Every finding on record at Rehabilitation Center of Orlando

Based on observation, interview, and record review, the facility's Governing Body failed to timely ensure complete, consolidated, accurate accounting of personal funds, transactions, and balance transfers were provided upon and after transfer of ownership for 3 of 3 residents reviewed for Resident Rights, of a total sample of three residents, (#1, #2, #3). Findings:On 6/18/26 at 11:15 AM, resident #1, a cognitively impaired [AGE] year-old female resident was observed sitting on her bed in her room. She said she only had a little bit of cash for vending machines, and her husband managed all her financial affairs.In the afternoon on 6/18/26, two unsuccessful attempts were made by telephone to reach resident #1's spouse,On 6/18/26 at 12:29 PM, the Business Office Manager said the facility changed ownership the previous year and they were still transitioning resident funds into a new Resident Fund Management Service (RFIM) account. She explained she was still having difficulty obtaining records from their corporate department to consolidate all resident funds. The Business Office Manager said resident #1's account was the only one outstanding since March 2025. She said she was unaware how residents received accounting statements of the previous accounts and she only provided the facility's RFIM statements. On 6/18/26 at 2:36 PM, resident #2, a cognitively intact [AGE] year-old male was observed in his room, lying in bed. The resident stated he had been at the facility for a couple of years, and the previous year he had not received complete financial statements of transactions and personal funds from the facility. He explained he had complained to the Business Office Manager multiple times, and she indicated she had difficulty obtaining old records from previous ownership, and the facility was in process of consolidating the old account balances into one resident facility account. The resident said he received late statements that were incorrect in the charge transactions, he was unable to see credits/debits or check the accuracy, and he thought money was missing because it didn't look correct since the ownership change approximately one year prior.On 6/18/26 at 2:45 PM, the Business Office Manager provided photocopies of resident #2's 2025 statements. She said his funds were, off because of a pending credit consolidation from corporate. The documents did not indicate the resident receipt nor when/how they were provided to the resident. On 6/18/26 at 3:10 PM, and approximately 3:20 PM, unsuccessful attempts were made to reach the Corporate Business Office Manager by telephone. On 6/18/26 in the afternoon, two unsuccessful attempts were made to reach the Regional Business Office Manager by telephone.On 6/18/26 at approximately 3:30 PM, the Regional Nurse Consultant was informed the survey team was unable to reach their Corporate or Regional Business Office Managers. A phone number was provided with a request to have them contact the survey team.On 6/18/26 at approximately 3:50 PM, the Business Office Manager conveyed the process of consolidating RFIM accounts was not done immediately upon ownership transfer and was completed a few at a time since March 2025. She was unaware of the exact time resident #3's account was transferred.On 6/18/26 at 4:55 PM, the survey team had not received a return phone call from the facility's Regional nor Corporate Office Manager. Review of the facility's undated standards and guidelines titled Governing Body noted it was responsible for the management of the facility including use of additional support for cash management and/or other professionals. The Nursing Home Administrator's responsibilities included recognition that the institution's commitment was to serve the interests of the needs of the residents and provide supervision of consultants and advisors to the facility.

Based on observation, interview, and record review, the facility failed to ensure complete and accurate personal funds/financial accounting statements were provided to 2 of 3 residents reviewed for Resident Rights, of a total sample of 3 residents, (#1, #2). Findings: 1. Record review revealed resident #1 was admitted to the facility on [DATE]. Review of resident #1's most current care plan revealed a focus for impaired cognitive function or thought process related to dementia. Review of resident #1's record revealed the facility managed the resident's personal funds. Review of the records revealed bank statements for February, March, April, May and June of 2025 were not available. 2. Record review revealed resident #2 was admitted to the facility on [DATE]. Review of resident #2's quarterly Minimum Data Set with the assessment reference date of 4/23/26 showed he had a Brief Interview for Mental Status score of 15 out of 15 which meant he had normal thinking and good memory. On 6/18/26 at 2:36 PM, resident #2 stated he had not received statements from the facility for the year, and he did not receive his previous balance before they changed owners. He said he was missing $800 because the facility overcharged him $100 a month. Resident #2 said he received no statements in 2025. He continued, monthly charges went from $400 to $460, and he was not able to see the credits, so he did not notice anything was missing. On 6/18/26 at 12:29 PM, the Business Office Manager (BOM) said the statements for resident #1 were not available because the facility went through a period of transition from one management company to another in February 2025 and she acknowledged quarterly account statements should be provided to residents whose funds were managed by the facility. She confirmed resident #1's statements had not been issued as requested. The BOM explained the residents had direct deposits from Social Security, and some residents made payments with paper checks or money orders which she was responsible for mailing. She said she made copies of the checks, and the checks were mailed to accounting service for resident personal funds. Next, she stamped the copy of the check with the date it was mailed. The BOM explains that the accounting service utilized by the facility that included funds received from the family. The BOM said the residents received a quarterly statement every three months and as requested, with copies of the statements kept in their file. The BOM explained transition of facility ownership took place in February 2025 and during the transition from one owner company to another, the banks used for personal funds accounts changed. She said she asked their corporate for information about the resident funds because she needed to know if the residents had funds. She stated the corporate side handled the funds then the new company took over but the statements came from the previous bank to the new one. The BOM said there was one family member that called her every day for statements from the time of transition and he also called the Medicaid case manager for his wife (resident #1). She explained he sent a $500 monthly check from Social Security for resident #1 for deposit to the new bank. The care costs were taken out and the spending money stayed in the account. On 6/18/26 at 1:41 PM, the BOM explained that the money was not frozen and explained that resident #1's money was in transition to the new accounting service and prior to the company transition the corporate business staff provided the statements because she did not have this information. The BOM did not know the process to obtain statements but said she was in communication with the corporate business staff. She acknowledged resident #1's representative asked why these statements took so long but she could not answer the question. The BOM said the statements for February, March, April, May and June 2025 had not been released to the resident #1's representative. She explained the first $500 shown in the records was for 7/21/25; the interest-bearing accounts from previous months were not available and she said that corporate was working on this currently. On 6/18/26 at 2:45 PM, the BOM provided photocopies of statements for the resident #2 that did not include funds from previous ownership. She said his funds were off because a credit consolidation was still pending from corporate. She said he received statements, but documents she provided did not note statements were received by the resident, only stamped with dates. On 6/18/26 at 3:46 PM, the BOM stated the Corporate Business Office Manager had been working on the statements for resident #1 and she was called with no response after two attempts. The RNC called the Corporate Business Office Manager via telephone and there was no response. The Regional Business Office Manager was called via telephone and per recording she was not available. The facility had no policy for accounting and personal funds.

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to ensure two of two shower rooms were clean, sanitary, and homelike on one of two units, (East Wing), failed to ensure flooring in the back hallway was in good repair and homelike on one of two units, (West Wing), and failed to ensure 4 of 35 residents' rooms on the [NAME] Wing were maintained in good repair and in homelike condition, (#15, #27, #28, and #29).Findings: Cross reference F867 Observations during tour of the facility on 1/21/26 between 11:18 AM, and 11:30 AM revealed in room [ROOM NUMBER], the lower portion of the entrance door exhibited warping and breakage with sharp edges. The bottom panel of the door was lifted up approximately eight inches in length. The closet door was chipped, uneven and did not close properly. In room [ROOM NUMBER], the closet doors were missing. The baseboard next to the bathroom door was cracked open and measured approximately three to five inches in length. The bathroom door had several scratches along the edges. Unfinished drywall patchwork was noted on the walls next to the bathroom entrance and the window. In room [ROOM NUMBER], the left wall surface upon entrance to the room was deteriorated, particularly along the lower portion near the floor. The wall in room [ROOM NUMBER] exhibited unfinished drywall patchwork with spackling material visible. The baseboard next to the bathroom door was cracked, measuring approximately two to four inches in length. A few minutes later in the [NAME] wing back hallway, the floor around the drain area was missing multiple floor tiles. The floor tiles were mismatched, and patchworked, with visible cracked and broken tile edges surrounding the drain. The damaged area on the floor of the back hallway revealed exposed subfloor material, erosion and uneven flooring. Observation at that time in room [ROOM NUMBER] revealed the baseboard next to the bathroom door was cracked and measured approximately two to four inches in width. The bathroom door of room [ROOM NUMBER] had multiple scuff marks along the bottom section, and four to six round, penny-sized holes were noted on the wall above the B-side dresser. Black speckles were noted on the ceiling above bed B and the bathroom ceiling. On 1/21/26 at 12:42 PM, resident #9 stated the door in room [ROOM NUMBER] was ripped because her roommate's wheelchair got caught in it a few days ago. She indicated the closet door had been broken for a long time. On 1/21/26 at 1:08 PM, in a telephone interview, resident #1's family member shared there were holes in the wall and stains on the bedroom ceiling and bathroom ceiling of room [ROOM NUMBER]. He stated the facility had renovated the entire East Wing, but nothing had been done in the [NAME] Wing. He indicated he would continue to advocate if the facility did not want to put a nickel into resident #1's care. On 1/21/26 at approximately 5:25 PM, a tour of shower room one in the East Wing with Certified Nursing Assistant (CNA) A revealed the shower walls had discoloration and staining, particularly along tile surfaces and grout lines. The grout at the base of the walls was cracked, deteriorated, and separated. The shower stall floor consisted of 2-inch by 2-inch ceramic tiles that were worn, uneven, and visibly damaged. A section of the floor contained missing and mismatched tiles. During the tour of the second shower room in the East Wing the toilet bowl contained dark brown standing liquid which caused heavy staining, consistent with prolonged buildup, poor drainage, or inadequate cleaning and maintenance. CNA A stated she verbally reported identified issues to the Maintenance or Housekeeping Director when she saw them because she did not have their phone numbers. She added that reporting could occur the next day if they were not in the facility since her shift was from 3:00 PM to 11:00 PM. CNA A stated if an environmental issue was identified after hours, she would inform her supervisor. She further stated she had not taken any residents to the shower room that day and therefore did not know the condition of each shower room prior to the tour. On 1/22/26 at approximately 9:15 AM, during a tour of shower room two in the East Wing with CNA C, the toilet remained in the same condition as the previous day, with dark brown standing liquid and heavy staining. On 1/21/26 at 3:43 PM, the Maintenance Director stated he had been working at the facility for approximately six months. He shared he had recently hired a technician but had been working alone for the past three weeks. He indicated he was responsible for all aspects of maintenance including interior and exterior areas. He shared he asked CNAs to enter work orders when issues required his attention in resident rooms and indicated he checked work orders three to four times per day, prioritizing urgent issues. He mentioned issues were also discussed during morning meetings and addressed daily. He explained when he was hired in August 2025, he focused on completing the East Wing renovation project and the repairs for the [NAME] Wing were planned next. He stated issues identified in residents' rooms should be fixed as soon as possible. On 1/21/26 at 4:00 PM, a tour of the [NAME] Wing was conducted with the Maintenance Director and the Regional Life Safety Director. room [ROOM NUMBER] was confirmed to have stains on the ceiling near bed B and in the bathroom, as well as holes in the wall near the dresser on the B side. Hallway handrails on the [NAME] Wing had patches of red paint. The Maintenance Director validated the broken closet door and entrance door in room [ROOM NUMBER], the patchwork flooring, and the deteriorated conditions in rooms #28, #29, and #27. He stated repairs and painting were needed. The Regional Life Safety Director indicated they had paint and supplies available but were waiting for additional labor assistance. Both the Maintenance Director and the Regional Life Safety Director acknowledged the findings and stated the conditions observed on the tour did not reflect a homelike environment. On 1/22/26 at 12:05 PM, a tour of shower room one in the East Wing was conducted with the Maintenance Director. He acknowledged two 2-inch by 2-inch tiles were missing from the shower stall floor and stated he had been unaware of the condition. Review of the facility's maintenance logs from November 2025 through the present date of survey, 1/22/26, revealed no documented work orders or repairs related to the deteriorated shower room conditions, unsanitary toilet, damaged resident room doors, wall surfaces, or hallway flooring identified during the facility tour. On 1/22/26 at 2:06 PM, the Housekeeping Director stated he had been working at the facility for three weeks. The Environmental Services District Manager was present during the interview. The Housekeeping Director stated he was responsible for ensuring the housekeepers and floor technicians maintained all areas of the facility as clean. He indicated resident rooms were cleaned daily and inspected randomly, and a calendar was used for deep cleaning and special projects. The Housekeeping Director and District Manager reviewed the photographs of the East Wing shower rooms and stated the grouts were degraded or missing, there appeared to be growth on the walls, and the conditions looked funky. The Housekeeping Director stated both housekeeping and maintenance were responsible for ensuring the showers were clean and functional. The Housekeeping Director indicated replacement of tiles and grout repairs were maintenance's responsibility. The Housekeeping Director acknowledged housekeepers entered the shower rooms daily and were responsible for notifying him when additional work was needed. He stated no housekeeper had reported the clogged toilet in shower room two. The District Manager stated the toilet appeared clogged for some time due to the visible ring inside the bowl. The Housekeeping Director indicated he expected the staff to notify him so the issue could be corrected. On 1/22/26 at 4:45 PM, the Administrator stated she was aware of the environmental findings in the East Wing shower rooms and the resident rooms identified in the [NAME] Wing. She validated the conditions were unacceptable and not homelike. Review of the Director of Maintenance job description, revised July 2024, indicated the primary purpose of the position was to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current federal, state and local standards to ensure the facility was maintained in a safe and comfortable manner. Duties included conducting ongoing inspections to identify areas and equipment requiring improvement and repair. Review of the facility's policy titled Housekeeping, revised 3/10/23, stated its purpose was to promote a sanitary environment and reduce the transmission of infectious agents. Review of the facility's policy titled Preventive Maintenance Program, revised 3/10/23, revealed the intent to implement a program promoting a safe, functional and comfortable environment for all residents. The procedure indicated maintenance was based on regular and routine inspections and repairs.

Based on observation, interview, and record review, the facility failed to ensure implementation of its Quality Assurance and Performance Improvement (QAPI) program to the extent that previously identified areas of concern were thoroughly monitored and performance was adequately tracked to ensure prior improvement measures were realized and sustained. Findings: Cross reference F584 Review of the facility's survey history revealed a deficiency related to failure to provide a homelike environment during the last recertification survey dated 7/24/25. Review of the facility's Plan of Correction (POC), dated 8/18/25, identified staff was re-educated on the components of the regulation with emphasis on ensuring a clean and homelike environment in the dining room. The POC indicated newly hired and agency staff would receive education during orientation and prior to working a shift. During the current survey, a deficiency related to F584 was again identified. As a result of the repeat citation, it was determined the facility failed to implement sufficient auditing, monitoring, and oversight to ensure sustained compliance with the homelike environment requirements beyond the limited focus identified in the prior POC. On 1/22/26 at 4:45 PM, the Administrator (NHA) stated during the last recertification survey, the homelike environment concern was related specifically to centerpieces not being available in the dining room. She explained during development of the POC through QAPI, the facility focused primarily on common areas related to residents' dining experience and had not considered the homelike environment throughout the facility. She explained the POC and auditing process did not include shower rooms or residents' rooms. The NHA further shared ever since she began working as the NHA, there had been significant turnover and operational challenges, including three changes of Director of Nursing within six months, a new Maintenance Director, and periods without a Staffing Coordinator. She stated the facility had been in survival mode for a period of time and acknowledged the lack of key personnel may have contributed to missed environmental concerns. She indicated continuity had been difficult to maintain but stated the facility was in the process of building a new management team. The NHA mentioned housekeeping had been an area of focus, however limited progress had been made. She acknowledged the facility was aware there were a lot of things to fix and time was needed to address the issues. Review of the facility's policy Quality Assurance and Performance Improvement, revised 3/10/23, revealed the program was intended to ensure comprehensive, data-driven activities focused on indicators of outcomes of care and quality of life. The policy indicated the QAPI program was designed to address all care and services provided by the facility and ensure ongoing monitoring and sustained improvement.

Based on observation, interview, and record review, the facility failed to adhere to proper infection control practices related to the use of personal protective equipment (PPE) outside of a resident's room, on one of two units, (West Wing).Findings: On 1/21/26 at 11:05 AM, Certified Nursing Assistant (CNA) B was observed standing by a medication cart in the [NAME] Wing hallway talking with a nurse while holding a soiled bag and wearing gloves on both hands. After a couple of minutes, CNA B continued walking down the hallway toward the soiled utility room. CNA B then removed the glove from her left hand but kept the glove on her right hand while holding the soiled bag and entering the utility room. On 1/21/26 at 11:08 AM, CNA B acknowledged she was observed wearing gloves in the hallway, then explained she was not really wearing gloves while holding the bag. She confirmed the finding and stated she knew she was not supposed to wear gloves in the hallway because it was a break in infection control practice. CNA B said, I guess I got distracted. On 1/21/26 at 11:27 AM, the [NAME] Wing Unit Manager (UM) confirmed staff should not wear gloves in the hallways. She indicated doing so was an infection control concern as it could contaminate areas outside of the resident's room. The UM validated staff must remove their gloves inside the resident's room before exiting. On 1/22/26 at 3:35 PM, the Director of Nursing confirmed the CNA who walked down the hallway wearing gloves was an infection control concern. Review of the facility's policy titled Nursing - Infection Control Prevention and Control Program, effective 2/21/23, revealed its purpose was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. The policy described its purpose was to prevent the development and transmission of communicable diseases and infections.

Based on observation, and interview, the facility failed to provide residents a homelike dining environment for meals eaten in two of two dining rooms.Findings: On 7/21/25 at 12:10 PM, 13 residents were observed in the main dining room eating their meal with the dishes still on their trays. Tablecloths were on the tables, but they had no centerpieces as decoration. On 7/23/25 at 8:10 AM, four residents in the west wing dining room were seated in chairs throughout the room. There were six meals left on meal trays on the tables, all of the tables were otherwise bare, without tablecloths or centerpieces. Certified Nursing Assistant (CNA) N assisted one resident with their meal and explained the breakfast trays which arrived about 10 minutes earlier were being held there for residents who got up later. The main meal plates were covered by an insulated lid which sat over the ceramic plate, but there was nothing under the ceramic plates to help keep the food warm. On 7/23/25 at 12:13 PM, approximately 26 residents were observed eating in the main dining room. Nine residents were observed eating their lunch meals with the dishes remaining on their trays. Other residents in the dining room were observed to have their dishes removed from their trays and placed on the tables. At 12:22 PM, the Business Office Manager stated she was monitored the dining room to ensure residents were taken care of and staff were doing what they were supposed to. She stated she was unsure why the nine residents, who ate at the two long tables in the dining room still had the dishes on their trays while other residents seated elsewhere in the dining room had their dishes set directly on the tablecloth for dining. On 7/24/25 at 12:20 PM, three residents in the west wing dining room were observed as they ate their meals from dishes on their trays. CNA N explained the facility never had tablecloths or removed the dishes from the trays in this dining room. The [NAME] Wing Unit Manager acknowledged it was important to make the resident's environment as home-like as possible because the facility was their home. On 7/24/25 at 3:00 PM, the Administrator acknowledged from her first day at the facility she had noticed residents ate from trays and the room was not decorated or homelike. She explained they searched the facility for some table centerpieces but discovered previous decorations had been discarded. The Administrator added that a homelike environment was a resident right, and their goal was to provide it; even though the facility had no specific policy to address this.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 1 of 4 residents observed during the medication administration task, of a total sample of 38 residents, (#45). There were 3 errors in 28 opportunities for a medication error rate of 10.71%.Findings:Review of the medical record revealed resident #45 was admitted to the facility on [DATE] with diagnoses including hypertension, Chronic Obstructive Pulmonary Disease (COPD), schizophrenia, psychotic disorder with delusions, type 2 diabetes, chronic pulmonary edema, and chronic viral hepatitis C.On 7/22/25 at 9:04 AM, Registered Nurse (RN) A checked resident #45's blood pressure with an electronic wrist cuff and showed the reading of 124/81. She checked the electronic medical record and explained she would not administer the resident's scheduled 7:00 AM to 11:00 AM Losartan Potassium and Sotalol HCl due to parameters given by the physician. When preparing resident's Furosemide 40 milligrams (mg), RN A dropped the pill into the medication cart drawer. RN A stated the Furosemide medication card for that resident had no more pills and did not attempt to retrieve the medication from another source or call the physician. Review of the Medication Review Report revealed resident #45 had a physician order dated 3/30/25 for Sotalol HCl 80 mg oral tablet by mouth two times a day for hypertension. The order included a parameter to hold the drug if the resident's systolic blood pressure was less than 110 millimeters of mercury (mm Hg) and/or diastolic blood pressure less than 60 mmHg. The resident also had an order dated 5/17/25 for Losartan Potassium 50 mg oral tablet by mouth daily for hypertension. This order included a parameter to hold the drug if the resident's systolic blood pressure was less than 110 millimeters of mercury (mm Hg). Review of Medication Review Report revealed an order dated 6/12/25 for Furosemide 40 mg to give 0.5 tablets by mouth one time a day for edema.The American Heart Association indicates blood pressure is recorded as two numbers, the first or upper number, the systolic blood pressure (SBP), measures how much pressure blood exerts against artery walls when the heart contracts. The diastolic blood pressure is the second number, which measures the pressure your blood is pushing against your artery walls while the heart muscle rests between beats, (retrieved on 7/30/25 from www.heart.org).Review of resident #45's care plan revealed a focus of a risk for cardiovascular distress related to diagnosis of hypertension initiated 3/06/25. In addition, the resident had a care plan for diuretic therapy related to edema which was initiated 6/13/25 with an intervention to administer diuretic medications as ordered by physician and monitor for side effects and effectiveness each shift.On 7/22/25 at 10:28 AM, RN A was interviewed with the assistance of the Director of Nursing (DON) for translation for RN A as needed. RN A acknowledged she omitted the Losartan and Sotalol for resident #45 and replied she held the medications due to the parameters. The DON translated that these medications should not have been held due to SBP being higher than 110 and DBP higher than 60, RN A replied okay but did not supply an explanation as to why she decided to hold it. As translated by the DON, RN A stated the resident only had one 40 mg Furosemide tablet left in his card and confirmed when she went to administer the medication the tablet fell into the medication cart drawer. RN A was unable to explain why she did not check the backup medication supply or call the physician or pharmacy for further instructions. The DON explained the procedure for missing medication was to check the backup medication supply first, then call the pharmacy and notify the physician. In addition, she said nurses were expected to inform the resident and/or representative if applicable. Facility policy revised 2/21/23 titled Administering Medications states that the purpose of the policy is to ensure that medications are administered in a safe and timely manner and as prescribed. Medications are to be administered in accordance with prescribed order and current standards of practice.

