Every finding on record at Serenity Bay Nursing and Rehabilitation Center

Based on observations, interviews and record reviews facility failed to store and prepare food in a sanitary manner in the kitchen as evidenced by milk box temperature measured at 50 degrees Fahrenheit, a refrigerated serving of nectar thick milk temperature measured at 51 degrees Fahrenheit, a personal item on top of dishwasher, and a kitchen staff member with a beard not wearing a beard covering. These deficient practices had the potential to result in food borne illness for all residents who consume food prepared in the facility's kitchen. There were 129 residents residing in the facility at the time of survey. The findings included: During the initial kitchen tour on 12/01/2025 at 10:10 AM in the presence of the Kitchen Manager; the Milk Box Refrigerator temperature was measured at 50-degree Fahrenheit ( degrees F). A serving of nectar thick milk observed in the Milk Box, temperature was measured at 51 degrees F. Refrigerator #2 temperature measured at 42 degrees F. (The required temperature range for refrigerators and cold foods is at or below 41 degrees F). The Kitchen Manager was present during the temperature review. The dishwasher sanitizer test strips that were in use had an expiration date of October 1, 2025. After the surveyor notified the Kitchen Manager of the identified concern, the Kitchen Manager presented new unexpired test strips. At 11:00 AM on 12/01/2025, an observation was made of Styrofoam cup on top of the dishwashing machine. Staff E, Porter, was in the kitchen standing beside the dishwashing machine. The Surveyor notified the Kitchen Manager of the identified concern. The Kitchen Manager questioned Staff E, [NAME] about the Styrofoam cup. Staff E, [NAME] stated, was hot picked up the cup, and took a sip. The Kitchen Manager instructed Staff E, [NAME] to discard the cup. Staff E, [NAME] dumped the remaining liquid into a utensil bin. The Kitchen Manager told Staff E, Porter, You cannot do that and send the bin through the dishwasher alone due to contamination. On 12/01/25 at 11:50 AM during the kitchen tour staff member (Staff A, Porter) with a beard was observed carrying a tray of food without wearing a beard covering. Interview on 12/01/25 at 11:50 AM Staff A, [NAME] was asked about the facility's protocol for hair coverings in the kitchen. Staff A stated: I am new here and I was told to wear a covering. Surveyor asked Staff A, [NAME] why staff was not wearing a beard covering and Staff A, [NAME] replied They give me the covering. No beard coverings were observed in the kitchen at the time. Interview on 12/01/25 at 11:55 AM The Kitchen Manager was notified of the identified concern and stated, Staff are aware they need to wear a beard covering. Surveyor asked, Where are the beard coverings kept? The Kitchen Manager retrieved beard coverings from office and placed them in front of kitchen next to the hair nets. During a follow up kitchen tour on 12/02/25 at 12:15 PM revealed Staff A, [NAME] observed in kitchen wearing a surgical mask. Kitchen manager made aware and instructed staff to wear a beard covering. On 12/02/25 at 12:15 PM, the Kitchen Manager was interviewed about facility's protocol for wearing hair coverings and stated, Upon hire staff are trained to wear hair and beard coverings. I keep the coverings at the front. The coverings were not at the front yesterday because only one staff member uses it. The coverings are important to prevent any hairs from entering the food. Hair coverings must be worn upon entering the kitchen. Record review of a policy titled Dietary Employee Personal Hygiene implemented on 5/1/23 reviewed on 5/1/24 and revised on 5/1/25 revealed Policy: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Policy Explanation and Compliance Guidelines: 4. Hair Restraints All dietary staff must wear hair restraint (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. Head coverings must be clean.

Based on observations, interview, and record review, the facility failed to demonstrate and implement effective plan of actions to correct identified quality deficiency in the problem areas related to repeated deficient practice for F656-Develop/Implement Comprehensive Care Plan; F690- Bowel/Bladder; F761- Label/Store Drugs and Biologicals.; F812- Food Procurement, Store/Prepare/Serve Sanitary; there were 129 residents residing in the facility at the time of survey. The findings include. Record Review of the facility's survey history revealed, during a recertification conducted on June 17, 2024, through June 20, 2024, F656-Develop/Implement Comprehensive Plan. F690-Bowel/Bladder Incontinence, Catheter, UTI F761-Label/Store Drugs and Biologicals F812- Food Procurement, Store/Prepare/Serve Sanitary was cited as the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food services safety during observations. Review of the facility Policy and Procedure titled Quality Assurance and Performance Improvement (QAPI) dated 05/01/2023 and revised on 05/01/2025 states: It is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.Interview with the Administrator/Quality Assurance (QA) and Director of Nursing (DON) on 12/04/2025 at 4:38 PM, stated: The QAPI meetings are normally held on the third Wednesday of every month where we discuss the previous months. The last meeting was held on 11/19/2025 and we discussed the issues and findings for the month of October. The committee consists of: Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Medical Director, Registered Dietitian, Rehab Director, Nursing Supervisors, Social Services Director, Activities Director, Housekeeping Director, Administrator, and admission Director. In these meetings, we discuss opportunities for improvement focusing on quality of care/life, and resident safety. We address any gaps in the system for that goal of patient centered care if there were any gaps observed.

Based on observations, interviews and record review, the facility failed to secure confidential information for residents on one (Unit 1) out of 3 units as evidenced by paperwork with residents' medical information left visible and unattended at the Unit 1 nursing station and an open, unattended computer screen with resident information visible on The Unit 1 medication cart 1. There were 129 residents residing in the facility at the time of the survey. The findings included: 1. Observation on 12/01/25 at 12:58 PM revealed unattended medical information with residents' names at the Unit 1 nursing station. Interview on 12/01/25 at 1:05 PM, the Unit 1 Registered Nurse Manager was apprised of the identified concern. The Registered Nurse Manager stated: No information should be viewable to people as they walk by. Even on computers all information should be kept private. 2. Observation on 12/04/25 at 10:38 AM revealed an open unattended computer screen on the Unit 1 medication cart 1 with residents' information visible. Staff H, Registered Nurse acknowledged the identified concern and closed the computer screen. Record review of a policy titled HIPAA Sanctions implemented on 5/1/23, reviewed on 5/1/24 and revised on 5/1/25 revealed Policy: It is the policy of this facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of our residents' personal identifiable health information. Policy Explanation and Compliance Guidelines: 2. All employees are expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. 6. Examples of violations include but are not limited to: a. Accessing information that is not within the scope of the employee's duties. E. Leaving a secured application unattended while logged on.

Based on observations, record reviews and interviews the facility failed to implement the care plans for two (Resident #139 and Resident #142) out of two sampled as evidenced by: 1) The facility's staff positioned Resident #139's indwelling urinary catheter drainage collection bag above the bladder on the bed's side rail, causing backflow of urine in the tubing. 2) Facility staff failed to administer oxygen at the correct delivery flow rate setting for Resident # 139. 3) Facility's staff failed to follow infection control protocol related to Enhanced Barrier Precaution for Resident #142. The findings included:Resident #1391) During an observation on 12/02/25 at 4:50 PM, Staff C, Certified Nurse Assistant (CNA) was noted in Resident 139's room providing assistance. After Staff C, CNA exited Resident #139's room it was noted that the indwelling urinary drainage collection bag was anchored to the bed's side rail above the level of the bladder, and a back flow of urine was observed in the tubing. (photo evidence).Record review of a demographic sheet revealed Resident#139 was admitted on [DATE] with diagnoses that include but not limited to: Obstructive Uropathy, Urinary Tract Infection and End Stage Renal Disease.Record review of a care plan initiated and revised on: 11/20/25 revealed Resident #139 had an indwelling urinary catheter for Obstructive Uropathy with a goal to be/remain free from catheter-related trauma through review date and show no signs or symptoms of Urinary infection with interventions that included: Please position catheter bag and tubing below the level of the bladder. Interview on 12/01/25 at 4:55 PM, Staff B, Registered Nurse (RN) was notified of the above identified concern. Staff B, RN stated: I round every two hours to ensure proper placement. When I came on shift the bag was below the level of the bladder.Interview on 12/01/25 at 5:23 PM, Staff C, CNA stated, I take care of residents with catheters and make sure the bag is inside a cover, not touching the ground and below the level of bladder. I did not notice the bag was on the side rail when I was in the room.On 12/04/25 at 2:32 PM, the Director of Nursing (DON) stated, Staff are to position the bag below the level of the bladder because back flow can cause a UTI.2) Observation on 12/02/25 at 4:50 PM revealed Resident#139 in bed receiving oxygen via nasal cannula at a rate of 5 Liters Per Minute (LPM) (photo evidence).Record review of a demographic sheet revealed Resident#139 was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Failure with Hypoxia and Pleural Effusion.Record review of a physician's order sheet revealed an order dated 11/19/25 directions: Oxygen at 4 LPM via nasal canula continuously every shift for preventative measures.Record review of a care plan initiated and revised on: 11/20/25 revealed Resident#139 had a diagnosis of COPD and was at risk for complications with a goal to maintain optimal breathing and interventions that included: Oxygen at 4 LPM via nasal canula continuously.On 12/01/25 at 4:55 PM, Staff B, Registered Nurse (RN) stated was notified of the identified concern. Staff B, RN stated: The oxygen should be delivered at 4 LPM. Resident # 1423) Observation on 12/04/25 at 10:11 AM revealed Staff D, Registered Nurse (RN) provided Resident #142's tracheostomy care and was not wearing a disposable gown throughout the procedure.Record review of a demographic sheet revealed Resident#142 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Tracheostomy status.Record review of a physician's order sheet revealed an order dated 11/21/25 directions: Enhanced Barrier Precaution (EBP) to prevent transmission of multidrug-resistant organism (MDRO) related to presence of tracheostomy every shift for EBP protocol.Record review of a Minimum Data Set (MDS) reference dated 11/26/25 revealed Resident#142 had a Brief Interview for Mental Status score of 15, indicated no cognitive impairment, received substantial assistance for Oral hygiene and received Tracheostomy care, continuous oxygen therapy, and suctioning as needed.Record review of a care plan initiated on 11/21/25 and revised on: 11/30/25 revealed Resident#142 required Enhanced Barrier Precautions (EBP) related to Tracheostomy with interventions that included: Providers and staff must wear gown and gloves for the high contact care areas which include: dressing bathing/showering transferring changing linens, providing hygiene changing briefs, or assisting to toileting device care use: central line urinary catheters, feeding tube tracheostomy/ventilator wound care any skin opening requiring a dressing.Interview on 12/04/25 at 10:28 AM, Staff D, RN stated: I should have worn a gown, gloves, and face mask because Resident#142 is under Enhanced Barrier Precaution. I didn't put it on because I missed that part.Record review of the facility's policy titled Comprehensive Care Plan implemented on 5/1/23, revised and reviewed on 5/1/24; 5/1/25 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observations, record reviews, and interviews, the facility created an unsafe environment with potential accidents and hazards for one resident (Resident #64) out of 2 residents sampled. An electrical cord extended from a wall to behind Resident #64's bed, causing a tripping hazard. This deficient practice increased the risk of accidents and hazards that could have caused serious harm or injuries. The facility had 129 residents at the time of the survey. The findings include. Observation on 12/02/2025 at 11:07 AM, in Resident's #64's room revealed the resident was not in the room. An electrical cord was observed extending from the wall to behind the resident's bed. (Photo Evidence) Observation on 12/02/2025 at 12:34 PM, in Resident #64's room revealed an electrical cord still extending from the wall to behind resident's bed (Photo Evidence). On 12/02/2024 at 12:56 PM, the Director of Nursing (DON) acknowledged the identified concern and stated: Oh, that is not supposed to be there.this is an old building and there are not enough plugs. I will remove it now. Record Review of Resident #64's demographic sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to idiopathic Normal Pressure Hydrocephalus. Record Review of Quarterly Minimum Data Set (MDS) reference dated 11/19/2025 revealed Resident #64 is severely cognitively impaired and has no impairment to upper/lower extremities but uses walker and wheelchair and receives antipsychotics on a routine basis. Record Review of a Care Plan with start date 07/15/2025, last revised on 06/03/2025 revealed Resident #64 was at risk for falls due to history of falls and unsteady gait. Goal: Resident #64's risk of falls will have decreased through next review date. Intervention; Keep Resident #64's environment clear of clutter and obstacle. Interview on 12/04/2025 at 09:33 AM the Maintenance Director stated: I do not know why the electric cable was plugged that way because it is supposed to be plugged behind the bed. The reason for plugging it behind the bed is to prevent someone possibly tripping and falling if a cable is in the way. The facility's protocol for accident hazards is to ensure that all cables are not in any area where it can cause any person to fall or have any type of accident. During an interview on 12/04/2025 at 01:38 PM, Staff F, Licensed Practical Nurse (LPN) stated: Electronic cords should be plugged in the nearest outlet to the bed but behind the bed, not across like it was. If the outlet behind the bed is broken, we would need to call maintenance and notify them. I think maintenance was aware of the electronic cord being plugged where you found it. Honestly, I did not notice the cord when I made my rounds. Record Review of the facility's Policy and Procedure titled Accident Hazards dated 05/01/2023, revised 05/01/2025 indicated: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazard(s) and risk(s)Evaluating and analyzing hazard(s) and risk(s)Policy Explanation and Compliance Guidelines:Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident.a. All staff (e.g. professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident.b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.

