During a facility tour on 06/18/24 at 12:47 p.m., an observation was made of Resident #24's eye drops at the bedside. There were two vials observed on her the bedside table named [brand name of lubricant eye drops]. These medications were not secured. Resident #24 stated she could administer the medications on her own, but she was supposed to keep them locked in her bedside drawer. (Photographic evidence was obtained). Review of the admission record showed Resident #24 was admitted to the facility on [DATE] with a diagnosis of dry eye syndrome of bilateral lacrimal glands. Review of the June 2024 physician orders for Resident #24 showed self-administration orders for three types of eye drops, but not the eyedrops observed at the bedside. Review of the Medication self-administration screener dated 12/21/23 showed Resident #24 was assessed for self-administration of [name of eye drops] multi dose emulsion 0.05% and [Brand name] gel. Section B- Evaluation showed (7.)The resident can demonstrate secure storage of medication. On 06/19/24 at 4:30 p.m., an interview was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing (DON). The DON stated all medications should be locked up with or without self-administration orders. They stated residents with self-administration orders had lockable drawers at their bedside. (Photographic evidence was obtained). 2. During tour on 06/17/24 at 10:02 a.m., an observation was made of Resident #111's medication at the bedside (name brand inhaler/decongestant). Review of the admission record showed Resident #111 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease unspecified. Review of June 2024 physician orders for Resident #111 showed there were no orders for the inhaler/decongestant found at the bedside. 3. During a tour of Resident #58's room on 06/17/24 10:04 a.m., an observation was made of a medication, [Brand name of medicated powder] placed on a chair by the resident's bedside. (Photographic evidence was obtained). Review of June 2024 physician orders showed Resident #58 did not have current orders for the [Brand name of medicated powder]. On 06/19/24 at 12:40 p.m., an interview was conducted with Staff P Licensed Practical Nurse (LPN). She stated all medications were to be stored in the medication cart and administered by nurse unless the resident had self-administration orders. An interview was conducted on 06/19/24 at 12:46 p.m. with Staff B, LPN. She stated all medications were to be secured. She stated if she observed a resident with medications at bedside, she would remove them and check with the physician if orders were needed to self-administer. On 06/19/24 at 1:40 p.m., an interview was conducted with Staff D, LPN/Unit Manager. He stated he had one resident on self-administration orders for eye drops. He confirmed residents with self-administration orders had bedside lockable drawers. He reviewed the photographic evidence for the residents of concerned and stated these residents should not be keeping the medications in their rooms. The expectation was to have an assessment completed to ensure the resident was able to self-administer and obtain orders. 49227 4. During medication administration observation on 6/19/24 at approximately 9:05 a.m., Resident #34 appeared short of breath at the doorway to his room. Staff E, Licensed Practical Nurse (LPN) offered to administer his inhaler. Resident #34 said he had already taken the medication. Review of the Medication Administration Record for Resident #34 showed an order, with a start date of 6/6/24, for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for wheezing unsupervised self-administration rinse mouth after use. On 6/19/24 at 11:30 a.m. during an observation, Resident #34's inhaler was in a plastic bag taped to his bed siderails (Photographic Evidence Obtained). On 6/19/24 at 3:36 p.m. an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON said medications stored at the resident's bedside should be secured. On 6/20/24 at 10:22 a.m. during an interview, Resident #34 said he liked to keep his inhaler handy, he said he had an attack four days ago. Review of facility's policy titled Medication Administration; last review date 9/13 /22 showed. Policy: medication shall be administered in a safe and timely manner and as prescribed. Procedure: only persons licensed are permitted by the state to prepare administer and document the administration of medications may do so. 19) For narcotic medication administration, the nurse must sign them Medication Administration Record (MAR) as well as the narcotic book /control substance sheet at the time the medication is administered indicating the date and time the [medication] Med administration. 24) residents may self-administer their own medications if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely. 5. On 06/18/24 at 1:04 p.m., an observation was made of Staff S, Licensed Practical Nurse (LPN) walking away from the medication cart, leaving the cart and computer unlocked. The cart and computer were positioned outside the nurse's station in hall 100. A resident's information page was visible to others. During that time, Residents were observed walking/wheeling to their rooms from the dining room. An observation was made of a family standing at the other end of the nurse's station. This surveyor walked to the cart and waited for the nurse to return for approximately 3 minutes. Staff S, LPN stated she should have locked the medication cart and computer before walking away. Review of a facility policy titled, medication storage, Revised 02/24, showed medications and biologicals are to be stored safely, securely, and properly, following manufacturer's recommendations for the supplier. The medication supply is accessible only to nursing personnel, pharmacy personnel, or staff members authorized to administer medications. (2.) The nursing staff shall be responsible for maintaining medication storage (med cart and med room) and preparation areas in a clean, safe and sanitary manner. (8.) compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (11.) Only persons authorized to prepare and administer medications shall have access to the medication room, including keys. Review of a facility policy titled, Self-Administration of Medications - Resident, dated 03/24, showed to abide by the individual right to self-administer medications unless determined unsafe by the interdisciplinary team. Under procedure (2.) (g.) The resident will have the ability to lock and unlock the storage drawer and manage the key.

Based on observation, interview, and record review, the facility did not ensure respiratory equipment was stored appropriately on one (1st) of 2 floors, for three (#51, #24 and #6) of nine residents observed. The facility also failed to ensure tracheostomy care and suctioning was provided according to standards of practice for one (#59) of one resident sampled with a tracheostomy tube. Findings included: On 06/17/24 at 9:58 a.m., an observation was made of Resident #51's Nebulizer mask stored on her nightstand. The mask was resting on the top surface, exposed to the elements. The tubing was not labeled/dated. (Photographic evidence was obtained). Review of the admission record showed Resident #51 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #51 showed orders to change nebulizer tubing every night shift every Sunday, please label tubing with date and time. During an observation on 06/17/24 at 10:22 a.m., Resident #24's CPAP (Continuous Positive Airway Pressure) mask was observed on her bedside table, detached from the hose. The hose attachments were observed on the floor. (Photographic evidence was obtained). Review of the admission record showed Resident #24 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #24 showed orders to clean CPAP machine weekly as directed. Every Thursday day shift as resident used the machine at night. Wash mask daily in mild, fragrance-free soap and warm water, then rinse well in warm water and air dry. On 06/17/24 at 10:09 a.m., an observation was made of Resident #6's nebulizer mask stashed inside a drawer, not stored in a bag. (Photographic evidence was obtained). Review of the admission record showed Resident #6 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Review of June 2024 physician orders for Resident #6 showed orders to change nebulizer tubing to every night shift every Sunday for hygiene, please label tubing with date and time. On 06/19/24 at 12:40 p.m., an interview was conducted with Staff P, Licensed Practical Nurse (LPN). She stated the nurses should clean respiratory equipment after use and put it in a dated bag. She stated equipment should not be on the floor and it should not be stashed in a drawer without a dated bag. An interview was conducted on 06/19/24 at 12:46 p.m. with Staff A, LPN. She stated the expectation was to store the equipment in a sanitary manner. She stated it should be cleaned and stored in a bag with a date. She stated the tubing should be changed weekly or per orders. On 06/19/24 at 12:53 p.m., an interview was conducted with Staff Q, Registered Nurse (RN)/ Infection Preventionist. She stated she had educated all nurses on appropriate handling and storage of respiratory equipment. She stated the expectation was to prevent infections, therefore store all equipment in a sanitary manner inside a bag that was dated. She stated she expected nurses to clean respiratory machines as directed and replace equipment as ordered. Staff Q reviewed photographic evidence and stated, That's totally unacceptable. The nurses should have the know-how as professionals. she stated she would re-educate the nurses. A follow -up interview was conducted on 06/19/24 at 1:44 p.m. with Staff D, LPN/Unit Manager. He stated all respiratory equipment should be stored appropriately per their policy. Review of a facility policy titled, Handheld nebulizer / small volume nebulizer, revised 03/23, showed (11.) Store nebulizer equipment in a storage bag. Nebulizer tubing should be changed every two weeks or more often if malfunction or is visibly contaminated. Clean compressor per manufacturer's recommendation. 2. An observation and interview was conducted with Resident #59 on 6/17/2024 at 10:51 a.m. Resident #59 was observed sitting in the doorway of her room, in a wheelchair with oxygen via a nasal canula (NC) connected to a concentrator located next to her bed, set at 1 l/m (liter per minute). Resident #59 had a tracheostomy tube, no ties were visible, gauze was surrounding the tube. Resident #59 stated being able to suction herself and the nursing staff changed the dressing. Review of Resident #59's Admission Record revealed resident was admitted on [DATE] with the diagnoses that included acute and chronic respiratory failure with hypoxia, acute on chronic diastolic (congestive) heart failure and other co-morbidities. Review of the Minimum Data Set (MDS) assessment, dated 4/2/2024, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition. Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #59 revealed the following: Suction via trach as needed for excessive secretions, as needed for Trach Care, dated 3/29/2024; Change trach collar, mask & O2 weekly as well as PRN (as needed) for Preventative Measure and as needed for soiled, dated 3/29/2024; Oxygen at 2L/min via NC continuously for SOB, dated 3/29/2024. The care plan for Resident #59 revealed a focus are for: BREATHING: I have difficulty breathing related to recent hospitalization for pneumonia, Resp. failure w(with)/hypoxia, asthma, and Congestive Heart Failure (CHF). I am on oxygen and have a tracheostomy w/suctioning as ordered, see current MD orders, date Initiated: 03/29/2024. Interventions include: I am able to let the staff know if I am feeling short of breath, date initiated: 03/29/2024; I am not able to let the staff know when I am short of breath so monitor me for accessory muscle breathing, tachypnea, lethargy, change in mental status, agitation, cyanosis, date initiated: 03/29/2024; Focus Area: I have a tracheostomy r/t (related to) Impaired breathing mechanics, date initiated: 04/01/2024; Interventions include: Change oxygen tubing weekly and PRN (as needed) if soiled, date initiated: 04/01/2024; Change trach collar, mask and o2 weekly as well as PRN every night shift Sunday for preventative measures, date initiated: 04/01/2024; Change trach collar, mask, and o2 weekly and PRN as needed for soiling, date initiated: 04/01/2024; Ensure that trach ties are secured at all times, date initiated: 04/01/2024; Oxygen at 2L/min via NC continuously every shift for SOB, date initiated: 04/01/2024; Suction via trach as needed for excessive secretion as needed for trach care, date initiated: 04/01/2024. No other documentation was provided from the resident's medical record regarding education of suctioning of the tracheostomy. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 6/19/2024 at 12:48 p.m. Staff J, LPN stated being Resident #59's primary nurse and had been caring for her since her admission. Staff J stated the resident could suction herself although sometimes we (staff) suction her. Staff J reviewed Resident #59's physician's orders and confirmed no order for trach size, no order for the resident to suction herself, and oxygen was ordered for 2 l/m not 1 l/m. During an interview on 6/19/2024 at 4:09 p.m., the Director of Nursing (DON) stated Resident #59's tracheostomy order should include specifics of type and size. The DON stated the order was incomplete and needed to be fixed. The DON continued to state the resident should have an order to complete self-suctioning and assessment to include education. The DON stated not sure why the orders were not complete. Review of the facility's policy and procedure titled Tracheostomy Care dated 4/14/23 revealed: Policy: this policy will guide the facility to maintain patency of the airway, to prevent infection of the Airways and the area around the tracheostomy tube, to prevent excoriation of the area around the tracheostomy tube and to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Tracheostomy care is to be performed at least BID (twice daily) and PRN (as needed) as ordered by a physician. An extra tracheostomy tube should be available at bedside for emergency situations; The tube should be same size as currently used. Also, an additional tube should be available that is one size smaller than current size. Procedure: Preparation and Assessment - 1. Verify physician order for care and treatment. General Guidelines: . 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily/BID for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. 48223

Based on observation, interview, and record review, the facility failed to ensure three (#6, #25, and #33 ) of seven residents observed for assisted dining in hall 100 received a dignified dining experience during two of four days of survey. Findings included: 1. On 06/17/24 at 12:47 p.m., Resident #6 was observed in her room in her wheelchair positioned in front of her bed facing the window. The resident's lunch tray was observed positioned behind her. When asked if she was going to eat her lunch, Resident #6 proceeded to attempt to move herself, but her wheelchair was locked. This resident was not able to position herself in front of her lunch tray. On 06/17/24 at 12:52 p.m., the Social Services Director (SSD) walked into the room. She stated Resident #6 did not ambulate independently. She stated the resident could not unlock her wheelchair. She confirmed the resident needed help to position herself in front of her meal tray. The SSD proceeded to position the resident in front of her tray. She stated resident needed meal set up assistance and sometimes she needed encouragement to eat. Review of the admission record showed Resident #6 was admitted to the facility on [DATE] with diagnoses of unspecified protein-calorie malnutrition and personal history of traumatic brain injury. Review of Resident #6's care plan, dated 01/08/22, under daily care/ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit related to decline in overall function secondary to illness and hospitalization and decreased activity tolerance. The goal, revised on 04/17/24, showed interventions for eating included , I require set up and as needed assistance from staff to eat. Open packets and cartons and such to set me up for meal. Review of Resident #6's quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Section GG - Eating, showed the resident required set-up or clean-up assistance. An interview was conducted on 06/17/24 at 12:52 p.m. with Staff R, Registered Nurse (RN). She stated Resident #6 ate on her own, but she needed to be set up. She stated this resident could not open containers. On 06/18/24 at 12:55 p.m., Resident #6 was observed in her room during lunch. The resident asked this surveyor to open her milk carton and her apple juice. The two items were observed unopened. The resident stated she could not do it herself. (Photographic evidence was obtained). On 06/18/24 at 1:02 p.m., an interview with Staff S, RN confirmed Resident #6 needed assistance with meal set up. She stated meal set up meant position wheelchair accordingly, place tray in front of resident, and open everything. 2. During a facility tour on 06/18/24 at 8:40 a.m., Resident #25 was observed in his bed and stated he needed staff to assist him with his meal. His tray was observed at his bedside. An immediate interview was conducted with Staff O, Certified Nursing Assistant (CNA). She stated they started passing trays between 8:00 a.m. and 8:15 a.m. She stated once they passed the trays, they were to go to the residents they were assigned to assist with meals. Review of the admission record showed Resident #25 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, muscle weakness, contracture of left hand, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #25's care plan, dated 06/17/22, under ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit related to impaired mobility with weakness and a history of CVA (Cerebrovascular Accident). The goal, revised on 06/07/24, showed interventions to provide total assistance with meal trays. Review of Resident #25's quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Section GG showed the resident was dependent for eating. On 06/18/24 at 8:56 a.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN)/ Unit Manager. He stated he had seven residents who were dependent on staff for meal assistance. He confirmed Resident #25 was waiting for a CNA to assist him with his meal. He stated he did not know why the resident was not being assisted having waited approximately 45 minutes. He said, I will check. We can warm up his tray if necessary. 3. On 06/18/24 at 12:57 p.m., Resident #33 was observed waiting for meal assistance. The residents in his hall were noted having finished their meal and CNA's were observed removing trays from the resident's rooms. An interview was conducted on 06/18/24 at 1:02 p.m. with Staff S, RN. She stated Resident #33 was dependent on staff for meals. She said, He should be assisted. The aide assigned to the hall is supposed to feed him. I did not know he was waiting. I will look for the aide. Review of the admission record showed Resident #33 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dementia. Review of Resident #33's care plan, dated 04/19/22, under daily care/ADLs (Activities of Daily Living) focus, showed the resident had a self-care deficit decline in overall function secondary to illness and hospitalization related to decreased activity tolerance due to weakness and CVA, impaired cognition due to diagnosis of dementia. The goal, revised on 04/18/24, showed interventions for eating included , I require total assistance from staff to eat. Review of Resident #33's annual Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns, a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. Section GG showed the resident was dependent for eating. On 06/18/24 at 1:05 p.m., an interview was conducted with Staff A, CNA who was observed assisting residents from the dining room. She stated the staff assigned to hall 100 was supposed to assist with feeders in this hall. She said, I can go see where Resident #33's aide is. Or maybe I should stop pushing people and feed him. On 06/18/24 at 1:07 p.m., an interview was conducted with Staff T, CNA. She said, I know he is waiting. She [her aide] should be here. She confirmed the tray was dropped off to the resident's room approximately 45 minutes earlier. On 06/18/24 at 1:07 p.m., an interview was conducted with Staff D, LPN/UM. He stated, my apologies. He [Resident #33] should not be waiting. I will find out what is going on. A follow -up interview was conducted with Staff D, LPN/UM on 06/19/24 at 1:40 p.m. He stated he was aware there was a problem with ensuring assisted residents received their meals in a timely manner. He confirmed a resident should not be waiting 45 minutes to be assisted. He stated he expected the CNAs to work together as a team and prioritize resident's needs. He stated he would have expected to be notified if there was a reason why a CNA could not assist a resident in a timely manner. He stated their procedure was to bring the tray to the resident when they were ready to feed them and not leave it in the room for extended periods. He stated part of delivering trays included preparing the resident for the meal, seating them up, opening containers, and positioning them accordingly. He stated he would in-service the CNAs. Staff D said, Residents should not be referred to as Feeders it's an undignified term. During an interview on 06/19/24 at 4:30 p.m., the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) stated their expectation was for their residents to receive prompt assistance with their meals. Review of a facility policy titled, Dignity and Respect, dated 04/06/24, showed each resident shall be cared for in a manner that promotes and enhances quality of life dignity respect and individuality . Procedure: (1.) Residents shall be treated with dignity and respect at all times. (2.) Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. (7.) Staff should speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number diagnosis or care needs.

Based on observation, interview, and record review, the facility failed to ensure splints were applied to prevent the decrease of range of motion for two (#50 and #88) of eight sampled residents. Findings included: 1. On 6/17/2024 at 10:27 a.m. and 3:00 p.m., Resident #50 was observed sitting forward in a recliner watching TV. Resident #50's bilateral feet were pointing down with heel protectors on both feet. Resident #50's bilateral hands were in fist like positions. Nothing was in the resident's palms. 2. On 6/17/2024 at 10:55 a.m., Resident #50 was observed and interviewed in bed. She was lying on her back with her right wrist bent and her hand with her fingers curled toward her palm. Resident #50 stated her hand did not open like it used to. She said she had splints, but the staff did not put them on very often and she forgets to request them. On 6/18/2024 at 10:41 a.m., Resident #50 was observed sitting in a recliner with no splints or rolls in her hands. Both of her hands were observed closed with her fingers bent and touching her palms. On 6/18/2024 at 8:26 a.m. and 2:11 p.m., Resident #50 was observed sitting in a recliner with no splints or rolls in her hands. Both of her hands were observed each time closed, fingers bent, and touching palms. On 6/19/2024 at 11:55 a.m., Resident #50 was observed in bed, lying on her back, with no splint on either hand. Review of Resident #50's Admission Record revealed diagnoses that included hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting right non-dominant side, limitation of activities due to disability and other co-morbidities. Review of the Minimum Data Set (MDS) assessment, dated 10/24/2023, Section GG Functional Status revealed Resident #50 was dependent on staff with mobility and activities of daily living (ADL) performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides for lower extremity (hip, knee, ankle foot). Review of the MDS assessment, dated 4/25/2024, Section GG Functional Status revealed Resident #50 was dependent on staff with mobility and ADL performance and had functional limitations in range of motion on two sides for upper extremity (shoulder, elbow, wrist, hand) and impairment on both sides for lower extremity (hip, knee, ankle foot). Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #50 revealed the following: May have restorative/maintenance programs as indicated, order date 9/1/2023; Splint: right palm roll or wash cloth roll or as tolerated every shift, order date 8/3/2023. The care plan for Resident #50 revealed a focus area for MY DAILY CARE/ADLS: I have an ADL self care deficit r/t reduced mobility, weakness, and pain d/t (due to) dx (diagnosis) of seizure D.O. (disorder), muscle weakness, contractures, and anoxic brain damage r/t (related to) hx (history) of ischemic CVA. (cerebral vascular accident (stroke)). AD-Towel roll(wash cloth) in Rt. hand for skin integrity, On in the am [morning] and out in the pm [evening] or as tolerated. Provide hand hygiene daily before and after use, notify nurse/therapy of any concerns. Always leave resident in reclined position when in recliner to minimize risks for falls. History of refusal of having teeth brushed. Revised 4/28/2024. The following intervention was in place Encourage me to participate with my therapy or restorative programs on a regular basis. The care plan for Resident #50 revealed a focus area for Resident has a restorative program related to contracture management. Revised. 4/28/2024 and Date Initiated: 02/05/2024. The goal for this focus was for Resident #50 to participate in the restorative program as tolerated/as ordered and will improve or maintain present level of contracture through the review date. Date Initiated: 02/05/2024. The interventions showed: Right Palm roll or wash cloth roll as ordered/as tolerated. Date Initiated: 02/05/2024; Inspect skin around and under brace when donning, doffing, and every shift. Date Initiated: 02/05/2024; Restorative program will be reviewed by the interdisciplinary team on a periodic basis. Date Initiated: 02/05/2024; Provide education to resident and family regarding the purpose and benefits of restorative nursing programs. Date Initiated: 02/05/2024; Motivate and encourage by praising effort, not just successes. Date Initiated: 02/05/2024. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 6/19/2024 at 12:50 p.m. Staff J, LPN confirmed being assigned to Resident #50. Staff J stated only cleaning Resident #50's hands and did not leave anything in the resident's palm(s). An interview was conducted with Staff A, Restorative CNA, on 6/19/2024 at 2:52 p.m. Staff A explained restorative nursing received direction from therapy on what was needed for each resident who was on the restorative nursing program. Staff A explained, restorative nursing provided treatment to the residents on their list, 3 days per week for 15 minutes. Restorative provided a short recap of what was done with each resident. Staff A continued to state for resident's who had splints, range of motion (ROM) was completed, then the splint was placed on the resident. The CNAs were supposed to put the splints on but we (restorative) usually had to put them (splints) on when we got to the resident. 2. Review of Resident #88's Admission Record revealed diagnoses that included hemiplegia (partial paralysis) following cerebral infarction (stroke) affecting right dominant side, critical illness polyneuropathy, cognitive communication deficit, and other co-morbidities. Review of the MDS assessment, dated 5/4/2024, Section GG Functional Status showed Resident #88 was dependent on staff with mobility and ADL performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand) and impairment on one side for lower extremity (hip, knee, ankle foot). Review of the Order Summary Report with active physician orders as of 6/19/2024 for Resident #88 showed the following: May have restorative/maintenance programs as indicated, order date 8/31/2023; Restorative Nursing: PROM (passive range of motion) bilateral upper extremities and lower extremities, all joints, 15 minute 3x/weekly x 12 weeks, order date 4/15/2023; Restorative Nursing: Resident received gentle PROM 3x/days week to right hand, order date 2/20/2024; Splint: Right resting hand splint with AM care to PM care or as tolerated every shift, order date of 8/3/2023. The care plan for Resident #88 showed a focus area for splinting/ bracing restorative related to prevention of functional decline through daily activity. Resident may refuse to wear splint Rev. 5/6/2024 Date Initiated: 01/08/2024. The goal for this focus was for the resident to participate in the splinting/ bracing restorative program daily, as tolerated/accepted and will improve or maintain present level functional ability through the review date. Date Initiated: 01/08/2024 Target Date: 08/09/2024. The interventions showed Resident has an splinting/ bracing restorative program for: [Splint Program - Right resting hand splint, prevent further deterioration, am-hs (at night) as tolerated. Date Initiated: 01/08/2024. An interview was conducted with Staff N, Certified Nursing Assistant (CNA) on 6/17/2024 at 10:29 a.m. Staff N stated she was responsible for the care of Resident #88. Staff N continued to state splint responsibility was for restorative, she did not have to put the splint on the resident. An interview was conducted with Staff M, Registered Nurse (RN) on 6/17/2024 at 10:34 a.m. Staff M, RN stated restorative placed splints on all residents. An interview was conducted with the Director of Rehabilitation (DOR) on 6/19/2024 at 2:37 p.m. The DOR stated therapy screened all residents not on current case load, quarterly, for position/contracture management and other declines. If any change in status, then therapy would request orders for evaluation and treatment from the physician. Nursing also could give the therapy department a request for therapy to screen based on observation of a problem. An interview was conducted with the Director of Nursing (DON) on 6/19/2024 at 4:09 p.m. The DON stated the CNAs were responsible for placing splints on the residents. Restorative could put them on but the primary responsibility was for the CNA, as restorative was only 3 days per week. The DON continued to state the order should be followed and related care should be on the care plan. Review of the facility's policy and procedure titled ADL Care Limited Joint Mobility; and Restorative Splint/Brace Program dated 3/12/24 revealed: Policy: a resident who is admitted without a limited range of motion/joint mobility does not experience reduction unless the residents clinical condition demonstrates that a reduction in a range of motion/joint mobility is unavoidable. A resident with a limited range of motion/joint mobility receives appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/joint mobility. The facility will ensure that the resident reaches and/or maintains their highest level of range of motion/joint mobility to prevent avoidable decline. The resident's comprehensive assessment should identify individuals risk which could impact the residents range of motion/impair joint mobility including, but not limited to: immobilization (e.g., bed fast, reclining in a chair or remaining seated in a chair/wheelchair); neurological conditions causing functional limitations such as cerebral vascular accidents, multiple sclerosis, Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrigsdisease, [NAME] beret syndrome, muscular dystrophy, or cerebral palsy, etc.; any condition where improvement may result in pain, spasms or loss of movement such as cancer, presence of pressure ulcers, arthritis, gout, late stages of Alzheimer's, contractures, dependence on mechanical ventilation, etc.; or clinical conditions such as immobilized limbs or digits because of injury, fractures, or surgical procedures including amputations. a restorative nursing program may be recommended to improve/maintain function of joint mobility. A restorative program can be implemented upon admission, readmission, during course of stay, or after being discharged from therapy services based on needs. Nursing staff will receive education/training from the therapy department on the restorative nursing program(s) prior to the residents participation in the restorative program(s). Procedure: 1. Nursing staff performs/supervises application of splints and or braces based on a wearing schedule established after assessment of need. Physical therapy and Occupational Therapy will educate staff as necessary, if special splint/brace application instructions are required, when resident is discharged from therapy. 5. Based on PT/OT evaluation for joint limitation needs and/or treatment, in collaboration with nursing, the resident may be placed on a restorative nursing program.* The restorative program will provide appropriate treatment and services to improve joint mobility and/or prevent further decline in joint mobility;* a specific restorative nursing plan will be developed for the resident for the splint/brace program as indicated based on assessment needs established by PT/OT;* the splint/brace program includes checking residents skin condition and circulation under the splint/brace device, cleansing the resident's skin, and repositioning the affected limb in correct alignment.* The splint/brace program does not include range of motion before applying the device; Those ROM needs are to be captured in a separate ROM program if the need is identified. * restorative nursing services will be provided at least six days a week with a goal that least 15 minutes of treatment services period time services may be divided over a 24 hour period and or as tolerated by the resident; .

