Every finding on record at Pinellas Park FL Opco, LLC

Based on observation, interviews, and record review, the facility failed to ensure medications were stored under proper temperature controls in the two medication storage rooms (2nd and 3rd) of two facility medication storage rooms observed.Findings Included: On 6/3/26 at 8:54 a.m., during a tour of the 2nd floor medication room, the Maintenance Director (DOM) checked the ambient temperature, which measured 82.20 F.On 6/3/26 at 9:27 a.m., during a tour of the 3rd floor medication room, Regional Maintenance Director (RDOM) checked the ambient temperature, which measured 85.2 F.During an interview on 6/3/26 at 8:54 a.m. the DOM said the air conditioning unit for the 2nd floor medication rooms has been out of service for approximately one month. He stated after the facility received three repair proposals, the repairs were approved the previous week, and the work would be completed soon. During both observation tours conducted on 6/3/26 at 8:54 a.m. and 9:27 a.m., the Over the counter (OTC) medications were observed stored in both medication rooms, and the automated medication dispensing machine was located in the third floor medication room. A random check of OTC medications stored in the 2nd and 3rd floor medication rooms showed the manufacturer storage recommendations for loperamide HCL 2 mg (milligrams) tablets, acetaminophen 650 mg suppositories, and acetaminophen 500 mg tablets was to store the medications between 68 F and 77 F and/or in a cool place.During an interview on 6/3/26 at approximately 9:00 a.m., Staff A, a Registered Nurse (RN) and Unit Manager (UM), stated her expectation was for medications to be stored at the appropriate temperature.During an interview on 6/3/26 at 9:53 a.m. the Director of Nursing (DON) stated, normally this is not an issue,' and stated she would remove and discard all the over the counter (OTC) medications.During an interview on 6/3/26 at 3:36 p.m., the Regional Director of Maintenance (RDOM) provided a copy of a facility estimate statement, titled estimate to replace restricted Thermal Expansion Valve (TXV) and filter drier, dated 5/14/26 for the rooftop unit (RTU) . not cooling properly and work will start 2-3 days after approval. A report of the project timeline showed on 5/29/26 work for this job is not complete .temporarily fixed.During a telephone interview on 6/3/26 at 11:18 a.m., the facility pharmacy pharmacist stated loperamide HCL 2 mg tablets, acetaminophen 650 mg suppositories, and acetaminophen 500 mg tablets could tolerate elevated temperature conditions for 1 to 3 days, but not for a period of one month.Review of a facility policy titled, Medication Storage, revised, 4/2026, showed the following: Policy: It is the policy of this facility to ensure that all medications housed on the premises are stored, secured, and maintained under proper conditions to preserve integrity, . and ensure resident safety in accordance with federal and state regulations and according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Review of facility pharmacy policy, titled medication storage showed the following Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health guidelines G. Medications will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following:1. Controlled Room Temperature: 20 - 25 degrees Celsius (68 - 77 degrees F)2. Cool Place: 8 - 15 degrees Celsius (46 - 59 degrees F)3. Cold Place: 2-8 degrees Celsius (36 -46 degrees F)4. Warm Place: 30 -40 degrees Celsius (86 - 104 degrees F)5. Excessive Heat: >40 degrees Celsius (104 degrees F)(Photographic Evidence Obtained.)

Based on observations, interviews, and record review, the facility failed to ensure sanitation requirements were met in 1 out of 1 kitchens observed.Findings included,On 06/01/2026 at 05:51 AM, a kitchen tour was conducted. During the tour, a steam table was observed to be soiled with white debris on the bottom shelf. In the dishwasher area, a metal faucet with spiraling metal was observed with brown corrosion and deformed. A stove in the kitchen was observed, with ash-like debris in various areas on the stove top. Discolored noodles were observed on the stove top near an open flame. A dish rack in the kitchen was observed soiled with debris on various dishes, such as metal pans and lids. On a wall located in the bottom left corner, a tile was observed missing. In the area, a tile was missing from, the insides of the wall were visible, including metal, various wall construction elements, and debris. A cart in the kitchen was observed with various wet and dry discolored liquids and debris.On 06/02/2026 at 04:35 PM, a kitchen tour was conducted. The kitchen stove top was observed with black and white ash and an open flame. A griddle was observed with tan and taupe colored buildup. Dishware on a rack was observed with debris, in tan to taupe colors. The facet in the dishwasher area with spiraling metal was observed with brown corrosion. Ceiling vents were observed to be soiled. A ceiling above a food preparation area, adjacent to the dining hall was observed in disrepair with vinyl peeling off the ceiling tile.During an interview on 06/02/2026 at 04:39 PM, the Senior Certified Dietary Manager, (SCDM), stated the facility staff performed deep cleanings every month. The SCDM stated I don't even know how we're going to clean that, steam table, we obviously have missed it. The SCDM stated old food on a gas stove with an open flame was dangerous. The SCDM grabbed a metal dishware item from a dish rack of clean dishes, and stated I think these are dirty, I don't know why someone put them here. The SCDM stated the faucet in the dishwasher room, with spiraling metal definitely has rust on it, but I think it is clean.During an interview on 06/03/2026 at 10:13 AM, the SCDM stated the cleanliness of the kitchen was not where we want to be, and that the kitchen staff had been the problem.During an interview on 06/04/2026 at 12:48 PM, the SCDM stated some staff members had been signing the daily cleaning log and hadn't performed the cleaning. The SCDM stated the charge cook was responsible for supervision of task that needed to be completed. The SCDM stated the Certified Dietary Manager, (CDM), and the supervisor were responsible for supervision of the charge cook. The SCDM stated there was a failure in the process.During an interview on 06/04/2026 at 01:11PM, the Nursing Home Administrator, (NHA), explained having expectations for the kitchen to be clean. The NHA stated the CDM was responsible for performing audits in the kitchen. The NHA stated there should not be debris on the kitchen dish rack not with all that stuff. The NHA stated she would not feel comfortable eating items from the kitchen.A facility policy titled Sanitation Inspection, revised 01/2026 revealed:Policy: it is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:All food service areas shall be kept clean, sanitary, free from liter, rubbish and protected from rodents, roaches, flies, and other insects. Photographic evidence obtained.

Based on observation and interview, the facility failed to ensure the resident environment was free from accident hazards in one unsecured utility rooms (third floor) of two observed.Finding included: An observation on 06/01/2026 at 6:15 AM revealed the biohazard/ soiled utility room on the third floor was not locked or secured in a manner that would prevent residents on the third floor from accessing the contents of the room that could have the potential to cause injury or illness. The room was observed to contain a sharps container, a refrigerator marked with a biohazard symbol, and soiled linens. During multiple tours, residents were observed ambulating independently through the hallways on the third floor, near and around this utility room.An interview with Staff K, Registered Nurse (RN), on 06/03/2026 at 2:52 PM revealed the biohazard room should always be locked because there is a small refrigerator with biological samples in the room which need to be protected from contamination and/or tampering. Staff K said additionally, the room contains potentially hazardous items, such as a sharps container and linens that has been soiled with bodily fluids.An interview with Staff D, License Practical Nurse (LPN) on 06/03/2026 at 3:06 PM revealed the biohazard room should be locked because it contained materials and substances that residents should not come into contact with such as biohazardous waste. An observation was made with Staff D and Staff K of the biohazard/soiled utility room on the third floor, which was not locked. At the time of the observation of the biohazard/soiled utility room with Staff D and Staff K, residents were observed ambulating independently throughout the hallways on the third floor.On 06/03/2026 at 3:36 PM an observation and interview with Staff J, LPN/ Unit Manager (UM), revealed the biohazard/soiled utility room on the third floor was not locked or secured in a manner that would prevent residents from gaining access to the potentially hazardous materials contained in the room. Staff J said the room should be locked because it contained dangerous biohazardous materials such as used sharp medical instruments and linen soiled with bodily fluids. Staff J said all staff are responsible for ensuring the biohazard/soiled utility room is locked, and maintenance is responsible for ensuring that all door locks are functioning properly.On 06/04/2026 at 9:26 AM, and interview with the Maintenance Director revealed the maintenance department is responsible for ensuring that door locks in the facility are functioning properly. The Maintenance Director said all staff should notify maintenance via their online reporting system if they observe door locks that are not functioning properly. The Maintenance Director did not have previous maintenance requests for the repair of the lock for the door of the biohazard/soiled utility room on the third floor. The director said the online maintenance reporting system has an automated monthly prompt that reminds maintenance staff to check the functioning of doors and locks throughout the facility. The Maintenance Director did not provide an explanation for not verifying the functioning of the door lock.A review of a facility policy titled Accidents and Supervision, implemented on 09/01/2023, revised on 01/2026, revealed all staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Various sources provide information about hazards and risks in the resident environment. Implementation of interventions showed - using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident), ensuring that the interventions are put into action. Monitoring and modification processes include: ensuring that interventions are implemented correctly and consistently. A review of a facility policy titled Regulated (Biohazard) Medical Waste, implemented 09/01/2023, revised on 01/2026, revealed it is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State and local guidance and regulations. According to the policy, regulated waste means liquid or semi-liquid blood or other potentially infectious materials: contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials that are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.(Photographic evidence obtained)

Based on interviews and record reviews the facility failed to address and respond to resident council members, related to grievances voiced in their council meetings for four months (January, February, March, and April 2026) of five months reviewed and failed to respond to grievances for one resident (#84) of one resident reviewed.Findings included: Review of resident council minutes and the facility's grievance logs dated January 2026 through May 2026 showed grievance forms were not completed for grievances voiced in resident council meetings and a response was not provided to the committee members for the four-month period reviewed.Review of the Resident Council minutes dated 1/8/26 showed the residents reported concerns regarding cold food. The minutes showed there were no nursing, therapy, housekeeping/laundry, administration/social services, and maintenance concerns listed. The committee's concern about cold food was not listed on the grievance log and the facility did not provide a grievance form or documentation indicating the concern was addressed or that feedback was provided to the resident council.Review of the Resident Council minutes dated 2/12/26 showed the residents reported concerns regarding cold food and that place settings were not being provided. The minutes showed there were no nursing, therapy, housekeeping/laundry, administration/social services, and maintenance concerns. The committee's concern about cold food and place settings was not listed on the grievance log and the facility did not provide a grievance form or documentation indicating the concern was addressed or that feedback was provided to the council.Review of the Resident Council minutes dated 3/12/26 showed the residents reported concerns about cancellation of Wednesday outings and access to money from their Resident Funds Management System (RFMS) accounts when requested. The minutes showed there were no nursing, therapy, housekeeping/laundry, administration/social services, and maintenance concerns. A grievance form documenting the committee's concern about resident access to their RFMS accounts did not show the facility provided feedback to the council.Review of the facility's RFMS withdrawal record between 3/13/26 and 3/16/26 showed 20 resident withdrawals of less than $50.00, less than what the residents requested.Review of the Resident Council minutes dated 4/16/26 showed the residents reported concerns regarding activities. The minutes showed there were no nursing, therapy, housekeeping/laundry, administration/social services, and maintenance concerns. The committee's concern about activities were not listed on the grievance log and the facility did not provide a grievance form or documentation indicating the concern was addressed or that feedback was provided to the council.Review of the Resident Council minutes dated 5/18/26 showed no concerns were documented. During an ad hoc Resident Council meeting conducted on 06/02/26 at 10:01 a.m., the council members reported, kitchen and food services are at a stalemate regarding frequently cold and inedible meals. The residents who require dialysis treatments are sent to their appointments without snack or a bagged meal. One of the residents said due to the lack of food post dialysis, their fatigue is increased. They reported these issues have worsened over the past two months. The committee attendees reported due to a lack of staff the first-floor dining room is often closed, and they miss having social interactions during mealtime. The council members stated the facility does not honor requests for access of up to $50.00 of their funds daily and daily withdrawals limited to $25.00. The committee members said the facility does not provide feedback regarding their concerns. While discussing concerns listed in the council meeting minutes, the attendees reported concerns about untimely call light response, delayed activities of daily living (ADL) assistance and facility maintenance concerns.An interview and resident council minutes review was conducted with the Regional Activities Director (RAD) and Staff H, Activities Assistant (AA) on 06/03/2026 at 4:07 p.m Staff H, AA said the previous Activity Director left in April and she had completed the resident council minutes for April 2026 and May 2026. She said she was not shown how to complete the minutes and uses a form with instructions. In response to the concerns reported by the committees not listed in the minutes, she said she did not write down all of the concerns discussed during the meeting. She said she did not receive any training. Staff H said each month she gives a copy of the minutes to the Certified Dietary Manager (CDM) and the Nursing Home Administrator (NHA).During an interview on 6/3/26 at 4:30 p.m. with the NHA and the Regional Business Office Manager (RBOM). The NHA said changes in staffing contributes to the residents' access to community events and she was not aware the residents were concerned about having access to the first-floor dining room. Regarding the residents' access to their RFMS accounts the RBOM, said the facility withdraws $600.00 three times each week, which was not enough to cover all the resident's requests. The NHA said sometimes resident council concerns trigger a grievance, depending on what it is. Review of Resident #84's admission record revealed she was admitted [DATE] with a diagnosis to include dementia, hypertension, heart failure and anemia.Review of Resident #84's admission Minimum Data Set (MDS) dated [DATE] showed Brief Interview for Mental Status (BIMS) score was 00/15, indicating he resident could not complete the test.During a telephone interview on 6/2/26 at 1:15 p.m., Resident #84's family member stated that the facility does not follow up on the grievances they have filed. She said they have given the facility several notes with grievances and have not received a response. Resident #84's family member provided photographs of letters handed to facility staff containing the following information: A note dated 4/13/26 at 1:30 p.m. requested assistance in arranging (name of transportation company) transportation for Resident #84 and asked that the family member be contacted to confirm the transportation was scheduled.A note dated 4/18/26 at 3:56 p.m. addressed to the Administrator, DON, and Floor Manager regarding feet and ankle swelling and requested the facility and the doctor follow-up with the family member.A note dated 4/18/26 at 4:05 p.m. addressed to the Administrator, DON, Floor Manager. The note informed them to ensure that Resident #84's linens are changed every Monday, Wednesday, and Friday, and at any other time if soiled. The reason for the request was that the linens don't get changed. The family member also wrote that the facility should contact them with any questions.A note dated 4/18/26 at 4:15 p.m. addressed to the Administrator, DON, Floor Manager. The note informs the facility the family member spoke with facility staff about bathing and hygiene concerns. The family member wrote I look forward to hearing from someone.A review of the facility's grievance log dated April 2026 showed one grievance documented regarding Resident #84. A review of the grievance form showed dietary concerns. The documentations showed the facility addressed the concerns and followed up with the family member. The grievances dated 4/13/26 and 4/18.26 were not documented on the grievance log and the family said the facility did not provide feedback.During an interview on 6/4/26 at 11:26 a.m. the interim Social Services Director (SSD) stated not being familiar with the grievances filed by Resident #84's family member. She said once s grievance is received, it is reviewed and forwarded to the relevant department. The SSD said grievances that are not documented on the grievance form are transcribed to the form. In reference to the notes received from Resident #84's family member, the SSD said the facility should have written them on a grievance form. She said the facility notifies the person who files the grievance of the resolution.During an interview on 6/4/26 at 1:44 p.m. the Nursing Home administrator (NHA) said when grievances are received they are given to the appropriate department and the department is responsible for resolving the grievance. She said she had not seen the notes dated 4/13/26 and 4/18/26 regarding Resident #84. Sher said handwritten notes are transcribed to a grievance form. She said Resident #84's family members visit the facility often, and sometimes the facility will handle a concern from a family without completing a grievance form.Review of facility policy titles Resident and Family Grievances, reviewed 1/2026 showed the following:Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.Definitions: Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance.Policy Explanation and Compliance Guidelines:1. Facility will have a designated Grievance Officer. Their name and contact information will be posted in the facility so residents, family and staff have access to it.2.The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; coordinating any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay .7 Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Officer. b. Written complaint to a staff member or Grievance Officer, c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings . 10.Procedure:a. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form.i. Take any immediate actions needed to prevent further potential violations of any resident right.b. Forward the grievance form to the Grievance Officer as soon as practicable.c. The Grievance Officer will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up.ii. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Officer.

Based on observations, interviews and record review, the facility failed to maintain an effective pest control program in one kitchen (Main) out of one kitchen observed.Findings included: On 6/1/2026 at 6:02 a.m., during a tour of the kitchen, a small, slender winged, flying insect was observed in the hallway leading to the kitchen. Upon entering the kitchen, an observation was made of more of the same flying bugs in the dishwasher room, in the hallway where a locker room was located, and near the office located inside the kitchen. There were numerous flying bugs observed on the lid of a container on the ground near the dishwasher, and around a food disposal unit connected to a countertop near the dishwasher. A flying bug was observed on the handle of a cooking pot on a drying rack.During an interview on 6/2/2026 at 4:50 p.m., the Senior Certified Dietary Manager (SCDM) said he knew there were some flying bugs the day before, but he had not seen these many flying bugs previously.During an interview on 6/2/2026 at 4:44 p.m. the SCDM said the pest control company serviced the kitchen every other week. The SCDM stated the staff deep cleaned, scrubbed floors, and cleaned walls once a week.During an interview on 6/4/2026 at 1:11 p.m., the Nursing Home Administrator (NHA), stated the expectations for the kitchen were for it to be clean. The NHA stated the Certified Dietary Manager (CDM), was responsible for auditing the kitchen's cleanliness. The NHA said she was aware of gnats and stated she saw some little gnats, a few weeks ago. The NHA stated she had toured the kitchen with the pest control company and saw gnats. The NHA stated the pest control company treated the facility for pests as needed. The NHA confirmed there was a risk of gnats getting into resident's food, the fridge and freezer since the gnats were present in the kitchen. The NHA stated the gnats were difficult to eliminate. The NHA said maybe the pest control company needed to use different chemicals, as the gnats were probably getting used to whatever they are using. The NHA stated she was not aware of the hole in the pantry wall and stated she believed bugs could get into the pantry through the hole. The NHA stated the kitchen's food disposal should not have had leftover debris or standing water as it could have caused gnats to infest the kitchen. The NHA said she would not be comfortable eating food from the kitchen and that she was responsible for the kitchen's cleanliness.A review of the facility's pest control company's service inspection reports showed a report dated 3/23/2026 with comments including Heavy Phorid fly activity seen in the kitchen by wash sink and juices syrup boxes and in multiple floor drains. Multiple drains had food debris/organic build up. Standing water and organic build up by wash sinks.A review of the pest control company's service inspection reports showed a report dated 5/18/2026 with comments including Phorid fly activity in the kitchen by wash sink and juices syrup boxes.Review of the facility policy titled, Pest Control Program policy and procedures, revised 01/2026, revealed a policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measured to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flied, mice and rats).

Based on observations, interviews and record review, the facility failed to ensure the medication error rate was not greater than 5%. A total of 28 opportunities were observed with 2 errors constituting an error rate of 7.14%. Findings included: On 6/2/2026 at 9:26 a.m. a medication observation was conducted with Staff F, Registered Nurse (RN) for Resident# 59. Staff F, RN confirmed the tablets prior to administration. Staff F dispensed the following medication:-Methadone hydrochloride 10 MG/ML (milligrams per milliliter) Oral Solution 1ml-Amlodipine 5 MG Oral - 1 Tablet [Norvasc] this medication was held due to low blood pressure.-Folic acid 400 Mcg (microgram) Oral -1 Tablet-Tamsulosin hydrochloride 0.4 MG Oral Capsule - 1 capsule-Sertraline 50 MG Oral - 1 Tablet-Tiotropium 0.018 MG Inhalation Powder Review of Residents# 59's admission records showed she was admitted to the facility on [DATE] with a diagnosis to include: Type 2 Diabetes Mellitus, Cerebral Infarction, Atherosclerotic Heart disease, Acute Kidney failure, Abdominal Aortic Aneurysm.Review of Residents #59's active orders showed: -Folic Acid 1MG, give 1 tablet by mouth for Anemia with a start date 5/28/2026. An interview was conducted on 06/02/2026 at 2:45 p.m. with Staff F, RN regarding the medication observation. Staff F, RN administered Folic Acid 400 Micrograms (mcg) dose instead of the ordered dose of 1MG. Staff F, RN stated she was aware this is not the correct dose. Staff F said she did not want Resident #59 to not receive any of the medication, so she administered the 400-microgram dose. Staff F, RN said this was an over-the-counter medication.On 6/1/2026 at 11:00 a.m. a medication observation for Resident #33 was conducted with Staff G, RN. Staff G, RN obtained a blood glucose level reading of 196. Staff G, RN then opened the cover to the 3 ML (milliliter) insulin Aspart, Human 100 UNIT/ML (unit/milliliter) Pen Injector and pushed on the injection button without the needle attached. Staff G, RN then cleaned the hub of the injection pen and attached the needle. Staff G then turned the dial to show 2 units and administered the dose in the left lower abdomen and held the dose for approximately 2 seconds. Review of Resident #33's admission record showed he was admitted to the facility on [DATE] with a diagnosis to include Diabetes Mellitus (DM) Type 2.Review of Resident #33's Active orders showed:Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML Inject as per sliding scale:if 151 - 200 = 2 units;201 - 250 = 4 units;251 - 300 = 6 units;301 - 350 = 8 units;351 - 400 = 10 units Notify MD if >400 or <70 and follow hypoglycemia protocol,subcutaneously before meals and at bedtime for DM (Active) On 6/1/2026 at 11:15 a.m. an interview was conducted with Staff G Registered Nurse (RN) for Resident#33. During the medication observation Staff G, RN did not prime the insulin pen prior to administering. Regarding the question on how to properly prime the insulin pen, Staff G, RN responded, can I have a do over? Review of the manufacturer's Novolog Aspart Flex Pen found on the manufacturer's website www.novomedlink.com retrieved on 6/1/2026, showed, Priming your Pen. Prime before each injection. Called the Air Shot after applying the needle turn the dial to reflect the number 2 holding pen upright push on the bottom of the penPriming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly.If you do not prime before each injection, you may get too much or too little insulin.Giving your injection-Insert the needle into your skin.-Push the dose knob all the way in.-Continue to hold the dose knob in and slowly count to 5 (5 seconds) before removing the needle. An interview was conducted on 6/04/2026 at 1:30 p.m. with Director of Nursing (DON). In reviewing the findings of the medication administration observations, the DON confirmed the correct dose of Folic Acid milligrams should have been administered. The DON said the nurse should have held the medication and reached out to the pharmacy for a refill or physician for an order. The DON confirmed the nurse should have primed the insulin pen prior to administration to ensure the resident receives the correct dose of insulin. The DON said she will immediately ensure education is provided to the nurses.Review of the facility's policy titled, Administering Medications, with a revision date, 1/1/2026, revealed: Administer medications as ordered; correct any discrepancies and report to nurse manager.Medication should be verified, the right resident, the right medication, the right dosage, the right time, and the right route of administration before giving the medication. Review of the facility policy titled, Insulin Pen, Revision date, 1/1/2026, showed: It is the policy of the facility to use insulin pen to improve the accuracy of insulin dosing. A new needle will be used for each injection; Insulin pen will be primed prior to each use to avoid collecting air in the insulin reservoir.

Based on record review and interviews, the facility failed to ensure dialysis residents were provided with snacks/meals consistent with professional standards of practice and the care plan for one resident (#8) of one sampled.Findings included: Record review revealed Resident #8 had medical diagnoses of dependence on renal dialysis and end stage renal disease. The order summary report for Resident #8 revealed an order to send snack with resident on dialysis days in the morning every Tuesday, Thursday, Saturday, with a start date of 04/09/2026. The care plan report for Resident #8 revealed a focus of Resident #8 is at risk for renal failure with dialysis, last revised on 01/19/2026. The intervention for that focus included to send snack/meal with Resident #8 on dialysis days, last revised on 10/22/2025. A progress note dated 05/30/2026 revealed no snacks available nor delivered by dietary staff. An interview with Staff M, Certified Nursing Assistant (CNA) on 06/03/2026 at 12:45 PM revealed it is the CNA's responsibility to ensure residents have breakfast or lunch before exiting the facility to be transported to receive dialysis services. Staff M said dietary staff should prepare and bring resident's meals up to the nourishment rooms before the resident's scheduled transportation time. Staff M said if a resident was scheduled to be transported for dialysis services before breakfast is served at the facility, dietary staff will bring their meal up to the nourishment room during the shift prior to their scheduled dialysis service. Staff M said if dietary staff do not bring the meal up, it is the CNAs or nurses responsibility to go to the kitchen to obtain the meal prior to the resident exiting the facility.An interview with Staff N, CNA on 06/03/2026 at 2:30 PM, revealed the facility's process for ensuring residents have meals when they leave the facility for dialysis services is for dietary staff to bring meals to the nourishment room sin the facility prior to the residents' scheduled transportation times. Staff N said if dietary staff do not bring resident dialysis meals, the CNAs should go to the kitchen to obtain a meal for the residents. Staff N said the expectation is for the resident to receive a meal to take with them to dialysis every time they go to dialysis.An interview with Staff K, Registered Nurse (RN), on 06/03/2026 at 2:52 PM revealed the facility's expectation for residents receiving dialysis services is for dietary staff to bring resident meals to the nourishment rooms the day before their scheduled dialysis. Staff K said residents are also provided with snacks to take with them to dialysis. Staff K said if dietary staff does not bring meals and/or snacks to the nourishment rooms, staff should go down to the kitchen to obtain resident meals or snacks prior to being transported for dialysis services. Staff K said nurses assigned to residents that receive dialysis services are always aware when the resident leaves the facility to be dialyzed because the nurse has to enter current information in the resident's medical record prior to their exit. Staff K said residents should never leave the facility to go to dialysis without a snack.An interview with the Senior Certified Dietary Manager (CDM) on 06/04/2026 at 9:43 AM revealed before a resident leaves the facility in order to be transported for dialysis services, dietary staff should place meals for those residents in the nourishment rooms during the shift prior to the resident's appointment. The CDM said if dialysis meals have not been placed in the nourishment room refrigerator, then nursing staff should go to the kitchen to obtain a resident meal prior to the resident exiting the facility. The CDM said dietary staff uses a log to ensure the meals and snacks for dialysis have been prepared but was unaware of a system used to ensure those meals are received by the resident prior to exiting the facility to be dialyzed. The CDM was unsure why there was a progress note for Resident #8 showing the resident did not receive nourishment prior to being transported to dialysis on 05/30/2026.An interview with the Director of Nursing (DON) on 06/04/2026 at 10:08 AM, revealed when a resident goes to dialysis, their assigned CNA assists them in getting ready for their appointment, such as performing or assisting with personal hygiene and activities of daily living. The DON said residents are always provided with a snack and/or meal before being transported from the facility to their dialysis appointment. The DON said the dialysis nourishment should be brought to the nourishment rooms by dietary staff, and nurses should give the dialysis nourishment to residents prior to them leaving the facility. The DON said the process for ensuring that residents receive their snack or meals for dialysis if for the nurses to visually verify that the resident has their meal when leaving the facility. The DON said if no snacks or meals are available in the nourishments rooms, the nursing staff should go to the kitchen and ask for a snack, meal, or some form of nourishment to be provided to the residents. The DON said there are also snacks available at the nurses' stations in residents living areas. The DON said regarding Resident #8 on 05/30/2026, her expectation was for the nurse to assemble a form of nourishment to be provided to the resident if the kitchen did not supply one. The DON was unsure of the most recent education provided to staff informing them to ensure that residents are provided with nourishment when they leave the facility for dialysis services.Review of a facility policy titled Hemodialysis, implemented on 09/01/2023, revised 01/2026, revealed this facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Additionally, the policy states the licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include but not limit itself to: nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.

Based on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two residents (#1 and #85) of 4 residents reviewed for PASARRs. Findings included: 1. Review of the transfer/discharge report showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, psychosis, psychoactive substance abuse, and schizophrenia. Review of Resident #1's level I PASARR dated 1/8/26 showed qualifying diagnoses including anxiety disorder, depressive disorder, psychosis, were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview on 6/4/26 at 12:57 p.m. with the Director of Nursing (DON) and the Interim Social Services Director (SSD) the SSD said, I have to do his (Resident #1) level II. He is on my list to do, and I have not gotten to him. 2. Review of Resident #85 admission record revealed an original admission date of 3/28/2026. Resident #85 was admitted to the facility with diagnosis to include but not limited to major depressive disorder - 3/28/2026, and other schizoaffective disorders - 3/28/2026. Review of a Level I PASARR for Resident #85 dated 3/27/2026 revealed a blank PASARR and the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a Level II was not submitted for consideration following qualifying diagnoses. During an interview on 6/4/2026 at 12:57 p.m., the Director of Nursing (DON) stated her process for PASARR was that she would determine if it was done by the hospital and if the resident required a level II. The Social Services Interim, Staff E, said her process was different as she waited for a psychiatry physician to do the resident's evaluation and then proceed with their recommendations. Staff E stated she had been attempting to catch up and fix everything. Staff E stated having a long list of PASARRs to work on as it was her responsibility to maintain their accuracy. Staff E said the PASARR the facility currently had for Resident #85 was wrong as it was not filled out. She said Resident #85 was on her to do list. Staff E said the diagnoses depression and schizoaffective disorders should have been checked in the PASARR. During an interview on 6/3/2026 at 10:54 a.m., Staff J, Licensed Practical Nurse (LPN) and Unit Manager (UM) said residents were sometimes admitted from the hospital with a completed PASARR. Staff J, Nurses, social services, administrators and Minimum Data Set (MDS) coordinators were responsible for checking PASARRs upon admission. Staff J said for the residents who did not have a completed PASARR, social services was responsible for filling them out. Staff J said an inaccurate or incomplete PASARR would be due to an oversight. Review of the facility policy titled, Resident Assessment – Coordination with PASARR Program policy and procedures, Revised 01/2026, revealed a policy: This facility coordinates assessments with The pre admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy explanation and compliance guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A. PASARR Level I – initial pre-screening that is completed prior to admission.

Based on observations, interviews and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment in four resident rooms (235, 251, 304 and 324) of 36 rooms observed. Findings included: During an observation of room [ROOM NUMBER] with the Director of Maintenance (DOM) on 06/03/2026 at 11:15 a.m., the DOM observed and stated, he's seeing what appears to be water intrusion in to the walls from outside with the walls damaged. During an observation of room [ROOM NUMBER], the DOM stated, he was seeing that the window had failed and there was a leak in the thermal lining of the panes, there was also water intrusion into the wall with bubbling of the paint and unpainted surfaces. During an interview on 6/4/26 at 09:30 a.m. with the resident in room [ROOM NUMBER], she stated, the windows and the walls are in need of repair and has asked staff to fix, with no response. During an interview on 6/4/26 at 12:00 p.m. with the resident in room [ROOM NUMBER], he stated, the walls and the window are in disrepair. During a tour and observation on 6/1/2026 at 8:30 a.m. of room [ROOM NUMBER] the bathroom was observed with ceiling tiles removed and pushed to the side. This exposed pipes and wiring. During an observation on 6/2/26 at 9:56 a.m. of the ceiling tiles in room [ROOM NUMBER]. The ceiling had misaligned tiles in the closet, exposing the space above the ceiling. During an interview on 6/3/26 at 12:05 p.m. with the NHA, the DOM and the Director of Plant Operations, The DOM stated regarding determining what to repair, If I get a notice from someone verbally I'll fix the issue, but I do not have a plan to prioritize and identify issues throughout the structure. He said they do use angel rounds to help identify issues, but we don't have a current order to place priority to these issues, and we don't have angel round documentation to review. The DOM stated they did not currently have anything in their electronic reporting system or work orders for the two issues identified in rooms [ROOM NUMBERS]. He said we do use weekly monthly products to help us in the electronic reporting system to assist us in identifying items to fix, however we don't use an organized system to identify items to repair in each room. He said he uses life safety as a guide to help him prioritize issues once they're identified, meaning that life safety comes first and everything comes thereafter. He stated the staff is supposed to be putting issues in the electronic reporting system and they should have been trained during orientation regarding entering maintenance issues in the electronic reporting system. The DOM said they did not have any documentation of the training. Review of a document titled Maintenance Director Job Description, undated, signed on 4/8/26 by the employee and supervisor revealed;Major Duties and Responsibilities, Plans develops, organizes, implements, evaluates, and diets the Maintenance Department, it's programs and activities. Ensure the facility remains in compliance with all federal, state and local regulations for Life Safety Code compliance. Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, which includes painting, plumbing, carpentry, HVAC (heating ventilation and air conditioning), and electrical work.