Based on observations, record reviews, and interviews, the facility's staff position an indwelling urinary catheter drainage bag and tubing in accordance with professional standards of care for one (Resident#139) out of three sampled residents, who had an indwelling urinary catheter. The facility's staff positioned Resident#139's indwelling urinary catheter drainage collection bag above the bladder on the bed's side rail, causing backflow of urine in the tubing. This increased the risk of catheter-associated urinary tract infections and other serious medical issues. Ten residents with indwelling urinary catheters resided in the facility at the time of the survey.The findings include: During an observation on 12/02/25 at 4:50 PM, Staff C, Certified Nurse Assistant (CNA) was noted in Resident 139's room providing assistance. After Staff C, CNA exited Resident #139's room it was noted that the indwelling urinary drainage collection bag was anchored to the bed's side rail above the level of the bladder, and a back flow of urine was observed in the tubing. (photo evidence).Record review of a demographic sheet revealed Resident#139 was admitted on [DATE] with diagnoses that include but not limited to: Obstructive Uropathy, Urinary Tract Infection (UTI) and End Stage Renal Disease.Record review of a care plan initiated and revised on: 11/20/25 revealed Resident #139 had an indwelling urinary catheter for Obstructive Uropathy with a goal to be/remain free from catheter-related trauma through review date and show no signs or symptoms of Urinary infection with interventions that included: Please position catheter bag and tubing below the level of the bladder. Record review revealed the admission Medicare 5-day Minimum Data Set (MDS) reference dated 11/22/25 was in progress.Interview on 12/01/25 at 4:55 PM, Staff B, Registered Nurse (RN) was notified of the above identified concern. Staff B, RN stated: I round every two hours to ensure proper placement. When I came on shift the bag was below the level of the bladder.Interview on 12/01/25 at 5:23 PM, Staff C, CNA stated, I take care of residents with catheters and make sure the bag is inside a cover, not touching the ground and below the level of bladder. I did not notice the bag was on the side rail when I was in the room.Interview on 12/03/25 at 1:08 PM, the Infection Control Preventionist stated, I educate staff on ways to prevent urinary infections that include proper perineal care.and to ensure the tubing is below the level of the bladder and not kinked because urine can reflux back into the bladder and cause urinary infection.On 12/04/25 at 2:32 PM, the Director of Nursing (DON) stated, Staff are to position the bag below the level of the bladder because back flow can cause a UTI.Record review of the facility's policy titled Preventing Urinary Tract Infection implemented on 5/1/23, revised and reviewed on 5/1/24; 5/1/25 revealed Policy: Policy: To reduce the incident of urinary tract infection in patients and residents by using evidence-based practice for hygiene, hydration, catheter care and early identification of risk factors.

Based on observations, interviews, and records reviewed, the facility failed to provide adequate respiratory care and services for one (Resident#139) out of two sampled residents receiving oxygen therapy, as evidence by inaccurate oxygen delivery flow rate setting for Resident # 139. This deficient practice increases the risk for worsening respiratory conditions with the potential of an adverse effect. There were 129 residents residing in the facility at the time of survey.The findings included: Observation on 12/02/25 at 4:50 PM revealed Resident#139 in bed receiving oxygen via nasal cannula at a rate of 5 Liters Per Minute (LPM) (photo evidence).Record review of a demographic sheet revealed Resident#139 was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Failure with Hypoxia and Pleural Effusion.Record review of a physician's order sheet revealed an order dated 11/19/25 directions: Oxygen at 4 LPM via nasal canula continuously every shift for preventative measures.Record review of a care plan initiated and revised on: 11/20/25 revealed Resident#139 had a diagnosis of COPD and was at risk for complications with a goal to maintain optimal breathing and interventions that included: Oxygen at 4 LPM via nasal canula continuously.On 12/01/25 at 4:55 PM, Staff B, Registered Nurse (RN) stated was notified of the identified concern. Staff B, RN stated: The oxygen should be delivered at 4 LPM.On 12/04/25 at 2:32 PM The Director of Nursing (DON) revealed Nurses are to follow physician orders when administering oxygen.Record review of the facility's policy titled Physician Orders implemented on 5/1/23, revised and reviewed on 5/1/24; 5/1/25 revealed Policy: It is the policy of the facility to ensure Physician Services are in accordance with State and Federal regulations. Procedure: 6. All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.

Based on observations reviewed and interview the facility's staff failed to maintain the medication refrigerator temperature within the required range of 36 degrees Fahrenheit to 46 degrees Fahrenheit in one out of three medication room refrigerators. The refrigerator thermometer in Unit 3's medication room displayed a reading of 55 degrees Fahrenheit. There were 129 residents that resided in the facility at the time of survey. The findings include.Observation on 12/03/2025 at 10:48 AM, of the Unit 3 medication room with Staff F, a Licensed Practical Nurse (LPN) revealed the temperature log outside the refrigerator was last signed on 12/03/2025 with a documented temperature reading of 39 degrees Fahrenheit. However, the thermometer inside the refrigerator indicated a reading of 55 degrees Fahrenheit. Staff F, LPN stated I do not know what the proper temperature for the refrigerator should be.Interview on 12/03/2025 at 2:24 PM, the Pharmacist stated The medication room refrigerator temperature should be between 36-46 degrees Fahrenheit.Record Review of the facility policy on Medication Storage 05/01/2023 states Refrigerated Products:1. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room.2. Temperatures are maintained within 36-46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee.