Based on observation, and interview, the facility failed to ensure the snack/nourishment refrigerators on the nursing units had food items labeled and dated with open and use by dates and failed to ensure outdated foods were discarded to prevent the potential for foodborne illness, on two of two nursing units of the facility. This had the potential to affect all 110 residents at the facility.Findings:On 7/24/25 at 2:00 PM, on a tour of the west wing nourishment room, the west wing Unit Manager (UM) verified three large cartons of thickened juice were undated as to when they had been previously opened. In addition to the juice the refrigerator contained a package of unlabeled and undated cheese, previously opened bologna, three undated containers of peaches, one container of applesauce, two undated containers of unidentified leftover resident food and a package of undated salami. The UM stated nursing staff were responsible for labeling and dating the resident's food items when received and labeling food items when opened. She said it was the dietary department's responsibility to monitor the resident leftovers and discard them when expired or outdated.On 7/24/25 at 2:30 PM, in the east wing nourishment room the Certified Dietary Manager (CDM) verified the refrigerator contained undated cartons of thickened water and Med Pass nutritional supplement. In addition, numerous food items were expired, and/or unlabeled/undated; a sandwich was dated 7/02/25 (22 days prior); an unlabeled and undated loaf of bread; an undated bag of a resident's food items; an unlabeled bag of food items, was expired, dated 7/02/25; a plastic container of leftover chicken was dated 6/23/25 (32 days prior), a plastic container of rice and beans and a container of a casserole were labeled for a resident and dated 6/26/25, (28 days prior); and leftover pizza was dated 7/19/25 (6 days prior). The Assistant Director of Nursing verified the food items and confirmed it was nursing staff's responsibility to label and date the items when opened and the dietary department's responsibility to dispose of outdated food items.The facility's policy entitled Foods Brought by Family/Visitors dated March 2022, indicated food items held for residents were to be labeled with the resident's name, food item, and the use by date. The policy added, nursing staff would discard perishable foods on or before the use by date.

Based on observation, and interview, the facility failed to dispose of garbage properly by keeping dumpster lids closed and the area surrounding the dumpster free of debris which had the potential to affect all 112 residents residing at the facility.Findings:On 7/21/25 at 10:30 AM, rubbish was observed scattered on the ground around the three dumpsters in the dumpster area. The Certified Dietary Manager (CDM) stated the housekeeping department was responsible for keeping the dumpster area clean.On 7/22/25 at 5:00 PM, Housekeeper C was observed throwing garbage in the facility's garbage dumpster without shutting the lid. He stated he was aware he needed to shut the lid but just didn't do it. He stated it was important to keep the lids closed to keep pests/animals out of the dumpster.On 7/23/25 at 10:50 AM, [NAME] B and Dietary Aide D were observed throwing garbage in the dumpster but did not close the lid when finished. They stated the lid was already opened before they threw their trash in it. They acknowledged they were supposed to close the lid to the bin after using it. [NAME] B and Dietary Aide D stated they knew it was important to keep the lids closed on the garbage bins, so animals did not get in.On 7/23/25 at 2:10 PM, Laundry Aide E was observed throwing trash into the garbage dumpster and did not close the lid when finished. He stated he was aware he was supposed to close the lid after putting trash in it but just didn't do so this time. He stated it was important to keep the lid closed because it has a lot of bacteria. Two other staff members, including the CDM were present at the time of this conversation and assisted with translating in Spanish, so Laundry Aide E was sure to understand the issue. He then went and shut the lid on the dumpster.On 7/23/25 at 2:43 PM, Laundry Aide E was observed throwing trash in the dumpster and leave the lid open. A few minutes later, the Environmental Services Regional Manager was informed of the concerns with the dumpster and said there was no excuse for not closing the lid to the dumpster. He added, it was a safety issue and important to keep the dumpster area free of debris and the lids on the dumpsters closed to prevent pests from getting in.The facility's policy entitled Dispose of Garbage and Refuse dated August 2017, indicated all garbage would be disposed of in a safe and efficient manner. The policy directed the CDM and Director of Maintenance to coordinate and ensure the area surrounding the exterior dumpster was maintained in a manner free of debris and other rubbish.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Review of the facility's QAPI Policy and Procedure dated 4/01/22 revealed, The facility will take actions aimed at performance improvement. It will measure the success of these actions and track performance to ensure that improvements are realized and sustained. The facility had deficiencies cited at F759 for medication error rate over five percent, and F867 for QAPI during the previous recertification survey conducted 1/07/24 through 1/11/24. During this survey, the facility was again found to be in noncompliance with F759, and F867. As a result of the repeat deficiencies, it was identified there was insufficient auditing and oversight to prevent the citation. On 7/24/2025 at 4:48 PM, the Administrator stated the facility had a QAPI committee that met monthly. She explained the committee reviewed department audits which addressed departmental concerns such as grievances, infection control, falls, weight loss, etc. The Administrator said a Performance Improvement Plan (PIP) would be put into place for areas of concern identified. The PIP would include the problem identified, goals and approaches which could include audits, medical record reviews, interviews and education. Findings from the current survey were reviewed with the Administrator. She verified she was employed at the facility during the previous survey but not as the Administrator. She explained she left to pursue her career and returned as the Administrator of the facility two days ago. She confirmed she was aware of the citations from the previous recertification survey and acknowledged there were repeat citations. The Administrator stated she only returned a few days ago and was unable to say where the process failure occurred. She explained there was a recent change in ownership as well as administrative changes. The Administrator expressed focus could have been lost due to those changes in staff. She acknowledged the performance improvement process should continue even with staff changes for the benefit of the residents and staff.

Based on observation, and interview, the facility failed to ensure residents were treated with dignity by standing while assisting them to eat for 1 out of the 5 residents observed for dining assistance, of a total sample of 38 residents, (#34).Findings:Resident #34 was admitted the facility on 7/10/17 for Parkinson's disease, diabetes mellitus type II, seizures, depression, anxiety, and psychotic disorder. Resident #34's care plan indicated he had a deficit in activities of daily living (ADL's) and required maximum to total assistance for eating meals related to risk for nutritional decline and history of weight loss with a low Body Mass index. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #34's Brief Interview for Mental Status score was 6/15, which indicated severe cognitive impairment.On 7/23/25 at 12:13 PM, Certified Nursing Assistant (CNA) F was observed standing in the main dining room as she assisted resident #34 with lunch. At 12:19 PM, CNA F explained she had stood while assisting the resident with his meal in case she needed to move and do something else during the meal. She added she sat while assisting residents with their meals in their rooms but did not sit down in the dining room. CNA F acknowledged she was supposed to sit when she assisted residents with meals. A short time later at 12:22 PM, the Business Office Manager stated she monitored the dining room to ensure residents were taken care of and staff were doing what they were supposed to. She confirmed CNA F was standing while assisting resident #34 with his lunch and said she saw her do the same at breakfast as well. On 7/24/25 at 3:00 PM, the facility's Administrator stated staff were expected to sit while assisting residents with their meals as doing so communicated to the residents, they and their meal, was important and was not to be rushed; and it was a matter of dignity for the residents. The Administrator stated the facility did not have a policy on staff sitting while assisting with meals but said it would fall under resident's rights to be treated with dignity.

Based on interview, and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin for one of one resident reviewed for falls, of a total sample of 38 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] for atrial fibrillation, dementia, muscle wasting and atrophy, disorders of bone density and structure, and repeated falls added on 6/02/25. She had an order for an anticoagulant medication due to her atrial fibrillation. On her most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], her Brief Interview for Mental Status score was determined to be 14 of 15, which indicated an intact cognitive status.Resident #3 had a care plan with a focus area dated 6/03/25 which described the resident had a fall. The care plan intervention was to determine and address causative factors of the fall, which did not happen.On 7/22/25 at 10:02 AM, resident #3 said about two months ago an aide was pushing her too fast in the wheelchair and she fell forward onto a concrete patio. She added she had told the staff member to slow down, but she fell and spent a couple days in the hospital after the fall.A progress note dated 5/28/25 by the night Nursing Supervisor indicated at approximately 7:04 PM, he was notified by a nurse that resident #3 was on the floor face down in the smoking area. He documented when he entered the area, he saw the patient on her back with a large blood-filled bruise on her right forehead. The note indicated the resident was unable to verbalize any sentences, and she was groaning. The Supervisor described a 911 call was made, and the resident's physician was notified of the emergency transfer. The Emergency Medical Services (EMS) team arrived at approximately 7:10 PM, she was transferred to the hospital on a stretcher, and the facility's Director of Nursing (DON) was notified. The medical record showed the resident was readmitted on [DATE] at approximately 2:41 PM.A progress note dated 6/03/25 from the Interdisciplinary team (IDT) noted the fall incident was discussed and resident #3 was unable to describe what occurred as her baseline mentation was altered and at the time, she was only able to moan. The plan was for IDT to evaluate the wheelchair position and to have the resident continue with Occupational Therapy (OT) and her plan of care. A progress note dated 6/03/25 by the Nursing Supervisor indicated the resident was seen by a wound doctor and an ointment was ordered for her right frontal forehead. A skilled nursing note written dated 6/03/25 at 2:41 PM, by the Advanced Practice Registered Nurse (APRN) indicated the resident was oriented to person and place and that monitoring for fall and safety precautions were to continue along with strengthening and gait training. On 7/22/25 at approximately 4:00 PM, a request was made to the Regional Nurse to review a copy of the facility's investigation of the incident/fall from 5/28/25. Two days later, on the morning of 7/24/25 at approximately 9:30 AM, the Regional Nurse was again asked for a copy of the investigation for review, which was provided a few hours later by the DON. Review of the investigation report included three staff interviews, of which none actually witnessed the incident/fall. The facility was asked to provide interviews or witness accounts from anyone who actually witnessed the incident, but the DON later reported the facility did not have any additional documentation for that. On 7/24/25 at approximately 2:30 PM, Certified Nursing Assistant (CNA) K stated she could not remember who the other CNA was who she helped and as the conversation progressed, she stated there was not another CNA there. CNA K stated once all of the residents were in the outdoor smoking area, she went back into the facility to the smoking box which was located just inside the glass door. CNA K said she gathered cigarettes to bring to residents when she heard a commotion outside and turned around and saw the resident lying on the ground.Review of CNA K's witness statement indicated she was in the smoking area helping another CNA monitor the smokers at the time of the incident. Her statement indicated she did not witness the incident because she was helping someone else when the resident fell on the ground.In a joint interview on 7/24/25 at approximately 4:30 PM, with the Regional Nurse, Administrator, and Director of Nursing (DON), the facility's investigation into the event of 5/28/25 was reviewed. The DON stated the facility went by the information CNA K gave in her statement and acknowledged they did not follow up with other staff working at the time to determine if what she said was accurate. They confirmed that although CNA K said there was another CNA present at the time of the incident, they never attempted to find out who the staff was and get a statement from the staff member; nor did they interview any of the residents present outside in the smoking area as part of their investigation. They did not explain why they did not interview the resident herself after she returned from the hospital to get her version of what happened. The Regional Nurse, Administrator and DON were informed that resident #3 reported facility staff were pushing her too fast in a wheelchair when the incident occurred and acknowledged a more thorough investigation was needed. They acknowledged additional staff should have been interviewed to determine which staff were actually present during the incident in attempt to clarify the circumstances of the incident. The facility's policy entitled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of Unknown Source and Investigations dated 4/01/22 indicated investigations into an injury of an unknown source would be conducted within seven days. The policy indicated the facility environment, staff, visitors and other residents would be monitored to minimize and prevent any potential injuries. The policy specified the facility would conduct an internal investigation including, but not limited to staff, residents, and family/resident representative interviews.The facility's policy entitled Falls and Fall Risk Managing dated 4/01/22, reiterated the facility would monitor environmental factors that could contribute to falls and that after a fall, they would identify interventions to reduce the risk of the fall occurring again.

Based on interview and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Cross reference F565 and F609 Review of the facility's survey history revealed deficiencies related to Resident Council's grievances and recommendations to improve residents' care had not been considered or acted upon and an allegation of abuse was not reported were identified during the current survey ending on 8/08/24. The facility had deficiencies at F565 and F609 for similar concerns with Resident Council and reporting of abuse allegations from the last Recertification survey dated 1/11/24. Review of the Plan of Correction (POC) which serves as the facility's allegation of compliance with the citations, approved by the Quality Assurance and Performance Improvement (QAPI) committee on 2/15/24 included education to the Interdisciplinary team for understanding of the QAPI process. The POC mentioned implementation of appropriate plans of action to prevent repeat deficiencies. The POC mentioned identifying areas for continuous quality monitoring using tools to conduct quality reviews which would be reviewed in QAPI for identification of areas that could potentially affect resident outcomes. On 8/08/24 at 9:33 AM, the Administrator stated he was responsible for overseeing all areas in the facility. He explained his main function was to manage the different departments and ensure compliance. He shared his passion was for residents to be treated fairly and received the best quality of life they could get. The Administrator stated when he took the position in January, he met with the Resident Council and had a crowd of about 30 residents. He stated he informed them he would walk around the first few weeks, to see what resident saw and address those issues, which he did. He stated they were currently working on quality measures, and he stated he was surprised about the survey findings.

Based on interview, and record review, the facility failed to act promptly upon Resident Council group concerns with appropriate responses and rationale for facility decisions. Findings: On 8/07/24 at 3:18 PM, the Resident Council President stated there were issues brought up in resident council meetings for many months that were still unresolved. The first issue was a long response time to call lights by staff. He stated staff often told the residents; they would be right back but then forgot to return. He added staff would say, That's not my section, when asked to answer a call light or pass meal trays when the assigned Certified Nursing Assistant (CNA) was busy. The Resident Council President explained there were other ongoing issues such as late meals, cold food due to the plate warmer being broken for months, and residents not being able to get ice. He explained the Resident Council had concerns about language barrier issues with staff, and smoking issues. The Resident Council President stated the group was concerned the Activities Director had at times invited staff to the resident council meetings without the knowledge or invitation of the group and the group meeting location was not private enough. The Resident Council President explained there were told by the facility Administration that their concerns were being worked on but no details, progress updates, or results were provided. He stated he often wondered why the Resident Council group met at all, because residents felt like they were ignored. On 8/07/24 at 3:00 PM, the Activities Director stated she helped run the Resident Council and the Food Committee meetings. She acknowledged sometimes she invited other facility staff to attend the Resident Council meetings. On 8/07/24 at 4:30 PM, Resident Council meeting minutes dated January 2024 to July 2024 which included many unresolved issues. The 2/06/24 meeting minutes indicated the old business regarding medication pass issues were, In process and still being worked on. Regarding the issue of call lights, the action plan on these minutes stated call lights should be answered within 5 minutes, the head nurses would monitor call lights, and all department heads could answer a call light and assist that resident. In addition, new concerns about ice were raised. Call light response times concerns were brought up repeatedly at meetings on 3/05/24, 4/02/24, 5/07/24, 6/04/24 and 7/02/24. The feedback given was the resolution was, In progress. Late meals delivery was brought up as an issue at meetings on 4/02/24, 5/07/24, 6/04/24 and 7/02/24 and an issue of room checks not being conducted during night shifts was brought up on 5/07/24, 6/04/24, and 7/02/24. These items were still unresolved with their resolution noted in the meeting minutes also, In progress. On 8/08/24 at 2:15 PM, the Certified Dietary Manager (CDM) stated they were still having difficulty with late delivery of meals. He confirmed the plate warmer had been broken for about a month. He stated the Director of Maintenance was ordering a part for it. The CDM stated the ice machine was not broken but it did not produce a sufficient amount of ice. He said the repair company stated the ice machine was working as it should. The CDM was not aware residents had complained about not having enough ice. On 8/08/24 at 6:00 PM, the Administrator stated the facility investigated and addressed grievances from residents as they arose. The Administrator stated a grievance regarding call light response time had an action plan to audit the response times. Three audits were completed in February and March 2024 and the Administrator stated call light response times were not deemed to be an issue any longer after this. The Administrator acknowledged the call light complaints brought up at the Resident Council meetings from February 2024 through July 2024. He also acknowledged the action plan which indicated the correction was In progress. The Administrator explained call light issues would never be corrected. He stated he probably should pay more attention to issues brought up by the Resident Council. The facilities Resident's Rights policy dated April 1, 2022 states resident groups have the right to meet in a private space with other staff and visitors only attending only at the group's invitation. It also states the facility must consider the views and recommendations of the group and act promptly on the grievances and recommendations of the group. It states the facility must be able to demonstrate its response and the rationale for it. It was not evident this policy is being followed effectively.