Based on observation, interview, and record review, the facility did not ensure confidentiality of records was maintained for one resident (#58) of 59 residents on Hall 100, and failed to ensure two of five medication cart computer screens on Hall 100 were locked. Findings included: 1. On 6/17/24 at 1:05 p.m., an observation was made of an MDI (metered dose inhaler) box with Resident #58's chart sticker on the side of it, in the medication cart trash. The medication cart was in the middle of the common hallway on Hall 100 and visible to approximately five non staff persons walking through the hall at the time. During an interview conducted on 6/17/24 at 12:54 p.m. Staff R, Registered Nurse (RN) stated they normally remove PHI (protected health information) from packaging, shred the portion with the PHI and put the rest in the trash. During an interview conducted on 6/19/24 at 11:20 a.m., the Director Of Nursing (DON) stated she would expect the staff would shred all PHI. During an interview conducted on 6/19/24 at 1:47 p.m., Staff D, Licensed Practical Nurse/First Floor Unit Manager (LPN/UM) stated he would expect his staff to obliterate all PHI before putting it in the trash. 43453 2. On 6/18/24 at 1:04 p.m., an observation was made of Staff S, Licensed Practical Nurse (LPN) walking away from the medication cart, leaving the cart and computer unlocked. The cart and computer were positioned outside the nurses' station in Hall 100. A resident's information page on the computer screen was visible to others. During this time residents were observed walking/wheeling to their rooms from the dining room. An observation was made of a family standing at the other end of the nurses' station. Staff S returned approximately three minutes later. Staff S, LPN stated she should have locked the cart and computer before walking away. On 6/19/24 at 9:22 a.m., an observation was made of a medication computer screen open with a resident's information open to the public outside Hall 100. The nurse was not within sight. Staff B, LPN came out of a resident's room and said, I'm sorry, I did not mean to leave the computer unlocked. It was my mistake. I should have locked it before walking away. During an interview on 6/19/24 at 1:36 p.m., Staff D, LPN/UM stated the nurses should lock the computer screen when stepping away and the medication cart should be locked. Review of a facility policy titled, Health Information Manual, dated 07/01/23, showed the facility will protect and safeguard all medical records; medical records will be maintained . following state and/or federal regulations. Under Procedure (2.) The facility shall protect and safeguard all medical records (a) current medical records are maintained on the nursing unit and/or in an electronic health record. (Photographic Evidence Obtained)

Based on record review and interview, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (#43, #18,#24, #31 and #56) of nine residents reviewed for PASARRs . Findings included: 1. Review of Resident #43's admission record revealed an admitted [DATE] with diagnoses to include Unspecified Dementia, Anxiety Disorder and Major Depressive disorder. Review of a level I PASARR for Resident #43 dated 09/29/23 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. 2. Review of Resident #18's admission record revealed an original admitted [DATE] with diagnoses to include Schizophrenia, Major Depressive disorder and Bipolar disorder and Anxiety disorder. Review of a level I PASARR for Resident #18 dated 04/29/24 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. 3. Review of Resident #24's admission record revealed an admitted [DATE] with diagnoses to include Schizophrenia, Major Depressive disorder and generalized anxiety disorder. Review of a level I PASARR for Resident #24 dated 08/26/19 revealed the qualifying diagnoses were not checked and recommendations for a level II PASARR were not acted upon. On 06/18/24 at 3:39 p.m., an interview was conducted with the Regional Nurse Consultant (RNC), Director of Nursing (DON), and the Social Services Director (SSD). The RNC stated they had initiated revising the PASARRs in December with the previous DON. The DON stated they had submitted a bunch of level II PASARRs for review. She said, We do not have any evidence. I cannot pull the record. We are unable to find it. The RNC stated they did not identify their system had an issue until the surveyor requested the PASARRs. The DON stated their expectation was to review the PASARRs prior to admission, when the residents are newly admitted , or if readmitted with newly acquired mental health diagnoses. On 06/18/24 at 3:47 p.m., the RNC stated they did not have a PASARR policy. She stated they follow state regulations. The RNC presented an undated document titled Level I Screen. The document showed an accurate and complete level I screen is required prior to admission into a Medicaid- certified nursing facility. If relevant PASARR information was missing, such as mental health diagnosis, then a new level I and level II if indicated, must be completed prior to admission. 4. Resident #31 was initially admitted to the facility on [DATE] with diagnoses of psychotic disorder with delusions due to known physiological condition, bipolar disorder, and major depressive disorder. Review of Resident #31's Preadmission Screening and Resident Review (PASARR) dated 5/6/24 revealed qualifying mental health diagnosis of anxiety disorder, bipolar disorder, Psychotic Disorder with delusions due to known physiological condition and no PASARR Level II was required. Review of the admission Minimum Data Set (MDS), Section I, Active Diagnoses, with an Assessment Reference Date (ARD) of 4/17/24 and significant change MDS with ARD of 5/8/24 revealed medical diagnoses of depression, bipolar disorder, and psychotic disorder. Review of Resident #31's medical record revealed Resident #31 was not assessed for PASARR Level II. An interview was conducted on 06/20/24 at 11:44 a.m. with the Director of Nursing (DON). She said the resident had the diagnosis of anxiety on the PASARR because the resident was on hospice services and she received Ativan for agitation and anxiety. She reviewed Resident #31's medical diagnoses and confirmed she did not have a diagnosis of anxiety. 5. Review of Resident #56's Admission Record revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of post traumatic stress disorder (PTSD), major depressive disorder, mood disorder due to known physiological condition with mixed features, and dementia. Review of Resident #56's PASARR dated 7/14/22 revealed a mental illness diagnoses of Depressive disorder and a recommendation for a level II assessment. Review of Resident #56's PASARR dated 7/27/23 revealed no mental illness diagnoses and no recommendation for a level II assessment. Review of Resident #56's medical record revealed Resident #56 was not assessed for PASARR Level II. An interview was conducted on 06/20/24 at 11:45 a.m. with the DON. She reviewed Resident #56' PASARR and confirmed it was not accurate and Resident #56's mental illnesses were not identified. She also confirmed the resident did not have a PASARR level II assessment completed. 43453

Based on observation, interview, and record review, the facility failed to ensure negative wound pressure was monitored and maintained for one (#94) of one sampled resident, and failed to ensure an upper extremity elevation support wedge was ordered and monitored after application for one (#47) of two residents sampled for positioning devices. Findings Included: 1. On 6/17/24 at 2:01 p.m., during an interview and observation, Resident #94 was laying in bed. His negative pressure wound machine tubing was hanging on the floor. The machine was not functioning. On 6/18/24 at 10:07 a.m., Resident #94 was observed without the negative pressure wound machine connected. Resident #94 said the negative pressure wound machine causes pain and always comes off the day after replacement. On 6/18/24 at 12:56 p.m., Resident #94 said he had weekly appointments at the wound care center and did not want to continue using the negative pressure wound machine after his next appointment. Resident #94's next appointment was scheduled for 6/21/24. Review of Resident #94's admission record, with an admitted [DATE], showed diagnoses to include necrotizing fasciitis and Fournier gangrene. Review of Resident #94's order dated 6/7/24, start date 6/7/24, showed negative pressure wound therapy dressing change three times per week and as needed. Attach negative pressure wound therapy at [specified setting] [intermittent/ continual] to [specify wound/dressing site] [specify color(s) of foam] as needed for any leaking. Review of Resident #94's order dated 6/7/24, start date 6/10/24, showed negative pressure wound therapy dressing change three times per week and as needed. Attach negative pressure wound therapy at [specified setting] [intermittent/ continual] to [specify wound/dressing site] [specify color(s) of foam] every shift every Monday, Thursday for surgical side scrotal perineum: cleanse with normal saline, pat dry then apply the granulation black foam to cover wound vac and apply the wound vac. Review of Resident #94's Burn and Plastic Surgery Center Discharge Instructions, dated 6/12/24, showed negative pressure wound therapy to the scrotum wound at 125 millimeters of mercury) (mm) pressure (Hg) continuous. Special instructions written showed: in the event you lose suction to negative pressure wound machine, place normal saline wet to dry [dressing] and call for sooner appointment. Review of Resident #94's order dated 6/19/24, showed check for placement, function, seal, and negative pressure wound therapy setting every shift for wound vac therapy/ prevention. Review of Resident #94's eMAR Medication administration note, dated 6/13/24 at 3:35 p.m. showed negative pressure wound therapy dressing change three times a week and PRN. Attach negative pressure wound therapy at [specify setting] [intermittent/ continuous] to [specify wound/dressing site] [specify color (s) of foam] every Monday, Thursday for surgical side scrotal-perineum: cleanse with NS, pat dry then apply the granulation black foam to cover wound vac and apply the wound vac. As per patient wound vac dressing changed yesterday it is working properly and he refuses dressings at this time. Review of Resident #94's care plan initiated on 6/5/24 showed focus, my open skin areas, I have a wound vac dressing on my scrotum .The care plan's goal is to show signs of healing. Interventions to include: -Negative pressure wound therapy dressing change three times a week and PRN. Attach negative pressure wound therapy at 125 mm/hg continual to scrotal/ perineum wound [with] foam as ordered, initiated 6/10/24 -wound vac at 125 mm hg continuous pressure, change Monday /Thursday, dated 6/10/24 On 6/19/24 at 2:55 p.m., an interview was conducted with Staff G, Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The DON said all resident orders should be entered in the resident's medical record. She confirmed orders to document the negative pressure of Resident #94's machine had not been entered into the orders. Staff G said he had tried for several days to contact Resident #94's wound care doctor. 2. On 6/17/24 at 11:34 a.m., during an interview and observation Resident #47 was sitting in a geriatric chair in the 2nd floor activities area watching the television. A black foam forearm and hand elevation support wedge was laying in Resident #47's left armchair rest. Resident #47's flaccid arm was on his lap parallel to the support wedge with a foam strap secured above his elbow. Resident #47 said his left arm paralysis was due to a motor vehicle accident when he was 9 years old. Review of Resident #47's admission record showed 6/14/18, admitted and diagnoses to include unspecified fracture of shaft of humerus and left arm. Review of the Resident #47's task list, dated June 2024 did not reveal directions for the nursing staff to apply positioning devices. Review of Resident #47's care plan, review last completed on 3/12/24 did not show a focus, goal, or interventions related to positioning devices. On 06/17/24 at 12:47 p.m., Resident #47 was in the TV room with his left arm and hand out of the wedge support and laying on his lap. During an interview on 6/18/24 at 1:24 p.m., Staff H, Occupational Therapist (OT) said the last time Resident #47 was evaluated by OT was after a hospitalization in 2023. Staff H, said OT did not follow residents with chronic conditions, the residents were referred for restorative nursing therapy. The expectation was for the restorative care staff to notify the OT department with therapy related concerns. During an interview on 6/18/24 at 1:32 p.m., Staff L, Certified Occupational Therapist Assistant (COTA), Director of Rehabilitation (DOR), said the therapy department staff evaluated or screened residents after admission. Staff L, COTA, DOR said splinting directions and schedule would be added to the nursing staff task list for application and monitoring. During an interview on 6/19/24 at 12:16 p.m., the Director of Nursing (DON) said a Certified Nurse Assistant (CNA) observed Resident #47's girlfriend positioning Resident #47's arm on the positioning device the girlfriend brought to the facility. She said CNAs continued to use the support device for Resident #47. The DON said PT and OT evaluate residents to determine if positioning devices were needed. Residents who required positioning devices were listed on the nursing staff list. Review of facility's policy titled Consultants, last revised 3/5/24 revealed. Policy: .it is the policy of the facility to obtain additional information or assessment form outside source about/for a resident to assist in care and treatment. Procedure upon return and/ or completion of a consultation visit: a) check consult sheet for consultant's findings, diagnosis, recommendations, date and signature of consultant . b) notify attending physician of consultant's findings and recommendations. C) no recommendations by a consultant may be initiated before the attendant physician gives the order. Review of the facility's Care Planning Process and Care Conference policy, last revised on 7/3/23. In the procedure section 11) All resident/patient care and interventions must be carried out per the care plan (ex. Adaptive equipment, such as braces, restraints, dentures, hearing aids; transfers, ADL's, skin care, etc.)

Based on observations, interviews, and record reviews, the facility failed to assure accurate acquiring of medications for 3 (Resident #4, Resident #5, and Resident #7) of 3 residents sampled for availability of medications, and failed to assure accurate accountability of medications in 3 (100 unit, one cart and 200 unit, two carts) of 3 medication carts inspected. Findings included: An inspection of a medication cart on the 100 unit of the facility was conducted on 1/17/2023 at 09:27 AM with Staff A, Licensed Practical Nurse (LPN). A review of the narcotics inventory log revealed the following: - A medication card for Resident #8 containing 12 pills labeled as Xanax 0.25 milligrams (mg). The inventory sheet documented the card contained 13 pills. - A medication inventory sheet for Hydromorphone 4 mg ordered for Resident #9. An entry on the inventory sheet dated 1/15/2023 at 12:00 PM revealed a hand written note reading wasted. The sheet only contained one nurse's signature on the entry line and did not document the name of a witness to the medication being wasted. - A medication inventory sheet for Diazepam 10 mg ordered for Resident #10. An entry on the inventory sheet dated 1/6/2023 at 9:00 AM revealed a hand written note reading waste. The sheet only contained one nurse's signature on the entry line and did not document the name of a witness to the medication being wasted. An interview was conducted following the inspection with Staff A, LPN. Staff A, LPN stated she had just administered a dose of Xanax 0.25 mg to Resident #8 at 9:00 AM and forgot to document the administration on the medication inventory sheet. Staff A, LPN also stated she would normally sign off on the medication inventory sheet at the time the medication was administered but she did not. Staff A, LPN identified the signatures on the medication inventory sheets for Resident #9 and Resident #10 as her own and another nurse should have signed as a witness to the wasted medications. An observation of medication administration for Resident #4 was conducted on 1/17/2023 at 9:54 AM with Staff B, LPN. Staff B, LPN removed the following medications from the medication cart for administration for Resident #4: - Allopurinol 100 mg, 1 tablet - Coreg 25 mg, 1 tablet - Gabapentin 100 mg, 1 tablet - Losartan 100 mg, 1 tablet - Chlorthalidone 50 mg, 1 tablet During the observation, Staff B, LPN stated Resident #4's Apixaban 5 mg and Nifedical 90 mg scheduled for administration at 9:00 AM could not be found inside of the medication cart and she would make a note in the resident's chart to document the medications were not available. Staff B, LPN was not able to state why the medications were not available for Resident #4 but stated she would call the pharmacy and Resident #4's physician following the completion of her medication pass. Staff B, LPN administered the 5 medications to Resident #4 and did not inform the resident of the missing medications. A review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of hypertension, peripheral vascular disease, heart failure, and embolism and thrombosis of vein. A review of Resident #4's physician's orders revealed an order, dated 8/11/2022 for Nifedical 90 mg by mouth one time daily at 9:00 AM for hypertension. Resident #4's physician's orders also revealed an order, dated 5/27/2020, for Apixaban 5 mg by mouth two times a day at 9:00 AM and 5:00 PM for embolism and thrombosis of vein. A review of Resident #4's progress notes revealed an electronic medication administration record (eMAR) note, dated 1/17/2023 at 9:56 AM, documenting Apixaban 5 mg for Resident #4 was not in the medication cart and needed to be reordered. Resident #4's progress notes also revealed an eMAR note, dated 1/17/2023 at 9:58 AM, documenting Nifedical 90 mg for Resident #4 was not in the medication cart and needed to be reordered. An inspection of a medication cart on the 200 unit of the facility was conducted on 1/17/2023 at 10:11 AM with Staff C, LPN. A review of the narcotics inventory log revealed a medication inventory sheet for Tramadol 50 mg for Resident #11. Entry line #2 of the inventory sheet revealed a remaining count of 23 tablets. Entry line #3 of the inventory sheet, dated 1/9/2023 at 1:10 PM, revealed the on hand amount of medication was covered up in black ink and changed to 22 tablets, one tablet was documented as amount given, and the remaining count of pills was 22 tablets. Entry line #4 of the inventory sheet dated 1/9/2023 with no time documented revealed a hand written note reading error. The Name of person Administering line contained one signature crossed out with a single line in black ink and another signature next to it. The amount given box was left blank and the on hand count of pills was changed from 22 to 21. An interview was conducted following the inspection with Staff C, LPN. Staff C, LPN stated I don't know what that situation is, it's not me. An interview was conducted on 1/17/2023 at 10:28 AM with Resident #5. Resident #5 stated she was feeling dizzy because she needed her morning blood pressure medication and the facility did not have it available. Resident #5 was not able to state which medications she was supposed to take but stated she had been taking them for a while. A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with a diagnosis of hypertension. A review of Resident #5's physician's order revealed an order, dated 8/23/2022 for Furosemide 20 mg by mouth one time daily for hypertension. Resident #5's physician's orders also revealed an order, dated 8/5/2022 for Metoprolol Tartrate 50 mg by mouth three times a day for hypertension. A review of Resident #4's progress notes revealed the following: - An eMAR note, dated 1/16/2023 at 10:38 AM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not administered and the medication was reordered. - An eMAR note, dated 1/16/2023 at 3:43 PM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not available and the medication was awaiting delivery from the pharmacy. - An eMAR note, dated 1/17/2023 at 9:50 AM, documenting Metoprolol Tartrate 50 mg for Resident #5 was not in the medication cart and the pharmacy was notified. - An eMAR note, dated 1/17/2023 at 9:50 AM, documenting Furosemide 20 mg for Resident #5 was not in the medication cart and the pharmacy was notified. An inspection of a medication cart on the 200 unit of the facility was conducted on 1/17/2023 at 10:30 AM with Staff D, Registered Nurse (RN) and Staff E, LPN. An inspection of the controlled medication drawer revealed a medication card for Resident #12 containing 3 pills labeled as Xanax 1 mg. The inventory sheet documented the card contained 4 pills. An interview was conducted following the observation with Staff D, RN and Staff E, LPN. Staff D, RN stated she administered a dose of Xanax 1 mg to Resident #12 and forgot to sign the medication off on the inventory sheet. Staff E, LPN stated nurses are to sign for the medication on the inventory sheet at the time it is administered to the resident. A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] with a diagnosis of primary insomnia. A review of Resident #7's physician's orders revealed an order, dated 1/31/2022, for Melatonin 3 mg, 2 tablets at bedtime for primary insomnia. A review of Resident #7's progress notes revealed an eMAR note, dated 1/15/2023 at 8:21 PM, documenting Melatonin 3 mg, 2 tablets for Resident #7 was unavailable. A review of Resident #7's progress notes, dated 1/15/2023 at 10:33 PM, also revealed Resident #7 was very angry due to not being administered his Melatonin as ordered and he was tired of not sleeping due to not receiving the medication. It was explained to Resident #7 the medication was not available. An interview was conducted on 1/17/2023 at 1:34 PM with the facility's Director of Nursing (DON). The DON stated when a medication runs out in the medication carts, the nurse can select the reorder button in the electronic medical record and the medication will arrive from the pharmacy. Nurses are expected to reorder medications when the resident has about 5 or so left in the package. If a nurse was not able to locate a medication, they should check in the emergency drug kit (EDK) or call the pharmacy to let them know they do not have the medication in stock. If the medication was not able to be administered, the nurse should notify the MD for further orders and note the communication in the resident's progress notes. The DON also stated she was recently put in charge of ordering the over-the-counter medications, such as the Melatonin for Resident #7, and they had arrived late. The DON stated if a narcotic medication needed to be wasted, another nurse must sign the inventory sheet to witness the destruction of the medication and narcotic medications should be signed out of the inventory sheet as soon as they are administered to the resident. Nursing staff should be verifying the correct medication counts at shift change. A review of the facility policy titled Narcotic Management, last revised in May 2018, revealed under the section titled Policy, narcotics and schedule II medication will be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Narcotics and schedule II medications will be logged into a bound book or a separate master index page once received from the pharmacy as well as individual countdown records. The policy also revealed the following under the section titled Procedure: 5. Use the prescribing information on the sheet from pharmacy for documenting on the individual page of the bound book or countdown record. Complete all applicable sections. Photographic evidence obtained.

