Every finding on record at Palm Garden of West Palm Beach

Based on record reviews and interviews, the facility failed to ensure care and services to prevent pressure ulcers, as evidenced by no interventions ordered or in place to prevent, 1 of 3 sampled residents, Resident #3, from acquiring pressure ulcers. The findings included:Record review revealed Resident #3 was readmitted to the facility on [DATE]. Review of the admission assessment dated [DATE] documented Resident #3 had redness to her buttocks area. Review of the quarterly minimum data set assessment dated [DATE] documented Resident #3 was dependent on staff for toileting and required moderate assistance for turning right to left in bed.Review of the physician orders for Resident #3 did not reveal any orders to prevent skin breakdown.Review of a skin assessment dated [DATE] documented Resident #3 had an open wound to her sacrum and left buttocks.Review of a progress note dated 04/25/25 revealed documentation that staff called Resident #3's daughter to inform her of an open area and redness to the resident's buttocks area. It further stated that staff told the daughter the Resident had non blanchable redness to her buttocks when she returned to the facility and the daughter said she was not aware or informed about the redness.Review of the care plan did not reveal any documented focus that stated Resident #3 was at risk of developing pressure ulcers.Review of a wound care consult dated 04/28/25 revealed documentation that Resident #3 had a Stage 4 pressure ulcer to the sacrum and a Stage 3 pressure ulcer to the left buttocks. During an interview with the Director Of Nursing (DON) on 12/29/25 at 4:18 PM, she was asked if Resident #3 had facility acquired pressure ulcers. She stated, I pulled some information regarding her wounds; let me get it for you. The DON returned with copies of progress notes regarding other skin issues the resident had. When asked if she was aware of when Resident #3 got the pressure ulcers to her sacrum and left buttocks and if there were any interventions in place to prevent them, she stated I wasn't here at that time. I will get the person that does the care plans.During an interview on 12/29/25 at 4:25 PM, Staff A, Care Plan Specialist, Staff A was asked if there were any interventions ordered or in place to prevent Resident #3 from getting pressure ulcers. She looked in her computer and stated, I see a care plan that was initiated on 04/22/25 that said she was at risk and is being treated for pressure ulcer. When asked whether there was anything prior to her getting the pressure ulcers, she stated, No I don't see anything care planned.

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 of 31 sampled residents, related to the comatose status for Resident #65, related to diagnosis and oxygen therapy for Resident #77, and related to diagnosis for Resident #96.The findings included:1. Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65 was comatose, defined as a persistent vegetative state and no discernible consciousness.An observation and interview were conducted on 08/11/25 at 4:17 PM with Resident #65 was noted lying in bed and moving about. When asked if she was doing OK, the resident nodded her head yes. When asked if the care and services was good, Resident #65 stated, Yes.An interview was conducted on 08/14/25 at 1:02 PM with Staff Q, Registered Nurse (RN), who when asked why Resident #65 was coded as being comatose on the most recent MDS assessment, Staff Q, RN/Care Plan Specialist, stated that section was completed by Staff P, Social Services Assistant (SSA). Staff Q volunteered, She has been told she was coding that question incorrectly. When asked if Resident #65 had ever been comatose, Staff Q stated, I have been here a long time and know (name of Resident #65), and she's never been comatose.An interview was conducted on 08/14/25 at approximately 1:30 PM, who when asked why she coded Resident #65 as comatose, Staff P, SSA, stated when she went to assess the resident, the resident did not speak to her, so she thought she had to code the resident as comatose. The SSA stated she had been in-serviced about that code. When asked if she went back to correct any MDS with an incorrect comatose coding, the SSA stated I think someone did, but this one must have been missed. 2. Review of the Resident Assessment Instrument (RAI) dated October 2024 documented, in part, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. High-concentration: Check if oxygen therapy was provided via a high-concentration delivery system. A high-concentration delivery system can include either high- or low-flow systems (e.g., simple face masks, partial and nonrebreather masks, face tents, venturi masks, aerosol masks, and high-flow cannula or masks).Review of the record revealed Resident #77 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] lacked any type of pulmonary diagnosis. This same MDS also lacked any type of oxygen use.Review of the current orders documented the following:a) As of 07/15/24, Resident #77 had orders for the use of a BiPAP mask at bedtime to be removed in the morning. b) As of 07/12/24, Resident #77 received the nebulizer treatment, via a high-concentration delivery system, of Pulmicort two times daily for Chronic Obstructive Pulmonary Disease (COPD).c) As of 07/12/24. Resident #77 received the nebulizer treatment, via a high-concentration delivery system, of Ipratropium-Albuterol four times a day for COPD.During an observation on 08/11/25 at 10:46 AM, Resident #77 was noted lying in bed. A nebulizer machine, a high-concentration delivery system, was noted at bedside. During an observation on 08/11/25 at 2:59 PM, Resident #77 was observed with the nebulizer mask on and the machine functioning.During an interview on 08/14/25 at 1:28 PM, when asked why there was no pulmonary diagnosis or oxygen use coded on the most current MDS assessment, Staff Q, RN/Care Plan Specialist, stated she was told by their regional staff they could not take credit for the nebulizer treatment unless the nurse stayed with the resident for the full 15 minutes, unless the resident had the nebulizer treatment three or more times daily. Staff Q reviewed the record at that time and identified the diagnosis of COPD in the orders and confirmed the nebulizer treatments for Resident #77 were three and four times daily. Staff Q agreed with the inaccurate assessment. 3. Review of the record revealed Resident #96 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had not had a urinary tract infection (UTI) in the past 30 days.Further review of the record revealed a urinalysis completed on 07/31/25 that indicated Resident #96 had a UTI. Subsequent orders revealed the resident was started on antibiotics for the UTI on 08/04/25, within 30 days of the assessment.

Based on interview and record review, the facility failed to develop care plans for 2 of 31 sampled residents, as evidenced by lack of care plans for Resident #8 regarding the administration of diuretics and anticoagulants, and Resident #31 related to assessed trauma.The findings included: 1.Review of the record documented Resident #8 was admitted to the facility on [DATE], and March 27, 2025, with a diagnosis that included Hypertension (high blood pressure). Review of the physician's orders dated March 27, 2025, included the following: Spironolactone 25 mg tablet to be taken once daily in the morning for fluid retention, and Apixaban 2.5 mg oral tablet to be taken twice daily for non-valvular atrial fibrillation. Review of the Medication Administration Record (MAR) for August 2025 documented that both the anticoagulant and diuretic medications were administered from August 1 to August 14, 2025. Review of the most recent care plan, revised on June 3, 2025, showed no evidence of individualized care plans addressing the use of the anticoagulants and diuretics. On August 14 at 1:14 PM, the Director of Nursing (DON) was made aware of the lack of care plans for this resident. She acknowledged the absence of care plans for these medications and admitted that she could not find any. She mentioned that she would check the baseline care plans, which were stored in a binder, but she had not provided the care plans during the survey. 2. Review of the record revealed Resident #31 was admitted to the facility on [DATE]. Review of a Trauma Informed Care Questionnaire dated 03/21/25 documented a yes answer to the question, Have you ever had a life-threatening illness, such as cancer, heart attack, leukemia, multiple sclerosis, etc.? This form instructed staff to initiate a Trauma Informed Care Plan if any question was marked yes. Review of the current care plans documented, Resident has a history of significant trauma exposure related to: . and the sentence was not completed. This care plan was initiated on 03/21/25 by the Social Services Director (SSD), who was not available during the survey. During an interview on 08/14/25 at 1:14 PM, Staff Q, Registered Nurse (RN) Care Plan Specialist, was asked to review the current trauma care plan for Resident #31. Staff Q confirmed it was completed by the SSD in response to the Trauma Informed Care Questionnaire, and stated, She has told there needs to be a reason or explanation of the trauma on the care plan.

Based on observation, interview, record review, and policy review, the facility failed to ensure care and services for 3 of 31 sampled residents as evidenced by the failure to timely assess and treat diarrhea for Resident #65, failure to ensure timely initiation of an antibiotic for a urinary tract infection (UTI) for Resident #96, and failure to assess Resident #48's blood pressure and heart rate prior to administration of an antihypertensive medication with physician ordered parameters.The findings included:1. Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65 was totally dependent upon staff for all Activities of Daily Living (ADLs).Review of the current orders documented Resident #65 was started on Milk of Magnesium (given for constipation) daily since 07/10/25. Review of the Certified Nursing Assistant (CNA) documentation in the electronic medical record (EMR) revealed Resident #65 had had loose/diarrhea bowel movements at least daily on 23 of the past 30 days (07/15/25 through 08/13/25). Nine days of the 30 the resident had loose/diarrhea bowel movements on two shifts, and once the resident had loose/diarrhea bowel movements on all three shifts.A skilled nursing note dated 08/09/25 by Staff D, Registered Nurse (RN) Clinical Services Coordinator, documented a lack of diarrhea. Additional skilled nursing notes on 05/29/25, 06/08/25, 06/10/25, 06/13/24, and 07/09/25 all document a lack of diarrhea.During a medication pass observation on 08/13/25 at 12:15 PM, Resident #65 was noted lying in bed with watery diarrhea stool from her mid arm down past her buttock.During an interview on 08/13/25 at 12:33 PM, when asked what care had been provided to Resident #65 that day, Staff O, CNA, stated he had cleaned her up before breakfast, and provided AM care to her roommate at about 10:30 AM at which time Resident #65 was clean and dry. Staff O stated, I'm guessing that (name of Resident #65) needs to be cleaned up? She sometimes has diarrhea. She's on a tube feed. Staff O stated he hadn't taken care of Resident #65 in the past few weeks so was unsure if this was a continued issue.During an interview on 08/13/25 at 4:14 PM, when asked about the bowel movements of Resident #65, Staff N, CNA, stated the resident had had loose stools since she had been there. When asked if she had reported it to anyone, the CNA stated she believed they knew because when I document something they ask me about it.During a phone interview on 08/14/25 at 9:00 AM, when asked about Resident #65, the Registered Dietician (RD) stated the resident was tolerating the feeding, but at a slow rate, so they run the feeding continuously. The RD stated the resident had been slowly gaining weight. When asked what he would do if a resident had diarrhea, the RD stated he would review the medications and see if she is on a stool softener. If so, he would ask that it be discontinued. Then if the diarrhea continued, he would recommend an anti-diarrheal, and if that didn't work, he would consider changing the feeding. When told of the documented and observed diarrhea for Resident #65, the RD was unaware and unaware of the concern. The RD did note that Resident #65 was on an antibiotic and Milk of Magnesia.During an interview on 08/14/25 at 9:29 AM, when asked how bowel movements are monitored, Staff D, RN Clinical Services Coordinator, stated the bowel movements were recorded in the EMR by the CNAs, and if there were none in 3 days, she would be notified via the EMR. The RN also stated if the resident had two loose stools the EMR would trigger and notify her through a report. When asked about the history of Resident #65, Staff D stated she had the Milk of Magnesium discontinued yesterday, after a second diarrhea stool. The RN reviewed the CNA documentation and agreed to the continuous loose stools and was unsure why the computer did not trigger that in the report. The RN also stated she was not made aware of the loose/diarrhea stool by any staff.During an interview on 08/14/25 at about 10:30 AM, when asked about the stool consistency of Resident #65, Staff B, CNA, stated the last time she took care of her the resident had loose/diarrhea stools. When asked if she reported it to anyone, she stated she did not as she was taught to report two or more in one shift, and she had only had one that day. When asked if Resident #65 had had previous loose/diarrheal stools, the CNA stated that every time she had taken care of Resident #65, she had had loose stools. 2. Review of the record revealed Resident #96 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact.During an interview on 08/11/25 at 11:15 AM, Resident #96 stated she had a UTI (Urinary Tract Infection) and had to get up a lot at night to go to the bathroom. On 08/13/25 at 11:20 AM during a medication observation, Resident #96 stated, I have to get up a lot at night because I have a UTI.Review of the laboratory results revealed Resident #96 had urine collected on 07/29/25 and reported as a positive UTI on 07/29/25. The culture and sensitivity results, to identify which medication would treat the infection, were reported to the facility on [DATE] at 12:18 PM.The following physician orders related to the UTI and needed antibiotics were noted:a) On 07/31/25 at 4:00 PM the order to insert a midline (type of intravenous/IV line) was given by the nurse practitioner.b) An order dated 07/31/25 was given to administer 1 gram of IV Ertapenem on 08/01/25. This medication was not provided.c) On 08/01/25 at 5:00 PM a second order to insert a midline was given by the nurse practitioner.d) A second order for the IV antibiotic Ertapenem was given on 08/02/25. The medication was not provided.e) A third order to insert the midline was written on 08/02/25.f) An order for an oral antibiotic, Augmentin, was started on 08/04/25, four days after the reported culture and sensitivity. A progress note dated 08/03/25 at 4:52 PM documented the technician was unable to insert the midline on 08/02/25 and retried on 08/03/25 without success.During an interview on 08/14/25 at 10:34 AM, Staff D, RN Clinical Services Coordinator, was unsure why there was a delay in providing the antibiotics. During a subsequent interview on 08/14/25 at approximately 4 PM, the Regional Clinical Nurse reported she had spoken with the IV technician, and Resident #96 had originally refused the IV line, then the next day the IV technician was unable to insert the IV line. The Regional Clinical Nurse stated, I know that is not what the record documented. 3. Review of the policy, General Dose Preparation and Medication Administration revised 11/15/24, documented in part, 3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: .3.5 If necessary, obtain vital signs.Review of the physician order, dated 07/14/25, for Resident #72 documented:07/14/25 Propranolol HCl Tablet 10 MG, Give 1 tablet by mouth two times a day for hypertension Hold for BP <110 or HR <60 [blood pressure / heart rate / <=less than].A medication pass observation was made on 08/13/25 beginning at 9:21 AM with Staff S, Licensed Practical Nurse (LPN), for Resident #72. The LPN prepared medication to include Propranolol 10 milligrams (mg). The label on the medication documented to hold the medication for a blood pressure reading less than 110 or a heart rate less than 60. Staff S did not obtain the resident's blood pressure or heart rate but proceeded to administer the medication.Review of the record documented a blood pressure reading of 144/78 with a pulse of 70 documented by Staff S at 9:27 AM.During an interview on 08/13/25 at 9:57 AM, when asked the process for obtaining vital signs, Staff S, LPN, stated, Sometimes they do them [BPs] around shift change and I will use them. When asked specifically about Resident #72 and the observed medication pass, the LPN stated he didn't do the vitals, but they automatically showed up on the top of the eMAR (electronic Medication Administration Record). The LPN showed the surveyor the Current Vitals on the resident banner of the EMR. When asked again if he obtained the blood pressure and pulse, as the readings were documented by him, the LPN stated he got them in report that morning. When asked if he remembered them from report or if he wrote them down, the LPN looked at his report and could not find the vitals. When asked again if he remembered the vitals from report, the LPN stated, I don't remember the exact numbers, but it was close to that.

Based on facility policy, observation, record review and interview, the facility failed to provide proper care and maintenance for indwelling catheters for 2 of 3 sampled residents, as evidenced by failure to ensure that the catheter was secured to prevent dislodgement and care was performed properly for Resident #5, and by failure to ensure that there were physician orders to provide catheter care and maintenance for Resident #160. The findings included:1.Review of the facility policy titled Catheter Care dated 07/2023 documented in part, Purpose: To provide safe and proper care of a resident with an indwelling catheter by evaluating elimination status, minimizing risk of bladder infection, and maintaining skin integrity. Procedure: 1. Verify physician orders for catheter care and maintenance. 6. Fill basin with warm water. 7. Wash hands and apply gloves. 16. Check that the catheter is attached to the thigh or abdomen or as ordered. Maintain catheter anchor to prevent excess tension. 19. Empty gravity drainage bag every shift or more frequently as needed. 26. Change the drainage bag if it leaks or is damaged or according to physician's order. Record review revealed Resident #5 was readmitted to the facility on [DATE]. Review of annual assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, on a 0-15 scale, indicating no cognitive impairment. Review of the care plan dated 07/8/25 revealed that Resident #5 had been diagnosed and treated with antibiotics for a UTI on 07/07/25, 05/15/25 and 04/29/25. Review of the physician orders revealed Resident #5 had an indwelling suprapubic catheter (tube inserted in through the abdomen into the bladder to drain urine) due to obstructive uropathy (urine flow is interrupted). A second order instructed staff to use Enhanced Barrier Precautions (EBP, infection control strategy that uses gloves and gown to reduce spread of infection). When applying the gloves and gown for EBP, the recommended order is to apply the gown first then the gloves. Review of the physician orders failed to instruct staff to change the statlock device. During an interview on 08/11/25 at 11:22 AM, Resident #5 stated My catheter bag was not emptied all day yesterday. I get a lot of Urinary Tract Infections (infection in the bladder). When asked when the last time the catheter was changed, the resident stated, Not recently. An observation of indwelling catheter care on 08/13/25 at 12:20 AM, was performed by Staff J, Certified Nursing Assistant, (CNA). Staff J washed her hands in Resident #5's bathroom and applied a pair of gloves taken from inside the resident's room. After applying the gloves, the CNA opened the residents room door with the gloves on and reached for a yellow gown and put it on. With her gloved hands, Staff J closed the room door. She grabbed the wash basin and went into the bathroom and filled it with soap and water. Staff J put the basin on the bedside table and while trying to adjust the height of the table, the table slightly tilted over causing items from the table to fall on the floor. With her gloved hands, Staff J picked some of the items off the floor. After picking the items up she moved the basin to the other bedside table. She did not remove the gloves from her hands. As she began catheter care, she removed a gauze dated 08/13/25 from the catheter insertion site. A statlock device (anchor device to secure catheter) was noted to be attached to the catheter but the tape that was supposed to be secured to the resident's thigh to prevent the catheter from dislodging was soiled and folded. When asked what the device was, Resident #5 stated, It's supposed to be used to secure the catheter, so I don't pull it out. When asked if it been changed recently, the resident stated, It's been a while. Staff J stated, I will tell the nurse to change it. 2. Review of the policy titled Catheter Care, dated 07/2023, documented to provide safe and proper care of a guest/resident with an indwelling catheter by evaluating elimination status, minimizing risk of bladder infection, and maintaining skin integrity. The procedure included: verify physician's order for catheter care and maintenance. Review of the record revealed Resident #160 was admitted to the facility on [DATE], with a diagnosis to include Urinary Tract Infection (UTI). Further review of the record revealed a lack of documented care plans for the catheter and no physician orders for catheter maintenance. On 08/11/25 at 9:59 AM, the computer system did not document the urinary catheter; however, during that time, the resident was observed with a urinary catheter bag under his wheelchair. On 08/14/25 at 9:32 AM, during an interview with the Infection Preventionist, she was informed about the observation regarding Resident #160 having a catheter without any existing orders or care plans for maintenance. She acknowledged these findings.

