Every finding on record at Sunrise Point Health and Rehabilitation Center

Based on interview, and record review, the facility failed to conduct a thorough investigation of an allegation of physical abuse for 1 of 3 residents reviewed for abuse, of a total sample of 3 residents, (#1).Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, unspecified dementia unspecified severity with other behavior disturbance and major depressive disorder. Resident #1 also had contractures of the right hand, right wrist, right elbow, left hand, left wrist, left elbow, muscle of right shoulder and muscle of left shoulder. Review of the Minimum Data Set quarterly assessment with assessment reference date of 6/18/26 revealed resident #1 had a Brief Interview for Mental Status score of 04/15 which indicated she had severe cognitive impairment. The document indicated the resident was dependent on staff for care. Per the facility's Five-Day report to the state agency, on 7/20/26 at approximately 12:30 PM, Certified Nursing Assistant (CNA) A reported she witnessed CNA B swing her fist toward resident #1's right shoulder but her sight was obscured by CNA B. The report indicated that CNA C heard what she believed to be an impact sound coming from resident #1's room. Skin checks of resident #1 showed no discolorations. Per the report, CNA B denied all allegations. The facility concluded the allegation was refuted by evidenced collected during the investigation. On 8/25/26 at 12:59 PM, Licensed Practical Nurse (LPN) D confirmed she worked on 7/20/26. She recalled that CNA A approached her around 12:30 PM and reported an allegation of abuse. She stated CNA A informed her she witnessed CNA B hit resident #1. LPN D explained CNA A reported resident #1 was in the second bed on her left side facing the door and CNA B was behind her, between the bed and the window. She reported to the nurse she observed CNA B hit resident #1 with her fist on her neck and shoulder area. LPN D stated CNA A explained CNA B said she knew the other staff saw her, but she was leaving the facility anyway. LPN D explained she took CNA A to the office to report the incident to the Administrator. The three CNAs involved in the incident were no longer employed at the facility and were not available for interview during the survey by phone or in person. During review of the facility investigation on 8/25/26 at 12:10 PM, the Administrator and Director of Nursing (DON) recalled the events as they were in the facility's report to the state agency. The Administrator had hand-written statements from the three CNAs which had been typed onto a sheet of paper. The Administrator explained he wrote the statements as he spoke to each staff member and then typed them up. He acknowledged neither the hand-written nor the typed statements were signed by any of the staff members to acknowledge accuracy. The facility had a copy of a police report that was filed the day of the event. Per the report, the law enforcement officer interviewed the two witnesses on the day of the event. The report detailed that CNA A walked into the victim's room where she observed CNA B strike resident #1 with a closed fist on the left side of her shoulder. CNA A told the law enforcement officer that CNA B then said, I'm tired of this [expletive] job. The officer then reported that CNA C reported she heard a loud smack noise come from resident #1's room. CNA C stated to the officer that CNA B came out of the room and stated, [Resident #1] hit me, and yup, I [expletive] sure hit her back. Per the report, the officer felt he had sufficient cause and took CNA B into custody. The DON explained the facility did not obtain the police report until it was requested by another surveyor on 8/12/26. The Administrator and DON both confirmed the facility decision to not substantiate the allegation was made prior to obtaining the police report. The Administrator and DON acknowledged there were discrepancies in statements after reviewing the police report and stated they were not aware of what the witnesses had told the law enforcement officer the day of the event. The facility's policy and procedure for Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin revised August 2024 indicated that when an incident or suspected incident of abuse or neglect was reported, the Administrator or designee would investigate the incident with the assistance of appropriate personnel. The document clarified that the investigation should be thorough with witness statements from staff, residents, family members who were interviewable and had information regarding the allegation. The policy directed that the investigation should include a review of all circumstances surrounding the incident.

Based on interview, and record review, the facility failed to protect the residents' right to be free from abuse and neglect by not ensuring staff utilized a mechanical lift for transfer of resident #1 resulting in a leg fracture, for 1 of 9 residents reviewed for transfers with a mechanical lift, out of a total sample of 10 residents, (#1).On 10/16/25 at approximately 2:40 PM, the facility failed to ensure nursing staff followed resident #1's plan of care for safe transfers resulting in serious injury and pain of the physically impaired resident during a transfer from wheelchair to bed. Two certified nursing assistants (CNAs) failed to follow resident #1's care plan which required her to be transferred using a mechanical lift with assistance of two staff. The two CNAs transferred the resident from her wheelchair by manually lifting the resident and pivoting her to the bed. Resident #1 complained of pain in her left leg during the transfer and was lowered to the floor. The two CNAs then manually lifted her from the floor and placed her in bed. Resident #1 continued to complain of extreme pain to her left leg. An X-ray performed on 10/17/25 of resident #1's left leg indicated she had sustained a fractured tibia. Record review revealed a total of 23 residents were identified in the facility who required a mechanical lift for transfers. The facility's failure to ensure staff transferred residents according to their transfer status and care plan contributed to the injury of resident #1 and placed her and all other residents who required mechanical lifts for transfer at risk for serious impairment and/or death.This failure resulted in Immediate Jeopardy which started on 10/16/25 and was removed on 10/21/25 after verification of the immediate actions implemented by the facility. The scope and severity was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings: Cross reference F689 Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (one-sided weakness and paralysis) following stroke affecting left non-dominant side, obesity, chronic lower back pain and muscle weakness. Review of resident #1's Quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 which indicated she was cognitively intact. The assessment indicated resident #1 was dependent on staff for transfers. It was noted that due to her medical conditions and/or safety concerns, evaluations of resident's ability to sit to stand, transfer to the toilet or walk ten feet were not attempted. Review of the resident's electronic medical record (EMR) revealed an Activities of Daily Living (ADL) self-care performance deficit care plan initiated 5/30/23 and revised 10/18/25. The care plan contained an intervention which identified resident #1 as dependent (on staff) for transfers and required the assistance of 2 staff using a total mechanical lift. Review of the ADL task history revealed resident #1 was first identified as requiring the use of a mechanical lift on 5/16/24. In a phone interview on 10/27/25 at 12:08 PM, CNA A confirmed she was resident #1's assigned CNA on 10/16/25. She recalled resident #1 put on her call light and asked to go back to bed around the end of the shift. CNA A stated she was not aware of resident's transfer status or where to find the information but resident #1 told her that staff usually got her up with a 2-person pivot. CNA A explained she looked outside the room and asked another staff member to help her. CNA A stated she did not know the name of the other CNA she asked for assistance. She recalled that resident #1 said she had a little pain during the transfer and they lowered her to the floor, gave her a few minutes to rest and then lifted her and transferred her to bed. CNA A acknowledged she did not report the complaint of pain to the nurse. She explained it was the end of the shift and she had already given report and was about to leave when resident #1 asked for help. A witness statement from CNA B given on 10/17/25 revealed she clocked in for work at approximately 2:36 PM on 10/16/25 and went to her assigned unit. She reported that while she was on her way, CNA A opened the room door, saw her and asked her how strong she was. CNA A indicated she needed help with resident #1. CNA B recalled she recognized resident #1 but was not aware she required a mechanical lift for transfer. She documented that CNA A told her she would normally use the mechanical lift for resident #1's transfer but would just have the resident stand and pivot to put her in bed. CNA B noted she was hesitant as she observed a mechanical lift sling already under resident #1 in the wheelchair but agreed to help. Her statement indicated the wheelchair was positioned next to the bed with the left side of the wheelchair turned slightly toward the bed with the wheels locked. The statement indicated CNA B and CNA A stood on either side of resident and lifted her under her arms. CNA B reported the resident felt like dead weight. The statement indicated resident #1 started yelling about her leg hurting during the transfer. CNA B looked down and saw resident #1's left foot was turned in slightly. She reported they lowered resident #1 to the floor and her left leg was bent backwards at the knee out to her left side. CNA B stated that resident #1 complained that her leg hurt really badly and she was in a lot of pain. Resident #1 asked if they would get the mechanical lift and CNA A responded if they did that they were going to see her on the floor, and they would get in trouble. CNA B expressed she thought they should have gotten the mechanical lift, but CNA A told her she did not want to get her in trouble. She reported that after about 30-40 seconds, they lifted the resident from the floor under her arms and quickly placed her in a sitting position on the side of the bed. She was then positioned in bed with her feet on the bed. CNA B noted resident #1 was breathing heavily, said her leg hurt really badly and was in a lot of pain. CNA B recalled she told CNA A that this was a transfer gone very wrong. The statement revealed CNA A agreed and said that was the first and last time; adding they would use the mechanical lift next time. CNA B indicated she asked CNA A if she needed anything else, then left the room and went to her assignment. CNA B reported she did not have any further interaction with CNA A or resident #1 for the remainder of her shift. CNA B explained she did not inform the nurse of the fall or resident #1's complaint of pain because she thought CNA A would have reported it. On 10/27/25 at 10:15 AM, resident #1 was observed in bed with the head of bed elevated and a leg immobilizer on her left leg that extended from her thigh to her ankle. She confirmed two CNAs transferred her without the use of a mechanical lift on 10/16/25. She stated her foot slipped and hit the floor. Resident #1 explained the pain was immediately 10 out of 10 and continued throughout the night. Resident #1 recalled she told the assigned evening shift (3:00-11:00 PM) CNA C that her leg hurt. She stated CNA C reported it to the nurse, who did not do anything. In a follow up interview on 10/28/25 at 8:50 AM, resident #1 clarified the two CNAs lifted her under her arms from the wheelchair when she hit her foot on the floor and yelled out in pain. She stated the CNAs lowered her to the floor and lifted her again under her arms to put her back in bed. Resident #1's roommate verified her account and added that CNA A asked the residents not to say anything to anyone because they (the two CNAs) would get in trouble. In a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 10/28/25 at 11:17 AM, the Administrator stated the facility investigation showed resident #1 was transferred inappropriately using a stand and pivot technique rather than a mechanical lift as directed in her plan of care. The Administrator, DON and RNS reported during the transfer, resident #1 complained of pain and was lowered to the floor. She was then lifted from the floor and placed in bed. They confirmed neither CNA reported the incident to the nurse. The Administrator explained resident #1 complained of pain to CNA C (her assigned 3-11 shift CNA) during ADL care. The investigation showed CNA C reported resident #1's complaint to Licensed Practical Nurse (LPN D, an agency nurse, at 4:00 PM, 6:00 PM and 8:00 PM. CNA C then went to another nurse for assistance with resident #1's pain. Per the investigation, LPN D did not go to assess resident #1 until approximately 10:50 PM, almost seven hours after it was initially reported to her. LPN D then contacted the provider and received an order for a STAT (immediate) X-ray. Per the Administrator, the X-ray was not performed until 10/17/25 at 9:30 AM, (19 hours after the incident). The facility received the X-ray results on 10/17/25 at 11:13 AM, which showed a proximal tibia (lower leg) fracture with mild displacement. The Administrator reported that a Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/19/25 to review the investigation and a root cause analysis was conducted. He reported the committee determined the staff willingly chose to ignore previous training and chose not to follow the resident's plan of care for safe transfers. He explained the agency nurse also failed to respond to resident #1's complaints timely and was no longer allowed to return to work at the facility. Per the facility's investigation, an allegation of neglect was substantiated due to the actions of CNA A, CNA B and LPN D. Review of the facility's policy and procedure for Abuse, Neglect and Exploitation revised 11/16/23 revealed neglect was identified as failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/16/25 at 4:00 PM, resident #1 reported to her CNA that she had pain in her left leg. The CNA reported the complaint to the nurse at 4:00 PM, 6:00 PM and again at 8:00 PM. *On 10/16/25 at 10:50 PM, resident #1 was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging. *On 10/17/25 at 9:30 AM, X-ray was performed and results were received at 11:13 AM which showed a proximal tibia fracture with mild displacement. *On 10/17/25 at 11:13 AM, resident's physician was notified of the abnormal X-ray results and orders were received for a leg immobilizer and an outpatient orthopedic physician consult. *On 10/17/25 at 2:26 PM, a knee immobilizer was placed to resident's left leg as ordered. *On 10/17/25 resident #1 and roommate were interviewed by the former DON and reported that resident #1 was transferred without the use of the mechanical lift by two CNAs on 10-16-25. *On 10/17/25, the facility initiated an investigation. *On 10/17/25, the ADON began education on identifying resident's transfer status, safe transfers and skills validation. *On 10/17/25 an Ad Hoc QAPI meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident including physician orders obtained related to the resident's fracture. Resident #1's individualized plan of care including outpatient orthopedic consult and leg immobilizer deemed appropriate by the Medical Director. Discussed staff training to be conducted as a result of incident on 10/16/25. *On 10/18/25, the CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident #1's transfer status and subsequent disregard by performing a stand and pivot transfer. Resident #1's care plan and Kardex indicated she required two person assistance with the use of mechanical lift for transfers. *On 10/18/25 through 10-19-25, each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected. *On 10/19/25 as part of the investigation process, residents were interviewed by the Social Services Director to determine if there were additional concerns of abuse or neglect with no findings. *On 10/19/25, the facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations. *On 10/20/25, resident #1 was seen by the provider. Her pain regime was reviewed and adjusted. The facility scheduled an orthopedic appointment for 10/24/25 as per the physician order. *On 10/20/25, the former DON discussed transfer options to the hospital with resident #1. *On 10/21/25, the former DON spoke to the resident and resident voiced wanting to go to the hospital. *On 10/21/25, resident #1 was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture. The resident returned to the facility. *On 10/21/25, resident #1's provider was contacted, and pain regimen was reviewed and adjusted. *On 10/17/25 through 10/21/25, the nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. As of 10/21/25, 77 out of 92 nursing staff received education, (84%), The remaining 15 total nursing staff members to receive education prior to next shift worked. *On 10/17/25 through 10/21/25, facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. As of 10/21/25, 111 out of 128 staff members received education, (86%). The remaining 17 total staff members to receive education prior to next shift worked. *Ad Hoc QAPI meetings were completed 10/20/25 and 10/21/25 with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan. From 10/29/25 to 10/30/25, interviews were conducted with 18 staff members representing all shifts (1 Registered Nurse, 4 LPNs, 9 CNAs, 1 dietary, 2 environmental services and 1 activity aide/CNA). Staff interviews revealed they were knowledgeable of identifying abuse and neglect, following a resident's plan of care, safe handling of resident and who to report any violations or suspected violation. The resident sample was expanded during the survey to include five additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to abuse and neglect, care plans and transfer status for residents #6 through #10.