Based on observations, record reviews, and interviews, the facility's staff failed to follow infection control protocol related to Enhanced Barrier Precaution for one resident (Resident #142) out of two sampled residents. The staff member did not wear the required Personal Protective Equipment during tracheostomy care, which increases the risk of transmitting Multidrug-Resistant Organisms. At the time of the survey, 129 residents resided in the facility.The findings included: Observation on 12/04/25 at 10:11 AM revealed Staff D, Registered Nurse (RN) provided Resident #142's tracheostomy care and was not wearing a disposable gown throughout the procedure.Record review of a demographic sheet revealed Resident#142 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Tracheostomy status.Record review of a physician's order sheet revealed an order dated 11/21/25 directions: Enhanced Barrier Precaution (EBP) to prevent transmission of multidrug-resistant organism (MDRO) related to presence of tracheostomy every shift for EBP protocol.Record review of a Minimum Data Set (MDS) reference dated 11/26/25 revealed Resident#142 had a Brief Interview for Mental Status score of 15, indicated no cognitive impairment, received substantial assistance for Oral hygiene and received Tracheostomy care, continuous oxygen therapy, and suctioning as needed.Record review of a care plan initiated on 11/21/25 and revised on: 11/30/25 revealed Resident#142 required Enhanced Barrier Precautions (EBP) related to Tracheostomy with interventions that included: Providers and staff must wear gown and gloves for the high contact care areas which include: dressing bathing/showering transferring changing linens, providing hygiene changing briefs, or assisting to toileting device care use: central line urinary catheters, feeding tube tracheostomy/ventilator wound care any skin opening requiring a dressing.Interview on 12/04/25 at 10:28 AM, Staff D, RN stated: I should have worn a gown, gloves, and face mask because Resident#142 is under Enhanced Barrier Precaution. I didn't put it on because I missed that part. Record review of the facility's policy titled Enhanced Barrier Precautions implemented on 5/1/23, revised and reviewed on 5/1/24; 5/1/25 revealed Policy: It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for Unit #1 (13 resident rooms, 1 community shower room, and beauty salon/dialysis storage room), Unit #2 (13 resident rooms and 1 soiled utility room, and Unit #3 (23 resident rooms, 1 community shower and dining room). The findings included: During the resident screenings conducted by the surveyors on 06/16/2024 to 06/17/2024 and the Environmental Tour conducted on 06/17/2024 at 1:00 PM accompanied with the Administrator and Director of Maintenance, the following were noted, 1) Unit #1: room [ROOM NUMBER]: Room walls damaged and in disrepair, over-bed light cord too short for resident use (W-bed), privacy curtain too short to provide resident with visual privacy (D-bed), bathroom water faucet had a large accumulation of yellow matter, and one of two-bathroom lights not working. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), and bathroom water faucet had a large accumulation of yellow matter. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), exterior surface of over-bed table was heavy worn and exposed wood, exterior of bathroom door heavily damaged and in disrepair, and bathroom toilet requires re-caulking to the floor. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), bathroom door frame rust laden, exterior surface of over-bed tables (2) heavily worn, bathroom water faucet had a large buildup of yellow matter, one out of two-bathroom lights not working, and Right brake of wheelchair not working for resident (W-bed). room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), privacy curtain soiled and stained (1/2), room base baseboards damaged and in disrepair, room entry door damaged and in disrepair. room [ROOM NUMBER]: Bathroom water faucet had a large accumulation of yellow matter. room [ROOM NUMBER]: Room walls damaged and in disrepair, exterior of over-bed tables (20 heavily worn and exposed wood, air-conditioning filter was dirt and dust laden, broken wall electrical cover, privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: Bathroom emergency pull cord too short (more than 4: from floor). and privacy curtain too short to provide resident with visual privacy (D-bed). room [ROOM NUMBER]: bathroom water faucet had a large accumulation of yellow matter. room [ROOM NUMBER]: Wall mounted television not working/no reception (D-bed - resident complaint), air-conditioning filter dust and dirt laden, exterior of over-bed table (1) heavily worn, room walls damaged and in disrepair, exterior of room chair (1) stained. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (D-bed), exterior of over-bed table (1) heavily worn, bathroom floor soiled and large black stains, privacy curtains soiled and stained, and cable television wire hanging down and not properly attached to the wall. room [ROOM NUMBER]: Privacy curtain too short to provide resident with visual privacy (A & B beds), air-conditioning filter was dirt and dust laden, bathroom emergency pull cord was tied around the wall handrail, and room walls damaged and in disrepair. Community Shower: Entry door frame rust laden. Beauty Salon: Room was being used for dialysis supply storage and hair salon and noted to have large balls of hair accumulation around the room floor with clean dialysis supplies, soiled equipment (brooms and dust pans stored in middle of the room, clean dialysis supplies stored on wooden pallets and floor area was heavily soiled underneath could not be properly cleaned, dialysis staff noted to eat their meals in the room and interior of staff room refrigerator was heavily soiled and stained. 2) Unit #2: room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, damaged/broken room base boards, large black stains to room floor, bathroom pull cord too long and resting on the floor, bathroom walls soiled and stained, bathroom door damaged and in disrepair, room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, window curtain broken and will not close, and bathroom door opening handle was falling off of the door. room [ROOM NUMBER]: strong urine odor throughout the room. The bathroom floor, ceiling and walls noted to have a build-up of black mold type matter, bathroom entry door heavy damaged and in disrepair, one of two-bathroom lights not working, bathroom base boards missing, room [ROOM NUMBER]: Strong urine odor throughout the room, and bathroom floor heavily soiled and stained. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, and 1 of 3 dresser drawers do not shut properly. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, room floor noted to have numerous and large black stains, and room floor tiles (10) cracked). room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, oxygen concentrator (A-bed) filter was dirt/dust laden, room floor had numerous large black stains, bathroom floor had black stains throughout,, and broken window blinds. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy room [ROOM NUMBER]: Privacy curtain too short to promote resident with visual privacy, bathroom entry door damaged and in disrepair, bathroom floor had numerous black stains throughout, bathroom toilet seat was loose, oxygen concentrator filer was dirt/dust laden, room floor numerous large black stains. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy, oxygen concentrator missing filter, bathroom numerous black stains, IV poor numerous areas of dried brown matter, bathroom toilet seat was loose, room floors and walls damaged and in disrepair. room [ROOM NUMBER]: Privacy curtain too short (A-bed) to promote resident with visual privacy. Soiled Utility Room: Specimen refrigerator interior and exterior was rust laden, and heavy ice buildup with the cavity of the unit. Unit #3: Nurses Station: Floor area within and around the front of the station noted to have numerous large black stains, and 3/3 of chair noted to be torn and stained. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, rooms walls damaged, and in disrepair, and room floor soiled and stained. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and bathroom toilet seat was loose. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, bathroom floor soiled and stained, toilet requires re-caulking to the floor, and exterior of over-bed table (A-bed) was worn with exposed wood splinters. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absence of a window curtain. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absence of window curtain or blinds. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and room floor soiled and had numerous black stains. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain, bathroom emergency lull cord wrapped around the wall mounted handrail, no over-bed light cord (D & W Bed), and one of two-bathroom lights not working. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, and absent window curtain. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, window blinds broken and do not operate, exterior of room closet damaged and in disrepair, no over-bed light cord (W-bed), bathroom toilet bowl soiled and stained, and exterior of over-bed table (W-bed) worn with exposed wood. room [ROOM NUMBER]: Privacy curtain (A & B-beds) was to short and did not promote resident privacy, and two of 3-bathroom lights not working). room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, absent window curtain, bathroom floor soiled and numerous black stains, portable commode seat handles were cracked, and one of 3-bathroom lights were not working. room [ROOM NUMBER]: Privacy curtain (A & B-beds) was to short and did not promote resident privacy, room floor soiled with numerous large black stains, exterior of bathroom door had numerous large black scuff markings, room wall vent noted to be dirt/dust laden, and absence of over-bed light cord (W-bed). room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy, absent window curtain, exterior of over-bed light (W-bed) was rust laden, bathroom door handle broken and loose, and bathroom floor soiled had large black stain areas. room [ROOM NUMBER]: Privacy curtain (A-bed) was to short and did not promote resident privacy. room [ROOM NUMBER]: Privacy curtain (A, B, and C-beds) was to short and did not promote resident privacy, room ceiling tiles (3) stained yellow in color, room floor soiled and black stains, bathroom floor numerous black stains, bathroom sink basin black stains, and television cable wire not properly attached to wall and hanging down off the wall. room [ROOM NUMBER]: Privacy curtain (A, B and C-beds) was to short and did not promote resident privacy, room floor numerous large black stains, absence of window curtain, bathroom toilet seat loose, room walls damaged and in disrepair. Community Shower: Wall vent dirt/dust laden. Nursing Supply Closet: Numerous resident care supplies stored directly on the soiled floor. Dining Room: Room floor soiled and stained, and one of five ceiling lights not working. On 06/20/24 a meeting was conducted with the Administrator to confirm the housekeeping/maintenance issues noted from 06/16-18/24. The administrator stated she was aware of the issues located on the Unit #1, #2, and #3 Units. During the meeting it was also noted that each of the nurses stations located on the units (3) have a maintenance log that staff are required to date and document and housekeeping/maintenance issues. Further stated that maintenance staff check the logs daily, however, are not documenting their issues on the maintenance logs.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included. 1) During the initial kitchen/food service observation tour conducted on 06/17/2024 at 9:00 AM accompanied with the facility's Foods Service Director (FSD) and Registered Dietitian (RD), the following were noted: a) There was a large leak in the ceiling area located in front of the steam table and milk cooler. Further noted that there was an accumulation of water on the floor beneath the leak area. It was revealed by the Registered Dietitian that the leak occurred a few days ago. It was discussed that there was the potential for the contamination of food, equipment, and staff from the dripping of contaminated water. It was requested that the floor area underneath the leak be repaired immediately and to stop any food, staff and equipment from going under the leak area. b) Observation noted a ceiling mounted air-conditioning vent located over the steam table serving area had an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for food contamination from the contaminated drippings. c) Observation noted a ceiling mounted air-conditioning vent located over the commercial milk storage refrigerator. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for the milk to become contaminated from the condensation drippings. d) Observation noted a ceiling mounted air-conditioning vent located over the 3-compartment sink area. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for clean preparation equipment to become contaminated from the condensation drippings. e) Observation noted a ceiling mounted air-conditioning vent located over the juice dispenser area. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for juice's to become contamination from the condensation drippings. f) Observation noted a ceiling mounted air-conditioning vent located over the center of the dish machine room. Further observation noted that there was an accumulation and dripping of condensation from the vent surface. It was discussed with the Registered Dietitian that there was a potential for clean dishes and staff to become contaminated from the condensation drippings. g) At the request of the surveyor a chemical test was conducted by the FSD of the low-temperature commercial dish machine. The chemical test noted that the Chlorine test strip indicated no presence of sanitizing chemical present in the final rinse and did not meet the regulatory requirement of a 50 PPM. The washing of dishes was requested to be stopped until the regulatory requirement was met. h) At the request of the surveyor a chemical test of the 3-compartment sink was conducted by the FSD. The chemical test noted that the Quaternary chemical exceeded the minimum requirement (150 PPM) and was determined to be a toxic level of over 300 PPM. The washing of food preparation equipment was requested to be stopped until the regulatory chemical level was met. i) During the observational tour it was noted that a large pan of raw chicken (approximately 10 pounds) was located in the cooks preparation sink. Further observation noted that only a small stream of water was flowing over the raw chicken. It was also noted that small stream of water flowing onto the chicken was warm to the touch. At the request of the surveyor the temperature of the flowing water was tested with the facility's calibrated bayonet thermometer; the temperature of the water was recorded at 85 degrees F. The surveyor informed the FSD that the thawing process did not meet regulatory requirement. The FSD was informed that the temperature of the flowing water must be 70 degrees F or below and must be at a high force to remove particle of chicken. The surveyor requested that the chicken be discarded. (J) Observation of the reach-in refrigerator there was a large tear noted in the door gasket and 5 of the food storage shelves located within the unit were rusted. (K) The surveyor requested the cleaning cloth bucket #1 be tested for sanitizing chemical presence. The test conducted by the facility Registered Dietitian noted that there was no sanitizing chemical (Quaternary) present in the bucket to meet regulatory requirement. (L) Numerous cooking equipment (pots & pans - 5) were noted to be covered in a thick black carbon matter. The surveyor discussed with the facility's Registered Dietitian that the carbon could result in food contamination during preparation and that the equipment be replaced as soon as possible. 2) During a second observation of the main kitchen on 06/18/2024 at 6:45 AM accompanied with the FSD and Registered Dietitian, the following were noted: a) The interior of the main exhaust system located above the major cooking equipment was noted to be rust laden throughout the entire surface of the unit. b) The plate warming lowerator was noted to be broken and too many resident entree plates were being stored within the unit. c) Numerous resident entree plates located within the plate lowerator were noted to be broken and chipped (15). The surveyor requested that the plates be observed prior to serving and to discard the broken/chipped plates. d) The maintenance director was noted to be located within the food production and serving area. Further observation noted that the director failed to don a beard/mustache guard. e) The temperatures of foods located on the steam table were taken with the facility's calibrated bayonet thermometer by the facility's Registered Dietitian. The temperature testing noted that hot foods were not being held at the minimum regulatory temperature of 135 degrees or greater. The temperatures were recorded as follows: * Pureed Scrambled Eggs (20 servings) = 110 degrees F * Pureed French Toast (20 servings) = 112 degrees F 3) During a third kitchen observation conducted on 06/19/2024 at 11:30 AM it was noted that a diet aide was wrapping silverware in an unsanitary manor. Specifically, the silverware was located in a large open dish reach. Staff were noted to be handling the silverware by the eating stem and putting it into silverware bags. The facility's Registered Dietitian was requested to observe the handling of the silverware and confirm the findings. Further stated that the silverware not being washed properly in the required 3-step process to ensure proper handling.

Based on observation and interview it was determined that the facility failed to dispose of garbage and refuse properly. The findings included: Observation of the garbage/dumpster area located outside at the rear of the facility on 06/17/2024 at 9 :15 AM and accompanied with the facility's Registered Dietitian, the following were noted: (a) The dumpster was noted to be overflowing and that resulted in the lids (2) being unable to be closed. Broken bags of garbage/trash were noted to be within the open dumpster cavity and falling down onto the ground area in front of the dumpster. (b) Due to the overflowing dumpster addition bags (30) of trash /garbage and nursing waste was noted to be stored on the ground area approximately 10 feet from the dumpster. Numerous bags were noted to be ripped open resulting in trash, garbage, and soiled PPE supplies (gloves, gowns, etc.) to be strewn around the ground area in front of the bags. c) Interview with the Administrator following the 06/17/24 tour noted to state that there was recent flooding in the area resulting in delay of routine trash pick-up. It was discussed that the ground area and bags should be monitored daily for torn bags that contain garbage, trash and PPE be cleaned daily. * Photographic evidence obtained for examples (a) and (b).