Based on facility policy, observation, record review and interviews, the facility failed to provide respiratory care and services for the administration of oxygen and nebulizer treatment for 4 of 5 sampled residents, as evidenced by failure to administer oxygen per physician orders for Resident #35 and failure to perform respiratory assessment post nebulizer treatment for Resident #5, #15 and #77. The findings included: Review of the facility policy titled Medication Administration dated 07/2023, documented in part.Nebulizer . 14. Instruct resident to breathe slowly and deeply, holding each breath at the end of inspiration. 15. Encourage residents to cough and expectorate during and after treatment. 17. Evaluate respiratory status to include breath sounds, cough effort and sputum, heart rate, respiratory rate. Oxygen.Guidelines for Initiation or oxygen therapy 1. Oxygen via all oxygen delivery devices shall be administered as per physician's orders. 1. Record review revealed Resident #35 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 03, on a 0-15 scale indicating severe cognitive impairment. Review of physician orders revealed an order dated for 05/25/25 instructing staff to administer oxygen at 2 LPM [liters per minute] via nasal cannula as needed every shift. Review of the documented medical diagnosis indicated that Resident #35 had a history of Congested Heart Failure (fluid on the heart) and Chronic Obstructive Pulmonary Disease (restricted oxygen in lungs making it difficult to breathe). Review of a care plan dated 07/09/25, revealed that Resident #35 has potential for difficulty breathing related to Congested Heart Failure and the goal is for the resident to maintain his respiratory baseline with a patent airway and unlabored respirations with an intervention of the nursing staff to administer oxygen as ordered. Review of the Medication Administration Record (MAR) for August 2025 revealed that the staff were signing the MAR (Medication Administration Record) acknowledging that Resident #35 was receiving oxygen at 2 LPM via nasal cannula daily. During an observation on 08/11/25 at 12:20 PM, Resident #35 was observed sitting on the side of the bed eating lunch and wearing oxygen. The oxygen concentrator was set at 0L, and the tubing was observed to be in only 1 nostril. Photographic Evidence Obtained. During an observation on 08/12/25 at 10:30 AM, Resident #35 was observed sleeping prone wearing oxygen. The oxygen concentrator was set on 0L and the concentrator was beeping. During an interview on 08/13/25 at 10:45 AM, Staff F, Licensed Practical Nurse (LPN), was asked if Resident #35 uses oxygen all the time, who stated, I was told it's ordered as needed. He's a new resident on this unit and I don't know him that well. 2. Record review revealed Resident #5 was readmitted to the facility on [DATE]. Review of the medical diagnosis indicated Resident #5 had a history of Congested Heart Failure (excess fluid on the heart) and Chronic Obstructive Pulmonary Disease (constriction of airway in the lungs). Review of the physician order dated 06/18/25 instructed staff to administer Ipratropium- Albuterol Solution 0.5-2.5 (3) MG/3ML (steroid inhalation) orally via nebulizer four times a day for shortness of breath, document pre and post nebulizer treatment lung sounds, pulse, respirations and oxygen saturation and enter the number of minutes of nurse time for medication administration. During an interview on 08/11/25 at 11:22 AM, when Resident #5 was asked if they used oxygen all the time, Resident #5 stated Yes. The resident was observed with a nebulizer mask on his face, but there was not any medication in nebulizer. The nurse was not at bedside or near the resident's room. When asked how long have you been on the nebulizer machine, the resident stated, Not sure. During an observation at 11:38 AM Resident #5 turned on his call light for assistance. Staff G, LPN, was observed walking down the hall to respond to the resident's call light. When she entered the room, the resident stated, Can you turn that off please? Staff G turned off the nebulizer machine, sanitized her hands and walked out of room. Staff G was not observed doing a post respiratory assessment on Resident #5 prior to walking out of the room. Review of the August 2025 time stamped Medication Administration Record (MAR) for Resident #5 revealed that Staff G, LPN administered the nebulizer treatment scheduled for 12:00 PM at 2:22PM. 3. Record review revealed Resident #15 was readmitted to the facility on [DATE] with diagnosis of Pleural Effusion (fluid between the lungs and chest). During an observation on 08/12/25 at 3:00 PM, Resident #15 was observed sitting up in bed with a nebulizer on her face, and there was no medication in the nebulizer. There wasn't a nurse at bedside or in the hallway near her room. Staff E, Certified Nursing Assistant (CNA), walked in the resident's room and checked the nebulizer mask on the resident's face and stated, It's finished. I'm going to remove it. Staff E removed the nebulizer mask from Resident #15 face and placed the mask in the plastic bag and walked out the room. During an interview on 08/12/25 at 3:20 PM, Staff G, LPN, was asked what her process was for administering a nebulizer treatment. She stated If there is liquid in the nebulizer, I will rinse it out and dry it, then I put the medication in nebulizer and place the mask on the resident. I stay with the resident for about 5 minutes, then I go to the next resident. I know that I'm supposed to stay with the resident for 15 minutes but it's impossible. During an interview on 08/12/25 at 3:45 PM, when asked what the process for the nurse is when administering a nebulizer treatment, Staff M, Clinical Service Coordinator (CSC), stated The nurse would go to resident room, if the resident is on contact precautions (to prevent spread of infection) the nurse would put on a gown and gloves. The nebulizer mask should be separated and washed after use and in bag. So, then the nebulizer would be taken from the bag and the medication put in the mask. I tell the nurse to stay by the resident's door and do some charting; it usually takes maybe 7-8 minutes for the treatment. When asked if she expected the nurse to stay near by the resident's room receiving the treatment, she stated Yes. On 08/12/25 at 3:50 PM, when Staff M, CSC, was asked if she had taken care of Resident #15 yesterday, Staff M stated I was assisting Staff F, LPN, because the resident wasn't doing well. When asked who applied the nebulizer treatment, Staff M, CSC stated, She received a treatment because she was not doing well and I think Staff F, LPN applied it. I can't remember. She hasn't been doing well for a long time. When asked whether Resident #15 have an order to receive nebulizer treatments, as she looked into the record, Staff M stated, I know she had an order before she went out to the hospital. After reviewing the resident's orders, she stated, No she did not come back with an order for breathing treatments, she came back with an order for an inhaler. When asked why Resident #15 was receiving a treatment without an order, Staff M, CSC stated, The nurse must have thought she had an order. I will talk to the nurse. When asked if she knew who removed the nebulizer mask from the resident Staff M, CSC stated, No. She was made aware that Staff E, CNA was observed removing the nebulizer mask from Resident #15 face and the nurse was nowhere in the hallway. During an interview on 08/13/25 at 10:35 AM when asked about the nebulizer treatment administered to Resident #15 on Monday 08/13/25, Staff F, LPN, stated I was not working on Monday, I do not work on Mondays. I haven't worked on a Monday in over a year. During an interview on 08/13/25 at 10:38 AM, Staff M, CSC approached the surveyor and stated I forgot that I was the one working the 220 Unit on Monday not Staff F, LPN. I never work on the floor, but I worked that day. During an interview on 08/13/25 at 12:06 PM, Staff M, CSC was asked, if she was the nurse working the 220 Unit on Monday 08/11/25, she stated, Yes. When asked if she had administered the nebulizer treatment to Resident #1, Staff M, CSC stated, Yes, and I forgot to remove it. 4. Review of the record revealed Resident #77 was admitted to the facility on [DATE]. Review of the most current MDS assessment documented that the resident had a BIMS score of 1, on a 0 to 15 scale, indicating severe cognitive impairment. Current physician orders dated 07/21 25 documented the resident was receiving Pulmicort, an inhalant medication provided by a nebulizer machine twice daily, and Ipratropium-Albuterol, another nebulizer, four times daily. These orders instructed the nurse to conduct pre and post lung sounds, and pre and post vital signs to include pulse, respiration rate, and oxygen saturation. These orders also instructed the nurse to enter the number of minutes of nurse time for the medication administration. Review of a current care plan initiated on 08/25/23 and revised on 07/31/24 documented Resident #77 had breathing difficulty and nurses were to administer nebulizer treatments as ordered. On 08/11/25 at 2:59 PM, Resident #77 was noted in bed with a nebulizer mask on her face and the nebulizer machine functioning. Observation of the nebulizer canister revealed the medication had finished. Continued observation until 3:35 PM was made with no staff entering the room to check on the resident. At 3:35 PM, with continued observation of Resident #77, the evening nurse entered the room, confirming the nebulizer was running and empty. The surveyor went to the nurse's station and found Staff C, Licensed Practical Nurse (LPN), the day nurse for Resident #77. When asked if she forgot a nebulizer treatment, Staff C stated, Oh (name of Resident #77). Staff C confirmed she applied the nebulizer treatment to Resident #77 earlier but did not specify the time. Review of the record revealed the Ipratropium-Albuterol nebulizer had been administered at 1:56 PM. The Medication Administration Record (MAR) documented a post assessment with the number of minutes of nurse time as 9 minutes. The nurse did not do a post-nebulizer assessment as the surveyor found the running nebulizer and brought it to the attention of Staff C. During an interview on 08/13/25 at 12:43 PM, when asked the process for nebulizer treatments, Staff C, LPN, described placing the medication into the nebulizer canister and administering it for about 8 or 9 mins, as that's what the computer says, or until it's done. When asked about the 9-minute time the LPN again stated, That's what the computer says, and showed the surveyor the order. During a side-by-side record review, the LPN reviewed the order and stated, oh, it says to document the number of minutes., not nine minutes. When asked why she documented the post vitals for Resident #77 that were found by the surveyor, the LPN agreed with the findings and had no explanation. During an interview on 08/14/25 at 10:16 AM, when told of the observation made of Resident #77 with the nebulizer that had finished, Staff D, RN Clinical Services Coordinator, was unaware of the situation and that the nurse documented post assessments that had not been completed.

Based on record reviews and interviews, the facility failed to properly document the removal of narcotics in the medication administration records (MARs) and the controlled medication utilization record (the narcotic record) for 3 of 6 sampled residents, Residents #52, #104, and #134.The findings included: Medication storage review was conducted on 08/13/24 at 3:42 PM on 200 Unit. Three residents were selected for narcotic reviews. The review revealed the following: 1. The controlled medication utilization record for Resident #104 revealed that Tramadol 100mg 1 tablet was signed out on 07/24/25 at 2:25PM. Review of the Medication Administration Record (MAR) for July 2025, did not reveal any documentation of Tramadol 100mg being administered on 07/24/25 at 2:25 PM. 2. Review of the controlled medication utilization for Resident #104 revealed that Tramadol 50mg, 2 tablets were signed out on 08/05/25 at 8:59 PM. Further review of the MAR for August 2025 did not reveal any documentation of Tramadol 50mg, 2 tablets by mouth being administered on 08/05/25 at 8:59 PM to Resident #104. 3. Review of the controlled medication utilization record for Resident #134 revealed that Oxycodone with Acetaminophen 325mg, 1 tablet was signed out on 08/11/25 at 9:35 AM. Review of the MAR for the month of August did not reveal any documentation of Oxycodone with Acetaminophen 325mg, 1 tablet being administered on 08/11/25 at 9:35 AM for Resident #134. During an interview with Director Of Nursing (DON) on 08/14/25 at 9:20 AM, she verified that Staff G, Licensed Practical Nurse (LPN) was the nurse who failed to sign the MAR on 07/24/25 at 2:25 PM for the administration of the Tramadol 100mg. The DON also verified that Staff I, Registered Nurse (RN) was the nurse who failed to sign the MAR on 08/05/25 at 8:59 PM for medication administration of Tramadol 50mg to Resident #104. The DON verified that Staff M, Clinica Service Coordinator (CSC), failed to sign the MAR on 08/11/25 at 9:35 AM for the administration of the Oxycodone with Acetaminophen 325mg, but she signed the MAR indicating that she administered the medication at 12:39 PM to Resident #134. The DON called Staff M into the office to get clarification of her documentation. During an interview with Staff M, CSC when asked if she had administered the Oxycodone to Resident #134 at 9:35AM on 08/11/25 she stated No, I did not give the resident the medication at 9:35 AM. I gave it at 12:39 PM as indicated on the MAR. I'm not sure why I signed the narcotic sheet for 9:35 AM. 4. On 08/13/25 at 9:53 AM, a review of medication storage was conducted at Unit 400. Three residents' names were selected for a narcotic review. The review revealed the following: Resident #52 had a prescription for Tramadol 50 mg to be administered as one tablet by mouth every eight hours as needed for moderate pain. The August 2025 Medication Administration Records (MARs) were compared with the August 2025 controlled medication utilization record, revealing a discrepancy. The controlled medication utilization record indicated that the medication was signed out for removal on 08/12/25 at 9:05 AM and again at 5:15 PM. The MARs did not reflect any documentation for the removal at 5:15 PM. On 08/14/25 at 1:13 PM, an interview and side-by-side review of Resident #52's records were conducted with the DON, who acknowledged the findings.

Based on record review, the physician failed to provide a rationale for declining a pharmacy recommendation on a Medication Regimen Review (MRR) for Resident #8. The findings included: Review of records revealed that Resident #8 was admitted on [DATE] with a recent readmission on [DATE]. Further review of record revealed that an order dated 03/28/25 for Temazepam Capsule 30 mg to be given 1 capsule by mouth and bedtime for insomnia.Record review of Medication Regimen Review (MRR) dated 05/05/25 had a comment from the pharmacist that Resident # 8 had received Temazepam 30 mg at bedtime for insomnia and had made a recommendation to attempt a gradual dose reduction (GDR) of Temazepam to 15 mg at bedtime. The physician's response area was not checked off about accepting or declining the recommendation and no rationale for declining the recommendation was given. The physician had documented only No change on the top of the form and then signed it at the bottom of the form and it was without a date next to the signature.

Based on observation, interview, policy review, and record review, the medication error rate was 7.41% percent. Two medication errors were identified while observing a total of 27 opportunities, affecting 2 of 10 residents observed during medication pass observation, Residents #72 and #96.The findings included:Review of the policy General Dose Preparation and Medication Administration revised 11/15/24, documented in part, 3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.1. Review of the physician orders for Resident #72 revealed the following order: On 05/22/23, ordered Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth in the morning for supplement.A medication pass observation was made with Staff S, Licensed Practical Nurse (LPN), on 08/13/25 beginning at 9:21 AM for Resident #72. The LPN prepared medications to include seven pills.Upon reconciliation of the observed medications administered with the current physician orders, it was noted that the LPN had missed the medication Thiamine 100 milligrams (mg), that was also due to be given at that time. The LPN had signed out the Thiamine as administered on the electronic Medication Administration Record (eMAR).During an interview on 08/13/25 at 9:57 AM, when asked if he had given any medications to Resident #72 earlier that morning, the LPN stated he gave the controlled medication Clonazepam. When asked if he had given anything else he stated he had not. When asked about the Thiamine for Resident #72, Staff S stated, Oh yea . I forgot that one. The LPN confirmed he had signed off the Thiamine on the eMAR as given but had not given it. 2. Review of the physician orders for Resident #96 revealed the following order: On 02/06/25 ordered Pantoprazole Sodium Tablet Delayed Release 40 MG Give 1 tablet by mouth in the morning for gerd [Gastroesophageal Reflux Disease] administer before breakfast.A medication pass observation was made with Staff C, LPN, on 08/13/25 beginning at 10:25 AM for Resident #96. The LPN obtained the morning medication to include Pantoprazole 40 mg, a medication for acid reflux. Review of the label revealed the medication was specifically order for before breakfast. Staff C provided Resident #96 her morning medication.During an interview on 08/13/25 at 11:12 AM, when asked if Resident #96 had eaten breakfast that morning prior to administration of the observed medication pass, the LPN stated she had. When asked if there was a medication during that observation that should have been given prior to breakfast, the LPN was unsure and questioned, probably the antibiotic? When told the order for the Pantoprazole was specifically ordered before breakfast, the LPN stated, Oh, I need to reach out to the physician, and agreed with the finding.

Based on record review and interviews, the facility failed to ensure that laboratory services were done in a timely manner for 1 of 5 sampled residents as evidenced by the Valproic Acid level (blood level to monitor antiseizure medication) was not drawn for Resident #6. The findings included:Record review revealed Resident #6 was admitted to the facility on [DATE]. Review of annual assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 02 on a 0-15 scale indicating severe cognitive impairment. Review of the physician orders for Resident #6 revealed that he is prescribed Divalproex Sodium Tablet Delayed Release (Valproic acid) 500 MG, 1 tablet by mouth two times a day for seizure disorder. Review of the pharmacy consultation review for the month of April 2025 revealed that the pharmacy recommended that the valproic acid level be monitored for Resident #6, because he was receiving Divalproex Sodium XR and there was no documented valproic acid level in the past previous six months. The physician signed the consultation on 04/11/25 acknowledging that he agreed with the pharmacy recommendation and wrote that the valproic acid level was ordered for 04/17/25. Review of the physician orders for Resident #6 revealed that the valproic acid level was added on 04/17/25 to an existing order for other labs that were ordered to be drawn on 04/21/25. Review of the laboratory results for the labs drawn for Resident #6 on 04/21/21 revealed that the other labs ordered were drawn but the valproic acid level was not. During an interview with the DON on 08/14/24 at 1:30 PM, she was asked if the valproic acid level that was ordered for Resident #6 on 04/21/25 was drawn. She stated, I will have to check. The DON returned and stated that she could not find the valproic acid level result from 04/21/25 and she would have to call the lab. During an interview with the Regional Nurse on 08/14/24 at 1:45 PM, she was asked for the name of the laboratory that would have drawn the valproic acid lab on 04/21/25 for Resident #6. She provided the name and phone number of the contact person in charge at Florida Laboratory. A call was placed to the manager in charge at [Name] Laboratory on 08/14/25 at 1:47 PM, when asked if she was the providing laboratory for the facility she stated yes, and the valproic acid lab result for Resident #6 was requested. The manager in charge said that she would look for the result and call back. During an interview with the Regional Nurse at 08/14/25 at 2:15 PM, she stated that the manager in charge at the laboratory had emailed her stating that the valproic acid level for Resident #6 was not drawn on 04/21/25, because it was not seen printed on the order that the other labs were. She provided a copy of the order that the manager in charge had attached to the email. A call back from the manager in charge was requested. The Regional Nurse called the manager in charge at [Name] Laboratory and told her that the surveyor would like a call back. Photographic Evidence Obtained. During an interview on 08/14/25 at 2:17 PM, with the manager in charge at [Name] laboratory, she stated that the valproic acid level ordered on 04/21/25 for Resident #6 was not drawn because part of the order was cut off and the lab did not know that a valproic acid level was ordered.

Based on record review and interview, the facility failed to ensure it had he most recent hospice plan of care for 1 of 1 sampled resident (Resident #31)The findings included:Review of the record revealed Resident #31 was admitted to the facility under hospice care and services on 11/08/24. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicting the resident was cognitively intact. Further review of this MDS documented that the resident was receiving hospice services and had a terminal diagnosis.Review of the current orders documented a physician order dated 11/13 24 for the provision of hospice care. A subsequent facility care plan also documented the resident was receiving hospice care and services. The facility orders and care plan lacked any frequency of hospice services for Resident #31.Further review of the record revealed the most current hospice plan of care, that documented the services and frequency of hospice services provided to Resident #31 was dated 10/08/24, for the certification period upon admission to hospice services, of 10/08/24 through 01/05/25. The record lacked any other hospice plan of care.During an interview on 08/12/25 at 10:23 AM, when asked about hospice services and the frequency of visits, Resident #31 stated the hospice nurse only visited about once a month. When asked if a Certified Nursing Assistant (CNA) from hospice made visits, the resident stated, once in a while.During an interview on 08/13/25 at 12:00 PM, when asked about the nurse visits for Resident #31, Staff R, Hospice Registered Nurse (RN), stated she visits the resident weekly. When asked about Hospice aides, the Hospice RN stated they come twice weekly. During a side-by-side review of the record and interview at this time, the Hospice RN was unable to locate a current hospice plan of care with the frequency of hospice visits for Resident #31. Staff D, RN Clinical Services Coordinator, was sitting at the nurse's station with the Hospice RN. When asked who was responsible for ensuring the current Hospice plan of care was in the facility, Staff D stated, she knew that each hospice patient had a binder, but she never looked at it. Staff D also stated she was not sure who was responsible for maintaining the current hospice record.