Based on interview and record review, the facility failed to report an allegation of verbal abuse to State agencies as required for 1 of 2 residents reviewed for abuse, of a total sample of 8 residents, (#1). Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia (paralysis of lower body) and dementia. Her medical record showed her daughter was her Power of Attorney (POA) and responsible party. Resident #1 was discharged from the facility on 6/30/24. Review of the Minimum Data Set (MDS) Annual assessment with assessment reference date of 5/27/24 revealed resident #1 had unclear speech but sometimes understood and responded adequately to simple, direct communication only. The assessment showed a Brief Interview for Mental Status (BIMS) was not conducted because she was rarely or never understood. The MDS assessment showed resident #1 had no behavioral symptoms and did not reject evaluation or care necessary to achieve her goals for health and well-being. Resident #1 was totally dependent on staff for all activities of daily living. The assessment revealed her preferred language was Creole and she needed an interpreter to communicate with a doctor or health care staff. Review of the care plan with a focus area of little community life involvement revised on 11/05/23 revealed resident #1 was French Creole speaking and needed a translator. Another focus revised on 1/19/23 was communication problem related to dementia and language barrier, Creole speaking. Review of the Monthly Grievance Log from February to August 2024 showed resident #1's POA had filed 7 grievances. The June log included a grievance/concern dated 6/10/24 for customer service/nursing care which was assigned to the Unit Manager on 6/11/24 and the resolution noted education of customer service to Certified Nursing Assistants (CNAs). The Grievance Report on 6/10/24 read, [resident #1's daughter name] called today 6/10/24 stating she came in yesterday, Sunday 6/09/24. Her mother told her that either on Friday or Saturday a CNA was yelling and cursing at her mother in Creole. The CNA was calling her a witch and said that is why your body is like that. The mother was very upset and crying, she didn't even want to eat. [Resident #1's name] even told her to stop talking on her behalf because people are now being mean. Review of the facility abuse log since did not show any entries for resident #1 over the past 3 months, including June 2024. On 8/07/24 at 2:46 PM, the Social Services Director stated she was the Grievance Officer. She shared the grievance process included reviewing the new grievances, assigning the grievance to the appropriate department and ensuring they were resolved within five days. Later on 8/08/24 at 4:40 PM, the SSD reviewed resident #1's grievance dated 6/10/24. The Social Services Director read the grievance out loud as requested by the surveyor. When she finished reading the statement, she stated resident #1's BIMS was zero, which indicated her cognition was severely impaired. She indicated the grievance form was completed by her assistant, but she was also in the office when the call came in. The Social Services Director stated she mentioned the grievance the next morning in their daily meetings with the Administrator and other management, but she did not discuss the concerns thoroughly. She explained the only thing discussed during those meetings was a new grievance was received for resident #1 and which was given to the Unit Manager for follow up. When asked, the Social Services Director stated she did not know who the abuse coordinator was. She did not consider this grievance an abuse allegation because it was not that a CNA hit her. The SSD re-read the grievance and acknowledged it described verbal abuse, but said this was one sided, because her mom doesn't talk. She added, In that instance, who are we to believe? It is all one sided because her mom doesn't talk. On 8/07/24 at 4:53 PM, the Administrator joined the interview with the Social Services Director and indicated he was the abuse coordinator. He stated he was, a little confused when he read the grievance dated 6/10/24. The Social Services Director interjected and said resident #1 did not talk. The Social Services Director told the Administrator the grievance was about the daughter saying what allegedly resident #1 told her. The Administrator read the grievance out loud. He stated he did not recall if he learned about this grievance before. He explained abuse could be physical or verbal. He added, Sounds like that could be a verbal abuse allegation that we would investigate. He explained they would have tried to identify the CNA and suspend her/him and filed an immediate report for verbal abuse. He indicated the investigation would include interviewing some of the surrounding residents in the CNA assignment or in the same area and concluded submitting a 5-day report with their findings. He stated they took all abuse allegations seriously and reported within the required time frames. Later on 8/08/24 at 5:39 PM, the Administrator stated the Assistant Director of Nursing (ADON) had investigated it quickly and found out there was no Creole speaking staff assigned, to resident #1 on the dates noted. He mentioned the best course of action was to do a customer inservice with staff. When asked for the copy of the staff assignments for that weekend and results of the quick investigation he said the ADON did not keep copies or documentation of what she reviewed. Review of the facility's policy and procedure titled Abuse: Florida, dated 4/01/22, revealed reports of abuse were promptly and thoroughly investigated. The document included abuse allegations were to be reported per Federal and State Law, immediately but not later than two hours after the allegation was made if it resulted in serious body injury or not later than 24 hours if no serious body injury occurred. The document indicated the facility was required to comply with external reporting requirements including the State Agency and law enforcement. Review of the facility's policy and procedure titled Grievance Program, dated 4/01/22, revealed concerns related to alleged abuse would be handled according to state and federal guidelines.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to respiratory care, pressure ulcer care, nurse staffing postings and kitchen sanitation. Findings: Cross reference F686, F695, F732 and F812 Review of the facility's survey history revealed repeat deficiencies related to the delivery of oxygen per physician orders, provision of preventive care for pressure ulcers, retaining and posting of daily nurse staffing sheets and the cleanliness and sanitation of the kitchen during the current survey ending 1/11/24. Past deficiencies revealed systemic concerns with comparable findings on the previous recertification survey of 5/31/22 for pressure ulcer care and prevention, posting and retaining of daily nurse staffing forms, and following physician orders for oxygen delivery. As well as a repeat deficiency for sanitation of food surfaces in the kitchen from a recent complaint survey on 12/14/23. Review of the Quality Assurance and Performance Improvement (QAPI) Policy and Procedure with most recent revision date of April 2022 revealed the purpose and guidelines for implementation, To provide continuous evaluation of (company name) systems with the objectives of keeping systems functioning satisfactorily; preventing deviation from care processes; discerning issues and concerns; providing points of accountability for ensuring quality of care and quality of life; allowing the Facility to deal with quality deficiencies in a confidential manner; and correcting inappropriate care processes. The document further described QAPI as a multi-level management process that must be ongoing and facility wide. The procedure section detailed the facility's QAPI would take action aimed at performance improvement and would prioritize problem prone areas. The document further described the facility would measure the success of the improvements and track the performance to ensure they were realized and sustained. On 1/11/24 at 4:11 PM, a meeting was held to discuss the facility's QAPI program with the Executive Director of Clinical Services, the Administrator, the Social Service Director and the Director of Nursing. The Executive Director of Clinical Services stated their new company took over the facility in May of 2023 and started a new QAPI agenda in November 2023. She described how their QAPI looked at previous action plans, reports by department heads, mock survey results and review of regulatory compliance in order to determine what areas they would focus on. The Administrator stated QAPI went over a lot of things and gave him a recap of those things to which he gave his input. He stated he was unaware of what concerns or citations the facility had on the last survey. The group was asked how they ensured the work of the QAPI program was effective to prevent repeat deficiencies? The Administrator then stated they were very aware of past survey history and what was received. He explained the committee knew there were previous concerns with pressure wounds but was not able to provide an explanation of what the committee did to ensure previous concerns were not a continued problem. The Administrator and the Executive Director of Clinical Services acknowledged the facility was unaware of the concerns brought to their attention over the course of the current survey which included repeat deficiencies. They were unable to give an explanation as to how the facility QAPI ensured any problems identified and addressed by the committee were realized and sustained.

Based on group interview and record review, the facility failed to ensure group grievances were acted upon promptly and provide a response and/or possible solution to group concerns for 6 months reviewed. Findings: During the Resident Council meeting held on 01/08/24 at 2:04 PM, members of Resident Council confirmed they met monthly. The members in attendance stated they were frustrated and upset about grievances that had not been resolved regarding dietary, staffing, and staff speaking other languages. All residents in attendance agreed they had the same concerns and their grievances had not been addressed. The residents stated the eggs served to them were uncooked and were not real eggs; eggs were cold, liquid and runny; portion size was small; the meals did not match the meal ticket; hot food was served cold; and food trays did not close properly for food to stay hot. They noted it took 10 to 15 minutes after the food carts arrived on the unit for the staff to pass out the meal trays. They explained there was no team work with the staff. If Certified Nursing Assistants (CNAs) were busy, there was no other staff to distribute the meal trays and the trays remained in the cart until the CNA was ready to pass them out. They discussed that at times there was no protein with their meal, only starch accompanied by more starch and carbohydrates. The Resident Council President stated the dietary manager attended the meetings sometimes and discussed he was working on the issues but there had been no changes. The Resident Council members discussed issues with staffing and noted there was a high turnover of staff and reported there was not enough time for the CNAs to care for all their assigned residents. They explained on several occasions they had to wait more than three hours for their call lights to be answered and call light response times were worse during nights and weekends. Sometimes they had to telephone the front desk from their cellular phones or room phones to have the front desk page the CNA to their rooms. The residents stated when CNAs were not available, they requested help from licensed nurses but some of the nurses were not willing to help saying it was not their responsibility. They stated some nurses were not able to understand them as they did not speak much English. They explained they had to use gestures and their basic knowledge of Spanish to explain what they needed. Residents indicated they spoke to Social Services, the Administrator and the Assistant Director of Nursing about this issue but there had not been any resolution. Some residents recalled they received the wrong medication due to the nurses not being able to speak English and nothing was done to correct the error. Resident Council members discussed lack of activities and reported the facility did not offer variety of activities. They said they spoke to the Activities Director who made them aware there was no budget for supplies. Some residents stated they did their own activities such as card games and bingo. Review of Resident Council minutes from May 2023 to December 2023 revealed several repeat grievances concerning staffing, dietary, call lights, and activities.

Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative, and the Ombudsman for 6 of 6 residents reviewed for hospitalization s of a total sample of 57 residents, (#6, #83, #567, #33, #98 and #46). Findings: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included seizures, impulse disorders, anxiety disorder, mood disorder. A nurse's progress note dated 5/18/23 indicated resident #6 was aggressive with other residents by the smoking door. The nurse described resident #6 as having to be restrained and law enforcement was called for assistance. Further review of the medical record revealed the Psychiatric Advanced Practice Registered Nurse (APRN) signed a form for involuntary inpatient placement after she assessed resident #6 to be a risk to others in the facility and required transfer to a higher level of care. Review of resident #6's medical record revealed no written Notification of Transfer or Discharge form for the hospitalization , nor documentation of notification to the state Ombudsman. 2. Resident #83 was admitted to the facility on [DATE] with diagnoses that included disturbed brain function, anxiety disorder, mood disorder due to unknown psychological condition, stroke and Lyme disease. Review of resident #83's medical record revealed a nurse's note dated 5/10/23 that noted due to psychosis and agitation, the physician recommended the resident be transferred to a behavioral health hospital due to dangers posed to himself and others. A form for involuntary inpatient placement was signed by the Psychiatric APRN to transfer resident #83 to a higher level of care due to his aggressive behaviors that were unable to be stabilized at the facility. Review of resident #83's medical record revealed no written Notification of Transfer or Discharge form for the hospitalization , nor documentation of notification to the state Ombudsman. 3. Resident #567 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, traumatic brain injury, seizures, and psychotic disorder with delusions. On 5/13/23 a social service department note detailed resident #567 physically attacked a staff member, punching them multiple times in the face and head. Review of the medical record revealed a form for involuntary inpatient placement was signed by the Psychiatric APRN to transfer resident #567 to a higher level of care due to uncontrolled impulses, mania, delusions and psychosis that made him a threat to the safety of himself and others. The medical record did not contain a written Notification of Transfer or Discharge form for the hospitalization , nor documentation of notification to the state ombudsman. 35086 4. Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His diagnoses included fractured femur, orthopedic aftercare, and anemia. Review of resident #46's medical record revealed a nursing progress note dated 12/13/23 that noted he was hospitalized for a change of condition, Pain [uncontrolled] and the primary provider instructed to send to the hospital. The facility Transfer to Hospital form dated 12/13/23 indicated unplanned transfer due to recent fall on 12/8/23. Review of the hospital record dated 12/13/23 revealed his principal problem was fractured femur due to fall 5 days ago at SNF (Skilled Nurse Facility). The medical record did not contain Nursing Home Transfer and Discharge Notice form for this hospitalization . On 1/11/24 at 1:40 PM, the facility Nursing Home Administrator stated he was not aware who was responsible for completing the Nursing Home Transfer and Discharge Notice form and notification to the Ombudsman when a resident was transferred to the hospital. 45646 5. Resident #33 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, type 2 diabetes, emphysema, chronic pulmonary edema and atrial fibrillation. Review of resident #33's medical record revealed he was hospitalized on [DATE] due to rectal bleeding and again on 9/17/23 due to pain in left side. The medical record did not contain Notification of Transfer or Discharge forms for the hospitalization s on 6/06/23 and 9/17/23. 6. Resident #98 was admitted to the facility on [DATE] with diagnoses including sepsis, cholecystitis, occlusion and stenosis of right carotid artery, chronic respiratory failure, type 2 diabetes and brain compression status post craniotomy Review of resident #98's medical record revealed she was hospitalized on [DATE] after being found unresponsive. The medical record did not contain Notification of Transfer or Discharge forms for the hospitalization . On 1/10/24 at 9:55 AM, the Social Services Director (SSD) stated she completed the Notice of Transfer or Discharge forms for residents who discharged to the community, but not for residents who transferred to the hospital. She explained she was not aware the forms needed to be completed for residents who went to a higher level of care. She stated she had not completed any since she was hired in May 2023 nor had she notified the Ombudsman of those transfers. The SSD was unable to identify who completed the Notice of Transfer or Discharge forms for residents who were transferred to the hospital. On 1/11/24 at 1:40 PM, the Nursing Home Administrator explained he did not realize facility initiated transfers required the form to be completed and provided to the resident or resident representative. On 1/11/24 at 2:22 PM, the Social Services Director verified she had not completed Nursing Home Transfer and Discharge Notice forms which included notification to the Ombudsman since she started working at the facility on May 29, 2023. She stated she was unable to locate the Notice of Transfer and Discharge Forms for any resident transferred to the hospital since May 2023. The facility's policy and procedure for Resident Transfer and discharge date d April 1, 2022 read, Before the Facility transfers or discharges a resident, the Facility shall, in a written notice: Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The Facility must send a [NAME] of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to prevent worsening of contractures for 1 of 1 residents reviewed for limited range of motion, out of a total sample of 57 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (brain dysfunction), paraplegia, stroke, and contractures of all extremities. A contracture is limited movement of a join caused by shortening or contracting of muscles in the arms or legs due to inactivity or inability to move. Contractures are prevented and treated by regular movement and range of motion or stretching exercises, and use of splints to maintain a contracture in a stretched position (retrieved on 1/17/24 from www.drugs.com/cg/contracture-ambulatory-care.html). The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/28/23 revealed resident #44 had severely impaired cognitive skills for daily decision making. The document showed the resident exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment revealed the resident had contractures and was totally dependent on staff for self-care and mobility. Review of Section O, Special treatments, Procedures, and Programs, showed resident #44 did not receive any Restorative Nursing Program (RNP) services including range of motion exercises or assistance with splints in the 7-day lookback period. Review of the medical record revealed resident #44 had a care plan initiated on 7/29/20 for activities of daily living self-care performance deficit related to limited mobility and limited range of motion. The goal was the resident would maintain her current level of function. An intervention dated 4/20/23 revealed RNP staff were to perform passive range of motion (PROM) exercises for the resident's shoulders, wrists, and fingers as tolerated, and apply left and right hand and elbow splints for four to six hours as tolerated. Review of an Occupational Therapy Discharge Summary dated 10/1023 revealed resident #44 was on Occupational Therapy caseload from 9/01/23 to 10/08/23. She was discharged and referred to the RNP when she achieved her maximum potential. The document indicated therapy staff instructed RNP staff on conducting skin checks and the schedule for application of the resident's splints .in order to preserve current level of function. The discharge summary indicated resident #44's prognosis was excellent with participation in the RNP for bilateral hand and elbow splints. Review of Restorative Nursing Program Instructions dated 10/09/23 revealed resident #44's RNP goal was PROM to her bilateral upper extremities with splint applications, three times weekly. The program activities included instructions to perform PROM on all joints to the resident's end range, three sets of ten, with a 3-second hold for each, in preparation for splinting. The documents indicated bilateral resting hand splints and bilateral elbow splints were to be worn for four to six hours as tolerated, and skin checks performed pre and post splinting. The RNP instruction form was signed on 10/10/23 by Restorative Aide F to verify she received training on the RNP requirements for resident #44. On 1/07/24 at 2:52 PM, resident #44's elbows, wrists, and fingers were tightly contracted and held close to her chest. She did not have splints applied, and her long fingernails with sharp edges were pressed into both palms. The Wound Nurse and Restorative Aide F confirmed the resident's fingernails were too long. They explained the resident's daughter usually cut her fingernails but both staff acknowledged facility staff were responsible for contacting the family if the task was not done or to request permission to provide the necessary care. The Wound Nurse and Restorative Aide F validated resident #44's fingernails needed to be cut to prevent injury to her palms and fingers due to her contractures. Restorative Aide F verified skin and fingernail checks should be performed before and after splint application. On 1/07/24 at 3:07 PM, Restorative Aide F showed two hand splints and two elbow splints on the top shelf of resident #44's closet. When asked why the resident did not have the splints applied to her arms, Restorative Aide F explained she had not been able to perform RNP duties for any residents today as she was reassigned at the start of the shift to monitor residents in the the facility's smoking area. She stated resident #44's name had not been on her list of residents who needed splints for a while and only got back on the RNP assignment last week. Restorative Aide F said, I did not do her yesterday as I did not know she was on caseload. I just saw it today. Truthfully, when I had her, I did her as often as I could. My goal was three times a week. She stated the purpose of RNP services was for residents to maintain their abilities. She explained regular splint application was important for residents with contractures as it prevented increased stiffness. On 1/08/24 at 11:12 AM, resident #44 had her splints in place. However, due to contractures of her fingers, the right middle fingernail pressed into the top of her right index finger. The Wound Nurse confirmed the resident's fingernails still had not been cut or filed. On 1/09/24 at 11:21 AM and 1/10/24 at 5:41 PM, the Director of Rehab confirmed resident #44 had significant upper extremity contractures and was seen by Occupational Therapy for management of her contractures related to range of motion and splinting of her elbows and hands. The Director of Rehab said, It is absolutely important for her to wear her splints.We give [RNP] instructions as we want to maintain what we accomplished. She explained the use of splints prevented further contractures, increased range of motion, prevented skin breakdown, and was essential for any resident who had contractures. On 1/10/24 at 5:24 PM, during review of the Documentation Survey Reports, the Assistant Director of Nursing stated resident #44 had her splints applied on six days in October 2023, five days in November 2023, one day in December 2023, and one day in January 2024. The Director of Nursing (DON) confirmed she was the facility's Restorative Nurse and was responsible for the RNP. She stated she met with therapy staff and Restorative Aides once monthly, but she was not aware resident #44's splints had not been applied three times weekly according to therapy recommendations. When asked if she reviewed the flow sheets completed by Restorative Aides, the DON said, Honestly I don't check it. On 1/11/24 at 12:39 PM, Occupational Therapist G stated resident #44 had therapy recommendations for PROM and splinting three times weekly. She explained on Monday 1/08/24, she was informed that RNP staff had not applied the splints as required for three months and she was asked to evaluate the resident's current status. Occupational Therapist G stated her assessment showed resident #44 was no longer able to tolerate her splints for the 4-hour period she achieved on discharge from Occupational Therapy caseload in October 2023. She explained therapists would work with resident #44 until she attained her maximum potential and then she would be referred to the RNP again. The facility's policy and procedures for Specialized Rehabilitative and Restorative Services, dated 4/01/22, revealed the facility would provide restorative services to include range of motion and application of splints and braces as indicated by assessment of the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to provide sufficient licensed nurses on the 7:00 AM to 7:00 PM shift to meet the needs and achieve the goals according to the plans of care for residents on 2 of 2 units, (West and East Wings). Findings: 1. On 1/07/24 at 11:43 AM, Licensed Practical Nurse (LPN) E stood at his medication cart in the hallway outside room [ROOM NUMBER]. The computer screen displayed medication administration tasks in red and LPN E explained the red color indicated the residents' medications were late. He confirmed most of the medications were scheduled for 9:00 AM and should have been given by 10:00 AM at the latest. He stated he was scheduled to work from 7:00 AM to 7:00 PM but came in late for his shift this morning. LPN E explained he was scheduled to work from 7:00 AM to 7:00 PM yesterday, but ended up working until almost 1:00 AM as no nurse showed up to take his assignment. He stated the facility was eventually able to find a nurse from a staffing agency to relieve him, but he was tired after yesterday's unplanned 18-hour shift, so he came in late. On 1/07/24 at 12:00 PM, Registered Nurse (RN) C exited a resident's room and walked towards her medication cart in the hallway. She confirmed she was still administering scheduled 9:00 AM medications. RN C explained she got a late start due to a staffing issue this morning. She stated she was originally assigned to the other medication cart on the unit but her assignment was changed to allow LPN E to return to the assignment he had yesterday. On 1/08/24 at 11:24 AM, RN H stated she just completed administration of her assigned residents' scheduled 9:00 AM medications. She explained she had been on staff for three days so her medication administration process was very slow. RN H acknowledged she had not asked the Unit Manager (UM) or a supervisor for assistance, and she did not notify the physician(s) that medications were administered outside the required timeframe. On 1/09/24 at 10:41 AM, LPN I stood at her medication cart near room [ROOM NUMBER]. She stated she worked for a nurse staffing agency and was unfamiliar with her assigned residents because she had not worked at this facility for about a year. She confirmed she was still administering residents' scheduled 9:00 AM medications. LPN I checked her computer and counted 14 residents' names displayed in red on the screen. She acknowledged their medications still had to be administered. LPN I said, I'm late as there are a lot of residents. On 1/09/24 at 10:47 AM, the [NAME] Wing UM stated she was not aware a significant number of residents' medications were administered outside the acceptable range of one hour before or one hour after the scheduled time. She acknowledged sometimes nurses might be delayed when they had to locate residents who were not in their rooms, for example, those who required close supervision in the unit's common area. She said, That takes more time. When asked if she ever assisted with medication administration in the mornings, the [NAME] Wing UM stated she did not. She explained she assisted nurses with paperwork or notification of the physician if there was an incident such as a fall. She stated the unit's census was 65 residents and there were two licensed nurses assigned to the care for them. The [NAME] Wing UM confirmed each nurse was therefore tasked to medicate 32 to 33 residents within a 2-hour window. She acknowledged it was not possible due to the number of residents and the quantity of medications, and another nurse would be helpful. The [NAME] Wing UM denied knowledge of any current plans in place to solve the problem. On 1/10/24 at 11:50 AM, LPN E stood at his medication cart and confirmed he was still administering scheduled 9:00 AM medications. He said, Only two left, so will finish by 12:00 PM. This assignment is heavy, especially for morning med pass. Lots of pills. Definitely needs three nurses to complete med pass on time. On 1/09/24 at 1:30 PM, during review of the facility's Grievance Log with the Social Service Director (SSD), she discussed a grievance related to late administration of medications. She stated a resident's family member reported on 1/07/24 that scheduled 9:00 PM medications were not given until 12:00 AM. The SSD verified the issue occurred on the [NAME] Wing and said, We are aware that side is a little heavy. 48878 2. On 01/07/2024 at 2:35 PM, RN C stated she was responsible for 34 residents on the [NAME] Wing. She had been assigned to a maximum of 35 residents. She acknowledged that her workload was heavy and it was difficult to manage the resident's 9:00 AM medication pass. She noted majority of the 34 residents had their medications scheduled at 9:00 AM, and some residents did not receive their medications on time. On 01/09/2024 at 10:40 AM, RN D stated her workload was difficult, managing 34 residents on the [NAME] Wing. The highest number of residents assigned to her was 38. RN D confirmed the morning medication passes were very challenging due to the number of residents scheduled to receive 9:00 AM medications. She acknowledged she did not complete her 9:00 AM medication pass timely and some residents received their medications late. On 01/10/2024 at 9:34 AM, the Director of Nursing (DON) stated the nurses on the [NAME] Wing Long Term Care (LTC) Unit had a maximum of 35 residents on their assignment. The nurses on the East Wing were assigned a maximum of 25 residents. She explained the level of staffing required for each unit was based on census, acuity, and resident's needs. She noted workload concerns brought to her attention were discussed with the Assistant Director of Nursing (ADON) and the Administrator. The DON acknowledged she received a grievance from a resident's family member via email on 12/15/23 that indicated resident # 25 received her medications late. On 12/18/23, the DON witnessed the administration of medications to residents and reviewed the Medication Administration Records (MAR). She stated they identified the residents on the [NAME] Wing received their medications a couple of hours late. She stated she was aware of the excessive number of residents scheduled to receive their medications simultaneously. The DON expressed concern for the nurses' workload and recognized there was a need for additional staff. The DON said she discussed her findings with the Administrator, and the Administrator agreed with the need for additional staff. The DON explained while in the process of recruiting new nurses to ensure residents' needs were met, they had only two nurses managing the unit's workload. The DON confirmed the facility had a new medication cart since December 2023, however, there was a lack of facility staff to utilize the new medication cart to support the nursing team. The DON acknowledged that she and the Administrator jointly decided against hiring agency staff in the interim of hiring new nurses because of the cost. On 01/10/24 at 1:28 PM, LPN E stated he had 31 residents on his assignment on the [NAME] Wing. He articulated it was very difficult to manage the morning medication pass as almost all his 31 residents had their morning medications scheduled at 9:00 AM. He confirmed that some of the residents did not receive their 9:00 AM medications until 12:00 pm which coincided with their afternoon medications. He noted that despite voiced concerns about the unmanageable workload and its impact on the timely administration of resident medications, management had not provided any feedback, and no action had been taken to address the issue. Review of the Facility Assessment Tool updated on 10/18/23, revealed a factor that the facility must take into account is the acuity of the resident case mix that needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental and psychosocial well-being. The facility assesses the needs for all residents on an individual level and assigns direct care staff accordingly. Review of the Nursing Home Administrator's job description revealed the administrator implements operational and financial objectives of Management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident. Review of the Director of Nursing's (DON) job description revealed the DON develops staffing plans that assure sufficient numbers of qualified, competent nursing staff to meet direct care needs, conducts assessments as required, develops plans of care, evaluates residents' responses to interventions and documents effectively in compliance with state and federal requirements. Recommends numbers and types of nursing personnel necessary to provide care and to maintain compliance with facility mission and with regulations. Hires and retains qualified competent nursing staff to provide nursing and nursing related services to attain or maintain highest practicable physical, mental and psycho-social well-being of each resident.