Based on record reviews and interviews, the facility failed to obtain orders that accurately reflected code status for one (Resident #39) out of two residents reviewed for Advanced Directives. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set, dated dated [DATE], Resident #39 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Review of the resident's electronic health record revealed that there was no determination made regarding a code status for the resident. During an interview, on [DATE] at 9:02 AM, with Staff L, Unit Manager, when asked about the code status not being in Resident #39's electronic health record, the Unit Manager stated, then we have to find out. Maybe it is not signed or might have been rescinded. During an interview, on [DATE] at 10:29 AM, with Staff M, Assistant Social Worker, when asked about the responsibility related to admissions and putting in Code Status, If I become aware of the status not being there, I will inform them (admissions) or my Supervisor. She (Resident #39) was here before I came here. it is usually on the face sheet. She is not a DNR, we usually get the information from the family, we get the order from the doctor for the DNR. During an interview, on [DATE] at 11:12 AM, with the Admissions Director, when asked about the procedure for ensuring code status is determined and an order is obtained to reflect the code status, the Admissions Director replied, Social Services (SS) does the Advanced Directives. I ask on admission for living will, POA (Power Of Attorney) I ask them, but I don't put them in. If they are DNR (Do Not Resuscitate), I ask them for a copy of it. I refer to the Director of Nursing (DON) and SS if Advanced directives for full code and DNR are not established. During an interview, on [DATE] at 11:17 AM with the DON, when asked about the communication regarding the code status of Resident #39, the DON replied, there was a previous DON that took a lot of staff with her. When I heard that some of the residents did not have a code status or order for code status, I checked everyone in the facility and got orders for the code status. If a patient is a DNR, they have a red arm band that indicates DNR, otherwise they have a green arm band that indicates that CPR should be done.

Based on interviews and record reviews the facility failed to ensure accuracy of medical personnel title for 1 of 29 sampled residents (Resident #32). The findings included: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set for Resident #32 dated 03/27/2024 revealed in section C for Cognitive Pattern documented a Brief Interview of Mental Status score of 15 out of indicating a cognitive response. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) revealed she has worked at the facility since beginning of May 2024. When asked when Resident #32 was last seen by a physician, she reported it was 12/28/2023 by Staff G (later discovered to be a Nurse Practitioner). When asked what kind of physician it was that had seen the resident on 12/28/2023, if it was the primary physician or some other type of physician, she said she was not familiar with all of the physicians yet since she is still fairly new to the facility, it was revealed she did not know. She contacted the Admission Director to pull the physician's license who had seen the resident on 12/28/2023. When the license was provided to the DON, she acknowledged Staff G who saw the resident on 12/28/2023 was a Nurse Practitioner and not a physician as indicated in the electronically signed Physician's Note. When asked who is responsible for entering the medical personnel title into the facility's electronic system, she said she believes it is the Admission Director who also verifies medical personnel credentials. During an interview conducted on 06/20/2024 at 10:00 AM with the Admission Director who reported she is the one to verify credentials for the Physicians, PAs (Physician Assistants), and NPs (Nurse Practitioners) up until 6 months ago she was the one who entered them into the facility's electronic system including their title. The Admission Director reported now she believes it is the DON who enters the information. The Admission Director was asked about the Physician's Note for Resident #32 dated 12/28/2023 electronically signed by Staff G Nurse Practitioner (NP) but identified in the EMR (Electronic Medical Records) as a physician, the Admission Director acknowledged Staff G is not a physician. Review of the Physician's Notes for Resident #32 revealed on 12/28/2023 the Physician's Note was electronically signed by Staff G NP as a physician.

Based on observations, interviews and record reviews, the facility failed to develop and implement care plans for the use of bed rails for 3 of 3 residents reviewed for bed rails, Residents #54, 5, and 120. The facility failed to develop and implement a care plan for a urinary catheter for 1 (Resident #7) of 1 resident reviewed for catheter. The findings included: The facility's policy, Proper use of Bed Rails, implemented 05/01/2023, documented: Ongoing Monitoring and Supervision. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan . During an interview, on 06/20/2024 at 1:50 PM, with Staff N, MDS (Minimum Data Set) Coordinator, when asked about the lack of care plan for Resident #54's bed rails, the MDS Coordinator stated that Restorative was responsible for initiating care plans for bed rails. During an interview, on 06/20/2024 at 1:57 PM, with Staff O, LPN (License Practical Nurse) /Restorative Nurse, when asked about care plans that the Restorative staff are responsible for, Staff O replied, falls, ADLs, (Activities Of Daily Living) incontinence - I am in the middle of training in the department. The DON (Director Of Nursing) oversees the restorative program. During an interview, on 06/20/2024 at 2:01 PM, with the DON, when asked about the Restorative staff responsible for care plans, the DON replied, He was just hired for that less than a month ago. 1). Resident #54 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE], Resident #54 had a Brief Interview for Mental Status (BIMS) score of 10, indicating that Resident #54 was 'moderately' cognitively impaired. Resident #54's diagnoses at the time of the assessment included: Hypertension, Parkinson's disease, Malnutrition, Schizophrenia, Mood disorder, Blindness in one eye and low vision in the other eye, Corneal disorder due to contact lens, contracture to right wrist, right hand and left hand. Resident #54's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 10/13/2022. Resident requires 2 persons to assist with the use of mechanical lift for transfer - 04/30/2021. Further review of Resident #54's electronic health record revealed that there was no care plan for the rails. On 06/18/2024 at 10:18 AM Resident #54 was observed in bed and was noted to appear highly agitated. The resident was yelling out loud in Spanish and shaking from side to side by grabbing the rails through one of the openings near the top of the rail that went from HOB (Head Of Bed) to approximately the middle of the bed. Resident #54 then was observed on her right side clutching the rail on the residents left side of the bed and was able to pull upper body up while on her side. 2). Resident #5 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], Resident #5 had a BIMS score of 15, indicating the resident was 'cognitively intact'. Resident #5's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Non-Alzheimer's dementia, Seizure disorder, Anxiety disorder, Bipolar disorder, Schizophrenia, Difficulty in walking, Unsteadiness on feet, Lack of coordination, Insomnia, Hereditary and idiopathic neuropathy, Muscle weakness. Resident #5's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 12/05/2023. On 06/18/2024 at 9:35 AM, Resident #5 was observed in bed with side rails that extended from the head of the bed to approximately the middle of the bed. It was noted that the rails were covered with a foam material that appeared to be floatation devices (pool noodles) held to the rails using scotch tape. During an interview, on 06/20/2024 at 9:43 AM, Staff L stated, she is alert and oriented and when she has a UTI (Urinary Tract Infection), she gets agitated and confused. She has recurring UTI. at least a couple of times a year. She has been here a long time. Staff L confirmed orders for half rails. Further review of Resident #5's electronic health record revealed that there was no care plan for the use of the bed rails. 3). Resident #120 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly MDS, dated [DATE], Resident #120 had a BIMS score of 10, indicating that Resident #120 was 'moderately cognitively impaired. Resident #120's diagnoses at the time of the assessment included: Hypertension, Non-Alzheimer's dementia, Encephalopathy, Muscle weakness, Unsteadiness on feet, Insomnia. Resident #120's orders included: Pressure reduction mattress with bilateral 1/2 rails for bed mobility and positioning to promote independence - 12/13/2023. Further review of Resident #120's health record revealed that there was no care plan for the use of the bed rails. On 06/17/2024 at 11:29 AM, Resident #120 was observed in her wheelchair to the left side of the bed with rails that extended from the head of the bed to approximately middle of the bed raised with green foam taped to rails that appeared to be floatation devices (pool noodles) held to the rails using scotch tape. An interview was attempted, however the resident was agitated and appeared confused and was providing nonsensible answers to questions. On 06/19/2024 at 9:39 AM, Resident #120 was observed in bed sleeping with rails in raised position and green foam material on the rails. During an interview, on 06/20/2024 at 9:38 AM, with Staff L, when asked about the use of the rails, Staff L replied, she is supposed to have grab bars, the little, short ones that are around the shoulder and they should not be those. She ambulates on her own free will. Sometimes the residents will sleep against it or get a bruise from it (referring to the use of the foam material). 49060 4). Review of the facility's policy titled, Appropriate Use of Indwelling Catheters, dated 05/01/2023, included the following: Policy Explanation and Compliance Guidelines: Item 9. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. Review of the Nursing Progress notes revealed that on 03/25/2024 Resident #7 had a Urologist appointment located outside of the facility. During the appointment, Resident #7 had a procedure for indwelling catheter placement. Resident #7 returned to the facility with an indwelling catheter and orders for clinical monitoring for signs of upper urinary tract deterioration and/or recurrent UTIs. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 had a Brief Interview for Mental Status of 11, which indicated that he was moderately cognitively impaired. Review of Section H revealed that Resident #7 did not have an indwelling catheter. Review of the Care Plan dated 03/27/2024 documented that Resident #7 had incontinence of Bowel functions and at risk for alteration in skin integrity and infection related to the diagnosis neuromuscular dysfunctions, BPH, history of chronic UTI, and Bacteremia. Interventions were to currently take antibiotics for UTI prophylaxis, monitor urine for odor and output and report abnormalities to physician. No care plan nor interventions were noted for an indwelling catheter. An interview was conducted on 06/20/2024 at 1:52 PM with MDS nurse. She stated that the care plans are based on the residents' diagnoses and their problems. She gathers the residents' information from daily clinical meetings, social services, restorative services and the current physician's orders. The MDS nurse stated that Resident #7's indwelling catheter was added to the care plan dated 03/27/2024. Upon review of the Care plan dated 03/27/2024 she noted that the plan of care did not refer Resident #7 having an indwelling catheter nor any interventions or strategies to prevent UTIs.