Based on policy reviews, observations, interviews, and record reviews, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were initiated for 2 of 42 residents recorded on the EBP List, Resident #159 and Resident #160; failed to ensure infection control practices were adhered to during wound care for 1 of 3 sampled residents, Resident #81; failed to ensure a glucometer was disinfected adequately for 1 of 3 residents observed during blood glucose monitoring, Resident #65; and failed to ensure a barrier was maintained for an eye drop bottle during administration for 1 of 1 resident observed during eye drop administration, Resident #96) who was on Contact Precautions. The findings included: Review of the policy titled enhanced barrier precautions, dated 08/16/22, revealed that it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions refer to the use of gowns and gloves for the use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g residents with wounds or indwelling medical devices). Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gowns and gloves. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. An order for enhanced barrier precautions will be obtained for residents with any of the following: wound, and or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Make gowns and gloves available immediately outside of the resident's room. 1. Review of the record showed that Resident #159 was admitted to the facility on [DATE]. Further review of the records indicated that there was no documented evidence of physician orders or care plans regarding Enhanced Barrier precautions. On 08/11/25 at 9:25 AM, Resident #159 was observed lying in bed with a wound vacuum actively functioning. There were no Enhanced Barrier precautions in place. There was no personal protective equipment (PPE) kit available, and no signage to inform the staff about the required precautionary measures. 2. Review of the records indicated that Resident #160 was admitted to the facility on [DATE] with a diagnosis of Urinary Tract Infection (UTI). Further review of the records revealed a lack of documented evidence for care plans regarding Enhanced Barrier Precautions (EBP), and there were no physician orders for EBP. On 08/11/25 at 9:59 AM, Resident #160 was observed with a urinary catheter. There were Enhanced Barrier Precautions were in place. There was no personal protective equipment (PPE) kit, and no signage to alert the staff about precautionary measures. During an interview with the infection preventionist on 08/14/25 at 9:32 AM, she was informed of the above findings and observations regarding the absence of EBP and lack of following of EBP protocols for Residents #159 and #160. She acknowledged these findings. 3. Review of the clinical record for Resident #81 documented he was admitted to the facility on [DATE], and 07/14/25 with a diagnosis of non-Alzheimer's Dementia. The admission Minimum Data Set (MDS) assessment, dated 07/20/25 recorded a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #81 was moderately cognitively impaired. On 07/29/25 physician orders were issued for wound care, that specified that the right heel should be cleansed with normal saline, patted dry, and a foam silicone border dressing should be applied three times a week in the morning. On 08/24/25 at 9:57 AM, wound care observations were conducted for Resident #81 with the Wound Care Nurse, Registered Nurse. The nurse did not adhere to proper infection control practices during this procedure. The sequence of actions was as follows: a. The wound care nurse obtained gauze from the treatment cart with bare hands and placed it into a tray. b. She then put on personal protective equipment (PPE). c. She then went to the bathroom to wash her hands, after which she touched the bed remote to raise the bed and the garbage can to bring it closer. d. She put on gloves without performing hand hygiene first. e. The nurse removed the old dressing and then removed her gloves before putting on new gloves, again without performing hand hygiene. f. She used the gauze, which had been touched with her bare hands, to cleanse the wound with normal saline, dry the wound, and then applied the foam dressing. On 08/14/25 at 10:05 AM, the Director of Nursing (DON) was informed of the infection control concerns arising from the wound care procedure. 4. Review of the policy Blood Glucose Testing dated 07/2023, documented in part, 11. Disinfect the blood glucose monitor after each use with 1:10 dilution of sodium hypochlorite (bleach) unless the manufacturer recommendations say otherwise. Note: Do not use alcohol to disinfect the monitor. A medication pass observation was made with Staff C, Licensed Practical Nurse (LPN), on 08/13/25 beginning at 11:21 AM for Resident #8. The LPN gathered the supplies needed to check the resident's blood sugar level, including a glucometer. The LPN obtained a sample of blood from the resident and obtained the blood sugar level. On 08/13/25 at 11:29 AM, the LPN took the glucometer back to her medication cart, obtained an alcohol wipe, and cleaned the glucometer with the alcohol swab. The LPN immediately placed the glucometer back into the plastic bag. During an interview on 08/13/25 at 1:08 PM, when asked about the process for cleaning and or disinfecting the glucometers, Staff C, LPN, explained she used either the disinfectant wipes or the alcohol wipes. The LPN explained the bleach (disinfectant) wipes had a contact time, which was between 30 seconds and 3 minutes, depending upon the bacteria or virus. When asked if the alcohol disinfected the glucometer, the LPN stated it did not. 5. Review of the policy General dose Preparation and Medication Administration revised 11/15/24, documented in part, 1.2 Medications should not come in contact with any surface except for the medication cup. A medication pass observation was made with Staff C, LPN, 08/13/25 beginning at 10:26 AM. The LPN gathered medications to include eye drops to administer to Resident #96, who was also on contact precautions. The LPN administered the eye drops to the resident and then placed the eye drop medication bottle on the resident's over-the-bed table, that the resident used for her personal items and use. The LPN returned to the medication cart after administration of the medications, placed the eye drop bottle into the box, and returned it to the medication cart. When asked if the eye drop bottle had been contaminated, the LPN was unsure. When informed the LPN placed the bottle directly on the resident's over-the-bed table, the LPN understood and agreed with the finding.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance for 4 of 5 sampled residents, Resident #22 who requested assistance; and failed to provide proper positioning in bed during mealtime for Residents #8, #41, and #98.The findings included: 1.Record review revealed Resident #22 was admitted on 04//21 with a primary diagnosis of Rheumatoid Arthritis (a chronic autoimmune disease where the body's immune system mistakenly attacks its own tissues, primarily the joints.) Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current care plans dated 07/18/25 documented, Resident #22 has an ADL [Activities of Daily Living] Self-Care and/or mobility deficit and needs assistance with all ADLs and is At risk of developing complications associated with decreased ADL self-performance related to: Rheumatoid Arthritis, with a goal that stated Will maintain ADL self-performance levels as evidenced by no decline in current level of functioning through next review date and an intervention that documented Resident prefers baths, no showers. Review of Resident #22's task titled ADL- Bathing Type, showers Wed/Sat 7-3 and PRN [Wednesday / Saturday 7 AM - 3 PM shifts and as needed] revealed her bathing schedule was Wednesdays and Saturdays (7AM-3 PM) shift and as needed. During an interview and observation on 08/11/25 at 11:11AM, Resident #22 was observed using a dressing stick (an assistive device used by people who have limited mobility) and joint deformities on bilateral hands were seen. When asked how her care was, Resident #22 stated she wished she received more assistance with a sponge bath. Resident #22 stated she gave herself a sponge bath daily and voiced I would like more help regularly; I would like it if they would ask instead of me having to ask. The resident stated she often spends almost 2 hours getting ready. Resident #22 voiced Since I'm semi capable of getting ready, they often don't help. My roommate is total care, and I often get left out, I don't get the care that I need. Resident #22 stated that when her hair got oily, she would like assistance washing it. She stated, If they could just give me 15 minutes of their time it would help. Resident #22 stated her left ankle had a wound in the past which was now healed; and that area on her skin needed to be washed and oiled once a week. Resident #22 showed the surveyor her left ankle, which was observed to have the skin cracked, and dry with a scaley appearance. During an interview on 08/13/25 at 11:29 AM Resident #22 stated, Yesterday my aide helped me wash my back and that normally doesn't happen. She was helpful but I don't think it will change because that was just one person When asked when the last time was that she received assistance with ADLS, Resident #22 stated Occupational Therapy (OT) helped her last week. The resident voiced, the regular aides don't usually ask if I need help. When asked if her preference was a sponge bath or shower, Resident #22 stated it was a sponge bath due to her knees and legs being too weak to sit in a shower chair. When asked how many times a week she would like assistance with ADLs, Resident #22 stated she wanted help a couple times a week. When asked if staff had assigned her specific bathing schedules or asked her for her preferred bathing schedule, Resident #22 stated there were no agreements made but that she liked to clean herself daily. When asked when the last time she received assistance cleaning and moisturizing her ankle, the resident stated about 3 weeks ago OT helped her wash up and oil her ankle. During an interview on 08/14/25 at 9:42 AM when asked if Resident #22 preferred a shower or bed bath, Staff K, Certified Nursing Assistance (CNA), stated she takes herself in the bathroom alone, we give her privacy When asked how many times a week she gets cleaned up, Staff K stated it was 3 times a week for everyone. When asked if the resident was able to bathe herself alone, Staff K stated she would need assistance for a shower but for a sponge bath she could do herself without assistance. When asked if Resident #22 had ever asked for assistance for bathing, Staff K stated Resident #22 had never asked for assistance. Staff K was made aware of Resident #22's concerns with lack of assistance. Staff K voiced she would offer the resident more assistance when she was assigned to her and would let the CNA who normally took care of Resident #22, know when she returned from vacation. During an interview on 08/14/25 at 9:54 AM, when asked if Resident #22 preferred a shower or a bed bath, Staff L, CNA, who was assigned to her care stated she preferred a bed bath, but she was not regularly assigned to the resident. When asked how many times a week Resident #22 preferred a bath, Staff L stated she gives herself a bath every day because the resident liked to stay clean. When asked if the resident was able to bathe herself alone, Staff L stated yes, she could do it herself and that they gave her independence so she could do things at her own pace. Staff L stated Resident #22 could benefit from help in setting things up and then let the resident take things from there. When Staff L was made aware of Resident #22's concerns with lack of ADL assistance, Staff L stated that the resident did ask for assistance bathing and moisturizing her feet in the morning, but she was passing out breakfast trays when she asked. Staff L voiced She couldn't wait so she did it herself; she is very impatient, and I didn't want the food to get cold. Staff L stated she went back to assist Resident #22, but she was already in the bathroom. Staff L agreed with the voiced concerns and stated she would communicate with the CNA who normally took care of her. During an interview on 08/14/25 at 10:02 AM, when asked if Resident #22 preferred a shower or a bath, Staff M, Registered Nurse (RN) / Clinical Services Coordinator stated she preferred showers. When asked if Resident #22 could do it herself, Staff M stated, CNAs give her a shower; she is pretty independent. Staff M was made aware that Resident #22 preferred sponge baths. Staff M voiced I thought she gave herself a shower; I didn't know that she went in there every day to give herself a sponge bath. Staff M was made aware of Resident #22's voiced concerns of lack of ADL assistance and agreed with the findings. During a follow-up interview on 08/14/25 at 3:05 PM when asked if she received assistance with getting cleaned up and getting her ankle washed up, Resident #22 stated she did get assistance with getting her ankle washed and oiled. The resident voiced that normally this doesn't happen and thanked the surveyor for assistance in getting the staff to help her. 2. Review of record revealed that Resident #98 was admitted to the facility on [DATE] with an original admission date of 07/01/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #98 had a Brief Interview for Mental Status (BIMS) score of 6 on a 0-15 scale, indicating the resident had severe cognitive impairment. Further review of the MDS dated [DATE], section GG for Functional Abilities, revealed Resident #98 was coded as needing Supervision / Touching Assistance for eating and Substantial to Maximum Assistance for positioning from lying to sitting in bed, and is Dependent for all other Self Care Categories. Review of the care plans dated 07/18/22, revised 01/26/23, had a Focus for Activities of Daily Living (ADLs) Self-Care and/or mobility deficit that revealed Resident #98 needed assistance with ADL's and is at risk of developing complications associated with decreased ADL self-performance related to disease process/condition, and weakness. An interview was conducted on 08/12/25 at 8:22 AM with Resident #98 who stated he was hungry, he needed help with eating, and that he could not open the containers of juice and milk. The meal tray was on his bedside table that was positioned over his bed with the lid removed from the plate. It showed that a maple syrup container was opened, and all other containers were unopened. Photographic Evidence Obtained. Resident #98 was observed lying on the bed with the head of the bed in a slightly elevated position and reached for the spoon to feed himself and was able to take one bite of food but then stated, it is too hard for me and put the spoon back on the plate. Resident #98 was not sitting upright in the proper position to eat. Resident #98 was able to push the call bell and Staff C, Licensed Practical Nurse (LPN), came into his room. Staff C was asked if Resident #98 needs assistance with feeding and stated he does need some help and that usually one of the Certified Nursing Assistants (CNA's) would come back to feed him. Staff C was asked if Resident #98 could open the juice and milk himself to which she responded, No, he cannot. Staff C agreed the staff member who brought his tray into the room and took off the lid, should have also made sure he was sitting up in bed, opened all containers to allow him to try and feed himself until they returned to assist him. At 8:35 AM, three staff members came in to reposition Resident #98 in bed and Staff C sat next to Resident #98 and assisted him as needed with his breakfast. 3. Record review revealed Resident #41 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented Resident #41 had a BIMS score of 12 on a 0-15 scale, indicating the resident had moderate cognitive impairment. Further review of the MDS dated [DATE], section GG for Functional Abilities, revealed Resident #41 was coded as needing Supervision / Touching Assistance for Eating and was Dependent for Lying to Sitting in Bed, and is Dependent for all other Self Care Categories. Further review of record revealed Resident #41 had a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side. Review of the care plan dated 03/21/25 had a Focus for Resident #41 for Activities or Daily Living (ADL) Self-Care and/or mobility deficit, needs assistance with ADL's, at risk of developing complications associated with decreased ADL self-performance related to Disease process/condition, Poor motivation, and Weakness and required set-up with supervision with meals. During an observation and interview on 08/13/25 at 8:27 AM, Resident #41 was in bed and leaning to the left side with her full breakfast tray on the bedside table in front of her. When Resident #41 was asked if she was able to eat in that position she replied, No, I need to get pulled up and over in my bed to reach the tray. Resident #41 pressed her call bell and staff responded and Resident #41 requested to be repositioned. 4. Record review revealed Resident #8 was admitted to the facility on [DATE] with a recent readmission date of 03/27/25. Review of the MDS assessment dated [DATE] documented Resident #8 had a BIMS score of 9 on a 0-15 scale, indicating the resident had moderate cognitive impairment. Further review of the MDS dated [DATE] revealed Resident #8 had a significant change in status since the 02/23/25 MDS that included in Section GG for Functional Abilities that Resident #8 had declined in her ability for Eating from Independent to Substantial to Maximum assistance and continued to require Substantial to Maximum assistance for positioning from Lying to Sitting in bed. Review of records revealed an order for Occupational Therapy dated 08/07/25 for Resident #8 to receive skilled Occupational Therapy three times and week for thirty days for therapeutic exercises, therapeutic activities, self-care training, and caregiver training. An observation was conducted on 08/12/25 at 8:09 AM of Resident #8 who was observed in bed sleeping with her full breakfast tray in front of her on the bedside table. On 08/12/25 at 9:14 AM, Resident #8 was noted calling out for help from her bed and requested help to get up. She was assisted in locating her call bell and was able to push the call bell herself. During an interview on 08/13/25 at 8:05 AM, Resident #8 was in bed with her full breakfast tray in front of her on the bedside table. Resident #8 asked for help to eat her breakfast. At 8:09 AM, Staff A, Certified Nursing Assistant (CNA), responded to the call bell and was asked if Resident #8 needs help to eat and Staff A responded that Resident #8 can usually feed herself but may need some help. Staff A was then asked if she thought Resident #8 would be able to feed herself in that position and Staff A replied, No, I do not know who left her like that. Staff C started to raise the head of Resident #8's bed and then agreed that raising the head of the bed was not helping since Resident #8 needed to be lifted upright in the bed in order to sit up correctly to eat. Staff C left the room to get assistance to reposition Resident #8. During an interview on 08/14/25 at 8:11AM, Resident #8 requested help and when asked what do you need help with, she responded, I need help to get up, I am too low. Resident #8 was in bed with her full breakfast tray on her bedside table and resident was low in the bed with the head of the bed elevated only moving R#8's head forward. Resident #8 was able to press the call bell and Staff B, Certified Nursing Assistant (CNA) came into her room at 8:19 AM. Staff B was asked if she thinks that R#8 was in a good position to eat breakfast in bed and Staff B responded, No, she needs to pulled up and repositioned before setting her up for breakfast. Staff B was then asked if she feels she has time to reposition each patient that needs help before meals and Staff B replied that we make the time and I get help if I cannot do it myself. Additional staff came into the room to assist with repositioning Resident #8.

Based on observation, record review and interviews, the facility failed to ensure that 1of 3 sampled residents received a shower as evidenced by not providing a shower to Resident #48. The findings included: Record review revealed Resident #48 was readmitted to the facility on [DATE]. Review of the annual comprehensive assessment, dated 08/03/25, documented a Brief Interview Mental Status (BIMS) score of 15 on 0-15 scale, indicating no cognitive impairment. Review of the care plan, dated 08/05/25, revealed Resident #48 required partial assistance with a shower. During an interview on 08/11/25 at 2:46PM with Resident #48's spouse, she stated I have spoken to administration about an issue, and it is still not fixed. My husband has not received a shower for two weeks before I complained last Tuesday (08/05/25). I had a meeting with the Director of Nursing (DON) and Social Worker (SW) last Tuesday regarding him not getting a shower. He finally got a shower on Tuesday late in the afternoon and he hasn't had once since. When asked if she knew what the resident's shower days were, the resident stated, I think on Monday and Thursday. The spouse stated, He needs a shower. He is dirty. Resident #48 stated She's right. Review of a care plan progress note dated 08/05/25 revealed that the DON, SW and Staff M, Clinical Service Coordinator/CSC, had a meeting with Resident #48 and his spouse and the spouse was concerned that the resident was not getting a shower. Staff M informed the spouse she would speak to the Certified Nursing Assistants (CNAs) about the resident getting a shower. An interview was conducted on 08/12/25 at 3:32 PM with Staff H, CNA, who was asked if there was a shower book. Staff H stated, Yes. She looked around at the nurse's station and was not able to find the book. Staff H stated, Normally, I give my residents a bed bath unless they request a shower. When asked, but there is a shower schedule, she stated, Yes, usually the nurses have the schedule. When asked is there a task on the computer that tells you what days the resident is scheduled for a shower, Staff H acted as if she was unsure of where to go in the record to show where to find the shower schedule. She went to Staff M to ask her about the shower schedule and it was provided to her by Staff M. Review of the shower schedule revealed Resident #48 was scheduled to receive a shower on Monday and Thursday during the 7:00 AM to 3:00 PM shift. An interview was conducted with Staff H on 08/12/25 at 3:42 PM who was asked if the CNAs are aware of the shower schedule and how they knew when the resident was scheduled to get a shower, she stated, It is under the task in computer. Staff H showed the surveyor that it was under 'task' in the computer where the CNA could find the resident's shower days. When asked what if the resident refused the shower, she stated, Then the CNA should document refused under the task. When asked if she was familiar with Resident #48, she stated, Yes. When asked if she was at the meeting that the DON and SW had with the spouse regarding the resident not receiving a shower, Staff H, CSC, stated, Yes, it was discussed at the care plan meeting. You must understand this resident, the spouse wanted him to receive a shower, but he is ok with a bed bath. When asked if she had spoken to the CNAs regarding offering the resident a shower as stated in her plan of care progress note, she stated, Yes, they are aware that he wants a shower. When asked why the resident hadn't received a shower since the meeting last Tuesday, Staff H had no response. Review of the CNA task revealed that Resident #48 had not received or refused a shower as scheduled on Thursday, 08/07/25 or Monday, 08/11/25.