Based on observation, interview, and record review, the facility failed to implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 10/15/23 at 4:25 AM, the facility failed to prevent a moderate cognitively impaired resident from exiting the facility unsupervised. Resident #1 exited the facility through the front door by holding the emergency push bar for 15 seconds which activated the door alarm but the red screamer alarm did not sound. Certified Nursing Assistant (CNA) B disengaged the door alarm at 4:37 AM without initiating a search and did not alert other staff of the alarm. Resident #1 walked approximately 707 feet to the sidewalk adjacent to a 6-lane, moderately trafficked road. She proceeded down the side walk and walked approximately 2.2 miles in the dark, crossing two major intersections and a drainage ditch. The resident crossed the 6-lane road and was found by law enforcement in front of a closed fast-food restaurant. The facility was unaware of resident #1's whereabouts until she was located at approximately 6:15 AM in front of the fast-food restaurant. The facility failed to ensure resident #1 was adequately supervised, failed to initiate appropriate interventions for a door alarm and failed to monitor the front lobby door to ensure vulnerable residents did not exit the facility without supervision. The weather at 5:01 AM on 10/15/23 was 71 degrees Fahrenheit (F) and sunrise occurred at 7:26 AM. (Retrieved from www.timeanddate.com on 11/08/23). There were a total of 9 residents who were identified at risk for elopement at the time of the survey. The facility's failure to implement appropriate interventions and to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/15/23 and was removed on 10/18/23. The scope and severity of the deficiency was decreased to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was a [AGE] year-old, admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included metabolic encephalopathy, presence of cardiac pacemaker, atrial fibrillation, psychosis, major depressive disorder and cognitive communication deficit. Review of the hospital records revealed resident #1 was hospitalized on [DATE] for chest pain. A psychiatric assessment conducted at the hospital indicated resident #1 did not have the capacity to participate in the informed consent process for medical decisions. Review of the Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) of 8/17/23 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated moderate cognitive impairment. The document showed she required supervision and assistance of one staff member for mobility and did not use any mobility devices. The assessment noted resident #1 did not wander and did not use a wander/elopement alarm. Review of the medical record revealed an Elopement Risk Evaluation dated 8/13/23 that indicated resident #1 was alert and oriented, happy with placement and did not have a history of elopement attempts. Review of resident #1's care plan for impaired cognitive function or impaired thought processes related to encephalopathy initiated 8/16/23 included interventions to cue, reorient and supervise as needed. A falls risk care plan initiated 8/14/23 included interventions to keep room well lit, provide verbal reminders not to transfer or ambulate without assistance and to provide assistance as appropriate to meet resident's needs. A progress note dated 9/01/23 read, Resident was exit seeking and removed her [electronic wandering device]. Review of the medical record revealed no evidence of a change in condition evaluation, an Elopement Risk Evaluation, a wandering/at risk for elopement care plan or any further progress notes to address the change in behavior. Review of nursing progress notes revealed resident #1 was transferred to the hospital on 9/06/23 due to complaints of chest pain. She was readmitted to the facility on [DATE]. Review of the hospital record from resident #1's admission on 9/06/23 revealed a psychiatric assessment dated [DATE] which read, Patient is expressing a choice over where she wants to live, but her decision-making seems impaired in regards to understanding this decision, appreciation of the risks and benefits of the decision and rationale for her choice. Treatment team also reports patient may have been wandering the streets alone in the middle of the night when she lived independently in New York. Another psychiatric assessment conducted 9/10/23 indicated the resident informed the provider, They wanted to put a bracelet on my leg and I was not allowing that. Resident was noted to be restless, fidgety, mildly agitated, uncooperative and confused with poor attention span and easily distracted. Throughout the hospital stay, resident #1 stated several times she did not want to return to the rehabilitation center. She wanted to go home to New York. An Elopement Risk Evaluation dated 9/13/23 indicated resident #1 was fully ambulatory and wandered aimlessly. The elopement assessment score was 14 which indicated she was an elopement risk. The document indicated safety measures implemented included a wander bracelet/roam alert. Review of the medical record revealed no order for use of a wander/elopement alarm, a wandering/at risk for elopement care plan or any further progress notes to address resident #1's wandering behavior. The medical record did not contain any evidence the wander bracelet was ever implemented. Review of the MDS 5-Day Medicare assessment with ARD of 9/17/23 revealed resident #1 had a BIMS score of 9 out of 15 which indicated she had moderate cognitive impairment. The document indicated she now required limited assistance of one staff member for mobility and used a walker. The document indicated resident #1 did not wander but did not indicate if she used a wander/elopement alarm. A nursing progress note dated 10/15/23 read, the Director of Nursing (DON) was notified resident #1 left the building unsupervised at approximately 5:30 AM on 10/15/23. Resident was agitated and aggressive after she returned to the facility. Her physician ordered her to be sent to the hospital for evaluation due to altered mental status. On 11/06/23 at 10:08 AM, during a telephone interview, Licensed Practical Nurse (LPN) D verified resident #1 eloped from the facility on 10/15/23. She said she was assigned to resident #1 on 10/15/23 and the resident was confused and wandered around the unit. LPN D recalled seeing resident #1 in the front lobby between 10:00-11:00 PM and instructed the resident to go back to her room and she did. LPN D recalled she went to the resident's room around midnight and did her vital signs. She remembered seeing resident #1 in bed at about 3:00 AM. She explained that when she went to the resident's room to administer medications at 5:30 AM, the resident was not there. LPN D stated she began looking for her and asked staff if anyone had seen her. She reported a staff member told her to look in the front lobby. LPN D reported when she got to the front lobby, she noted the front door had a blinking light which indicated someone had gone out the front door. She recalled there were no alarms sounding at the time. She verified the door also had a red screamer alarm box which was not making any noise. LPN D stated she alerted everyone and a search began as well as notification to the DON. She explained she had only worked with the resident for about a month and was sure she did not wear an electronic wandering device. She could not recall exactly where the resident was located but remembered it was down the street away from the facility. LPN D stated when resident #1 returned to the facility, she was very agitated and tried to get out again. On 11/05/23 at 11:29 AM, the Maintenance Assistant verified the facility had security cameras and captured some of the events of 10/15/23 when resident #1 left the building. He explained the camera in the front lobby detected motion and recorded, but stopped recording when there was no motion. He stated the front door had an electronic alarm system which would automatically lock if a resident with an electronic wandering device came near. He did not know if resident #1 had a wander device. The Maintenance Assistant showed the surveillance video dated 10/15/23 that showed resident #1 entered the front lobby at 3:30 AM. The resident then sat on the sofa just outside of the camera range. At 3:37 AM, CNA B entered the front lobby and proceeded to the doorway that led to the back maintenance hallway. She returned back into the font lobby at 3:40 AM and proceeded back down the hallway to the left into the facility. At 3:52 AM, resident #1 stood up and proceeded down the hallway into the facility while pushing her wheelchair. At 3:57 AM, the resident entered the front lobby and sat on the sofa just out of sight of the camera. At 3:59 AM, CNA B again entered the lobby from the hallway carrying a food tray and entered the door to the maintenance hallway. She returned at 4:01 AM and spoke to resident #1 which could not be heard due to the camera not having audio. At 4:24 AM, resident #1 stood up and walked toward the front exit door without her wheelchair. She approached the door and attempted to enter a code on the keypad. At 4:25 AM, she pushed on the release bar to open the door. The camera skipped to 4:26 AM when a pharmacy delivery person entered through the front door. At 4:37 AM, CNA B disengaged the door alarm at 4:37 AM without initiating a search. At 5:57 AM, facility staff were seen looking in the office and out the front door for resident #1. At 6:31 AM, Registered Nurse (RN) C exited the back door of the maintenance hallway that led to the back parking lot. At 6:55 AM, RN C returned through the back door with the resident and Director of Nursing. The Maintenance Assistant explained the resident had pushed on the exit door's release bar for 15 seconds which then released the door as it was a fire exit door. He explained a breach alarm would have sounded and the door would remain unsecured until a code was entered to reset the door. On 11/06/23 at 1:48 PM, Cook A verified she worked on 10/15/23. She recalled as she drove to work, she saw a woman standing close to the street. Cook A explained the woman was on the same side of the street facing oncoming traffic and was very close to the traffic. She stated she moved over into the far-left lane because she was afraid she would hit the woman if she walked into the street. Cook A recalled she arrived at work a few minutes after 5:30 AM and began to prepare breakfast. She stated she was approached by a staff member who said a resident was missing. Cook A told the person she saw a woman down the street but did not know if she was the missing resident. Cook A confirmed she traveled that way regularly for work. She stated it was fortunate the resident was found as it was not safe to walk around on the street after dark. She remarked, There are a lot of crazy people on the street. On 11/05/23 at 11:17 AM, Receptionist E stated she was not working at the time resident #1 eloped from the facility. She verified there was a red screamer alarm on the front door and recalled that alarm being installed several months ago. Receptionist E explained the front door also had an electronic alarm system that would lock the door if a resident with an electronic wandering device approached. She stated the evening receptionist was responsible for engaging the red screamer alarm at night at the end of the shift. On 11/06/23 at 5:37 PM, Receptionist F acknowledged she worked evenings and weekends. She stated she was responsible for watching who came in and went out of the facility. She explained she had to make sure everyone signed in and out including residents. Receptionist F validated the front door had an electronic alarm system that would sound if a resident wearing an electronic wandering device got close to the door. She explained the door locked and would not open. She stated the alarm could be silenced once the resident moved away from the door. Receptionist F reported her shift ended at 9:00 PM. She stated her normal routine was to announce the lobby would close at 9:00 PM to alert visitors. She stated at 9:00 PM, it was her responsibility to engage the red screamer alarm, pull down the metal door that closed the reception desk off from the lobby, and forward incoming telephone calls. Receptionist F insisted she had a set routine and was certain she turned on the red screamer alarm before she left. On 11/06/23 at 11:56 AM, the Social Services Director (SSD) stated she spoke with resident #1's son and was told the resident lived alone in New York. She was hospitalized in New York and told she would be placed in a nursing home. The son said he brought her to live at his home but she became aggressive with him. The SSD recalled resident #1 told her son she wanted to go back to New York. The SSD acknowledged she was aware of resident's hospitalization on [DATE]. She explained she advised the admission department not to re-admit resident #1 because she did not want to be here. The SSD reviewed the psychiatric evaluation done in the hospital on 9/07/23 and noted she had not seen that evaluation before. She acknowledged resident #1 should have been listed as an elopement risk and interventions implemented. The SSD could not say if staff discussed resident #1 being an elopement risk in daily morning meeting or in clinical meetings. The SSD recalled she received a call from the DON the morning resident #1 got out of the building. She said she spoke with the resident after she returned to the facility and the resident told her she just wanted to get out and left through the front door. The SSD explained the police were with resident #1 by the time the facility staff got there. She obtained a report number from the police but had not requested a copy of the report. On 11/06/23 at 4:04 PM, the Rehabilitation Director stated resident #1 was on caseload from 9/13/23 through 10/12/23. The Director reported resident #1 was able to ambulate with moderate assistance meaning she either needed an assistive device or just needed more time to ambulate. She stated resident #1 was cognitively impaired and disoriented to situation. She recalled she was fixated on going back to New York. On 11/07/23 at 10:23 AM, the MDS Coordinator verified a care plan for wandering and at risk for elopement was not initiated until 10/15/23, the date resident #1 eloped. She reviewed the care plan history and acknowledged no care plan was in place prior to that date. The MDS Coordinator reviewed psychiatric note dated 9/07/23 from the hospital and Elopement Risk Evaluation completed by the facility on 9/13/23 which indicated resident was an elopement risk. The MDS Coordinator did not explain why a care plan was not developed at the time resident #1 was identified as a wandering/elopement risk. She clarified the Unit Manager usually reviewed the assessments and evaluations completed by the nurses and added, This one got missed, unfortunately. In a telephone interview on 11/03/23 at 2:14 PM, resident #1's son stated he brought his mother to live with him this past summer. He conveyed she lived independently in New York but one morning, she left her home in South Manhattan and was found in South Bronx at 2:30 AM. He recalled he was contacted by the police and told he either had to come get her or she would be placed in a nursing home in New York. Resident #1's son stated she was always trying to leave to go back to New York. He recalled a time when she got into a car with strangers and asked them to take her to the bus stop. He stated she would get in the car with anyone. He explained he lost his job because he had to stay home with his mom to take care of her and be sure she did not leave and get lost. He reported she had only been with him for 3 weeks when he realized he could not care for her and started a search to to place her in a facility. He confirmed he was contacted about his mother leaving the facility on 10/15/23. He recounted the facility told him she snuck behind a visitor and went out the door when they buzzed the visitor out. He recalled he was told she got down the road less than a mile away. He expressed he did not know how she made it that far down the street. He stated she was constantly falling and had fallen twice while living with him as she was unsteady on her feet. He verbalized she would not be safe outside by herself. He stated the facility should have known about her wandering as it was in all the hospital paperwork. He reported she was transferred to the hospital after she eloped from the facility. He explained she kept trying to get out of the hospital and they had to restrain her. He stated she was sent to a nursing home that had a secure unit. He said he was in agreement and felt it was safer for her to be in a secured unit. On 11/07/23 at 4:56 PM, the Regional Director of Clinical Services stated the facility identified several areas of opportunity for improvement during their investigation. She noted the nurse who documented resident #1's exit seeking behavior failed to complete a change in condition assessment and an elopement risk evaluation, did not notify the physician of a change in behavior and did not initiate any interventions to keep the resident safe. She explained the the nurse who completed the Elopement Risk Evaluation on 9/13/23 failed to implement elopement risk interventions, did not notify the physician or management team and did not document any actions after she identified elopement risk. She noted the Interdisciplinary Team (IDT) failed to review hospital documentation, progress notes and the medical record for newly admitted or readmitted residents which resulted in failure to implement appropriate care plan and interventions. The Regional Director of Clinical Services stated the facility also determined that staff failed to respond appropriately to the door alarm. She explained they observed on the video that CNA B turned off the door alarm on 10/15/23 at 4:37 AM, without checking if a resident got out and did not alert any staff to the alarm. She explained the Quality Assessment and Performance Improvement committee determined the Root Cause of the elopement were failures to properly assess and identify resident #1 as an elopement risk, and failure to implement appropriate interventions for the risk and failure to follow elopement protocols. Review of the policy and procedure Elopement revised 10/24/22 revealed a purpose to assure the safety and security of all residents. The document directed staff to assess the resident status upon admission and quarterly thereafter to determine if the resident should be considered at risk for elopement. Prevention protocols should be followed and documented on the care plan for any resident identified as at risk for elopement. The document identified several multi-faceted interventions for resident at risk which included identifying information being placed in the elopement binder, increased supervision and implement and/or update care plan for the resident. On 10/15/23 at 5:30 AM, resident #1's probable elopement route was re-traced. She exited the facility's front lobby door and turned right, walked through the parking lot, and left the property. Resident #1 walked approximately 707 feet to the sidewalk adjacent to a 6-lane, moderately trafficked road. She turned left and proceeded down the side walk approximately 2 miles crossing two major intersections and a drainage ditch. The resident crossed the 6-lane road where she was stopped by law enforcement in front of a closed fast-food restaurant. Observation of the probable route revealed a dense commercial area with restaurants, offices, gas stations and stores. The 6-lane road had two major intersections where the 6-lane road converged with another 6-lane road with additional turn lanes on each side. Historical weather data revealed on the morning resident #1 eloped, 10/15/23, the temperature at 5:01 AM was 71 degrees Fahrenheit (F) and mostly cloudy. Sunrise occurred at 7:26 AM (retrieved on 11/08/23 from www.timeanddate.com). Review of the Facility Assessment Tool revealed the facility accepted and could care for residents with psychiatric and mood disorders including psychosis, impaired cognition, depression, anxiety, and behaviors that needed intervention. The document indicated the facility provided person-centered care including identification of hazards and risks for residents. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/15/23 at 5:30 AM, resident #1 was discovered missing and the facility implemented its elopement policy and procedures. *On 10/15/23 at 6:55 AM, resident #1 returned to the facility with facility staff. She was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on 1:1 supervision. *On 10/15/23, resident #1 was re-evaluated for elopement risk and a comprehensive care plan was initiated due to her increased risk. *On 10/15/23, the facility re-evaluated all residents' elopement risk and there were no newly identified concerns. A quality review audit of the 9 residents who were at risk for elopement revealed no concerns related to their electronic wandering devices, care plans and physicians' orders. The elopement binders were reviewed to ensure identified residents at risk were in the books. *On 10/15/2023, Plant Operations checked all doors and alarms center wide for proper functioning. A new red screamer alarm (keyed alarm) was installed on the double doors between the west wing and the front lobby. All red screamer alarms were labeled with on and off positions identified facility wide. *On 10/15/2023, the facility initiated 24-hour front door coverage to monitor the front lobby exit door. *On 10/15/23, the facility held an ad hoc QAPI meeting and conducted a Root Cause Analysis and reviewed recommendations to develop a plan for correction to include education, post-tests, drills and audits. The ad hoc QAPI committee including the Medical Director (via telephone) approved the recommendations. *On 10/17/2023, the facility reviewed hospital medical records and resident/family interviews for all new admissions in the last 30 days to ensure identification of potential elopement risks. *On 10/18/23, the facility held an ad hoc QAPI meeting to evaluate the plan put into place on 10/15/2023. Education, actions taken and audits were reviewed. The ad hoc QAPI committee including the Medical Director approved the current plan and recommendations for continued education and audits. *From 10/15/23 to 10/18/23, licensed nurses were re-educated on accuracy of elopement risk evaluations and providing appropriate supervision for residents with wandering or exit seeking behaviors. Education included completion of accurate elopement evaluations, supervisor notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking. As of 10/18/2023, 22 out of 31 nurses received education, a total of 71%. *From 10/15/23 to 10/18/23, staff were educated on Abuse/Neglect; Missing Residents Policy and Procedures; Elopement and Missing Persons; Response to Door Alarms; and Elopement Post Test were completed. Elopement Drills were conducted on all 3 shifts. As of 10/18/2023, a total of 129 of 138 staff members received elopement education and participated in the elopement drills, a total of 93%. *From 10/15/23 to 10/18/23, the facility completed 9 elopement drills to cover all 3 shifts with satisfactory staff response documented on elopement drill worksheets. *Interviews were conducted from 11/05/23 to 11/08/23 with 22 staff members (8 CNAs representing all shifts, 2 receptionists, 2 RNs, 4 Licensed Practical Nurses, 2 therapists, 2 environmental services, 1 activity staff and 1 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures and supervision of residents at risk for elopement. The resident sample was expanded during the survey to include 4 additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #3, #13, #14, and #15.