Based on observation, interviews, and record review the facility failed to ensure adequate staffing in the kitchen in order to provide residents with timely meals, during three of four meal services observed on 4/6/2022 and 4/7/2022. It was determined one hundred and nine residents out of one hundred and fourteen residents in the building receive meal trays and meal service. Findings included: On 4/5/2022 at 9:20 a.m. the kitchen was toured with Staff A, Kitchen Manager. During the tour, Staff A pointed out he had two dietary aides, Staff E and Staff Y, in the kitchen as well as himself, a total of three dietary staff members. He confirmed there were one hundred and fourteen residents in the building as of 4/5/2022. Staff A was asked if he had enough staff to prepare, cook and send out food to all the residents in the building in timely manner. He indicated he works up to seventy hours a week to ensure appropriate staffing in the kitchen. He did not offer any information as to why he had to work so much. Staff A confirmed the kitchen staff is contracted and there have been new hires recently but they don't stay. He was asked what number of kitchen staff would be appropriate in the kitchen and he could not answer. Staff A did confirm he could use more help and does not know if his agency is trying to hire new staff or not. Staff A revealed he had been working at the facility for about five months now and has had a large staff turnover. He also confirmed he works seven days a week. At 9:25 a.m. an interview was conducted with Staff E, Dietary Aide and Staff Y, Dietary Aide, neither staff member would answer if they felt the kitchen was short staffed. They did, however, reveal they do the best that they can with what they have. Staff members A, E and Y were asked if meal trays were being sent out to the floor and dining room late on a routine basis. None wanted to answer the question with a clear yes or no. On 4/5/2022 at 9:45 a.m. both the first floor and second floor hallways were still observed with meal tray carts and with staff picking up completed meal trays from resident rooms. Interviews with Certified Nursing Assistants (CNAs) Staff I, J, K, L, and M all revealed meals generally come out late in the mornings and they try to pass the meal trays to residents as quickly as they can, when the cart arrives. None of the aides interviewed were able to say why the meal tray carts come out late from the kitchen. Staff I and K stated they felt the Kitchen was short on staff. On 4/5/2022 at 11:00 a.m. the Kitchen Manager, Staff A provided the Tray Meal Service times document for review. The breakfast meal service times revealed the following: Cart 1 Rooms 134 - 132 7:15 a.m. Cart 2 Rooms 111 - 121 7:30 a.m. Cart 3 Rooms 101 - 110 7:40 a.m. Cart 4 Rooms 223 - 232 7:50 a.m. Cart 5 Rooms 211 - 222 8:00 a.m. Cart 6 Rooms 201 - 209 9:00 a.m. During tour of the facility on 4/5/2022 from 11:30 a.m. through to 1:00 p.m. random interviews with Residents #94, #38, #17, #101, #49, #86, #11, and #34 all revealed they typically eat all three meals in their rooms and confirmed the kitchen is routinely late sending out food. The residents revealed breakfast meals are typically the main meal that is sent out late. They were all aware of when they are supposed to receive their tray and further revealed they typically receive their trays in their room about thirty to forty minutes later than what is posted. On 4/6/2022 the facility was entered at 7:08 a.m. to observe the breakfast meal service. There were three dietary aides working in the kitchen, Staff Y, E, and Z. Staff Z stated she was asked to come in from her regular working facility to help out. Staff Z was not listed as an employee at the facility. The Kitchen Manager, Staff A was not in the kitchen at the time of the observation. An interview was conducted with Staff Y, and E. They stated they did not know where Staff A was. An observation of the breakfast meal was conducted on 4/6/22, the meal trays made it out to the floor during the following times: a. Cart for rooms 101 - 110 arrived on the floor at 8:46 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:40 a.m. It was found the cart arrived on the floor one hour and six minutes late. b. Cart for rooms 111 - 121 arrived on the floor at 8:36 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:30 a.m. It was found the cart arrived on the floor one hour and six minutes and one hour and sixteen minutes late. c. Cart for rooms 132 - 134 arrived on the floor at 8:26 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:15 a.m. It was found the cart arrived on the floor one hour and eleven minutes late. d. Cart for rooms 223 - 232 arrived on the floor at 8:20 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:50 a.m. It was found the cart arrived on the floor thirty minutes late. An observation of the breakfast meal was conducted on 4/7/22, the meal trays made it out to the floor during the following times: e. Cart for rooms 101 - 110 arrived on the floor at 8:24 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:40 a.m. It was found the cart arrived on the floor one hour and nine minutes late. f. Cart for rooms 111 - 121 arrived on the floor at 8:05 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:30 a.m. It was found the carts arrived on the floor thirty-five minutes late. g. Carts 132 - 134 arrived on the floor at 8:30 a.m. A review of the meal service time sheet revealed the cart was supposed to arrive on the floor at 7:15 a.m. It was found the cart arrived on the floor one hour and fifteen minutes late. Interviews conducted on 4/7/22, during the meal observation, with Staff F, Licensed Practical Nurse (LPN), Staff K, CNA, and Staff M, CNA, all confirmed the meals are still getting out late and they felt there was not enough staff in the kitchen to prepare and get meals out in a timely manner. Staff F, K, and M stated residents continually ask where their breakfast is and all they (staff) can do is to serve them coffee and hydration. On 4/8/2022 at 6:30 a.m. the building was entered to review 11-7 shift staffing for both nursing staff and the kitchen staff and also meet with the Staffing Coordinator. She confirmed she completes daily staffing for direct care and does not handle staffing for the kitchen, as they are contracted. She revealed sometimes the facility will pull activities staff during meal service to assist with meal tray pass and to get tray carts from the kitchen. The Staffing Coordinator confirmed there used to be sufficient staffing in the kitchen prior to the contracted company taking over and she does not know why kitchen staffing at this time constantly has turn over. The Staffing Coordinator did not have any further information to provide with relation to appropriate staffing in the kitchen. On 4/8/2022 an interview with the Kitchen Manager, Staff A, the other new Dietary Manager Staff B, and the Regional Dietary Manager, all revealed they believed they had sufficient kitchen staffing numbers in the kitchen during the lunch and dinner meal service but confirmed they could have more kitchen staff during the breakfast meal service. They confirmed having more staff in the kitchen could have ensured breakfast tray carts getting out from the kitchen and to the floor in a timelier manner, and in a manner with following the meal tray service times sheet. They were aware meals were brought out from the kitchen in an untimely manner, resulting in residents receiving their meals late. The Kitchen Manager, the Director of Nursing and the Regional Dietary Manager revealed the facility did not have a specific Kitchen Staffing policy and procedure.

Based on observations, interviews and record review, the facility did not ensure respiratory equipment was stored appropriately during three days of four days surveyed, for one floor (second floor) of two floors in the facility, and for nine residents (#56, #28, #52, #51, #102, #213, #313, #314 and #315) of 15 residents receiving respiratory care. Findings included: On 4/5/22 at 1:28 p.m. Resident #56's nebulizer equipment was observed stored on the nightstand, the cannula and tubing were exposed to the air. A review of the Admission Record for Resident #56 showed an admitted [DATE] with a diagnosis, to include but not limited to, [CONDITION(S)] ([CONDITION(S)]). The Physician Orders for Resident #56, dated 4/7/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/22 at 12:29 p.m. Resident #28's Continuous Positive Airway Pressure ([CONDITION(S)]) machine was observed stored on her bedside, her mask and tubing on her bed. Resident #28 stated she wears her [CONDITION(S)] every night. Resident #28 stated it is always on the bed. The resident did not know how often the tubing and mask were replaced. A review of the Admission Record showed Resident #28 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/22 at 11:47 a.m. an observation was made of Resident #52's oxygen and nebulizer cannula's on the nightstand not stored in a bag. Resident #52 did not know how often she used either one of them. A review of Physician Orders for Resident #52 showed orders, dated 3/23/22, to administer oxygen at 2 L (liters) via NC (nasal cannula) for oxygen percentage under 90% as needed; [MEDICATION(S)] nebulization solution 2.5 mg/3 ml 0.083%, 3 ml inhale orally via nebulizer every 6 hours for wheezing; [MEDICATION(S)] solution 3 ml inhale orally via nebulizer every 6 hours as needed for SOB; and [MEDICATION(S)] solution 3 ml inhale orally via nebulizer two times a day for SOB for oxygen percentage under 90%. An observation was made on 4/7/22 at 9:21 a.m. of Resident #51's nebulizer machine stored on the floor, oxygen cannula and tubing were noted on the floor. An immediate interview was conducted with Resident #51. Resident #51 stated she used the nebulizer 2-3 times a day. A review of Resident #51's Admission Record showed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician Orders for Resident #51 showed orders, dated 2/1/22, for oxygen at 3 liters per nasal cannula continuously for [CONDITION(S)], and an order, dated 4/5/22, for [MEDICATION(S)] nebulization solution 2.5 mg/3 ml 0.083%, 3 ml inhale orally via nebulizer every 8 hours as needed for SOB. On 4/7/22 at 12:20 p.m. an observation was made of Resident #102's oxygen tubing and cannula on the floor. Resident #102 stated he is supposed to be on his oxygen. Resident #102 stated the oxygen tubing fell off. A review of Resident #102's Admission Record showed an admitted [DATE], with a diagnosis, including but not limited to, chronic respiratory failure and shortness of breath. A review of the Physician Orders showed an order, dated 3/7/22, for oxygen at 3 liters/minute via nasal cannula for SOB / dyspnea. An observation was made on 4/7/22 at 9:39 a.m. of a [CONDITION(S)] machine/tubing stored inside the bedside drawer, mask not stored in a bag for Resident #213. A review of Resident #213's Admission Record showed an admitted [DATE] with a diagnosis, including but not limited to, [CONDITION(S)] and acute respiratory failure. A review of the Physician Orders showed an order, dated 3/24/22, to use [CONDITION(S)] daily at bedtime related to [CONDITION(S)], acute respiratory failure with [CONDITION(S)]. On 4/5/22 at 11:58 a.m., an observation was made of Resident #313's nebulizer mask on top of a bedside table not stored in a bag. Resident #313 was not interviewable. A review of the Admission Record for Resident #313 showed an admitted [DATE]. A review of Physician Orders for Resident #313, dated 3/20/22, showed to change nebulizer tubing every night shift and to administer [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3 mg / 3 ml), inhale orally every 6 hours as needed for SOB. On 4/7/22 at 12:44 p.m., an observation was made of Resident #314's oxygen tubing and cannula on the floor. Resident #314 did not respond to interview. A review of the Admission Record for Resident #314 showed an admitted [DATE]. A review of the Physician Orders for Resident #314 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 4/7/22 at 12:48 p.m. of Resident #315's [CONDITION(S)] supplies resting on the nightstand mask not stored in a bag. The tubing was observed to be on the floor. Resident #315 stated he wears his [CONDITION(S)] every night. Resident #315 was not aware if his [CONDITION(S)] should be stored in a bag. A review of the Admission Record for Resident #315 showed an admitted [DATE] and diagnosis, including but not limited to, [CONDITION(S)]. A review of the Physician Orders for Resident #315 showed orders to wear [CONDITION(S)] at bedtime every evening for apnea, dated 4/6/22. On 4/7/22 at 12:57 p.m. an interview was conducted with Staff Q, Licensed Practical Nurse (LPN). Staff Q stated the nebulizer's tubing, [CONDITION(S)] masks, and oxygen cannula's should be stored in a clear bag. Staff Q said, it should be dated and labeled. Staff Q indicated it was third shift nurse's responsibility to place clean bags and tubing. An interview was conducted with Staff R, LPN on 4/7/22 at 1:01 p.m. Staff R stated the nebulizer's should be unplugged when not in use, cleaned, and stored appropriately. Staff R stated appropriate storage means as ordered, covered, and dated. Staff R stated she would conduct an audit of her assigned areas and replace cannula's and masks. On 4/7/22 at 1:08 p.m. an interview was conducted with Staff U, LPN. Staff U stated the nurse administering the respiratory treatment should take responsibility and make sure to clean and store the equipment in a dated bag after each use. An interview was conducted on 4/7/22 at 1:10 p.m. with Staff S, Unit Manager. Staff S said, respiratory equipment should not be on the floor. Staff S reviewed photographic evidence and said, no, that is not appropriate storage. Tubing should not be on the floor. Masks and cannula's should be in a dated bag. Staff S stated some residents refuse to store their units in bags or they remove them. Staff S said, yes ultimately it is our responsibility to ensure sanitary storage. On 4/7/22 at 1:27 p.m., a follow-up was conducted with the Director of nursing (DON). The DON stated respiratory equipment is expected to be in a bag, sometimes it is in a drawer, but it is supposed to be in a bag either way. The DON stated tubing should be changed weekly, on Sundays. The DON said, it should be dated and labeled with the resident's name and room number. The DON stated the expectation is for patients to wear it as ordered and if resident does not follow orders, the physician should be notified. The DON stated equipment is kept on beside table. The DON said, mask should be kept in a bag, placed on the machine and not on the floor. The DON stated if resident refuses appropriate storage, it should be documented, and care planned. An interview was conducted on 4/8/22 at 9:22 a.m. with the DON. The DON confirmed respiratory equipment should be stored and changed per physician order and policy. A review of a facility policy titled, Handheld nebulizer / small volume nebulizer, revised 3/2020, showed (11.) Store nebulizer equipment in a storage bag. Nebulizer tubing should be changed every two weeks or more often if malfunction or visibly contaminated. Clean compressor per manufacturer's recommendation. A review of the facility policy titled, [CONDITION(S)] [CONDITION(S)], revised 5/2021, showed (7.) the machine, tubing and masks must be cleaned according to facility policy. A review of a facility policy titled, Oxygen Administration policy and procedure, revised 3/27/2020, showed (11.) all tubing will be changed and dated every two weeks or more if malfunction or visibly soiled. (12.) Oxygen concentrators will be maintained by vendor per facility.

The facility failed to ensure food preferences and meal choices were honored for one resident (#94) out of two residents investigated for choices, during two meals observed on 4/5/2022 and 4/7/2022. It was determined Resident #94 had expressed his food preferences related to not receiving eggs during the breakfast meal to multiple staff members and he continued to receive eggs on a routine basis. Findings included: On 4/5/2022 at 9:30 a.m. Resident #94 was visited in his room and interviewed with permission. The resident was observed seated in his wheelchair next to his bed and had his over the bed table placed in front of him. He still had his breakfast meal tray placed in front of him on the table. The lid was still in place as if he did not eat anything. Resident #94 was observed dressed for the day and pleasant to speak with. Resident #94 expressed he routinely receives food items he hates and he has spoken with the Dietary Manager, Staff A about his choices. Resident #94 indicated he hates eggs and gets them almost every morning. Resident #94 pointed to the wall next to the bathroom door and said to look at the menu sheet. Upon review of weekly menu sheet, the word eggs was penned out and with large bold letters all over the sheet, indicating NO EGGS. Photographic evidence was taken. Resident #94 stated he has spoken to his care aides as well when they drop off the tray. He continued to state staff drop off the tray so fast and leave before he can lift the lid off and see if he had eggs or not. Resident #94 was asked about the meal tray in front of him and he lifted the lid. An egg omelet was observed on his plate. Resident #94 did not touch or eat anything due to the fact he does not like the sight of eggs. He stated he was hungry and would eat something if they brought him something else. However, it was 9:30 a.m. and staff were observed in the hallways picking up trays for residents who have already eaten. There was a meal slip/ticket on his meal tray and it had documentation printed light in color and not clear to read. Most of the ticket was unreadable. It appeared that the printer where this ticket was printed was either out of ink or almost out of ink. No preferences were able to be seen. On 4/5/2022 at 11:00 a.m. the Kitchen Manager Staff A confirmed he was aware Resident #94 did not like eggs and they have tried to accommodate the resident by not providing eggs. Staff A stated the tray ticket system only indicates food allergies and does not indicate food likes and dislikes. Staff A was asked how he and his dietary line staff would know and honor resident food preferences, and he indicated he does not have a good tracking system for preferences. On 4/7/2022 at 8:20 a.m. Resident #94 was observed in his room and seated in a wheelchair next to his bed. He was observed with the over the bed table placed in front of him and with his breakfast meal tray placed on the table. The lid was on and the resident appeared to be upset. He shook his head in a no manner and revealed, they did it again. He pointed to his breakfast tray and lifted the lid. The meal he was provided was a double portion of scrambled eggs, one round sausage patty, and one Danish. The tray also included one bowl of hot oatmeal, a glass of juice, and a carton of 2% milk with an empty glass. Photographic evidence was obtained. Resident #94 expressed he was not going to touch anything on his plate because he hates eggs and further expressed the staff were completely aware of his likes and dislikes, especially eggs. The meal ticket placed on the meal tray was reviewed and indicated: 4/7/22 Regular diet, apple juice, assorted Danish, hot coffee, creamer, low fat fruited yogurt. Photographic evidence was taken. Resident #94 placed the lid back on the plate and stated staff just placed it on his table and left before he could lift the lid and see what he got. He stated he was hungry and wanted to eat but would not eat what was provided on the plate. On 4/7/22 at 8:25 a.m. the floor nurse, Staff F stated she was not aware if Resident #94 liked or disliked eggs until she heard him call out he did not want eggs during the breakfast meal service on 4/5/2022. She stated she floats to different floor assignments and does not know the resident well. She did express she would follow up with the resident. On 4/7/2022 at 8:33 a.m. the Certified Nursing Assistant (CNA) Staff I, who had Resident #94 on her work assignment, stated she knew the resident and also knew he did not like eggs. Staff I, CNA stated she did not serve him his meal this a.m. and didn't know who did. She stated Resident #94 does receive eggs and when she sees this she will tell the kitchen and get another tray. She confirmed she has seen Resident #94 receive eggs often. A review of Resident #94's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the Advance Directives revealed Resident #94 was his own responsible party. A review of the current Minimum Data Set (MDS) quarterly assessment, dated 3/7/2022, revealed: In Section C-Cognition, a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #94 was able to speak on behalf of himself and his care and services. In Section G-Functional Abilities, Activities of Daily Living indicated Resident #94 was able to eat independently with set up only and was on a regular diet. A review of the Physician's Order sheet for the month 4/2022, revealed a diet order to include: Regular Diet, Regular texture, thin liquid consistency. A review of the Progress Notes revealed, dietary notes dated from 1/2022 through 4/7/2022, did not indicate any food likes/dislikes or food preference documented for Resident #94. A note dated 4/7/22 at 9:54 a.m. was added to the record and indicated, Resident food preference updated by Kitchen Staff/Management and tray cards have been updated. Will continue to monitor and follow up with needs as needed. A review of the Comprehensive Care Plan for Resident #94 revealed the following: Focus: Potential for nutrition decline: (last revised on 3/7/2022) with interventions, to include but not limited to, Registered Dietician to evaluate and make diet change recommendations. An interview with the Interim Certified Dietary Manager, Staff B, confirmed Resident #94 does not like eggs and they are going to update the tray slip to show his dislikes. She revealed she had spoken to some staff to include dietary and nursing, and the staff had confirmed Resident #94 does not like to receive eggs. She indicated she was just hired on as the manager of this facility and her first observation indicated the kitchen did not have a good ticket tracker and food preference identification system. On 4/7/2022 at 11:00 a.m. an interview with the Director of Nursing (DON), Staff A, and Staff B was conducted. They stated they did not have specific policies and procedures with relation to food preferences and or food likes/dislikes.

Based on interview and record reviews, the facility failed to ensure behavior monitoring was in place for one resident (#59) out of five residents sampled for unnecessary medications. Findings included: A review of the Admission Record for Resident #59 indicated the resident was admitted on [DATE] with a diagnoses, including but not limited to, anxiety, dementia in other disease classified elsewhere without behavioral disturbance, and major depressive disorder. A review of Physician Orders for Resident #59 showed the following: [MEDICATION(S)] tablet 7.5 milligram (mg) give 7.5 mg by mouth two times a day related to anxiety disorder, unspecified. Start date: 4/23/2021 [MEDICATION(S)] XR capsule extended release 24-hour 150 mg give one capsule by mouth one time a day related to major depressive disorder, recurrent, unspecified. Start date: 8/12/2021 [MEDICATION(S)] capsule 400 mg give 1 tablet by mouth three times a day for [CONDITION(S)]. Start date: 4/21/2021 [MEDICATION(S)] tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain management. Start date 4/7/2022 A review of the Comprehensive Care Plan for Resident #59 revealed the following: A focus area of Mood Disorder was in place and had interventions, including but not limited to, monitor my mood and behaviors for change and notify psychiatric doctor of any concerns. A focus area of Behavior was in place and had interventions, including but not limited to, observe/document for side effects and effectiveness of medications. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for April 2022 revealed no behavior monitoring was in place for Resident #59. An interview was conducted on 4/8/22 at 10:22 a.m. with Staff O, Licensed Practical Nurse (LPN). Staff O looked in Resident # 59's clinical record to check for behavior monitoring for [CONDITION(S)] medication use. Staff O stated behavior monitoring should be on the MAR and monitoring should be completed every shift by the nurse. Staff O was unable to find any behavior monitoring in Resident #59's clinical record. Staff O opened another resident's record to confirm the location of behavior monitoring and to demonstrate how it should be displayed in the record. Staff O confirmed Resident #59 should have behavior monitoring in place and the monitoring was not present in the record. An interview was conducted on 4/8/22 at 10:50 a.m. with the Director or Nursing (DON). The DON stated if a resident is prescribed [CONDITION(S)] medication the resident should have a proper diagnosis for the medication. The DON stated her and the Advanced Registered Nurse Practitioner (ARNP) review the orders and the resident when any resident is prescribed a [CONDITION(S)] medication. She stated a gradual dose reduction (GDR) is done if needed. The DON stated behavior monitoring and modifications should be completed every shift for residents on [CONDITION(S)] medications. The DON stated the order for monitoring should be entered into the MAR when the medication order is entered. She confirmed the behavior monitoring would be completed by the nurse and documented in the MAR. A review of the facility policy titled [CONDITION(S)] Medication Use, revised 5/2019 was conducted on 4/8/2022. The policy indicated: 3. The facility supports the goals of determining the underlying cause of behavior symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident.

Based on observations, interviews and record review the facility failed to ensure one resident (#62) out of thirty-three residents was properly assessed and monitored for self-administration of eye drop medications. Findings included: During a facility tour on 4/7/22 at 9:12 a.m. an observation was made of a bottle of artificial tears eye drops and a vial of eye drops [[MEDICATION(S)]] on Resident #62's bed side table. On 4/7/22 at 9:12 a.m. an interview was conducted with Resident #62. Resident #62 stated she takes the eye drops on her own. Resident #62 stated the nurses usually bring the medicine to her. Resident #62 said, I need them to lubricate my eyes. Resident #62 stated she did not know if she has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #62's Admission Record showed an admitted [DATE] with a diagnosis, to include but not limited to, [CONDITION(S)]. A Minimum Data Set (MDS) assessment for Resident #62, dated 2/15/22, showed in Section C-Cognitive Abilities, a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Section G-Functional Abilities showed Resident #62 required extensive assistance for activities of daily living (ADLs). A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for self-administration of medications. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Comprehensive Care Plan for Resident #62 dated 2/18/22 showed a focus area for ADL self-care deficit related to decline in overall function secondary to illness and hospitalization with an intervention to give Resident #62 medications as ordered. There was no focus area for self-administration of medications on the care plan for Resident #62. On 4/7/22 at 09:45 a.m. an interview was conducted with Staff S, Unit Manager. Staff S stated she was not aware of any residents who had self-administration orders for medications. Staff S stated a few residents have orders for eyedrops. Staff S stated if a resident was on self-administration orders, there would be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/8/22 at 9:52 a.m. a second observation was made of Resident #62's [MEDICATION(S)] eyedrops on her bedside table. The vial was noted unopened. Photographic evidence was obtained. In an immediate interview, Resident #62 stated she would administer the eye drops later. Resident #62 stated the nurse had removed the artificial eye drops from the room and left the [MEDICATION(S)] vial. On 4/8/22 at 9:55 a.m. an interview was conducted with Staff X, LPN. Staff X stated the expectation for medication administration is for the nurse to stay with the resident. When asked about eye drops, Staff X stated the expectation was the same, to provide supervision. Staff X stated the nurse should make sure administration is complete before walking away. On 4/8/22 at 10:02 a.m. an interview was conducted with Staff V, Licensed Practical Nurse (LPN). Staff V stated she was assigned to Resident #62 the two days eye drops were left at bedside. Staff V confirmed having left the Resident #62's eye drops on her nightstand. Staff V said, I should not have done that. I thought she had completed the administration. I thought she started to administer. I guess she must have put it down. Staff V stated Resident #62 does not have self-administration orders. Staff V said, she should be supervised. A follow -up interview was conducted with the Director of Nursing (DON) on 4/8/22 at 10:42 a.m. The DON stated residents should be supervised during medication administration by nursing. The DON said, the nurse should stay with the resident. The expectation is the same for oral pills or eye drop.