Based on record review, interview, policy review, and surveillance camera review, the facility failed to ensure a resident's advance directive choices were honored for a resident's expressed wishes for a Do Not Resuscitate (DNR) order for 1 of 4 sampled residents reviewed for DNR status (Resident #1). The deficient practice caused Resident #1 to have likely suffered serious psychological harm by the facility's attempt to be resuscitated against his wishes. Resident #1 could not express his reaction to this event; therefore, the reasonable person concept was applied. Additionally, there was a likelihood that Resident #1 experienced severe physical pain; broken ribs; broken sternum and bleeding in the chest area from the resuscitation efforts (https://pubmed.ncbi.nlm.nih.gov/38206442/). The facility staff did not follow their procedure to verify code status prior to initiating CPR. These actions resulted in the identification of Immediate Jeopardy. The facility administrator was informed of the Immediate Jeopardy on [DATE] at 9:45 AM. The Immediate Jeopardy was removed after verification of the facility's removal plan on [DATE], with an effective date of [DATE]. The scope and severity was reduced to D, no actual harm with potential for more than minimum harm. At the time of the investigation, there were 63 residents who were identified as DNR status. The findings included: A review of the facility's policy titled Advanced Directives and Code Status, dated [DATE] and [DATE], revealed the code status order will be documented in the electronic record and will serve as the primary source of validation of code status by a licensed nurse should a resident be found unresponsive. If the electronic record has an order for DNR, then CPR will not be initiated. If the electronic record is down, the code status must be verified by a licensed nurse using the backup code status notebook. The State of Florida DNR form will be used to communicate a resident's DNR code status wishes to 911/Emergency Medical Services (EMS) should the resident be found unresponsive. Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the prostate (prostate cancer), Type 2 Diabetes Mellitus, Hypertension, and Muscle weakness. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required substantial/maximum assistance with activities of daily living. Resident #1 was care planned for a DNR on [DATE]. An intervention included to verify the presence of physician order for a DNR. The resident had an order for DNR date [DATE]. Resident #1's DNR form/document was signed on [DATE] by the resident. The document was signed by the physician, but not dated. A review of Resident #1's progress notes, written by Staff Nurse A, a Licensed Practical Nurse (LPN), dated [DATE] at 5:30 AM, revealed Resident #1 became unresponsive while care was being provided by Staff B, a Certified Nursing Assistant (CNA) and Staff C, a Certified Nursing Assistant (CNA). Staff Nurse A went to the room and the resident was difficult to arouse. Staff Nurse A, checked the computer for the code status, which was a DNR. Staff A then proceeded to check the DNR status binder for a signed yellow DNR document, which was not in the binder. Staff Nurse A returned to the room, tried to arouse the resident again without success, and called 911. There was no documentation in the progress note on whether or not the nurse assessed the resident for a pulse or respirations, or that she had initiated CPR. The progress note stated the resident was transferred to the hospital for further evaluation and treatment. During an interview with the Director of Nursing (DON) on [DATE] at 11:30 AM. The DON acknowledged Resident #1 had a Do Not Resuscitate Order (DNRO) and a signed DNR document. During an interview with the Unit Manager (UM) on [DATE] at 1:20 PM. The UM stated she received a call on [DATE] at approximately 5:55 AM from Staff A, who stated Resident #1 was being dressed for dialysis and stopped talking. The resident was not responding. The UM asked for the code status of the resident, and was told the resident was a DNR and had been sent out. The UM stated she called the nurse back and asked if she did CPR, and nurse stated yes. Then the UM called the Director of Nursing (DON) to inform her of the incident. The UM stated when she came in the facility, Resident #1 did not have a DNR form/document in the Red book/DNR status binder. The UM stated, she printed out the form and placed it in the binder. The UM stated, residents should have a DNR form in the binder for when residents transfer out, or in the case of a power outage. A telephone interview was conducted with the Risk Manager (RM) via telephone on [DATE] at 2:30 PM. The RM stated, he was notified via telephone that Resident #1 was sent out via 911 on [DATE]. The RM stated, he started a chart review and spoke to staff about what occurred. The RM reviewed the surveillance cameras, and interviewed Staff A, Staff B, and Staff C, who all provided written statements. The RM stated, the root cause analysis was human error. The RM stated, Staff A knew Resident #1 had an order for a DNR in the electronic records, but second guessed herself and looked in the DNR status binder. The RM further stated that Staff A stated she did CPR on the resident. During an interview on [DATE] at 4:00 PM with Staff Nurse A, LPN, Staff Nurse A explained that 10 minutes prior to the incident, Resident #1 was getting ready for dialysis and being helped by two CNAs, Staff B and Staff C. When she got notified of the resident being unresponsive, she was shocked, ran to the room, shook him and called his name, and there was no response. Staff A stated she went back to the nursing station, checked the DNR Status binder and did not find the DNR document. Staff A stated she called 911 and the operator said to start CPR. Staff A stated she got the crash cart and went to the resident's room, a few seconds later EMS arrived. Staff A stated, there was no time for me to perform CPR. CPR was started by EMS. Staff A stated that in the 8 years that she had been working in this facility, she was always told that the confirmation of a DNR status relied on the yellow DNR document in the binder on each unit. If no DNR document was found in the binder, the resident should be treated like a full code. But they changed management so many times. Staff A stated she did not tell the 911 operator or EMS that the resident had a DNR order because they did not ask. There was conflicting information from Staff Nurse A's interview with the surveyors. Staff A stated to the surveyors that she did not initiate CPR prior to EMS arriving. However, a review of the EMS report, dated [DATE] 05:24 AM, stated upon their arrival Rescue found the patient lying supine in a hospital bed with CPR in progress. On [DATE], the DON provided a copy of the Advance Directive Acknowledgment form signed by Staff Nurse A, dated [DATE], which demonstrated Staff Nurse A had read and understood the facility's Advance Directive policy, which stated that the primary source to verify code status is the order in the electronic health record in PCC (Point Click Care). During an interview with the Social Service Director (SSD) on [DATE] at 5:00 PM. The SSD stated her department is responsible for placing DNR documents in the chart and binder. Before the DNR document is placed in the DNR status binder, it has to be signed and dated by resident/representative and physician. The document is placed in the binder and scanned into the electronic medical record (EMR) within the same day. The SSD stated she probably took the resident's DNR document from the binder, scanned it into EMR, and did not replace it back into the binder. The SSD stated it is an expectation that every resident that has a DNR order has a DNR document in the DNR status binder. On [DATE] the surveyors reviewed the [DATE] surveillance footage which showed the paramedics wheeling Resident #1 down the hallway of the facility with the chest compression machine operating and ambu bag for oxygenation (the full form of AMBU is Artificial Manual Breathing Unit. This device is used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). A review of the hospital emergency department admission record, dated [DATE] at 5:47 AM, revealed Resident #1 was admitted while receiving CPR. The hospital emergency department notes documented EMS was called for patient unresponsiveness, the call was placed approximately 10 minutes prior to their arrival. There was no pulse on their arrival. At the time of the patient arrival in the Emergency Department, there had been no pulse for at least 30 minutes. IJ Removal: On [DATE] the facility provided an acceptable plan to remove the Immediate Jeopardy. The plan included the following immediate actions which were verified as implemented before the survey exit to prevent this event from reoccurring: 1. [DATE] Resident pronounced deceased at 5:51 AM by hospital personnel. 2. [DATE] MD was notified that the resident was transported to the hospital. 3. [DATE] Notification to unit manager. 4. [DATE] Notification of event to DCS (Director of Clinical Services). 5. [DATE] Notification to ED (Executive Director) 6. [DATE] - [DATE] Education on code status, DNR policy, abuse and neglect policy initiated for current license staff. With post quiz and attestation. 7. [DATE]- New hired licensed nurses will be educated on the advanced directive DNR policy with post quiz and attestation. Ongoing. 8. [DATE] Resident's chart review completed. 9. [DATE] Audit of medical records of current residents to validate DNR/CPR orders. 10. [DATE] Federal immediate report submitted with the notification to DCF and law enforcement. 11. [DATE] Code books reviewed for accuracy. Books located at each nursing station. 12. [DATE] The nurse involved in the incident was removed from the schedule pending investigation. 13. [DATE] Code blue drills to be performed as follows: every shift times 7 days, then every other day on different shift times 7 days, then weekly times 7 days, then monthly to include weekends and holidays starting on [DATE] until all nurses have attended a code blue drill with no deficiencies, alternating different scenarios of code status to increase staff understanding. 14. [DATE] Medical director notified of events and interventions. 15. [DATE] Crash carts audited. 16. [DATE] - [DATE] CPR cards audited for validation. 17. [DATE] Ad hoc meeting with Interdisciplinary Team (IDT) and medical. director. 18. [DATE] - [DATE] Quiz presented to licensed nurses to validate knowledge on code status and procedures competency as needed. 19. [DATE] Licensed nurse hires to be educated on current advanced directive policy attestation and competency and post quiz. Ongoing. 20. [DATE] New admissions/readmissions records to be reviewed daily Monday through Friday and AM clinical meeting on weekends by the nursing supervisor for accurate cold status. Ongoing. 21. [DATE] Reeducate SSD, UM, DCS, DQA on DNR policy and obtaining form DH1896 (DNR document) with physician and resident representative signature as soon as an order is received for DNR. 22. [DATE] - ongoing SSD/designee will do audit daily Monday through Friday during clinical meeting of binders kept at the nurses' station to ensure that form 1896 is in place for those residents with an order for DNR. 23. [DATE] - ongoing Results and outcome of audits of binders for Form 1896 to be presented monthly. 24. [DATE]- ,d+[DATE] audit results and outcome of drills to be presented weekly times 3 at ad hoc meeting. Then monthly times three months or until compliance to determine the effectiveness of the plan. Plan to be revised as necessary. 25. [DATE] Federal five day report submitted. 26. [DATE] Report to the board of nursing. 27. [DATE] - [DATE] Physician to be re educated on signing and dating Form 1896. IJ Removal date [DATE]. Review of the in-service attendance sheets validated the participation of licensed staff education on the above topics. 100% of the nurses were in-serviced. Review of the code blue audits revealed no concerns. On [DATE] and [DATE], interviews were conducted with licensed staff that represented all three shifts. All staff interviewed confirmed they were made aware of the incident that involve a resident with a DNR status that received CPR. They verbalized understanding the education provided and verified participation in at least one mock Code Blue drill. SSD acknowledged education on ensuring resident's DNR document was signed and dated by resident/representative, and placed in the DNR status binder on each unit, and continued audits. A telephone interview was conducted with the Medical Director on [DATE] at 11:00 AM. He acknowledged the above information.

Based on observation, record review, and interview, the facility failed to accurately assess 2 of 33 sampled residents. The Minimum Data Set (MDS) assessment was inaccurate related to indwelling urinary catheter use for Resident #79 and related to the discharge status for Resident #141. The findings included: 1. Review of the record revealed Resident #79 was admitted to the facility on [DATE] with a return to the facility on [DATE]. Review of the admission progress note on 03/15/24 at 8:48 AM documented the resident was readmitted to the facility with a Foley catheter (indwelling urinary catheter) in place. Additional progress notes, to include those on 03/25/24, 04/01/24, and 04/03/24, all referred to the use of the indwelling urinary catheter. An observation on 04/15/24 at 12:32 PM revealed Resident #79 in bed. An indwelling urinary catheter bag was noted to bedside drainage. Review of the Admission Minimum Data Set (MDS) assessments dated 03/21/24 lacked the documented use of the indwelling urinary catheter. During an interview on 04/18/24 at 11:00 AM, Staff D, MDS Coordinator, explained her process for the completion of the Admission MDS was mainly by review of the record and interview of the resident for the pain assessment. The MDS Coordinator agreed with the inaccurate Admission MDS for Resident #79, and stated she most likely missed it because of the lack of an order. 39026 2. On 04/15/24, a closed record review for hospitalization was conducted for Resident #141. The discharge MDS dated [DATE] revealed the resident was coded as going to a short term general hospital but had actually been discharged home. A review of a social service progress note dated 01/25/24 revealed the resident was discharged with belongings and home health care had been arranged for him. An interview was conducted with Staff D, MDS coordinator, on 04/17/24 at 3:55 PM. Staff D was asked to review the discharge MDS for Resident #141 then read the social service progress note. Staff D stated the discharge assessment was coded wrong since it should have been coded as going home and not hospitalized . She stated it would be modified.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident reviewed with an indwelling urinary catheter (Resident #79). The findings included: 1. Review of the record revealed Resident #79 was admitted to the facility on [DATE] with a return to the facility on [DATE]. Review of the admission progress note on 03/15/24 at 8:48 AM documented the resident was readmitted to the facility with a Foley (indwelling urinary catheter) in place. Additional progress notes, to include those on 03/25/24, 04/01/24, and 04/03/24, all referred to the use of the indwelling urinary catheter. An observation on 04/15/24 at 12:32 PM revealed Resident #79 in bed. An indwelling urinary catheter bag was noted to bedside drainage. Review of the current care plans lacked any care plans related to the use of the indwelling urinary catheter. During an interview on 04/18/24 at 11:00 AM, Staff D, Minimum Data Set (MDS) Coordinator, agreed with the lack of a care plan for the indwelling catheter for Resident #79, and stated she most likely just missed it as there was no other documentaiton.

Based on record review and interview, the facility failed to ensure ordered labs were completed timely for 1 of 5 sampled residents, Resident #194. The findings included: Review of the record revealed Resident #194 was admitted to the facility on [DATE], after a hospitalization for a hip replacement. Review of the record revealed a physician order dated 04/05/24, for a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP) to be drawn on 04/06/24. Review of the record revealed a CBC was collected on 04/08/24. The record lacked a BMP on or about 04/06/24. Review of the progress notes lacked any documentation related to the failure to obtain the CBC on 04/06/24 as ordered, the reason for the late collection on 04/08/24, and or the failure to obtain the BMP. An additional order dated 04/16/24 at 8: 23 AM ordered a CBC, CMP (comprehensive metabolic panel), and BMP for a follow up. The record revealed intravenous fluids were ordered on 04/17/24 at 4:27 PM for dehydration, and a progress note revealed the fluids were initiated on 04/18/24 at 12:35 AM. During an interview and side-by-side record review on 04/18/24 at 10:34 AM, the Unit Manager explained the process for obtaining physician ordered labs was to enter the order into the electronic record so that it will be generated for the night shift to fill out the requisition for the laboratory technician. When asked about the failure to obtain the BMP for Resident #194 on 04/06/24 as per physician order, the Unit Manager was unaware. The Unit Manager obtained information directly from the laboratory's website that documented on 04/08/24 at 11:31 AM, they had rejected the order because they did not receive a specimen in accordance with the testing ordered. Additional details were documented as, Incorrectly ordered a CMP but testing would not be able to be completed due to only receiving a lavender vial. Note a lavender vial is used by the laboratory for a CBC but is not able to be used for a CMP. During an interview on 04/18/24 at 12:35 PM, the Director of Nursing (DON) verbalized the same process for ordering labs and ensuring the requisition was in the binder. The DON stated they review the labs during the morning meetings. When asked how or why the facility did not catch the missing BMP order, the DON had no answer. A side-by-side review of the CBC that was completed on 04/08/24 revealed it had been reviewed by the Unit Manager.

Based on observation, record review, and interview, the facility failed to ensure accurate and complete resident records for 4 of 33 sampled residents, as evidenced by: the record for Resident #79 lacked an order for the indwelling urinary catheter; the record for Resident #36 lacked documentation related to a change in a code status; the record for Resident #57 had inaccurate documentation related to a dressing change; and the record for Resident #92 lacked documentation related to blood sugar monitoring. The findings included: 1. Review of the record revealed Resident #79 was admitted to the facility on [DATE] with a return to the facility on [DATE]. Review of the admission progress note on [DATE] at 8:48 AM documented the resident was readmitted to the facility with a Foley catheter (indwelling urinary catheter) in place. Additional progress notes, to include those on [DATE], [DATE], and [DATE], all referred to the use of the indwelling urinary catheter. An observation on [DATE] at 12:32 PM revealed Resident #79 in bed. An indwelling urinary catheter bag was noted to bedside drainage. Review of all orders on [DATE] and [DATE], both current and discontinued, lacked the documented use of the indwelling urinary catheter. Review of the record on [DATE] revealed an order as of [DATE] at 4:11 PM for the indwelling urinary catheter. As per the Unit Manager, the nursing staff informed her today that there was no order for the urinary catheter. The Unit Manager agreed the record had lacked the order for the past month, which led to the inaccurate Minimum Data Set (MDS) assessment and lack of associated care plan. 39026 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction without residual deficits, Type 2 Diabetes Mellitus, and Pressure Ulcer of sacral region. Resident #36's Brief Interview for Mental Status (BIMS) documented a score of 11 on the Minimum Data Set (MDS) admission assessment with an assessment reference date of [DATE], indicating the resident had mild cognitive impairment. On admission to the facility, the resident's code status was full code. On [DATE], a DNR (Do Not Resuscitate) was signed by the resident and the Medical Director. On [DATE], the DNR was rescinded by resident request and a CPR (Cardio-Pulmonary Resuscitation) order was signed by the Medical Director. Upon review of the electronic health record (EHR), the surveyor could not find any documentation of a conversation with the resident about the change in code status. There was no documented conversation that the resident understood what CPR was or what DNR was. An interview was conducted with the Social Service Director (SSD) on [DATE] at 10:45 AM. The SSD was asked about the change in code status for Resident #36 and if there was any documentation regarding the change. On [DATE] at 11:10 AM, the SSD produced a Partners in Care POC / Individualized Plan of Care (IPOC) summary that stated on [DATE] she met with the resident to discuss Advance Directives. The document documented: 'The resident expressed wishes of changing from DNR to CPR [full code]. The Medical Director would be notified and update records. Hospice to be updated.' The note did not indicate who explained DNR to the resident or if it had been explained to the resident. The SSD stated a nurse was with her at the time of the visit. An interview was conducted with Staff C (Licensed Practical Nurse / Unit Manager) on [DATE] at 11:13 AM. Staff C revealed when the patient was first admitted he was asked what his wishes were and he wanted to be DNR. He was his own responsible party. He said he wanted to live when interviewed on [DATE] and he wanted to change from DNR to CPR and the family also wanted him to have CPR. She stated she was in the room when the SSD discussed the Advance Directives. Staff C stated she fully explained what CPR meant and the resident said that he wanted to live. The findings were discussed with the Administrator on [DATE] at 11:30 AM that these code status notes should have been in the EHR. The Administrator agreed with this surveyor. 41837 3. Review of the facility's policy, titled, Midline Catheter Dressing Change, with a revised date of ,d+[DATE], included, in part, under Guidance: 1. Sterile dressing change using transparent dressing is performed: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label. Record review for Resident #57 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. The resident's diagnoses included: Severe Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Personal History of Urinary (Tract) Infections. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated [DATE] documented in Section C, a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #57 revealed an order dated [DATE] for Midline Insertion Date: Arm Circumference: Total Catheter Length: External Catheter Length: Measure arm circumference and external catheter length with each dressing change and PRN [as needed] one time only for Midline placement for 1 Day Measure circumference 10 cm above antecubital and in the morning every 7 day(s) for Midline evaluation Measure arm circumference 10 cm above antecubital. Contact MD if external measurement has changed from previous measurement and as needed for Midline evaluation Measure arm circumference 10 cm above antecubital. Contact MD if external measurement has changed from previous measurement. Review of the Physician's Orders for Resident #57 revealed an order dated [DATE] for Change Dressing on admission, 24 hours after insertion if applicable, then weekly and as needed in the morning every 7 day(s) for Midline Care Use transparent dressing, no gauze on site and as needed for Midline Care Use transparent dressing, no gauze on site and one time only for Midline Care for 7 Days Use transparent dressing, no gauze on site. Review of the Medication Administration (MAR) for Resident #57 for the month of [DATE] documented the midline dressing was changed on [DATE] by Staff B, Registered Nurse (RN). Review of the Care Plans for Resident #57 dated [DATE] documented a focus on: the resident has an active infection (UTI) in the urine and is on antibiotic intravenously. The goal was for the resident to maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable lab values and administration of IV antibiotic until resolution of infection process by [DATE]. The interventions included: educating family / visitor on contact precautions as needed. Encourage good, clean hygiene techniques, especially hand washing. Enhanced Precautions. Isolation as ordered. Medication as ordered. Observe IV site for infiltration. Offer and encourage increase PO fluids intake. On [DATE] at 11:59 AM, an observation was made of Resident #57 lying in bed with a midline central catheter dated [DATE] in the resident's right upper arm. Photographic Evidence Obtained. On [DATE] 9:30 AM, an observation was made of Resident #57 lying in bed with midline central catheter in resident's right upper arm with dressing dated [DATE]. During an interview conducted on [DATE] at 9:33 AM with Resident #57, who was asked if the dressing for the midline central catheter had been changed today or in the past 2 -3 days, he said 'no it has never been changed, it is supposed to come out soon because I finished the medicine.' An interview was conducted on [DATE] at 10:35 AM with Staff A, Licensed Practical Nurse (LPN), who was asked to look at the midline central catheter dressing for Resident #57. The LPN acknowledged the date on the dressing was [DATE]. Staff LPN. An interview was conducted on [DATE] at 10:55 AM with the Director of Clinical Services (DOCS) who acknowledged the dressing for the midline central catheter for Resident #57 was dated [DATE]. The DOCS also acknowledged the Medication Administration Record for Resident #57 documented the midline dressing was changed on [DATE] by Staff B, RN. A telephone interview was conducted on [DATE] at 11:03 AM with Staff B, RN, who stated she works at the facility PRN (as needed). When asked if she remembered taking care of Resident #57 on [DATE], she said she did. When asked if she performed a midline dressing change on [DATE] for the resident, she said no she did not. She said at most places where she works, the dressing changes are performed by the night shift. When asked why she documented on Resident #57's MAR that she did a midline dressing change, she said she must have clicked on it by accident, she has no problem doing the dressing changes. 32078 4. Record review revealed Resident #92 was admitted on [DATE] with diagnoses that included Diabetes Mellitus 2. Review of physician orders included an order for Humulin R to be administered per sliding scale, with a note that if blood glucose reading, which was to be taken before meals and at bedtime, was greater than 401, 22 units of insulin was to be administered and the physician or nurse practitioner was to be notified. Review of the [DATE] electronic Medication Administration Record (eMAR) for Resident #92 showed no blood sugar results recorded for [DATE] at 6:30 AM or [DATE] at 9:00 PM. There was no nurse documentation as to why the blood sugar results were not recorded, nor were there any notes to document if any insulin was given, and if not, why the insulin was not provided. On [DATE] at 9:16 AM, the Director of Nursing (DON) was informed of the missing 'nurse initials' and documentation regarding Resident #92's sliding scale insulin. She stated she would look into the concern and report back after her investigation. On [DATE] at approximately 2:00 PM, the DON stated that she had spoken with the resident's nurse, and the nurse had made a late entry addressing the missing documentation.

