Every finding on record at Melbourne Terrace Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure food items were stored in a safe manner by failing to accurately label and date food items, keep food items properly contained, and used by the discard date. This failure had the potential to negatively affect all 165 of the 165 residents who consumed food by mouth at the facility. Findings: 1. On 12/02/4 at 10:15 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM) in the walk-in refrigerator, a previously opened plastic container of chicken base and another of beef base were noted to not have dates as to when they had been opened. The CDM verified this and removed these from the refrigerator to discard. She stated all opened food items were to be dated with the date when they were opened. Two of five previously opened mayonnaise containers were found to also be undated. The CDM verified this and removed them to discard. A previously opened and undated container of barbeque sauce and one of garlic cloves were also noted and removed from the refrigerator by the CDM to be discarded. A large, deep steamtable pan which held several previously opened cheese products was noted. It contained one undated plastic bag with about 15 slices of Swiss cheese and one resealed package of about 20 Swiss cheese slices dated 11/20 (13 days previous). The CDM verified these findings and stated their policy was to use an opened package of cheese within seven days of opening. She removed these items along with an undated plastic bag of approximately 25 slices of American cheese and another with 10 slices dated 11/02 (31 days previous). There was also a previously opened, resealed and undated half-full bag of shredded mozzarella cheese which the CDM removed to discard. There were three unlabeled and undated 1/3 size steamtable pans noted, each contained a resealed plastic bag of an unrecognizable food item. The CDM stated the first one contained leftover scrambled eggs that were from breakfast and the other two bags contained pureed bread. She removed these items to discard. An unlabeled, undated, and unsealed (open to the air) plastic container of soup, which the CDM stated was chicken enchilada soup was also found and removed by the CDM along with a 1/2-size steam table pan that contained an unlabeled, undated, and unsealed (open to the air) bag of diced chicken. A cardboard box contained two plastic bags of hot dogs which were open to air and undated so staff would know when they had been opened. The CDM removed the hot dogs along with a box containing two packages of unsealed and undated pork sausages. A pre-prepared plastic container contained approximately two cups of chicken salad which was dated 11/21 (12 days previous) along with another container that held approximately four cups of egg salad that was dated 11/23 (10 days previous). These were verified by the CDM who removed the items to discard. The CDM stated their policy was to use or discard these products within seven days of being opened. A resealed, unlabeled and undated approximately 1 by 3 cube of cream cheese was noted along with an undated plastic bag of whipped topping. These items were also verified by the CDM and removed to discard along with an unlabeled and undated sheet pan of a prepared, leftover fish dish. 2. A short time later at approximately 10:45 AM on 12/02/24, the dry storage room was toured with the CDM. Spaghetti noodles, egg noodles, and elbow macaroni were seen in their original but previously opened plastic bags, now wrapped in plastic wrap along with 2 cardboard boxes that contained dry oatmeal and a previously opened package of mashed potatoes. None of these food items had been dated with the date when they were received or when they were opened. There were also three boxes of paper supplies (drinking cups and wrapped eating utensils) found stacked on the floor in the overflow paper product storage area. 3. At approximately 11:00 AM on 12/02/24 in the walk-in freezer, a half steamtable pan of an unrecognizable, unlabeled and undated food item was found. The CDM thought it might be chicken and removed it from the freezer to discard. On a shelf in the lower left corner of the walk-in freezer, were three full-sized steamtable pans of unrecognizable food items dated 11/28 and labeled, only Tavern. The foil covering for one of these pans had ripped and the food was exposed, open to the air. The CDM was not able to identify what the food items were, but stated the employee responsible for preparing the meals for the Tavern food service area would know what they were. She agreed all leftover food items should be labeled with their contents in case another staff retrieved them for service. The CDM acknowledged this would be important for resident safety including food preferences and/or possible food allergens. In the same corner of the freezer were two unlabeled, sealed plastic bags of what the CDM stated was chicken. The bag of chicken had an imprinted date of [DATE]. The other bag she said she thought was beef, was dated December 2022, both dates over two years ago. The CDM was not able to verify when these items were received but stated their policy was to use or discard food from the freezer within one year of receiving it. The CDM stated the cooks and dietary aides were adults and should be responsible to follow the department's policies for food storage including the labeling and dating of food items. On 12/05/24 at 1:52 PM, the Assistant Administrator stated their research did not provide any information as to when the meats found in the freezer with dates from 2022 were received by the facility. He stated it was important to know when all food received into the facility should be used or discarded by to prevent foodborne illness and keep the residents safe. He explained the guidelines and policies were so foods could be tracked and handled properly. He stated the cooks were responsible for dating foods when they opened a container, but the facility was responsible for their oversight. He added it was important for food items to be labeled as to what they were when they were stored so when someone went to use it, the user would know what it was and what ingredients were in it so they wouldn't provide it to someone with allergies to a food item. The facility's food storage policy labeled from the Dietary Guideline Manual entitled Food Storage Overview, with a copyright date of 2015, stated for dry storage, plastic containers with tight-fitting covers were to be used for storing cereals and broken lots of bulk foods and their containers were to be labeled. In addition, the policy stated food should be dated with the date received as it was placed on the shelves and all stock was to be rotated with old stock used first. For refrigerator storage, the policy stated leftover food was to be stored in covered containers or wrapped securely, and each item was to be clearly labeled and dated with the month, date and year before being refrigerated. It also stated leftover food was to be used within two days or discarded. For freezer storage, the policy indicated all foods should have a careful rotation procedure and food items should be covered, labeled, and dated to include the month, day and year. The frozen foods including any leftovers should be discarded after six months.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's current QAPI Plan revealed the facility would use a performance improvement focus to increase quality throughout the facility. This process included identifying areas of weakness to create potential solutions. The plan indicated these solutions would be identified on the Performance Improvement Plan (PIP) which would be monitored by associates using specific audit tools to determine if changes were successful. The plan indicated the sources of data monitored through QAPI included quality measures and state and federal survey results. Review of the previous survey results revealed the facility had a deficiency cited at F812 related to food safety during the previous recertification survey conducted from [DATE] through [DATE]. The facility was found to be in noncompliance with holding temperatures for food on the steam table. During the current survey process, concern for food safety at F812 was again determined when numerous food items in the walk-in refrigerator, dry storage and walk-in freezer were found unlabeled, undated, expired and sometimes left uncovered/opened as observed during the initial kitchen tour with the Certified Dietary Manager (CDM) on [DATE]. Meat was found in the walk-in freezer over two years old, pans of unrecognizable and unlabeled food items were partially uncovered with food inside exposed. Previously opened cheese in the walk in refrigerator was found undated and some with dates had been open for over a month. Pans of unrecognizable, unlabeled, and undated leftover food were also found in the refrigerator. The CDM acknowledged the department policy on labeling and dating of foods items and to ensure food safety by discarding foods past the dates determined by their policy and procedures. She said staff were responsible to follow these policies and procedures. As a result of the repeat deficiency, it was identified that audits performed by the facility and reported to QAPI were insufficient and lacked appropriate oversight to prevent the citation. On [DATE] at 2:42 PM, the Administrator reported QAA/QAPI meetings were held monthly. She explained each department conducted audits and reports that were presented to the committee for review. She stated a PIP would be developed and implemented for any issue identified as needing improvement. She stated audits would be conducted to verify the results. The Administrator was asked if the QAA/QAPI committee was aware of any of the concerns identified during the current survey which included the repeat deficiency at F812 for food safety. She explained the facility developed a plan of correction which included audits to resolve the deficiency. The Administrator described audits performed weekly in the kitchen for sanitation which included labeling and dating of food by the Assistant Administrator and similar audits completed by the Dietitian monthly. The audits revealed open and undated food was observed in the kitchen only in April and [DATE], but could not explain the numerous food items found as a concern during the initial kitchen tour. The Administrator presented education attendance logs dated [DATE] and [DATE] regarding opened and undated food items. She could not explain why numerous opened and undated items were still found after education and audits were being performed. The Administrator acknowledged the CDM let standards slip and the system failed.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 1 resident reviewed for hearing, of a total sample of 47 residents, (#25). Findings: Review of resident #25's medical record revealed he was initially admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 9/17/23. His diagnoses included dementia, anxiety, dysphagia (difficulty swallowing) and speech and language deficits following cerebral infarction. Review of the Annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 8/21/24 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. The MDS assessment showed resident #25 had moderate difficulty hearing and did not use hearing aids or other hearing appliances. The Quarterly MDS assessment with ARD of 11/21/24 revealed a BIMS score of 12 out of 15. The assessment noted moderate difficulty hearing and no use of hearing aids or other hearing appliances. On 12/02/24 at 12:31 PM, resident #25 stated he could not hear well. He reported to be deaf on his left ear. He mentioned he needed a hearing aid. Review of resident #25's discontinued physician orders showed orders dated 1/19/23 and 2/08/23 for consults with audiology. An order dated 4/03/23 and 4/11/23 indicated appointments with the audiologist scheduled for 4/06/23 and 6/29/23 respectively. Review of resident #25's comprehensive care plan revealed hearing was not a focus area developed after the completion of the annual MDS assessment on 8/21/24 or the quarterly MDS assessment on 11/21/24. Review of the Hearing section of the Admission / Readmission Evaluation dated 9/17/23 included resident #25 hears only when the speaker makes special efforts (e.g. louder voice) and he used no hearing aids. Review of the Nursing Quarterly Evaluation dated 5/22/24, 8/21/24 and 11/21/24 revealed resident #25 had hearing impairment. The evaluation date 5/22/24 included a comment he was not a candidate for hearing aids per audiology. Review of the Speech Therapy Screen forms dated 2/29/24, 5/15/24, 7/30/24 and 10/22/24 read, The resident is hard of hearing and hearing aides are not currently used. Review of the Social Service Initial History form dated 9/28/23 showed resident #25's sensory impairment was hearing. Review of a Psychiatric Follow Up Encounter progress note dated 9/18/23 read, Patient is hard of hearing and communication was difficult though achieved through talking loudly. On 12/05/24 at 11:17 AM, the MDS Lead explained whoever completed the MDS assessments determined what would be included in the care plan. She indicated each care plan was specific and individualized. She stated staff referred to the care plan for any questions about the resident's care. She indicated a communication care plan would be created for a resident with a hearing impairment. After reviewing Section B of the last two most recent MDS assessments for resident #84, the MDS Lead validated there should had been a care plan addressing the hearing impairment. She explained there was a care plan for hearing, but it was resolved on 6/06/23 because the MDS assessment with ARD of 5/31/23 was coded with adequate hearing. She validated there was documentation in the medical record that showed hearing impairment and therefore the care plan should include it. She stated it was important to include it in the care plan because the deficit may affect communication with others and the staff needed to know what interventions to use. On 12/05/24 at 11:51 AM, during a telephone interview, the Social Services Director (SSD) stated resident #25 was beyond hard of hearing. She explained he was seen by audiology last year and was told he was, beyond help because his hearing was that bad. The Administrator, present during the telephone interview, explained resident #25 was not included in the current list of residents to be seen by their new audiology provider because of his previous exam results. The SSD stated resident #25's hearing was far gone, and hearing aids would not benefit him. Review of the audiologist visit note dated 6/29/23 revealed the Chief Complaint was difficulty hearing in the right ear within 1-2 years. The Assessment/Plan section included, Sensorineural hearing loss, bilateral - pt (patient) has severe hearing loss in both ears with no speech discrimination in right ear and only 16% in left ear. Pt is not a hearing aid candidate. On 12/05/24 at 1:34 PM, Certified Nursing Assistant (CNA) G stated resident #25 was able to communicate his needs but, You have to talk loud to him because he is hard of hearing. She said, He always says he cannot hear. but sometimes he can hear her. She shared he has asked her to speak a little louder. She indicated she had never seen him wearing hearing aids. She explained she would ask the nurse or refer to the care plan if she was not familiar with the care of one of her residents. On 12/05/24 at 2:05 PM, the East Wing Unit Manager stated resident #25 was hard of hearing but could communicate with her. She indicated hearing impairment affected communication with others, hearing music, or alarms. On 12/05/24 at 2:42 PM, the Director of Nursing (DON) stated the care plan included all information pertaining to the resident's care. The DON indicated there should have been a care plan to correlate with the hearing impairment. Later at 3:26 PM, the DON stated the facility did not have a policy and procedure for care plans. Review of the Facility Assessment revised on 2/24/24 revealed the facility provided person-centered/directed care. The document read, Find out what resident's preferences and routines are; what makes a good day for the resident; what upset him/her and incorporate that information into the care planning process. Make sure staff caring for the resident have this information.

Based on observation, interview, and record review, the facility failed to promote dignity in dining for 1 of 2 residents reviewed for dignity, out of a total sample of 47 residents, (#66). Findings: Review of resident #66's medical record revealed he was initially admitted to the facility on [DATE]. Resident #66 had diagnoses including malnutrition, senile degeneration of the brain and muscle weakness. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 9/11/24 revealed resident #66 was dependent on staff for activities of daily living, including eating. On 12/04/24 at 12:19 PM, Certified Nursing Assistant (CNA) D explained she needed to assist three residents with their meals. She said resident #66 was a feeder and she often assisted her feeders. Later at 1:02 PM, CNA D was observed as he entered resident #66's room and noticed he had not yet eaten his lunch. CNA D moved the bedside table closer to resident #66's bed, removed the lid from the plate and began feeding the resident while standing. At 1:55 PM, CNA D validated she was not seated when assisting resident #66 with his lunch and stated she knew she was supposed to sit down, face the resident and be at eye level. She explained during her orientation, she had not learned it was inappropriate to call the residents feeders. On 12/04/24 at 12:47 PM, CNA E stated residents who needed assistance with their meals were called assisted feeders. She explained a lot of them are not exactly feeders because they get finger foods. On 12/04/24 at 2:06 PM, the East Wing Unit Manager (UM) explained there was no specific way to refer to residents who needed assistance with meals. She stated they should not be called feeders due to respect and dignity issues. The UM validated using labels were against their rights. On 12/05/24 at 12:35 PM, Licensed Practical Nurse (LPN) F indicated sometimes CNAs sat and other times they stood up while assisting residents with their meals because sitting was not always conducive to reaching the patient's mouth to get them to eat. LPN F concluded, They should be sitting but [it was] not always feasible, [it] depends on the resident. On 12/04/24 at 4:59 PM, the Director of Nursing (DON) stated residents who needed assistance with meals should be referred to as assisted diners. The DON explained residents should not be called feeders because it was a dignity issue. The DON indicated CNAs should be sitting next to the resident at eye level, but in resident #66's case, CNA D raised the bed to be at the same level. The DON then clarified CNAs should be sitting when assisting residents to eat. Later at 5:43 PM, the DON stated they had no policy and procedure for dignity or resident rights. Review of the Orientation Education/In-Service Record completed by CNA D on 11/05/24 revealed they included Resident Rights, Dignity and Preferences. Review of the facility's Resident's [NAME] of Rights undated read, Every resident of the Facility shall have the following rights: . The right to be treated courteously, fairly, and with the fullest measure of dignity . Review of the Facility Assessment revised on 2/24/24 revealed all staff received education about resident's rights upon hire, general orientation and annually.

Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards when assisting a resident with his meal for 1 of 12 residents observed during dining, (#66), and 1 of 5 residents observed for medication administration, (#318), of a total sample of 47 residents. Findings: 1. Review of resident #66's medical record revealed he was initially admitted to the facility on [DATE]. Resident #66 had diagnoses including malnutrition, senile degeneration of brain and muscle weakness. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 9/11/24 revealed resident #66 was dependent on staff for activities of daily living, including eating. On 12/04/24 at 1:02 PM, Certified Nursing Assistant (CNA) D entered resident #66's room and noticed he had not yet eaten his lunch. CNA D moved the bedside table closer to resident #66's bed, then grabbed a pair of gloves from a box inside the resident's room and donned the gloves without washing her hands. CNA D began feeding the resident and stated she needed to put on gloves because sometimes he spits while eating. Later at 1:55 PM, CNA D validated she did not perform hand hygiene prior to donning gloves. She explained she was required to perform hand hygiene when entering a resident's room and when done caring for the residents. She stated she was also supposed to wear a gown and gloves before helping him with his lunch because he was on enhanced barrier precautions. The East Wing Unit Manager (UM), present during the interview, explained there was a green sticker by resident #66's name on the door which indicated he was on enhanced barrier precautions. The UM indicated staff was required to don PPE when providing any direct care to a resident on enhanced barrier precautions. CNA D stated hand hygiene was important to keep all residents safe and using the proper PPE was part of universal precautions. On 12/05/24 at 12:22 PM, CNA E was near the meal cart and was asked to show how much resident #66 ate for lunch. She took a pair of gloves from a bin near the meal cart and donned gloves without performing hand hygiene. When asked, CNA E stated she forgot but was supposed to perform hand hygiene when donning and doffing gloves. 2. Review of resident #318's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, pneumonitis and dementia. On 12/03/24 at 9:31 AM, during a Medication Administration pass observation, Registered Nurse (RN) C retrieved a mobile vital signs device with stand from near the nurse's station in the 500 hallway and brought it into resident #318's room. She did not disinfect the mobile vital signs device before using it. She obtained resident #318 blood pressure, heart rate and temperature. She exited resident #318's room and prepared the 9:00 AM medications for resident #318 without performing hand hygiene or cleaning the mobile vital signs device. She returned to resident #318's room with the medications, crushed in applesauce, and administered it to the resident. She noticed applesauce around resident #318's mouth and grabbed a pair of gloves, donned the gloves, without performing hand hygiene, and cleaned the resident's mouth. RN C then removed her gloves and discarded them in a garbage bin inside the resident's room. She exited the room without performing hand hygiene. When asked, RN C indicated she was supposed to perform hand hygiene before and after taking the vital signs, before preparing the medications and when done giving them to the resident. She explained she was supposed to perform hand hygiene before donning and after doffing gloves. She validated she did not disinfect the mobile vital signs device before or after use. She mentioned she did not know if the last person who used it before her disinfected it. She stated wipes were kept in the mobile vital signs device's basket which she could have used. She indicated hand hygiene was important to reduce the risk of infection to the residents and avoid cross contamination. On 12/03/24 at 10:28 AM, the UM stated nurses were expected to perform hand hygiene with soap and water or hand sanitizer before preparing medications, and when entering and exiting resident's room. She explained the mobile vital signs device should be disinfected prior and after each use. She indicated the first line of defense to prevent infection was washing hands which helped avoid the spreading of infection. On 12/04/24 at 4:39 PM, the Director of Nursing (DON) indicated nurses were expected to sanitize their hands before and after medication preparation and administration. She stated staff was expected to perform hand hygiene if they had to don or change gloves during care. She mentioned nurses were expected to clean the mobile vital signs device before and after use. The DON stated these were important for infection control. Review of the policy and procedure titled Infection Surveillance - Infection Prevention Overview dated 2013 read, The facility uses prevention strategies to reduce the risk of transmission of infections including, but not limited to, barrier precautions, immunizing residents, cleaning, disinfecting, and education. Review of the Facility Assessment revised on 2/24/24 revealed all staff received education about Infection Control upon hire, general orientation and annually. The infection prevention and control program education included the written standards, policies and procedures for the program.

