Every finding on record at Melbourne Healthcare and Rehabilitation Center

Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to follow proper sanitation practices to prevent the outbreak of foodborne illness. This had the potential to affect all residents at the facility who eat food prepared in the kitchen. Findings: 1. On 3/03/25 at 10:00 AM, during the initial kitchen tour with the Assistant Dietary Manager I, observations in the walk-in found there were four, one-third steamtable pans of leftover food items including mechanical soft pork dated 3/1 and use by 3/07/25, sweet potatoes dated 3/2 and use by 3/08/25, corn dated 3/1 use by 3/07/25, and mashed potatoes dated 3/2 use by 3/08/25. Assistant Dietary Manager I stated their policy was to keep leftover fish, meat, and poultry for three days after prepared, and vegetables for five days. She could not explain why it was written to keep all these food items for six days each. There were two packages of hard-boiled eggs, unsealed and left open to the air, and undated; and a carton of whole eggs was open and did not have a date as to when it had been opened. There was a bag which contained approximately 20 pieces of tilapia fish inside the cardboard box, the bag was open to the air and undated. A bag of approximately 15 fried eggs was also left open to the air and undated in the cardboard box. Assistant Dietary Manager I threw away the eggs and fish. In a plastic bin with other cheese items, were two bags of what the Assistant Dietary Manager I thought was unlabeled and undated, rancid shredded mozzarella. Assistant Dietary Manager I eventually decided the unlabeled food was hash brown potatoes. In the same bin, there were two bags of shredded mozzarella cheese dated 2/11 (20 days ago) with a marker and 1/28/25 (33 days) indicated on a sticker label. Assistant Dietary Manager I was unsure which date was accurate and how long the bags of cheese should be kept. She threw the hash browns and cheese away. 2. In the walk-in freezer was a storage bag of leftover pork and a bag of salisbury steak. Both items had frost built up on the meat and were not dated. Assistant Dietary Manager I stated these items were old and should have been thrown away. There was also a bag of approximately 20 chicken tenders, undated as to when they were opened, which she threw away. 3. In the cook's reach-in refrigerator, in an unlabeled, round plastic bin, there were two stacks of approximately 15 American cheese slices wrapped in plastic wrap and two unwrapped stacks of approximately 35 slices of American cheese. There were no dates on any of this cheese. Assistant Dietary Manager I stated they were from sandwiches made yesterday and she meant to put them in storage bags and date them. She stated this cheese should not be kept for more than one week. There were also two covered plastic tubs, one with leftover peaches and the other with leftover fruit cocktail; both were unlabeled and undated and Assistant Dietary Manager I discarded them. 4. In the dry storage room, there was an unlabeled and undated bin with a bag of sugar inside and a bag of opened and resealed, but undated evaporated milk. There was also a dirty tray which held approximately 15 clean drinking glasses which Assistant Dietary Manager I stated the glasses were used for residents in the dining room. 5. Under the cook's food preparation table, there were three dry storage bins. All three were lined with a large plastic (garbage) bag. The lining bag was dirty on the outside of the bin labeled FLOUR and inside this bin were two paper (original shipping) bags of flour. One of the paper shipping bags indicated the flour was manufactured on 1/07/24, but had no date that indicated when it was received or opened. There was a flying insect that hovered outside of the dirty flour bin. None of these three bins had a date for when these items were received, opened, and/or stored in these bins. In the kitchen was also a dirty sheet pan with approximately 16 glasses of juice that had been poured for today's upcoming lunch meal, sitting on the dirty tray (photo evidence acquired)). 6. On 3/5/25 at 11:25 AM, during the follow-up visit to the kitchen, it was noted the kitchen floor tiles and grout had a build-up of a black substance which was also prevalent on and around the floor drains. (pictures taken). The facility's policy entitled Food Storage: Dry Goods dated 9/17 indicated all dry goods would be stored appropriately in accordance with the Food and Drug Administration (FDA) Food Code and would be date marked as appropriate. The policy entitled Food Storage: Cold Foods and dated 9/17 and revised 4/18, stated all foods would be stored wrapped or in covered containers, labeled, and dated. The provided Healthcare Services Group Labeling and Dating Inservice (undated) indicated all foods should be dated upon receipt before being stored with the food name, date of preparation, receipt, and/or removal from the freezer, and the use by date. It added, the manufacturer's expiration date may be used as the use by date for unopened items and the manufacturer's instructions for discarding of opened items may be used. If not available, the day of preparation or opening was considered as day one when establishing a use by date and all ready-to-eat and time/temperature controlled for safety food items would be labeled and dated with a prepared date (day one) and a use by date (day seven).

Based on observation, interview, and record review, the facility failed to honor resident's with dignity by using labels when referring to residents, such as feeders, and failed to timely protect and promote the rights of a resident who requested support with insurance, for 1 of 1 residents reviewed for healthcare coordination support, (# 25), of a total sample of 42 residents. Findings include: 1. On 3/03/25 at 12:24 PM, residents were observed in the dining room for the lunch meal service. A few minutes later at 12:36 PM, two staff members moved several residents to a large table in the dining room when the Activities Director stated to Certified Nursing Assistant (CNA) E to leave spaces between the residents for staff to help the feeders. On 3/03/25 at 4:39 PM, Licensed Practical Nurse (LPN) F stated the nurses took turns to assist the residents with dining and rotated through dining room. LPN F described helping in the dining room earlier in the day and referred to the dependent diners, as you could see, we had a lot of feeders. On 3/06/25 at 10:24 AM, the Administrator acknowledged staff should not label dependent diners as feeders. The Administrator stated staff had been educated on the importance of dignity of all residents including not using labels, such as feeders for them. The facility's policy entitled Quality of Life-Dignity dated November 2010 indicated staff should not label or refer to residents by their room number, diagnosis or care needs. 51234 3. Review of resident #25's record revealed an admitted [DATE]. His diagnoses include unspecified atrial fibrillation, acquired absence of right leg below knee, and acquired absence of left leg below knee. His quarterly 11/29/24 Minimum Data Set included a Brief Interview of Mental Status score of 15/15, which indicated intact cognition. On 3/03/25 at 11:05 AM, resident #25 said he had a skin growth on the left side of his nose since his admission to the facility in 2023. He explained in October 2024 he requested help from the facility's Business Office Manager to recertify his health insurance, Medicaid. He said the dermatology group that visited the facility did not take the type of Medicaid he had when he attempted to be seen by them last year; so, he waited for a dermatology visit to be arranged with an outside provider who took his insurance. He said he found out in last December 2024 from the outside dermatology appointment he did not have any active health insurance. He said he has missed a specialty appointment for another skin issue below his right eye, after he was seen by a dermatologist who provided care in the facility in January 2024. On 3/05/25 at 9:12 AM, the Business Office Manager said on 10/14/24 she faxed resident #25's recertification paperwork to maintain his health insurance, Medicaid, and then she did not check on the status after that fax went through until she emailed contact #1 at the Florida Department of Children and Families on 12/26/24 after she was told that resident #25 did not have active health insurance. She said she applied for Medicaid online for resident #25 on 1/30/25. She said she lost an electronic report which maintained her history of inquiries to check if resident #25's Medicaid eligibility had been reinstated. On 3/05/25 at 4:15 PM, the Social Services Director said that she has known since 3/04/24 of resident #25's desire to move to an assisted living facility. On reviewing her notes she said in November 2024 he had a plan to move into Assisted Living Facility #1 when an apartment was available. She said his Medicaid not being active had been holding up the process for him to be admitted into Assisted Living Facility #1. Review of resident #25's medical record revealed a dermatology referral for wound care note dated 1/02/25 that resident #25 should be referred to an outside ophthalmologist or local general dermatologist for right lower eyelid growth removal. It also noted resident #25 should be seen for the follow up in 1 month. On 3/05/25 12:08 AM, the Medical Records Coordinator, who also coordinates referrals for healthcare appointments outside the facility, did not recall when she was asked to make an outside dermatology referral for resident #25. She recalled in December 2024 when resident #24 went to an offsite dermatologist he was told he did not have active health insurance. She said she knew his Medicaid was still pending in status in January 2025 because she said the facility paid for the dermatology group who provided services within the facility to see resident #25 for care. She verified it had been 2 months since that appointment when a referral was requested by the inhouse visiting dermatology group until a follow-up ophthalmology appointment was scheduled. In a telephone interview on 3/06/25 at 11:53 AM, the Business Office Manager's contact #1 at the Florida Department of Children and Families stated that the October 2024 application to continue resident #25's Medicaid was never received. He verified that the submission done on 1/30/25 was considered a late recertification and a recertification that was sent in August 2024 was too early a submission. In a telephone interview on 3/06/25 at 3:40 PM, contact #1 at Assisted Living Facility #1 said she was the Admissions Coordinator for Assisted Living Facility #1. She recalled that resident #25 had been on their wait list since August 2024. She said it was due to the facility not obtaining resident #25's appropriate Medicaid that had delayed the process in his transferring to Assisted Living Facility #1. She said he was currently on their waitlist and April or May 2025 she thought he would potentially be able to move in if the facility did their part regarding supporting resident #25 with his Medicaid. The facility's policy entitled Resident Right- Exercise of Rights dated 4/01/22, stated all activities and interactions with residents shall focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices.

Based on observation, interview, and record review, the facility failed to provide a homelike environment by failing to de-emphasize the institutional character of the dining room for one of one dining room reviewed for dining and failed to maintain a sanitary and comfortable interior of the resident rooms for 3 of 3 residents rooms reviewed for cleanliness, (#13, #20, and #62). Findings: 1. On 3/03/25 at 12:24 PM, in the main dining room, 36 residents were observed eating lunch. There were no table cloths, no centerpieces on the tables and there was no music playing to create a homelike atmosphere for dining. At 12:33 PM, loud country music was started. On 3/05/25 between 10:25 AM and 12:00 PM, residents were observed eating morning snacks at the dining tables in the dining room. A short time later a couple of tables were moved so residents could exercise in an open area of the dining room. Later, the tables were moved back so residents could eat lunch, but no dining room table additions such as tablecloths or centerpieces were added to create a homelike environment for the residents. On 3/06/25 at 9:31 AM, the Director of Activities, acknowledged the lack of tablecloths or centerpieces to create a homelike environment. She stated they used to have centerpieces for the dining tables and had tablecloths, but no longer did. The Director of Activities stated she could not say why the tablecloths or centerpieces were not being utilized for the residents. She added she believed the facility still had some of the seasonal centerpieces. 2. On 3/03/25 at 1:00 PM, upon entrance to residents #13's room the floor had dirty shoe marks and gray smudge lines about 6 to 8 inches long in the middle of the floor. The area outside the bathroom floor was brown and dingy with dirt the whole length of the doorway. The bedroom and bathroom floors were very sticky and dirty, and stuck to the bottom of any shoes. A large patched area of a wall was seen that had not been repainted. Resident #13 agreed the room floors and baseboards looked dirty and stated housekeeping had already come to clean the room that day, (photographic evidence obtained). On 3/04/25 at 8:30 AM, the floors resident #13's room had more grime and dirty shoe marks than seen the previous day. Resident #13 acknowledged the dirty floors. Certified Nursing Assistant (CNA) E who came in the room, stated a cup of juice had been spilled and tracked through the room which made the floors sticky. He added, he had told housekeeping to use two mop heads instead of just one because the floor was so dirty, (photographic evidence obtained). On 3/05/25 at 10:11 AM, Housekeeping staff G was observed deep cleaning room [ROOM NUMBER]. She explained resident rooms were cleaned between 7 AM to 3 PM. She stated she mopped the floor with premeasured soap and water, but if other staff used too much soap, the floor got sticky. She stated she used one mop head per room but did not change the mop water throughout the course of her shift and added that no one did. She stated that for floor edges, she sprayed with a cleaner and then wiped or mopped to see if the dirt came out. She demonstrated on the wall and baseboards of the room but stated the areas were not able to come clean. On 3/05/25 at 2:53 PM, the Environment Director stated four rooms were deep cleaned daily, which included cleaning the air conditioner filter, the blinds, dusting the furniture, moving furniture, and cleaning beds after blankets were removed. When observing the room that was deep cleaned today by Staff G, he acknowledged it looked like the baseboards were missed. The Environment Director stated he expected housekeeping staff to use fresh floor cleaning water first thing in the morning and get fresh water again when the food carts arrived on the resident units around lunch time. The Environmental Director provided a Deep Cleaning Schedule for February and March 2025, which indicated four resident rooms at the facility were deep cleaned that day by the staff during their usual cleaning shift. He also provided instructions from the Housekeeping Operations manual which stated each housekeeper was responsible for one complete room cleaning per day which required cleaning of corners and edges using a scrubbing pad (doodlebug pad), wall washing, and floor buffing and burnishing (which is assigned to the porter assigned to that section). 51234 3. On 3/03/25 at 12:13 PM, observation of resident #20's room revealed shoes stuck to the floor as one walked around the bilateral sides and foot of resident #20's bed. On 3/04/25 at 12:31 PM, shoes stuck to the floor of resident #20's room as one walked around the bilateral sides and foot of the bed. On 3/04/25 at 4:49 PM, resident #20's family member said they or their significant other visited resident #20 almost daily. Resident #20's family member confirmed the brown hue within the abraded surface of the toilet seat and the notable sewer-like odor within the bathroom itself. Resident #20's family member and their significant other noted the stickiness of the floor on both sides of the bed and at the foot of the bed as well. They said they often experienced the floor being sticky when they visited resident #20. On 3/05/25 at 10:31 AM, shoes stuck to floor as one walked around both sides and the foot of resident #20's bed. On 3/05/25 at 10:32 AM, numerous white splatters were observed on the wall area below the light switch in resident #20's room. Multiple scraped, dented areas of plaster and missing paint were noted below the light switch area and above the baseboard. A notable damaged area, that was irregularly shaped and of irregular depth to the plaster was observed to be approximately 1 foot by 1 foot. 4. On 3/03/25 at 12:24 PM, black and gray colored debris was observed on the floor at the head of resident #62's bed and to the floor on the window side of bed. On 3/03/25 at 3:51 PM, resident #62's family member said they visited often, and felt her room was dirty. Gray and black colored debris was observed on the floor at the base of resident #62's feeding pump pole. Scratched, peeling paint was observed at the head of resident #62's bed. On 3/05/25 at 10:44 AM, the Environmental Director verified there was stickiness on both sides and at the foot of resident #20's bed. He also verified the notable sewer odor in resident #20's bathroom-he was not sure of the source of the odor. He noted the brown hue within the abraded toilet seat. He was unclear what caused the brown hue. Next he observed and confirmed the gray black debris on the floor at the head of resident #62's bed. The Environmental Director explained staff should clean the floor under the beds, as well as under the small furniture like the three drawer chest of drawers. He said he spot checked the cleanliness of the rooms on Monday through Friday. He said he did not keep a record of environmental concerns expressed to him. The Environmental Director said he tried to address concerns as they arose. Scratched peeling paint was observed behind resident #62's bed. He removed resident #62's air conditioning filter and noted what he described as more than a week's worth of debris on the filter. He said the air conditioning filter cleaning should be done Monday, Wednesday, and Friday of each week. He acknowledged he needed to review the work of his staff more to ensure they cleaned sufficiently. On 3/05/25 at 11:39 AM, the Maintenance Director observed the wall area under the light switch in resident #20's room. He said he was not sure what caused the numerous white splatters between the light switch and the baseboard. He stated he was not aware of the plaster damaged area, that was irregularly shaped and of irregular depth that was approximately 1 foot by 1 foot. The facility's policy entitled Resident Rights-Safe, Clean, Comfortable Homelike Environment dated 4/01/22, indicated the resident had a right to a safe, clean, comfortable and homelike environment, and the facility should provide the housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation, interview, and record review, the facility failed to post the nursing staffing hours daily, which identified the number of staff working in the facility on the form posted. Findings: On 3/03/05 at 10:24 AM, 3/04/25 at 10:15 AM, 3/05/25 at 8:34 AM, and 3/06/25 at 8:37 AM, the daily Nurse Staffing Form located by the receptionist in the lobby failed to identify the number and type of nursing staff working in the facility on the form posted. On 3/06/25 at 9:53 AM, the Staffing coordinator stated she was responsible for posting the form. The Staffing Coordinator acknowledged that the facility name was not on the Nurse Staffing Form, and that the form did not identify the number and type of staff working. The Coordinator stated the company was undergoing changes, so she was not sure what company name to put on the sheet. ON 3/06/25 at 1:03 PM, the Administrator stated there was a staffing meeting at about 11:00 AM daily. The Administrator explained that last week, the facility received a call that their name was changing, so we stopped putting the facility name on the posted daily staffing sheet. The Administrator confirmed the posting was for public viewing, so it should reflect the facility's name.

Based on observation, interview, and record review, the facility failed to establish a system for the prevention of communicable diseases by failing to ensure all residents were offered and encouraged to perform hand hygiene before meals for all residents eating meals in the dining room. Findings: On 3/04/25 at 12:00 PM, in the main dining room, approximately 28 residents were observed eating lunch. Several of the residents stated they were not offered a way to clean their hands prior to meals while one resident stated he was only offered a napkin. On 3/05/25 at 10:25 AM, approximately ten residents were observed finishing a morning snack in the main dining room, after which they proceeded to move to the front of the dining room for morning exercise. A short time later at 11:00 AM, 12 residents were observed participating in exercises to music while sitting in their wheelchairs, after which most of these residents moved to the dining tables to eat lunch. None of these residents, nor others who joined the dining room afterwards, were offered a means to clean their hands before the meal was served. On 3/05/25 at 12:13 PM, Recreation Aide H stated many of the residents who participated in the morning snack then stayed in the dining room for lunch. She stated if they requested to wash their hands, they used the sink in the dining room that the staff used to wash their hands. Recreation Aide H explained if the residents' hands were very dirty, staff would take the resident back to their rooms for the CNA to clean them. She stated the residents were cleaned in the morning before they came to morning activities. Then after lunch, they would take them back to their room to be changed and cleaned again before Bingo at 2 PM. On 3/06/25 at 9:31 AM, Activities Director stated as an activity person, they sent the residents back to their room to be cleaned up and she expects that if a resident goes to their room, they will be changed and their hands washed. She acknowledged that some residents will go to therapy or somewhere else on their own, but it never occurred to her to wipe or disinfect their hands right before meals and she will discuss this with the Administrator. The facility' policy entitled Hand Hygiene and Resident Cleanliness Policy During Meal Times stressed the importance of hand hygiene to prevent the spread of infection and to maintain a safe, sanitary environment for both residents and staff. It included a Reminder to ensure staff clean resident's hands and face before and after eating and that wet wipes were to be available at all times.

Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 62 residents, (#44, and #92). Findings: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, emphysema, and general anxiety disorder. A review of the Minimum Data Set (MDS) Admission assessment, with an assessment reference date of 12/09/24, revealed resident #44 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. On 3/03/25 at 4:12 PM, resident #44 was observed with an Albuterol Tartrate HFA inhaler on her overbed table. The resident stated she took it as needed. On 3/3/25 at 4:33 PM, primary care nurse, License Practical Nurse (LPN) C observed and acknowledged the resident's inhaler at her bedside. LPN C stated the resident had physician orders that she may have the inhaler at the bedside. Review of the Electronic medical record (EMR) revealed a physician order dated 1/16/25 for Levalbuterol Tartrate inhalation Aerosol 45 micrograms/actuation (MCG/ACT) 2 packet inhale orally every 6 hours as needed for shortness of breath. There was no order to keep the medicine at bedside or for the resident to self-administer the medication. 2. Resident #92 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, major depression, and emphysema. A review of the MDS Quarterly assessment, with an assessment reference date of 1/29/25, revealed resident #44 had a BIMS score of 15/15, indicating she was cognitively intact. On 3/03/25 at 4:41 PM, LPN C, the primary nurse, acknowledged resident #92 with her inhaler in her jacket pocket. LPN C stated that resident #92 had a physician order that allowed her to keep her inhaler at the bedside. A review of the EMR reflected a physician order dated 4/30/24: Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 1 puff inhale orally every 4 hours as needed for SOB. The resident may have at the bedside. On 3/02/25 at 5:10 PM, the Assistant Director of Nursing searched the EMR for orders for self administration for residents #44 and #92. The ADON confirmed there was a physician order for resident #92 to keep the inhaler at bedside, but resident #44 did not. On 3/06/25 at 10:45 AM, the Director of Nursing (DON) explained before a resident could keep medications at the bedside, an assessment for self-administration should be performed by nursing staff. The DON continued, that if a resident wanted to self-administer medications, they needed to have a physician's order for self-administration, a self-administration evaluation was completed and a care plan for self-administration of drugs was initiated. The DON acknowledged that staff had not followed the facility's policy and procedures to ensure resident self-administration safety for resident #44 and #92. Review of the facility's policy and procedure for administering medication dated 2/21/23 revealed, residents may self -administer their medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they had the decision-making capacity to do so.

Based on interview, and record review, the facility failed to rensure an accurate Preadmission Screening and Resident Review (PASARR) level I and level II evaluation was completed for 2 of 2 residents reviewed for PASARRs, of a total sample of 62 residents, (#55, and #26). 1. Review of the medical record revealed resident #55 was admitted to the facility on [DATE] from an acute care hospital. Some of her diagnoses included type 2 diabetes, morbid obesity, hypothyroidism, pain, major depressive disorder, panic disorder, anxiety disorder and Post-Traumatic Distress Disorder (PTSD). Resident # 55's Quarterly Minimum Data Set (MDS) assessment with assessment reference date of 11/30/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated she had no cognitive impairment. Her active diagnoses listed under Psychiatric Disorders included anxiety, depression and PTSD. On 3/04/25, upon further review of resident #55's electronic medical records, the PASARR dated 2/22/24 Level I screen was found to have not been updated since anxiety disorder was the only Mental Illness diagnosis listed in Section 1A of the form. The diagnoses included on the Level I screen did not include major depressive disorder, panic disorder or PTSD. On 3/05/25 at 1:45 PM, the Lead MDS coordinator acknowledged resident # 55's Level I PASARR was missing the diagnoses and was inaccurate. 51023 2. Resident #26 was initially admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy. She was discharged from the facility on 4/26/24 and readmitted on [DATE] following a right hip fracture. The Admission Record or face sheet listed diagnoses including dementia with behavioral disturbances, insomnia, depression, and psychotic disorder with delusions due to known physiological condition, and anxiety. A psychiatry consult from 6/26/24 revealed that resident #26 was admitted with medications for diagnoses of dementia and insomnia. Resident #26 was started on Depakote sprinkles 250 milligrams (mg) two times a day for psychotic disorder on 1/02/24. Resident #26's care plan initiated on 7/12/24 indicated the resident had impaired cognition which affected communication, functional abilities, decision making, and judgement related to psychosis and dementia. The resident's PASARR forms dated 11/03/23 and 6/24/24 were completed by prior to admission to the facility. The form had no diagnosis listed under Section IA Mental Illness or suspected Mental Illness. On 3/05/25 a new Level I PASARR, completed by the Lead MDS Coordinator, was added to the Resident's clinical record. Under Section 1: Mental Illness or Suspected Mental Illness the following diagnoses were listed: anxiety disorder, depressive disorder and insomnia. The Lead MDS Coordinator on 3/05/25 at 10:44 AM, stated the facility had been reviewing and updating PASARRS of residents within the facility. She reviewed resident #26's PASARR from 3/05/25 and confirmed that the diagnosis of anxiety disorder, depressive disorder and insomnia were listed under Section 1 on the PASARR. The Lead MDS Coordinator confirmed that the PASARR she had just completed was incomplete as it did not have psychotic disorder with delusions listed. She then stated, I'm old and miss things sometimes. On 3/05/25 at 1:2 PM, the Lead MDS Coordinator revealed that the facility initiated a Performance Improvement Project following a discussion with the Psychologist Consultant and a subsequent email on 2/26/25. The email revealed, here is the info for the PASRRs from today's patients followed by a 25 resident names with diagnoses next to them. Resident #26 was listed with the diagnoses of depression, insomnia and dementia next to her name. When asked if the diagnoses next to the resident's names were current diagnoses or instead what was listed on the PASARR at the present time, she replied I'm not sure. But I think they are either missing or need to be added to the PASARR. On 3/05/25 at 1:45 PM, the Social Service Director revealed that the diagnosis listed in the email was the same diagnoses that should be listed on the PASARR. The Social Service Director was unable to answer whether if a diagnosis was not listed next to a resident's name, it meant that the diagnosis was no longer current and thus did not need to be on the PASARR. She stated the facility was performing daily audits but was unable to clarify how she was able to complete these audits herself every day. The facility policy titled Social Services - PASARR indicated, the facility shall ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission and that individuals identified with a mental disorder or intellectual disability are evaluated and receive care and services in the most integrated setting appropriate to their needs.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents reviewed for choices, of a total sample of 62 residents, (#93). Findings: Resident # 93 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Parkinsonism, anemia, syncope and collapse, and hypertensive heart disease without heart failure. Her most recent Minimum Data Set (MDS) showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which meant she had no impairment in cognition. On 3/03/25 at 4:47 PM, resident #93 explained she and facility staff were very careful with her blood pressure because she passed out a few times and so she spent most of the day at the therapy gym. Review of the physician orders included Vital signs every shift and Midodrine HCL oral tablet 10 milligrams (mg). Give one tablet via G-Tube three times a day for hypotension. Parameters included Hold for Systolic Blood Pressure greater than 120 millimeters of mercury. A review of resident # 93's Care Plan initiated on 12/17/24 revealed a focus on the potential for alterations in blood pressure had interventions which included administer medication as ordered, blood pressure as indicated or as ordered and to report signs and symptoms of complications related to alterations in blood pressure. Review of the blood pressure summary for resident # 93 since admission on 12/16/24 indicated that the resident's blood pressure had been measured only once after 2/26/25, on 3/03/25. There were no record of blood pressure measurements for 3/04/25 or 3/05/25. Upon further review, no blood pressure measurement was documented for 2/01/25 through 2/08/25 nor from 1/11/25 through 1/17/25. At 12:56 PM, the assigned nurse Registered Nurse (RN) A stated she administered the morning medication Midodrine and checked resident #93's blood pressure. She was unable to show where she documented the blood pressure in the resident's electronic medical record. RN A could not find documentation anywhere. RN A checked her report sheet but confirmed she did not record the blood pressure there either. She stated she would have held the Midodrine if the systolic blood pressure was greater than 120. RN A in reference to the documentation of resident #93's blood pressure reading, said there was something missing. On 3/05/25 at approximately 1:02 PM, the South Wing Unit Manager confirmed the findings that blood pressure was not documented and explained that it may have been when their electronic record system changed over. She acknowledged from the record, the blood pressure measurement was not done but medication was given. The South Wing Unit Manager did not know if the medication was administered within the prescribed parameters. On 3/05/25 at 1:17 PM, the Director of Nursing (DON) said that based on what was documented, the resident's blood pressure was not taken but the medication was administered. The DON acknowledged she was not here during that time and that supplemental orders for blood pressures to be recorded were now in the system. A review of the facility's policy for Administering Medications with an effective date of 4/01/22 and revised on 2/21/23 revealed the purpose was to ensure that medications were administered in a safe and timely manner and as prescribed. Section 9 b. indicated that vital signs were checked, if necessary, for each resident prior to administering medications.

Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice, and per physician orders for 2 out of 2 residents reviewed for respiratory care, of a total sample of 62 residents, (#35, & #85). Findings: 1. Resident #35 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, unspecified ulcerative colitis, celiac disease, pulmonary embolism (PE) and history of breast cancer. A review of the annual Minimum Data Set (MDS) assessment with reference date 2/12/25 revealed resident #35 had no cognitive impairment, no behaviors, no rejection nor refusal of care and required the use of oxygen. The physician orders for oxygen read continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Resident #35 had a plan of care for shortness of breath related to COPD, recent pneumonia and PE with interventions that included oxygen as ordered and for staff to notify the physician if the resident refused oxygen therapy. On 3/03/25 at 3:51 PM, resident #35 was observed sitting up in bed and explained she was here for rehabilitation. The level of oxygen on the oxygen concentrator was set at 3 LPM and she stated it was at 3 LPM of oxygen because her oxygen levels kept dropping. On 3/04/25 at 12:48 PM, resident #35 was up in her wheelchair with a portable oxygen tank set at 3 LPM of oxygen. She said she was comfortable and had no complaints at the time. On 3/05/25 at 10:47 AM, the assigned nurse Licensed Practical Nurse (LPN) A confirmed the amount of oxygen resident #35's concentrator was set to as 3 LPM of oxygen. Resident #35 then told LPN A that the Pulmonologist had seen her and said that 3 LPM of oxygen was ok. LPN A confirmed the physician order was for 2 LPM. LPN A stated she knew to check the orders to ensure the resident was on the correct amount of oxygen. She confirmed she did not do it this morning. A few minutes late the Unit Manager for the South wing verified the resident was recently seen by the Pulmonologist but they had not written anything in the notes about increasing her oxygen to 3 LPM. She also indicated that the Pulmonologist does not enter orders by herself, instead, she would have written an order for facility staff to enter new orders. The Director of Nursing (DON) was also present at the nurses' station and along with the South Wing Unit Manager (UM) acknowledged that oxygen orders were not followed for resident #35. On 3/06/25 at 3:52 PM, the DON stated her expectation was that nurses would check the oxygen orders and verify the concentrator setting so that the resident received oxygen as ordered. The facility's Policy on Oxygen Administration dated 4/01/22 indicated The purpose of the procedure is to provide guideline for safe oxygen administration and the preparation in section 1. described, Verify that there is a physician order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 50401 2. Resident #85 was admitted on [DATE] with diagnoses of type II diabetes mellitus, abnormal posture and unsteadiness of feet, muscle weakness, sepsis, hypertensive disease with heart failure, chronic kidney disease, and heart failure. The MDS assessment dated [DATE], revealed the resident was assessed with a BIMS of 15/15, which indicated he was cognitively intact. Section O of the MDS revealed the resident was not on oxygen at admission nor during this stay at the facility. On 3/03/25 at 1:32 PM, resident #85 was in his room with his sister. He was receiving 2 liters of oxygen from an oxygen concentrator, connected to a nasal cannula. The resident stated he arrived with oxygen from the hospital and used it daily, even when he received dialysis. He reported he had labored breathing and was short of breath without it. Resident #85 added nursing staff changed the oxygen tubing every Sunday night or early Monday morning, but they didn't do it this week. On 3/05/25 at 12:37 PM, LPN F confirmed there was no order for oxygen, nor an order for changing oxygen tubing, that was active or discontinued during the resident's current stay. LPN F verified resident #85 received oxygen and stated assigned nurses were supposed to ensure the tubing was changed weekly by checking the date on the tubing during their daily shift rounds. LPN F checked the date on resident #85's oxygen tubing and found it to be dated 2/24/25, 9 days prior. She removed the oxygen nasal cannula from the resident's nose and told him she needed to change the tubing. LPN F confirmed resident #85 had been receiving oxygen during his stay without a physician's order and the tubing had not been changed in the past 9 days. Review of the hospital discharge form indicated resident #85 received continuous oxygen at 2 LPM. The facility-Admission NURSING Data collection form indicated the resident was admitted on [DATE] with an oxygen saturation rate of 96% from oxygen via nasal cannula. In error, the form indicated in the Respiratory Risk section; the resident did not have any issues which might create a risk for respiratory complication such as Congestive Heart Failure (CHF). Review of nine Nursing and APRN Progress Notes from between 2/13/25 to 2/18/25 revealed resident #85 received oxygen through a nasal cannula and the APRN's Note on 2/13/25 confirmed the resident did have CHF. On 3/06/25 at 10:24 AM, the Administrator stated it was her expectation for nursing to not provide patient care treatment without Physician orders. The Administrator confirmed in addition to nurses checking dates on tubing, staff were also to check oxygen tubing dates during angel rounds as a back-up for increased accuracy of compliance to infection control policies. The facility's policy entitled Nursing-Physician orders dated 4/01/22 and revised 3/10/23, stated its purpose was to ensure the plan of care is followed in accordance with the orders established by the physician or nurse practitioner. It added, medications and treatments would be administered only upon the written order of a person duly licensed to prescribe them.

Based on observation, interview, and record review, the facility failed to ensure Pharmacist recommendations were addressed by the physician for 1 of 5 resident reviewed for unnecessary medications, of a total sample of 62 residents, (#57). Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral brain hemorrhage, muscle weakness, abnormalities of gait and mobility, moderate protein-calorie malnutrition, anxiety, depression, and hypertension. The resident's Care Plan dated 12/16/24 stated the resident was at risk for falls due to weakness and adverse effects of psychotropic medications with intervention to watch for signs and symptoms such as gait disturbance, sedation, lightheadedness, dizziness and change in mental status, mentation, and mood. Review of the medical record revealed on 1/13/25, the pharmacist submitted a recommendation for the physician to evaluate the order for the antidepressant, Mirtazapine (Remeron), and to consider tapering the dose from 15 milligrams (mg) to 7.5 mg per night or implementing an alternative treatment due to resident's recent fall. The record revealed this recommendation was never addressed by the physician. On 1/13/25, the pharmacist recommended the physician evaluate possible causal relationship between resident receiving Gabapentin for neuropathy and anxiety at 200 mg, three times day and his recent fall. They also recommended to consider a trial to taper this medication to 200 mg, two times per day if appropriate. Review of the record revealed this recommendation was never addressed by the physician. On 3/06/25 at 9:30 AM, the Director of Nursing (DON) confirmed resident #57's Pharmacist drug regimen reviews and recommendations had not been addressed prior to her starting at the facility, nor had they been addressed yet by her. She stated she was trying to catch up on the incomplete work from the previous DON. On 3/06/25 at 10:24 AM, the Administrator started her expectation was for the DON to address pharmacist recommendations by notifying the physician and documenting their response in a timely manner. She added that she was not aware some of them from January had not been addressed, but that the new DON was trying to catch up. The facility's policy entitled Pharmacy Services-Drug Regimen Review dated 1/10/25 indicated the drug regimen of each resident should be evaluated at least monthly by a licensed pharmacist, and any irregularities reported to the attending physician, Medical Director, and DON. It continued, the attending physician shall document the recommendation that has been reviewed, and what, if any, action has been taken to change the medication and their rationale for doing so.

Based on interview, and record review, the facility failed to ensure an allegation of neglect was reported to the relevant State Agencies within the regulatory timeframe for 1 of 2 resident reviewed for Abuse and Neglect, (#1). Findings: Resident #1, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease, hypertension, dysphagia (difficulty swallowing), anxiety disorder, and dementia. Review of the resident's quarterly Minimum Data Set assessment dated [DATE], revealed the resident was rarely/never understood, and was dependent on staff assistance for her activities of daily living (ADLs). Review of the facility's incident log reflected the resident had a fall on 11/01/24, and review of the reportable log revealed an entry for resident #1 dated 11/01/24, classified as neglect. On 12/02/24 at 1:40 PM, the entries for the resident on the facility's incident and reportable logs were discussed with the Director of Nursing (DON). She recalled that on 11/01/24 the Evening Supervisor called her and reported that the resident fell . The DON explained that on 11/01/24 at 10:45 PM, Certified Nursing Assistant (CNA) A called for help, and when the resident's assigned nurse responded, she found resident #1 lying on the floor on her right side, blood was coming from the resident's right temple. The DON recalled she asked the resident's assigned nurse Registered Nurse (RN) B how the fall happened, since the resident was bedbound. She said the RN explained that while CNA A was providing incontinence care for the resident, the CNA pulled the resident towards her using the bed linen, she then turned the resident away from her, and the resident rolled to the opposite side of the bed, fell to the floor, sustained a laceration/injury to her right temple, and was sent out to the hospital. The DON stated the incident happened because CNA A rolled the resident away from her, instead of towards her. She explained that after each fall, the Interdisciplinary (IDT) team would meet to discuss the fall, evaluate, and implement interventions to prevent a fall from happening again, and during the IDT meeting on 11/04/24, the facility decided that the incident was possible neglect, and an immediate [State Survey Agency] report should be submitted. When asked why an Immediate Report was not submitted as per regulatory guidelines of two hours after an allegation was made, or within 24 hours if no serious bodily injury occurred, the DON stated that when a fall occurred on a Friday, the IDT would meet on the following Monday to discuss the fall. She stated that while watching the re-enactment of the event by CNA A on 11/04/24 she saw where the error was, and the management team decided then that it was a reportable incident. However, the CNA's action of turning the resident away from her, instead of towards her was discussed and reported to the DON on 11/02/24 by RN B. On 12/02/24 at 3:37 PM, in an interview conducted with CNA A, who was accompanied by the Assistant Director of Nursing, the CNA confirmed that on 11/01/24 she was resident #1's assigned CNA. She stated the resident required total care with her ADLs, and verbalized that prior to the resident's fall on 11/01/24, the resident required one person assist for ADLs, and mechanical lift with two persons for transfers. CNA A recalled that on 11/01/24 at approximately 9:00 PM to 10:00 PM while providing incontinence care for the resident, she turned the resident to her left side away from her, by crossing the resident's legs, and pulling the pad or bedsheet. She said the resident was lying on her left side and demonstrated that she was standing on the right side of the resident's bed. CNA A said resident #1 reached towards the bedside table on the left of her bed and fell from the bed. She said she tried to grab the resident but could not hold on to her, and the resident sustained an injury to her right temple. On 12/02/24 at 4:48 PM, the Evening Supervisor recalled that on 11/01/24 at approximately 10:00 PM-11:00 PM, she was called to the South Wing. She verbalized that Licensed Practical Nurse B, and CNA A were with resident #1, who was lying on the floor on her back. The Supervisor said she observed a scratch to the resident's right temple, and the nurse was applying pressure to the area and monitoring the resident's blood pressure. She recalled CNA A stated the resident rolled out of bed when she was trying to change her. She recalled that after the resident was sent to the emergency room , CNA A re-enacted the scene for her, and she notified the DON. The Supervisor said in the reenactment the CNA had turned the resident away from her to provide care. On 12/03/24 at 8:22 AM, in a telephone interview, the resident's family member stated the resident had dementia, spoke English but had reverted back to her native language Hungarian. The family member said the resident could not move her body, could not grab something or move if asked/told to. She recalled that on 11/01/24 the facility notified the family that the resident had a fall and had to go to the hospital. She said the facility dropped the resident, and recalled the resident's roommate at the time told her that at approximately 10:00 PM, resident #1 soiled herself, and needed changing. The roommate recounted that one CNA came in, pulled the bedsheet, and rolled the resident off the bed, and she hit the ground hard. The family member said she completed a grievance on 11/02/24 and documented negligence in the care of resident #1. On 12/03/24 at 11:38 AM, the DON acknowledged that an Immediate [State Survey Agency] report should have been completed for the incident on 11/01/24. She stated she had access to the reporting system on the weekend, but at the time of the incident she was focusing on the fact that CNA A followed the resident's plan of care pertaining to the number of persons required to provide incontinence care for resident #1. On 12/03/24 at 12:01 PM, the Social Service Director (SSD) recalled that on 11/04/24 she received a grievance pertaining to resident #1 that was documented by the resident's daughter on 11/02/24 at 12:00 PM and placed under the SSD's door. The SSD stated that on 11/04/24 she along with the Administrator and the DON called the resident's daughter, and at that time the daughter wanted to vent her frustration and kept using the word neglect. The SSD stated the facility then decided to do a reportable, since the resident's daughter wanted, more than a grievance process. Review of the grievance documented by the resident's daughter dated 11/02/24 at 12:00 PM, indicated the resident fell out of bed, due to the negligence of her CNA. Interviews with staff involved and record review of resident #1's medical record revealed the incident with resident #1 occurred on 11/01/24 at approximately 10:45 PM. CNA A neglected to use the proper technique for turning/positioning while providing incontinence care for the resident. A grievance alleging negligence was documented on 11/02/24 at 12:00 PM, however this was not acknowledged or acted upon until 11/04/24. An Immediate [State Survey Agency] report pertaining to neglect was not submitted until 11/04/24 at 6:26 PM, 42 hours after the allegation was made. The facility's policy Abuse: Florida dated April 1, 2022, read, The facility will ensure that all alleged violations involving .neglect .are reported immediately, but not later than 2 hours after the allegation is made .or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials (including to the State Survey Agency).