Based on observations, interviews, and record review, the facility failed to ensure nursing staff demonstrated competency in ensuring life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The facility staff's failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F600 and F678Findings included: Review of an undated facility job description titled, License Practical Nurse (LPN), revealed required qualifications included: current CPR certification.Major duties and responsibilities showed:Directs the daily activities of the certified nursing assistants (CNAs) in accordance with current federal, state and local regulations and guidelines and established facility policies and procedures.Follows the nursing model to promote holistic care for the residents.Ensures that policies and procedures are complied with by nursing personnel assigned.Collaborates with other members of the interdisciplinary team as needed to ensure residents' needs are holistically met.Participates in end-of-life care as required.Additional tasks include:Treats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Review of a physician progress note dated [DATE] showed Resident #3's code status was Full Code.On [DATE], Resident #3 was found unresponsive and with vital signs absent by facility staff and CPR was not performed. On [DATE] Resident #3 had a meeting with the facility's Advanced Practical Registered Nurse (APRN) and expressed his Advance Care wishes. The progress note read, We had an extensive conversation concerning full code vs. (versus) DNR (Do Not Resuscitate) status. Patient verbalizes an understanding of the difference and elects/confirms full code status. On [DATE] at 5:30 a.m., Resident #3 was found unresponsive by Staff A, CNA (Certified Nursing Assistant). Staff A notified his nurse, Staff C, Licensed Practical Nurse (LPN). Facility staff demonstrated incompetency by denying Resident #3 his right to be resuscitated as CPR was not initiated by facility staff. This failure to perform CPR resulted in Resident #3's death at the facility.On [DATE] at 11:14 a.m. a telephone interview was conducted with Staff A, CNA. Staff A stated Resident #3 was not assigned to her. She said she worked with Staff B, CNA, who had come to her hallway and stated her resident was not responding and he was not moving. She said this was around 5:30 a.m. Staff A said as she was walking down the hall she ran into Staff C, Licensed Practical Nurse (LPN) who was at the desk on the phone. She said she notified Staff C the resident was not responding and she said, Yes, I'm on my way, but she continued with what she was doing. She said the nurse, Staff C came and put on the oximeter on the resident and his oxygen level was 60 (indicating moderate to severe hypoxemia, low blood oxygen). Staff A reported Staff C said, That is kind of low. Staff A said to the nurse, I said he is not here. Staff A stated she asked Staff C, Don't we need to call code?. Staff C said to hold on. She said let me go and check his status. Staff A stated Staff C left the room again and after a couple minutes she came and said [Resident #3] was a Full Code. Staff A stated, I said we need to start CPR. She said I should call another nurse. She said she did not know how to call the code. Staff A stated they were all standing there, waiting for her [Staff C, LPN] to tell them what to do. She said, I did not see anyone doing CPR. The nurses were asking us questions, they were from another floor. Staff A stated Staff D, RN said we needed to call 911. Staff A said, I believe it was around 5:45 a.m. now. She said she walked EMS (Emergency Medical Services) to Resident #3's room and left them in the room. Staff A said, When I walked in with EMS, I did not see anyone doing CPR. EMS asked what was going on. EMS asked for the paperwork for the resident, they asked, Why isn't anyone doing CPR if this man is a Full Code? Staff A stated she walked out of the room as EMS started CPR. She said later on, she gave a statement. Staff A said, I told them the truth. I said, code blue was not called and CPR was never initiated, not by our staff. Staff A, CNA stated having been suspended pending investigation.A telephone interview was conducted on [DATE] at 11:02 a.m. with Staff B, CNA, assigned to Resident #3. The CNA said, I found him [Resident #3] sometime close to 6:00 a.m. He was my resident. I went to the room and found him unresponsive. She stated she spoke to the nurse Staff C, LPN, she was on the med cart. Then she called another CNA, Staff A. Staff B stated Staff A went to the room with her and also tried to wake Resident #3 up. Then Staff C, LPN came. She stated Staff C, LPN said, He is not breathing. She said she needed another nurse, she said she did not know how to call the code on the intercom. Staff B, CNA said, I did not observe anybody doing CPR. Staff B answered, No, I did not observe Staff B, LPN or the other nurses doing CPR. There was no paging, no one called code blue. I do not re-call any of that. A telephone interview was conducted with Staff C, LPN on [DATE] at 11:36 a.m. Staff C was assigned to Resident #3 on [DATE]. She stated she only worked night shift and had taken care of the resident before. She said Resident #3 was sleeping, or I should say he appeared to be sleeping and in no distress. Staff C stated around 6:00 a.m. his CNA, Staff B came and said to take a look because he does not look right. Staff C said, I walked into the room, he was muddled, meaning he looked like he was not moving. I did a sternal rub, his feet were a little cold, and he was not responding. Staff C stated two CNAs (Staff A and B) were in the room. She said, I went to the nurse's station and called 911, and then I went and got the crash cart. Staff C stated she asked Staff B to go get the nurse from upstairs. Staff C said, I did not start CPR because I needed a back board. I was in the room waiting for the nurses to come and help put me put him on the board. He was a big guy, there is no way I could have moved him, I needed to have him on the floor. Staff C stated she did not ask the CNA to help her. Staff C said, I did not do compressions either. He was cold and he was dead. Staff C stated Resident #3 had oxygen on him. She said, He was gone. I did not call the code. Staff C stated the other nurses came pretty quickly. She said, We did not do anything. All of us stood there. Staff C stated within about 5 minutes the EMS were there. Staff C stated she had received training. She stated, Yes, I have been trained. If or when someone is in distress, you should call code blue, everyone should respond, get the crash cart and begin CPR. It did not happen for [Resident #3], I said because I believe he was gone, I am not certified to pronounce. Staff C stated Staff D, RN, was in the room. Staff C, LPN stated Staff D, RN should have started CPR or pronounced him. Staff C said, Not none of us did CPR. Everybody was in agreement he was gone and there was no way to bring him back. It was obvious. There was no AED (automated external defibrillator) to shock him or anything. We did not do anything. Staff C stated she gave a statement in writing to the DON. Staff C confirmed Resident #3 was a full Code. She said, I did not perform CPR because he was cold. Staff C restated she needed someone to move him from the bed and put him to the board, and nobody tried to help her with that. Staff C, LPN said, He was a big guy. I just looked at him, he was gone. She stated when EMS came, they tried to work on him for 30 - 45 minutes and they could not bring him back either.On [DATE] at 12:14 p.m. a telephone interview was conducted with Staff D, RN. She stated she was, in charge per say. She said he was not my resident. She said, I asked Staff C, LPN who they had called, and she said no one. I called the DON (Director of Nursing). Staff D stated the DON asked if the resident was a full code, and she confirmed and said, Yes. I yelled to them to start CPR. She said in that moment the paramedics came in. Staff D stated she had walked into the room when the CNA got her and observed him [Resident #3] laying on his back. She said she saw a table but does not remember there being a crash cart. Staff D said, I kept hearing they wanted me to pronounce the resident that was why I called the DON. Staff D, RN said their protocol if there was an unresponsive resident, is to check code status, and depending on the status act. If they are a full code, check pulse, check pupils, check for breathing, start CPR until the paramedics get there, and get a CNA to call Code. Staff D stated CPR was never done. She said, I do not know why it was not started. Staff D stated the for the reason she did not start CPR, She said, I did not start CPR myself because I did not know the code status, I assumed he was a DNR and that was why they were asking me to pronounce. I did not check myself. The whole time I was trying to figure out why. Staff D stated never been in that situation before. She stated she never had to pronounce anybody. She said, It is not our policy. Staff D stated not being told his code status. She said, I did not call the Code, the nurse should have told me. I had never pronounced a resident before. In my head I thought there was a change in policy I did not ask what his status was. I should have. Staff D, RN said she called the DON to find out what she wanted her to do about the pronouncing. She stated the DON said to check his code status and start CPR. Staff D, RN confirmed that night code blue was not called, and CPR was not started.On [DATE] at 1:05 p.m. a telephone interview was conducted with Staff E, LPN. Staff E stated that night she was called by the CNA (Staff B) who said his nurse needed another nurse to come and pronounce a resident. She said the nurse who is an LPN needed an RN. Staff E said, While I was in the room we did not start CPR, I assumed because we did not know the code and the way the CNA presented it when she came to the 3rd floor, was that the nurse was needed to pronounce the resident deceased . Code blue was not called. No one started CPR. Staff E stated the facility protocol when a resident is found unresponsive is to call the code. She stated she had not done code blue before. She said normally as a nurse, she should assess the patient and check the code status. Staff E stated, For me, because the CNA said the nurse was needed to come and verify the resident was deceased , I assumed the resident was a DNR. Staff E stated she exited the room after that. She stated she had not participated in a code blue, or CPR. Staff E stated she was suspended pending the investigation.On [DATE] at 2:14 p.m. a telephone interview was conducted with the facility's Medical Director (MD). The MD stated having received a phone call the previous day and was told Resident #3 had died. The MD said the expectation as the Medical director was that if a resident was unresponsive, there should be an immediate CPR started if they are a full Code. Chest compressions should start and have other people call the code and 911. She stated they did talk about the need for the staff to be educated on timeliness. The MD stated it was her understanding that the nurses were in the process of trying to get the board, and by that time there was no time for CPR to be initiated. The MD said, Nonetheless, with or without the board they should have started CPR. The MD stated they spoke about how long the patient was down and they could not tell. The MD stated how long the resident was down was good for documentation, but it should not matter. The MD stated they gave her a specific timeline. She said, I'm concerned if they failed to start CPR and were talking about pronouncing. Absolutely not, that is why we are having a. QAPI (quality assurance and performance improvement). The MD stated regarding failure to honor Resident #3's wishes, I wholeheartedly agree with you, the staff should have started CPR and then called 911. I do not know why the nurse said they did not do CPR and they did not tell me anything about the pronouncing. The MD stated it was not the facility's protocol to check if the feet were cold. The MD said, It is not our protocol for a nurse to pronounce. They should confirm code status. They should have initiated the CPR period. The MD stated this was an opportunity for education. She stated it was not their protocol for the nurse to determine if the resident had expired or not.On [DATE] at 2:09 p.m. an interview was conducted with the Regional Nuse Consultant (RNC), the Director of Nursing (DON) and the [NAME] President of Clinical Services, (VPCS). The RNC said, an allegation occurred after an all staff meeting on [DATE]. She stated Staff A, CNA said a resident was found unresponsive at 5:30 a.m. and the CNA felt the nurse did not do CPR. The RNC said the nurse did a sternal rub, there was no pulse/respirations, and he was not breathing. The RNC stated Staff C reported she checked code status and confirmed Resident #3 was a full code. She stated in about 2-3 minutes, she told Staff B to go get the nurses upstairs as she called 911 from her personal cell phone and verified the 6:04 a.m. call. The RNC stated Staff C said she called and got the crash cart and then got to the resident's room. She stated per Staff E, LPN and Staff D, RN, they came downstairs along with Staff B, CNA. The RNC stated Staff D, RN did an assessment, checked for pulse and walked to the med cart and verified the code status and by this time the paramedics were right there, at 6:09 a.m. The RNC stated the EMTs (Emergency Medical Technicians) intubated him and worked on him for 45 minutes and they were not able to get a pulse. She stated they pronounced him and Staff C, LPN called the family and the doctor.During the interview on [DATE] at 2:41 p.m., the DON stated she had arrived to work about 7:00 a.m. for a scheduled townhall/staff meeting. She stated Resident #3 had already been pronounced. The DON stated the EMTs started CPR.During the interview on [DATE] at 2:43 p.m., the RNC stated Staff C, LPN was educated as she knew the process. The RNC said they reviewed the process and identified the problem was that Staff C, LPN did not call code and instead she sent the CNAs upstairs to get the nurses. The RNC said, The time is close, but they could have started CPR.On [DATE] at 2:45 p.m. the VPCS stated the nurses should have started CPR. She stated Staff C, LPN could have started compressions even if they were waiting for the board. She said, They elected not to. They had training prior to this process. They did not follow our policies and procedure. The VPCS said, They acted [NAME]. We will be reporting their licenses. Review of a facility policy titled, Nursing Services and Sufficient Staff, revised 1/2026, revealed - It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.Policy Explanation and Compliance Guidelines:4. The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care.5. Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.6. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.The facility's immediate actions to remove the Immediate Jeopardy included: On [DATE] at 8:49 a.m. an internal investigation was initiated resident record review, staff interviews, and notifications to DCF, AHCA and local Law enforcement. On [DATE] Assigned nurse was suspended and terminated, with report of license to licensing board on [DATE] On [DATE]- two additional nurses that responded to the scene were suspended and terminated, with report of license to licensing board on [DATE] On [DATE] a complete facility audit was conducted by the Director of Clinical Services of resident code status preferences and verification of orders and care plans being correct. On [DATE] residents whose preference was a Do Not Resuscitate Order was reviewed to ensure that a valid Florida DNRO is physically available at the facility. On [DATE] 100% audit of current residents was conducted by the Director of Clinical Services of the three crash carts in the facility to ensure that all required items were present. On [DATE] Ad Hoc QAPI meeting was held with Executive Director, Director of Clinical Services, Medical Director via telephone, and at least three other department heads. On [DATE] overheard page system instructions were placed by the telephones at the nurse's station, reception area and dining room with detailed instructions on how to page overhead by the Activities Director. On [DATE] a review of facility deaths from the last 3 months were conducted by the Director of Clinical Services to ensure residents Advance Directives were followed related to Code Status. On [DATE] Executive Director completed an audit of licensed nurse Licensure and Cardiopulmonary Resuscitation Cards were valid.Emergency Response Process Changes On [DATE] Implementation of the following: All new employees must participate in a Code Blue Drill upon hire Licensed nursing staff must sign an Honoring Advance Directive Attestation upon hireStaff Education On [DATE], Director of Clinical Services and/ or designee educated facility staff on Resident Rights' including the right to choose Code Status. On [DATE] and [DATE] Director of Clinical Services and/or designee educated licensed staff on the following:- Honoring Advance Directives- Timeliness of initiated CPR- Following physician's orders- Code blue process- Monthly code drill will continue On [DATE] - All staff -Abuse, Neglect and Exploitation education with 100 percent completion On [DATE]- All staff- Resident Rights education- 100 percent completion On [DATE]- Licensed nursing staff received education with 100 percent completion on - Honoring Advance Directive Education, Physicians Orders Education, Timeliness of initiated CPR, and Code blue process. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Director of Clinical Services and/or designee conducted code blue quality assurance drill. Licensed Nurse will not work prior to attending a mock code blue quality assurance drill. On [DATE] interviews were conducted with 40 staff members, including 5 Registered Nurses, 7 Licensed Practical Nurses (LPNs),15 Certified Nursing Assistants (CNAs), and ancillary staff to include; therapy, dietary, housekeeping, social services, MDS nurse, Receptionist, and maintenance personnel. The staff members were able to state they had been trained and were knowledgeable about the facility policies regarding code status, their roles during a code blue, and where to find advanced directives. The staff members confirmed they had received abuse and neglect training.Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on interviews and record review, the facility failed to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F600 and F726.Findings included: Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include Type 2 diabetes, other persistent atrial fibrillation, abnormal gait, need for assistance with personal care, blindness of Right eye, shortness of breath, muscle wasting, mood disorder and essential hypertension.Review of the physician order summary report for Resident #3 dated [DATE] revealed code status orders; Full Code, dated [DATE].Review of form 3008 (Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form) dated [DATE], revealed upon admission to the facility Resident #3 did not have a DNR (Do Not Resuscitate) order in place. The form revealed Resident #3 was alert, oriented, follows instructions and was capable to make healthcare decisions.Review of an Advanced Practical Registered Nurse (APRN) progress note revealed Advance Care Planning (ACP) occurred on [DATE]. The note read, Face to face conversation with patient for greater than 16 minutes to discuss ACP/GOC (goals of care) conversation. We had an extensive conversation concerning Full Code vs. (versus) DNR (Do Not Resuscitate) status. Patient verbalizes an understanding of the difference and elects/confirms Full Code status.Review of a physician progress note dated [DATE] revealed, Advanced Care Planning (ACP): Reviewed code status in the facility EMR (Electronic Medical Record) and discussed with patient. Verified ACP in the facility EMR. Code status - Full Code.Review of an admission/readmission nursing evaluation dated [DATE] revealed:15. code Status, Full Code - CPR. The neurological assessment revealed the resident was alert, oriented to person, place, time and situation. Resident #3 communicated appropriately with no obvious problems. Review of a care plan for Resident #3 initiated on [DATE] revealed a focus - Resident has an established advanced directive: Resident is Full Code. No other AD (Advanced Directive) on file. The goal indicated the resident or healthcare decision maker shall participate in decisions regarding medical care and treatment by next review date, initiated on [DATE]. Interventions included to allow opportunities for expression of feelings or concerns. Maintain signed consent and review annually. Promote opportunities for resident healthcare decision maker to participate in decisions regarding care.Review of a 5-day Minimum Data Set (MDS) for Resident #3 dated [DATE] revealed in Section B, the resident's speech was clear, makes self-understood and understands others. Section C revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Section GG revealed the resident required partial/moderate assistance for ADLs (Activities of Daily Living). Review of Resident #3's physician note dated [DATE] revealed: Resident was seen today for follow up on stability. He was seen in the chair on the hallway. Chart, MAR (medication administration record) and recent vitals reviewed. No acute issues or significant changes since last evaluation. Resident appears at baseline and remains clinically stable. No new complaints voiced. Current diagnosis and plan of care reviewed; no changes indicated at this time. Continue current treatments. POC (plan of care) was reviewed and discussed with the resident, nursing staff, and PCP (primary care physician). Denies fever, chills, SOB (shortness of breath). Code Status: Full Code. Review of a physician progress note dated [DATE], showed Resident #3's code status was Full Code.On [DATE] at 11:14 a.m. a telephone interview was conducted with Staff A, CNA. Staff A stated Resident #3 was not assigned to her. She said she worked with Staff B, CNA, who had come to her hallway and stated her resident was not responding and he was not moving. She said this was around 5:30 a.m. Staff A said as she was walking down the hall she ran into Staff C, Licensed Practical Nurse (LPN) who was at the desk on the phone. She said she notified Staff C the resident was not responding and she said, Yes, I'm on my way, but she continued with what she was doing. Staff A said she went to the room and Staff B, CNA, was in the room. Staff A said Staff B was shaking Resident #3 and was calling his name. Staff A said, I checked his pulse on his arm and neck and he was not breathing. A few minutes later, the nurse, Staff C, came. She started calling him, I told her I did not get a pulse. She left to get a pulse oximeter. Staff A stated Resident #3 was laying on the bed, hanging on the side of the bed and one of the legs was off the bed. Staff A stated she and the other CNA, Staff B, positioned the resident back in bed. She said the nurse, Staff C came and put on the oximeter on the resident and his oxygen level was 60 (indicating moderate to severe hypoxemia, low blood oxygen). Staff A reported Staff C said, That is kind of low. Staff A said to the nurse, I said he is not here. Staff A stated she asked Staff C, Don't we need to call code?. Staff C said to hold on. She said let me go and check his status. Staff A stated Staff C left the room again and after a couple minutes she came and said [Resident #3] was a Full Code. Staff A stated, I said we need to start CPR. She said I should call another nurse. She said she did not know how to call the code. Staff A stated they were all standing there, waiting for her [Staff C, LPN] to tell them what to do. Staff A stated B, CNA asked, Do you want me to get another nurse? She stated Staff C did not answer so, at this point she said let me go. Staff A stated they all left the room, and she and Staff B went to get the RN (Registered Nurse) from upstairs. She said she took the stairs and Staff B took the elevator. She stated after she came downstairs she went to get the crash cart. Staff A stated Resident #3 was by himself during this time. She stated it was hard to tell how long it took. She said the time was moving slowly and fast at the same time. Staff A stated when she got to the room, the nurses, Staff D, RN, Staff E, LPN and Staff C, LPN all came in together. Staff A stated they were all in the room and Staff C was telling them what was happening. She said and the one nurse, Staff D, RN came and she was checking his oxygen and asking what happened. Staff A confirmed no one was doing CPR. She stated at this time the nurses took over. She said, I did not see anyone doing CPR. The nurses were asking us questions, they were from another floor. Staff A stated Staff D, RN said we needed to call 911. Staff A stated she asked Staff C if she had called, she said she was on her way down to call. Staff A stated she left the room together with Staff C and went to her assignment. She sated Staff B, CNA was very upset and she was trying to calm her down. She stated Staff B was saying maybe she could have done something different. Staff A stated she took Staff B to her assignment, and they started attending to her residents. Staff A stated the whole thing probably took about 15 minutes. She said they were in her hall when they heard the ambulance people coming up the stairs. She said they asked her where the room was. Staff A said, I believe it was around 5:45 a.m. now. She said she walked EMS (Emergency Medical Services) to Resident #3's room and left them in the room. Staff A said, When I walked in with EMS, I did not see anyone doing CPR. EMS asked what was going on. EMS asked for the paperwork for the resident, they asked, Why isn't anyone doing CPR if this man is a Full Code? Staff A stated she walked out of the room as EMS started CPR. She said later on, she gave a statement. Staff A said, I told them the truth. I said, code blue was not called and CPR was never initiated, not by our staff. Staff A, CNA stated having been suspended pending investigation.A telephone interview was conducted on [DATE] at 11:02 a.m. with Staff B, CNA, assigned to Resident #3. The CNA said, I found him [Resident #3] sometime close to 6:00 a.m. He was my resident. I went to the room and found him unresponsive. She stated she spoke to the nurse Staff C, LPN, she was on the med cart. Then she called another CNA, Staff A. Staff B stated Staff A went to the room with her and also tried to wake Resident #3 up. Then Staff C, LPN came. She stated Staff C, LPN said, He is not breathing. She said she needed another nurse, she said she did not know how to call the code on the intercom. Staff B stated she ran upstairs and got another nurse. Staff B stated being new and had not done a code before. She said she went and got Staff E, LPN and Staff D, RN. She said they all went down to the room. Staff B stated she started to have a panic attack, so she left the room. She said she could not tell what was said or done. Staff B, CNA said, I did not observe anybody doing CPR. Staff B answered, No, I did not observe Staff B, LPN or the other nurses doing CPR. There was no paging, no one called code blue. I do not re-call any of that. Staff B stated Resident #3 was not fully dependent, he was an assist. She said If he had an accident she would change him. She stated he wore briefs at night and in morning he would be assisted to the bathroom. She stated they document after they provide care. She said there was no documentation because she did not toilet him at all that night. Staff B stated her shift started at 11:15 p.m. Staff B said, I checked on him earlier, around 4:00 a.m. and he was breathing, until sometime close to 6:00 a.m., not exactly 6:00 a.m. I found him unresponsive. Staff B stated time was moving fast and it was hard to tell what was happening.A telephone interview was conducted with Staff C, LPN on [DATE] at 11:36 a.m. Staff C was assigned to Resident #3 on [DATE]. She stated she only worked night shift and had taken care of the resident before. She said he was legally blind, he had cardiac issues, he always asked for snacks, was wearing oxygen, and he needed ADL (Activities of Daily Living) assistance. He could eat/drink by himself. His B/P (blood pressure) was okay as he was taking medications. Staff C, LPN said on that night it was around 1:20 a.m. or 2:00 a.m. when she changed a dressing on his roommate's leg. She said Resident #3 was sleeping, or I should say he appeared to be sleeping and in no distress. Staff C stated around 6:00 a.m. his CNA, Staff B came and said to take a look because he does not look right. Staff C said, I walked into the room, he was muddled, meaning he looked like he was not moving. I did a sternal rub, his feet were a little cold, and he was not responding. Staff C stated two CNAs (Staff A and B) were in the room. She said, I went to the nurse's station and called 911, and then I went and got the crash cart. Staff C stated she asked Staff B to go get the nurse from upstairs. Staff C said, I did not start CPR because I needed a back board. I was in the room waiting for the nurses to come and help put me put him on the board. He was a big guy, there is no way I could have moved him, I needed to have him on the floor. Staff C stated she did not ask the CNA to help her. Staff C said, I did not do compressions either. He was cold and he was dead. Staff C stated Resident #3 had oxygen on him. She said, He was gone. I did not call the code. Staff C stated the other nurses came pretty quickly. She said, We did not do anything. All of us stood there. Staff C stated within about 5 minutes the EMS were there. Staff C stated she had received training. She stated, Yes, I have been trained. If or when someone is in distress, you should call code blue, everyone should respond, get the crash cart and begin CPR. It did not happen for [Resident #3], I said because I believe he was gone, I am not certified to pronounce. Staff C stated Staff D, RN, was in the room. Staff C, LPN stated Staff D, RN should have started CPR or pronounced him. Staff C said, Not none of us did CPR. Everybody was in agreement he was gone and there was no way to bring him back. It was obvious. There was no AED (automated external defibrillator) to shock him or anything. We did not do anything. Staff C stated she gave a statement in writing to the DON. She stated her timeline was around 6:00 a.m., and a soon as she checked him, she called 911 with her personal cell phone which showed an outgoing phone call at 6:04 a.m. She denied having been notified at 5:30 a.m. that there was anything wrong with Resident #3. Staff C stated during the course of the night, she gave the resident medications between 9:00 p.m. and 9:30 p.m., snacks and cough drops. She said at 1:30 a.m. or 2:00 a.m. she saw him in bed, he was breathing. She said I checked the oxygen it was in his nares. Staff C confirmed Resident #3 was a full Code. She said, I did not perform CPR because he was cold. Staff C restated she needed someone to move him from the bed and put him to the board, and nobody tried to help her with that. Staff C, LPN said, He was a big guy. I just looked at him, he was gone. She stated when EMS came, they tried to work on him for 30 - 45 minutes and they could not bring him back either.On [DATE] at 12:14 p.m. a telephone interview was conducted with Staff D, RN. She stated she was, in charge per say. She said he was not my resident. She stated she was sitting at the desk when a Staff B, CNA came and said they needed an RN because, We need someone to pronounce someone who was dead. Staff D stated she and Staff E, LPN followed Staff B to the room. She stated Staff C walked in too. She said, I asked Staff C, LPN who they had called, and she said no one. I called the DON (Director of Nursing). Staff D stated the DON asked if the resident was a full code, and she confirmed and said, Yes. I yelled to them to start CPR. She said in that moment the paramedics came in. Staff D stated she had walked into the room when the CNA got her and observed him [Resident #3] laying on his back. She said she saw a table but does not remember there being a crash cart. Staff D said, I kept hearing they wanted me to pronounce the resident that was why I called the DON. Staff D, RN said their protocol if there was an unresponsive resident, is to check code status, and depending on the status act. If they are a full code, check pulse, check pupils, check for breathing, start CPR until the paramedics get there, and get a CNA to call Code. Staff D stated CPR was never done. She said, I do not know why it was not started. Staff D stated the for the reason she did not start CPR, She said, I did not start CPR myself because I did not know the code status, I assumed he was a DNR and that was why they were asking me to pronounce. I did not check myself. The whole time I was trying to figure out why. Staff D stated never been in that situation before. She stated she never had to pronounce anybody. She said, It is not our policy. Staff D stated not being told his code status. She said, I did not call the Code, the nurse should have told me. I had never pronounced a resident before. In my head I thought there was a change in policy I did not ask what his status was. I should have. Staff D, RN said she called the DON to find out what she wanted her to do about the pronouncing. She stated the DON said to check his code status and start CPR. Staff D, RN confirmed that night code blue was not called, and CPR was not started.On [DATE] at 1:05 p.m. a telephone interview was conducted with Staff E, LPN. She stated she would normally take care of Resident #3 on night shift. She stated when Resident #3 came to the facility, at first he was very confused but became alert over time. She said he slept intermittently and would be watching television. Staff E stated that night she was called by the CNA (Staff B) who said his nurse needed another nurse to come and pronounce a resident. She said the nurse who is an LPN needed an RN. She said the three of them got in the elevator and went to the room. Staff E stated Staff C was standing in the doorway, and she and Staff D, RN walked in. She stated Staff D checked the resident's pupils and respirations. She said Staff C came back in the room and Staff D asked Staff C if she had called the DON. Staff E stated Staff D, RN stepped out and she followed behind her. She stated Staff D called the DON and as she followed down the hall, she had seen the paramedics coming. She stated it was approximately or around 6:00 a.m. Staff E stated she remembered herself and Staff D in the room at first. She said Staff C was not in the room. She said she remembered her coming in and telling Staff D the patient had been dead. Staff E said, While I was in the room we did not start CPR, I assumed because we did not know the code and the way the CNA presented it when she came to the 3rd floor, was that the nurse was needed to pronounce the resident deceased . Code blue was not called. No one started CPR. Staff E stated the facility protocol when a resident is found unresponsive is to call the code. She stated she had not done code blue before. She said normally as a nurse, she should assess the patient and check the code status. Staff E stated, For me, because the CNA said the nurse was needed to come and verify the resident was deceased , I assumed the resident was a DNR. Staff E stated she exited the room after that. She stated she had not participated in a code blue, or CPR. Staff E stated she was suspended pending the investigation.On [DATE] at 2:14 p.m. a telephone interview was conducted with the facility's Medical Director (MD). The MD stated having received a phone call the previous day and was told Resident #3 had died. The MD stated they said the aide checked on him at 6:00 a.m. and notified the nurse and they came and assessed him and within 2-3 minutes they called 911. The MD said his nurse got the other nurses to assist and then EMS arrived and that EMS started CPR. The MD stated the facility called her and spoke of the preliminary plan and was waiting for them to tell her when they were going to meet and discuss the issue. The MD said the expectation as the Medical director was that if a resident was unresponsive, there should be an immediate CPR started if they are a full Code. Chest compressions should start and have other people call the code and 911. She stated they did talk about the need for the staff to be educated on timeliness. The MD stated it was her understanding that the nurses were in the process of trying to get the board, and by that time there was no time for CPR to be initiated. The MD said, Nonetheless, with or without the board they should have started CPR. The MD stated they spoke about how long the patient was down and they could not tell. The MD stated how long the resident was down was good for documentation, but it should not matter. The MD stated they gave her a specific timeline. She said, I'm concerned if they failed to start CPR and were talking about pronouncing. Absolutely not, that is why we are having a. QAPI (quality assurance and performance improvement). The MD stated regarding failure to honor Resident #3's wishes, I wholeheartedly agree with you, the staff should have started CPR and then called 911. I do not know why the nurse said they did not do CPR and they did not tell me anything about the pronouncing. The MD stated it was not the facility's protocol to check if the feet were cold. The MD said this was not presented to her. The MD stated if the resident were a DNR, two nurses should have assessed the resident. The MD said, It is not our protocol for a nurse to pronounce. They should confirm code status. They should have initiated the CPR period. The MD stated this was an opportunity for education. She stated it was not their protocol for the nurse to determine if the resident had expired or not. The MD further stated not knowing Staff C, LPN had a similar situation in her past, where she did not initiate CPR on an unresponsive patient.On [DATE] at 2:09 p.m. an interview was conducted with the Regional Nuse Consultant (RNC), the Director of Nursing (DON) and the [NAME] President of Clinical Services, (VPCS). The RNC said, an allegation occurred after an all staff meeting on [DATE]. She stated Staff A, CNA said a resident was found unresponsive at 5:30 a.m. and the CNA felt the nurse did not do CPR. The RNC said at that point they filed the immediate report. She stated the immediate was too vague and it was kicked back. She stated they refiled the report that CPR was done by EMS, but not timely. She said they initiated an investigation on [DATE]. The RNC said they interviewed all the staff who were working and they were able to put together a timeline. The RNC stated their timeline revealed between 5:55 a.m. and 6:00 a.m., Staff B, CNA went in the room and about 6:00 a.m. found Resident #3 was not talking or arousing. The RNC stated they did not review the camera to confirm this timeline because the footage was no longer available. She stated Staff B, CNA went to the nurse, Staff C, LPN who was at the med cart and said Resident #3 did not seem right and could she check on him. She said the nurse reported she left the cart went to the room with the two CNAs, Staff A and B and she checked the resident. The RNC said the nurse did a sternal rub, there was no pulse/respirations, and he was not breathing. The RNC stated Staff C reported she checked code status and confirmed Resident #3 was a full code. She stated in about 2-3 minutes, she told Staff B to go get the nurses upstairs as she called 911 from her personal cell phone and verified the 6:04 a.m. call. The RNC stated Staff C said she called and got the crash cart and then got to the resident's room. She stated per Staff E, LPN and Staff D, RN, they came downstairs along with Staff B, CNA. The RNC stated Staff D, RN did an assessment, checked for pulse and walked to the med cart and verified the code status and by this time the paramedics were right there, at 6:09 a.m. The RNC stated the EMTs (Emergency Medical Technicians) intubated him and worked on him for 45 minutes and they were not able to get a pulse. She stated they pronounced him and Staff C, LPN called the family and the doctor.During the interview on [DATE] at 2:41 p.m., the DON stated she had arrived to work about 7:00 a.m. for a scheduled townhall/staff meeting. She stated Resident #3 had already been pronounced. The DON stated she spoke to the nurse who said she had already called the family. The DON stated after the townhall/staff meeting, Staff A, CNA reported something went wrong with Resident #3. The DON said she immediately called the nurses and asked for statements. She stated she contacted the RNC and they started their investigation which included notifying DCF (department of children and families) and the police. The DON stated the EMTs started CPR.During the interview on [DATE] at 2:43 p.m., the RNC said regarding their findings, I think it was a very close time. I don't believe 5:30 a.m. is accurate even though the CNA reported that time. We believe the Nurse could have paged code blue overhead, versus sending the CNAs upstairs. This could have saved time. The RNC stated Staff C, LPN was educated as she knew the process. The RNC said they reviewed the process and identified the problem was that Staff C, LPN did not call code and instead she sent the CNAs upstairs to get the nurses. The RNC said, The time is close, but they could have started CPR.On [DATE] at 2:45 p.m. the VPCS stated the nurses should have started CPR. She stated Staff C, LPN could have started compressions even if they were waiting for the board. She said, They elected not to. They had training prior to this process. They did not follow our policies and procedure. The VPCS said, They acted [NAME]. We will be reporting their licenses.Review of a facility policy titled, Cardiopulmonary Resuscitation (CPR), revised 1/2026, revealed, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR).Policy Explanation and Compliance Guidelines:1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR.2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directives or a Do Not Resuscitate order; andc. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition).3. CPR certified staff will be available at all times.4. Staff will maintain current CPR certification for healthcare providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards.Review of a facility policy titled, Communication of Code Status, revised [DATE], revealed, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.a. Full Codeb. Do Not Resuscitatec. Do Not Intubated. Do not Hospitalize.The facility's immediate actions to remove the Immediate Jeopardy included: On [DATE] at 8:49 a.m. an internal investigation was initiated resident record review, staff interviews, notification to DCF, AHCA and local Law enforcement. On [DATE] Assigned nurse was suspended and terminated, with report of license to licensing board on [DATE]. On [DATE]- two additional nurses that responded to the scene were suspended and terminated, with report of license to licensing board on [DATE] On [DATE] a complete facility audit was conducted by the Director of Clinical Services of resident Code status preferences and verification of orders and care plans being correct. On [DATE] 100% audit of current residents was conducted by the Director of Clinical Services of the three crash carts in the facility to ensure that all required items were present. On [DATE] Ad Hoc QAPI meeting was held with Executive Director, Director of Clinical Services, Medical Director via telephone, and at least three other department heads. On [DATE] overheard page system instructions were placed by the telephones at the nurse's station, reception area and dining room with detailed instructions on how to page overhead by the Activities Director. On [DATE] a review of facility deaths from the last 3 months were conducted by the Director of Clinical Services to ensure residents Advance Directives were followed related to Code Status. On [DATE] Executive Director completed an audit of licensed nurse Licensure and Cardiopulmonary Resuscitation Cards were valid.Emergency Response Process Changes On [DATE] Implementation of the following: All new employees must participate in a Code Blue Drill upon hire Licensed nursing staff must sign a Honoring Advance Directive Attestation upon hireStaff Education: On [DATE], Director of Clinical Services and/or designee educated facility staff on Resident Rights' including the right to choose Code Status. On [DATE] and [DATE] Director of Clinical Services and/or designee educated licensed staff on the following:- Honoring Advance Directives- Timeliness of initiated CPR- Following physician's orders- Code blue process On [DATE] - All staff -Abuse, Neglect and Exploitation education with 100 percent completion On [DATE]- All staff- Resident Rights education- 100 percent completion On [DATE]- Licensed nursing staff received education with 100 percent completion on - Honoring Advance Directive Education, Physicians Orders Education, Timeliness of initiated CPR, and Code blue process. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] Director of Clinical Services and/or designee conducted Code blue drill quality assurance drills. Licensed Nurse will not work prior to attending a mock code blue drillOn [DATE] interviews were conducted with 40 staff members, including 5 Registered Nurses, 7 Licensed Practical Nurses (LPNs), 15 Certified Nursing Assistants (CNAs), and ancillary staff to include: therapy, dietary, housekeeping, social services, MDS nurse, Receptionist, and maintenance personnel. The staff members were able to state they had been trained and were knowledgeable about the facility policies regarding Code status, their roles during a Code Blue, and where to find advanced directives. The staff members confirmed they had received abuse and neglect training.Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on interviews and record review, the facility failed to protect the residents' right to be free from neglect by failing to honor a resident's expressed Advanced Directive for end of life by failing to ensure life saving measures of cardiopulmonary resuscitation (CPR) were performed, for one resident (#3) of two residents sampled. The failure to initiate CPR for approximately 35 minutes resulted in physical pain and ultimate death for Resident #3.On [DATE] Resident #3 was found unresponsive and absent of vital signs by facility staff and CPR was not performed. On [DATE] Resident #3 had a meeting with the facility's Advanced Practical Registered Nurse (APRN) and expressed his Advance Care wishes. The progress note read, We had an extensive conversation concerning full code vs. (versus) DNR (Do Not Resuscitate) status. Patient verbalizes an understanding of the difference and elects/confirms full code status. On [DATE] at 5:30 a.m. Resident #3 was found unresponsive by Staff A, CNA (Certified Nursing Assistant). Staff A notified his nurse, Staff B, LPN (Licensed Practical Nurse). Facility staff denied Resident #3 his right to be resuscitated as CPR was not initiated by facility staff. On [DATE] at 6:09 a.m. EMS (Emergency Medical Services) arrived to the facility, and the paramedics confirmed Resident #3's code status and initiated CPR. EMS performed CPR on Resident #3 for approximately 45 minutes. Resident #3 was pronounced dead at the facility.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Cross reference to F678 and F726.Findings included: On [DATE] at 11:14 a.m. a telephone interview was conducted with Staff A, CNA. Staff A stated Resident #3 was not assigned to her. She said she worked with Staff B, CNA, who had come to her hallway and stated her resident was not responding and he was not moving. She said this was around 5:30 a.m. Staff A said as she was walking down the hall she ran into Staff C, Licensed Practical Nurse (LPN) who was at the desk on the phone. She said she notified Staff C the resident was not responding and she said, Yes, I'm on my way, but she continued with what she was doing. Staff A said she went to the room and Staff B, CNA, was in the room. Staff A said Staff B was shaking Resident #3 and was calling his name. Staff A said, I checked his pulse on his arm and neck and he was not breathing. A few minutes later, the nurse, Staff C, came. She started calling him, I told her I did not get a pulse. She left to get a pulse oximeter. Staff A stated Resident #3 was laying on the bed, hanging on the side of the bed and one of the legs was off the bed. Staff A stated she and the other CNA, Staff B, positioned the resident back in bed. She said the nurse, Staff C came and put on the oximeter on the resident and his oxygen level was 60 (indicating moderate to severe hypoxemia, low blood oxygen). Staff A reported Staff C said, That is kind of low. Staff A said to the nurse, I said he is not here. Staff A stated she asked Staff C, Don't we need to call code?. Staff C said to hold on. She said let me go and check his status. Staff A stated Staff C left the room again and after a couple minutes she came and said [Resident #3] was a Full Code. Staff A stated, I said we need to start CPR. She said I should call another nurse. She said she did not know how to call the code. Staff A stated they were all standing there, waiting for her [Staff C, LPN] to tell them what to do. Staff A stated B, CNA asked, Do you want me to get another nurse? She stated Staff C did not answer so, at this point she said let me go. Staff A stated they all left the room, and she and Staff B went to get the RN (Registered Nurse) from upstairs. She said she took the stairs and Staff B took the elevator. She stated after she came downstairs she went to get the crash cart. Staff A stated Resident #3 was by himself during this time. She stated it was hard to tell how long it took. She said the time was moving slowly and fast at the same time. Staff A stated when she got to the room, the nurses, Staff D, RN, Staff E, LPN and Staff C, LPN all came in together. Staff A stated they were all in the room and Staff C was telling them what was happening. She said and the one nurse, Staff D, RN came and she was checking his oxygen and asking what happened. Staff A confirmed no one was doing CPR. She stated at this time the nurses took over. She said, I did not see anyone doing CPR. The nurses were asking us questions, they were from another floor. Staff A stated Staff D, RN said we needed to call 911. Staff A stated she asked Staff C if she had called, she said she was on her way down to call. Staff A stated she left the room together with Staff C and went to her assignment. She sated Staff B, CNA was very upset and she was trying to calm her down. She stated Staff B was saying maybe she could have done something different. Staff A stated she took Staff B to her assignment, and they started attending to her residents. Staff A stated the whole thing probably took about 15 minutes. She said they were in her hall when they heard the ambulance people coming up the stairs. She said they asked her where the room was. Staff A said, I believe it was around 5:45 a.m. now. She said she walked EMS (Emergency Medical Services) to Resident #3's room and left them in the room. Staff A said, When I walked in with EMS, I did not see anyone doing CPR. EMS asked what was going on. EMS asked for the paperwork for the resident, they asked, Why isn't anyone doing CPR if this man is a Full Code? Staff A stated she walked out of the room as EMS started CPR. She said later on, she gave a statement. Staff A said, I told them the truth. I said, code blue was not called and CPR was never initiated, not by our staff. Staff A, CNA stated having been suspended pending investigation.Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include Type 2 diabetes, other persistent atrial fibrillation, abnormal gait, need for assistance with personal care, blindness of Right eye, shortness of breath, muscle wasting, mood disorder and essential hypertension.Review of the physician order summary report for Resident #3 dated [DATE] revealed code status orders; Full Code, dated [DATE].Review of form 3008 (Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form) dated [DATE], revealed upon admission to the facility Resident #3 did not have a DNR (Do Not Resuscitate) order in place. The form revealed Resident #3 was alert, oriented, follows instructions and was capable to make healthcare decisions.Review of an Advanced Practical Registered Nurse (APRN) progress note revealed Advance Care Planning (ACP) occurred on [DATE]. The note read, Face to face conversation with patient for greater than 16 minutes to discuss ACP/GOC (goals of care) conversation. We had an extensive conversation concerning Full Code vs. (versus) DNR (Do Not Resuscitate) status. Patient verbalizes an understanding of the difference and elects/confirms Full Code status.Review of a physician progress note dated [DATE] revealed, Advanced Care Planning (ACP): Reviewed code status in the facility EMR (Electronic Medical Record) and discussed with patient. Verified ACP in the facility EMR. Code status - Full Code.Review of an admission/readmission nursing evaluation dated [DATE] revealed:15. code Status, Full Code - CPR. The neurological assessment revealed the resident was alert, oriented to person, place, time and situation. Resident #3 communicated appropriately with no obvious problems. Review of a care plan for Resident #3 initiated on [DATE] revealed a focus - Resident has an established advanced directive: Resident is Full Code. No other AD (Advanced Directive) on file. The goal indicated the resident or healthcare decision maker shall participate in decisions regarding medical care and treatment by next review date, initiated on [DATE]. Interventions included to allow opportunities for expression of feelings or concerns. Maintain signed consent and review annually. Promote opportunities for resident healthcare decision maker to participate in decisions regarding care.Review of a 5-day Minimum Data Set (MDS) for Resident #3 dated [DATE] revealed in Section B, the resident's speech was clear, makes self-understood and understands others. Section C revealed the resident had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Section GG revealed the resident required partial/moderate assistance for ADLs (Activities of Daily Living). Review of Resident #3's physician note dated [DATE] revealed: Resident was seen today for follow up on stability. He was seen in the chair on the hallway. Chart, MAR (medication administration record) and recent vitals reviewed. No acute issues or significant changes since last evaluation. Resident appears at baseline and remains clinically stable. No new complaints voiced. Current diagnosis and plan of care reviewed; no changes indicated at this time. Continue current treatments. POC (plan of care) was reviewed and discussed with the resident, nursing staff, and PCP (primary care physician). Denies fever, chills, SOB (shortness of breath). Code Status: Full Code. Review of a physician progress note dated [DATE], showed Resident #3's code status was Full Code.A telephone interview was conducted on [DATE] at 11:02 a.m. with Staff B, CNA, assigned to Resident #3. The CNA said, I found him [Resident #3] sometime close to 6:00 a.m. He was my resident. I went to the room and found him unresponsive. She stated she spoke to the nurse Staff C, LPN, she was on the med cart. Then she called another CNA, Staff A. Staff B stated Staff A went to the room with her and also tried to wake Resident #3 up. Then Staff C, LPN came. She stated Staff C, LPN said, He is not breathing. She said she needed another nurse, she said she did not know how to call the code on the intercom. Staff B stated she ran upstairs and got another nurse. Staff B stated being new and had not done a code before. She said she went and got Staff E, LPN and Staff D, RN. She said they all went down to the room. Staff B stated she started to have a panic attack, so she left the room. She said she could not tell what was said or done. Staff B, CNA said, I did not observe anybody doing CPR. Staff B answered, No, I did not observe Staff B, LPN or the other nurses doing CPR. There was no paging, no one called code blue. I do not re-call any of that. Staff B stated Resident #3 was not fully dependent, he was an assist. She said If he had an accident she would change him. She stated he wore briefs at night and in morning he would be assisted to the bathroom. She stated they document after they provide care. She said there was no documentation because she did not toilet him at all that night. Staff B stated her shift started at 11:15 p.m. Staff B said, I checked on him earlier, around 4:00 a.m. and he was breathing, until sometime close to 6:00 a.m., not exactly 6:00 a.m. I found him unresponsive. Staff B stated time was moving fast and it was hard to tell what was happening.A telephone interview was conducted with Staff C, LPN on [DATE] at 11:36 a.m. Staff C was assigned to Resident #3 on [DATE]. She stated she only worked night shift and had taken care of the resident before. She said he was legally blind, he had cardiac issues, he always asked for snacks, was wearing oxygen, and he needed ADL (Activities of Daily Living) assistance. He could eat/drink by himself. His B/P (blood pressure) was okay as he was taking medications. Staff C, LPN said on that night it was around 1:20 a.m. or 2:00 a.m. when she changed a dressing on his roommate's leg. She said Resident #3 was sleeping, or I should say he appeared to be sleeping and in no distress. Staff C stated around 6:00 a.m. his CNA, Staff B came and said to take a look because he does not look right. Staff C said, I walked into the room, he was muddled, meaning he looked like he was not moving. I did a sternal rub, his feet were a little cold, and he was not responding. Staff C stated two CNAs (Staff A and B) were in the room. She said, I went to the nurse's station and called 911, and then I went and got the crash cart. Staff C stated she asked Staff B to go get the nurse from upstairs. Staff C said, I did not start CPR because I needed a back board. I was in the room waiting for the nurses to come and help put me put him on the board. He was a big guy, there is no way I could have moved him, I needed to have him on the floor. Staff C stated she did not ask the CNA to help her. Staff C said, I did not do compressions either. He was cold and he was dead. Staff C stated Resident #3 had oxygen on him. She said, He was gone. I did not call the code. Staff C stated the other nurses came pretty quickly. She said, We did not do anything. All of us stood there. Staff C stated within about 5 minutes the EMS were there. Staff C stated she had received training. She stated, Yes, I have been trained. If or when someone is in distress, you should call code blue, everyone should respond, get the crash cart and begin CPR. It did not happen for [Resident #3], I said because I believe he was gone, I am not certified to pronounce. Staff C stated Staff D, RN, was in the room. Staff C, LPN stated Staff D, RN should have started CPR or pronounced him. Staff C said, Not none of us did CPR. Everybody was in agreement he was gone and there was no way to bring him back. It was obvious. There was no AED (automated external defibrillator) to shock him or anything. We did not do anything. Staff C stated she gave a statement in writing to the DON. She stated her timeline was around 6:00 a.m., and a soon as she checked him, she called 911 with her personal cell phone which showed an outgoing phone call at 6:04 a.m. She denied having been notified at 5:30 a.m. that there was anything wrong with Resident #3. Staff C stated during the course of the night, she gave the resident medications between 9:00 p.m. and 9:30 p.m., snacks and cough drops. She said at 1:30 a.m. or 2:00 a.m. she saw him in bed, he was breathing. She said I checked the oxygen it was in his nares. Staff C confirmed Resident #3 was a full Code. She said, I did not perform CPR because he was cold. Staff C restated she needed someone to move him from the bed and put him to the board, and nobody tried to help her with that. Staff C, LPN said, He was a big guy. I just looked at him, he was gone. She stated when EMS came, they tried to work on him for 30 - 45 minutes and they could not bring him back either.On [DATE] at 12:14 p.m. a telephone interview was conducted with Staff D, RN. She stated she was, in charge per say. She said he was not my resident. She stated she was sitting at the desk when a Staff B, CNA came and said they needed an RN because, We need someone to pronounce someone who was dead. Staff D stated she and Staff E, LPN followed Staff B to the room. She stated Staff C walked in too. She said, I asked Staff C, LPN who they had called, and she said no one. I called the DON (Director of Nursing). Staff D stated the DON asked if the resident was a full code, and she confirmed and said, Yes. I yelled to them to start CPR. She said in that moment the paramedics came in. Staff D stated she had walked into the room when the CNA got her and observed him [Resident #3] laying on his back. She said she saw a table but does not remember there being a crash cart. Staff D said, I kept hearing they wanted me to pronounce the resident that was why I called the DON. Staff D, RN said their protocol if there was an unresponsive resident, is to check code status, and depending on the status act. If they are a full code, check pulse, check pupils, check for breathing, start CPR until the paramedics get there, and get a CNA to call Code. Staff D stated CPR was never done. She said, I do not know why it was not started. Staff D stated the for the reason she did not start CPR, She said, I did not start CPR myself because I did not know the code status, I assumed he was a DNR and that was why they were asking me to pronounce. I did not check myself. The whole time I was trying to figure out why. Staff D stated never been in that situation before. She stated she never had to pronounce anybody. She said, It is not our policy. Staff D stated not being told his code status. She said, I did not call the Code, the nurse should have told me. I had never pronounced a resident before. In my head I thought there was a change in policy I did not ask what his status was. I should have. Staff D, RN said she called the DON to find out what she wanted her to do about the pronouncing. She stated the DON said to check his code status and start CPR. Staff D, RN confirmed that night code blue was not called, and CPR was not started.On [DATE] at 1:05 p.m. a telephone interview was conducted with Staff E, LPN. She stated she would normally take care of Resident #3 on night shift. She stated when Resident #3 came to the facility, at first he was very confused but became alert over time. She said he slept intermittently and would be watching television. Staff E stated that night she was called by the CNA (Staff B) who said his nurse needed another nurse to come and pronounce a resident. She said the nurse who is an LPN needed an RN. She said the three of them got in the elevator and went to the room. Staff E stated Staff C was standing in the doorway, and she and Staff D, RN walked in. She stated Staff D checked the resident's pupils and respirations. She said Staff C came back in the room and Staff D asked Staff C if she had called the DON. Staff E stated Staff D, RN stepped out and she followed behind her. She stated Staff D called the DON and as she followed down the hall, she had seen the paramedics coming. She stated it was approximately or around 6:00 a.m. Staff E stated she remembered herself and Staff D in the room at first. She said Staff C was not in the room. She said she remembered her coming in and telling Staff D the patient had been dead. Staff E said, While I was in the room we did not start CPR, I assumed because we did not know the code and the way the CNA presented it when she came to the 3rd floor, was that the nurse was needed to pronounce the resident deceased . Code blue was not called. No one started CPR. Staff E stated the facility protocol when a resident is found unresponsive is to call the code. She stated she had not done code blue before. She said normally as a nurse, she should assess the patient and check the code status. Staff E stated, For me, because the CNA said the nurse was needed to come and verify the resident was deceased , I assumed the resident was a DNR. Staff E stated she exited the room after that. She stated she had not participated in a code blue, or CPR. Staff E stated she was suspended pending the investigation.On [DATE] at 2:14 p.m. a telephone interview was conducted with the facility's Medical Director (MD). The MD stated having received a phone call the previous day and was told Resident #3 had died. The MD stated they said the aide checked on him at 6:00 a.m. and notified the nurse and they came and assessed him and within 2-3 minutes they called 911. The MD said his nurse got the other nurses to assist and then EMS arrived and that EMS started CPR. The MD stated the facility called her and spoke of the preliminary plan and was waiting for them to tell her when they were going to meet and discuss the issue. The MD said the expectation as the Medical director was that if a resident was unresponsive, there should be an immediate CPR started if they are a full Code. Chest compressions should start and have other people call the code and 911. She stated they did talk about the need for the staff to be educated on timeliness. The MD stated it was her understanding that the nurses were in the process of trying to get the board, and by that time there was no time for CPR to be initiated. The MD said, Nonetheless, with or without the board they should have started CPR. The MD stated they spoke about how long the patient was down and they could not tell. The MD stated how long the resident was down was good for documentation, but it should not matter. The MD stated they gave her a specific timeline. She said, I'm concerned if they failed to start CPR and were talking about pronouncing. Absolutely not, that is why we are having a. QAPI (quality assurance and performance improvement). The MD stated regarding failure to honor Resident #3's wishes, I wholeheartedly agree with you, the staff should have started CPR and then called 911. I do not know why the nurse said they did not do CPR and they did not tell me anything about the pronouncing. The MD stated it was not the facility's protocol to check if the feet were cold. The MD said this was not presented to her. The MD stated if the resident were a DNR, two nurses should have assessed the resident. The MD said, It is not our protocol for a nurse to pronounce. They should confirm code status. They should have initiated the CPR period. The MD stated this was an opportunity for education. She stated it was not their protocol for the nurse to determine if the resident had expired or not. The MD further stated not knowing Staff C, LPN had a similar situation in her past, where she did not initiate CPR on an unresponsive patient.On [DATE] at 2:09 p.m. an interview was conducted with the Regional Nuse Consultant (RNC), the Director of Nursing (DON) and the [NAME] President of Clinical Services, (VPCS). The RNC said, an allegation occurred after an all staff meeting on [DATE]. She stated Staff A, CNA said a resident was found unresponsive at 5:30 a.m. and the CNA felt the nurse did not do CPR. The RNC said at that point they filed the immediate report. She stated the immediate was too vague and it was kicked back. She stated they refiled the report that CPR was done by EMS, but not timely. She said they initiated an investigation on [DATE]. The RNC said they interviewed all the staff who were working and they were able to put together a timeline. The RNC stated their timeline revealed between 5:55 a.m. and 6:00 a.m., Staff B, CNA went in the room and about 6:00 a.m. found Resident #3 was not talking or arousing. The RNC stated they did not review the camera to confirm this timeline because the footage was no longer available. She stated Staff B, CNA went to the nurse, Staff C, LPN who was at the med cart and said Resident #3 did not seem right and could she check on him. She said the nurse reported she left the cart went to the room with the two CNAs, Staff A and B and she checked the resident. The RNC said the nurse did a sternal rub, there was no pulse/respirations, and he was not breathing. The RNC stated Staff C reported she checked code status and confirmed Resident #3 was a full code. She stated in about 2-3 minutes, she told Staff B to go get the nurses upstairs as she called 911 from her personal cell phone and verified the 6:04 a.m. call. The RNC stated Staff C said she called and got the crash cart and then got to the resident's room. She stated per Staff E, LPN and Staff D, RN, they came downstairs along with Staff B, CNA. The RNC stated Staff D, RN did an assessment, checked for pulse and walked to the med cart and verified the code status and by this time the paramedics were right there, at 6:09 a.m. The RNC stated the EMTs (Emergency Medical Technicians) intubated him and worked on him for 45 minutes and they were not able to get a pulse. She stated they pronounced him and Staff C, LPN called the family and the doctor.During the interview on [DATE] at 2:41 p.m., the DON stated she had arrived to work about 7:00 a.m. for a scheduled townhall/staff meeting. She stated Resident #3 had already been pronounced. The DON stated she spoke to the nurse who said she had already called the family. The DON stated after the townhall/staff meeting, Staff A, CNA reported something went wrong with Resident #3. The DON said she immediately called the nurses and asked for statements. She stated she contacted the RNC and they started their investigation which included notifying DCF (department of children and families) and the police. The DON stated the EMTs started CPR.During the interview on [DATE] at 2:43 p.m., the RNC said regarding their findings, I think it was a very close time. I don't believe 5:30 a.m. is accurate even though the CNA reported that time. We believe the Nurse could have paged code blue overhead, versus sending the CNAs upstairs. This could have saved time. The RNC stated Staff C, LPN was educated as she knew the process. The RNC said they reviewed the process and identified the problem was that Staff C, LPN did not call code and instead she sent the CNAs upstairs to get the nurses. The RNC said, The time is close, but they could have started CPR.On [DATE] at 2:45 p.m. the VPCS stated the nurses should have started CPR. She stated Staff C, LPN could have started compressions even if they were waiting for the board. She said, They elected not to. They had training prior to this process. They did not follow our policies and procedure. The VPCS said, They acted [NAME]. We will be reporting their licenses. Review of the facility policy titled, Abuse, Neglect and Exploitation, revised [DATE] revealed - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Policy Explanation and Compliance Guidelines:1.The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;b. Establish policies and procedures to investigate any such allegations; andc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of property, reporting procedures, and dementia management and resident abuse prevention; andd. Establish coordination with the QAPI program.2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.III. Prevention of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:A.B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment;A. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;B. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions;C. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed;D. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; andE. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.The facility's immediate actions to remove the Immediate Jeopardy included: On [DATE] at 8:49 a.m. an internal investigation was initiated with resident record review, staff interviews, and notification to DCF, AHCA and local Law enforcement. On [DATE] Assigned nurse was suspended and terminated, with report of license to licensing board on [DATE] On [DATE]- two additional nurses that responded to the scene were suspended and terminated, with report of license to licensing board on [DATE] On [DATE] a complete facility audit was conducted by the Director of Clinical Services of resident code status preferences and verification of orders and care plans being correct. On [DATE] 100% audit of current residents was conducted by the Director of Clinical Services of the three crash carts in the facility to ensure that all required items were present. On [DATE] Ad Hoc QAPI meeting was held with Executive Director, Director of Clinical Services, Medical Director via telephone, and at least three other department heads. On [DATE] a review of facility deaths from the last 3 months were conducted by the Director of Clinical Services to ensure residents Advance Directives were followed related to Code Status. On [DATE] Implementation of the following:- Licensed nursing staff must sign Honoring Advance Directive Attestation upon hire.Staff Education On [DATE], Director of Clinical Services and/ or designee educated facility staff on the following:- Abuse, Neglect and Exploitation with the emphasis on Advance Directives. On [DATE] and [DATE] Director of Clinical Services and/or designee educated licensed staff on the following:- Honoring Advance Directives - Timeliness of initiated CPR- Following physician's orders - Code blue process. On [DATE] - All staff -Abuse, Neglect and Exploitation education with 100 percent completion On [DATE]- All staff- Resident Rights education- 100 percent completion On [DATE]- Licensed nursing staff received education with 100 percent completion on - Honoring Advance Directive Education, Physicians Orders Education, Timeliness of initiated CPR, and Code blue process. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Director of Clinical Services and/or designee conducted code blue quality assurance drill. Licensed Nurse will not work prior to attending a mock code blue quality assurance drill. Verification of the facility's removal plan was conducted by the survey team on [DATE].On [DATE] interviews were conducted with 40 staff members, including 5 Registered Nurses, 7 Licensed Practical Nurses (LPNs),15 Certified Nursing Assistants (CNAs), and ancillary staff to include; therapy, dietary, housekeeping, social services, MDS nurse, Receptionist, and maintenance personnel. The staff members were able to state they had been trained and were knowledgeable about the facility policies regarding code status, their roles during a code blue, and where to find advanced directives. The staff members confirmed they had received abuse and neglect training.Based on verification of the facility's immediate jeopardy removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D.