Based on observation, interview and record review, the facility failed to provide care and services to prevent the development of a pressure ulcer and shear injury (#10), and failed to ensure application of pressure reducing devices to prevent further skin breakdown (#22 & #55) for 3 of 7 residents reviewed for pressure ulcers of a total sample of 44 residents. The facility's failure to implement preventative interventions consistent with resident #10's risk for skin breakdown, and failure to identify areas of skin injury according to accepted standards of practice resulted in actual harm, development of a stage 3 pressure ulcer to the right ear. Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 3/09/22 revealed resident #10 had severe hearing impairment and did not speak. The MDS assessment indicated she had both short- and long-term memory problems and severely impaired cognitive skills. The resident was incontinent of bladder and bowel, required oxygen therapy and needed extensive assistance from two staff for bed mobility and transfers. The MDS assessment also indicated resident #10 was at risk for pressure ulcers and had one unhealed, stage 4 pressure ulcer. The document listed current skin and pressure ulcer treatments such as a pressure reducing device for the bed, but it did not include a turning/repositioning program. According to the National Pressure Injury Advisory Panel (NPIAP), a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The injury can present as intact skin or an open ulcer and may be painful. The NPIAP defines a stage 3 pressure injury is a full-thickness loss of skin that may have rolled wound edges with fat and slough visible in the wound (retrieved on 3/31/22 from www.npiap.com). Slough is dead tissue, often wet, that needs to be removed from a wound for healing to take place (retrieved from www.woundsource.com on 4/5/22). A skin injury caused by shear or friction occurs when skin is dragged across a coarse surface. Shear is defined as a mechanical force that acts internally on the skin tissue in a direction parallel to the body's surface. These forces can cause older adults to be vulnerable to deeper pressure injuries to their skin (retrieved on 4/04/22 from www.dermatoljournal.com). Resident #10 had care plans for potential impairment to skin integrity related to fragile skin and for a pressure ulcer to her sacrum. The goal was the resident would be free from injury. The care plan interventions directed staff to monitor, document, and report any changes in skin status as needed. The document listed an additional intervention to teach the resident the importance of changing positions for prevention of pressure ulcers and encourage her to make small frequent position changes. However, due to resident #10's cognitive impairment, memory problems and need for extensive assistance for movement, the interventions were not appropriate for the resident. The care plan directed staff to follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan did not include an intervention related to frequently turning and repositioning resident #10 while she was in bed Review of the medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order specified the nurse was to complete a head to toe skin sweep under the assessment tab. On 3/28/22 at 11:03 AM, resident #10 was in bed turned to her left side, and faced the door. She had a nasal cannula, dated 2/25/22, that was connected to an oxygen concentrator. Resident #10's head rested on a pillow and she had a small black scabbed area noted on the cartilage of her right, outer ear. Her hair was pulled back and she had clumps of yellowish, dried crusty substance in her hair above the right ear and also at the crease of her right ear where the tubing of the nasal cannula rested. On 3/28/22 at 12:45 PM, resident #10 remained on her left side facing the door and still wore the nasal cannula dated 2/25/22. Her face was unwashed and there was mucous that drained from her nostrils and accumulated under the nasal cannula. The nasal cannula tubing fit tightly around her neck and there were purple-colored marks on her neck, under the tubing, coming up towards her right ear. On 3/28/22 at 2:05 PM, resident #10's position was unchanged. She still lay on her left side with her head on a pillow, facing the door. The yellow crusty substance remained clumped in her hair above the right ear and the same nasal cannula,dated 2/25/22 was in place. On 3/28/22 at 3:46 PM, during an observation of resident #10 with the East Wing Unit Manager (UM), the resident was in bed and still lay on her left side. The East Wing UM acknowledged the date on the resident's nasal cannula tubing showed it had not been changed for over a month. She explained nurses were expected to change the nasal cannula tubing once weekly on Fridays. She validated there was crusted, yellowish drainage in resident #10's hair above her right ear. The East Wing UM observed the dark colored wound to the resident's outer ear and confirmed she had no previous knowledge of the area of breakdown. She carefully pulled down resident #10's right ear and removed the nasal cannula which was lying in the crease of her upper ear. A wound about the size of a small raisin where the nasal cannula had been resting was identified. The wound was open and draining, with redness noted to the surrounding tissue. The East Wing UM rolled resident #10 to her right side and removed the nasal cannula tubing from behind her left ear and found the skin underneath reddened and moist. She reported she was not aware of the wounds to resident #10's right ear. She explained the resident's last skin assessment would have been performed the past Tuesday, 3/22/22. The East Wing UM explained the wound behind the resident's right ear was at the minimum a stage 3 wound and the wound to the outside of her right ear was unstageable. On 3/28/22 at 4:10 PM, the East Wing UM stated she was unable to find any documentation of skin assessments for resident #10 for the past 10 weeks, since 1/18/22. She confirmed the assigned floor nurses were supposed to perform skin sweeps weekly on the 3 PM to 11 PM shift on Tuesdays as ordered by the physician. On 3/28/22 at 4:20 PM, the Wound Care Registered Nurse (RN) assessed resident #10's wounds. She validated there were purplish marks around the resident's neck, and two wounds to her right ear. On 3/28/22 at 4:26 PM, Certified Nursing Assistant (CNA) C stated she had just completed care for resident #10. She confirmed she washed the crusty substance from the resident's hair. CNA C said checking the resident's skin was part of daily hygiene care and she was aware any skin issues should be reported to the nurse. On 3/28/22 at 5:30 PM, the Wound Care RN described taking resident #10's nasal cannula off to assess the wound to the back of her right ear. She stated she assessed the wound to the back of the right ear as a stage 3 pressure ulcer as it was open and the tissue in the wound was yellow and draining. She noted the wound to the outer ear was an unstageable pressure ulcer as it was blackened. The Wound Care RN recalled she assisted the Wound Doctor that morning during care to the resident's sacral pressure wound. She remembered the resident was turned to her left side. She added that CNAs should turn and reposition the resident to prevent worsening of the existing wound and development of new wounds. The Wound Care RN acknowledged the wounds to resident #10's ear could have been there since the past weekend. On 3/28/22 at approximately 5:35 PM, the Assistant Director of Nursing (ADON) stated CNAs were supposed to wash residents and observe for any skin issues. He explained the expectation was for CNAs to immediately report any changes in a resident's skin condition. He stated the CNAs were to let the nurse know even if the resident's skin was just pink. He indicated that treatments put into place at an early stage could prevent further damage to the skin. The ADON explained CNAs should turn the resident every two hours to prevent skin breakdown because her skin was so fragile and she was at high risk for skin breakdown. He validated the wounds to resident #10's ear should have been identified as part of her hygiene care when the CNA washed her face, including her ears. He explained the floor nurse was supposed to do a whole-body assessment during the skin sweep and confirmed that no skin sweeps were done in the past 10 weeks, since 1/18/22. He validated there was a breakdown in preventative treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated if the CNAs had washed resident #10's face, they should have seen the wounds to her ear and notified the nurse. The ADON agreed the wound was possibly there since Saturday. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:30 PM, revealed an unstageable, pressure type wound 0.2 centimeters (cm) by 0.3 cm by 0.1 cm to resident #10's right ear that was not present on admission. The wound bed was described as 100% dead tissue with no drainage. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:31 PM, revealed a stage 3, pressure type wound measuring 0.5 cm by 0.6 cm by 0.2 cm to the back of resident #10's right ear that was not present on admission. The wound bed was described as yellow slough with redness in the area around the wound. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the medical record revealed the Weekly Skin Integrity Review was actually documented by nurses only 5 times over the 6 months prior to March 2022. The last skin sweep assessment for resident #10, completed on January 18, 2022, indicated her skin was intact on that date. Review of the CNA care plan or Bedside Kardex Report for resident #10 dated 3/31/22, revealed directions for a weekly skin inspection requiring an observation of redness, open areas, scratches, cuts or bruises and to report to nurse and changes. The Kardex report detailed that resident #10 required total assistance from 2 staff for turning and repositioning for bed mobility as necessary, but it did include the required frequency for the task to meet the needs of resident #10 who was at high risk for skin breakdown. Review of the CNA task documentation report revealed no documentation of bed mobility performed on the day shift on 3/26/22, the night shifts on 3/27/22 and 3/28/22 and for the entire day of 3/29/22. On 3/29/22 at 10:15 AM, Licensed Practical Nurse (LPN) B stated she worked with resident #10 on the Friday 3/25/22 evening shift and Monday 3/28/22 day shift. LPN B stated CNAs were to provide care and wash the resident including behind the ears while the nasal cannula was moved. She confirmed the CNA did not notify her of any skin changes, and she was not aware of the wounds to resident #10's right ear. LPN B stated checking the resident's skin was part of the nurse's assessment during her shift. She stated she did not look at resident #10's nasal cannula during the day shift on Monday. She recalled she was too busy and did not look behind resident #10's ears during the shift although it was normally part of her assessment. She explained wounds from a medical device like a nasal cannula might be prevented if kept from resting on the skin by placing a cushion or gauze. She said another intervention to prevent pressure ulcers was frequent repositioning and as the nurse she was responsible to ensure CNAs turned and repositioned residents frequently. LPN B recalled resident #10 was turned toward the door during the day shift on Monday. On 3/29/22 at 12:38 PM, LPN E stated she was familiar with resident #10 as she was assigned to her on the day and evening shifts on Sunday 3/27/22. She explained resident #10 was at risk for skin breakdown and should be repositioned every two hours. She stated she did not check resident #10's skin nor was she informed by the CNA of any skin impairments for resident #10 during either shift. On 3/29/22 at 1:05 PM, CNA A stated she cared for resident #10 on Monday 3/28/22 on the 7AM to 3 PM shift. CNA A explained bed baths included washing the resident's face, body and hair and stated resident #10 needed total care from her. She said she gave resident #10 a bed bath, and combed her hair, but did not wash behind her ears or under her nose where the nasal cannula rested. She explained she thought she was not supposed to touch the nasal cannula, so she did not wash the areas where the cannula rested. CNA A did not explain how she gave the resident a bed bath but did not notice the wound to her outer right ear, the red marks on her neck, the dried drainage in her hair and her injured right ear. CNA A acknowledged resident #10 should be turned every two hours and stated she had turned her. She could not explain how resident #10 was turned every two hours if she was observed on her left side facing the door for 5 hours from approximately 11:00 AM until 4:00 PM during her shift on 3/28/22. She recalled resident #10 had a favorite side and possibly moved herself. However, CNA A then verified resident #10 was unable to move her upper body including her torso, shoulders and head on her own to change positions. CNA A confirmed resident #10's upper body was turned to her left side, towards the door during those hours. On 3/30/22 at 12:07 PM, the Hospice nurse and LPN B were at resident #10's bedside and acknowledged the resident was not able to turn herself. The Hospice nurse noted she performed a complete assessment and resident #10 was barely able to move. On 3/29/22 at 2:05 PM and 2:19 PM, the Director of Nursing (DON) stated the standard of care was for residents to be turned every two hours or more if needed. She identified resident #10 was at high risk for skin breakdown because she was bed bound. The DON verbalized CNAs were supposed to wash behind the ears and under the nose when they provided care to residents. She acknowledged CNA A's statement regarding not washing or looking behind resident #10's nasal cannula. The DON confirmed she assessed resident #10's wounds as unstageable and explained that she always considered anything above the neck as unstageable. The DON stated that turning and repositioning was an area of improvement for the facility. She acknowledged the issue of skin sweeps not being performed per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/22 at 11:34 AM, the Executive Director and DON stated a possible reason the resident was turned to her left side towards the door for approximately 5 hours, from 11:00 AM until 4:00 PM on 3/28/22, was the wound doctor asked for her to be offloaded for the debridement he performed in the morning to the pressure wound to her sacrum. Review of the Order Summary Report dated 3/28/22 at 4:04 PM, revealed no orders for nurses to leave resident #10 on her left side after her procedure that morning. On 3/31/22 at 10:55 AM, the wound physician confirmed he asked the nurse to offload resident #10 due to the debridement procedure he performed. However, he said, I did not give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he expected resident #10 to be turned every two hours as a standard of practice. He explained the ear is different from other parts of the body and could break down quickly because it had very little fatty tissue. The wound physician explained he felt the wound to resident #10's right outer ear was caused by shearing forces when her body was moved without lifting her head. He stated the wound to the back of her right ear was a stage 3 pressure wound. The wound physician said, The nurses should be evaluating them head to toe and looking at them everywhere, behind the ears included. He noted if a nasal cannula was in the same position for a while it needed to be offloaded from the skin to prevent breakdown. The wound physician explained, if you didn't look under something like a nasal cannula you could miss a problem. He elaborated that for most residents, the skin assessment should be done at a minimum weekly, but resident #10's skin should be checked at a minimum daily due to her poor nutrition and high risk for skin breakdown. On 3/30/22 at 1:00 PM, during a telephone interview, the Medical Director stated he assessed resident #10 via video. He stated resident #10 was at high risk for skin breakdown and explained interventions like turning and repositioning were important for prevention. He confirmed the wounds to her ear and stated the nasal canula rubbing around her skin could cause skin breakdown. He explained the nasal cannula around her neck, rubbing the skin likely caused the purplish marks to her neck. He noted the wounds to resident #10's ear would not typically appear on their own and were likely caused from the nasal cannula. The Medical Director stated he expected nurses to do skin assessments at least weekly. Review of the undated document Job Description- Clinical Nurse I, revealed the purpose of the position was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. The document described duties and responsibilities which included the nurse conduct and document a thorough assessment of each resident's medical status throughout their course of treatment, and complete required documentation in an accurate and timely manner. Specific requirements of the Clinical Nurse I included demonstration of knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Review of the Job Description - Wound Care Nurse dated 1/15/16, revealed duties and responsibilities included assistance in implementation and monitoring of compliance with policies, procedures and standards of practice consistent with corporate and external regulatory guidelines, monitoring of accurate and effective documentation, assistance with implementing an individualized treatment plan for each assigned resident. Review of the Policies and Procedures, Clinical Guideline Skin & Wound with effective date 4/01/17 revealed an overview, To provide a system for identifying skin at risk, implementing individual interventions including evaluating and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Procedures included licensed nurse to complete skin evaluations weekly and document in the medical record, CNA to complete skin observations and report changes to licensed nurse, and to develop individualized goals and interventions and document on the care plan and CNA Kardex. 2. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Systemic lupus erythematosus is an [CONDITION(S)] disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels (retrieved on 4/01/22 from www.cdc.gov). Thrombophlebitis is an [CONDITION(S)] process that causes a blood clot to form and block one or more veins, usually in the legs. The affected vein might be near the surface of the skin or deep within a muscle (retrieved on 4/01/22 from www.mayoclinic.com). Review of the MDS Admission assessment with ARD of 3/18/22 revealed resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #22 was at risk for developing pressure ulcers and pressure injuries and had skin conditions including pressure ulcers and pressure injuries presenting as deep tissue injury. A care plan for actual impairment of skin integrity as evidenced by pressure wound to sacrum, deep tissue injury right big toe, deep tissue injury left and right heel, pressure ulcer left ischium and excoriation to right buttocks was initiated on 3/14/22. Interventions included follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #22's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for March 2022 revealed nursing documentation of resident #22's bilateral boots applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #22 had a suspected deep tissue injury on her right heel that measured 1.8 cm long, 2.0 cm wide and 0.1 cm deep. A Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident also had a suspected deep tissue injury on her left heel 0.5 cm long, 1.0 cm wide and 0.1 cm deep. On 3/28/22 at 5:12 PM, 3/29/22 at 11:01 AM and 3/30/22 at 5:01 PM, resident #22 was observed in bed without boots on her feet. She was also observed in her wheelchair on 3/28/22 at 3:55 PM, 3/29/22 at 2:40 PM and 3/30/22 at 12:29 PM without boots to both feet. On 3/31/22 at 10:06 AM, CNA F verified she was assigned to resident #22. She stated she was familiar with the resident and worked with her last week. CNA F stated she did not know if resident #22 had bilateral boots. She explained she had not seen any boots previously. CNA F searched resident #22's room but did not locate any boots. On 3/31/22 at 10:33 AM, LPN G confirmed she was the nurse assigned to resident #22. She said she saw the resident with bilateral boots last week but did not remember seeing them this week. LPN G reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN G searched the room but did not find the boots. She identified resident #22 was at risk for skin breakdown and needed the boots to protect her heels, promote healing and prevent further breakdown. On 3/31/22 at 1:45 PM, the DON reported resident #22 had pressure ulcers on both heels. She confirmed the resident should have bilateral boots in place to promote healing and prevent further breakdown. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS Significant Change in Status assessment with ARD of 3/12/22 revealed resident #55 had a BIMS score of 0 which indicated she had severe cognitive impairment. She required extensive to total assistance with ADLs. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #55 was at risk for developing pressure ulcers and pressure injuries but did not have any at the time of the assessment. A care plan for actual impairment of skin integrity revised 3/24/22, indicated resident #55 had a pressure ulcer to her right heel. Interventions included Podus boot to right foot for offloading. Review of resident #55's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR and MAR for March 2022 revealed no documentation to validate resident #55's podus boot was applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #55 had a Stage 3 pressure ulcer on her right heel that measured 3.0 cm long, 3.0 cm wide and 0.1 cm deep. On 3/28/22 at 10:27 AM, resident #55 was observed in her reclining chair without a Podus boot on her right foot. On 3/29/22 at 12:00 PM, 3/29/22 at 2:59 PM, 3/30/22 at 9:41 AM and 3/30/22 at 5:01 PM, the resident was observed in bed without a Podus boot on her right foot. On 3/31/22 at 10:11 AM, CNA F verified she was assigned to resident #55. She stated she did not know if the resident had a boot and had not seen her with one. CNA F lifted the covers and acknowledged resident #55 was not wearing a Podus boot. She searched the resident's room but did not find the boot. On 3/31/22 at 10:24 AM, LPN G observed resident #55's right foot and verified she had a pressure ulcer on her right heel. She acknowledged the resident did not have a Podus boot on her right foot. LPN G reviewed resident #55's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN G stated she had never seen resident #55 with a boot. On 3/31/22 at 1:45 PM, the DON stated resident #55 was at risk for skin breakdown and had a pressure ulcer on her right heel. She acknowledged resident #55 did not have a Podus boot. She explained the reason for the Podus boot was to prevent the pressure area from getting worse.