Based on interview, and record review, the facility failed to ensure a safe environment to prevent an accident resulting in leg fracture during resident transfer, for 1 of 9 residents reviewed for use of mechanical lifts, of a total sample of 10 residents, (#1).On 10/16/25 at approximately 2:40 PM, the facility failed to ensure nursing staff followed resident #1's plan of care for safe transfers resulting in serious injury and avoidable pain of a physically impaired resident during a transfer from wheelchair to bed. Two certified nursing assistants (CNAs) failed to follow resident #1's care plan which required her to be transferred using a mechanical lift with assistance of two staff. The two CNAs transferred the resident from her wheelchair by manually lifting her to an upright position and pivoting her to the bed. Resident #1 immediately complained of pain in her left leg during the transfer and was lowered to the floor. The two CNAs then manually lifted her from the floor and placed her in bed. Resident #1 continued to complain of extreme pain to her left leg. An X-ray performed on 10/17/25 of resident #1's left leg indicated she had sustained a fractured tibia (lower leg). Record review revealed a total of 23 residents were identified who required a mechanical lift for transfers. The facility's failure to ensure staff transferred residents according to their transfer status and care plan contributed to the injury of resident #1 and placed her and all other residents who required mechanical lifts for transfer at risk for serious impairment and/or death.This failure resulted in Immediate Jeopardy which started on 10/16/25 and was removed on 10/21/25 after verification of the immediate actions implemented by the facility. The scope and severity was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.Findings: Cross reference F600 Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (one-sided paralysis and weakness) following stroke affecting left non-dominant side, obesity, chronic back pain and muscle weakness. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated she was cognitively intact. The assessment indicated resident #1 was dependent on staff for transfers. It was noted that due to her medical conditions and/or safety concerns, evaluations of resident's ability to sit to stand, transfer to the toilet or walk ten feet were not attempted. Review of the Significant Change MDS assessment dated [DATE], after resident #1 sustained the tibia fracture, revealed a decline in mood from the previous assessment. Resident reported feeling down, depressed or hopeless and had a poor appetite for 7 to 11 of the previous 14 days; and reported trouble falling or staying asleep or sleeping too much and feeling tired or having little energy for 12 to 14 of the previous 14 days. The assessment also showed a decline in resident #1's functional status and documented she became dependent on staff for sit to lying, lying to sitting on side of bed. Resident #1 reported an increase in pain frequency which occasionally made it hard for her to sleep at night. Her worst pain over the last five days increased from a pain intensity of 5/10 on the Quarterly assessment to a pain intensity of 7/10 on the Significant Change assessment after the incident. Review of the resident's electronic medical record (EMR) revealed an Activities of Daily Living (ADL) self-care performance deficit care plan initiated 5/30/23 and revised 10/18/25. The care plan indicated resident #1 had a recent fracture of left tibia. The interventions identified resident #1 as dependent for transfers and required the assistance of two staff using a total mechanical lift. The ADL task history showed resident #1 was first identified as requiring the use of a mechanical lift on 5/16/24. Review of physician orders revealed an order dated 10/17/25 for non-weight bearing pending orthopedic appointment and to apply brace to left knee for immobilization. An order dated 10/21/25 read, Transfer to ER [Emergency Room] for evaluation of left tibia fx [fracture]. The EMR contained a radiology results report from 10/17/25 which revealed resident #1 sustained a left proximal (closer to the body) tibia fracture with mild displacement. Review of resident #1's Medication Administration Record (MAR) for October 2025 revealed between 10/01/25 to 10/16/25 resident #1 had complaints of pain on 6 days. Her complaints of pain increased to daily, after the incident from 10/17/25 through 10/28/25. In a phone interview on 10/27/25 at 12:08 PM, CNA A confirmed she was resident #1's assigned CNA on 10/16/25. She recalled resident #1 put on her call light and asked to go back to bed around the end of the shift. CNA A stated she was not aware of the resident's transfer status or where to find the information but resident #1 told her that staff usually got her up with a two-person pivot. CNA A explained she looked outside the room and asked another staff member to help her. CNA A stated she did not know the name of the other CNA she asked for assistance. She recalled that resident #1 said she had a little pain during the transfer and they lowered her to the floor, gave her a few minutes to rest and then lifted her and transferred her to bed. CNA A acknowledged she did not report the complaint of pain to the nurse. She explained it was the end of the shift; she had already given report to the oncoming CNA and was about to leave when resident #1 asked for help. She stated she was not aware resident #1 was injured until she was notified the next day by the (former) Director of Nursing (DON). Review of CNA B's witness statement given on 10/17/25 revealed she clocked in for work at approximately 2:36 PM on 10/16/25 and went to her assigned unit. She reported that while she was on her way, CNA A opened the room door, saw her and asked her how strong she was. CNA A asked her to help transfer the resident back to bed. CNA B recalled she recognized resident #1 but was not aware she required a mechanical lift for transfer. She documented that CNA A told her she would normally use the mechanical lift to transfer resident #1 but now would just have the resident stand and pivot to put her in bed. CNA B noted she was hesitant as she observed a mechanical lift sling already under resident #1 in the wheelchair but agreed to help. Her statement indicated they positioned the wheelchair next to the bed with the left side of the wheelchair turned slightly toward the bed and locked the wheels. CNA B and CNA A stood on either side of resident and lifted her under her arms. CNA B indicated in her statement the resident felt like dead weight. CNA B recalled resident #1 started yelling about her leg hurting during the transfer. CNA B looked down and saw resident #1's left foot was turned in slightly. She reported they lowered resident #1 to the floor and her left leg was bent backwards at the knee out to her left side. CNA B stated that resident #1 complained that her leg hurt really badly and she was in a lot of pain. Resident #1 asked if they could get the mechanical lift and CNA A responded if they got the lift that they were going to see her on the floor and would get in trouble. CNA B stated she thought they should have gotten the mechanical lift, but CNA A told her she did not want to get her in trouble. She reported that after about 30-40 seconds, they lifted the resident from the floor under her arms and quickly placed her in a sitting position on the side of the bed. She was then positioned in bed with her feet on the bed. CNA B noted resident #1 was breathing heavily and said her leg hurt really badly. She stated the resident was in a lot of pain. CNA B recalled she told CNA A that this was a transfer gone very wrong. CNA B reported that CNA A agreed and said that it was the first and last time, as they would use the mechanical lift next time. CNA B indicated she asked CNA A if she needed anything else, then left the room and went to her assignment. She stated she did not have any further interaction with CNA A or resident #1 for the remainder of her shift. CNA B explained she did not inform the nurse of the fall or resident #1's complaint of pain as she thought CNA A reported it. On 10/27/25 at 10:15 AM, resident #1 was observed in bed with the head of bed elevated and leg immobilizer on her left leg that extended from her thigh to her ankle. She confirmed that two CNAs transferred her without the use of a mechanical lift on 10/16/25. Resident #1 stated her foot slipped and hit the floor. She reported the pain was immediately a 10 out of 10 and continued throughout the night. Resident #1 expressed she felt she should have been sent out to the hospital when it happened. She recalled the X-ray was not done until the next day and came back as a fracture of her leg. She stated she had still not been sent out to the hospital, but the former DON and Assistant Director of Nursing put a brace on her leg and told her they were going to schedule an orthopedic appointment for her. Recalled she went to a local hospital about a week ago for her pain but did not see an orthopedic doctor. She reported she was sent to an orthopedic doctor in another city approximately an hour away on 10/24/25 but they did not take her insurance, so she was sent back to the facility without being seen for the fracture. Resident #1 expressed that her leg still hurt and was painful during ADL care, especially with rolling and positioning in bed. On 10/27/25 at 11:00 AM, Registered Nurse (RN) E confirmed she was a provider with resident #1's insurance. She stated she was familiar with the resident and was aware of the tibia fracture. RN E verified resident #1 had not had an orthopedic follow-up since the incident on 10/16/25. She recalled the former DON made an appointment for resident #1 for one day last week and verified they accepted the resident's insurance. RN E stated when resident #1 arrived, she was told they did not take her insurance and sent her back to the facility. She explained they were having difficulty finding a provider that accepted her insurance. RN E acknowledged it had been 11 days since resident #1 sustained the fracture and she had not had her orthopedic physician consultation. RN E stated it had been too long and explained they were still working on getting the resident an appointment. In a follow up interview on 10/28/25 at 8:50 AM, resident #1 stated the facility had now set her an appointment this morning with an orthopedist approximately an hour away. She explained she was supposed to leave shortly. In a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) on 10/28/25 at 11:17 AM, the Administrator stated the facility investigation showed CNA A and CNA B transferred resident #1 inappropriately using a stand and pivot technique rather than a mechanical lift as directed in her plan of care. During the transfer, resident #1 complained of pain and an X-ray revealed she sustained a left tibia fracture. The physician was notified and ordered a leg immobilizer and an orthopedic consultation. The Administrator was unable to state why the physician did not order the resident to be sent to the hospital for evaluation of the fracture. He stated the resident had requested to go to the hospital a couple of days later and then changed her mind but then requested again the next day. The Administrator reported the resident went to the hospital for uncontrolled pain but refused to allow them to do additional imaging. He was unable to explain why she was sent to the hospital for uncontrolled pain instead of for the tibia fracture when the physician order in the EMR was for evaluation of left tibia fracture. He stated that an orthopedic appointment was scheduled for 10/24/25. He explained the facility verified resident #1's insurance would be accepted, but when she arrived, they refused to see her based on her insurance. The Administrator stated the facility offered to pay but the clinic declined and resident #1 returned to the facility without being evaluated. On 10/28/25 at 2:27 PM, resident #1 was in a reclined chair at bedside. She recounted it had been a long day, and she was in pain from her toes all the way up. She stated the orthopedic doctor had ordered STAT (immediate) imaging and she was now going to the hospital for the tests. At 3:00 PM, resident #1 was leaving out the front door of the facility for transportation to the hospital. Resident #1 remained in the hospital and did not return to the facility prior to the end of the survey. On 10/30/25 at approximately 1:27 PM, the RNC confirmed resident #1 was still in the hospital. She stated resident #1 had been diagnosed with deep vein thrombosis in her left leg. Deep vein thrombosis (DVT) is a blood clot in a vein located deep within your body, usually in your leg. This occurs when a blood clot develops in veins deep in the body because the veins are injured or the blood flowing through them is too sluggish. The clots may partially or completely block the blood flow through the vein and may dislodge moving to the lungs which is a medical emergency. Conditions which increase the risk for DVT include not moving for long periods of time, being immobile after surgery or a serious injury including fractures, (retrieved from my.clevelandclinic.org on 10/30/25).In a phone interview on 10/30/25 at 5:04 PM, resident #1 stated she still had extreme pain in her leg. She said the consulting orthopedist on 10/28/25 sent her to the hospital right away because he could not make any recommendations without viewing the X-ray images, and the facility had not provided them. Resident #1 explained now the hospital informed her she had a blood clot in her leg. She said the facility should have sent her to the hospital right away when they knew of her injury from the transfer. Resident #1 said she never refused or declined to go to the hospital but recalled the former DON had told her on 10/20/25 the facility had made an appointment with the orthopedist for a consultation the next day, so she agreed not to go at that time. She said when she did go to the hospital ER for pain, the hospital didn't offer to do an X-ray or MRI, and she never refused any imaging. Resident #1 said she finally saw a surgeon at the hospital but was told they couldn't do surgery because of the DVT, so she has to wear the brace instead and she is in a lot of pain. Review of the facility's policy and procedure for Safe Resident Handling/Transfers revised 11/29/22 revealed it was the policy of the facility to ensure that residents were handled and transferred safely to prevent or minimize the risks for injury and provide and promote a safe, secure and comfortable experience for the resident. The guidelines instructed staff that resident lifting and transferring would be performed according to the resident's individual plan of care. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/16/25 at 10:50 PM, resident #1 was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging. *On 10/17/25 resident #1 and roommate were interviewed by former DON and reported that resident #1 was transferred without the use of the mechanical lift by two CNAs on 10-16-25. *On 10-17-25 the CNAs who were noted as failing to follow resident's plan of care correctly for use of mechanical lift were immediately suspended. *On 10/17/25, the ADON began education on identifying resident's transfer status, safe transfers and skills validation. *On 10/17/25 an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident and training to be conducted as result of incident that occurred on 10/16/25. *On 10/18/25, the CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident #1's transfer status and subsequently disregarded this information by performing a stand and pivot transfer. Resident #1's care plan and Kardex indicated she required a two person assist with the use of mechanical lift for transfers. *On 10/18/25 through 10-19-25, each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected. *On 10/19/25, the facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education/training and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations. *On 10/17/25 through 10/21/25, the nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering the resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. As of 10/21/25, 77 out of 92 nursing staff received education, (84%), The remaining 15 total nursing staff members would receive education prior to next shift worked. *Ad Hoc QAPI meetings were completed 10/20/25 and 10/21/25 with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan. Interviews were conducted from 10/29/25 to 10/30/25 with 18 staff members representing all shifts (1 RN, 4 LPNs, 9 CNAs, 1 dietary, 2 environmental services and 1 activity aide/CNA). Staff interviews revealed they were knowledgeable of identifying abuse and neglect, following a resident's plan of care, safe handling of resident and who to report any violations or suspected violations. The resident sample was expanded during the survey to include five additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to abuse and neglect, care plans and transfer status for residents #6 through #10.