Based on record review and interviews the facility failed to maintain complete and accurate medical records related to documentation of activities of daily living (ADLs) for one resident (#2) out of two residents reviewed.Findings included: A review of Resident #2's admission record revealed an admission date of 11/21/25 and a discharge date of 11/24/25, with diagnoses to include Parkinson's disease, sarcopenia, cognitive communication deficit, dementia, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits.A review of Resident #2's toileting task from 11/21/25-11/24/25 revealed there was no documentation showing Resident #2 had received incontinence care during 8 out of10 opportunities.A review of Resident #2's nutrition/eating task from 11/21/25-11/24/25 revealed there was no documentation showing Resident #2 received their meals 7 out of 9 opportunities.During attempted interviews conducted with staff on 3/4/26 and 3/5/26, they revealed they did not remember who the resident was due to the short stay and could not speak of the care that was provided.An interview conducted on 3/5/26 at 1:36 p.m. with the Director of Nursing (DON) revealed she was not familiar with this resident. She stated documentation should verify if care was provided or not. The DON said it was her expectation for staff to provide incontinent care to residents. The DON stated there was no reason for any of the care opportunities to be blank. The DON said reviewing the record, she was unable to be determine if the resident received incontinence care and meals as expected, because there was no documentation or refusal of the same. The DON stated she expected staff to provide timely care and services and document accordingly.A review of Resident #2's quarterly Minimum Data Set (MDS) assessment, dated 11/27/25 section C - cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of 04, indicating severe impairment. Resident #2's section GG- Functional abilities revealed the resident scored a 01-meaning the resident was dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene. A review of Resident #2's section H- Bladder and Bowel revealed the resident scored a 3-Always incontinent (no episodes of continent voiding) for both bowel and urinary continence. A review of Resident #2's care plan dated 11/21/25 revealed Resident #2 had a potential/actual impairment to skin integrity related to decreased cognition, decreased mobility, incontinence, pain, and weakness. The interventions included to keep skin clean and dry. There were no documented behaviors of refusing care.A review of the facility's incontinence policy revealed the following: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.A review of the facility's policy titled Activities of Daily Living (ADLs) revealed the following: Care and services will be provided for the following activities of daily living: Toileting . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation.A review of the facility's policy, Serving a Meal, revealed the following: It is the policy of this facility to serve meals that meet the nutritional needs of residents. Diets should be served in accordance with the physician's order. Prepare the room or serving area for mealtime (decrease noise level, provide lighting, position comfortably) and make sure hands and face are clean. Place tray on dining table or overbed table if the resident eats in their room. Check on the resident at regular intervals. Alternate foods, readily available foods, or supplements should be offered, in accordance with diet restrictions, when a resident consumes less than half of the meal.The facility did not provide a policy on documentation.

Based on observations, interviews, and policy reviews, the facility failed to ensure kitchen equipment and surfaces were maintained in a clean and sanitary manner, hand washing sink was accessible with the supplies needed, and the overhead lighting was adequate in one of one kitchen. Findings included: On 4/21/25 between 9:40 a.m. and 10:45 a.m., a tour of the facility kitchen was conducted with the Certified Dietary Manager (CDM) and the Dietary Supervisor. The following were observed during the kitchen tour: - The handwashing sink located in the food preparation area was on the floor. There were three holes penetrating the wall, surrounded by wrinkled paper-like outer wall material and exposed dry, chalklike material. An uncapped white plastic accordion style drainpipe extended from the wall. The Certified Dietary Manager (CDM) said the handwashing sink fell off the wall and has been out of service for approximately two weeks. The CDM said the sink in the dishwashing area was available for staff. The sink in the dishwashing area was blocked by a dish rack cart, the paper towel dispenser was empty, and a trash can was not beside the sink. Pieces of food partially blocked the flow of water in the sink. - The commercial ice maker had dry white, tan, and black mineral like material around the perimeter of the ice storage bin and on three sides of the exterior surface. Mineral-like material was on the floor below the ice machine. The CDM said the ice machine vendor routinely cleans the ice machine. - The kitchen lighting was inadequate and there were five separate florescent ceiling lights not luminating. The CDM was unsure how long the lights had not been working. - The floor drain in the dessert preparation had brown/grey standing liquid approximately 1 inch below the floor. The grate cover of the drain was on the floor approximately 8 inches from the drain. - The industrial can opener located in the dessert preparation area was rusted with black substance around the tip of the blade. The CDM said a replacement opener was requested. - In the walk-in refrigerator and freezer, there was a used glove laying on the top shelf of a plastic cart, prepackaged food containers and trash lying on the floor, an open beverage can, and a carton of chocolate milk. The floors were covered with a thick layer of black, grey, and brown substance. The CDM said the kitchen cleaning checklist included cleaning the refrigerator and freezer. - The bottom shelves of the metal food preparation tables throughout the kitchen had brown rust appearing spots and a large crumbs and dry substances. - A red sanitizing bucket on the shelf below the steam table, with approximately 1/2 inch of cloudy liquid in a blue and white patterned cleaning cloth. Wet, cream-colored crumbs and a cooked noodle was on top of the cleaning cloth. The observation was completed after breakfast was served. The CDM said the solution in the cleaning buckets are changed every two hours and said the bucket was last changed during the previous shift. - The kitchen floor perimeters and under equipment had debris and dirt build up. The floor appeared sticky and rough and the grout between the tiles discolored. (Photographic Evidence Obtained) During an interview on 4/23/25 at 9:11 a.m., Staff D, Dietary Aide (DA), said every morning there are dishes from the previous evening and the food carts are disgusting and must be wiped down. Staff D, DA said she tried to keep everything clean but can only do so much. The handwashing sink has been broken for a few weeks. The walk-in refrigerator and freezer are cleaned weekly. Staff D, DA said there is not a schedule to deep clean the kitchen. The can opener is typically cleaned by the night cook. Staff D, DA cleans the can opener when it is noticed to be dirty. During an interview on 4/23/25 at 9:15 a.m., Staff E, DA, said each morning there are dirty dishes in the dish area, and it does not look like the night shift cleans. The facility does not have a routine to clean the entire kitchen. The hand washing sink has been broken for a few weeks. Staff E, DA said the walk-in refrigerator and freezers are cleaned weekly. During an interview on 4/23/25 at 10:13 a.m., the Dietary Supervisor said a cleaning schedule is posted in the kitchen and should be completed by the end of each shift. There has been concerns with the night shift not cleaning and this morning there were dirty dishes. The Dietary Supervisor said she checks to see what was cleaned the night before and before the day shift goes home she verifies everything was cleaned. The kitchen was deep cleaned in March 2025. Cleaning the can opener is assigned to the cook, the dietary aid assigned to desserts. The ice machine gets wiped down and is typically cleaned when it is serviced. The hand washing sink fell and it has not been up for about two weeks. There are a few lights that still need to be fixed. She checks the dish machine with the aides every morning to ensure it is running properly. During an interview on 4/23/25 at 10:15 a.m., after the Nursing Home Administrator (NHA) reviewed the photographic evidence of the kitchen taken on 4/21/25, the NHA said she was aware the sink was fixed, fell from the wall, and it was being worked on. She expected the kitchen to be cleaned. Review of the facility's Employee Cleaning List revealed listed tasks to be completed by the morning and evening cooks and the morning and evening dietary aids. Some of the daily tasks listed include, wash can opener, wipe down prep tables, sweep and mop walk in cooler floor, sweep freezer floor, wipe down ice machine, and polish. From 4/1/25 to 4/22/25, all daily tasks were documented as completed. Review of the facility's Dietary Aide Job Description, last updated on 9/4/20, showed under Job Summary, a dietary aide will keep food preparation areas sanitized and orderly. Review of the facility's Dietary [NAME] Job Description, undated, revealed under Additional Tasks, Ensures the department, necessary equipment and supplies are cleaned and maintained in a safe manner. Review of the facility's Certified Dietary Manager Job Description, undated, showed under Job Summary, . Dietary Department is maintained in a clean, safe and sanitary manner.

Based on observations, interviews, and record review, the facility failed to ensure all drugs used in the facility were labeled in accordance with clinical professional standards, on two of two floors and two of six medication carts. Findings included: On [DATE] at 12:07 P.M., during observation and interview with Staff A, Registered Nurse (RN), Staff A, RN opened the top drawer of a medication cart. During an inspection of the medication cart, labeling of two translucent brown medication bottles containing eye drops had labels affixed with the following information: Notice to discard after forty-two days, with space to write the medication expiration date after the medication is first used and a yellow label with space to write the medication open date, expiration date, and staff initials. No information was written on the label. The inspection also revealed an insulin injector pen with a label to document the date opened of the medication, instructions to discard after 28 days, and an orange label with instructions, do not use after with space to write the date. The medication did not have dates documented. During an interview, Staff A, RN, said she did not know the expiration dates for the eye drops and insulin and the labels should have been dated. (Photographic Evidence Obtained) On [DATE] at 12:20 P.M. during an observation of a 2nd floor medication storage cart and interview with Staff B, Licensed Practical Nurse (LPN) , there was one insulin injector pen labeled [DATE] as the open date and discard date was not listed. Staff B, LPN said the insulin pen should be discarded 28 days after the first use. She immediately removed the insulin injector pen from the medication cart. During an interview on [DATE] at 12:40 P.M, the Director of Nursing (DON) said when medications are first used, the facility expects staff to write the medication expiration dates on the labels. Review of the facility's policy titled Medication Administration, implemented on [DATE], showed: Policy: Medications are administered by licensed nurses, . and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 12. Identify the expiration date. If expired, notify the nurse manager.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure opened food was labeled and dated in one of one kitchen. Findings included: On 12/11/23 at 9:30 a.m., an initial tour of the kitchen was conducted with the Assistant Dietary Manager. The following was observed in the reach in cooler: opened sliced cheese wrapped in saran wrap with no date, opened ham wrapped in saran wrap with no date, an opened bag of diced chicken with no date, and an opened bag of shredded cheese with no date. In addition, a container of liquid substance with no label or date was observed underneath the food preparation table. (Photographic Evidence Obtained) The Assistant Dietary Manager stated he wasn't sure what was in the container while smelling it. Additionally, an opened bag of biscuits with no date was observed in the walk-in freezer. All findings were confirmed by the Assistant Certified Dietary Manager during the tour. The policy provided by the facility and titled, Date Marketing for Food Safety, undated, revealed the following: Policy The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.

Based on record review, and interviews the facility failed to ensure the accuracy and revision of Preadmission Screening and Resident Review (PASARR) for seven residents (#1, #22, #50, #72, #100, #15, and #97) out of 36 sampled residents. Findings included: 1. A review of Resident #1's Admission Record showed the resident was admitted on [DATE] with diagnoses not limited to subsequent encounter (for) diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified bipolar disorder, unspecified anxiety disorder, and other seizures. Review of Resident #1's PASARR Level I, dated 11/22/22, did not include the resident's qualifying mental health diagnosis of anxiety disorder or the intellectual disability related condition of traumatic brain injury, and showed no PASARR Level II was required. Review of the Quarterly Minimum Data Set (MDS) with a target date of 8/1/23, and a 5-Day scheduled MDS, with a target date of 9/18/23, revealed Resident #1's diagnoses of traumatic brain injury and anxiety disorder. Review of the resident's Annual MDS, with a target date of 10/28/23, did not include the resident's diagnoses of anxiety disorder, or depression (other than bipolar) and did reveal the diagnosis of traumatic brain injury. Review of the medical record revealed Resident #1's PASARR Level I was not revised by the facility following admission to include the mental health illness of anxiety disorder or the related condition of traumatic brain injury. Review of the medical record revealed the resident was not assessed for a PASARR Level II. During an interview on 12/13/23 at 2:13 p.m. Staff A, Social Worker/Administrator-in-training (SW/AIT) stated she was able to redo PASARRs as she had been a social worker for a long time. Staff A reviewed Resident #1's PASARR and medical diagnoses and confirmed the PASARR should have been redone to capture the resident's diagnoses of anxiety and traumatic brain injury. 2. A review of Resident #50's Admission Record and comprehensive assessments showed the resident was admitted on [DATE] with diagnoses not limited to schizophrenia and moderate major depressive disorder. Review of Resident #50's PASARR Level I, dated 5/3/18, did not include the resident's qualifying mental health diagnosis of depression. The resident's PASARR Level II Summary Report, dated 5/24/18, did not include the diagnosis of depression. Review of Resident #50's Annual Minimum Data Set (MDS) with a target date of 4/28/23, Change in Status Assessment with a target date of 6/8/23, and a Quarterly MDS with target date of 9/8/23, revealed a diagnosis of depression (other than bipolar). Review of the medical record revealed Resident #50's PASARR Level I was not revised to include the resident's diagnosis of depression nor was the resident's PASARR Level II re-evaluated. During an interview on 12/13/23 at 1:59 p.m., Staff A, SW/AIT reviewed Resident #50's PASARR and medical diagnoses and said the PASARR should have been redone so it could have captured the resident's diagnosis of major depressive disorder. 3. A review of Resident #72's Admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified severity (of) unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified mood disorder due to known physiological condition, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. Review of Resident #72's PASARR Level I, dated 3/9/22, did not reveal the resident's diagnoses of unspecified mood disorder due to known physiological condition and unspecified anxiety disorder and that no PASARR Level II was required. Review of Resident#72's Quarterly MDS, with a target date of 8/9/23, revealed the resident's diagnosis of anxiety disorder. Review of the Annual MDS, with a target date of 10/31/23, included the diagnosis of anxiety disorder. During an interview on 12/13/23 at 2:09 p.m. Staff A, SW/AIT reviewed Resident #72's PASARR and medical diagnoses and stated the PASARR should have been revised to capture the resident's mood and anxiety disorders. Staff A stated she couldn't say if the resident needed a PASARR Level II. 46498 4. Review of Resident #15's Admission Record showed the resident was admitted originally on 10/22/19 and readmitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, unspecified. Review of Resident #15's PASARR Level I, dated 10/17/19, revealed bipolar disorder as a qualifying mental health diagnosis, and that a PASARR Level II was not required. 5. Review of Resident #97's Admission Record showed the resident was admitted originally on 03/02/22 and readmitted on [DATE] with diagnoses to include Down Syndrome unspecified, unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, major depressive disorder, recurrent moderate, and generalized anxiety disorder. Review of Resident #97's PASARR Level I, dated 10/21/19, revealed bipolar disorder as a qualifying mental health diagnosis, and that a PASARR Level II was not required. During an interview on 12/13/23 at 1:00 p.m., Staff A, SW/AIT said she had been trained on how to complete and update the PASARR forms. She stated the PASARRs should be resubmitted when there is a change in the diagnoses or if there is a sufficient change with a resident mental status to see if the resident qualifies for a Level II (PASARR). PASARRs for newly admitted residents are reviewed during morning meeting by the interdisciplinary team to ensure the accuracy of the PASARRs. She said she was not the actual director of Social Services so she can't explain how the director is notified when new diagnoses are added, or when a resident has a change in order to submit for a Level II change. She stated the way the system is in [provider name], once they put the information in the system it would automatically trigger for a Level II PASARR to be completed. Resident #15's and #97's PASARRs should have been updated and resubmitted for a Level II and both residents' PASARRs needed to be updated. 49497 6. Review of the Admission Record showed Resident #22 was admitted on [DATE], with diagnoses to include major depressive disorder recurrent moderate, schizoaffective disorder bipolar type and generalized anxiety. Review of the PASARR Level I, completed on 10/24/19, showed, in Section 1 Part A, anxiety as the only listed diagnosis. Section IV PASARR Screen Completion showed that a Level II PASARR was not required. Review of the electronic medical record (EMR) revealed the diagnosis of schizoaffective disorder, bipolar type was added on 5/16/23. On 5/25/23 diagnoses of major depressive disorder and generalized anxiety were added to the EMR. Review of the medical record revealed Resident #22 was not assessed for a PASARR Level II when the new diagnoses were added to resident's EMR in May of 2023. Review of Resident #22's care plan revealed diagnoses to include major depressive disorder, generalized anxiety disorder, and schizoaffective disorder bipolar type. Review of the care plan revealed: Focus, created on 11/19/19, initiated on 5/26/23, and revised on 9/28/23, [Resident #22] has a potential for alteration in communication r/t [related to] use of psychotropic medication and a past history of CVA [cerebral vascular accident]. Strengths: she is able to hear at normal tones and is able to communicate her needs to staff members. Focus, initiated on 6/21/23 and revised on 6/26/23, Anti-Anxiety Care Plan Resident is at risk for adverse side effects related to use of anti-depressant medication. Focus, initiated on 5/26/23, Antidepressant Care Plan [Resident #22] is at risk of experiencing adverse side effects associated with her use of antidepressant medication. Focus, initiated on 5/26/23, [Resident #22] has a potential for alteration in thought process r/t: has periods of forgetfulness, psych dx [diagnosis] bipolar disorder d/o [disorder], anxiety disorder d/o, MDD [major depressive disorder]. Focus, created on 11/19/19, initiated 5/26/23 and revised on 6/21/23, [Resident #22] has an alteration OR potential for alteration in mood AEB [as evidenced by] c/o [complaint of] or displays the following: has trouble falling or staying asleep, has dx of anxiety, has dx of bipolar d/o, has dx of depression. Review of a progress note by [provider], dated 12/11/23, showed the reason for visit due to staff reporting patient exhibiting increase irritability and agitation yelling out continuously for staff assist till assisted by staff. States per staff and resident interview and resident is unstable. Assessment is that behavior is related to underlying mood disorder causing daily distress to resident with plan to complete medication changes. Increasing Valproic acid to 250 mg (milligrams) PO TID (by mouth three times per day). Interview conducted on 12/13/23 at 1:58 p.m. with Staff A, SW/AIT stated Resident #22 should have had a new PASARR completed when the new diagnosis of schizoaffective disorder, bipolar type was added on 7/9/2023 to see if it would have prompted for a Level II PASARR. 39438 7. Review of the Admission Record for Resident #100 showed the resident was admitted on [DATE] with diagnoses of muscle wasting and atrophy and mixed receptive expressive language disorder. Review of Resident #100's PASARR Level I Assessment, dated 08/11/22, revealed no qualifying mental health diagnosis and that a PASARR Level II was not required. Review of Resident #100's medical record revealed a new diagnosis of psychotic disorder with delusions due to known physiological condition documented on 03/06/23 and the resident was not assessed for PASARR Level II. Review of Section I Active Diagnoses of the Minimum Data Set (MDS), dated [DATE], revealed a diagnosis of psychotic disorder and the resident was not assessed for PASARR Level II. A review of the care plan, initiated 05/03/23, showed a Focus area to include Resident #100 received an antipsychotic medication as ordered to help alleviate symptoms associated with psychotic disorder with delusions due to known physiological condition. He had episodes of extreme anxiousness, his anxiety escalates suddenly, and he was hostile and physically threatening. Interventions included to approach him calmly and attempt redirection with any of his behavioral outbursts as able. On 12/13/23 at 1:58 p.m., Staff A, SW/AIT confirmed the PASARR Level I did not reflect Resident #100's current psychiatric diagnosis and a PASARR Level II was not completed. Review of facility policy titled, Resident Assessment - Coordination with PASARR Program, dated 09/07/2022, showed: Policy: This facility coordinates assessment with the preadmission screening and resident review ( PASARR) program under Medicaid to ensure that individual with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the Stat's Medicaid rules for screening. a. PASARR level I -initial pre-screening that is completed prior to admission. i. Negative Level I Screen -permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.

Based on observations, record reviews, and interviews, the facility failed to administer antibiotics for the duration as prescribed by the provider for one resident (#72) out of five residents sampled for unnecessary medications. Findings included: Review of Resident #72's Admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified obstructive and reflux uropathy and unspecified protein-calorie malnutrition. On 12/11/23 at 10:01 a.m., Resident #72's door held an isolation caddy and was posted with a sign showing Contact Precautions, the resident and roommate was not observed in the room. An interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM), on 12/11/23 at 10:07 a.m. The staff member stated Resident #72 was on contact precautions due to extended spectrum beta-lactamase (ESBL) in the urine. The staff member reported not knowing where the resident was. The staff member stated, on 12/11/23 at 10:08 a.m., the resident was downstairs in the Dining Room drinking hot chocolate. On 12/14/23 at 8:22 a.m., Resident #72 was observed lying bed, the door to the room was posted for Contact precautions. Review of Resident #72's December 2023 Medication Administration Record (MAR) revealed on 12/3/23 at 5:00 p.m. the facility received an order for the antibiotic, Ciprofloxacin 500 milligram (mg) to be administered two times a day for Urinary Tract Infection (UTI) for 7 days. The MAR showed the order was administered at 5:00 p.m. on 12/3/23, held at 9:00 a.m. on 12/4/23, and was discontinued at 1:18 p.m. on 12/4/23. A continued review of Resident #72's December MAR showed the resident was to be on contact isolation for ESBL in urine from 12/5 to 12/12/23. The MAR revealed an order for Ertapenem Sodium injection solution reconstituted 1 gram (GM) - inject 1 gram intramuscularly every 24 hours for UTI for 7 days, started on 12/5/23. The MAR showed the 12/5/23 dose of the antibiotic was not administered and was administered on 12/6, 12/7, 12/8, 12/9, 12/10, and 12/11/23, revealing Resident #72 received 6 out of the 7 ordered doses of the antibiotic. During an interview on 12/14/23 at 2:24 p.m., the Director of Nursing (DON) confirmed Resident #72 had been on an antibiotic for ESBL in urine, it's concluded. The DON reviewed Resident #72's December MAR and confirmed the resident had not received the antibiotic for the ordered 7 days. She stated the resident had been started on Cipro but that doesn't count. During an interview on 12/14/23 at 11:03 a.m., an request was made to the Director of Nursing to provide the policy for Medication Administration, it was not received.

Based on observations, record review, and interviews, the facility failed to ensure one resident (#17) of one sampled resident, who was diagnosed with Post Traumatic Stress Disorder (PTSD), was provided care and services to account for experiences and preferences, nor did staff address the resident's needs by minimizing triggers and/or re-traumatization. Resident #17's direct care staff were unaware of trauma behaviors, and were not aware of what to monitor for, with relation to PTSD behaviors. Findings included: On 12/11/23 at 12:05 p.m., Resident #17 was observed in bed in her room. During an attempt to interview Resident #17, she was asked if staff were providing appropriate care to her. She yelled, No! She was then asked if she would like to explain, and she yelled I'm not telling you! A review of the Admission Record showed Resident #17 was originally admitted to the facility on [DATE] with diagnoses to included bipolar disorder, current episode manic severe with psychotic features, major depressive disorder, anxiety disorder, and PTSD. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognitively intact. Section D Mood showed Resident #17 was feeling down, depressed, or hopeless for 2-6 days over the last two weeks. Section E Behavior indicated Resident #17 showed verbal behavioral symptoms directed toward others 1 to 3 days and rejection of care 1 to 3 days. Section I Active Diagnoses showed Resident #17 had diagnoses to include anxiety disorder, depression, bipolar disorder, and PTSD. Review of the Complete Evaluation dated 12/14/20 (upon admission) completed by the psychiatric nurse practitioner showed Resident #17 reported a history of bipolar disorder, PTSD, and anxiety. Reports that bipolar has been life long and anxiety and PTSD symptoms started after she served in the military. The last Social Services Trauma Screen dated 10/01/22 revealed the resident did not have a history of trauma and/or PTSD. A review of the Progress Notes revealed the following: A psychiatry follow up note dated 12/11/23 showed summaries of the past notes to reveal the following: on 04/11/23, the patient was anxious, on 05/15/23, the patient was anxious, on 05/18/23, the patient was depressed and anxious, on 07/31/23, the patient was depressed, on 08/10/23, the patient was depressed, on 08/24/23, the patient had insomnia, on 09/11/13, the patient was depressed, and on 10/12/23, the patient was depressed. A medication administration note dated 12/10/23 indicated the resident refused and smacked the writer's hand that was holding the medication. A dietary note dated 11/21/23 revealed Resident #17 utilized a melamine dinner plate because of her history of throwing her meal trays. An Interdisciplinary Team (IDT) Care Conference note dated 11/19/23 revealed Resident #17 had behaviors of having delusions, anxiety, occasional yelling out and inappropriate language. A psychiatry (psych) subsequent note dated 11/13/23 showed the resident was more alert and had mild symptoms of depression. Patient reports she was feeling a little anxious. A psychiatry subsequent note dated 09/13/23 showed the resident was seen due to being unstable. Patient had been with increased confusion. The patient was non-compliant with medication and had periods of agitation. Nurse reported patient refused medications intermittently. Review of the progress notes dated from 11/01/2023 to present did not reveal any specific behaviors related to PTSD, nor did the notes or psych. services notes indicate any past PTSD behaviors. It could not be determined why Resident #17 had a diagnosis of PTSD. The only reference showing the resident had a history of PTSD was from the Complete Evaluation dated 12/14/20 (upon admission) completed by the psychiatric nurse practitioner. The behavior care plan initiated on 02/07/23 revealed a focus area to include the following: Resident #17 was at risk for impaired or inappropriate behaviors related to diagnoses of bipolar disorder with delusions, manic psychosis, paranoia, PTSD, and the discontinuation of psychotropic medications due to her refusals. She will throw her meal tray onto the floor, will not eat, kicks, hits, yells obscenities, and also refuses medications. She had delusional thoughts and relived past trauma events associated with diagnosis of PTSD, history of confabulation, and associates based events with current present time. Interventions included anticipate and meet her basic needs, apply topical antianxiety and anti-psychotic medications as ordered, and minimize potential for the resident's disruptive behaviors of kicking over meal trays by offering as needed antianxiety medications and reapproaching and offering meals after antianxiety medications given. The mood care plan initiated on 07/19/23 revealed a focus area to include the following: Potential for mood state issues related to delusions, bipolar with psychotic features, manic psychosis, and PTSD. Resident had tendency to relive past trauma and/or confabulates past events or overheard events as reality. Interventions included consultation with psychological/psychiatric per order, encourage and allow open expression of feelings, observe for effectiveness/side effects of medications as ordered, and reinforce appropriate expression of feelings. Per review of the PTSD care plans, it did not specify a reason or specific behavior related to trauma. The care plan did not specify what types of behaviors she would need to be monitored for, nor did it mention what type of behaviors that needed to be reported to the Physician with regards to past trauma. Training related to PTSD specifically for Resident #17 was requested and not provided. On 12/14/23 at 09:00 a.m., Staff F, Certified Nursing Assistant (CNA), stated she works with Resident #17 every Tuesday, Wednesday, and Thursday. The resident moved to another unit, but staff brought her back to the unit that she was in now so Staff F, CNA, could be her aide due to her being calmer. She had to be in a private room due to behaviors. She was screaming at the top of her lungs saying men were climbing in the window to rape her. She would sometimes say it was staff and other men. Resident #17 had moments where she would scream at the top of her lung and when you go in the room, she would say that was not her screaming. The resident would turn the call light on and say she didn't turn it on when entering the room to see what she needed. Two staff members must always provide care to her due to her attacking staff and throwing herself on the floor. The resident likes to hit you from the back. She once snatched a housekeeper by her hair from the back. She now has cancer and was upset about that. She was also upset about her son not being able to see her in the facility. Something happened between them before she came here, stated Staff F, CNA. Resident #17 reported to her that she sees a shadow who was a tall male CNA in her room, and he was having sex with everyone on the unit. Staff F, CNA, reported she was aware that the resident had PTSD because the resident told her she had PTSD and it had something to do with the military. She was never told by staff that the resident had PTSD and they have never discussed any triggers with her. Staff have told her to report behaviors, but nothing related to her having PTSD. Staff F, CNA, reported she just usually lets the nurse know the resident was yelling. She revealed nobody had ever told her that Resident #17 had PTSD nor has anyone explained to her the reason for PTSD and how to look for behaviors related to any type of trauma. She also confirmed she had not been educated or in serviced with relation to PTSD behavior monitoring specifically for Resident #17. On 12/14/23 at 9:16 a.m., Staff G, Registered Nurse (RN), reported she had Resident #17 routinely. The resident was very isolated, down, and sad about the situation with her having cancer. Staff G, RN, reported Resident #17 had PTSD on her list of diagnoses, but she did not know why. She reported she was not aware of any triggers to look for related to PTSD. She monitors the resident for behaviors related to her medications. She also confirmed she had not been educated or in serviced with relation to PTSD behavior monitoring specifically for Resident #17. On 12/14/23 at 9:57 a.m., an interview was conducted with Staff A, Social Worker, Administrator in Training, and the Administrator. Staff A, Social Worker, Administrator in Training, stated she assisted the social services director with completing assessments. For residents with PTSD, they would complete the trauma informed screening to get more history on the diagnosis. The Administrator stated they would ask psych to see the resident to see if the resident needed any assistance related to the trauma. PTSD would be placed on the care plan specifically related to the incident. The Administrator confirmed Resident #17 had PTSD as it was listed on her face sheet. She reported the care plan stated the resident relives events associated with PTSD. At 10:05 a.m., the Administrator stated she would review the psych notes to see why the resident had PTSD. She reported the resident had tons of psych notes. A trauma informed screening was completed related to the hurricane evacuation. The trauma informed screen from October did not show anything related to PTSD and the old trauma informed screening was retired. The Administrator stated she found a psych note that indicated the resident reported PTSD started after she served in the military. She stated she expected psych to do a deeper dive to see what happened in the military with the resident. She stated, It doesn't appear that a deeper dive was conducted. The Administrator stated the provider did not do a deeper dive to provide staff with additional education on the PTSD diagnosis. She stated psych seen all residents last year in October and if something would have triggered on the trauma informed screening, she expects psych to follow up. On 12/14/23 at 10:48 a.m., the Director of Nursing (DON) reported a trauma informed screening should be completed for residents with PTSD. You must find out if the resident was comfortable talking about the trauma to find out the triggers. The care plan should be very individualized, and it should be listed on the care plan for the sake of communication and on the Kardex. If the patient had triggers, they should be on the care plan. There needs to be a conversation. Psych must be involved and the interprofessional team. Let's dig into it and find out what happened and what are the triggers to avoid re-traumatization stated the DON. The care plan was very individualized, and you need to see what's the root cause to avoid causing any problems for other people. Best practice was to educate the staff, specifically to the resident. The policy provided by the facility, Trauma Informed Care implemented on 09/07/22 revealed the following: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals to develop and implement individualized care plan interventions. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan.

Based on observations, interviews, and record review the facility failed to ensure the care plan for one resident (#18) out of 36 sampled residents was reviewed and revised to accurately reflect the fluid intake of the resident. Findings included: A review of Resident #18's Admission Record revealed an admitted [DATE] and included diagnoses not limited to hypo-osmolality and hyponatremia (sodium levels in blood are abnormally low), other specified disease of biliary tract, unspecified neuromuscular dysfunction of bladder, and presence of urogenital implants. An observation conducted on 12/14/23 at 8:25 a.m. revealed Resident #18 lying in bed, with an approximate half full large-sized bottle of commercially-produced water and a facility-provided foam cup on the over-bed table next to the resident's bed. A review of Resident #18's active care plan, initiated on 6/1/23, showed a Focus for ADL (Activities of Daily Living) related to the resident's self-care performance deficit which included an intervention, dated 8/15/23, instructing staff of NO WATER CUP AT BEDSIDE (on a fluid restriction). The Focus revealed the resident was non-adherent with medication regime causing an alteration in functional abilities. Further review of the resident's care plan revealed a Focus, initiated on 7/23/23, indicating the resident had dehydration or potential fluid deficit r/t (related to) diuretic medication usage. The interventions of this Focus included: - Encourage the resident to drink fluids of choice, initiated on 7/23/23; - Ensure that (resident) has cold water whenever possible, initiated 7/23/23; and - Educate the resident/family/caregivers on importance of fluid intake, initiated 7/23/23. The review of Resident #18's current, as of 12/14/23, and discontinued physician orders did not reveal a current physician order revealing the resident's fluid restriction. A review of discontinued physician orders revealed an order, started on 8/18/23 and discontinued on 8/23/23, of the resident had been on a fluid restriction of 1500 milliliters (mL) per day. On 12/14/23 at 9:58 a.m. the Director of Nursing stated Resident #18 was not on fluid restrictions. She stated the resident was on hospice (services) so it was all about quality of life. An interview was conducted on 12/14/23 at 3:33 p.m. with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) and Staff C, Minimum Data Set Coordinator. Staff B, LPN/UM stated Resident #18 was not on fluid restrictions. Staff C stated a care plan was changed when there was a change (in condition) and quarterly. Staff B and C reviewed Resident #18's care plan and confirmed the active intervention showed the resident was on fluid restrictions. Staff C stated it (care plan) should have been revised and she missed it. Staff C reported being responsible for all care plans in the whole building.