Based on observation, record and policy review and interviews with resident, resident family and staff, the facility failed to provide adequate supervision and safe environment for 1 of 14 residents reviewed for risk of actual and potential elopement (#30). These failures contributed to the elopement of resident #30 and placed him at risk for serious injury/impairment/death. While resident #30 was out of the facility in the dark, unsupervised, there was a high likelihood he could have fallen or been hit by a car. On 5/16/2020 at approximately 4:30 AM, resident #30 who was cognitively impaired was not found in the facility. At 4:53 AM, the resident exited the facility through the rear kitchen dark in the dark, unsupervised. He wheeled himself approximately 400 feet through an unlit, uneven parking lot. He was found by the Certified Nursing Assistant (CNA) at 6 AM in his wheelchair with bare feet stuck in the mud by the facility fence. There were 14 residents who were at risk for wandering at that time. The facility's failure to provide adequate supervision, and secure environment resulted in Substandard Quality of Care at the Immediate Jeopardy level. The Immediate Jeopardy began starting on 5/16/20 and removed as of 5/16/20. The facility's corrected the noncompliance at F689 on 5/28/20. At this time, the facility is in substantial compliance with F689. Findings: Resident #30 was admitted to the facility on [DATE] from an acute care hospital. His [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS) assessment with reference date of 4/08/20 showed his Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. He had not exhibited any wandering behavior at the time of admission and was not deemed at risk for elopement. His locomotion was identified as extensive assist with one person assisting. He was able to move around the facility independently in his wheelchair. The resident was receiving insulin injections daily. A review of the facility's investigation report revealed that resident #30's routinely assigned 11 PM to 7 AM CNA S checked on the resident at the beginning of his shift on 5/16/20 and the resident was in his room. A short time later, resident #30 was observed propelling himself in his wheelchair. During room rounds at approximately 5:15 AM, CNA S did not find resident #30 in his room. He began to search the interior perimeter of the facility and did not locate the resident. He informed resident #30's Licensed Practical Nurse (LPN) T who was an agency nurse. At approximately 6 AM, CNA S located the resident in the unlit rear parking lot in his wheelchair. The resident did not have shoes on, and his wheelchair was stuck in the mud. The resident told CNA S that he wanted to go home and see his wife. The resident was brought back inside at 6:11 AM. The facility's Policy and Procedure for Missing patient/resident revised 8/23/17 defined elopement as, . occurs when a patient/resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so, placing the patient/resident at risk for harm or injury. A review of the nursing progress note dated 5/16/20 at 7:55 AM, read 'the CNA (identified as CNA S) stated when he started his morning rounds at 5 AM he noticed that resident #30 was not in his room. The CNA notified the nurse that he was missing and began looking for the resident all over the building. The CNA stated that he found the resident in the parking lot. The resident stated that he was trying to go home, and he had been trying to speak to his wife. The resident was placed on 1:1 supervision. A wander bracelet was also placed on the resident.' The facility identified that the resident had wandered into the unlocked dining room and entered the kitchen through the door in the dining room that was not locking properly. He wandered through the unlit kitchen and exited through the rear service door of the kitchen at 4:53 AM. The facility was unaware of the resident's location for more than an hour after he was not found in his room. On 7/24/20 at 12:53 PM, the administrator explained that resident #30's CNA S was doing his rounds at approximately 4:30 AM on 5/16/20 and did not see resident #30. She explained that after reviewing the facility's video, the resident had exited through the rear door of the kitchen at 4:53 AM. At the time, resident #30 was not assessed as an elopement risk. Because he got out of the facility, we considered it an elopement. She said the investigation revealed that resident #30 was determined to be at home and did not want to be at the facility. She added the root cause was the entry door to the dining room was not locked and the kitchen door was not locking properly. On 7/23/20 at 3:00 PM, the surveyor and maintenance director retraced the likely path that resident #30 took when he exited the facility unsupervised. The resident resided on the West wing near the activity and dining room. From his room he wheeled himself through the area into the unlocked dining room. He then entered the kitchen through the unlocked door and entered the dark kitchen. It was noted that the walk-in refrigerator and walk-in freezer were not locked. There were multiple hazardous equipment present including tables stoves, ovens, knives, and carts which he navigated around in the dark. He would have remained in the unlit kitchen for approximately 1 hour. The resident then exited the dark kitchen on the east side of the building at 4:53 AM. He wheeled himself in the unlit parking lot with cracked, uneven pavement, broken curbs and some cement debris in the grassy area. He continued toward the front of the building which was approximately 379 Feet from the exit door. The parking lot and facility driveway led toward a major 7 lane heavily trafficked highway. A review of the facility's video recording of the resident's exit showed the back entrance/kitchen door opened at 4:53 AM and the resident in a wheelchair exiting. The poor-quality video showed the resident mobilizing in his wheelchair down the gravely parking lot until 4:56 AM when he was no longer visible. The maintenance director said that there was a camera outside the therapy entrance which would have given a better view of the back-parking lot, however it had been damaged by a hurricane some years ago. The video showed on 5/16/20 at 1:52 AM car lights flashed at the camera. On 7/23/20 at 4:40 PM, licensed practical nurse (LPN) T stated When I came on my shift, (11 PM on 5/15/20) I saw resident #30 in his bed. He just looked at me and did not answer. She said that CNA S approached her at 4:30 AM, to inform that resident #30 was not in his room. He also told CNA Z and they both started searching for the resident in other rooms. I was starting my medication pass at this time. CNA S came back a short time later and told me he could not find the resident. CNA S then went outside of the facility and found the resident outside in his wheelchair. LPN T stated that she did not follow the missing resident/elopement procedure. On 7/23/20 at 11:03 PM, during a phone interview, CNA S said that he had worked the 11 PM to 7 AM shift on 5/16/20 and was resident #30's CNA since his admission. He said that the resident was always up and out of his bed, in and out of his room roaming the halls. He never entered other resident rooms. On 5/16/20, he was up as usual in and out of his room, in the hallway and sometimes at the nurses' station. At 1-2 AM he was in his room. Around 4-4:30 AM, resident #30 was not in his bed. CNA S said he did not alert the nurse right away that he did not see the resident. He stated that he checked both sides building. I did a sweep of everywhere. I told CNA Z and we checked all the rooms. I went outside the door by the therapy area which was on the other side of the facility. He was not there. I did not want to panic anyone because I was not sure. I then let the nurse know and we all began to look for him. CNA S said that the procedure for missing persons was not implemented. He said at 6:00 AM, he found the resident sitting in his wheelchair with bare feet at the end of the parking lot near the facility fence. He was stuck in the mud. On 7/23/20 at 3:28 PM, the dietary cook V said she worked on 5/16/20. She arrived at the facility about 5:45 AM and parked in the back-parking lot. The lot was dark and there were only 3-4 cars parked there. She entered the back door of the kitchen using her key. The lights were not on. She did not see the resident when she drove into the parking lot. On 7/23/20 at 4:48 PM, Dietary Aide U was interviewed by phone. She said I come in between 5:30 -6 AM. I park in the back lot and come in through the therapy door, someone lets me in. Then I go out the same door, knock on the kitchen back door and wait until someone opens the door. It was so dark; I was not able to see anything. She was working the morning (5/16/20) that resident #30 got out of the building. She said he was found in the back far side of parking lot. A telephone call to the resident's wife on 7/23/20 at 4:47 PM noted that she was informed of the resident trying to leave the facility on 5/16/20. She stated that he was missing and was found outside the building. She said he was on his way to the major highway located near the facility as he knew how to get home. A review of the Facility Assessment last updated on 5/16/20 noted that the facility offered care and services for residents with cognitive impairment, anxiety and psychiatric diagnosis. The facility began putting corrective actions into place on 5/16/20 and came into substantial compliance on 5/28/20. The facility's corrective actions included the following: * Review of the facility corrective measures implemented by the facility revealed the following: *On return to the facility on [DATE], resident #30 had a head to toe assessment with no injuries. He was placed on 1:1 supervision and the physician was notified. He was seen by the nurse practitioner on 5/16. Lab work was obtained. A wander alert bracelet was applied. An elopement care plan was initiated. * On 5/16/20, a screamer alarm was added to the entry door to the dining room. The door was locked when staff not present. The door handle with a new lock was installed on the kitchen door from the dining room. *Dietary staff were educated on 5/16/20 to report any malfunctioning equipment or knobs. *On 5/16/20 the Wander Alarm company checked the alarm systems on all doors. *The Federal 5-day Abuse report was submitted on 5/16/20. *An adverse incident report was submitted to the State Agency on 5/29/20. *Staff received education starting on 5/16/20 through 5/28/20 on Elopement Policy and Procedures, Wander Guard system, missing resident policy, elopement drills with post-test completed. *On 5/16/20, the facility reviewed all residents for elopement and did not identify any additional residents. All progress notes and clinical documentation were reviewed during the daily clinical meetings, any missing data was discussed, and care plans were updated/and initiated if indicated immediately. * Elopement drills were done on 3 shifts for 7 days then weekly for 1 month, then monthly as of July 2020. Door audits/wander guard checks were done daily by maintenance staff and any concerns addressed at QAPI meetings. *An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 5/16/20 to address elopement issues and an action plan was initiated. The committee reviewed staff training and education. The QAPI committee met weekly through 6/18/20. *On 7/24/20 tour of the facility the Director of Maintenance verified that all work on doors was complete. The front lobby door was monitored by receptionist during the day and locked when the receptionist left. The facility had a total of 10 exterior alarmed doors, that activated with wander bracelets. The alarm was added to the dining room door that was locked in the evening. Only staff had codes to the doors. *Elopement Quality reviews to be completely weekly and brought to the weekly QAPI meetings through 6/11/20. Reduction in frequency to be determined by QAPI Committee. *Interviews conducted by the survey team with 24 staff from 7/23/20 at 10:48 AM to 7/25/20 at 11:20 AM revealed they were knowledgeable of the elopement prevention policies and procedures. *The survey team validated the facility's corrective actions during the survey and determined that F689 was past noncompliance.

Based on observation, interview and record review, the facility failed to identify, report and appropriately treat signs and symptoms of severe pain in accordance with accepted standards of clinical practice for 1 of 3 residents reviewed for pain management (#99). Findings: Resident #99 was admitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Review of the medical record revealed a hospital History and Physical assessment dated [DATE]. The document indicated resident #99 arrived at the hospital with a chief complaint of a fall, and lower back pain. Diagnostic X-rays showed resident #99 had severe [MEDICAL CONDITIONS] disk disease and chronic compression deformity of the lumbar spine. She wore a left knee brace and complained of left leg pain. The document revealed resident #99's home medication included the pain medication [MEDICATION NAME]. The physician's assessment and plan of care for resident #99 revealed she had gait disturbance, right hip bruise and lumbar spine concern post-fall. The physician wrote, We are going to use [MEDICATION NAME] and [MEDICATION NAME] . as needed for pain. The patient transfer form revealed resident #99 received pain medication on 7/16/19 at 9:35 AM for a pain level of 7 on a 0 to 10 scale, prior to transfer from the hospital to the facility. The hospital Discharge Instructions included the pain medications [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams (mg.) 4 times daily as needed for severe pain, for pain levels 7 to 10, and [MEDICATION NAME] 50 mg. twice daily for pain. The document indicated a prescription for [MEDICATION NAME]-[MEDICATION NAME] was provided for resident #99 on discharge from the hospital. The Admission/Readmission Data Collection form, effective 7/16/19 at 6:28 PM, revealed resident #99 was admitted to the facility on [DATE] at 5:28 PM. The evaluation indicated resident #99 was alert to person, had a memory problem, but had clear speech, was usually understood and had the ability to understand. The document showed resident #99 was pleasant and had no obvious behavioral problems. Section L Pain revealed Resident experiencing pain. Review of the Pain Evaluation form, effective 7/16/19 at 6:28 PM, revealed the Wong-Baker Faces Pain Rating Scale was used to evaluate resident #99's pain level. This method for pain evaluation links a patient's facial expression to the corresponding level on the numerical 0 to 10 pain scale. Resident #99 used the facial scale to report pain that Hurts Even More, which indicated a pain level of 6 to 7 on the numerical scale. The form revealed resident #99 had daily, chronic, aching pain and tenderness to her leg and back. She expressed her pain verbally with vocal complaints at rest and with movement. During the evaluation, resident #99 had non-verbal pain indicators including facial grimacing and massaging the affected area with movement. On 7/17/19 at 10:34 AM, repeated cries were heard from a room approximately 20 feet away. Loud, continuous requests of help, help, help me and softer intermittent sobbing and moaning were heard. Two nurses stood in the hallway beside a medication cart, next to the doorway of the room. Both nurses did not attempt to approach the room, identify the source of the cries, and investigate the cause of the cries. At 10:37 AM, while the intermittent cries for help continued, the 2 nurses, who remained near the doorway, were asked if someone in the room was crying out for help. Licensed practical nurse (LPN) G did not respond to the question, instead she remained focused on the computer screen on the medication cart. The other nurse, the Minimum Data Set (MDS) Director confirmed she heard the cries and said, It's not a resident. It's the TV. The cry for help was heard again and the MDS Director dismissively waved her arm towards the room and repeated, It's the TV. Another cry for help was heard, not on the television, but from an occupant of the room who said, It hurts. Please help me. Although the sobbing and moaning was a little louder, both nurse did not approach the room. On entrance to the room on 7/17/19 at 10:39 AM, resident #99 was observed in bed. She had pronounced facial grimacing, clenched teeth, and shifted her body restlessly from side to side. Resident #99 grabbed and massaged her right hip and the back of her right thigh as she continued to cry for help. Attempts to console and distract resident #99 were unsuccessful, and she was not able to use the numerical pain scale and answer questions coherently. On 7/17/19 at 10:40 AM, LPN G remained at the medication cart. Observation of the computer screen revealed she was not reviewing resident #99's medications. LPN G explained she worked for a staffing agency and arrived at the facility at 8:50 AM that morning, almost 2 hours after the day shift started. She was informed resident #99 showed signs and symptoms of pain. LPN G was accompanied into resident #99's room to do a pain evaluation, and she acknowledged resident #99 was grimacing, and had a distressed facial expression. LPN G attempted to do a verbal pain assessment but resident #99 responded with garbled speech and repetitive cries for help. LPN G explained resident #99 was not able to participate in a verbal pain assessment probably due to dementia. LPN G denied hearing resident #99's cries while she stood at the medication cart. On 7/17/19 at 10:42 AM, LPN G prepared [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg., 1 tablet, for resident #99. She entered the room at 10:45 AM to administer the pain medication. Resident #99 continued to cry out in pain as LPN G elevated the head of her bed, and said, The back of my upper leg. She pointed to the area of her right hip and thigh. After medication administration, LPN G stated she received no information in report regarding resident #99's pain from the nurse who had the medication cart. She showed a report sheet that included resident #99's [DIAGNOSES REDACTED]. Review of the pain medication blister pack and reconciliation sheet with LPN G revealed resident #99 received 8 [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. tablets from the pharmacy, and she stated she just administered the first pill from the blister pack. On 7/17/19 at 11:17 AM, the wound nurse stated he completed resident #99's head-to-toe skin evaluation that morning. The wound nurse explained resident #99 complained of pain in her right hip during the evaluation. He stated her pain level was severe enough that he had to assist her with turning and give her time to move slowly. The wound nurse stated resident #99 informed him she had chronic pain. He acknowledged resident #99's pain was significant, and should have been addressed at the time. The wound nurse showed his notepad with written findings of resident #99's skin evaluation that included notation of right leg pain. He stated to his knowledge, resident #99 did not have orders for pain medication yet, and he planned to address the issue with the physician when he arrived in the facility. The wound nurse said, I did not follow up. I did not look to see if she had any pain medication ordered. I reported to the agency nurse. However, later that afternoon at 1:01 PM, when he was informed that LPN G was unaware of resident #99's pain, the wound nurse said, It's a possibility that I did not tell her. On 7/17/19 at 11:22 AM, the assistant director of clinical services (ADCS) confirmed she overheard the wound nurse admit although he was aware resident #99 was in pain, he did not check for availability of pain medication. The ADCS explained she was certain resident #99 had orders for pain medication because she assisted with the admission paperwork and transcribed the orders herself. The ADCS recalled resident #99 had pain on admission so she co-signed with LPN H, the assigned nurse, for removal of 1 tablet [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. from the emergency kit. Review of the Medication Administration Record [REDACTED]. She could not explain why it was not documented, and validated that without documentation, the facility could not show resident #99 received the medication. The ADCS stated her expectation was that nurses would acknowledge residents' complaints of pain, evaluate and medicate as ordered in a timely manner. She validated the wound nurse, LPN G and the MDS Director did not respond appropriately to resident #99's report of pain and cries for help. On 7/17/19 at 12:36 PM, a telephone interview was conducted with LPN H. She stated she was assigned to resident #99 on the previous afternoon when she was admitted . LPN H recalled resident #99 complained of level 7 pain on a 0 to 10 scale. She stated she administered Tylenol to resident #99 at the direction of the ADCS. When asked if resident #99 had orders for Tylenol, LPN H said, I saw the hospital discharge orders. LPN H explained she then faxed the prescription for resident #99's narcotic pain medication to the pharmacy and received authorization to remove the narcotic pain medication from the emergency kit. She confirmed the ADCS co-signed for the narcotic pain medication. LPN H was informed there was no physician's order for Tylenol, and the MAR indicated [REDACTED]. LPN H explained she did not document anything on the MAR for the entire shift because the patient was not showing up in the system, and the meds were not generated in the computer at that time. LPN H validated no one accompanied her to administer resident #99's medication, and acknowledged if it was not documented there was no way to prove any medication was given. On 7/17/19 at 12:52 PM, resident #99 was alert with confusion, relaxed and smiling as she watched TV. Resident #99 had coherent speech and stated she felt much better. She explained she needed her pain medicine or else her pain was very bad. Resident #99 could not recall whether or not she received pain medication the previous night, but said, I know I was hurting for a long time this morning. Nobody gave me medicine. When asked if she reported her pain to staff, resident #99 said, I told some people that my leg hurt. She confirmed no one returned with pain medication, and the pain worsened while she waited. At 12:56 PM, LPN G stated resident #99's pain medication was effective in less than 30 minutes after administration this morning. LPN G said, Once she got the medicine, her pain went from a 7 to a 0. I believe it was the pain that was making her so confused this morning. On 7/17/19 at 3:41 PM, the ADCS stated she did not direct LPN H to administer Tylenol, and verbalized that all nurses were expected to follow physician's orders. She confirmed that although she co-signed for the narcotic pain medication removed from the emergency kit, she did not observe administration of the medication. The ADCS explained LPN H had access to document on the MAR indicated [REDACTED]. Review of resident #99's MAR indicated [REDACTED]. every 6 hour for severe pain levels 7 to 10, had a start date and time of 7/16/19 at 7:30 PM. There was no signature on the document to indicate administration of pain medication prior to LPN G's initials the following day, on 7/17/19 at 10:42 AM. The Request for Removal of Controlled Substance Medication form revealed that on 7/16/19 at 9:15 PM, LPN H received approval from the pharmacy to remove up to 4 tablets of [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. for resident #99. However, the form listed the incorrect room number for resident #99. The room listed on the document was assigned to another resident who was admitted to the same unit on the same day. Review of the policy and procedure Pain Management Guideline, revised 8/28/17, revealed the purpose was To ensure residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The process included identification, evaluation, treatment and monitoring of signs and symptoms of pain to ensure residents achieve their highest practicable level of well-being.