Based on interview, and record review, the facility failed to report an allegation of abuse made by a resident within the required timeframe and failed to report and investigate an allegation of abuse made by a resident to the state agency (SA) for 2 of 6 residents reviewed for abuse, of a total sample of 15 residents, (#4, and #10). Findings: 1. Review of resident #4's medical record revealed he was readmitted to the facility on [DATE] with diagnoses of encephalopathy, hemiplegia and hemiparesis (muscle weakness and paralysis to one side of the body) following a stroke, type 2 diabetes and chronic pain. Encephalopathy is a change in how the brain functions. It may cause confusion or agitation or temporary disturbance or it could permanently damage the brain, (retrieved from www.clevelandclinic.org on 1/26/25). Review of resident #4's Minimum Data Set (MDS) annual assessment with Assessment Reference Date (ARD) 11/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated he was cognitively intact. The MDS assessment noted no rejection of evaluation or care necessary to obtain goals for health and well-being. The MDS showed resident #4 was dependent on staff for toileting, shower/bathe, upper and lower body dressing and personal hygiene. He required substantial assistance for oral hygiene. On 1/09/25 at 11:05 AM, in a joint interview with the Administrator (NHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) , the NHA stated he was the Abuse Coordinator and explained an immediate report was submitted to the SA on 12/31/24 for an allegation of physical abuse made by resident #4. He explained due to an odd set up in resident #4's room, turning off the call light was very difficult to get to because the Certified Nursing Assistants (CNA) had to lean on his bed to turn the call light off. He indicated resident #4 reported on 12/26/24 his assigned CNA smacked his hand. He explained a skin assessment was done and no injuries were noted. The NHA stated the CNA had already left for the day, but she was called and informed she was suspended until the investigation was completed. The NHA indicated the DON interviewed resident #4 but was unable to interview his roommate because he was not interviewable, due to severe cognitive impairment. The DON explained the assigned CNA told her when she was changing resident #4's brief, he touched her breast but she denied hitting the resident. The DON stated Licensed Practical Nurse (LPN) B entered two progress notes on 12/26/24 regarding resident #4's inappropriate behavior, one at 10:06 AM, and one at 4:50 PM, and LPN B reported this to her that same day. Review of Registered Nurse (RN) A's witness statement dated 1/02/25 revealed, On the night of Thursday December 26, 2024 this nurse was passing medication to his assigned residents when he heard the sounds of an altercation taking place behind him. This nurse moved to investigate. He heard [CNA C] say something like You will not touch me. This nurse moved to separate the two when [resident #4] mentioned that [CNA C] had hit him. Once [CNA C] was out in the hall, this nurse asked if she had hit [resident #4] to which [CNA C] answered yes but clarified she had forcefully pushed [resident #4]'s hand away from her and that he had been trying to touch her in an inappropriate way. This nurse went to ask [resident #4] what happened. He stated that he had touched [CNA C]'s stomach by accident and that [CNA C] had hit his hand away. The other nurse on the floor that night [LPN B] then took [CNA C] to the DON's office to report the incident. The witness statement from LPN B dated 1/02/25 was included in the 5-day report submitted to the SA on 1/07/25. The statement read, I was sitting at nurses' station while CNA [C] was in resident's room. CNA's voice got louder and stated, Do not touch me like that. Do not even do that to me. The nurse asked the CNA did you just hit him? The CNA stated yes, he just grabbed my breast. LPN B's statement included that she asked CNA C to walk to the DON's office. Review of the witness statement from CNA C dated 1/03/25 mentioned she was changing resident #4's brief when he decided to put his hand over her breast. She described she pushed his hand off her breast and reported it to his nurse and the DON. The SA 5- day report included an interview by the DON with resident #4 which read, Resident stated he touched [CNA C]'s stomach when she leaned over, and she pushed his hand away. Then the resident later stated that the CNA slapped his hand away. During the interview on 1/09/25 at 11:05 AM, the DON stated the information included in the written statements about CNA C hitting resident #4 was not relayed to her on 12/26/24. She explained it was not until 12/31/24 when resident #4's assigned CNA reported resident #4 said he was hit by CNA C on 12/26/24. She indicated RN A or LPN B did not report CNA C hit resident #4. She indicated it was not handled as a physical abuse allegation and an investigation was not initiated on 12/26/24. She mentioned when LPN B and CNA C spoke to her, she saw it as a behavior issue as there was history of the same behavior in the past. The RNC stated there was a care plan for his behavior which had been last updated on 11/08/24. The NHA explained abuse allegations were reported to the appropriate agencies within 2 hours of learning about the incident and 24 hours for neglect or misappropriation. When asked about the two nurses not reporting that CNA C hit the resident on the day of the incident, there was no response from the NHA or the DON. The NHA explained education of staff was ongoing and mentioned they had challenges ensuring staff understood the education. 2. Review of resident #10's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of bladder cancer, cirrhosis of liver, and heart failure. Review of resident #10's MDS quarterly assessment with ARD 9/30/24 revealed a BIMS score of 15 out of 15, which indicated she was cognitively intact. The MDS assessment noted no rejection of evaluation or care necessary to obtain goals for health and well-being. The MDS showed resident #10 was dependent on staff for toileting, shower/baths, upper and lower body dressing and personal hygiene. Review of the Grievance Log revealed two grievances were filed by resident #10 in October 2024. A Grievance and Comment Form dated 10/18/24 taken by the Social Services Director read, [Resident #10] requesting for CNA [name] not to provide care. The DON was listed as the person investigating the complaint. The follow up read, CNA will not be assigned to resident. A Grievance and Comment Form dated 10/31/24 read, CNA very rough. Needs help to learn how to help turn, need help to roll over and she pushes very hard. Had this problem before. I cried out. The result of the investigation cited, Corrective Action to Employee. The form was signed by the DON and the SSD. On 1/08/25 at 3:59 PM, the Social Services Director confirmed she was the grievance officer. She indicated she spoke to resident #10 on 10/18/24 and resident shared the CNA did not provide good customer service. She explained residents requested changes of staff for various reasons which could include personality conflict, call light response or any customer service issue. She stated she asked resident #10 if she got hurt and resident responded no. the Social Services Director stated the grievance filed on 10/31/24 was not reported to the SA but confirmed the DON took disciplinary action with the employee. The Social Services Director explained she was not involved in determining what constituted abuse. Review of the Reportable Event Log for October and November 2024 revealed no events listed for resident #10. On 1/09/25 at 3:35 PM, the NHA and DON did not reply to why resident #10's allegation of abuse was not reported and investigated by the facility. The NHA stated they did not discuss the entire grievance details during their morning meetings and only identified the department or person who would be assigned to investigate. The DON stated she interviewed the CNA, took corrective action and provided education to her. Later, at 5:00 PM, the NHA stated the DON could not find the corrective action or any documentation for this employee or the incident. Review of the facility Resident Right-Grievances policy dated 11/7/24 read, . immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the Administrator of the provider; and as required by State law; Review of the facility Abuse, Neglect and Exploitation policy revised on 11/16/23 revealed the purpose was to provide protection for the health, welfare and rights of each resident. The policy read, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. The investigation included identifying and interviewing all involved including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The document included alleged violations would be reported to the Administrator, state agency and other required agencies immediately, but not later than 2 hours after the allegation was made, if the events involved abuse or resulted in serious bodily injury. The policy revealed the facility would analyze the occurrence to determine why abuse occurred and make changes needed to prevent further occurrences, and train staff on changes made with demonstration of staff competency after the training was implemented.

Based on observation, interview, and record review, the facility failed to honor resident's rights to choose their preferred bathing preferences for 1 of 3 residents reviewed for choices, of a total sample of 38 residents, (#81). Findings: Review of the medical record revealed resident #81 was admitted to the facility on [DATE] from the hospital. Her diagnosis included end stage renal disease, type II diabetes, heart failure, and dependence on renal dialysis. Resident #81's Admission Minimum Data Set (MDS) with an assessment reference date of 6/27/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status indicating she did not have any cognitive impairment. The MDS assessment also indicated resident #81 required substantial/maximal assistance with bathing, it was very important to her to choose between a shower and bed bath, and she participated in the assessment and goal setting. It also revealed the resident did not exhibit behavior symptoms or rejection of care that was necessary to achieve the resident's goals for health and well-being. Resident #81's Nursing Readmission Screen dated 6/20/24 noted the resident preferred a shower three times a week in the evening. Review of resident 81's Certified Nursing Assistant (CNA) Kardex added on 8/07/24 noted the resident preferred a shower on Wednesday and Fridays in the evening. Review of resident #81's medical record revealed an activities of daily living self-care performance deficit care plan was initiated on 6/25/24 and revised on 8/07/24 that noted the resident preferred a shower on Wednesday and Fridays in the evenings and required substantial/maximal assistance by one staff with bathing. It also noted the resident required a mechanical lift for transfers. The bathing task report for resident #81 showed she received only three showers from 7/10/24 to 8/08/24, on 7/31/24, 8/04/24, and 8/07/24. The report noted the resident received bed baths on 23 of 29 days since she was admitted . On 8/06/24 at 1:02 PM, resident #81 stated she was only given bed baths but preferred showers. She conveyed she had told the staff she preferred showers, but they told her she was unable to have showers, only bed baths. She stated she did not care what day or time they were scheduled, but would just like to have a shower. She stated her hair was not clean and was only washed once since she was admitted . She expressed that she celebrated how good it made her feel when she received her one and only shower from the staff last week. On 08/08/24 at 4:41 PM, the Assistant Director of Nursing (ADON) accessed resident #81's medical record and confirmed the Kardex, care plan, and nursing admission assessment indicated the resident's bathing preference was showers on Wednesday and Fridays in the evenings. The ADON accessed the resident's bathing task report and acknowledged the resident received only three showers in the past 30 days on Wednesday 7/31/24, Sunday 8/04/24, and Wednesday 8/07/24 with one day documented as the resident refused to be bathed. She expressed the resident's choices were not honored and she should have received showers instead of bed baths. She acknowledged the importance of ensuring the resident received her preferred means of bathing, as it was the resident's right. The facility's Resident Showers policy, dated November 2020 read, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice .Residents will be provided showers as per request .

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 38 residents, (#47). Findings: Resident # 47 was admitted on [DATE] to the facility and then readmitted on [DATE] with diagnoses including cerebral infarction (stroke), unspecified glaucoma, asthma, and shortness of breath. Review of the Minimum Data Set (MDS) admission assessment with an assessment reference date of 4/30/24 revealed resident #47 had a Brief Interview for Mental Status score of 00 out of 15, which indicated she was severely cognitively impaired. On 8/06/24 at 11:20 AM, resident #47 was observed lying back in bed watching television. Her bedside table was over her lap, with personal items, including a 15 milliliter (ml) Afrin nasal spray. The resident said she used the nose spray because her nose got stuffy sometimes. On 8/06/24 at 11:30 AM, the resident's bedside table was observed with License Practical Nurse (LPN) B, her primary care nurse. She acknowledged the Afrin nasal spray 15 ml unsecured on her table. A review of the resident's physician orders with LPN B revealed no orders for the Afrin nasal spray found on the resident's overbed table. LPN B explained for someone to self-administer medications, they must have a physician's order and a self-administration evaluation completed. LPN B confirmed there was no physician's order for the Afrin nasal spray and that the resident had not completed a self-administration evaluation. On 8/06/24 at 11:39 AM, the Director of Nursing (DON) stated the self-administration assessment should be completed to ensure the resident could safely self-administer medication. A review of the facility's policy and procedure for Resident Self-Administration of Medication, dated 11/2020, revealed, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview, and record review, the facility failed to follow accepted standards of practice to prevent cross-contamination during wound care for 1 of 2 residents reviewed for pressure ulcers, of a total sample of 38 residents, (#350). Findings: Resident #350 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included dementia, seizures, hypertension, heart failure, acute kidney failure, unstageable pressure ulcer sacral wound and urinary tract infection. Review of the wound care physician orders dated 8/03/24 included daily treatment of the resident's sacrum. The order directed the nurses to cleanse with wound cleanser, pat dry, apply Santyl, super absorbency and cover with border foam. As defined by Centers for Medicare and Medicaid Services (CMS), Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar [i.e. dry, adherent, intact without erythema or fluctuance] . (Retrieved from the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Rev. 211, 02-03-23). Review of resident #350's medical record revealed a baseline care plan initiated on 8/02/24 for impaired skin integrity due to sacral pressure ulcer. The goal was the wound would show evidence of healing and be free from infection. The approaches included provide incontinence care as needed, provide treatment as ordered by physician, and weekly and as needed skin evaluations. Review of the most recent wound care note documented by the Advanced Practice Registered Nurse (APRN) dated 8/07/24, showed the resident had an unstageable pressure wound present since admission measuring 10.5 centimeters (cm) by 11.5 cm by 0.3 cm deep. The wound was noted with 20% granulation tissue, 80% eschar and exposed subcutaneous (fat) tissue with heavy purulent malodorous drainage. On 8/07/24 at 2:40 PM, prior to observation of resident #350's wound care, the North Wing Unit Manager (UM) was observed placing all treatment supplies (Santyl ointment in small plastic medicine cup, wound cleanser, border foam, tongue blade, super absorbency sponge and non-sterile gauze) on the residents' bedside table and did not clean, sanitize or place barrier drape on the table prior. Certified Nursing Assistant (CNA) A assisted with positioning the resident onto her left side during the wound care procedure. The UM performed hand hygiene, donned clean gloves and proceeded to do the wound care. She removed the soiled dressing from the resident's sacral/buttock region revealing a wound that presented as per the APRN's note dated 8/07/24. After removing the soiled dressing, the UM failed to perform hand hygiene before she donned the gloves to continue wound care and apply the new dressing as ordered. On 8/07/24 at 3:05 PM, after the wound care was completed the North Wing UM could not answer why she did not set up a clean field to place the wound dressing supplies nor why she did not wash her hands after removing the soiled dressing/gloves prior to applying the new dressing. She acknowledged she did not know the facility's policy and procedures. On 8/08/24 at 3:41 PM, the Director of Nursing (DON) and Regional Nurse expressed concern when informed of the break in infection control twice during resident #350's sacral wound care by the North Wing UM. The DON confirmed the North Wing UM should have sanitized the table in the resident's room before placing the dressing supplies on some type of barrier. The DON also confirmed the UM should have performed hand hygiene after removing the soiled dressings and before applying a new pair of clean gloves and the clean dressing to resident #350 to help reduce the spread of infection. The DON explained the UM was a new nurse to the facility, and said they needed to do further education with her regarding the wound dressing change process. Review of the facility policy and procedure for Clean Dressing Change revised 11/23/23 read, It is a policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. B. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field . A review of the facility's policy and procedure for Hand Hygiene, revised on 5/21/22, read Staff will perform proper hand hygiene procedures to prevent the spread of infection . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 evaluation for 3 of 5 residents reviewed for PASARR, of a total sample of 38 residents, (#15, #46 & #55). Findings: 1. Resident #46 was admitted to the facility on [DATE]. His diagnoses included anxiety, hypertension and schizophrenia. Review of resident #46 Minimum Data Set (MDS) dated [DATE] revealed a diagnosis of schizophrenia. The MDS assessment also revealed the resident was on antipsychotic medications listed under the section for high-risk drug class medications. Review of the resident's orders revealed an order for Quetiapine Fumarate 50 milligrams (mg) twice daily and 150 mg at bedtime. The care plan for resident #46 listed him as being at a risk for complications related to the use of psychotropic drugs; the antipsychotic which was initiated 12/17/20. The care plan indicated the resident has a tendency to distort and confabulate information/statements related to schizophrenia/schizoaffective disorder initiated on 5/17/24. Review of resident #46's PASARR dated 11/25/20 under Section 1 part A; mental illness or suspected mental illness, revealed a handwritten note of N/A and the diagnosis of anxiety and Schizophrenia were not selected. 2. Resident #15 was admitted to the facility on [DATE]. His diagnoses included cerebral atherosclerosis, schizoaffective disorder (bipolar type), dementia with agitation, epilepsy, mood disorder, anxiety, autistic disorder, unspecified intellectual disability, bipolar disorder, and pseudobulbar affect. Resident #15's Admission MDS dated [DATE] revealed the resident was admitted to the facility with the diagnoses of non-Alzheimer dementia, seizure disorder, anxiety, depression, and bipolar disorder. The MDS noted the resident was on antipsychotic, antianxiety and antidepressant medications. Review of resident #15's medical record revealed a care plan initiated on 9/16/20 noted the resident was at risk for communication problem due to difficulty making needs known, difficulty understanding related to (r/t) diagnosis of dementia, intellectual disabilities, autism and cognitive communication deficit. He also had a care plan for impaired cognitive function/dementia or impaired thought process r/t bipolar disorder, dementia, autism and unspecified intellectual disorder which was initiated on 12/19/22. Resident #15's care plan also revealed a risk for harm, self-directed or other directed behavior potentially causing harm. The care plan noted he had a history of kicking the foot board and hitting his fist on the mattress and hitting arm on siderail which was initiated on 1/21/23. A focus initiated on 9/22/20 listed Resident 15's as having the potential to be verbally and physically aggressive, use racial slurs toward staff and other residents, tends to make unfounded accusations about staff and family, hits self at times, yells out in room and makes sexually inappropriate comments. One of the interventions for this behavior was one to one supervision. Resident #15's Order Summary Report showed the resident had an order for Quetiapine Fumarate 400 mg at bedtime for schizoaffective disorder dated 6/11/24, Quetiapine Fumarate 200 mg two times a day for schizoaffective disorder dated 7/28/24, Trazadone 100 mg three times a day for depression dated 10/09/23, and Ativan 0.5 mg at bedtime for anxiety dated 7/27/24. Review of resident #15's PASARR dated 1/22/20 noted the Section 1: PASARR Screen Decision-Marking to be partially blank and the sections A and B to be missing the listed mental illness and intellectual disorders. In interviews on 8/07/24 at 3:32 PM and on 8/08/24 at 11:21 AM, the Director of Nursing (DON) acknowledged resident #46 and resident #15's level I PASARRs were incorrect. She confirmed no updates had been made to them by the facility at that time, but confirmed the facility should have updated them due to inaccuracies. She revealed once they were updated resident #15 triggered the need for a Level 2 screening. 48878 3. Review of the medical record revealed resident #55 was admitted to the facility on [DATE] from the hospital. Her diagnoses included bipolar disorder, recurrent severe major depressive disorder, and paraplegia. Resident #55's Admission Minimum Data Set (MDS) with an assessment reference date of 6/27/24 revealed the resident was admitted to the facility with the diagnoses of bipolar disorder and depression. The MDS noted the resident's high-risk drug class medications included antidepression medication. The admission assessment also noted the resident scored 15 out of 15 on the Brief Interview for Mental Status that indicated she did not have any cognitive impairment. Review of resident #55's medical record revealed a care plan initiated on 6/24/24 noted the resident was at risk for alterations in comfort related to bipolar disorder and depression. Resident #55's Order Summary Report showed the resident had an order dated 6/22/24 for Fluoxetine HCI 40 milligrams (mg) one time a day for depression. On 08/07/24 at 3:32 PM, the Director of Nursing (DON) stated it was the DONs responsibility to review PASARRs on admission to ensure they were accurate and submitted timely. The DON stated resident #55 was admitted on [DATE] with a diagnosis that included bipolar and major depressive disorder. She confirmed resident #55's PASARR Level I dated 12/28/22 did not list the diagnoses of bipolar and major depressive disorder which she was admitted with. She acknowledged a new PASARR should have been resubmitted since the level I was not accurate. The facility's Resident Assessment-Coordination with PASARR Program with revision date 9/18/23 read, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs .PASARR Level I initial pre-screening that is completed prior to admission .The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission

Based on interview, and record review, the facility failed to notify the physician of an acute (requires immediate care), significant change of condition for 1 of 3 residents reviewed for Quality of Care and Treatment, of a total sample of 3 residents, (#1). Finding: Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from an acute care hospital on 4/16/24. The resident had diagnoses that included metabolic encephalopathy (brain dysfunction), sepsis (blood infection), myocardial infarction (heart attack), hypertension, dysphagia (difficulty swallowing), Urinary Tract Infection (UTI), muscle weakness, bipolar disorder, and cognitive communication deficit. On 4/21/24, the resident was transferred back to an acute care hospital via 911 Emergency Medical Services. The Minimum Data Set 5-day Assessment with Assessment Reference Date 4/21/24 noted the resident was unable to complete the Brief Interview for Mental Status, and she had severely impaired cognitive skills. The assessment showed the resident had not exhibited behaviors, psychosis, or rejection of evaluation or care symptoms. The resident had functional range of motion limitations to both lower extremities and was dependent on staff to complete Activities of Daily Living (ADL). She was incontinent of bladder and bowel functions, received high-risk anti-anxiety, anti-depressant, antibiotic, and anti-platelet medications, and required supplemental intermittent oxygen during the look back period. Resident #1's Comprehensive Care Plan included focuses for staff assistance with ADL care, high risk of falls and injury, UTI, and dependence on staff for physical and social needs with interventions to notify the physician of health status changes or concerns. In a telephone interview on 6/02/24 at 9:21 AM, Licensed Practical Nurse (LPN) A recalled she worked the 11:00 PM to 7:00 AM shift on 4/21/24, and resident #1 was on her assignment. The LPN explained she was concerned after she assessed the resident and stated, She didn't look good. She said the resident's oxygen saturation was low, so she administered supplemental oxygen and then called the Assistant Director of Nursing (ADON) per the facility's policy. The LPN said the ADON told her to monitor the resident and attempt to provide oral fluids. She said after the phone call, she felt uncomfortable because the resident had difficulty swallowing and she didn't want her to aspirate. The LPN said she became further concerned because the resident wasn't improving much, so she placed a crash cart outside the resident's door. The LPN stated, I didn't want to over-react; I should have called the doctor. On 6/02/24 at 10:04 AM, in a telephone interview, Registered Nurse (RN) B said he worked the 11:00 PM to 7:00 AM shift on 4/21/24, and recalled at approximately 3:00 AM, LPN A requested his assistance with resident #1 because she was concerned the resident wasn't doing well. The RN stated, I thought she had called the doctor. In a telephone interview on 6/03/24 at 11:38 AM, the RN Weekend Supervisor recalled she reported for work on the 4/21/24 at approximately 6:30 AM, and LPN A asked her to assess resident #1. The RN explained she told LPN A to call the doctor and they needed to send the resident out via 911. Referring to resident #1, the RN stated, She wasn't responding to me; she had labored breathing and was using her accessory muscles. On 6/02/24 at 11:51 AM, the ADON recalled on 4/21/24, she was the Interim Director of Nursing (DON) when she spoke on the telephone with LPN A in the middle of the night about resident #1's change in condition. She said LPN A told her she had called the physician and he had not responded. The ADON said she told LPN A to use nursing judgement about sending her out, and she had not received any additional calls until the next morning after the resident left the facility. The ADON stated, She (LPN A) should have called the doctor; I thought that happened and expected that to happen. Review of the eInteract Change in Condition Evaluation - V 5.1 form revealed LPN A noted on 4/21/24 at 1:02 AM, resident #1 was identified with functional decline (worsening function and/or mobility) and worsening symptoms or signs that had not occurred before. The evaluation read, Vitals declined and O2 [oxygen] levels continued to stay in the low 90's after placing resident on O2 at 3 liters [per minute], via nasal cannula. Resident grimaced when taking blood pressure, like she was in pain . Resident's body was limp and she was unable to perform any strength/neuro tests, in which she used her hands . While doing my rounds at 1:00 AM this morning, I noticed resident was having labored breathing, her vitals were B/P [blood pressure] 94/64, Pulse 106, Respirations 18, Temp [temperature] 97.4 and O2 sat [saturation] 89% on room air. I immediately placed resident on O2 at 3 liters [per minute] via nasal cannula and called the ADON. I was advised to encourage increased thickened fluids and to continue O2 and to monitor the resident closely. The Provider Notification and Feedback section showed the primary care clinician was notified on 4/21/24 at 7:36 AM, over six hours after the resident's significant decline in condition was identified. In a joint interview with the Nursing Home Administrator (NHA), ADON, and DON at 12:05 PM on 6/02/24, the NHA explained, the facility reviewed the incident, and found LPN A discovered resident #1's change in condition at approximately 1:00 AM on 4/21/24 but did not notify the physician until around the time of her transfer to the hospital. The NHA stated, We think she should have called the doctor. On 6/03/24 at 12:42 PM, in a telephone interview, the Medical Director said he expected nurses to call and inform him when there was a significant change in a resident's condition. He recalled resident #1's emergency transfer to the hospital and stated, I probably would have sent her out earlier if I had known of a significant change in her condition . but had the opinion this would not have affected the outcome for her in this case. The facility's standards and guidelines dated 8/16/22 titled Notification of Changes, read, . Compliance Guidelines . Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition .

Based on interview, and record review, the facility failed to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and readily available to nursing staff. As a result, the nursing staff failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 2 residents reviewed for CPR, of a total sample of 6 residents, (#1). These failures contributed to resident #1 receiving CPR against his wish for a natural, dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE], resident #1's sister/Healthcare Proxy signed a State of Florida Do Not Resuscitate Order (DNRO) and placed her brother in Hospice. He was readmitted to the facility on [DATE], at which time the DNRO had not yet been signed by the physician. On [DATE] the Hospice nurse handed the completed and signed DNRO form to the South Court Unit Manager (UM). The UM entered the DNRO Physician order in the Electronic Medical Record (EMR) and flagged the paper order in the Hospice chart instead of the Code Status Binder. Upon receipt of the DNRO form, per facility policy, the UM should have entered the order into the EMR, scanned the DNRO form into the EMR and placed the paper copy in the Code Status binder on the unit. The Code Status Binder was a quick reference the nursing staff utilized to confirm the residents' code status in case of an emergent situation. On [DATE], at approximately 10:00 PM the attending nurse, Licensed Practical Nurse (LPN) D found resident #1 unresponsive with no pulse or respirations. LPN D checked the EMR for physician orders and headed to the North Court to find the Director of Nursing (DON) who was working as a floor nurse at that time. LPN D informed the DON resident #1 expired, was in hospice and a DNR. The DON went to the South Court and LPN E informed her resident #1 had a Physician's order for DNRO in the EMR but no DNRO form scanned into the EMR nor placed in the Code Status Binder. The DON instructed LPN E to call 911 and have the crash cart brought to resident #1's room. The DON and LPN D went to resident #1's room and initiated CPR. CPR continued until Emergency Medical Services (EMS) arrived, assessed the resident, and pronounced the resident's time of death to be 10:20 PM. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a DNRO at risk for serious psychosocial harm, physical trauma, and prolonged undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE], and the facility corrected the noncompliance at F678 on [DATE]. The noncompliance at F678 was determined to be past noncompliance. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral ischemia, chronic obstructive lung disease and respiratory failure with hypoxia. Review of the Minimum Data Set Significant Change in Status assessment with Assessment Reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 00 which indicated severe cognitive impairment. The document indicated the resident received Hospice services. Review of resident #1's medical record revealed a copy of the State of Florida DNRO canary yellow form signed by the resident's sister/Healthcare Proxy on [DATE]. The form was signed by the physician on [DATE]. The document showed the sister's signature under the statement, Based upon informed consent I, the undersigned hereby direct that CPR be withheld or withdrawn. The proxy box was checked. The physician's statement read, . I direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. Review of the physician's order dated [DATE] read, Do Not Resuscitate. On [DATE] at 4:25 PM, the South Court UM stated when resident #1 returned from the hospital he was a full code. She explained the Hospice nurse informed her that although resident #1's sister had signed the DNRO form, the physician had not signed it and she would bring it to the facility on ce it was signed. The UM stated she received the now complete DNRO form from Hospice on [DATE]. She confirmed she entered the Physician's order for DNR in the EMR. She explained she then incorrectly placed the DNRO form in resident #1's Hospice chart instead of the Code Status binder. The UM recalled, I remember that I flagged it so I would get back to it. I am not sure what happened after that. The UM noted DNR forms were usually completed by the Social Worker or Admissions staff and were scanned into the electronic medical record. The UM stated scanning the document into the electronic medical record had always been the facility's process, but the new process was to place the document in the Code Status binder. She acknowledged she had received training and was aware of the process to place the DNRO form into the Code Status binder. She stated resident #1's canary yellow DNRO form was later found lying on the chart rack instead of being in the Code Status binder. On [DATE] at 5:04 PM, Registered Nurse (RN) A stated on [DATE] he worked on the North Court with the DON when LPN D informed resident #1 had expired. He said the DON and LPN D proceeded to the resident's room. RN A explained he went to the resident's room shortly after and the DON instructed him to take over chest compressions so she could call Hospice to clarify resident #1's code status. RN A stated he performed CPR for about ,d+[DATE] minutes before EMS arrived. He recalled EMS did not perform CPR and stopped the code. He explained the DON came back to the room at that moment and said resident #1 was not to be resuscitated. On [DATE] at 5:30 PM, Certified Nursing Assistant (CNA) B stated she was assigned to resident #1 on [DATE]. She recalled resident #1 was awake when she provided incontinence care between 9:,d+[DATE]:30 PM. She stated CNA F checked on him after she provided incontinence care, and he was watching television at that time. On [DATE] at 12:34 PM, during a telephone interview, the DON who no longer worked at the facility, described the sequence of events on [DATE]. She stated on [DATE] she worked the 3 PM to 11 PM shift. She said she worked extra shifts to avoid using agency and it gave her a chance to work with the staff and get to know the residents better. She recalled LPN D came to the unit and informed her resident #1 was not breathing, did not have a pulse and was a DNR. The former DON remembered as she proceeded to resident #1's room, LPN F said resident #1 was a full code as there was no canary yellow DNR form in the Code Status binder. She said, I looked for the Hospice binder but could not find it, so I looked in the medical record for the scanned DNR copy. I questioned whether the physician's DNR order was entered in error as there was no yellow DNR form located. She indicated she and LPN D proceeded to the resident's room and started CPR. She explained when RN A arrived, she instructed him to take over chest compressions and she left to verify the resident's code status with Hospice. She said Hospice services verified resident #1 had advance directives for DNR. She recalled when she returned to resident #1's room, EMS had already stopped the code. On [DATE] at 4:36 PM, during a telephone interview resident #1's sister stated her brother went on Hospice services and she signed the DNR form. She explained she wanted her brother to die in peace and not endure any prolonged suffering. She said she was informed the facility performed CPR against their wishes and, That made me very upset because he was a DNR and then they did do it after I said not to do it. It really irritates me. On [DATE] at 4:04 PM, an interview with the Administrator, Interim DON, Assistant Director of Nursing (ADON), and Corporate Nurse Consultant was conducted to review the incident. The Administrator stated a full investigation was completed following the incident with resident #1 and all nurses involved were suspended pending the investigation. He said the DON was terminated after the investigation was completed and LPN D who was an agency nurse was put on the Do Not Return list. The Administrator said the root cause was the Code Status binder was not updated. The ADON stated the Code Status binder was a new process that began in February and all nursing staff were educated. She said the nurse who received the canary yellow DNRO form should have placed the form in the Code Status binder. The Administrator said the Social Service Director (SSD) should have verified the Code Status of all residents monthly. On [DATE] at 5:30 PM, the SSD stated she previously completed monthly audits of resident charts for code status but now did them weekly. She explained the process included review of the Code Status on the profile and ensured it matched the order from the doctor. She said now she also checked care plans and verified the code sheet was scanned into the electronic medical record. The SSD stated all resident charts were reviewed in morning meetings. The SSD acknowledged she missed resident #1's order and said, I was getting behind in my charting and wanted to create a more effective process. Review of Advanced Directives Code Status policy dated ,d+[DATE] read: Do Not Resuscitate (DNR)- A DNR code status would indicate the person would not want CPR performed and would be allowed to die naturally if their heart stopped beating and/or they stopped breathing. Review of the facility's corrective actions were verified by the survey team and included the following: On [DATE], the Attending Physician, Medical Director, Administrator, and family were notified of the incident and an investigation was initiated. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) was completed with the Medical Director, Administrator, Assistant Director of Nursing and additional administrative staff members on the adherence to policy and procedures for Advanced Directives code status related to the Electronic Health record, Code Status binders, following physician orders and a review of the root cause analysis. The ADON completed an audit of Code Status binders for current residents residing in the facility to validate DNR forms were in the appropriate binder. No additional concerns were identified. On [DATE] and [DATE], and [DATE], QAPI meetings were held with the Administrator, Director of Nursing, Medical Director, and administrative staff. Education, audits, and drills were reviewed and revised as indicated. On [DATE] to [DATE], 27 of 29 licensed nurses were educated on Advanced Directives Code Status standards and guidelines with emphasis on updating Code Status binders with the appropriate form when Code Status orders were obtained, ensure DNR form was scanned into the medical record and on following Code Status orders. Code Status Competencies were completed with licensed nurses to validate education received. Two of 29 nurses were currently on leave and were to be educated prior to return to work. Any contracted nurses at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. New hired nurses at the facility will receive the above education during orientation and prior to working an assignment. From [DATE] through [DATE], a total of twenty-nine mock code drills were completed to ensure competency of Code Blue process. All nurses attended the drill and were given a posttest after the drill was completed. On [DATE], the Social Services Director received education on Advanced Directives Code Status standards and guidelines with emphasis on Social Services' roles and responsibilities from Regional Nurse Consultant. Weekly audits were conducted to ensure the EMR and Code Status binder matched, knowledge checks with 5 nursing staff to conduct knowledge of training, new admissions/readmissions, and residents with changes in Code Status orders verified three times a week for accuracy. Reviews completed [DATE], [DATE], [DATE], [DATE], [DATE] with 100% compliance. From [DATE] to [DATE], the facility took actions to reduce the risk of future occurrences. All staff were educated regarding the policy and procedure related to Advanced Directives with a focus on Code Status and following the Physician's orders with post-test. New Hire staff orientation to include Code Blue response and verification of Code Status in EMR and Code Status Binder, Code Status and Advanced Directives confirmed at the time of admission and orders placed in EMR. Code Status and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Interviews conducted on [DATE] to [DATE] with staff members (8 Certified Nursing Assistants, 4 Licensed Practical Nurses, 5 RNs, and the SSD) indicated they were knowledgeable of Advance Directives and where to verify the Code Status in the EMR and Code Status binder prior to providing CPR. The surveyors validated the education with attendance sheets for Code Blue drills and in-services. Review of QAPI audits revealed the audits were completed as described per Performance Improvement plan. The resident sample was expanded to include eight additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #7, #8, #9, #10, #11, #12, #13, #14 related to Advance Directives. Residents #13 and #14 expired in the facility and their DNR status was honored. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance as of [DATE].

Based on observation, interview, and record review, the facility failed to identify and provide effective fall management approaches and increased supervision for physically and cognitively impaired residents to avoid falls with major injury for 1 of 6 residents reviewed for falls, (#4). Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. On [DATE], he sustained a fall that resulted in a fracture of his left femur (hip bone) that required hospitalization and surgical repair. The resident returned from the hospital on [DATE] and fell two more times, on the day of readmission and again on [DATE]. The facility's failure to develop and implement appropriate fall management interventions and provide the level of staff supervision required to ensure his safety, contributed to resident #4's fall with major injury and placed all residents who were at risk for falls at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600, and F777 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, osteopenia (bone weakness), osteoporosis (weak, thin, and brittle bones), displaced fracture of left femur, hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on [DATE] from the [NAME] Hopkins Medicine website at www.hopkinsmedicine.org). Review of the Incident Status Report included an entry for resident #4, that read, Fall - Unwitnessed on [DATE] at 10:29 AM. The Hospital Transfer Form completed by the Assistant Director of Nursing (ADON) dated [DATE] did not note, High Fall Risk under the section, Risk Alerts. A Risk Alert for seizures was checked. Activities of Daily Living (ADLs) was noted as the resident required assistance. The section titled, Usual Mental Status/Cognitive Function before the Acute Change in Condition was noted as, Alert, oriented, follows instructions. The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of [DATE] revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and he had two or more falls since the assessment, three months prior. Review of resident #4's Medication Administration Record (MAR) for [DATE] showed active physicians orders for medications that included Heparin (blood thinner) 5000 units every 12 hours to prevent blood clots after surgery, Hydralazine 50 milligrams (MG) every 12 hours for hypertension, Keppra (anti-seizure) 750 MG every 12 hours for seizures, Oxycodone ,d+[DATE] MG every 4 hours as needed for pain, Amlodipine 2.5 MG once a day for hypertension, Lisinopril 40 MG once a day for hypertension, Metoprolol Tartrate 50 MG two times a day for hypertension, Aspirin 81 MG once a day for heart disease, and Lasix 20 MG once a day for edema, The Treatment Administration Record (TAR) for [DATE] noted on [DATE], resident #4 had a surgical wound on his left hip that required daily skilled nursing care and treatments. On [DATE] at 1:17 PM, Certified Nursing Assistant (CNA) B said he knew resident #4 well and had cared for him many times. He recalled when the resident fell on [DATE] he observed him on the floor in his room as he was walking by the room. He stated after the fall, he completed a handwritten statement within about 10 minutes and gave it to the North Court Unit Manager. He said CNA tasks specific to residents were listed on the software program and included any safety checks or special instructions. He said he was not aware of any extra supervision or fall safety duties that were required from CNAs for the resident. On n [DATE] at 9:18 AM, the North Court Unit Manager stated on [DATE], she and the Assistant Director of Nursing (ADON) jointly responded to resident #4's fall. She explained she observed the resident on the floor lying flat on his back in front of the sink in his room. She said the resident fell from his wheelchair while he attempted to transfer himself. On [DATE] at 10:39 AM, the ADON said she had known and cared for resident #4 for many years, and he had a poor capacity to remember he needed help to transfer from the bed or chair. She said the resident frequently spent time off the unit in the reception area, and nurses checked on him when he was on safety checks. She said she participated in the morning Interdisciplinary Team (IDT) meetings, and all falls were discussed. She recalled no fall prevention supervision had been discussed or considered for the resident, aside from the 15 to 30 minute checks by nurses for 72 hours after a fall. She said the facility had implemented one to one supervision for safety in the past with other residents but could not remember resident #4 being on one to one supervision. She stated CNAs used the Kardex included in the medical record for residents' plan of care, safety concerns, and to document the tasks they completed. She recalled on [DATE], she worked on the North Court Unit with a regular shift assignment. She stated when she administered medications to another resident, a CNA alerted her that resident #4 was on the floor in his room. She said when she observed him on the floor, he moaned very loudly in pain and pointed to his groin area. She said she was very concerned because, he doesn't cry like that. On [DATE] a 2:45 PM, Licensed Practical Nurse (LPN) A said nurses were responsible for checking residents on fall and neurological safety checks every 15 to 30 minutes for 72 hours after falls. She said she knew resident #4 well as she was assigned to care for him many times. She recalled there were no restrictions or person-centered supervision interventions for the resident, and he was able to propel himself anywhere around the facility. She said she had worked at the facility for about 9 months and one on one supervision had been utilized in the past to prevent falls for a different resident but not for resident #4. On [DATE] at 4:17 PM, the Director of Nursing (DON) said the facility had a standard policy for fall prevention and safety which included nurses to conduct neurological checks for 24 hours and as needed, and 30 minute checks for 72 hours for any resident who fell . Review of the Comprehensive Care Plan noted resident #4 was at risk for falls and injury related to history of falls, seizures, and impaired mobility, risk for injury related to osteopenia and osteoporosis, impaired cognitive function with interventions to cue, supervise, and reorient the resident, as needed, monitoring for complications of a femur fracture, risk for decrease in ADL self-functioning as the resident required cueing for safety and staff assistance to complete ADLs with goals that he would maintain his level of functioning, risk and monitoring for adverse effects of anti-seizure and diuretic (fluid excretion) medications, risk for injury or complications of medications that could cause abnormal or excess bleeding. Goals included that the resident would not sustain a serious fall related injury. On [DATE], fall prevention interventions were revised and noted staff were to remind, and reinforce safety awareness; educate resident to request assistance prior to ambulation, place fall mats to both sides of the bed, and a scoop mattress. An intervention for staff to remind the resident to use his call light when he attempted to ambulate, or transfer had been in place since [DATE] despite the resident's impaired cognition and poor safety awareness. The physician's Progress Note dated [DATE] documented the Advanced Practice Registered Nurse (APRN) assessed resident #4 after nursing reported he fell from his wheelchair. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. The note included the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included a diagnosis of history of falls that read, frequent visual of patient to assist with care and prevent falls-continue fall precautions. The Late Entry Progress Notes completed by the APRN effective [DATE] noted nurses asked her to examine resident #4 after he fell out of his wheelchair. The assessment documented the APRN had examined the resident while he was sitting in the wheelchair and read, Patient is complaining of left groin pain and unable to move. Patient is crying in pain which is unusual for him. The Safety Check Log dated [DATE], completed and signed by the ADON showed from 7:00 AM to 10:45 AM, resident #4 was checked every 15 minutes at various locations in the facility. Entries documented at 10:15 AM he was in the hallway near the North Court nurses' station, in his room at 10:30 AM, and he was sent out to the hospital at 10:45 AM. The Post Fall Evaluation report dated [DATE] documented at 10:28 AM, resident #4 was in his room and fell while sitting in his wheelchair and he experienced a 10 out of 10 on a Numeric Rating Scale for pain intensity (numeric pain scale, from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable). The report indicated 911 emergency transportation was required to transport the resident to the hospital. The IDT Post Fall Review report dated [DATE] documented resident #4 had a history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to his fall on [DATE] when he sustained a displaced hip fracture. The report showed the IDT reviewed the incident and recommended the equipment, parameter mattress. The Incident Status Report showed resident #4 had 2 additional unwitnessed falls when he returned from the hospital post hip fracture surgery, on [DATE] at 7:36 PM, the same day he returned, and again on [DATE] at 1:50 PM. The Post Fall Evaluation report dated [DATE] documented at 7:30 PM, resident #4 fell from his bed during an unassisted transfer. Immediate interventions read, low bed frequent checks to coincide with neuro checks and non-skid footwear. Review of the medical record included 7 Morse Fall Scale (source Morse, J. M. Preventing Patient Falls 1st edition. Thousand Oaks, California: SAGE Publications. Inc., 1997) evaluations from [DATE] to [DATE] that indicated resident #4's scores continued to increase from 35 (moderate risk) on [DATE], to 55 (high risk) on [DATE], 75 (high risk) on [DATE], and 95 (high risk) on [DATE]. Review of the resident's care plans did not show any evidence that any increased monitoring or supervision of the resident was implemented when his risk of falls changed from medium risk to high risk. On [DATE] at 11:33 AM, Physical Therapist (PT) E said she knew resident #4 and had treated him for skilled physical therapy before and after his fall on [DATE]. She recalled the resident independently propelled himself around the facility in his wheelchair and was able to walk about 25 feet with moderate staff assistance before he fell . She explained the resident returned from the hospital from hip surgery with functional declines that required skilled therapy services at least 5 days per week. She recalled, the resident was, quick, and had multiple falls mostly because of his impaired cognition and poor safety awareness. On [DATE] at 10:20 AM, the MDS Coordinator said residents' care plan interventions were updated during the IDT morning meeting. She said all interventions implemented after falls were included in the Comprehensive Care Plan. She said the date of revision was the date the intervention was added or revised. She said a MDS Significant Change in Status assessment with ARD [DATE] was done after resident #4 sustained a fall with major injury and had a decline in his ADLs. Review of the MDS Significant Change assessment with Assessment Reference Date of [DATE] revealed resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed a decline in functional status since the previous assessment as the resident required extensive assistance of 2 staff for bed mobility and toileting, was unable to use the toilet, and he was dependent on staff to move between locations in his room and off the unit. He was unsteady during transfer transitions and was only able to stabilize with staff assistance. The assessment noted the resident had two or more falls since the discharge assessment on [DATE]. The physician's Progress Note dated [DATE] by the APRN showed she examined the resident after he returned to the facility from the hospital after left hip surgery. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care again included diagnosis of history of falls with -frequent visual of patient to assist with care and prevent falls - continue fall precautions. On [DATE] at 12:50 PM, CNA C said she knew resident #4 very well, and she had cared for him frequently. She recalled there had been no safety or fall check duties aside from the 15 or 30 minute checks by the nurse assigned to the resident, and he had multiple falls even though she tried to remind him to ask for help. She did not explain how the resident would be able to remember to ask staff for help with his severe cognitive impairment. She explained, after the resident returned from the hospital, he required more assistance and supervision. She said the resident became worse as the week progressed. She stated she was concerned and informed nurses the resident not been eating well, and he coughed a lot, especially when she assisted him to eat. The IDT Post Fall Review report dated [DATE] documented resident #4 had a history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to the fall from his wheelchair on [DATE]. The report showed the IDT reviewed the incident and recommended, therapy referral for seating and positioning in wheelchair. On [DATE] at 12:37 PM, the Rehabilitation Manager said he participated in IDT morning meetings. He said the IDT falls and intervention approaches were collaborative decisions. He recalled resident #4 was a known high fall risk with a history of multiple falls while attempting to self-transfer. He said the resident received skilled therapy services at various times. He could not recall any discussions about an intervention for increased staff supervision for the resident to prevent falls. On [DATE] at 10:13 AM, the DON said the facility investigated resident #4's fall with major injury on [DATE]. She explained she took statements from several nurses and CNAs who worked with the resident. She said the resident had fallen out of bed while attempting to transfer himself. She provided typewritten, unsigned and undated documents as statements she received from nurses and CNAs. She said the facility added a perimeter mattress to the resident's bed before he returned from the hospital as an intervention to prevent further falls. She was not able to provide a statement from the North Court Unit Manager who assessed the resident immediately after the fall. On [DATE] at 1:31 PM, Occupational Therapist (OT) D said she knew resident #4 well and treated him frequently. She recalled the resident, and explained after he returned from the hospital his cognition and abilities to complete ADL functions were worsened. She stated, he was different; he had a decline. On [DATE] at 4:28 PM, the DON said falls were reviewed during morning clinical meetings and plan of care was updated and revised. She checked resident #4's medical record and reviewed 14 falls from [DATE] to [DATE]. In 9 months, 13 falls occurred while the resident transferred himself, 9 from his bed, and 4 from his wheelchair. One fall occurred during staff assisted wheelchair transport. The interventions that were implemented after the falls included, 15 to 30 minute nurse checks, a non-slip cushion added to the wheelchair, a scoop (perimeter) mattress added to the bed, floor mats added to both sides of the bed, bed in low position, non-skid footwear, leg rests added to the wheelchair, therapy services, and scheduled ADL assistance. The DON did not explain if any increased supervision or monitoring of the resident was implemented after he sustained 14 falls in 9 months. On [DATE] at 10:02 AM, the APRN said she knew resident #4 well. She said the resident had very poor cognition and was not able to understand safety concerns. She acknowledged her notes mentioned the plan of care was for frequent visual of patients to prevent falls. She clarified that by frequent, she meant for staff to follow the facility's policy. She said she was aware the facility routinely utilized 15 to 30 minute checks after falls occurred. She recalled the facility had implemented one on one supervision in the past for resident safety concerns, and she was not aware of why it had not been implemented for resident #4. She stated a chair or bed alarm could have alerted staff when the resident attempted to get up but did not explain why it was not utilized for resident #4. The MDS quarterly assessment with Assessment Reference Date of [DATE] noted resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed there were no behavioral symptoms or rejections of care or treatment. Functional Status noted the resident required the assistance of 1 staff to complete ADLs, was not steady during transitions from seated to standing, and he was independent to move from locations in his room and off the unit. The assessment indicated the resident had two or more falls in the three months prior to the assessment. The DON provided all Safety Check Logs implemented after the resident returned from the hospital. The logs were dated from [DATE] at 11:45 AM to [DATE] at 7:00 AM with 30 minute checks, and 15 minute checks from [DATE] at 7:00 AM to [DATE] at 3:00 PM. The medical record contained Post Fall Evaluation and IDT Post Fall Review reports for 11 falls resident #4 sustained over 9 months prior to [DATE] when he sustained a fall with major injury. No documentation was found that addressed the 15 to 30 minute nurse Safety Checks that were implemented multiple times failed and were proved ineffective to prevent falls that could have caused major injuries/impairment/death. The Occupational Therapy Evaluation and Plan of Treatment completed on [DATE] revealed resident #4 was cognitively impaired and difficult to redirect, did not feel unsteady when standing, scored 3 out of 12 on the Self Care Function Score, varied from dependency to having required substantial/maximum assistance in his functional mobility (bed, transfers) and to complete ADLs, was not appropriate/safe to use of adaptive equipment, unable to problem solve, and he had severely impaired decision making abilities and capacity for new learning with a severe cognitive decline and exacerbation of cognitive impairment that required maximum cognitive redirection. The Assessment Summary showed after the resident returned from the hospital, he required therapy services and the assessment read, pt (patient) presents /c (with) functional decline in ADLs, generalized weakness, decreased functional mobility, impaired mentation, pt requires skilled OT services to max (maximize) ADL for safe return to NRS/LTC (Nursing Long Term Care) for ease of caregiver burden is skilled OT services pt remains at risk for falls, functional decline, or rehospitalization . Complexities . Lacks insight into condition and risk factors. Multiple medical conditions/history/medications/Other (h/o (history of) agitation/resistant behaviors.). The Physical Therapy Evaluation and Plan of Treatment completed on [DATE] revealed after resident #4 returned from the hospital he showed a decline in his functional mobility, was dependent on staff to transfer and use a wheelchair, had impaired decision making for routine activities, complexities of dementia, and he required inpatient skilled PT as without it, he was at risk for falls, contractures, skin injury, and rehospitalization . On [DATE] at 4:23 PM, the DON acknowledged there were conflicting versions between the North Court Unit Manager and the ADON who responded to the resident immediately after he fell . She was unable to locate a statement from the North Court Unit Manager in the fall investigation record. She explained, the facility's investigation concluded the resident fell because he transferred himself while he was unsupervised. She stated, there was nothing we could have done to prevent it. On [DATE] at 5:34 PM, the facility's Medical Director said he was not aware resident #4 fell 11 times in 8 months prior to the fall that resulted in a major injury until after the resident returned from the hospital. He recalled the facility reported to him that there were therapy interventions that had not been documented or done. He stated the facility could improve their processes so they could catch potential problems earlier. Review of the hospital medical records revealed on [DATE] resident #4 was admitted to the Intensive Care Unit and assessed by the physician to have acute hypoxemic (low levels of oxygen in your body tissues) respiratory failure due to pneumonia, sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection) due to pneumonia, suspect aspiration, hypernatremia (low blood sodium), acute kidney injury, acute metabolic encephalopathy (brain dysfunction), recent fall with hip fracture and surgical repair, and anemia. Records documented the resident died on [DATE], 2 days after he was admitted . The facility's Fall Prevention Program revised [DATE], read, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 5. High Risk Protocols: a. Provide patient centered interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions . including but not limited to . increased frequency of rounds. 6. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], licensed nurse education was initiated on the facility's Fall Prevention Program that included providing resident care and services to minimize the likelihood of falls and reviewing and updating care plans when residents fell . *On [DATE], the facility conducted an ad hoc Quality Assurance and Performance Improvement Committee meeting for fall prevention and follow up actions post fall. *On [DATE], Morse Fall Scale Evaluations were completed on all residents to identify their risk *On [DATE], the IDT reviewed and revised fall care plan interventions for residents at moderate to high level of fall risk. *On [DATE], Fall Prevention Program education for licensed nurses was completed and included: providing resident care and services to minimize the likelihood of falls, reviewing and updating care plans when residents sustain a fall, newly hired nurses to receive same education during orientation. All nurses with the exception of 6 were educated, and the remaining 6 were to receive the education prior to working. Agency nurses were to receive education prior to acceptance of an assignment. *On [DATE], the nursing management team was educated by the DON for staff monitoring and audits of implemented fall interventions to ensure appropriateness and verify implementation. The Unit Manager or designee to conduct at minimum daily unit rounds to verify interventions are in place. IDT clinical meetings will include discussions. A dedicated Fall Monitor staff position was implemented for duty from 7:00 AM to 11:00 PM every day tasked to hourly visualize 17 residents identified as high fall risk. The Fall Monitor will notify the Charge Nurse should a resident concern for fall safety arise. The resident with an identified concern will be placed on one to one supervision until the IDT reviews the resident and determines if enhanced supervision is needed. New resident admissions or readmissions who have undergone orthopedic surgery will be included in the Fall Monitor's rounds assignment regardless of their fall risk status until the IDT team reviews the resident and determines Fall Monitor supervision is no longer necessary. Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. From [DATE] to [DATE], interviews were conducted with 16 staff members that included 5 CNAs, 5 LPNs, 3 RNs, 1 PT, 1 OT, the APRN, Admissions Coordinator, Activities Assistant, Staffing Coordinator, and Fall Monitor verbalized understanding of the education provided. *On [DATE], 62 out of 67 nurses and CNAs were re-educated in person, onsite, and remotely. No clinical staff will be permitted to work without receiving in person education. Newly hired staff will receive the above education in orientation. The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to falls for residents #1, #2, #3, #5, and #6.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by failing to provide necessary care and services to prevent falls with major injuries and failed to develop and revise fall management approaches to mitigate the fall risk for 1 of 6 residents reviewed for falls of a total sample of 6 residents, (#4). These failures contributed to falls with major injury for resident #4 who required hospitalization , surgery, and rehabilitation for hip fracture. Resident #4 suffered excruciating pain, and was placed at risk blood clots, infection, pneumonia and decline in function. Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. On 8/08/2023, he sustained a fall that resulted in a fracture of his left femur (hip bone) that required hospitalization and surgical repair. The facility relied on safety equipment and staff monitoring at 15-minute to 30-minute intervals for 72 hours to prevent falls. These approaches proved ineffective as resident #4 had two additional falls in 5 days after he returned from the hospital from hip surgery. The facility did not increase or individualize supervision and monitoring of the resident in his plan of care to prevent falls with major injuries. The facility's failure to provide necessary fall prevention care and services to mitigate the risk for falls with major injury contributed to resident #4's fall with major injury and placed all residents at risk for falls at risk for injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 8/08/2023 and was removed on 9/02/2023. Findings: Cross reference F689 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, osteopenia (bone weakness), osteoporosis (weak, thin, and brittle bones), displaced fracture of left femur, hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on 9/08/2023 from the [NAME] Hopkins Medicine website at www.hopkinsmedicine.org). The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of 8/11/2023 revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and had two or more falls since the assessment, three months prior. Review of the Comprehensive Care Plan noted resident #4 was at risk for falls and injury related to history of falls, seizures, and impaired mobility. He had impaired cognitive function with interventions to cue, supervise, and reorient the resident. He required monitoring for complications of a femur fracture, and was at risk for decrease in self-functioning. The goal included that the resident would not sustain a serious fall related injury. On 8/14/23, fall prevention interventions were revised and noted staff were to remind, and reinforce safety awareness; educate resident to request assistance prior to ambulation, place fall mats to both sides of the bed, and a scoop mattress. An intervention for staff to remind the resident to use his call light when he attempted to ambulate, or transfer had been in place since 6/02/2020. On 8/29/2023 at 10:20 AM, the MDS Coordinator said residents' care plan interventions were updated during the Interdisciplinary Team (IDT) morning meeting. She said all interventions implemented after falls were included in the Comprehensive Care Plan. She explained a MDS Significant Change in Status assessment with ARD 8/15/2023 was done after resident #4 sustained a fall with major injury and had a decline in his Activities of Daily Living (ADLs). The Safety Check Log dated 8/08/2023, completed and signed by the Assistant Director of Nursing (ADON) showed from 7:00 AM to 10:45 AM resident #4 was checked every 15 minutes at various locations in the facility. Entries documented at 10:15 AM he was in the hallway near the North Court nurses' station, in his room at 10:30 AM, and he was sent out to the hospital at 10:45 AM. The Post Fall Evaluation report dated 8/08/2023 documented at 10:28 AM, resident #4 was in his room, fell while sitting in his wheelchair and he experienced a 10 out of 10 on a Numeric Rating Scale for pain intensity (numeric pain scale from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable). The report indicated 911 emergency transportation was required to transport the resident to the hospital. On n 8/29/2023 at 9:18 AM, the North Court Unit Manager stated on 8/08/2023, she and the ADON jointly responded to resident #4's fall. She explained she observed the resident on the floor lying flat on his back in front of the sink in his room. She said the resident fell from his wheelchair while he attempted to transfer himself. On 8/31/23 at 10:39 AM, the ADON recalled on 8/08/2023, she worked on the North Court Unit with a regular shift assignment. She stated when she was administering medications to another resident, a Certified Nursing Assistant (CNA) alerted her the resident was on the floor in his room. She said when she observed him on the floor, he moaned very loudly in pain and pointed to his groin area. She said she was very concerned because, he doesn't cry like that. A late entry Progress Notes completed by the Advance Practice Registered Nurse (APRN) effective 8/08/2023 noted nurses asked her to examine resident #4 after he fell out of his wheelchair. The assessment documented the APRN had examined the resident while he was sitting in the wheelchair and read, Patient is complaining of left groin pain and unable to move. Patient is crying in pain which is unusual for him. The IDT Post Fall Review report dated 8/09/2023 documented resident #4 had history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to his fall on 8/08/2023 when he sustained a displaced hip fracture. The report showed the IDT reviewed the incident and recommended the equipment, parameter mattress. There was no evidence the facility discussed increased supervision of the resident to prevent further falls after he sustained a fall with hip fracture. On 8/29/2023 at 4:17 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) reviewed their investigation of resident #4's fall with major injury of 8/08/2023. The DON said the facility had a standard policy for fall prevention and safety which included nurses to complete neurological checks for 24 hours and as needed, and 30 minute checks for 72 hours on any resident who fell . The DON did not indicate whether any enhanced supervision of the resident was considered post fall other than half hour checks for 3 days. On 8/29/2023 at 12:37 PM, the Rehabilitation Manager said he participated in IDT morning meetings. He said the IDT discussion of falls and intervention approaches were collaborative decisions. He recalled resident #4 was a known high fall risk with a history of multiple falls while attempting to self-transfer. He said the resident received skilled therapy services at various times. He could not recall any discussions about an intervention for increased staff supervision for the resident to prevent falls. On 8/31/2023 at 1:17 PM, CNA B said he knew resident #4 well and had cared for him many times. He recalled when the resident fell on [DATE] he observed him on the floor in his room as he was walking by the room. He stated after the fall, he completed a handwritten statement within about 10 minutes and gave it to the North Court Unit Manager. He said he wrote on the document that he had not witnessed the fall and that was all the information he had provided. He said CNA tasks specific to residents were listed on the software program and included any safety checks or special instructions. He said he was not aware of any extra supervision or fall safety duties that were required from CNAs for the resident. On 8/29/2023 a 2:45 PM, Licensed Practical Nurse (LPN) A said nurses were responsible for checking residents on fall and neurological safety checks every 15 to 30 minutes for 72 hours after falls. She stated she knew resident #4 well as she had him on her assignments. She recalled there were no restrictions or person-centered supervision interventions for the resident, and he was able to propel himself anywhere in and around the facility. She said she had worked at the facility for about 9 months and one on one supervision had been utilized in the past to prevent falls for a different resident but not for resident #4. On 8/31/2023 at 10:39 AM, the Assistant Director of Nursing (ADON) said she had known and cared for resident #4 for many years, and he had a poor capacity to remember he needed help to transfer from the bed or chair. She said the resident frequently spent time off the unit in the reception area, and nurses checked on him there when he was on safety checks. She said she participated in the morning Interdisciplinary Team (IDT) meetings, and all falls were discussed. She recalled no fall prevention supervision had been discussed or considered for the resident, aside from the 15 to 30 minute checks by nurses for 72 hours after a fall. She said the facility had implemented one on one supervision for safety in the past with other residents. She did not explain why one to one supervision was not implemented for resident #4 who sustained 11 falls in the past 10 months and a recent fall with hip fracture. The medical Progress Note dated 8/08/2023 documented the Advanced Practice Registered Nurse (APRN) assessed the resident after nursing reported he had a fall from his wheelchair. It was noted the resident was known to transfer himself without using the call light to request assistance and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included a diagnosis of history of falls and read, -frequent visual of patient to assist with care and prevent falls - continue fall precautions. Review of the medical record included 7 Morse Fall Scale (source: Morse, J. M. (1997), Preventing Patient Falls, 1st edition. Thousand Oaks, California: SAGE Publications, Inc., 1997). evaluations from 4/30/2023 to 8/11/2023 that indicated resident #4's scores continued to increase from 35 (moderate risk) on 4/30/2023, 55 (high risk) on 7/17/2023, 75 (high risk) on 8/08/2023, and 95 (high risk) on 8/11/2023. The Incident Status report showed resident #4 had 2 entries that read, Fall - Unwitnessed after he returned to the facility from the hospital for surgical repair of fractured hip on 8/11/2023. The report showed he sustained a fall the day he returned at 7:36 PM. The Post Fall Evaluation dated 8/11/23 showed the facility's intervention for the fall was low bed frequent checks to coincide with neurological checks and non-skid footwear. There was no indication of any enhanced monitoring of the resident after he had just returned to the facility from recent fractured hip surgery and fell . It was noted the resident had another fall five days after his readmission, on 8/16/2023 at 1:50 PM. The evaluation report noted resident #4 fell from his bed during an unassisted transfer. The intervention added was therapy referral for seating and positioning in wheelchair. Review of the MDS Significant Change assessment with Assessment Reference Date of 8/15/2023 revealed resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed a decline in functional status since the previous assessment as the resident required extensive assistance of 2 staff for bed mobility and toileting, was unable to use the toilet, and was dependent on staff to move between locations in his room and off the unit. He was unsteady during transfer transitions and was only able to stabilize with staff assistance. The assessment noted the resident had two or more falls since the discharge assessment on 8/08/2023. On 8/29/2023 at 11:33 AM, Physical Therapist (PT) E said she knew resident #4 and had treated him for skilled physical therapy before and after his fall on 8/08/2023. She recalled the resident independently propelled himself around the facility in his wheelchair and was able to walk about 25 feet with moderate staff assistance before he fell . She explained the resident returned from the hospital from hip surgery with functional declines that required skilled therapy services at least 5 days per week. She recalled, the resident was, quick, and had multiple falls mostly because of his impaired cognition and poor safety awareness. The medical Progress Note dated 8/15/2023 by the Advanced Practice Registered Nurse (APRN) showed she examined the resident after he had returned to the facility after hospitalization for left hip fracture surgery. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included Repeated Falls and History of Falls with comments that read, -frequent visual of patient to assist with care and prevent falls - continue fall precautions. On 8/29/2023 at 1:31 PM, Occupational Therapist (OT) D said she knew resident #4 well and treated him frequently. She recalled the resident, and explained after he returned from the hospital his cognition and abilities to complete ADL functions were worsened. She stated, he was different; he had a decline. The Physical Therapy Evaluation and Plan of Treatment completed on 8/14/2023 revealed after resident #4 returned from the hospital he showed a decline in his functional mobility, was dependent on staff to transfer and use a wheelchair, had impaired decision making for routine activities, complexities of dementia, and he required inpatient skilled PT as without it, he was at risk for falls, contractures, skin injury, and rehospitalization . On 8/31/2023 at 12:50 PM, CNA C said she knew resident #4 very well, and she had cared for him frequently. She recalled there had been no safety or fall check duties aside from the 15 or 30 minute checks by the nurse assigned to the resident. She noted he had multiple falls and she tried to remind him to ask for help. She explained, after the resident returned from the hospital, he required more assistance and supervision. She said the resident became worse as the week progressed. She stated she was concerned and informed nurses the resident had not been eating well, and he coughed a lot, especially when she assisted him to eat. On 8/29/2023 at 4:28 PM, the DON said falls were reviewed by the IDT during morning clinical meetings where interventions were discussed, and the plan of care was updated and revised. She checked resident #4's medical record and reviewed 14 falls from 11/05/2022 to 8/16/2023. In 9 months, 13 falls occurred while the resident transferred himself, 9 from his bed, and 4 from his wheelchair. One fall occurred during staff assisted wheelchair transport. The interventions that were implemented after the falls included, 15 to 30 minute nurse checks, a non-slip cushion added to the wheelchair, a scoop (perimeter) mattress added to the bed, floor mats added to both sides of the bed, bed in low position, non-skid footwear, leg rests added to the wheelchair, therapy services, and scheduled ADL assistance. On 8/31/2023 at 10:13 AM, the DON said the facility investigated resident #4's fall with major injury of 8/08/2023. She explained she took statements from several nurses and CNAs who worked with the resident. She explained the resident fell out of bed while attempting to transfer himself. She provided typewritten, unsigned and undated documents as statements she received from nurses and CNAs. She said the facility added a perimeter mattress to the resident's bed before he returned from the hospital as an intervention to prevent further falls. She was not able to provide a statement from the North Court Unit Manager who assessed the resident immediately after the fall. She did not explain why there was not any additional supervision of the resident implemented aside from the half hour checks for 3 days. She provided all Safety Check Logs implemented after the resident returned from the hospital. The logs were dated from 8/11/2023 at 11:45 AM to 8/12/2023 at 7:00 AM with 30 minute checks, and 15 minute checks from 8/12/2023 at 7:00 AM to 8/13/2023 at 3:00 PM. There was no documentation that addressed why the 15 to 30 minute Safety Checks continued to be implemented after each fall but proved to be ineffective to prevent further falls that caused a fracture. On 9/01/2023 at 10:02 AM, the APRN said she knew resident #4 well. She said the resident had very poor cognition and was not able to understand safety concerns. She acknowledged her notes mentioned the plan of care was for frequent visual of patients to prevent falls. She clarified that by frequent, she meant for staff to follow the facility's policy. She said she was aware the facility routinely utilized 15 to 30 minute checks after falls occurred. She recalled the facility had implemented one on one supervision in the past for resident safety concerns, and she was not aware of why it had not been implemented for resident #4. She stated a chair or bed alarm could have alerted staff when the resident attempted to get up but did not explain why this measure was not used for resident #4. On 9/01/2023 at 5:34 PM, the facility's Medical Director said he was not aware resident #4 fell 11 times in 8 months prior to the fall that resulted in a major injury until after the resident returned from the hospital. He recalled the facility reported to him that there were therapy interventions that had not been documented or done. He stated the facility could improve their processes so they could catch potential problems earlier. The facility's policies and procedures titled, Abuse, Neglect, and Exploitation revised 10/01/2022, read, Policy . facility to provide protection for the health, welfare, and rights of each resident . and prevent abuse, neglect, and exploitation . Neglect means failure of the facility, it's employees, or it's service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 8/28/2023, licensed nurse education was initiated on the facility's Fall Prevention Program that included providing resident care and services to minimize the likelihood of falls and reviewing and updating care plans when residents fell . *On 8/28/2023, the facility conducted an ad hoc Quality Assurance and Performance Improvement Committee meeting for fall prevention and follow up actions post fall. *On 8/29/2023, Morse Fall Scale Evaluations were completed on all residents to identify their risk *On 8/30/2023, the IDT reviewed and revised fall care plan interventions for residents at moderate to high level of fall risk. *On 8/30/2023, Fall Prevention Program education for licensed nurses was completed and included: providing resident care and services to minimize the likelihood of falls, reviewing and updating care plans when residents sustain a fall, newly hired nurses to receive same education during orientation. All nurses with the exception of 6 were educated, and the remaining 6 were to receive the education prior to working. Agency nurses were to receive education prior to acceptance of an assignment. *On 9/02/2023, the nursing management team was educated by the DON for staff monitoring and audits of implemented fall interventions to ensure appropriateness and verify implementation. The Unit Manager or designee to conduct at minimum daily unit rounds to verify interventions are in place. IDT clinical meetings will include discussions. A dedicated Fall Monitor staff position was implemented for duty from 7:00 AM to 11:00 PM every day tasked to hourly visualize 17 residents identified as high fall risk. The Fall Monitor will notify the Charge Nurse should a resident concern for fall safety arise. The resident with an identified concern will be placed on one to one supervision until the IDT reviews the resident and determines if enhanced supervision is needed. New resident admissions or readmissions who have undergone orthopedic surgery will be included in the Fall Monitor's rounds assignment regardless of their fall risk status until the IDT team reviews the resident and determines Fall Monitor supervision is no longer necessary. Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. From 8/29/2023 to 9/02/2023, interviews were conducted with 16 staff members that included 5 CNAs, 5 LPNs, 3 RNs, 1 PT, 1 OT, the APRN, Admissions Coordinator, Activities Assistant, Staffing Coordinator, and Fall Monitor verbalized understanding of the education provided. *On 9/02/2023, 62 out of 67 nurses and CNAs were re-educated in person, onsite, and remotely. No clinical staff will be permitted to work without receiving in person education. Newly hired staff will receive the above education in orientation. The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to falls for residents #1, #2, #3, #5, and #6.