Based on observations, interviews, record review, physician interview, and facility policy review, the facility failed to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses were free from hazards during meal service. Resident #1 is a vulnerable adult with a history of hemiplegia and hemiparesis affecting the left non-dominant side, dysphagia, and muscle weakness. On 08/16/23, during evening meal service, Resident #1 requested a bowl of soup. The facility staff provided Resident #1 with a cup of bubbling hot tomato soup that had been warmed in a microwave for approximately 3-4 minutes and was not cooled prior to serving. The soup was served in an 8-ounce disposable foam cup and was not checked for temperature before it was served to Resident #1. The resident who does not have use of her left arm reached to the hot cup with her right arm, dropped the cup of soup on herself and suffered 2nd degree burns to her left forearm and the left side of her abdomen. Resident #1 suffered pain, infection of the skin and subcutaneous tissue and permanent body disfigurement related to scarring as a result of the facility's failure to ensure this resident's safety during meal service. The facility's failure to monitor food temperatures prior to food service and failure to provide supervision and assistance to a vulnerable resident with physical limitations resulted in the determination of Immediate Jeopardy on 8/16/23. The findings of Immediate Jeopardy were determined to be removed on 9/29/23 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Review of a Resident Information Record dated 09/29/23 showed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was her own responsible party. She was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia following cerebral infarction. Review of the physician's active orders dated 09/29/23 showed Resident #1 was on a regular diet, pureed texture, nectar thickened fluids consistency for nutrition related to COPD. An interview and observation was conducted on 09/28/23 at 10:00 a.m. with Resident #1. The resident was observed to be in her wheelchair with her portable oxygen on via nasal cannula. The resident appeared clean, well-kept, and dressed in day clothes. She was observed to have a bandage on her left forearm dated 09/27/23, 7a.m-3 p.m. and signed. The resident said, I burned myself. She said it was carelessness. I picked up the soup, it was in a cup, and it was just falling on me like a waterfall. It hurts, the pain is an 8 to 10, achy and throbbing. I cannot move my left arm, it is paralyzed. The resident stated she did not need help with eating. On 09/28/23 at 12:04 p.m., Resident #1 was observed in the dining room for lunch. The resident was observed sitting in her wheelchair with three other residents at the table. The resident was observed leaning to her left. Her right arm was stretched out on the table, trying to reach the spoon in front of her. The resident was served pureed brat (sausage), mashed potatoes with gravy and apple juice. Resident #1 used only her right arm. Her left arm had a contracture. Review of a Minimum Data Set (MDS) dated [DATE] showed the resident had a Brief Interview Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Section G - Functional status showed the resident was totally dependent on staff for Activities of Daily Living (ADLS) to include bed mobility, dressing, personal hygiene, and toileting with a two-person physical assistance required. The resident was totally dependent on staff for locomotion on and off unit. Resident #1 required supervision and set up for eating. Section G0400 assessment of functional limitation Range of Motion (ROM) showed on her upper extremities, Resident #1 was impaired on one side of the shoulder, elbow, wrist, and hand. The lower extremity evaluation revealed impairment on one side to the hip, knee, ankle, and foot. Section G0600 mobility assessment showed the resident used a wheelchair. Section K assessment of swallowing and nutritional status showed the resident had possible symptoms of swallowing disorder due to coughing or choking during meals or when swallowing. Section K0510 showed the resident received a mechanically altered diet. On 09/28/23 at 12:20 p.m., an interview was conducted with Staff A, Cook. He stated he was the evening cook, and he was on duty on 08/16/23 the day Resident #1 was burned with hot soup. He stated they had already finished serving dinner when a Certified Nursing Assistant (CNA) came and requested soup for a resident. He stated he could not remember who the CNA was and did not know the resident who was to receive the soup. He said, I had a small amount of tomato soup left. I normally make it for 3-4 residents. The tomato soup was an additional option to the meal. It was already cold. I put it in the microwave. I heated it for 3-4 minutes and gave it to the CNA in a [disposable foam] cup. When it came out of the microwave, it was hot and steamy just like any other foods. It was bubbling hot. I put it in a [disposable foam] cup because we did not have any regular dishes. The dishwasher was not working. I filled it to the top. It was a small cup. I handed it to the CNA. I think it had a lid, but it was one of those that don't stay on. The Cook confirmed he did not wait for the soup to cool down before handing it to the CNA to serve Resident #1. Staff A said, honestly I did not check the temperature. Staff A stated the next thing he heard was a resident was burned by the tomato soup. He said, it was the CNA's fault. The CNA should not have given it to her like that. She should have known it was hot. He stated he did not know the facility's expectation on re-heating food in the microwave. Staff A stated if he knew the resident had use of only one arm, he would have made sure it was cooler. Staff A said, I did not expect the resident was going to pick it up and put it in her mouth straight away. Staff A stated what he could have done differently was not serve that soup all together. A wound observation was conducted on 09/28/23 at 12:44 p.m. with Staff B, Licensed Practical Nurse (LPN) Agency. She performed wound care on Resident #1's left arm burn, and her left abdomen burn. When Staff B removed Resident #1's left arm bandage she stated, Wow that looks better the wound was observed to be clean, linear from her upper forearm, just below her antecubital, down to her mid forearm that tapered down to a point. The wound bed was reddish pink and contained slough to the lower left portion of the wound edge. Staff B stated I saw the wounds the day after this happened and this wound was long. It went from above her antecubital down to her forearm about 9 centimeters (CM) long and 2CM wide. You can see the pink areas around the wound, that's the scarring. Staff B removed the resident's left abdominal dressing and said yeah, this one looks better too. The wound was clean, wide, linear, and wrapped around from the front of the abdomen to her side. The wound bed was pink with 2 separate white areas that were deeper than the rest of the wound. The wound had a light purple border surrounding the wound. Staff B said this wound is deeper, and it was the worst of the 2 wounds. It used to take 2 boarder dressings to cover it but now it only needs one and you can also see the scarring around the wound, so it became smaller. Staff B confirmed Resident #1 received antibiotics for the abdominal wound. During the wound observation on 09/28/23 at 12:44 p.m., Resident #1 said I went to the ICU (Intensive Care Unit) and the doctor said my burns were bad and that I needed to have a burn doctor come look at them and they might have to send me to [a local hospital burn unit] but, the burn doctor came and said they didn't need to transfer me to the other hospital that they weren't that bad. I used to have a spot on my [chest] but that's all healed up. And they tell me they are getting better. My stomach is more tender than the other one. Review of a Resident Information Record dated 09/29/23 showed on 8/17/23 new diagnoses were added. A burn of second degree of left forearm sequela, a burn of second degree of abdominal wall sequela and a burn of second degree of other site of trunk, subsequent encounter. On 8/25/23 a new diagnosis of local infection of the skin subcutaneous tissue, unspecified was indicated. Review of an undated article titled, Burn depth. Nature Reviews Disease Primers, showed burns extending into the underlying skin layer (dermis) are classed as partial thickness or second-degree. These burns frequently form painful blisters. These burns range from superficial partial thickness, which are homogenous, moist, hyperemic and blanch, to deep partial thickness, which are less sensate, drier, may have a reticular pattern and do not blanch. Source: https://www.nature.com/articles/s41572-020-0145-5/figures/1 Review of Hospital records showed Resident #1 was admitted to [name of hospital] on 08/21/2023 and discharged on [DATE]. The resident was admitted to the ICU (intensive care unit) with acute respiratory failure. During her stay, Resident #1 was seen for burn wounds. On 08/21/23, the record showed Resident #1 had a left forearm burn, left abdominal burn and a left nipple burn. The hospital admission record showed a dermatology/integumentary assessment was conducted revealing erythematous patch with fluid-filled bullae and medial forearm consistent with burn, no evidence of purulent drainage, no warmth. Hospital records revealed photographic evidence of Resident #1's burns showing an abdomen burn on the left side extending from below her naval towards her left side and a left arm burn showed an elongated wound from mid arm to triceps muscle, above her elbow. Review of Hospital care notes showed on 08/22/23 patient [Resident #1] was examined at bedside. Wound care saw her the day before and wrapped her burns and applied Silvadene on her abdomen/left forearm. The patient stated she was in no pain as long as she was taking her medications. A hospital care note dated 08/24/23 showed Resident #1 stated her burns are hurting this morning. On 8/25/23, Patient stated that her burns are slightly painful this morning. Patient's left forearm and abdominal burn marks were covered with bandages and maintained by wound care with application of silver sulfadiazine cream. Review of a progress note marked late entry effective 08/16/23 by Staff C, Registered Nurse (RN) evening Supervisor showed Resident in main dining room on first floor, summoned by one of the CNAs, resident had slipped [sic] soup on herself. Went to resident assessed resident. Resident left arm and left side of abdomen pink/red in color. Resident was cleaned up in dining room. Immediately resident was brought in resident's w/c [wheelchair] to room, washed areas with soap and water and changed into clean gown by CNA. Reported to primary nurse to monitor resident. Notified DON [Director of Nursing]. Notified [name of doctor], Primary Care Physician [PCP] and did not respond with any orders. 2200 checked on resident before end of shift - resident in bed resting quietly, site to abdomen and left arm remained pink/red. Resident stated feels better, no blisters at this time. Left OTA [Open to Air]. MD [Medical Doctor] notified by assigned nurse. Review of a progress note dated 08/16/23 at 22:30, Resident spilled soup while eating dinner. Abdomen with clear fluid filled blister, forearm with open area. MD and family notified. Skin prep applied to blister, forearm cleansed with NS (normal saline), TAO ([NAME] Antibiotic Ointment) and wrapped with gauze. Therapy screen completed. Site is painful . Review of an 8/17/23 the SBAR (Situation Background Assessment Recommendation) revealed resident received a burn to her left lower abdomen and left lower arm PCP responded with orders to cleanse with TAO and dressing applied. The SBAR dated 08/17/23, marked [late entry] signed by the ADON (Assistant Director of Nursing) showed, A Change in Condition (CIC) evaluation was conducted following a trauma incident. Resident received burn to resident's left lower abdomen and left arm. PCP was contacted with instructions to cleanse with NS TAO and dressing applied. An IDT (Interdisciplinary Team) note dated 08/17/23 revealed, Resident alert and oriented, able to make complex needs known. Recent BIMS on 06/30/23 score of 13. Spoke with resident regarding accident with soup, resident states the following, Resident decided not to use available spoon and when picking up cup of soup by brim to bring it to face and consume, resident's nail was caught in cup and soup spilled .Abdomen assessed with clear fluid filled blisters observed without erythema to surrounding site, site measuring 18 x 8 cm (centimeters), left arm assessed with popped blisters, measuring 9 x 6.5 cm. MD notified by assigned nurse at the time of incident with NO (new orders) to cleanse with normal saline, TAO and dry dressing and skin prep to closed blister. MD in to see resident on this day and telehealth visit completed by wound doctor with new orders along with antibiotics. Therapy screen referral completed for dexterity assessment and ADL assessment related to eating. Hot liquid screen completed. Plan of care reviewed and updated. A physician's progress note dated 08/17/23 revealed, patient scalded herself on hot soup causing a second-degree burn patient was eating hot soup when it accidentally fell on her lap and scalded her thigh, Silvadene cream BID (twice daily) is ordered to affected areas x 14 days as well as wound care. A skin observation note dated 08/17/23, signed by the ADON, showed, Resident has new skin impairment. Resident received burn to her abdomen and left lower arm from hot liquid. Abdomen - left lower abdomen measurements 15 cm x 8 cm, left lower arm 9 cm x 6.5 am. An SBAR assessment was completed for new skin impairment. Treatment orders were obtained. Responsible party was notified. Review of Resident #1's Medication Administration Record (MAR) dated 08/01/23 to 08/31/23 revealed Resident #1 received new medications related to burn wounds as follows: Ascorbic Acid Tablet 500 milligram. Give 1 tablet by mouth one time a day for supplement to promote wound healing. Medication was administered from 08/18/23 to 08/21/23. Stat oral liquid - Protein. Give 45 ml (milliliters) by mouth two times a day for wound healing. Medication was administered from 08/18/23 to 08/21/23. Doxycycline Monohydrate 100 mg capsule. Give 1 tablet orally two times a day for wound burn for 14 days. Medication was administered from 08/18/23 to 08/21/23. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Medication was administered from 08/17/23 to 08/20/23 for complaint of left arm and abdomen burned areas. Review of Resident #1's Medication Administration Record (MAR) dated 09/01/23 to 09/30/23 revealed Resident #1 continued to receive new medications related to burn wounds as follows: Doxycycline Hyclate oral tablet 100 mg. Give 1 tablet by mouth two times a day for cellulitis for 14 days. Stat oral liquid - Amino acids Protein hydrolysate. Give 45 ml (milliliters) by mouth two times a day for wound healing for 30 days. Tramadol HCI tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Review of a care plan for Resident #1 showed a focus initiated on 08/17/23, [Resident #1] has 2nd degree burns on her left forearm, LLQ (left lower quadrant) of abdomen. The resident sustained these burns while attempting to pick up a cup of soup (with her unaffected hand) and bring it to her mouth. Interventions included to document weekly length x width x depth x odor, progress, or lack of progress. Provide protein and other nutritional supplements to promote wound healing as ordered. Provide wound care to affected areas as ordered. Report signs and symptoms of infection, failure to heal, abnormalities, maceration, etc. of burned area to MD. The care plan showed an ADL focus revised on 08/18/23, showing the resident had an ADL self-care performance deficit associated with limited mobility, CVA (Cerebral Vascular Accident) with the left sided hemiplegia. Interventions related to eating showed the resident was able to feed self after set up. The care plan showed a focus indicating Resident #1 was at risk for injury related to hot liquids due to poor trunk control initiated on 08/19/23. Interventions included to complete hot liquid evaluation as scheduled, fluids were served at proper temperature, occupational therapy to screen with decline in function, and ensure resident maintained upright position when served hot liquids. Review of skin/wound care notes for Resident #1 revealed: On 08/17/23 resident was seen. History of present illness (HPI), Location: Left forearm and left lower abdomen. Quality: Patient is able to advise if in pain, Severity: Moderate , Timing: When palpitated burn, Context: 2nd degree burn. Modifying factors: pain is relieved with medication. Associated Signs and Symptoms: Limited mobility; history MRSA (Methicillin-Resistant Staphylococcus Aureus) HPI Description: As per nursing staff this was an acquired burn from soup, patient has had a CVA which limits use of her abilities . Doxycycline for cellulitis associated with wound. Diagnosis included: Burn of second degree of abdominal wall, initial encounter and burn of second degree of left upper arm, initial encounter. Orders: Doxycycline 100 mg po BID x 14 days. Wound Care: Cleanse wound with normal saline and Xeroform dressing. Wound #3: Left forearm, Partial thickness 9.0 cm length x 6.5cm width 45.946 cm^2 area. Wound #4: Left abdomen, Partial thickness, 15 cm length x 8cm width 94.248 cm^2 area, erythema, peri wound tenderness. On 09/11/23 Resident #1 was seen for wound care. Wound #1 Partial thickness wound, wound bed has slough present 75% of wound bed covered in serous drainage, moderate no odor, No tunnelling/undermining present. Well defined wound edges no signs of infection observed, wound is unchanged. Wound #2 Full thickness wound, wound bed has slough tissue 75% of wound bed covered with serosanguineous drainage, moderate amount of discharge well defined wound edges, no signs of infection. Wound is unchanged from previous. Left Abdomen: length 3.5cm/ width 12 cm / depth 0.1 cm Left forearm: length 8cm / width 2cm / depth 0.1cm. On 9/11/23 wound care was provided. Weeks of treatment: 3. Left arm: Partial thickness burn. Patient consented to debridement. Wound description: Full thickness without exposed support structures. Wound Margin: Distinct, outline attached. Under Assessments: Wound #3, pre-procedure diagnosis of wound #3 is a second-degree burn located on the left forearm. There was an excisional of skin/subcutaneous tissue debridement with a total of 12 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. Round #4: pre procedure diagnosis of wound #4 is a second-degree burn located on the left abdomen, lower quadrant. There was an excisional skin/subcutaneous tissue debridement with a total of 24 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. On 9/25/23 Resident #1 was seen for wound care. The wound assessment note showed, Resident #1 has wounds, MD notification 09/25/23, Family notification 09/25/2023, Followed by wound care. Resident denied pain, no new orders received care Resident aware of wound progress and orders, care plan reviewed and updated. Abdomen-Wound #1: Full-thickness wound, wound bed has slough present, 50% of wound covered . Epithelizing wound edges. There are signs of infection present. Wound shows signs of improvement. Left forearm: Wound#2: Partial thickness wound, wound bed have slough tissue present. 75% of wound bed covered .scant drainage, epithelializing wound edges. Wound shows improvement. Abdomen: 2.5cm L/ 10.0cm W/ 0.1cm D and Left Forearm: 4.5cm L/ 1.4 cm W/ 0.1 cm D. On 09/28/23 at 3:16 p.m., an interview was conducted with Staff G, CNA. He stated he was assigned to Resident #1 the day she was burned. He stated he was working in the dining room with the evening supervisor (Staff J, RN) and was assisting passing coffee and juice to the residents, but not the tomato soup. He stated the meal was already served and the residents were eating. He stated [Resident #1] did not ask him for soup. He said, I believe someone else passed the soup to her. In the middle of them eating, one of the resident's on the same table called me and said [Resident#1] had spilled something on herself. I went to the kitchen, asked for cold water and a towel, and wiped her up. I took her to her room to change her clothes. I did not notice any difference in her skin when I was wiping her at that time. There were blisters later in the evening. I did not know she was badly burned at that time. I told the nurse [Staff K, LPN] when I observed the blisters. She helped me change her. She saw her skin. It was pink/red. On 09/28/23 at 3:25 p.m., a telephone interview was conducted with Staff K, LPN (agency). She stated she remembered she was passing medications after dinner when a CNA (Staff G) stated (Resident #1) had spilled hot soup on herself and asked for help changing her. Staff K said, In that moment, I saw her arm. It was red. I called the supervisor [Staff J, RN] just to make her aware of the redness. l saw the redness in her left chest and stomach area. It did not look like a burn until I went in when the aide was changing her for bed. He [Staff G] came and got me because the areas were starting to blister. I notified the supervisor again and she called the MD and notified the DON. I did not think it would blister that quickly. Within 2 hours she was full of blisters on her left arm and stomach. Staff K stated the resident did not complain of pain at the moment. She stated the resident's skin was irritated. Staff K stated she wrote a progress note and received doctor's orders to treat the burned areas. An interview was conducted with Staff D, LPN, Unit Manager on 09/28/23 at 10:05 a.m. She said, [Resident #1] was burned by a hot liquid. I was not here that day. She was burned on her abdomen and her arm. What we found out is her nail or something had put a hole in the cup, and it spilled on her and burned her. Her dressings get changed daily and every Monday she is seen by the wound care physician. I saw the wounds on Monday with the wound care physician and they are both getting better. Both of the wounds are superficial. The abdomen wound has sloughing and the skin around it is red. After she was burned, she had cellulitis around the wound and was on antibiotics for 10 days, but I think she has completed them. Staff D stated the antibiotics would help the wounds get better. She stated the wound on the arm did not have any slough and it was also improving. On 09/28/23 at 09:15 a.m., an interview was conducted with Staff F, Certified Dietary Manager (CDM)/Kitchen Manager. She stated Resident #1 was burned with soup on 08/16/23. She stated the incident happened in the dining room. Staff F said, I don't know exactly who served the soup. The dish machine was not working, we used regular serving bowls for all the other residents and a disposable foam cup for [Resident #1]. The resident did not receive soup with her tray. She requested and received tomato soup after we were done serving. The resident was served hot tomato soup in an 8-ounce disposable foam cup because we were out of bowls. I did not know if she required special equipment. It was a last-minute request. I don't think we in the kitchen knew whom the soup was going to. Staff F stated the soup was requested outside of the tray line and was taken straight to the resident upon preparing it. She stated they conducted an investigation and determined the resident's dexterity was the problem, more than the beverage itself. She said, the problem was not the beverage which was served or the container in which it was served. It was the resident's dexterity. Staff F stated dexterity meant the resident's ability to use her hands. She stated Resident #1 had some limitations. She confirmed the resident was served hot soup in a disposable foam cup and consequently suffered burns. Staff F stated they should have considered lag time the time it takes from the moment food is scooped into a serving dish and when it is served to the resident. She stated that would have helped the soup to cool down. Review of a document titled, Food Temperature Chart, dated 08/16/23, showed soup was served for dinner. The log revealed acceptable temperature range for soup should be between 140-165 degrees Fahrenheit. The log confirmed at tray line the temperature of the soup was recorded at 180 degrees Fahrenheit. Review of a PubMed article titled, Hot Soup! Correlating the severity of liquid scald burns and biomedical properties, dated May 2016, revealed, While the temperature of the soup is obviously the most important fact in determining the degree of burn, we also find that more viscous fluids result in more severe burns, as the slower flowing thicker fluids remain in contact with the skin for longer. Furthermore, other factors can also increase the severity of burn such as a higher initial fluid temperature, a greater fluid thermal conductivity, or a higher thermal capacity of the fluid. Our combined experimental and numerical investigation finds that for average skin properties a very viscous fluid at 100 C, the fluid must be in contact with the skin for around 15-20s (seconds) to cause second degree burns, and more than 80s to cause a third- degree burns. Source: https://pubmed.ncbi.nlm.nih.gov/26796241/ On 09/28/23 at 12:08 p.m., an interview was conducted with the Director of Rehabilitation (DOR). She was observed assisting residents in the dining room during a meal. She stated Resident #1 used her right hand only. She stated the resident fed herself. She stated the resident had not been herself since the burn incident and had shown decreased performance. She stated they had offered to assist the resident with her meal and moved her to the restorative table. She stated all residents required supervision for safety during meal and support for positioning as needed. On 09/28/23 at 2:18 p.m., an interview was conducted with Staff E, Activities/CNA. She stated she assisted residents with little things like getting water. She stated she was working in the dining room and was assisting with serving when Resident #1 burned herself with hot soup. She stated Resident #1 sat in the far-right corner of the dining room, probably 10 steps from the serving window. She stated the resident did not need assistance with feeding at the time, but she was now at the new restorative table, meaning her diet was downgraded and someone had to sit with her. Staff E stated the resident was served tomato soup because she had requested it. Staff E stated she went to the window and asked Staff A, the Cook, for the soup. She stated she heard Staff A say they were out of bowls. She stated she heard Staff F, CDM/ Kitchen Manager instruct Staff A to put the tomato soup in a coffee cup. Staff E stated she did not see how the soup was prepared. She confirmed she received the soup from Staff A in a disposable foam cup and handed it to Staff G, CNA who was assigned to the resident. Staff E stated she could not recall the soup being hot to touch. She stated she handed it to Staff G who brought it to the resident. Staff E stated she was at the front of the dining room when she heard Staff G stating he needed a towel because (Resident #1) had wasted the tomato soup. Staff E stated she grabbed a towel from the service counter and handed it to Staff G. Staff E stated at the time she did not realize Resident #1 had suffered significant burns. On 09/28/23 at 2:30 p.m., an interview was conducted with Staff H, Corporate Registered Dietician (RD). She said, the facility's policy is not specific to re-heating meals, however you would assist a resident if food needed to be re-heated. It should be heated to 165 degrees for 15 seconds. You check the temperature, and if it is above 180 degrees you wait for it to cool before you serve. She stated the facility staff failed to wait for the soup to cool down prior to serving it. She stated she would not recommend putting food in a microwave for 3 minutes and serving it without checking temperature. Staff H stated different microwaves heat at different levels so she would expect to stop and check after every 15 seconds. She stated there was no regulation on how hot is too hot. She stated she would expect staff to check the temperature every 15 seconds during the re-heating process. Staff H said, Everyone should use common sense. Staff H stated Resident #1 requested and received some soup which she picked up from the rim of the cup and she had put her finger through it. Staff H stated the resident spilled the soup on herself, causing the burns. She stated the resident had some blistering that appeared later from the soup burn. Staff H confirmed the blisters were caused by hot soup. She stated blistering occurred at temperatures above 125 degrees. On 09/28/23 at 2:40 p.m., a telephone interview was conducted with Staff I, Facility RD. She stated she was informed a resident had burned themselves with hot soup. She stated they immediately started in-services on hot liquids. Staff I stated she expected foods and liquids to be served at proper temperatures. She said, I heard the resident was having trouble holding the cup because she was served in a [disposable foam] cup. I don't know how she burned that quickly. She stated they had regular soup dishes, but the dish machine was down. Staff I stated the policy on re-heating any food was to heat it, bring it to temperature and then re-test the temperature. Staff I said, We should test the temperature after heating and before you bring it out to the resident. On 09/28/23 at 2:53 p.m., an interview was conducted with Staff J, RN/evening Supervisor. She stated she was working the day Resident #1 burned with soup. Staff J said, I was in the dining room during dinner and a CNA, I can't remember whom, said that [Resident #1] spilled soup on herself. That CNA cleaned her up with soap and water wiped her up and she was fine. Her skin was pink at that time. Later, before the end of the shift, I checked on her. Her abdomen on the left side and her left arm were pink and red in color. You could tell the hot soup had scalded her skin but there were no blisters at the time. Staff J stated she forgot to document her observations. She stated she did not put in any skin assessments or progress notes. She stated she called the doctor and the DON. She said, There were no orders at that time. It was too busy that night I had other patients to take care of and I forgot to write something. Staff J stated she entered her notes a couple days later. On 09/28/23 at 3:39 p.m., an interview was conducted with the DON. She stated she received a phone call from the evening supervisor (Staff J, RN) around 10:30 p.m. and was notified Resident #1 spilled hot soup on herself and she had no issues. The MD had also been notified. The DON stated the following day she read the 24-hour report and called Staff J to review the incident. She stated they went through the report again because the resident had developed blisters. The DON stated she had the Assistant Director of Nursing (ADON) assess Resident #1. The ADON reported to the DON the resident had open blisters on her abdomen and le [TRUNCATED]

Based on observations, interviews, record review, physician interview, and facility policy review the facility failed to protect the resident's right to be free from neglect, to ensure one Resident (#1) out of 13 residents with hemiparesis and hemiplegia diagnoses was provided care and assistance to prevent an injury from a burn during meal service times. Resident #1 suffered pain, infection of the skin and subcutaneous issue, and permanent body disfigurement related to scarring as a result of the facility's neglect to ensure this resident's safety during meal service. The facility neglected to provide care and services during a meal to a vulnerable resident with physical limitations, resulting in findings of Immediate Jeopardy on 8/16/23. The findings of Immediate Jeopardy were determined to be removed on 9/29/23 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: Review of a Resident Information Record dated 09/29/23 showed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was her own responsible party. She was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia following cerebral infarction. Review of the physician's active orders dated 09/29/23 showed Resident #1 was on a regular diet, pureed texture, nectar thickened fluids consistency for nutrition related to COPD. An interview and observation were conducted on 09/28/23 at 10:00 a.m. with Resident #1. The resident was observed to be in her wheelchair with her portable oxygen on via nasal cannula. The resident appeared clean, well-kept, and dressed in day clothes. She was observed to have a bandage on her left forearm dated 09/27/23, 7a.m-3 p.m. and signed. The resident said, I burned myself. She said it was carelessness. I picked up the soup, it was in a cup, and it was just falling on me like a waterfall. It hurts, the pain is an 8 to 10, achy and throbbing. I cannot move my left arm, it is paralyzed. The resident stated she did not need help with eating. On 09/28/23 at 12:04 p.m., Resident #1 was observed in the dining room for lunch. The resident was observed sitting in her wheelchair with three other residents at the table. The resident was observed leaning to her left. Her right arm was stretched out on the table, trying to reach the spoon in front of her. The resident was served pureed brat (sausage), mashed potatoes with gravy and apple juice. Resident #1 used only her right arm. Her left arm had a contracture. On 09/28/23 at 4:30 p.m., an interview was conducted with the DOR and Staff L, OT. Staff L stated Resident #1 had hemiplegia weakness on core muscles and had recently worked with her on wheelchair mobility, self-feeding, lower-level ADLs, and positioning. Staff L stated Resident #1 tended to lean posteriorly for lower leg support. Staff L stated she tried to adjust the resident's wheelchair to manage trunk stance. Staff L said, She had a positioning trough which was closer to her a lap and would impact how far she sat from the table. I switched it to a lap tray. The original one which she had at the time of the accident did not work. She tends to lean to the left. Her hips should be positioned better to support her trunk. Since her last hospital visit, she has been weaker. She has a bunch of comorbidities and weakness post-hospitalization . The DOR stated they looked to see if she needed adaptive equipment and determined she did not. She needed a regular cup to allow better grip. Staff L said, we determined using a [disposable foam] cup was not appropriate for her use. It was not the safest for her. She should have been served with regular kitchen wear. On 09/28/23 at 4:23 p.m., hot liquid assessments for Resident #1 were reviewed with the DON and the ADON. The DON stated if the assessment resolved in 2 or more checkmarks of yes, it would indicate the resident was at risk of burns. The assessments conducted on 12/22/23 and 08/17/23 showed the resident scored a 2 indicating the resident was not at risk. The assessments revealed on question 2, Functional limitations and contractures, the resident was observed not to have any limitations, contrary to her history of left side impairment. The DON said, We learned the assessment is not a good tool for this situation because she had a dominant side that was functional, her right side, even though she was totally impaired on her left side. She stated the impairment affected Resident #1's trunk control and positioning. The DON stated they were looking at other factors that may have contributed to the incident such as impaired judgement. Review of an OT treatment note date 08/17/23 showed, Patient custom wheelchair is modified to provide additional support to L UE (left upper extremities) as currently used trough is ineffective as patient is contracted and limbs falls off due to poor fit of device. Device is removed and lap tray installed. Review of an OT treatment note date 08/28/23 showed, Patient is observed in dining room as she returns from hospital following spillage of hot liquids. Screen is completed and a number of factors appear to have contributed to the accident. OT to address positioning primarily to ensure patient is optimal level of neutral, to ensure good body to table/food distance and fine motor control to ensure that self-feeding is managed at maximum level of 1, and safety with potential need for adaptive equipment to manage hot liquids. Review of a document titled, Occupational Therapy Treatment Encounter Note(s) showed on 08/18/23, an assessment was conducted on Resident #1 as follows, splint applied to left hand/wrist and lap tray installed for light sustained stretch. 2. Right upper extremity is flexion/abduction and with digits in extension results to promote normalized position of effected limb, prevent worsening of contractures. Patient educated on safe mobility while in chair using compensatory movement patterns. PN (Proprioception) completed and self-feeding goals incorporated into patient's plan of care due to event related to spilling hot soup. Recommendations made related to proper positioning to allow for increased safety and independent self-feeding. AE (Acute exacerbation) to be trialed as per patient needs. Patient stated understanding of need for upright sitting so that table/food is easily accessible. Staff collaboration with good return demonstrated. Modifications to chair continues as per patient response and further need to address safety slip and fall from chair and spilling of soup both of which appear to be related to positioning. Chair is dumped appropriately to ensure hips remain centered with decreased tendency for posterior pelvic tilt. Additional support posteriorly to increased height of back support to promote mid trunk flexion. Further head support is placed to ensure head remains in alignment and in neutral. The above modifications allow for optimal ability to participate in tabletop activities, namely self-feeding. Continue to monitor for safety and patient comfort. Review of a Resident Information Record dated 09/29/23 showed on 8/17/23 new diagnoses were added. A burn of second degree of left forearm sequela, a burn of second degree of abdominal wall sequela and a burn of second degree of other site of trunk, subsequent encounter. On 8/25/23 a new diagnosis of local infection of the skin subcutaneous tissue, unspecified was indicated. Review of a progress note dated 08/16/23 at 22:30, Resident spilled soup while eating dinner. Abdomen with clear fluid filled blister, forearm with open area. MD and family notified. Skin prep applied to blister, forearm cleansed with NS (normal saline), TAO ([NAME] Antibiotic Ointment) and wrapped with gauze. Therapy screen completed. Site is painful . Review of an 8/17/23 the SBAR (Situation Background Assessment Recommendation) revealed resident received a burn to her left lower abdomen and left lower arm PCP (primary care physician) responded with orders to cleanse with TAO and dressing applied. The SBAR dated 08/17/23, marked [late entry] signed by the ADON (Assistant Director of Nursing) showed, A Change in Condition (CIC) evaluation was conducted following a trauma incident. Resident received burn to resident's left lower abdomen and left arm. PCP was contacted with instructions to cleanse with NS TAO and dressing applied. A skin observation note dated 08/17/23, signed by the ADON, showed, Resident has new skin impairment. Resident received burn to her abdomen and left lower arm from hot liquid. Abdomen - left lower abdomen measurements 15 cm x 8 cm, left lower arm 9 cm x 6.5 am. An SBAR assessment was completed for new skin impairment. Treatment orders were obtained. Responsible party was notified. Review of Resident #1's Medication Administration Record (MAR) dated 08/01/23 to 08/31/23 revealed Resident #1 received new medications related to burn wounds as follows: Ascorbic Acid Tablet 500 milligram. Give 1 tablet by mouth one time a day for supplement to promote wound healing. Medication was administered from 08/18/23 to 08/21/23. Stat oral liquid - Protein. Give 45 ml (milliliters) by mouth two times a day for wound healing. Medication was administered from 08/18/23 to 08/21/23. Doxycycline Monohydrate 100 mg capsule. Give 1 tablet orally two times a day for wound burn for 14 days. Medication was administered from 08/18/23 to 08/21/23. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Medication was administered from 08/17/23 to 08/20/23 for complaint of left arm and abdomen burned areas. Review of Resident #1's Medication Administration Record (MAR) dated 09/01/23 to 09/30/23 revealed Resident #1 continued to receive new medications related to burn wounds as follows: Doxycycline Hyclate oral tablet 100 mg. Give 1 tablet by mouth two times a day for cellulitis for 14 days. Stat oral liquid - Amino acids Protein hydrolysate. Give 45 ml (milliliters) by mouth two times a day for wound healing for 30 days. Tramadol HCI tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Norco Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. The care plan showed an ADL focus revised on 08/18/23, showing the resident had an ADL self-care performance deficit associated with limited mobility, CVA (Cerebral Vascular Accident) with the left sided hemiplegia. Interventions related to eating showed the resident was able to feed self after set up. The care plan showed a focus indicating Resident #1 was at risk for injury related to hot liquids due to poor trunk control initiated on 08/19/23. Interventions included to complete hot liquid evaluation as scheduled, fluids were served at proper temperature, occupational therapy to screen with decline in function, and ensure resident maintained upright position when served hot liquids. Review of skin/wound care notes for Resident #1 revealed: On 08/17/23 resident was seen. History of present illness (HPI), Location: Left forearm and left lower abdomen. Quality: Patient is able to advise if in pain, Severity: Moderate, Timing: When palpitated burn, Context: 2nd degree burn. Modifying factors: pain is relieved with medication. Associated Signs and Symptoms: Limited mobility; history MRSA (Methicillin-Resistant Staphylococcus Aureus) HPI Description: As per nursing staff this was an acquired burn from soup, patient has had a CVA which limits use of her abilities . Doxycycline for cellulitis associated with wound. Diagnosis included: Burn of second degree of abdominal wall, initial encounter and burn of second degree of left upper arm, initial encounter. Orders: Doxycycline 100 mg po BID x 14 days. Wound Care: Cleanse wound with normal saline and Xeroform dressing. Wound #3: Left forearm, Partial thickness 9.0 cm length x 6.5cm width 45.946 cm^2 area. Wound #4: Left abdomen, Partial thickness, 15 cm length x 8cm width 94.248 cm^2 area, erythema, peri wound tenderness. On 09/11/23 Resident #1 was seen for wound care. Wound #1 Partial thickness wound, wound bed has slough present 75% of wound bed covered in serous drainage, moderate no odor, No tunnelling/undermining present. Well defined wound edges no signs of infection observed, wound is unchanged. Wound #2 Full thickness wound, wound bed has slough tissue 75% of wound bed covered with serosanguineous drainage, moderate amount of discharge well defined wound edges, no signs of infection. Wound is unchanged from previous. Left Abdomen: length 3.5cm/ width 12 cm / depth 0.1 cm Left forearm: length 8cm / width 2cm / depth 0.1cm. On 9/11/23 wound care was provided. Weeks of treatment: 3. Left arm: Partial thickness burn. Patient consented to debridement. Wound description: Full thickness without exposed support structures. Wound Margin: Distinct, outline attached. Under Assessments: Wound #3, pre-procedure diagnosis of wound #3 is a second-degree burn located on the left forearm. There was an excisional of skin/subcutaneous tissue debridement with a total of 12 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. Round #4: pre procedure diagnosis of wound #4 is a second-degree burn located on the left abdomen, lower quadrant. There was an excisional skin/subcutaneous tissue debridement with a total of 24 square centimeters performed by the wound doctor. Blade material removed includes subcutaneous tissue after achieving pain control using Lidocaine. A minimum amount of bleeding was controlled with pressure. On 9/25/23 Resident #1 was seen for wound care. The wound assessment note showed, Resident #1 has wounds, MD notification 09/25/23, Family notification 09/25/2023, Followed by wound care. Resident denied pain, no new orders received care Resident aware of wound progress and orders, care plan reviewed and updated. Abdomen-Wound #1: Full-thickness wound, wound bed has slough present, 50% of wound covered . Epithelizing wound edges. There are signs of infection present. Wound shows signs of improvement. Left forearm: Wound#2: Partial thickness wound, wound bed have slough tissue present. 75% of wound bed covered .scant drainage, epithelializing wound edges. Wound shows improvement. Abdomen: 2.5cm L/ 10.0cm W/ 0.1cm D and Left Forearm: 4.5cm L/ 1.4 cm W/ 0.1 cm D. On 09/28/23 at 3:16 p.m., an interview was conducted with Staff G, CNA. He stated he was assigned to Resident #1 the day she was burned. He stated he was working in the dining room with the evening supervisor (Staff J, RN) and was assisting passing coffee and juice to the residents, but not the tomato soup. He stated the meal was already served and the residents were eating. He stated [Resident #1] did not ask him for soup. He said, I believe someone else passed the soup to her. In the middle of them eating, one of the resident's on the same table called me and said [Resident#1] had spilled something on herself. I went to the kitchen, asked for cold water and a towel, and wiped her up. I took her to her room to change her clothes. I did not notice any difference in her skin when I was wiping her at that time. There were blisters later in the evening. I did not know she was badly burned at that time. I told the nurse [Staff K, LPN] when I observed the blisters. She helped me change her. She saw her skin. It was pink/red. On 09/28/23 at 3:25 p.m., a telephone interview was conducted with Staff K, LPN (agency). She stated she remembered she was passing medications after dinner when a CNA (Staff G) stated (Resident #1) had spilled hot soup on herself and asked for help changing her. Staff K said, In that moment, I saw her arm. It was red. I called the supervisor [Staff J, RN] just to make her aware of the redness. l saw the redness in her left chest and stomach area. It did not look like a burn until I went in when the aide was changing her for bed. He [Staff G] came and got me because the areas were starting to blister. I notified the supervisor again and she called the MD and notified the DON. I did not think it would blister that quickly. Within 2 hours she was full of blisters on her left arm and stomach. Staff K stated the resident did not complain of pain at the moment. She stated the resident's skin was irritated. Staff K stated she wrote a progress note and received doctor's orders to treat the burned areas. On 09/28/23 at 09:15 a.m., an interview was conducted with Staff F, Certified Dietary Manager (CDM)/Kitchen Manager. She stated Resident #1 was burned with soup on 08/16/23. She stated the incident happened in the dining room. Staff F said, I don't know exactly who served the soup. The dish machine was not working, we used regular serving bowls for all the other residents and a disposable foam cup for [Resident #1]. The resident did not receive soup with her tray. She requested and received tomato soup after we were done serving. The resident was served hot tomato soup in an 8-ounce disposable foam cup because we were out of bowls. I did not know if she required special equipment. It was a last-minute request. I don't think we in the kitchen knew whom the soup was going to. Staff F stated the soup was requested outside of the tray line and was taken straight to the resident upon preparing it. She stated they conducted an investigation and determined the resident's dexterity was the problem, more than the beverage itself. She said, the problem was not the beverage which was served or the container in which it was served. It was the resident's dexterity. Staff F stated dexterity meant the resident's ability to use her hands. She stated Resident #1 had some limitations. She confirmed the resident was served hot soup in a disposable foam cup and consequently suffered burns. Staff F stated they should have considered lag time the time it takes from the moment food is scooped into a serving dish and when it is served to the resident. She stated that would have helped the soup to cool down. On 09/28/23 at 2:18 p.m., an interview was conducted with Staff E, Activities/CNA. She stated she assisted residents with little things like getting water. She stated she was working in the dining room and was assisting with serving when Resident #1 burned herself with hot soup. She stated Resident #1 sat in the far-right corner of the dining room, probably 10 steps from the serving window. She stated the resident did not need assistance with feeding at the time, but she was now at the new restorative table, meaning her diet was downgraded and someone had to sit with her. Staff E stated the resident was served tomato soup because she had requested it. Staff E stated she went to the window and asked Staff A, the Cook, for the soup. She stated she heard Staff A say they were out of bowls. She stated she heard Staff F, CDM/ Kitchen Manager instruct Staff A to put the tomato soup in a coffee cup. Staff E stated she did not see how the soup was prepared. She confirmed she received the soup from Staff A in a disposable foam cup and handed it to Staff G, CNA who was assigned to the resident. Staff E stated she could not recall the soup being hot to touch. She stated she handed it to Staff G who brought it to the resident. Staff E stated she was at the front of the dining room when she heard Staff G stating he needed a towel because (Resident #1) had wasted the tomato soup. Staff E stated she grabbed a towel from the service counter and handed it to Staff G. Staff E stated at the time she did not realize Resident #1 had suffered significant burns. On 09/28/23 at 2:30 p.m., an interview was conducted with Staff H, Corporate Registered Dietician (RD). She said, the facility's policy is not specific to re-heating meals, however you would assist a resident if food needed to be re-heated. It should be heated to 165 degrees for 15 seconds. You check the temperature, and if it is above 180 degrees you wait for it to cool before you serve. She stated the facility staff failed to wait for the soup to cool down prior to serving it. She stated she would not recommend putting food in a microwave for 3 minutes and serving it without checking temperature. Staff H stated different microwaves heat at different levels so she would expect to stop and check after every 15 seconds. She stated there was no regulation on how hot is too hot. She stated she would expect staff to check the temperature every 15 seconds during the re-heating process. Staff H said, Everyone should use common sense. Staff H stated Resident #1 requested and received some soup which she picked up from the rim of the cup and she had put her finger through it. Staff H stated the resident spilled the soup on herself, causing the burns. She stated the resident had some blistering that appeared later from the soup burn. Staff H confirmed the blisters were caused by hot soup. She stated blistering occurred at temperatures above 125 degrees. On 09/28/23 at 2:40 p.m., a telephone interview was conducted with Staff I, Facility RD. She stated she was informed a resident had burned themselves with hot soup. She stated they immediately started in-services on hot liquids. Staff I stated she expected foods and liquids to be served at proper temperatures. She said, I heard the resident was having trouble holding the cup because she was served in a [disposable foam] cup. I don't know how she burned that quickly. She stated they had regular soup dishes, but the dish machine was down. Staff I stated the policy on re-heating any food was to heat it, bring it to temperature and then re-test the temperature. Staff I said, We should test the temperature after heating and before you bring it out to the resident. On 09/28/23 at 2:53 p.m., an interview was conducted with Staff J, RN/evening Supervisor. She stated she was working the day Resident #1 burned with soup. Staff J said, I was in the dining room during dinner and a CNA, I can't remember whom, said that [Resident #1] spilled soup on herself. That CNA cleaned her up with soap and water wiped her up and she was fine. Her skin was pink at that time. Later, before the end of the shift, I checked on her. Her abdomen on the left side and her left arm were pink and red in color. You could tell the hot soup had scalded her skin but there were no blisters at the time. Staff J stated she forgot to document her observations. She stated she did not put in any skin assessments or progress notes. She stated she called the doctor and the DON. She said, There were no orders at that time. It was too busy that night I had other patients to take care of and I forgot to write something. Staff J stated she entered her notes a couple days later. On 09/28/23 at 3:39 p.m., an interview was conducted with the DON. She stated she received a phone call from the evening supervisor (Staff J, RN) around 10:30 p.m. and was notified Resident #1 spilled hot soup on herself and she had no issues. The MD had also been notified. The DON stated the following day she read the 24-hour report and called Staff J to review the incident. She stated they went through the report again because the resident had developed blisters. The DON stated she had the Assistant Director of Nursing (ADON) assess Resident #1. The ADON reported to the DON the resident had open blisters on her abdomen and left arm. The DON stated she initiated an investigation and spoke to the staff to see what had happened. She stated they called the doctor who came in and saw the resident. The DON said, My investigation from my perspective was that it appeared to be an isolated incident which prompted further assessments like hot liquid assessments for all the residents. The DON stated there were no other residents who complained about safety of hot liquids. She stated they did skin checks and mouth checks, and no concerns were observed. The DON said, The incident prompted us to start working with OT [Occupational Therapy] on the way residents who have CVA [cerebrovascular accidents], and physical limitations are more at risk especially due to positioning. The DON stated OT referrals were made for those who were identified to be at risk. On 09/28/23 at 4:03 p.m., an interview was conducted with the ADON. She stated the following day they had reviewed the 24-hour report and read Resident #1 spilled soup on herself. She stated originally the report showed just pink skin was observed. The ADON stated she conducted an assessment on Resident #1 and at the time blisters had developed on her left arm and stomach area. The ADON stated she interviewed the staff to find out what had happened and contacted the family and the doctor. The ADON said, We did not know what really happened. I learned she was in the dining room and wasted soup on her arm. I received orders from the doctor. I did a CIC and skin sweep on her. I observed she had red and pink areas, and the first layer of skin was not there. Her skin had rolled to the side. It had blistered and broken on her stomach. We notified the wound care doctor. The ADON stated her investigation revealed the hot soup was provided to the resident in a (disposable foam) cup. She stated the soup was hot, just made out of the kitchen. The ADON stated when Resident #1 went to pick it up it, it fell over. The ADON stated Resident #1 had prior CVA and left side weakness. The ADON stated the resident required accommodation with meal set up which meant to open everything for her and place within reach. The ADON stated resident #1 fed herself and only needed supervision. The ADON said, It was an accident, we can improve on a lot of things. It was not intentional. It made me look at things differently, like consider other factors including positioning and diagnosis. The ADON stated supervision in the dining room was provided by the nurses and the CNAs. She stated they should know each resident's meal preferences, positioning, and level of supervision. On 09/28/23 at 4:30 p.m., an interview was conducted with the DOR and Staff L, OT. Staff L stated Resident #1 had hemiplegia weakness on core muscles and had recently worked with her on wheelchair mobility, self-feeding, lower-level ADLs, and positioning. Staff L stated Resident #1 tended to lean posteriorly for lower leg support. Staff L stated she tried to adjust the resident's wheelchair to manage trunk stance. Staff L said, She had a positioning trough which was closer to her a lap and would impact how far she sat from the table. I switched it to a lap tray. The original one which she had at the time of the accident did not work. She tends to lean to the left. Her hips should be positioned better to support her trunk. Since her last hospital visit, she has been weaker. She has a bunch of comorbidities and weakness post-hospitalization . The DOR stated they looked to see if she needed adaptive equipment and determined she did not. She needed a regular cup to allow better grip. Staff L said, we determined using a [disposable foam] cup was not appropriate for her use. It was not the safest for her. She should have been served with regular kitchen wear. On 09/28/23 at 5:01 p.m., a follow-up interview was conducted with Staff F, CDM. She stated the microwave in the kitchen was used to reheat food. She said, we do not use it a whole lot. If I do, I will put the food to be warmed in a microwavable bowl and heat it to 165 degrees for 15 seconds and if the temperature is greater than 180 degrees, wait to send it out. Staff F stated they had established a holding/cooling/lag time/rest period for anything 180 degrees and above. Staff F confirmed prior to this day, 09/28/23, she had provided education on monitoring food temperatures on the tray line, but not necessarily on re-heating food in the microwave. A telephone interview was conducted on 09/28/23 at 11:26 a.m. with Resident #1's wound care Physician. He stated he saw her wounds to the left forearm and the left abdomen right after the burns occurred and initially there was blistering but then both wounds developed necrotic tissue. He stated both wounds had to be debrided to remove the necrotic tissue. He stated during that procedure lidocaine was used to numb the area, a 13-inch blade was used to cut out the necrotic tissue, a compression gauze was used to stop the bleeding and treatment dressings were applied to both wounds. He stated the abdomen wound developed an infection of cellulitis and antibiotics were ordered. He said, Both of the wounds were improving, but once you have a wound, you will lose your skin, granulated tissue will grow back, and [Resident #1] will have permanent scarring. That goes for any wound. A telephone interview was conducted with Resident #1's Primary Care Physician (PCP) on 09/29/23 at 10:38 a.m. He stated he had been working with Resident #1 for 5 years and was very familiar with her. He stated he was made aware of the resident getting burned by soup. He stated he saw her the day after it happened, and he could not recall what degree of burns she had sustained. He stated they had been treating the wounds and had seen the resident weekly including yesterday, (09/28/23), he stated the wounds were covered, clean, and intact and the resident appeared to be comfortable. On 09/28/23 at 5:16 p.m., an interview was conducted with the Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC) and the DON. The NHA said, on 08/17/23 during stand-up meeting the 24-hour report revealed Resident #1 had spilled soup on herself while attempting to drink it. The NHA stated she contacted the state abuse agency and the police department and reported the incident as abuse and the report was not accepted. She stated the resident was assessed and had blisters on her upper abdomen and left arm. The NHA stated the DON had interviewed the resident and she had said her thumb had punched a hole in the cup causing it to spill on her. The NHA said, We focused on maintaining appropriate dietary temperatures and serving food in suitable containers. In the investigation we reviewed temperature logs and saw the soup was documented to have been served at 180 degrees. I interviewed the Cook (Staff A). I asked him how he served the soup he said he served it in a [disposable foam] cup. The NHA stated they suspended Staff A pending investigation. She stated on 08/22/23 they educated dietary staff on ensuring food temperatures are taken at the beginning and end of meal service and if the dish machine malfunctions, the Cook will make menu adjustments to ensure hot liquids are not served if they did not have appropriate dishes. The NHA stated they educated staff not to serve soup in paper products. The NHA stated on 08/22/23 a QAPI (Quality Assurance Performance Improvement) was held at which they determined the burn was not caused by their staff negligence. The NHA said, The root cause was the type of container the soup was served in. The resident squeezed the cup while she was drinking and that caused the thumb to go through the cup causing the soup to spill on the resident. The RNC stated the resident chose not to use the spoon. The RNC said, We determined if the resident would have used a different container, the soup would have been okay. The resident caused the accident because her nails poked the cup. She did not want to cut her nails and she did not want to use the spoon. The RNC confirmed it was their responsibility to ensure the resident had an appropriate container for the soup. The NHA stated on 09/28/23 they re-interviewed Staff A, Cook because they heard the surveyors were asking about re-heating food. The NHA stated Staff A said he had served two soups that day, a veggie soup, and the tomato soup that was served to Resident #1. The NHA said, He said he had put the soup in the microwave. He did not say that he checked the temperature before serving. I asked him and he said he did not. We learned he failed to be forthcoming about the investigation initially. He did not tell us he had reheated the soup in the microwave. We started