Based on observation and interview, the facility failed to meet the needs and requests of residents to reasonably accommodate the residents needs for 4 of 4 sampled residents (Residents #81, #22, #81 and #79), as evidenced by failure of answer call lights timely, provide additional assistance, and unable to locate a staff member to assist residents. The findings included: 1. Record review revealed Resident #81 was readmitted to the facility on [DATE]. The Annual minimum data set (MDS) assessment, reference date 12/07/22, recorded a brief interview for mental status (BIMS) score of 15, indicated Resident #81 was cognitively intact, and had no cognition impairment. The annual minimum data set (MDS) dated [DATE] indicated Resident #81 required supervision with bed mobility, limited assistance with transfer, supervision with locomotion on and off unit, extensive assistance with dressing, independent with eating, limited assistance toilet use and personal hygiene. On 01/23/23 at 9:50 AM, an interview was held with Resident #81, who stated, the facility did not have enough staff on the weekend. The resident stated, they're not here to answer call lights in a timely manner, she has waited a long time for staff to answer call lights. 2. Record review revealed Resident #22 was readmitted to the facility on [DATE]. The Quarterly MDS assessment, reference date 10/21/22, recorded a BIMS score of 15, indicated Resident #22 was cognitively intact, and had no cognition impairment. The quarterly minimum data set (MDS) dated [DATE] indicated Resident #22 Required extensive assistance one person assist with bed mobility, transfer, walk in room, locomotion on and off unit, and dressing, supervision with eating and toilet use, limited assistance with personal hygiene. On 01/24/23 at 9:55 AM, an interview was conducted with Resident #22, who stated, often times the facility was short staffed, she'd like to have some extra help. They expected her to ask for everything. They're not checking on her regularly. They take care of her neighbor, but they bypass her, it happens a lot. They're in and out of her room so fast, sometimes they say they don't have time to get things done. On 01/24/23 at 10:44 AM, an interview was held with Staff G, Certified Nursing Assistant (CNA), who stated the facility was short staff a lot. On 01/24/23 at 10:47 AM, an interview was held with Staff H, CNA, who stated she did not have enough time to care for the residents, but she tried her best. She stated, sincerely you can't provide care at 100% to the residents, we provide care at 40-70% sometimes 90%. She voiced the facility was short staffed. 3. Review of the quarterly minimum data set (MDS) dated [DATE] indicated Resident #98 required extensive assistance one person assist with bed mobility, transfer, and locomotion on unit, total dependence by one staff assistance with locomotion off unit, extensive assistance one person with dressing, limited assistance by one person with eating, extensive assistance by one staff assistance with toilet use, total dependence assistance one person with personal hygiene. Observation of Resident #98 on 01/24/23 at 11:18 AM revealed the surveyor went in room [ROOM NUMBER] and the resident in the window bed was lying in bed flat with yellowish / white mucous-like substance coming from her mouth and on her chin. The resident stated what happened and was trying to wipe her mouth with her hand. There was additional mucous like substance on her blankets. The surveyor pressed call light for help. The call light was not in the resident's reach. At 11:27 AM, the surveyor went to look for help since the call light was not responded to. There were no staff in the halls or at the nurse's station. On 01/26/23 at 9:06 AM, an interview was held with the Nursing Home Administrator (NHA) in the presence of the Director Of Nursing (DON) and the Regional Nurse Consultant. They were made aware of the residents' concerns relating to the residents' lack of care. On 01/26/23 at 9:50 AM, while the surveyor was going to the first floor, the surveyor heard a beeping sound, that indicated a resident had activated the call system, to call staff. The surveyor noted Resident #79's call light was on. At that time, the surveyor stood at the nursing station to monitor the call light, the light at the top of the resident's room entrance door was on. There was a staff member, Staff J, Certified Nursing Assistance (CNA) / clinical support specialist, sitting at the nursing station. Staff J did not acknowledge the call light. The first-floor unit manager was noted walking on the first floor. She came to the nursing station and left without acknowledging the call light. At 10:01 AM, the DON, who came to the nursing station, sat at the nursing station and asked Staff J to go and answer the call light. During this time, the surveyor had informed the DON, the surveyor was monitoring the call light, and had observed that staff had not acknowledged the call light. 4. Review of the quarterly minimum data set (MDS) dated [DATE] indicated Resident #79 required extensive assistance one person assist with bed mobility, total dependence by 2+ staff assistance with transfer, total dependence by one staff assistance with locomotion on and off unit, extensive assistance one person with dressing, supervision assistance by one person with eating, total dependence by one staff assistance with toilet use, extensive assistance one person with personal hygiene. On 01/26/23 at 11:42 AM, an interview was held with Resident #79, who voiced the facility did not have enough staff to respond timely to her needs. She stated, she has stayed in dirty adult brief for 4 hours sometimes. Resident #79 continued to state, the staff did not answer her call light in a timely manner. During the interview Resident #79 became upset and raised her voiced a couple of times. She indicated that, she currently has a migraine, and she hasn't seen the nurse yet, she hasn't received her morning medications yet.

Based on interview and record review, the facility failed to monitor the effectiveness of interventions and revise a resident's comprehensive care plans for a resident with dementia and known behaviors including wandering, entering other resident rooms, physical aggression, inappropriate behaviors towards female residents, and exit seeking, for 1 of 1 residents (Resident #1) reviewed for an elopement out of 3 residents listed in the facility's Adverse Incident log. The resident was able to elope from the facility on April 11, 2020 and was found by police at a nearby shopping center. Upon return to the facility after an evaluation at the hospital, the resident was observed with swelling to the face and knuckles, abrasions, discoloration, and scratches. He was discharged from the facility on April 16, 2020 related to another incident with a female resident after returning to the secured unit. The facility's failure to adequately address Resident #1's behavior of unsafe wandering and exit seeking resulted in the finding of Immediate Jeopardy, past non-compliance on 04/11/2020. The Immediate Jeopardy was determined to be corrected on 04/20/2020, prior to the survey. The findings included: Review of the facility's policy titled: Risk Management: Elopement Risk (effective date: April 2006 and revision date: March 2016) showed: 1. If the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Center staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. Review of Resident #1's clinical record on 04/23/2020 showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing assessment dated [DATE] showed his behavioral concerns included: Confusion/forgetfulness; [DIAGNOSES REDACTED]. Resident #1 was also admitted with an order for [REDACTED]. Review of Resident #1's comprehensive care plans included: -(Resident #1) has Wandering Behavior and is at risk for Elopement related to: history of wandering through hallways. (Date initiated: 11/07/2019) Goal: (Resident #1) will have physical, emotional, and psychological needs met as evidenced by reduction in behaviors or decreased wandering. (Date initiated 11/07/2019) Goal: (Resident #1) will be protected from elopement and unsafe wandering through next review. (Date initiated: 01/24/2020) Interventions: Ensure environment is clutter free (Date initiated 01/24/2020) Ensure resident identifier is in place (Date initiated: 11/17/2019 and Date created: 12/16/2019) Include staff in information processes for observances for cues to behavior (Date initiated: 01/24/2020) Observe for wandering that effects other and redirect as needed. (Date initiated 01/24/2020) Wander guard (Date initiated: 11/17/2019 and Date created: 12/16/2019) -(Resident #1) has impaired cognition as evidenced by: Decision making problem/Short term memory deficit/Long term memory deficit/Problems understanding others. (Date initiated: 10/13/2019) -(Resident #1) is at risk for falls related to: [DIAGNOSES REDACTED]. (Date initiated 01/11/2019) Review of Resident #1's clinical record on 04/23/2020, and a subsequent request made on 04/24/2020 for all of Resident #1's comprehensive care plans, showed no care plans were found addressing exhibited behaviors such as physical aggression, inappropriate behaviors towards female residents, and wandering into other resident rooms. The care plans reviewed did not describe the type or frequency of supervision needed to address Resident #1's wandering, including into other resident rooms while on the secured unit, or show any change in level of supervision needed when he was transferred to the unsecured unit. His care plan for wandering behavior showed an intervention for a wanderguard but was not revised when it was discovered he could remove the wanderguard prior to his elopement. Review of Resident #1's January 2020 Progress Notes showed: -1/18/2020 Resident #1 was found in (room #) without clothes in bed. He was given his clothes and redirected to his room. He refused to leave and became physically abusive to a female resident hitting her on her hand. He stated he will kill staff. -1/18/2020 Resident #1 seen by Dr., new order for Ambien -1/24/2020 Resident #1 was combative, going room to room looking after the woman, all meds given as per ordered, not effective Review of Resident #1's physician's orders [REDACTED]. -1/18/2020 Send resident to hospital for Altered Mental Status. Physical Aggression and Hitting other resident -1/18/[MEDICATION NAME] 5 milligrams give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] -1/24/2020 Resident meets criteria for gated 100 unit Review of Resident #1's Elopement Risk Scale dated 1/24/2020 showed: -Resident #1 is ambulatory, expresses a desire and plans to leave, has a strong identification with past roles, has 2 or more attempts to leave the facility in last 90 days, has a medical [DIAGNOSES REDACTED]. -His score was 17 indicating high risk for elopement. -The care planning section showed one intervention marked: include staff in information process for observances for cues to behavior. Review of Resident #1's February 2020 progress notes showed: -2/26/2020 Ambulated up and down the hallway throughout entire 11-7 shift resident redirected, offered fluids, toileted and allowed time to vent. No change in behavior Review of Resident #1's March 2020 progress notes showed: -3/7/2020 Resident #1 was sitting in the dining room. A female resident came and waved her finger at his face. Resident #1 then kicked the resident's leg. The other resident swung her purse at him. Staff intervened and removed the aggressor. Resident #1 grabbed a wet floor sign and attempted to hit the aggressor. -3/23/2020 Observed pushing and punching another resident on the floor. Biting on staff member. Resident pacing the floor backwards and forward in an aggressive behavior. Awake alert and confused, broken glass in resident room and trying to get out of lock down unit. Recommendation: Send resident to ER intake for psych -3/24/2020 Returned to facility. Interdisciplinary Team meeting with new interventions to include a complete review of resident medications, psych consult, and resident will be removed from unit and placed on the 400 unit with a wanderguard. -3/26/2020 Wandering on floor, shift had to continue to redirect him -3/28/2020 Resident #1 made two attempts to escape floor, with the second nearly ended with resident taking north stair, but stopped by other nurse and aide. After giving some sleeping aids and redirecting back to bed, remained there for the duration of the night. -3/30/2020 Resident wanderguard was not in place Review of the Federal Immediate Report submitted by the facility for the 03/24/2020 incident showed: According to staff reports on 03/24/2020 at approximately 00.15 AM, (Resident #1) and (female resident) were having an altercation; both residents reside in the secured/dementia unit of this facility. They were observed screaming at each other and (Resident #1) attempted to hit (female resident); staff members immediately intervened and separated both residents. (Resident #1) tried to bite and punch staff members when they tried to redirect him. (Resident #1) was sent to the hospital for aggressive behaviors. (Female resident) had a thorough skin assessment performed, no bruises or other injuries noted or reported. Investigation began in facility. Review of the Federal 5 Day Report submitted by the facility showed: (Resident #1) is a [AGE] year old male who was admitted to this facility in October 2019 for long-term care in the secured unit. He has a history of kidney failure, hypertension, dementia, muscle weakness and [MEDICAL CONDITION]. He is alert with confusion and has a BIMs of 7. Upon investigation, on 3/24/2020 at approximately 00.15 AM both (Resident #1) and (female resident) were observed screaming at each other. Staff tried to redirect both residents, at this time (Resident #1) became aggressive an attempted to hit (female resident) and the staff. Both residents were separated immediately. (Resident #1) was sent to the hospital for aggressive behaviors. (Resident #1) returned to this facility a few hours later. He was moved to another floor and a wanderguard placed on his ankle for monitoring. (Female resident) remained in the secured unit with close supervision. Based upon investigation, chart review and staff interviews; this facility cannot substantiate this incident as abuse. Actions taken by the facility showed: DCF and family notified Residents separated Skin assessment Wanderguard placed on (Resident #1) (Resident #1) moved to another floor Review of Resident #1's physician's orders [REDACTED]. -3/24/2020 Send resident to ER for aggression and hitting other resident -3/25/2020 Check wanderguard placement every shift -3/25/2020 Check wanderguard every shift to ensure its functioning properly Review of Resident #1's April 2020 progress notes showed: -4/2/2020 Confused noted being combative and pushing staff. Writer personally bathed patient for staff protection as patient was covered in dried feces. meds well tolerated patient noted resting for 2 hours before wandering. hourly rounds done due to patient not having wanderguard -4/4/2020 Received resident resting from another room for at least two hours and then wake up. Resident was wandering, redirected him to his room and then resting for the of the night -4/11/2020 Resident was observed on unit most part of the shift. Resident is very agitated/energetic, constantly wandering down the hall. Redirection was given several times/unsuccessfully. Around 2030, the nursing staff became aware of Resident's disappearance by the Nursing Supervisor. -4/11/2020 Change of Condition form. Room search was done after 911 call, alarm was sounding on 400 wing stair exit door. Police notified the facility that resident was walking in the parking lot at (local shopping plaza), awake alert and confused. Police officer had him in the back of squad car, ambulance called, and resident transferred to (hospital) via 911 ambulance for evaluation and treatment. MD and family member notified. -Late Entry for 4/11/2020 (created 04/14/2020) Patient alert with confusion noted. Patient transferred from 400 wing. Patient has abrasion to right shoulder with redness noted and right cheekbone is red and swollen. Right hand swollen/knuckles are bruised with discoloration noted. -4/12/2020 returned from (hospital) Diagnosis: [REDACTED].Resident received with facial raised area/swollen to right cheekbone. Right shoulder abrasion, red with no bleeding present. Right hand swollen, knuckles with discoloration Resident with no wanderguard on, will address in AM. -4/12/2020 Xrays and CT scan reveal no abnormal structures or fractures .resident roamed halls and entered other room. Tried redirecting many times but continued to persist on eloping. Forcibly removed wanderguard. -4/13/2020 Received resident alert but with confusion, wandering hallways and touching exit doors constantly. A bruise was noted just below right eye, same appears to be healing well. Right fingers noted to be swollen with small bruises on same, bruises. scratches noted near left elbow .Resident was seen in (room #) at 21:00 shaking the resident in (room #'s) TV. No picture can be seen on TV when turned on .Resident was medicated as per Medication Administration Record [REDACTED]. -4/14/2020 Resident alert and confused he wanders all over the floor he's in and out of resident's room. He removed his wanderguard. -4/14/2020 Became combative early in the morning. was redirected and wanderguard placed on right ankle. Patient was calm during this time/placing wanderguard on ankle. -4/16/2020 Risk Manager was informed by a female resident that Resident #1 came into her room last night on 4/15/2020 and pulled down his pants .she stated she was going to scream and that is when he left. -4/16/2020 Social Worker informed Resident #1's family member that the facility is no longer able to meet the needs of resident .Resident #1 wanders into other residents' room taking items that do not belong to him -4/16/2020 resident discharged to an assisted living facility Review of the facility's Adverse Incident report to the State related to Resident #1's elopement dated 04/16/2020 showed: (Resident #1) is a [AGE] year-old male who was admitted to this facility in October of 2019 for long-term care in the secured unit. He has a history of kidney failure, hypertension, dementia, muscle weakness and [MEDICAL CONDITION]. He is alert with confusion and has a BIMs of 7. (Resident #1) had engaged in an altercation with a female resident on 3/24/2020 and as a result was referred to the hospital for evaluation of physical aggression and psychotic behaviors. Upon his readmission, he was placed on the short term Covid 19 monitoring unit as required by law for 14 days in an attempt to manage the spread of the Covid 19 pandemic from new hospital admissions and readmissions. After readmission, (Resident #1) presented with no symptoms and was managed on the 400 unit with a wander guard and close supervision away from the secured unit. After the 14 days he was not returned to the secured unit because the victim from the previous altercation still resides there. On (DATE), the facility transferred (Resident #1) to the 200 wing long-term care unit with a wander guard and under close supervision by staff. The resident was stable and was kept engaged through one to one activities with several departments within the facility during the day. On Saturday April 11th, at approximately 2030, the nursing staff became aware that the resident was not on the 200 wing. The supervisor was notified as soon as the resident was noted to be missing. A room search and a facility search were initiated immediately. The search was in progress when the facility received a phone call from the police asking if there was a missing resident. The supervisor verbally identified the resident for the police officer. The officer said the resident was found wandering in a nearby parking lot. The resident was brought to the facility by the officer who requested a face sheet. The face sheet was provided, an ambulance was called, and the resident transferred to (hospital) via 911 for evaluation and treatment. An interview was conducted with Registered Nurse A (RN A), who was familiar with Resident #1 while he resided on the secured unit, on 04/23/2020 at 3:10 PM. RN A stated Resident #1 wandered a lot. On a typical day he is always back and forth and back and forth the halls. He was going to exits and pushing. She stated she works on the locked unit normally the doors alarm. He does this constantly. Wanderguards work everywhere. She stated Resident #1 had a female resident on the locked unit who followed him around. He would go in her room when she was on that side where he was. After that they moved her to the other hall. The locked unit is two halls. She stated staff know him so they watch him closely. She explained 'we know how he is and he has to always be in someone's sight, nurses and CNAs (Certified Nursing Assistant)'. An interview was conducted with CNA B on 04/23/2020 at 3:47 PM. CNA B was assigned to Resident #1 the day he eloped. She stated 'everybody on the floor was watching on him'. After he finished eating all his food she went to assist another resident. The remaining staff were watching him. She stated when she finished she did not see him. Staff started checking the building but every door was closed. By the time staff were looking for him the Supervisor called to say the police called. She stated the door in the 400 unit had an alarm but no one was in the 400 unit to hear it. She stated she only worked with Resident #1 after he was transferred to the 200 hall but knew he walked around alot and tried to leave. An interview was conducted with CNA C on 04/23/2020 at 3:53 PM. CNA C was working on the 200 unit when Resident #1 eloped. She stated Resident #1 always walked back and forth and she would redirect him to sit down. She stated staff knows where he is and when she would pass by him she would keep her eyes on him. An interview was conducted with Licensed Practical Nurse D (LPN D) on 04/23/2020 at 4:04 PM. LPN D was listed as the nurse on the 200 unit when Resident #1 eloped. She stated Resident #1 did not stay still and would go up and down the hallway. He would always go into other residents' rooms. She administered his [MEDICATION NAME] at 6 PM. He was still very agitated and it was ineffective. She stated he was always at the doors trying to leave. She stated he ate dinner and by 7:30 PM staff picked up the trays. He was still pacing the halls. At 8 PM staff started looking for him because they realized he wasn't there. He does not stay in his room. Staff always see him because he is near the nurse's station. He removed his wanderguard. The doors have alarms but the alarm to the 400 unit exit door was not heard all the way in the 200 unit. He has a steady gait. She stated there were no problems between Resident #1 and any residents on the 200 unit except he did wander into other residents' rooms and some may yell. She stated she was aware of his behaviors and that he doesn't stay still. Normally they do not have that type of resident in the 200 unit. An interview was conducted with the Executive Director, Director of Clinical Services, Risk Manager, and Assistant Executive Director on 04/23/2020 at 4:18 PM. The Director of Clinical Services explained that Resident #1 was on the locked unit at first but because he had the altercation he was transferred to the other unit. She stated Resident #1 and (female resident) had a little thing going but staff thought it was okay. The attraction became more aggression. Staff have seen them argue with each other but they let it slide. It was noted the interactions became more aggressive. (Female resident) would approach him and hit him with her purse. The facility reported the March 23 incident as resident-to-resident. The doctor re-evaluated him and sent him to the hospital. He was not kept and when he came back he was placed on the mandatory 14 day quarantine on the 400 unit. He was kept busy and a wanderguard placed. Staff knew he was a risk but he had never actually eloped. She stated staff found they could keep him busy with a broom because of his former job in a factory. Resident #1 and (female resident) were kept on separate areas. Resident #1 was sent to the 200 unit to separate him because they did know what would happen if he returned to the locked unit. The 400 unit was empty and staff never could have surmised that he would find his way all the way to the 400 hall. Everyone was aware of behaviors and redirected him with wanderguard on. The Risk Manager stated at some point he took his wanderguard off. The Director of Clinical Services stated they decided to put him back on the secured unit after his elopement. Resident #1 was discharged from the facility for another behavior. She stated when he eloped the police called to advise the facility they had Resident #1 while staff were still searching the building. The Risk Manager stated the police did not return Resident #1 to the facility but took him directly to the hospital and did not tell the facility why. She stated he did not have injuries prior to eloping. The Director of Clinical Services explained the facility allocated the 400 unit for a 14 day quarantine after returning from the hospital. There were other residents on the unit at the time Resident #1 was there. Since that time the 400 unit was closed to consolidate staff and residents. She stated Resident #1 is fast and steady on his feet. The Risk Manager stated the only time they noticed the wanderguard was not on him was when he eloped. The Director of Clinical Services stated Resident #1 was transferred from the facility after an incident with another female resident. She stated staff previously found Resident #1 in bed with (female resident) a few times and separated them. Nothing happened and he was fully clothed at the time. She stated initially she thought they were just holding hands but when it became aggressive then staff moved the residents to opposite halls. They would find each other in the morning and hold hands. But then it became aggressive. The Risk Manager stated Resident #1 had taken off his wanderguard the day he eloped. The alarm to the door went off but because it was so far away the staff did not hear it until they searched for him. Resident #1 walked from the 200 wing where he was admitted and walked to the 400 wing where he previously stayed. He found the back exit and went out to the parking lot. He was about 5 minutes away, 2 blocks in a straight line. She stated during their investigation Administrative staff re-enacted the steps. The staff on the unit that day did not see him walking to the 400. They said he was at the nurses station to be monitored. The CNA went to give care and when she came out she did not see him. The Director of Clinical Services stated since his elopement they put an alarm on the double doors on the 400 unit and a plastic zippered curtain at the entrance to the hall. She stated the facility was trying to keep both safe and both in the facility, Resident #1 and (female resident). He did not have the wanderguard while on the locked unit because he did not need it. She stated the doors throughout the facility have wanderguard alarms. She stated staff just had close supervision and tried to engage him in activities during the day time. He did well on 400 hall. He liked to clean. He was not on the 200 unit long. He was on the 400 unit for a longer period of time. He had done excellent on 400. He was happier on the 400. He wanted to sleep and clean. Review of Resident #1's progress notes and April 2020 MAR indicated [REDACTED]. He was documented as being able to remove it. Review of the Police Report on 04/28/2020 showed a call was made to the Police Department on 04/11/2020 around 08:49 PM from a nearby residence. Upon arrival, police observed Resident #1 on the sidewalk where he had been for approximately 10 minutes. Resident #1 was observed with a knot on his head and was described as confused and possibly lost. Emergency Services was called but Resident #1 began walking away towards the shopping plaza. Police also noted a hand injury. Emergency Services was called again. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, showing severe cognitive impairment. The Facility's actions to remove the Immediate Jeopardy included: 1) Resident #1 was placed back on the secured unit upon return from the hospital on [DATE]. A full body assessment was completed for Resident #1 upon return from the hospital. 2) All current residents with a [DIAGNOSES REDACTED]. No other residents were identified as an elopement risk except the residents currently on the secured unit. 3) An elopement drill was conducted with staff on 04/13/2020. 4) All exit door maglocks were inspected on 04/13/2020 to ensure proper functioning. 5) An additional alarm was placed on the double doors leading to the closed unit to make the alarm sound more audible on 04/13/2020. Nursing Supervisors were inserviced on 04/13/2020 regarding the new alarm on the double doors. 6) A zippered plastic partition was placed in the hallway of the closed unit as an additional barrier. 7) An ad hoc QAPI meeting was conducted on 04/13/2020 that included the Executive Director, the Director of Clinical Services, the Medical Director, the Assistant Executive Director, the Director of Quality Assurance, and other department heads. A Performance Improvement Plan was established. The corrective actions included: 1) Follow-up QAPI/Risk Management meetings were conducted on 04/16/2020 and 04/20/2020. 2) Residents with behaviors towards other residents were identified and interventions reviewed and revised beginning on 04/13/2020. 3) Administration completed daily checks of the newly installed door alarm. 4) Additional staff on Leave of Absence (LOA) or in quarantine were educated on elopement procedures via telephone and additional staff onsite beginning 04/14/2020 through 04/16/2020. As of 04/16/2020 the following portion of the facility's staff were educated about elopement procedures: 50 out of 77 CNAs, 25 out of 28 LPNs, 28 out of 38 RNs, 19 out of 23 staff listed under Administration, 11 out of 18 Environmental Services staff, 7 out of 20 culinary staff, and 12 rehabilitation staff. 4) New employee orientation packets for certified nursing assistants include information and quizzes regarding dementia care and elopement. Random staff interviews conducted by Surveyor confirmed knowledge of elopement procedures. Interviews conducted in person and via phone were conducted as follows: On 04/29/2020 from 02:25 PM until 04:06 PM, 2 CNAs and 2 RNs. On 04/30/2020 beginning at 01:31 PM, 1 Respiratory Therapist, 1 Social Services staff, 1 Medical Records staff, 1 Housekeeping staff, 1 Administrative staff, 4 RNs, 1 LPN, and 2 CNAs. An initial tour conducted on 04/23/2020 revealed the alarm to the double doors was in place leading to the closed unit and the zippered plastic partition was also in place further down the hall. A subsequent tour on 04/30/2020 revealed the alarm and barrier remained in place. No residents were observed actively exit seeking on 04/23/2020 or on 04/30/2020. Immediate Jeopardy was determined to be past non-compliance, corrected on 04/20/2020.