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate risks to prevent elopement for 1 of 5 residents reviewed for elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, harm, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died . On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of 35 miles per hour. The route along the way had uneven terrain and curbs. Approximately 0.1 miles from the facility was a large lake, and approximately 0.4 miles, there was a high speed railroad crossing. The facility was unaware of the resident's elopement until a Registered Nurse (RN) realized he was missing but they failed to search for him for approximately 90 minutes. At approximately 9:50 PM, staff located the resident in the parking lot of a shopping center. The facility staff were unaware of the resident's whereabouts for approximately two hours until the resident's son called to inform them of his location. Findings: Cross reference F689 Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from an acute care hospital on [DATE]. His diagnoses included dementia, diabetes, speech and language deficits following stroke, abnormalities of gait (walking pattern) and mobility, unsteadiness on feet, and history of falls. The Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of [DATE] revealed resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively impaired. Functional Abilities and Goals showed the resident required staff assistance with eating, self-care, mobility, and to complete Activities of Daily Living (ADL). The assessment noted the resident required skilled Physical Therapy, insulin for diabetes, anti-platelet medication to prevent blood clots, and diuretics (fluid removing) medications. The MDS Admission Assessment with ARD of [DATE] noted it was very important to the resident to be outside to get fresh air in good weather, and he fell within the previous month, and fell prior to his admission to the facility. The Admission Data Set assessment dated [DATE] revealed resident #1 was only oriented to himself and he required extensive staff assistance of 1 person for transfers, mobility, ADLs, and ambulated with the assistance of a walker. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 required a surrogate for decision making, a front-wheeled walker for ambulation and 1 assistant for transferring. Review of the Order Summary Report noted active physician's medication orders included: Jardiance (blood sugar lowering) 10 Milligrams (MG) once daily, Glargine Insulin 7 Units once daily for diabetes, Humalog Lispro Insulin 100 Units/Milliliter before meals and at bedtime if needed, Atorvastatin 40 MG at bedtime for cholesterol, Metoprolol 25 MG once daily for blood pressure, Midodrine 10 MG every 8 hours for blood pressure, Aldactone (diuretic) 12.5 MG once daily for excess fluid, Entresto (heart receptor response) ,d+[DATE] MG once daily and at bedtime for heart failure, Plavix (anti-platelet) 75 MG once daily for heart disease, Xarelto (blood thinner) 10 MG once daily for heart disease, Trazodone (anti-depressant) 100 MG at bedtime for depression, and Lithium Carbonate (mood stabilizer) 150 MG three times daily for mood. Medications due when the resident eloped were Entresto, Atorvastatin, and Humalog Insulin at 9:00 PM, and Midodrine at 10:00 PM. Physician orders included behavior monitoring for wandering, (initiated on [DATE]), wandering/elopement risk ([DATE] and [DATE]), close monitoring for safety ([DATE]), one on one with sitter for exit seeking behavior ([DATE]). and wanderguard (alerting bracelet) placement and monitoring ([DATE]). A comprehensive Care Plan included potential for abnormal bleeding related to anticoagulant and antiplatelet medications, potential for falls/fall related injuries related to weakness, potential for elopement related to being ambulatory with intermittent confusion, and pacemaker ([DATE]), impaired cognition affecting communication, decision making, and judgement ([DATE]). Interventions in the care plan included to assist the resident as needed to specific destinations such as activity room or dining room, assist outside to patio if requested, divert from exits as needed, if goes outside, stay with resident and then assist back inside and report to nursing, report any noted exit seeking behaviors such as verbalizations of wanting to go home, verbalizations of plans to leave, and physical attempts to leave facility, ([DATE]). Elopement Risk Screens dated [DATE], [DATE], and [DATE] showed nurses determined resident #1 was at risk for elopement due to cognitive impairment, mobility, poor decision-making skills, wandering oblivious to safety needs, and his ability to exit the facility. Instructions indicated that if the resident exhibited any of the above behaviors, staff were to report to the Director of Nursing (DON). There were no other interventions noted. The Social Services Initial Social assessment dated [DATE] noted resident #1 fell and hit his head prior to admission to the facility, and he was slow in making decisions with memory problems. The Social Services Update note dated [DATE] showed the resident had short term and long term memory problems with slow cognition, communication, and decision making abilities. Fall Risk Screens dated [DATE], [DATE], and [DATE] noted resident #1 fell at the facility. The Physical Therapist (PT) Evaluation and Plan of Treatment Assessment Summary completed on [DATE] noted diagnoses of unsteadiness on feet, abnormalities of gait and mobility, generalized muscle weakness, and abnormal posture. The resident was referred for skilled physical therapy following notable changes in function since his skilled therapy was discontinued on [DATE]. The assessment noted the resident had impaired hip, knee, and ankle strength, had increased difficulty with transfer, ambulation and balance, felt unsteady when walking, and worried about falling. The Plan of Treatment dated [DATE] noted resident #1 had an uneven step length and wide support base with Fall Predictors due to asymmetrical stance and discontinuity of steps with a Risk Factors of falls. The daily shift Behaviors records from [DATE] to [DATE] documented the resident had wandered 22 times prior to elopement. The Elopement Book used for staff to identify residents at high risk of elopement included resident #1's record dated [DATE], more than two months before the resident eloped. The psychiatric provider's progress notes dated [DATE] indicated resident #1 was diagnosed with Adjustment Disorder and noted agitation, wandering, verbal or physical aggressiveness, and safety concerns of fall risk. The [DATE] note revealed resident #1 was assessed for dementia with impaired insight and judgement, and the inability to complete instrumental or basic ADL activities without staff assistance. The report read, . Staff counseled regarding safety concern: Fall risk, risk of wandering, and physical aggression . According to historical data by zip code, on [DATE] between 8:00 PM and 10:00 PM the outside temperature was 75 degrees Fahrenheit (retrieved from timeanddate.com on [DATE]) and sunset was at 5:42 PM (retrieved from aa.usno.navy.mil on [DATE]). On [DATE] at 6:19 PM, resident #1 was observed in his room sitting on the bed supervised by Certified Nursing Assistant (CNA) E. The resident said he remembered leaving the facility, but not why he left and stated, I went home. I didn't make it because I stopped, this is the place where they crash people. The CNA said she knew the resident well, and was regularly assigned to his care. She added, he doesn't know where he is; he thinks he's at an apartment right now. On [DATE] at 2:15 PM, resident #1 was observed in his room walking to the bathroom with the assistance of a walker. The resident walked with short steps, and his feet did not fully clear the floor. The resident attempted to walk without the walker and visibly became unbalanced after two steps. In a telephone interview on [DATE] at 12:58 PM, RN B said he worked the 7:00 PM to 7:00 AM shift on [DATE] and was assigned to resident #1. The RN recalled after he received off going report at approximately 8:05 PM, he was unable to locate resident #1, so he began looking around the building because the resident was known to wander everywhere. He said CNA D told him she last saw the resident around the time he received report. The RN explained he tried to locate resident #1 himself for about 30 minutes. He said the Wound Care Nurse was the Supervisor, and at approximately 8:45 PM, he told her he could not find resident #1. He explained at approximately 9:15 PM, he told the Supervisor a second time he still had not located resident #1. On [DATE] at 3:18 PM, CNA D said she knew resident #1 well and he was often included in her assignments during the 3:00 to 11:00 PM shift. The CNA described the resident as shaky, he wandered the facility, and often told staff he wanted to go home. She said the resident's son lived close by and visited frequently which made the resident feel better. The CNA recalled she was assigned to the resident #1's care on [DATE] on the evening shift and last saw him in his room between 7:45 PM and 8:00 PM, before he eloped. On [DATE] at 5:59 PM, Licensed Practical Nurse (LPN) C noted resident #1 was exit seeking and paced all over the place; he walked up and down the building. She recalled on [DATE] at approximately 9:00 PM, RN B asked her if she had seen resident #1. She said she checked back with the RN at 9:15 PM and he had not located the resident. She explained she was concerned the RN did not seem overly worried. She remembered within about 15 minutes, at approximately 9:30 PM, an elopement/missing resident alert was initiated and all staff engaged in an active search for the resident. On [DATE] at 11:00 AM, the Wound Care Nurse/Supervisor said she worked in her office and supervised staff during the 3:00 PM to 11:00 PM shift on [DATE]. She recalled LPN C called her at 9:33 PM to let her know staff were unable to locate resident #1. She explained she called the Director of Nursing (DON) who assisted her by telephone as she implemented the facility's missing resident/elopement protocol. She explained that while they searched for the resident, the resident's son telephoned and informed them the resident was at a nearby shopping center. Review of a nursing progress note written by RN A on [DATE] noted on [DATE] at 9:30 PM, the RN was alerted a resident was missing and a facility wide search was initiated. The note showed during the search, resident #1's son called the facility to inform them the resident was at a nearby shopping center and two nurses drove to the location and brought the resident back to the facility. On [DATE] at 7:44 PM, RN A said she knew resident #1 well and said he frequently wandered around the facility with his walker. The RN recalled on [DATE] at approximately 9:30 PM, she assisted with the search and drove around the surrounding area in the dark looking for resident #1. She said she returned to the facility after she was unable to locate the resident and received a call from the resident's son to let staff know resident #1 was at a nearby shopping center. She said the resident's son was concerned as his father was lost and did not know how to get back to the facility. She explained she immediately drove to the shopping center and saw the resident in the parking lot with LPN C. The RN stated, he said he went for a ride and there was a lady at the door. On [DATE] at 5:59 PM, LPN C recalled on [DATE] at approximately 9:50 PM, they found resident #1 lost and alone without his walker in the nearby shopping center parking lot. She said the resident told her he went for a walk. The nurse said she was concerned about the resident because his gait was unsteady, and he needed his walker. The LPN stated, I couldn't believe he got that far, I was worried because there's water right over there, and his cognition is off. In a telephone interview on [DATE] at 10:03 AM, CNA G said he worked during the 3:00 PM to 11:00 PM shift on [DATE] but was not assigned to resident #1. He said he assisted residents for a group smoke break from about 9:00 PM to 9:30 PM. The CNA explained all staff started a search for resident #1 at approximately 9:30 PM and stated, I didn't even know what he looked like. On [DATE] at 1:31 PM, the DON explained on [DATE], the Wound Care Nurse was in the building during the evening shift and covered staff supervision. The DON recalled at approximately 9:30 PM, she received a call from her and learned resident #1 was missing. She said she directed her to implement the facility's missing resident policy. On [DATE] at 11:18 AM, resident #4 who was cognitively intact said he was resident #1's roommate for a few months, including the day he eloped. Resident #4 recalled resident #1 often told staff he was leaving and stated, especially when he got mad. On [DATE] at 11:33 AM, PT I explained the resident required assistance of a walker for stability, to walk safely, and to decrease his risk for falls. He said the resident was assessed outside for unleveled surfaces and curb navigation. The PT said the resident required increased staff assistance while outside with the additional obstacles and stated, he does not walk very fast; I would say he had no shot navigating streets independently; if it's dark outside, it's even worse. On [DATE] at 12:07 PM, the South Unit Manager said staff were expected to notify her if any resident was noted to be exit seeking or if they verbalized they wanted to leave. She explained nurses completed an Elopement Risk Assessment and Change In Condition form, and the Elopement Books contained information of residents at risk for elopement. She stated the facility utilized additional one to one supervision when at risk residents verbalized they wanted to leave. She said she was never notified by any staff that resident #1 verbalized threats or the desire to exit the facility. On [DATE] at 12:26 PM, the North Unit Manager said staff were expected to notify the supervisors when residents at risk for elopement expressed desire to leave. She explained, any identified issues were discussed daily with the Interdisciplinary Team (IDT) as additional interventions may be required to prevent elopement and the physician and family were notified. On [DATE] at 12:32 PM, the Social Services Director said she participated in resident #1's care planning, care plan meetings, and IDT discussions. She recalled she was never asked to initiate any interventions nor participated in discussions about the resident's risk for elopement or his verbal expressions to leave the facility. On [DATE] at 12:43 PM, CNA L said he knew resident #1 well. He explained the resident was confused, and he did not walk very well without his walker because his balance was poor. The CNA recalled a month or two prior to the incident, resident #1 was distressed and told staff he wanted to go home. He said the resident packed a bag and nurses had to call his son to come to the facility to calm him down. The CNA stated, he loved to pack his things in a bag, like he's ready to go. On [DATE] at 3:45 PM, RN K said she sometimes worked the 7:00 PM to 7:00 AM shift and she knew resident #1 well. She said resident #1 often had trouble using his phone to call his son and she had to help him. The RN recalled an occurrence before the resident eloped when he said he wanted to go home. She discussed the resident being out in the dark by himself and said the resident could have easily fallen and hit his head because he had a shuffled gait. The RN stated, I never thought he would go out of the building. On [DATE] at 3:45 PM, CNA Q said he worked on [DATE] during the 3:00 PM to 11:00 PM shift. The CNA recalled he assisted in the search to locate resident #1, but he did not know what the resident looked like, so he checked the computer. The CNA explained he started work at the facility approximately two weeks prior to the incident and he did not recall receiving education about how to locate missing residents during his new employee orientation. The CNA stated, the active search was mostly word of mouth. On [DATE] at 3:19 PM, the DON said before resident #1 eloped, he was included in the Elopement Books for staff reference, and the Electronic Health Record (EHR) noted special instructions to alert staff of his elopement risk. She explained nurses and CNAs were expected to know who the high risk residents were and they relied on the binders and EHR to alert them. In a telephone interview on [DATE] at 11:22 AM, resident #1's son recalled on [DATE] at approximately 9:50 PM, he spoke to his father by phone. He said the resident told him the phone was not working, he was lost and did not know how to get home. The resident's son stated, he was incoherent, calling me about money and the phone. He said he determined through their conversation the resident was close to a nearby grocery store. He explained he immediately hung up, called the facility to let them know where the resident was, and called his father back while he maintained the call until the resident was located by facility staff. The resident's son conveyed he was very concerned because it was dark and there was a train crossing and open water nearby where his father could have fallen into. He stated, he has in an out confusion and needs a walker just to get to the bathroom. He explained the resident had history of falls and wandered into traffic. He recalled he informed staff that police had once found his father laying down on a 4 lane road at 3:00 AM. He added, he didn't know where he was, or which way to go. He explained his father had a simple flip-style cellular phone with my name in it so it's easier for him to call me. He stated it was a wonder his father managed to call him when he eloped as he usually could not remember how to use the phone. He recalled about a month ago, he was asked to come to the facility to calm the resident down and added, he was packing his stuff to leave. On [DATE] at 10:17 AM, the DON explained she expected staff to immediately initiate the facility's elopement protocols when they were unable to locate a resident. She said she was not aware the resident often verbalized he wanted to leave and stated, he wasn't exit-seeking; if he was, I would put him on one to one immediately. The DON conveyed staff did not act timely or with a sense of urgency after they realized the resident was missing. She stated, it wasn't activated per policy. On [DATE] at 3:30 PM, the DON was asked why local police were not called to assist their search to which she replied, that's a great question; they should have called the police before they called me. The DON acknowledged resident #1 was subjected to dangerous hazards while out in the dark unsupervised and she did not explain why she did not direct staff to call law enforcement after she was notified the resident was missing. In a telephone interview on [DATE] at 11:21 AM, the Medical Director recalled the facility notified him resident #1 eloped. He said he was not familiar with the resident and conveyed he expected the facility to ensure residents at risk for elopement were kept safe with appropriate interventions and re-evaluations when behaviors escalated. Review of the facility's standards and guidelines dated [DATE] titled Nursing Elopement Prevention read, . it is the policy of this facility to provide a safe environment for all residents and to eliminate and/or control elopement behavior of residents. The facility shall do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should either occur. Examples of wandering or elopement behaviors include . exit seeking with or without rational purpose, verbalization of plans to leave the facility . if the resident is not located promptly, the Administrator/Director of Nursing should notify the local police (or 911) . Review of the facility's standards and guidelines dated [DATE] titled Nursing Missing Resident/Elopement read, . the staff who noted the resident to be missing should notify the Nursing Supervisor immediately. The Nursing Supervisor/designee on duty should be responsible for: I. Organizing a search team . Review of the facility's standards and guidelines dated [DATE] titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of Unknown Source and Investigation read, . Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as noted in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyors: *On [DATE], the resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event. *On [DATE], the Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision. *On [DATE], the facility conducted a head count of all current residents; all were safe and accounted for. *On [DATE] and [DATE], all exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified. *On [DATE], re-evaluations/review of all current residents for elopement risk was conducted. *On [DATE], all door codes were changed. *On [DATE], an Immediate Federal Report was filed. *On [DATE], DCF (Florida Department of Children and Families) agent arrived to investigate inadequate supervision with findings unsubstantiated. *On [DATE] and [DATE], the DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified. *On [DATE], the Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process. *On [DATE], weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review. *On [DATE], French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased. *On [DATE], review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders. *On [DATE], the Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed [DATE], with no identified concerns. *From [DATE] to [DATE], the DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests. *On [DATE], 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation. *On [DATE], electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation. *On [DATE], 24-hour door monitors were scheduled until the wanderguard system installation completion. *On [DATE], Ad Hoc QAPI attended by Medical Director, DON, and Regional [NAME] President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review. *[DATE], plans and interventions in place were determined by the facility to be effective. Review of the facility's attendance records noted staff participated in education on the topics listed above. *From [DATE] to [DATE] interviews were conducted with 32 staff members who represented all shifts. The facility's staff included 37 licensed nurses and 67 CNAs. Interviewed staff included 6 RNs, 6 LPNs, 14 CNAs, 1 Certified Dietary Manager, 1 Housekeeper, 1 Physical Therapy Assistant, 2 Receptionists, and 1 Maintenance Director. All interviewed staff verbalized understanding of the education provided. The resident sample was expanded to include 4 additional residents at risk for elopement/neglect. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #2, #3, #5 and #6.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 5 residents reviewed for Elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious life-threatening injury, harm, or even death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died . On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of 35 miles per hour. The route along the way had uneven terrain and curbs. Approximately 0.1 miles from the facility was a large lake, and approximately 0.4 miles, there was a high speed railroad crossing. The facility was unaware of the resident's elopement until a Registered Nurse (RN) realized he was missing but they failed to search for him for approximately 90 minutes. At approximately 9:50 PM, staff located the resident in the parking lot of a shopping center. The facility staff were unaware of the resident's whereabouts for approximately two hours until the resident's son called to inform them of his location. Findings: Cross reference F600 Review of the medical record revealed resident #1, a [AGE] year-old male, was admitted to the facility from an acute care hospital on [DATE]. His diagnoses included dementia, diabetes, speech and language deficits following stroke, abnormalities of gait (walking pattern) and mobility, unsteadiness on feet, and history of falls. The Admission Data Set assessment dated [DATE] revealed resident #1 was only oriented to himself and he required extensive staff assistance of 1 person for transfers, mobility, Activities of Daily Living (ADLs), and required a walker to walk safely. The Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of [DATE] revealed resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated he was cognitively impaired. Functional Abilities and Goals showed the resident required staff assistance with eating, self-care, mobility, and to complete Activities of Daily Living (ADL). The assessment noted the resident required skilled Physical Therapy, insulin for diabetes, anti-platelet medication to prevent blood clots, and diuretics (fluid removing) medications. The MDS Admission Assessment with ARD of [DATE] noted it was very important to the resident to be outside to get fresh air in good weather, and he fell within the previous month, and fell prior to his admission to the facility. The Speech and Language Pathologist (SLP) Evaluation and Plan of Treatment completed [DATE] noted the resident's memory function and cognitive impairments were unsafe for participation in daily life tasks with risk factors that read, fall risk. The SLP Discharge Summary dated [DATE] showed the resident required cues to recall important information. Review of Elopement Risk Screens dated [DATE], [DATE], and [DATE] showed nurses determined resident #1 was at risk for elopement due to cognitive impairment, decreased mobility, poor decision-making skills, wandering oblivious to safety needs, and his ability to exit the facility. Instructions indicated a positive risk finding was to be reported to the Director of Nursing (DON). No other interventions were noted. The Social Services Initial Social assessment dated [DATE] noted the resident fell and hit his head prior to admission to the facility, and he was slow in making decisions with memory problems. The Social Services Update note dated [DATE] noted the resident had short term and long term memory problems with slow cognition, communication, and decision making abilities. In a telephone interview on [DATE] at 11:22 AM, resident #1's son recalled on [DATE] at approximately 9:50 PM, his father called him and told him he was lost and did not know how to get home. The resident's son stated, he was incoherent, telling me about money and the phone. He said he determined through their conversation that his father was close to a nearby grocery store. He explained he immediately hung up, called the facility to let them know where the resident was, and called his father back while he maintained the call until the resident was located by facility staff. The resident's son conveyed he was very concerned because it was dark and there was a train crossing and open water nearby that his father could have fallen into. He said, he has in an out confusion and needs a walker just to get to the bathroom. He explained the resident had history of falls and wandered into traffic. He recalled he informed staff that police had once found his father laying down on a 4 lane road at 3:00 AM. He added, he didn't know where he was, or which way to go. He explained his father had a simple flip-style cellular phone with my name in it so it's easier for him to call me. He stated it was a wonder his father managed to call him when he eloped as he usually could not remember how to use the phone. He recalled about a month ago, he was asked to come to the facility to calm the resident down and added, he was packing his stuff to leave. According to historical data by zip code, on [DATE] between 8:00 PM and 10:00 PM at the facility, the outside temperature was 75 degrees Fahrenheit (retrieved from timeanddate.com on [DATE]) and sunset was at 5:42 PM (retrieved from aa.usno.navy.mil on [DATE]). On [DATE] at 3:45 PM, RN K said she knew resident #1 well. She said resident #1 often had trouble using his phone to call his son and she had to help him. The RN recalled an occurrence before the resident eloped when he said he wanted to go home. She said the resident could have easily fallen and hit his head when he left the facility in the dark as his gait was not steady and he shuffled. On [DATE] at 6:19 PM, resident #1 was observed in his room sitting on the bed supervised by Certified Nursing Assistant (CNA) E. The resident said he remembered leaving the facility, but not why he left and stated, I went home. I didn't make it because I stopped, this is the place where they crash people. The CNA said she knew the resident well and was regularly assigned to his care. She added, he doesn't know where he is; he thinks he's at an apartment right now. On [DATE] at 2:15 PM, resident #1 was observed in his room walking to the bathroom with the assistance of a walker. The resident walked with short steps, and his feet did not fully clear the floor. The resident attempted to walk without the walker and visibly became unbalanced after two steps. On [DATE] at 11:33 AM, Physical Therapist I explained the resident required assistance of a walker to stabilize and walk safely. He said the resident required increased staff assistance while outside with the additional obstacles and stated, he does not walk very fast; I would say he had no shot navigating streets independently; if it's dark outside, it's even worse. On [DATE] at 12:43 PM, CNA L said resident #1 was confused, and he did not walk very well without his walker because his balance was not good. He said CNAs were expected to check residents who wandered every 15 minutes. He noted that before resident #1 eloped, he was not aware of all the high risk residents, only those he was assigned to or informed of by other staff. The CNA recalled a month or two prior to the incident, resident #1 was distressed and told staff he wanted to go home. He said the resident packed a bag and nurses had to call his son to come to the facility to calm him down. The CNA stated, he loved to pack his things in a bag, like he's ready to go. On [DATE] at 10:22 AM, CNA O explained before resident #1 eloped, residents who were a high risk for elopement and falls were checked by CNAs every 15 minutes and after the alerting bracelet system was implemented, checks were changed to every hour. She said if a resident was missing, she reported it to the nurse and staff started a facility wide head count. On [DATE] at 3:45 PM, CNA Q said he worked on [DATE] during the 3:00 PM to 11:00 PM shift. The CNA recalled he assisted in the search to locate resident #1, but he did not know what the resident looked like so he checked the computer. The CNA explained he started work at the facility approximately two weeks prior to the incident and he did not recall receiving education about how to locate missing residents during his new employee orientation. The CNA stated, the active search was mostly word of mouth. On [DATE] at 5:59 PM, Licensed Practical Nurse (LPN) C noted resident #1 was exit seeking and paced all over the place; he walked up and down the building. She recalled on [DATE] at approximately 9:00 PM, RN B asked her if she had seen resident #1. She said she checked back with the RN at 9:15 PM and he had not located the resident. She explained she was concerned the RN did not seem overly worried. She remembered within about 15 minutes, at approximately 9:30 PM, an elopement/missing resident alert was initiated and all staff engaged in an active search for the resident. In a telephone interview on [DATE] at 12:58 PM, RN B said he worked the 7:00 PM to 7:00 AM shift on [DATE] and was assigned to resident #1. The RN recalled after he received off going report at approximately 8:05 PM, he was unable to locate resident #1, so he began looking around the building because the resident wandered everywhere. He said CNA D told him she last saw the resident around the time he received report. The RN explained he tried to locate resident #1 himself for about 30 minutes. He said the Wound Care Nurse was the supervisor that evening and at approximately 8:45 PM, he told her he could not find resident #1. He explained at approximately 9:15 PM, he told the Wound Care Nurse a second time he still hadn't found the resident. The RN explained when he worked after hours, staff left the inside lobby french doors opened. He recalled when he worked on [DATE] he passed the lobby on his way to get report and, the two double doors were not locked, and residents could get into the lobby. On [DATE] at 3:18 PM, CNA D said she knew resident #1 well and he was often included in her assignments during the 3:00 to 11:00 PM shift. The CNA described the resident as shaky, he wandered the facility, and often told staff he wanted to go home. She said the resident's son lived close by and visited frequently which made the resident feel better. The CNA recalled she was assigned to the resident #1's care on [DATE] on the evening shift and last saw him in his room between 7:45 PM and 8:00 PM, before he eloped. On [DATE] at 9:50 AM, the Wound Care Nurse recalled on [DATE] at 8:11 PM, she sent a group text asking if a new admission was expected because ambulance personnel had arrived with a patient. The nurse said CNA Q assisted her in the lobby and entered the code to unlock the front entrance doors to let the ambulance personnel out. She explained the inside lobby french doors did not lock and made a sound to alert staff when they opened. The nurse stated, we try to have the inside doors open. On [DATE] at 3:45 PM, CNA Q recalled on ,d+[DATE]//24 at approximately 8:15 PM, he assisted the Wound Care Nurse with ambulance personnel at the front lobby entrance. The CNA explained prior to resident #1's elopement, the inside lobby double doors were never closed. On [DATE] at 4:49 PM, Receptionist F explained visitors were required to sign in and out at the reception desk and there was an Elopement Book with photos and information kept there to alert staff of residents that were high risk. She said she activated the front door exit alarms when she left for the day and staff had to use the keypad code to unlock it. She recalled on [DATE] at approximately 4:45 PM, she left for the day and after that, the staff were responsible for the front keypad visitor entrance/exit access. On [DATE] at 8:17 AM, the Maintenance Director recalled before resident #1 eloped, the inside lobby double doors were not alarmed. He explained, the former Nursing Home Administrator (NHA) was aware the doors required an electrical inspection in order to use the alarm box because it was connected to the fire panel alarm system for magnetic doors. He said the double doors never had a lock. On [DATE] at 7:44 PM, RN A said she knew resident #1 well and staff knew he frequently wandered around the facility with his walker and he paced. The RN recalled on [DATE] at approximately 9:30 PM, she assisted the search and drove around the surrounding area which was more difficult to see in the dark. The nurse said she returned to the facility after she was unable to locate the resident and received a call from the resident's son to let staff know resident #1 was at a nearby shopping center. She said the resident's son was concerned as his father was lost and did not know how to come back. She explained she immediately drove to the shopping center and saw the resident in the parking lot with LPN C. The RN stated, he said he went for a ride and there was a lady at the door. On [DATE] at 11:00 AM, the Wound Care Nurse said she worked in her office and supervised staff during the 3:00 PM to 11:00 PM shift on [DATE]. She said according to her phone record, LPN C called her at 9:33 PM to let her know staff were unable to locate resident #1. She explained she called the DON who assisted her by telephone as she implemented the facility's missing resident/elopement procedures. The nurse said while staff searched, a call came in from the resident's family member who informed them the resident was at a nearby shopping center. Review of a nursing progress note written by RN A on [DATE] noted on [DATE] at 9:30 PM, the RN was alerted a resident was missing and a facility wide search was initiated. It was noted during the search, resident #1's son called the facility to inform them the resident was at a nearby shopping center; two nurses drove to the location and he was transported back to the facility. On [DATE] at 5:59 PM, LPN C recalled on [DATE] at approximately 9:50 PM, she found resident #1 lost and alone without his walker in the nearby shopping center parking lot. She said the resident told her he went for a walk. The nurse said she was concerned about the resident because his gait was unsteady and he needed his walker. The LPN stated, I couldn't believe he got that far; I was worried because there's water right over there, and his cognition is off. On [DATE] at 3:19 PM, the DON said before he eloped, resident #1 was included in the Elopement Books for staff reference, and the Electronic Health Record (EHR) noted special instructions to alert staff of his elopement risk. She explained nurses and CNAs were expected to know who the high risk residents were and they relied on the books and EHR to alert them. Review of the Elopement Book used for staff to identify residents at high risk of elopement included resident #1's record dated [DATE], more than two months before the resident eloped. On [DATE] at 1:31 PM, the DON recalled on [DATE], the Wound Care Nurse was in the building during the evening shift and covered staff supervision. She said at approximately 9:30 PM, she received a call from the nurse to inform her resident #1 was missing and she assisted her over the phone to implement the facility's elopement policy. The DON explained after 5:00 PM on weekends, the front exit doors were unlocked by keypad and all staff had the code. She said between approximately 8:00 PM and 8:15 PM, the front lobby exit doors were unlocked by staff for entry of ambulance personnel with a stretcher. She said after the incident, resident #1 was interviewed and gave a physical description of CNA G who was outside in the parking lot when he exited. She concluded the CNA may have been outside on a smoke break. The DON said resident #1 left his walker and told them when transportation personnel exited, he got to the door before it latched and she stated, as his words, I high-tailed it; I had to move fast. On [DATE] at 10:17 AM, the DON explained she expected staff to immediately initiate the facility's resident/elopement protocols when they were unable to locate a resident. She said she was not aware resident #1 often verbalized he wanted to leave and stated, he wasn't exit-seeking; if he was I would put him on one to one supervision immediately. The DON conveyed staff did not act timely or with a sense of urgency after they realized the resident was missing and noted, it wasn't activated per policy. On [DATE] at 3:30 PM, the DON was asked why local police were not called to assist their search and she replied, that's a great question, they should have called the police before they called me. The DON acknowledged resident #1 was subjected to dangerous hazards while out in the dark unsupervised and she did not explain why she did not direct staff to call law enforcement after she was called. In a telephone interview on [DATE] at 11:21 AM, the Medical Director recalled that some time shortly after the incident, the facility notified him resident #1 eloped. He said he was not familiar with the resident and conveyed he expected the facility to ensure residents at risk for elopement were kept safe with appropriate interventions and re-evaluations when behaviors escalated. Review of the facility's standards and guidelines dated [DATE] titled Nursing Elopement Prevention read, . it is the policy of this facility to provide a safe environment for all residents and to eliminate and/or control elopement behavior of residents. The facility shall do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should either occur. Examples of wandering or elopement behaviors include . exit seeking with or without rational purpose, verbalization of plans to leave the facility . if the resident is not located promptly, the Administrator/Director of Nursing should notify the local police (or 911) . All staff are to be aware of the potential wandering/elopement attempts and be prepared to intervene: a. All door alarms must be operational 24 hours per day . Review of the facility's standards and guidelines dated [DATE] titled Nursing Missing Resident/Elopement read, . the staff who noted the resident to be missing should notify the Nursing Supervisor immediately. The Nursing Supervisor/designee on duty should be responsible for: I. Organizing a search team . Review of the facility's standards and guidelines dated [DATE] titled Visitor Sign In Policy stated the facility's policy ensured residents were not accidentally let out of the facility. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as noted in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyors: *On [DATE], the resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event. *On [DATE], the Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision. *On [DATE], the facility conducted a head count of all current residents; all were safe and accounted for. *On [DATE] and [DATE], all exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified. *On [DATE], re-evaluations/review of all current residents for elopement risk was conducted. *On [DATE], all door codes were changed. *On [DATE], an Immediate Federal Report was filed. *On [DATE], DCF (Florida Department of Children and Families) agent arrived to investigate inadequate supervision with findings unsubstantiated. *On [DATE] and [DATE], the DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified. *On [DATE], the Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process. *On [DATE], weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review. *On [DATE], French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased. *On [DATE], review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders. *On [DATE], the Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed [DATE], with no identified concerns. *From [DATE] to [DATE], the DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests. *On [DATE], 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation. *On [DATE], electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation. *On [DATE], 24-hour door monitors were scheduled until the wanderguard system installation completion. *On [DATE], Ad Hoc QAPI attended by Medical Director, DON, and Regional [NAME] President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review. *[DATE], plans and interventions in place were determined by the facility to be effective. Review of the facility's attendance records noted staff participated in education on the topics listed above. *From [DATE] to [DATE] interviews were conducted with 32 staff members who represented all shifts. The facility's staff included 37 licensed nurses and 67 CNAs. Interviewed staff included 6 RNs, 6 LPNs, 14 CNAs, 1 Certified Dietary Manager, 1 Housekeeper, 1 Physical Therapy Assistant, 2 Receptionists, and 1 Maintenance Director. All interviewed staff verbalized understanding of the education provided. The resident sample was expanded to include 4 additional residents at risk for elopement/neglect. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #2, #3, #5 and #6.