Based on observations to include review of facility-recorded camera footage, review of medical records and facility policies, and interviews with facility staff, the Medical Director (MD), a Family Member, and a resident, it was determined that the facility failed to provide supervision and an assistive device for one (Resident #2) of four residents sampled for high risk elopement out of a total sample size of 12. The facility assessed Resident #2 at risk for elopement on 05/26/22 and failed to place a wanderguard (an electronic monitoring device) on Resident #2 per facility protocol and as suggested by the elopement evaluation tool. The wanderguard device triggers alarms and can lock monitored doors to prevent the resident from leaving the facility unattended. On 06/01/22 at approximately 10:30 a.m., Resident #2, an elderly, cognitively impaired resident who required a wheelchair or walker to safely ambulate due to unsteady balance was able to exit the facility undetected by facility staff. Facility investigation showed that Resident #2 walked down a facility hallway on the 2nd floor without a walker or wheelchair. She opened an alarmed (wanderguard monitored) fire door to enter into a stairwell without response to the alarms by facility staff. The resident descended 18 steps, while carrying a purse, jacket, and a stuffed animal, and then exited the building, which was located alongside a busy 6 lane road that runs on the west side of the building with a speed limit of 40 miles per hour (mph). After exiting the building, Resident #2 traveled approximately 300 feet on an uneven sidewalk with visible tree roots and limbs and into the facility's parking lot with curbs, parking bumpers, and moving vehicles. Resident #2 approached an unoccupied parked car in the facility's parking lot and began calling out for a family member before being observed and assisted by a staff member who was outside. The likelihood of serious physical harm, injury, or death to Resident #2 as a result of the facility's failure to provide adequate supervision and assistive devices to prevent elopement and promote safety resulted in findings of Immediate Jeopardy on 06/01/2022, removed on 07/08/2022, with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross reference F656 Record review of facility log titled Incidents By Incident Type for date range 05/01/2022 - 06/21/2022 revealed one elopement incident: Resident #2 eloped from the facility on 06/01/2022. Observation of facility camera footage of Resident #2 outside of the facility on 06/01/22 was reviewed with the facility Director of Nursing (DON) on 06/22/2022 at 11:50 a.m. The beginning of the footage revealed the resident walked west on the sidewalk along the South side of the building and continued along the sidewalk turning north walking between the West side of the building and a parking lot. The resident continued to walk along the West side of the building and then turned north still on the sidewalk. The resident traveled across the facility driveway, where cars enter and exit from the roadway to and from the parking lot. She then walked toward a parked car in a visitor parking space directly across from the main entry door of the facility. The car was empty, but the resident began knocking on the car window. A staff member (Staff F, Housekeeping Manager) was then observed on the footage to approach the resident, visually identifying her. The staff member alerted additional staff (Staff E, Licensed Practical Nurse [LPN]), and Resident #2 was assisted back into the facility. Resident #2 was observed in the footage to be wearing soft slippers, carrying a jacket, a large purse, and a stuffed cat. She was walking without any assistive device. Photographic evidence obtained. On 06/21/22 at 2:18 p.m., a telephone interview was conducted with Staff F, Housekeeping Manager. She confirmed that at about 10:30 a.m. on 06/01/22 she witnessed Resident #2 in the northside parking lot knocking on a car window and calling out for her brother. She did not see which direction the resident came from. She yelled to the front door of the facility, asking for help. She stated that Staff E, LPN ran out to help. They tried to get the resident to walk back into the building, but the resident said she was too tired. They helped pull her slacks up, and she (Staff F) ran to therapy to get a wheelchair while Staff E, LPN remained with the resident. Staff F reported she took Resident #2 up to the 2nd floor where she was assessed by the nurse on duty. On 06/21/22 at 1:10 p.m., Staff E reported on 06/01/22 at about 10:30 a.m. he was at the front desk of the facility using the computer when Staff F reported that a resident was in the parking lot. He ran outside and observed Resident #2 knocking on a car window with her pants around her ankles. Staff E stated he helped her pull her pants up and helped her into the wheelchair that Staff F had brought out. Staff E reported that Staff F wheeled the resident back up to the 2nd floor, and the 2nd floor nurse took over the investigation. Staff E reported he was questioned during the investigation by administration and to his knowledge, Resident #2 never left the facility property. He did not know if Resident #2 was wearing a wanderguard at the time of the incident. On 06/21/2022 at 10:15 a.m., Resident #2 was observed standing in the doorway of her room without any assistive device. She was wearing non-skid socks and an elopement alarm bracelet was observed on her left ankle. An attempt to interview the resident revealed she was significantly confused and unable to provide coherent responses to questions. However, when asked if she had left the facility by herself recently, she initially replied no, but then said, oh yeah .I almost broke my neck. The resident was not able to provide any additional information related to her elopement. Resident #2 was observed walking around her room. She was unsteady on her feet at times and held onto furniture and the doorframe to keep her balance from time to time. On 06/21/2022 at 10:30 a.m., an interview was conducted with Staff A, the Certified Nursing Assistant (CNA) assigned to work with Resident #2 the day she eloped from the facility. She stated she had worked at the facility for [AGE] years and knew Resident #2 very well. Staff A stated Resident #2 was very confused and regularly displayed agitated behaviors. Staff A stated she was usually the only staff member who could calm the resident down. Staff A stated on 06/01/2022 the resident was agitated right after breakfast and wanted to find her brother. She stated that was typical for the resident because her brother visited her at the facility daily. Staff A stated she redirected the resident to her room, assisted her to lie down in bed, and at the request of the resident, she closed the resident's door. Staff A stated after that, I had to go to [another resident room] for patient care so I went there and did the care and then went to the bathroom and when I got out of the bathroom, they said she had gotten out and was found in the parking lot downstairs. Staff A confirmed she did not witness Resident #2 leave the facility. She stated it happened around 10:30 a.m. She stated the facility's investigation determined the resident exited through the stairwell exit at the end of her hallway. Staff A said, I don't see how .the alarm [on the door] never went off .we would have heard it .it's loud. Staff A said, she [referring to Resident #2] didn't have a wanderguard [electronic monitoring device] at that time. A follow up interview with Staff A, CNA on 07/07/22 at 10:22 a.m. revealed she had a larger assignment on the date of the incident due to a call in. Staff A reported that after she provided morning care to Resident #2 she went to provide care to another resident in a room down another hallway. She then was notified that Resident #2 had left the building and was returned by nursing. Staff A went to her room and found her seated in another wheelchair holding her pocketbook, stuffed cat, and a jacket. Staff A reported that in her opinion, there was no way the resident could have walked down two flights of stairs with loose slacks and clutching personal articles. Staff A stated, She must have used the elevator. On 07/07/22 at 12:35 p.m., a telephone interview with Staff K, Licensed Practical Nurse (LPN) confirmed that she was caring for Resident #2 on the date of incident. She last saw the resident at 9:00 a.m. on 06/01/22 when she gave the resident her morning medications in her room. She did not know her well and did not note any agitation. She did not hear any alarms going off and would not know how to turn alarms off if she had heard the alarm. If she heard an alarm, she confirmed that she knew the general protocol for a missing resident and would have followed the protocol. She was first notified of the missing resident when another nurse returned her to the floor. An interview was conducted with Staff B, Social Services Assistant (SSA) on 06/21/2022 at 10:39 a.m. She confirmed the facility used an elopement alarm system as a measure to prevent elopement. She stated she oversaw monitoring elopement alarm bracelet function and placement for residents in the facility. Regarding Resident #2's elopement on 06/01/2022, Staff B said, I know they said they found her in the parking lot .at that time she did not have a wanderguard because she had never been exit seeking. Staff B said, nursing does elopement assessment .anything 5 or higher should have a wanderguard on. Staff B stated Resident #2 was confused. On 06/21/2022 beginning at 11:01 a.m., the facility Maintenance Director and Staff C, Maintenance Assistant both confirmed Resident #2 eloped from the facility on 06/01/2022 and that she did not have an elopement monitoring device on at that time. Follow-up interview on 07/07/22 at 10:42 a.m. with Staff C, Maintenance Assistant revealed he checks the fire alarms/doors every day and documents on a log. He stated they were working on 06/01/22 and has it logged. Staff C reported that the door to enter the stairwell on the second floor has two alarms. One required a code to turn off the wanderguard/magnetic (mag) lock and the second required a key to turn off the fire alarm. The Maintenance Assistant stated the maintenance department, administration, and the nursing staff (nurses) are the only ones who have the keys and code to the alarms. To open the door without the alarms going off the key must be placed in the fire alarm and unlocked, and the code must be entered to unlock the magnetic lock. If someone had opened the door prior to the incident on 06/01/22, the fire alarm only rang for 45 seconds and then went off automatically. The second alarm for the magnetic lock would continue to sound until the code could be entered, and then it would turn off. Since the 06/01/22 elopement, it has been adjusted so the fire alarm continuously sounds until someone uses the key. In case of an emergency, the door can be opened by pushing on the bar for 15 seconds, but it will sound both alarms. If a resident has a wanderguard device, the magnetic lock will not release the door, but alarms would still sound to notify staff. He stated at the time of the elopement, the fire alarm may have silenced itself after 45 seconds, someone could have turned off the code to the magnetic lock, and not looked to see if anyone had used the door. The resident could have gone down the two flights of stairs because she had no electronic monitoring device on at that time. Staff C reported that if the resident was an electronic monitoring device on at the time of the incident, it would have prevented the 2nd story stairwell door from opening. An additional interview with Staff C, Maintenance Assistant on 07/08/22 at 10:50 a.m. revealed a resident with an electronic monitoring device cannot get on the elevator without staff entering a keypad code on the second floor. Staff C confirmed again, on the date of this incident Resident #2 did not have an electronic monitoring device on. Staff C stated there was a camera that faces down the hall from the elevator, past therapy to the outside. Staff C, reported that Resident #2 was not observed on this camera/tape therefore it did not appear that Resident #2 used the elevator. On 07/07/22 at 12:11 p.m., the Nursing Home Administrator (NHA) and the DON revealed Resident #2 had dementia, was easily redirected, and had resided at the facility for a few years before the elopement incident. On 06/01/22 the Management staff was in a nursing meeting in the conference room. They were told Resident #2 was outside in the parking lot, and they had just brought her back in. They stated they did not see her outside walking down the sidewalk through the conference room window. She was found outside by the housekeeper. They stated that the investigation included interviews with all the second floor staff and nurses and witness statements were received. They conducted a Root Cause Analysis (RCA) and based on the camera footage, they felt like she went down the stairs, out the exit door and walked along the sidewalk. They stated that the investigation indicated that both alarms went off on the second-floor stairwell door. They stated that someone must have turned off both alarms. The DON and NHA were not aware of how the alarms worked and how they functioned. They both thought they kept alarming until someone came and turned them off. The NHA stated, During the investigation no staff member would admit to knowing the code or to turning it off. Someone had to have turned it off, we just don't know who. On 07/07/22 at approximately 3:00 p.m., Staff S, LPN/Unit Manager for the 2nd floor revealed she had worked at the facility since March 2022. On the date of the incident, 06/01/22, she attended a department head meeting and then went to the social services office before returning to the floor. While she was in the social services office, Resident #2 was returned to the building in a wheelchair. She accompanied the resident back to her room, assessed the situation, got her a drink of water, called the family who reported to the building, and called her psychiatrist who came out that day and changed her medications. The nurse stated the resident was in a manic state that day due to medication reduction that had occurred at the hospital (resident was hospitalized from 04/26/22 to 05/02/22). The psych team increased her [MEDICATION(S)] on 06/01/22 after the elopement occurred. On 07/07/22 at 10:42 a.m., the path Resident #2 was thought to have traveled on 06/01/22 was followed beginning in the resident's room on the 2nd floor of the facility. The resident would have ambulated approximately 100 feet down the hallway to the stairwell at the end of the hall. The resident would have opened the stairwell door and ambulated down two flights of stairs or 18 steps to reach the first floor. The resident then opened the nearest exit door leading to the exterior of the facility. The resident was thought to exit the building facing south and walked approximately 300 feet on a sidewalk and into the facility parking lot. The sidewalk was uneven, and had visible tree roots and limbs. The parking lot had curbs, parking bumpers, and moving vehicles. According to https://www.wunderground.com/history/daily/us/fl/[NAME]/KPIE/date/2022-6-1 the temperature at the time of the elopement was between 82 and 84 degrees on 06/01/22. The facility faces north with a busy 6 lane roadway running along the west side of the building with a speed limit of 40 miles per hour (mph). Review of Resident #2's admission record revealed she was [AGE] years old, was initially admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)], anxiety disorder, [CONDITION(S)] disorder [CONDITION(S)] type, manic episode, generalized muscle weakness, [CONDITION(S)], and cognitive communication deficit. The admission record also revealed the resident's most recent hospital stay was 04/26/22 to 05/02/22. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 05/09/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section E, Behavior, revealed the resident exhibited delusions and was displaying verbal behavioral symptoms directed towards others. The verbal behavioral symptoms occurred 1 to 3 days. The resident did not exhibit any wandering behavior. Section G, Functional Status showed she required limited assistance of one for walking in room and in corridor and limited assistance of one for locomotion on and off the unit. A nursing progress note dated 05/21/2022 revealed: The resident is disoriented/confused. Resident has impaired decision-making ability. Resident's neurological evaluations is WNL (within normal limits) for resident. Behaviors: Hallucinations Wandering rejects/resists care. makes negative statements. Inappropriate Verbal Behavior Disrupts Living Environment/Care Delusions. A nursing elopement assessment dated [DATE] revealed an elopement risk score of 5. The score of 5 was determined based upon the resident being independent with a wheelchair (2 points), intrusion into others areas (2 points), and diagnosis of dementia or cognitive impairment (1 point). The question, Is resident a elopement risk? was answered Yes and the intervention put in place to prevent potential elopement was Move resident to secure unit of building. Instructions for interpreting the scoring were documented on the assessment: Total Score of 5 or greater = (equals) at risk for potential elopement. Preventative interventions should be initiated and documented in the care plan. The elopement assessment was completed by Staff D, LPN/Unit Manager (UM). Review of the resident's care plans revealed no evidence that a care plan was put in place following this 5/26/22 elopement assessment identifying the resident at risk. Record review of the Physical Therapy Discharge Summary dated 05/27/22 revealed resident ambulated using rolling walker, exhibiting slow cadence, short step length on level surface. Standing balance was a fair minus. Discharge recommendations were for nursing staff to ambulate resident with assistive device if needed. The resident had improved her ambulation from a baseline on 05/03/22 of 25 feet with contact guard assistance (CGA) to 200 feet with stand by assistance (SBA) using a rolling walker on 05/27/22. This surpassed her long term goal of 150 feet. Discharge recommendations were for nursing staff to ambulate resident with assistive device if needed. A progress note titled, Alert Note dated 06/01/2022 at 14:57 (2:47 p.m.) revealed: Resident presents alert with confusion .Resident reportedly was found outside of the facility by staff member, resident was redirected safely back onto her assigned area .Wander-guard (elopement alarm bracelet) was placed on residents left ankle and she was placed on one-on one supervision. Psych will evaluate and treat as indicated. At the time of this documentation resident condition remains stable Progress note dated 06/01/22 at 14:50 (2:50 p.m.) showed resident was assessed by wound care nurse after she was safely returned to the building. Resident had no new skin issues, written by Staff Z, Wound Care Nurse. Progress note titled, Risk Evaluation dated 06/01/22 at 17:02 (5:02 p.m.) showed Risk Evaluation: 12. Resident was an elopement risk. Has care plan that identifies resident as being at risk for elopement. 15-minute checks initiated. Staff educated that resident was a risk of elopement. CNA Kardex updated with the resident was at risk for elopement. Resident had a wander bracelet. Family notified of elopement risk, written by Staff S, UM. A document titled, SBAR (situation, background, assessment, documentation) Communication Form and Progress Note with an effective dated of 6/01/2022 at 18:09 (6:09 p.m.) revealed on 06/01/2022, Staff member observed client ambulating outside on the sidewalk adjacent to the facility. Client had increased yelling out and delusions this day responding to questions in ways inappropriate to the situation and this was prior to the client being observed outside. The note was signed by the DON 06/03/2022. Following the resident's 06/01/22 elopement a new nursing elopement assessment dated [DATE] showed an elopement risk score of 12. The score of 12 was determined based upon the resident being independent with ambulation (4 points), prior episodes of elopement or exit seeking (4 points), diagnosis of dementia or cognitive impairment (1 point), and exhibiting behavior of packing items/belongings (3 points). The question, Is resident a elopement risk? was answered Yes The interventions documented on the elopement assessment were: develop care plan that identifies resident as being at risk for elopement; educate staff that resident is at risk for elopement; place notation on CNA Kardex the resident is at risk for elopement; place wander bracelet on resident; take resident's picture, complete Missing Resident Identification Form and place in all elopement books; place name of resident at risk on 24-hour report as risk for elopement; notify family that resident is at risk for elopement ; initiate every 15 minutes checks. Review of the care plan for Resident #2 revealed a focus area of Wandering/Elopement initiated on 05/31/22, created on 06/01/22, and revised on 06/08/22. The focus care area stated The resident is an elopement risk with wandering/exit seeking behaviors and requires the use of a wanderguard. History of attempts to leave facility unattended, history of attempting to remove wanderguard, Impaired safety awareness. The interventions were all initiated on 06/01/22 and included: wanderguard per MD (medical doctor) orders; assess for fall risk; check placement of wanderguard every shift and function daily; distract resident from wandering by offering pleasant diversions; educate all staff on alarm response, elopement protocol, abuse, neglect; full skin assessment; monitor for fatigue and weight loss; provide structured activities; and psych referral. Review of the Physician orders and Treatment Administration Record (TAR) June 2022 revealed an order for apply wander guard to right or left ankle. Check for placement Q (every) shift, start date 06/01/22, start time 3:00 p.m. Also on the TAR was an order for Check wander guard function every day to left or right ankle, start date 06/17/2022, start time 3:00 p.m. Start date and times for elopement alarm orders were after Resident #2's elopement from the facility on 06/01/2022 at 10:30 a.m. Review of the Physician orders revealed Resident #2 had received [MEDICATION(S)] [MEDICATION(S)] Capsule 150 mg - 2 capsules by mouth at 9 a.m. (with a start date of 01/30/21) and 2 capsules at bedtime for [CONDITION(S)] (with a start date of 01/29/21) through the time of her hospitalization on [DATE]. Resident #2 returned to the facility on [DATE] and review of the May 2022 Medication Administration Record (MAR) revealed Resident #2 did not receive the two 150 mg capsules of [MEDICATION(S)] in the morning and at bedtime. This order was discontinued and a decreased dose of [MEDICATION(S)] was given of 150 mg one capsule twice a day (9 a.m. and 5 p.m.), a reduction of 300 mg daily. Record review of the Psychiatric note dated 06/01/22 showed a follow up visit was conducted after the elopement occurred. The note stated resident was not doing well and seems worse. Was unstable and was having episodes of agitation and has not been sleeping. Today she walked out the front door of the facility and was found in the parking lot. Stated she was looking for her brother. Her brother was present during the visit and reports that his sister seems like she was getting manic again. Continues to describe signs and symptoms of psychotic process. Others reported bizarre behavior had occurred. Inappropriate behavior was described by others. Others described her behavior suggested that auditory hallucinations were occurring. Delusional thoughts were reported by resident. Symptoms of [CONDITION(S)] were present. Increased physical activity was occurring. She was experiencing decreased sleep. She was distractible. Resident energy level was increased. She talked excessively. She currently uses a wheelchair to ambulate. She was over talkative. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Suggests that hallucinations are being experienced. Suggests that auditory hallucinations are being experienced. Suggests that visual hallucinations are being experienced. Delusional ideas were experienced. Thinking was tangential. Suicidal ideas or intent were denied. Homicidal ideas were denied. Not aware of current events. Does not give her current location, date and time and situation. Diffuse memory loss for recent and remote events is present. Periods of confusion and disorientation and memory problems were in evidence. Insight into problems seems to be poor. Judgment appears to be poor. Signs of anxiety. No signs of withdrawals or intoxication were in evidence. Recommendation was to increase [MEDICATION(S)] to 300 mg BID. Physician progress note dated 06/02/22 at 21:44 (9:44 p.m.) showed being seen today for follow-up. Resident was found outside per staff; she did not have a wanderguard on. Discussed with nursing. She appears chronically ill and fatigued but in no acute distress at this time. Plan included: follow up with psych, urinalysis, continue to closely monitor and wanderguard on. Record review of the Psychiatric Nurse Practitioner Note dated 06/13/22 showed she met with resident who was known to the writer to follow up on recent behaviors. Recently (6/10/22) neurology began her on [MEDICATION(S)] 25 mg twice a day. Her urinalysis from one week ago was negative. Her other blood work was benign. We will wait to see how she does with the [MEDICATION(S)] before making any further changes. She was pleasantly confused at this time, but her mood does vacillate. The resident was mostly aware of herself and circumstances. She displays a vacillating mood. Her thought processes are circumstantial. Her insight and judgment are impaired. She does not appear to be a danger to herself or anyone else. Record review of the Psychiatric Nurse Practitioner Note dated 06/24/22 showed Resident had a slight apparent response to treatment since [MEDICATION(S)] was increased. Symptoms of manic process continue to be described today. Her symptoms of manic process have lessened, and she is better. Continues to describe signs and symptoms of psychotic process. Symptoms today are less frequent or intense, and resident was considered better. Currently uses wheelchair to ambulate. Resident appears calm, minimally communitive, but slow to respond . Psychotic or borderline psychotic symptoms seem to be present .Judgement appears to be poor .recommend no changes to [CONDITION(S)] medication at this time. An interview was conducted with the DON on 06/21/2022 at 4:02 p.m. She confirmed Resident #2 had eloped from the facility on 06/01/2022 and was found in the parking lot on facility grounds. She stated the facility protocol for conducting elopement assessments was that the assessment was conducted by a nurse upon admission, quarterly, and as needed with any changes in status or behavior. Regarding the elopement assessment she said, it detects whether they (residents) have a wanderguard on them because if they score a 5 or higher, we place a wanderguard on them. If BIMS is less than 13 even without behaviors, we put wanderguard on them until IDT (interdisciplinary team) can meet and discuss further because if they scored a 5, they are displaying exit seeking behaviors. Regarding why an elopement alarm was not placed on Resident #2 on 05/26/2022 when she was assessed with a score of 5, the DON said, I believe the IDT team met and she wasn't displaying any exit seeking behaviors at the time, and I'm pretty confident she was the only one. We decided that she didn't need it. A request was made for documentation of the IDT teams decision to not place the monitoring device and not develop a care plan, but no such documentation could be located. Regarding the intervention documented on the 05/26/2022 elopement assessment for Resident #2, to move her to a secure unit, the DON stated the facility did not have a secure unit and did not know what that intervention meant. A second interview was conducted with the DON on 06/22/2022 beginning at 9:06 a.m. related to not identifying that Resident #2 should have had an elopement alarm placed on her on 5/26/22 based on a score of 5 on the elopement assessment. The DON said, that was an isolated incident .she was the only one that we missed .every other resident that had a 5 or higher we had a wanderguard on them. She stated she knew that because after Resident #2 eloped on 06/01/2022 a facility-wide audit for elopement scores and elopement alarm use was conducted. When asked how Resident #2 got missed she said, just human error .it happens, it was an accident, we just overlooked her. The DON said, she should have had a wanderguard placed on 05/26 [2022]. On 06/22/2022 at 10:43 a.m., Staff D, LPN Unit Manager for the 3rd floor confirmed she was aware that Resident #2 eloped from the facility on 06/01/2022 and was found in the parking lot on facility grounds. She confirmed she had completed the elopement assessment for Resident #2 on 05/26/2022. She stated she had done it that date because she was assigned to audit resident charts related to elopement assessments and intervention to make sure everything was in place. She stated that a score of 5 or above meant the resident should have an elopement alarm. She stated she identified that Resident #2 scored a 5 but did not have an elopement alarm. She stated she reported that finding to the DON and Social Services on 05/26/2022. Regarding the documented intervention on her assessment for moving resident to secure unit of the building she said, second floor is considered a secure unit here .supposed to be more of a secure unit. A follow up interview was conducted with the DON on 06/22/2022 at 12:31 p.m. She confirmed Staff D's report that she had been assigned to audit charts related to elopement on 05/26/2022 and said the audit was done as preparation for a corporate mock survey. She stated she did receive information from Staff D that day but could not recall details. She said, well on that day we did put everybody on a wanderguard . the only one that we missed was [Resident #2]. During an interview on 07/08/22 at 11:19 a.m. the Director of Rehab stated that the last time Resident #2 received therapy services was from 05/02/22 to 05/27/22. Upon completion of her rehab her balance was fair minus. She was able to walk 200 feet with a walker and stand by assist. She stated she did not know if the resident could walk without a walker. She was not steady, so it was not recommended to ambulate without a walker due to her balance. The Director of Rehab reported there were varying opinions from the therapists regarding her being able to walk down the stairs. She stated that she did not know how the resident eloped, but in her professional opinion, a rolling walker was what Resident #2 needed because of her lack of balance. She stated that they had never evaluated her on stairs because she needed a walker due to her balance or lack thereof. During an interview on 07/07/22 at 12:11 p.m. the NHA and the DON revealed Resident #2 was no longer a resident at the facility and had transferred to another facility to be closer to her brother, her only family. They stated that following the 06/01/22 elopement the facility immediately placed Resident #2 on one-to-one supervision. The physician and her brother were notified. Immediately she was evaluated by Staff S, LPN, Unit Manager (UM). A skin check was completed. They did a head count of every resident in the building and ensured all were present an [TRUNCATED]

Based on observations to include facility-recorded camera footage, interviews with facility staff, the Medical Director (MD), a resident and a family member, and review of medical records and facility policies, the facility failed to develop and implement a patient-centered care plan with interventions to prevent an unwitnessed exit from the facility for one (Resident #2) of four residents reviewed for elopement out of a total sample of 12 residents. On 06/01/22 at approximately 10:30 a.m., Resident #2, an elderly, cognitively impaired resident who required a wheelchair or walker to safely ambulate was able to leave the facility undetected by facility staff. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews with staff and record review showed the resident was in a manic state prior to the elopement, and the resident had received physical therapy services resulting in significant improvement in her mobility in the days and weeks leading up to her exit. On 05/26/22, six days prior to the elopement, Resident #2 was assessed as an elopement risk. Instructions on the facility ' s elopement assessment directed the facility staff to initiate preventative interventions and document these in the care plan. The facility failed to develop a care plan and initiate any interventions to include application of a wanderguard (electronic monitoring device) per the facility ' s normal protocol. Resident #2 ambulated without an assistive device down 18 steps, traveled on an uneven sidewalk with multiple trip hazards and into a parking lot placing her at serious risk of falling, being hit by a car, or becoming lost. The facility ' s failure to develop and implement a plan of care to maintain the resident's safety resulted in findings of Immediate Jeopardy on 06/01/2022, removed on 07/08/2022, with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: Cross reference F689 On 06/21/2022 at 10:15 a.m., Resident #2 was observed standing in the doorway of her room without any assistive device. She was wearing non-skid socks and an elopement alarm bracelet was observed on her left ankle. An attempt to interview the resident revealed she was significantly confused and unable to provide coherent responses to questions. However, when asked if she had left the facility by herself recently, she initially replied no, but then said, oh yeah .I almost broke my neck. The resident was not able to provide any additional information related to her elopement. Resident #2 was observed walking around her room. She was unsteady on her feet at times and held onto furniture and the doorframe to keep her balance from time to time. Review of Resident #2's admission record revealed she was [AGE] years old, was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record also revealed the resident's most recent hospital stay was 04/26/22 to 05/02/22. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 05/09/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section E, Behavior, revealed the resident exhibited delusions and was displaying verbal behavioral symptoms directed towards others. The verbal behavioral symptoms occurred 1 to 3 days. The resident did not exhibit any wandering behavior. Section G, Functional Status showed she required limited assistance of one for walking in room and in corridor and limited assistance of one for locomotion on and off the unit. A nursing progress note dated 05/21/2022 revealed: The resident is disoriented/confused. Resident has impaired decision-making ability. Resident's neurological evaluations is WNL (within normal limits) for resident. Behaviors: Hallucinations Wandering rejects/resists care. makes negative statements. Inappropriate Verbal Behavior Disrupts Living Environment/Care Delusions. A nursing elopement assessment dated [DATE] revealed an elopement risk score of 5. The score of 5 was determined based upon the resident being independent with a wheelchair (2 points), intrusion into others areas (2 points), and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The question, Is resident a elopement risk? was answered Yes and the intervention put in place to prevent potential elopement was Move resident to secure unit of building. Instructions for interpreting the scoring were documented on the assessment: Total Score of 5 or greater = (equals) at risk for potential elopement. Preventative interventions should be initiated and documented in the care plan. The elopement assessment was completed by Staff D, LPN/Unit Manager (UM). Review of the resident's care plans revealed no evidence that a care plan was put in place following this 5/26/22 elopement assessment identifying the resident at risk. Record review of the Physical Therapy Discharge Summary dated 05/27/22 revealed resident ambulated using rolling walker, exhibiting slow cadence, short step length on level surface. Standing balance was a fair minus. The resident had improved her ambulation from a baseline on 05/03/22 of 25 feet with contact guard assistance (CGA) to 200 feet with stand by assistance (SBA) using a rolling walker on 05/27/22. This surpassed her long term goal of 150 feet. Discharge recommendations were for nursing staff to ambulate resident with assistive device if needed. A progress note titled, Alert Note dated 06/01/2022 at 14:57 (2:47 p.m.) revealed: Resident presents alert with confusion .Resident reportedly was found outside of the facility by staff member, resident was redirected safely back onto her assigned area .Wanderguard (elopement alarm bracelet) was placed on residents left ankle and she was placed on one-on one supervision. Psych will evaluate and treat as indicated. At the time of this documentation resident condition remains stable Progress note titled; Risk Evaluation dated 06/01/22 at 17:02 (5:02 p.m.) showed Risk Evaluation: 12. Resident was an elopement risk. Has care plan that identifies resident as being at risk for elopement. 15-minute checks initiated. Staff educated that resident was a risk of elopement. CNA (Certified Nursing Assistant) Kardex updated with the resident was at risk for elopement. Resident had a wander bracelet. Family notified of elopement risk, written by Staff S, Unit Manager (UM). A document titled, SBAR (situation, background, assessment, documentation) Communication Form and Progress Note with an effective dated of 6/01/2022 at 18:09 (6:09 p.m.) revealed on 06/01/2022, Staff member observed client ambulating outside on the sidewalk adjacent to the facility. Client had increased yelling out and delusions this day responding to questions in ways inappropriate to the situation and this was prior to the client being observed outside. The note was signed by the Director of Nursing (DON) 06/03/2022. Following the resident's 06/01/22 elopement a new nursing elopement assessment dated [DATE] showed an elopement risk score of 12. The score of 12 was determined based upon the resident being independent with ambulation (4 points), prior episodes of elopement or exit seeking (4 points), diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The question, Is resident a elopement risk? was answered Yes The interventions documented on the elopement assessment were: develop care plan that identifies resident as being at risk for elopement; educate staff that resident is at risk for elopement; place notation on CNA Kardex the resident is at risk for elopement; place wander bracelet on resident; take resident's picture, complete Missing Resident Identification Form and place in all elopement books; place name of resident at risk on 24-hour report as risk for elopement; notify family that resident is at risk for elopement ; initiate every 15 minutes checks. Review of the care plan for Resident #2 revealed a focus area of Wandering/Elopement initiated on 05/31/22, created on 06/01/22, and revised on 06/08/22. The focus care area stated The resident is an elopement risk with wandering/exit seeking behaviors and requires the use of a wanderguard. History of attempts to leave facility unattended, history of attempting to remove wanderguard, Impaired safety awareness. The interventions were all initiated on 06/01/22 and included: wanderguard per MD (medical doctor) orders; assess for fall risk; check placement of wanderguard every shift and function daily; distract resident from wandering by offering pleasant diversions; educate all staff on alarm response, elopement protocol, abuse, neglect; full skin assessment; monitor for fatigue and weight loss; provide structured activities; and psych referral. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] guard to right or left ankle. Check for placement Q (every) shift, start date 06/01/22, start time 3:00 p.m. Also on the TAR was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 returned to the facility on [DATE] and review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued, and a decreased dose of [MEDICATION(S)] was given of 150 mg one capsule twice a day (9 a.m. and 5 p.m.), a reduction of 300 mg daily. Record review of the Psychiatric note dated 06/01/22 showed a follow up visit was conducted after the elopement occurred. The note stated resident was not doing well and seems worse. Was unstable and was having episodes of agitation and has not been sleeping. Today she walked out the front door of the facility and was found in the parking lot. Stated she was looking for her brother. Her brother was present during the visit and reports that his sister seems like she was getting manic again. Continues to describe signs and symptoms of psychotic process. Others reported bizarre behavior had occurred. Inappropriate behavior was described by others. Others described her behavior suggested that auditory hallucinations were occurring. Delusional thoughts were reported by resident. Symptoms of [CONDITION(S)] were present. Increased physical activity was occurring. She was experiencing decreased sleep. She was distractible. Resident energy level was increased. She talked excessively. She currently uses a wheelchair to ambulate. She was over talkative. Psychotic or borderline psychotic symptoms seem to be present. Disorganized behavior has been observed. Bizarre behavior has been observed. Suggests that hallucinations are being experienced. Suggests that auditory hallucinations are being experienced. Suggests that visual hallucinations are being experienced. Delusional ideas were experienced. Thinking was tangential. Suicidal ideas or intent were denied. Homicidal ideas were denied. Not aware of current events. Does not give her current location, date and time and situation. Diffuse memory loss for recent and remote events is present. Periods of confusion and disorientation and memory problems were in evidence. Insight into problems seems to be poor. Judgment appears to be poor. Signs of anxiety. No signs of withdrawals or intoxication were in evidence. Recommendation was to increase [MEDICATION(S)] to 300 mg BID. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was found outside per staff; she did not have a wanderguard on. Discussed with nursing. She appears chronically ill and fatigued but in no acute distress at this time. Plan included: follow up with psych, urinalysis, continue to closely monitor and wanderguard on. Observation of facility camera footage of Resident #2 outside of the facility on 06/01/22 was reviewed with the facility Director of Nursing (DON) on 06/22/2022 at 11:50 a.m. The beginning of the footage revealed the resident walked west on the sidewalk along the South side of the building and continued along the sidewalk turning north walking between the West side of the building and a parking lot. The resident continued to walk along the West side of the building and then turned north still on the sidewalk. The resident traveled across the facility driveway, where cars enter and exit from the roadway to and from the parking lot. She then walked toward a parked car in a visitor parking space directly across from the main entry door of the facility. The car was empty, but the resident began knocking on the car window. A staff member (Staff F, Housekeeping Manager) was then observed on the footage to approach the resident, visually identifying her. The staff member alerted additional staff (Staff E, Licensed Practical Nurse [LPN]), and Resident #2 was assisted back into the facility. Resident #2 was observed in the footage to be wearing soft slippers, carrying a jacket, a large purse, and a stuffed cat. She was walking without any assistive device. Photographic evidence obtained. On 07/07/22 at 10:42 a.m., the path Resident #2 was thought to have traveled on 06/01/22 was followed beginning in the resident's room on the 2nd floor of the facility. The resident would have ambulated approximately 100 feet down the hallway to the stairwell at the end of the hall. The resident would have opened the stairwell door and ambulated down two flights of stairs or 18 steps to reach the first floor. The resident then opened the nearest exit door leading to the exterior of the facility. The resident was thought to exit the building facing south and walked approximately 300 feet on a sidewalk and into the facility parking lot. The sidewalk was uneven, and had visible tree roots and limbs. The parking lot had curbs, parking bumpers, and moving vehicles. According to https://www.wunderground.com/history/daily/us/fl/[NAME]/KPIE/date/2022-6-1 the temperature at the time of the elopement was between 82 and 84 degrees on 06/01/22. The facility faces north with a busy 6 lane roadway running along the west side of the building with a speed limit of 40 miles per hour (mph). On 06/21/22 at 2:18 p.m., a telephone interview was conducted with Staff F, Housekeeping Manager. She confirmed that at about 10:30 a.m. on 06/01/22 she witnessed Resident #2 in the northside parking lot knocking on a car window and calling out for her brother. She did not see which direction the resident came from. She yelled to the front door of the facility, asking for help. She stated that Staff E, LPN ran out to help. They tried to get the resident to walk back into the building, but the resident said she was too tired. They helped pull her slacks up, and she (Staff F) ran to therapy to get a wheelchair while Staff E, LPN remained with the resident. Staff F reported she took Resident #2 up to the 2nd floor where she was assessed by the nurse on duty. On 06/21/22 at 1:10 p.m., Staff E reported on 06/01/22 at about 10:30 a.m. he was at the front desk of the facility using the computer when Staff F reported that a resident was in the parking lot. He ran outside and observed Resident #2 knocking on a car window with her pants around her ankles. Staff E stated he helped her pull her pants up and helped her into the wheelchair that Staff F had brought out. Staff E reported that Staff F wheeled the resident back up to the 2nd floor, and the 2nd floor nurse took over the investigation. Staff E reported he was questioned during the investigation by administration and to his knowledge, Resident #2 never left the facility property. He did not know if Resident #2 was wearing a wanderguard at the time of the incident. On 06/21/2022 at 10:30 a.m., an interview was conducted with Staff A, the Certified Nursing Assistant (CNA) assigned to work with Resident #2 the day she eloped from the facility. Staff A stated Resident #2 was very confused and regularly displayed agitated behaviors. Staff A stated she was usually the only staff member who could calm the resident down. Staff A stated on 06/01/2022 the resident was agitated right after breakfast and wanted to find her brother. She stated that was typical for the resident because her brother visited her at the facility daily. Staff A stated she redirected the resident to her room, assisted her to lie down in bed, and at the request of the resident, she closed the resident's door. Staff A confirmed she did not witness Resident #2 leave the facility. She stated it happened around 10:30 a.m. She stated the facility's investigation determined the resident exited through the stairwell exit at the end of her hallway. Staff A said, I don't see how .the alarm [on the door] never went off .we would have heard it .it's loud. Staff A said, she [referring to Resident #2] didn't have a wanderguard [electronic monitoring device] at that time. An interview was conducted with Staff B, Social Services Assistant (SSA) on 06/21/2022 at 10:39 a.m. She confirmed the facility used an elopement alarm system as a measure to prevent elopement. She stated she oversaw monitoring elopement alarm bracelet function and placement for residents in the facility. Regarding Resident #2's elopement on 06/01/2022, Staff B said, I know they said they found her in the parking lot .at that time she did not have a wanderguard because she had never been exit seeking. Staff B said, nursing does elopement assessment .anything 5 or higher should have a wanderguard on. Staff B stated Resident #2 was confused. On 06/21/2022 beginning at 11:01 a.m., the facility Maintenance Director and Staff C, Maintenance Assistant both confirmed Resident #2 eloped from the facility on 06/01/2022 and that she did not have an elopement monitoring device on at that time. An interview was conducted with the DON on 06/21/2022 at 4:02 p.m. She confirmed Resident #2 had eloped from the facility on 06/01/2022 and was found in the parking lot on facility grounds. She stated the facility protocol for conducting elopement assessments was that the assessment was conducted by a nurse upon admission, quarterly, and as needed with any changes in status or behavior. Regarding the elopement assessment she said, it detects whether they (residents) have a wanderguard on them because if they score a 5 or higher, we place a wanderguard on them. If BIMS is less than 13 even without behaviors, we put wanderguard on them until IDT (interdisciplinary team) can meet and discuss further because if they scored a 5, they are displaying exit seeking behaviors. Regarding why an elopement alarm was not placed on Resident #2 on 05/26/2022 when she was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . We decided that she didn't need it. A request was made for documentation of the IDT teams decision to not place the monitoring device and not develop a care plan, but no such documentation could be located. Regarding the intervention documented on the 05/26/2022 elopement assessment for Resident #2, to move her to a secure unit, the DON stated the facility did not have a secure unit and did not know what that intervention meant. A second interview was conducted with the DON on 06/22/2022 beginning at 9:06 a.m. related to not identifying that Resident #2 should have had an elopement alarm placed on her on 5/26/22 based on a score of 5 on the elopement assessment. The DON said, that was an isolated incident .she was the only one that we missed .every other resident that had a 5 or higher we had a wanderguard on them. She stated she knew that because after Resident #2 eloped on 06/01/2022 a facility-wide audit for elopement scores and elopement alarm use was conducted. When asked how Resident #2 got missed she said, just human error .it happens, it was an accident, we just overlooked her. The DON said, she should have had a wanderguard placed on 05/26 [2022]. On 06/22/2022 at 10:43 a.m., Staff D, LPN Unit Manager for the 3rd floor confirmed she was aware that Resident #2 eloped from the facility on 06/01/2022 and was found in the parking lot on facility grounds. She confirmed she had completed the elopement assessment for Resident #2 on 05/26/2022. She stated she had done it that date because she was assigned to audit resident charts related to elopement assessments and intervention to make sure everything was in place. She stated that a score of 5 or above meant the resident should have an elopement alarm. She stated she identified that Resident #2 scored a 5 but did not have an elopement alarm. She stated she reported that finding to the DON and Social Services on 05/26/2022. Regarding the documented intervention on her assessment for moving resident to secure unit of the building she said, second floor is considered a secure unit here .supposed to be more of a secure unit. A follow up interview was conducted with the DON on 06/22/2022 at 12:31 p.m. She confirmed Staff D's report that she had been assigned to audit charts related to elopement on 05/26/2022 and said the audit was done as preparation for a corporate mock survey. She stated she did receive information from Staff D that day but could not recall details. She said, well on that day we did put everybody on a wanderguard . the only one that we missed was [Resident #2]. On 07/07/22 at 12:11 p.m., the Nursing Home Administrator (NHA) and the DON revealed Resident #2 had dementia, was easily redirected, and had resided at the facility for a few years before the elopement incident. They stated that the investigation included interviews with all the second-floor staff and nurses and witness statements were received. They conducted a Root Cause Analysis (RCA) and based on the camera footage, they felt like she went down the stairs, out the exit door and walked along the sidewalk. They stated that the investigation indicated that both alarms went off on the second-floor stairwell door. They revealed Resident #2 was no longer a resident at the facility and had transferred to another facility to be closer to her brother, her only family. They stated that following the 06/01/22 elopement the facility immediately placed Resident #2 on one-to-one supervision. The physician and her brother were notified. Immediately she was evaluated by Staff S, LPN, Unit Manager (UM). A skin check was completed. The psych nurse evaluated her. An Elopement Assessment was performed, and a wanderguard was applied. They stated they started education on elopement, supervision, 1-1 supervision, and responding to alarms the day of the incident. All residents were reassessed for risk of elopement. The elopement binder was updated as well as the care plans. The wanderguard list was updated by the Social Services Director (SSD). They stated that the SSD evaluated and monitored for psychosocial changes for 72 hours. The care plan was updated with 1-1 supervision. They reviewed the cameras on the inside, lower level, and outside. A new Elopement Assessment was to be performed on new admissions, readmissions, or change in condition. They stated they are looking at the elopement scores, possible interventions, and updating the care plans depending on the resident's score. An ADHOC/QAPI (quality assurance performance improvement) meeting was held on 06/02/22. They created data collection forms to monitor system changes weekly for 4 weeks then monthly for 4 months. Staff knowledge was to include what to do and knowledge of elopement risk scores and interventions. The results will be brought to the QAPI meetings to ensure compliance. They confirmed that the Elopement Assessment on 05/26/22 with a score of 5 should have included an intervention of a wanderguard at that point. The DON stated that they were purchased by a new company, and the new Elopement Assessment risk guidelines started on 05/04/22 which changed the risk score from a 9 to a 5 as being at risk for elopement. The assessor (Staff D) for Resident #2 on 05/26/22 made a mistake and did not have a wanderguard placed on her. Resident #2 was not displaying any exit seeking behavior at the time. The DON stated, she could get up, but she was immobile. The DON stated that she had a medication change. The DON stated that they did not increase her monitoring with her medication change. The NHA and the DON stated they felt the change of the elopement assessment risk score from 9 to 5 caused part of the problem. On 06/02/22 they had an ADHOC committee meeting and had drills and audits for staff to audit the door alarms. They noted that during the post audits the staff does get numb to alarms going off. They stated alarms and elopements are important. They educated that you must check the stairwell and perimeter. The search procedure determines who is missing. The NHA stressed, They follow the process. That whoever hears the alarm responds to it. If you can hear it, respond. They stated that they have about 70% of the staff educated, and they have sent out a mass text message. They do use agency staff, and they have reached out to the agency supervisor to give them the elopement education. They have been educating for about a month to include the PRN (as needed) staff. We are making sure that they are signing off once they complete the education. They stated they are confident that all staff currently in the facility has received the education. If they walk in the door, they validate that they have received the education. The NHA stated, They focused on how to fix it by educating the staff. On 07/07/22 at approximately 3:00 p.m., Staff S, LPN/Unit Manager for the 2nd floor revealed on the date of the incident, 06/01/22, she attended a department head meeting and then went to the social services office before returning to the floor. While she was in the social services office, Resident #2 was returned to the building in a wheelchair. She accompanied the resident back to her room, assessed the situation, got her a drink of water, called the family who reported to the building, and called her psychiatrist who came out that day and changed her medications. The nurse stated the resident was in a manic state that day due to medication reduction that had occurred at the hospital (resident was hospitalized from 04/26/22 to 05/02/22). The psych team increased her [MEDICATION(S)] on 06/01/22 after the elopement occurred. During an interview on 07/08/22 at 11:19 a.m. the Director of Rehab stated that the last time Resident #2 received therapy services was from 05/02/22 to 05/27/22. Upon completion of her rehab her balance was fair minus. She was able to walk 200 feet with a walker and stand by assist. She stated she did not know if the resident could walk without a walker. She was not steady, so it was not recommended to ambulate without a walker due to her balance. She stated that she did not know how the resident eloped, but in her professional opinion, a rolling walker was what Resident #2 needed because of her lack of balance. She stated that they had never evaluated her on stairs because she needed a walker due to her balance or lack thereof. On 07/12/2022 at 1:45 p.m., a telephone interview with the facility ' s Medical Director and Physician of Resident #2 revealed he had been caring for Resident #2 for about 5 years. She was not acting quite herself that week and they thought she may have had a Urinary Tract Infection. They performed a urinalysis, but it was negative. He was surprised she was able to leave. He was shocked she was able to get down the stairs. He had only seen her wheeling around in her wheelchair. She had never tried to elope before. He stated she was a nice lady and would get in a verbal argument sometimes but had no real red flags. He had no concerns about her. He reported she may have had some medication changes by psych, but he was still surprised she was able to leave. He felt the facility did what they were supposed to do and everything was within reason. He was informed of the QAPI and reviewed the corrective action with the NHA. A telephone interview on 06/21/22 at 10:45 a.m. was conducted with the brother of Resident #2. He stated that he visits daily and was happy to look after his older sister because she always looked after him growing up. He confirmed that he was notified of the alleged elopement on 6/1/22 and had no further concerns related to that incident. He stated that his sister just smiled when he asked her about incident. He stated that he was actively seeking another facility for his sister because of several lost items and a diarrhea medication error. He confirmed that the facility Social Services director was assisting in that move to another facility. Record review of facility ' s policy, Wandering and Elopements revised March 2019 revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy and Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review of the facility ' s policy, Elopements and Wandering Residents, undated showed this facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or necessary supervision to do so. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care team. b. The interdisciplinary team. will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Record review of the facility ' s policy, Emergency Procedure - Missing Resident dated 2001 revealed: Director of Nursing: 7. Ensure care plan is updated. Nursing Staff: 6. Update the care plan. Record review of the facility ' s policy, Elopement Guidelines Practice Guidelines, revised January 2021 showed Practice Guidelines: 1. On admission, quarterly, annually, and with significant change of condition all residents are to be evaluated for elopement risk quarterly, annually, and with significant change of condition using based on the