Based on interview and record review, the facility failed to provide necessary supervision and monitor the effectiveness of interventions for a resident with dementia and known behaviors including wandering, entering other resident rooms, physical aggression, inappropriate behaviors towards female residents, and exit seeking, for 1 of 1 residents (Resident #1) reviewed for an elopement out of 3 residents listed in the facility's Adverse Incident log. The resident was able to elope from the facility on April 11, 2020 and was found by police at a nearby shopping center. Upon return to the facility after an evaluation at the hospital, the resident was observed with swelling to the face and knuckles, abrasions, discoloration, and scratches. He was discharged from the facility on April 16, 2020 related to another incident with a female resident after returning to the secured unit. The facility's failure to adequately address Resident #1's behavior of unsafe wandering and exit seeking, including the provision of needed supervision, resulted in the finding of Immediate Jeopardy, past non-compliance on 04/11/2020. The Immediate Jeopardy was determined to be corrected on 04/20/2020, prior to the survey. The findings included: Review of the facility's policy titled: Abuse Prohibition Policy and Procedure (effective date: March 2015 and revision date: January 2018) showed: Neglect: Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's policy titled: Risk Management: Elopement Risk (effective date: April 2006 and revision date: March 2016) showed: 1. If the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Center staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behavior according to the plan of care. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. Review of Resident #1's clinical record on 04/23/2020 showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing assessment dated [DATE] showed his behavioral concerns included: Confusion/forgetfulness; [DIAGNOSES REDACTED]. Resident #1 was admitted with an order for [REDACTED]. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, showing severe cognitive impairment. Review of Resident #1's comprehensive care plans included: -(Resident #1) has Wandering Behavior and is at risk for Elopement related to: history of wandering through hallways. (Date initiated: 11/07/2019) Goal: (Resident #1) will have physical, emotional, and psychological needs met as evidenced by reduction in behaviors or decreased wandering. (Date initiated 11/07/2019) Goal: (Resident #1) will be protected from elopement and unsafe wandering through next review. (Date initiated: 01/24/2020) Interventions: Ensure environment is clutter free (Date initiated 01/24/2020) Ensure resident identifier is in place (Date initiated: 11/17/2019 and Date created: 12/16/2019) Include staff in information processes for observances for cues to behavior (Date initiated: 01/24/2020) Observe for wandering that effects other and redirect as needed. (Date initiated 01/24/2020) Wander guard (Date initiated: 11/17/2019 and Date created: 12/16/2019) -(Resident #1) has impaired cognition as evidenced by: Decision making problem/Short term memory deficit/Long term memory deficit/Problems understanding others. (Date initiated: 10/13/2019) -(Resident #1) is at risk for falls related to: [DIAGNOSES REDACTED]. (Date initiated 01/11/2019) Review of Resident #1's clinical record on 04/23/2020, and a subsequent request made on 04/24/2020 for all of Resident #1's comprehensive care plans, showed no care plans were found addressing exhibited behaviors such as physical aggression, inappropriate behaviors towards female residents, and wandering into other resident rooms. The care plans reviewed did not describe the type or frequency of supervision needed to address Resident #1's wandering, including into other resident rooms while on the secured unit, or show any change in level of supervision needed when he was transferred to the unsecured unit. His care plan for wandering behavior showed an intervention for a wanderguard but was not revised when it was discovered he could remove the wanderguard prior to his elopement. Review of Resident #1's January 2020 Progress Notes showed: -1/18/2020 Resident #1 was found in (room #) without clothes in bed. He was given his clothes and redirected to his room. He refused to leave and became physically abusive to a female resident hitting her on her hand. He stated he will kill staff. -1/18/2020 Resident #1 seen by Dr., new order for Ambien -1/24/2020 Resident #1 was combative, going room to room looking after the woman, all meds given as per ordered, not effective Review of Resident #1's Physican's Orders for January 2020 showed: -1/18/2020 Send resident to hospital for Altered Mental Status. Physical Aggression and Hitting other resident -1/18/[MEDICATION NAME] 5 milligrams give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] -1/24/2020 Resident meets criteria for gated 100 unit Review of Resident #1's Elopement Risk Scale dated 1/24/2020 showed Resident #1 is ambulatory, expresses a desire and plans to leave, has a strong identification with past roles, has 2 or more attempts to leave the facility in last 90 days, has a medical [DIAGNOSES REDACTED]. His score was 17 indicating high risk for elopement. Care planning section showed one intervention marked: include staff in information process for observances for cues to behavior. Review of Resident #1's February 2020 progress notes showed: -2/26/2020 Ambulated up and down the hallway throughout entire 11-7 shift resident redirected, offered fluids, toileted and allowed time to vent. No change in behavior. Review of Resident #1's March 2020 progress notes showed: -3/7/2020 Resident #1 was sitting in the dining room. A female resident came and waved her finger at his face. Resident #1 then kicked the resident's leg. The other resident swung her purse at him. Staff intervened and removed the aggressor. Resident #1 grabbed a wet floor sign and attempted to hit the aggressor. -3/23/2020 Observed pushing and punching another resident on the floor. Biting on staff member. Resident pacing the floor backwards and forward in an aggressive behavior. Awake alert and confused, broken glass in resident room and trying to get out of lock down unit. Recommendation: Send resident to ER intake for psych -3/24/2020 Returned to facility. Interdisciplinary Team meeting with new interventions to include a complete review of resident medications, psych consult, and resident will be removed from unit and placed on the 400 unit with a wanderguard. -3/26/2020 Wandering on floor, shift had to continue to redirect him -3/28/2020 Resident #1 made two attempts to escape floor, with the second nearly ended with resident taking north stair, but stopped by other nurse and aide. After giving some sleeping aids and redirecting back to bed, remained there for the duration of the night. -3/30/2020 Resident wanderguard was not in place Review of the Federal Immediate Report submitted by the facility for the 03/24/2020 incident showed: According to staff reports on 03/24/2020 at approximately 00.15 AM, (Resident #1) and (female resident) were having an altercation; both residents reside in the secured/dementia unit of this facility. They were observed screaming at each other and (Resident #1) attempted to hit (female resident); staff members immediately intervened and separated both residents. (Resident #1) tried to bite and punch staff members when they tried to redirect him. (Resident #1) was sent to the hospital for aggressive behaviors. (Female resident) had a thorough skin assessment performed, no bruises or other injuries noted or reported. Investigation began in facility. Review of the Federal 5 Day Report submitted by the facility showed: (Resident #1) is a [AGE] year old male who was admitted to this facility in October 2019 for long-term care in the secured unit. He has a history of kidney failure, hypertension, dementia, muscle weakness and [MEDICAL CONDITION]. He is alert with confusion and has a BIMs of 7. Upon investigation, on 3/24/2020 at approximately 00.15 AM both (Resident #1) and (female resident) were observed screaming at each other. Staff tried to redirect both residents, at this time (Resident #1) became aggressive an attempted to hit (female resident) and the staff. Both residents were separated immediately. (Resident #1) was sent to the hospital for aggressive behaviors. (Resident #1) returned to this facility a few hours later. He was moved to another floor and a wanderguard placed on his ankle for monitoring. (Female resident) remained in the secured unit with close supervision. Based upon investigation, chart review and staff interviews; this facility cannot substantiate this incident as abuse. Actions taken by the facility showed: DCF and family notified Residents separated Skin assessment Wanderguard placed on (Resident #1) (Resident #1) moved to another floor Review of Resident #1's physician's orders [REDACTED]. -3/24/2020 Send resident to ER for aggression and hitting other resident -3/25/2020 Check wanderguard placement every shift -3/25/2020 Check wanderguard every shift to ensure its functioning properly Review of Resident #1's April 2020 progress notes showed: -4/2/2020 Confused noted being combative and pushing staff. Writer personally bathed patient for staff protection as patient was covered in dried feces. meds well tolerated patient noted resting for 2 hours before wandering. hourly rounds done due to patient not having wanderguard -4/4/2020 Received resident resting from another room for at least two hours and then wake up. Resident was wandering, redirected him to his room and then resting for the of the night -4/11/2020 Resident was observed on unit most part of the shift. Resident is very agitated/energetic, constantly wandering down the hall. Redirection was given several times/unsuccessfully. Around 2030, the nursing staff became aware of Resident's disappearance by the Nursing Supervisor. -4/11/2020 Change of Condition form. Room search was done after 911 call, alarm was sounding on 400 wing stair exit door. Police notified the facility that resident was walking in the parking lot at (local shopping plaza), awake alert and confused. Police officer had him in the back of squad car, ambulance called, and resident transferred to (hospital) via 911 ambulance for evaluation and treatment. MD and family member notified. -Late Entry for 4/11/2020 (created 04/14/2020) Patient alert with confusion noted. Patient transferred from 400 wing. Patient has abrasion to right shoulder with redness noted and right cheekbone is red and swollen. Right hand swollen/knuckles are bruised with discoloration noted. -4/12/2020 returned from (hospital) Diagnosis: [REDACTED].Resident received with facial raised area/swollen to right cheekbone. Right shoulder abrasion, red with no bleeding present. Right hand swollen, knuckles with discoloration Resident with no wanderguard on, will address in AM. -4/12/2020 Xrays and CT scan reveal no abnormal structures or fractures .resident roamed halls and entered other room. Tried redirecting many times but continued to persist on eloping. Forcibly removed wanderguard. -4/13/2020 Received resident alert but with confusion, wandering hallways and touching exit doors constantly. A bruise was noted just below right eye, same appears to be healing well. Right fingers noted to be swollen with small bruises on same, bruises. scratches noted near left elbow .Resident was seen in (room #) at 21:00 shaking the resident in (room #'s) TV. No picture can be seen on TV when turned on .Resident was medicated as per Medication Administration Record [REDACTED]. -4/14/2020 Resident alert and confused he wanders all over the floor he's in and out of resident's room. He removed his wanderguard. -4/14/2020 Became combative early in the morning. was redirected and wanderguard placed on right ankle. Patient was calm during this time/placing wanderguard on ankle. -4/16/2020 Risk Manager was informed by a female resident that Resident #1 came into her room last night on 4/15/2020 and pulled down his pants .she stated she was going to scream and that is when he left. -4/16/2020 Social Worker informed Resident #1's family member that the facility is no longer able to meet the needs of resident .Resident #1 wanders into other residents' room taking items that do not belong to him -4/16/2020 resident discharged to an assisted living facility Review of the facility's Adverse Incident report to the State related to Resident #1's elopement dated 04/16/2020 showed: (Resident #1) is a [AGE] year-old male who was admitted to this facility in October of 2019 for long-term care in the secured unit. He has a history of kidney failure, hypertension, dementia, muscle weakness and [MEDICAL CONDITION]. He is alert with confusion and has a BIMs of 7. (Resident #1) had engaged in an altercation with a female resident on 3/24/2020 and as a result was referred to the hospital for evaluation of physical aggression and psychotic behaviors. Upon his readmission, he was placed on the short term Covid 19 monitoring unit as required by law for 14 days in an attempt to manage the spread of the Covid 19 pandemic from new hospital admissions and readmissions. After readmission, (Resident #1) presented with no symptoms and was managed on the 400 unit with a wander guard and close supervision away from the secured unit. After the 14 days he was not returned to the secured unit because the victim from the previous altercation still resides there. On (DATE), the facility transferred (Resident #1) to the 200 wing long-term care unit with a wander guard and under close supervision by staff. The resident was stable and was kept engaged through one to one activities with several departments within the facility during the day. On Saturday April 11th, at approximately 2030, the nursing staff became aware that the resident was not on the 200 wing. The supervisor was notified as soon as the resident was noted to be missing. A room search and a facility search were initiated immediately. The search was in progress when the facility received a phone call from the police asking if there was a missing resident. The supervisor verbally identified the resident for the police officer. The officer said the resident was found wandering in a nearby parking lot. The resident was brought to the facility by the officer who requested a face sheet. The face sheet was provided, an ambulance was called, and the resident transferred to (hospital) via 911 for evaluation and treatment. An interview was conducted with Registered Nurse A (RN A), who was familiar with Resident #1 while he resided on the secured unit, on 04/23/2020 at 3:10 PM. RN A stated Resident #1 wandered a lot. On a typical day he is always back and forth and back and forth the halls. He was going to exits and pushing. She stated she works on the locked unit normally the doors alarm. He does this constantly. Wanderguards work everywhere. She stated Resident #1 had a female resident on the locked unit who followed him around. He would go in her room when she was on that side where he was. After that they moved her to the other hall. The locked unit is two halls. She stated staff know him so they watch him closely. She explained we know how he is and he has to always be in someone's sight, nurses and CNAs (Certified Nursing Assistant). An interview was conducted with CNA B on 04/23/2020 at 3:47 PM. CNA B was assigned to Resident #1 the day he eloped. She stated 'everybody on the floor was watching on him'. After he finished eating all his food she went to assist another resident. The remaining staff were watching him. She stated when she finished she did not see him. Staff started checking the building but every door was closed. By the time staff were looking for him the Supervisor called to say the police called. She stated the door in the 400 unit had an alarm but no one was in the 400 unit to hear it. She stated she only worked with Resident #1 after he was transferred to the 200 hall but knew he walked around alot and tried to leave. An interview was conducted with CNA C on 04/23/2020 at 3:53 PM. CNA C was working on the 200 unit when Resident #1 eloped. She stated Resident #1 always walked back and forth and she would redirect him to sit down. She stated staff knows where he is and when she would pass by him she would keep her eyes on him. An interview was conducted with Licensed Practical Nurse D (LPN D) on 04/23/2020 at 4:04 PM. LPN D was listed as the nurse on the 200 unit when Resident #1 eloped. She stated Resident #1 did not stay still and would go up and down the hallway. He would always go into other residents' rooms. She administered his [MEDICATION NAME] at 6 PM. He was still very agitated and it was ineffective. She stated he was always at the doors trying to leave. She stated he ate dinner and by 7:30 PM staff picked up the trays. He was still pacing the halls. At 8 PM staff started looking for him because they realized he wasn't there. He does not stay in his room. Staff always see him because he is near the nurse's station. He removed his wanderguard. The doors have alarms but the alarm to the 400 unit exit door was not heard all the way in the 200 unit. He has a steady gait. She stated there were no problems between Resident #1 and any residents on the 200 unit except he did wander into other residents' rooms and some may yell. She stated she was aware of his behaviors and that he doesn't stay still. Normally they do not have that type of resident in the 200 unit. An interview was conducted with the Executive Director, Director of Clinical Services, Risk Manager, and Assistant Executive Director on 04/23/2020 at 4:18 PM. The Director of Clinical Services explained that Resident #1 was on the locked unit at first but because he had the altercation he was transferred to the other unit. She stated Resident #1 and (female resident) had a little thing going but staff thought it was okay. The attraction became more aggression. Staff have seen them argue with each other but they let it slide. It was noted the interactions became more aggressive. (Female resident) would approach him and hit him with her purse. The facility reported the March 23 incident as resident-to-resident. The doctor re-evaluated him and sent him to the hospital. He was not kept and when he came back he was placed on the mandatory 14 day quarantine on the 400 unit. He was kept busy and a wanderguard placed. Staff knew he was a risk but he had never actually eloped. She stated staff found they could keep him busy with a broom because of his former job in a factory. Resident #1 and (female resident) were kept on separate areas. Resident #1 was sent to the 200 unit to separate him because they did know what would happen if he returned to the locked unit. The 400 unit was empty and staff never could have surmised that he would find his way all the way to the 400 hall. Everyone was aware of behaviors and redirected him with wanderguard on. The Risk Manager stated at some point he took his wanderguard off. The Director of Clinical Services stated they decided to put him back on the secured unit after his elopement. Resident #1 was discharged from the facility for another behavior. She stated when he eloped the police called to advise the facility they had Resident #1 while staff were still searching the building. The Risk Manager stated the police did not return Resident #1 to the facility but took him directly to the hospital and did not tell the facility why. She stated he did not have injuries prior to eloping. The Director of Clinical Services explained the facility allocated the 400 unit for a 14 day quarantine after returning from the hospital. There were other residents on the unit at the time Resident #1 was there. Since that time the 400 unit was closed to consolidate staff and residents. She stated Resident #1 is fast and steady on his feet. The Risk Manager stated the only time they noticed the wanderguard was not on him was when he eloped. The Director of Clinical Services stated Resident #1 was transferred from the facility after an incident with another female resident. She stated staff previously found Resident #1 in bed with (female resident) a few times and separated them. Nothing happened and he was fully clothed at the time. She stated initially she thought they were just holding hands but when it became aggressive then staff moved the residents to opposite halls. They would find each other in the morning and hold hands. But then it became aggressive. The Risk Manager stated Resident #1 had taken off his wanderguard the day he eloped. The alarm to the door went off but because it was so far away the staff did not hear it until they searched for him. Resident #1 walked from the 200 wing where he was admitted and walked to the 400 wing where he previously stayed. He found the back exit and went out to the parking lot. He was about 5 minutes away, 2 blocks in a straight line. She stated during their investigation Administrative staff re-enacted the steps. The staff on the unit that day did not see him walking to the 400. They said he was at the nurses station to be monitored. The CNA went to give care and when she came out she did not see him. The Director of Clinical Services stated since his elopement they put an alarm on the double doors on the 400 unit and a plastic zippered curtain at the entrance to the hall. She stated the facility was trying to keep both safe and both in the facility, Resident #1 and (female resident). He did not have the wanderguard while on the locked unit because he did not need it. She stated the doors throughout the facility have wanderguard alarms. She stated staff just had close supervision and tried to engage him in activities during the day time. He did well on 400 hall. He liked to clean. He was not on the 200 unit long. He was on the 400 unit for a longer period of time. He had done excellent on 400. He was happier on the 400. He wanted to sleep and clean. Review of Resident #1's progress notes and April 2020 MAR indicated [REDACTED]. He was documented as being able to remove it. Review of the Police Report on 04/28/2020 showed a call was made to the Police Department on 04/11/2020 around 08:49 PM from a nearby residence. Upon arrival, police observed Resident #1 on the sidewalk where he had been for approximately 10 minutes. Resident #1 was observed with a knot on his head and was described as confused and possibly lost. Emergency Services was called but Resident #1 began walking away towards the shopping plaza. Police also noted a hand injury. Emergency Services was called again. The Facility's actions to remove the Immediate Jeopardy included: 1) Resident #1 was placed back on the secured unit upon return from the hospital on [DATE]. A full body assessment was completed for Resident #1 upon return from the hospital. 2) All current residents with a [DIAGNOSES REDACTED]. No other residents were identified as an elopement risk except the residents currently on the secured unit. 3) An elopement drill was conducted with staff on 04/13/2020. 4) All exit door maglocks were inspected on 04/13/2020 to ensure proper functioning. 5) An additional alarm was placed on the double doors leading to the closed unit to make the alarm sound more audible on 04/13/2020. Nursing Supervisors were inserviced on 04/13/2020 regarding the new alarm on the double doors. 6) A zippered plastic partition was placed in the hallway of the closed unit as an additional barrier. 7) An ad hoc QAPI meeting was conducted on 04/13/2020 that included the Executive Director, the Director of Clinical Services, the Medical Director, the Assistant Executive Director, the Director of Quality Assurance, and other department heads. A Performance Improvement Plan was established. The corrective actions included: 1) Follow-up QAPI/Risk Management meetings were conducted on 04/16/2020 and 04/20/2020. 2) Residents with behaviors towards other residents were identified and interventions reviewed and revised beginning on 04/13/2020. 3) Administration completed daily checks of the newly installed door alarm. 4) Additional staff on Leave of Absence (LOA) or in quarantine were educated on elopement procedures via telephone and additional staff onsite beginning 04/14/2020 through 04/16/2020. As of 04/16/2020 the following portion of the facility's staff were educated about elopement procedures: 50 out of 77 CNAs, 25 out of 28 LPNs, 28 out of 38 RNs, 19 out of 23 staff listed under Administration, 11 out of 18 Environmental Services staff, 7 out of 20 culinary staff, and 12 rehabilitation staff. 4) New employee orientation packets for certified nursing assistants include information and quizzes regarding dementia care and elopement. Random staff interviews conducted by Surveyor confirmed knowledge of elopement procedures. Interviews conducted in person and via phone were conducted as follows: On 04/29/2020 from 02:25 PM until 04:06 PM, 2 CNAs and 2 RNs. On 04/30/2020 beginning at 01:31 PM, 1 Respiratory Therapist, 1 Social Services staff, 1 Medical Records staff, 1 Housekeeping staff, 1 Administrative staff, 4 RNs, 1 LPN, and 2 CNAs. An initial tour conducted on 04/23/2020 revealed the alarm to the double doors was in place leading to the closed unit and the zippered plastic partition was also in place further down the hall. A subsequent tour on 04/30/2020 revealed the alarm and barrier remained in place. No residents were observed actively exit seeking on 04/23/2020 or on 04/30/2020. Immediate Jeopardy was determined to be past non-compliance, corrected on 04/20/2020.