Based on observations, interviews and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for one resident (#70) out of thirty-three residents, and for one (second floor medication cart) of two medications carts observed. Findings included: During a facility tour 4/7/22 at 09:44 a.m. an observation was made of two tablets in a plastic med cup on resident's nightstand. Resident #70 was not in the room at the time. Her roommate stated Resident #70 had gone to the store to pick up some snacks. On 4/7/22 10:02 a.m. an interview was conducted with Staff R, LPN. Staff R stated she had administered Resident #70's medications earlier in the morning. Staff R stated the resident had taken her medications. Staff R walked into the room and observed two tablets in a plastic cup on Resident #70's nightstand. Staff R said, I am surprised. She usually takes her medications. It is my fault. I should have stayed and watched her swallow. Staff R stated she was assisting Resident #70's roommate and had assumed she took her medications. Staff R could not confirm what they were. On 4/7/22 at 10:40 a.m. an interview was conducted with Resident #70 and Staff R. Resident #70 stated she had just returned from the store. Resident #70 said, I got distracted. I didn't have enough water to swallow the pills. I spit them out. I forgot to take my meds. It was not the nurse's fault. It was me. I forgot. I will take them now. Resident #70 stated she usually takes her morning meds between 8 a.m. and 9 a.m. A review of Resident #70's Admission Record showed an admitted [DATE] with a primary diagnosis, including but not limited to, [CONDITION(S)] unspecified. A review of the MDS assessment for Resident #70, dated 2/15/22, showed a BIMS of 14, indicating intact cognition. A review of the Comprehensive Care Plan for Resident #70 revealed a focus area, dated 2/15/21, as ADL self-care deficit related to decline in overall function secondary to illness and hospitalization with an intervention to give Resident #70 medications as ordered. Another focus area in the care plan, initiated on 4/8/22, revealed Mood and Behavior: behaviors include pocketing medications and spitting out meds after administering from nurse with interventions to include nursing staff to monitor and check for pocketing of medications and validate no pills left in mouth with each med pass. An interview was conducted on 4/7/22 at 10:50 a.m. with Staff S, Unit Manager. Staff S confirmed medications should not be left unattended. Staff S stated the expectation is to stay with the resident until they swallow the medications. On 4/7/22 at 10:10 a.m. an observation was made of the medication cart on the second floor, the cart was unlocked and the keys were left on the cart. The nurse was not by her cart. Residents, staff, and families were observed walking by the medication cart. Photographic evidence was obtained. An interview was conducted on 4/7/22 at 10:16 a.m. with Staff V, LPN. Staff V stated the medication cart should be locked all the times. Staff V said, I know, I should have locked the cart and taken the keys with me. It's my fault, I'm sorry. Staff V stated the expectation is not to leave the medication cart unlocked. An interview was conducted on 4/7/22 at 10:50 a.m. with Staff S, Unit Manager. Staff S confirmed medications should not be left unattended. The medication cart should be locked any time the nurse is walking away. Staff S stated the nurse should have the keys on them. Staff S said, It is for the safety of everyone. On 4/8/22 at 9:55 a.m. an interview was conducted with Staff X, LPN. Staff X stated the expectation for medication administration is for the nurse to stay with the resident and make sure they swallow all their pills. When asked about eye drops, Staff X stated the expectation was the same, to provide supervision. Staff X stated the nurse should make sure administration is complete before walking away. A follow -up interview was conducted with the Director of Nursing (DON) on 4/8/22 at 10:42 a.m. The DON stated residents should be supervised during medication administration. The DON said, the nurse should stay with the resident. The expectation is the same for oral pills or eye drop. A review of a facility policy titled, Medication Storage, revised 3/21, indicated: Policy: for medications and biological's to be stored safely, securely, and properly, following manufacturer's recommendations for the supplier. The medication is accessible only to nursing personnel, pharmacy personnel, or staff members authorized to administer medications. (8.) compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (11.) Only persons authorized to prepare and administer medications shall have access to the medication room, including keys.

Based on staff interviews, clinical record review, and policy review, the facility failed to submit an immediate report of an alleged misappropriation of resident property within the required 24-hour timeframe for one (Resident #4) of four sampled residents. Findings included: On 09/08/2021 at 2:45 p.m., an interview was conducted with the Business Office Manager (BOM). She said, the only people with direct access to the resident's funds were herself, the Medicaid specialist (who was no longer employed at the facility), and the corporate office. The facility process for resident notification of funds, was achieved through quarterly statements. If a resident had a Power of Attorney or guardian, the statement was mailed to them. Some residents had asked the BOM to hold onto the statement because they wanted to protect their information, or they did not have enough drawer space in their room to keep it themselves. If there were any issues regarding resident funds, the grievance process was started. Grievances were given to the Social Worker. If a resident was missing money, by misplacing it, leaving it in their pockets and it ended up in laundry, the facility replaced it. The BOM was unaware of any issues in general regarding missing funds within the last 6 months. The BOM did report that there was a concern relating to staff access to resident funds. The BOM stated, There was an allegation made involving the DON [Director of Nursing]. The allegation was made by [Resident #4]. The resident has a problem remembering things. Resident#4 had told the BOM that she was concerned about her money. The BOM considered the incident to be a concern and had written it up as such. The DON was helping Resident #4 with her funds. Resident #4 had a home in foreclosure. The DON took her to appointments with lawyers. The DON went shopping for the resident. Resident #4's brother was her healthcare surrogate. The DON contacted him if there were any issues with the resident. The BOM said a grievance was filed related to the allegation, and she called the social services office to provide a copy of the grievance. On 09/08/21 at 3:15 p.m., an interview was conducted with the DON. She said Resident #4 came to her for, lots of things. The resident was her own person for financial matters. The DON said she was going to doctor's appointments with the resident because she was not the best historian. The DON reported that Resident #4 brought her paperwork from a lawyer relating to the resident's home that was in foreclosure last year. This was how she started taking her to attorney appointments. The resident was supposed to be getting around $90,000 from selling her house. The resident alleged that the DON stole $100,000.00. The DON called Resident #4's brother and he said not to worry about it as she had accused him of taking her money too. According to the DON, the resident was incapacitated. The DON stated, I did not report the allegation because I did not think I needed to because the resident is incapacitated. I did notify [Resident #4's] brother, and he said do not worry about it because she has accused him of stealing things in the past too. That is what happens when you try to help people. Review of Resident # 4's MDS (Minimum Data Set) assessment, dated 07/30/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Review of the grievance filed by the BOM on behalf of Resident #4, dated 08/17/21, revealed that Resident #4, alleged that the DON, Used a remainder of her money towards her moving expenses to her new home. Resident #4 also wanted to know why the DON was her Power of Attorney? A review of the Abuse Policy, created on 03/2016, last revised on 03/2021, revealed a section which outlined the protocol for abuse, neglect, misappropriation of resident funds and property. POLICY: The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. PROTOCOL: Abuse, Neglect and Misappropriation of Resident funds and Property education is completed upon hire and annually for all employees. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. Implementation of ongoing monitoring consists of the following: Screening, training, prevention, identification, protection, investigation, reporting INVESTIGATION: The shift supervisor/charge nurse is identified as responsible for immediate initiation of the reporting process. The Administrator and the Director of Nursing are responsible for investigation and reporting. Initiate the Incidents Entry report, Investigation, in the electronic health record. Collect factual data on the Incident Entry Report. Initiate the investigative process. Refer to the Investigation- How to Conduct Protocol. The investigation should be thorough with witness statements from staff, residents, visitors, and family members who be interview able and have information regarding the allegation. Document results of the investigation in the incident Follow Up in the electronic file. Conclusion must include whether the allegation was substantiated or not and what information supported the decision . REPORTING: Notify the shift supervisor/charge nurse/manager immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. Report the incident to the Administrator and Director of Nursing (DON). The Administrator and DON or designee will report to the Regional Clinical Manager and RDO. Notify the local law enforcement and appropriate State agency(s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to the Elder Justice Act and State-specific regulations. Notify legal guardian, spouse, or responsible family members/significant other of the alleged or suspected abuse, neglect, mistreatment and or misappropriation of property (ensure resident safety is priority). Notify the Physician. Report results of investigation to the proper authorities as required by State law. Florida.

Based on resident record review, policy review, staff interviews, and observations, the facility's Quality Assessment and Assurance Committee failed to identify errors and omissions in Administration's implementation of facility policies, which rose to the level of Immediate Jeopardy for 1. 4 (#3, #4, #7 and #109) of 7 residents including 2 (#7 and #109) who previously eloped or residents who were at risk for elopements and/or wore wander guards from eloping through an outdoor smoking area located on the back of the facility. Furthermore, the facility failed to assess and ensure that an unsecured fenced area that separated the residents from a large body of water located behind the facility was not accessible, creating the potential for serious harm or death due to the lack of any supervision and failing to ensure that residents could not leave the area unescorted. 2. The facility failed to provide a safe environment free of hazards for 10 (#109, #84, #7, #129, #112, #117, #77, #162, #34, and #29) of 18 residents who utilized the smoking patio unsupervised and were permitted to hold their own cigarettes and lighters in the facility and utilize the smoking patio 24 hours a day without supervision in violation of the facility smoking policy. The Quality Assessment and Assurance Committee demonstrated a lack of action and commitment to protect residents who had previously eloped from the facility and who were at risk for elopement. Residents who were identified as those who smoked did not receive supervision per facility policy including residents identified as having previous elopements. These system failures resulted in findings of Immediate Jeopardy which were removed on [DATE] at 4:25 p.m. and the scope and severity was reduced to an E. Findings included: 1. A: Review of the Elopement Policy, dated [DATE], found: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Reporting Practices: 1). Resident leaving the premises unauthorized. 2). Nursing Service duties upon return of resident who was observed leaving the facility: 1. If an employee observes a resident leaving the premises, he/she shall: a. Determine if the resident is out on an authorized leave or pass. If the resident is not on an authorized leave or pass he/she should attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary, and do not leave the resident alone; and c. Instruct another staff member to inform Charge Nurse or Director of Nursing that a resident has left the premises; d. Notify the attending Physician; e. Notify the Administrator/Risk Manager; f. Notify the resident ' s legal representative (sponsor) of the incident; g. Initiate an Incident Report; and h. Document the event in the resident ' s medical record. 2. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall: a. Examine the resident for injuries; b. Obtain order and place a wander guard on the resident; c. Notify the attending Physician; d. Notify the Administrator/ Risk Manager; e. Notify the resident ' s legal representative (sponsor) of the incident; f. Complete and file an Incident Report; and g. Document the event in the resident ' s medical record. Reporting Practices: 1). Discovery of missing resident from facility. 2). Nursing Service duties upon return of missing resident. 3). If the resident is not located: 1. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident is not out on an authorized leave or pass, staff will call/page code purple 5 times over head. Then he/she will initiate a search of the building and premises. c. If the resident is not located, notify the Administrator/ Risk Manager and the Director of Nursing, the resident ' s legal representative (sponsor), and volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); Staff will provide a description of the resident to the appropriate authorities; and d. Initiate an extensive search of the surrounding area. 2. When the resident returns to the facility, the Director of Nursing or Charge Nurse shall: a. Examine the resident for injuries; b. Obtain order and place a wander guard on the resident; c. Notify the attending Physician, and report finding and condition of the resident; d. Notify the Administrator/ Risk Manager; e. Notify the resident ' s legal representative (sponsor) of the incident; f. Notify search teams that the resident has been located; g. Complete and file an Incident Report; and h. Document the event in the resident ' s medical record. 3. If the resident is not found, Charge Nurse or Director of Nursing shall: a. Notify the attending Physician; b. Notify the resident ' s legal representative (sponsor); c. Notify Administrator/ Risk Manager; d. Complete and file an Incident Report; and e. Documents the event in the resident ' s medical record. A review of the Facility ' s Wander Guard Policy, dated [DATE], was reviewed and stated: Policy: Resident ' s with a wandering potential will be kept safe through the use of wander guard bracelet system. Purpose: To alert staff when a resident has wandered away from area. Procedure: Once wandering or elopement behavior is established through mobility, intent and impaired judgement factors the wander guard bracelet is applied to the resident or their ambulation device. · Nurse will obtain a Physicians order to place a wander guard bracelet and document in the medical record. · Social Service will be notified and picture and elopement sheet will be placed in the elopement book. · Placement is checked daily to assure that bracelet has not been removed or lost. · The wander guard is checked for functioning every shift and documented. · Wander guard system is checked nightly for functioning by 11p.m. to 7a.m. supervisor. · Care plan is developed for elopement/wander guard use. B: At 6:23 p.m. on [DATE], an interview was conducted with the Administrator. She stated that after Resident #109 ' s elopement in [DATE] that during their next Quality Assessment and Assurance meeting the event was discussed. The intervention put into place after the elopement was to lock the gate. She said that by locking the gates it made the area a safe enclosed area. When asked if she had assessed the entire area to ensure it was a safe enclosed area she responded, apparently not. She said that during that time they had walked up and down the fence, but did not get back to where the open fence was, stating, they did not go back into where the woods were. (the area was not found to be wooded but, had some brush and trees at the fence line). She stated that never had the situation arisen before to having had a resident elope by stepping over the low fence so she didn ' t know how she would handle it. She confirmed there were no cameras outside in the area. She was asked about the area where the sidewalk went around the side of the building and a resident would be out of sight. She said that none of her elopement residents had ever attempted to go over the fence stating, residents are not going to go over a 4-foot fence. When asked about staff supervising the smoking patio and back fenced area she stated that they had not had a smoking aid and that it had been that way forever. She said that the back door was always unlocked, even at night. The Administrator stated that staff would now be outside on the smoking patio with residents. She was asked if the door would be locked if no staff were going to be present. She stated that the door would not be locked and that staff would either be outside with the residents or in the dayroom near the door if no one was outside so that they could accompany them out. At 11:13 a.m. on [DATE], the DON was shown the unlocked back gate. She said that maybe housekeeping left it unlocked. Cigarette butts were observed on the ground in the area of the gate. At 11:19 a.m. on [DATE], the Administrator came outside and was shown the unlocked gate. The Housekeeping Director then came with the key and unlocked the chain from the fence and locked the gate. The Administrator stated that all staff had been in-serviced regarding locking gates. She said that no staff had been assigned to checking the gates. She stated that the expectation of the gates was that they are kept locked. Prior to this week she said that they had an audit after the last elopement, but she is unsure if there is a current one. She was asked what could be the possible outcome of the gate being left unlocked? She responded, someone could get out . On [DATE] at 4:15 p.m., 4 residents (#7, #34, #84, #112) were identified and observed to be sitting unsupervised outside smoking on the smoking patio located on the center back side of the facility. It was noted that directly behind the building was a sidewalk that spanned the length of the building and went around the side of the building on one side. Adjacent to the sidewalk was a large body of water separated by a fence. On [DATE] at 4:38 p.m., an alarm was heard sounding at the door leading outside to the smoking patio from the activity room. No staff were present on the patio. Resident #109 was observed exiting the door using a rolling walker where she then lit a cigarette. She was wearing a wander guard on her right ankle. The alarm silenced but no staff came outside onto the patio to check the status of the resident who triggered the alarm. When the alarm sounded Resident #84 stated that Resident #109 wore a wander guard, that she wanders, and recently the police brought her back to the facility. On [DATE] at 4:40 p.m., staff (H) came out onto the patio. He stated that he had only come out to get Resident #34 to take him in to dinner. He then took Resident #34 inside. The Administrator came out onto the patio relocated residents to another table with an ashtray and went back inside. At 4:48 p.m. Licensed Practical Nurse (AA) stated that Resident #109 went outside by herself and that she was a smoker. He said that he believed the area in the back of the facility was fenced in. At 4:51 p.m. Residents #117 and #129 who were smokers were now present outside on the smoking patio unsupervised and smoking. At 5:10 p.m. Resident #109 was again observed walking out the door to the patio. The fence separating the facility property on the back side of the building and the large body of water (pond) was observed at 5:00 p.m. on [DATE]. A sidewalk extended the length of the building. At one end of the building the side walk ended and there was a locked gate. At the other end of the building the sidewalk went around the building where, if a resident had gone, they would be out of sight of staff on the smoking patio. There was a locked gate at the end of the sidewalk. On the other side of the sidewalk was a large pond where a fence separated the grassed area and the water. The fence was observed to have an area where the fence did not meet the ground leaving a gap. At the far end of the building there was a gap between the chain link fence and another taller fence that were perpendicular to each other. This area of disconnect allowed a person to easily walk through the opening which led to the water ' s edge. The fence was observed to be very low in areas allowing an individual to easily step or fall over it. An interview was conducted with the Administrator and the Director of Nursing (DON) at 5:36 p.m. on [DATE]. The Administrator stated that Resident #109 wore a wander guard. She said that it was determined that the resident was an elopement risk. She said that because of the resident ' s psych she can become confused and that she was [MEDICAL CONDITION] and hallucinated. She said that during an incident on [DATE] at 9:30 p.m. the resident was found about a block away from the facility. The Administrator provided and reviewed the documentation that revealed that the resident left from the back enclosed fenced area. The documentation said that the resident stated that she was out on the smoking patio when a man started chasing her with a chain saw so she left the patio to get away from the man. The corrective action taken per the report included: Wander guard bracelet in place and resident placed on 15 minute checks. The Administrator stated she completed an investigation where it was determined that there was no lock on the gate at the time. Afterwards they put a lock on that gate also stating that then both ends of the facility ' s outdoor area were locked, making the area secure. The concerns identified with the gaps and the height of the fence were then presented to the Administrator and the DON. The Administrator stated that she was aware that there were gaps on the chain link fence. The DON stated that the gaps were very small at the bottom of the fence. She stated that she (Resident #109) would have to swim across the lake to get out, stating her cognition was not impaired, that is was her delusions. The Administrator stated they believed that the patio was a safe area and that the resident had enough cognition not to go into the lake. The DON stated that the wander guard was put on Resident #109 after her elopement in May. They were asked about the resident ' s care plan pertaining to elopements and the wander guard. The Administrator stated that she was care planned for the door leading outside of the facility, but not the door leading to the patio stating, why would we care plan that. The [DATE] physician order [REDACTED]. C: Resident #109 ' s medical record was reviewed. Per the resident ' s face sheet [DIAGNOSES REDACTED]. The resident ' s annual data collection assessment, dated [DATE], included the following areas: Musculoskeletal: No weakness or deficit noted. Mood and Behavior: Audio and visual Hallucinations. Wandering was not checked on the assessment. The Care Plan included: Focus: Resident has following behavior problem(s): Wandering, resists care, hears things, outbursts, other, believe husband is shooting guns, stolen inheritance from father . Date initiated: [DATE]. Interventions included but were not limited to: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect way from doors as needed. Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident is actively exit seeking. Diagnosis: [REDACTED]. The interventions included but were not limited to: Check for proper functioning of the audible alarm system daily and PRN (as needed) and Monitor resident for tailgating when visitors are in the building. Focus: Resident is a safe smoker and will smoke safely at designated area(s) at scheduled times. Interventions included: Monitor for changes in/development of signs and symptoms of breathing difficulty and report to nurse if noted: SOB (shortness of breath), Cough (productive or non-productive), fever, chills, difficulty breathing, bluish skin color, change in cognition, Monitor oral hygiene, Notify charge nurse if it is suspected resident has violated facility smoking policy, Observe clothing and skin for signs of cigarette burns, Remind resident not to share smoking materials with other Resident who may be unsafe, Remind that it is an infection control hazard to smoke butts from ashtray or ground, Resident oriented to smoking procedures and areas, Resident will demonstrate ability to physically hold the smoking device while smoking, Resident will demonstrate safe technique for putting out matches, lighter and disposing of ash, and Safe smoking screen completed on admission and as needed. Date initiated [DATE]. [DIAGNOSES REDACTED]. Focus: Use of [MEDICAL CONDITION] antipsychotic drug places resident at risk for drug related: [MEDICAL CONDITION], gait disturbance, cognitive impairment, behavioral impairment, activity of daily living decline, abnormal involuntary movements. [DIAGNOSES REDACTED]. Date initiated: [DATE]. Interventions included administer medication as prescribed by the physician. The Residents ' Minimum Data Set, dated dated [DATE], included: Section C: Brief Interview for Mental Status Summary Score to be 15. (15 being the highest attainable for cognition). Section E: Behavior: Hallucinations and Delusions were checked. Wandering: Has the resident wandered? A zero was entered as the code. (zero = Behavior not exhibited). The [DATE] Treatment Administration Record (TAR) for Resident #109 was reviewed and revealed: Check wander guard placement and function every shift (elopement). The TAR reflected an order date of [DATE]. The date indicated that the wander guard order was 2 days prior to her elopement on [DATE]. On [DATE] at 9:22 a.m., Resident #109 was observed outside on the smoking patio. The area of the fence section that was open to walking through now had fencing attached to it closing it off and the section of the fence with the gap at the bottom had a fencing patch in place. A gas grill with a propane tank was observed outside to one end of the back of the facility where there was a second patio. Cigarette butts were observed on the ground near the grill. Resident #109 was observed at 3:08 p.m. on [DATE] exiting the door that went out onto the smoking patio. No alarm sounded. The resident was wearing her wander guard. Certified Nursing Assistant (C.N.A.) (staff Y) who was present on the smoking patio confirmed that the alarm did not go off. She said that maybe it was the battery. An interview was then conducted with Resident #109 on [DATE] at 3:10 p.m. The resident stated that sometimes she goes outside to smoke at night. She said that sometimes staff come out, sometimes other residents are present, and sometimes she is alone. She was asked why she wore a wander guard and she responded, because she has mental problems. She said that if she gets up early in the morning she hears and sees things. She stated that she can see people down by the water , different kinds of animals and children. She said that she just sat and watched. At 3:22 p.m. on [DATE], Unit Manager (P) was asked to test Resident #109 ' s wander guard. He took her to the door and the alarm sounded. C.N.A. (Y) told him that it did not work earlier when the resident came outside and that was why she had gone and told him. Resident #123 who was also outside at the time, added to the conversation that sometimes it works and sometimes it doesn ' t (referring to Resident #109 ' s wander guard). At 4:19 p.m. on [DATE], an interview was conducted with the DON. She stated that the supervisors have a box that checks the function of the wander guards. She said the box is run past the wander guard and if it sounds it works and is performed every shift. The staff then document it in the treatment book. On [DATE] at 11:07 a.m., the back gate located at the end of the sidewalk around the corner of the building was discovered unlocked. No staff were present near the unlocked gate. Residents were observed on the smoking patio. A Certified Nursing Assistant (Y) was present, but she was reading a magazine with her back to the sidewalk which led in each direction. At 12:02 p.m. on [DATE], the Administrator provided a locked gate audit. The form was blank with no entries. On [DATE] at 4:24 p.m., Resident #109 was observed coming in from the outdoor patio. The alarm sounded and a visitor was observed to get up from his chair and turn the alarm off. The alarm box was attached to the doorway on the inside of the exit door in the activity room. It was observed to be turned off by inserting a thin object into a hole in the bottom of the box. At 4:32 p.m. an interview was conducted with the visitor. He stated that he was a relative of Resident #32. He said he noticed how to turn off the alarm so as people go in and out and the alarm goes off and no one comes because they are busy he will shut it off. On [DATE] at 9:36 a.m., an interview was conducted with the Social Worker. She stated that Resident #109 was alert and oriented according to the Minimum Data Set questions, but has mental illness. The Social Worker stated that the resident knows she has mental illness. She said that the resident wears a wander guard because when she gets into one of her episodes she will take off running. She said that the resident will run from one end of the facility to the other trying to get out of the door. She stated, whatever it is when it chemically hits her she takes off. At 11:42 a.m. on [DATE], an interview was conducted with Resident #79 who attended resident council meetings. She stated that when a resident with a wander guard went out the back door that she would turn the alarm off. She said that the residents know how to do it and that staff do not always respond to the alarm. The alarm box for the exit door in the activity room that leads to the smoking patio can be turned off by inserting an object such as a pencil into the bottom hole of the box. On [DATE] at 10:57 a.m., an interview was conducted with Unit Manager (S). She stated she kept a log with the dates of expiration for the wander guards. All resident wander guards were checked for function. At 11:07 a.m. Unit Manager (P) stated he used the last wander guard on the previous day and had informed the Administrator so that more could be ordered. At the time of the interview there were no additional wander guards available in the facility. Unit Manager (P) stated he did not keep a log on his unit of when they expired. At 9:14 p.m. during an interview with the Administrator she stated that she ordered more of the wander guards since they had run out. She stated that if someone needed one then they would be placed on one to one until the new ones came in which she said should be on Monday. D: On [DATE] at 12:23 p.m., measurements were taken of the fence and openings in the fenced area behind the building. The Maintenance Director measured the areas using his tape measure while photographs were taken and measurements were documented by the Surveyor. The end of the building where the sidewalk went around the corner he identified as the east side of the building. He stated that he installed a gate on that side about 8 months prior. The fence next to the gate was measured at 42 inches in height. Near that area a gas grill with a propane tank was observed sitting. He said that the tank was disconnected. Near the gas grill the height of the fence separating the area behind the building and the pond was measured at 25 inches in height. The repaired fence previously identified as having a gap between the fence and the ground was measured. Chain link fencing was secured to the previously open area which measured 13 inches in height. Near the smoking patio the height of the fence was measured to be 28 inches in height. A portion of the fence was in disrepair near the smoking patio. The top pole was loose causing the fence to sag to a height of 25 inches. Near this area the sidewalk was higher than the ground next to it creating a 16 inch drop off with no railing. Facing the pond from the smoking area the portion of the sidewalk that extended to the left the Maintenance Director identified as the east/south wing. About half way down the sidewalk on the east/south side the fence was measured at 34 inches in height in one section and 29 inches in height in another section of the fence. He stated that the gate on this side of the building was already in place when he started his position a little over a year ago. At 12:56 p.m. the open area of the fence area identified on [DATE] now had fencing securing the opening. The opening had been measured by the Maintenance Director as 36 inches in width and 32 inches in height. There was an 88-inch area of ground on the other side of the fence opening to the water ' s edge. On [DATE] at 2:21 p.m., an interview was conducted with the Maintenance Director. He provided purchase invoices for fencing and gate materials dated [DATE], [DATE], and [DATE]. He stated that the receipts were related to installing the gate and fence on the east side of the building. At the time of Resident #7 ' s elopement on [DATE] there was not a fence nor gate on the east side of the building securing the area. This was the area where Resident #109 also per Administrator interview exited the property through the unlocked gate that was installed after Resident #7 ' s elopement. Environmental Rounding Sheets dated [DATE] through [DATE] were provided where audits were conducted and included: Hazards around the lake/fence: Safe for all entries. (22 dates reviewed). E: A list of elopements for 2016 was provided and included Resident #7 on [DATE] and Resident #109 on [DATE]. Both were also smokers who used the unsupervised smoking patio. A list of residents who were an elopement risk was provided and included: Residents #3, #4, #7, #22, #31, #35, #109. At 6:30 p.m. on [DATE], the Administrator and DON were taken outside to the area of concern and shown the fence. The area of the fence where there was a large gap where one could walk through was shown to them. The Administrator walked through the opening in the fence. She stated that a tree was in the way and would prevent them from going through there. It was noted that the tree was to the side and did not block access and was passable as shown by the Administrator. At 12:29 p.m. on [DATE], an interview was conducted with the Administrator, and revealed Resident #7 eloped on [DATE] through an unlocked gate. At that time there was only one gate located at the end of the side walk to the right of the back of the building facing the pond (east/south side). The Administrator stated that the fence and gate at the other end (east side) of the sidewalk did not exist at that time. The Administrator was asked how did she ensure that the area was safe and secure so that Resident #7 would not have eloped since he was at risk. The resident had a [DIAGNOSES REDACTED]. She responded, there was nothing. She continued to say, I can ' t tell you why I decided that at the time. She said that the fence and 2nd gate were put up after Resident #109 eloped on [DATE] and then that gate had a lock. She said that prior to this day there was no formal audit for the gates. The Administrator provided a report dated [DATE] that she reviewed with the surveyor stating that it was noticed that the back gate was open after the resident was missing. Resident #7 ' s [DIAGNOSES REDACTED]. Per the [DATE] Physician order [REDACTED]. The resident did not wear a wander guard. The wander guard was not present on the POS. Physician orders: [DATE]: Discontinue wander guard to ankle. Diagnosis: [REDACTED]. [DATE]: Every 15 minute checks due to wandering. [DATE]: Discontinue 1:1 supervision. Floor mats at bedside. [DATE]: 1:1 Supervision until patient discharges to locked facility. [DATE]: Every 15 minute checks. Diagnosis: [REDACTED]. Documentation of performing the 15 minute checks was requested and reviewed from [DATE] through [DATE]. Every page reviewed had missing areas where the staff were not documenting that they were performing the 15 minute checks. The resident was a smoker and was observed on [DATE] at 4:15 p.m. unsupervised on the smoking patio. Resident #7 ' s Care Plan was reviewed and included: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident has a history of elopement. Date initiated: [DATE]. Reviewed on [DATE] and [DATE]. Interventions included: Safety alarm on chair. Wander guard. [DATE] Wander guard to wheel chair. Focus: Resident has following behavior problem(s): Physically abusive, socially inappropriate, wandering, resists care, outbursts, verbally abusive/aggressive. Date initiated: [DATE]. Interventions included: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect away from doors as needed. Wander guard Discontinued. Nursing Progress Notes: [DATE] 2:10 p.m.: Patient found near stairway sitting on stairway floor. [DATE] 5:30 p.m.: At approximately 11:45 a.m. patient noted by staff member to be outside in parking lot area in wheel chair. Staff attempted to bring patient back inside. Patient became agitated. Will continue to monitor [DATE] included: 18:00, While making rounds staff were not able to locate this resident. Room search and grounds around facility searched. Resident found off campus. Resident located at corner store (name of intersection). Extremely agitated and combative . 23:00, Bed resting quietly with eyes closed at this time. Resident was placed on 1:1 supervision after his return to facility. F: A review of the Treatment Administration Records (TAR) for all resident ' s identified by the facility as wearing a wander guard (#3, #4, 22, #31, #35, and #109) was conducted. All wander guards were present on the TARs except for Resident #4. At 5:49 p.m. [DATE], an interview was conducted with Licensed Practical Nurse (V) who was assigned to Resident #4 on this day. She stated that the resident did not wear a wander guard. She said that for residents who wore a wander guard she took them near a door and checked for function. She was not aware of any device that could be brought to the resident to check for function. She was asked how often wander guards were checked for placement and function. She stated they are checked every shift. The TAR was reviewed with the nurse. The nurse confirmed the wander guard was not listed on the TAR. At 5:59 p.m. on [DATE], Resident #4 was observed in the dining room wearing a wander guard on his left ankle. Nurse (V) confirmed that the resident was wearing the wander guard. Nurse (V) stated that the TAR for Resident #4 consisted of only one page and that the wander guard was not present on it. She provided a copy of it. At 6:17 p.m. on [DATE], Licensed Practical Nurse (CC) returned Resident#4 ' s medical record to the nursing station. The medical record contained a new physician order [REDACTED]. Check wander guard placement every shift and function every day. The order was signed by Unit Manager (S). Nurse (V) was then asked if the order was a clarification order since no other orders for the wander guard were located in the chart. The DON stated at 6:2