Based on observation, and interview, the facility's administration failed to implement it's resources to maintain effective elopement prevention measures to ensure the safety of residents known to be at high risk of elopement. On 10/26/24 at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of 35 miles per hour. The route along the way had uneven terrain and curbs. Approximately 0.1 miles from the facility was a large lake, and approximately 0.4 miles, there was a high speed railroad crossing. The facility was unaware of the resident's elopement until a Registered Nurse (RN) realized he was missing but they failed to search for him for approximately 90 minutes. At approximately 9:50 PM, staff located the resident in the parking lot of a shopping center. The facility staff were unaware of the resident's whereabouts for approximately two hours until the resident's son called to inform them of his location. Findings: On 11/17/24, it was noted the facility's inside lobby doors and alerting bracelet alarm systems were not activated. Facility staff stated the former Nursing Home Administrator (NHA) was aware of the problems since approximately March 2024, however measures required to fully inspect and activate the equipment were not taken, for 9 months. In an interview on 11/20/24 at 8:17 AM, the Maintenance Director recalled when he began work at the facility approximately nine months prior, the facility's magnetic lock system was not working properly. He said the inside lobby double door alarm worked, but it was not being utilized by staff. He said equipment was installed prior to his employment however, it was connected to the fire alarm system and unknown if the double door alarm box was programmed for proper functioning without arming the fire alarms. He said a certified service company was required for electrical and alarm inspections to ensure there were correct operations. He said approximately four to five months prior, partial inspections were completed but required additional fire system operational revisions which were not completed until after resident #1 eloped. He said on 7/29/24, invoices were provided to secure the alarms and alerting bracelet systems and stated, it was very costly; the administrator said the person before him wanted to get it started, but he never got it started. I believe it was on the back burner for some time. Review of an Invoice and Call Summary for services provided on 7/25/24 read, . wiring mag (magnetic) locks on front door . unable to test . need to get door locks to activate before testing . In a telephone interview on 11/18/24 at 12:58 PM, Registered Nurse (RN) B recalled on 10/26/24, at approximately 7:45 PM, he passed the lobby on his way to receive shift report. He said there was no receptionist on duty and the inside double doors were open, the double doors were not locked and residents could get into the lobby. On 11/20/24 at 3:19 PM, the Director of Nursing (DON) recalled when she began working at the facility approximately 5 months prior, she was concerned the facility did not have an alerting bracelet system. She said the former NHA relayed there was an equipment box installed at the front exit doors that was not activated. She explained she asked about having the system implemented and was aware of a very high cost requirement. The DON stated, it was constantly at my forefront trying to get the system. We were always told it was being looked at but never given a reason why the system wasn't fixed. On 11/18/24 at 1:45 PM, the Regional Nurse Consultant said the NHA was not available and was not working at the facility. Review of the facility's standards and guidelines dated 4/01/22 and titled Administration/Governing Body read, . Policy Interpretation and Implementation: . provision of a safe physical environment equipped and staffed to maintain the facility and services . Review of the facility's standards and guidelines dated 4/01/22 and titled Nursing-Elopement Prevention read, . If identified as high risk for elopement, the nurse should apply an electronic monitoring device to the resident, initiate an elopement risk care plan and obtain an MD (Medical Doctor) order for the electronic monitoring device. Review of the facility's undated job description with the job title, Nursing Home Administrator read, . Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of Management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.

Based on interview, and record review, the facility failed to ensure a Do Not Resuscitate Order (DNRO) form was signed and properly completed for 1 of 1 resident reviewed for advanced directives from a total sample of 36 residents, (#52). Findings: Review of medical record revealed resident #52 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of heart and circulatory disease, stroke, speech and language deficits, malnutrition, and dysphagia (difficulty swallowing), schizoaffective disorder and moderate dementia with behavioral disturbance. The record showed the resident was placed under Hospice care and services on 11/07/2022. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date 5/21/2023 noted staff assessed the resident was rarely or never understood, had cognitive skills for decision making that were severely impaired, disorganized thinking was continually present, inattention was present and fluctuated, and the resident had not rejected evaluation or care. The assessment showed the resident required extensive staff assistance to complete activities of daily living, was frequently incontinent of urine and bowels, received antidepressant medications for 7 out of 7 days, was under hospice care and services, and there were no active plans for him to be discharged from the facility during the look back period. The Order Summary Report included active physician's orders dated 12/18/2021 for the resident's code status as, Do Not Resuscitate (DNR). The Determination of Incapacity dated 2/03/2022 showed a physician determined the resident lacked capacity to provide informed consent to make medical decisions and he had no reasonable medical probability of recovering mental and physical capacity to directly exercise his rights. The Health Care Proxy document scanned to the medical record noted the resident's daughter was appointed as his health care decision maker on 2/04/2022. The comprehensive care plan included focus items for, DNR advanced directives with interventions to verify the presence of yellow DNR form and the physician's order, appointed health care surrogate for health care decisions, and the goal was to ensure the advanced directives were in effect and carried out, on an ongoing basis, dated 11/25/2020. The electronic health record and paper chart kept at the North Unit nurses station contained a yellow-colored State of Florida DNRO (DH Form 1896 revised December 2002) that was signed by the physician on 11/19/202. The form did not have any applicable boxes checked for surrogate, proxy, court appointed guardian, or durable power of attorney as required when no informed consent could be directly obtained from the patient. The Patient's Statement portion noted an undated signature line that included the handwritten name of the resident's son and the word, verbal. The Care Plan Conference Sheet noted on 5/11/2022 a meeting was held and the resident's son participated with discussions that included, code status, dc (discharge) plans will remain at (facility name) long term care. On 6/21/2023 at 2:25 PM, the Social Services Director stated she was responsible for the advanced directives and DNR documents process. She explained the DNRO yellow form for incapacitated residents must include a box checked under the patient's statement with a physical signature and date. She said there was a process in place to secure signatures for family representatives who could not complete it with her face to face at the facility. She checked the medical record and acknowledged resident #52's DNRO form was not signed, nor was the resident's son the appointed health care surrogate. She stated the form also did not have any of the required applicable boxes checked. She said the form was completed before she began working at the facility and could not explain why it was not completed properly or later verified for accuracy. She said resident #52's DNRO was, not valid. Review of the facility's policies and procedures form CCG 00521 dated 2020 read, VIII. The Facility shall: A. not be required to provide care that conflicts with an advanced directive . PROCEDURE I B. The facility shall update and disseminate amended information as soon as possible, but no later than 90 days from the effective date of the changes .

Based on interview and record review, the facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a later identified Mental Illness (MI) for 1 of 1 resident reviewed for PASARR from a total sample of 36 residents, (#52). Findings: Review of resident #52's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including metabolic encephalopathy (brain function abnormality), rhabdomyolysis (muscle injury), and stroke. Diagnoses of other schizoaffective disorders, adjustment disorder with mixed anxiety, anxiety disorder, moderate dementia with behavioral disturbance, speech and language deficits, malnutrition, and dysphagia (difficulty swallowing) were added to the resident's plan of care after he was admitted . The medical record showed a PASARR screen was completed on 1/25/2021 by acute care hospital staff. Section I noted there was no Mental Illness (MI) present or suspected. The diagnosis of other schizoaffective disorders noted as, during stay was added to resident #52's plan of care, effective 8/04/2021. On 6/21/2023 at 1:46 PM, the Social Services Director said residents' PASARRs were reviewed by Admissions staff and any clinical questions or concerns were reviewed by the Director of Nursing (DON). She explained the former DON had completed any updates for residents who remained in the facility, and she was not a designated screener. On 6/22/2023 9:10 AM, the Interim DON provided a copy of the PASARR completed on 1/25/2021 located in the resident's medical record. She acknowledged the form indicated there were no known or suspected mental illnesses and schizoaffective disorder was included on the list in section I. She said the medical record showed on 8/04/2021 the diagnosis of other schizoaffective disorders was added and noted, during stay. On 6/21/23 at 4:33 PM, the Interim DON said she had not completed any PASARRs and she had just started working at the facility on 6/19/2023. She explained she was not aware who the designated screener was for the facility, and the former DON completed them. She could not explain why a PASARR was not completed for the resident after a mental illness was diagnosed . Review of the facility's policies and procedures dated 4/01/2022 titled, Pre-Admission Screening and Resident Review (PASRR) program, read, 2. Coordination includes: . b. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review . , and 5., A nursing facility must notify the state mental health authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) level I for possible Serious Mental Illness (SMI) for 1 of 1 resident from a total sample of 36 residents (#55). Findings: Review of resident #55's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include schizoaffective disorder, major depressive disorder, psychotic disorder with delusions, unspecified dementia. A level I PASARR screen was completed on 2/11/2022 by acute care hospital staff. Section I inaccurately noted there was no Mental Illness (MI) present or suspected. The medical record revealed all the above diagnoses to be present on admission. Review of physician orders included Lexapro for depressive disorder with a start date of 2/16/22, Seroquel for schizoaffective with a start date of 5/12/23. On 6/21/23 at 10:00 AM, the Director of Nursing (DON) stated the Social Service Director (SSD) and the Director of Admissions should ensure the resident has an accurate PASARR upon admission. She stated the PASARR should be reviewed by the DON for accuracy when the resident was admitted to the facility. The DON said the SSD should also review it for accuracy. Review of the facility's policy and procedure titled, Pre-Admission Screening and Resident Review (PASRR) program, dated 4/01/2022 read: The facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program. Coordination includes: Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Based on observation, interview, and record review, the facility failed to implement care and services to maintain or prevent decline in Activities of Daily Living (ADL) abilities, for 1 of 3 residents reviewed for Rehabilitation and Restorative services from a total sample of 36 residents, (#98). Findings: Review of the medical record revealed resident #98 was admitted on [DATE] and readmitted on [DATE] from an acute care hospital and had diagnoses that included stroke, encephalopathy (brain dysfunction), aphasia (difficulty speaking/understanding speech), dysphagia (difficulty swallowing), malnutrition, gastrostomy dependence (feeding tube), lack of coordination, muscle weakness, syncope (fainting) and collapse, heart failure, dependence on supplemental oxygen, type 2 diabetes mellitus, and depression. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 5/22/2023 noted the resident was unable to complete the Brief Interview for Mental Status and was assessed by staff to have moderately impaired cognitive skills for decision making, inattention fluctuations, and no behaviors or rejections of evaluation or care for health and well-being. The assessment noted it was very important for the resident to participate and engage in her daily routines and preferences. She was noted to be totally dependent on staff to complete ADLs, required an indwelling urinary catheter, was incontinent of bowel, received more than 51% of nutrition from a tube feeding, was at risk for developing pressure injuries, received skilled Speech and Language (SLP) therapy services for 3 days, Occupational Therapy (OT) for 5 days, and Physical Therapy (PT) for 5 days during the lookback period. On 6/19/2023 at 2:30 PM, resident #98 was observed awake in bed and her daughter was sitting at her bedside. The resident's daughter stated that her mother had been hospitalized for a while after she had a massive stroke before coming to the facility. She explained she was distressed that the resident had not received therapy services for at least a week after she had progressed and improved over the past month. She said the only range of motion or muscle exercise assistance her mother received since then was provided by her when she visited every day. She indicate her mother had already gotten worse with moving in bed. She said therapy staff told her they had tried to get approval to continue therapy but they weren't able to. She was visibly upset while she explained therapy stopped providing services because, we can't pay. The Order Summary Report included physician's orders for Full Code status, left resting hand splint, skilled PT services 5 times per week for 30 days starting on 5/17/2023, speech therapy for 30 days with 20 total visits, starting on 5/17/2023, and OT 5 times per week for 30 days starting on 5/16/2023. On 6/21/2023 at 12:23 PM, the Therapy Director said residents' length of skilled therapy services was sometimes affected by contractual payment agreements between the discharging hospital and the facility, because the hospital was paying for a specific number of days. She reviewed the resident's medical record and explained the resident was discharged from therapy services because it was her, last covered day. She said after therapy services ended on 6/13/2023, therapy staff developed a functional maintenance/restorative program of exercises to be provided by nursing services so the resident could maintain the progress she made and prevent declines. She provided an undated copy of the Functional Maintenance Program Instructions form that outlined an individualized program of exercises for the resident. She could not explain why there was no date on the form and stated the services should have been started on 6/14/2023. She said she had given the form to the Director of Nursing (DON) to implement. Review of the medical record revealed a letter of agreement was completed by the hospital prior to the resident's admission to the facility for payment of care and services including skilled therapy for 30 days. The comprehensive care plan included focus items that showed the resident was interested in her choice of activities, had impaired communication with an intervention for SLP treatment, risk for skin injury, risk for respiratory complications with interventions to assist with positioning to maximize lung functioning, ADL and mobility impairment with dependence on staff assistance and a goal to minimize complications through nursing and therapeutic interventions. The OT Evaluation and Plan of Treatment assessed the resident required services to facilitate her increased ability to participate in functional daily activities, and the use of a left-hand splint to reduce the risk of further immobility. The report noted skilled services were required to gain strength, restore cognitive and perceptual abilities, and maximize rehabilitation potential and without treatment, the resident was at risk for further decline in function, immobility, compromised general health, and decreased ability to return to her prior level of supervision. The OT Discharge Summary completed on 6/12/2023 noted the resident had responded and consistently progressed during the last 30 days of treatments but she had not reached her, highest practicable level. The prognosis for functional maintenance was, good with consistent staff follow-through with a risk of developing contractures (muscle tightening) and further decline in her ADL functioning abilities without maintenance exercises. The PT Evaluation and Plan of Treatment noted the resident required services to facilitate improvement in self-functioning with treatments for restoration/compensation, use of assistive devices, compensatory strategies to minimize falls, and enhance the resident's quality of life by improving her ability to return to her prior level of functioning. The PT Discharge Summary completed on 6/13/2023 noted the resident had made consistent progress throughout the plan of treatment, recommendations for an exercise program to continue, long term care, and a good prognosis to maintain her level of functioning abilities with, consistent staff follow-through. The Functional Maintenance Program Instructions form for the resident noted instructions for staff to provide active and passive range of motion activities 3 to 5 times per week and transferring from the bed to a high back wheelchair for 4 to 6 hours, 3 to 5 times per week. Review of the Task Listing Report for Certified Nursing Assistants (CNAs) did not include instructions or tasks to complete resident #98's Functional Maintenance Program exercises. On 6/22/2023 at 10:03 AM, the interim South Unit Manager said she received the Restorative/Functional Maintenance program on 6/21/2023 to enter into CNA tasks so Restorative CNAs could complete exercises with the resident according to the individualized plan. She explained the resident's program had not been implemented because she was not aware of, nor had she been provided the plan of care. She stated that Restorative CNAs reported to her, and they documented completion of Restorative/Functional Maintenance exercises in the CNA task software. On 6/21/2023 at 4:37 PM, the interim DON said resident #98 had not received functional maintenance/restorative nursing services because there was a delay in receiving the program from the Therapy Director. She said she received the plan earlier that day right after it had been developed. She explained that she was unable to locate restorative program forms for any residents and she did not know which residents were received restorative services. She stated, I'm not sure they every existed. Review of the facility's policies and procedures dated 4/01/2022 titled Specialized Rehabilitative and Restorative Services, read, 4. The facility will provide restorative services such as . walking, transfer training, . Range of Motion (ROM), splint and brace, eating and/or swallowing, . care and communication, when necessary as indicated by the assessment of the Interdisciplinary team.

Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for oxygen of a total sample of 36 residents, (#79). Findings: Resident #79 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, and anxiety. On 6/20/23 at 1:36 PM, the resident was seen lying in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:10 AM, the resident was seen sitting up in bed with oxygen at 2 liters per nasal cannula. On 6/21/23 at 9:20 AM, a review of resident #79's medical record revealed no order for oxygen therapy. Review of the Medication Administration Record and Treatment Record reflected no documentation of oxygen being administered for resident #79. On 6/21/23 at 9:30 AM, Registered Nurse B stated resident #79 was on oxygen but he could not find an order in the computer for the resident's oxygen liter flow. He stated it may be in the hospice book. On 6/21/23 at 9:40 AM, the South wing Unit Manager (UM) acknowledged there was no physician order for oxygen therapy for resident #79. The UM stated the hospice nurse gave the facility written orders to place in the electronic medical record (EMR) because they did not have access to the EMR. She clarified there was no order for oxygen in the resident's hospice chart. On 6/22/23 at 12:48 PM, the Director of Nursing stated her expectation was that residents on oxygen would have a physician order for oxygen.

Based on observation, interview, and record review, the facility failed to ensure behavior monitoring and side effects of antipsychotic medication were documented for 2 of 5 residents reviewed for unnecessary medications out of a total sample of 36 resident, (#55, #67). Findings: 1. Resident #67 was readmitted to the facility on [DATE] with a previous admission on 7/20/22 with diagnoses of dementia, Alzheimer's disease, malignant neoplasm of prostate, bipolar disorder, and hallucinations. Review of quarterly Minimum Data Set (MDS) with assessment reference date of 4/30/23 revealed short- and long-term memory problems. The resident's care plan initiated 1/23/23 revealed a focus for potential side effects related to psychotropic medications with interventions to observe for potential side effects, notify physician and psych services to follow. Review of the resident's physician orders revealed antipsychotic medication, Risperidone 1 milligram (mg) ordered 1/27/23 to be given by mouth twice a day for dementia, psychotic disturbance, mood disturbance, anxiety, hallucinations, and bipolar disorder. A physician order dated 4/29/23 noted antianxiety medication, Diazepam 2 mg, give 1 mg by mouth at hours of sleep for anxiety. Review of behavioral note dated 7/25/22 showed monitor for mood and behaviors. Psych note dated 4/4/23 revealed resident #67 has a history of dementia with behaviors and is taking Risperidone for bipolar disorder. Psych note dated 5/1/23 and 6/1/23 showed staff to document and monitor behaviors. Review of resident #67 physician orders for the month of June 2023 revealed no order for behavior or side effect monitoring, and no documentation noted on medication administration record (MAR) or treatment administration record (TAR) for behavior or side effects monitoring. On 6/21/23 at 10:57 AM, the interim Director of Nursing said behavior monitoring and side effect monitoring were done for residents receiving psychotropic medications. She stated it is a batch order and it has to be activated by nursing and documented on the MAR. She stated the unit managers monitored nursing documentation but ultimately, she was responsible. On 6/21/23 at 1:10 PM, Licensed Practical Nurse (LPN) H stated nurses were to assess and document on residents' psychotic medications for behavior monitoring and side effects. On 6/21/23 at 1:24 PM, Registered Nurse (RN) B stated resident #67 had no behaviors, and did not yell out. He stated they were supposed to monitor, and document behaviors and side effects on the MAR if a resident received psychotropic medications. He stated the resident received the medication for dementia. Review of physician orders entered into the MAR with RN B revealed medications related to unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hallucinations, unspecified bipolar with dementia. On 6/21/23 at 5:02 PM, during a telephone interview, the facility's consultant pharmacist stated behavior monitoring for psychotropic medications was a routine part of their drug regimen review, and she could not explain how it was missed for resident #67. 39943 2. Resident #55 was admitted to the facility on [DATE] with diagnoses to include schizoaffective depression, psychotic disorder, anxiety disorder, and mood disorder. Review of the physician active orders noted antianxiety medication, Lorazepam (Ativan) Gel 25mg/ml, apply to wrist topically every 8 hours as needed for anxiety, antipsychotic medication, Seroquel 100 mg once a day and 300 mg at bedtime for schizoaffective disorder, antidepressant medication, Trazadone 100 mg at bedtime for depression. There was no order noted for behavior monitoring. Review of the MAR and TAR reflected no documentation of behavior monitoring for any of the psychotropic medications. On 6/21/23 at 3:53 PM, the interim DON stated resident's new orders and admission orders were reviewed Monday through Friday and in clinical morning meeting, which is how they ensured behavior monitoring, and side effect monitoring was ordered for residents on psychotropic medications. The DON did not explain how behavior and side effect monitoring was missed. Review of the facility's policy for Psychotropic Drug Use with no effective date showed each customer receiving antipsychotic medications for organic mental disorders is observed for episodes of the behavioral symptoms being treated and /or manifestation(s) of the disordered thought process, adverse reactions and side effects.