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer medications safely for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 47 residents, (#84). Findings: Resident #84 was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes, dysphagia (difficulty swallowing), lack of coordination, muscle weakness, and cognitive communication deficit. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 11/25/24 revealed resident #84 had a Brief Interview for Mental Status score of 6 out of 15 which indicated he was cognitively impaired. The MDS assessment noted no behaviors and no rejection of care necessary to obtain goals for his health and well-being. Review of resident #84's medical record revealed a care plan for impaired cognitive function or impaired thought processes related to (r/t) history of cerebrovascular accident (stroke) revised on 9/21/22. The interventions directed the nurses to Administer medications as ordered . Cue, reorient, and supervise as needed. Another care plan for activities of daily living self-care performance deficit r/t activity intolerance, impaired mobility, left sided hemiplegia r/t history of stroke revised on 9/21/22. The interventions included Provide the amount of assistance/supervision that is needed. On 12/02/24 at 2:31 PM, resident #84 was observed in bed with two pills, a long brown capsule and a round pink tablet, in a disposable medicine cup. A tube of Benadryl cream was also on his bedside table. When asked, resident #84 stated he asked his nurse to leave the medicine cup with the pills there for him to take later. He mentioned whenever he asked the nurses to leave his pills, they did, but sometimes they watched him until he took the medications. He indicated he applied the Benadryl cream on his left buttock two times at night. On 12/02/24 at 2:37 PM, Licensed Practical Nurse (LPN) F entered resident #84's room and noticed the medication cup with the pills in it and told him, You got me in trouble. I am getting written up, [resident #84's name]. LPN F stated the pills were Gabapentin and Hydralazine. She said, I know better. When asked about the Benadryl cream at the bedside table, LPN F said, Oh, I do not even know where that came from. LPN F handed the tube to the surveyor and stated it was empty and discarded it. The tube read, Benadryl extra strength itch stopping gel. Outside the resident's room, LPN F stated she left the pills at bedside about 10 minutes ago because someone else called for help and she left them for resident #84 to take. She explained resident #84 had taken the cup in his hands but, he did not take them, I guess and she left his room prior to ensuring he took them. She indicated before today she always made sure he took his medications before she left the room. LPN F stated she was supposed to ensure the resident took his pills before she left the room because someone else could wander into his room and take them and it was also important for him to take his medications. She mentioned no one on her assignment was authorized to self administer medications for themselves. Review of resident #84's physician's orders included Gabapentin 300 milligrams (mg) three times a day (TID) for neuropathy (nerve pain) and Hydralazine 10 mg TID for hypertension. The Medication Administration Record showed Gabapentin was scheduled to be given at 9:00 AM, 2:00 PM and 6:00 PM. Hydralazine was scheduled for 6:00 AM, 2:00 PM and 9:00 PM. Review of the Medication Admit Audit Report showed Hydralazine and Gabapentin were administered on 12/02/24 at 2:09 PM and 2:10 PM respectively. On 12/03/24 at 10:14 AM, the East Wing Unit Manager (UM) stated medications were not kept at bedside for residents' safety. She indicated resident #84 was not deemed safe to self-administered medications. She explained if a resident refused his medications, she expected the nurse to discard the medications, notify the physician and document the refusal. On 12/04/24 at 4:01 PM, the Director of Nursing (DON) explained if a resident wanted to self-administer their medications, a nurse would complete a self-administration evaluation to determine if it was safe for the resident to take by themselves. She indicated after the assessment, the nurse would obtain a physician's order and the care plan would be updated to reflect this. The DON indicated her expectation was nurses stayed with residents until medications were taken and not left at bedside. Review of resident #84's medical record did not reveal a Self-Administration of Medication Evaluation or a physician's order for self-administration of medications. Review of resident #84's physician's orders did not include an order for Benadryl extra strength itch stopping gel. Review of the Employee Coaching Report for LPN F on 12/02/24 included a document titled, Principles of Medication Administration which directed nurses to give medication administration complete attention and to never leave medications unattended, even for a moment. Review of the facility's policy and procedures titled Self Administration of Medication dated 2008 revealed one of the purposes was, To provide evaluation process to determine if a resident is capable of self-administration . To maintain the safety and accuracy of medication administration. The procedure list included the interdisciplinary team (IDT) would assess the competence of the resident to participate by completing a Self Administration of Medication Evaluation and based on the IDT assessment, a decision was made as to whether or not the resident was a candidate for self-administration. Then the nurse would obtain a physician's order and educate the resident regarding reaction and side effects of the medication.

Based on interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement of 1 of 5 residents reviewed for elopement, of a total sample of 5 residents, (resident #1). On 8/02/24 resident #1 a cognitively impaired [AGE] year-old female was admitted to the facility from the hospital. While at the hospital she was determined to be at risk of falls, wandering, and elopement. On 8/04/24, at approximately 7:45 PM, resident #1, exited the facility's front entrance when the receptionist, distracted by other departing visitors unlocked the front door and allowed her to leave from the facility unsupervised. The facility was unaware of her whereabouts overnight, for approximately 13 hours. Due to her cognitive deficits and diagnosis of dementia, the elopement placed her at risk of serious injury, being abducted, or hit by a motor vehicle and die. The walking distance from the facility to the Assisted Living Facility (ALF) where she was found was approximately 8 miles from the facility, depending on the route taken, (retrieved on 10/02/24 from www.googlemaps.com). The temperature in [NAME] on the evening of 8/04/24 was approximately 81 degrees Fahrenheit, with a relative humidity of 80 percent, (retrieved on 10/02/24 from www.timeanddate.com). The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to resident #1's elopement and placed all residents who wandered or were at risk for elopement at risk. This failure resulted in Immediate Jeopardy starting on 8/04/24. The Immediate Jeopardy was determined to be removed on 8/06/24 after verification of the immediate actions implemented by the facility. The Immediate Jeopardy was determined to be past noncompliance as of 8/20/24 after verification of the facility's corrective actions. There were a total of 4 residents who were identified as at risk for elopement. Findings: Cross reference F600 Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease, type 2 diabetes mellitus, hypertension, major depressive disorder and dementia without behaviors. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 8/02/24 revealed the resident was admitted with a diagnosis of altered mental status and urinary tract infection. The form listed the resident as needing a surrogate for making healthcare decisions, and as alert, but disoriented. Under the section Patient risk alert the options of fall risk and elopement risk were checked by hospital staff. Review of resident #1's hospital discharge record from 8/02/24 revealed she was brought to the emergency roiagnom on [DATE] due to resident being confused and disoriented. The record revealed she had a Geriatric Consult on 7/25/24 for dementia with behavioral disturbances. The history of present illness noted the resident was recently diagnosed with dementia and started on Namenda (Memantine). The record indicated the resident's daughter, who was the resident's legal guardian, was the main historian. The resident previously had lived with her son but had not been taking her medications including the dementia medication. The history described the resident as combative and irritable, and at risk for wandering, for falls and for elopement. The physician documented the resident had a diagnosis of major cognitive disorder for approximately 2 to 3 years, now with worsening behavioral symptoms. The resident was noted to have a history of abnormal brain imaging and possible lesions to the brain. Review of the hospital progress note from 7/28/24 revealed the resident continued to be confused and lacked capacity. Resident #1's admission assessment dated [DATE] indicated the resident was unable to ambulate and needed the use of a manual wheelchair. Review of the fall risk section indicated resident #1 as a possible fall risk. Review of the elopement section revealed the resident was listed as alert and oriented to person, place, time and situation in contrast with the Hospital transfer form completed the same day. The assessment described resident #1 as independent with a wheelchair. The elopement score indicated resident #1 was not a risk for elopement. Resident #1 had a care plan initiated on 8/03/24 for a risk for falls related to poor safety awareness as well as gait and balance problems. There were no care plans or interventions in place for risk for elopement, wandering, or other related behaviors. Review of the medical record revealed physician orders for Memantine 5 milligrams (mg) twice a day for dementia and Risperidone 0.5 mg once a day for psychosis. Both had a start date of 8/02/24. There were no physician orders for an electronic wander prevention bracelet or other elopement prevention measures such as increased supervision in the medical record. Namenda (Memantine is a drug used to treat moderate to severe Alzheimer's type dementia, (retrieved on 10/02/24 from www.drugs.com). A Physical Therapy Evaluation dated 8/03/24 revealed resident #1's level of function prior to being at the facility was independent for indoor mobility. Her level of functional cognition prior to being at the facility was dependent. The assessment summary for cognition was listed as severely impaired for decision making ability for routine activities. Her reasons for needing physical therapy were listed as decreased balance, decreased functional capacity, decreased insight, and decreased safety awareness. Occupation Therapy Evaluation from 8/3/24 revealed the resident walks too fast and could be unsteady on her feet. Under the section cognitive and communication assessment it was revealed that the resident was moderately impaired in decision making ability for routine activities, and as having impaired safety awareness. An Occupational Therapy Evaluation dated 8/03/24 revealed the resident walked too fast and could be unsteady on her feet. Under the section cognitive and communication assessment it described resident #1 as moderately impaired in decision making ability for routine activities, and as having impaired safety awareness. On 9/17/24 at 10:02 AM, video footage obtained from the evening of 8/04/24 was reviewed with the Administrator. Two visitors were seen walking into the front lobby, up to the reception desk to sign out on the electronic visitor system after their visit. Receptionist D was noted to be looking up towards the two visitors who were signing out instead of towards resident #1 who then entered the lobby a few seconds behind the two visitors. Resident #1 was seen to hesitate for a minute, then took a few steps to the right of the reception desk, toward the Administrator's office. She was seen to quickly change course and walk out the front of the unlocked lobby door. The resident did not use any assistive devices, and was dressed in a long sleeve shirt, pants and shoes. The video footage did not capture which direction the resident proceeded after she left the facility. In a telephone interview with receptionist D on 9/18/24 at 2:26 PM, she recalled speaking with two visitors who were signing out on the electronic system the facility uses for visitors to the facility on the evening of 8/04/24. She explained when she saw resident #1 by the door, she assumed she accompanied the two departing visitors. Receptionist D described that often when visitors are leaving, one visitor signed out while the other visitors hung back by the door, waiting for them. Receptionist D stated she had assumed any residents who were an elopement risk would have an electronic wander prevention bracelet on, which would alert her if they came near the door. She explained she had assumed that any residents with elopement risk would look confused, disheveled and more than likely would use a wheelchair. The receptionist described resident #1 as looking relatively young and wearing regular clothes, so she didn't take her to be a resident. Review of the Police Case Report and Incident Details dated 8/05/24 revealed an officer was called to an ALF on 8/05/24 at 9:00 AM. An unknown caller to 911 reported the resident was found at the door of the facility. The Incident Details indicated the call response was changed from missing person in progress to found. The report described for the County Sheriff's office to Call off the bloodhounds (search dogs). The document also described Emergency Medical Personnel were requested as the resident was, Wet, cold and has been out, possibly on foot all night. The reporting officer documented that resident #1 told him she was in bed all night and lived at home with her daughter. He reported resident #1 did not know what year it was, how many quarters in a dollar or her date of birth. She was transported to the hospital by Emergency Medical Personnel for treatment. Review of the hospital Emergency Department documentation dated 8/05/24 noted the resident to be shivering and her clothing soaking wet. The documentation showed Resident #1 had facial trauma including abrasions to her forehead and nose as well as bruises to her bilateral knees. Further hospital workup revealed a diagnosis of pneumonia. Resident #1 was noted to have no recollection of the events leading up to the hospitalization . In interviews with the Director of Nursing (DON) and the Administrator on 9/16/24 at 9:58 AM, and continued at 10:22 AM, the Administrator stated once she was alerted, she immediately drove over to the facility to help with the search. She explained the resident's daughter who previously worked at the facility as an Advanced Practice Registered Nurse (APRN) told them her mother would not leave the building and must be hiding somewhere due to the thunderstorms. The DON stated they repeatedly searched inside the building for the resident at the daughter's insistence. She said the daughter never mentioned the resident was an elopement risk. The Administrator said then she looked at the cameras and saw the resident walk out the front door. She stated that was when she called 911. The Administrator explained the resident was not brought back to the facility. She revealed they were aware of the hospital discharge paperwork from 8/02/24 which showed in multiple places that resident #1 was an elopement risk prior to her being admitted to the facility. They described resident #1's daughter had recently become her legal guardian, and the DON stated she discussed the resident being labeled as an elopement risk throughout the hospital paperwork with her, but the daughter insisted she was just an, avid walker, and not an elopement risk. She stated resident #1's daughter was present during admission to the facility and on the following days, and did not report any instances where she thought her mother was an elopement risk. The DON stated that upon admission nurses performed an elopement assessment, and her score was a 3 which meant she was not a risk for elopement, based on the information provided by her daughter. When asked if resident #1 was evaluated by the facility's in house physician to determine cognition and elopement risk, they replied that she was admitted on a Friday night and would not have been seen by the physician until Monday. She explained all orders and hospital paperwork were reviewed and verified by on-call provider at that time. On 9/16/24 at 1:08 PM, the Regional [NAME] President stated he was familiar with resident #1's daughter who was an APRN and had reached out to him regarding the resident being admitted to the facility. He stated the resident had previously been denied admission to the facility for insurance reasons. He explained he had asked the DON to talk to the daughter related to the medical side of the admission and asked the daughter to do the same. He stated the daughter told him she was aware of what the hospital documented in the resident's chart about her mother being an elopement risk. The Regional [NAME] President stated the daughter explained by saying providers at the hospital just copied and pasted the information and did not write accurate notes. The Regional [NAME] President explained the daughter discussed some family conflicts and told them she had just recently become her mother's legal guardian. In a telephone interview with resident #1's daughter on 9/17/24 at 8:47 AM, she confirmed she was an APRN at the facility about 5 years ago and she left on good terms to pursue her specialty. She explained her mother had short term memory loss, but she did not consider her to be an elopement risk. She confirmed she had told the facility that she felt the hospital documentation was inaccurate because she felt the providers did not properly assess the patients and often copied and pasted the information. She stated she felt the most devastating part was that the receptionist had not paid attention when she unlocked the front doors, and let her mother slip out. In a phone interview with Registered Nurse (RN) A on 9/18/24 at 2:50 PM, he confirmed resident #1 was on his assignment the night of 8/04/24 on the evening shift. He stated he had not been informed that resident #1 had a history of being an elopement risk. He stated he did not read the hospital discharge paperwork or any of the documents sent from the hospital at time of admission, so he did not know she was at risk for elopement. He explained he typically only read that paperwork if he was the admitting nurse, which he was not. He explained, as a floor nurse, he did not have time to sit and read through the charts and paperwork due to his workload. He would typically rely on the off-going nurse to pass along any behaviors or risks in shift report. Nurse A described when new patients arrive and the nurse has a full patient load, things can get rushed. He stated sometimes they didn't have the time they would like to spend on assessments of the new residents. He stated there were multiple interventions that could have been put into place to prevent resident #1's elopement, if he knew the risk such as a wanderguard or 48-hour checks. He explained 48-hour checks were hourly checks staff perform on the resident for a total of 48-hours. In a telephone interview with RN B on 9/18/24 at 1:09 PM, she described after RN A informed her of the missing resident around 8:45 PM, she checked the Bistro and the Tavern where many residents tended to congregate. She continued when she did not find her in those areas, she alerted the team to start a search including places such as the courtyard. She then paged the resident's name overhead three times and returned to her room to check for the resident. When she still could not be found, she notified the DON. Nurse B stated she did not have access to the camera so she could not check those. She stated she continued to check inside the facility and in the surrounding areas. Review of the facility's standards and guidelines dated 2017 titled Resident Elopement Risk Management Guidelines revealed the facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative to ensure to minimize elopement occurrences. The Facility Assessment updated 2024 revealed the facility maintained it would consistently look for ways to enhance their skilled nursing and rehabilitation services. The facility would have approved guidelines for various diseases including Dementia. The assessment described the facility took an individualized and personalized approach to care and services. The assessment indicated the facility would develop an individualized plan of care focused on patient safety and skill level. The assessment also described staff competencies related to elopement were given to all staff upon hire and annually. Elopement individualized training would occur as the need arose. Review of the facility's corrective actions were verified by the survey team and included the following: * Resident #1 identified to have exited the facility on 8/04/24 and located on 8/05/24 at a local Assisted Living Facility, she was transported to the hospital. * Missing Resident Process initiated by the weekend supervisor on 8/04/24. * The Weekend Supervisor and Director of Nursing verified 159 of 160 residents to be in the facility on 8/04/24 (the one resident not present was resident #1). * 10 of 10 door guardians and 12 of 12 screamer alarms inspected by the Maintenance Assistant, with proper function verified on 8/04/24. * The Administrator and Director of Nursing verified staffing level appropriate: licensed nurses (1.51) and certified nursing assistants (2.42) on 8/04/24. * Identified receptionist provided education by the Administrator related to responsibilities/functions of a receptionist on 8/05/24 and subsequently suspended on 8/05/24. * With census of 160, 157 residents were assessed and deemed not at risk for elopement. Reviewed for accuracy of evaluation and care plan verified by the Director of Nursing on 8/05/24. * 2 of 2 residents deemed at risk for elopement reviewed for accuracy of evaluation and care plan verified by the Director of Nursing on 8/05/24. * 11 of 12 facility employees who function as receptionist provided education by the Administrator related to the responsibilities and functions of receptionists including but not limited to sign-in/sign-out process initiated 8/05/24 and completed 8/06/24. One employee was currently on maternity leave, to be educated upon return. * 210 of 333 facility employees received education provided by the Director of Nursing and the Staff Development Coordinator related to sign-in/sign-out process, leave of absence/pink card process and elopement/wander process, including but not limited to review of transfer paperwork to ensure elopement prevention intervention (electronic wander prevention bracelet), implemented if indicated. Education initiated 8/04/24 and completed 8/06/24. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From 9/15/24 until 9/19/24, interviews were conducted with 20 staff members across all shifts. This included 8 Licensed nurses, 6 Certified Nursing Assistants, 2 receptionists, 2 housekeepers, 1 Dietary aide, and 1 Physical therapist who verbalized their understanding of the education provided. The resident sample was expanded to include 4 additional residents identified as at risk for elopement. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #2, #3, and #4.