Based on observation, interview, record review, and review of the administrator ' s job description, it was determined the facility administration demonstrated a lack of action and commitment to use its resource management to ensure that a level of supervision was provided to meet the needs of residents and provide a safe and secure environment for four (#3, #4, #7 and #109) out of 7 residents who either had a history of [REDACTED].#7, #109) or were a current elopement risk. The facility administration failed to ensure that a safe, secure smoking area was provided for 2 (#7 and #109) of the 7 residents who went outside to smoke in an unsupervised area; and that they documented that they performed safety checks for 1 (#7) of 1 resident. The facility administration failed to ensure that an unsecured fenced area, located behind the facility, was not accessible to residents without providing either supervision or ensuring that the residents could not leave the area unescorted. The facility administration failed to provide a safe environment free of potential dangerous hazards for ten (#109, #84, #7, #129, #112, #117, #77, #162, #34, and #29) of 18 residents who utilized the smoking patio and were permitted to hold their own cigarettes, lighters in the facility and smoke unsupervised in violation of the facility smoking policy. Further, the facility administration did not ensure side rails were maintained in a manner to prevent accidents for residents that were high risk for injury from climbing over full rails, for 3 (# 22, #53, #110) of 11 residents reviewed for side rails. These system failures resulted in findings of Immediate Jeopardy which was identified [DATE] and removed on [DATE] at 4:25 p.m. and severity was reduced to E . Findings included: 1. On [DATE] the Administrator provided the Nursing Home Administrator position description and Director of Nursing position description for review. The position description was signed and dated by the Administrator on [DATE] and revealed the following relevant information: Administrator Job Description: Job Summary: Contributes to the physical, medical, emotional and spiritual well- being of the residents by coordination, supervision and directing of all facility personnel; must maintain the dignity, respect and privacy, at all times for the resident and staff, work with all facility departments to provide overall care and comfort for each resident. Job Duties: Managing of the ongoing functions of the Nursing Center as required to fulfill all regulations of local, county, state and federal agencies. 8. Ensure the implementation of established resident care policies, personnel policies, Preparation of budget, etc. 10. Evaluates and as deemed appropriate implements those recommendations from the Nursing Center ' s QA (quality assurance) committee. 11. Ensures the Nursing Center admits only those residents, for whom it can provide Adequate care. Responsible for: Treating all resident, employees, visitors with respect and dignity. Knowing and protecting all resident rights. Organizing and directing the operation of the facility; defining lines of authority and delegation of duties. Serving as a member of the facility ' s admission and discharge committee. Maintains supplies and equipment necessary for the efficient operation of the nursing center. Enforcement of the facility ' s policies and procedures related to personnel and safety matter. Presenting a favorable image to the residents, visitors and general public. A review of the Wander Guard Policy, dated [DATE], found: Policy: Resident ' s with a wandering potential will be kept safe through the use of wander guard bracelet system. Purpose: To alert staff when a resident has wandered away from area. Procedure: Once wandering or elopement behavior is established through mobility, intent and impaired judgement factors the wander guard bracelet is applied to the resident or their ambulation device. Nurse will obtain a Physicians order to place a wander guard bracelet and document in the medical record. Social Service will be notified and picture and elopement sheet will be placed in the elopement book. Placement is checked daily to assure that bracelet has not been removed or lost. The wander guard is checked for functioning every shift and documented. Wander guard system is checked nightly for functioning by 11p.m. to 7a.m. supervisor. Care plan is developed for elopement/wander guard use. A review of the Elopement Policy, dated [DATE], found: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Reporting Practices: 1). Resident leaving the premises unauthorized. 2). Nursing Service duties upon return of resident who was observed leaving the facility: If an employee observes a resident leaving the premises, he/she shall: Determine if the resident is out on an authorized leave or pass. If the resident is not on an authorized leave or pass he/she should attempt to prevent the departure in a courteous manner; Get help from other staff members in the immediate vicinity, if necessary, and do not leave the resident alone; and Instruct another staff member to inform Charge Nurse or Director of Nursing that a resident has left the premises; Notify the attending Physician; Notify the Administrator/Risk Manager; Notify the resident ' s legal representative (sponsor) of the incident; Initiate an Incident Report; and Document the event in the resident ' s medical record. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall: Examine the resident for injuries; Obtain order and place a wander guard on the resident; Notify the attending Physician; Notify the Administrator/ Risk Manager; Notify the resident ' s legal representative (sponsor) of the incident; Complete and file an Incident Report; and Document the event in the resident ' s medical record. Reporting Practices: 1). Discovery of missing resident from facility. 2). Nursing Service duties upon return of missing resident. 3). If the resident is not located: If an employee discovers that a resident is missing from the facility, he/she shall: Determine if the resident is out on an authorized leave or pass; If the resident is not out on an authorized leave or pass, staff will call/page code purple 5 times over head. Then he/she will initiate a search of the building and premises. If the resident is not located, notify the Administrator/ Risk Manager and the Director of Nursing, the resident ' s legal representative (sponsor), and volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); Staff will provide a description of the resident to the appropriate authorities; and Initiate an extensive search of the surrounding area. When the resident returns to the facility, the Director of Nursing or Charge Nurse shall: Examine the resident for injuries; Obtain order and place a wander guard on the resident; Notify the attending Physician, and report finding and condition of the resident; Notify the Administrator/ Risk Manager; Notify the resident ' s legal representative (sponsor) of the incident; Notify search teams that the resident has been located; Complete and file an Incident Report; and Document the event in the resident ' s medical record. If the resident is not found, Charge Nurse or Director of Nursing shall: Notify the attending Physician; Notify the resident ' s legal representative (sponsor); Notify Administrator/ Risk Manager; Complete and file an Incident Report; and Documents the event in the resident ' s medical record. A review of the facility Smoking Policy dated [DATE] found: Purpose: To ensure residents shall be safe when smoking and maintain a non-smoking environment within the facility. Policy: 1. No smoking signs shall be posted wherever smoking is prohibited 2. Residents shall be observed for safe smoking practices upon admission, annually and as needed 3. Safe smoking equipment, such as smoking aprons, shall be available for those residents requiring it 4. Residents may smoke in designated areas outside the facility with supervision 5. All smoking materials, including lighters and cigarettes, shall be kept by staff at all time. Residents shall not keep smoking materials on their person or in their room 6. A safe smoking care plan shall be developed for residents who smoke 7. Staff shall be available to assist residents with smoking or smoking materials throughout the day 8. The facility may impose smoking restrictions when it is determined that a resident cannot smoke safely with the available level of supervision or assistance 9. The facility shall maintain a strict no smoking policy in the facility 2. On [DATE] at approximately 5:00 p.m. the fence separating the facility property on the back side of the building and the large body of water (pond) was observed. A sidewalk extended the length of the building. At one end of the building the side walk ended and there was a locked gate. At the other end of the building the sidewalk went around the building where if a resident had gone they would be out of sight of staff on the smoking patio. There was a locked gate at the end of the sidewalk. On the other side of the sidewalk was a large pond where a fence separated the grassed area and the water. The fence was observed to have an area where the fence did not meet the ground leaving a gap. At the far end of the building there was a gap between the chain link fence and another taller fence that were perpendicular to each other. This area of disconnect allowed a person to easily walk through the opening which lead to the water ' s edge. The fence was observed to be very low in areas allowing an individual to easily step or fall over it. On [DATE] at 4:15 p.m., 4 Residents (#7, #34, #84, #112) were identified and observed to be sitting unsupervised outside smoking on the smoking patio, located on the center back side of the facility. It was noted that directly behind the building was a sidewalk that spanned the length of the building and went around the side of the building on one side. Adjacent to the sidewalk was a large body of water separated by a fence. At 4:38 p.m. on [DATE], an alarm was heard sounding at the door leading outside to the smoking patio from the activity room. No staff were present on the patio. Resident #109 was observed exiting the door using a rolling walker where she then lit a cigarette. She was wearing a wander guard on her right ankle. The alarm silenced but no staff came outside onto the patio to check the status of the resident who triggered the alarm. When the alarm sounded Resident #84 stated that Resident #109 wore a wander guard, that she wanders, and recently the police brought her back to the facility. On [DATE] at 12:23 p.m., measurements were taken of the fence and openings in the fenced area behind the building. The Maintenance Director measured the areas using his tape measure while photographs were taken and measurements were documented by the Surveyor. The end of the building where the sidewalk went around the corner he identified as the east side of the building. He stated that he installed a gate on that side about 8 months prior. The fence next to the gate was measured at 42 inches in height. Near that area a gas grill with a propane tank was observed sitting. He said that the tank was disconnected. Near the gas grill the height of the fence separating the area behind the building and the pond was measured at 25 inches in height. The repaired fence previously identified as having a gap between the fence and the ground was measured. Chain link fencing was secured to the previously open area which measured 13 inches in height. Near the smoking patio the height of the fence was measured to be 28 inches in height. A portion of the fence was in disrepair near the smoking patio. The top pole was loose causing the fence to sag to a height of 25 inches. Near this area the sidewalk was higher than the ground next to it creating a 16 inch drop off with no railing. Facing the pond from the smoking area the portion of the sidewalk that extended to the right the Maintenance Director identified as the east/south wing. About half way down the sidewalk on the east/south side the fence was measured at 34 inches in height in one section and 29 inches in height in another section of the fence. He stated that the gate on this side of the building was already in place when he started his position a little over a year ago. At 12:56 p.m., on [DATE], the open area of the fence, identified on [DATE], now had fencing securing the opening. The opening had been measured by the Maintenance Director as 36 inches in width and 32 inches in height. There was an 88-inch area of ground on the other side of the fence opening to the water ' s edge. The concerns with the fencing separating the facility property and the body of water created the potential for serious harm or death due to allowing residents who had [DIAGNOSES REDACTED]. Additionally, the unsecured area allowed residents who were identified by the facility as an elopement risk to leave the property. These residents who were at risk were left unsupervised in the outdoor area with access 24 hours a day through the unlocked door. A list of elopements for 2016 was provided and included Resident #7 on [DATE] and Resident #109 on [DATE]. Both were also smokers who used the unsupervised smoking patio. A list of residents who were an elopement risk was provided and included: Residents #3, #4, #7, #22, #31, #35, #109. At 4:40 p.m. on [DATE], staff (H) came out onto the patio. He stated that he had only come out to get Resident #34 to take him in to dinner. He then took Resident #34 inside. The Administrator came out onto the patio relocated residents to another table with an ashtray and went back inside. At 4:48 p.m. Licensed Practical Nurse (AA) stated that Resident #109 went outside by herself and that she was a smoker. He said that he believed the area in the back of the facility was fenced in. At 5:10 p.m. Resident #109 was again observed walking out the door to the patio. At 4:51 p.m. Residents #117 and #129 who were smokers were now present outside on the smoking patio unsupervised. An interview was conducted with the Administrator and the Director of Nursing (DON) at 5:36 p.m. on [DATE]. The Administrator stated that Resident #109 wore a wander guard. She said that it was determined that the resident was an elopement risk. She said that because of the resident ' s psych she can become confused and that she was [MEDICAL CONDITION] and hallucinated. She said that during an incident on [DATE] at 9:30 p.m. the resident was found about a block away from the facility. The Administrator provided and reviewed the documentation that revealed that the resident left from the back enclosed fenced area. The documentation said that the resident stated that she was out on the smoking patio when a man started chasing her with a chain saw so she left the patio to get away from the man. The corrective action taken per the report included: Wander guard bracelet in place and resident placed on 15 minute checks. The Administrator stated she completed an investigation where it was determined that there was no lock on the gate at the time. Afterwards they put a lock on that gate also stating that then both ends of the facility ' s outdoor area were locked, making the area secure. The concerns identified with the gaps and the height of the fence were then presented to the Administrator and the DON. The Administrator stated that she was aware that there were gaps on the chain link fence. The DON stated that the gaps were very small at the bottom of the fence. She stated that she (Resident #109) would have to swim across the lake to get out, stating her cognition was not impaired, that is was her delusions. The Administrator stated they believed that the patio was a safe area and that the resident had enough cognition not to go into the lake. The DON stated that the wander guard was put on Resident #109 after her elopement in May. They were asked about the resident ' s care plan pertaining to elopements and the wander guard. The Administrator stated that she was care planned for the door leading outside of the facility, but not the door leading to the patio stating, why would we care plan that. The [DATE] physician order [REDACTED]. At 6:30 p.m. on [DATE], the Administrator and DON were taken outside to the area of concern and shown the fence. The area of the fence where there was a large gap where one could walk through was shown to them. The Administrator walked through the opening in the fence. She stated that a tree was in the way and would prevent them from going through there. It was noted that the tree was to the side and did not block access and was passable as shown by the Administrator. At 12:29 p.m. on [DATE], an interview was conducted with the Administrator. Resident #7 eloped on [DATE] through an unlocked gate. At that time there was only one gate located at the end of the side walk to the right of the back of the building facing the pond (east/south side). The Administrator stated that the fence and gate at the other end (east side) of the sidewalk did not exist at that time. The Administrator was asked how did she ensure that the area was safe and secure so that Resident #7 would not have eloped since he was at risk. The resident had a [DIAGNOSES REDACTED]. She responded, there was nothing . She continued to say, I can ' t tell you why I decided that at the time. She said that the fence and 2nd gate were put up after Resident #109 eloped on [DATE] and then that gate had a lock. She said that prior to this day there was no formal audit for the gates. The Administrator provided a report dated [DATE] that she reviewed with the surveyor stating that it was noticed that the back gate was open after the resident was missing. 3. On [DATE] at 9:22 a.m., Resident #109 was observed outside on the smoking patio. The area of the fence section that was open to walking through now had fencing attached to it closing it off and the section of the fence with the gap at the bottom had a fencing patch in place. A gas grill with a propane tank was observed outside to one end of the back of the facility where there was a second patio. Cigarette butts were observed on the ground near the grill. At 9:55 a.m. on [DATE], the Administrator stated, since you feel there is a safety concern someone will be out on the patio now until forever. Resident #109 was observed at 3:08 p.m. exiting the door that went out onto the smoking patio. No alarm sounded. The resident was wearing her wander guard. Certified Nursing Assistant (C.N.A.) (staff Y) who was present on the smoking patio confirmed that the alarm did not go off. She said that maybe it was the battery. An interview was then conducted with Resident #109 on [DATE] at 3:10 p.m. The resident stated that sometimes she goes outside to smoke at night. She said that sometimes staff come out, sometimes other residents are present, and sometimes she is alone. She was asked why she wore a wander guard and she responded, because she has mental problems . She said that if she gets up early in the morning she hears and sees things. She stated that she can see people down by the water , different kinds of animals and children. She said that she just sat and watched. At 3:22 p.m. on [DATE], Unit Manager (P) was asked to test Resident #109 ' s wander guard. He took her to the door and the alarm sounded. C.N.A. (Y) told him that it did not work earlier when the resident came outside and that was why she had gone and told him. Resident #123 who was outside added to the conversation that sometimes it works and sometimes it doesn ' t (referring to Resident #109 ' s wander guard). At 6:23 p.m. on [DATE], an interview was conducted with the Administrator. She stated that after Resident #109 ' s elopement in [DATE] that during their next Quality Assessment and Assurance meeting the event was discussed. The intervention put into place after the elopement was to lock the gate. She said that by locking the gates it made the area a safe enclosed area. When asked if she had assessed the entire area to ensure it was a safe enclosed area she responded, apparently not. She said that during that time they had walked up and down the fence, but did not get back to where the open fence was. Stating, they did not go back into where the woods were (the area was not found to be wooded but, had some brush and trees at the fence line). She said that never had the situation arisen before to having a resident elope by stepping over the low fence so she didn ' t know how she would handle it. She confirmed there were no cameras outside in the area. She was asked about the area where the sidewalk went around the side of the building and a resident would be out of sight. She said that none of her elopement residents had ever attempted to go over the fence stating, residents are not going to go over a 4-foot fence. When asked about staff supervising the smoking patio and back fenced area she stated that they had not had a smoking aide and that it had been that way forever. She said that the back door was always unlocked, even at night. The Administrator stated that staff would now be outside on the smoking patio with residents. She was asked if the door would be locked if no staff were going to be present. She stated that the door would not be locked and that staff would either be outside with the residents or in the dayroom near the door if no one was outside so that they could accompany them out. It was discovered on [DATE] at 6:59 a.m. that the facility did not ensure that supervision was maintained outside on the smoking patio as stated during the interview with the Administrator on [DATE]. Two residents (#109 and #84) were observed outside smoking on the patio. No staff were present outside and no staff were present in the day room located inside of the door. At 7:04 a.m. staff (Y) came out and sat down. At 4:19 p.m. on [DATE], an interview was conducted with the DON. She stated that the supervisors have a box that checks the function of the wander guards. She said the box is run past the wander guard and if it sounds it works and is performed every shift. The staff then document it in the treatment book. On [DATE] at 11:07 a.m., the back gate located at the end of the sidewalk around the corner of the building was discovered unlocked. No staff were present near the unlocked gate. Residents were observed on the smoking patio. A Certified Nursing Assistant (Y) was present, but she was reading a magazine with her back to the sidewalk which lead in each direction. At 11:13 a.m. on [DATE], the DON was shown the unlocked back gate. She said that maybe housekeeping left it unlocked. Cigarette butts were observed on the ground in the area of the gate. At 11:19 a.m. on [DATE], the Administrator came outside and was shown the unlocked gate. The Housekeeping Director then came with the key and unlocked the chain from the fence and locked the gate. The Administrator stated that all staff had been in-serviced regarding locking gates. She said that no staff had been assigned to checking the gates. She stated that the expectation of the gates was that they are kept locked. Prior to this week she said that they had an audit after the last elopement, but she is unsure if there is a current one. She was asked what could be the possible outcome of the gate being left unlocked? She responded, someone could get out . At 12:02 p.m. on [DATE], the Administrator provided a locked gate audit. The form was blank with no entries. On [DATE] at 4:24 p.m., Resident #109 was observed coming in from the outdoor patio. The alarm sounded and a visitor was observed to get up from his chair and turn the alarm off. The alarm box was attached to the doorway on the inside of the exit door in the activity room. It was observed to be turned off by inserting a thin object into a hole in the bottom of the box. At 4:32 p.m. an interview was conducted with the visitor. He stated that he was a relative of Resident #32. He said he noticed how to turn off the alarm so as people go in and out and the alarm goes off and no one comes because they are busy he will shut it off. On [DATE] at 9:36 a.m., an interview was conducted with the Social Worker. She stated that Resident #109 was alert and oriented according to the Minimum Data Set questions, but has mental illness. The Social Worker stated that the resident knows she has mental illness. She said that the resident wears a wander guard because when she gets into one of her episodes she will take off running. She said that the resident will run from one end of the facility to the other trying to get out of the door. She stated, whatever it is when it chemically hits her she takes off. At 11:42 a.m. on [DATE], an interview was conducted with Resident #79 who attended resident council meetings. She stated that when a resident with a wander guard went out the back door that they would turn the alarm off. They said that the residents know how to do it and that staff do not always respond to the alarm. The alarm box for the exit door in the activity room that leads to the smoking patio can be turned off by inserting an object such as a pencil into the bottom hole of the box. On [DATE] at 10:57 a.m., an interview was conducted with Unit Manager (S). She stated she kept a log with the dates of expiration for the wander guards. All resident wander guards were checked for function. At 11:07 a.m. Unit Manager (P) stated he used the last wander guard on the previous day and had informed the Administrator so that more could be ordered. At the time of the interview there were no additional wander guards available in the facility. Unit Manager (P) stated he did not keep a log on his unit of when they expired. At 9:14 p.m. on [DATE], during an interview with the Administrator she stated that she ordered more of the wander guards since they had run out. She stated that if someone needed one then they would be placed on one to one until the new ones came in which she said should be on Monday. Environmental Rounding Sheets dated [DATE] through [DATE] were provided where audits were conducted and included: Hazards around the lake/fence: Safe for all entries. (22 dates reviewed). On [DATE] at 2:21 p.m., an interview was conducted with the Maintenance Director. He provided purchase invoices for fencing and gate materials dated [DATE], [DATE], and [DATE]. He stated that the receipts were related to installing the gate and fence on the east side of the building. At the time of Resident #7 ' s elopement on [DATE] there was not a fence nor gate on the east side of the building securing the area. This was the area where Resident #109 also per Administrator interview exited the property through the unlocked gate that was installed after Resident #7 ' s elopement. Resident #109 ' s medical record was reviewed. Per the resident ' s face sheet [DIAGNOSES REDACTED]. The resident ' s annual data collection assessment dated [DATE] included the following areas: Musculoskeletal: No weakness or deficit noted. Mood and Behavior: Audio and visual Hallucinations. Wandering was not checked on the assessment. The Care Plan included: Focus: Resident has following behavior problem(s): Wandering, resists care, hears things, outbursts, other, believe husband is shooting guns, stolen inheritance from father . Date initiated: [DATE]. Interventions included but were not limited to: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect way from doors as needed. Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident is actively exit seeking. Diagnosis: [REDACTED]. The interventions included but were not limited to: Check for proper functioning of the audible alarm system daily and PRN (as needed) and Monitor resident for tailgating when visitors are in the building. Focus: Use of [MEDICAL CONDITION] antipsychotic drug places resident at risk for drug related: [MEDICAL CONDITION], gait disturbance, cognitive impairment, behavioral impairment, activity of daily living decline, abnormal involuntary movements. [DIAGNOSES REDACTED]. Date initiated: [DATE]. Interventions included administer medication as prescribed by the physician. The Residents Minimum (MDS) data set [DATE] included: Section C: Brief Interview for Mental Status Summary Score to be 15. (15 being the highest attainable for cognition). Section E: Behavior: Hallucinations and Delusions were checked. Wandering: Has the resident wandered? A zero was entered as the code. (zero = Behavior not exhibited). The [DATE] Treatment Administration Record (TAR) for Resident #109 was reviewed and revealed: Check wander guard placement and function every shift (elopement). The TAR reflected an order date of [DATE]. The date indicated that the wander guard order was 2 days prior to her elopement on [DATE]. Resident #7 ' s [DIAGNOSES REDACTED]. Per the [DATE] Physician order [REDACTED]. The resident did not wear a wander guard. The wander guard was not present on the POS. Physician orders: [DATE]: Discontinue wander guard to ankle. Diagnosis: [REDACTED]. [DATE]: Every 15 minute checks due to wandering. [DATE]: Discontinue 1:1 supervision. Floor mats at bedside. [DATE]: 1:1 Supervision until patient discharges to locked facility. [DATE]: Every 15 minute checks. Diagnosis: [REDACTED]. Documentation of performing the 15 minute checks was requested and reviewed from [DATE] through [DATE]. Every page reviewed had missing areas where the staff were not documenting that they were performing the 15 minute checks. The resident was a smoker and was observed on [DATE] at 4:15 p.m. unsupervised on the smoking patio. Resident #7 ' s Care Plan was reviewed and included: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident has a history of elopement. Date initiated: [DATE]. Reviewed on [DATE] and [DATE]. Interventions included: Safety alarm on chair. Wander guard. [DATE] Wander guard to wheel chair. Focus: Resident has following behavior problem(s): Physically abusive, socially inappropriate, wandering, resists care, outbursts, verbally abusive/aggressive. Date initiated: [DATE]. Interventions included: Address wandering behavior by walking with resident; redirec