Based on observation, interview and record review, the facility failed to identify, report and appropriately treat signs and symptoms of severe pain in accordance with accepted standards of clinical practice for 1 of 3 residents reviewed for pain management (#99). Findings: Resident #99 was admitted to the facility from the hospital on [DATE]. Her [DIAGNOSES REDACTED]. Review of the medical record revealed a hospital History and Physical assessment dated [DATE]. The document indicated resident #99 arrived at the hospital with a chief complaint of a fall, and lower back pain. Diagnostic X-rays showed resident #99 had severe [MEDICAL CONDITIONS] disk disease and chronic compression deformity of the lumbar spine. She wore a left knee brace and complained of left leg pain. The document revealed resident #99's home medication included the pain medication [MEDICATION NAME]. The physician's assessment and plan of care for resident #99 revealed she had gait disturbance, right hip bruise and lumbar spine concern post-fall. The physician wrote, We are going to use [MEDICATION NAME] and [MEDICATION NAME] . as needed for pain. The patient transfer form revealed resident #99 received pain medication on 7/16/19 at 9:35 AM for a pain level of 7 on a 0 to 10 scale, prior to transfer from the hospital to the facility. The hospital Discharge Instructions included the pain medications [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams (mg.) 4 times daily as needed for severe pain, for pain levels 7 to 10, and [MEDICATION NAME] 50 mg. twice daily for pain. The document indicated a prescription for [MEDICATION NAME]-[MEDICATION NAME] was provided for resident #99 on discharge from the hospital. The Admission/Readmission Data Collection form, effective 7/16/19 at 6:28 PM, revealed resident #99 was admitted to the facility on [DATE] at 5:28 PM. The evaluation indicated resident #99 was alert to person, had a memory problem, but had clear speech, was usually understood and had the ability to understand. The document showed resident #99 was pleasant and had no obvious behavioral problems. Section L Pain revealed Resident experiencing pain. Review of the Pain Evaluation form, effective 7/16/19 at 6:28 PM, revealed the Wong-Baker Faces Pain Rating Scale was used to evaluate resident #99's pain level. This method for pain evaluation links a patient's facial expression to the corresponding level on the numerical 0 to 10 pain scale. Resident #99 used the facial scale to report pain that Hurts Even More, which indicated a pain level of 6 to 7 on the numerical scale. The form revealed resident #99 had daily, chronic, aching pain and tenderness to her leg and back. She expressed her pain verbally with vocal complaints at rest and with movement. During the evaluation, resident #99 had non-verbal pain indicators including facial grimacing and massaging the affected area with movement. On 7/17/19 at 10:34 AM, repeated cries were heard from a room approximately 20 feet away. Loud, continuous requests of help, help, help me and softer intermittent sobbing and moaning were heard. Two nurses stood in the hallway beside a medication cart, next to the doorway of the room. Both nurses did not attempt to approach the room, identify the source of the cries, and investigate the cause of the cries. At 10:37 AM, while the intermittent cries for help continued, the 2 nurses, who remained near the doorway, were asked if someone in the room was crying out for help. Licensed practical nurse (LPN) G did not respond to the question, instead she remained focused on the computer screen on the medication cart. The other nurse, the Minimum Data Set (MDS) Director confirmed she heard the cries and said, It's not a resident. It's the TV. The cry for help was heard again and the MDS Director dismissively waved her arm towards the room and repeated, It's the TV. Another cry for help was heard, not on the television, but from an occupant of the room who said, It hurts. Please help me. Although the sobbing and moaning was a little louder, both nurse did not approach the room. On entrance to the room on 7/17/19 at 10:39 AM, resident #99 was observed in bed. She had pronounced facial grimacing, clenched teeth, and shifted her body restlessly from side to side. Resident #99 grabbed and massaged her right hip and the back of her right thigh as she continued to cry for help. Attempts to console and distract resident #99 were unsuccessful, and she was not able to use the numerical pain scale and answer questions coherently. On 7/17/19 at 10:40 AM, LPN G remained at the medication cart. Observation of the computer screen revealed she was not reviewing resident #99's medications. LPN G explained she worked for a staffing agency and arrived at the facility at 8:50 AM that morning, almost 2 hours after the day shift started. She was informed resident #99 showed signs and symptoms of pain. LPN G was accompanied into resident #99's room to do a pain evaluation, and she acknowledged resident #99 was grimacing, and had a distressed facial expression. LPN G attempted to do a verbal pain assessment but resident #99 responded with garbled speech and repetitive cries for help. LPN G explained resident #99 was not able to participate in a verbal pain assessment probably due to dementia. LPN G denied hearing resident #99's cries while she stood at the medication cart. On 7/17/19 at 10:42 AM, LPN G prepared [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg., 1 tablet, for resident #99. She entered the room at 10:45 AM to administer the pain medication. Resident #99 continued to cry out in pain as LPN G elevated the head of her bed, and said, The back of my upper leg. She pointed to the area of her right hip and thigh. After medication administration, LPN G stated she received no information in report regarding resident #99's pain from the nurse who had the medication cart. She showed a report sheet that included resident #99's [DIAGNOSES REDACTED]. Review of the pain medication blister pack and reconciliation sheet with LPN G revealed resident #99 received 8 [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. tablets from the pharmacy, and she stated she just administered the first pill from the blister pack. On 7/17/19 at 11:17 AM, the wound nurse stated he completed resident #99's head-to-toe skin evaluation that morning. The wound nurse explained resident #99 complained of pain in her right hip during the evaluation. He stated her pain level was severe enough that he had to assist her with turning and give her time to move slowly. The wound nurse stated resident #99 informed him she had chronic pain. He acknowledged resident #99's pain was significant, and should have been addressed at the time. The wound nurse showed his notepad with written findings of resident #99's skin evaluation that included notation of right leg pain. He stated to his knowledge, resident #99 did not have orders for pain medication yet, and he planned to address the issue with the physician when he arrived in the facility. The wound nurse said, I did not follow up. I did not look to see if she had any pain medication ordered. I reported to the agency nurse. However, later that afternoon at 1:01 PM, when he was informed that LPN G was unaware of resident #99's pain, the wound nurse said, It's a possibility that I did not tell her. On 7/17/19 at 11:22 AM, the assistant director of clinical services (ADCS) confirmed she overheard the wound nurse admit although he was aware resident #99 was in pain, he did not check for availability of pain medication. The ADCS explained she was certain resident #99 had orders for pain medication because she assisted with the admission paperwork and transcribed the orders herself. The ADCS recalled resident #99 had pain on admission so she co-signed with LPN H, the assigned nurse, for removal of 1 tablet [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. from the emergency kit. Review of the Medication Administration Record [REDACTED]. She could not explain why it was not documented, and validated that without documentation, the facility could not show resident #99 received the medication. The ADCS stated her expectation was that nurses would acknowledge residents' complaints of pain, evaluate and medicate as ordered in a timely manner. She validated the wound nurse, LPN G and the MDS Director did not respond appropriately to resident #99's report of pain and cries for help. On 7/17/19 at 12:36 PM, a telephone interview was conducted with LPN H. She stated she was assigned to resident #99 on the previous afternoon when she was admitted . LPN H recalled resident #99 complained of level 7 pain on a 0 to 10 scale. She stated she administered Tylenol to resident #99 at the direction of the ADCS. When asked if resident #99 had orders for Tylenol, LPN H said, I saw the hospital discharge orders. LPN H explained she then faxed the prescription for resident #99's narcotic pain medication to the pharmacy and received authorization to remove the narcotic pain medication from the emergency kit. She confirmed the ADCS co-signed for the narcotic pain medication. LPN H was informed there was no physician's order for Tylenol, and the MAR indicated [REDACTED]. LPN H explained she did not document anything on the MAR for the entire shift because the patient was not showing up in the system, and the meds were not generated in the computer at that time. LPN H validated no one accompanied her to administer resident #99's medication, and acknowledged if it was not documented there was no way to prove any medication was given. On 7/17/19 at 12:52 PM, resident #99 was alert with confusion, relaxed and smiling as she watched TV. Resident #99 had coherent speech and stated she felt much better. She explained she needed her pain medicine or else her pain was very bad. Resident #99 could not recall whether or not she received pain medication the previous night, but said, I know I was hurting for a long time this morning. Nobody gave me medicine. When asked if she reported her pain to staff, resident #99 said, I told some people that my leg hurt. She confirmed no one returned with pain medication, and the pain worsened while she waited. At 12:56 PM, LPN G stated resident #99's pain medication was effective in less than 30 minutes after administration this morning. LPN G said, Once she got the medicine, her pain went from a 7 to a 0. I believe it was the pain that was making her so confused this morning. On 7/17/19 at 3:41 PM, the ADCS stated she did not direct LPN H to administer Tylenol, and verbalized that all nurses were expected to follow physician's orders. She confirmed that although she co-signed for the narcotic pain medication removed from the emergency kit, she did not observe administration of the medication. The ADCS explained LPN H had access to document on the MAR indicated [REDACTED]. Review of resident #99's MAR indicated [REDACTED]. every 6 hour for severe pain levels 7 to 10, had a start date and time of 7/16/19 at 7:30 PM. There was no signature on the document to indicate administration of pain medication prior to LPN G's initials the following day, on 7/17/19 at 10:42 AM. The Request for Removal of Controlled Substance Medication form revealed that on 7/16/19 at 9:15 PM, LPN H received approval from the pharmacy to remove up to 4 tablets of [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. for resident #99. However, the form listed the incorrect room number for resident #99. The room listed on the document was assigned to another resident who was admitted to the same unit on the same day. Review of the policy and procedure Pain Management Guideline, revised 8/28/17, revealed the purpose was To ensure residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The process included identification, evaluation, treatment and monitoring of signs and symptoms of pain to ensure residents achieve their highest practicable level of well-being.

Based on observation, interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 3 sampled residents. Resident #4 did not receive [MEDICATION NAME] as per physician orders. As a result of the facility's failure, resident #4 was not able to maintain his highest level of practicable well being and endured actual [MEDICATION NAME] withdrawal symptoms. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment completed on 04/18/19 documented he was cognitively intact, independent with activities of daily living, required supervision with dressing, used a wheelchair for mobility, was continent of bowel and bladder, and received scheduled pain management for occasional, severe pain which had occurred in the past 5 days. Resident #4's plan of care dated 01/17/19 included chronic pain with a goal that he will voice a level of comfort through the review date. Interventions included to administer pain medication as per physician order, to anticipate the resident's need for pain relief and respond immediately to any complaints of pain. On 05/28/19 at 1:41 PM, resident #4's wife was observed at the West Wing nursing station. She was visibly upset and yelling in a loud voice at the staff. She yelled that she was having problems with getting her husband's pain medication and that he was going through withdrawal symptoms. I have been here Saturday, Sunday, Monday and now Tuesday waiting for Pain Management to come and see him so they can write a prescription for his pain medication. I am sick of cleaning him up because now he is incontinent of stool. The Director of Nursing (DON) was present and asked resident #4's wife to step into the Social Services' office to discuss her concerns. Resident #4's wife responded loudly, I am not going in there. I have been to Social Services and they don't do anything. On 05/28/19 at 1:45 PM, resident #4 was observed sitting in his wheelchair with his head down, eyes closed and was difficult to arouse. He responded to his name but then closed his eyes and put his head down after speaking. This occurred several times while attempting to speak with him. He apologized and stated, I am sorry, I am just so tired I can't stay awake. , He stated that he was feeling shaky, sweaty, had chills, felt very weak, tired and was now having diarrhea incontinence. He was able to remove his baseball cap and his hair was wet and matted and his forehead was wet with sweat running down both sides of his face. He stated that he was jittery, shaky, could not focus and could not keep his head up. His wife then stated, The last dose of [MEDICATION NAME] he received was on Saturday (3 days ago) and he should receive it daily. She said that he was admitted to the facility on [DATE] and had been on [MEDICATION NAME] for [AGE] years. Somebody was here today from Pain Management but they did not write a prescription for his [MEDICATION NAME]. When the medication was due for a refill they ran out and there is no prescription to get the [MEDICATION NAME] refilled by the pharmacy. If the facility admitted him here they should be able to take care of him. According to WebMD, [MEDICATION NAME] is part of a category of medications called Opioids. It is used for addiction to heroin or narcotic painkillers. [MEDICATION NAME] changes the way the brain and nervous system respond to pain so that the patient feels relief. It blocks the high one gets from drugs like [MEDICATION NAME], heroin, [MEDICATION NAME] and [MEDICATION NAME]. Withdrawal symptoms include: anxiety, restlessness, [MEDICAL CONDITION], yawning, body aches, sweating, vomiting, diarrhea, fever, shaking, faster than normal heartbeat, rapid breathing, high blood pressure, hallucinations, and [MEDICAL CONDITION]. These can show up within 12 hours after you take the last dose of the drug. On 05/28/19 at 2 PM, Licensed Practical Nurse (LPN) A stated that they did not have any [MEDICATION NAME] at the facility for the resident. She said that the resident was ordered a pain consult for the [MEDICATION NAME]. Pain Management was here this morning and we needed authorization from Pain Management but they did not complete the authorization or prescription for the [MEDICATION NAME]. LPN A stated that the physician order [REDACTED]. On Sunday, 05/26/19 I gave him 5 ml of [MEDICATION NAME] (1/3 the dose the resident was to receive) because that is what remained in the [MEDICATION NAME] bottle. On Monday, 05/27/19 there was no [MEDICATION NAME] so I called the Pharmacy. Pharmacy informed me that the resident's insurance would not cover the cost of the medication. I then called the Medical Director and the on-call Nurse Practitioner called back. She told me that she did not have a fax machine in her home and that she would call the [MEDICATION NAME] order into the pharmacy. On 05/28/19 there was still no [MEDICATION NAME] for resident #4 and I called the Pharmacy. The person at the Pharmacy told me there was no fax from the Nurse Practitioner. On 5/28/19 at 2:40 PM, the Administrator and the Regional Nurse Consultant stated that they were not aware of the resident's present condition. They were unaware that the resident had not received his [MEDICATION NAME]. On 05/28/19 at 5:24 PM, Registered Nurse (RN) K stated that the [MEDICATION NAME] still had not been delivered to the facility. Review of resident #4's physician orders [REDACTED]. 15 ml = 150 mg. End date 05/20/19. A second order dated 05/20/19 for [MEDICATION NAME] (HCL) Concentrate 10 mg/ml , give 15 ml by mouth in the morning for acute chronic pain. 15 ml = 150 mg. End date 05/25/19. A third order dated 05/25/19 for [MEDICATION NAME] (HCL) Concentrate 10 mg/ml , give 15 ml by mouth in the morning for acute chronic pain. 15 ml = 150 mg. Review of the Medication Administration Record [REDACTED]. Review of the Progress Notes dated 05/27/19 at 2:47 PM completed by LPN A documented she called the Pharmacy. The representative stated that the insurance will not cover the medication and their system noted that there was no prior authorization and no alternative recommendations. She said that even if a prescription was sent the medication would not be sent out because there was a problem with the insurance. The on-call physician was called and nurse practitioner said that she would try and fax script but the office was closed. The resident's wife was contacted and explained the issue with the [MEDICATION NAME]. The wife stated that she called the insurance company and they told her that they would cover the medication. The customer service representative told her that the facility needed to fax a prescription with a pre-authorization form. LPN A explained to the wife that this was not what she was told by the pharmacy and that she will continue to look into it to find a solution. Review of the Progress Note dated 05/28/19 at 3:46 PM completed by LPN A documented that she was informed by the DON that resident #4 was in the front lobby crying and distressed because the resident did not receive his [MEDICATION NAME]. Spoke to the Nurse Practitioner from the Medical Director's practice and informed that she was going to call the prescription into the pharmacy. The [MEDICATION NAME] was still not received. The Pharmacy explained that the resident's insurance was not able to cover the medication anymore. LPN A and the Social Worker went to explain to resident #4 what the pharmacy said. Resident #4 explained that his wife was told something else. LPN A attempted to get a prescription from resident #4's attending physician but she stated that she can not write the prescription any longer because a Pain Management consult was ordered and they were to write the prescription. The Pain Management Advanced Register Nurse Practitioner (ARNP) was called. She stated that the attending physician should be able to write the prescription. Review of the Pain Management consult note dated 05/28/19 documented that resident #4 was upset that his [MEDICATION NAME] had not been filled by the pharmacy. The nurse stated that there was an issue with re-ordering it. He stated that he felt anxious and was crying. He stated that he had been without [MEDICATION NAME] for 2 days. Resident is at high risk for withdrawal and I would recommend going to the Emergency Department (ED). This was also discussed with resident #4's attending physician. Plan: resident was without [MEDICATION NAME] for 2 days, pain management just informed now. Discussed with the resident's attending physician that the resident may go into withdrawals from [MEDICATION NAME] and she stated she will send him to the ED. On 05/29/19 at 12:24 PM, resident #4 was observed in his room sitting upright in his wheelchair. He was alert, calm and relaxed. He was well dressed and was actively sweeping his room with a long handled broom. He smiled and stated, I received my [MEDICATION NAME] yesterday in the evening and again this morning. I feel so much better and am not having any pain. On 05/30/19 at 5:24 PM, the Director of Nursing stated that she was aware the resident had withdrawal symptoms from not receiving his [MEDICATION NAME]. She said she had checked resident #4 and he was in withdrawal. He took off his hat and he was sweaty, lethargic, not focused and stated he was cold and needed his [MEDICATION NAME]. The DON did not explain why the resident did not receive his [MEDICATION NAME] for more than 58 hours. She did not explain why the facility had failed in coordinating the resident's care to ensure that the resident received his [MEDICATION NAME] medication as prescribed and did not endure withdrawal symptoms. On 05/31/19 at 4:39 PM, a call was placed to the facility's Pharmacy. The Pharmacist stated that [MEDICATION NAME] should never be suddenly stopped. It should always be tapered down to prevent withdrawal from occurring. Withdrawal can result from not receiving the [MEDICATION NAME] and can start in as little as 24-48 hours.