Based on 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 the risk to prevent elopement for 1 of 5 residents reviewed for elopement, of a total sample of 5 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury, impairment, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, been accosted by unknown persons, become lost or been hit by a vehicle. On 8/04/24 at approximately 7:45 PM, the facility failed to prevent resident #1, a newly admitted female with a documented risk of elopement from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts for approximately 13 hours until law enforcement located her at an Assisted Living Facility approximately 8 miles away at 9:00 AM the next morning. The resident was transported to a local hospital for minor injuries and dehydration. The route resident #1 likely traveled was along heavily trafficked roads noted to have uneven pavement, retention ponds, train tracks, and ran along a large body of water. The facility failed to ensure resident #1 was adequately supervised to ensure vulnerable residents did not exit the facility unsupervised. The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to resident #1's elopement and placed all residents who wandered at risk. This failure resulted in Immediate Jeopardy starting on 8/04/24. The Immediate Jeopardy was determined to be removed on 8/06/24 after verification of the immediate actions implemented by the facility. The Immediate Jeopardy was determined to be past noncompliance as of 8/20/24 after verification of the facility's corrective actions. Findings: Cross reference F689 Review of the medical record revealed resident #1 was admitted to the facility from an acute care hospital on 8/02/24 with diagnoses including cerebrovascular disease, type 2 diabetes mellitus, hypertension, major depressive disorder and dementia without behaviors. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 8/02/24 revealed the resident was admitted with a diagnosis of altered mental status and urinary tract infection. The form listed the resident as needing a surrogate for making healthcare decisions, and as alert, but disoriented. Under the section Patient risk alert the options of fall risk and elopement risk were checked by hospital staff. A Physical Therapy Evaluation dated 8/03/24 revealed resident #1's level of function prior to being at the facility was independent for indoor mobility. Her level of functional cognition prior to being at the facility was dependent. The assessment summary for cognition was listed as severely impaired for decision making ability for routine activities. Her reasons for needing physical therapy were listed as decreased balance, decreased functional capacity, decreased insight, and decreased safety awareness. An Occupation Therapy Evaluation dated 8/03/24 revealed the resident walked too fast and could be unsteady on her feet. Under the section cognitive and communication assessment it described resident #1 as moderately impaired in decision making ability for routine activities, and as having impaired safety awareness. Resident #1's admission assessment dated [DATE] indicated the resident was unable to ambulate and needed the use of a manual wheelchair. Review of the fall risk section indicated resident #1 as a possible fall risk. Review of the elopement section revealed the resident was listed as alert and oriented to person, place, time and situation in contrast with the Hospital transfer form completed the same day. The assessment described resident #1 as independent with a wheelchair. The elopement score indicated resident #1 was not a risk for elopement. Resident #1 had a care plan initiated on 8/03/24 for a risk for falls related to poor safety awareness as well as gait and balance problems. There were no care plans in place for risk for elopement, wandering, or other related behaviors. Review of the medical record revealed physician orders for Memantine 5 milligrams (mg) twice a day for dementia and Risperidone 0.5 mg once a day for psychosis. Both had a start date of 8/02/24. There were no physician orders for an electronic wander prevention bracelet or other elopement prevention measures such as increased supervision in the medical record. Namenda (Memantine is a drug used to treat moderate to severe Alzheimer's type dementia, (retrieved on 10/02/24 from www.drugs.com). Review of resident #1's hospital discharge record from 8/02/24 revealed she was brought to the emergency roiagnom on [DATE] due to resident being confused and disoriented. The record revealed she had a Geriatric Consult on 7/25/24 for dementia with behavioral disturbances. The history of present illness noted the resident was recently diagnosed with dementia and started on Namenda (Memantine). The record indicated the resident's daughter, who was the resident's legal guardian, was the main historian. The resident previously had lived with her son but had not been taking her medications including the dementia medication. The history described the resident as combative and irritable, and at risk for wandering, for falls and for elopement. The physician documented the resident had a diagnosis of major cognitive disorder for approximately 2 to 3 years, now with worsening behavioral symptoms. The resident was noted to have a history of abnormal brain imaging and possible lesions to the brain. Review of the hospital progress note from 7/28/24 revealed the resident continued to be confused and lacked capacity. On 9/17/24 at 10:02 AM, video footage obtained from the evening of 8/04/24 was reviewed with the Administrator. Two visitors were seen walking into the front lobby, up to the reception desk to sign out on the electronic visitor system after their visit. Receptionist D was noted to be looking up towards the two visitors who were signing out instead of towards resident #1 who then entered the lobby a few seconds behind the two visitors. Resident #1 was seen to hesitate for a minute, then took a few steps to the right of the reception desk, toward the Administrator's office. She was seen to quickly change course and walk out the front of the unlocked lobby door. The resident did not use any assistive devices, and was dressed in a long sleeve shirt, pants and shoes. In a telephone interview on 9/18/24, with receptionist D she stated she assumed the resident was accompanying the two visitors who were signing out. She explained that often when visitors left the facility, one visitor signed out for all of them and the other visitors hung back by the door until it opened. The receptionist assumed that any residents who were an elopement risk would have an electronic wander prevention bracelet on, and the alarm would have alerted her to their presence. She said she also presumed all elopement risk residents would look confused, disheveled and more than likely use a wheelchair. The receptionist described resident #1 as relatively young looking. Review of the disciplinary action form dated 8/05/24, the receptionist acknowledged she had understood the protocol for checking visitors in and out of the facility but did not follow the procedure. In interviews with the Director of Nursing (DON) and the Administrator on 9/16/24 at 9:58 AM, and continued at 10:22 AM, the Administrator explained the resident's daughter who previously worked at the facility as an Advanced Practice Registered Nurse (APRN) told them her mother would not leave the building and must be hiding somewhere due to the thunderstorms. The DON said the daughter did not feel the resident was an elopement risk. The Administrator revealed they were aware of the hospital discharge paperwork from 8/02/24 which showed in multiple places that resident #1 was an elopement risk prior to her being admitted to the facility. They described resident #1's daughter had recently become her legal guardian, and the DON stated she discussed the resident being labeled as an elopement risk throughout the hospital paperwork with her daughter, but she insisted she was just an, avid walker, and not an elopement risk. The DON stated resident #1's daughter was present during admission to the facility and on the following days, and did not report any instances where she thought her mother was an elopement risk. The DON stated upon admission nurses performed an elopement assessment, and her score was a 3 which meant she was not a risk for elopement, based on the information provided by her daughter. When asked if resident #1 was evaluated by the facility's in house physician to determine cognition and elopement risk, they replied that she was admitted on a Friday night and would not have been seen by the physician until Monday. She explained all orders and hospital paperwork were reviewed and verified by on-call provider at that time. In a phone interview with Registered Nurse (RN) A on 9/18/24 at 2:50 PM, he confirmed resident #1 was on his assignment the night of 8/04/24 on the evening shift. He stated he had not been informed that resident #1 had a history of being an elopement risk. He stated he did not read the hospital discharge paperwork or any of the documents sent from the hospital at time of admission, so he did not know she was at risk for elopement. He explained he typically only read that paperwork if he was the admitting nurse, which he was not. He explained, as a floor nurse, he did not have time to sit and read through the charts and paperwork due to his workload. He would typically rely on the off-going nurse to pass along any behaviors or risks in shift report. Nurse A described when new patients arrive and the nurse has a full patient load, things can get rushed. He stated sometimes they didn't have the time they would like to spend on assessments of the new residents. He stated there were multiple interventions that could have been put into place to prevent resident #1's elopement, if he knew the risk such as a wanderguard or 48-hour checks. He explained 48-hour checks were hourly checks staff perform on the resident for a total of 48-hours. The facility's policy and procedure titled, Resident Mistreatment, Abuse and Neglect Prohibition dated 2017 revealed that, Neglect is failure to provide goods and services necessary to avoid physical harm, metal anguish or mental illness. Review of the facility's corrective actions were verified by the survey team and included the following: * Resident #1 identified to have exited the facility on 8/04/24 and located on 8/05/24 at a local Assisted Living Facility, she was transported to the hospital. * Missing Resident Process initiated by the weekend supervisor on 8/04/24. * The weekend supervisor and Director of Nursing verified 159 of 160 residents to be in the facility on 8/04/24 (the one resident not present was resident #1). * 10 of 10 door guardians and 12 of 12 screamer alarms inspected by the Maintenance Assistant, with proper function verified on 8/04/24. * The Administrator and Director of Nursing verified staffing level appropriate: licensed nurses (1.51) and certified nursing assistants (2.42) on 8/04/24. * On 8/05/24 facility Administrator notified the Department of Children and Families of resident #1's elopement. * A Federal; Immediate Report was also submitted on 8/05/24. * Identified receptionist provided education by the Administrator related to responsibilities/functions of a receptionist on 8/05/24 and subsequently suspended on 8/05/24. * With census of 160, 157 residents were assessed and deemed not at risk for elopement. Reviewed for accuracy of evaluation and care plan verified by the Director of Nursing on 8/05/24. * 2 of 2 residents deemed at risk for elopement reviewed for accuracy of evaluation and care plan verified by the Director of Nursing on 8/05/24. * 11 of 12 facility employees who function as receptionist provided education by the Administrator related to the responsibilities and functions of receptionists including but not limited to sign-in/sign-out process initiated 8/05/24 and completed 8/06/24. One employee was currently on maternity leave, to be educated upon return. *210 of 333 facility employees received education provided by the Director of Nursing and the Staff Development Coordinator related to abuse, neglect, and misappropriation. Education includes but is not limited to 8/04/24 up until 8/06/24. * 49 of 67 current facility nurses were educated to review transfer paperwork to ensure elopement prevention intervention (electronic wander prevention bracelet) implemented if indicated to prevent neglect. Education initiated 8/04/24 and completed by 8/06/24. * 3 of 3 admission employees have received education provided by the facility Administrator related to accurately reflecting resident conditions including but not limited to history of wandering/elopement on 8/06/24. * 11 of 12 facility employees who function as a receptionist provided education by the Administrator related to responsibilities/functions of receptionist including but not limited to sign/in-sign/out process initiated 8/05/24 and completed 8/06/24. One employee who functions as receptionist is currently on maternity leave and will have competency verified prior to return. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From 9/15/24 until 9/19/24, interviews were conducted with 20 staff members across all shifts. This included 8 Licensed nurses, 6 Certified Nursing Assistants, 2 receptionists, 2 housekeepers, 1 Dietary aide, and 1 Physical therapist who verbalized their understanding of the education provided. The resident sample was expanded to include 4 additional residents identified as at risk for elopement. Observations, interviews, and record reviews revealed no concerns related to elopement for residents #2, #3, and #4.

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were at a hot holding temperature of 135 degrees Fahrenheit, or above, to prevent foodborne illness. Findings: On 4/11/23 at 11:55 AM, observation of 1 of 2 facility kitchenettes/dining areas called The Tavern was conducted. Dietary Aide A used a thermometer to check the hot food temperature on the steam table but failed to remove the thermometer probe cover. The temperature of the shredded barbeque pork read 99 degrees Fahrenheit. Dietary Aide A then removed the probe cover and calibrated the thermometer in ice water. The Certified Dietary Manager arrived at the mini kitchenette and proceeded to check the temperature of the food items on the steam table with the calibrated thermometer. The barbeque pork had a holding temperature of 131 degrees Fahrenheit and the sliced pork loin was 126 degrees Fahrenheit. The Certified Dietary Manager stated the holding temperature was supposed to be between 120 to 130 degrees Fahrenheit. On 4/12/23 at 5:11 PM, a follow up interview was conducted with the Certified Dietary Manager. She stated safe holding temperature for food items on the steam table/tray line should be 135-degrees Fahrenheit or above to ensure that bacteria do not grow. The United States Food and Drug Administration's Food Code 2017, noted that potentially hazardous foods, need to be at a holding temperature of 135 degrees or above.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' condition and status during the observation period, for 2 of 11 sampled residents, (#1 & #3). Findings: 1. Resident #1 was admitted to the facility for rehabilitation services on 10/07/19. His [DIAGNOSES REDACTED]. He was discharged on [DATE]. Symbolic dysfunction is a communication disorder that can range from sound substitutions to the inability to comprehend or express oneself in a native language. (www.worldheritage.org) Review of the MDS admission assessment with assessment reference date (ARD) of 10/14/19 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. The assessment showed resident #1 had no behavioral symptoms and did not reject evaluation or care . necessary to achieve the resident's goals for health and well-being . during the 7-day look back period. However, review of nursing progress notes revealed resident #1 rejected evaluation or care on 3 days. On 10/08/19, he repeatedly removed his nasal cannula and refused to use his oxygen as ordered. On 10/11/19, he refused to elevate his legs to decrease swelling in his feet, declined to use oxygen as ordered, refused injectable medication and a lab draw, and . continues to resist care from staff. On 10/12/19, resident #1 refused a catheterization procedure to collect a urine sample. The MDS discharge return not anticipated assessment with ARD of 12/02/19, revealed resident #1's BIMS score increased to 13 which indicated little to no cognitive impairment. Section J1800 of the assessment showed resident #1 had no falls since the previous assessment dated [DATE]. On 2/12/20 at 2:06 PM, during a review of fall incidents with the Director of Nursing (DON), she stated resident #1 had falls with no injuries on 11/02/19 and 11/21/19. On 2/13/20 at 10:27 AM, MDS Coordinator D acknowledged resident #1's BIMS score on discharge was significantly higher than it was on admission. She stated she completed section C of the discharge assessment which included the BIMS score, but was not able to find her notebook with details of the interview. When asked if she actually interviewed resident #1, she said, Typically I print out the C section and take it with me. I am not the usual person who does the BIMS. A few minutes later at 10:41 AM, MDS Coordinator D was informed the incident log showed resident #1 had 2 falls in (MONTH) 2019, after the admission assessment on 10/14/29. She reviewed the discharge assessment dated [DATE] and acknowledged it reflected no falls in the time period. MDS Coordinator D stated she missed resident #1's falls and the assessment data was incorrect. On 2/13/20 at 2:40 PM, speech therapist (ST) C stated she provided rehabilitation services for resident #1 to treat issues with safety awareness and cognition. During review of the ST Evaluation and Plan of Treatment with ST C, she explained on 10/09/19 resident #1 scored 3/30 on the St. Louis University Mental Status (SLUMS) examination which indicated severe cognitive impairment. She explained one month later on 11/07/19, resident #1's SLUMS score increased to 5/30 which still reflected severe cognitive impairment. ST C stated on 11/10/19, resident #1 was tested with the Global Deterioration Scale (GDS) and scored 5 which indicated severe cognitive decline associated with dementia. She explained resident #1 could not recall his birthday or the names of his children during the GDS examination. ST C was asked if resident #1's BIMS score could have increased from 4 on admission to 13 on discharge. She said, If a person had a 3 on the SLUMS and advanced only 2 points with therapy . It would be unlikely he could score a 13 on the BIMS. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Section J1900 of the MDS admission assessment with ARD of 1/20/20 revealed since admission, resident #3 had 1 fall with no injury. On 2/12/20 at 2:06 PM, during review of fall incidents with the DON, she stated resident #3 had 1 fall with no injury on 1/14/20 at 2:30 AM. However, on 2/12/20 at 3:26 PM, resident #3's wife stated her husband had 2 falls since admission. The DON was asked to review the incident log again, and she provided documentation of a second fall for resident #3 that occurred on 1/14/20 at 8:45 PM. On 2/13/20 at 2:14 PM, the DON was informed of the inaccuracies found in the MDS assessments reviewed for residents #1 and #3. She stated MDS Coordinators followed the Resident Assessment Instrument (RAI) manual guidelines to ensure assessment accuracy. Review of the Centers for Medicare & Medicaid Services' (CMS) Long-Term Care Facility RAI User's Manual (October 2019) revealed instructions for completion of Section J regarding falls. The Steps for Assessment included reviewing information from all available sources, incident reports, fall logs and progress notes. In addition, the the RAI read, Ask the resident and family about falls during the look-back period. Resident and family reports of falls should be captured here whether or not these incidents are documented in the medical record.

Based on record review and interview, the facility failed to maintain an accurate and complete interdisciplinary discharge summary for 1 of 3 discharged residents, (#1). Findings: Resident #1 was admitted to the facility for rehabilitation services on 10/07/19 with [DIAGNOSES REDACTED]. He was discharged to an assisted living facility on 12/02/19. The Minimum Data Set discharge return not anticipated assessment dated [DATE], revealed resident #1 required extensive assistance with activities of daily living (ADLs) and was frequently incontinent of bowel and bladder. He received physical, occupational and speech therapy services during his stay in the facility. The physical therapy discharge summary dated 12/03/19 indicated resident #1 used a wheelchair for mobility. Review of resident #1's medical record revealed an Interdisciplinary Discharge Summary with instructions to Complete this form when a resident is discharged . All items must be addressed . However, the section of the form for Recapitulation of Resident's Stay indicated resident #1 received skilled nursing care and therapy services, but did not include an admitting [DIAGNOSES REDACTED]. The section entitled Final Summary of the Resident's Status required specific data from interdisciplinary team (IDT) members of 5 departments i.e. social services, nursing, dietary, activities and rehab services. The nursing services summary did not provide resident #1's vital signs at the time of discharge, indicate his need for a wheelchair as an assistive device or that he needed assistance with ADLs. The documentation erroneously showed resident #1 was continent of bowel and bladder and had his own teeth. There was no documentation in the sections of the interdisciplinary discharge summary form designated for input from dietary services, activities and rehab services. The facility's policy and procedure Discharge Record - Timely Assembly and Closure (2015) revealed upon a resident's discharge, the medical record would be reviewed for completeness. . Interdisciplinary Team member(s) will be informed of the expectation to complete the records as soon as possible. On 2/13/20 at 1:08 PM, the interdisciplinary discharge summary was reviewed with the administrator. She stated each department was responsible for completing and signing the appropriate section of the form. The administrator acknowledged the sections for summaries by dietary, activities and rehab services were left blank. On 2/13/20 at 3:32 PM, the Medical Records Director (MRD) stated resident #1's interdisciplinary discharge summary form was incomplete since all sections were not filled in by the required staff. She stated to her knowledge, the final step in closing a discharged resident's chart was to ensure the discharge summary was completed. The MRD acknowledged the only incomplete form in resident #1's chart was the discharge summary. She confirmed she attended a daily clinical meetings with members of the IDT and recalled the discharge summary forms used to be brought to that meeting and signed by the appropriate members. The MRD stated her usual timeframe for closing a chart was 30 days after a resident was discharged . However, she explained due to an increased workload, the department was delayed and resident #1's discharge summary was still not complete after more than 60 days.

Based on record review and interview, the facility failed to notify the authorized representative of a new physician's order for an antipsychotic medication for 1 of 4 residents reviewed for [MEDICAL CONDITION] medications, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Symbolic dysfunction is a communication disorder that can range from sound substitutions to the inability to comprehend or express oneself in a native language. (www.worldheritage.org) Review of the Minimum Data Set admission assessment with assessment reference date of 10/14/19, revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 that indicated severe cognitive impairment. The assessment showed resident #1 received an antipsychotic medication on 4 days in the 7-day look back period. [MEDICAL CONDITION] drugs are a group of medications . that affect the functioning of the mind through pharmacological action on the central nervous system. An antipsychotic drug is used to treat [MEDICAL CONDITION] and other acute psychotic illnesses such as delusions and hallucinations. (www.encyclopedia.com) Review of resident #1's medical record revealed a physician's order dated 10/09/19 to consult the psychiatrist for confusion, and another order dated 10/11/19 to consult the psychiatrist for agitation. Resident #1 was assessed by the psychiatrist on 10/11/19, and the antipsychotic medication [MEDICATION NAME] was prescribed to treat agitation. The Psychiatric Initial Mental Status Exam conducted during the visit revealed the psychiatrist provided counseling and coordinated care with facility staff and the therapist regarding resident #1's [DIAGNOSES REDACTED]. A Psychiatric Follow-Up note dated 10/14/19 indicated the psychiatrist re-assessed resident #1 and reviewed data with facility staff. However, review of psychiatry and nursing progress notes revealed no documentation related to counseling and notification of resident #1's authorized representatives regarding the psychiatry consult or initiation of [MEDICAL CONDITION] drug therapy. The policy and procedure for Notification of Change in Condition (2016), defined a change in condition as a clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains. The procedure revealed the nurse was expected to notify the resident's representative regarding a change in condition and any new plan of care. In addition, the nurse should document the notification in the representative in the medical record. The facility's policy and procedure for Psychoactive Medication Consent (2008), read The Psychoactive Medication Consent form will be completed each time a psychoactive drug is ordered. The purpose was to obtain consent for medication administration and provide information on the specific behavior being treated and possible side effects of the drug. The procedure indicated the nurse would document on the drug, resident's behavior and the side effects, and the resident or responsible party would consent to or decline treatment based on the information. The form would be signed by the resident or the representative, the nurse and the physician, and be retained in the medical record. During interviews on 2/13/20 at 2:29 PM and 3:11 PM, the Director of Nursing (DON) explained initiation of [MEDICAL CONDITION] medication therapy required consent from a resident or authorized representative. She stated every resident signed a general Consent To Treatment form on admission but there was a separate consent form required for [MEDICAL CONDITION] medication administration. The DON stated the purpose of the consent form was to inform the resident and/or representative about the [MEDICAL CONDITION] drug and its possible side effects. She stated the consent form included a section to document whether the medication was accepted or declined. The DON reviewed resident #1's medical record and was unable to locate a Psychoactive Medication Consent form for the antipsychotic medication [MEDICATION NAME] or nursing documentation of representative notification. She stated nursing staff should have notified either resident #1's wife, his emergency contact, or his daughter who had power of attorney prior to starting the new medication. The DON said, Due to his cognition, a representative should have given permission.