Based on observation, interview, and record review the facility failed to 1. provide the level of supervision and monitoring needed to provide an environment to ensure the safety of residents for 4 (#3, #4, #7 and #109) out of 7 residents who had either a history of elopement or were a current elopement risk. The Facility did not ensure that it took effective measures to ensure that, an area fenced off for resident use, was maintained and securely closed to ensure the safety for 2 (#7 and #109) of 2 residents who were at risk of elopement and utilized the smoking patio without any supervision and that they documented safety checks for 1 (#7) of 1 residents. The facility failed to ensure that an unsecured fenced area located behind the facility, and overlooking a body of water, was not accessible to residents due to not providing either supervision or ensuring that residents could not leave the area unescorted. 2.The facility failed to provide a safe environment free of hazards for 10 (#84, #109, #7, #77, #129, #34, #112, #29, #162, #117) of 18 residents identified by the facility as smokers who utilized the smoking patio unsupervised and were permitted to carry their own cigarettes and lighters, in violation of the facility smoking policy. 3.The facility did not ensure side rails were used in a manner to prevent accidents for residents that were at risk for injury from climbing over full rails for 3 (# 22, #53, #110) of 11 residents reviewed for side rails. These system failures resulted in findings of Immediate Jeopardy which was identified on [DATE] and was removed on [DATE] at 4:25 p.m. The scope and severity was reduced to an E. Findings included: 1. On [DATE] at 4:15 p.m., 4 residents (#7, #34, #84, #112) were identified and observed to be sitting unsupervised outside smoking on the smoking patio located on the center back side of the facility. It was noted that, directly behind the building, was a sidewalk that spanned the length of the building and went around one side of the building. Adjacent to the sidewalk was a large body of water separated by a fence. At 4:38 p.m. on [DATE], an alarm was heard sounding at the door leading outside to the smoking patio from the activity room. No staff were present on the patio. Resident #109 was observed exiting the door using a rolling walker where she then lit a cigarette. She was wearing a wander guard on her right ankle. The alarm silenced, but no staff came outside onto the patio to check the status of the resident who had triggered the alarm. When the alarm sounded Resident #84 stated that Resident #109 wore a wander guard and, recently, the police had brought her back to the facility. At 4:40 p.m. on [DATE], Certified Nursing Assistant (C.N.A.) (H) came out onto the patio. He stated that he had only come out to get Resident #34 to take him in to dinner. He then took Resident #34 inside. The Administrator came out onto the patio and relocated residents to another table with an ashtray and then went back inside. At 4:48 p.m., Licensed Practical Nurse (AA) stated that Resident #109 went outside by herself and that she was a smoker. He said that he believed the area in the back of the facility was fenced in. At 5:10 p.m. Resident #109 was, again, observed walking out the door to the patio. At 4:51 p.m. Resident ' s #117 and #129, who were smokers, were now present outside on the smoking patio unsupervised. The fence, separating the facility property on the back side of the building and the large body of water (pond), was observed at 5:00 p.m. on [DATE]. A sidewalk extended the length of the building. At one end of the building the side walk ended and there was a locked gate (south/east side). At the other end of the building the sidewalk went around the building where, if a resident had gone, they would be out of sight of staff on the smoking patio (east side). There was a locked gate at the end of the sidewalk. On the other side of the sidewalk, was a large pond where a fence separated the grassed area and the water. The fence was observed to have an area where the fence did not meet the ground leaving a gap. At the far end of the building, there was a gap between the chain link fence and another taller fence that were perpendicular to each other (south/east side). This area of separation allowed a person to easily walk through the opening which lead to the water ' s edge. The fence was observed to be very low in areas allowing an individual to easily step or fall over it. An interview was conducted with the Administrator and the Director of Nursing (DON) at 5:36 p.m. on [DATE]. The Administrator stated that Resident #109 wore a wander guard. She said that it was determined that the resident was an elopement risk. She said that because of the resident ' s psych she can become confused and that she was Schizophrenic and hallucinated. She said that during an incident on [DATE] at 9:30 p.m. the resident was found about a block away from the facility. The Administrator provided and reviewed the documentation that revealed that the resident left from the back enclosed fenced area. The documentation said that the resident stated that she was out on the smoking patio when a man started chasing her with a chain saw so she left the patio to get away from the man. The corrective action taken per the report included: Wander guard bracelet in place and resident placed on 15 minute checks. The Administrator stated she completed an investigation where it was determined that there was no lock on the gate at the time. Afterwards they put a lock on that gate also stating that then both ends of the facility ' s outdoor area were locked, making the area secure. The concerns identified with the gaps and the height of the fence were then presented to the Administrator and the DON. The Administrator stated that she was aware that there were gaps on the chain link fence. The DON stated that the gaps were very small at the bottom of the fence. She stated that she (Resident #109) would have to swim across the lake to get out, stating her cognition was not impaired, that it was her delusions. The Administrator stated they believed that the patio was a safe area and that the resident had enough cognition not to go into the lake. The DON stated that the wander guard was put on Resident #109 after her elopement in May. The Administrator and the DON were asked about the resident ' s care plan pertaining to elopements and the wander guard. The Administrator stated that she was care planned for the front door leading outside of the facility to the parking lot, but not the door through the activity room leading to the smoking patio. She stated, why would we care plan that. The [DATE] physician order [REDACTED]. A list of elopements for 2016 was provided and included Resident #7 on [DATE] (wrong date provided on list) and Resident #109 on [DATE]. Both were also smokers who used the unsupervised smoking patio. A list of residents who were an elopement risk was provided and included: Residents #3, #4, #22, #31, #35, #109. Resident #7 was not included on the elopement risk list despite having a care plan for elopement and having a previous elopement. At 6:30 p.m. on [DATE], the Administrator and DON were taken outside to the area of concern and shown the fence. The area of the fence where there was a large gap where one could walk through was shown to them. The Administrator walked through the opening in the fence. She stated that a tree was in the way and would prevent them from going through there. It was noted that the tree was to the side and did not block access and was passable as shown by the Administrator. At 12:29 p.m. on [DATE], an interview was conducted with the Administrator. She stated that Resident #7 eloped on [DATE] through an unlocked gate. At that time there was only one gate located at the end of the side walk to the right of the back of the building facing the pond (south/east side). The Administrator stated that the fence and gate at the other end (east side) of the sidewalk did not exist at that time. The Administrator was asked how she ensured that the area was safe and secure so that Resident #7 would not have eloped since he was at risk. The resident had a [DIAGNOSES REDACTED]. She responded, there was nothing . She continued to say, I can ' t tell you why I decided that at the time. The Administrator provided a report, dated [DATE], that she reviewed with the surveyor stating that it was noticed that the back gate was open after Resident #7 was missing. She said that the fence and 2nd gate were put up after Resident #109 eloped on [DATE] and that gate had a lock. She said that prior to this day there had been no formal audit for the gates. Resident #7 ' s [DIAGNOSES REDACTED]. Per the [DATE] Physician order [REDACTED]. The resident did not wear a wander guard. The wander guard was not present on the POS. Physician orders: [DATE]: Discontinue wander guard to ankle. Diagnosis: [REDACTED]. [DATE]: Every 15 minute checks due to wandering. [DATE]: Discontinue 1:1 supervision. Floor mats at bedside. [DATE]: 1:1 Supervision until patient discharges to locked facility. [DATE]: Every 15 minute checks. Diagnosis: [REDACTED]. Documentation of performing the 15 minute checks was requested and reviewed for the dates from [DATE] through [DATE]. Every page reviewed had missing areas where the staff were not documenting that they were performing the 15 minute checks. Fifteen pages were reviewed. There were 957 blank incomplete spaces out of a possible 1,440 spaces to enter that the 15 minute check had been completed. The resident was a smoker and was observed on [DATE] at 4:15 p.m. unsupervised on the smoking patio. Resident #7 ' s Care Plan was reviewed and included: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident has a history of elopement. Date initiated: [DATE]. reviewed on [DATE] and [DATE]. Interventions included: Safety alarm on chair. Wander guard. [DATE] Wander guard to wheel chair. Focus: Resident has following behavior problem(s): Physically abusive, socially inappropriate, wandering, resists care, outbursts, verbally abusive/aggressive. Date initiated: [DATE]. Interventions included: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect away from doors as needed. Wander guard Discontinued. Nursing Progress Notes: [DATE] 2:10 p.m.: Patient found near stairway sitting on stairway floor. [DATE] 5:30 p.m.: At approximately 11:45 a.m. patient noted by staff member to be outside in parking lot area in wheel chair. Staff attempted to bring patient back inside. Patient became agitated. Will continue to monitor [DATE] included: 18:00, While making rounds staff were not able to locate this resident. Room search and grounds around facility searched. Resident found off campus. Resident located at corner store (name of intersection). Extremely agitated and combative . 23:00, Bed resting quietly with eyes closed at this time. Resident was placed on 1:1 supervision after his return to facility. Resident #109 ' s medical record was reviewed. Per the resident ' s face sheet [DIAGNOSES REDACTED]. The resident ' s annual data collection assessment dated [DATE] included the following areas: Musculoskeletal: No weakness or deficit noted. Mood and Behavior: Audio and visual Hallucinations. Wandering was not checked on the assessment. The Care Plan included: Focus: Resident has following behavior problem(s): Wandering, resists care, hears things, outbursts, other, believe husband is shooting guns, stolen inheritance from father. Date initiated: [DATE]. Interventions included but were not limited to: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect way from doors as needed. Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident is actively exit seeking. Diagnosis: [REDACTED]. The interventions included but were not limited to: Check for proper functioning of the audible alarm system daily and PRN (as needed) and Monitor resident for tailgating when visitors are in the building. Focus: Use of psychotropic antipsychotic drug places resident at risk for drug related: Hypotension, gait disturbance, cognitive impairment, behavioral impairment, activity of daily living decline, abnormal involuntary movements. [DIAGNOSES REDACTED]. Date initiated: [DATE]. Interventions included administer medication as prescribed by the physician. The residents ' Minimum Data Set, dated dated [DATE], included: Section C: Brief Interview for Mental Status Summary Score to be 15. (15 being the highest attainable for cognition). Section E: Behavior: Hallucinations and Delusions were checked. Wandering: Has the resident wandered? A zero was entered as the code. (zero = Behavior not exhibited). The [DATE] Treatment Administration Record (TAR) for Resident #109 was reviewed and revealed: Check wander guard placement and function every shift (elopement). The TAR reflected an order date of [DATE]. The date indicated that the wander guard order was 2 days prior to her elopement on [DATE]. On [DATE] at 9:22 a.m., Resident #109 was observed outside on the smoking patio. The area of the fence section that was open to walking through now had fencing attached to it closing it off and the section of the fence with the gap at the bottom had a fencing patch in place. A gas grill with a propane tank was observed outside to one end of the back of the facility where there was a second patio. Cigarette butts were observed on the ground near the grill. At 9:55 a.m. on [DATE], the Administrator stated, since you feel there is a safety concern someone will be out on the patio now until forever. Resident #109 was observed at 3:08 p.m. on [DATE] exiting the door that went out onto the smoking patio. No alarm sounded. The resident was wearing her wander guard. Staff Y, C.N.A., who was present on the smoking patio confirmed that the alarm did not go off. She said that maybe it was the battery. An interview was then conducted with Resident #109 on [DATE] at 3:10 p.m. The resident stated that, sometimes, she goes outside to smoke at night. She said that, sometimes, staff come out, sometimes other residents are present, and sometimes she was alone. She was asked why she wore a wander guard and she responded, because she has mental problems. She said that, if she gets up early in the morning, she hears and sees things. She stated that she can see people down by the water, different kinds of animals and children. She said that she just sat and watched. At 3:22 p.m. on [DATE], an interview was conducted with Unit Manager/LPN (P) who was asked to test Resident #109 ' s wander guard. He took her to the door and the alarm sounded. Staff Y, C.N.A., told him that it did not work earlier when the resident came outside and that was why she had gone and told him. Resident #123, who was outside, added to the conversation that sometimes it works and sometimes it doesn ' t (referring to Resident #109 ' s wander guard). At 6:23 p.m. on [DATE], an interview was conducted with the Administrator. She stated that after Resident #109 ' s elopement in [DATE] that during their next Quality Assessment and Assurance meeting the event was discussed. The intervention put into place after the elopement was to lock the gate. She said that by locking the gates it made the area a safe enclosed area. When asked if she had assessed the entire area to ensure it was a safe enclosed area she responded, apparently not. She said that during that time they had walked up and down the fence, but did not get back to where the open fence was. Stating, they did not go back into where the woods were. (the area was not found to be wooded, but had some brush and trees at the fence line). She said that never had the situation arisen before to having had a resident elope by stepping over the low fence so she didn ' t know how she would handle it. She confirmed there were no cameras outside in the area. She was asked about the area where the sidewalk went around the side of the building and that a resident would be out of sight. She said that none of her elopement residents had ever attempted to go over the fence stating, residents are not going to go over a 4-foot fence. When asked about staff supervising the smoking patio and back fenced area she stated that they had not had a smoking aid and that it had been that way forever. She said that the back door was always unlocked, even at night. The Administrator stated that staff would now be outside on the smoking patio with residents. She was asked if the door would be locked if no staff were going to be present. She stated that the door would not be locked and that staff would either be outside with the residents or in the dayroom near the door if no one was outside so that they could accompany them out. It was discovered on [DATE] at 6:59 a.m. that the facility did not ensure that supervision was maintained outside on the smoking patio as stated during the interview with the Administrator on [DATE]. Two Resident ' s (#109 and #84) were observed outside smoking on the patio. No staff were present outside and no staff were present in the day room located inside of the door. At 4:19 p.m. on [DATE], an interview was conducted with the DON. She stated that the supervisors have a box that checks the function of the wander guards. She said the box is run past the wander guard and if it sounds it works and is performed every shift. The staff then document it in the treatment book. On [DATE] at 11:07 a.m., the back gate located at the end of the sidewalk around the corner of the building was discovered unlocked. No staff were present near the unlocked gate. Residents were observed on the smoking patio. Staff Y, C.N.A., was present, but she was reading a magazine with her back to the sidewalk which lead in each direction. At 11:13 a.m. on [DATE], the DON was shown the unlocked back gate. She said that maybe housekeeping left it unlocked. Cigarette butts were observed on the ground in the area of the gate. At 11:19 a.m. on [DATE], the Administrator came outside and was shown the unlocked gate. The Housekeeping Director then came with the key and unlocked the chain from the fence and locked the gate. The Administrator stated that all staff had been in-serviced regarding locking gates. She said that no staff had been assigned to checking the gates. She stated that the expectation of the gates was that they are kept locked. Prior to this week she said that they had an audit after the last elopement, but she is unsure if there is a current one. She was asked what could be the possible outcome of the gate being left unlocked? She responded, someone could get out. At 11:23 a.m. on [DATE], the Housekeeping Director brought a key to lock the gate. Resident #109, who was an elopement risk, was present on the smoking patio at that time. At 12:02 p.m. on [DATE], the Administrator provided a locked gate audit. The form was blank with no entries. On [DATE] at 4:24 p.m., Resident #109 was observed coming in from the outdoor patio. The alarm sounded and a visitor was observed to get up from his chair and turn the alarm off. The alarm box was attached to the doorway on the inside of the exit door in the activity room. It was observed to be turned off by inserting a thin object into a hole in the bottom of the box. At 4:32 p.m. an interview was conducted with the visitor. He stated that he was a relative of Resident #32. He said he noticed how to turn off the alarm so as people go in and out and the alarm goes off and no one comes because they are busy he will shut it off. On [DATE] at 9:36 a.m., an interview was conducted with the Social Worker. She stated that Resident #109 was alert and oriented according to the Minimum Data Set questions, but has mental illness. The Social Worker stated that the resident knows she has mental illness. She said that the resident wears a wander guard because when she gets into one of her episodes she will take off running. She said that the resident will run from one end of the facility to the other trying to get out of the door. She stated, whatever it is, when it chemically hits her, she takes off. At 11:42 a.m. on [DATE], an interview was conducted with Resident #79 who attended resident council meetings. She stated that when a resident with a wander guard went out the back door that she or another resident would turn the alarm off. She said that the residents know how to do it and that staff do not always respond to the alarm. The alarm box for the exit door in the activity room that leads to the smoking patio can be turned off by inserting an object such as a pencil into the bottom hole of the box. A review of the Treatment Administration Records (TAR) for all resident ' s identified by the facility as wearing a wander guard (#3, #4, 22, #31, #35, and #109) was conducted. All wander guards were present on the TARs except for Resident #4. At 5:49 p.m. on [DATE], an interview was conducted with Licensed Practical Nurse (LPN) (V) who was assigned to Resident #4 on this day. She stated that the resident did not wear a wander guard. She said that for residents who wore a wander guard she took them near a door and checked for function. She was not aware of any device that could be brought to the resident to check for function. She was asked how often wander guards were checked for placement and function. She stated they are checked every shift. The TAR was reviewed with the nurse. The nurse confirmed the wander guard was not listed on the TAR. At 5:59 p.m. on [DATE], Resident #4 was observed in the dining room wearing a wander guard on his left ankle. Staff V, LPN, confirmed that the resident was wearing the wander guard. LPN (V) stated that the TAR for Resident #4 consisted of only one page and that the wander guard was not present on it. She provided a copy of it. At 6:17 p.m. on [DATE], LPN (CC) returned Resident #4 ' s medical record to the nursing station. The medical record contained a new physician order [REDACTED]. Check wander guard placement every shift and function every day. The order was signed by Unit Manager (S). LPN (V) was then asked if the order was a clarification order since no other orders for the wander guard were located in the chart. The DON stated at 6:20 p.m. that it was a clarification order and that the old order fell off of the physician order [REDACTED].#4 had the wander guard since 2015. The DON then called the Unit Manager and told her that she needed to write it correctly. Unit Manager/LPN (S) then rewrote the physician order [REDACTED]. Check wander guard placement every shift. Check wander guard function every day on ,[DATE] shift. The Unit Manager stated that apparently the order dropped off the POS and she didn ' t catch it. Resident #4 ' s Care Plan included: [DIAGNOSES REDACTED]. Personal history of healed traumatic fracture. Care Plan: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident is actively exit seeking. Date initiated: [DATE]. Interventions included: Check for proper functioning of the audible alarm system daily and PRN (as needed). Educate resident/responsible party regarding sign out procedures. Facilitate resident to call close family/friend for reassurance when exit-seeking behaviors occurring. Initiate facilities code purple protocol if resident ' s whereabouts are unknown. Monitor resident for tailgating when visitors are in the building. Reassure resident when distressed over placement. Refer to Social Services as needed. Seek referral for a mental health evaluation from a primary care physician as needed. Use audible monitoring system to alert staff of exit seeking behaviors. Use discrete resident identifier so staff is aware of the resident ' s elopement risk. Use diversional activities when exit-seeking behavior is occurring. (ie: offer food, activities, one on one company). Use verbal cues and gestures for redirection to persuade exit-seeking behaviors. Resident #3 was admitted in 2016 and had [DIAGNOSES REDACTED]. The resident ' s MDS (Minimum Data Set) assessment, dated [DATE], assessed the resident as having delusions, wandering ,[DATE] days in the past 7 days, having mild memory problems, having balance problems, using a wheelchair and being independent with Activities of Daily Living. A review of the nurse's note for [DATE] at 10:30 a.m., revealed that Resident #3 had left the facility through the front door and headed towards the bus stop to find his son. The resident was returned to the building and placed on every 15 minutes ' checks. A wander guard (device attached to a resident that sounds an alarm if the resident leaves thru an alarmed door) was ordered to be applied when available. The wander guard was documented as checked starting [DATE] on the Treatment Administration Record (TAR). Resident #3's brother was notified. The POS included orders on [DATE] to place the resident on every 15 minute checks and apply wander guard when available. On [DATE] there was an order to begin Haldol 0.25 mg twice a day for treatment of [REDACTED]. Per nurse documentation on the December TAR the resident has continued on 15 minute checks. On [DATE] at 6:38 p.m., Resident #3 was visually checked for the presence of a wander guard. The expiration date on the wander guard which was on the resident ' s right ankle was checked and was valid. The function was checked by the nurse and was working. A care plan for elopement risk was initiated on [DATE] with a focus that the resident displayed cognitive impairment, was independently mobile and was actively exit seeking. Interventions included: Educate resident/responsible party regarding sign out procedures. Facilitate resident to call close family/friend for reassurance when exit-seeking behaviors occurring. Initiate facilities CODE PURPLE protocol if resident ' s whereabouts are unknown. Monitor resident for tailgating when visitors are in the building. Provide direct staff supervision for resident when attending an out-of-facility activity Reassure resident when distressed over placement. Refer to Social Services as needed. Seek referral for a mental health evaluation from a primary care physician as needed. Use discrete resident identifier so staff is aware of the resident ' s elopement risk. Use diversional activities when exit-seeking behavior is occurring. (ie: offer food, activities, one on one company). Use verbal cues and gestures for redirection to persuade exit-seeking behaviors. On [DATE] at 10:57 a.m., an interview was conducted with Unit Manager/LPN (S). She stated she kept a log with the dates of expiration for the wander guards. All resident wander guards were checked for function. At 11:07 a.m. Unit Manager (P) stated he used the last wander guard on the previous day and had informed the Administrator so that more could be ordered. At the time of the interview there were no additional wander guards available in the facility. Unit Manager (P) stated he did not keep a log on his unit of when they expired. At 9:14 p.m. on [DATE], during an interview with the Administrator she stated that she ordered more of the wander guards since they had run out. She stated that if someone needed one then they would be placed on one to one until the new ones came in which she said should be on Monday. On [DATE] at 12:23 p.m., measurements were taken of the fence and openings in the fenced area behind the building. The Maintenance Director measured the areas using his tape measure while photographs were taken and measurements were documented by the Surveyor. The end of the building where the sidewalk went around the corner he identified as the east side of the building. He stated that he installed a gate on that side about 8 months prior. The fence next to the gate was measured at 42 inches in height. Near that area a gas grill with a propane tank was observed sitting. He said that the tank was disconnected. Near the gas grill the height of the fence separating the area behind the building and the pond was measured at 25 inches in height. The repaired fence previously identified as having a gap between the fence and the ground was measured. Chain link fencing was secured to the previously open area which measured 13 inches in height. Near the smoking patio the height of the fence was measured to be 28 inches in height. A portion of the fence was in disrepair near the smoking patio. The top pole was loose causing the fence to sag to a height of 25 inches. Near this area the sidewalk was higher than the ground next to it creating a 16 inch drop off with no railing. Facing the pond from the smoking area, the portion of the sidewalk that extended to the right, the Maintenance Director identified as the south/east wing. About half way down the sidewalk on the south/east side the fence was measured at 34 inches in height in one section and 29 inches in height in another section of the fence. He stated that the gate on this side of the building was already in place when he started his positon a little over a year ago. At 12:56 p.m. the open area of the fence area identified on [DATE] now had fencing securing the opening. The opening had been measured by the Maintenance Director as 36 inches in width and 32 inches in height. There was an 88-inch area of ground on the other side of the fence opening to the water ' s edge. On [DATE] at 2:21 p.m., an interview was conducted with the Maintenance Director. He provided purchase invoices for fencing and gate materials dated [DATE], [DATE], and [DATE]. He stated that the receipts were related to installing the gate and fence on the east side of the building. At the time of Resident #7 ' s elopement on [DATE] there was not a fence nor gate on the east side of the building securing the area. This was the area where Resident #109 also per Administrator interview exited the property through the unlocked gate that was installed after Resident #7 ' s elopement. Environmental Rounding Sheets, dated [DATE] through [DATE], were provided where audits were conducted and included: Hazards around the lake/fence: Safe for all entries. (22 dates reviewed). A review of the Elopement Policy, dated 0