Based on interviews with the Nursing Home Administrator, Nursing Home Administrator in training, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident, the resident's family member, attending Physician staff and review of the of the facilities policies and the resident's medical record, the facility failed to prevent and report neglect through lack of supervision for Resident #3, one of 8 sampled residents. The facility failed to provide supervision for Resident #3 who had known wandering behaviors, impaired decision-making skills, short term and long-term memory impairment, a history of falls and impulsive behavior, was fidgety and restless at times, was exit seeking and wandered the unit. During the evening of 6/17/19, the facility staff were unaware the resident had gotten out of bed, left his room located on the second floor of a three-story building, used a key pad secured elevator to go to the first floor of the facility and walked out of the building. The facility failed to ensure the safety of Resident #3 on the evening of 6/17/2019 when he was able to exit the facility, leave the property and cross 6 lanes of traffic, putting Resident #3 at risk of physical harm. The facility failed to accurately document Resident #3's elopement by falsifying documentation which stated he was found on the first floor when multiple staff members reported the resident was found outside, off the facility's property, down the road, and across 6 lanes of traffic by a traffic light at a busy four-way intersection. The facility's failure to accurately document Resident #3's elopement and the facility's failure to prevent and report the lack of supervision of Resident #3 resulted in findings of Immediate Jeopardy on 7/3/2019, which was ongoing. Findings included: Review of the facility's Elopement policy revised (MONTH) 2007 found: Policy statement: Staff shall investigate and report all cases of missing residents. Further review of the facility's Elopement policy revised, (MONTH) 2007 found: Policy interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observed a resident leaving the premises, he/she should a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Exam the resident for injuries; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident: d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the residents legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Record review of Resident #3's care plans found he was care planned on 5/28/2019 to have had alteration or potential alteration in mood AEB (as evidenced by) c/o (complaints of) or displays the following: fidgety or restless at times. Resident #3 was also care planned on 5/28/2019 that he was at risk for falls and or fall related injury related to: impaired balance, unsteady gait .is impulsive; attempts to transfer. It was also found through review of Resident #3's care plans dated on 5/28/2019, that he had impaired cognitive function AEB and had impaired decision-making skills. He also had short term, long term memory impairment related to history of alcohol/drug abuse. A review of Resident #3's nursing notes was conducted and found: on 5/16/2019 Resident #3 keeps insisting he needs to go home. Explained to resident that he is here for therapy, but redirection is continuously needed. Also, on 5/16/2019 a different nurse's note revealed Resident #3 was frequently redirected for safety. On 5/21/2019 Resident #3's nurse wrote he was alert with confusion. Continues to try to get out of the chair and the bed without assistance. Also, on 5/21/2019 it is noted by Resident #3's nurse will not stay in chair, attempts to get up and walk alone. On 7/3/2019 at 10:30 a.m. Staff I, CNA participated in a phone interview. Staff I was asked if Resident #3 had ever eloped? Staff I said, Yes, I was the one who found him. I don't remember the exact date, but it was a couple weeks to a month ago. When I found him, he was walking up 49th street. It was about 8 o'clock at night. Resident #3 was on one to one supervision at one point, then, he was on 15 minutes checks. They said something about how corporate said no more one to ones, but he was on 15-minute checks because I think he was a fall risk. I don't remember him ever falling but, he would wander in and out of everyone's rooms. It's just the dementia. There is only so much we can do because of how many people we have to take care of. But anyways, his aide that night (Staff M, CNA) checked on Resident #3 because he was on the 15-minute checks, then asked me to help him change another resident because that resident was being combative. When we were done Staff M went and checked on Resident #3. Then, he came back to me and said, hey! can you help me find Resident #3, he's not in his room. We couldn't find him in any of the other rooms on the second floor, he wasn't in the utility rooms, he was nowhere so we checked on the third floor because he could've got on the elevator with someone because we have people coming on and off our unit all the time, but we couldn't find him on the third floor either, so we told the staff up there and they said, let's check the entire building. We checked on the first floor, we checked outside and still couldn't find him. So, then I said let me get in my truck and look for him. I found him as soon as I got onto 49th street. I saw him walking by the stop light to the left when you are pulling out of the facility's parking lot. He was by the intersection at the light. Staff I was asked if Resident #3 was found on the same side of the road as the facility? Staff I said no, unfortunately he did cross the street. Staff I said when he pulled up to Resident #3 he asked, Resident #3, where are you going? and he said he was going home, he wanted to drink. I was able to get him in my truck and I brought him back. He wasn't hurt or anything, so I brought him back up to his room on the second floor and his nurse, Staff K, RN, and I did an incident report. Staff K, RN wrote what happened, I read it and signed it. I don't know who was told about the incident after that. Staff I said, Resident #3 wasn't gone long, maybe about 5 minutes because as soon as I got in my truck and got on the street I saw him. Review of Resident #3's admission record and physician notes revealed he was a [AGE] year-old admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Review of the interdisciplinary team note on 5/21/2019 at 7:19 a.m. revealed Resident #3 had a fall. Resident was found in another resident's closet on the ground. Wheelchair outside of room. Further review of Resident #3's medical record found an elopement care plan, created on 6/18/2019 by Staff F, Minimum Data Set (MDS) Coordinator, which revealed Resident #3 had a potential for elopement due to: has cognitive impairment, is exit seeking, is ambulatory, is able to wheel self in w/c (wheelchair), wanders the unit and wanders near exit doors, has a hx (history) of elopement. Goal: resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions included: educate resident/responsible party regarding sign out procedure as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; 1:1's as needed, include resident in elopement Book. Update physician and responsible party if resident elopes. Further review of Resident #3's same elopement care plan revealed on 7/2/2019 (the day the survey started) Staff F revised the care plan to remove has a hx of elopement. An observation and interview were conducted with Resident #3 on 7/2/2019 at 2:40 p.m. Resident #3 was in his room lying in bed on top of his sheets dressed in day clothes watching television. The surveyor knocked on the door to the resident's room and asked for permission to come in. The resident said yes, please come in. Resident #3 was asked, have you ever left this building? The resident responded and said no. Then Resident #3 proceeded to say, My wife lives a couple doors down. Her birthday is tomorrow. She still works but I am the retiree. She's actually my ex-wife. Medical record review revealed on 5/16/2019 a brief interview of mental status (BIMS) was conducted and Resident #3 scored 8 out of 15 indicating moderate cognitive impairment. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 7/2/2019 at 2:43 p.m. Staff G stated she had worked for the facility for almost a year. Staff G was asked if Resident #3 had ever left the building? Staff G said, actually yeah, I think a couple weeks ago he left, and I don't know how he got back but when he came back he had his meal ticket, you know the kind the residents get with their meals here? I have just heard this through other people that this happened so I'm sorry I can't be more help. That's all I know. On 7/2/19 at 2:44 p.m. Staff H, CNA was interviewed, and she stated she had worked at the facility for about a year and a half. Staff H was asked if she was familiar with Resident #3? Staff H stated, I know him. I don't usually work on that hall, but he's asked me a couple times to go down with him to smoke because he needs supervision to go smoke now. Staff H was asked why does he need supervision to smoke now? Staff H said because I think it was 2 or 3 weeks ago someone found him outside. Everyone was looking for him including myself. They announced it over the intercom that Resident #3 was missing. I think Staff I, CNA found him outside. I'm not sure how far away he was. Since then Resident #3 really has been better about asking to go somewhere. During an interview with Staff J, CNA on 7/2/2019 at 3:09 p.m. she said, I have worked here about a year and some change. Staff J was asked, does Resident #3 smoke? Staff J stated, yes he does. The surveyor asked, does he need supervision when he smokes? Staff J said yes, now he does. Staff J was then asked, why does he need supervision now? Staff J responded he wanders. This surveyor asked, what do you mean by wander? Staff J said, he will wander in and out of resident's rooms. Staff J was asked, has Resident #3 ever wandered out of the building? Staff J hesitated, looked away from the surveyor and stated no, not that I know of. Staff J looked back at the surveyor and said I usually work on the 11-7 shift, so this 3-11 shift is new for me. But no, I haven't heard of him leaving. On 7/2/19 at 4:19 p.m. Staff F, MDS Coordinator was asked if Resident #3 had ever eloped from the facility? Staff F said, I was not here but I know we talked about how he was at the front door. I care planned him for elopement on 6/18 so it must've happened the day before or on that day because the 18th was a Tuesday. When Resident #3 first came here he was agitated but he is not as agitated anymore. From what I understood the evening before the 18th he had got on the elevator, down to the front lobby, gone to the front door, and was trying to go somewhere. Everyone met about it and then we thought, I guess we should consider him an elopement risk. Staff F was asked if she could explain why on 6/18/2019 Resident #3's care plan stated he had a history of [REDACTED].? Staff F stated, I did not do that. A lot of people have access to changing the care plans. Staff F was asked if she could pull up Resident #3's elopement care plan and click on the H to pull up the care plans history which revealed Staff F created Resident #3's care plan on 6/18/2019 which included has a hx of elopement then on 7/2/2019 the care plan was revised by Staff F and has a hx of elopement was not on the 7/2/2019 elopement care plan anymore. When Staff F was asked if what the elopement care plan history was showing was true she did not answer. Staff F then asked the surveyor to close her office door. Staff F then stated, Okay, I have a license to maintain and I am going to be very honest with you. I came in on 6/18/2019 and I was told Resident #3 got out of the front door. I was not here when it happened, so I don't know if he was gone for 5 seconds, 5 minutes, or 5 hours, or where he went. But, to me with his BIMS being so low and he got out of the front door, he eloped and something really bad could've happened to that man. Then, I was told Resident #3 did not get out of the front door that he was found on the first floor and that was the story that I was told to stick to. They will tell you he didn't get out, but he did and they all know it. An interview was conducted on 7/2/19 at 5:14 p.m. with the Administrative group which included the Nursing Home Administrator (NHA), Nursing Home Administrator in training, Staff E, Director of Nursing (DON), and Staff D, Assistant Director of Nursing (ADON). The administrative group was asked what do you consider an elopement? The NHA responded, an elopement is someone getting totally off of the property as long as they meet the criteria according to their elopement risk score, which is a low BIMS, 12 and under and a no leave of absence order. If they step off the property and if they were at risk for elopement, we would redo their BIMS, reassess their elopement, place them in the elopement book if they became a risk. We would call the family and try to get them moved to a sister facility or to a different facility. The facility's administrative group was asked how they assess someone on admission for an elopement risk? Staff E, DON said we should use the elopement assessment on admission, with a change in condition, or if someone becomes exit seeking or if they are more confused we should reassess. We also do it quarterly on their comprehensive evaluation. The administrative staff were then asked, if someone did elope what do you do? the NHA stated, we would bring them back on the property, start a four point plan, place the resident on a one to one supervision, start discharge planning, assess the other residents, assess the resident who eloped, notify the doctor, notify the family, and update the care plan. The administrative staff was asked if they would report the elopement? The NHA quickly responded, we haven't had anything happen that was reportable. Staff [NAME] then said, so if we notice someone is gone we would make sure we are secured, all other residents are accounted for, we would search our grounds, and if we could not find them we would reach out to local law enforcement, contact any family to see if they could assist us in finding the resident, contact the physician and we would basically be searching until we found the person. The NHA spoke up and said then we would definitely report it, definitely, 100 percent. Our company believes in over reporting. I'm sure someone has told you that already from all the reports you guys get. We would do an adverse, 5-day, 15-day, all that. The surveyor asked if Resident #3 walked out of the building on the evening of 6/17/2019? The NHA immediately responded, Resident #3 did walk out of the front door, probably, maybe. Staff D, ADON looked at the NHA and quickly stated, no, we found him in the lobby. The nurse reported that to me. All that was reported to me was that he was in the lobby on the 3-11 shift. The surveyor said, looking at Staff D, so you say it was reported to you that he was found in front lobby and you say (the surveyor looked at the NHA,) that he got out of the front door? The NHA then stated, I said he probably, maybe got out of the front door, but it sounds like he was found on the first floor. The surveyor asked Staff D, if they found Resident #3 on the first floor why would the staff report that to you? Staff D said, because he was exit seeking probably a couple weeks ago. It was just reported to me he was found in the lobby, the aide (CNA) brought him back up. Staff D was asked, what aide? Staff D said, actually I don't know if it was an aide, they just brought him back upstairs. Staff K, Registered Nurse (RN) was the nurse who reported it to me, she was Resident #3's nurse that night and Staff L, RN was the second-floor supervisor that night. We reassessed Resident #3 and I believe he is at risk for elopement and his care plan should reflect that. The NHA then stated, after 5:00 p.m. the front doors lock and you need a code in order to get out. We have a receptionist till 7:00 p.m. and she can let people in and out. After 7:00 p.m., the second floor has a camera and a buzzer to let people in and out. The Nursing Home Administrator in training then spoke up and said, to our knowledge he did not get out of the front door. Then, Staff D said, all that was reported to me was Resident #3 was found in the lobby. The surveyor then stated to the administrative team, I have interviews that the resident got out of the building. The NHA, the NHA in training and Staff D all looked at each other then, they all said all they knew was he was found on the first floor. The NHA then asked the surveyor, who told you that? The NHA was told, I cannot give out that information. The NHA said, oh come on, I just want to know I'm not going to do . the NHA did not say anymore. Review of the nurse's daily skilled note created on 6/17/19 at 23:08 (11:08 p.m.) revealed during the start of last rounds it was discovered that Resident #3 was not in his room. He can be exit seeking. We searched the building and located him on the first floor. Further record review was conducted for Resident #3. The record was silent regarding the resident having left the building on the evening of 6/17/2019. A review of Resident #3's nursing notes was conducted and there was no documentation that the physician was notified of Resident #3's elopement. Further review of the facility's nursing notes was conducted and there was no documentation that Resident #3's significant other was contacted about his elopement. A review of the facility's Incident Log for the month of (MONTH) was conducted which revealed no documentation of Resident #3's elopement. Review of the facility's (MONTH) Social Services: Abuse, Neglect, Exploitation Log did not have any documentation related to Resident #3. A phone interview was conducted with Resident #3's significant other on 7/2/19 at 3:50 p.m. Resident #3's significant other stated she and Resident #3 were never married but they lived together for [AGE] years. She stated she still worked, and he lives at the facility because he acts better there. He is confused in the head. Sometimes he will answer me the right way and sometimes he will talk about something that doesn't make any sense to what we are talking about. She stated she lived about 15 minutes away and she visited twice a week. The significant other was asked, has the facility has ever notified you of Resident #3 leaving the building or that he went missing? Resident #3's significant other stated, No, never. I did tell them he could go outside to smoke because he likes to be with that group. During a phone interview with Staff N, Licensed Practical Nurse (LPN) on 7/3/19 at 8:52 p.m. She stated, I was not Resident #3's nurse that night but he did get out of the facility. I don't recall what night it was, but I did get in my car to go find him. Staff I, CNA was the one who found him. When we could not find him in the building Staff I and myself got in our cars and I told him to head South and I will head North on 49th Street. When Staff I brought him back I asked Resident #3 in Spanish, because he speaks English and Spanish, Resident #3, where did you go? He said he went to the bar and that he had 2 beers. I asked him how he paid for the beers and he pulled out his lunch meal ticket, you know the ones that tell you what's on the resident's meal trays. So, then I said to him oh that won't pay for beers and then he told me a couple guys at the bar paid for him. A phone interview was conducted with Staff K, RN on 7/3/19 at 1:53 p.m. Staff K was asked, can you tell me if Resident #3 has ever eloped? Staff K said, Yes, a couple weeks ago I don't remember the exact date, but you can look at my note in the chart. Staff K paused before saying, He got out of the building. What happened was, he had been going in and out of other residents' rooms and being disruptive. He was on one to one supervision then they changed him to every 15-minute checks. He had gone to lie down in his room and his aide went to change another resident. So, I peeked in on Resident #3 while he did that. Resident #3 was awake, but he was in his bed. It was about the middle of the 3p.m.-11p.m. shift that I checked on him. When the aide went back in to check Resident #3 he was not in his room, so everyone started looking in rooms because he liked to go into empty beds. When we didn't find him on the second floor we notified the Unit Manager on the third floor and we did a sweep of the third, and first floor. We still could not find him, so we did a sweep of the property because he liked to smoke and he could have gone outside to smoke. When he wasn't on the property, Staff I, CNA got in his truck and Staff N, Licensed Practical Nurse (LPN) got in her car to go look for him. They both drove in opposite directions and Staff I, CNA, found him right away. Resident #3 was on the sidewalk across the street from the facility. Staff K said, Fortunately, he was not hurt, he had just gone for a walk. Staff I brought Resident #3 back to the facility. I did a complete check of his skin, his range of motion was all good, I checked to make sure he didn't have any injuries. He was fine, there was no marks or injuries and he was his normal self which is confused but he understands everything that is going on he just doesn't have good safety awareness or make good choices. After I assessed Resident #3, I wrote an incident report, my statement on what happened, then wrote exactly what happened on a daily skilled note. Staff I wrote his statement on what happened then I cosigned Staff I's statement and we both signed the incident report describing what happened. I gave the 3-11 supervisor, who was involved in this whole thing, the incident report and all the statements. He called Staff D, who was the DON at the time, but now she's the ADON, to tell her what happened. The next day when I came in Staff D called me into her office. Staff K said, Staff D, called me into her office the next day and she had the statement and the incident report describing exactly what happened and she said, we really can't say Resident #3 was found out of the building. We can get in a lot of trouble for that. Staff K said, Then, she made me change my daily note that I wrote that night, saying he was found outside, to say we found him on the first floor. Staff K said, Things in the facility are not good relationship wise in the authority positions. Especially when it comes to doing the right thing. I find it being a threat because if you don't do exactly what they say, you're going to have a problem. Further review of Staff K's Daily Skilled Note dated 6/17/2019, which stated the resident was located on the first floor, revealed the note was created on 6/17/19 at 23:08 (11:08 p.m.) but the note was not locked until 6/18/2019 at 15:31 (3:31 p.m.). On 7/3/19 at 6:20 p.m. there was a camera observed to be mounted on the outside of the facility building facing the front entry and exit doors of the facility's lobby (photographic evidence obtained). On 7/3/19 at 7:43 p.m. an interview was conducted with the NHA and Staff E, DON. The NHA stated the camera out front does record but the recorded footage does not store as far back as 6/17/2019 or 6/18/2019. The NHA also said the DON was the one who does the incident, accident reporting, but we have not had any to report. The NHA and the DON, were asked if a resident got out, crossed the street would that be something you as a facility would investigate and report? The NHA stated, Yeah, absolutely, definitely. Then he said as long as I had knowledge about it. On 7/8/2019 at 11:30 a.m. the case manager for Resident #3's physician called back for a phone interview and stated, The facility never called to notify us the resident left the facility. He does not have orders to leave unsupervised. We keep very good records of all of our residents and I am very familiar with Resident #3. There is nothing in his records saying he ever went missing or got out of the building. Review of Resident #3's physician order [REDACTED]. On 7/3/19 at 8:03 p.m. Staff D, ADON, was interviewed. She confirmed that on 6/17/2019 and on 6/18/2019 she was the DON for the facility. She also confirmed if a resident got out of the building and crossed the street during the time she was the DON it would have been her responsibility to report that to the state agency. The surveyor asked Staff D when did you get notified that Resident #3 went missing? Staff D said, I got a call at home and they told me Resident #3 was exit seeking and that he was in the lobby. That was all that was told to me. I don't remember who called me, it might have been the 3-11 supervisor. He called me to say he was missing, maybe around 8 o'clock at night and then they called to say he was downstairs in the lobby. Staff D was asked if she was called twice that night regarding Residents #3? Staff D hesitated then said there was only one phone call and they said they couldn't find him. It was after everything was said and done and they said he was in the lobby. Normally it is not Resident #3's behavior to wander so we did an assessment and put him on the elopement watch list to watch. Staff D was asked, Did you report to the state agency what happened with Resident #3? Staff D said there was nothing to investigate and there was nothing to report. He didn't get out of the building. It was abnormal behavior for him to be exit seeking so we put him on the elopement risk. Then, Staff D contradicted herself and said, His exit seeking isn't to go off the unit. He would always do his activities upstairs and not come off the second floor. Staff D stated she defines exit seeking as Resident #3 coming off of the second floor. Staff D continued to say, what was reported to me was that he was pacing a lot and walking, walking, walking and somehow throughout the night during their rounds they found him on the first floor in the lobby. All the pacing and the walking was reported to me at the same time they called to say he was missing then found in the lobby. He was not on 15-minute checks before I got the call that he went missing, there would be no reason for him be. After he was missing he should have been on 15-minute checks right away that's what I told them to do. In our clinical morning meeting we reevaluated what happened, and he should have had 15-minute checks started right away but it's not documented until the morning of 6/18/2019. Review of Resident #3's 15-minute checks documentation found the 15-minute checks were started on 6/18/2019 at 08:45 a.m. and ended on 6/20/2019 at 23:45 (11:45 p.m.). During the survey entrance conference with Staff E, DON and the Nursing Home Administrator in training on 7/2/19 at 9:15 a.m. Staff [NAME] said she had been the DON for 5 days and Staff D, ADON was the DON before her. The Nursing Home Administrator in training stated that Staff D stepped down to the ADON position because she needed to gain more experience. Further review of the facility's Abuse, Neglect, and Exploitation: Prevention and Prohibition policy, which was not dated, revealed: Standard: The prevention and prohibition of abuse, neglect and exploitation. To create an environment within the facility which promotes resident well-being, safety, and prohibits abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. .II. Each resident/patient has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. .7. Neglect: neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting/Response: -The facility will report all allegations of abuse, neglect, injuries of unknown origin, and exploitation/misappropriation of resident property immediately to the designated facility abuse coordinator, the director of Nursing, the administrator, the Florida abuse hotline at 1-800-96-ABUSE, to the Agency for Health Care Administration, to the Department of Children and Families, to all other agencies as required, and take any necessary corrective actions depending on the results of the investigation. -Report to the state, or licensing authorities any knowledge it has of any actions by a court of law which would indicate and employee is unfit for service; and -Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. -The facility will take immediate action to investigate and stop the alleged abuse of against a person (the facility will take action to prevent the abuse if against a person's property) -The facility will also notify the appropriate agencies, based on the nature of the abuse allegation in accordance with State statute and Federal law. Review of the facilities Abuse Protection and Response Policy that was not dated, found: .VII Reporting and Response, Policy: all allegations involving abuse, neglect, exploitation, sexual abuse, mistreatment, injuries of unknown sources, and misappropriation of resident property will be reported Immediately by not later than (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than (24 hours) if the ev