Based on record review and interview, the facility failed to develop and implement non-pharmacological interventions to address behavioral symptoms; failed to adequately investigate possible causative factors for behaviors prior to initiating antipsychotic medication therapy; and failed to monitor medication effectiveness and potential adverse effects, to avoid unnecessary use of a [MEDICAL CONDITION] medication for 1 of 4 residents reviewed for [MEDICAL CONDITION] medications, of a total sample of 11 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Symbolic dysfunction is a communication disorder that can range from sound substitutions to the inability to comprehend or express oneself in a native language. (www.worldheritage.org) Review of the Minimum Data Set admission assessment with assessment reference date of 10/14/19, revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. The assessment showed resident #1 had no behavioral symptoms and did not reject evaluation or care such as medications and assistance with activities of daily living (ADLs). Resident #1 received an antipsychotic medication on 4 days in the 7-day look back period. [MEDICAL CONDITION] drugs are a group of medications . that affect the functioning of the mind through pharmacological action on the central nervous system. An antipsychotic drug is used to treat [MEDICAL CONDITION] and other acute psychotic illnesses such as delusions and hallucinations. (www.encyclopedia.com) Review of resident #1's medical record revealed nursing documentation on 10/08/19 regarding his repeated removal of oxygen via nasal cannula and a low oxygen saturation level. The note read, He did not listen and was upset. On room air, the level of oxygen in resident #1's blood was 79%. Normal oxygen saturation readings are between 95 and 100%, and readings below 90% are considered to be low. The symptoms of low oxygen levels include confusion, anxiety, agitation and [MEDICAL CONDITION]. (www.webmd.com) Review of the progress notes revealed on 10/10/19, resident #1 was assessed by a licensed clinical social worker (LCSW). The Initial Evaluation and Assessment Treatment Plan indicated the LCSW was referred to assess resident #1's cognitive function. The document revealed resident #1 had no mental health history or related medications. He was found to have behavior within normal limits, was alert with confusion and had poor insight and judgement. The note read, [MEDICAL CONDITION]: Not Present and the LCSW recommended supportive and cognitive therapy with a goal of adjustment to the environment. A nursing progress note on 10/10/19 revealed resident #1 was confused in the evening and requested to leave the facility. He spoke to his family and responded positively to reassurance they would return the following day. Resident #1 remained at the nurses' station for a while, accepted a snack and was assisted to bed with no issues. On 10/11/19 at 2:10 AM, a nursing note revealed resident #1 displayed increased confusion after 5:00 PM the previous afternoon and refused to use oxygen as ordered. A few hours later at 8:17 AM a nurse documented resident #1 had not slept, continued to resist staff attempts to provide ADL care and had a consult scheduled with the psychiatrist. Later that afternoon at 5:29 PM, nursing documentation indicated resident #1 refused a lab draw and most care that day. A Psychiatric Initial Mental Status Exam dated 10/11/19 revealed resident #1 was seen for depression, confusion, agitation and refusal of care. The examination findings indicated resident #1 had confused thought content, delusions and impaired judgement/insight. The psychiatrist diagnosed resident #1 with [MEDICAL CONDITION], ordered [MEDICATION NAME] and recommended a urinalysis (UA) to rule out a urinary tract infection [MEDICAL CONDITION] as a cause of his behaviors. The progress note revealed the psychiatrist counseled and coordinated care with facility staff and the LCSW regarding resident #1's diagnosis, possible treatment options, risks versus benefits, and helpful behavioral and/or environmental changes. Review of the Order Summary Report revealed a UA with culture and sensitivity (C&S) to identify specific organisms was ordered on [DATE] to determine if resident #1's confusion was caused by a UTI. On the same day, the psychiatrist ordered an antipsychotic medication, [MEDICATION NAME] 12.5 milligrams (mg) twice daily, and [MEDICATION NAME] 25 mg at bedtime, for agitation. A nursing note dated 10/12/19 at 2:04 PM revealed resident #1 refused catheterization for the UA and C&S. Resident #1's order for [MEDICATION NAME] was discontinued 1 week later on 10/18/19, at his daughter's request when she discovered he had been placed on the [MEDICAL CONDITION] medication. Review of lab results revealed resident #1 was diagnosed with [REDACTED]. A Psychiatric Follow-Up Note dated 10/14/19 revealed the psychiatrist assessed resident #1 and reviewed data with facility staff. A nursing progress note on 10/15/19 at 4:01 AM showed the resident remained awake all night, sat in wheelchair and refused to get into bed. On 10/16/19 at 7:51 AM, nursing documentation showed resident #1 was exit-seeking but when re-directed he willingly remained in a common area. He refused injectable medication and staff were unable to provide ADL care. Resident #1 had a care plan for impaired cognitive function initiated on 10/14/19. The interventions included medications as ordered, simple yes/no questions, reduce distractions, cue, reorient and supervise as needed. All care plan approaches were dated 10/14/19 and there were no revised or updated interventions to reflect interdisciplinary team (IDT) involvement, effective strategies developed in cognitive therapy or attempts to decrease resident #1's cognitive communication issues. The facility did not develop care plans for resident #1's behavioral symptoms and antipsychotic medication use. There was no documentation of IDT discussion regarding possible causative factors for resident #1's behaviors including dementia with sundowning symptoms and decreased oxygen levels. In addition, appropriate and individualized approaches such as collaboration with family members, distraction and re-direction were not implemented consistently and re-evaluated for effectiveness. On 2/12/20 at 3:28 PM, the West Wing Unit Manager (UM) recalled resident #1 was very confused on admission to the facility and required oxygen 24 hours daily. She stated he was easily agitated by stimulation, but calmed down once he became accustomed to the facility's routine. During interviews on 2/13/20 between 2:29 PM and 4:00 PM, the Director of Nursing (DON) stated prior to starting an antipsychotic medication for a resident, there had to be a reason or identified behaviors. She explained the psychiatrist would then assess the resident and order medication if indicated. The DON stated either the resident or an authorized representative had to consent to use of a [MEDICAL CONDITION] medication after education on possible side effects. On review of resident #1's medical record, the DON was not able to find the specific consent form. She provided a blank Psychoactive Medication Consent form as an example, and stated it should have been completed by nursing staff. The consent form read, Medication interventions are not used for disciplinary action or for the convenience of the facility to control behavior. Psychoactive medication intervention would be initiated only after less restrictive non-drug measures were attempted and found to be ineffective. On 2/13/20 at 4:00 PM, after review of the medical record with the DON, she stated the psychiatrist ordered an antipsychotic medication for resident #1 without awaiting results of the UA and C&S. The DON stated prior to initiating a [MEDICAL CONDITION] medication, staff should attempt non-pharmacological interventions including re-direction with activities, walks to the courtyard, 1:1 visits, and distraction with food, drink or music. She explained residents with dementia or cognitive issues could have symptoms and behaviors that presented as psychotic events such as refusal of care and aggression. The DON said, Any infective process can cause behaviors. He was started on an antibiotic for pneumonia and possibly had a UTI. The DON stated after initiation of a [MEDICAL CONDITION] medication, nurses should monitor a resident's behaviors and status to determine medication effectiveness and any negative effects. Physicians' orders, and medication and treatment administration records for resident #1 were reviewed with the DON. She stated there was no documentation to show resident #1's behavior was monitored regularly by nursing staff and no monitoring for adverse effects related to [MEDICATION NAME]. At 4:15 PM, the DON mentioned she had recently been promoted from Assistant Director of Nursing (ADON) to the position of DON. She could not provide an explanation regarding the previous DON's process to ensure that [MEDICAL CONDITION] drugs were appropriately used and monitored. The DON explained the facility's psychiatrist was either terminated or resigned within the past week. The DON stated she recognized the need to implement a better process to monitor [MEDICAL CONDITION] drug use. She held a sheet of paper during the interview and stated it was a list of residents on [MEDICAL CONDITION] drugs. She explained that in her new position she was now responsible for reviewing those residents. The DON did not provide a copy of the form/paperwork, nor mention Quality Assurance Performance Improvement committee involvement or an active Performance Improvement Plan regarding [MEDICAL CONDITION] medications. Review of the policy and procedure for Psychoactive Medication Consent (2008) revealed the resident and/or family would be informed of potential side effects, and be required to provide consent, prior to administration of a [MEDICAL CONDITION] drug. The policy and procedure for [MEDICAL CONDITION] Medication Evaluation & Monitoring (2010), revealed a purpose to administer and monitor effects of [MEDICAL CONDITION] medications. The procedure indicated the IDT would evaluate and monitor residents on [MEDICAL CONDITION] medications.

Based on observation, interview and record review, the facility failed to ensure use of required personal protective equipment (PPE) to prevent the transmission of infection from 1 of 6 rooms designated for contact isolation precautions, (room [ROOM NUMBER]). Findings: On 2/12/20 at 11:04 AM, housekeeper A was observed cleaning room [ROOM NUMBER]. A caddy with PPE including yellow gowns and gloves hung on the door. The housekeeper A wore gloves only. Housekeeper A completed cleaning the bathroom and exited the room. She removed her gloves and dropped them into a trash container on the housekeeping cart. Housekeeper A did not perform hand hygiene after removal of her gloves and immediately entered the adjacent room and walked into the bathroom. A few minutes later, at 11:07 AM, housekeeper A returned to her cart. When asked about the type of PPE required to enter room [ROOM NUMBER], housekeeper A paused to think, glanced at the caddy on the door and stated she should have worn a gown. During the interaction with housekeeper A, rehab aide B returned a resident to room [ROOM NUMBER]. She did not use hand sanitizer prior to entering the room, and touched surfaces and items including the over bed table and television remote control without donning gloves. When rehab aide B exited the room she explained she did not need to wear any PPE inside the isolation room because she did not work directly with the resident. On 2/12/20 at 11:10 AM, the Housekeeping Director (HD) arrived in the hallway outside room [ROOM NUMBER]. She was informed housekeeper A cleaned room [ROOM NUMBER] without donning a yellow gown, did not sanitize her hands after exiting the room or prior to entering another room. The HD stated housekeepers were expected to wear a yellow gown and gloves when they worked inside an isolation room. Housekeeper A explained she did not wear a gown because the resident was not in the room. The HD acknowledged the signage on the caddy was prominently displayed. The cover sheet read, Please lift this sheet and read the instructions prior to entering this room. The HD lifted the cover sheet to reveal contact isolation was indicated for the occupant of the room. The document revealed transmission of infections could occur from person to person or by contact with potentially contaminated items in the room. The HD pointed to specific instructions for housekeeping staff that read, Gown and gloves MUST be worn during cleaning . PERFORM HAND HYGIENE (handwashing or use of alcohol-based hand rub) before exiting room. Nursing and rehab staff were instructed to perform hand hygiene before entering the room, wear gloves if touching any infectious material, remove gloves and perform hand hygiene before exiting the room. On 2/12/20 at 12:35 PM, the Director of Nursing stated all staff were expected to follow transmission-based precautions as directed by signage placed on doors. She acknowledged items in an isolation room might be contaminated and have the potential to transmit infections. Review of the policy and procedure for Isolation - Contact Precautions (2013) revealed contact precautions would be utilized in addition to standard precautions for residents with infectious organisms . that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces . in the resident environment. The procedure directed staff to wear gloves when entering the room and wash or sanitize hands before leaving the room.

Based on observation, interview and record review, the facility failed to ensure clean linen storage, proper placement of employee reference materials for chemical exposure (Safety Data Book) and storage of food products in the laundry department to prevent prevent cross-contamination and exposure to blood-borne pathogens and infectious microorganisms according to established guidelines. Findings: On 11/07/19 at 4:03 PM, an observation of the laundry area was conducted with the Laundry Supervisor (LS) and Administrator. The hallway leading to the laundry area revealed a large floor buffer which was plugged into an electrical outlet, an exit/entrance door in which several staff were observed to be entering and exiting the facility and multiple boxes and a vacuum cleaner sitting directly across from the clean laundry area door. The door to the resident's clean clothing folding area was propped open and a broom and high duster mop were observed on the floor behind the door. The LS stated that the door was to be kept closed at all times to ensure the resident's clothing was kept clean. She said the broom and the duster were used to clean the laundry area and should not be stored in the clean room. On 11/07/19 at approximately 4:09 PM, the soiled laundry processing area which contained the facility's two washing machines revealed a 5 compartment metal locker directly across from the washing machines (approximately 4 feet). One of the compartments contained 2 individual sized French vanilla coffee creamers, 1 (4) ounce can of caffeine free diet ginger ale, 3 individual sized lemonade packets and a 1.75 ounce bag of mixed snacks. At 4:11 PM, the LS stated that staff were not allowed to eat or drink in the laundry area. When the LS was asked if food was allowed to be stored in the soiled laundry area, the Administrator stopped her from answering stating, Don't answer. The Administrator stated that he will get the information. On 11/07/19 at 4:42 PM, the Safety Data Book (a reference book for chemical exposure) was observed in a metal holder attached to the wall approximately 4 feet from the washing machine closest to the wall. The LS stated that the Safety Data Book book was exposed to soiled laundry when it is loaded into the washing machine. Laundry Aide X stated, The book is used if a chemical gets on you and information on what you do. The Administrator then stated, Then everything in this room is soiled. The staff use gloves when touching the book. Laundry Aide X stated that she used gloves when loading the washing machine with soiled laundry but not when accessing the Safety Data Book. Review of the facility's Department Guidelines-Laundry, dated 2013, read, Overview, The facility will strive to protect resident and employees from nosocomial infections (disease originating in the facility) and to reduce the risk of cross-infection by utilizing hygienic practices for the handling and processing of soiled linens appropriate procedures are to be followed to minimize potential nosocomial and occupational risks associated with soiled linen handling Standard Precautions will be followed when handling soiled linens Review of the Occupational Safety and Health Administration (OSHA), Occupational Safety and Health Standards, Blood-Borne Pathogens, (OSH[NAME]gov), revealed, . Contaminated laundry means laundry which has been soiled with blood or other potentially infectious material . eating , drinking, smoking, application of lip balm and use of contact lens are prohibited in work areas where there is a reasonable likelihood of occupational exposure Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or counter tops or bench tops where blood or other potential infectious materials are present. Review of the Healthcare Laundry Accreditation Council (HLAC), dated 01/01/16, (hiacnet.org), Accreditation Standards for Processing Reusable Textiles for Use in Healthcare Facilities, read, Part 1, Basic Elements . 5.3 Health and Hygiene . 5.3.2 Employee Safety, 5.3.2.1 Personnel must adhere to good work practices to minimize or eliminate exposure to blood . hazards 5.3.2.2 Eating, drinking . must be prohibited in work areas where there is reasonable likelihood of occupational exposure to blood-borne pathogens Part 2, 6. Storage . 6.1.1 The providers storage strategies and handling methods of healthcare textiles must preserve the textiles in a hygienically clean state for delivery to the customer 6.2.5 Storage Area Entry and Exit, 6.2.5.1 The door to the clean textile storage shall remain closed at all times, except for entrance or exit

Based on observation, interview and record review, the facility failed to obtain a physician's order and complete a self-administration of medication assessment for a resident's medication at bedside for 1 of 1 resident, (#532). Findings: Resident #532 was a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His 5-day admission minimum data set (MDS) assessment dated [DATE] indicated his brief interview for mental status was 15 which indicated he had no cognitive deficits. He had no identified behaviors or refusals of care. He required limited assistance of 1 person for all activities of daily living (ADL's) except for supervision for eating. On 11/05/19 at 1:45 PM, the resident was observed resting in bed. There were 2 medications observed on a shelf above near his bed. A bottle of [MEDICATION NAME] 50 micrograms (mcg) nasal spray and a bottle of refresh eye drops. Resident #532 stated I take eye drops 4 times a day, and the nasal spray twice a day. I had acute [MEDICAL CONDITION] for a long time, and I was taking these at home. I brought them with me and have been using them every day. On 11/05/19 at 2:00 PM, licensed practical nurse (LPN) A stated, I'm not aware of resident #532 taking medications on his own. If someone wants to take their own medications, they would have to have a self-administration evaluation to see if they are safe. If so then we can get an order for [REDACTED]. We do ask them if they have medications with them on admission, we can't search their rooms. On 11/06/19 at 1:16 PM, resident #532 stated, They put a digital safe in the closet for my meds. I've always had them on my shelf above my head, where everyone can see them. I never tried to hide them. I didn't know I had to have a doctors order to take those medications. On 11/07/19 at 2:17 PM, the director of nursing (DON) stated, The facility has 2 admissions concierges who are certified nursing assistants (CNA) and they complete the inventory sheets for new admissions. They are supposed to check belongings, and ask residents if they have any medications with them. We can't search their belongings but if they come in with meds, we will send them home with family or lock them up until they are discharged . We just didn't know he was taking the medications. Interviews were attempted with the admissions concierges but they were not available. On 11/08/19 at 12:29 PM, CNA B said she never noticed resident #532 taking medications on his own but had only taken care of him a few times. Review of resident #532's inventory of personal effects dated 10/11/19 did not reveal any medications listed. A review of resident #532's Medication Administration Record [REDACTED]. Review of facility policy, Self-Administration of Medication, dated, 2008, read, . Purpose: To respect the wishes of competent residents to self-administer prescribed medications, as allowed by state regulations. Procedure: 1. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self-Administration of Medication Evaluation . 4. The nurse will obtain a physician's order to each resident conducting self-administration of medications

Based on observation and interview, the facility failed to store potentially hazardous products properly to ensure proper cooling within the appropriate time period. The facility also failed to maintain the West wing nourishment room at a safe temperature for food storage and failed to have prepared sandwich meats held at safe holding temperatures in the Bistro dining room. Findings: 1. On 5/06/19 at 10:25 AM, observation of the walk-in cooler with the nutrition service director (NSD) revealed the back shelf below the fans had multiple pans of leftover pureed bread and oatmeal. There was a 1/2 pan of bacon and egg omelets stacked on top of the two pans. The two pans were warm to the touch. The six inch deep 1/4 steam table pans were filled to a depth of 4 inches. On 5/06/19 at 10:25 AM, cook E stated that she had prepared the pureed bread to 98° Fahrenheit (F) and the oatmeal for 5/07/19. She had placed the pans in the refrigerator before 10 AM. Foods were not stored in the walk-in refrigerator to allow air circulation to promote proper cooling surface to bring the prepared items to a safe storage temperature within 6 hours. The NSD confirmed that the food was not stored for proper cooling. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous foods/ temperature controlled sensitive foods has been consistently identified as one factor contributing to foodborne illness. Foods that have been cooked and held at improper temperatures promote the growth of disease-causing microorganisms that may have survived the cooking process (e.g., spore-formers). Dense food item such as the pureed items should be placed in shallow pans, utilize ice water baths and periodic stirring in order to be chilled within the allowed time period. The cooling time also potentially increased by having additional food items on top of the pureed items. (U.S. Food and Drug Administration's Food Code (YEAR)). 2. On 5/06/19 at 12:48 PM, the nourishment room on the 500 hall was very warm. The cabinets contained a loaf of bread and thickened beverage products including milk. On 5/07/19 at 3:17 PM, the nourishment room was observed with the food service director. The temperature of the room was 88° F. The NSD explained that they had replaced the ice machine recently and it was producing more heat. The maintenance director revealed that part of the cooling system to that room was not functioning at full capacity, and the vent was not strong enough to remove the heat from the ice machine. Safe dry food storage should be at a temperature is 82° F or below. On 5/08/19 at 11:43 AM, observation of the kitchen area of the Bistro revealed sliced meat on the cart with ice under the containers. The temperature was assessed with [REDACTED]. The sliced turkey was 51° F, corned beef was 51° F, and the ham was 50° F. Safe holding temperature of the meats should be 41° F or below. The NSD confirmed that the holding temperature was not appropriate.