Based on observation, interview, and record review, the facility failed to follow the plan of care for 3 (#4, #7 and #109) out of 7 residents who, either had a history of [REDACTED].#109), were a current elopement risk (#4, #7, #109), or were smokers who had access to an unsupervised and unsecured area, which overlooked a large body of water, through an unlocked door (#7, #109), and failed to follow the plan of care related to checking for proper functioning and placement of the wander guard (#4, #109). The facility failed to follow the plan of care related to smoking for 2 (#29 and #112) of 2 residents who required supervision during smoking per the resident smoking assessment and care plan out of 18 residents who smoked and who utilized the unsupervised smoking patio. This failure to follow elopement and smoking care plans resulted in findings of Immediate Jeopardy identified on 12/22/2016 and removed on 12/23/2017 at 4:25 p.m. Findings included: 1. a. A record review was completed for Resident #109. [DIAGNOSES REDACTED]. The Resident's Care Plan was reviewed and included: Focus: Resident has the following behavior problem(s): Wandering and hears things. Date initiated: 11/30/2016. Interventions included but were not limited to: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect away from doors as needed. Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evidenced by: Resident is actively exit seeking. Diagnosis: [REDACTED]. Goals: Resident will not leave facility unattended through the review date (02/26/2017), Resident ' s safety will be maintained through the review date (02/26/2017), and Visitors will verbalize understanding of the sign out procedure through review date (02/26/2017). Use diversional activities when exit-seeking behavior is occurring (i.e. offer food, activities, one on one company). Interventions included but were not limited to: Check for proper functioning of the audible alarm system daily and prn. (as needed). Monitor resident for tail gating when visitors are in the building. On 12/19/2016 at 4:15 p.m. Residents were observed to be sitting unsupervised outside smoking on the smoking patio, located on the center back side of the facility. It was noted that directly behind the building was a sidewalk that spanned the length of the building and went around one side of the building. Adjacent to the sidewalk was a large body of water separated by a fence. At 4:38 p.m. on 12/19/2016, an alarm was heard sounding at the door leading outside to the smoking patio from the activity room. No staff were present on the patio. Resident #109 was observed exiting the door using a rolling walker where she then lit a cigarette. She was wearing a wander guard on her right ankle. The alarm silenced, but no staff came outside onto the patio to check the status of the resident who had triggered the alarm. The fence separating the facility property on the back side of the building and the large body of water (pond) was observed at 5:00 p.m. on 12/19/2016. A sidewalk extended the length of the building. At one end of the building the side walk ended and there was a locked gate (south/east side). At the other end of the building the sidewalk went around the building where if a resident had gone they would be out of sight of staff on the smoking patio (east side). There was a locked gate at the end of the sidewalk. On the other side of the sidewalk was a large pond where a fence separated the grassed area and the water. The fence was observed to have an area where the fence did not meet the ground leaving a gap. At the far end of the building there was a gap between the chain link fence and another taller fence that were perpendicular to each other (south/east side). This area allowed a person to easily walk through the opening which lead to the water ' s edge. The fence was observed to be very low in areas allowing an individual to easily step or fall over it. An interview was conducted with the Nursing Home Administrator and the Director of Nursing (DON) at 5:36 p.m. on 12/19/2016. The Administrator stated that Resident #109 wore a wander guard. She said that it was determined that the resident was an elopement risk. She said that because of the resident ' s psych she can become confused and that she was [MEDICAL CONDITION] and hallucinated. She said that during an incident on 05/29/2016 at 9:30 p.m. the resident was found about a block away from the facility. The Administrator provided and reviewed the documentation that revealed that the resident left from the back enclosed fenced area. The documentation said that the resident stated that she was out on the smoking patio when a man started chasing her with a chain saw so she left the patio to get away from the man. The corrective action taken per the report included: Wander guard bracelet in place and resident placed on 15 minute checks. The Administrator stated she completed an investigation where it was determined that there was no lock on the gate at the time. Afterwards, they put a lock on that gate also stating that then both ends of the facility ' s outdoor area were locked, making the area secure. The concerns identified with the gaps and the height of the fence were then presented to the Administrator and the DON. The Administrator stated that she was aware that there were gaps on the chain link fence. The DON stated that the gaps were very small at the bottom of the fence. She stated that she (Resident #109) would have to swim across the lake to get out , stating her cognition was not impaired, that it was her delusions. The Administrator stated they believed that the patio was a safe area and that the resident had enough cognition not to go into the lake. The DON stated that the wander guard was put on Resident #109 after her elopement in May. The Administrator and the DON were asked about the resident ' s care plan pertaining to elopements and the wander guard. The Administrator stated that she was care planned for the front door leading outside of the facility to the parking lot, but not the door through the activity room leading to the smoking patio. She stated, why would we care plan that. A list of elopements for 2016 was provided by the Administrator and included Resident #109 who on 05/29/2016 eloped from the facility. The resident used the unsupervised smoking patio. At 6:30 p.m. on 12/19/2016 the Administrator and DON were taken outside to the area of concern and shown the fence. The area of the fence where there was a large gap where one could walk through was shown to them. The Administrator walked through the opening in the fence. She stated that a tree was in the way and would prevent them from going through there. It was noted that the tree was to the side and did not block access and was passable as shown by the Administrator. An interview was then conducted with Resident #109 on 12/20/2016 at 3:10 p.m. The resident stated that, sometimes, she goes outside to smoke at night. She said that, sometimes, staff come out, sometimes other residents are present, and, sometimes, she is alone. She was asked why she wore a wander guard and she responded, because she has mental problems. She said that if she gets up early in the morning she hears and sees things. She stated that she can see people down by the water, different kinds of animals and children. She said that she just sat and watched. At 4:48 p.m. on 12/19/2016 Licensed Practical Nurse (LPN) (AA) stated that Resident #109 went outside by herself and that she was a smoker. He said that he believed the area in the back of the facility was fenced in. Resident #109 was observed on 12/19/2016 at 5:10 p.m. coming out the activity room door to the smoking patio setting the wander guard alarm off again. The alarm was silenced, but no staff came outside to check on the resident. On 12/20/2016 at 12:27 p.m. the Administrator stated that staff would be outside on the patio with residents who were smoking. On 12/21/2016 at at 6:59 a.m. Resident #109 was observed smoking unsupervised on the smoking patio. This was directly opposite of what the Administrator said on the previous day. There were also no staff present in the activity day room to observe residents on the smoking patio. On 12/22/2016 at 11:07 a.m. the back gate located at the end of the sidewalk around the corner of the building was discovered unlocked. No staff were present near the unlocked gate. Residents were observed on the smoking patio. Certified Nursing Assistant (C.N.A.) (Y) was present, but she was reading a magazine with her back to the sidewalk which lead in each direction. At 11:13 a.m. on 12/22/2016, the DON was shown the unlocked back gate. She said that maybe housekeeping left it unlocked. Cigarette butts were observed on the ground in the area of the gate. At 11:19 a.m. on 12/22/2016, the Administrator came outside and was shown the unlocked gate. The Housekeeping Director then came with the key and unlocked the chain from the fence and locked the gate. The Administrator stated that all staff had been in-serviced regarding locking gates. She said that no staff had been assigned to checking the gates. She stated that the expectation of the gates was that they are kept locked. Prior to this week she said that they had an audit after the last elopement, but she was unsure if there was a current one. She was asked what could be the possible outcome of the gate being left unlocked? She responded, someone could get out. Resident #109 was observed on the smoking patio at this time. An interview was conducted on 12/22/2016 at 11:40 a.m., with the housekeeping director. The housekeeping director was asked if any of his staff smoked since there were cigarette butts observed by the unlocked gate that is only accessed by housekeeping. The housekeeping director responded after speaking to his employees that none of the housekeeping employees smoke. At 12:02 p.m. on 12/22/2016, the Administrator provided a locked gate audit. The form was blank with no entries. On 12/22/2016 at 4:24 p.m. Resident #109 was observed coming in from the outdoor patio. The alarm sounded and a visitor was observed to get up from his chair and turn the alarm off. The alarm box was attached to the doorway on the inside of the exit door in the activity room. It was observed to be turned off by inserting a thin object into a hole in the bottom of the box. At 4:32 p.m. an interview was conducted with the visitor. He stated that he was a relative of a current resident. He said he noticed how to turn off the alarm so as people go in and out and the alarm goes off and no one comes because they are busy he will shut it off. On 12/23/2016 at 9:36 a.m. an interview was conducted with the Social Worker. She stated that Resident #109 was alert and oriented according to the Minimum Data Set questions, but had mental illness. The Social Worker stated that the resident knows she has mental illness. She said that the resident wears a wander guard because when she gets into one of her episodes she will take off running. She said that the resident will run from one end of the facility to the other trying to get out of the door. She stated, whatever it is when it chemically hits her she takes off. At 11:42 a.m. on 12/23/2016 an interview was conducted with Resident #79 who attended resident council meetings. She stated that when a resident with a wander guard went out the back door that she or another resident would turn the alarm off. She said that the residents know how to do it and that staff do not always respond to the alarm. The alarm box for the exit door in the activity room that leads to the smoking patio can be turned off by inserting an object such as a pencil into the bottom hole of the box. b. A record review was completed for Resident #7 and included: Resident #7 ' s [DIAGNOSES REDACTED]. unspecified. Resident #7 ' s Care Plan was reviewed and included: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evidenced by: Resident has a history of elopement. Date initiated: 02/24/2016. Reviewed on 04/05/2016 and 07/22/2016. Interventions included but were not limited to: Check for proper function of the audible alarm system daily and prn (as needed). Monitor resident for tail gating when visitors are in the building. Provide direct staff supervision for resident when attending an out of facility activity. Routine monitoring every 15 minute with documentation. Use audible monitoring system to alert staff of exit seeking behaviors. Safety alarm on chair. Wander guard; 07/20/2016 wander guard to wheel chair. Focus: Resident has following behavior problem(s): Physically abusive, socially inappropriate, wandering, resists care, outbursts, verbally abusive/aggressive, and yells for help does not use call light. Date initiated: 02/24/2016. Last reviewed 10/18/2016. Interventions included but were not limited to: Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity. Redirect away from doors as needed. Wander guard discontinued. Per the December 2016 Physician order [REDACTED]. A wander guard was not present on the December 2016 POS. Physician orders [REDACTED].>Every 15 minute checks due to wandering, dated 07/20/2016. 1:1 Supervision until patient discharges to locked facility, dated 04/04/2016. Documentation of performing the 15 minute checks was requested and reviewed for the dates from 12/01/2016 through 12/23/2016. Every page reviewed had missing areas where the staff were not documenting that they were performing the 15 minute checks. Fifteen pages were reviewed. There were 957 blank incomplete spaces out of a possible 1,440 spaces to enter that the 15 minute checks had been completed. The resident was a smoker and was observed on 12/19/2016 at 4:15 pm unsupervised on the smoking patio. Nursing Progress Notes included: On 04/02/2016 at 2:10 p.m.: Patient found near stairway sitting on stairway floor. On 04/02/2016 at 5:30 p.m.: At approximately 11:45 a.m. patient noted by staff member to be outside in parking lot area in wheel chair. Staff attempted to bring patient back inside. Patient became agitated. Will continue to monitor On 04/04/2016 at (6:00 p.m).: While making rounds staff were not able to locate this resident. Room search and grounds around facility searched. Resident found off campus. Resident located at corner store (name of intersection). Extremely agitated and combative . (11:00 p.m.), Bed resting quietly with eyes closed at this time. Resident was placed on 1:1 supervision after his return to facility. On 12/19/2016 at 4:15 p.m. Resident #7 was observed to be sitting outside smoking on the unsecure, unsupervised smoking patio. No staff were present. A list of elopements for 2016 was provided by the Administrator and included Resident #7 where it listed the resident as having had an elopement on 04/05/2016 (wrong date provided on list). The resident was a current smoker who used the unsupervised smoking patio. Resident #7 was not included on the elopement risk list despite having a care plan for elopement and having a previous elopement (Actual date 04/04/2016). Review of an Elopement Risk assessment, dated 12/22/2016, however, found that Resident #7 was not legally able to make own decisions, presents cognitively or psychologically impaired and is mobile, has a history of elopement, is angry at placement, presents with a desire to leave, and is exit seeking. At 12:29 p.m. on 12/22/2016 an interview was conducted with the Administrator. She stated that Resident #7 eloped on 04/04/2016 through an unlocked gate. At that time there was only one gate located at the end of the side walk to the right of the back of the building facing the pond (south/east side). The Administrator stated that the fence and gate at the other end (east side) of the sidewalk did not exist at that time. The Administrator was asked how she ensured that the area was safe and secure so that Resident #7 would not have eloped since he was at risk. She responded, there was nothing. She continued to say, I can ' t tell you why I decided that at the time. The Administrator provided a report, dated 04/04/2016, that she reviewed with the surveyor stating that it was noticed that the back gate was open after Resident #7 was missing. She said that the fence and 2nd gate were put up after Resident #109 eloped on 05/29/2016. She said that prior to this day there had been no prior formal audit for the gates. c. A record review was completed for Resident #4 and included: [DIAGNOSES REDACTED]. Resident #4 ' s Care Plan included: Focus: Resident is at risk for elopement because they present with cognitive impairment and are independently mobile as evident by: Resident is actively exit seeking. Date initiated: 06/14/2016. Interventions included: Check for proper functioning of the audible alarm system daily and PRN (as needed). Educate resident/responsible party regarding sign out procedures. Facilitate resident to call close family/friend for reassurance when exit-seeking behaviors occurring. Initiate facilities code purple protocol if resident ' s whereabouts are unknown. Monitor resident for tailgating when visitors are in the building. Reassure resident when distressed over placement. Refer to Social Services as needed. Seek referral for a mental health evaluation from a primary care physician as needed. Use audible monitoring system to alert staff of exit seeking behaviors. Use discrete resident identifier so staff is aware of the resident ' s elopement risk. Use diversional activities when exit-seeking behavior is occurring. (ie: offer food, activities, one on one company). Use verbal cues and gestures for redirection to persuade exit-seeking behaviors. A review of the Treatment Administration Records (TAR) for all resident ' s identified by the facility as wearing a wander guard was conducted. All wander guards were present on the TARs except for Resident #4. It was discovered that the resident was wearing a wander guard and that staff were not checking for function of the device as listed on the care plan. At 5:49 p.m. on 12/23/2016 an interview was conducted with Licensed Practical Nurse (LPN) (V) who was assigned to Resident #4 on this day. She stated that the resident did not wear a wander guard. She said that for residents who wore a wander guard she took them near a door and checked for function. She was not aware of any device that could be brought to the resident to check for function. She was asked how often wander guards were checked for placement and function. She stated they are checked every shift. The TAR was reviewed with the nurse. The nurse confirmed the wander guard was not listed on the TAR. At 5:59 p.m. on 12/23/2016 Resident #4 was observed in the dining room wearing a wander guard on his left ankle. LPN (V) confirmed that the resident was wearing the wander guard. LPN (V) stated that the TAR for Resident #4 consisted of only one page and that the wander guard was not present on it. She provided a copy of it. At 6:17 p.m. on 12/23/2016 LPN (CC) returned Resident #4 ' s medical record to the nursing station. The medical record contained a new physician order [REDACTED]. Check wander guard placement every shift and function every day. The order was signed by Unit Manager (S). LPN (V) was then asked if the order was a clarification order since no other orders for the wander guard were located in the chart. The DON stated at 6:20 p.m. that it was a clarification order and that the old order fell off of the physician order [REDACTED].#4 had the wander guard since 2015. The DON then called the Unit Manager and told her that she needed to write it correctly. Unit Manager/LPN (S) then rewrote the physician order [REDACTED]. Check wander guard placement every shift. Check wander guard function every day on 11-7 shift. The Unit Manager stated that apparently the order dropped off the POS and she didn ' t catch it. d. Elopement Policy dated 06/06/2012: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation: Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Reporting Practices: 1). Resident leaving the premises unauthorized. 2). Nursing Service duties upon return of resident who was observed leaving the facility: 1. If an employee observes a resident leaving the premises, he/she shall: a. Determine if the resident is out on an authorized leave or pass. If the resident is not on an authorized leave or pass he/she should attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary, and do not leave the resident alone; and c. Instruct another staff member to inform Charge Nurse or Director of Nursing that a resident has left the premises; d. Notify the attending Physician; e. Notify the Administrator/Risk Manager; f. Notify the resident ' s legal representative (sponsor) of the incident; g. Initiate an Incident Report; and h. Document the event in the resident ' s medical record. 2. When a departing individual returns to the facility, the Director of Nursing or Charge Nurse shall: a. Examine the resident for injuries; b. Obtain order and place a wander guard on the resident; c. Notify the attending Physician; d. Notify the Administrator/ Risk Manager; e. Notify the resident ' s legal representative (sponsor) of the incident; f. Complete and file an Incident Report; and g. Document the event in the resident ' s medical record. Reporting Practices: 1). Discovery of missing resident from facility. 2). Nursing Service duties upon return of missing resident. 3). If the resident is not located: 1. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident is not out on an authorized leave or pass, staff will call/page code purple 5 times over head. Then he/she will initiate a search of the building and premises. c. If the resident is not located, notify the Administrator/ Risk Manager and the Director of Nursing, the resident ' s legal representative (sponsor), and volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); Staff will provide a description of the resident to the appropriate authorities; and d. Initiate an extensive search of the surrounding area. 2. When the resident returns to the facility, the Director of Nursing or Charge Nurse shall: a. Examine the resident for injuries; b. Obtain order and place a wander guard on the resident; c. Notify the attending Physician, and report finding and condition of the resident; d. Notify the Administrator/ Risk Manager; e. Notify the resident ' s legal representative (sponsor) of the incident; f. Notify search teams that the resident has been located; g. Complete and file an Incident Report; and h. Document the event in the resident ' s medical record. 3. If the resident is not found, Charge Nurse or Director of Nursing shall: a. Notify the attending Physician; b. Notify the resident ' s legal representative (sponsor); c. Notify Administrator/ Risk Manager; d. Complete and file an Incident Report; and e. Documents the event in the resident ' s medical record. The Facility ' s Wander Guard Policy, dated 08/11/2015, was reviewed and stated: Policy: Resident ' s with a wandering potential will be kept safe through the use of wander guard bracelet system. Purpose: To alert staff when a resident has wandered away from area. Procedure: Once wandering or elopement behavior is established through mobility, intent and impaired judgement factors the wander guard bracelet is applied to the resident or their ambulation device. · Nurse will obtain a Physicians order to place a wander guard bracelet and document in the medical record. · Social Service will be notified and picture and elopement sheet will be placed in the elopement book. · Placement is checked daily to assure that bracelet has not been removed or lost. · The wander guard is checked for functioning every shift and documented. · Wander guard system is checked nightly for functioning by 11p.m. to 7a.m. supervisor. · Care plan is developed for elopement/wander guard use. 2.a. Resident #112 ' s medical record was reviewed. Per the face sheet [DIAGNOSES REDACTED]. The Resident ' s Care Plan was reviewed and included: Focus: Resident is a unsafe smoker. Current level of assistance. Resident needs following while smoking: Observation at times. Date initiated: 06/07/2016. Reviewed on 09/06/2016 and 12/07/2016. Interventions included but were not limited to: Notify charge nurse if it is suspected resident has violated facility smoking policy. Resident requires supervision while smoking. An observation was made on 12/19/2016 at 4:15 p.m. where Resident #112 was observed smoking without supervision. At 10:15 a.m. on 12/22/2016 Resident #112 was observed propelling independently down the hall. During a five-minute observation Resident #112 was observed putting a cigarette in their mouth three different times with their left hand. Also, contained in Resident #112 ' s hand was a lighter. Resident #112 sat freely, without staff intervention. At this time, the resident finally propelled self to smoking patio. An interview was conducted with C.N.A. (Z) on 12/23/2016 at 10:01 a.m. The C.N.A. was assigned to be the smoking aide for the 7:00 a.m.-3:00 p.m. shift on 12/23/2016. The C.N.A. stated that he had training before on how to be a smoking aide, but had not received any training recently. He said that he did not have a list of any residents who required supervision. He was asked how he knew who he needed to keep an eye on and the C.N.A. responded that he used his inside skills and applied them, meaning his knowledge of the residents. He was asked what was the process now for residents smoking. He responded that he was told that if the resident was alert they could keep their own cigarettes and lighter while outside. b. Resident #29 ' s medical record was reviewed. The [DIAGNOSES REDACTED]. The Resident ' s Care Plan included: Focus: Resident is a unsafe smoker. Current level of extensive assistance, set up extensive assist. Resident needs following while smoking: Constant supervision, observation, protective gear. Date initiated: 02/22/2016. Review dates: 05/20/2016, 08/18/2016, and 11/11/2016. Interventions included but were not limited to: Notify charge nurse if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. Resident requires supervision while smoking. Safe smoking screen completed on admission and as needed. Smoking policy given to resident and/or responsible party. The resident ' s smoking supplies are stored by nursing department. An observation was made on 12/23/2016 at 3:25 p.m. of Resident #29 smoking with supervision by C.N.A. (Z). Resident #29 was not, however, wearing protective gear. In an interview with Staff BB at 6:05 p.m. on 12/20/2016, she stated supervision of resident smoking began on this day. She said that she had been outside since 3:00 p.m. and will stay out in the smoking area until 11:00 p.m. She said that Resident #29 uses a smoking apron. Aprons were observed out on smoking patio. She said that she had been working at the facility for 9 years and she knows who needs assists or they ask her. She said that the supervised smokers included Resident #29. She said that this was the first time being a smoke aide. She had never seen a list for who was independent. On this day they did not give her a list of independent and supervised smokers. On 12/20/2016 at 6:23 p.m. The Administrator stated that someone would be outside all night to monitor the residents. The door to the smoking patio would be unlocked all night. The Administrator assured that someone would watch the door at all times throughout the night. She responded that until now there had not been a smoking aide, that there have never been any set smoking times, and the door to the smoking patio was always unlocked. She said that Resident #29 was the only supervised smoker she knew about. Safe Smoking Policy: Dated 03/18/2011. Purpose: To ensure residents shall be safe when smoking and maintain a non-smoking environment within the facility. Policy: 1.No smoking signs shall be posted wherever smoking is prohibited. 2.Residents shall be observed for safe smoking practices upon admission, annually, and as needed. 3.Safe smoking equipment, such as smoking aprons, shall be available for those residents requiring it. 4.Residents may smoke in designated areas outside the facility with supervision. 5.All smoking materials, including lighters and cigarettes, shall be kept by staff at all times. Residents shall not keep smoking materials on their person or in their room. 6.A safe smoking care plan shall be developed for residents who smoke. 7.Staff shall be available to assist residents with smoking or smoking materials throughout the day. 8.The facility may impose smoking restrictions when it is determined that a resident cannot smoke safely with the available levels of supervision or assistance. 9.The facility shall maintain a strict no smoking policy within the facility. 3. The survey team met with the facility ' s Administrator, Director of Nursing (DON), and Administrator in Training on 12/22/2016 at 03:24 p.m. The administrative team was informed that Immediate Jeopardy had been identified. As a result of this meeting, the Administrator provided the following corrective action plan on 12/23/2016 at approximately 03:45 p.m.: Locks on all wooden and metal gates have been changed and the keys will be stored in the safe in the supervisor office. Keys may be accessed by: Administrator, Maintenance Director, or designated nursing personnel (DON, Assistant Director of Nursing, Unit managers, and Shift supervisors) if an emergency arises and accessed to enclosed area is needed. Safety Monitor assigned to the back enclosed area to monitor residents that smoke. Monitor will have procession of cigarettes and lighters and give cigarettes to resident as they come to patio and light cigarette for them. All smoking materials removed from the residents an