Based on interview, and record review, the facility failed to allow a resident to remain in the facility, failed to provide rationale as to why the resident's care needs could not be met at the facility and failed to document attempts at meeting those needs before transfer for 1 of 3 residents reviewed for transfers of a total sample of 5 residents, (#1). Findings: Resident #1 was admitted to the facility on the evening of 4/04/23 from an acute care hospital with diagnoses that included heart failure, chronic lung disease, anxiety disorder, left great toe amputation and alcohol abuse. The Admission Record dated 5/05/23 indicated resident #1 had a previous admission to the facility in March of 2019 with primary diagnosis of acute respiratory failure and additional diagnoses of alcohol abuse and anxiety disorder. Resident #1 had a Minimum Data Set (MDS) Entry dated 4/04/23. A second MDS Discharge assessment was dated 4/05/23 and indicated resident #1 had an unplanned discharge to a nursing home and was not expected to return. Section C of the assessment which assessed mental status was not completed. Section D which assessed the resident's mood was not completed. Section E which assessed behaviors indicated resident #1 had wandered 1-3 days. The behavior assessment also documented resident #1 had no physical, verbal or other behaviors, rejection of care nor any psychosis during the look back period. Review of a late entry progress note dated 4/04/23 at 11:00 PM, revealed the Director of Nursing (DON) received a phone call from the charge nurse who reported resident #1 was disruptive, loud, cursing and trying to enter other sleeping residents' rooms. The DON recommended one to one supervision with a male Certified Nursing Assistant (CNA) and instructed the nurse to call the attending physician for resident #1's behavior and for medication review related to disruptive behavior. Review of an Admission Summary dated 4/05/23 at 2:12 AM, revealed Licensed Practical Nurse (LPN) B, documented resident #1 was alert, but confused and experiencing tactile and visual hallucinations upon admission. LPN B documented resident #1 was very agitated and uncooperative during the assessment. She wrote that although his speech was clear and he was alert to person, he was agitated, and she was unable to orient him to the facility. Review of a progress note dated 4/05/23 at 2:57 AM, by LPN C noted resident #1 was very agitated and aggressive toward staff earlier that evening with cursing and threats to get physical with staff. She wrote resident #1 stated he would not go to his room and was monitored while he sat on a chair in front of the nurses station. The progress note read that he eventually stopped cursing, became tired and staff was able to direct him back to his room to sleep. Review of a Progress Note dated 4/05/23 at 6:45 AM, by the DON indicated the charge nurse told her resident #1 had eaten during the night and calmed down on his own without any medications. She documented resident #1 was in bed that morning and the physician had been notified of resident #1's behaviors with no new orders received. She wrote the charge nurse affirmed resident #1 was on one to one staff supervision at that time. Review of an additional Progress Note by the DON dated 4/05/23 at 7:45 AM, read that she and the Nursing Home Administrator went to see resident #1 in his room to follow up on the reported disruptive behavior from the previous night. She explained resident #1 was not in his room and a search of the facility was initiated when he could not be located. The progress note showed the resident was located by staff and redirected back inside for breakfast. She described resident #1 as conversive and in a pleasant mood, but his thoughts were nonsensical. She indicated he was able to ambulate on his own with no injuries sustained. A few hours later the DON wrote another Progress Note dated 4/05/23 at 10:45 AM, which revealed, Writer notified PCP [Primary Care Physician] of resident behavior. PCP provided orders for resident to transfer to secured unit. Arrangements made to facilitate resident relocation. Review of the last Progress Note dated 4/05/23 at 3:11 PM, written by LPN A revealed, Resident transferred to (name of facility) in [NAME] to a locked down unit. On 5/04/23 at 10:59 AM, the Admissions Director stated resident #1 had been a resident at the facility previously so he was preapproved to return during the admission process from the hospital. She explained he was preapproved because the facility had cared for the resident previously and thus they could care for the resident again. The Admission Director stated the DON came to her when she got to work on the morning of 4/05/23, after resident #1's elopement to say he had a change and she needed to look for alternative placement on a more secure unit. She explained she contacted every facility with a locked unit in the area and eventually expanded her search to [NAME] and Miami when local facilities could not accommodate him in their locked units. The Admission Director explained she informed resident #1 and told him, The clinical team could not meet his care needs, and there were other facilities that would do his wound care that were more secure, and he gave her the approval to search for another facility. She elaborated, It all happened by noon and they picked him up before 4:00 PM. In a telephone interview on 5/04/23 at 10:37 AM, the resident's assigned nurse, LPN C, stated when she came in for her night shift at 7:00 PM on 4/04/23, resident #1 was pacing the halls, ranting, and mumbling to himself in an unintelligible way. She described resident #1's behavior as threatening to herself and the other staff, so she called the DON who directed her to place him on 1:1 observation and to call the doctor to see if there were any medications to help with his behaviors. LPN C explained a short time after that phone call resident #1 calmed himself down, was sleepy and went to bed in his room. She said they didn't have any problems with him the rest of the night and the one to one sitter remained with him. She stated sometime during the early morning he had an episode of incontinence, and he allowed the CNAs to assist him with incontinence care and change into clean clothes. LPN C then explained the procedure when residents were transferred or discharged from the facility was for the nurse to have the resident or their representative sign the Agency for Healthcare Administration (AHCA) transfer form. On 5/04/23 at 11:20 AM, LPN A stated she was the assigned day shift nurse for resident #1 when he eloped and was discharged to [NAME]. She described after resident #1 returned from outside she was told by another manager that he was going to another facility. LPN A stated she signed the transfer form but said she didn't have the resident sign it because she didn't think he would sign. Review of resident #1's medical record revealed during less than 24 hours of his stay at the facility, he signed at least 14 documents on both 4/04/23 and on 4/05/23. These documents included the clinical consent to treat, the baseline care plan, the bed hold policy, the influenza and pneumonia vaccine consents, and the use of psychotropic drug therapy form. Review of the AHCA Nursing Home Transfer and Discharge Notice dated 4/05/23 revealed the reason for discharge was, Your needs cannot be met in this facility. The section for a brief explanation to support this action was left blank and no explanation as to what services could not be provided by the facility or what was to be provided at the receiving facility was given. The document was signed by LPN A on 4/05/23 but the resident signature was left blank as well as the section that indicated notice was given to the resident or representative. In an interview on 5/04/23 at 11:33 AM, CNA D stated she was assigned to sit with resident #1 when he was brought back to the facility. She said although he was a bit confused, he seemed to know where he was, and he was pleasant. She stated he was, ok and she had no problems with him nor felt threatened by him during her several hours observing resident #1 during one to one supervision in his room. She stated he did not curse, pace, or act angry and added he didn't have any inappropriate behavior during her time with him. In an interview on 5/04/23 at 12:00 PM, CNA E stated she was assigned to resident #1's care on 4/05/23 during the day shift. She described seeing resident #1 on the South wing at the nurse's station sitting in the weight chair, fussing but not carrying on. She offered him coffee which he declined, and she didn't see him again until he was brought back from outside after the elopement. She stated CNA D provided one to one supervision and she was in and out of the room during her shift several times. She described resident #1 as, okay, not upset, yelling or anything. She stated he never caused any problems the rest of her shift until he discharged in the afternoon. CNA E explained when the transport company arrived and tried to get resident #1 in the wheelchair he initially refused and wanted to walk, but after being re-directed, he complied with no problems. Review of the consult note dated 4/05/23 by the Psychiatric Advanced Practice Registered Nurse (APRN) revealed the chief complaint was new evaluation. The history and physical section described resident #1 upon arriving to the facility on [DATE] being placed on one to one observations due to his non-compliance and being intrusive. The APRN continued that resident #1 was able to exit the facility that morning and was brought back to the facility unharmed. She documented when she interviewed resident #1 he was in bed, alert and cooperative. He was able to describe to her that he lived on the streets and his intent was he thought he was going home. The APRN documented resident #1 had excessive anxiety and worry with aggravating factors of ongoing medical problems, life stressors and being in the facility. She indicated emotional and social support would help with these factors. She recommended regular follow up, psychiatric medication adjustment depending on the residents' presentation as long as he resided in the facility. The APRN documented, The patient denies homicidal ideation; has no intention of hurting others. She continued, Considering risks and protective factors, the patient appears to be at low risk of harming self or others intentionally. Review of the Order Summary Report dated 5/05/23 revealed resident #1 had orders for daily blood pressure medication, pain medication, and antipsychotic medication for agitation. Review of the Medication Administration Record for April 2023 revealed that although resident #1 had orders for medications he received none of the medications ordered during his approximate 18 hour stay from 4/04/23 to 4/05/23. Review of the Baseline Care Plan dated 4/04/23 and signed by resident #1 indicated problems, or potential concerns for falls, impaired skin integrity, recent infection, pain, assistance with activities of daily living and constipation. There were no care plans selected for behaviors or history of behaviors nor for use of psychoactive medications and therefore no interventions put into place. In interviews on 5/03/23 at 12:08 PM, and on 5/05/23 at 12:19 PM, with the DON, Administrator and the Regional Nurse, the DON stated she was at the facility for an early morning meeting on 4/05/23 and staff on the South wing told her the resident was good, he was resting and not to bother him. The staff had taken resident #1 off one to one monitoring as his behaviors had improved overnight and it was no longer a concern. She explained that a short time later she and the NHA discovered resident #1 was not in the facility and started a search. He was found outside a short time later and brought back to the facility. The DON described resident #1 as being easily re-directed back to the facility, and he was easily appeased with food, He liked eating. She said after the physician laid eyes on resident #1 that morning the team got together and as a group decided he needed to be discharged to a safer place. The physician wrote a discharge order to a secure unit based on his alcoholism. The DON explained that neither she nor the Administrator gave the AHCA transfer form to resident #1 and was not sure whether the nurse did. She stated she felt resident #1 being discharged to a secure unit in [NAME] was the best thing for resident #1, the other residents in the facility and the staff. The DON acknowledged the facility could not show what needs the resident had that could not be met by the facility and could not show what interventions had been made to provide the needed care to resident #1. She was unable to explain why they felt the facility was unable to care for resident #1 when he had no further elopement attempts and his behaviors were described by staff and the psychiatric consult as cooperative, calm, and non-threatening. She explained she felt resident #1 wanted to skedaddle out, and felt he was totally unpredictable. The DON stated we didn't know what was going to happen with his behavior, and explained he was discharged to [NAME] in too short a time to say what would happen. In a telephone interview on 5/05/23 at 10:32 AM, the physician stated he gave the order to discharge resident #1 to a secure unit as a mutual decision with facility administration. He stated resident #1 was aggressive, difficult, and non-compliant with an, explosive attitude. The physician explained he felt resident #1 posed a risk for the nursing staff and himself because he could not control his anger. He explained he did not feel he needed to send him back to the hospital for emergency psychiatric care and said when he was fine he was nice, but if you set limits on him he could explode. The physician stated he felt the staff at the facility was not equipped to take care of resident #1 at the time, because he needed more psychiatric help or closer supervision, but he agreed the fact that resident #1 had eloped from the facility also was a factor in the decision. The physician reiterated he was the covering physician and had tried to do what was best at the time. The Admission Nursing Data Collection dated 4/05/23 at 2:08 PM, revealed documentation by Licensed Practical Nurse (LPN) A that resident #1 was oriented to person, place, time, and situation. He was able to transfer and ambulate independently. The document indicated he had depression or other mental health conditions which should be taken to care plan and a mental health consult requested. The Discharge and Orientation to Center section of the document indicated the plan to discharge, Once cellulitis is gone. LPN A documented she oriented resident #1 that afternoon to call lights, staff, life enrichment schedule, business office, schedule, mealtimes, lighting and overbed table. In a telephone interview on 5/05/23 at 5:01 PM, in response to previous phone attempt made on 5/04/23 and on 5/05/23 the DON from the [NAME] skilled nursing facility where resident #1 currently resided stated he was on their secured, locked unit and asked him if he would agree to speak with the surveyor. He answered the phone and stated his name and knew he was in a facility in [NAME] but did not know how he had come to be there. He recalled he was originally from [NAME] and indicated several times he was worried about his stuff that was still in [NAME] somewhere. Resident #1 stated he had family including a brother and sister in [NAME], but he didn't think they knew he was in [NAME]. He relayed he had not had any visitors since he arrived in [NAME], nor had he spoken to any of his family as they didn't know where he was. Resident #1 again explained he did not remember how he came to be in [NAME], did not know how long he would be there and said he would like to return to [NAME] but was worried how he would get there. In a telephone interview on 5/10/23 at 2:05 PM, from a returned call placed on 5/03/23 at 2:27 PM, the brother of resident #1 stated he and his family were shocked when he received a phone call from him on Monday saying he was in a nursing home in [NAME]. Resident #1's brother stated neither he nor any of resident #1's other family knew where resident #1 was after he was discharged from the hospital in April. He said no one from the facility contacted him to let him know his brother was being transferred to [NAME], explaining, I didn't know where he was. He said he had visited his brother in the hospital in [NAME] and was upset he was so far away he could not visit him there. He stated his brother was upset he was so far from his family and could not remember how he ended up in [NAME]. His brother told him he would try and figure out how he could get back to [NAME]. Review of the Facility Assessment Tool dated 12/10/22 revealed Psychiatric/Mood disorders were common diagnoses such as impaired cognition, psychosis, depression, anxiety and behavior that needs interventions that made up their resident profile and required complex medical care and management. The assessment indicated on average the facility had 4 residents with behavioral symptoms and cognitive performance in the last 3 months of the assessment. Section 2.1 of the assessment detailed the facility was able to give care to residents in the area of mental health and behavior to manage the medical conditions and medication related issues causing psychiatric symptoms and behavior and staff was able to assess, identify and manage deterioration of medical and psychiatric symptoms. Review of the Resident Transfer and Discharge Policy and Procedure dated 4/01/22 revealed the facility would maintain a transfer and discharge process that complied with regulatory requirements and maintained the resident's quality of care. The procedure detailed residents may be transferred or discharged as a result of different conditions including those necessary for the resident's welfare and the resident's needs cannot be met in the facility. The policy described that all transfers or discharges must be documented in the medical record and must include, The basis for the transfer, and, The specific resident need(s) that cannot be met, facility attempts to meet the resident needs and the service available at the receiving facility to meet the need(s). The policy indicated the previous documentation must be made by the resident's physician. The document further indicated that the facility should provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge for the facility in a form and manner the resident can understand.

Based on interview and record review, the facility failed to honor advance directives for a Do Not Resuscitate Order (DNRO) for 1 of 7 residents reviewed for advance directives, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) despite her explicit wish for a natural, dignified death and placed her at risk for serious injury/impairment/prolonged death. While resident #1 suffered resuscitation attempts including chest compressions for about 30 minutes, there was high likelihood she could have experienced pain, broken bones, organ damage and a prolonged dying process on mechanical life support. On [DATE] at 6 AM, resident #1 was found with shallow respirations and no pulse. Her assigned nurse, Registered Nurse (RN) A, immediately began CPR. The nurse then asked the Certified Nursing Assistant (CNA) B to continue CPR while she checked the physician's orders [REDACTED]. The nurse did not follow the facility's policy to check the physician's orders [REDACTED]. The nurse was not aware resident #1 had an active DNRO which had been changed on [DATE] and placed in the paper medical record. When emergency medical personnel arrived, they continued aggressive resuscitation until she was transported to the Emergency Department where she expired. The facility's failure to honor advance directives put 12 residents with advance directives for DNR at risk, and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for a change in condition dated [DATE] revealed she had moderate cognitive impairment and required extensive assistance with eating, was no longer walking in her room or on/off the unit, and frequently incontinent of bowel and bladder. Review of resident #1's plan of care dated [DATE], documented the resident was a Full Code. The care plan was not updated to reflect the change in her advance directive from Full Code to DNR initiated on [DATE]. Review of the progress note completed by the Director of Nursing (DON) on [DATE], documented resident #1's daughters met with the facility to discuss concerns related to her decline, lethargy and not eating for the past 2 days. The family stated they had already spoken to the Advanced Practice Registered Nurse (APRN) and they were aware of her decline. They were in agreement the resident was to be placed on Hospice services. They also wished to change her advanced directive from Full Code to DNR. The DNR form was then signed by the resident's daughter and attending physician. On [DATE] at 9 AM, the DON said she had met with resident #1's daughters on [DATE] to discuss her declining condition. She said the daughters wanted the resident on Hospice services and completed the DNR form. The DON stated she asked Licensed Practical Nurse (LPN) C to enter the DNR order into the EMR and to place the DNR form in front of resident #1 paper medical record. Review of LPN C's nursing note dated [DATE] at 2:47 PM, read, .daughters visited with resident today and decided to change their mom to a DNR and start Hospice. On-coming nurse made aware Review of resident #1's care plan dated [DATE] documented the resident was a Full Code. The care plan had not been updated to reflect the change in her advance directive on [DATE] from Full Code to DNR. Review of resident #1's paper medical record revealed a form titled, DO NOT RESUSCITATE ORDER which read, Based upon informed consent, I the undersigned, hereby direct that CPR be withheld or withdrawn. The physician's statement read, . I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. The document was dated [DATE] and was signed by resident #1's daughter and attending physician. Review of resident #1's EMR revealed physician's orders [REDACTED]. Resident #1's EMR did not include the physician's orders [REDACTED]. Review of the Exception Report dated [DATE] at 6 AM, noted resident #1 was checked several times during the shift with no issues. At 6 AM, resident #1's respirations were slow, she was lethargic, nonresponsive and she had no pulse. 911 was called and CPR was initiated by the nurse at 6 AM with the help of the CNA B. At 6:12 AM, 911 took over chest compressions and the resident was transferred to the hospital at approximately 6:22 AM. Review of the 11 PM-7 AM staffing assignment for [DATE] documented that RN A was assigned to the North Wing. She was assigned to provide care and services for 27 residents. Twelve of the 27 residents had a DNRO. On [DATE] at 9 AM, the Administrator stated on [DATE] at 6 AM, CNA B had notified RN A there was something wrong with resident #1. RN A immediately went to resident #1's bedside and found that she had shallow respirations and no pulse. RN A immediately began CPR without checking the resident's medical record for her advance directive. It is our policy to check the paper medical record chart to determine the resident's advance directive status before starting CPR. The Administrator stated RN A asked CNA B to continue CPR while she went to check the resident's advance directive. The nurse reviewed resident #1's EMR which indicated that she was a Full Code. She called 911, gathered the necessary paperwork for transfer to the hospital. When the Emergency Medical Services (EMS) arrived at the facility they continued CPR. They were given the necessary paperwork and resident #1 was transferred to the hospital at 6:22 AM. The Administrator said that after EMS left the facility, CNA B asked RN A, why CPR was done on a Hospice resident? The Administrator added that RN A then looked through resident #1's record and noted a DNRO. It is the facility's policy that the DON and/or Administrator be notified if a resident required CPR, was sent to the hospital and/or expired. The nurse did not notify the DON or myself that she had provided CPR to the resident or that the resident was transferred to the hospital and expired. He said on [DATE], the APRN notified us that she had reviewed resident #1's progress notes and wanted to know why resuscitation was attempted when the resident had a DNRO. A telephone interview on [DATE] at 4:25 PM, with RN A revealed that on [DATE] at 6 AM, CNA B called her to assess resident #1. She said the resident had shallow respirations and she could not find a pulse. I immediately started CPR. I then realized that I needed to check the resident's chart for her advance directive. I instructed CNA B to continue the CPR. I checked the electronic medical record and saw an order for [REDACTED].#1's status and EMS continued CPR. I then provided EMS with the copies of her medical record and she was transported to the hospital at approximately 6:20 AM. After resident #1 left the facility, I saw the yellow DNR form under all of the papers and realized resident #1 should not have been resuscitated. CNA B also informed me that resident #1 was on Hospice. I did not see the yellow DNR form. I realized I should have checked resident #1's paper medical record for the DNR form and not the EMR. I realized that providing CPR to resident who did not wish to be resuscitated was wrong and I should have notified the DON immediately. RN A stated, I don't know why I did not check resident #1's paper medical record for the advance directive. On [DATE] at 6:35 AM, Licensed Practical Nurse (LPN) D stated that she had been working at the facility for just 1 year and her orientation included training for advanced directives and DNR. LPN D recalled that on [DATE], she assisted RN A to make copies of the forms to transfer the resident to the emergency department. I recall that RN A reviewed the EMR and identified that resident #1 was a Full Code. Later, RN A identified that resident #1 was a DNR. She added that if the nurse had entered the DNR order in the electronic medical record, the resident would not have endured what she did. On [DATE] at 3:19 PM, resident #1's physician stated that on [DATE], resident #1 was placed on Hospice services and a DNR form was signed by her family. They did not want CPR done. I was made aware that she had received CPR and was sent to the hospital on [DATE]. She should not have received CPR when there is a DNRO. The nurse should have looked at the order in the paper chart before performing any CPR. A telephone interview with the facility's Medical Director on [DATE] at 8:20 PM revealed he had been informed that resident #1 had received CPR despite a DNRO. A nurse works under the direction of the physician and when there is a DNRO, the nurse needs to follow the physician order [REDACTED].#1 should not have gone through what she did. The nurse should not have provided CPR to a DNR resident. On [DATE] at 9 AM, the Administrator stated on [DATE], the facility held an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting with the Medical Director. The meeting included a review of the [DATE] event, suspension of RN A, discussion and review of the investigation, and education provided to all staff on Advanced Directives and DNR. The Administrator stated that the Medical Director did not have any further recommendations to the facility's plan for correction. Review of RN A's Orientation In-Service Acknowledgement form dated [DATE] documented she had received education and training of advanced directives. The form read, I have received training, handouts and understand all of the information listed above. The form was initialed and signed by RN A and the facility's Staff Development Coordinator on [DATE]. Review of the In-Service Sign-In Sheet for Advanced Directives dated [DATE], [DATE] and [DATE] included education on the facility's Advance Directive Policy, Self Determination and Health Care Advance Directives . the patient's right to decide. The Sign-In Sheet revealed RN A had not attended the inservice. Review of the facility's Advance Directives Policy, dated [DATE], read, A resident's choice about Advance Directives will be respected. Policy Interpretation and Implementation . 2. Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, the Center will require that copy of such directives be included in the medical record. 3. Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy, or representative have directed that no cardiopulmonary resuscitation (CPR) or life-saving methods are to be used Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy, dated February 2021, read, It is the policy of the center to initiate CPR if the resident is without pulse or respirations and is a full code. Procedure: . 5. Code status is verified from the medical record Review of the Facility Assessment Tool reviewed on [DATE] revealed services and care provided is based on the resident's needs. The facility will provide person-centered/direct care by discussing treatment and care preferences. The types of care provide to the resident population included hospice, palliative and end of life care. Staff receive training on Resident Rights and Advance Directives upon new hire orientation and annually. Competencies are completed yearly and include person-centered care planning, education of resident and family/resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care and advance care planning. Review of the corrective measures for Immediate Jeopardy removal implemented by the facility as of [DATE] revealed the following: * All staff were educated on Following Physician Orders, CPR, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, Advance Directive, Resident Rights, Nursing Care in line with Professional Standards. In-service attendance sheets were provided for [DATE] * An audit of all resident advanced directives was completed on [DATE] to ensure yellow State DNRO's were in place in front of the medical record chart and the EMR had a DNRO. Audit form provided for [DATE]. * 2 Code Nurse Stat Drills were conducted on [DATE] at 7:15 PM and [DATE] at 6:50 AM. The center will complete code drills for 100% of all working licensed staff by [DATE] to ensure competency and are on-going. Code Nurse Stat Drill forms dated [DATE] and [DATE] were provided. * All new admissions were reviewed daily by DON to ensure the EMR and advanced directive orders in the paper medical record matched. Form dated [DATE] provided and on-going. * New hire licensed nurse, agency and travel nurses will be trained on the centers' process and policies and procedures prior to working. New Hire Orientation provided. * The next Quality Assessment and Assurance (QAA)/QAPI meeting is scheduled for [DATE] to review and analyze data for necessary revisions if needed.