Based on observation, interview and record review, the facility failed to identify an new injury 1 of 2 residents reviewed for skin conditions (#83). Findings: Resident #83 was admitted with [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME] used as a blood thinner. On 5/06/19 at 4:37 PM, resident #83 was lying in bed with the head of her bed elevated. There was a small amount of blood on her sheet near her lower right leg. She pulled back her sheet to reveal an open area on the right shin with a partial scab coming off the area. On 5/08/19 at 11:13 AM, certified nursing assistant (CNA) A said she was aware of the small injury on her shin but did not report it to anyone. On 5/08/19 at 11:16 AM, licensed practical nurse (LPN) B stated that he did not notice the area on 5/06/19. He did not work on 5/07/19. He confirmed that there was no documentation of the injury. He stated he would report it to the physician and get orders. He said the area was approximately 1 centimeter (cm.) long by 1/2 cm. by 1/4 cm. deep. It was reddish and appeared that a scab came off. On 5/08/19 at 3:12 PM, registered nurse (RN) C confirmed that she had not seen the injury when she worked 5/07/19. On 5/08/19 at 4:37 PM, the director of nursing revealed that the wound was not present on the skin assessment 5/03/19, and it should have been identified when it occurred. Review of the clinical record revealed that no area was identified during the skin assessment on 5/03/19. There was no documentation in the progress noted from 5/03/18-5/08/19 related to the open area on the right shin. The facility was not aware of the injury until it was brought to their attention on 5/08/19. Review of the admission minimum data set (MDS) assessment reference date (ARD) of 3/30/19, signed as complete on 4/08/19, identified her at risk for pressure ulcers, and had a skin tear. Review of the plan of care, initiated 4/01/19, identified the resident at risk for abnormal bleeding because of anti-coagulant/anti-platelet usage. Interventions included daily skin inspection; report abnormalities to the nurse; monitor and report to nurse any of the following signs or symptoms (s/s) of bleeding gums, and unusual bruising; report to physician any s/s ofabnormal bleeding or bruising; plan of care specific to fragile skin or skin tears. Plan of care, dated 4/09/19, identified the resident had actual impairment to skin integrity of the bilateral lower extremities. Goals was free of infections through next review. The facility failed to identify a wound that had the potential of causing excessive bleeding, and the potential of a pressure sore on a bony prominence for a resident with impaired mobility.

Based on interview and record review the facility failed to provide adequate supervision, and implement interventions to prevent multiple falls for 1 of 5 resident reviewed for falls, (#41). Findings: Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with assessment reference date 9/18/18 showed that resident #14 was rarely/never understood, and required extensive assistance with toilet use, and limited assistance with bed mobility, transfer, dressing, and personal hygiene. On 12/04/18 at 2:59 PM resident #41's daughter said the resident had falls, and crawled many times to the bathroom. The daughter said that family was with the resident from 9 AM- 11 PM daily, and they paid for a sitter to stay with the resident at nights. The daughter said the resident's falls happened during the nights. She said the call light response was not timely and help was not prompt. She said the resident had to crawl to the bathroom, because she could not hold her urine. Review of the incident log showed that for the period 9/29/18-11/11/18 resident #16 had twelve (12) falls. On 12/06/18 at 2:48 PM the resident's falls were reviewed with the director of nursing (DON)/risk manager, and the assistant DON (ADON). 9/29/18 - observed on floor mat near recliner, as per resident was trying to get out of wheel chair. 10/01/18- 1 AM observed lying on floor at end of bed , resident could not recall why she was on the floor 10/08/18- 2 AM observed on floor mats. 8 AM observed lying on floor in room next to wheel chair. 10/14/18- 8:30 AM observed sitting upright at side of bed holding on to air mattress pump- said she was trying to turn off alarm clock- fire alarm was alarming at time of fall-no injury 10/16/18- 9 PM noted lying on floor. 10/17/18- 9 AM- observed sitting on floor in front of wheelchair- stated head and left shoulder hurting-transferred to the hospital. 10/20/18 -10 PM attempting to get out of bed (OOB) slid to floor mat. 10/27/18- 9:15 AM observed lying on left side beside floor mat, verbalized trying to get off the bed by herself, attempting to go to the bathroom- no injuries. 10/30/18- 8:30 AM Observed on floor lying next to bed, Patient was attempting to crawl to the bathroom 11/07/18- 4:45 AM noted sitting on her buttocks, beside her bed- no injuries 11/11/18- 6:05 AM observed on floor patient reportedly eased herself out of bed, crawled into the bathroom, and urinated on the towel. no injury A care plan for at risk for Falls related to confusion, gait, balance problems, vision/hearing problems, impulsive behavior, poor safety awareness, attempts to get up on her own, was created on 10/01/18 with revision on 11/15/18. The goal on 10/01/18, read, Potential for falls/fall-related injuries will be minimized through next review date. Interventions included : 10/01/18 low bed, anticipate and meet the resident needs, encourage and assist the resident to wear appropriate non-skid footwear, resident needs activities that minimize the potential for falls while providing diversion and distraction, encourage the resident to use call light, 10/20/18 fall mats while in bed, 11/02/18 toilet resident prior to breakfast. On 12/06/18 at 11:29 AM licensed practical nurse (LPN) B said resident #41 was very confused, and required constant reminders. LPN B said the resident was assessed as a fall risk, attempts to transfer self, and has to be reminded that she could not walk. LPN B said interventions for the resident included, fall mats, answer light frequently, toileting, and visits from her family. On 12/06/18 at 3:10 PM the ADON said she reviewed falls with the unit coordinator, and DON to identify times of falls, any significance with the falls, and to place intervention. All falls were reviewed by the interdisciplinary team (IDT). The ADON said resident #41's cognition was poor, most time she did not know where she was. The resident's family stay with her from 8:00 AM every day. For falls which occurred in the early mornings, the resident was placed on a toileting schedule, prompted voiding, check and change, taken to bathroom. The ADON said in-service was done with staff regarding purposeful rounding and toileting. CNA/ nurses should make sure call light was within reach, the floors were clean, dry, and uncluttered. A fall risk screen, and therapy screen was completed status [REDACTED]. An interview was conducted with certified nursing assistant (CNA) A on 12/06/18 at 05:30 PM. She stated that resident #16 had falls, and needed assistance of one person for activities of daily living (ADL). CNA A said the resident was confused, called for companionship, had dementia and was very forgetful. CNA A said she made sure the resident's call light was within reach. The resident was able to use the call light sometimes. She made sure the bed was in the low position, and floor mats were in place when the resident was in bed. The CNA A could did not provide an answer as to how often the resident was observed for safety as she was not able to use her call light for help. On 12/06/18 at 05:33 PM LPN C said she was not aware of the amount of falls the resident had. She was aware that the resident was at risk for falls, and interventions included, call light within reach, low bed, and bilateral floor mats at nights. LPN C said the resident's family left the facility approximated 9:30 PM each day, and the resident had a sitter during the nights. The LPN did not know the hours for the sitter. The LPN did not provide an answer as to how often the resident was monitored for safety to prevent falls as she was unable to use the call light. On 12/07/18 at 09:23 AM the Director of Rehab said, all falls were reviewed by the interdisciplinary team at clinical meeting daily. If residents were at the facility for short term care, they would usually be on therapy, if not, a therapy screen would be completed. If the resident was on caseload, a therapy rescreen would be done for added intervention. The Director of Rehab said resident# 41 was on caseload for Physical therapy (PT), Speech therapy (ST), and Occupational therapy (OT). She said the resident's cognition was very poor, and her falls were cognition related. The Director of rehab said resident #41 needed a structured environment, and facility was working with the resident's family, and activities. Documentation on the ST plan of care with start of care 10/12/18 and 10/20/18 read,Unable to identify or retain call button training .recommended to nursing that pt be monitored to reduce fall risk .Pt (patient) was holding call button and was able to state its purpose but was unable to use it effectively The facility had some interventions in place, but the resident continued to have falls. The resident's daughter, and LPN C stated the resident had a sitter at nights, time/duration unknown, however eight of twelve falls occurred between 1 AM-9:15 AM. Resident #41's care plan for falls did not identify or implement interventions to address incidents during these times. Family sitting with the resident during the day was not addressed in the care plan, and there were no interventions initiated status [REDACTED]. The facility did not have a policy and procedure for falls, as per the DON. The policy and procedure, Notification Of Change in Condition read, Change in condition-a clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains .The licensed nurse is to implement treatment interventions and any received physician orders.