Based on interviews with the Nursing Home Administrator, Nursing Home Administrator in training, the Director of Nursing, Assistant Director of Nursing, Nursing staff, the attending Physician staff, the resident's family member, record review of the resident's medical record and review of the facility's policies, the facility's Administration failed to utilize the facility's resources effectively for Resident #3, one of eight sampled residents requiring supervision. The facility failed to ensure Resident #3's safety through the oversight warranted due to known and documented behaviors. The Administration failed to ensure the nursing and certified nursing staff provided supervision for Resident #3 who had impaired decision-making skills, short term and long-term memory impairment at [AGE] years old, a history of falls and impulsive behavior, was exit seeking, and wandered the unit. During the evening of 6/17/19, the Administration failed to ensure that nursing and certified nursing assistant staff provided the level of safeguards necessary to protect Resident #3, who exited the facility, left the property, and crossed six lanes of traffic. The Administrative staff failed to take action to maintain the safety of the resident when he was returned to his floor and failed to ensure accurate documentation was maintained following Resident #3's elopement. The Administration failed to take action to discover the details about the elopement in order to keep the resident safe. The failure of the Administrator to ensure the Staff carried out their duties of supervision and safety of Resident #3 resulted in findings of Immediate Jeopardy on 7/3/2019, which was ongoing. Findings included: Review of the job description titled Administrator, undated, revealed the primary purpose of your position is to direct the day to day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality of care can be provided to our residents at all times. Duties and responsibilities: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the VP (Vice President) of Operations . Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures. Personal functions: Assist in the recruitment and selection of competent department directors, supervisors, Facility non-licensed staff, consultants, etc. Safety and Sanitation: Review accident and incident reports (e.g., falls, injuries of an unknown source, abuse, etc.) Monitor to determine the effectiveness of the facility's risk management program. Working conditions: Communicates with the medical staff, nursing personnel, and other department personnel. Specific requirements: Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served . Must possess the ability to make independent decisions when circumstances warrant such action . Must posses the ability to plan, organize, develop, implement, and interpret the program goals, objectives, policies and procedures, etc., that are necessary for providing quality care and maintaining a sound operation. Must be thoroughly familiar with laws, regulations, and guidelines governing personnel administration. Review of the job description titled, Director of Nursing Services, undated, revealed The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority: As Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. You are charged with carrying out the resident care policies established by the Facility. Duties and Responsibilities Administrative functions: plan, develop, implement, evaluate, and direct the nursing service department, as well as it programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities . Make written and oral reports and recommendations to the Administrator concerning the operation of the nursing service department. Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care. Develop, implement, and maintain an ongoing quality assurance program for the nursing service department . Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting etc./ as necessary . Assist in developing plans of action to correct potential or identified problem areas. Provide leadership, education, counseling, and discipline, when appropriate, to assigned Certified Nursing Assistants (CNA) and other nursing personnel . Ensure that CNA's, department personnel residents, and visitors follow the department's established policies and procedures at all times . Develop and maintain a good working rapport with inter-department personnel as well as other departments within the Facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the residents. Nursing Care Functions: .Provide the Administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs . Ensure that direct nursing care can be provided by Licensed Practical Nurse's, CNA's, and/or a nurse aid trainee qualified to perform the procedure. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Specific Requirements: . Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served . Must possess the ability to make independent decisions when circumstances warrant such action. Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities. Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel. Review of Resident #3's admission record and physician notes revealed he was a [AGE] year-old admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. An interview was conducted on 7/2/19 at 5:14 p.m. with the Administrative group which included the Nursing Home Administrator (NHA), Nursing Home Administrator in training, Staff E, Director of Nursing (DON), and Staff D, Assistant Director of Nursing (ADON). The administrative group was asked what do you consider an elopement? The NHA responded, an elopement is someone getting totally off of the property as long as they meet the criteria according to their elopement risk score, which is a low BIMS, 12 and under and a no leave of absence order. If they step off the property and if they were at risk for elopement, we would redo their BIMS, reassess their elopement, place them in the elopement book if they became a risk. We would call the family and try to get them moved to a sister facility or to a different facility. The facility's administrative group was asked how they assess someone on admission for an elopement risk? Staff E, DON said we should use the elopement assessment on admission, with a change in condition, or if someone becomes exit seeking or if they are more confused we should reassess. We also do it quarterly on their comprehensive evaluation. The administrative staff were then asked, if someone did elope what do you do? the NHA stated, we would bring them back on the property, start a four point plan, place the resident on a one to one supervision, start discharge planning, assess the other residents, assess the resident who eloped, notify the doctor, notify the family, and update the care plan. The administrative staff was asked if they would report the elopement? The NHA quickly responded, we haven't had anything happen that was reportable. Staff [NAME] then said, So, if we notice someone is gone we would make sure we are secured, all other residents are accounted for, we would search our grounds, and if we could not find them we would reach out to local law enforcement, contact any family to see if they could assist us in finding the resident, contact the physician and we would basically be searching until we found the person. The NHA spoke up and said then we would definitely report it, definitely, 100 percent. Our company believes in over reporting. I'm sure someone has told you that already from all the reports you guys get. We would do an adverse, 5-day, 15-day, all that. The surveyor asked if Resident #3 walked out of the building on the evening of 6/17/2019? The NHA immediately responded, Resident #3 did walk out of the front door, probably, maybe. Staff D, ADON looked at the NHA and quickly stated, no, we found him in the lobby. The nurse reported that to me. All that was reported to me was that he was in the lobby on the 3-11 shift. The surveyor said, looking at Staff D, so you say it was reported to you that he was found in front lobby and you say (the surveyor looked at the NHA) that he got out of the front door? The NHA then stated, I said he probably, maybe got out of the front door, but it sounds like he was found on the first floor. The surveyor asked Staff D, if they found Resident #3 on the first floor why would the staff report that to you? Staff D said, because he was exit seeking probably a couple weeks ago. It was just reported to me he was found in the lobby, the aide (CNA) brought him back up. Staff D was asked, what aide? Staff D said, actually I don't know if it was an aide, they just brought him back upstairs. Staff K, Registered Nurse (RN) was the nurse who reported it to me, she was Resident #3's nurse that night and Staff L, RN was the second-floor supervisor that night. We reassessed Resident #3 and I believe he is at risk for elopement and his care plan should reflect that. The NHA then stated, after 5:00 p.m. the front doors lock and you need a code in order to get out. We have a receptionist till 7:00 p.m. and she can let people in and out. After 7:00 p.m., the second floor has a camera and a buzzer to let people in and out. The Nursing Home Administrator in training then spoke up and said, to our knowledge he did not get out of the front door. Then, Staff D said, all that was reported to me was Resident #3 was found in the lobby. The surveyor then stated to the administrative team, I have interviews that the resident got out of the building. The NHA, the NHA in training and Staff D all looked at each other then, they all said all they knew was he was found on the first floor. The NHA then asked the surveyor, who told you that? The NHA was told, I cannot give out that information. The NHA said, oh come on, I just want to know I'm not going to do . the NHA did not say anymore. On the morning of 7/3/2019 at 10:30 a.m. Staff I, CNA participated in a phone interview. Staff I was asked if Resident #3 had ever eloped? Staff I said, Yes, I was the one who found him. I don't remember the exact date, but it was a couple weeks to a month ago. When I found him, he was walking up 49th street it was about 8 o'clock at night. Resident #3 was on one to one supervision at one point, then, he was on 15 minutes checks. They said something about how corporate said no more one to ones, but he was on 15-minute checks because I think he was a fall risk. I don't remember him ever falling but, he would wander in and out of everyone's rooms. It's just the dementia. There is only so much we can do because of how many people we have to take care of. But anyways, his aide that night (Staff M, CNA) checked on Resident #3 because he was on the 15-minute checks, then asked me to help him change another resident because that resident was being combative. When we were done Staff M went and checked on Resident #3. Then, he came back to me and said, hey! can you help me find Resident #3, he's not in his room. We couldn't find him in any of the other rooms on the second floor, he wasn't in the utility rooms, he was nowhere so we checked on the third floor because he could've got on the elevator with someone because we have people coming on and off our unit all the time, but we couldn't find him on the third floor either, so we told the staff up there and they said, let's check the entire building. We checked on the first floor, we checked outside and still couldn't find him. So, then I said let me get in my truck and look for him. I found him as soon as I got onto 49th street. I saw him walking by the stop light to the left when you are pulling out of the facility's parking lot. He was by the intersection at the light. Staff I was asked if Resident #3 was found on the same side of the road as the facility? Staff I said no, unfortunately he did cross the street. Staff I said when he pulled up to Resident #3 he asked, Resident #3, where are you going? and he said he was going home, he wanted to drink. I was able to get him in my truck and I brought him back. He wasn't hurt or anything, so I brought him back up to his room on the second floor and his nurse, Staff K, RN, and I did an incident report. Staff K, RN wrote what happened, I read it and signed it. I don't know who was told about the incident after that. Staff I said, Resident #3 wasn't gone long, maybe about 5 minutes because as soon as I got in my truck and got on the street I saw him. An observation and interview were conducted with Resident #3 on 7/2/2019 at 2:40 p.m. Resident #3 was in his room lying in bed on top of his sheets dressed in day clothes watching television. The surveyor knocked on the door to the resident's room and asked for permission to come in. The resident said yes, please come in. Resident #3 was asked, have you ever left this building? The resident responded and said no. Then Resident #3 proceeded to say, My wife lives a couple doors down. Her birthday is tomorrow. She still works but I am the retiree. She's actually my ex-wife. Medical record review revealed on 5/16/2019 a brief interview of mental status (BIMS) was conducted and Resident #3 scored 8 out of 15 indicating moderate cognitive impairment. A review of Resident #3's care plans revealed he was care planned on 5/28/2019 to have had alteration or potential alteration in mood AEB (as evidenced by) c/o (complaints of) or displays the following: fidgety or restless at times. Resident #3 was also care planned on 5/28/2019 that he was at risk for falls and or fall related injury related to: impaired balance, unsteady gait .is impulsive; attempts to transfer. It was also found through review of Resident #3's care plans dated on 5/28/2019, that he had impaired cognitive function AEB and had impaired decision-making skills. He also had short term, long term memory impairment related to history of alcohol/drug abuse. A review of Resident #3's nursing notes was conducted and found: on 5/16/2019 Resident #3 keeps insisting he needs to go home. Explained to resident that he is here for therapy, but redirection is continuously needed. Also, on 5/16/2019 a different nurse's note revealed Resident #3 was frequently redirected for safety. On 5/21/2019 Resident #3's nurse wrote he was alert with confusion. Continues to try to get out of the chair and the bed without assistance. Also, on 5/21/2019 it is noted by Resident #3's nurse will not stay in chair, attempts to get up and walk alone. Review of the interdisciplinary team note on 5/21/2019 at 7:19 a.m. revealed Resident #3 had a fall. Resident was found in another resident's closet on the ground. Wheelchair outside of room. Further review of Resident #3's medical record found an elopement care plan, created on 6/18/2019 by Staff F, Minimum Data Set (MDS) Coordinator, which revealed Resident #3 had a potential for elopement due to: has cognitive impairment, is exit seeking, is ambulatory, is able to wheel self in w/c (wheelchair), wanders the unit and wanders near exit doors, has a hx (history) of elopement. Goal: resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions included: educate resident/responsible party regarding sign out procedure as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; 1:1's as needed, include resident in elopement Book. Update physician and responsible party if resident elopes. Further review of Resident #3's same elopement care plan revealed on 7/2/2019 (the day the survey started) Staff F revised the care plan to remove has a hx of elopement. A phone interview was conducted with Resident #3's significant other on 7/2/19 at 3:50 p.m. Resident #3's significant other stated she and Resident #3 were never married but they lived together for [AGE] years. She stated she still worked and he lives at the facility because he acts better there. He is confused in the head. Sometimes he will answer me the right way and sometimes he will talk about something that doesn't make any sense to what we are talking about. She stated she lived about 15 minutes away and she visited twice a week. The significant other was asked, has the facility has ever notified you of Resident #3 leaving the building or that he went missing? Resident #3's significant other stated, No, never. I did tell them he could go outside to smoke because he likes to be with that group. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 7/2/2019 at 2:43 p.m. Staff G stated she had worked for the facility for almost a year. Staff G was asked if Resident #3 had ever left the building? Staff G said, actually yeah, I think a couple weeks ago he left, and I don't know how he got back but when he came back he had his meal ticket, you know the kind the residents get with their meals here? I have just heard this through other people that this happened so I'm sorry I can't be more help. That's all I know. On 7/2/19 at 2:44 p.m. Staff H, CNA was interviewed, and she stated she had worked at the facility for about a year and a half. Staff H was asked if she was familiar with Resident #3? Staff H stated, I know him. I don't usually work on that hall, but he's asked me a couple times to go down with him to smoke because he needs supervision to go smoke now. Staff H was asked why does he need supervision to smoke now? Staff H said because I think it was 2 or 3 weeks ago someone found him outside. Everyone was looking for him including myself. They announced it over the intercom that Resident #3 was missing. I think Staff I, CNA found him outside. I'm not sure how far away he was. Since then Resident #3 really has been better about asking to go somewhere. During an interview with Staff J, CNA on 7/2/2019 at 3:09 p.m. she said, I have worked here about a year and some change. Staff J was asked, does Resident #3 smoke? Staff J stated, yes he does. The surveyor asked, does he need supervision when he smokes? Staff J said yes, now he does. Staff J was then asked, why does he need supervision now? Staff J responded he wanders. This surveyor asked, what do you mean by wander? Staff J said, he will wander in and out of resident's rooms. Staff J was asked, has Resident #3 ever wandered out of the building? Staff J hesitated, looked away from the surveyor and stated no, not that I know of. Staff J looked back at the surveyor and said I usually work on the 11-7 shift, so this 3-11 shift is new for me. But no, I haven't heard of him leaving. A phone interview was conducted with Staff N, Licensed Practical Nurse (LPN) on 7/3/19 at 8:52 p.m. She stated, I was not Resident #3's nurse that night but he did get out of the facility. I don't recall what night it was, but I did get in my car to go find him. Staff I, CNA was the one who found him. When we could not find him in the building Staff I and myself got in our cars and I told him to head South and I will head North on 49th Street. When Staff I brought him back I asked Resident #3 in Spanish, because he speaks English and Spanish, Resident #3, where did you go? He said he went to the bar and that he had 2 beers. I asked him how he paid for the beers and he pulled out his lunch meal ticket, you know the ones that tell you what's on the resident's meal trays. So, then I said to him oh that won't pay for beers and then he told me a couple guys at the bar paid for him. On 7/2/19 at 4:19 p.m. Staff F, MDS Coordinator was asked if Resident #3 had ever eloped from the facility? Staff F said, I was not here but I know we talked about how he was at the front door. I care planned him for elopement on 6/18 so it must've happened the day before or on that day because the 18th was a Tuesday. When Resident #3 first came here he was agitated but he is not as agitated anymore. From what I understood the evening before the 18th he got on the elevator, down to the front lobby, gone to the front door, and was trying to go somewhere. Everyone met about it and then we thought, I guess we should consider him an elopement risk. Staff F was asked if she could explain why on 6/18/2019 Resident #3's care plan stated he had a history of [REDACTED].? Staff F stated, I did not do that. A lot of people have access to changing the care plans. Staff F was asked if she could pull up Resident #3's elopement care plan and click on the H to pull up the care plans history which revealed Staff F created Resident #3's care plan on 6/18/2019 which included has a hx of elopement then on 7/2/2019 the care plan was revised by Staff F and has a hx of elopement was not on the 7/2/2019 elopement care plan anymore. When Staff F was asked if what the elopement care plan history was showing was true she did not answer. Staff F then asked the surveyor to close her office door. Staff F then stated, okay, I have a license to maintain and I am going to be very honest with you. I came in on 6/18/2019 and I was told Resident #3 got out of the front door. I was not here when it happened, so I don't know if he was gone for 5 seconds, 5 minutes, or 5 hours, or where he went. But, to me with his BIMS being so low and he got out of the front door, he eloped and something really bad could've happened to that man. Then, I was told Resident #3 did not get out of the front door that he was found on the first floor and that was the story that I was told to stick to. They will tell you he didn't get out, but he did and they all know it. Review of the nurses' daily skilled note created on 6/17/19 at 23:08 (11:08 p.m.) revealed during the start of last rounds it was discovered that Resident #3 was not in his room. He can be exit seeking. We searched the building and located him on the first floor. Further record review was conducted for Resident #3. The record was silent regarding the resident having left the building on the evening of 6/17/2019. A review of Resident #3's nursing notes was conducted and there was no documentation that the physician was notified of Resident #3's elopement. Further review of the facility's nursing notes was conducted and there was no documentation that Resident #3's significant other was contacted about his elopement. A review of the facility's Incident Log for the month of (MONTH) was conducted which revealed no documentation of Resident #3's elopement. Review of the facility's (MONTH) Social Services: Abuse, Neglect, Exploitation Log did not have any documentation related to Resident #3. Further review of Staff K's Daily Skilled Note dated 6/17/2019, which stated the resident was located on the first floor, revealed the note was created on 6/17/19 at 23:08 (11:08 p.m.) but the note was not locked until 6/18/2019 at 15:31 (3:31 p.m.). On 7/3/19 at 6:20 p.m. there was a camera observed to be mounted on the outside of the facility building facing the front entry and exit doors of the facility's lobby (photographic evidence obtained). On 7/3/19 at 7:43 p.m. an interview was conducted with the NHA and Staff E, DON. The NHA stated the camera out front does record but the recorded footage does not store as far back as 6/17/2019 or 6/18/2019. The NHA also said the DON was the one who does the incident, accident reporting, but we have not had any to report. The NHA and the DON, were asked if a resident got out, crossed the street would that be something you as a facility would investigate and report? The NHA stated, Yeah, absolutely, definitely. Then he said as long as I had knowledge about it. On 7/8/2019 at 11:30 a.m. the case manager for Resident #3's physician called back for a phone interview and stated, The facility never called to notify us the resident left the facility. He does not have orders to leave unsupervised. We keep very good records of all of our residents and I am very familiar with Resident #3. There is nothing in his records saying he ever went missing or got out of the building. Review of Resident #3's physician order [REDACTED]. A phone interview was conducted with Staff K, RN on 7/3/19 at 1:53 p.m. Staff K was asked, Can you tell me if Resident #3 has ever eloped? Staff K said, Yes, a couple weeks ago I don't remember the exact date, but you can look at my note in the chart. Staff K paused before saying, He got out of the building. What happened was, he had been going in and out of other residents' rooms and being disruptive. He was on one to one supervision then they changed him to every 15-minute checks. He had gone to lie down in his room and his aide went to change another resident. So, I peeked in on Resident #3 while he did that. Resident #3 was awake, but he was in his bed. It was about the middle of the 3p.m.-11p.m. shift that I checked on him. When the aide went back in to check Resident #3 he was not in his room, so everyone started looking in rooms because he liked to go into empty beds. When we didn't find him on the second floor we notified the Unit Manager on the third floor and we did a sweep of the third, and first floor. We still could not find him, so we did a sweep of the property because he liked to smoke and he could have gone outside to smoke. When he wasn't on the property, Staff I, CNA got in his truck and Staff N, Licensed Practical Nurse (LPN) got in her car to go look for him. They both drove in opposite directions and Staff I, CNA, found him right away. Resident #3 was on the sidewalk across the street from the facility. Staff K said, Fortunately he was not hurt, he had just gone for a walk. Staff I brought Resident #3 back to the facility. I did a complete check of his skin, his range of motion was all good, I checked to make sure he didn't have any injuries. He was fine, there was no marks or injuries and he was his normal self which is confused but he understands everything that is going on he just doesn't have good safety awareness or make good choices. After I assessed Resident #3, I wrote an incident report, my statement on what happened, then wrote exactly what happened on a daily skilled note. Staff I wrote his statement on what happened then I cosigned Staff I's statement and we both signed the incident report describing what happened. I gave the 3-11 supervisor, who was involved in this whole thing, the incident report and all the statements. He called Staff D, who was the DON at the time, but now she's the ADON, to tell her what happened. The next day when I came in Staff D called me into her office. Staff K said, Staff D, called me into her office the next day and she had the statement and the incident report describing exactly what happened and she said, we really can't say Resident #3 was found out of the building. We can get in a lot of trouble for that. Staff K said, Then, she made me change my daily note that I wrote that night, saying he was found outside, to say we found him on the first floor. Staff K said, Things in the facility are not good relationship wise in the authority positions. Especially when it comes to doing the right thing. I find it being a threat because if you don't do exactly what they say, you're going to have a problem. On 7/3/19 at 8:03 p.m. Staff D, ADON, was interviewed. She confirmed that on 6/17/2019 and on 6/18/2019 she was the DON for the facility. She also confirmed if a resident got out of the building and crossed the street during the time she was the DON it would have been her responsibility to report that to the state agency. The surveyor asked Staff D when did you get notified that Resident #3 went missing? Staff D said, I got a call at home and they told me Resident #3 was exit seeking and that he was in the lobby. That was all that was told to me. I don't remember who called me, it might have been the 3-11 supervisor. He called me to say he was missing, maybe around 8 o'clock at night and then they called to say he was downstairs in the lobby. Staff D was asked if she was called twice that night regarding Residents #3? Staff D hesitated then said there was only one phone call and they said they couldn't find him. It was after everything was said and done and they said he was in the lobby. Normally it is not Resident #3's behavior to wander so we did an assessment and put him on the elopement watch list to watch. Staff D was asked, Did you report to the state agency what happened with Resident #3? Staff D said there was nothing to investigate and there was nothing to report. He didn't get out of the building. It was abnormal behavior for him to be exit seeking so we put him on the elopement risk. Then, Staff D contradicted herself and said, His exit seeking isn't to go off the unit. He would always do his activities upstairs and not come off the second floor. Staff D stated she defines exit seeking as Resident #3 coming off of the second floor. Staff D continued to say, what was reported to me was that he was pacing a lot and walking, walking, walking and somehow throughout the night during their rounds they found him on the first floor in the lobby. All the pacing and the walking was reported to me at the same time they called to say he was missing then found in the lobby. He was not on 15-minute checks before I got the call that he went missing, there would be no reason for him be. After he was missing he should have been on 15-minute checks right away that's what I told them to do. In our clinical morning meeting we reevaluated what happened, and he should have had 15-minute checks started right away but it's not documented until the morning of 6/18/2019. Review of Resident #3's 15-minute checks documentation found the 15-minute checks were started on 6/18/2019 at 08:45 a.m. and ended on 6/20/2019 at 23:45 (11:45 p.m.). During the entrance conference with Staff E, DON and the Nursing Home Administrator in training on 7/2/19 at 9:15 a.m. Staff [NAME] said she had been the DON for 5 days and Staff D, ADON was the DON before her. The Nursing Home Administrator in training stated that Staff D stepped down to the ADON position because she needed to gain more experience. <

Based on interviews with the Nursing Home Administrator, Nursing Home Administrator in training, Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing assistant staff, the resident, the resident's family, the attending Physician staff and review of the facility policies and the resident's medical record, the facility failed to ensure that Resident #3, one of a sample of 8 residents requiring supervision was provided with the needed supervision for known wandering behaviors. The facility failed to provide supervision for Resident #3 who had impaired decision-making skills, short term and long-term memory impairment, a history of falls and impulsive behavior, was exit seeking, and wandered the unit. On 6/17/19, the facility staff were unaware the resident had gotten out of bed, left his room located on the second floor of a three-story building, used a key pad secured elevator to go to the first floor of the facility and walked out of the building. The facility failed to ensure the safety of Resident #3 on the evening of 6/17/2019 when he was able to exit the facility, leave the property, cross 6 lanes of traffic and make it to a traffic light at a busy four-way intersection resulting in findings of Immediate Jeopardy on 7/3/2019, which was on-going. Findings included: On the morning of 7/3/2019 at 10:30 a.m. Staff I, CNA participated in a phone interview. Staff I was asked if Resident #3 had ever eloped? Staff I said, Yes, I was the one who found him. I don't remember the exact date, but it was a couple weeks to a month ago. When I found him, he was walking up 49th street it was about 8 o'clock at night. Resident #3 was on one to one supervision at one point, then, he was on 15 minutes checks. They said something about how corporate said no more one to ones, but he was on 15-minute checks because I think he was a fall risk. I don't remember him ever falling but, he would wander in and out of everyone's rooms. It's just the dementia. There is only so much we can do because of how many people we have to take care of. But anyways, his aide that night (Staff M, CNA) checked on Resident #3 because he was on the 15-minute checks, then asked me to help him change another resident because that resident was being combative. When we were done Staff M went and checked on Resident #3. Then, he came back to me and said, hey! can you help me find Resident #3, he's not in his room. We couldn't find him in any of the other rooms on the second floor, he wasn't in the utility rooms, he was nowhere so we checked on the third floor because he could've got on the elevator with someone because we have people coming on and off our unit all the time, but we couldn't find him on the third floor either, so we told the staff up there and they said, let's check the entire building. We checked on the first floor, we checked outside and still couldn't find him. So, then I said let me get in my truck and look for him. I found him as soon as I got onto 49th street. I saw him walking by the stop light to the left when you are pulling out of the facility's parking lot. He was by the intersection at the light. Staff I was asked if Resident #3 was found on the same side of the road as the facility? Staff said no, unfortunately he did cross the street. Staff I said when he pulled up to Resident #3 he asked, Resident #3, where are you going? and he said he was going home, he wanted to drink. I was able to get him in my truck and I brought him back. He wasn't hurt or anything, so I brought him back up to his room on the second floor and his nurse, Staff K, RN, and I did an incident report. Staff K, RN wrote what happened, I read it and signed it. I don't know who was told about the incident after that. Staff I said, Resident #3 wasn't gone long, maybe about 5 minutes because as soon as I got in my truck and got on the street I saw him. Review of Resident #3's admission record and physician notes revealed he was a [AGE] year-old admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. A review of Resident #3's care plans revealed he was care planned on 5/28/2019 to have had alteration or potential alteration in mood AEB (as evidenced by) c/o (complaints of) or displays the following: fidgety or restless at times. Resident #3 was also care planned on 5/28/2019 that he was at risk for falls and or fall related injury related to: impaired balance, unsteady gait .is impulsive; attempts to transfer. It was also found through review of Resident #3's care plans dated on 5/28/2019, that he had impaired cognitive function AEB and had impaired decision-making skills. He also had short term, long term memory impairment related to history of alcohol/drug abuse. A review of Resident #3's nursing notes was conducted and found: on 5/16/2019 Resident #3 keeps insisting he needs to go home. Explained to resident that he is here for therapy, but redirection is continuously needed. Also, on 5/16/2019 a different nurse's note revealed Resident #3 was frequently redirected for safety. On 5/21/2019 Resident #3's nurse wrote he was alert with confusion. Continues to try to get out of the chair and the bed without assistance. Also, on 5/21/2019 it is noted by Resident #3's nurse will not stay in chair, attempts to get up and walk alone. Review of the interdisciplinary team note on 5/21/2019 at 7:19 a.m. revealed Resident #3 had a fall. Resident was found in another resident's closet on the ground. Wheelchair outside of room. Further review of Resident #3's medical record found an elopement care plan, created on 6/18/2019 by Staff F, Minimum Data Set (MDS) Coordinator, which revealed Resident #3 had a potential for elopement due to: has cognitive impairment, is exit seeking, is ambulatory, is able to wheel self in w/c (wheelchair), wanders the unit and wanders near exit doors, has a hx (history) of elopement. Goal: resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions included: educate resident/responsible party regarding sign out procedure as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; 1:1's as needed, include resident in elopement Book. Update physician and responsible party if resident elopes. Further review of Resident #3's same elopement care plan revealed on 7/2/2019 (the day the survey started) Staff F revised the care plan to remove has a hx of elopement. An observation and interview were conducted with Resident #3 on 7/2/2019 at 2:40 p.m. Resident #3 was in his room lying in bed on top of his sheets dressed in day clothes watching television. The surveyor knocked on the door to the resident's room and asked for permission to come in. The resident said yes, please come in. Resident #3 was asked, have you ever left this building? The resident responded and said no. Then Resident #3 proceeded to say, My wife lives a couple doors down. Her birthday is tomorrow. She still works but I am the retiree. She's actually my ex-wife. Medical record review revealed on 5/16/2019 a brief interview of mental status (BIMS) was conducted and Resident #3 scored 8 out of 15 indicating moderate cognitive impairment. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 7/2/2019 at 2:43 p.m. Staff G stated she had worked for the facility for almost a year. Staff G was asked if Resident #3 had ever left the building? Staff G said, actually yeah, I think a couple weeks ago he left, and I don't know how he got back but when he came back he had his meal ticket, you know the kind the residents get with their meals here? I have just heard this through other people that this happened so I'm sorry I can't be more help. That's all I know. On 7/2/19 at 2:44 p.m. Staff H, CNA was interviewed, and she stated she had worked at the facility for about a year and a half. Staff H was asked if she was familiar with Resident #3? Staff H stated, I know him. I don't usually work on that hall, but he's asked me a couple times to go down with him to smoke because he needs supervision to go smoke now. Staff H was asked why does he need supervision to smoke now? Staff H said because I think it was 2 or 3 weeks ago someone found him outside. Everyone was looking for him including myself. They announced it over the intercom that Resident #3 was missing. I think Staff I, CNA found him outside. I'm not sure how far away he was. Since then Resident #3 really has been better about asking to go somewhere. During an interview with Staff J, CNA on 7/2/2019 at 3:09 p.m. she said, I have worked here about a year and some change. Staff J was asked, does Resident #3 smoke? Staff J stated, yes he does. The surveyor asked, does he need supervision when he smokes? Staff J said yes, now he does. Staff J was then asked, why does he need supervision now? Staff J responded he wanders. This surveyor asked, what do you mean by wander? Staff J said, he will wander in and out of resident's rooms. Staff J was asked, has Resident #3 ever wandered out of the building? Staff J hesitated, looked away from the surveyor and stated no, not that I know of. Staff J looked back at the surveyor and said I usually work on the 11-7 shift, so this 3-11 shift is new for me. But no, I haven't heard of him leaving. On 7/2/19 at 4:19 p.m. Staff F, MDS Coordinator was asked if Resident #3 had ever eloped from the facility? Staff F said, I was not here but I know we talked about how he was at the front door. I care planned him for elopement on 6/18 so it must've happened the day before or on that day because the 18th was a Tuesday. When Resident #3 first came here he was agitated but he is not as agitated anymore. From what I understood the evening before the 18th he got on the elevator, down to the front lobby, gone to the front door, and was trying to go somewhere. Everyone met about it and then we thought, I guess we should consider him an elopement risk. Staff F was asked if she could explain why on 6/18/2019 Resident #3's care plan stated he had a history of [REDACTED].? Staff F stated, I did not do that. A lot of people have access to changing the care plans. Staff F was asked if she could pull up Resident #3's elopement care plan and click on the H to pull up the care plans history which revealed Staff F created Resident #3's care plan on 6/18/2019 which included has a hx of elopement then on 7/2/2019 the care plan was revised by Staff F and has a hx of elopement was not on the 7/2/2019 elopement care plan anymore. When Staff F was asked if what the elopement care plan history was showing was true she did not answer. Staff F asked the surveyor to close her office door. Staff F then stated, okay, I have a license to maintain and I am going to be very honest with you. I came in on 6/18/2019 and I was told Resident #3 got out of the front door. I was not here when it happened, so I don't know if he was gone for 5 seconds, 5 minutes, or 5 hours, or where he went. But, to me with his BIMS being so low and he got out of the front door, he eloped and something really bad could've happened to that man. Then, I was told Resident #3 did not get out of the front door that he was found on the first floor and that was the story that I was told to stick to. An interview was conducted on 7/2/19 at 5:14 p.m. with the Administrative group which included the Nursing Home Administrator (NHA), Nursing Home Administrator in training, Staff E, Director of Nursing (DON), and Staff D, Assistant Director of Nursing (ADON). The administrative group was asked what do you consider an elopement? The NHA responded, an elopement is someone getting totally off of the property as long as they meet the criteria according to their elopement risk score, which is a low BIMS, 12 and under and a no leave of absence order. If they step off the property and if they were at risk for elopement, we would redo their BIMS, reassess their elopement, place them in the elopement book if they became a risk. We would call the family and try to get them moved to a sister facility or to a different facility. The facility's administrative group was asked how they assess someone on admission for an elopement risk? Staff E, DON said we should use the elopement assessment on admission, with a change in condition, or if someone becomes exit seeking or if they are more confused we should reassess. We also do it quarterly on their comprehensive evaluation. The administrative staff were then asked, if someone did elope what do you do? the NHA stated, we would bring them back on the property, start a four point plan, place the resident on a one to one supervision, start discharge planning, assess the other residents, assess the resident who eloped, notify the doctor, notify the family, and update the care plan. The administrative staff was asked if they would report the elopement? The NHA quickly responded, we haven't had anything happen that was reportable. Staff [NAME] then said, so if we notice someone is gone we would make sure we are secured, all other residents are accounted for, we would search our grounds, and if we could not find them we would reach out to local law enforcement, contact any family to see if they could assist us in finding the resident, contact the physician and we would basically be searching until we found the person. The NHA spoke up and said then we would definitely report it, definitely, 100 percent. Our company believes in over reporting. I'm sure someone has told you that already from all the reports you guys get. We would do an adverse, 5-day, 15-day, all that. The surveyor asked if Resident #3 walked out of the building on the evening of 6/17/2019? The NHA immediately responded, Resident #3 did walk out of the front door, probably, maybe. Staff D, ADON looked at the NHA and quickly stated, no, we found him in the lobby. The nurse reported that to me. All that was reported to me was that he was in the lobby on the 3-11 shift. The surveyor said, looking at Staff D, so you say it was reported to you that he was found in front lobby and you say (the surveyor looked at the NHA,) that he got out of the front door? The NHA then stated, I said he probably, maybe got out of the front door, but it sounds like he was found on the first floor. The surveyor asked Staff D, if they found Resident #3 on the first floor why would the staff report that to you? Staff D said, because he was exit seeking probably a couple weeks ago. It was just reported to me he was found in the lobby, the aide (CNA) brought him back up. Staff D was asked, what aide? Staff D said, actually I don't know if it was an aide, they just brought him back upstairs. Staff K, Registered Nurse (RN) was the nurse who reported it to me, she was Resident #3's nurse that night and Staff L, RN was the second-floor supervisor that night. We reassessed Resident #3 and I believe he is at risk for elopement and his care plan should reflect that. The NHA then stated, after 5:00 p.m. the front doors lock and you need a code in order to get out. We have a receptionist till 7:00 p.m. and she can let people in and out. After 7:00 p.m., the second floor has a camera and a buzzer to let people in and out. The Nursing Home Administrator in training then spoke up and said, to our knowledge he did not get out of the front door. Then, Staff D said, all that was reported to me was Resident #3 was found in the lobby. The surveyor then stated to the administrative team, I have interviews that the resident got out of the building. The NHA, the NHA in training and Staff D all looked at each other then, they all said all they knew was he was found on the first floor. The NHA then asked the surveyor, who told you that? The NHA was told, I cannot give out that information. The NHA said, oh come on, I just want to know I'm not going to do . the NHA did not say anymore. Review of the nurses' daily skilled note created on 6/17/19 at 23:08 (11:08 p.m.) revealed during the start of last rounds it was discovered that Resident #3 was not in his room. He can be exit seeking. We searched the building and located him on the first floor. Further record review was conducted for Resident #3. The record was silent regarding the resident having left the building on the evening of 6/17/2019. A review of Resident #3's nursing notes was conducted and there was no documentation that the physician was notified of Resident #3's elopement. Further review of the facility's nursing notes was conducted and there was no documentation that Resident #3's significant other was contacted about his elopement. A review of the facility's Incident Log for the month of (MONTH) was conducted which revealed no documentation of Resident #3's elopement. Review of the facility's (MONTH) Social Services: Abuse, Neglect, Exploitation Log did not have any documentation related to Resident #3. A phone interview was conducted with Staff K, RN on 7/3/19 at 1:53 p.m. Staff K was asked, Can you tell me if Resident #3 has ever eloped? Staff K said, Yes, a couple weeks ago I don't remember the exact date, but you can look at my note in the chart. Staff K paused before saying, He got out of the building. What happened was, he had been going in and out of other residents' rooms and being disruptive. He was on one to one supervision then they changed him to every 15-minute checks. He had gone to lie down in his room and his aide went to change another resident. So, I peeked in on Resident #3 while he did that. Resident #3 was awake, but he was in his bed. It was about the middle of the 3p.m.-11p.m. shift that I checked on him. When the aide went back in to check Resident #3 he was not in his room, so everyone started looking in rooms because he liked to go into empty beds. When we didn't find him on the second floor we notified the Unit Manager on the third floor and we did a sweep of the third, and first floor. We still could not find him so we did a sweep of the property because he liked to smoke and he could have gone outside to smoke. When he wasn't on the property, Staff I, CNA got in his truck and Staff N, Licensed Practical Nurse (LPN) got in her car to go look for him. They both drove in opposite directions and Staff I, CNA, found him right away. Resident #3 was on the sidewalk across the street from the facility. Staff K said, Fortunately, he was not hurt, he had just gone for a walk. Staff I brought Resident #3 back to the facility. I did a complete check of his skin, his range of motion was all good, I checked to make sure he didn't have any injuries. He was fine, there was no marks or injuries and he was his normal self which is confused but he understands everything that is going on he just doesn't have good safety awareness or make good choices. After I assessed Resident #3, I wrote an incident report, my statement on what happened, then wrote exactly what happened on a daily skilled note. Staff I wrote his statement on what happened then I cosigned Staff I's statement and we both signed the incident report describing what happened. I gave the 3-11 supervisor, who was involved in this whole thing, the incident report and all the statements. He called Staff D, who was the DON at the time, but now she's the ADON, to tell her what happened. The next day when I came in, Staff D called me into her office. Staff K said, Staff D, called me into her office the next day and she had the statement and the incident report describing exactly what happened and she said, we really can't say Resident #3 was found out of the building. We can get in a lot of trouble for that. Staff K said, Then, she made me change my daily note that I wrote that night, saying he was found outside, to say we found him on the first floor. Staff K said, Things in the facility are not good relationship wise in the authority positions. Especially when it comes to doing the right thing. I find it being a threat because if you don't do exactly what they say, you're going to have a problem. Further review of Staff K's Daily Skilled Note dated 6/17/2019, which stated the resident was located on the first floor, revealed the note was created on 6/17/19 at 23:08 (11:08 p.m.) but the note was not locked until 6/18/2019 at 15:31 (3:31 p.m.). A phone interview was conducted with Staff N, Licensed Practical Nurse (LPN) on 7/3/19 at 8:52 p.m. She stated, I was not Resident #3's nurse that night but he did get out of the facility. I don't recall what night it was, but I did get in my car to go find him. Staff I, CNA was the one who found him. When we could not find him in the building Staff I and myself got in our cars and I told him to head South and I will head North on 49th Street. When Staff I brought him back I asked Resident #3 in Spanish, because he speaks English and Spanish, Resident #3, where did you go? He said he went to the bar and that he had 2 beers. I asked him how he paid for the beers and he pulled out his lunch meal ticket, you know the ones that tell you what's on the resident's meal trays. So, then I said to him oh that won't pay for beers and then he told me a couple guys at the bar paid for him. On 7/3/19 at 6:20 p.m. there was a camera observed to be mounted on the outside of the facility building facing the front entry and exit doors of the facility's lobby (photographic evidence obtained). On 7/3/19 at 7:43 p.m. an interview was conducted with the NHA and Staff E, DON. The NHA stated the camera out front does record but the recorded footage does not store as far back as 6/17/2019 or 6/18/2019. The NHA also said the DON was the one who does the incident, accident reporting, but we have not had any to report. The NHA and the DON, were asked if a resident got out, crossed the street would that be something you as a facility would investigate and report? The NHA stated, Yeah, absolutely, definitely. Then he followed it up with as long as I had knowledge about it. A phone interview was conducted with Resident #3's significant other on 7/2/19 at 3:50 p.m. Resident #3's significant other stated she and Resident #3 were never married but they lived together for [AGE] years. She stated she still worked and he lives at the facility because he acts better there. He is confused in the head. Sometimes he will answer me the right way and sometimes he will talk about something that doesn't make any sense to what we are talking about. She stated she lived about 15 minutes away and she visited twice a week. The significant other was asked, has the facility has ever notified you of Resident #3 leaving the building or that he went missing? Resident #3's significant other stated, No, never. I did tell them he could go outside to smoke because he likes to be with that group. On 7/8/2019 at 11:30 a.m. the case manager for Resident #3's physician called back for a phone interview and stated, The facility never called to notify us the resident left the facility. He does not have orders to leave unsupervised. We keep very good records of all of our residents and I am very familiar with Resident #3. There is nothing in his records saying he ever went missing or got out of the building. Review of Resident #3's physician order [REDACTED]. On 7/3/19 at 8:03 p.m. Staff D, ADON, was interviewed. She confirmed that on 6/17/2019 and on 6/18/2019 she was the DON for the facility. She also confirmed if a resident got out of the building and crossed the street during the time she was the DON it would have been her responsibility to report that to the state agency. The surveyor asked Staff D when did you get notified that Resident #3 went missing? Staff D said, I got a call at home and they told me Resident #3 was exit seeking and that he was in the lobby. That was all that was told to me. I don't remember who called me, it might have been the 3-11 supervisor. He called me to say he was missing, maybe around 8 o'clock at night and then they called to say he was downstairs in the lobby. Staff D was asked if she was called twice that night regarding Residents #3? Staff D hesitated then said there was only one phone call and they said they couldn't find him. It was after everything was said and done and they said he was in the lobby. Normally it is not Resident #3's behavior to wander so we did an assessment and put him on the elopement watch list to watch. Staff D was asked, Did you report to the state agency what happened with Resident #3? Staff D said there was nothing to investigate and there was nothing to report. He didn't get out of the building. It was abnormal behavior for him to be exit seeking so we put him on the elopement risk. Then, Staff D contradicted herself and said, His exit seeking isn't to go off the unit. He would always do his activities upstairs and not come off the second floor. Staff D stated she defines exit seeking as Resident #3 coming off of the second floor. Staff D continued to say, what was reported to me was that he was pacing a lot and walking, walking, walking and somehow throughout the night during their rounds they found him on the first floor in the lobby. All the pacing and the walking was reported to me at the same time they called to say he was missing then found in the lobby. He was not on 15-minute checks before I got the call that he went missing, there would be no reason for him be. After he was missing he should have been on 15-minute checks right away that's what I told them to do. In our clinical morning meeting we reevaluated what happened, and he should have had 15-minute checks started right away but it's not documented until the morning of 6/18/2019. Review of Resident #3's 15-minute checks documentation found the 15-minute checks were started on 6/18/2019 at 08:45 a.m. and ended on 6/20/2019 at 23:45 (11:45 p.m.). During the entrance conference with Staff E, DON and the Nursing Home Administrator in training on 7/2/19 at 9:15 a.m. Staff [NAME] said she had been the DON for 5 days and Staff D, ADON was the DON before her. The Nursing Home Administrator in training stated that Staff D stepped down to the ADON position because she needed to gain more experience. Review of the facility's Elopement policy revised (MONTH) 2007 found: Policy statement: Staff shall investigate and report all cases of missing residents. Policy interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observed a resident leaving the premises, he/she should a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Exam the resident for injuries; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident: d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the residents legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record.