Based on observations, interviews and record reviews, the facility failed to apply splint devices as ordered to prevent further decrease in range of motion for 1 of 1 resident reviewed, Resident #39. The findings included: Resident #39 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #39 had a Brief Interview for Mental Status score of 10, indicating that the resident was moderately cognitively impaired. The MDS documented that Resident #39 had bilateral impairments to upper and lower extremities and was dependent upon staff for all activities of daily living (ADLs). Resident #39's diagnoses at the time of the assessment included: Hypertension, Diabetes Mellitus, Hyperlipidemia, Aphasia, Depression, difficulty in walking, Unsteadiness on feet, Lack of Coordination, Muscle weakness, History of falling, Idiopathic pulmonary hemosiderosis, Personal history of disease of the circulatory system. Resident #39's Orders included: RNP:(R) Knee splint daily for 4 hours daily. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. RNP: (L) knee splint daily for 4 hours daily. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. RNP: (R) elbow extension splint daily for 4 hours. May remove for ADLs and skin audit. - every day shift for Contracture Prevention/Management - 07/18/2023 with a start date of 07/19/2023. On 06/17/2024 at 11:11 AM, Resident #39 was observed up in her wheelchair, while staff was tending to room. It was noted that the resident's right hand was clinched and there was no splint or device noted. On 06/18/2024 at 7:20 AM, Resident #39 was observed in bed sleeping with no device noted. On 06/18/2024 at 9:20 AM, Resident #39 was observed in bed and awake. When the resident was asked about the use of splints or devices, Resident #39 did not provide a response. It was determined that the resident was not interviewable. On 06/18/2024 at 12:08 PM, Resident #39 was observed up in her wheelchair and no brace noted. On 06/18/2024 at 1:44 PM, Resident #39 was observed in her wheelchair in activities with no braces noted. On 06/19/2024 at 6:44 AM, Resident #39 was observed in bed sleeping with no braces noted. During an interview, on 06/19/2024 at 6:58 AM, with Staff P, LPN, when asked about the use of splints or devices for Resident #39, Staff P replied, she is not contracted when asked about the resident's right hand being contracted, Staff P replied, yes she is. During an interview, on 06/19/2024 at 9:28 AM, with Staff O, LPN/Restorative Nurse, when asked about Resident #39 's contractures, Staff O replied, She is contracted, she has contractures, They (referring to splints and braces) are to avoid further contraction and they are care planned. When asked about staff applying the devices, Staff O replied, They do their rounds downstairs and are up here by 8:30 AM for rounds (referring to the restorative CNAs), and that is when they put the braces on prior to ADLs. Sometimes she does not last all 4 hours. she is able to tell them when she has pain and is not tolerating when she points to the areas. During an interview, on 06/20/2024 at 9:24 AM, Staff Q, Restorative Aide, when asked about applying splints and devices to Resident #39, Staff Q replied, we come in at 7:00 AM and at 7:30 AM we start with the braces. The CNAs take the braces off to clean them (referring to the residents). The CNA this morning started to take it off to clean her and I told her not to because it was too soon. After the CNAs take the brace off to clean, we leave it off. It is supposed to be on for 4 hours and sometimes they take it off half hour early. The CNA always tells us when they take it off. This one today is not the regular one. Sometimes she takes it off. She doesn't talk. If she doesn't want it, she takes it off many times. Staff Q further reported they do not document resident removing brace/device. During an interview, on 06/19/2024 at 10:14 AM, the Director of Nursing stated, When I came here in May, there was no Restorative program. I promoted Staff O, and he has done very well. Review of progress notes for the time period 05/20/24 to 06/19/2024 revealed no documentation of Resident # 39 not tolerating devices or having the devices removed.

Based on observations, interviews, and record review, the facility failed to obtain physician's orders for an Indwelling urinary catheter and properly document the care for prevention of urinary tract infections for 1 out of 2 residents reviewed for bladder incontinence with an Indwelling Catheter (Resident #7). The findings included: During an observation conducted on 06/17/2024 at 10:31 AM, Resident #7 was noted to have an Indwelling Catheter in place. A brief interview was conducted with Resident #7 in which he stated that he has had the catheter for a long time. In addition, he acknowledged that the catheter is medically necessary because otherwise he would be in a lot of pain. Record review for Resident #7 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract Infection (UTI), Neuromuscular Dysfunction of Bladder, Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms. Review of the Nursing Progress notes revealed that on 03/25/2024 Resident #7 had a Urologist appointment located outside of the facility. During the appointment, Resident #7 had a procedure for Indwelling Catheter placement. Resident #7 returned to the facility with an indwelling Catheter and orders for clinical monitoring for signs of upper urinary tract deterioration and/or recurrent UTIs. Review of the Physician's Orders showed that Resident #7 had orders dated 12/21/2023 for Tamsulosin HCl Capsule 0.4 mg(milligrams) in the evening for BPH. Methenamine Hippurate (Hiprex) 10mg tablet for UTI; Enhanced Barrier Precaution (EBP) to prevent transmission of multidrug-resistant organism (MDRO) for Obstructive Uropathy with Indwelling medical device dated 05/29/2024 (no orders for an Indwelling Catheter or implementations for catheter care). Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 had a Brief Interview for Mental Status (BIMS) of 11, which indicated that he was moderately cognitively impaired. Review of Section H revealed that Resident #7 did not have an Indwelling Catheter and was not taking antibiotics. Review of the Care Plan dated 03/27/2024 documented that Resident #7 had incontinence of Bowel functions and at risk for alteration in skin integrity and infection related to the diagnosis neuromuscular dysfunctions, BPH, history of chronic UTI, and Bacteremia. Interventions were to currently take antibiotics for UTI prophylaxis, monitor urine for odor and output and report abnormalities to physician. Review of the Medication Administration Record (MAR) for March, April, May, and June 2024 revealed that no documentation was noted of Resident #7 having an Indwelling Catheter. In addition, there was no documentation for interventions or maintenance for the Indwelling Catheter. An interview was conducted on 06/17/2024 at 2:48 PM with Staff F, Licensed Practical Nurse (LPN). She stated that a resident with a Indwelling Catheter would have physician's orders in the computer system. In addition, Staff F noted that as needed orders (PRN) for irrigation or if the tubing or catheter bag required changing, would also be included in the physician's orders. She confirmed that Resident #7 has an Indwelling Catheter in place. Upon review of Resident #7's orders, Staff F acknowledged no orders existed for an Indwelling Catheter nor the interventions for catheter care. During an interview conducted on 06/18/2024 at 11:27 AM, with Staff E, LPN, noted that a resident returning from a doctor's appointment comes back to the facility with paperwork including any new orders. If there are no orders and the resident has an Indwelling Catheter, the nurse receiving the resident would need to contact the doctor's office for the Indwelling Catheter order and then enter it into the computer system. Furthermore, the nurse receiving the resident would do a head-to toe assessment and document the information under the nursing progress notes. During an interview conducted on 06/18/2024 at 11:55 AM, with Staff D, Certified Nursing Assistant (CNA), she noted that Resident #7 has had the Indwelling Catheter for a while. Staff D does not recall how long Resident #7 had the catheter, however, it has been months. An interview was conducted on 06/19/24 at 12:20 PM with the Assistant Director of Nursing (ADON). She stated that Resident #7 went out of the facility in March for an appointment and returned to the facility with an Indwelling Catheter. The ADON acknowledged that the nurse did not enter Resident#7's Indwelling Catheter orders into the computer system. In addition, when she was questioned as to where the nurses were documenting the Indwelling Catheter care and interventions, she .shrugged her shoulders, and did not respond. Review of the facility's policy titled, Appropriate Use of Indwelling Catheters, dated 05/01/23, included the following: It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. Policy Explanation and Compliance Guidelines: 1. It is the policy of this facility to ensure each resident with urinary incontinence: c. Who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable).

Based on interviews and record reviews the facility failed to ensure timeliness of physician visits for 1 of 29 sampled residents (Resident #32). The findings included: Review of the facility's policy titled, Physician Visits and Physician Delegation dated 05/01/2023 included in part the following: 2. The Physician should: b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. h. At the option of the physician, required visits in SNFs (Skilled Nursing Facilities), after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by State law and under the supervision of the physician. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnosis including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set for Resident #32 dated 03/27/2024 revealed in section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) she revealed she has worked at the facility since beginning of May 2024 When asked how often the primary physician is required to visit the resident, she said upon admission, then every month for the first 90 days then every 60 days, she added they can assign the Nurse Practitioner (NP) or the Physician's Assistant (PA) to see the resident in their place. When asked where the Physicians, Nurse Practitioners (NPs) and Physician Assistants (PAs) document their visits, the DON said in the resident's electronic medical record (EMR). When asked who is responsible for ensuring physician's visits are performed timely, she said it is ultimately the responsibility of the DON. The DON said she runs a report monthly to ensure the resident was seen by the Physician, NP or PA. When asked when Resident #32 was last seen by a physician, she stated it was 12/28/2023 by Staff G (Physician but later discovered to be a Nurse Practitioner). Review of the Physician's Notes for Resident #32 revealed the following: On 12/28/2023 the Physician's Note was electronically signed by Staff G, NP as a physician. On 01/18/2024, 02/01/2024, 03/06/2024, 04/11/2024, 05/20/2024, 05/22/2024 all Physician's Note was electronically signed by Physician's Assistant (PA). This indicated the resident was not seen by the Primary Physician in the past 6 months. During a telephone interview conducted on 06/20/2024 at 10:57 AM with Staff H's Primary Care Physician (PCP) for Resident #32 who was asked about the frequency of physician visits for residents, Staff H's PCP stated, the goal is to see all patients quarterly. Staff H's PCP reported residents are seen monthly by the NP or PA. Staff H's PCP revealed the facility does not provide a list or schedule of patients to be seen, his practice controls from their end which patients are seen, additionally sometimes residents come and go from the facility, and they may slip through the system and not be seen.