Based on observation, interview and record review the facility failed to meet professional nursing standards of practice for 1 of 11 sampled residents (#1) who was administered an excessive dose of an antipsychotic, [MEDICATION NAME] ([MEDICATION NAME]). The facility allowed an unauthorized psychiatric consultation that resulted in an unnecessary antipsychotic medication administered in an excessive dose in the absence of any documented behaviors or symptoms, and without the involvement of the attending physician, the interdisciplinary team, or the family. The resident suffered from adverse consequences from a significant medication error and unnecessary antipsychotic medication when she became lethargic and exhibited symptoms from an adverse drug event. [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) The resident was placed on 24-hour crisis care and was transferred to the hospital on [DATE]. Her admitting hospital [DIAGNOSES REDACTED]. This resulted in Substandard Quality of Care and immediate jeopardy starting on 9/21/17. The immediate jeopardy was determined to be ongoing as of the exit date, 1/05/18. The failure to meet standards of practice for medication orders, antipsychotic medications, and monitoring residents for adverse drug reactions puts all residents at risk. Cross reference to F755, F758, F760, F835, F867. Findings: American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-46. Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Prior to admission, the resident resided at home with her daughter and was under the care of hospice for her end stage [MEDICAL CONDITION]. Resident #1 was admitted to the facility for respite care with plans to remain living there as a long-term care resident under hospice care. The resident did not have any psychiatric diagnoses or symptoms upon admission. The Pre -Admission Screening and Resident Review (PASRR) dated 9/07/17 indicated the resident had no [DIAGNOSES REDACTED]. A review of Resident #1's Admission Minimum Data Set (MDS) comprehensive assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) assessment of 12 which meant she was moderately cognitively impaired. Resident #1 was assessed to have the ability to understand others and to make herself understood. Resident #1 was assessed to have no behavior symptoms present. The resident needed extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident#1 was assessed to need limited assistance to eat and was occasionally incontinent of bowel and bladder. The assessment showed the resident did not have any triggers for Psychosocial Well-Being, Mood State, or Behavioral Symptoms. The Medication Administration Record [REDACTED]. The Interim care plan dated 9/07/17 had a check mark next to Behavior Problem with areas to indicate related to and as evidenced by. None of the related to areas were checked and area for evidenced by was handwritten, [MEDICAL CONDITION]. The goal of the care plan was not checked. The approach was checked to administer and observe the effectiveness and side effects of medication as ordered (see physician orders/MAR). The care plan did not identify any behaviors or symptoms and did not include any non-pharmacological approaches. During an interview on 1/02/18 at 11:50 AM, Nurse A said the documentation in progress notes is by exception only, meaning nurses do not document daily unless there is an exception to the resident's usual state. The progress notes did not contain any documentation of any behaviors or symptoms of distress or [MEDICAL CONDITION]. The resident was seen by a psychiatrist on 9/21/17. The record did not contain an order for [REDACTED].icd10data.com). The recommendation was hand written as, generally pleasant, but appears distressed. Will trial [MEDICATION NAME] (0.25 mg) times 2 weeks and follow. A Physicians Order dated 9/21/17, indicated the psychiatrist wrote an order for [REDACTED]. Review of the Medication Order Summary Recapitulation dated 9/1/17-1/31/18, showed an order 9/21/17, for [MEDICATION NAME] tablet 20 MG-Give 1 tablet two times a day for [MEDICAL CONDITION]. The 20 mg dose is 80 times the amount the psychiatrist ordered and the order was entered as continuous, not to stop after 14 days. Review of the Medication Administration Record [REDACTED]. During an interview on 1/02/18 at 1:35 PM, Nurse A stated he entered the [MEDICATION NAME] order into the computer. When asked if he had informed the family or hospice of the new order for [MEDICATION NAME], he could not remember. No documentation was provided indicating calls to the attending physician, hospice, or the resident's family. Nurse A could not explain how he entered the [MEDICATION NAME] order for 20 mg instead of 0.25 mg into the electronic order system. When asked if he would have questioned a new 20 mg dose of [MEDICATION NAME], before giving it to a resident without any documented behaviors, he did not reply. He said that once an order is entered into the system, it is the assigned task of the 11 PM to 7 AM nurse to verify each order against the electronic order record to ensure the information has been entered correctly. The nurse reconciles the order, marks it with a red check-24-the date and initials. Nurse A verified the [MEDICATION NAME] order had not been checked (no markings on order). Nurse A stated the night nurse missed checking the order. If the order had been checked, the error might have been caught and corrected. During an interview on 1/02/18 at 4:05 PM, the Psychiatrist stated he is in the facility daily following residents. On the 21st, I was asked by a nurse (couldn't remember who) to see a resident (#1) because she was having behaviors. After seeing the resident, she appeared anxious, so I prescribed a low dose of [MEDICATION NAME] (0.25 mg) to calm the resident. I would never have ordered 20 mg for this resident. The plan was to prescribe a very low dose to give a therapeutic calming effect. When asked during an interview on 1/02/17 at 5:15 PM if he had been consulted prior to the psychiatrist consult and/or the [MEDICATION NAME] order for resident #1, the attending physician indicated he was not. When I was informed of the wrong dose, I immediately stopped the [MEDICATION NAME] and had hospice provide crisis care to monitor the resident and the effects of the medication. I understand that the psychiatrist sees residents all the time in this facility and his intent was to prescribe 0.25 mg not 20 mg. During an interview with Resident #1's daughter on 1/01/18 at approximately 7 PM. She said she was never contacted regarding any behaviors that required a visit by a psychiatrist for antipsychotic medication. She said she visited resident #1 on 9/22/17 and she appeared to be drugged up. She asked the nurse at that time if the resident had any new medications and after checking the computer, the nurse told her there were no new medications. When she visited again two days later on 9/24/17, she said her mother was in bad shape. She asked the nursing staff again what was happening to her mother and it was discovered that she was receiving large doses of [MEDICATION NAME]. She said she was agitated and more confused. She said her mother did not sleep and had been moving her legs in a repeated bicycle motion so much that the skin on her heels was rubbed red and raw. Review of a Progress Note dated 9/24/17 at 1:17 PM, indicated the resident was experiencing side effects. Upon observation, resident (#1) lethargic, vitals stable, family stated resident is not at her baseline less communicative. Reviewed resident orders with MD (resident's attending doctor and medical director) and hospice, received orders from MD to d/c (discontinue) [MEDICATION NAME]. Hospice here this afternoon observed resident and will place resident on crisis care for further observation for any changes. The medical record did not contain any documentation regarding resident #1's adverse reaction to the [MEDICATION NAME] until the family member brought it to their attention. A Physician order [REDACTED]. Review of hospice Continuous Care Shift Care Note dated 9/25/17, indicated Resident #1 restless, attempting to get out of bed, confused, agitated, kicking all the pillows out, encourage heels up 2 inches from bed due to restless movement on bed and calling out repeatedly. Pt is bed bound with weakness and requires total care with all activities of daily living (ADLs). The nursing progress notes for the same day, 9/25/17 indicated the resident had poor intake by mouth and had no distress. The hospice Continuous Care Shift Care Note dated 9/26/17, indicated Resident #1 rubbing hands on pillow, kicking at sheets and resident sliding her heels over the bed all night nearly causing blisters. A Progress Note dated 9/27/17 indicated Resident #1 was sent to the hospital emergency room for evaluation. The Hospital Progress Note dated 9/27/17, indicated Resident #1 Given [MEDICATION NAME], but unintentionally given at a higher dose than was prescribed or intended. Brought in at acute [MEDICAL CONDITION] ([MEDICAL CONDITION] and acute confusional state) with mental status changes. To be closely watched. Chief complaint: Decreased mental status and confusion (given 20 mg of [MEDICATION NAME] rather than prescribed 0.25 mg.). Patient has generalized weakness and difficulty walking. Patient has been off medication for 2 days and is waking more but still confused, too weak to walk and hallucinating. This seems to be all medication induced. Family does not want pt (patient) back at facility. Will look for placement at different LTCF (long term care facility). Review of Hospital Progress Note dated 9/28/17 and 9/29/17, indicated No change in progress. Patient still confused and groggy. Staff interviews were conducted related to the following concerns: Not getting a psychiatric consultation order from the attending physician, not transcribing the prescribed order correctly, not reconciling the order against the electronic medication record, not asking about the use of antipsychotic medication in the absence of any psychiatric symptoms, the excessive dose, and not developing a plan of care to monitor for side effects or adverse drug reaction of the medication. During an interview on 1/02/17 at 1:10 PM, the Risk Manager indicated she completed an investigation at the time of the incident with resident #1. The Risk Manager stated, following her investigation, it was determined the nurse made a medication transcription error. She did not discuss the other areas in which standards of practice for nurses were not followed regarding an order for [REDACTED]. During an interview on 1/2/18 at 2:50 PM, Nurse D stated I remember the resident but do not remember her (resident #1) having any behaviors. She was very quiet. I would not have questioned the 20 mg [MEDICATION NAME] order unless I had issues with vital signs. Since the resident is on hospice, they sometimes order extreme doses. If there was an issue, the pharmacy would have informed us. During an interview on 1/2/17 at 4:35 PM, the Pharmacist stated the pharmacy would immediately receive the order when placed electronically. The pharmacist filling the order would not have gotten a warning because 20 mg of [MEDICATION NAME] is an order that can be prescribed. During an interview on 1/2/17 at 2:15 PM, the Director of Nursing (DON) stated she was the Assistant Director of Nursing (ADON) in September 2017 and remembered resident (#1) to be very quiet with no behaviors. The DON confirmed a series of errors occurred resulting in a system failure. She could not provide any evidence of how the systems were reviewed and/or revised and monitored to address sustained compliance with standards of nursing practice.

Based on observation, interview and record review, the facility failed to accurately acquire, dispense and safely administer an antipsychotic medication with appropriate parameters for usage for 1 of 11 sampled residents, (#1). The facility failed to recognize that this incident of 9/21/17 started with the resident being seen by a psychiatrist for undocumented reasons, a [MEDICAL CONDITION] medication being prescribed to the resident without indication, and the medication order being transcribed incorrectly. The facility's failure to establish a process for medication reconciliation and the nurses failing to apply standards of practice for medication management resulted in resident #1 receiving an antipsychotic medication, 80 times more than the ordered dose 4 times and subsequently being hospitalized for [REDACTED]. [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) This failure resulted in Immediate Jeopardy starting on 9/21/17. The immediate jeopardy was ongoing as of the exit date on 01/05/18. Cross reference: F658, F758, F760, F835, F867. Findings: Resident #1 was an [AGE] year old female, admitted to the facility on the south wing on 9/07/2017 with [DIAGNOSES REDACTED]. The resident had resided at home with her daughter and was receiving hospice care for end stage [MEDICAL CONDITION]. She was admitted to the facility for respite care with plans to continue residing as a long term care resident with hospice care. On 9/21/2017, the resident was transferred to the north wing. A nursing progress note dated 9/21/2017 noted that the resident was moved to the north wing as previously agreed with family as resident to remain at the facility for long term care with hospice services. On the day the resident was transferred to the north wing, an unknown nurse requested the consulting psychiatrist to see the resident despite no physician order for [REDACTED]. The order dated 9/21/2017 read, [MEDICATION NAME] 0.25 mg at 2:00 PM and at bedtime by mouth for 14 days. The licensed practical nurse, (LPN) A processed the psychiatrist's written order and transcribed the order in the electronic medical record as [MEDICATION NAME] 20 mg, give 1 tablet by mouth two times a day at 9:00 AM and 5:00 PM for [MEDICAL CONDITION]. The resident received 4 doses of [MEDICATION NAME] 20 mg on 9/22/17 at 9:00 AM, on 9/23/17 at 9:00 AM, 5:00 PM and on 9/24/17 at 9:00 AM. An interview with LPN A on 01/02/18 at 12:15 PM revealed that he had entered the [MEDICATION NAME] order into the electronic system with the wrong dose, 20 mg instead of 0.25 mg, with the wrong times, 9 AM and 5 AM instead of 9:00 AM and bedtime and with no stop date. The LPN was unable to explain how the error occurred except that he was very busy. He could not explain how he obtained the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The nurse reconciles the order, marks it with a red check mark, dates and initials the written order. The LPN A verified the [MEDICATION NAME] order had not been checked as there were no markings on the written order by the night nurse. He stated, the night nurse missed checking the order. If the order had been checked, the error could have been corrected immediately. A check of written physician orders was done with the unit manager of the north wing on 1/4/17 at 1:30 PM. Out of 11 written physician orders checked, only 2 had check marks, date and initials by the order indicating that they had been checked by the night nurses. The unit manager stated that the night nurses were responsible for checking the orders but added that the process was not being followed consistently. On 01/05/18 at 3:15 PM, the clinical educator was asked to show the process for physician order entry into the electronic medical record system. She stated that the process was that when the physician wrote an order in the paper medical record, the order is flagged, and the nurse then transcribes the order into the electronic medical record system. She showed how to enter the [MEDICATION NAME] into the system. Once she selected [MEDICATION NAME] for a resident, there was a drop down menu for the dosage. It was noted that there was no 0.25 mg dosage for [MEDICATION NAME]. The smallest dose was 0.5 mg. She stated that the nurse would have to select 0.5 mg and then in the narrative section, would write, give ½ tablet. She stated that there was no option to enter 0.25 mg. When asked, if this was why the error was made, she stated no, as the 20 mg was well below the 0.5 mg option. She stated, I don't know how LPN A selected 20 mg. She stated that there was no other double check system in the system in the computer system. Once the order is transcribed into the computer system, it is directly transmitted to the pharmacy. The double check was for the night shift staff to reconcile the written orders with the electronic orders. During an interview on 01/05/18 at 3:00 PM with the risk manager who was acting DON during the time of the medication error confirmed that the medication error was discovered after the resident had received 4 doses of the medication. The resident's family became concerned on 9/24/17 as she was lethargic and was very confused. She stated that the process for medication order reconciliation was that the night nurses working 11:00 PM-7:00 AM would obtain an electronic report of all medication orders written during the day and compare the written orders to ensure that the electronic orders matched the physician orders. Unfortunately, this did not happen. The medication should also have been checked during the morning meeting when all physician orders obtained in the last 24 hours were reviewed. She said, I don't know what happened, I guess the order was not checked. She confirmed that their system for double checks failed. The risk manager was questioned as to how the LPN A obtained a [DIAGNOSES REDACTED]. The risk manager was not able to provide an answer stating, I am not sure. When she was asked how medication orders were monitored to ensure residents received the correct medication in a safe manner, she stated that they are now working on implementing the double and triple check system as it was evident that it was not being done consistently. An interview with the pharmacy consultant on 01/05/18 at 11:30 AM revealed that she was made aware of the [MEDICATION NAME] medication error on the day it was discovered, 9/24/17. She stated that once the written physician order is entered into the facility's computer system, it is automatically received at the pharmacy. The facility is not required to fax the written order to the pharmacy. She said that the [MEDICATION NAME] 20 mg twice daily order would not have caught the pharmacist's attention. The pharmacy serviced many types of facilities and 20 mg of [MEDICATION NAME] was not a red flag as high doses were used. She stated that if she had seen the resident, an order for [REDACTED]. An interview with the north wing registered nurse (RN) unit manager on 1/4/17 at 1:30 PM noted that the night nurses were responsible for checking the orders but stated that the process was not being done consistently. When the unit manager was asked if she would question an order of [MEDICATION NAME] 20 mg for a geriatric resident with no behaviors, she stated she would not. She said she would not question the order but would ensure the resident's vital signs were okay. She stated that if it was an issue, pharmacy would alert us. An interview with LPN B on 1/4/17 at 4:25 PM, noted that she would not question the order for [MEDICATION NAME] 20 mg twice daily for a geriatric resident. She stated that they were accustomed to seeing large doses of medications being used for some residents especially residents receiving hospice care. Review of the facility policy Psychopharmacologic Drugs dated 11/2017, states the purpose is to provide guidelines for the use of psychopharmacologic drug treatment of [REDACTED]. The Procedural Guidelines included: 1. Psychopharmacologic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics, and other drugs that affect behaviors. 2. Psychopharmacologic drugs shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician. Notification must be complete with the resident or his/her representative for antipsychotic drug therapy. 3. The resident or his/her representative will be given information regarding the need for, the desired effects and the potential side effects of the antipsychotic medication. This enables the resident or his/her representative to make an informed decision regarding the use of an antipsychotic medication. 4. Psychopharmacologic drugs will not be used to limit or control behavior . 5. Nurses will observe for side effects and medical staff will reduce dosage to the minimum required .6. Nurses will document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects. 7. Nursing services, social services and other members of the interdisciplinary team will address the behaviors on the care plan. Medication is not the sole approach for behavioral intervention. Other interventions will be identified on the care plan . Unnecessary Drugs read; each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are any drugs when used: a. In excessive dose, c. Without adequate monitoring, and d. Without adequate indications for its use. The Antipsychotic Drugs section read, 1. Residents who have not used antipsychotic drugs will not be given such drugs unless antipsychotic drug therapy is necessary to treat a specific condition: a. [MEDICAL CONDITION], b. Schizo-affective disorder, c. Schizophreniform disorder, d. Delusional disorder, e. Mood disorders, f. [MEDICAL CONDITION] in the absence of dementia The facility did not ensure that pharmaceutical services were used safely and effectively. The systems failed starting from the resident being prescribed an unnecessary drug. The failure continued with the inaccurate transcription process and the resident receiving an excessive dose of an antipsychotic medication without any monitoring for adverse consequences.

Based on interview and record review the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs when 1 of 11 sampled residents reviewed for antipsychotic medication (#1) received a new antipsychotic medication, [MEDICATION NAME], without documented evidence of an indication for use and in the absence of any behavioral symptoms that presented a danger to the resident or others. The resident received an excessive dose that was 80 times the ordered amount and continued to receive the excessive doses of [MEDICATION NAME] after she began experiencing adverse consequences. The resident was placed on 24-hour crisis care and was transferred to the hospital on [DATE]. Her admitting hospital [DIAGNOSES REDACTED]. [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) This resulted in Substandard Quality of Care and immediate jeopardy starting on 9/21/17. The immediate jeopardy was determined to be ongoing as of the exit date, 1/05/18. The failure to ensure residents do not receive unnecessary antipsychotic medication puts all residents at risk. Cross reference: F658, F755, F760, F835, F867. Findings: Resident #1 was [AGE] year old female and was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Prior to admission, the resident resided at home with her daughter and was under the care of hospice for her end stage [MEDICAL CONDITION]. Resident #1 was admitted to the facility for respite care with plans to remain living there as a long term care resident under hospice care. The Pre -Admission Screening and Resident Review (PASRR) dated 9/07/17 indicated the resident had no [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) comprehensive assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) assessment of 12 indicating the resident had moderated cognitive impairment. Resident #1 was assessed to have the ability to understand others and to make herself understood. Resident#1 was assessed to have no behavior symptoms present. The resident needed extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident#1 was assessed to need limited assistance to eat and was occasionally incontinent of bowel and bladder. Review of the MDS Care Area Assessment (CAA) Summary indicated that any concerns for Psychosocial Well-Being, Mood State, and Behavioral Symptoms did not trigger and a care plan was not developed for these areas. Review of the Medication Administration Record [REDACTED]. The Interim care plan dated 9/07/17 had a check mark next to Behavior Problem with areas to indicate related to and as evidenced by. None of the related to areas were checked and area for evidenced by was handwritten, [MEDICAL CONDITION]. The goal of the care plan was not checked. The approach was checked to administer and observe the effectiveness and side effects of medication as ordered (see physician orders/MAR). The care plan did not identify any other behaviors or symptoms and did not include any nonpharmacological approaches. The Admission Progress Note dated 9/07/17 by the licensed nurse, indicated, Resident (#1) arrived on the South Unit at approximately 7 PM with some forgetfulness. Resident denies any pain, very pleasant, Diagnosis: [REDACTED]. Review of the Hospice Interdisciplinary Note dated 9/12/17, indicated a visit to the resident in facility. Resident (#1) sitting up in wheelchair and denies pain. Resident smiling and in good spirits. No needs at this time. Review of Progress Note dated 9/21/17 at 2:15 PM, indicated Resident's room changed to 12 D (North Unit) as previously agreed with family due to resident staying with us for LTC and hospice. Resident tolerated move well. All belongings and medications moved with resident. MD aware. During an interview on 1/02/18 at 11:50 AM, the documentation in progress notes is by exception only, meaning nurses do not document daily unless there is an exception to the resident's usual state. The progress notes did not contain any documentation of any behaviors or symptoms of distress or [MEDICAL CONDITION]. Review of Psychiatric Initial Mental Status Exam dated 9/21/17, indicated the resident was alert and clean, the mood/affect was sad, increased sleep, decreased appetite, thought content was confused and the resident did not have any delusions or hallucinations. The Assessment/[DIAGNOSES REDACTED].icd10data.com). The recommendation was hand written as, generally pleasant, but appears distressed. Will trial [MEDICATION NAME] (0.25 mg) times 2 weeks and follow. The psychiatrist wrote an new order for [MEDICATION NAME] 0.25 mg every 2 PM and HS (bedtime) for 14 days. The indication-[DIAGNOSES REDACTED].icd10data.com). The resident already had an order for [REDACTED]. During an interview on 1/02/18 at 4:05 PM, the Psychiatrist who completed the exam on 9/21/17 stated he is in the facility daily to see residents. He said, On the 21st (September), I was asked by a nurse, I can't remember who, to see a resident (#1) because she was having behaviors. After seeing the resident, she appeared anxious, so I prescribed a low dose of [MEDICATION NAME] 0.25 mg to calm the resident. I would never have ordered [MEDICATION NAME] 20 mg twice a day for this resident. The plan was to give a very low dose for therapeutic calming effect. The psychiatrist said he was not aware of any other behaviors other than yelling out when staff provided care. He was unaware if any other non-pharmacological interventions were attempted prior to initiating an antipsychotic medication. Review of the Medication Order Summary for resident #1 dated 9/1/17-1/31/18, showed an order 9/21/17, for [MEDICATION NAME] tablet 20 MG-Give 1 tablet two times a day for [MEDICAL CONDITION]. It did not include any times for administration. [MEDICAL CONDITION] was not listed as the [DIAGNOSES REDACTED]. The medical record did not contain any evidence of any other evaluation from the interdisciplinary team IDT reading the initiation of a new antipsychotic medication. A plan of care was not developed for any individualized, non-pharmacologic interventions. Review of the record for Behaviors from 9/1/17- 9/30/17, listed the following behaviors: hallucination, paranoia, delusions, restlessness starting 9/22/17 for 3 shifts each day. The record documented that the behaviors did not occur from 9/22/17 to the day the resident went to the hospital on [DATE]. The record also included areas to document any of the side effects for [MEDICATION NAME]. The side effects included, but were not limited to: sedation/drowsiness, anxiety/agitation, weakness, appetite change/weight change, [MEDICAL CONDITION], confusion, and Akathisia-restlessness. The record documented that no side effects occurred from 9/22/17 to the day the resident went to the hospital on [DATE]. During an interview on 1/02/18 at 12:15 PM, Nurse A stated he entered the [MEDICATION NAME] order into the computer for the wrong dose for 20 mg instead of 0.25 mg and entered the wrong times as 9 AM and 5 PM, instead of 2 PM and bedtime, and did not include the stop date after 14 days. Nurse A was unable to explain how the error occurred except that he was very busy. Nurse A stated Resident #1 had behaviors, but could not state specific times and types of behaviors. Nurse A was unable to explain why no behaviors were documented. Review of the MAR from 9/1/17- 9/30/17, indicated four doses of [MEDICATION NAME] 20 MG were administered: 9/22/17 at 9 AM, 9/23/17 at 9 AM and 5 PM and 9/24/17 at 9 AM, with no documentation/monitoring of types/times of behavior. During an interview with Resident #1's daughter on 1/01/18 at approximately 7 PM, she said she was never contacted regarding any behaviors that required a visit by a psychiatrist for antipsychotic medication. She said she visited resident #1 on 9/22/17 and she appeared to be drugged up. She asked the nurse at that time if the resdient had any new medications and after checking the computer, the nurse told her there were no new medications. When she visited again two days later on 9/24/17, she said her mother was in bad shape. She asked the nursing staff again what was happening to her mother and it was discovered that she was receiving large doses of [MEDICATION NAME]. She said she was agitated and more confused. She said her mother did not sleep and had been moving her legs in a repeated bicycle motion so much that the skin on her heels was rubbed red and raw. A review of a Progress Note dated 9/24/17 at 1:17 PM, indicated the resident was experiencing side effects. Upon observation, resident (#1) lethargic, vitals stable, family stated resident is not at her baseline less communicative. Reviewed resident orders with MD (resident's attending doctor and medical director) and hospice, received orders from MD to d/c (discontinue) [MEDICATION NAME]. Hospice here this afternoon observed resident and will place resident on crisis care for further observation for any changes. A Physician Order dated 9/24/17 (no time) was written to discontinue the [MEDICATION NAME] per attending physician. A telephone Physician Order dated 9/24/17, (no time) was written for hospice to Start crisis care for change in L(NAME) (level of condition) due to [MEDICATION NAME]. Review of hospice Continuous Care Shift Care Note dated 9/25/17, following the administration of [MEDICATION NAME], indicated Resident #1 was experiencing the side effects from the high doses of [MEDICATION NAME]. restless, attempting to get out of bed, confused, agitated, kicking all the pillows out, encourage heels up 2 inches from bed due to restless movement on bed and calling out repeatedly. Pt is bed bound with weakness and requires total care with all activities of daily living (ADLs). A review of the hospice Continuous Care Shift Care Note dated 9/26/17, indicated Resident #1 was experiencing side effects, rubbing hands on pillow, kicking at sheets and resident sliding her heels over the bed all night nearly causing blisters. The of hospice Visit Summary dated 9/27/17, indicated Resident to be discontinued from continuous crisis care. No longer non-responsive with less daytime anxiety/agitation. Family requests that resident be sent to the hospital for evaluation. Resident still confused and anxious. A Progress Note dated 9/27/17 indicated Resident #1 was sent to the hospital emergency room for evaluation. The Hospital Progress Note dated 9/27/17, indicated Resident #1 Given [MEDICATION NAME], but unintentionally given at a higher dose than was prescribed or intended. Brought in at acute [MEDICAL CONDITION] ([MEDICAL CONDITION] and acute confusional state) with mental status changes. To be closely watched. Chief complaint: Decreased mental status and confusion (given 20 mg of [MEDICATION NAME] rather than prescribed 0.25 mg.). Patient has generalized weakness and difficulty walking. Patient has been off medication for 2 days and is waking more but still confused, too weak to walk and hallucinating. This seems to be all medication induced. Family does not want pt (patient) back at facility. Will look for placement at different long term care facility (LTCF). The Hospital Progress Note dated 9/28/17 and 9/29/17, indicated No change in progress. Patient still confused and groggy. Review of Hospital Progress Note dated 10/1, 10/2, 10/3 and 10/4/17, indicated Patient oriented frequently to place and time. No change. Review of Hospital Progress Note dated 10/05/17, indicated Patient confused and disoriented. Calling out at times. Transportation via stretcher to new LTCF. During an interview on 1/2/18 at 12:45 PM, the Risk Manager stated following the investigation regarding the excessive dose of [MEDICATION NAME], it was determined the nurse made a medication transcription error. The Risk Manager was unable to explain the absence of documentation of any resident (#1) behaviors before the [MEDICATION NAME] was ordered, the nurses failure to question the excessive dose and the lack of monitoring/reporting the adverse drug reactions Resident #1 demonstrated following the administration of [MEDICATION NAME]. During an interview on 1/2/18 at 2:50 PM, Nurse D stated I remember the resident but do not remember her having any behaviors. She was very quiet. I would not have questioned the 20 mg [MEDICATION NAME] order unless I had issues with vitals. Since the resident is on hospice, they sometimes order extreme doses. If there was an issue, the pharmacy would have informed us. During an interview on 1/2/18 at 4:35 PM, the pharmacist stated the pharmacy would immediately receive the order when placed electronically. The pharmacist filling the order would not have gotten a warning as 20 mg of [MEDICATION NAME] is an order that can be prescribed. During an interview on 1/2/17 at 5:15 PM, the attending physician stated When I was informed of the wrong dose, I immediately stopped the [MEDICATION NAME] and had hospice provide crisis care to monitor the resident and the effects of the medication. The 20 mg dose of [MEDICATION NAME] is a dose that can be prescribed. The psychiatrist sees residents all the time and his intent was to prescribe 0.25 mg not 20 mg. The attending physician did not acknowledge the antipsychotic medication, [MEDICATION NAME], as an unnecessary drug for resident #1. During an interview on 1/2/18 at 2:15 PM, the Director of Nursing (DON) stated she was the Assistant Director of Nursing (ADON) at the time and remembers resident (#1) to be very quiet with no behaviors. The census and condition report completed by the DON dated 1/02/18 indicated the facility has 67 residents receiving psychoactive medication and 32 residents receiving antipsychotic medication. Review of the facility policy Psychopharmacologic Drugs dated 11/2017, states the purpose is to provide guidelines for the use of psychopharmacologic drug treatment of [REDACTED]. The Procedural Guidelines included: 1. Psychopharmacologic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics, and other drugs that affect behaviors. 2. Psychopharmacologic drugs shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician. Notification must be complete with the resident or his/her representative for antipsychotic drug therapy. 3. The resident or his/her representative will be given information regarding the need for, the desired effects and the potential side effects of the antipsychotic medication. This enables the resident or his/her representative to make an informed decision regarding the use of an antipsychotic medication. 4. Psychopharmacologic drugs will not be used to limit or control behavior . 5. Nurses will observe for side effects and medical staff will reduce dosage to the minimum required .6. Nurses will document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects. 7. Nursing services, social services and other members of the interdisciplinary team will address the behaviors on the care plan. Medication is not the sole approach for behavioral intervention. Other interventions will be identified on the care plan . Unnecessary Drugs: 1. Each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are any drugs when used: a. In excessive dose; b. for excessive duration; c. without adequate monitoring; d. without adequate indications for its use; e. in the presence of adverse consequences that indicate the dose should be reduced or discontinued . Antipsychotic Drugs: 1. Residents who have not used antipsychotic drugs will not be given such drugs unless antipsychotic drug therapy is necessary to treat a specific condition. 2. Unless the resident's medical record clearly indicated that the resident has one or more of the following specific conditions, antipsychotic drugs should not be used. These specific conditions include: [MEDICAL CONDITION]; Schizo-affective disorder; Schizophreniform disorder; Delusional disorder; Mood disorders (e.g. [MEDICAL CONDITION] disorder); [MEDICAL CONDITION] in the absence of dementia; medical illnesses with psychotic symptoms; [MEDICAL CONDITION]'s disorder; [MEDICAL CONDITION]'s disease; Hiccups; Nausea and vomiting associated with [MEDICAL CONDITION]; behavioral and psychological symptoms of dementia. The policy contained a letter to inform the resident and/or representative of the use of antipsychotic drug therapy with the possible negative outcomes including cognitive/behavior impairment and Akathisia (restlessness/constant movement).

Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors for 1 of 11 sampled residents (#1). Resident #1 was administered an excessive dose (80 times the dose) of [MEDICATION NAME] ([MEDICATION NAME]) which was not in accordance with the prescriber's order. The facility failed to have an established system in place to verify orders entered into the Medication Administration Record [REDACTED]. [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) Resident #1 was subject to adverse consequences such as extra pyramidal symptoms including lethargy, weakness and difficulty walking, increased confusion, hallucinations, and uncontrolled constant leg movements resulting in blisters to her feet. This resulted in Substandard Quality of Care and immediate jeopardy starting on 9/21/17. The immediate jeopardy was determined to be ongoing as of the exit date, 1/05/18. The failure to ensure residents are free for significant medication errors puts all residents at risk. Cross reference: F658, F755, F758, F835, F867. Findings: Resident #1 was [AGE] year-old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission, the resident resided at home with her daughter and was under the care of hospice for end stage [MEDICAL CONDITION]. Resident #1 was admitted to the facility for respite care with plans to remain living there as a long term care resident under hospice care. Review of Psychiatric Initial Mental Status Exam dated 9/21/17, indicated the psychiatrist's recommendation was Will give trial [MEDICATION NAME] times 2 weeks and follow. The psychiatrist wrote an order in the medical record for [MEDICATION NAME] 0.25 mg (milligrams) every 2PM and bedtime for 14 days for a [DIAGNOSES REDACTED]. The Medication Order Summary Recapitulation dated 9/1/17-1/31/18, showed an order for [REDACTED]. The facility schedule for twice a day is 9 AM to 5 PM. The Medication Administration Record [REDACTED]. The resident did not have any physicians order for 20 mg of [MEDICATION NAME] to be given twice a day for [MEDICAL CONDITION]. The Medication Discrepancy Report dated 9/21/17, revealed Order was written for [MEDICATION NAME] 0.25 MG, nurse entered order for [MEDICATION NAME] 20 MG. Increased lethargy noted. Attending physician notified on 9/24/17 and family notified on 9/25/17. Resident #1 placed on hospice continuous crisis care to monitor adverse effects of the excessive dose of [MEDICATION NAME]. Review of the hospice Continuous Care Shift Care Note dated 9/26/17, indicated Resident #1 rubbing hands on pillow, kicking at sheets and resident sliding her heels over the bed all night nearly causing blisters. Review of Progress Note dated 9/27/17 indicated Resident #1 sent to ER for evaluation. The Hospital Progress Note dated 9/27/17, indicated Resident #1 Given [MEDICATION NAME], but unintentionally given at a higher dose than was prescribed or intended. Brought in at acute [MEDICAL CONDITION] ([MEDICAL CONDITION] and acute confusional state) with mental status changes. To be closely watched. Chief complaint: Decreased mental status and confusion (given 20 mg of [MEDICATION NAME] rather than prescribed 0.25 mg.). Patient has generalized weakness and difficulty walking. Patient has been off medication for 2 days and is waking more but still confused, too weak to walk and hallucinating. This seems to be all medication induced. The hospital record indicated the resident was in the hospital for 6 days. During an interview on 1/2/17 at 1:35 PM, Nurse A stated he entered the [MEDICATION NAME] order incorrectly into the computer. He verified that once an order is entered, it is the assigned task of the 11 PM to 7 AM nurse to verify each order against the electronic order record to ensure the information has been entered correctly. The nurse reconciles the order, marks it with a red check-24-the date and initials. Nurse A verified the [MEDICATION NAME] order had not been checked (no markings on order) by the night nurse. Nurse A stated the night nurse missed checking the order. If the order had been checked, the error could have been corrected immediately. During an interview on 1/3/18 at 7:30 AM, Nurse B confirmed how orders are checked and stated she had Resident #1 assigned to her on the night shift on 9/22/17. She confirmed the order had been missed and could not remember the resident or the order. During an interview on 1/2/18 at 1:10 PM, the Risk Manager indicated Resident #1 was prescribed an order for [REDACTED]. Four incorrect doses of the medication were administered 9/22/17 at 9 AM, 9/23/17 at 9 AM and 5 PM and 9/24/17 at 9 AM). The Risk Manager stated, following her investigation for the medication error report, it was determined the nurse made a medication transcription error. At that time the Risk Manager was unable to provide additional documentation of processes put in place to prevent future significant medication errors. It was noted that only 6 nurses received the education that was provided and the audit to review [MEDICAL CONDITION] medications occurred only once within a few days of the incident. There was no evidence of any continued monitoring for sustained compliance or any other education regarding medication errors. An interview with LPN A on 01/02/18 at 12:15 PM revealed that he had entered the [MEDICATION NAME] order into the electronic system with the wrong dose, 20 mg instead of 0.25 mg, with the wrong times, 9 AM and 5 AM instead of 9:00 AM and bedtime and with no stop date. The LPN was unable to explain how the error occurred except that he was very busy. He could not explain how he obtained the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The nurse reconciles the order, marks it with a red check mark, dates and initials the written order. The LPN A verified the [MEDICATION NAME] order had not been checked as there were no markings on the written order by the night nurse. He stated, the night nurse missed checking the order. If the order had been checked, the error could have been corrected immediately. A check of written physician orders was done with the unit manager of the north wing on 1/4/17 at 1:30 PM. Out of 11 written physician orders checked, only 2 had check marks, date and initials by the order indicating that they had been checked by the night nurses. The unit manager stated that the night nurses were responsible for checking the orders but added that the process was not being followed consistently. The Hospital Progress Note dated 9/27/17, indicated Resident #1 Given [MEDICATION NAME], but unintentionally given at a higher dose than was prescribed or intended. Brought in at acute [MEDICAL CONDITION] ([MEDICAL CONDITION] and acute confusional state) with mental status changes. To be closely watched. Chief complaint: Decreased mental status and confusion (given 20 mg of [MEDICATION NAME] rather than prescribed 0.25 mg.). Patient has generalized weakness and difficulty walking. Patient has been off medication for 2 days and is waking more but still confused, too weak to walk and hallucinating. This seems to be all medication induced. Review of the Medication Discrepancy Report dated 9/25/17, indicated Resident received an unordered dose of medication. Order was written for [MEDICATION NAME] 0.25 mg. Nurse entered order for [MEDICATION NAME] 20 mg, increased lethargy noted. Family, physician and hospice notified. Crisis care provided, [MEDICATION NAME] discontinued. Review of the facility policy for Medication Errors and Adverse Reactions dated 11/2017, indicated Drug errors and adverse drug reactions should be reported to the resident's attending physician. Policy Interpretation and Implementation: 1. Adverse drug reactions and drug errors with adverse clinical consequences should be reported to the resident's attending physician. 2. Nursing services should implement and follow the physician orders. The resident's condition should be closely observed for 72 hours or as may be directed .4. Documentation of the resident's condition and response to treatment should be recorded during the observation period.

Based on interview and record review, the facility failed to administer its resources effectively to ensure that 1 of 11 residents, (#1) was not seen by a psychiatrist for unknown reasons, did not get started on an unnecessary antipsychotic medication without indication and did not receive the antipsychotic medication in an excessive dose (80 times more) than the ordered amount without monitoring. Resident #1 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/21/2017, a psychiatrist saw the resident and ordered [MEDICATION NAME] 0.25 milligrams, (mg). The nurse transcribed the order as [MEDICATION NAME] 20 mg. The resident received 4 doses of [MEDICATION NAME] 20 mg (80 times more than the ordered dose) and was subsequently hospitalized for [REDACTED]. She was sent to a different skilled nursing facility upon discharge from hospital. Administration failed to identify that the resident was seen by a psychiatrist for undocumented reasons, an unnecessary medication was prescribed to the resident and the nurses failed to apply standards of practice for medication management. As a result of these failures, resident #1 was subjected to an excessive dose of an antipsychotic medication [MEDICATION NAME] ([MEDICATION NAME]), with subsequent decline in health status and hospitalization . [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) This resulted in immediate jeopardy starting on 9/21/17. The immediate jeopardy was determined to be ongoing as of the exit date, 1/05/18. Cross Reference: F658, F755, F758, F760, F867. Findings: A review of the resident #1's admission Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed that she had no behaviors. A review of the resident's care plan noted no behaviors. A review of the nursing progress notes from admission, 9/07/2017 to 9/21/2017 noted the resident had some forgetfulness, was very pleasant, smiling and in good spirits. There was no documentation of any behaviors. Despite no physician order for [REDACTED]. Will trial [MEDICATION NAME] 0.25 milligrams, (mg) times 2 weeks and follow. The order dated 9/21/2017 showed, [MEDICATION NAME] 0.25 mg at 2 PM and at bedtime for severe depressive episode for 14 days. The resident received four doses of [MEDICATION NAME] 20 mg on 9/22/17 at 9:00 AM, 9/23/17 at 9 AM and 5 PM and 9/24/17 at 9 AM. On 9/24/2017, the resident's family became concerned about the resident during their visit, as the resident appeared lethargic and, very dopey. A nurse reviewed the resident's medication order summary and discovered that instead of [MEDICATION NAME] 0.25 mg, the order was transcribed as [MEDICATION NAME] 20 mg give 1 tablet two times per day for [MEDICAL CONDITION]. The order had been transcribed with the wrong dose, the wrong times, and the wrong indication with no stop date. A nursing progress note dated 9/24/17 read, upon observation, resident lethargic, vitals stable, family stated resident is not at her baseline, less communicative. The medications were reviewed and the [MEDICATION NAME] was discontinued. The resident was placed on crisis continuous care for change in level of condition due to [MEDICATION NAME]. A telephone interview was conducted with the consulting psychiatrist on 1/5/2018 at 2:00 PM. He stated that he was not scheduled to see the resident. A nurse asked him to see the resident but could not recall which nurse. He was not aware if a psychiatric consult had been ordered by the attending physician. He stated that he did not usually check if a consult had been ordered as the nurses would obtain an order. He stated that the nurse asked him to see the resident, as she was a new resident and was shouting. When he saw the resident, she was being resistive to care and shouting at the staff. I was told she would not allow staff to provide care and repositioning. He was not aware of any other behaviors but stated that she appeared distressed during care times. When asked if any non-pharmacological interventions were attempted to calm the resident, he stated he was not aware. He stated that he prescribed a very small dose of [MEDICATION NAME] as it would calm the resident and not cause sedation. He would have increased the [MEDICATION NAME] to 0.5 mg but no more than that. He stated that [MEDICATION NAME] 20 mg was an excessive dose, something he never would have considered. When he was asked if he ordered the [MEDICATION NAME] for staff convenience, he stated that the resident appeared distressed during care times. A telephone interview with the medical director on 1/5/18 at 11:50 AM revealed that he was the resident's attending physician. He stated that he saw the resident once when she was admitted . He was not asked to see her again as she was stable. He was not made aware of any behaviors therefore he did not order a psychiatric consult. An interview with the licensed practical nurse, LPN A on 1/02/2017 at 4:10 PM revealed that he transcribed the [MEDICATION NAME] order into the electronic system incorrectly which caused the error. He stated that he was in a hurry and mistakenly entered 20 mg from the drop down menu. He did not offer any other explanation other than the error should have been caught on the night shift during order checks. A hospice care note on 9/25/17 read that the resident was restless, attempting to get out of bed, confused, agitated, kicking all pillows out, encourage heels up 2 inches from bed due to restless movement on bed and calling out repeatedly. Resident was bed bound with weakness and required total care with all activities of daily living, (ADLs). A hospice note on 9/26/17 read that the resident was rubbing hands on pillow, kicking at sheets and resident sliding her heels over the bed all night nearly causing blisters. On 9/27/17, the hospice note read that the family requested resident to be sent to hospital for evaluation. Resident still confused and anxious. An interview with the director of nursing, (DON) on 1/4/17 at 10:00 AM revealed that she had been the director for the past 3 months. She stated that the risk manager was the acting DON at the time the incident occurred. She said the Administrator would not be present during the survey. An interview with the risk manager on 1/4/17 at 10:00 AM noted that there was no consult order for the psychiatrist to see the resident. She stated that the nurse assigned to the resident on 9/21/2017 did not remember asking the psychiatrist to see the resident but it makes sense that she must have made the request. She said the psychiatrist saw the resident as she was agitated but confirmed there was no documentation to verify the resident was agitated. She also confirmed that non pharmacological interventions should have been tried to calm the resident before asking for a psychiatric consult but this did not happen. She stated that the nurse, LPN A who transcribed the [MEDICATION NAME] order incorrectly chose the wrong dose of 20 mg from the drop down menu in the electronic system. The only explanation that the LPN gave was that he was in a hurry and did not double check the order. She said the error should have been caught on the night shift, 11 PM-7 AM. The routine in the facility was that the night shift nurses were responsible for checking all physician orders written during the day. They were to pull a report from the electronic system of all orders and verify them with the written orders. She said that the night shift staff did not do this. There was a triple check system for medication reconciliation when all physician orders were reviewed during the morning meeting but this also did not happen. She was not able to explain why these checks did not occur. She stated that it was very hectic during that time and she was fulfilling the role of acting DON and risk manager. She stated that if the verification checks were done, the resident would not have received the excessive doses of [MEDICATION NAME]. She could not explain why the nurses did not question the administering of an excessive dose of the antipsychotic, [MEDICATION NAME] to a resident with no indication for the medication. Furthermore, there was no documentation of the resident's response to starting the antipsychotic medication. She stated, they should have documented it. She again, could not explain why there was no documentation. The administrator's job description read, Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and company policies so as to maintain excellent care for the resident while achieving the facility's business objectives. The director of nursing's job description read, Lead and direct the overall nursing operation of the Center in accordance with residents' needs, government regulations, and company policies so as to maintain excellent care for the residents while achieving the Center's business objectives. An interview with the risk manager on 1/5/17 at 3:00 PM revealed that she was trying to manage two positions during the time the incident occurred on 9/21/17. She was acting DON and risk manager. She stated that she was, pulled in all different directions. She stated that she should have been overseeing the care of residents during that time but, it was very hectic. She could not explain why the oversight of the psychiatric consult, the missed medication reconciliation on the night shift and during morning meetings, the lack of documentation of the resident condition including care plans were missed. She stated, we have a lot of work to do. The job descriptions for the Administrator and the DON indicated they had the responsibility to lead and direct the operations of the facility in accordance with resident needs to maintain excellent care for the resident. Although the facility had processes for pharmaceutical services and prevention of unnecessary drugs, the Administration did not provide the oversight and direction to ensure that resident #1 was provided the care to meet her highest sense of well-being.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance program for medication management. This failure resulted in a resident receiving an excessive dose, 80 times the prescribed amount of a potentially inappropriate antipsychotic medication, ([MEDICATION NAME]) for 1 of 11 sampled residents, (#1). Resident #1 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/21/2017, a psychiatrist saw the resident for unknown reasons and ordered [MEDICATION NAME] ([MEDICATION NAME]) 0.25 milligrams, (mg). The nurse transcribed the order as [MEDICATION NAME] 20 mg. The resident received 4 doses of [MEDICATION NAME] 20 mg, 80 times more than the ordered dose, which resulted in a significant drug error. The resident was subsequently hospitalized for [REDACTED]. She was sent to a different skilled nursing facility upon discharge from hospital. The facility's QAA committee failed to identify quality deficiencies. They did not complete a thorough investigation or analysis to identify the root cause of the significant medication error and failed to evaluate and analyze the risk once the medication error and the potential for serious injury/impairment/death had occurred. The facility failed to recognize that this potentially preventable event started with the psychiatrist assessing this resident for undocumented reasons, an unnecessary medication being prescribed for the resident, the physician order [REDACTED]. This preventable event ended when nurses administered this medication in excessive doses 4 times. As a result, resident #1 was subject to an excessive dose of an antipsychotic medication with subsequent decline in health condition and hospitalization . [MEDICATION NAME] has side effects and adverse reactions that may include: [DIAGNOSES REDACTED] (NMS), manifested by fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine), Extrapyramidal symptoms may occur including acute dystonic reactions, akathisia, tardive dyskinesia (facial/muscle twitching such as tongue thrusting, chewing movements, puffing or puckering of your mouth, or uncontrollable shaking), and pseudoparkinsonism, which may be permanent, Slow heartbeat, severe dizziness, chest pain, and [MEDICAL CONDITION]. (www.drugs.com) [MEDICATION NAME] is listed by The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution. (http://www.healthinaging.org/medications-older-adults/) The resident experienced weakness, lethargy, anxiety, confusion and uncontrollable leg movements and hand movements. These failures resulted in Immediate Jeopardy that was ongoing at exit on 1/05/18. Cross Reference: F658, F758, F760, F755, F835. Findings: A review of the Psychopharmacologic Drugs policy dated November 2017 section Unnecessary Drugs read; each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are any drugs when used: a. In excessive dose, c. Without adequate monitoring, and d. Without adequate indications for its use. The Antipsychotic Drugs section read, 1. Residents who have not used antipsychotic drugs will not be given such drugs unless antipsychotic drug therapy is necessary to treat a specific condition: a. [MEDICAL CONDITION], b. Schizo-affective disorder, c. Schizophreniform disorder, d. Delusional disorder, e. Mood disorders, f. [MEDICAL CONDITION] in the absence of dementia A review of the medical record noted that the resident did not have any of the [DIAGNOSES REDACTED]. An interview with the administrator and director of nursing, (DON) on 1/03/2018 at 4:15 PM revealed that although they identified the medication error as a serious event, they did not have an emergency QAA meeting following the incident. A QAA meeting was held on 9/27/2017 after the medication error was identified but the incident was not discussed formally until 32 days later at the October 26, 2017 meeting. The DON stated that the measures put in place were decided by the QAA team including herself, the administrator and the medical director. These measures included providing education to the nurse involved in the transcription error and conducting an audit of all antipsychotic medications to ensure the order was transcribed into the electronic system accurately as per physician orders. It was noted that only 6 nurses received the education that was provided and the audit to review [MEDICAL CONDITION] medications occurred only once within a few days of the incident. There was no evidence of any continued monitoring for sustained compliance. Although the pharmacy consultant was informed of the significant medication error, there was no evidence that she was involved in any efforts to assist the facility to identify, evaluate and resolve pharmaceutical concerns. Although this medication incident of 9/21/2017-9/24/2017 was serious and resulted in a significant medication error, the facility failed to recognize the root cause of the incident. The facility focused on the transcription error as the root cause and did not identify the deficiencies in the medication system as a whole. There was no psychiatric consult ordered from the primary physician therefore no reason for the psychiatrist to see the resident. There were no identified indications as to why the psychiatrist ordered the medication, [MEDICATION NAME]. The medical record did not show the resident exhibiting any behaviors. There was no care plans indicating any behaviors or the resident's usual behavior. The nurses did not follow standards of practice for medication transcription and entered the wrong dose into the electronic system. They administered the excessive dose of [MEDICATION NAME] to a geriatric resident who was not exhibiting any behaviors without questioning the order. The facility failed to recognize that their system for order reconciliation was not being followed. A telephone interview with the consulting psychiatrist on 1/5/2018 at 2:00 PM revealed that he was aware of the [MEDICATION NAME] medication error. He stated that he was not scheduled to see the resident. A nurse asked him to see the resident as she was new but could not recall which nurse. When asked if he ensured that there was a physician consult order, he stated he did not check for the consult order. He stated that the nurse asked him to see the resident, as she was new. When he saw the resident, she was being resistive to morning care and shouting at the staff. I was told she would not allow staff to provide morning care and repositioning. He was not aware of any other behaviors but she appeared distressed during care times. When asked if any non-pharmacological interventions were attempted to calm the resident, he stated he was not aware. He stated that he prescribed a very small dose of [MEDICATION NAME] as it would calm the resident and not cause sedation. He would have increased the [MEDICATION NAME] to 0.5 mg but no more than that. He stated that [MEDICATION NAME] 20 mg was an excessive dose, something he never would have considered. When he was asked if he ordered the [MEDICATION NAME] for staff convenience, he stated that the resident appeared distressed during care times. An interview with the licensed practical nurse, LPN A on 1/02/2017 at 4:10 PM revealed that he transcribed the order into the electronic system incorrectly which caused the error. He stated that he was in a hurry and mistakenly entered 20 mg from the drop down menu. He did not offer any other explanation other than the error should have been identified on the night shift during order checks. During an interview with the risk manager who was acting DON during the time of the medication error confirmed that their root cause of the incident was the nurse made a transcription error. She was not able to provide an answer as to why the resident was seen by the psychiatrist despite no documentation of any behaviors or a physician consult order. She confirmed that a physician order [REDACTED]. The resident's family became concerned as she was lethargic and was very confused. She said the nurse who made the transcription was provided education as soon as the error was discovered. The process for medication order reconciliation was that the night nurses working 11:00 PM-7:00 AM would review all medication orders written during the day and double check to ensure that the electronic orders matched the written physician orders. Unfortunately, this did not happen. The medication should have also been checked during the morning meeting when all written physician orders [REDACTED]. I guess the order was not checked. She confirmed that their system for double checks failed as it was not followed consistently. A telephone interview with the medical director on 1/5/18 at 11:50 AM revealed that he was the resident's attending physician. He stated that he only saw the resident at admission and did not see her after that, as there were no issues with the resident. He was not informed of any behaviors otherwise he would have assessed the resident again. He was aware that the resident had received an excessive amount of [MEDICATION NAME]. He stated that he was made aware of the error the day after it happened but it was not discussed formally until the October QAA meeting. He was informed of the plan to educate the staff and the antipsychotic medication audits. He stated that he did not recall getting any reports at the subsequent monthly QAA meetings as to the progress of the education or the results of the audits. He said the psychiatrist was not included in the QAA meetings but it would be a good idea to include him in the meetings. An interview with the pharmacy consultant on 1/5/17 at 11:30 AM revealed that she was made aware of the [MEDICATION NAME] medication error on the day it occurred. She stated that if she had seen the resident, the order for [MEDICATION NAME] 20 mg would have caught her attention as it was an excessive dose for an [AGE] year-old geriatric resident. The resident could have extra pyramidal symptoms to indicate toxicity such as lethargy, stupor and weakness. An interview with the director of nursing, acting administrator and risk manager was held on 1/5/18 at 12:20 PM. They stated that the initiative to reduce antipsychotic medications was very much a part of their QAA. The only evidence they provided to reduce antipsychotic medications was the pharmacy consultant's monthly reviews with recommendations for gradual dose reductions. The facility had a high population of younger, mental health residents on antipsychotic medications. They could not provide an answer when asked how they educate their staff on proper dosages and what clinical symptoms to observe for with geriatric residents verses younger population. It was pointed out to them that interviews with licensed nurses revealed that they would not question an order of [MEDICATION NAME] 20 mg twice daily for a geriatric resident. An interview with the unit manager of north wing on 1/4/17 at 1:30 PM revealed that she would not question an order for [REDACTED]. In an interview with LPN B on 1/4/18 at 4:25 PM, she stated that she would not question an order for [REDACTED]. They stated that it was obvious they had a lot of work to do. Significant medication errors are a serious issue and should be addressed at QAA meetings promptly. Although the facility had a significant medication error, it was not discussed formally at a QAA meeting until more than a month later. The facility had an [AGE] year-old resident who was given an excessive dose of an antipsychotic medication, [MEDICATION NAME] 80 times the ordered dose 4 times without any indication. The QAA committee failed to fully investigate this error that occurred on 9/24/2017. They did not identify the root cause of the incident and arrived at the conclusion that the nurse had made a transcription error. Therefore, they focused on the transcription error rather than focusing on why the antipsychotic medication was prescribed without any indication. They failed to assess why the resident was seen by the psychiatrist without an order, why the antipsychotic was prescribed without any indication, why the transcription error was made, why the process for reconciliation was not followed and why there was no documentation of the resident condition after the antipsychotic was started. There were no individualized care plans for the resident to reflect that a thorough assessment was done regarding her routine or normal behaviors. The census and condition report completed by the DON on 1/02/18 indicated the facility has 67 residents receiving psychoactive medication and 32 residents receiving antipsychotic medication.