Based on interview and record review the facility failed to reassess, revise and implement person centered interventions to help prevent falls for 1 of 5 resident reviewed for falls, (#41). Findings Resident #41 was admitted to the facility on [DATE] , and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with assessment reference date 9/18/18 showed that resident #16 was rarely/never understood, and required extensive assistance with toilet use, and limited assistance with bed mobility, transfer, dressing, and personal hygiene. Review of the incident log showed that for the period 9/29/18-11/11/18 resident #16 had twelve (12) falls. On 12/06/18 at 2:48 PM the resident's falls were reviewed with the director of nursing (DON) and assistant DON (ADON). 9/29/18 -observed on floor mat near recliner, as per resident was trying to get out of wheel chair. 10/01/18- 1 AM observed lying on floor at end of bed , resident could not recall why she was on the floor 10/08/18- 2 AM observed on floor mats. 8 AM observed lying on floor in room next to wheel chair. 10/14/18- 8:30 AM observed sitting upright at side of bed holding on to air mattress pump-said she was trying to turn off alarm clock-fire alarm was alarming at time of fall-no injury 10/16/18- 9 PM noted lying on floor. 10/17/18- 9 AM- observed sitting on floor in front of wheelchair- stated head and left shoulder hurting-transferred to hospital. 10/20/18 -10 PM attempting to get out of bed (OOB) slid to floor mat. 10/27/18- 9:15 AM observed lying on left side beside floor mat, verbalized trying to get off the bed by herself, attempting to go to the bathroom- no injuries. 10/30/18- 8:30 AM Observed on floor lying next to bed, resident was attempting to crawl to the bathroom 11/07/18- 4:45 AM noted sitting on her buttocks, beside her bed- no injuries 11/11/18- 6:05 AM observed on floor resident reportedly eased herself out of bed, crawled into the bathroom, and urinated on the towel. no injury A care plan for at risk for Falls related to confusion, gait, balance problems, vision/hearing problems, impulsive behavior, poor safety awareness, attempts to get up on her own, was created on 10/01/18 with revision on 11/15/18. The goal on 10/01/18, read, Potential for falls/fall-related injuries will be minimized through next review date. Interventions included : 10/01/18 low bed, anticipate and meet the resident needs, encourage and assist the resident to wear appropriate non-skid footwear, resident needs activities that minimize the potential for falls while providing diversion and distraction, encourage the resident to use call light,10/20/18 fall mats while in bed, 11/02/18 toilet resident prior to breakfast. On 12/06/18 at 3:10 PM, the ADON said she reviewed falls with the unit coordinator, and DON to identify times of falls, any significance with the falls, and to place interventions. All falls were reviewed by the interdisciplinary team (IDT). The ADON said resident #41's cognition was poor most of the time and she was not oriented to place. She stated that resident's family stayed with her from 8:00 AM every day due to falls. She said the falls occurred in the early morning. The resident was placed on a toileting schedule, prompted voiding, check and change, and taken to the bathroom. Review of the care plan with the DON, and ADON showed interventions were not individualized and specific to address the resident's frequent falls. The family sitting with the resident was not addressed in the care plan, and there were no interventions initiated post falls on 10/08/18, 10/14/18, 10/16/18, 10/27/18, 11/07/18, and 11/11/18. The ADON said that care plans should be individualized, and interventions specific to the resident and to her needs. Both the DON and ADON said the care plan for falls, was not specific, or individualized for resident # 41. On 12/06/18 at 5:21 PM the registered nurse ( RN) MDS coordinator said the interdisciplinary team (IDT) reviewed all falls. She stated that care plans were implemented by the IDT team, and the team should ensure that interventions in the care plan were specific for the resident.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect. The facility did not provide adequate supervision and this resulted in elopement and potential for serious harm for 1 resident (#106), and high potential for serious injury/impairment/death for 5 other residents (#162, #220, #264, #423, #433). Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. (42 CFR 488.301). The facility staff failed to provide services to supervise cognitively impaired residents with wandering and exit seeking behavior. As a result, resident #106, a [AGE] year-old, identified as an elopement risk upon admission to the facility, eloped from the facility on New Year's Day, 1/01/17, walked 0.3 miles from the facility using a 4 wheeled walker, and crossed a major 4 lane highway, not at a crosswalk. She was found by a Good Samaritan who was driving by at that time and stopped to help her so she was not hit by a car. The failure to identify and prevent neglect resulted in substandard quality of care and Immediate Jeopardy on 3/16/17. The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross Reference F323, F353, F456, F490, F520. A review of the Melbourne Police Department report dated 1/01/17 revealed that they responded to a call from a Good Samaritan at 5:15 PM. The Good Samaritan was driving by and stopped to render aid to a wandering elderly person attempting to cross a busy 4-lane highway, not at the crosswalk, utilizing a walker. The resident was non-verbal, very confused, and could not identify herself or from where she came. Her walker had her name on it. Law enforcement dispatch called nursing homes and rehabilitation centers in the area in an attempt to locate the person's residence. Melbourne Terrace Rehabilitation Center advised them that they had a resident (#106) they were currently attempting to locate. The resident was returned to the facility by EMS (emergency medical services) on 1/01/17 at 5:51 PM. Licensed Practical Nurse (LPN) E and the East Wing Unit Manager (UM) stated a wander bracelet was on resident #106's ankle. The purpose of the wander system was to alert staff when attempting to exit the facility. LPN E stated resident #106 had attempted to exit the facility 4 or 5 times throughout the day, setting off wander alarms. She also stated that since her admission on 12/13/16, staff were warned that she would frequently wander from her permanent residence, and that her altered mental status was the main reason for her being admitted to the facility. On 3/13/17 at 5:30 PM, the surveyor and facility administrator observed a video surveillance of the elopement incident of 01/01/2017. It showed resident #106 walking with a four-wheeled walker coming from the left side of the West exit doors at 4:56 PM. The first set of double doors opened immediately as she approached the doors. These doors should have alarmed as the resident approached because she was wearing a wander bracelet. She walked through the first set of doors and then the second set of double doors opened immediately allowing the resident to exit the facility to the parking lot. The second set of doors should have locked and stayed closed to prevent the resident from exiting the facility. The video showed the resident exiting the facility and she was in the parking lot at 4:57 PM. A reenactment of the elopement of resident #106 was conducted on 3/14/17 at 3:35 PM with the maintenance director. It showed that the facility had not tested the wander system on the doors under the same circumstances as when resident #106 eloped. The resident had a wander bracelet on her left ankle, but the maintenance director demonstrated that he had been checking the door system while holding on to the wander bracelet in his hand at waist level. He stated that he checked the door system at a lower level one time after the elopement by sliding the wander bracelet on the floor through the door. He stated that the doors alarmed and locked when he slid the bracelet on the floor through the doors. The surveyor applied the wander bracelet to the left ankle just as the resident was wearing and approached the exit door from the left as the resident had. The first set of doors did not alarm, as they should have. The surveyor walked through the first set of doors and the second set of doors opened immediately allowing the surveyor to exit the facility. The surveyor then walked back into the facility and the doors opened without any alarms. The surveyor exited through the doors a second time and the doors did not alarm or lock. The maintenance director stated that he could not understand how the doors did not alarm and lock. This reenactment was conducted three other times with the administrator and the survey team present and again, the surveyor was able to exit the facility while wearing an ankle bracelet to her left ankle and the doors failed to alarm and lock. Photographs were taken of the path that the resident would have taken when she eloped and headed towards the highway, including the west exit doors from where the resident exited the facility, the parking lot she walked through, and the street leading to the major 4-lane highway which she crossed not at crosswalk. This route measured 0.3 miles. There resident eloped at 5:00 PM on a busy holiday weekend where the speed limit on the major highway was 45 miles per hour. An interview with the administrator and director of nursing (DON) on 3/15/17 at 4 PM revealed they did not identify this incident involving resident #106 as neglect. Their root cause analysis of the incident was a malfunction of the door wander guard system. Therefore, their corrective action plan was based on reaction of the elopement, and failed to focus on the individual residents. The action plan involved providing education to staff regarding elopement and the door systems. Resident #106 is a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was admitted to the facility from an acute care hospital where she presented with a history of Alzheimer's dementia, hypertension, worsening altered mental status, and was unable to answer questions appropriately. Her neurological assessment revealed progressive worsening dementia exacerbated by hypertensive [MEDICAL CONDITION] (abrupt blood pressure elevation). An Elopement Risk Evaluation, completed on 12/13/16, documented that she was an elopement risk, and a wander bracelet was placed on her left ankle. The Minimum Data Set (used to complete a comprehensive assessment of each resident) with assessment reference date of 12/27/16, revealed that she had wandering behavior which occurred daily, had unclear speech, was rarely/never understood, had severely impaired vision, short and long-term memory problems, and severely impaired cognitive skills for decision-making. A review of the care plans for residents #106, #162, #220, #264, #423 and #433 identified them as elopement risk but failed to identify any individualized measures or their customary routines/habits. There was no documentation to specify if these residents had any patterns of exit seeking, such as any specific doors, any particular time, where they wanted to go, or what measures worked best to redirect them. There was no documentation as to their previous lifestyle, occupation or interests such as spending time outdoors. The care plans did not specify how often residents' whereabouts were to be observed. The care plans reviewed for Impaired Cognition Exit Seeking noted general approaches such as to observe resident location/whereabouts, assist as needed to specific destinations such as dining room, activity room, therapy gym, unit, etc., divert from exits as needed, observe for exit seeking behaviors, verbalizations of wanting to leave/go home, and/or physical attempts to leave the facility, and report if noted and document. In an interview conducted on 3/15/17 at 6:50 PM, certified nursing assistant (CNA) F stated that she had worked on the 3-11 PM shift on 1/01/17. This was the first time she was assigned to resident #106. She stated that the last time she saw the resident was at 4 PM on 1/01/17 and noted she was missing at 5:15 PM, because she was not in the dining room. While searching for the resident, she said staff were notified by the receptionist that the resident was found in the parking lot of the superstore, 0.3 miles away. CNA F stated that the resident had been wandering, looking for exit doors and wanting to get out that evening. She stated that she did not know anything about the resident's usual patterns or habits because it was the first time she was assigned to care for her. She stated that they were working 2 staff members short that evening and had no additional staff to cover the call offs from two staff members. She was assigned to care for 11 residents instead of 8 residents. She said that when she was in a resident's room, providing care, she did not know where a resident may be wandering. She said some of them walked fast and staff could get to the other wings quickly. She said We depend on the alarms, because we cannot be supervise residents closely. On 3/17/17 at 2:50 PM, CNA G stated he noted resident #106 missing at dinnertime, approximately 5:15 PM on 1/01/17. He noted she was not in the dining room and reported this to the charge nurse. He saw her last at 3 PM on 1/01/17 when he directed her back to the East wing because she was heading toward the West wing. He said, We checked her room first and then started a search. CNA G stated he did not know anything else about resident #106, her habits, usual routine, and where she liked to wander. He was not able to describe her usual behavior other than she was always wandering and exit seeking. On 3/16/17 at 5:45 PM, LPN E stated resident #106 was attempting to get out to the courtyard by the East doors on 1/01/17, and had to be redirected at least 5 times within an hour. She stated that CNA G notified her that resident #106 was not in the dining room and they started a search. She said they were short by 2 staff that evening and she had only 5 CNAs on the East wing and 4 residents who were elopement risk. She said she was concerned because she was responsible for these residents. She was not aware if staff were familiar with these 4 elopement risk residents. She stated that staff on the West wing would not know anything about resident #106. They would only be alerted that she was exit seeking when the doors alarmed. On 3/14/17 at 1:19 PM, the DON stated, We do not have a policy and procedure specific for how often we monitor the residents with the wander bracelet system. We monitor them routinely. The DON was unable to explain the frequency of routinely. On 3/18/17 at 12:43 PM, the DON stated that staffing for the units was done according to patient per day (PPD) and resident acuity. She did not include the elopement risk residents into the acuity. She stated that she would have to monitor the patterns of elopement risk residents to determine how many staff were needed and how to train them. The DON could not explain how all staff were made aware of the residents at risk for elopement and how their patterns/habits/customary routines were monitored and documented. The DON was aware that 5 CNAs were assigned to the East wing on 1/01/17 with 4 elopement risk residents, and could not give an explanation as to how the staff were to provide care and services for these residents with wandering and exit seeking behaviors when they were short staffed by 2 people. On 3/18/17 at 9:50 AM, resident #423 was in his wheelchair, wheeling himself in the 400 hallway, with a wander bracelet on his right wrist. On 3/18/17 at 9:50 AM, CNA N, caring for resident #423 said, There is no policy on how often we check the residents with wander bracelets. On 3/18/17 at 10:30 AM, resident #433 was in bed with his eyes closed. A wander bracelet was on his left wrist. At 10:30 AM, CNA O revealed that she could not give a time frame as to how often she checked on the resident's whereabouts. On 3/18/17 at 10:45 AM, resident #162 was on top of her bed. She had a wander bracelet on her left wrist. The bracelet was previously on her left ankle. At 10:45 AM, CNA P revealed she checked on the resident every hour to every hour and a half and said, When I am caring for my other residents, I do not know where she is. On 3/18/17 at 11 AM, resident #220 was on top of his bed, and had a wander bracelet was on his right wrist. At 11 AM, CNA I said, I check on him regularly. CNA P could not explain how often regularly meant. On 3/18/17 at 1 PM, resident #264 was observed walking in the East wing corridors. The East wing unit manager was not able to explain how often this resident was observed during an interview on 3/18/17 at 1:04 PM. She was not able to give any details as to the customary habits or routines of this resident. Interviews conducted on 3/18/17 with all 5 staff members caring for current residents assessed with [REDACTED]. Although one of the interventions implemented after the elopement on 1/01/17 was to increase monitoring at the West wing rehabilitation door by the outpatient coordinator from 7:30 AM to 4:30 PM from Monday through Friday, an interview with the coordinator on 3/16/17 at 11:30 AM revealed this was not being done. She stated she had informed administration that she could not possibly do her work and monitor the doors for elopement risk residents at the same time. She was not familiar with the elopement risk residents and stated she would have to look in the book at their pictures to identify them. She stated she relied on the alarm to alert her if a resident was approaching the exit door, because she was not familiar with these residents. Review of the facility's Quality Assurance & Improvement/Risk Management, Resident Elopement Risk Management Guidelines last reviewed 1/29/17, read, Purpose: The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventive measures to minimize elopement occurrences. Definitions: An elopement occurs when a resident, who is not alert/oriented, is found outside the property line of the facility without knowledge of staff, or when a resident is identified as missing from the facility Documentation: If the resident is care planned for a wander device, the facility should document that the resident is wearing the electronic device every shift or as indicated and documented on the Treatment Administration Record (TAR). The electronic device should be checked every day to ensure that it is functioning properly and documented on the TAR. Review of resident #106's December 2016 and January 2017 TARs did not reveal any documentation for daily wander bracelet placement or function checks. This was confirmed by the East wing unit manager on 3/16/17 at 11:10 AM. She could not explain why the checks were not being done. Even after the elopement incident of 1/01/17, the facility did not change their process for doing checks on the wander bracelets. They continued with their previous procedure to the check wander bracelets every shift and check the function of the wander bracelet once a day, and did not implement a process to ensure they were completed. The facility's guidelines, Quality Assurance & Improvement/Risk Management, Resident Elopement Risk Management, failed to address how often residents with wandering/exit seeking behaviors were monitored, placing them at risk for elopement with potential for serious harm. The facility relied on the wander system as a tool for supervision for cognitively impaired residents with wandering and exit seeking behaviors. The facility did not consider potential for neglect for resident #106, who left the facility and crossed a busy 4 lane highway on New Year's Day. They failed to provide services for the remaining 5 residents at risk for elopement. The facility policy and procedure for Neglect, last reviewed on 1/27/19, read any form of mistreatment of [REDACTED]. The policy included the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Under heading titled Prevention it read, .identify, correct, and intervene in situations where abuse, neglect, and/or misappropriation/exploitation of resident property are likely to occur .analyze, and assess the following situations to minimize the likelihood .Areas of the physical environment that may make abuse or neglect more likely to occur, such as secluded areas of the facility .Take appropriate steps so that personnel are provided in sufficient numbers, with adequate knowledge to meet the needs of individual residents. The section of the policy titled Identification listed practices to assist in monitoring and identifying potential abuse and neglect. Two of the practices listed were: daily staffing practices and regular direct/indirect supervision of nursing home employees and resident care by Supervisory and Administrative staff. The facility conducted Quality Assessment and Assurance (QAA) meetings on 3/16/17 and 3/17/17 with the medical director with 17 additional members, including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. The books were located at the front entrance, the West Rehabilitation entrance, and at each of 3 nursing stations for a total of 5 books. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the wander devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed, and additional safety measures included both entrances to be locked 24 hours a day, and a new security system installed at both doors. Both doors now required a manual switch by the receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week, including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM from Monday through Friday, including coverage for back-up. Signage was installed alerting visitors at the West doors to use the front entrance. An additional alarming mechanism was installed at the East wing dining room with a visual and audible sensor in the hallway of the main dining room, and a loud sensor installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays, and the manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors function properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff were being educated on the awareness of residents at risk of elopement and interventions for supervision including hourly checks for 48 hours of newly identified elopement risk residents. Staff were also educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with on-going in-services until all staff are educated prior to the start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to provide adequate supervision and secure environment for 6 of 6 residents at risk for actual and potential elopement. These failures contributed to the elopement of resident #106, placing her at risk for serious injury/impairment/death and placing 5 other residents for potential for serious injury/impairment/death (#162, 220, 264, 423 & 433). On 1/01/17 at 4:56 PM, resident #106 left the facility via the West exit doors. The whereabouts of resident #106 were unknown by the facility until she was located by law enforcement 0.3 miles from the facility. The resident was aided by a Good Samaritan who became concerned as the resident was crossing a busy 4 lane highway, not at the crosswalk using her walker. The Good Samaritan called law enforcement. The failure to provide adequate supervision and a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 3/16/17. The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross reference to F223, F353, F456 and F520. Resident #106 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was admitted to the facility from an acute care hospital with a history of Alzheimer's dementia, hypertension, worsening altered mental status, and was unable to answer questions appropriately. Her neurologic assessment revealed progressive worsening dementia exacerbated by hypertensive [DIAGNOSES REDACTED] (abrupt blood pressure elevation). An Elopement Risk Evaluation, completed on 12/13/16, documented that she was an elopement risk and a wander bracelet was placed on her left ankle. The Minimum Data Set (used to complete a comprehensive assessment of each resident) with assessment reference date of 12/27/16, revealed she had wandering behavior which occurred daily, had unclear speech, was rarely/never understood, had severely impaired vision, short and long-term memory problems, and severely impaired cognitive skills for decision making. A physician's orders [REDACTED]. The Physician's Progress Note, dated 12/22/16, documented the resident was very confused with severe senile dementia and required 24-hour around the clock monitoring. A review of the Minimum Data Set (MDS), used to complete a comprehensive assessment with assessment reference date of 12/27/16, revealed that resident #106 had wandering behavior which occurred daily, had unclear speech, was rarely/never understood, had severely impaired vision, short and long term memory problems, and severely impaired cognitive skills for decision making. She required supervision with bed mobility and transfer, and limited assistance with walking in room, corridor, dressing and toilet use. She also required extensive assistance with locomotion off the unit and personal hygiene. She is not steady but able to stabilize with staff assistance to a standing position, walking and turning around, and used a walker and wheelchair for mobility. The Interim Admission Care Plan for resident #106, dated 12/13/16, read, Elopement, Dementia with Goal: resident will not exit facility without staff's knowledge. Intervention was, wander bracelet applied. The Comprehensive Care Plan dated 12/28/16 noted episodes of non-compliance behaviors: wandering, going into others rooms, dated 12/28/16 with a goal, Will respond to redirection/education without aggressive behavior toward the staff. Approaches included to redirect as needed, encourage participation in activities of interest, education, cues, reminders as needed, provide and encourage activities of choice, document behavior and report any changes, declines in behavior to physician. The Care Plan for impaired cognition, dated 12/19/16, included cognition affecting communication, functional abilities, decision-making, and judgement related to dementia. Goals included to participate in activity of daily living (ADL) and activities without frustration. Interventions included to assist with maintaining a routine as much as possible, safety education, cues, and reminders as needed. The Care Plan for potential for falls, dated 12/21/16, related to poor safety awareness, severe confusion, and scoliosis. Approaches were to invite, encourage and assist, to adaptive sports, exercise groups/programs for increased mobility, safety device as ordered. The Care Plan for at risk for elopement, dated 1/03/17, related to wandering/exit seeking behaviors; resident verbalizes at times when she is leaving. The goal included that resident will not elope from the facility grounds through the next review date 4/03/17. Approaches included to observe whereabouts, attempt to divert from exits. If resident wanders outside stay with the resident until she returns to the facility. Apply wander bracelet if needed, check wander bracelet daily and replace as needed. Document exit seeking verbalizations or physical attempts to leave the facility. Encourage and assist to attend activities for diversion. The dementia Care Plan, dated 12/22/16, read, Monitor patient (resident) closely as she is impulsive and stands up from her wheelchair frequently, use simple communication: utilize yes/no questions and pay attention to non-verbal communication. Respond immediately if alarm sounds, simple social interactions, music, invite resident to attend simple facility offered activities. The activities Care Plan, dated 12/16/16, had goals that the resident will participate in self-directed activities of choice through the next review dated of 3/16/17, and will attend group activity of interest once weekly through the next review date 3/16/17. Approaches included to introduce the resident to other residents with similar interests, obtain prior level of activity involvement and interests by talking with resident, staff, family. Invite the resident to scheduled activities, offer variety of activity types and locations, and offer to assist/escort resident to activities. A telephone interview was held with the resident #106's daughter on 3/16/17 at 1:16 PM. She said that she was told the facility could no longer look after her mother as she was a flight risk and they were going to transfer her to a more appropriate setting. She stated that she did not know why they were discharging her. The facility knew about the wandering and exit-seeking behavior before she was admitted , and she had a wander bracelet on her ankle. She was told that the facility could meet her mother's needs before she decided to place her mom here but the facility discharged her on 1/03/17. The Nursing Progress Note, dated 1/01/17 at 10:03 PM reflected that resident #106, with severe confusion, was near the nurses' station in a wheelchair and kept going near the door that leads to the gazebo, setting off the wander bracelet alarm. When certified nursing assistant (CNA) G went to get her for dinner, she was not in the area. The CNA checked the dining room to see if she was already in there, and the CNA then asked the nurse if she knew the whereabouts of resident #106. CNA G and licensed practical nurse (LPN) E began looking for the resident. All rooms in the facility were searched, and the nurse went around the entire outside of the building to search for her. When the nurse returned back into the facility, she was notified by the receptionist that the resident was found at the superstore, and that law enforcement was bringing her back to the facility. Photographs were taken of the path that the resident would have taken when she eloped and headed towards the highway, including the west exit doors from where the resident exited the facility, the parking lot she walked through, and the street leading to the major 4-lane highway which she crossed not at crosswalk. This route measured 0.3 miles. There resident eloped at 5:00 PM on a busy holiday weekend where the speed limit on the major highway was 45 miles per hour. A statement by LPN E dated 1/01/17 at 7:12 PM reflected that she observed resident #106 on 1/01/17 at about 4 PM-4:30 PM. The resident attempted to exit the door to the courtyard several times and the alarms scared her. At 5 PM, LPN E went to take her to the dining room but could not find her. LPN E said CNA G informed me that the resident had been found at the superstore and the police were bringing her back to the facility. On 3/16/17 at 5:45 PM, LPN E stated that resident #106 was attempting to get out to the courtyard by the East doors on 1/01/17 and had to be redirected at least 5 times. On 3/16/17 at 7 PM, CNA Q stated she worked on the 3-11 PM shift. She stated when she was in a room providing care to a resident, she did not know where her other residents were wandering to. On 3/18/17 at 9:50 AM, CNA N stated that she was not aware of how often residents' whereabouts were to be checked. On 03/18/17 at 10:45 AM, CNA P stated that residents with wander bracelets are elopement risks. She stated that when she was caring for other residents, she did not know where the wandering residents were. On 3/18/17 at 11 AM, CNA I stated that she checked on her residents every 2 hours. On 3/14/17 at 1:19 PM, the director of nursing (DON) stated that staff monitor the residents routinely but could not provide an answer as to how often the monitoring routine was. There was no policy or standard on how often the residents with wander bracelets were checked. Based on interviews conducted with the facility staff and the DON, there was no protocol noting how often residents with wander bracelets were to be observed to prevent potential elopement. The facility's investigation of the elopement incident of resident #106 on 1/01/17 identified that the wander bracelet system did not function properly at the West exit door when worn at ankle level. On 3/13/17 at 5:30 PM, the surveyor and facility administrator observed a video surveillance of the elopement incident of 01/01/2017. It showed resident #106 walking with a four-wheeled walker coming from the left side of the West exit doors at 4:56 PM. The first set of double doors opened immediately as she approached the doors. These doors should have alarmed as the resident approached because she was wearing a wander bracelet. She walked through the first set of doors and then the second set of double doors opened immediately allowing the resident to exit the facility to the parking lot. The second set of doors should have locked and stayed closed to prevent the resident from exiting the facility. The video showed the resident exiting the facility and she was in the parking lot at 4:57 PM. A reenactment of the elopement of resident #106 was conducted on 3/14/17 at 3:35 PM with the maintenance director. It showed that the facility had not tested the wander system on the doors under the same circumstances as when resident #106 eloped. The resident had a wander bracelet on her left ankle, but the maintenance director demonstrated that he had been checking the door system while holding on to the wander bracelet in his hand at waist level. He stated that he checked the door system at a lower level one time after the elopement by sliding the wander bracelet on the floor through the door. He stated that the doors alarmed and locked when he slid the bracelet on the floor through the doors. The surveyor applied the wander bracelet to the left ankle just as the resident was wearing and approached the exit door from the left as the resident had. The first set of doors did not alarm, as they should have. The surveyor walked through the first set of doors and the second set of doors opened immediately allowing the surveyor to exit the facility. The surveyor then walked back into the facility and the doors opened without any alarms. The surveyor exited through the doors a second time and the doors did not alarm or lock. The maintenance director stated that he could not understand how the doors did not alarm and lock. This reenactment was conducted three other times with the administrator and the survey team present and again, the surveyor was able to exit the facility while wearing an ankle bracelet to her left ankle and the doors failed to alarm and lock. The facility failed to follow manufacturer's guidelines in the application of the wander bracelets. A review of the wander bracelet system user instruction insert read, Devices are designed to be worn on a wrist, it can also be placed on an ankle .you must contact wander bracelet technical service for further instructions before using ankle or other alternate placement. Do not use more than one signaling device on a resident. No device is a substitute for proper nursing care. The wander bracelet system is only one part of a comprehensive wanderer management program. Always anticipate that some problems could occur and have other reliable systems in place to help protect your wandering residents. A telephone call to the wander bracelet technical support representative on 3/14/17 at 4:19 PM revealed that wander bracelet devices should be used uniformly throughout the facility. He stated that a facility cannot have one resident with a device on the ankle and another resident with a device on the wrist. He stated that the facility must decide on the placement first so that the technician can calculate the range and adjust the placement sensitivity of the system. He stated that the device is not designed to work on metal and should never be placed on a wheelchair or walker because the frequency signal will not be detected at the doorway. On 3/14/17 at 1:19 PM, the DON noted that the wander bracelet placement was decided by resident choice. If a resident prefers it on their ankle, we place it on the ankle. A review of the residents with wander bracelet alert devices showed that the devices were not placed as per manufacturer's instructions. Two of the residents had devices placed on areas that were contraindicated. Resident #106 had the device on her left ankle, resident #162 had device on her walker, residents #264, #220 and #402 had devices on their right wrist, and resident #433 had the device on his left wrist. An interview with the director of nursing, the administrator and the maintenance director on 3/16/17 at 11:15 AM revealed that the facility was not aware that devices had to be placed on residents uniformly and that the device could not be placed on metal such as walkers. Resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., which was contraindicated by the manufacturer's guidelines. A quarterly MDS with an assessment reference date (ARD) of 5/09/16 reflected her hearing was highly impaired, she was usually understood, had short and long term memory problems, wandering behavior occurred daily, and used a walker and wheelchair for mobility. A care plan for potential for elopement/impaired cognition/exit seeking dated 5/22/16 did not include any customary routines, reasons for exit-seeking behaviors, or approaches for individualized supervision based on comprehensive assessment to ensure a safe environment and prevent elopement. The resident was observed on 3/15/17, 3/16/17 and 3/18/17 at 2 PM, wandering throughout the facility including on the West wing, not her home unit. She was observed near the West wing rehabilitation doors. Resident #220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Elopement Risk Evaluation, completed on 1/10/17, deemed him a risk for elopement, and a wander bracelet was placed on the resident's right wrist. An MDS with ARD date of 1/30/17 reflected short-term memory problems, wandering occurred 1-3 days, supervision with activities of daily living (ADLs) and used a walker for mobility. A care plan for potential risk for elopement, dated 1/09/17, did not include customary routines, reasons for exit-seeking behaviors, and approaches for individualized supervision based on comprehensive assessment to ensure a safe environment and prevent elopement. Resident #264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Elopement Risk Evaluation, completed on 1/28/17, identified her as an elopement risk and a wander bracelet was placed on the resident's right wrist. A care plan for risk for elopement related to wandering/exit-seeking behaviors, dated 1/03/17 failed to include the resident's customary routines, reasons for exit seeking behaviors, and approaches for individualized supervision based on comprehensive assessment to ensure a safe environment and prevent elopement. The resident was observed wandering in the hallway of the East wing on 3/18/17 at 11:30 AM. Resident #423 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Elopement Risk Evaluation, dated 3/04/17, noted he was at risk for elopement and a wander bracelet was placed on the