Based on resident record review, staff and resident interview, observation and facility policy review, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent falls for two of three residents ( #49 and #168 reviewed for falls of a total of 24 residents reviewed in the stage 2 sample, resulting in a fall with a fracture for Resident #49 and a fall with no injuries for Resident #168. Findings include: 1. Review of the record for Resident #49 revealed that he had a history of [REDACTED]. The [DIAGNOSES REDACTED]. Review of the record revealed that the Resident had a "Determination and Certification That Resident Is Incapable of Making Medical Decisions Based on Informed Consent Attending Physicians" form dated 10/12/12, a family member was noted as Power of Attorney and Health Care Surrogate. Review of nursing progress notes for May 14, 2014 revealed " 5/14/14 9: 50 a.m. Writer responded to Unit clerk call for help, noted resident face down on floor in doorway of bathroom- walker tipped forward. Assisted resident onto back and checked ROM ( Range Of Motion) to upper and lower extremities. No complaints of pain at this time. Resident returning from bathroom but asking ' did I fall? '. Placed back in bed per charge nurse and writer. Attempted to do vitals and noted skin tear to right forearm -area cleansed and treatment put into place. Hand grips equal at this time. Will continue to monitor for pain and changes in mental status. 5/14/14 10: 20 a.m. Noted skin tear to left arm , treatment in place 5/14/14 10: 26 a.m. Son called and made aware of fall and injury. 5/14/14 10 : 40 a.m. Doctor in and orders received for x ray of left shoulder and elbow and right elbow due to c/o of pain. X ray company called and they will be here later today. Son notified at bedside." Additional nursing progress notes: 5/14/14 2:40 p.m. This nurse was notified by DON that a patient was on the floor. This nurse went to room and noted staff with patient noted on floor, face up. This nurse asked patient what happened. Patient did not respond. Staff transferred patient from floor onto bed. Vitals were taken and were Blood Pressure 103/68, Pulse 45 , Respirations 36 and Temperature 98. 2. Patient noted having nasal canula appropriately placed, 02 at 2 liters . POA and Dr. Notified." There was no documentation in the nursing progress note that staff was with the patient when he fell . Review of the physician note for 5/14/14 (untimed) revealed "Seen with nurse and son. Tried to get off toilet his self. Inconsistent with asking for help. Right lateral proximal forearm laceration, left post distal tricep area skin laceration. Examined with nurse. X ray, Tramadol (Ultram) 50 mg Q 6 hr PRN." The Ultram was not given until the patient returned from the hospital at 11:45 p.m. on 5/14/14 . Nursing notes indicated " 5/14/14 2: 50 p.m. X rays to left and right elbows and left shoulder done. Awaiting results at this time." " 5/14/14 6 p.m. X ray result received. Transportation called, family notified of estimated time of transfer to ( hospital )." " 5/14/14 10 p.m. Patient transported to (hospital_ at 8 p.m. via (transportation). " This was approximately nine hours and 50 minutes after the resident was found on the floor. Review of the x ray report , taken in the facility, revealed " There is felt to be a subtle undisplaced fracture of the surgical neck of the humerus. Clinical correlation and follow up is suggested. " Review of hospital records revealed " 5/14/14 20: 47 Patient presents to the emergency department after a nonsyncopal fall that occurred this morning at his nursing home. Son states that patient had his his head and has some left arm pain and reports that he had an x ray this morning. Radiology report states that there was a subtle undisplaced fracture to the surgical neck of the left humerus. Patient denies any loss of consciousness, neck or back pain. Hospital records indicate a CT scan of the head/brain and x rays were completed. The hospital report indicated " Fracture of Greater Tuberosity of Humerus, Closed" and " Head abrasion." An interview was conducted with the Assistant Director of Nursing who indicated that she does the fall investigations at the facility, on 6/12/14 at 10:00 a.m. She stated that the resident was on 15 minute checks because he would take his 02 on and off and would get up and move about on his own and needed assistance to transfer . She stated he was a " little confused: and would not remember instructions and would not remember to use the call light. She stated that the CNA took the resident to the bathroom assisted him onto the toilet , put the call light in his hand, closed the door, and left the room. She stated the CNA returned in five minutes and found the resident on the floor. She stated the resident said he had finished in bathroom and was trying to get to his chair. She stated that the Resident liked privacy in the bathroom and liked the door closed and no one to be present. She stated that if someone tried to stay on the other side of the door, the resident would get mad. She stated he was able to sit on the toilet and clean himself but needed assistance to get on and off the toilet. She stated he took an extremely long time in the bathroom and would not use the bathroom if someone would stand over him. An interview was conducted with the Unit Manager of the unit the Resident resided on 6/12/14 , at approximately 10: 30 a.m.. He stated that the Resident had a bed and chair alarm. He stated that the CNA helped the resident to the toilet, gave him his call light and left the room. He stated that the resident wanted the door shut when he was in the bathroom. He stated that sometimes he would use the call light when he was done and sometimes would not. He stated he did not know how long after closing the bathroom door and leaving the room that the aide came back to check on the Resident. An interview was conducted with Employee E, the CNA who assisted the Resident to the bathroom on 5/14/14, on 6/12/14 at 11: 00 a.m. She stated she regularly cared for Resident #49. She stated she took the Resident to the bathroom, handed him the call light and told him to put the light on when he was done, closed the bathroom door and left the room. She stated she left the room and went to take care of another patient and returned to the room five minutes later to find him on the floor. She stated the Resident did not need assistance to walk and could walk with his walker. She stated when the Resident's chair and bed alarms went off, she would go in and assist him to transfer from the chair or the bed and back and he could then walk with the walker. She stated for toileting, she would place him on the toilet. She stated he was to put the call light on when he was done in the bathroom and she would assist him to transfer off of the toilet. She stated that sometimes he would use the call light and sometimes would not. She confirmed there are no alarms on the toilet to indicate to staff that the Resident is transferring off the toilet. She stated that this was her regular routine with the Resident. An interview was conducted with the Director of Nursing, on 6/12/14 at 1:16 p.m. as to a why the Resident who required extensive assistance with transfer and toilet use was left alone on the toilet with the door closed and no staff in the room. She stated that the Resident was left alone because he asked for privacy and it is his right to have privacy. She stated that it would be a violation of the Resident's right to privacy to not honor his request for privacy. She stated they only needed to check on the resident every 15 minutes and the aide returned after 5 minutes. Review of a form entitled "Fall Risk Predictive Factors Observation", dated 12/10/13 and found in the resident's record revealed that the resident has a fall risk of 13. The form stated "Total Score of 10 or higher may represent High Risk" Review of a Monthly Return and PRN Data Collection form, dated 3/13/14 , revealed that the resident " Has [DIAGNOSES REDACTED]. " Review of the most recent Minimum Data Set ( MDS ) assessment, dated 2/26/14 revealed the following: Section C BIMS ( Brief Interview for Mental Status) of 6, indicative of severe cognitive impairment. Section G , Functional Status, revealed that the resident required extensive assist of one person for transfer and toilet use. Section J Health Conditions, revealed that the resident had one fall since the last full assessment which was an annual MDS on 12/21/13. Review of the "Individualized Care Plan for Activities of Daily Living ( ADLS) , last reviewed 2/26/14 revealed: "Resident has ADL Self -Care Deficit as evidenced by: Needs assistance with ( specify self performance): Bed mobility -3 (extensive assist) Transfer - 3 (extensive assist) Walking-2 ( Limited assist) Locomotion - 3 ( extensive assist Dressing -3 ( extensive assist) Eating- 0 ( independent) Toilet Use- 3 ( extensive assist) Personal Hygiene - 3 ( extensive assist) Bathing - 3 ( extensive assist) Review of the : "Individualized Care Plan for Fall/Fall Risk" for Resident # 49, last reviewed 2/26/14, revealed : "Problem: Resident is at risk for fall related injury re;ated to disease process, Functional Problem - weakness, Medication Usage - Psychotropic, Use of assistive device - wheelchair, and Other - actual fall 12/16/13. Goal : Resident will not sustain a serious fall related injury through next review Approach: Report falls to physician and responsible party Observed for side effects of any drugs that can cause: ( potential side effects list) Report to physician any side effects associated with the resident' medication use Provide environmental adaptations: Call light within reach, adequate glare free lighting, area free of clutter, other - PPA AAT ( Pressure Pad Alarm At All Times) , Q 15 minute checks). Provide /monitor use of adaptive devices: walker/cane, wheelchair. Remind resident and reinforce safety awareness: lock brakes on bed, chair, etc , before transferring, when rising from a lying position , sit on side of bed for a few minutes before transferring/standing Educate /remind resident to request assistance prior to ambulation Appropriate footwear. Invite, encourage , remind ,escort to activity programs consistent with resident's interests to enhance physical strengthening needs Referral for screen and treatment as needed; PT, OT, Mental Health Provide resident /family teaching to include: Safety measures to reduce fall risk,, What to do if fall occurs" Review of the CNA ADL flow sheet 7-3 shift for May 2014 revealed that the CNA documented the Resident was a 3/2 for transfer and a 3/2 for toilet use from May 1 through May 14, 2014 . Review of the legend at the bottom of the form revealed that the 3 is for extensive assist and 2 is one person physical assist. 2. Review of the record for Resident # 168 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. . Review of the nursing progress notes in the Resident's chart revealed that Resident had falls on 3/27/14, 4/6/14, 4/8/14 , 4/12/14 , 4/19/ 14 and 5/4/14 ( 2 falls). The Resident had been placed on 1:1 supervision after the fall of 4/12/14 and 1:1 supervision was discontinued on 5/1/14. The resident was placed on 1:1 supervision again on 5/4/14 after the second fall on that date and remained on 1:1 supervision. Review of a Quarterly MDS for Resident #168, dated 5/4/14 revealed : Section C: Cognitive Patterns: BIMS score of 7 ( indicative of severe cognitive impairment) Section G Functional Status: Bed Mobility 2/2 Limited assistance of one person Transfer 0 Independent Walk in room 0 Independent Walk in corridor 0 Independent Toilet Use - 0 Independent Review of Resident #168's record revealed a care plan entitled "Individualized Care Plan for Fall/Fall Risk" with a last reviewed date or 5/5/14. Review of this care plan revealed: Problem: Resident is at risk for fall related injury as evidenced by history of fall prior to admission related to Disease Process /Condition : Syncope, Orthotic Hypotension, Parkinson's, Generalized weakness , use of Psychotropic medication, and use of assistive device: wheelchair. Goal" Resident will not sustain a serious fall related injury through next review date. Approach: Report falls to physician and responsible party Observe for side effects of any drugs that can cause: gait disturbance, Orthostatic Hypotension, Weakness, Sedation, Lightheadedness, Dizziness, Change in Mental Status Report to physician any side effects associated with the resident's medication use. Provide environmental adaptations: call light within reach, adequate glare free lighting, area free of clutter. Provide/monitor use of adaptive devices: wheelchair Remind resident and reinforce safety awareness: Lock brakes on bed, chair etc. before transferring , when rising from a lying position, sit on side of bed for a few minutes before transferring/standing, educate/remind resident to request assistance prior to ambulation, appropriate footwear. Invite, encourage, remind, escort to activity programs consistent with resident's interests to enhance physical strengthening needs Referral for screen and treatment as needed: PT, OT, Mental Health Provide resident family teaching to include: safety measures to reduce fall risk, what to do if a fall occurs. Additional approaches: 4/19/14: 1:1 supervision. An additional note states 1:1 supervision - D/C ( discontinue ) 5/1/14 and 5/18/14 Continue 1:1 15 minute checks. Review of the Physician order [REDACTED]. 1:1 was discontinued by the physician on 5/1/14 and was re ordered by the physician after the second fall of 5/4/14. Review of the facility's policy entitled "One to One Supervision" ( undated) revealed : Policy statement : One to One supervision is close proximity staff assigned to patients who have been identified as an imminent danger to themselves or others. In addition, patients may be placed 1:1 if their self-care and/or medical needs require continuous support/assistance. Policy Interpretation and Implementation : One to One supervision requires that a patient have an assigned staff member in close proximity at all times. The patient is accompanied by the staff member at all times ( including bathing, showering, shaving, and toileting ). Although a physician must order 1:1 observation, a Charge nurse may place a patient on 1:1 and contact the physician for the order. Additional staffing may be obtained by contacting the Nursing Supervisor and/or Staffing Coordinator." Interview with the 7 a.m. to 3 p.m., nurse assigned to Resident #168, on 6/13/14 at 12:24 p.m. revealed "He tries to get up, tries to walk, has no clue what he is doing sometimes and is very weak. Have him on 1:1, even if he stands up to go to the bathroom, we have got to be right there." Interview with the Assistant Director of Nursing ,on 6/12/14 at 10:30 a.m., revealed that the Resident has to be put on 1:1 as falls continued and the resident has poor safety awareness. She stated that the facility has done laboratory work ups, tested the resident for Urinary Tract infections, had medication reviews by the physician but the falls did not stop. She stated the facility did a trial off of 1:1 because of no falls and within a day or two he fell again and was placed back on 1:1. Review of nursing progress notes in the Resident's record revealed" 5/17/14: 8:00 a.m. At 7:25 a.m. this nurse was called into the room. Patient was found sitting up in the entrance of (his room). No apparent injury noted. No injury to the head. Patient is alert with confusion, able to respond to questions. Educated patient on importance of using call light for assistance. Patient stated he was trying to walk around. No c/o of pain or s/s of discomfort. (vital signs done) MD and family member notified of fall." An interview was conducted with the Assistant Director of Nursing, on 6/12/14 at 10:30 a.m. At first she stated that the Resident was not on 1:1 at the time of this fall but then corrected that and stated he was on 1:1 supervision. She stated that the CNA who was assigned his 1:1 was going to the nursing station so she could find out who was relieving her. She stated the Resident was following the CNA and when she turned around, he was sitting on the floor in the doorway. She stated the Resident was not injured. On 6/12/14 at approximately 12:03 p.m., during a meal observation in Resident #168's room, the one to one aide, Employee F, was observed to leave the resident's side, go to the door of the Resident's room, looked down the hallway and asked another staff to bring ice for the Resident. On 6/12/14 at 5:05 p.m., the one to one aide, Employee I, was observed to be at the nursing station reporting to staff that the Resident had finished his meal. She then proceeded to walk back to the Rsident's room where the Resident was observed seated in his wheelchair without any staff present. Once back in the Resident's room, the one to one aide was observed by the door to the resident 's bathroom talking with the resident's roommate. The Resident was observed to be on the other side of his room, near the door in his wheelchair. An interview was held with the Administrator, on 6/13/14 at 5:05 p.m. regarding the Resident's fall on 5/17/14 while on 1:1 and subsequent observations of 1:1 not watching the Resident. She stated " 1:1 policy doesn't say you have to be looking at them but common sense would dictate that you should be."

Based on resident record review , observation and staff interview, it was determined that the facility failed to implement care plan interventions for 1 of 3 residents reviewed for falls (# 49) of a total of 24 stage 2 sampled residents resulting in a fall with a fracture for Resident # 49. Findings include : 1. Review of the form entitled "Fall Risk Predictive Factors Observation", dated 12/10/13 found in Resident #49's record revealed that the Resident had a fall risk of 13. The form stated "Total Score of 10 or higher may represent High Risk." Review of a Monthly Return and PRN Data Collection form, dated 3/13/14 , revealed that the Resident " Has [DIAGNOSES REDACTED]." Review of the "Individualized Care Plan for Activities of Daily Living ( ADLS) , last reviewed 2/26/14 revealed: " Resident has ADL Self -Care Deficit as evidenced by: Needs assistance with ( specify self performance): Bed mobility -3 (extensive assist) Transfer - 3 (extensive assist) Walking-2 ( Limited assist) Locomotion - 3 ( extensive assist Dressing -3 ( extensive assist) Eating- 0 ( independent) Toilet Use- 3 ( extensive assist) Personal Hygiene - 3 ( extensive assist) Bathing - 3 ( extensive assist) Review of the : "Individualized Care Plan for Fall/Fall Risk" for Resident #49, last reviewed 2/26/14, revealed : "Problem: Resident is at risk for fall related injury related to disease process, Functional Problem - weakness, Medication Usage - [MEDICAL CONDITION], Use of assistive device - wheelchair, and Other - actual fall 12/16/13. Goal : Resident will not sustain a serious fall related injury through next review Approach: Report falls to physician and responsible party Observed for side effects of any drugs that can cause: ( potential side effects list) Report to physician any side effects associated with the resident' medication use Provide environmental adaptations: Call light within reach, adequate glare free lighting, area free of clutter, other - PPA AAT ( Pressure Pad Alarm At All Times) , Q 15 minute checks). Provide /monitor use of adaptive devices: walker/cane, wheelchair. Remind resident and reinforce safety awareness: lock brakes on bed, chair, etc , before transferring, when rising from a lying position , sit on side of bed for a few minutes before transferring/standing Educate /remind resident to request assistance prior to ambulation Appropriate footwear. Invite, encourage , remind ,escort to activity programs consistent with resident's interests to enhance physical strengthening needs Referral for screen and treatment as needed; PT, OT, Mental Health Provide resident /family teaching to include: Safety measures to reduce fall risk,, What to do if fall occurs" Review of the CNA ADL flow sheet 7 -3 shift for May 2014 revealed that the CNA documented the resident was a 3/2 for transfer and a 3/2 for toilet use from May 1 through May 14,2014 . Review of the legend at the bottom of the form revealed that the 3 is for extensive assist and 2 is one person physical assist. Review of nursing progress notes for May 14, 2014 revealed "5/14/14 9: 50 a.m. Writer responded to Unit clerk call for help, noted resident face down on floor in doorway of bathroom- walker tipped forward. Assisted resident onto back and checked ROM ( Range Of Motion) to upper and lower extremities. No complaints of pain at this time. Resident returning from bathroom but asking ' did I fall? '. Placed back in bed per charge nurse and writer. Attempted to do vitals and noted skin tear to right forearm -area cleansed and treatment put into place. Hand grips equal at this time. Will continue to monitor for pain and changes in mental status. 5/14/14 10: 20 a.m. Noted skin tear to left arm , treatment in place 5/14/14 10: 26 a.m. Son called and made aware of fall and injury. 5/14/14 10 : 40 a.m. Doctor in and orders received for x ray of left shoulder and elbow and right elbow due to c/o of pain. X ray company called and they will be here later today. Son notified at bedside." Additional nursing progress notes stated: 5/14/14 at 2:40 p.m. This nurse was notified by the DON that a patient was on the floor. This nurse went to room and noted staff with patient noted on floor, face up. This nurse asked patient what happened. Patient did not respond. Staff transferred patient from floor onto bed. Vitals were taken and were Blood Pressure 103/68, Pulse 45 , Respirations 36 and Temperature 98. 2. Patient noted having nasal canula appropriately placed, 02 at 2 liters . POA and Dr. Notified." Review of the physician note for 5/14/14 (untimed) revealed "Seen with nurse and son. Tried to get off toilet his self. Inconsistent with asking for help. Right lateral proximal forearm laceration, left post distal tricep area skin laceration. Examined with nurse. X ray, [MEDICATION NAME] 50 mg Q 6 hr PRN." Nursing notes indicated "5/14/14 2:50 p.m. X rays to left and right elbows and left shoulder done. Awaiting results at this time." " 5/14/14 6 p.m. X ray result received. Transportation called, family notified of estimated time of transfer to ( hospital )." " 5/14/14 10 p.m. Patient transported to (hospital_ at 8 p.m. via (transportation). " This was approximately nine hours and 50 minutes after the resident was found on the floor. There was no documentation in the nursing progress note that staff was with the patient when he fell . Review of the x ray report, taken in the facility, 5/14/14, revealed "There is felt to be a subtle undisplaced [MEDICAL CONDITION] neck of the humerus. Clinical correlation and follow up is suggested." Review of hospital records revealed "5/14/14 8:47 p.m. Patient presents to the emergency department after a nonsyncopal fall that occurred this morning at his nursing home. Son states that patient had hit his head and has some left arm pain and reports that he had an x ray this morning. Radiology report states that there was a subtle undisplaced fracture to the surgical neck of the left humerus. Patient denies any loss of consciousness, neck or back pain. Hospital records indicate a CT scan of the head/brain and x rays were completed. The hospital report indicated " Fracture of Greater Tuberosity of Humerus, Closed" and " Head abrasion." An interview was conducted with the Assistant Director of Nursing who indicated that she does the fall investigations at the facility, on 6/12/14 at 10:00 a.m. She stated that the resident was on 15 minute checks because he would take his 02 on and off and would get up and move about on his own and needed assistance to transfer . She stated he was a " little confused: and would not remember instructions and would not remember to use the call light. She stated that the CNA took the resident to the bathroom assisted him onto the toilet , put the call light in his hand, closed the door, and left the room. She stated the CNA returned in five minutes and found the resident on the floor. She stated the resident said he had finished in bathroom and was trying to get to his chair. She stated that the resident liked privacy in the bathroom and liked the door closed and no one to be present. She stated that if someone tried to stay on the other side of the door, the resident would get mad. She stated he was able to sit on the toilet and clean himself but needed assistance to get on and off the toilet. She stated he took an extremely long time in the bathroom and would not use the bathroom if someone would stand over him. An interview was conducted with the Unit Manager of the unit the Resident resided on 6/12/14 , at approximately 10: 30 a.m.. He stated that the Resident had a bed and chair alarm. He stated that the CNA helped the resident to the toilet, gave him his call light and left the room. He stated that the Resident wanted the door shut when he was in the bathroom. He stated that sometimes he would use the call light when he was done and sometimes would not. He stated he did not know how long after closing the bathroom door and leaving the room that the aide came back to check on the Resident. An interview was conducted with employee E, the CNA who assisted the Resident to the bathroom on 5/14/14, on 6/12/14 at 11: 00 a.m. She stated she regularly cared for Resident #49. She stated she took the Resident to the bathroom, handed him the call light and told him to put the light on when he was done, closed the bathroom door and left the room. She stated she left the room and went to take care of another patient and returned to the room five minutes later to find him on the floor. She stated the Resident did not need assistance to walk and could walk with his walker. She stated when the Resident's chair and bed alarms went off, she would go in and assist him to transfer from the chair or the bed and back and he could then walk with the walker. She stated for toileting, she would place him on the toilet. She stated he was to put the call light on when he was done in the bathroom and she would assist him to transfer off of the toilet. She stated that sometimes he would use the call light and sometimes would not. She confirmed there are no alarms on the toilet to indicate to staff that the Resident is transferring off the toilet. She stated that this was her regular routine with the Resident. An interview was conducted with the Director of Nursing, on 6/12/14 at 1: 16 p.m. as to a why the Resident who required extensive assistance with transfer and toilet use was left alone on the toilet with the door closed and no staff in the room. She stated that the Resident was left alone because he asked for privacy and it is his right to have privacy. She stated that it would be a violation of the Resident's right to privacy to not honor his request for privacy. She stated they only needed to check on the resident every 15 minutes and the aide returned after 5 minutes.