Based on interview and record review, the facility failed to follow nursing practice standards to ensure that resident assessments were performed by a Registered Nurse (RN) for 1 of 4 sampled residents who needed assessments status after falls (#3). Failure to perform accurate assessment after accidents/falls put residents at risk for harm, severe injuries, and subsequent death. Resident #3 sustained a serious head injury after a fall from a wheelchair which was assessed by licesened practical nurses (LPNs) rather than by an RN. The resident later died as a result of the head injury. Findings: Per the Florida Statutes, Chapter 464 Nursing Part I Nurse Practice Act (ss 464XXX,[DATE].027): "(3)(a) 'Practice of Professional Nursing' means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based on applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to": 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. "(3)(b) 'Practice of practical nursing' means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist." On [DATE] at approximately 3 p.m., review of the medical record for resident #3 revealed an "Exception Report" completed for this resident due to a fall the resident sustained [REDACTED]. The "Exception Report" revealed that on [DATE] at 7:45 p.m., the resident returned from an outing where the resident fell and sustained a head injury. The "Exception Report" indicated that it was completed by an LPN. The "Exception Report" form revised ,[DATE], as related to its content, is an assessment of the resident at the time of the incident. The report contains observation of the resident; assessment of the resident's condition including wound measurements; the plan and the interventions to that plan, and an evaluation of that plan. The form included a place for a nurse to sign. It did not include a place for a RN to sign the assessment. During an interview on [DATE] at 4:25 p.m., the LPN said she was resident #3's nurse on the night of the accident. She said the other LPN working that night called her and told her the activity director had called and said they were on the way back to the facility. She said no one told her the resident was injured. She said she tried to call the activity director back on his cell phone at that time, but he did not answer. She stated when she first saw the resident in the wheelchair, she had an ice bag on her face. She said she took the resident's vital signs, did a neurological check, including hand grasps, and she could move all extremities. The resident did not complain of any pain at that time. She stated she called the physician and he said the resident is on [MEDICATION NAME], she needs to go to the hospital. She called local transport ambulance and requested the trip as non-emergent, as the physician requested. The LPN stated non-emergent transport can take up to 4 hours to arrive at the facility. The resident stayed with her, in her wheelchair, by the nurses' station. She said the resident was oriented that night. The resident had a large purple area on her face near the right eye, a bump about the size of an orange, and a small laceration over her eye. She confirmed the "Exception Report" is considered a fall assessment and she said she completed it the night of the accident. The other nurse working that night was also an LPN. She said the resident returned to the facility at about 7:,[DATE] p.m. and the doctor was called at 8:30 p.m. This was confirmed by review of the "Exception Report" documentation. Per the "Exception Report", the physician was not notified until 8:30 p.m. The neurological checks were not initiated until 8:30 p.m. Review of the documentation related to resident #3 showed many inconsistencies in the times of the documentation. The transport fax was at 8:20 p.m., 10 minutes prior to contacting the physician. The LPN stated she obtained vital signs when the resident returned to the facility, however none were documented until 8:30 p.m. The order to send resident #3 to the hospital is dated [DATE] at 8 p.m., however on the incident report the physician was documented as notified on [DATE] at 8:30 p.m. The activity assistant stated the bump on resident #3's forehead was the size of a walnut, while the LPN stated it was the size of an orange when the resident returned to the facility. Review of the staffing sheet for [DATE] revealed that there were no RNs scheduled to work the ,[DATE] shift that evening. An RN did not come to the facility to do the assessment of the resident. The risk manager was called that evening at 8:30 p.m. There was no evidence that she came back to the facility to assess the resident. During an interview with the RM on [DATE] at 11:45 a.m., she was asked why she did not consider calling 911 when she was notified of the resident's fall and head injury. She replied, "I did not call 911 because I wasn't there." Per the "Exception Report", the director of nursing (DON) was not notified of the incident until 9 a.m. the next day, [DATE]. Per the "Nurse Practice Act", an RN is the only licensed nurse to complete an assessment on a resident. An RN was not scheduled that evening and a RN did not come to the facility to assess the resident. The LPN did the assessment since there was no RN available. The LPN assessed the resident, a nursing practice out of the scope of her license. This resident was taken to the emergency room , just across the street from the facility. Per information related in the medical record,the resident had to have surgery for [REDACTED].

Based on record review and interview, the facility failed to maintain a safe environment for 2 of 4 residents after falling inside and outside of the facility (#3 & 7). The facility failed to provide an immediate assessment of the resident after falling and sustaining a serious head injury resulting in resident #3's death (#3); failed to ensure staff are trained to identify and response to and manage residents' emergency needs when out of the facility on an activity event (#3); failed to ensure nursing staff are available for outings (#3); failed to ensure staff followed the exception policy related to moving a resident after a fall/accident (#3); failed to report an accident to the director of nursing/assistant director of nursing (DON/ADON) immediately as required by policy (#7); and failed to ensure the facility was free of accident hazards for 1 of 2 wings (South). Failure to provide emergency care and services for accidents and falls put residents at risk for harm, severe injuries, and subsequent death. Immediate Jeopardy was identified on [DATE] as starting on [DATE]. The administrator was advised on [DATE]. On-going Jeopardy was determined at the exit on [DATE]. Findings: Cross Reference F281 and F490. 1. Record review for resident #3 revealed a Federal Immediate and 5-Day Report for neglect was submitted by the risk manager of the facility on [DATE] and [DATE] after a visit from Adult Protective Services (APS). The APS investigator was at the facility to investigate allegations of medical neglect and lack of supervision related to a fall with a head injury sustained by the resident on [DATE]. The resident was participating in an activity at a restaurant outside of the facility with the activity director, activity assistant, and three other residents, one in a wheelchair, one using a walker, and one able to walk. The report indicated that during the time residents were leaving the restaurant, the activities director was 12 feet from resident #3. The resident unlocked the brakes of her wheelchair (w/c) and rolled down the handicap ramp. The wheelchair tipped and the resident fell out of the wheelchair, hitting her head on the ground. Additional record review revealed a nurse was not present during the activity at the restaurant to assess the resident's injuries. The staff members present at this activity did not call 911. A bystander assisted the resident back into the w/c. The resident returned to the facility at 7:45 p.m., approximately 30 minutes after the fall and injury. Physician notification, assessment of her injuries, and neurological checks did not occur until 8:30 p.m., one hour and 15 minutes after the head injury. The ambulance arrived at 9 p.m. to transport the resident to the hospital. The local transport company record, dated [DATE], indicated that the resident had a fall out of her w/c. Priority request was listed as "routine-stable patient". Per hospital records, resident #3 required emergency surgery to remove a subdural hematoma. The resident subsequently died at the hospital. During an interview on [DATE] at 3:15 p.m., the activity assistant said resident #3's accident happened on [DATE] during "Ladies Night Out." She said none of the outside activity related information was documented in the medical record. She said when they finished dinner, it was dark and windy. She was assisting one of the other residents when she saw resident #3's w/c fall over to the right on the wheelchair ramp. After the fall, a man ran over, a bystander, picked the resident up and put her back in her w/c while she held it for the man. She said she just did not have time to tell the man not to pick her up, it all happened very fast. She said she received first aide training as a part of her training, and she can apply ice. She said normally she would not have moved the resident, but it just happened so fast, she did not have time to stop the bystander. It was very dark, and neither she nor the activity director could see the resident's injuries. She said after returning to the facility she could see the resident had a black right eye, a small cut under the right eye/cheek, approximately ? inch, and a bump the size of a walnut over the right eye. She said she is a certified nursing assistant (CNA) and maintains her CNA certification, but does not work as a CNA in the facility. She said the last time she worked as a CNA was about 4 months ago, and that was for about 1 hour. During an interview on [DATE] at 3:45 p.m., the activity director said they left the faciity on [DATE] at about 5 p.m. to go to a local restaurant. He said the resident requested to go out. He said she told him she could not go out, because she did not have any money, but the resident's daughter came in previously and deposited some money into her account for her. He said her daughter was aware the resident was going to go out to the restaurant. He said resident #3 was oriented that night. He said when he left her in her wheelchair, he told her to stay and he would be back for her, and locked her w/c. He was in the process of locking another resident in her w/c in the van, when out of the corner of his eye he saw resident #3 coming very fast down the wheelchair ramp. He saw the w/c turn over and went to the resident's side. He said the injury did not look bad at first. He went and got ice inside of the restaurant and applied the ice to the resident's face/head. She began to swell very quickly. However, the resident said nothing hurt, and wanted to go back to the nursing home. He said when they returned to the facility, he took the resident to the nurses' station and the licensed practical nurse (LPN) took care of the resident. When asked if the residents are assessed for appropriateness for outings, he said yes, but nothing is documented in the resident's medical records. He said if the staff had to do all of that documentation, then there would not be time to go on outings. He said he spoke with resident #3's daughter prior to the trip and she was OK with the trip. He showed copies of information taken with all residents on trips, including do not resuscitate (DNR) and face sheets. A review of the personnel records, dated effective [DATE], revealed the facility does not require employees to have basic first aid training. A review of the "Exception Reports" policy, dated [DATE], included "Assisting Accident/Incident Victims - Render immediate assistance. Do not move the person until he/she has been examined for possible injuries." Review of the policy "Off-Premise Activities", dated ,[DATE], revealed, "At least one member of Nursing Services, if available, will accompany the Activities Coordinator on trips." During an interview on [DATE] at 12:40 p.m., the activities assistant said she is a CNA, but said she does not normally work in that capacity. During an interview on [DATE] at 4:25 p.m., the LPN said she was resident #3's nurse on the night of the accident. She said the other LPN working that night called her and told her the activity director had called and said they were on the way back to the facility. She said no one told her one of the resident's was injured. She said she tried to call the activity director back on his cell phone at that time, but he did not answer. She stated when she first saw the resident in the wheelchair, she had an ice bag on her face. She said she took the resident's vital signs, did a neurological check, including hand grasps, and the resident could move all extremities. The resident did not complain of any pain at that time. She stated she called the physician and he said the resident is on Coumadin, she needs to go to the hospital. She called local transport ambulance and requested the trip as non-emergent, as the physician requested. The LPN stated non-emergent transport can take up to 4 hours to arrive at the facility. The resident stayed with her in her w/c by the nurses' station. She said the resident was oriented that night. The resident had a large purple area on her face near the right eye, a bump about the size of an orange, and a small laceration over her eye. She confirmed the "Exception Report" is considered a fall assessment and she said she completed it the night of the accident. The other nurse working that night was also an LPN. She said the resident returned to the facility at about 7:,[DATE] p.m. and the doctor was called at 8:30 p.m. This was confirmed by review of the "Exception Report" documentation. Coumadin is a blood thinner medication and increases the risk for a subdural hematoma. Subdural hematomas are usually the result of a serious head injury. Bleeding fills the brain rapidly and compresses the brain tissue. This often results in brain injury and may lead to death. (U.S. National Library of Medicine National Institute of Health (NIH) www.nlm.nih.gov) Review of the medical record and documentation related to resident #3 showed she was re-admitted to the facility on [DATE] following an acute care hospital stay for cellulitis in her legs. A significant change Minimum Data Set (MDS) Assessment was completed on the resident on [DATE] to reflect changes in her condition following her hospital stay. Her most recent 30 day MDS assessment dated [DATE] indicated under Section C for Cognitive Patterns Summary Score of ,[DATE] (,[DATE] = severe impairment). Section E- Behavior indicated that no delusions or hallucinations were observed. Section G Functional Status reflected transfers as 3 (Extensive Assist) and locomotion on/off unit as 1 (Supervision-oversight, encouragement or cueing), Moving from seated to standing position and surface to surface transfer as a 2 (Not steady, only able to stabilize with staff assistance, Mobility devices listed as a walker and wheelchair. Section I Active [DIAGNOSES REDACTED]. Section J1800 Falls since admission was "0". Section N Medications included Antipsychotic (7 days), Antidepressants (7 days), Diuretic (7 days) and Anticoagulant (7 days). Section O indicated Occupational Therapy (OT) and Speech Therapy (ST) and Physical Therapy (PT) to start on [DATE]. The Nursing Resident Admission Data Collection dated [DATE] indicated that the resident's functional status with transfers and ambulation was a 1 person assist. The Initial Fall Risk Screen indicated a total score of 14, with 10 or above representing high risk for falls. The resident's care plans included potential for falls, assistance with activities of daily living (ADL) function and mobility, and behavior monitoring. The care plan for ADLs and falls was initiated on [DATE] and reviewed and/or updated on ,[DATE], ,[DATE], ,[DATE], and ,[DATE], and [DATE]. Care plans for behavior were initiated on [DATE] and updated on ,[DATE], reviewed on ,[DATE], ,[DATE], ,[DATE], and [DATE]. The resident had a fall on [DATE] with injury. The "Injuries Report Post-Fall," dated [DATE], documented the "resident did not lock her brakes on a 4-wheeled walker, causing her to fall with abrasions and bruises, and complaint of pain right forearm and cheek." The care plan interventions included notified therapy, neurological checks, continue safety education, cues, and reminders, assist with mobility, ambulation, toileting as needed, and notify physician of changes. On [DATE], X-ray of the right forearm and right facial bone was negative for fracture. On [DATE], the resident had a fall without injury. She stated she slid out of chair. The "Exception Report" listed measures put in place were to keep recliner foot elevated when sitting in chair. physician's orders [REDACTED]. The resident had a previous radiology report dated [DATE] for CT head/brain and it indicated moderate generalized atrophy with mild micro-angiopathy. No acute abnormality. Nurses' note on [DATE] indicated the resident had been seen by the physician and that the daughter had concerns about resident's mental well-being. A new order for a CT scan of brain was obtained at that time. Also per daughter's request, a psychiatry consultation to wean off Cymbalta and try an alternative was ordered by the physician. Nurse's note dated [DATE] indicated that the "resident was brought back from activity dinner, they stated she took her brakes off the w/c and w/c tipped and she fell and hit head. Large bruise over right (rt) eye, rt eye swollen shut, purple, laceration under rt eye. Alert with usual confusion. No complaints of pain." Review of the documentation related to resident #3 showed many inconsistencies in the times. The transport fax was at 8:20 p.m., 10 minutes prior to contacting the physician. The LPN stated she obtained vital signs when the resident returned to the facility, however none were documented until 8:30 p.m. The order to send resident #3 to the hospital was dated [DATE] at 8 p.m. However, on the incident report the physician was documented as notified on [DATE] at 8:30 p.m. The activity assistant stated the bump on resident #3's forehead was the size of a walnut, while the LPN stated it was the size of an orange. Staff are not trained to identify or handle emergency situations when outside the facility on resident activity events. Review of the personnel files for the activity director and the activity assistant showed neither has current documented first aid training. Review of the last annual education for both employees showed first aid was not on the list of education items. 2. Review of medical record for resident #7 revealed she was admitted on [DATE] for pneumonia, cough, allergy, atrial Fibrillation, [DIAGNOSES REDACTED], and ischemic heart disease. The facility failed to report an accident to the director of nursing/assistant director of nursing (DON/ADON) immediately as required by facility policy. Review of the "Exception Report" dated [DATE] at 3 p.m. showed the resident reported falling on [DATE] at 3 a.m. She did not tell the nurse until 3 p.m. on [DATE] when her shoulder starting hurting. The "Exception Report" showed the DON as notified of the fall on [DATE] at 9 a.m. and the administrator notified on [DATE] at 9 a.m., two days after the event occurred. The risk manager (RM) was notified on [DATE] at 8 a.m. During an interview on [DATE] at 2:45 p.m. the RM said, "I am the one who is called when a resident has fallen." She said she is the one that needs to be called, because she has questions for the staff and directions for them. The RM and the DON both confirmed the policy, "Exception Reports," dated [DATE], read to "Report all accidents/incidents to the DON/ADON immediately, who will subsequently contact the Administrator." The DON stated immediately would mean within 24 hours of the event. The DON also said the "Exception Report" signatures are dated when the report is signed off as completed, and that currently there is no log or documentation of when the DON/ADON, administrator, or risk manager receives a call from the staff for notification of incidents. 3. On [DATE], at approximately 3 p.m. while touring the facility, the following was observed: on the South wing, there was a housekeepers bucket and mop by room 39. The bucket was ? full of some type of fluid. There was no housekeeping person visible by the bucket. In the same area was observed a pyramid shaped container on the handrail, right by the doorway to room 39. In that container contained 4 wire connectors that had 2 cut wires protruding from each connector. The ends of the wires were sharp and had the potential to scratch if a resident were to touch or grab them. There were unsupervised vulnerable residents around that hallway. There was a yellow wet floor sign approximately 5 feet away from the bucket but it was folded up and was leaning against the wall instead of being open and by the bucket so as to alert someone of the bucket filled with fluid. On the other side of the South wing nurse's station, close to the therapy room, was a cart in the small hallway with a ladder on top of it. On top of that were 2 boxes with low voltage cable wires in it. Both boxes were open and had cut wires sticking out of the boxes. There were no caution signs visible to alert vulnerable residents of the hazard.

Based on record review and interview, the facility failed to have a written policy/protocol on emergency transport and the failed to to provide care and services for emergencies/accidents that occur outside the facility for 2 of 4 resident sampled for falls (#3 & 7). Resident #3 sustained a serious head injury after a fall from a wheelchair that occurred during a facility outing. Resident #3 was not provided emergency care and not transported timely for further evaluation of an emergent medical condition. This failure put residents at risk for harm, severe injuries, and subsequent death. Findings: 1. During an interview on 11/29/12 at 10:40 a.m., the director of nursing (DON) said there was no written policy/protocol on emergency transport. She stated that when the nurse notifies the physician of the resident's status, the physician makes the decision on how to transport the resident regarding 911 versus non-emergent transport. She added that the nurse at any time can call 911 if the resident has a change in condition that would warrant 911. She confirmed the physician's telephone order written on 10/24/12 at 8 p.m. for resident #3 to be sent to the hospital did not specify whether or not the resident should be sent as 911 (emergency) or regular transport. Resident #3 had a fall while in her wheelchair during an outside activity on 10/24/12. Per the facility's policy regarding emergency situations, it stated that the resident was not to be moved until assessed by medical personnel stating that the resident is stable enough to move. The activity staff failed to follow this policy and not only had the resident put in her wheelchair, but allowed a bystander to pick up the resident while the activity assistant put the wheelchair underneath her. Neither the DON nor the administrator were notified of this incident until the next day at 9 a.m., thus not following their policy on notifying administrative staff, which states the DON is to be notified immediately, and will then notify the administrator. The nursing administration failed to have a registered nurse (RN) available to complete an assessment on resident #3 upon her return to the facility. A licensed practical nurse (LPN) completed the assessment in the form of an "Exception Report." Per the Nurse Practice Act, only an RN is allowed to perform assessment on residents. Therefore, the LPN was working outside the scope of her license. 2. The nursing administration failed to ensure that resident #7's care plan was followed as outlined. Resident #7 had a fall and per his care plan, and the facility's protocol included neurological checks to be done for 72 hours following the fall. There was no evidence in the medical record of the neuro check sheet. When the DON was asked to produce the neuro sheet, she was not able to locate one. The administration made a decision to not require staff to keep current First Aide training. Per an interview with the administrator on 11/30/12 at approximately 1 p.m., he stated that it is not required to have his staff renew First Aid and he did not see the reason for having a current First Aide card. He stated that if they had taken the class, at least once, then that should be ok since nothing changes when they update their status. In the group that resident #3 was with, there were two staff members who were not current on first aid techniques, and therefore were not qualified to administer first aide to one of their residents who had a fall and sustained a head injury.