resident's right wrist. An admission MDS dated [DATE] reflected he sometimes understands, had short and long-term memory problems, wandering occurred 1-3 a day, needed limited to extensive assistance with ADLs, and used a walker and wheelchair for mobility. A care place for at risk for elopement related to wandering/exit-seeking behaviors, dated 3/17/17, failed to include the resident's customary routines, reasons for exit-seeking behaviors, and approaches for individualized supervision based on comprehensive assessment to ensure a safe environment and prevent elopement. The resident was observed on 3/17/17 at 4 PM wandering to the fire exit door on the West wing. He was redirected by a facility staff member. On 3/17/17 at 3:20 PM, CNA S revealed that she was assigned to resident #423, a resident identified as elopement risk. She stated that she redirected him from the fire exit but could not provide any interventions used to distract him or explain why he tried to exit. She was not aware of his previous occupation or any individualized, customary routines for this resident. Resident #433 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Elopement Risk Evaluation, dated 3/11/17, noted that he was at risk for elopement, and a wander bracelet was placed on the resident's left wrist. An MDS was not completed. A care plan for at risk for elopement related to wandering/exit-seeking behaviors, dated 3/14/17, failed to include the resident's customary routines, reasons for exit seeking behaviors, and approaches for individualized supervision based on comprehensive assessment to ensure a safe environment and prevent elopement. The facility's Quality Assurance & Improvement/Risk Management, Resident Elopement Risk Management Guidelines last reviewed 1/29/17, reflected that the facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventive measures to minimize elopement occurrences. If the resident is care planned for a wander device, the facility should document that the resident is wearing the electronic device every shift or as indicated and documented on the Treatment Administration Record (TAR). The electronic device should be checked every day to ensure that it is functioning properly and documented on the TAR. Resident #106's December 2016 and January 2017 TARs did not reveal any documentation for daily wander bracelet placement or function checks. This was confirmed by the East wing unit manager on 3/16/17 at 11:10 AM. She could not explain why the checks were not done. Even after the elopement incident of 1/01/17, the facility did not change their process for doing checks on the wander bracelets. The facility conducted Quality Assessment and Assurance (QAA) meetings on 3/16/17 and 3/17/17 with the medical director and 17 additional members including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed and additional safety measures including both entrances locked 24 hours a day with new security system installed at both doors. Both doors now required a manual switch by the receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM Monday through Friday, including coverage for back up. Signage was installed alerting visitors at the West doors to use the front entrance. An additional alarming mechanism was installed at the East wing dining room with a visual and audible sensor in the hallway of the main dining room, and a loud sensor was installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays and manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors function properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff were being educated on the awareness of residents at risk of elopement and interventions for supervision, including hourly checks for 48 hours of newly identified elopement risk residents. Staff were also educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with on-going in-services until all staff are educated prior to start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to provide adequate nursing staff and adequate supervision for residents with wandering and exit-seeking behavior for 6 of 6 residents at risk for elopement. This resulted in the elopement of resident #106, and placed 5 other resident (#162, 220, 264, 423 & 433) at risk for potential serious injury/impairment/death. Resident #106, a [AGE] year old cognitively impaired resident, identified at risk for elopement, eloped from the facility on New Year's Day, 1/01/17 at 4:56 PM, walked 0.3 miles from the facility using a 4 wheel walker and crossed a major 4 lane highway not at a crosswalk, and was assisted by a good Samaritan who was driving by and became concerned for her safety. The good Samaritan called law enforcement. The resident was unable to identify herself or where she came from. Her walker had her nametag printed on it and law enforcement dispatch began calling nursing facilities in the area. The resident was returned to the facility on [DATE] at 5:51 PM by EMS (emergency medical services). The resident was discharged from the facility on 1/03/17 to another long-term care facility. The facility's action plan did not consider staffing supervision of the residents at risk for elopement. The facility must provide sufficient nursing staff with the appropriate competencies and skills sets to care for residents' needs as identified through resident assessments and individual plans of care. Care includes assessing, evaluating, planning and implementing resident care plans and responding to resident' needs. The failure to identify and provide sufficient staffing and supervision resulted in substandard quality of care at the Immediate Jeopardy level, starting on 3/16/17. The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross reference to F223, F323. Resident #106 resided in the East wing hallway and was last seen there at 4 PM on 1/01/17. She wore a wander bracelet on her left ankle and used a 4 wheeled walker to assist with ambulation. She walked from one end of the facility to the other through at least 6 hallways, each measuring at least 200 feet. The facility's total number of wander behavior residents, #162, #220, #264, #423, and #433, had wander bracelets in place, and interviews with staff caring for these residents revealed staff was not aware of the residents' need for supervision to ensure their safety and prevent elopement. On 3/15/17 at 6:50 PM, certified nursing assistant (CNA) F stated she worked on the 3-11 PM shift on 1/01/17. This was the first time she was assigned to resident #106. She stated the last time she saw the resident was at 4 PM, and noted she was missing at 5:15 PM, because she was not in the dining room. While searching for the resident, staff was notified by the receptionist that the resident was found in the parking lot of a superstore. CNA F stated that the resident was always wandering, looking for exit doors and wanting to get out. She stated that she did not know anything about the resident's usual patterns or habits because it was the first time she was assigned to her. She stated they were working 2 staff short that evening. She was assigned to care for 11 residents. She said that when she is in a resident's room, providing care, she does not know the whereabouts of the wandering residents. She said some of them walk fast and can get to the other wings quickly. We depend on the alarms, because we cannot be supervising residents closely. On 3/17/17 at 2:50 PM, CNA G stated that he noted resident #106 missing at dinnertime, approximately 5:15 PM. He noted she was not in the dining room and reported this to the charge nurse. He saw her last at 3 PM when he directed her as she was heading toward the West wing. He said, We checked her room first and then started a search. CNA G stated he did not know anything else about resident #106, her habits, her usual routine, or where she liked to wander. On 3/17/17 at 2:45 PM, CNA P revealed that she worked on the East wing where resident #106 resided. She stated that she did not know the resident, and was not aware that the resident was an elopement risk. On 3/16/17 at 5:45 PM, licensed practical nurse (LPN) E stated resident #106 was attempting to get out to the courtyard by the East doors on 1/01/17, and had to be redirected at least 5 times. She stated that CNA G notified her that resident #106 was not in the dining room, and staff started a search. She said the unit was short by 2 staff that evening, and she had only 5 CNAs and 4 residents with elopement risk. She said she was concerned because she was responsible for these residents. When asked if all the staff were familiar with the elopement risk residents, she stated she was not aware. She stated that staff on the West wing would not know resident #106 and that she was an elopement risk. They would only find out that a resident was exiting the facility when the doors alarmed. On 3/18/17 at 12:43 PM, the director of nursing (DON) stated that staffing was calculated according to patient per day (PPD) and resident acuity. The DON stated that there were usually 7-8 CNAs on the East wing on the 3-11 PM shift. She stated that there were 5 CNAs on the East wing on 1/01/17 on the 3-11 PM shift because they had 2 staff call off duty, and they were unable to replace them. The DON stated that she looked at wound care, intravenous therapy, gastric tubes and other special procedures, when determining staffing numbers. The DON did not include the elopement risk residents into the acuity until this was pointed out to her. She stated she would have to monitor their patterns of exit-seeking. The DON could not provide an answer of how all staff were made aware of the need for supervision for residents at risk for elopement, and how their patterns/habits/customary routines were monitored and documented. The DON did not provide any facility policy regarding staffing. On 3/15/17 at 4:41 PM, the staffing coordinator stated staffing for the East wing, where resident #106 resided, was usually 7-8 CNAs on the 3-11 shift. On 1/01/17, there were 2 staff who called off duty, and she was not able to replace them. The staffing coordinator could not explain how residents with elopement risk played a part in assessing the acuity of the wing. She stated that the West wing has more staff because the residents there are short-term and have greater care needs. She could not explain if and how the staffing was calculated to accommodate wandering residents when working with less staff. A review of the care plans of the residents identified as elopement risk failed to identify any individualized measures or their customary routines/habits. There was no documentation to specify if the resident had any patterns of exit-seeking, such as any specific doors, any particular time, where they want to go, and what measures work best to redirect. The care plans did not specify how often residents' whereabouts were to be observed. The care plans reviewed for Impaired Cognition Exit Seeking noted general approaches such as observe resident location/ whereabouts, assist as needed to specific destinations such as dining room, activity room, therapy gym, unit, etc., divert from exits as needed, observe for exit seeking behaviors, verbalizations of wanting to leave/go home, and/or physical attempts to leave the facility-report if noted and document. On 3/16/17 at 6:15 PM, CNA Q noted that her unit was working short staffed. She stated that she had 10 residents to care for and it was stressful. She stated that she could not keep track of the wandering residents. She said that when she was in a room providing care to one of her residents, she did not know the whereabouts of the other residents. On 3/17/17 at 3:20 PM, CNA S revealed she was assigned to resident #423, a resident identified as elopement risk. She stated she redirected him from the fire exit but could not provide any interventions used to distract him or explain why he tried to exit. She was not aware of his previous occupation or any individualized, customary routines for this resident. On 3/16/17 at 11:30 AM, the out-patient rehabilitation coordinator said she was responsible for monitoring the West exit door. She stated that everyone was responsible for watching the exit door, not just her. She stated she had informed administration that she could not possibly do her work and monitor the doors for elopement risk residents at the same time. She was not familiar with the elopement risk residents, and stated that she would have to look in the book at their pictures to identify them. She stated that she relied on the alarm to alert her if a resident was approaching the exit door as she was not familiar with these residents. The facility conducted Quality Assessment and Assurance (QAA) meetings on 3/16/17 and 3/17/17 with the medical director with 17 additional members including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed and additional safety measures including: both entrances locked 24 hours a day with new security system installed at both doors. Both doors now required manual switch by receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM Monday through Friday, including coverage for back up. Signage was installed alerting visitors at the west doors to use the front entrance. An additional alarming mechanism was installed at the East wing dining room with a visual and audible sensor in the hallway of the main dining room, and a loud sensor installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays and manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors function properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff are being educated on the awareness of residents at risk of elopement and interventions for supervision including hourly checks for 48 hours of newly identified elopement risk residents. Staff were educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with on-going in-services until all staff were educated prior to start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to ensure that the wander bracelet system, installed in 2013, was maintained and applied in a safe operating condition and according to manufacturer's recommendations. This failure contributed to the elopement and potential for serious injury/impairment/death of resident #106, and placed 5 other residents at risk for potential for serious harm (#162, 220, 264, 423 & 433). Resident #106 was a [AGE] year old cognitively impaired person identified as an elopement risk at the time of admission. She was placed with a wander bracelet device to her left ankle on 12/14/16. On New Year's Day, 1/01/17, the resident eloped from the facility by the West exit doors. The West exit doors should have alarmed and automatically locked, preventing the resident from exiting, but they failed to alarm and lock. The resident walked 0.3 miles away from the facility with her 4 wheeled walker to a busy 4 lane highway, crossed the highway (not at a crosswalk) and was aided by a good Samaritan who was driving by and became concerned for her safety. The good Samaritan telephoned law enforcement. The resident was unable to identify herself or her residence. Her walker had her name tag printed on it, and dispatch began calling nursing facilities in the area. The resident was returned to the facility by EMS (Emergency Medical Services). The failure to ensure that the wander device system was operating in safe condition resulted in Immediate Jeopardy being declared on 3/16/2017 The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross reference to F223, F323, F353, F490, F520. After the elopement of resident #106, the facility did an investigation and identified that the wander bracelets were functional on 1/02/17 but the West exit doors did not alarm when the sensor was at ankle level. It was noted that the maintenance director was not called to the facility on the date of the incident. He adjusted the sensors on 1/02/17 so that the alarm would sound and the doors lock by increasing the range of the sensor from 2 feet to 4 feet. He stated that the doors would pick up the signal if the device was worn at ankle level. The facility also failed to call the wander bracelet service representative to check the system at the time of the incident. The service representative did not come to the facility until 18 days after the incident, on 1/19/17, to inspect the doors and the wander bracelet system. In response to the incident, the facility implemented locking the West entrance doors between the hours of 4:30 PM and 7:30 AM, and locked the doors 24 hours a day on Saturdays and Sundays. In addition, the outpatient rehabilitation coordinator was responsible for monitoring the West exit door between the hours of 7:30 AM and 4:30 PM, Monday through Friday. The date of this intervention was unknown. On 3/13/17 at 5:30 PM, the surveyor and facility administrator observed a video surveillance of the elopement incident of 01/01/2017. It showed resident #106 walking with a four-wheeled walker coming from the left side of the West exit doors at 4:56 PM. The first set of double doors opened immediately as she approached the doors. These doors should have alarmed as the resident approached because she was wearing a wander bracelet. She walked through the first set of doors and then the second set of double doors opened immediately allowing the resident to exit the facility to the parking lot. The second set of doors should have locked and stayed closed to prevent the resident from exiting the facility. The video showed the resident exiting the facility and she was in the parking lot at 4:57 PM. A reenactment of the elopement of resident #106 was conducted on 3/14/17 at 3:35 PM with the maintenance director. It showed that the facility had not tested the wander system on the doors under the same circumstances as when resident #106 eloped. The resident had a wander bracelet on her left ankle, but the maintenance director demonstrated that he had been checking the door system while holding on to the wander bracelet in his hand at waist level. He stated that he checked the door system at a lower level one time after the elopement by sliding the wander bracelet on the floor through the door. He stated that the doors alarmed and locked when he slid the bracelet on the floor through the doors. The surveyor applied the wander bracelet to the left ankle just as the resident was wearing and approached the exit door from the left as the resident had. The first set of doors did not alarm, as they should have. The surveyor walked through the first set of doors and the second set of doors opened immediately allowing the surveyor to exit the facility. The surveyor then walked back into the facility and the doors opened without any alarms. The surveyor exited through the doors a second time and the doors did not alarm or lock. The maintenance director stated that he could not understand how the doors did not alarm and lock. This reenactment was conducted three other times with the administrator and the survey team present and again, the surveyor was able to exit the facility while wearing an ankle bracelet to her left ankle and the doors failed to alarm and lock. The facility failed to follow manufacturer's guidelines in the application of the wander bracelets. A review of the wander bracelet system user instruction insert read, Devices are designed to be worn on a wrist, but can also be placed on an ankle you must contact wander bracelet technical service for further instructions before using ankle or other alternate placement. Do not use more than one signaling device on a resident. No device is a substitute for proper nursing care. The wander bracelet system is only one part of a comprehensive wander management program. Always anticipate that some problems could occur and have other reliable systems in place to help protect your wandering residents. An interview with the director of nursing on 3/14/2017 at 1:19 PM revealed that wander bracelet placement was decided by resident choice. If a resident prefers it on their ankle, we place it on their ankle. A telephone call to the wander bracelet technical support representative on 3/14/17 at 4:19 PM revealed that wander bracelets should be used uniformly throughout the facility. He stated that a facility cannot have one resident with a device on the ankle, and another resident with a device on the wrist. He stated that the facility must decide on the placement first so that the technician can calculate the range and adjust the placement sensitivity of the system. He stated that the device is not designed to work on metal and should never be placed on a wheelchair or walker as the frequency signal will not be detected at the doorway. A review of the residents with wander bracelets showed that the devices were not placed as per manufacturer's instructions. Two of the residents had devices placed on areas that were contraindicated. Resident #106 had the device on her left ankle, and resident #162 had device on her walker. Residents #264, #220 and #423 had devices on their right wrist, and resident #433 had the device on his left wrist. An interview with the director of nursing, the administrator,.and the maintenance director on 3/16/17 at 11:15 AM revealed the facility was not aware that devices had to be placed on residents uniformly, and that the device could not be placed on metal such as walkers. A review of the facility's Resident Elopement Risk Management Guidelines, last reviewed on 1/29/17 read, The electronic device should be checked every day to ensure that it is functioning properly and documented on the treatment administration record (TAR). A review of resident #106's medication administration record (MAR) and TAR for December 2016 did not contain any documentation that the device was being checked. A review of the January 2017 MAR and TAR did not contain any documentation that the device was checked from 1/01/17 to 1/02/17. The resident was discharged from the facility on 1/03/17. The DON could not explain why the placement and function of the device was not checked during an interview on 3/14/17 at 1:19 PM. Although one of the interventions implemented was to increase monitoring of the West exit doors by the outpatient rehabilitation coordinator, an interview with the coordinator on 3/16/17 at 11:30 AM revealed that the monitoring was not being done. She stated that she had informed administration that she could not possibly do her work and monitor the doors for elopement risk residents at the same time. She said she was not familiar with the elopement risk residents, and stated she would have to look in the book at their pictures to identify them. She stated she relied on the door alarm to alert her if a resident was attempting to exit the door because she was not familiar with these residents. Interviews with other facility staff reflected that they also relied on the door alarms to alert them that a resident was attempting to exit the facility. On 3/16/17 at 6:15 PM, certified nursing assistant (CNA) Q noted that her unit was working short staffed. She stated that she had 10 residents assigned to care for and it was stressful. She stated that she could not keep track of wandering residents. She said that when she was in a room providing care to one of her residents, she did not know the whereabouts of her other residents. She said she relied on the door alarms to alert her that a resident was trying to exit the facility. On 3/15/17 at 6:50 PM, CNA F stated she worked on the 3-11 PM shift on 1/01/17 and was assigned to care for resident #106 on 1/01/17. She said that they were working 2 staff short that evening, and she was assigned to care for 11 residents. She said that when she was in a resident's room, providing care, she did not know where a resident may be wandering. She said Some of them walk fast, and can get to the other wings quickly. We depend on the alarms as we cannot be supervising residents closely. A meeting was held with the administrator, director of nursing, director of maintenance and regional consultant on 3/18/17 at 3:30 PM. The administrator provided the following corrective action plan. The facility conducted Quality Assessment and Assurance (QAA) meetings on 3/16/17 and 3/17/17 with the medical director and 17 additional members, including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed and additional safety measures including both entrances locked 24 hours a day with new security system installed at both doors. Both doors now require manual switch by the receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week, including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM Monday through Friday, including coverage for back up. Signage was installed alerting visitors at the west doors to use the front entrance. An additional alarming mechanism was installed at the East wing dining room with a visual and audible sensor in the hallway of the main dining room and a loud sensor installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays and manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors functioned properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff are being educated on the awareness of residents at risk of elopement and interventions for supervision including hourly checks for 48 hours of newly identified elopement risk residents. Staff were educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with ongoing in-services until all staff were educated prior to start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to administer its resources effectively to ensure the safety of 1 of 6 sampled resident's safety (#106), staffing and supervision and their wander alert system. This failure resulted in the elopement and potential for serious injury/impairment/death of resident #106, and placed 5 other residents at risk for potential for serious injury/impairment/death (#162, 220, 264, 423 & 433). Resident #106, a [AGE] year old cognitively impaired resident, identified at risk for elopement, eloped from the facility on New Years Day, 1/01/17, walked 0.3 miles away from the facility using a 4 wheel walker, crossed a major 4 lane highway, not at a crosswalk, and was assisted by a good Samaritan who was driving and became concerned for her safety. The good Samaritan called law enforcement. The resident was unable to identify herself or where she came from. Her walker had her name tag printed on it and dispatch began calling nursing facilities in the area. The resident was returned to the facility by EMS (emergency medical services). The administration failed to use their resources effectively and efficiently to ensure resident #106, at risk for elopement, was free from neglect, and failed to provide adequate supervision in a safe and secure environment. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration failed to identify the level of supervision and staffing needed for residents at risk for elopement and were unable to provide adequate care that led to an Immediate Jeopardy being declared on 3/16/17. The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross Reference F223, F323, F353, F456, F520. On 3/15/17 at 6:50 PM, certified nursing assistant (CNA) F stated she worked on the 3-11 PM shift on 1/01/17. This was the first time she was assigned to resident #106. She stated the last time she saw the resident was at 4 PM, and noted she was missing at 5:15 PM because she was not in the dining room. While searching for the resident, they were notified by receptionist that the resident was found in the parking lot of the superstore. CNA F stated that the resident was always wandering, looking for exit doors and wanting to get out. She stated that she did not know anything about the resident's usual patterns or habits because it was the first time she was assigned to her. She stated that they were working 2 staff short that evening. She was assigned to care for 11 residents. She said that when she is in a resident's room, providing care, she does not know where a resident may be wandering. She said, Some of them walk fast and can get to the other wings quickly. We depend on the alarms as we cannot be supervising residents closely. On 3/17/17 at 2:50 PM, CNA G stated he noted resident #106 missing at dinner time, approximately 5:15 PM. He noted she was not in the dining room and reported this to the charge nurse. He saw her last at 3 PM when he directed her as she was heading toward the West wing. He said, We checked her room first and then started a search. CNA G stated he did not know anything else about resident #106, her habits, her usual routine and where she liked to wander. On 3/16/17 at 5:45 PM, licensed practical nurse (LPN) E stated that resident #106 was attempting to get out to the courtyard by the East doors on 1/01/17, and had to be redirected many times. She stated that CNA G notified her that resident #106 was not in the dining room and started a search. She said that they were short by 2 staff that evening and she had only 5 CNAs and 4 residents who were elopement risks, and she was concerned because she was responsible for these residents. When asked if all the staff were familiar with the elopement risk residents, she stated she was not aware. She stated, Staff on the West wing would not know her. They would only find out when the doors alarmed. On 3/18/17 at 12:43 PM, the director of nursing (DON) stated that staffing for the units was done according to patient per day (PPD) and resident acuity. The DON stated there were usually 7-8 CNAs on the East wing on the 3-11 PM shift. She stated there were 5 CNAs on the East wing on 1/01/17 on the 3-11 PM shift because they had 2 staff that called off from duty and they were unable to replace them. When questioned about staffing according to acuity, the DON stated that she looked at wound care, intravenous therapy, gastric tubes and other special procedures. She said that the sub-acute residents needed more care, whereas they knew the long-term care residents better, and could meet their needs easier. The DON did not include the elopement risk residents into the acuity until this was pointed out to her. She stated that she would have to monitor their patterns. The DON could not explain how all staff were made aware of the residents at risk for elopement and how their patterns, habits, and customary routines were monitored and documented. It was noted that resident #106 resided in the 100 hallway and was last seen there at 4 PM, wearing a wander bracelet on her left ankle, and used a 4 wheeled walker. She walked from one end of the facility to the other through at least 6 hallways, each measuring at least 200 feet. The facility's total square footage was 45,000 square feet. According to staff interviews done by the facility, the resident had walked from the 100 hallway, through the main hallway, then through the 400 hallway, and was seen near room [ROOM NUMBER]. She then walked the length of the 800 hallway, was observed near the bistro and exited through the West exit doors at 4:56 PM. The resident was able to walk through the entire facility without staff recognizing her or identifying her as an elopement risk, and redirecting her back to her home unit. Because the resident was wearing a wander bracelet, the first set of doors of the West exit sliding doors should have alarmed, and the second set of doors should have locked automatically, preventing the resident from exiting but the system failed. The facility's root cause was a malfunction of the doors. On 3/15/17 at 4 PM, the administrator revealed the measures put into place after the incident included developing appropriate care plans for elopement risk residents, assessing all door alarms for function, and monitoring the West exit doors by the outpatient rehabilitation coordinator. A review of the care plans of the residents identified as elopement risks failed to identify any individualized measures or their customary routines/habits. There was no documentation to specify if the resident had any patterns of exit seeking, such as any specific doors, any particular time, where they wanted to go, what measures work best to redirect. The care plans did not specify how often residents' whereabouts were to be observed. The care plans reviewed for Impaired Cognition Exit Seeking noted general approaches such as observe resident location, whereabouts, assist as needed to specific destinations such as dining room, activity room, therapy gym, unit, etc., divert from exits as needed, observe for exit seeking behaviors, verbalizations of wanting to leave, go home, and/or physical attempts to leave the facility-report if noted and document. A reenactment of the elopement of resident #106 was conducted on 3/14/17 at 3:35 PM with the maintenance director. It showed that the facility had not tested the wander system on the doors under the same circumstances as when resident #106 eloped. The resident had a wander bracelet on her left ankle, but the maintenance director demonstrated that he had been checking the door system while holding on to the wander bracelet in his hand at waist level. He stated that he checked the door system at a lower level one time after the elopement by sliding the wander bracelet on the floor through the door. He stated that the doors alarmed and locked when he slid the bracelet on the floor through the doors. The surveyor applied the wander bracelet to the left ankle just as the resident was wearing and approached the exit door from the left as the resident had. The first set of doors did not alarm, as they should have. The surveyor walked through the first set of doors and the second set of doors opened immediately allowing the surveyor to exit the facility. The surveyor then walked back into the facility and the doors opened without any alarms. The surveyor exited through the doors a second time and the doors did not alarm or lock. The maintenance director stated that he could not understand how the doors did not alarm and lock. This reenactment was conducted three other times with the administrator and the survey team present and again, the surveyor was able to exit the facility while wearing an ankle bracelet to her left ankle and the doors failed to alarm and lock. The maintenance director stated that he had changed the range of the system so that it would pick up the signal at a further distance. He stated that the service company came to the facility 18 days after the incident on January 19, 2017 to check all the doors for proper functioning with the wander bracelet alert system. They came in and adjusted all 5 doors, tested them, and all were working correctly. The maintenance director stated that he should have checked the doors at ankle height as he had been checking at waist height. A telephone call to the wander bracelet system service representative on 3/14/17 at 4:19 PM noted that the wander bracelet device was to be placed on the resident's wrist or the ankle but not a combination of both. Depending on the facility's decision regarding placement, the technician will calculate the range and adjust the exit door placement sensitivity. According to the guidelines, the device was not to be placed on metal objects such as wheelchairs or walkers because the signal frequency will not be detected at the doorway. The facility had failed to identify this in their investigation as they currently had placed the devices on ankles, wrists and on resident's walkers. Although one of the interventions implemented was to increase monitoring at the West door by the outpatient coordinator, an interview with the coordinator on 3/16/17 at 11:30 AM revealed that this was not being done. She stated she had informed administration that she could not possibly do her work and monitor the doors for elopement risk residents at the same time. She was not familiar with the elopement risk residents, and stated she would have to look in the book at their pictures to identify them. She stated that she relied on the alarm to alert her if a resident was approaching the exit door as she was not familiar with these residents. The administrator's job description read, Responsible for overall operations and daily management of the facility by planning, developing, directing, monitoring and supporting all operational administrative, clinical, human resources, customer service and fiscal activities for the facility programs and services. Ensures quality resident care is provided to meet and exceed company expectations and in accordance with state and federal laws, rules and regulations. Promotes a clean, safe and comfortable environment for all residents, visitors and staff in accordance with facility guidelines. The facility's policy and procedure Resident Elopement Risk Management Guidelines, last reviewed 1/29/17 read, The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences If wandering behavior escalates, safety checks should be implemented and the resident should be evaluated for possible cause and new interventions implemented as needed. On 3/16/17 at 5:45 PM, LPN E who was resident #106's nurse on 1/01/17 revealed the resident had attempted to exit the East door at least 5 times within 1 hour on 1/01/17. However, the facility failed to gain an overall awareness of the serious threat for residents posed by elopement. The facility relied on the wander system as a substitute for supervision, and did not strive to identify any preventative measures to minimize elopement occurrences or implement safety checks as per policy. A meeting was held with the administrator, director of nursing, director of maintenance and regional consultant on 3/18/17 at 3:30 PM. The administrator provided the following corrective action plan. The facility conducted Quality Assessment and Assurance (QAA) meetings on 3/16/17 and 3/17/17 with the medical director and 17 additional members, including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed and additional safety measures including both entrances locked 24 hours a day with new security system installed at both doors. Both doors now require manual switch by the receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week, including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM Monday through Friday, including coverage for back up. Signage was installed alerting visitors at the west doors to use the front entrance. An additional alarming mechanism was installed at the East wing dining room with a visual and audible sensor in the hallway of the main dining room and a loud sensor installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays and manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors functioned properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff are being educated on the awareness of residents at risk of elopement and interventions for supervision including hourly checks for 48 hours of newly identified elopement risk residents. Staff were educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with ongoing in-services until all staff were educated prior to start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.