Based on interview, record review and a review of facility documentation, the facility failed to ensure a comprehensive assessment of a fall risk resident's functional capacity was completed to prevent injury to 1 of 7 sampled residents (#1) when removing one-to-one (1:1) observations which had initially been instituted to provide resident safety. Subsequently, the resident fell and sustained fractures of the left femur, right humerus and left side of the ribs in addition to a left eyebrow laceration. Findings: Cross reference to F373, F281, and F329. A review of the medical record of resident #1 revealed this [AGE] year old was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. Other [DIAGNOSES REDACTED]. Medication included [MEDICATION NAME] 50 milligrams (mg.) twice a day for joint pain, [MEDICATION NAME] 50 mg, every 6 hours as needed, [MEDICATION NAME] 4.6 mg./24 hours daily for dementia, [MEDICATION NAME] 20 mg. daily for depression, and [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg. every 8 hours as needed for anxiety. The resident also had an order for [REDACTED]. Review of the facility's "Admission/Readmission Data Collection" form, dated 10/31/13 at 12 PM, read, "... resident is a fall risk." It indicated the resident had 2 falls within the last month. However, the assessment did not include all accurate information regarding falls in the past 3 months. In the section for falls in the past 3 months, no falls were documented even though the resident was admitted with a shoulder fracture from a fall prior to admission. The "Admission/Readmission Data Collection" form also indicated that the resident required total assistance with bed mobility, needed the assistance of one person with transfers, and ambulated by wheelchair only. The communication section indicated the resident sometimes understood/sometimes understands, and hearing is highly impaired. The cognition section indicated the resident was severely impaired for decision making skills. The behavior/mood section listed the resident was agitated when the nurse tried to do a skin check, resists care, and had poor concentration. A Fall Prevention care plan was implemented on 10/31/13. It deemed the resident at risk for falls related to a fall risk score of greater than 10, cognitive status - dementia, unsteady gait, and history of falls. The goal was that the resident will have no falls within the next 90 days and will not experience injury from falls. One of the interventions included the use of a low bed. The resident had physician orders [REDACTED]." Physician orders [REDACTED]. Neither the floor mats nor an alarm were not included on the current Fall Prevention care plan. The Behavior Management care plan was not dated. It listed the problem as "Potential for impaired or inappropriate behaviors-related to." The section for "related to" was not completed. The goal was that the resident will not demonstrate behaviors of removing self from bed/chair. Among some of the approaches were: "assess behaviors for underlying medial causes and assess resident for pain as indicated." The Behavior Management care plan indicated that the resident was on 1:1 observation with a date of 11/01/13. In an interview with the administrator on 1/18/14 at 10:36 PM, she stated that the 3-11 PM shift registered nurse (RN) supervisor called her on 10/31/13 at an undetermined time after dinner and stated that resident #1 needed to be on 1:1 because she was anxious. She stated that the supervisor told her, "I'm afraid she's going to fall on the floor." The daily skilled nurse's note for 10/31/13 at 12 AM indicated the resident was sleeping. It did not include any documentation of anxious behaviors. The "Admission/Readmission Data Collection" form read that the resident was admitted at 12:30 PM on 10/31/13 in stable condition, had no complaints of pain, and no signs of distress. The advanced registered nurse practitioner (ARNP) verified the medications and a head to toe assessment was completed by the unit manager (UM). The notes indicated the resident was a fall risk. There was no evidence that the certified nursing assistant (CNA) used for 1:1 observation for resident #1 was removed from the resident during hours of sleep on this day, 10/31/13, into the next day, or at any other time until late on 11/02/13. Review of the facility's "KARDEX-HOH" read, "transfer assist of 1, incont (incontinent) of B&B (bowel & bladder) - assist of one, check and change (uses bathroom bsc (bedside commode)", bedpan urinal (NOT checked). Safety section: "alarms - bed is checked, 2 half side rails, mat on floor and low bed." Behavior interventions: hand written "one on one (1:1)". A review of the CNA ADL (activities of daily living) tracking form read, "walk in room not completed for 3-11 shift for 11/01 or 11/02 (2013). Toilet use (how the resident cleanses self after elimination) - total dependence." The daily skilled nurse's note dated 11/01/13 at 7 AM read, "Resident was continued on 1:1 with CNA, 0 (no) any issues noted, slept all night shift." The note for the same date at 3 PM indicated the resident attended the Starlight program with no acute distress. The Starlight program is a program where residents who need extra supervision are placed together in a special room with CNAs who stay in this room to supervise the residents. The notes for 11 PM indicated the resident attended the Starlight program and was restless and anxious. The resident attempted to get up from the wheelchair 3 times. She was medicated with [MEDICATION NAME] for anxiety with good effect. A physical therapy (PT) note of 11/01/13 at an unknown time read, "Patient (resident) found with weakness both LE (lower extremities). Deficits in functional bed mobility, deficits in functional transfer. H/O (history of) falls and high risk of falling, impaired safety awareness, impaired cognition." An occupational therapy (OT) note of 11/02/13 at 12:33 PM read, "Resident needed max (maximum) a (assistance) for all ADLs this date. The daily skilled nurse's note for 11/02/13 at 3 PM indicated that the resident was "anxious with sitter at side." The next nurse's note dated 11/02/13 at 11:30 PM read the resident was found on the floor. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at 10:03 PM on 11/02/13 for anxiety. During an interview of licensed practical nurse (LPN) #H on 2/14/14 at 12:30 PM, she said registered nurse (RN) #G instituted removal of the sitter (1:1) on the evening of 11/02/13 for resident #1, after speaking with the LPN #H and CNA #I. She indicated that RN #G had voiced a need for the sitter to be with another resident. She stated that when she was informed of this, she then went to check on resident #1 herself and she noted the resident was resting. She confirmed that she did not formally evaluate the resident beyond this observation. She then took measures to place the resident on checks every fifteen minutes. The preceding account of the cessation of a sitter for resident #1 was revealed only through interview. The resident's medical record made no mention of the actions leading to the discontinuation of 1:1 for resident #1. Interview revealed that LPN #H complied with RN #G's decision. The administrator stated during an interview on 1/18/14 at 10:36 PM that RNs and LPNs are authorized to remove residents from 1:1. She stated that 1:1 observation is a "safety intervention" and does not require an RN assessment. During an interview of CNA #J on 1/19/14 at 2 PM, who had been with the resident during the evening of 11/02/13, she stated that RN #G had come to the room and told her to go to the other resident in need. The administrator confirmed in the above interview of 10:36 PM on 1/18/14 that there was no documentation in the record or in post-event investigation materials regarding the specific issue of removal of 1:1 for resident #1. Resident #1 had 1:1 observations written on her care plan. There was no stated termination date on the care plan. The care plan indicated concern with the resident attempting to get out of bed. There was neither documented evidence from any source of an RN assessment having been performed prior to removal from this 1:1 observation to determine suitability nor any documentation in the medical record throughout the resident's stay of a decrease in fall risk. Shortly after thr removal of 1:1 observation, the resident fell and sustained fractures of the left femur, right humerus and left side of the ribs in addition to a left eyebrow laceration.

Based on record review and interview, the facility failed to ensure that assessments to ascertain safe levels of supervision for a resident at risk for falls was provided to 1 of 7 sampled residents (#1). The resident fell and sustained fractures of the left femur, right humerus and left side of the ribs in addition to a left eyebrow laceration. Findings: Cross reference to F373, F272, F329. A review of the medical record of resident #1 revealed the resident was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. Other [DIAGNOSES REDACTED]. The medication orders included [MEDICATION NAME] 50 milligrams (mg.) 2 times per day, [MEDICATION NAME] 50 mg. every 6 hours as needed, [MEDICATION NAME] 10 mg. daily, Aspirin 81 mg. daily, [MEDICATION NAME] 4.6 mg./24 hours daily, [MEDICATION NAME] 20 mg. daily, and [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg. every 8 hours as needed for anxiety. The resident also had an order for [REDACTED]. The "Admission/Readmission Data Collection," dated 10/31/13 at 12:00 PM, read, "... resident is a fall risk." It indicated a fall risk score of 9 for the resident. The assessment did not include all accurate information regarding falls in the past 3 months. In the section for falls in the past 3 months, no falls were documented even though the resident was admitted with a shoulder fracture from a fall. The Data Collection form also indicated that the resident required total assistance with bed mobility, needed the assistance of one person with transfers, and ambulated by wheelchair only. The communication section indicated the resident sometimes understood/sometimes understands and hearing is highly impaired. The cognition section indicated the resident was severely impaired for decision making skills. The behavior/mood section listed the resident was agitated when the nurse tried to do a skin check, resists care, and had poor concentration. A Fall Prevention care plan was implemented on 10/31/13. It deemed the resident at risk for falls related to: a fall risk score of greater than 10, cognitive status-dementia, unsteady gait, and history of falls. The goal was that the resident will have no falls within the next 90 days and will not experience injury from falls. One of the interventions included the use of a low bed. The resident had physician orders [REDACTED]." Physician orders [REDACTED]. The floor mats were not included on the current care plan, nor was an alarm. The Behavior Management care plan was not dated and listed the problem as "Potential for impaired or inappropriate behaviors-related to." The section for "related to" was not completed. The goal was that the resident will not demonstrate behaviors of removing self from bed/chair. Among some of the approaches were: assess behaviors for underlying medial causes and assess resident for pain as indicated. The care plan indicated that the resident was on one-to-one (1:1) observation with a date of 11/01/13. In an interview with the administrator on 1/18/14 at 10:36 PM, she stated that the 3-11 PM shift registered nurse (RN) supervisor called her on 10/31/13 at an undetermined time after dinner and stated that resident #1 needed to be on 1:1 because she was anxious. She stated that the supervisor told her, "I'm afraid she's going to fall on the floor." The daily skilled nurses note for 10/31/13 at 12 AM indicated the resident was sleeping. It did not include any documentation of anxious behaviors. The admission data collection note documented the resident was admitted at 12:30 PM. The documented indicated the resident was in stable condition, had no complaints of pain, and not signs of distress. The advanced registered nurse practitioner (ARNP) verified the medications and a head to toe assessment was completed by the unit manager (UM). The notes indicated the resident is a fall risk. There was no evidence that the certified nursing assistant (CNA) used in 1:1 observation was removed from the resident during hours of sleep on this day into the next day, or at any other time until late on 11/02/13. Review of the facility's KARDEX, it indicated: "transfer assist of 1, incont (incontinent of B&B (bowel & bladder) - assist of one, check and change (uses bathroom bsc, bedpan urinal - (NOT checked). Safety section: alarms-bed is checked, 2 half side rails, mat on floor and low bed. Behavior interventions: hand written one on one." The daily skilled nurse's note dated 11/01/13 at 7 AM read, "Resident was continued on 1:1 with CNA, 0 (no) any issues noted, slept all night shift." The note for the same date at 3 PM indicated the resident attended the Starlight program with no acute distress. The notes for 11 PM indicated the resident attended the Starlight program and was restless and anxious, attempting to get up from the wheelchair 3 times. She was medicated with [MEDICATION NAME] for anxiety with good effect. A physical therapy note of 11/01/13 at an unknown time read, "Patient found with weakness both LE (lower extremities). Deficits in functional bed mobility, deficits in functional transfer. H/O (history of) falls and high risk of falling, impaired safety awareness, impaired cognition." An occupational therapy note of 11/02/13 at 12:33 PM read, "Resident needed max a (maximum assistance) for all ADLs this date. The daily skilled nurse's note for 11/02/13 at 3 PM indicated that the resident was "anxious with sitter at side." The next nurse's note was dated 11/02/13 at 11:30 PM in which the resident was noted on the floor. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at 10:03 PM on 11/02/13. During an interview of licensed practical nurse (LPN) #H on 2/14/14 at 12:30 PM, she said RN #G instituted removal of the sitter (and thus 1:1) on the evening of 11/02/13, after having spoken with the LPN #H and CNA #I. She indicated that RN #G had voiced a need for the sitter with another resident in another room. She stated that when she was informed of this, she then went to check on resident #1 herself and noted the resident was resting. She confirmed that she did not formally evaluate the resident beyond this observation. She then took measures to place the resident on safety checks every fifteen minutes. The preceding account of the cessation of a sitter was revealed only through interview. Resident #1's medical record made no mention of the actions leading to the change. Interview revealed that LPN #H complied with RN #G's decision. She said the administrator stated during the interview of 1/18/14 at 10:36 PM that RNs are authorized to remove residents from 1:1. She stated that 1:1 is a "safety intervention" and does not require a RN assessment. During an interview of CNA #J on 1/19/14 at 2 PM, who had been with the resident during the evening of 11/02/13, she stated that a facility RN #G had come in the room and told her to go to the other resident in need. The administrator confirmed in the above interview of 10:36 PM on 1/18/14 that there was no documentation in the record or in post-event investigation materials regarding the specific issue of removal from one-one-one. Resident had 1:1 observations written on the care plan, which did not have a stated termination date. The care plan documented concern with the resident attempting to get out of bed. There was no documented evidence from any source of an RN assessment having been performed prior to removal from this coverage to determine suitability. There was no documentation in the medical record throughout the resident's stay of a decrease in fall risk. Shortly after the removal of 1:1 observation, resident #1 fell and sustained fractures of the left femur, right humerus and left side of the ribs in addition to a left eyebrow laceration.

Based on interview and record review, the facility failed to ensure that 1 of 7 sampled residents with a history of a fall received adequate supervision to prevent accidents and injury that required hospitalization for a fractured left proximal femur, proximal right humerus and left sided rib fractures in addition to a left eyebrow laceration (#1). Findings: Cross reference to F272, F281, F329. A review of the medical record of resident #1 revealed this [AGE] year old resident was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. Other [DIAGNOSES REDACTED]. The medication orders included Tramadol 50 milligrams (mg.) 2 times per day, Tramadol 50 mg. every 6 hours as needed, Lisinopril 10 mg. daily, Aspirin 81 mg. daily, Exelon patch 4.6 mg./24 hours daily, Celexa 20 mg. daily, and Lorazepam (Ativan) 0.5 mg. every 8 hours as needed for anxiety. The resident also had an order for [REDACTED]. The "Admission/Readmission Data Collection," dated 10/31/13 at 12 PM, section N Fall Risk Evaluation, read "... resident is a fall risk." It indicated a fall risk score of 9. The assessment did not include all accurate information regarding falls in the past 3 months. In the section for falls in the past 3 months, no falls were documented even though the resident was admitted with a shoulder fracture from a fall. The Data Collection form also indicated that the resident required total assistance with bed mobility, needed the assistance of one person with transfers, and ambulated by wheelchair only. The communication section indicated the resident sometimes understood/sometimes understands and hearing is highly impaired. The cognition section indicated the resident was severely impaired for decision making skills. The behavior/mood section listed the resident was agitated when the nurse tried to do a skin check, resists care, and had poor concentration. A Fall Prevention care plan was implemented on 10/31/13. It deemed the resident at risk for falls related to: a fall risk score of greater than 10, cognitive status-dementia, unsteady gait, and history of falls. The goal was that the resident will have no falls within the next 90 days and will not experience injury from falls. One of the interventions included the use of a low bed. The resident had physician orders [REDACTED]." Physician orders [REDACTED]. The floor mats were not included on the current care plan, nor was an alarm. The Behavior Management care plan was not dated and listed the problem as "Potential for impaired or inappropriate behaviors-related to." The section for "related to" was not completed. The goal was that the resident will not demonstrate behaviors of removing self from bed/chair. Among some of the approaches were, "assess behaviors for underlying medial causes and assess resident for pain as indicated." The care plan indicated that the resident was on one-to-one (1:1) observation with a date of 11/01/13. In an interview with the administrator on 1/18/14 at 10:36 PM, she stated that the 3-11 PM shift registered nurse (RN) supervisor called her on 10/31/13 at an undetermined time after dinner and stated that resident #1 needed to be on 1:1 because she was anxious. She stated that the supervisor told her, "I'm afraid she's going to fall on the floor." The daily skilled nurses note for 10/31/13 at 12 AM indicated the resident was sleeping. It did not include any documentation of anxious behaviors. The admission data collection note documented the resident was admitted at 12:30 PM. The document indicated the resident was in stable condition, had no complaints of pain, and no signs of distress. The advanced registered nurse practitioner (ARNP) verified the medications and a head to toe assessment was completed by the unit manager (UM). The notes indicated the resident was a fall risk. There was no evidence that the certified nursing assistant (CNA) used for 1:1 observation was removed from the resident during hours of sleep on this day, 11/01/13, into the next day, or at any other time until late on 11/02/13, see below. Review of the facility's KARDEX read, "transfer assist of 1, incont (incontinent) of B&B (bowel & bladder) - assist of one, check and change (uses bathroom bsc, bedpan urinal) (NOT checked). Safety section: alarms-bed is checked, 2 half side rails, mat on floor and low bed. Behavior interventions: hand written 1:1." A review of the CNA (Certified Nursing Assistant) ADL (activities of daily living) tracking form read, "walk in room not completed for 3-11 shift for 11/01 or 11/02. Toilet use (how the resident cleanses self after elimination-total dependence)." The daily skilled nurse's note dated 11/01/13 at 7 AM read, "Resident was continued on 1:1 with CNA, 0 (no) any issues noted, slept all night shift." The note for the same date at 3 PM indicated the resident attended the Starlight program with no acute distress. The notes for 11 PM indicated the resident attended the Starlight program, was restless and anxious, and attempted to get up from the wheelchair 3 times. She was then medicated with Ativan for anxiety with good effect. A physical therapy note of 11/01/13 at an unknown time read, "Patient found with weakness both LE (lower extremities). Deficits in functional bed mobility, deficits in functional transfer. H/O (history of) falls and high risk of falling, impaired safety awareness, impaired cognition." An occupational therapy note of 11/02/13 at 12:33 PM read, "Resident needed max a (maximum assistance) for all ADLs this date." The daily skilled nurse's note for 11/02/13 at 3 PM indicated that the resident was "anxious with sitter at side." The next nurse's note is dated 11/02/13 11:30 PM in which the resident was noted on the floor. The Medication Administration Record revealed that the resident received Tramadol at 8:07 PM on 11/02/13 for joint pain and Lorazepam 0.5 mg. at 10:03 PM on 11/02/13 for anxiety. During an interview of licensed practical nurse (LPN) #H on 2/14/14 at 12:30 PM, it was revealed that RN #G instituted a removal of the sitter (and thus 1:1) on the evening of 11/02/13, after having spoken with the LPN #H and CNA #I. She indicated that RN #G had voiced a need for the sitter with another resident. She stated that when she was informed of this she then went to check on resident #1 herself and that she noted the resident was resting. She confirmed that she did not formally evaluate the resident beyond this observation. She then took measures to place the resident on checks every fifteen minutes. The preceding account of the cessation of a sitter was revealed only through interview. The record made no mention of the actions leading to the change. Interview revealed that LPN #H complied with RN #G's decision. These safety checks were documented on 11/02/13 starting at 10 PM. The resident was found on the floor at 11:30 PM with injury. The administrator stated during the interview of 1/18/14 at 10:36 PM that RNs and LPNs are authorized to remove residents from 1:1. She stated that 1:1 is a "safety intervention" and does not require an RN assessment. During an interview of the CNA #J on 1/19/14 at 2 PM, who had been with the resident during the evening of 11/02/13, she stated that RN #G had come in the room and told her to go to the other resident in need in another room. The administrator confirmed in the above interview of 10:36 PM on 1/18/14 that there was no documentation in the record or in post-event investigation materials regarding the specific issue of removal from 1:1. Resident #1 had 1:1 observations written on a care plan, and did not have a stated termination date. The care plan documented concern with the resident attempting to get out of bed. There was no documented evidence from any source of an RN assessment having been performed prior to removal from this coverage to determine suitability. There was no documentation in the medical record throughout the resident's stay of a decrease in fall risk. The document "Resident Safety Check" of 11/02/13 had the box "15 minute check" checked. It had initials next to boxes for the times of 10 PM, 10:15 PM, 10:30 PM and 10:45 PM. Incident investigation materials indicated that the resident was toileted at 10:20 PM. These materials also indicated that the fall took place at 10:35 PM on 11/02/13. Evidence regarding the status of the resident just before her fall was found in a statement by the resident's CNA #K of 11/02/13. It read, "... came in pt (resident) room 1 to do my 15 min check. Client (resident) was resting. I left out of room to go across the hall to another resident room and pt had fell down on floor. So called nurse and the Supervisor came in and assess pt....Bed was in low position and alarm was on...." A nurse's note of 11/02/13 at 11:30 PM by LPN #H read, "Resident was noted on floor in room 1A by staff person (CNA). Writer summoned to resident room and observed resident on floor. Resident was alert with confusion. Resident was observed with a laceration to left forehead extending to left eye....Writer was sent to call 911.... Resident was taken to....hospital...." A review of facility materials dated 11/02/13 revealed that family was notified at 10:45 PM on 11/02/13. It indicated that the fall was from bed. It indicated that the only injury was a laceration in the area of the left eye. However, review of the hospital record from the 11/03/13 admission revealed the resident sustained [REDACTED]. The resident was removed from continuous 1:1 observations in the evening of 11/02/13 and placed on every fifteen minute observations. The use of 1:1 had initially been instituted with no stated termination date to help prevent harm to the resident. The resident was removed from this protective measure and placed on every fifteen minute checks without documented evidence as to the suitability of such action in the form of a RN assessment. Without evidence from the medical record or any other source of the performance of an updated assessment of the resident's risk for injury and the suitability of every fifteen minute checks in the evening of 11/02/13, continued protection of the resident with adequate supervision had ceased. The 1:1 observations were discontinued and every 15 minute safety checks were initiated and documented beginning at 10 PM. Shortly after the change in supervision approach had been made, the resident incurred an unwitnessed fall and injury from a resident action which the initial care plan had expressed concerns: "trying to rise from the bed." The nurse documented this event as 11:30 PM on 11/02/13. This injury required hospitalization for a fractured left proximal femur, proximal right humerus and left sided rib fractures in addition to a left eyebrow laceration.