Based on observations, interviews, and record reviews the facility failed to adequately monitor behaviors for residents receiving psychotropic medications for 5 out of 81 residents receiving psychotropic medications (Resident #32, 34, 96, 5, 116). The findings included: Review of the facility's policy titled; Use of Psychotropic Medication dated 05/01/2023 included in part the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 3. The attending physician, and/or ARNP (Advanced Registered Nurse Practitioner) will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with resident, their families and/or representatives, other professionals and the interdisciplinary team. 1 Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Disorganized Schizophrenia, Other Psychotic Disorder Not Due to a Substance or Known Physiological Condition and Major Depressive Disorder. Review of the Minimum Data Set (MDS) for Resident #32 dated 03/27/2024 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #32 revealed an order dated 01/29/2021 for Behaviors - Monitor For The Following: (Hallucination and Pacing) Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. Review of the Physician's Orders for Resident #32 revealed an order dated 08/19/2021 for Psychoactive Meds - Monitor for dry mouth, constipation, blurred vision, confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (Nausea/Vomiting), lethargy, drooling, EPS (Extrapyramidal Symptoms) (Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement of Mouth or Tongue). Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. Review of the Physician's Orders for Resident #32 revealed an order dated 03/20/2024 Risperdal Oral Tablet 1 mg (milligram) give 1 tablet by mouth two times a day for Mood Disorder related to Disorganized Schizophrenia every shift. Review of the behavior notes and health status notes for Resident #32 for June 2024 revealed no notes related to behaviors or symptoms. Review of the Behavior Monitoring Record for Resident #32 from 06/10/2024 to 06/18/2024 revealed only a check mark each day on each shift (morning, evening and night) for each day. The documentation did not indicate a Y or N as ordered. Review of the CNA (Certified Nursing Assistant) Task for Monitor - Behavior Symptoms for Resident #32 from 06/10/2024 to 06/18/2024 documented the resident had no symptoms. Review of the Care Plan for Resident #32 dated 04/04/2023 with a focus on the resident has episodes of pacing the hallways and talking to the walls. The resident requires cueing and redirecting. The resident is utilizing anti-psychotic medication. The goal was for the resident to have fewer episodes of pacing and talking to the wall by review date. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet The resident's needs. Caregivers provide opportunity for positive interaction and attention. Stop and talk with him/her as passing by. Monitor for outbursts during pacing episodes and talking to the walls Delusional. Psych consult as needed. Redirect the resident and try to involve him in a group related activity. On 06/17/2024 at 12:09 PM Resident # 32 observed walking through the facility in a pace-like manner. On 06/18/2024 at 7:55 AM Resident # 32 observed walking through the facility in a pace-like manner. During an interview conducted on 06/19/2024 at 2:50 PM with Staff A Licensed Practical Nurse (LPN) who was asked about behavior monitoring how it is documented, she said there is no place to put a Y or N so if the resident has behaviors you mark N and write a behavior note/health status note. Staff A, LPN said it is confusing, but you put a Y if the resident has no behavior and a N if the resident has behaviors. If the resident has behaviors, you put a note in the chart under progress notes to indicate the behavior observed and intervention used like redirecting the resident. When asked about Resident #32 if the resident paces, she acknowledged that the resident paces all of the time. When asked if she documents his pacing, she said no because he does it all of the time, we only document if it is a new or different behavior from what he normally does. During an interview conducted on 06/19/2024 at 3:00 PM with Staff C Certified Nursing Assistant (CNA) who was asked about behavior monitoring, she stated there is a place to document behaviors under Tasks and she would tell the nurse if the resident had behaviors. When asked about Resident #32, she said she would only document behavior that is like hitting or punching or yelling. When asked if the resident paces, she acknowledged he does that all day, every day. When asked if she would document the pacing, for the resident she said no because he does it all of the time and this is his normal behavior. During an interview conducted on 06/19/2024 at 3:10 PM with Staff B Licensed Practical Nurse (LPN) who stated she has worked at the facility for [AGE] years. When asked about behavior monitoring, she said you document a Y if there are no behaviors for the resident, and a N if the resident is having behaviors. If the resident has behaviors, then you make a note of what the behavior(s) are that are observed. During an interview conducted on 06/20/2024 at 9:45 AM with the Director of Nursing (DON) who was asked about behavior monitoring for residents receiving psychotropic medications, she stated they are all monitored, and it is documented in the Behavior Monitoring Record (BMR). If the nurse observes behaviors the behavior is documented in a nurse's note and the intervention. 2 Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: Parkinsonism and Major Depressive Disorder. Review of the MDS for Resident #34 dated 05/16/2024 revealed in Section C for cognitive pattern a BIMS score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #34 revealed an order dated 01/8/2024 for Venlafaxine HCl Oral Tablet 75 mg give 75 mg by mouth one time a day related to Major Depressive Disorder. Review of the Physician's Orders for Resident #34 revealed an order dated Behaviors - Monitor for the Following: Agitation, Hitting, Increase in Complaints, Biting, Kicking, Spitting, Cussing, Racial Slurs, Elopement, Stealing, Delusions, Hallucinations, Psychosis, Aggression, or Refusing Care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and document findings and interventions. every shift for antidepressant medication use. Review of the BHR for antidepressant for Resident #34 from 06/10/2024 to 06/18/2024 revealed the following: On 06/10/2024 day and evening shift documented N indicating a behavior was observed. On 06/11/2024 day shift documented N indicating a behavior was observed. On 06/12/2024 day shift documented N indicating a behavior was observed. On 06/13/2024 day and evening shift documented N indicating a behavior was observed. On 06/14/2024 morning and evening shift documented N indicating a behavior was observed. On 06/17/2024 day shift documented N indicating a behavior was observed. On 06/18/2024 day shift documented N indicating a behavior was observed. Review of the Nurse Progress Notes and Health Notes for Resident #34 from 06/10/2024 to 06/18/2024 revealed no behaviors documented. Review of the behavior monitoring under CNA Tasks for Resident #34 from 06/10/2024 to 06/18/2024 revealed no behaviors documented. Review of the Care Plan for Resident #34 dated 08/15/2022 with a focus on the resident uses antidepressant medication due to his diagnosis of Depression which increases his risk for alterations in his mood & behavior and adverse effects of antidepressant medication. The goal was for the resident to be minimized from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor closely for signs and symptoms of EPS (Extrapyramidal symptoms) and notify MD for any new orders with medications. Monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy. 3 Record review for Resident #96 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Depressive Disorder, and Anxiety Disorder. Review of the MDS for Resident #96 dated 05/13/2024 revealed in Section C for cognitive pattern the resident had a Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #96 revealed an order dated 05/06/2024 for Behaviors - Monitor for the following: (yelling), picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: \'Y\' if monitored and none of the above observed. \'N\' if monitored and any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and document findings and interventions every shift for antianxiety medication use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 for Behaviors - Monitor for the following: (yelling), picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. Document: \'Y\' if monitored and none of the above observed. \'N\' if monitored and any of the above was observed, select chart code \'Other\/ See Nurses Notes\' and document findings and interventions every shift for antidepressant medication use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 for Psychoactive Meds - Monitor for dry mouth, constipation, blurred vision, confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (Nausea/Vomiting), lethargy, drooling, EPS (Extrapyramidal Symptoms) (Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement of Mouth or Tongue). Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift for Psychoactive Med Use. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/2024 Buspirone HCl oral tablet 7.5 mg give 1 tablet via PEG-Tube (Percutaneous endoscopic gastrostomy/feeding tube) two times a day related to Anxiety Disorder. Review of the Physician's Orders for Resident #96 revealed an order dated 05/07/24 for Mirtazapine Tablet 7.5 mg give 1 tablet via PEG-Tube at bedtime for Depression. Review of the care plan for Resident #96 dated 03/12/24 with a focus on the resident using anti-anxiety medications related to Anxiety disorder. The goals were for the resident to be free from discomfort or adverse reactions related to (r/t) anti-anxiety therapy and will show decreased number episodes of anxiety through the review date. The interventions included: Administer anxiolytic medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Monitor for safety. The resident is taking antianxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls with hip and leg fractures. Monitor/document/report PRN any adverse reactions to Anti-Anxiety therapy. Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Review of the care plan for Resident #96 date 03/12/2024 with a focus on the resident uses antidepressant medication r/t (related to) Depression. The goals were for the resident to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The resident will show decreased episodes of s/sx (signs and symptoms) of depression through the review date. The interventions included: Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions to antidepressant therapy. Review of the BHR for Resident #96 for the month of June 2024 documented for antidepressant medication use on 06/18/24 a N for the day and evening shift indicating behavior and/or symptoms observed. Review of the Health Status Note for Resident #96 on 06/18/24 during the day shift revealed no indication of behaviors. Review of the Health Status Note for Resident #96 dated 06/18/24 at 9:46 PM (evening shift) included the following: Resident attempted many times to remove the Foley catheter which was observed on the bed. MD was called and made aware with new order to remove the Foley catheter and monitor for voiding, if no urine within the hours, reinsert [indwelling catheter] Encourage resident to drink more fluids. Yellow urine was noted in the first diaper. Staff will continue to monitor resident. Hospice nurse was at the facility and informed of the resident's behavior and called hospice doctor who agreed to remove the Foley. All safety measures and comfort in place, close monitoring continue. 49060 4) Record review for Resident #5 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Schizophrenia, Dementia, Anxiety Disorder, and Insomnia. Review of the Physician's Orders showed that Resident #5 had orders dated12/06/2023 for Depakote Oral Tablet Delayed Release 250mg for agitation related to Schizophrenia; Risperdal Oral Tablet 1mg for Bipolar Disorder. Monitor for the following Behaviors: (Increased Restlessness) Itching, Picking at Skin, Hitting, Biting, Kicking, Spitting, Cussing, Racial Slurs, Elopement, Stealing, Delusions, Hallucinations, Psychosis, Aggression, Refusing Care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select Nurses Notes' and document findings and interventions, every shift for antianxiety medication use. Monitor for the following: Dry Mouth, Constipation, Blurred Vision, Confusion, Difficulty Urinating, Hypotension, Dark Urine, Yellow Skin, Lethargy, Drooling, Tremors, Disturbed Gait, Increased Agitation, Restlessness, Involuntary Movement Of Mouth Or Tongue; Document: 'Y' if monitored and none of the above observed, 'N' if monitored and any of the above was observed, and document findings in Nurses/Progress notes, every shift for psychoactive medication use. Review of the Care Plan dated 03/13/2024 documented that Resident #5 uses anti-anxiety medications with the following interventions: Monitor for side effects and effectiveness every shift; Monitor and record occurrence of for target behavior symptoms and document per facility protocol. The resident also uses psychotropic medications due to the diagnosis of Schizophrenia, Bipolar Disorder, and Anxiety. Interventions included: Monitor for side effects and effectiveness every shift; Monitor and record occurrence of for target behavior symptoms and document per facility protocol; Monitor/document/report PRN any adverse reactions of psychotropic medications; The resident is on a behavior management program. Review of the behavior monitoring located in the Medication Administration Records (MAR) for antianxiety medication for Resident #5 from 06/01/2024-06/09/2024 revealed the following: 06/01/2024: Day, evening, and night shift documented N (behavior was observed, document the findings and interventions in the Nurses' notes) 06/02/2024: Day, evening, and night shift documented N 06/03/2024: Day shift documented N 06/04/2024: Day shift documented N 06/05/2024: Day shift, evening, and night shift documented N 06/06/2024: Day, evening, and night shift documented Y (no behaviors noted) 06/07/2024: Evening shift documented N 06/08/2024: Day and evening shift documented N 06/09/2024: Evening shift documented N Review of the behavior monitoring located in the MAR for psychoactive medications for Resident #5 from 06/08/2024-06/15/2024 revealed the following: 06/08/2024: Day and evening shift documented N 06/09/2024: Day and evening shift documented N 06/10/2024: Day, evening, and night shift documented Y 06/11/2024: Day, evening, and night shift documented Y 06/12/2024: Day, evening, and night shift documented Y 06/13/2024: Day, evening, and night shift documented Y 06/14/2024: Day, evening, and night shift documented Y 06/15/2024: Day shift documented N Review of the Nursing Progress notes and the monitoring task for the Certified Nursing Assistants (CNAs) revealed no behaviors where documented for Resident #5 between 06/01/2024 - 06/15/2024. 5) Record review for Resident #116 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Antisocial Personality Disorder, Adjustment Disorder With Depressed Mood, and Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder. Review of the Physician's Orders showed that Resident #116 had orders dated 01/09/24 for Haloperidol Oral Tablet 5mg for Psychosis related to Antisocial Personality Disorder; Sertraline HCl Oral Tablet 100mg for Depression related to Antisocial Personality Disorder. Monitor behavior for the following: (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, document findings and interventions in Nursing/Progress notes every shift for antipsychotic medication use; Monitor the following: dry mouth, hypotension, dark urine, yellow skin, lethargy, drooling, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue, document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, document findings in nurses' notes and progress note every shift for psychoactive medication use. Review of the Care Plan dated 04/12/24 documented that Resident #116 uses psychotropic medications with the following interventions: Monitor for side effects and effectiveness every shift; Monitor and record occurrence of for target behavior symptoms and document per facility protocol. Monitor/document/report PRN any adverse reactions of psychotropic medications. Review of the behavior monitoring located in the MAR for antipsychotic medications for Resident #116 from 06/11/2024-06/18/2024 revealed the following: 06/11/2024: Day and evening shift documented N 06/12/2024: Day, evening, and night shift documented Y 06/13/2024: Day, evening, and night shift documented Y 06/14/2024: Day, evening, and night shift documented Y 06/15/2024: Day, evening, and night shift documented Y 06/16/2024: Day, evening, and night shift documented Y 06/17/2024: Day, evening, and night shift documented Y 06/18/2024: Day and evening shift documented N Review of the Nursing Progress notes and the monitoring task for the Certified Nursing Assistants (CNAs) revealed no behaviors where documented for Resident #116 between 06/11/2024 - 06/18/2024. An interview was conducted on 06/20/2024 at 3:15 PM with Staff J, Registered Nurse (RN). She stated that nurses monitor behaviors for residents on psychotropic medications. Staff J also stated the orders for monitoring behaviors are for all shifts and are documented in the MAR and in the progress notes if there's a behavioral concern. She acknowledged that the questions for behavior monitoring are confusing, and nurses can easily enter the wrong information. An interview was conducted on 06/20/2024 at 3:50 PM with Staff K, Certified Nursing Assistant (CNA). If observed a resident with behaviors, Staff K stated that she reports it to the floor nurse or the unit supervisor. She acknowledged that she would answer the questions under the Behavior task, but the documentation is done by the nurse.