Based on interviews with the Nursing Home Administrator, Nursing Home Administrator in training, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident, the resident's family member, attending Physician staff and review of the of the facility's policies and the resident's medical record, the facility failed to fully investigate the departure of Resident #3, who left the facility's premises, one evening, unnoticed. Resident #3 was on of eight sampled residents requiring supervision. The facility failed to provide supervision for Resident #3 who had known wandering behaviors, impaired decision-making skills, short term and long-term memory impairment, a history of falls and impulsive behavior, the resident could be fidgety and restless at times, was exit seeking and wandered the unit. On 6/17/19 the facility staff were unaware the resident had gotten out of bed, left his room located on the second floor of a three-story building, used a key pad secured elevator to go to the first floor of the facility and walked out of the building. The facility failed to ensure the safety of Resident #3 on the evening of 6/17/2019 when he was able to exit the facility, leave the property and cross 6 lanes of traffic. The facility failed to accurately document Resident #3's elopement by falsifying documentation which stated he was found on the first floor when multiple staff members reported the resident was found outside, off the facility's property, down the road, and across 6 lanes of traffic by a traffic light at a busy four-way intersection. The facility's failure to accurately document the location of where Resident #3 eloped and the facility's failure to identify and investigate the lack of supervision of Resident #3 resulted in findings of Immediate Jeopardy on 7/3/2019, which was ongoing. Findings included: Review of Resident #3's admission record and physician notes revealed he was a [AGE] year-old admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. A review of Resident #3's care plans revealed he was care planned on 5/28/2019 to have had alteration or potential alteration in mood AEB (as evidenced by) c/o (complaints of) or displays the following: fidgety or restless at times. Resident #3 was also care planned on 5/28/2019 that he was at risk for falls and or fall related injury related to: impaired balance, unsteady gait .is impulsive; attempts to transfer. It was also found through review of Resident #3's care plans dated on 5/28/2019, that he had impaired cognitive function AEB and had impaired decision-making skills. He also had short term, long term memory impairment related to history of alcohol/drug abuse. During a phone interview with Staff I, Certified Nursing Assistant (CNA) on the morning of 7/3/2019 at 10:30 a.m. Staff I was asked if Resident #3 had ever eloped? Staff I said, Yes, I was the one who found him. I don't remember the exact date, but it was a couple weeks to a month ago. When I found him, he was walking up 49th street. It was about 8 o'clock at night. Resident #3 was on one to one supervision at one point, then, he was on 15 minutes checks. They said something about how corporate said no more one to ones, but he was on 15-minute checks because I think he was a fall risk. I don't remember him ever falling but, he would wander in and out of everyone's rooms. It's just the dementia. There is only so much we can do because of how many people we have to take care of. But anyways, his aide that night (Staff M, CNA) checked on Resident #3 because he was on the 15-minute checks, then asked me to help him change another resident because that resident was being combative. When we were done Staff M went and checked on Resident #3. Then, he came back to me and said, hey! can you help me find Resident #3, he's not in his room. We couldn't find him in any of the other rooms on the second floor, he wasn't in the utility rooms, he was nowhere so we checked on the third floor because he could've got on the elevator with someone because we have people coming on and off our unit all the time, but we couldn't find him on the third floor either, so we told the staff up there and they said, let's check the entire building. We checked on the first floor, we checked outside and still couldn't find him. So, then I said let me get in my truck and look for him. I found him as soon as I got onto 49th street. I saw him walking by the stop light to the left when you are pulling out of the facility's parking lot. He was by the intersection at the light. Staff I was asked if Resident #3 was found on the same side of the road as the facility? Staff said no, unfortunately he did cross the street. Staff I said when he pulled up to Resident #3 he asked, Resident #3, where are you going? and he said he was going home, he wanted to drink. I was able to get him in my truck and I brought him back. He wasn't hurt or anything, so I brought him back up to his room on the second floor and his nurse, Staff K, RN, and I did an incident report. Staff K, RN wrote what happened, I read it and signed it. I don't know who was told about the incident after that. Staff I said, Resident #3 wasn't gone long, maybe about 5 minutes because as soon as I got in my truck and got on the street I saw him. An observation and interview were conducted with Resident #3 on 7/2/2019 at 2:40 p.m. Resident #3 was in his room lying in bed on top of his sheets dressed in day clothes watching television. The surveyor knocked on the door to the resident's room and asked for permission to come in. The resident said yes, please come in. Resident #3 was asked, have you ever left this building? The resident responded and said no. Then Resident #3 proceeded to say, My wife lives a couple doors down. Her birthday is tomorrow. She still works but I am the retiree. She's actually my ex-wife. Medical record review revealed on 5/16/2019 a brief interview of mental status (BIMS) was conducted and Resident #3 scored 8 out of 15 indicating moderate cognitive impairment. A review of Resident #3's nursing notes was conducted and found: on 5/16/2019 Resident #3 keeps insisting he needs to go home. Explained to resident that he is here for therapy, but redirection is continuously needed. Also, on 5/16/2019 a different nurse's note revealed Resident #3 was frequently redirected for safety. On 5/21/2019 Resident #3's nurse wrote he was alert with confusion. Continues to try to get out of the chair and the bed without assistance. Also, on 5/21/2019 it is noted by Resident #3's nurse will not stay in chair, attempts to get up and walk alone. Review of the interdisciplinary team note on 5/21/2019 at 7:19 a.m. revealed Resident #3 had a fall. Resident was found in another resident's closet on the ground. Wheelchair outside of room. A review of a Staff K's daily skilled note dated 6/17/19 at 23:08 (11:08 p.m.) revealed during the start of last rounds it was discovered that Resident #3 was not in his room. He can be exit seeking. We searched the building and located him on the first floor. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 7/2/2019 at 2:43 p.m. Staff G stated she had worked for the facility for almost a year. Staff G was asked if Resident #3 had ever left the building? Staff G said, actually yeah, I think a couple weeks ago he left, and I don't know how he got back but when he came back he had his meal ticket, you know the kind the residents get with their meals here? I have just heard this through other people that this happened so I'm sorry I can't be more help. That's all I know. On 7/2/19 at 2:44 p.m. Staff H, CNA was interviewed, and she stated she had worked at the facility for about a year and a half. Staff H was asked if she was familiar with Resident #3? Staff H stated, I know him. I don't usually work on that hall, but he's asked me a couple times to go down with him to smoke because he needs supervision to go smoke now. Staff H was asked why does he need supervision to smoke now? Staff H said because I think it was 2 or 3 weeks ago someone found him outside. Everyone was looking for him including myself. They announced it over the intercom that Resident #3 was missing. I think Staff I, CNA found him outside. I'm not sure how far away he was. Since then Resident #3 really has been better about asking to go somewhere. During an interview with Staff J, CNA on 7/2/2019 at 3:09 p.m. she said, I have worked here about a year and some change. Staff J was asked, does Resident #3 smoke? Staff J stated, yes he does. The surveyor asked, does he need supervision when he smokes? Staff J said yes, now he does. Staff J was then asked, why does he need supervision now? Staff J responded he wanders. This surveyor asked, what do you mean by wander? Staff J said, he will wander in and out of resident's rooms. Staff J was asked, has Resident #3 ever wandered out of the building? Staff J hesitated, looked away from the surveyor and stated no, not that I know of. Staff J looked back at the surveyor and said I usually work on the 11-7 shift, so this 3-11 shift is new for me. But no, I haven't heard of him leaving. A phone interview was conducted with Staff N, Licensed Practical Nurse (LPN) on 7/3/19 at 8:52 p.m. She stated, I was not Resident #3's nurse that night but he did get out of the facility. I don't recall what night it was, but I did get in my car to go find him. Staff I, CNA was the one who found him. When we could not find him in the building Staff I and myself got in our cars and I told him to head South and I will head North on 49th Street. When Staff I brought him back I asked Resident #3 in Spanish, because he speaks English and Spanish, Resident #3, where did you go? He said he went to the bar and that he had 2 beers. I asked him how he paid for the beers and he pulled out his lunch meal ticket, you know the ones that tell you what's on the resident's meal trays. So, then I said to him oh that won't pay for beers and then he told me a couple guys at the bar paid for him. Further review of Resident #3's medical record found an elopement care plan, created on 6/18/2019 by Staff F, Minimum Data Set (MDS) Coordinator, which revealed Resident #3 had a potential for elopement due to: has cognitive impairment, is exit seeking, is ambulatory, is able to wheel self in w/c (wheelchair), wanders the unit and wanders near exit doors, has a hx (history) of elopement. Goal: resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions included: educate resident/responsible party regarding sign out procedure as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; 1:1's as needed, include resident in elopement Book. Update physician and responsible party if resident elopes. Further review of Resident #3's same elopement care plan revealed on 7/2/2019 (the day the survey started) Staff F revised the care plan to remove has a hx of elopement. On 7/2/19 at 4:19 p.m. Staff F, MDS Coordinator was asked if Resident #3 had ever eloped from the facility? Staff F said, I was not here but I know we talked about how he was at the front door. I care planned him for elopement on 6/18 so it must've happened the day before or on that day because the 18th was a Tuesday. When Resident #3 first came here he was agitated but he is not as agitated anymore. From what I understood the evening before the 18th he got on the elevator, down to the front lobby, gone to the front door, and was trying to go somewhere. Everyone met about it and then we thought, I guess we should consider him an elopement risk. Staff F was asked if she could explain why on 6/18/2019 Resident #3's care plan stated he had a history of [REDACTED].? Staff F stated, I did not do that. A lot of people have access to changing the care plans. Staff F was asked if she could pull up Resident #3's elopement care plan and click on the H to pull up the care plans history which revealed Staff F created Resident #3's care plan on 6/18/2019 which included has a hx of elopement then on 7/2/2019 the care plan was revised by Staff F and has a hx of elopement was not on the 7/2/2019 elopement care plan anymore. When Staff F was asked if what the elopement care plan history was showing was true she did not answer. Staff F then asked the surveyor to close her office door. Staff F then stated, okay, I have a license to maintain and I am going to be very honest with you. I came in on 6/18/2019 and I was told Resident #3 got out of the front door. I was not here when it happened, so I don't know if he was gone for 5 seconds, 5 minutes, or 5 hours, or where he went. But, to me with his BIMS being so low and he got out of the front door, he eloped and something really bad could've happened to that man. Then, I was told Resident #3 did not get out of the front door that he was found on the first floor and that was the story that I was told to stick to. They will tell you he didn't get out, but he did and they all know it. An interview was conducted on 7/2/19 at 5:14 p.m. with the Administrative group which included the Nursing Home Administrator (NHA), Nursing Home Administrator in training, Staff E, Director of Nursing (DON), and Staff D, Assistant Director of Nursing (ADON). The administrative group was asked what do you consider an elopement? The NHA responded, an elopement is someone getting totally off of the property as long as they meet the criteria according to their elopement risk score. which is a low BIMS, 12 and under and a no leave of absence order. If they step off the property and if they were at risk for elopement, we would redo their BIMS, reassess their elopement, place them in the elopement book if they became a risk. We would call the family and try to get them moved to a sister facility or to a different facility. The facility's administrative group was asked how they assess someone on admission for an elopement risk? Staff E, DON said we should use the elopement assessment on admission, with a change in condition, or if someone becomes exit seeking or if they are more confused we should reassess. We also do it quarterly on their comprehensive evaluation. The administrative staff were then asked, if someone did elope what do you do? the NHA stated, we would bring them back on the property, start a four point plan, place the resident on a one to one supervision, start discharge planning, assess the other residents, assess the resident who eloped, notify the doctor, notify the family, and update the care plan. The administrative staff was asked if they would report the elopement? The NHA quickly responded, we haven't had anything happen that was reportable. Staff [NAME] then said, so if we notice someone is gone we would make sure we are secured, all other residents are accounted for, we would search our grounds, and if we could not find them we would reach out to local law enforcement, contact any family to see if they could assist us in finding the resident, contact the physician and we would basically be searching until we found the person. The NHA spoke up and said then we would definitely report it, definitely, 100 percent. Our company believes in over reporting. I'm sure someone has told you that already from all the reports you guys get. We would do an adverse, 5-day, 15-day, all that. The surveyor asked if Resident #3 walked out of the building on the evening of 6/17/2019? The NHA immediately responded, Resident #3 did walk out of the front door, probably, maybe. Staff D, ADON looked at the NHA and quickly stated, no, we found him in the lobby. The nurse reported that to me. All that was reported to me was that he was in the lobby on the 3-11 shift. The surveyor said, looking at Staff D, so you say it was reported to you that he was found in front lobby and you say (the surveyor looked at the NHA,) that he got out of the front door? The NHA then stated, I said he probably, maybe got out of the front door, but it sounds like he was found on the first floor. The surveyor asked Staff D, if they found Resident#3 on the first floor why would the staff report that to you? Staff D said, because he was exit seeking probably a couple weeks ago. It was just reported to me he was found in the lobby, the aide (CNA) brought him back up. Staff D was asked, what aide? Staff D stumbled over her words as she said, actually I don't know if it was an aide, they just brought him back upstairs. Staff K, Registered Nurse (RN) was the nurse who reported it to me, she was Resident #3's nurse that night and Staff L, RN was the second-floor supervisor that night. We reassessed Resident #3 and I believe he is at risk for elopement and his care plan should reflect that. The NHA then stated, After 5:00 p.m. the front doors lock and you need a code in order to get out. We have a receptionist till 7:00 p.m. and she can let people in and out. After 7:00 p.m., the second floor has a camera and a buzzer to let people in and out. The Nursing Home Administrator in training then spoke up and said, to our knowledge he did not get out of the front door. Then, Staff D said, all that was reported to me was Resident #3 was found in the lobby. The surveyor then stated to the administrative team, I have interviews that the resident got out of the building. The NHA, the NHA in training and Staff D all looked at each other then, they all said all they knew was he was found on the first floor. The NHA then asked the surveyor, who told you that? The NHA was told, I cannot give out that information. The NHA said, oh come on, I just want to know I'm not going to do . the NHA did not say anymore. Further record review was conducted for Resident #3. The record was silent regarding the resident having left the building on the evening of 6/17/2019. A review of Resident #3's nursing notes was conducted and there was no documentation that the physician was notified of Resident #3's elopement. Further review of the facility's nursing notes was conducted and there was no documentation that Resident #3's significant other was contacted about his elopement. A review of the facility's Incident Log for the month of (MONTH) was conducted which revealed no documentation of Resident #3's elopement. Review of the facility's (MONTH) Social Services: Abuse, Neglect, Exploitation Log did not have any documentation related to Resident #3. On 7/2/19 at 1:04 p.m. an interview was conducted with the Nursing Home Administrator in training. She stated we do not have any residents with wander guards on, we are not licensed to have a wander guard system and we're not licensed for a secure unit. We do have the key pad on the second floor to get on the elevator. The key pad is just there as an extra safety measure. On 7/3/19 at 6:20 p.m. there was a camera observed to be mounted on the outside of the facility building facing the front entry and exit doors of the facility's lobby (photographic evidence obtained). On 7/3/19 at 7:43 p.m. an interview was conducted with the NHA and Staff E, DON. The NHA stated the camera out front does record but the recorded footage does not store as far back as 6/17/2019 or 6/18/2019. The NHA also said the DON was the one who does the incident, accident reporting, but we have not had any to report. The NHA and the DON, were asked if a resident got out, crossed the street would that be something you as a facility would investigate and report? The NHA stated, Yeah, absolutely, definitely. Then he took a long pause and followed it up with as long as I had knowledge about it. A phone interview was conducted with Resident #3's significant other on 7/2/19 at 3:50 p.m. Resident #3's significant other stated she and Resident #3 were never married but they lived together for [AGE] years. She stated she still worked and he lives at the facility because he acts better there. He is confused in the head. Sometimes he will answer me the right way and sometimes he will talk about something that doesn't make any sense to what we are talking about. She stated she lived about 15 minutes away and she visited twice a week. The significant other was asked, has the facility has ever notified you of Resident #3 leaving the building or that he went missing? Resident #3's significant other stated, No, never. I did tell them he could go outside to smoke because he likes to be with that group. A phone interview was conducted with Staff K, RN on 7/3/19 at 1:53 p.m. Staff K was asked, can you tell me if Resident #3 has ever eloped? Staff K said, Yes, a couple weeks ago I don't remember the exact date, but you can look at my note in the chart. Staff K paused before saying, He got out of the building. What happened was, he had been going in and out of other residents' rooms and being disruptive. He was on one to one supervision then they changed him to every 15-minute checks. He had gone to lie down in his room and his aide went to change another resident. So, I peeked in on Resident #3 while he did that. Resident #3 was awake, but he was in his bed. It was about the middle of the 3p.m.-11p.m. shift that I checked on him. When the aide went back in to check Resident #3 he was not in his room, so everyone started looking in rooms because he liked to go into empty beds. When we didn't find him on the second floor we notified the Unit Manager on the third floor and we did a sweep of the third, and first floor. We still could not find him, so we did a sweep of the property because he liked to smoke and he could have gone outside to smoke. When he wasn't on the property, Staff I, CNA got in his truck and Staff N, Licensed Practical Nurse (LPN) got in her car to go look for him. They both drove in opposite directions and Staff I, CNA, found him right away. Resident #3 was on the sidewalk across the street from the facility. Staff K said Fortunately, he was not hurt, he had just gone for a walk. Staff I brought Resident #3 back to the facility. I did a complete check of his skin, his range of motion was all good, I checked to make sure he didn't have any injuries. He was fine, there was no marks or injuries and he was his normal self which is confused but he understands everything that is going on he just doesn't have good safety awareness or make good choices. After I assessed Resident #3, I wrote an incident report, my statement on what happened, then wrote exactly what happened on a daily skilled note. Staff I wrote his statement on what happened then I cosigned Staff I's statement and we both signed the incident report describing what happened. I gave the 3-11 supervisor, who was involved in this whole thing, the incident report and all the statements. He called Staff D, who was the DON at the time, but now she's the ADON, to tell her what happened. The next day when I came in Staff D called me into her office. Staff K said, Staff D, called me into her office the next day and she had the statement and the incident report describing exactly what happened and she said, we really can't say Resident #3 was found out of the building. We can get in a lot of trouble for that. Staff K said, Then, she made me change my daily note that I wrote that night, saying he was found outside, to say we found him on the first floor. Staff K said, things in the facility are not good relationship wise in the authority positions. Especially when it comes to doing the right thing. I find it being a threat because if you don't do exactly what they say, you're going to have a problem. Further review of Staff K's Daily Skilled Note dated 6/17/2019, which stated the resident was located on the first floor, revealed the note was created on 6/17/19 at 23:08 (11:08 p.m.) but the note was not locked until 6/18/2019 at 15:31 (3:31 p.m.). On 7/8/2019 at 11:30 a.m. the case manager for Resident #3's physician participated in a phone interview and stated, The facility never called to notify us the resident left the facility. He does not have orders to leave unsupervised. We keep very good records of all of our residents and I am very familiar with Resident #3. There is nothing in his records saying he ever went missing or got out of the building. Review of Resident #3's physician order [REDACTED]. On 7/3/19 at 8:03 p.m. Staff D, ADON, was interviewed. She confirmed that on 6/17/2019 and on 6/18/2019 she was the DON for the facility. She also confirmed if a resident got out of the building and crossed the street during the time she was the DON it would have been her responsibility to report that to the state agency. The surveyor asked Staff D when did you get notified that Resident #3 went missing? Staff D said, I got a call at home and they told me Resident #3 was exit seeking and that he was in the lobby. That was all that was told to me. I don't remember who called me, it might have been the 3-11 supervisor. He called me to say he was missing, maybe around 8 o'clock at night and then they called to say he was downstairs in the lobby. Staff D was asked if she was called twice that night regarding Residents #3? Staff D hesitated then said there was only one phone call and they said they couldn't find him. It was after everything was said and done and they said he was in the lobby. Normally it is not Resident #3's behavior to wander so we did an assessment and put him on the elopement watch list to watch. Staff D was asked, Did you report to the state agency what happened with Resident #3? Staff D said there was nothing to investigate and there was nothing to report. He didn't get out of the building. It was abnormal behavior for him to be exit seeking so we put him on the elopement risk. Then, Staff D contradicted herself and said, His exit seeking isn't to go off the unit. He would always do his activities upstairs and not come off the second floor. Staff D stated she defines exit seeking as Resident #3 coming off of the second floor. Staff D continued to say, what was reported to me was that he was pacing a lot and walking, walking, walking and somehow throughout the night during their rounds they found him on the first floor in the lobby. All the pacing and the walking was reported to me at the same time they called to say he was missing then found in the lobby. He was not on 15-minute checks before I got the call that he went missing, there would be no reason for him be. After he was missing he should have been on 15-minute checks right away that's what I told them to do. In our clinical morning meeting we reevaluated what happened, and he should have had 15-minute checks started right away but it's not documented until the morning of 6/18/2019. Review of Resident #3's 15-minute checks documentation found the 15-minute checks were started on 6/18/2019 at 08:45 a.m. and ended on 6/20/2019 at 23:45 (11:45 p.m.). During the entrance conference with Staff E, DON and the Nursing Home Administrator in training on 7/2/19 at 9:15 a.m. Staff [NAME] said she had been the DON for 5 days and Staff D, ADON was the DON before her. The Nursing Home Administrator in training stated that Staff D stepped down to the ADON position because she needed to gain more experience. Review of the facility's Elopement policy revised (MONTH) 2007 found: Policy statement: Staff shall investigate and report all cases of missing residents. Policy interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observed a resident leaving the premises, he/she should a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Exam the resident for injuries; b. Notify the attending physician; c. Notify the resident's legal representative (sponsor) of the incident: d. Complete and file Report of Incident/Accident; and e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the residents legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. The Care Center at Pinellas Park Review of the facilities Abuse, Neglect, and Exploitation: Prevention and Prohibition policy, that was not dated, revealed: Standard: The prevention and prohibition of abuse neglect and exploitation. To create an environment within the facility which promotes resident well-being, safety, and prohibits abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. .7. Neglect: neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. .Patients with needs and behaviors which might lead to conflict with staff or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict. Any patients identified as having behaviors which might lead to conflict or neglect, such as .b. patients who enter other resident's rooms while wandering, The interventions designed to meet the needs of such patients will include but will not be limited to: a. Identification of patients who personal histories render them at risk for abusing other patients or staff, b. Assessment of appropriate intervention strategies to prevent occurrences, c. Monitoring the patient for any changes that would trigger abusive behavior reassessment of the protective strategies on a regular basis. Investigation: The Social Services Director is the facility appointed abuse designee who is the staff member responsible for the initial reporting, investigation of alleged violations and reporting results to the proper authorities. The facility policy for any allegation of abuse is for it to be brought immediately to the attention of the immediate supervisor. The supervisor is to notify the Social Services Director, who is the facility appointed designee, the Administrator, and the D.O.N The facility will take immediate action to investigate and stop the alleged abuse if against a person (the facility will take action to prevent the abuse if against a person's property). The facility will also notify the appropriate agencies, based on the nature of the allegation in accordance with State and Federal

Based on clinical record review and staff, physician and family interview, the facility failed to ensure physician services were provided on a 24 hour basis in the event of an emergency for one of three sampled residents for accidents (#87). Resident #87 sustained a fall with a fracture on 4/29/2014 at approximately 10:40 p.m. X-rays were completed with results received at approximately 2:00 a.m. according to fax documentation. The physician was not contacted until at least 8:30 a.m. the following day to notify him of the fracture and receive orders to send the resident to the emergency room . Findings include: Telephone interview with Licensed Practical Nurse (LPN F) on 5/14/2014 at 3:11 p.m. revealed that on the night of 4/29/2014 one of the CNA's complained about a broken call light in another resident's room so he went to fix it and when coming back up the hall, he saw Resident #87 in a squatting position trying to turn his television off. LPN F stated Resident #87 just fell over backwards. He fell underneath one of the rolling bedside tables and he knocked the TV off the table as he fell . LPN F stated he called for help and caught the TV before it fell on the resident. LPN F stated the resident landed in a sitting position leaning on his left or right hip; "He hit that metal bar under the table so hard." LPN F did not hear an alarm sounding when he entered the room but stated the resident was "notorious for taking it off." LPN F did not know what type of alarm Resident #87 had. He was not sure if it was a sensor pad or a string alarm. LPN F stated that he was not assigned to the resident that night and was just passing by the room when this occurred. He stated LPN H, the resident's assigned nurse, came in to help and "we decided we needed to get x-rays," but LPN H handled all of that. Interview with Licensed Practical Nurse (LPN) H on 5/14/2014 at 3:36 p.m. revealed this nurse was assigned to Resident #87 on 4/29/2014, the night he sustained a fall resulting in a right [MEDICAL CONDITION]. Interview with LPN H revealed the fall was witnessed by LPN F. However, since Resident #87 was his patient, he was called to the room for assistance. LPN H stated around 10:40 p.m. on 4/29/2014 he heard a loud crash and when he arrived in the room LPN F was already there. LPN F had told LPN H that he was making rounds and saw Resident #87 out of his bed and walking around in his room. According to LPN H, LPN F was trying to assist the resident back to bed and the resident fell to the floor. LPN H stated there was no obvious injury at the initial time of the fall, however, once he and LPN F got the resident back in bed, the resident complained of pain. We put the alarm back on him and LPN F stayed with the resident while he called the doctor to request orders for an x-ray due to a fall with pain. LPN H stated he also called the resident's wife and informed her they were asking for an x-ray as a precautionary measure. LPN H stated he reported the event to the next nurse on duty (LPN G) who gave the resident his scheduled pain medication at midnight. LPN H stated the alarm was not going off when he entered the room that night. He stated Resident #87 has a history of taking the alarm off. It was a standard clip alarm, the portable type that is clipped to the back of his shirt collar. The Certified Nursing Assistant (CNA E) had checked on him and changed the resident about an hour prior to the fall and had put the alarm back in place. That night, LPN H stated he spoke to the on-call doctor and received an order to go ahead and get an X-ray but not to call back with the results. LPN H stated I wrote a telephone order stating the doctor did not want to be called back. She didn't want a call back that late at night. It was a female doctor and LPN H was unsure of her name. LPN H stated mobile x-ray had not arrived prior to him leaving that night. Attempts were made by telephone on 5/14/2014 at 3:30 p.m., 7:00 p.m. and 7:39 p.m. to reach LPN G, the assigned nurse to Resident #87 on 4/29/2014 from 11:00 p.m. -7:00 a.m.. No answer was received and the voicemail mailbox was full. A fourth attempt was made on 5/14/2014 at 9:05 p.m. A male answered the call and and stated this was not the correct number for LPN G. Administration was informed of this in the morning of 5/15/2014 and did not have another number on file for this employee. Interview with LPN C on 5/15/2014 at 11:22 a.m. revealed she was the 7:00 a.m. - 3:00 p.m. nurse on 4/30/2014 who contacted the physician with the positive x-ray results of a [MEDICAL CONDITION]. LPN C recalled her conversation with the physician and remembered telling him she needed an order to send Resident #87 to the hospital because he had a fracture of his hip. The nurse stated the doctor commented to her "so he could have surgery done? I said no, his wife did not want surgery due to religious beliefs and not wanting blood or blood products. The doctor said why are we sending him to the hospital because they are going to want to do surgery? I said maybe they could splint him or do something else. The doctor said usually they don't do that and 90% of the time they want to do surgery. The doctor did eventually say yes, you can go ahead and send him. At that point, I called the wife to update her and let her know we were going to send him out. The wife said, I don't want him to have surgery. The nurse informed the wife that perhaps the hospital could do something to make him more comfortable. The wife said she was on her way in and when she arrived, LPN C didn't really talk much to her as EMS (emergency medical services) was in the resident's room and talking to her. LPN C stated she thought she spoke to the physician around 8:30 a.m. - 9:00 a.m. on 4/30/2014 to get the order to send the resident out and inform the doctor of the x-ray results. LPN C said she knew it was after breakfast because they held his breakfast tray. LPN C said she thought the resident left the facility around 9:30 a.m. on 4/30/2014 to the hospital. LPN C stated she observed Resident #87 the morning of 4/30/2014 and he appeared to be in some pain (facial grimacing but not crying or calling out). He was receiving routine [MEDICATION NAME] and probably had received a dose at 6:00 a.m. so he appeared to be comfortable at that time. He was awake but not very talkative. Resident #87 was normally talkative with LPN C, however, over the last couple of weeks it was less so because his dementia was progressing rapidly towards the end. Telephone interview with Resident #87's primary care physician on 5/15/2014 at 9:58 a.m. revealed he remembered Resident #87 well. The physician stated "Our policy is to call back no matter what." They are to call all studies in, but it is at the nurse's discretion to call back normal results in the morning. If it's abnormal we want to get the resident moved to the emergency room as soon as possible. If it is abnormal they are to call us. The physician did not know who was on call the night of 4/29/2014 and stated he did not know if that was a true statement that they did not want to be called back. The physician stated Resident #87 has been on and off of palliative care, but he would still want to send the resident out immediately to the emergency room for evaluation. Telephone interview with the Medical Director on 5/15/2014 at 9:13 a.m. revealed he did not recall being told about Resident #87's fracture on the night of 4/29/2014. He was unaware that the on-call physician had told the nurse not to call back that night and to wait until the following morning to call the primary care physician. The Medical Director stated that if the staff are having trouble reaching a doctor he would be more than happy to contact that doctor and discuss it. The Medical Director stated that because the x-ray was positive for a fracture waiting until the following morning to call the doctor back would depend on several factors to include the condition of the patient, if the patient was in significant pain that could not be controlled on current pain medications, if it was an open fracture or potentially dangerous, and if the family indicated they wanted hospitalization or treatment. The Medical Director stated "They could have called me. Anytime they are not able to reach a physician they can call me." However, he did not recall this event or having received a call about it. Interview with the Director of Nursing (DON) on 5/14/2014 at 2:46 p.m. in the presence of the nursing home administrator (NHA) revealed she conducted an investigation into Resident #87's fall on 4/29/2014 and she found that LPN F walked by Resident #87's room that night and saw him walking around. The DON stated the resident would take his alarms off his shirt and no alarm was sounding at the time he was seen. According to the DON's investigation, LPN F was attempting to take Resident #87 back to bed and in doing so, the LPN and the resident got caught up between the bed and the air conditioning unit and the resident fell . The DON stated the resident was last changed at 9:30 p.m. prior to the fall. The DON stated the resident wore a personal alarm, the kind that clips on him. She did not recall this resident having a sensor pad and stated he had only fallen one time before that so she thought he had a personal alarm and not a sensor pad. The DON stated LPN H was assigned to Resident #87 on the night of 4/29/2014. LPN H called the doctor that night and received an order for [REDACTED]. The DON stated the resident's wife who was his responsible party, did not want him to go to the hospital. The wife wanted the resident to go on hospice because she didn't want him to have surgery. In addition, the order said to follow up with the PCP in the morning. The DON stated normally we would call the doctor with the results, but he was not called in this case because the doctor said to wait for the morning. The DON stated they could have called the medical director, but this was not done. The DON recalled telling LPN G she needed to call the doctor as soon as possible. The DON thought they were holding back on calling the doctor because the wife didn't want anything done. The DON stated at 6:45 a.m. on 4/30/2014 LPN G called the wife to inform her of what was going on and the wife was very pleased. In addition, the DON stated she spoke to the resident's wife on the telephone the morning of 4/30/2014 and she was still reluctant to have him go to the hospital. The DON stated the resident's wife was the hold out on sending the resident to the hospital. The DON stated she informed the wife that maybe the hip could be stabilized and maybe they wouldn't have to do surgery. Meanwhile, the nurse was medicating him for pain and he was comfortable. The DON stated I had to talk the wife into letting him go to the hospital. The DON stated she did not document these conversations in the resident's record and stated she probably should have made a late entry. Telephone interview on 5/14/2014 at 9:06 p.m. with Resident #87's spouse revealed she never told the facility she did not want her husband hospitalized . She stated he was on palliative care which meant to keep him comfortable, but as far as hospitalization goes this was considered on a case by case basis. She did not recall ever telling the facility she did not want the resident to have surgery, but as it turned out he was not a good candidate for the hip surgery due to his other health problems. She stated she never received a call from the DON trying to convince her to have him hospitalized . The resident's wife stated she was present at the facility when he was sent out the morning of 4/30/20 and followed the ambulance to the hospital. She stated the only reason her husband wasn't sent to the hospital sooner was because the doctor said he did not want to be bothered that night and to wait until the morning to follow up about the x-ray. She was just waiting for the facility and the doctor to tell her what to do next. The resident's wife stated she had told the facility prior to this fall that the alarm he had was not adequate. She stated it was not loud enough. The resident's spouse stated LPN C had told her that if she wanted a sensor pad alarm or a different type of alarm she would need to pay for it. She stated she asked LPN C how much it would be and she never gave her an answer or got back to her about this. Review of Resident #87's clinical record revealed an Admission Record Face Sheet documenting that this was an [AGE] year old male resident who was originally admitted to the facility on [DATE]. Review of the accumulative [DIAGNOSES REDACTED]. Review of the nurses notes revealed the following relevant entries: 4/29/2014 2:00 p.m. Certified Nursing Assistant (CNA) attempted to give care to resident. Resident resistant and combative, yelling and cursing, elbowing CNA in chest. Doctor in facility at time and changed order for resident. Give stat dose of [MEDICATION NAME] 5 mg intramuscularly (IM) one time, increase [MEDICATION NAME] to 0.5 mg by mouth every 12 hours and increase [MEDICATION NAME] to 0.5 every morning and 0.25 mg at 2:00 p.m. and 10:00 p.m. Stat dose of [MEDICATION NAME] given. Resident is resting in room at this time. 4/29/2014 3:15 p.m. call placed to ARNP related to family request for Hospice to evaluate patient, awaiting return call. 4/29/2014 3:20 p.m. New Order: Okay for Hospice to evaluate patient. 4/29/2014 10:40 p.m. Patient fell to the floor while attempting to walk around in his room, patient removed chair alarm. Complains of right hip pain. Will continue to monitor, no injury noted at this time. Signed by Licensed Practical Nurse H. 4/29/2014 10:45 p.m. Call placed to wife to make aware of fall. Signed by Licensed Practical Nurse (LPN) H. 4/29/2014 10:55 p.m. Call placed to Doctor on call - New Order OK for x-ray right hip, please call results to provider in a.m. Signed by LPN H. 4/29/2014 10:55 p.m. Call placed to mobile x-ray. Awaiting technician for x-ray. Signed by LPN H. 4/29/2014 11:00 p.m. 3:00 p.m. -11:00 p.m. Nurse gave me in report resident had fallen, He called the on call doctor. Orders were given to get x-ray of right hip, call primary care physician (PCP) in the morning with results. Signed by LPN G. 4/29/2014 11:30 p.m. Wife called to ask how husband was doing, writer told her what the nurse had given her in report about Doctor. said to call PCP with results, in a.m. "Wife stated to writer I do not want him to have surgery" "I would like him to have hospice if he goes to hospital." Signed by LPN G. 4/30/2014 12:00 a.m. Temperature 98.1, Respirations 16, Pulse 72, Blood Pressure 120/64 Medicated for pain. Resting quietly eyes closed, will continue to monitor. Signed by LPN G. 4/30/2014 6:45 a.m. Writer called wife back to let her know how her husband slept during the night. Wife stated to writer "She was quite pleased how everything was handle." Signed by LPN G. 4/29/2014 Late entry for 10:20 p.m. observed resident falling in his room in a sitting position partially on top of base of beside table. Called for help and assessed and assisted back to bed. Signed by LPN F. Review of the physician telephone orders revealed the following relevant information: 4/29/2014 X-ray right hip dx: pain call PCP (primary care physician) in a.m. with results (no time noted on the order) 4/30/2014 Send resident to hospital emergency room for evaluation (no time noted on the order) Review of the Resident Transfer Form dated 4/30/2014 revealed the reason for transfer was [MEDICAL CONDITION] hip. This transfer paperwork contained no time of the transfer. Review of the resident's hospital record revealed the following relevant information: Emergency Department Rapid Triage was performed at 10:14 a.m. on 4/30/2014. Review of the chief complaint on the emergency department triage report revealed "According to EMS, patient fell about 12 hours ago, received x-ray of hip + fracture, patient complains of right hip pain."

Based on staff and family interview and clinical record review, the facility failed to provide the necessary supervision and effective and appropriate assistive devices to prevent falls for one of three sampled residents (Resident #87). Resident #87 sustained a fall in the facility resulting in a hip fracture and hospitalization . Findings include: Review of Resident #87's clinical record revealed an Admission Record Face Sheet documenting that this was an [AGE] year old male resident who was originally admitted to the facility on [DATE]. Review of the accumulative [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with an assessment reference date of 4/30/2014 revealed the resident had a short term memory problem and was moderately impaired for daily decision making. In addition, the resident required extensive assistance with bed mobility, transfers, walking in room, walking in corridor, dressing, toilet use, and personal hygiene. He was also frequently incontinent of bladder and bowel and had additional relevant [DIAGNOSES REDACTED]. The MDS documented that this resident had experienced one major fall since the last MDS assessment and he had received antipsychotic and antidepressant medication 7 days during the last 7 days and received anti-anxiety medication 6 days during the last 7 days. Review of the MDS prior to this 4/30/2014 assessment revealed this was a quarterly assessment with an assessment reference date of 4/18/2014. This assessment documented the resident as having 2 falls since the prior assessment with no injuries. Review of the quarterly nursing information which included a fall risk evaluation completed 1/15/2014 and 4/14/2014 revealed the resident had a fall risk score of 16 (a resident who scores a 10 or higher is at risk). Review of the care plans revealed the following relevant information: Problem: 2/27/2013 Alteration in mobility with risk for changes, falls: weakness related to current Diagnosis: [REDACTED]. 2/5/2014 continue plan of care 3/21/2014 status [REDACTED]. 4/6/2014 status [REDACTED]. 4/21/2014 status [REDACTED]. 4/22/2014 continue plan of care Goal: Resident will not sustain a fall related injury by utilizing fall precautions through next review. Approach: Use fall risk screen to identify risk factors on admission and quarterly Remind resident when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. Educate/remind resident to request assistance prior to ambulation and/or transfers. Staff to assist with ambulation and/or locomotion as needed. Refer to therapy as needed. Provide call light within reach. Pharmacy consultant and/or physician to review medication usage for possible reductions. Provide/monitor use of adaptive devices. Give cues as needed: Uses walker and w/c for locomotion. Psych to evaluate and treat. Wheelchair for mobility as needed. Sensor alarm while in bed and wheelchair - check for placement and functioning. Review of the nurses notes revealed the following relevant entries: 3/21/2014 SBAR (Situation Background Assessment and Request) Writer heard resident yell and then a large sound coming from room 212. Staff noted that resident was sitting on his butt holding on to the side of the bed moaning. Resident was assessed by writer helped back up into his bed. Medium size area noted to resident's back. Spoke with Advanced Registered Nurse Practitioner (ARNP) for doctor. Doctor stated to continue to monitor resident. Call light remains in reach and will continue to monitor for changes. Wife notified on 3/21/14 at 1:45 a.m. and Doctor/ARNP notified at 1:52 a.m. 4/6/2014 2:00 p.m. Loud bang heard from resident's room. Upon entry resident observed lying on his back on floor in front of dresser. Resident assessed. No bumps, abrasions or bruises noted. Positive range of motion (ROM) all four extremities. Neuro assessment initiated. All parties notified. 4/29/2014 2:00 p.m. Certified Nursing Assistant (CNA) attempted to give care to resident. Resident resistant and combative, yelling and cursing, elbowing CNA in chest. Doctor in facility at time and changed order for resident. Give stat dose of Haldol 5 mg intramuscularly (IM) one time, increase Risperidone to 0.5 mg by mouth every 12 hours and increase Xanax to 0.5 every morning and 0.25 mg at 2:00 p.m. and 10:00 p.m. Stat dose of Haldol given. Resident is resting in room at this time. 4/29/2014 3:15 p.m. call placed to ARNP related to family request for Hospice to evaluate patient, awaiting return call. 4/29/2014 3:20 p.m. New Order: Okay for Hospice to evaluate patient. 4/29/2014 10:40 p.m. Patient fell to the floor while attempting to walk around in his room, patient removed chair alarm. Complains of right hip pain. Will continue to monitor, no injury noted at this time. Signed by Licensed Practical Nurse H. 4/29/2014 10:45 p.m. Call placed to wife to make aware of fall. Signed by Licensed Practical Nurse (LPN) H. 4/29/2014 10:55 p.m. Call placed to Doctor on call - New Order OK for x-ray right hip, please call results to provider in a.m. Signed by LPN H. 4/29/2014 10:55 p.m. Call placed to mobile x-ray. Awaiting technician for x-ray. Signed by LPN H. 4/29/2014 11:00 p.m. 3:00 p.m. -11:00 p.m. Nurse gave me in report resident had fallen, He called the on call doctor. Orders were given to get x-ray of right hip, call primary care physician (PCP) in the morning with results. Signed by LPN G. 4/29/2014 11:30 p.m. Wife called to ask how husband was doing, writer told her what the nurse had given her in report about Doctor. said to call PCP with results, in a.m. "Wife stated to writer I do not want him to have surgery" "I would like him to have hospice if he goes to hospital." Signed by LPN G. 4/30/2014 12:00 a.m. Temperature 98.1, Respirations 16, Pulse 72, Blood Pressure 120/64 Medicated for pain. Resting quietly eyes closed, will continue to monitor. Signed by LPN G. 4/30/2014 6:45 a.m. Writer called wife back to let her know how her husband slept during the night. Wife stated to writer "She was quite pleased how everything was handle." Signed by LPN G. 4/29/2014 Late entry for 10:20 p.m. observed resident falling in his room in a sitting position partially on top of base of beside table. Called for help and assessed and assisted back to bed. Signed by LPN F. Review of the x-ray report revealed the following: Radiology Report: DATE OF SERVICE: 4/29/2014 Electronically signed by radiologist on 4/30/2014 at 12:28 a.m. (fax time 4/30/2014 at 2:08 a.m.) Exam Hip uni-lat 1 view, right Results: There is a right intertrochanteric fracture with impaction. The joint shows no dislocation. Pubic rami are intact Conclusion: Acute impacted right intertrochanteric fracture Review of the physician telephone orders revealed the following relevant information: 4/29/2014 Haldol IM solution inject 5 mg IM stat for combative behavior; increase Risperidone 0.5 mg one every 12 hours; discontinue all prior Risperidone orders 4/29/2014 Alprazolam 0.25 mg 2 tabs every morning at 0600; Alprazolam 0.25 mg one tab by mouth at 2:00 p.m. and 2200. 4/29/2014 OK for hospice to evaluate 4/29/2014 X-ray right hip dx: pain call PCP in a.m. with results 4/30/2014 Send resident to hospital emergency room for evaluation None of the above orders had a time received. Review of the April 2014 medication administration record (MAR) revealed the resident received the following additional medications on a regular basis: Percocet 5-325 mg tab one tablet by mouth every 6 hours around the clock for a [DIAGNOSES REDACTED]. Lexapro 20 mg one by mouth daily at bed time for a [DIAGNOSES REDACTED]. Review of the resident's hospital record revealed the following relevant information: Emergency Department Rapid Triage was performed at 10:14 a.m. on 4/30/2014. Review of the chief complaint on the emergency department triage report revealed "According to EMS, patient fell about 12 hours ago, received x-ray of hip + fracture, patient complains of right hip pain." Telephone interview with LPN F on 5/14/2014 at 3:11 p.m. revealed that on the night of 4/29/2014 one of the CNA's complained about a broken call light in another resident's room so he went to fix it and when coming back up the hall, he saw Resident #87 in a squatting position trying to turn his television off. LPN F stated Resident #87 just fell over backwards. He fell underneath one of the rolling bedside tables and he knocked the TV off the table as he fell . LPN F stated he called for help and caught the TV before it fell on him. LPN F stated the resident landed in a sitting position leaning on his left or right hip; "He hit that metal bar under the table so hard." LPN F did not hear an alarm sounding when he entered the room but stated the resident was "notorious for taking it off." LPN F did not know what type of alarm Resident #87 had. He was not sure if it was a sensor pad or a string alarm. LPN F stated that he was not assigned to the resident that night and was just passing by the room when this occurred. He stated LPN H, the resident's assigned nurse, came in to help and "we decided we needed to get x-rays," but LPN H handled all of that. Interview with LPN H on 5/14/2014 at 3:36 p.m., the nurse assigned to Resident #87 the night of the 4/29/2014 fall, revealed the fall was witnessed by LPN F. However, since Resident #87 was his patient, he was called to the room. LPN H stated around 10:40 p.m. I heard a loud crash and when I got to the room LPN F was already there. LPN F said he was making rounds and saw Resident #87 out of his bed and walking around in his room. According to LPN H, LPN F was trying to assist the resident back to bed and the resident fell to the floor. LPN H stated there was no obvious injury at that time. He and LPN F got the resident back in bed and the resident then complained of pain. We put the alarm back on him and LPN F stayed with the resident while he called the doctor to request orders for an x-ray due to a fall with pain. LPN H stated he also called the resident's wife and informed her they were asking for an x-ray as a precautionary measure. LPN H stated he reported the event to the next nurse on duty (LPN G) who gave him his scheduled pain medication at midnight. LPN H stated the alarm was not going off when he entered the room that night. He stated Resident #87 has a history of taking the alarm off. It was a standard clip alarm, portable to back of his collar. The C.N.A. had checked on him and changed the resident about an hour prior to the fall and had put the alarm back in place. That night, LPN H stated he spoke to the on-call doctor and received an order to go ahead and get an X-ray but not to call back with the results. LPN H stated I wrote a telephone order stating the doctor did not want to be called back. She didn't want a call back that late at night. It was a female doctor and LPN H was unsure of her name. LPN H stated mobile x-ray had not arrived prior to him leaving that night. Attempts were made to reach LPN G by telephone at the phone number provided by the facility's nursing home administrator on 5/14/2014 at 3:30 p.m., 7:00 p.m. and 7:39 p.m., however no answer was received and the voicemail mailbox was full. A fourth attempt was made on 5/14/2014 at 9:05 p.m. A male answered the call and and stated this was not the correct number for LPN G. Administration was informed of this in the morning of 5/15/2014 and did not have another number on file for this employee. Interview on 5/14/2014 at 4:35 p.m. with the unit manager responsible for the 2nd floor where Resident #87 resided revealed she was the person responsible for writing sensor alarm on Resident #87's care plan. She stated we noticed the resident was becoming unsteady and staggering with the walker so we put him in a wheelchair with a sensor alarm. This was a tab alarm which he would wear when he was in the wheelchair and in bed. The resident was also being seen by psych because we was getting agitated. The resident was also on 15 minute checks all of April of 2014 because he tended to wander with his walker. The unit manager acknowledged that the resident's walker was taken away after the 4/6/2014 fall but stated he remained on Q 15 minute checks because he would also wander in the wheelchair. The Unit Manager stated these checks were done by the CNA's. Follow up interview at 5:03 p.m. on 5/14/2014 with the unit manager revealed she knew Resident #87 had a history of [REDACTED]. The unit manager stated that when he was in the wheelchair the alarm was placed on the back leg of the w/c rather than the arm and when he was in bed instead of putting it on the side rail we would place it more towards the bed frame. In addition, they would clip it toward the back of his pants so it would automatically go off and be difficult for him to reach. The Unit Manager stated we do have sensor pad alarms now but at the time Resident #87 was here we did not have all of the components for the sensor pad alarms. The unit manager stated he would have been a candidate for the sensor pad alarm but they did not have them at that time. Interview with CNA E on 5/14/2014 at 4:14 p.m. revealed she was the regular 3:00 p.m. - 11:00 p.m. CNA for Resident #87 and was assigned to him the night he fell on [DATE]. CNA E stated the resident was on 15 minutes checks and she had last checked on the resident on 4/29/2014 at 10:20 p.m. She stated she had put him to bed at that time with the alarm in place. CNA E stated Resident #87 used to take off his alarm all the time and would hide it in the bed. CNA E stated she would put it back on him and he would say not to. She would tell the resident you need it so you don't fall and he would say okay. Follow up interview with CNA E at 5:10 p.m. revealed she would clip the alarm to the resident's shirt at the shoulder or in the back of his collar so he couldn't get it easily. She was never told to clip it to the resident's pants and would always clip it to his shirt whether or not he was in the bed or the wheelchair. Interview with LPN C on 5/15/2014 at 11:22 a.m. revealed she was the 7:00 a.m. - 3:00 p.m. nurse on 4/30/2014 who contacted the physician with the positive x-ray results of a hip fracture. LPN C recalled her conversation with the physician and remembered telling him she needed an order to send him to the hospital because he had a fracture of his hip. The nurse stated the doctor commented to her "so he could have surgery done? I said no, his wife did not want surgery due to religious beliefs and not wanting blood or blood products. The doctor said why are we sending him to the hospital because they are going to want to do surgery? I said maybe they could splint him or do something else. The doctor said usually they don't do that and 90% of the time they want to do surgery. The doctor did eventually say yes, you can go ahead and send him. At that point, I called the wife to update her and let her know we were going to send him out. The wife said, I don't want him to have surgery. The nurse informed the wife that perhaps the hospital could do something to make him more comfortable. The wife said she was on her way in and when she arrived, I didn't really talk much to her as EMS (emergency medical services) was in the resident's room and talking to her. LPN C stated she thought she spoke to the physician around 8:30 a.m. - 9:00 a.m. on 4/30/2014 to get the order to send the resident out and inform the doctor of the x-ray results. LPN C said she thought the resident left the facility around 9:30 a.m. on 4/30/2014. LPN C stated she observed Resident #87 that morning and he appeared to be in some pain (facial grimacing but not crying or calling out). He was receiving routine hydrocodone and probably had received a dose at 6:00 a.m. so he appeared to be comfortable at that time. He was awake but not very talkative. Resident #87 was normally talkative with LPN C, however, over the last couple of weeks it was less so because his dementia was progressing rapidly towards the end. Interview with the Director of Nursing (DON) on 5/14/2014 at 2:46 p.m. in the presence of the nursing home administrator (NHA) revealed she conducted an investigation into Resident #87's fall on 4/29/2014 and she found that LPN F walked by Resident #87's room that night and saw him walking around. The DON stated the resident would take his alarms off his shirt and no alarm was sounding at the time he was seen. According to the DON's investigation, LPN F was attempting to take Resident #87 back to bed and in doing so, the LPN and the resident got caught up between the bed and the air conditioning unit and the resident fell . The DON stated the resident was last changed at 9:30 p.m. prior to the fall. The DON stated the resident wore a personal alarm, the kind that clips on him. She did not recall this resident having a sensor pad and stated he had only fallen one time before that so she thought he had a personal alarm and not a sensor pad. The DON stated LPN H was assigned to Resident #87 on the night of 4/29/2014. LPN H called the doctor that night and received an order for [REDACTED]. The night nurse, LPN G, called the DON around 3:00 a.m. on 4/30/2014 to inform her that the resident had a fracture. The DON stated the resident's wife who was his responsible party, did not want him to go to the hospital. The wife wanted the resident to go on hospice because she didn't want him to have surgery. In addition, the order said to follow up with the PCP in the morning. The DON stated normally we would call the doctor with the results, but he was not called in this case because the doctor said to wait for the morning. The DON stated they could have called the medical director, but this was not done. The DON recalled telling LPN G she needed to call the doctor as soon as possible. The DON thought they were holding back on calling the doctor because the wife didn't want anything done. The DON stated at 6:45 a.m. on 4/30/2014 LPN G called the wife to inform her of what was going on and the wife was very pleased. In addition, the DON stated she spoke to the resident's wife on the telephone the morning of 4/30/2014 and she was still reluctant to have him go to the hospital. The DON stated the resident's wife was the hold out on sending the resident to the hospital. The DON stated she informed the wife that maybe the hip could be stabilized and maybe they wouldn't have to do surgery. Meanwhile, the nurse was medicating him for pain and he was comfortable. The DON stated I had to talk the wife into letting him go to the hospital. The DON stated she did not document these conversations in the resident's record and stated she probably should have made a late entry. Continued interview with the DON on 5/14/2014 at 3:17 p.m. in regards to the two recent falls prior to the 4/29/2014 revealed that on 4/6/2014 the nurse heard a loud bang from the resident's room and found the resident lying flat on his back on the floor, in front of his dresser. No extremity deformities were found and the new intervention put in place was for the resident to no longer use his walker and use the wheelchair instead. The DON stated the resident had been having a decline. The DON also reviewed the incident of the fall on 3/21/2014. She stated he was sitting on the floor in his room and was noted with an area to his back. No new nursing interventions were put in place at that time. Telephone interview on 5/14/2014 at 9:06 p.m. with Resident #87's spouse revealed she never told the facility she did not want her husband hospitalized . She stated he was on palliative care which meant to keep him comfortable, but as far as hospitalization goes this was considered on a case by case basis. She did not recall ever telling the facility she did not want the resident to have surgery, but as it turned out he was not a good candidate for the hip surgery due to his other health problems. She stated she never received a call from the DON trying to convince her to have him hospitalized . The resident's wife stated she was present at the facility when he was sent out the morning of 4/30/20 and followed the ambulance to the hospital. She stated the only reason her husband wasn't sent to the hospital sooner was because the doctor said he did not want to be bothered that night and to wait until the morning to follow up about the x-ray. She was just waiting for the facility and the doctor to tell her what to do next. The resident's wife stated she had told the facility prior to this fall that the alarm he had was not adequate. She stated it was not loud enough. The resident's spouse stated LPN C had told her that if she wanted a sensor pad alarm or a different type of alarm she would need to pay for it. She stated she asked LPN C how much it would be and she never gave her an answer or got back to her about this.