Based on observation, interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for supervision of residents at risk for elopement. This resulted in the elopement of resident #106 and placed 5 other residents at risk for potential serious injury/impairment/death (#162, 220, 264, 423 & 433). On 1/01/17, resident #106, a [AGE] year old female identified as an elopement risk with a wander bracelet in place exited the facility at 4:56 PM through the west rehab doors. The resident had a 4 wheeled walker and walked 0.3 miles to a busy 4 lane highway. She crossed the busy 4 lane highway, not at a crosswalk and was assisted by a good Samaritan who became concerned for her safety. The Good Samaritan called law enforcement who responded at 5:15 PM. The resident was unable to identify herself or where she came from. Her walker had her name tag printed on it and dispatch began calling nursing facilities in the area. The resident was returned to the facility on [DATE] at 5:51 PM by EMS (Emergency Medical Services). The facility's QAA committee failed to identify quality deficiencies. They did not complete a thorough investigation or analysis to find the root cause for the elopement incident and failed to evaluate and analyze the risk once an elopement and the potential for serious injury/impairment/death had occurred. The facility failed to supervise residents at risk for elopement and did not identify their customary routines and habits. The facility also failed to perform comprehensive review of the wander bracelet system. As a result of these failures, the facility did not ensure that the immediate threat was lifted which resulted in Immediate Jeopardy being declared on 3/16/17. The immediate jeopardy was removed on 3/18/17 and the severity was lowered from K to E. Findings: Cross Reference F223, F323, F353, F456, F490 A review of the QAA policy on Resident Elopement Risk Management Guidelines last reviewed on 101/29/17 read, The facility will strive to provide a safe environment for residents and implement measures to identify residents at risk for elopement, as well as preventative measures to minimize elopement occurrences. An interview with the administrator and director of nursing on 3/15/17 at 4 PM revealed that although they identified the elopement incident of 1/01/17 as a serious event, they did not have an emergency QAA meeting following the incident. The incident was first discussed at the QAA meeting 54 days later on 2/24/17. The administrator stated that the measures put in place after the incident were decided by a team including himself, the director of nursing, department heads and the corporate consultants. He stated the medical director was included in the decision-making of the measures in person and via telephone. These measures included assessing all wander bracelets and door alarms for function, adjusting the West exit door sensor from a range of 2 feet to 4 feet, in-servicing all staff of elopement guidelines and procedures, scheduling of elopement drills, locking the West entrance doors from 4:30 PM to 7:30 AM and locked 24 hours a day on the weekend, and monitoring of the West entrance door by the rehab outpatient coordinator. He stated that the resident #106 was discharged to another long term facility with a secure unit two days post incident on 1/03/17 as the facility could not provide adequate supervision. Although the elopement incident of 1/01/17 was serious and could have potentially resulted in serious bodily injury or death, the facility failed to recognize the root cause of the incident. The facility focused on the wander bracelet alert system and did not look at the elopement risks as a whole. There was no documentation that the at risk residents were assessed regarding their customary routines. There were no interventions put into place regarding identifying the routine behaviors or habits of the residents that were wandering or the staffing/supervision of these residents to minimize elopement attempts. A review of the care plans of identified elopement risk residents did not show any individual interventions to minimize exit seeking behavior or tracking of exit attempts. The facility focused on the wander guard system for alerting staff when a resident was exiting yet this system failed even after the deficiencies were identified at QAA. A reenactment of the elopement of resident #106 was conducted on 3/14/17 at 3:35 PM with the maintenance director. It showed that the facility had not tested the wander system on the doors under the same circumstances as when resident #106 eloped. The resident had a wander bracelet on her left ankle, but the maintenance director demonstrated that he had been checking the door system while holding on to the wander bracelet in his hand at waist level. He stated that he checked the door system at a lower level one time after the elopement by sliding the wander bracelet on the floor through the door. He stated that the doors alarmed and locked when he slid the bracelet on the floor through the doors. The surveyor applied the wander bracelet to the left ankle just as the resident was wearing and approached the exit door from the left as the resident had. The first set of doors did not alarm, as they should have. The surveyor walked through the first set of doors and the second set of doors opened immediately allowing the surveyor to exit the facility. The surveyor then walked back into the facility and the doors opened without any alarms. The surveyor exited through the doors a second time and the doors did not alarm or lock. The maintenance director stated that he could not understand how the doors did not alarm and lock. This reenactment was conducted three other times with the administrator and the survey team present and again, the surveyor was able to exit the facility while wearing an ankle bracelet to her left ankle and the doors failed to alarm and lock. The maintenance director stated that he had changed the range of the door from 2 feet to 4 feet, so that it would pick up the wander bracelet system at 4 feet instead of at 2 feet, but re-enactment conducted on 3/14/17 showed this was not accurate. He stated that the service company came to the facility 18 days after the incident on January 19, 2017 to check all the doors for proper functioning with the wander bracelet system. They came in and adjusted all 5 doors, tested them and all were working correctly. He could not explain what the company adjusted on these doors but stated they, probably checked the range was at 4 feet instead of 2 feet. A telephone call to the wander bracelet system service representative on 3/14/17 noted that the bracelet was to be placed on the resident's dominant wrist or the ankle but not a combination of both. He stated that depending on the facility's decision of placement, the technician will calculate the range and adjust the exit door range sensitivity. According to the company guidelines, the device was not to be placed on metal objects such as wheelchairs or walkers as the signal frequency would not be detected at the doorway. The facility had failed to identify this in their investigation as they had placed the devices on ankles, wrists and on resident's walkers. Although one of the interventions implemented was to increase monitoring at the west exit door by the outpatient coordinator, an interview with the coordinator on 3/16/17 at 11:30 AM revealed that this was not being done. She stated that she had informed administration that she could not possibly do her work and monitor the doors for elopement risk residents at the same time. She was not familiar with the at risk residents and stated that she would have to look in the book at their pictures to identify them. She stated she relied on the alarm to alert her if a resident was approaching the exit door because she was not familiar with these residents. Elopement is a serious issue and should be addressed at QAA meetings routinely. The facility had an at risk [AGE] year old resident who eloped on a holiday weekend and walked 0.3 miles away from the facility with a wheeled walker and crossed a busy 4 lane highway (not at crosswalk). The QAA committee failed to fully investigate this elopement incident which occurred on 1/01/17. They did not identify the root cause of the elopement and arrived at the conclusion that the exit door had malfunctioned. Therefore, they focused on the wander bracelet that the resident was wearing rather than focusing on the resident as an individual. They failed to assess not only this resident but also 5 other residents who were at risk for elopement. The facility did not identify these residents' customary routines, habits or track their exit attempts. There were no individualized care plans which outlined preventative measures, approaches, or activities to minimize elopement occurrences and to maintain a safe environment. The failed to examine the nurse staffing to determine if it was sufficient to meet the supervision needs for residents at risk for elopement. The facility's action plan was based on reaction rather than prevention. A meeting was held with the administrator, director of nursing, director of maintenance and regional consultant on 3/16/17 at 10 AM. The administrative team was informed that immediate jeopardy had been identified. As a result of the meeting, the administrator provided the following corrective action plan on 3/18/17 at 3:30 PM. The facility conducted QAA meetings on 3/16/17 and 3/17/17 with the medical director and 17 additional members, including direct care staff and management staff. The team addressed the current elopement risk residents. After assessing all 128 residents, 6 were identified as elopement risk. The care plans for these residents were reviewed and updated to include resident specific interventions for safety and redirection of exit seeking behaviors. The elopement books were discussed and confirmed to be in all proper location containing the current resident information. A sign off sheet was added to the books to assure that each employee stationed at the locations have read and verified the residents identified to be at risk in the elopement books. The wander bracelet placement and testing was discussed. The QAA team confirmed acknowledgement and understanding of the new guidelines that the devices were being checked every shift for function and placement on the wrist by utilizing the signaling device tester. All exit doors and security systems were reassessed and additional safety measures including: both entrances locked 24 hours a day with new security system installed at both doors. Both doors now required manual switch by receptionist for entrance and exit. The front entrance now had receptionist staff coverage 24 hours a day, 7 days per week, including coverage for breaks. The West door access was provided by the outpatient coordinator from 7:30 AM to 4:30 PM Monday through Friday including coverage for back up. Signage was installed alerting visitors at the west doors to use the front entrance. An additional alarming mechanism was installed at the east wing dining room with a visual and audible sensor in the hallway of the main dining room and a loud sensor installed at the dining room exit door to provide a secondary notification system. All delayed egress systems were assessed to ensure function and security. A facility floor plan was developed to aid in the daily checks of each door by the maintenance director on weekdays and manager on duty on weekends. The administrator will round twice weekly with the maintenance director to ensure that all doors function properly. The plant operations staff are available 24 hours a day to respond to any issues with the doors. The wander bracelet monitors were checked at all 6 doors to ensure that they were functioning properly. All doors were checked for egress and wander bracelet functions. All staff are being educated on the awareness of residents at risk of elopement and interventions for supervision including hourly checks for 48 hours of newly identified elopement risk residents. Staff was educated on the operations and safety features of the exit doors and the wander bracelet system. As of the exit time on 3/18/17 at 6:45 PM, 157 out of 296 staff were in-serviced with ongoing in-services until all staff were educated prior to start of their shift. On 3/18/17, observations and record reviews verified the sufficient implementation of the allegation to remove immediacy, and the scope and severity was lowered from K to E.