Based on observations record review and interview; the facility failed to secure medications at bedside for 1 of 29 sampled residents (Resident #34). As evidenced by medication (eye drops) observed on the resident's nightstand. The findings included: Review of the facility's policy titled, Medication Storage dated 05/01/2023 included in part the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including: Parkinsonism and Major Depressive Disorder. Review of the Minimum Data Set for Resident #34 dated 05/16/2024 documented a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the physician's orders for Resident #34 revealed an order dated 11/23/2023 for Artificial Tears Ophthalmic Solution (Artificial Tear Solution) Instill 1 drop in both eyes two times a day for Dry eyes On 06/17/2024 at 3:15 PM an observation was made of Resident #34 sitting on side of his bed, on his nightstand in plain sight was Advanced Relief Moisture eye drops with an unreadable written date on the box of XX/15/2024 and another date of 06/15/2024 just below handwritten D/C (discontinue) The active ingredients were listed as: Dextan70 0.1%, Polyethylene glycol 400 1%, Povidone 1%, and Tetrahydrozoline HCL 0.05%. (Photographic Evidence Obtained). On 06/18/2024 at 8:20 AM a second observation was made of Resident #34 lying in bed and on his nightstand in plain sight was Advanced Relief Moisture eye drops with an unreadable written date on the box of XX/15/2024 and another date of 06/15/2024 just below handwritten D/C. During an interview conducted on 06/17/2024 at 3:15 PM with Resident #34 who was asked about the eye drops on the nightstand, he said the staff put them in his eyes twice a day for him. During an interview conducted on 06/18/2024 at 1:49 PM with Staff A Licensed Practical Nurse (LPN) who was asked if Resident #34 receives eye drops, she said yes, she gave them to the resident this morning with his other medications. When asked to see the eye drops, the LPN opened her med cart and pulled out a box with eye drops dated 06/14/2024. There was no room number or resident name on the box to identify which resident the drops were for. When asked how she knows the eye drops are for Resident #34, the LPN stated: he is the only one in my area that has over the counter eye drops, all other residents with eye drops are prescription and they are sent from the pharmacy with the resident name on them. The eye drops the LPN had pulled out of her med cart were Sterile Eye Drops Original containing 1 active ingredient: Tetrahydrozoline HCL 0.05% (Eye Redness Reliever). The LPN accompanied surveyor to the bedside of Resident #34 and acknowledged the eye drops on top of the nightstand. The LPN revealed she did not notice the eye drops at the bedside because the resident had so many items on top of his nightstand. The LPN was asked what the order for the eye drops stated for Resident #34, the LPN acknowledged the order was for Artificial Tears. When asked if either of the eye drops in the cart for the resident or the eye drops at the resident's bedside were artificial tears, she stated I think so. The LPN removed the eyedrops at the bedside immediately. During an interview conducted on 06/18/2024 at 1:55 PM with the Consultant Pharmacist who was asked if the Sterile Eye drops containing Tetrahydrozoline HCL 0.05% or the Advanced Relief Moisture eye drops containing: Dextan70 0.1%, Polyethylene glycol 400 1%, Povidone 1%, and Tetrahydrozoline HCL 0.05% were a substitute for the ordered Artificial Tears for Resident #34, he said no, but he will take care of it.

Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of four residents sampled during the time of this survey. The facility's staff failed to supervise and implement adequate measures to prevent the elopement of Resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on [DATE] at 10:32 AM. The resident was not located until 6:10 PM on [DATE] wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. There were 107 residents residing in the facility at the time of the survey. Refer to F 607, F 689 and F 835. The scope and severity for F600 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of [DATE]. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on ,d+[DATE]-,d+[DATE]. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on ,d+[DATE], the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A prompt thorough investigation will be conducted by the facility immediately. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated [DATE] documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated [DATE] time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated [DATE] time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated [DATE] time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated [DATE] time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated [DATE] time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son were notified; Dated [DATE] time stamped 19:30-No type specified: Late entry-MD was notified; Dated [DATE] time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated [DATE] time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated [DATE] time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated [DATE] time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated [DATE] time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated [DATE] time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated [DATE] time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated [DATE] time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated [DATE] time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated [DATE] time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated [DATE] time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated [DATE] time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated [DATE] time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due to constant exit seeking behavior; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated [DATE] time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated [DATE] time stamped 15:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate residents; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate resident; Dated [DATE] time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated [DATE] time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for [DATE], [DATE] and [DATE] documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on [DATE]). Medications were given as ordered by the medical doctor. The resident received medications on [DATE] at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on [DATE] and was discontinued on [DATE]. Review of the Elopement Risk Assessment/Evaluation dated [DATE] and [DATE] documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on [DATE] at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on [DATE] at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On [DATE] at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On [DATE], according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:,d+[DATE]:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency room s in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On [DATE] at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on [DATE] to keep an eye on the back patio. We called the emergency room s to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on [DATE] we continued to call the hospital emergency room . Around 8:00PM, the residents son came to talk to me and the Administrator. On [DATE], at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On [DATE], we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon [DATE]. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On [DATE] at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drills that night into the weekend and on elopement, abuse and neglect. On Friday [DATE] we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, [DATE]. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On [DATE] at 12:06 PM, the Social Service Director stated, On Wednesday about 5:,d+[DATE]:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On [DATE] at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on [DATE] I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the C N A (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ,d+[DATE] hours looking for him and I didn't find him. When I came back, the police was here. On [DATE], I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and redness were noted. Transportation came and the son left with the resident to the hospital. On [DATE] at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on [DATE] and the consult says he has cataracts. On [DATE] at 8:31 AM, Staff D, Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On [DATE] at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The C N A put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On [DATE] at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On [DATE] at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was not much evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On [DATE] at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on [DATE] and he received $20.00. The facility's immediate jeopardy removal plan included the following information: The staff were In-serviced/trained on [DATE] for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and [DATE] for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On ,d+[DATE]-,d+[DATE] on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on [DATE] for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on [DATE] for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from [DATE] - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the ,d+[DATE], ,d+[DATE] and ,d+[DATE] shifts. Reviewed inservices and sign in sheets for: Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Neglect; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Elopement Drill; Audience: All staff

Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to provide care and services including adequate supervision for one (Resident #1) out of four residents sampled during the time of this survey. This deficient practice has the potential to affect all 107 residents residing in the facility. This enabled resident #1 to elope from the facility undetected on [DATE] at 10:32 AM. The resident was not located until 6:10 PM on [DATE] wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. The scope and severity of F607 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of [DATE]. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on ,d+[DATE]-,d+[DATE]. Refer to F600, F689, F835 and F867. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on ,d+[DATE], the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A prompt thorough investigation will be conducted by the facility immediately. Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with a diagnosis of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated [DATE] documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated [DATE] time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated [DATE] time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated [DATE] time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated [DATE] time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated [DATE] time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated [DATE] time stamped 19:30-No type specified: Late entry-MD was notified; Dated [DATE] time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated [DATE] time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated [DATE] time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated [DATE] time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated [DATE] time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated [DATE] time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated [DATE] time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated [DATE] time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated [DATE] time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated [DATE] time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated [DATE] time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated [DATE] time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated [DATE] time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated [DATE] time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated [DATE] time stamped 15:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate residents; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate resident; Dated [DATE] time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated [DATE] time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for [DATE], [DATE] and [DATE] documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on [DATE]). Medications were given as ordered by the medical doctor. The resident received medications on [DATE] at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on [DATE] and was discontinued on [DATE]. Review of the Elopement Risk Assessment/Evaluation dated [DATE] and [DATE] documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on [DATE] at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on [DATE] at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On [DATE] at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On [DATE], according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:,d+[DATE]:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency room s in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On [DATE] at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on [DATE] to keep an eye on the back patio. We called the emergency room s to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on [DATE] we continued to call the hospital emergency room . Around 8:00PM, the residents son came to talk to me and the Administrator. On [DATE], at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On [DATE], we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon [DATE]. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On [DATE] at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday [DATE] we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, [DATE]. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On [DATE] at 12:06 PM, the Social Service Director stated, On Wednesday about 5:,d+[DATE]:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On [DATE] at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on [DATE] I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ,d+[DATE] hours looking for him and I didn't find him. When I came back, the police was here. On [DATE], I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and red were noted. Transportation came and the son left with the resident to the hospital. On [DATE] at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on [DATE] and the consult says he has cataracts. On [DATE] at 8:31 AM, Staff D, Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On [DATE] at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The cna put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On [DATE] at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On [DATE] at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On [DATE] at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on [DATE] and he received $20.00. The facility's immediate jeopardy removal plan included: The staff were In-serviced/trained on [DATE] for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and [DATE] for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On ,d+[DATE]-,d+[DATE] on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on [DATE] for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on [DATE] for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from [DATE] - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the ,d+[DATE], ,d+[DATE] and ,d+[DATE] shifts. Reviewed inservices and sign in sheets for: Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Neglect; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Elopement Drill; Audience: All staff

Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of four sampled residents with exit seeking behaviors. This deficient practice enabled Resident #1 to exit the facility at 10:32 AM on [DATE], undetected. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place allowed the resident to elope undetected by staff on [DATE] at 10:32 AM. The resident was not located until 6:10 PM on [DATE] wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. There were 107 residents residing in the facility at the time of the survey. The scope and severity of F689 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of [DATE]. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on ,d+[DATE]-,d+[DATE]. Refer to F 600, F 607 and F 835. The findings included: Record review of the facility's policy titled, Elopement and Wandering Residents revised February 2022 documented: Policy Statement: Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1) Wandering is random or repetitive locomotion that may be goal-directed (the person appears to be searching for something such as an exit) or non-goal directed or aimless; 2) Elopement occurs when a resident leaves the premises or a safe area without authorization; 5) The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions; 6) Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: d) Adequate supervision will be provided to help prevent accidents or elopements and 7) Procedure for Locating Missing Resident a) Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (internal alert code). Review of the facility's policy titled, Accidents and Supervision revised [DATE] documented: Policy Statement: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazards and risks, 2) Evaluating and analyzing hazards and risks, 3) Implementing interventions to reduce hazards and risks and 4) Monitoring effectiveness and modifying interventions; Policy Explanation and Compliance Guidelines: 5) Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of the Annual MDS (Minimum Data Set), dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment and the resident was able to make his needs known. The resident's vision was impaired, used no corrective lenses, required supervision to limited assistance with setup only to one person with physical assist for ADLs (Activities of Daily Living) and no wander/elopement alarms were used. He was able to make needs known and can follow simple commands. Review of the Elopement Risk Assessment/Evaluation dated [DATE] and [DATE] documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. Review of Resident's #1 Elopement care plan dated [DATE] documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated [DATE] time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated [DATE] time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated [DATE] time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated [DATE] time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated [DATE] time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated [DATE] time stamped 19:30-No type specified: Late entry-MD was notified; Dated [DATE] time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated [DATE] time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated [DATE] time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated [DATE] time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated [DATE] time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated [DATE] time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated [DATE] time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated [DATE] time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated [DATE] time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated [DATE] time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated [DATE] time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated [DATE] time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated [DATE] time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated [DATE] time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated [DATE] time stamped 15:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate residents; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate resident; Dated [DATE] time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated [DATE] time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for [DATE], [DATE] and [DATE] documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on [DATE]). Medications were given as ordered by the medical doctor. The resident received medications on [DATE] at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on [DATE] and was discontinued on [DATE]. Based on observational tour of the facility's parameter increased risk factors included the fact that, the facility is located in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Both locations where the facility is located and the location where the resident was found, are high traffic areas with busy two laned roads and four laned cross streets. The National Weather Service climate Data for the Miami area [DATE] to [DATE] ranged at record breaking temperatures of 82 degrees Fahrenheit (F) to 92 degrees F. During a telephone interview with Resident's #1 daughter on [DATE] at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on [DATE] at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On [DATE] at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On [DATE], according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:,d+[DATE]:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency room s in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On [DATE] at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on [DATE] to keep an eye on the back patio. We called the emergency room s to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on [DATE] we continued to call the hospital emergency room . Around 8:00PM, the residents son came to talk to me and the Administrator. On [DATE], at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On [DATE], we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon [DATE]. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On [DATE] at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday [DATE] we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, [DATE]. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On [DATE] at 12:06 PM, the Social Service Director stated, On Wednesday about 5:,d+[DATE]:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On [DATE] at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on [DATE] I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ,d+[DATE] hours looking for him and I didn't find him. When I came back, the police was here. On [DATE], I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and red were noted. Transportation came and the son left with the resident to the hospital. On [DATE] at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on [DATE] and the consult says he has cataracts. On [DATE] at 8:31 AM, Staff D Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On [DATE] at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The cna put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On [DATE] at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On [DATE] at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On [DATE] at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on [DATE] and he received $20.00. The facility's immediate jeopardy removal plan included: The staff were In-serviced/trained on [DATE] for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and [DATE] for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On ,d+[DATE]-,d+[DATE] on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on [DATE] for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on [DATE] for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from [DATE] - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the ,d+[DATE], ,d+[DATE] and ,d+[DATE] shifts. Reviewed inservices and sign in sheets for: Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Neglect; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Elopement Drill; Audience: All staff

Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of four sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 10:32 AM through an emergency exit door on [DATE] placing the resident at risk for harm and/or injury. There were 107 residents residing in the facility at the time of the survey. The scope and severity of F835 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of [DATE]. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of [DATE]. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on ,d+[DATE]-,d+[DATE]. Refer to F 600, F 607 and F 689. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on ,d+[DATE], the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A prompt thorough investigation will be conducted by the facility immediately. Review of the facility's policy titled, Elopement and Wandering Residents revised February 2022 documented: Policy Statement: Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1) Wandering is random or repetitive locomotion that may be goal-directed (the person appears to be searching for something such as an exit) or non-goal directed or aimless; 2) Elopement occurs when a resident leaves the premises or a safe area without authorization; 5) The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions; 6) Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: d) Adequate supervision will be provided to help prevent accidents or elopements and 7) Procedure for Locating Missing Resident a) Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (internal alert code). Review of the Job Description for the Nursing Home Administrator documented: The Administrator is responsible for developing, managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Nursing Supervisor documented: The Nursing Supervisor is responsible for supervising the day to day nursing activities in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Registered Nurse documented: The primary purpose of your job description is to provide direct nursing care the residents and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility and as may be required by the Director of Nursing services to ensure that the highest degree of quality care is maintained at all times. Review of the Job Description for the Licensed Practical Nurse documented: The Licensed Practical Nurse is responsible for providing professional care in accordance with established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Certified Nursing Assistant documented: The Certified Nursing Assistant is responsible for providing professional care in accordance with established certified nursing assistant policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated [DATE] documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated [DATE] time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated [DATE] time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated [DATE] time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated [DATE] time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated [DATE] time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated [DATE] time stamped 19:30-No type specified: Late entry-MD was notified; Dated [DATE] time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated [DATE] time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated [DATE] time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated [DATE] time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated [DATE] time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated [DATE] time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated [DATE] time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated [DATE] time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated [DATE] time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated [DATE] time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated [DATE] time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated [DATE] time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated [DATE] time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated [DATE] time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated [DATE] time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated [DATE] time stamped 15:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate residents; Dated [DATE] time stamped 08:00-No type specified: Late entry-Local hospital emergency room s contacted in effort to locate resident; Dated [DATE] time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated [DATE] time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for [DATE], [DATE] and [DATE] documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on [DATE]). Medications were given as ordered by the medical doctor. The resident received medications on [DATE] at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on [DATE] and was discontinued on [DATE]. Review of the Elopement Risk Assessment/Evaluation dated [DATE] and [DATE] documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on [DATE] at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on [DATE] at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On [DATE] at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On [DATE], according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:,d+[DATE]:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency room s in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On [DATE] at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on [DATE] to keep an eye on the back patio. We called the emergency room s to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on [DATE] we continued to call the hospital emergency room . Around 8:00PM, the residents son came to talk to me and the Administrator. On [DATE], at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On [DATE], we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon [DATE]. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On [DATE] at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday [DATE] we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, [DATE]. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On [DATE] at 12:06 PM, the Social Service Director stated, On Wednesday about 5:,d+[DATE]:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On [DATE] at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on [DATE] I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ,d+[DATE] hours looking for him and I didn't find him. When I came back, the police was here. On [DATE], I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and red were noted. Transportation came and the son left with the resident to the hospital. On [DATE] at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on [DATE] and the consult says he has cataracts. On [DATE] at 8:31 AM, Staff D Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On [DATE] at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The CNA put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On [DATE] at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On [DATE] at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On [DATE] at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on [DATE] and he received $20.00. The facility's immediate jeopardy removal plan included: The staff were In-serviced/trained on [DATE] for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and [DATE] for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On ,d+[DATE]-,d+[DATE] on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on [DATE] for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on [DATE] for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from [DATE] - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the ,d+[DATE], ,d+[DATE] and ,d+[DATE] shifts. Reviewed inservices and sign in sheets for: Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Neglect; Audience: All staff Date - [DATE]; Title of the In-Service: Elopement Drill; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Neglect; Audience: All staff Date - ,d+[DATE]-,d+[DATE]; Title of the In-Service: Elopement Drill; Audience: All staff

Based on observation, record review, and interview, the facility failed to ensure that its resources were efficiently and effectively used as evidenced by the persistent fire safety concerns and the amount of time which has passed since those concerns were noted. In addition, the facility failed to implement an effective quality assurance program which proactively addressed identified quality concerns in a timely manner. The facility failure to ensure life safety poses a significant threat to the well-being of all facility residents, staff, and the public. These conditions were determined to be an immediate and serious threat, resulting in the determination of Immediate jeopardy. Findings Include: Cross refer to F454. The facility failed to ensure the building was constructed and maintained in a manner that ensured compliance with life safety standards. Cross refer to F520. The facility failed to ensure its Quality Assurance committee acted on identified concerns in a timely manner. Cross refer to K0011. The facility failed to maintain the integrity of the fire protection features that make up the NFPA 220 (Standard for Types of Building Construction) construction type. Cross refer to K0017. The facility failed to ensure that the corridors were separate from populated areas by walls constructed with at least 1/2 hour fire resistance rating. Cross refer to K0038. The facility failed to provide exit access from the building without the use of a special tool or knowledge from the egress side. Cross refer to K0067. The facility could not substantiate the required maintenance and testing of air handler units that had been performed. These findings were determined to be an immediate and serious threat to resident well-being, resulting in the determination of Immediate Jeopardy. The administrator was notified of the existing Immediate Jeopardy on 4/13/2011 during the exit conference.

Based on observation, record review, and interview, that facility failed to ensure that its Quality Assurance (QA) commitee acted promptly on identified concerns in a timely manner. This includes Life Safety concerns which were identified as early as 2008, which, if acted upon promptly, based upon reports made by the facility's own consulatnts, could have been corrected well before the time of the survey. This was related to significant Life Safety hazards which included the existance of unprotected vertical shafts, air plenums, and cables that would potentially allow smoke, gas, and flame to spread throughout the facility in the event of a fire, posing a significant threat to all facility residents, staff, and the public. These conditions were determined to be an immediate and serious threat, resulting in the determination of Immediate Jeopardy. Findings Include: Interview with the facility's administrator on 4/13/2011 at approximately 3:30pm revealed that the facility had a QA committee consisting of the Administrator, DON, Assistant Director Of Nursing, Housekeeping, Pharmacy, Lab, Social Services, Therepy, Dietary, two Medical Directors, Human Resources, Restorative, Maintenance, Customer Service personnel, and an administrative assistant. The committee was led by the administrator, for the approximate past three years she had been the the facility's administrator. She indicated that the committee met on a monthly basis and discussed deficiencies cited on previous surveys. She also noted that the life safety (LSC) deficiencies (including unprotected vertical shafts and the other conditions which could allow the spread of smoke and fire) were discussed at each subsequent QA committee meeting. Record review of the facility's QA binder revealed that all that was noted regarding Life Safety deficiencies was that the facility was waiting for state approval. There was no way to determine that the committee actually discussed, in detail, the issues regarding Life Safety and ways in which to go about fixing those noted Life Safety deficient practices. Record review of a document from the original consultant company titled, "Timeline to satisfy K-tags (K017 & K147) per CMMS (sic) survey completed 11/20/2008," revealed that the estimated construction duration was six to eight months. From 2/27/2009, the document indicated that it would take up to 90 days for Plans and Construction to complete their review. It would take up to 14 days for authorities having jurisdiction to issue permits (the timeframe was given by the building department). When the document was used to calculate an estimated date for completion, using a start date of 2/27/2009, it appeared that the project should have taken approximately 354 days and would have placed the date in February 2010, a full year prior to the date of this survey. Further interview with the facility's administrator on 4/13/2011 at approximately 4:07pm revealed that a working proposal with its hired contactors was completed in January 2009 to address LSC concerns. By September 30, 2010, the facility submitted their plan to the State Agency's Office of Plans and Construction for review. Plans and Construction noted 23 suggestions on the plan. The facility re-submitted their plan to Plans and Construction on 4/8/2011 with the suggested changes included. When asked what was implemented physically to correct the LSC deficiencies since 2008, she responded that the return air plenum was cleaned by a professional vaccuming crew in December 2008 and that was the extent of the physical work that had been done towards alleviating this condition. The aformentioned Life Safety issues have been ongoing since 11/20/2008 (for the unprotected trusses) and 3/30/2009 (for the unprotected air plenums). The administrator was notified of the existing Immediate Jeopardy on 4/13/2011 during the exit conference.