Based on interview and record review, the facility failed to provide the supervision necessary to prevent an elopement for a resident with dementia and known behaviors including wandering, entering other resident rooms, physical aggression, inappropriate behaviors towards female residents, and exit seeking, for 1 of 1 residents (Resident #1) reviewed for an elopement out of 3 residents listed in the facility's Adverse Incident log. The resident eloped from the facility on April 11, 2020 and was found by police at a nearby shopping center. The Plaza is approximately 0.4 miles from the facility. The sidewalk is set back approximately 2-3 feet (grass easement) from a car-parking lane (approximately 4-5 feet) from the one-direction street, that leads to the plaza. Upon return to the facility after an evaluation at the hospital, the resident was observed with swelling to the face and knuckles, abrasions, discoloration, and scratches. He was discharged from the facility on April 16, 2020 related to another incident with a female resident after returning to the secured unit. The facility's failure to adequately supervise Resident #1, who was previously identified as a high risk for elopement, resulted in the finding of Immediate Jeopardy, past non-compliance on 04/11/2020. The Immediate Jeopardy was determined to be corrected on 04/20/2020, prior to the survey. The findings included: Review of the facility's policy titled: Risk Management: Elopement Risk (effective date: April 2006 and revision date: March 2016) showed: 1. If the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk. Center staff will provide supervision and engage the resident as needed to minimize wandering or exit seeking behaivor according to the plan of care. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. Review of the facility's Adverse Incident report to the State related to Resident #1's elopement dated 04/16/2020 showed: (Resident #1) is a [AGE] year-old male who was admitted to this facility in October of 2019 for long-term care in the secured unit. He has a history of kidney failure, hypertension, dementia, muscle weakness and [MEDICAL CONDITION]. He is alert with confusion and has a BIMs of 7. (Resident #1) had engaged in an altercation with a female resident on 3/24/2020 and as a result was referred to the hospital for evaluation of physical aggression and psychotic behaviors. Upon his readmission, he was placed on the short term Covid 19 monitoring unit as required by law for 14 days in an attempt to manage the spread of the Covid 19 pandemic from new hospital admissions and readmissions. After readmission, (Resident #1) presented with no symptoms and was managed on the 400 unit with a wander guard and close supervision away from the secured unit. After the 14 days he was not returned to the secured unit because the victim from the previous altercation still resides there. On (DATE), the facility transferred (Resident #1) to the 200 wing long-term care unit with a wander guard and under close supervision by staff. The resident was stable and was kept engaged through one to one activities with several departments within the facility during the day. On Saturday April 11th, at approximately 2030, the nursing staff became aware that the resident was not on the 200 wing. The supervisor was notified as soon as the resident was noted to be missing. A room search and a facility search were initiated immediately. The search was in progress when the facility received a phone call from the police asking if there was a missing resident. The supervisor verbally identified the resident for the police officer. The officer said the resident was found wandering in a nearby parking lot. The resident was brought to the facility by the officer who requested a face sheet. The face sheet was provided, an ambulance was called, and the resident transferred to (hospital) via 911 for evaluation and treatment. Review of the Police Report on 04/28/2020 showed a call was made to the Police Department on 04/11/2020 around 08:49 PM from a nearby residence. Upon arrival, police observed Resident #1 on the sidewalk where he had been for approximately 10 minutes. Resident #1 was observed with a knot on his head and was described as confused and possibly lost. Emergency Services was called but Resident #1 began walking away towards the shopping plaza. Police also noted a hand injury. Emergency Services was called again. Review of Resident #1's clinical record on 04/23/2020 showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing assessment dated [DATE] showed his behavioral concerns included: Confusion/forgetfulness; [DIAGNOSES REDACTED]. Resident #1 was also admitted with an order for [REDACTED]. Review of Resident #1's Quarterly Minimum Data Set assessment dated [DATE] showed Resident #1 had a BIMS score of 7, showing severe cognitive impairment. Review of Resident #1's comprehensive care plans included: -(Resident #1) has Wandering Behavior and is at risk for Elopement related to: history of wandering through hallways. (Date initiated: 11/07/2019) Goal: (Resident #1) will have physical, emotional, and psychological needs met as evidenced by reduction in behaviors or decreased wandering. (Date initiated 11/07/2019) Goal: (Resident #1) will be protected from elopement and unsafe wandering through next review. (Date initiated: 01/24/2020) Interventions: Ensure environment is clutter free (Date initiated 01/24/2020) Ensure resident identifier is in place (Date initiated: 11/17/2019 and Date created: 12/16/2019) Include staff in information processes for observances for cues to behavior (Date initiated: 01/24/2020) Observe for wandering that effects other and redirect as needed. (Date initiated 01/24/2020) Wander guard (Date initiated: 11/17/2019 and Date created: 12/16/2019) -(Resident #1) has impaired cognition as evidenced by: Decision making problem/Short term memory deficit/Long term memory deficit/Problems understanding others. (Date initiated: 10/13/2019) -(Resident #1) is at risk for falls related to: [DIAGNOSES REDACTED]. (Date initiated 01/11/2019) Review of Resident #1's clinical record on 04/23/2020, and a subsequent request made on 04/24/2020 for all of Resident #1's comprehensive care plans, showed no care plans were found addressing exhibited behaviors such as physical aggression, inappropriate behaviors towards female residents, and wandering into other resident rooms. The care plans reviewed did not describe the type or frequency of supervision needed to address Resident #1's wandering, including into other resident rooms while on the secured unit, or show any change in level of supervision needed when he was transferred to the unsecured unit. His care plan for wandering behavior showed an intervention for a wanderguard but was not revised when it was discovered he could remove the wanderguard prior to his elopement. Review of Resident #1's Elopement Risk Scale dated 1/24/2020 showed: -Resident #1 is ambulatory, expresses a desire and plans to leave, has a strong identification with past roles, has 2 or more attempts to leave the facility in last 90 days, has a medical [DIAGNOSES REDACTED]. -His score was 17 indicating high risk for elopement. -The care planning section showed one intervention marked: include staff in information process for observances for cues to behavior. Review of Resident #1's Progress Notes showed: January 2020 -1/18/2020 Resident #1 was found in (room #) without clothes in bed. He was given his clothes and redirected to his room. He refused to leave and became physically abusive to a female resident hitting her on her hand. He stated he will kill staff. -1/18/2020 Resident #1 seen by Dr., new order for Ambien -1/24/2020 Resident #1 was combative, going room to room looking after the woman, all meds given as per ordered, not effective February 2020 -2/26/2020 Ambulated up and down the hallway throughout entire 11-7 shift resident redirected, offered fluids, toileted and allowed time to vent. No change in behavior March 2020 -3/7/2020 Resident #1 was sitting in the dining room. A female resident came and waved her finger at his face. Resident #1 then kicked the resident's leg. The other resident swung her purse at him. Staff intervened and removed the aggressor. Resident #1 grabbed a wet floor sign and attempted to hit the aggressor. -3/23/2020 Observed pushing and punching another resident on the floor. Biting on staff member. Resident pacing the floor backwards and forward in an aggressive behavior. Awake alert and confused, broken glass in resident room and trying to get out of lock down unit. Recommendation: Send resident to ER intake for psych -3/24/2020 Returned to facility. Interdisciplinary Team meeting with new interventions to include a complete review of resident medications, psych consult, and resident will be removed from unit and placed on the 400 unit with a wanderguard. -3/26/2020 Wandering on floor, shift had to continue to redirect him -3/28/2020 Resident #1 made two attempts to escape floor, with the second nearly ended with resident taking north stair, but stopped by other nurse and aide. After giving some sleeping aids and redirecting back to bed, remained there for the duration of the night. -3/30/2020 Resident wanderguard was not in place April 2020 -4/2/2020 Confused noted being combative and pushing staff. Writer personally bathed patient for staff protection as patient was covered in dried feces. meds well tolerated patient noted resting for 2 hours before wandering. hourly rounds done due to patient not having wanderguard -4/4/2020 Received resident resting from another room for at least two hours and then wake up. Resident was wandering, redirected him to his room and then resting for the of the night -4/11/2020 Resident was observed on unit most part of the shift. Resident is very agitated/energetic, constantly wandering down the hall. Redirection was given several times/unsuccessfully. Around 2030, the nursing staff became aware of Resident's disappearance by the Nursing Supervisor. -4/11/2020 Change of Condition form. Room search was done after 911 call, alarm was sounding on 400 wing stair exit door. Police notified the facility that resident was walking in the parking lot at (local shopping plaza), awake alert and confused. Police officer had him in the back of squad car, ambulance called, and resident transferred to (hospital) via 911 ambulance for evaluation and treatment. MD and family member notified. -Late Entry for 4/11/2020 (created 04/14/2020) Patient alert with confusion noted. Patient transferred from 400 wing. Patient has abrasion to right shoulder with redness noted and right cheekbone is red and swollen. Right hand swollen/knuckles are bruised with discoloration noted. -4/12/2020 returned from (hospital) Diagnosis: [REDACTED].Resident received with facial raised area/swollen to right cheekbone. Right shoulder abrasion, red with no bleeding present. Right hand swollen, knuckles with discoloration Resident with no wanderguard on, will address in AM. -4/12/2020 Xrays and CT scan reveal no abnormal structures or fractures .resident roamed halls and entered other room. Tried redirecting many times but continued to persist on eloping. Forcibly removed wanderguard. -4/13/2020 Received resident alert but with confusion, wandering hallways and touching exit doors constantly. A bruise was noted just below right eye, same appears to be healing well. Right fingers noted to be swollen with small bruises on same, bruises. scratches noted near left elbow .Resident was seen in (room #) at 21:00 shaking the resident in (room #'s) TV. No picture can be seen on TV when turned on .Resident was medicated as per Medication Administration Record [REDACTED]. -4/14/2020 Resident alert and confused he wanders all over the floor he's in and out of resident's room. He removed his wanderguard. -4/14/2020 Became combative early in the morning. was redirected and wanderguard placed on right ankle. Patient was calm during this time/placing wanderguard on ankle. -4/16/2020 Risk Manager was informed by a female resident that Resident #1 came into her room last night on 4/15/2020 and pulled down his pants .she stated she was going to scream and that is when he left. -4/16/2020 Social Worker informed Resident #1's family member that the facility is no longer able to meet the needs of resident .Resident #1 wanders into other residents' room taking items that do not belong to him -4/16/2020 resident discharged to an assisted living facility Review of Resident #1's physician's orders [REDACTED].>-1/18/2020 Send resident to hospital for Altered Mental Status. Physical Aggression and Hitting other resident -1/24/2020 Resident meets criteria for gated 100 unit -3/24/2020 Send resident to ER for aggression and hitting other resident -3/25/2020 Check wanderguard placement every shift -3/25/2020 Check wanderguard every shift to ensure its functioning properly An interview was conducted with Registered Nurse A (RN A), who was familiar with Resident #1 while he resided on the secured unit, on 04/23/2020 at 3:10 PM. RN A stated Resident #1 wandered a lot. On a typical day he is always back and forth and back and forth the on the halls. He was going to exits and pushing. She stated she works on the locked unit normally the doors alarm. He does this constantly. Wanderguards work everywhere. She stated Resident #1 had a female resident on the locked unit who followed him around. He would go in her room when she was on that side where he was. After that they moved her to the other hall. The locked unit is two halls. She stated staff know him so they watch him closely. She explained 'we know how he is and he has to always be in someone's sight, nurses and CNAs (Certified Nursing Assistant)'. An interview was conducted with CNA B on 04/23/2020 at 3:47 PM. CNA B was assigned to Resident #1 the day he eloped. She stated 'everybody on the floor was watching on him'. After he finished eating all his food she went to assist another resident. The remaining staff were watching him. She stated when she finished she did not see him. Staff started checking the building but every door was closed. By the time staff were looking for him the Supervisor called to say the police called. She stated the door in the 400 unit had an alarm but no one was in the 400 unit to hear it. She stated she only worked with Resident #1 after he was transferred to the 200 hall but knew he walked around alot and tried to leave. An interview was conducted with CNA C on 04/23/2020 at 3:53 PM. CNA C was working on the 200 unit when Resident #1 eloped. She stated Resident #1 always walked back and forth and she would redirect him to sit down. She stated staff knows where he is and when she would pass by him she would keep her eyes on him. An interview was conducted with Licensed Practical Nurse D (LPN D) on 04/23/2020 at 4:04 PM. LPN D was listed as the nurse on the 200 unit when Resident #1 eloped. She stated Resident #1 did not stay still and would go up and down the hallway. He would always go into other residents' rooms. She administered his [MEDICATION NAME] at 6 PM. He was still very agitated, and it was ineffective. She stated he was always at the doors trying to leave. She stated he ate dinner and by 7:30 PM staff picked up the trays. He was still pacing the halls. At 8 PM staff started looking for him because they realized he wasn't there. He does not stay in his room. Staff always see him because he is near the nurse's station. He removed his wanderguard. The doors have alarms but the alarm to the 400 unit exit door was not heard all the way in the 200 unit. He has a steady gait. She stated there were no problems between Resident #1 and any residents on the 200 unit except he did wander into other residents' rooms and some may yell. She stated she was aware of his behaviors and that he doesn't stay still. Normally they do not have that type of resident in the 200 unit. An interview was conducted with the Executive Director, Director of Clinical Services, Risk Manager, and Assistant Executive Director on 04/23/2020 at 4:18 PM. The Director of Clinical Services explained that Resident #1 was on the locked unit at first but because he had the altercation he was transferred to the other unit. She stated Resident #1 and (female resident) had a little thing going but staff thought it was okay. The attraction became more aggression. Staff have seen them argue with each other but they let it slide. It was noted the interactions became more aggressive. (Female resident) would approach him and hit him with her purse. The facility reported the March 23 incident as resident-to-resident. The doctor re-evaluated him and sent him to the hospital. He was not kept and when he came back he was placed on the mandatory 14 day quarantine on the 400 unit. He was kept busy and a wanderguard placed. Staff knew he was a risk but he had never actually eloped. She stated staff found they could keep him busy with a broom because of his former job in a factory. Resident #1 and (female resident) were kept on separate areas. Resident #1 was sent to the 200 unit to separate him because they did know what would happen if he returned to the locked unit. The 400 unit was empty and staff never could have surmised that he would find his way all the way to the 400 hall. Everyone was aware of behaviors and redirected him with wanderguard on. The Risk Manager stated at some point he took his wanderguard off. The Director of Clinical Services stated they decided to put him back on the secured unit after his elopement. Resident #1 was discharged from the facility for another behavior. She stated when he eloped the police called to advise the facility they had Resident #1 while staff were still searching the building. The Risk Manager stated the police did not return Resident #1 to the facility but took him directly to the hospital and did not tell the facility why. She stated he did not have injuries prior to eloping. The Director of Clinical Services explained the facility allocated the 400 unit for a 14 day quarantine after returning from the hospital. There were other residents on the unit at the time Resident #1 was there. Since that time the 400 unit was closed to consolidate staff and residents. She stated Resident #1 is fast and steady on his feet. The Risk Manager stated the only time they noticed the wanderguard was not on him was when he eloped. The Director of Clinical Services stated Resident #1 was transferred from the facility after an incident with another female resident. She stated staff previously found Resident #1 in bed with (female resident) a few times and separated them. Nothing happened and he was fully clothed at the time. She stated initially she thought they were just holding hands but when it became aggressive then staff moved the residents to opposite halls. They would find each other in the morning and hold hands. But then it became aggressive. The Risk Manager stated Resident #1 had taken off his wanderguard the day he eloped. The alarm to the door went off but because it was so far away the staff did not hear it until they searched for him. Resident #1 walked from the 200 wing where he was admitted and walked to the 400 wing where he previously stayed. He found the back exit and went out to the parking lot. He was about 5 minutes away, 2 blocks in a straight line. She stated during their investigation Administrative staff re-enacted the steps. The staff on the unit that day did not see him walking to the 400. They said he was at the nurses station to be monitored. The CNA went to give care and when she came out she did not see him. The Director of Clinical Services stated since his elopement they put an alarm on the double doors on the 400 unit and a plastic zippered curtain at the entrance to the hall. She stated the facility was trying to keep both safe and both in the facility, Resident #1 and (female resident). He did not have the wanderguard while on the locked unit because he did not need it. She stated the doors throughout the facility have wanderguard alarms. She stated staff just had close supervision and tried to engage him in activities during the day time. He did well on 400 hall. He liked to clean. He was not on the 200 unit long. He was on the 400 unit for a longer period of time. He had done excellent on 400. He was happier on the 400. He wanted to sleep and clean. Review of Resident #1's progress notes and April 2020 MAR indicated [REDACTED]. He was documented as being able to remove it. The Facility's actions to remove the Immediate Jeopardy included: 1) Resident #1 was placed back on the secured unit upon return from the hospital on [DATE]. A full body assessment was completed for Resident #1 upon return from the hospital. 2) All current residents with a [DIAGNOSES REDACTED]. No other residents were identified as an elopement risk except the residents currently on the secured unit. 3) An elopement drill was conducted with staff on 04/13/2020. 4) All exit door maglocks were inspected on 04/13/2020 to ensure proper functioning. 5) An additional alarm was placed on the double doors leading to the closed unit to make the alarm sound more audible on 04/13/2020. Nursing Supervisors were inserviced on 04/13/2020 regarding the new alarm on the double doors. 6) A zippered plastic partition was placed in the hallway of the closed unit as an additional barrier. 7) An ad hoc QAPI meeting was conducted on 04/13/2020 that included the Executive Director, the Director of Clinical Services, the Medical Director, the Assistant Executive Director, the Director of Quality Assurance, and other department heads. A Performance Improvement Plan was established. The corrective actions included: 1) Follow-up QAPI/Risk Management meetings were conducted on 04/16/2020 and 04/20/2020. 2) Residents with behaviors towards other residents were identified and interventions reviewed and revised beginning on 04/13/2020. 3) Administration completed daily checks of the newly installed door alarm. 4) Additional staff on Leave of Absence (LOA) or in quarantine were educated on elopement procedures via telephone and additional staff onsite beginning 04/14/2020 through 04/16/2020. As of 04/16/2020 the following portion of the facility's staff were educated about elopement procedures: 50 out of 77 CNAs, 25 out of 28 LPNs, 28 out of 38 RNs, 19 out of 23 staff listed under Administration, 11 out of 18 Environmental Services staff, 7 out of 20 culinary staff, and 12 rehabilitation staff. 4) New employee orientation packets for certified nursing assistants include information and quizzes regarding dementia care and elopement. Random staff interviews conducted by Surveyor confirmed knowledge of elopement procedures. Interviews conducted in person and via phone were conducted as follows: On 04/29/2020 from 02:25 PM until 04:06 PM, 2 CNAs and 2 RNs. On 04/30/2020 beginning at 01:31 PM, 1 Respiratory Therapist, 1 Social Services staff, 1 Medical Records staff, 1 Housekeeping staff, 1 Administrative staff, 4 RNs, 1 LPN, and 2 CNAs. An initial tour conducted on 04/23/2020 revealed the alarm to the double doors was in place leading to the closed unit and the zippered plastic partition was also in place further down the hall. A subsequent tour on 04/30/2020 revealed the alarm and barrier remained in place. No residents were observed actively exit seeking on 04/23/2020 or on 04/30/2020. Immediate Jeopardy was determined to be past non-compliance, corrected on 04/20/2020.

Based on interview and record review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent injury, resulting in a fracture. This failure affected 1 of 3 sampled residents reviewed for accidents (Resident #1). The findings included: Facility policy titled Nursing/Risk Management Documentation of Resident Fall, dated (MONTH) (YEAR), documents, When a resident fall occurs the narrative nursing note should include: · Date, time and place of accident. · Where was resident moved, evaluate if resident should be moved, how was the resident moved, number of people, lifts, etc. · Review and revise the plan of care with interventions. Clinical record review conducted on 08/07/19 revealed Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Minimum Data Set, Quarterly assessment, with reference date 05/06/19, documents the resident was assessed as severely impaired for skills of daily decision making, has verbal behaviors directed towards others; requires extensive assistance with activity of daily living, is always incontinent of bowel and bladder; has a condition or disease that may result in life expectancy of less than six months. The resident had no falls and received antianxiety, antipsychotic and antidepressant medications and is receiving hospice care services. The Fall risk assessment dated [DATE] documents resident is high risk for falls. Care plan, related to fall risk dated 02/12/19 and revised 08/06/19, documents the resident is at risk due to use of antidepressant, decrease lower extremity strength, history of falls, pain, poor safety awareness, unsteady gait, urinary and bowel incontinence. If the resident attempts to stand without assistance she frequently falls. The interventions included: Bowel and bladder incontinence care as needed, encourage appropriate footwear, check for toileting needs, encourage frequent rest periods, minimize clutter, review medications, give verbal cues as needed, offer snacks as necessary, observe for unsafe evaluation, and post fall risk evaluation and floor mats. Nurses notes, dated 07/27/19, documents Resident noted to have bruise to left hip, is painful to touch. Physician was notified and ordered an x-ray. Resident was medicated for pain. Resident #1 was transferred to the acute care facility due to positive x-ray findings, fractured left hip. The resident returned to the facility on [DATE], as she was not a candidate for surgical intervention and was already receiving palliative care thru hospice services. Further review of the record indicates the resident had two prior falls. Progress notes dated 06/14/19 documents, walking down the hallway, the practitioner and another nurse noticed that the patient was out of bed and sitting on the floor. The outcome of physical assessment noted no change in functional status. No new recommendations. Progress notes, dated 06/07/19, documents, During morning medication pass, private duty aide in patient room, called the nurse and found patient sitting on the floor. The outcome of physical assessment noted no change in functional status. No new recommendations. Interview on 08/07/19 at 11:54 AM with the Director of Nursing (DON) and the Risk Manager (RM) revealed Resident #1 sustained an unwitnessed fall on 06/14/19. Review of the fall investigation lacked evidence of statements from the practitioner and nurse who found the resident on the floor and assisted her back into bed. It is not clear if the staff used a mechanical lift for the transfer. The DON stated Resident #1 required the use of the mechanical lift for transfers and the possibility the injury may have been caused by trauma due to the use of the mechanical lift. The post fall monitoring form, dated 06/14/19 thru 06/16/19, documents on six out of the nine nursing entries that the resident had sustained a bruise, skin tear, or other injury to the right eye. Upon request the risk manager researched the clinical record and was not able to locate documentation of the eye injury or the provision of treatment. Review of the facility documentation, related to the injury of unknown origin resulting in a fractured left hip, revealed the risk manager did not provide evidence of the supervision provided to the resident on the days leading to the discovery of the [MEDICAL CONDITION] (07/27/19). Interview with Staff C, a Registered Nurse, on 08/07/19 at 3:55 PM, revealed she was the registered nurse on duty on 07/27/19, the aide reported the resident had a bruise to her left leg and upon her assessment, the area was swollen with purple faded bruising, and painful to touch. Staff C is not sure is she had seen the bruise before, it is possible since the resident had a fall, weeks prior, but is not sure. Interview with Staff B, on 08/07/19 at 3:55 PM, revealed she was the aide who found and reported the bruise on the resident's hip on 07/27/19. The aide described the bruise as yellow and purplish in color. This is the first time that she had cared for this resident. The aide explained around 8:30 PM she assisted the resident back into bed, the resident was able to stand and with one-person assistance, and she was transferred into the bed. The aide did not use the mechanical lift and when she turned the resident over to change her brief, the resident made a sound, like a cry, she then noticed the bruise and reported it to the nurse immediately. Based on interviews and investigation record reviews, the facility failed to provide evidence that Resident #1 received appropriate supervision prior to the discovery of the [MEDICAL CONDITION]. The plan of care does not indicate the frequency of monitoring and as evidenced by staff interview, not all of the aides assigned to care for the resident were knowledgeable regarding the plan of care.

Based on record review and interview, it was determined the facility failed to individualize fall prevention interventions for 1 of 3 sampled residents (Resident #1). This failure is evident by a failure to include all fall prevention interventions in the plan of care, failure to address monitoring and supervision of the resident to ensure safety and failure to individualize post fall interventions to minimize reoccurrence. The findings included: Clinical record review conducted on 08/07/19 revealed Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Further review of the record indicates the resident had two incidents of 'found on floor'. Progress notes dated 06/14/19 documents walking down the hallway, the practitioner and another nurse noticed that the patient was out of bed and sitting on the floor. The outcome of the physical assessment noted no change in functional status. No new recommendations. Progress notes dated 06/07/19 documents, During morning medication pass, private duty aide in patient room, called the nurse and found patient sitting on the floor. The outcome of physical assessment noted no change in functional status. No new recommendations. Review of the facility's investigation related to the injury of unknown origin resulting in a fractured left hip revealed, the risk manager did not provide evidence of the supervision provided to the resident on the days leading to the discovery of the [MEDICAL CONDITION] (07/27/19). Clinical record review conducted on 08/07/19 revealed the following care plans: Care plan related to fall risk dated 02/12/19 and revised 08/06/19 documents the resident is at risk due to use of antidepressant, decrease lower extremity strength, history of falls, pain, poor safety awareness, unsteady gait, urinary and bowel incontinence. If the resident attempts to stand without assistance she frequently falls. The goal is to Strive to have falls and/or injuries minimized thru management of risk factors. The interventions included: Bowel and bladder incontinence care as needed, encourage appropriate footwear, check for toileting needs, encourage frequent rest periods, minimize clutter, review medications, give verbal cues as needed, offer snacks as necessary, observe for unsafe evaluation and post fall risk evaluation. The electronic version of this care plan did not have interventions implemented after the fall on 06/14/19. Care plans, dated 07/27/19, had a goal to Remain with minimal pain or none and Provide relief. The interventions included: No surgical intervention, palliative care due to Hospice services, medicate for pain as needed, notify MD and Hospice of fracture, notified family of fracture, and reposition frequently for comfort. On 08/07/19 at approximately 2:00 PM, the Unit Manager presented a copy of the printed care plan for falls with a hand written intervention dated 06/14/19 for floor mats. Review of the Treatment Administration Record (TAR), dated 06/2019, revealed the floor mats had been previously implemented as a safety measure. Interview on 08/07/19 at 11:54 AM with the Risk Manager and the Director of Nursing revealed, when the resident was first admitted to the facility, the hospice team had one to one supervision for safety. Hospice later decided the resident was not on crisis care and therefore the one to one supervision was discontinued. The Risk Manager explained the intervention for the fall on 06/07/19 was a physical therapy referral. Interview conducted on 08/07/19 at 1:31 PM with the Director of Therapy revealed the therapy referral for Resident #1 was not done because the resident was under hospice care. Hospice would have to write orders for a therapy screening. The care plan for Resident #1 failed to address the level of supervision and monitoring for a resident who had two prior falls. Interview with Staff B, a Certified Nursing Assistant, on 08/07/19 at 3:55 PM revealed she was the aide who found and reported the bruise on the resident's hip on 07/27/19. The aide described the bruise as yellow and purplish in color. Staff B siad this is the first time she had cared for this resident. The aide explained around 8:30 PM, she assisted the resident back into bed, the resident was able to stand with one-person assistance, and she was transferred into the bed. The aide did not use the mechanical lift and when she turned the resident over to change her brief, the resident made a sound, like a cry, she then noticed the bruise, and reported it to the nurse immediately.