Based on interview, and record review, the facility failed to follow the process for a verbal physician order for chest x-ray for 1 of 3 residents reviewed for diagnostic services out of a total sample of 5 residents, (#4). On [DATE] at 8 PM, the facility failed to obtain radiology diagnostic services for a resident with increased cough, 3 days post-surgery for fractured hip. A verbal order was given by the Advance Practice Registered Nurse (APRN) which was not entered into the electronic record and not processed by the nurse. On [DATE], the resident experienced acute respiratory distress and was transferred to the hospital where he died two days later of pneumonia. The facility's failure to process and implement a verbal order to obtain diagnostic services for resident #4's respiratory decline resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross reference F689 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, displaced fracture of left femur, hemiplegia and hemiparesis of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on [DATE] from the [NAME] Hopkins Medicine website at www.hopkinsmedicine.org). The record noted the resident was non-ambulatory and required assistance with transfers. The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of [DATE] revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and he had two or more falls since the assessment, three months prior. On [DATE] at 2:45 PM, during an interview, Licensed Practical Nurse, (LPN) A said she was giving medications near resident #4's room when she heard him coughing. She explained it was a continuous cough, and he coughed up phlegm. She said she listened to his lung sounds that were clear, and his oxygen saturation (percentage of the blood is saturated with oxygen) was at 97% on room air. She said she notified the Unit Manager (UM) of resident #4's increased cough. Review of resident #4's medical record noted nursing progress notes dated [DATE] at 8:05 PM, by the North Court UM documented the resident was noted to have increased cough. Thick phlegm noted, able to clear throat. HOB (head of bed) elevated and Advance Practice Registered Nurse (APRN) notified. Chest x-ray ordered 2 views. A nursing progress on [DATE] at 9:00 AM read, resident noted to be coughing during meals, primary physician and PT (physical therapy) made aware, ST (speech therapy) to see, Power of Attorney aware. On [DATE] at 8:27 AM, the progress note showed resident lethargic b/p (blood pressure) ,d+[DATE] (mm/Hg) temperature 102.9 (degrees Fahrenheit) heart rate 138 (beats per minute) oxygen saturation 70% - arousable but not speaking clearly. Sudden onset- refused meds and ate poorly drank health shake twice. Certified Nursing Assistant (CNA) called nurse to room for sudden onset of SOB. (shortness of breath). Resident placed on O2 (oxygen) via face mask at 5 L/M- (liters/minute) brought up to 82%. APRN called and order to send to Emergency department - 911 called and took resident to hospital. A nursing progress note on [DATE] at 12:25 AM, noted the resident was admitted to the Intensive Care Unit with diagnosis of pneumonia. A Progress Notes completed by the North Court Unit Manager on [DATE] noted resident #4 was lethargic, had been eating poorly, not speaking clearly, and was in respiratory distress when he was transferred to the hospital. A late entry Progress Note completed by the APRN on [DATE] showed that resident #4 was assessed for respiratory distress. It was noted the resident had abnormal vital signs with a fever of 102.8 degrees Fahrenheit, a heart rate of 130 beats per minute, blood pressure reading of 186 systolic over 96 diastolic, mmHg and his respirations were 55 breaths per minute. He had been administered 5 liters of supplemental oxygen per minute, and his blood oxygen saturation with oxygen was 82%. The resident was transported to the hospital by 911 emergency services where he was admitted to the Intensive Care Unit. Review of the resident's medical record revealed there was no physician order documented in the electronic record for the chest x-ray to be done. There was no documentation the x-ray company had been contacted nor any documentation the portable x-ray (radiology) company reported to the facility to complete a chest x-ray for resident #4. On [DATE] at 1:52 PM, the APRN stated she entered her own orders in the facility's electronic system and also gave verbal orders to nurses. She remembered during the morning meeting on [DATE], she was informed resident #4 had increased cough and gave a verbal order for a chest x-ray to be done. She said she did not know why it was not done, and indicated the nurse maybe got distracted and did not enter the order. She said if the x-ray had been done, she would have started the resident on antibiotics. She said she examined the resident on [DATE] but did not check for the x-ray results. She added the nurses should have been checking the resident's temperature regularly since he recently had surgery but noted she had not ordered additional vital signs including temperatures to be taken. She stated she was very upset when she found out the x-ray had not been done. On [DATE] at 3:00 PM, during an interview with the Unit Manager who received the telephone order from the APRN on [DATE] at 3:00 PM, she related she did not call the x-ray company as the APRN told her that she would put in the order and take care of it after the morning clinical meeting. She said most of the time, the APRN entered her own orders. She indicated if the APRN was not in the facility, the nurses implemented the orders. She explained she did not enter the verbal order on [DATE] at 8 PM as she was busy and did not ensure the order was entered in the electronic system. She said the next day, she was not at the morning meeting as staff had called off sick and she worked on the unit. She did not check if order was carried out. In an interview with the Director of Nursing on [DATE] at 1:15 PM, she related it was an expectation of the facility that when any verbal order was obtained from the physician or APRN, it was to be entered and transcribed in the medical record as soon as possible and followed up by the nurse during her shift. She confirmed the chest x-ray order for resident #4 was not entered into the medical record and the resident did not receive the chest x-ray as ordered by the APRN. Review of the hospital medical records revealed on [DATE] resident #4 was admitted to the Intensive Care Unit and assessed by the physician to have acute hypoxemic respiratory failure due to pneumonia, sepsis due to pneumonia, suspect aspiration, recent fall with hip fracture and surgical repair, and anemia. Records documented the resident died on [DATE], 2 days after he was admitted . An interview was conducted with the Medical Director on [DATE] at 5:34 PM. He said he was aware of the missed x-ray and noted perhaps the resident would have been transferred to the hospital earlier. He conveyed that missing an x-ray was inexcusable. He said he reviewed the resident's medical record including the hospital records and explained the resident was admitted and treated for pneumonia. He noted the resident's condition declined and palliative measures were provided by the hospital. He was aware of the lack of monitoring for resident #4 and said it was his understanding that staff checked vital signs at least daily especially temperature for post operative residents. I ' m sure there is room for improvement in every situation. Review of the facility policy entitled, Verbal Orders, reviewed February 2023, read under Policy Explanation and Compliance Guidelines: #4. Write T.O. (telephone order) or V.O. (verbal order) including date, time, name of resident, the complete order, and sign the name of the physician or health care provider and nurse or sign off the electronic order as per the software guidelines. #6 Follow through with orders by making appropriate contact or notification (e.g. lab or pharmacy) Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] the facility conducted an Ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting. Root Cause Analysis performed re: chest x-ray not being completed. *On [DATE], the ordering process was reviewed with APRN and Medical Director during Ad hoc QAPI Committee Meeting. *On [DATE], the DON completed review of progress notes for diagnostic orders and physician orders for current residents for last 30 days to ensure diagnostic orders were transcribed and completed. No additional concerns were identified. *On [DATE], Licensed Nurse education initiated on Radiology Services and Reporting to include order transcription in electronic health record and placing orders with the radiology company. *On [DATE] to [DATE] Licensed Nurse education on Radiology Services and Reporting continued to include order transcription in electronic health record and placing orders with the radiology company continued and completed. Newly hired nurses will be educated during orientation. 1 remaining facility nurse will be educated prior to working. Agency nurses will be educated prior to accepting nursing assignment. *On [DATE], the DON educated additional provider on ordering process and follow up. 10 remaining providers will be educated prior to next consultation in facility. *Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. *From [DATE] to [DATE], interviews were conducted with 5 LPNs, 3 RNs, 2 therapists, the APRN. They verbalized understanding of the education provided. *The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to diagnostic tests not performed for residents #1, #2, #3, #5, and #6.

Based on observation, interview and record review, the facility failed to prevent a cognitively impaired, vulnerable resident from exiting the facility unsupervised, on two separate occasions, for 1 of 5 residents reviewed for elopement of a total sample of 6 residents at risk for elopement, (#1). While resident #1 was outside the facility, unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a motor vehicle. On 6/18/22 at approximately 5:30 PM, resident #1 pushed the facility's back fire exit door open and left the facility unsupervised. A few minutes later, Certified Nursing Assistants (CNAs) A and C heard the alarm, found the back door ajar, but failed to notify nurses or other staff of the alarm or check whether a resident had exited the building. Once outside, resident #1 crossed the facility's back parking lot and walked half mile along a moderately busy street and crossed a major 5 lane intersection. He was found by facility staff approximately 30 minutes later near a convenience store located on a major thoroughfare after another resident informed them of resident #1's elopement. During interviews with staff and family, it was discovered the resident had also eloped from the facility a month before, on 5/09/22 at 10:00 PM. He had exited the unlocked front door of the facility, unsupervised while it was open for emergency transport services and proceeded onto the street in front of the facility. He was found a few minutes later in the middle of the road in the dark after emergency services personnel alerted facility staff of the resident's exit. The facility's failure to provide adequate supervision, a safe, secure environment and the failure of staff to respond to door alarms contributed to resident #1's elopements and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy, which began on 5/09/22 and was removed on 7/12/22. Findings: Cross Reference F600, F607, F726, F842 Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, delusional disorders, depression and hypertension. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 2/07/22 revealed resident #1 had an admitting diagnosis of dementia, was alert, but disoriented and could follow simple instructions. The form indicated resident #1 was able to ambulate independently and noted he was an elopement risk. An initial admission Skilled Evaluation dated 2/09/22 noted the resident was alert and oriented to person and place, and able to make needs known. Resident is exit-seeking and is currently on one-on-one care. An Elopement Evaluation dated on admission 2/09/22, incorrectly indicated resident #1 was dependent for activities of daily living (ADLs) or could not move without assistance. The remaining questions of the evaluation were left incomplete, and his elopement risk was not scored. Review of the medical record revealed a Social Service Admission assessment dated [DATE] that revealed resident #1 had Behavior Problems of wandering and was unhappy with nursing home placement and the absence of contact with family/friends. The evaluation summary indicated resident #1 had periods of confusion and forgetfulness. He was Cooperative to some degree but wanders through the facility. Social service staff documented, A [electronic wander monitoring bracelet] has been placed on him for his safety, and concluded, Resident remains appropriate for 24-hour long-term care here, due to the level of care required that family was unable to provide. A physician progress note dated 2/10/22 revealed resident #1 had a history of paranoia and delusions with a decline in memory and decrease in his ability to perform activities of daily living (ADLs) recently. The assessment and plan section of the note revealed the provider's main concern, Appears to be his safety in light of his dementia, recent [CONDITION(S)] requiring Baker Act (involuntary psychiatric examination of an individual through involuntary or emergency commitment) management through [previous facility] and exit-seeking behavior. The note also revealed, Exit seeking, nursing/Social Services/administration considering transferring to a locked facility. The provider recommended a psych consult and reconciled his medications. Review of a skilled nurse progress note dated 2/10/22 revealed resident #1 was, exit seeking, wanderguard placed on ankle. A psychiatry evaluation note dated 2/11/22 revealed resident #1 had poor interpersonal skills, disorganized thought processes, poor insight and judgement, and an impaired knowledge. The note indicated the consult was requested for the resident's increased confusion in the evening and night and exit seeking behaviors. The evaluation note indicated resident #1 was alert, but confused, He is adamant he wants to go home. Quite paranoid that something bad is going to happen to him at the facility. The psychiatrist noted resident #1 was unstable with, Symptoms occurring almost daily and causing severe distress. Resident #1 had a care plan initiated on 2/10/22, for risk for elopement/active exit seeking and aimless wandering due to cognition, with potential to approach exit doors. The goal was resident #1 would not leave the facility unattended. Interventions initiated on 2/10/22 included approach resident in calm manner, check placement of wander monitoring device every shift, monitor resident for tailgating when visitors were in the building, reassure resident when distressed over placement, and use audible monitoring system to alert staff of exit seeking behaviors. Additional interventions included staff to use diversion activities when exit seeking behaviors occurred, and use of verbal cues and gestures for redirection to persuade from exit-seeking behaviors. No other revisions or additional interventions were made to resident #1's care plan until after his second elopement on 6/18/22. An additional care plan for fall risk and fall related injury due to decreased safety awareness, potential side effects of medications and history of wandering. No revisions or additional interventions were made after the initial care plan was initiated on 2/10/22. Review of the medical record revealed resident #1 had a physician's order for an electronic wander monitoring bracelet to his left leg, check function every shift which started on 3/29/22. Resident #1 had additional physician orders for blood pressure medications once a day, [MEDICATION(S)] 10 milligrams (mg) for dementia, [MEDICATION(S)] 5 mg once a day for anxiety, [MEDICATION(S)] extended release (ER) 125 mg for mood disorder, Laical 200 mg for mood disorder, [MEDICATION(S)] 1 mg at bedtime for anxiety, [MEDICATION(S)] ER 50 mg once a day for depression and [MEDICATION(S)] 2 mg every 8 hours for [CONDITION(S)]. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months February 2022 to July 2022 revealed no documentation of function or placement checks of the electronic wander monitoring device until 3/29/22. A physician progress note dated 3/31/22 (in a late entry) revealed the assessment was requested by nursing staff due to resident #1's agitation, refusal to return to his room and requests of staff to open the door so he could leave. Per the note, resident #1 was confused about why he was at the facility and didn't understand why he couldn't leave. The note indicated resident #1 had cut off his electronic wander monitoring bracelet, and medication was ordered for agitation. Further review of the medical record revealed no documentation by nursing staff of resident #1 cutting off his electronic wander monitoring bracelet, nor any documentation of notification to the physician or the family about the incident. Review of psychiatry notes dated 5/04/22, 5/18/22, and 5/25/22 revealed resident #1 continued to have increased agitation and exit seeking behaviors that were worse in the afternoons and evenings. Review of a quarterly Elopement Evaluation dated 5/05/22 revealed resident #1 could follow instructions, was ambulatory, had medical diagnosis of dementia/cognitive impairment and had exit seeking behaviors in the past month (tailgating, packing belongings, and or actively exit seeking). The evaluation was scored at 12, High risk to wander. The Minimum Data Set Quarterly assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. The assessment indicated resident #1 had delusions and wandering behaviors daily. Section G of the assessment indicated resident #1 was able to transfer, walk and move on and off the unit with supervision only. Resident #1's most recent Elopement Evaluation dated 6/18/22 indicated resident #1 was alert, could follow instructions, was ambulatory, had medical diagnosis of dementia/cognitive impairment and had exit seeking behaviors in the past month (tailgating, packing belongings, and /or actively exit seeking). On 6/18/22 a change in condition evaluation summary was documented at 7:30 PM. The note indicated resident #1, a known elopement risk was observed outside of the facility and redirected back to the facility by staff. The document noted resident #1 was assessed by nursing staff, placed on one-to-one supervision and the physician and family were notified. The physician recommendation was increased supervision. The evaluation also indicated the condition of dementia and exit seeking behaviors stayed unchanged, had occurred before with the previous treatment of the resident placed on 15-minute checks for safety. In a telephone call on 7/10/22 at 12:00 PM, resident #1's daughter stated prior to his admission to the facility, he lived alone, but his dementia had worsened and sometimes he did not recognize his own home, family or possessions. She stated he would leave home, get lost, and she would have to go out and find him. She explained she filed a court order to hospitalize her father because he was unable to safely care for himself any longer. She recalled the facility put an electronic wander monitoring bracelet on her father shortly after he arrived at the facility but was later told by staff he had cut it off. The daughter remembered a phone call from staff informing her he had tried to leave the facility but was caught at the door. She then indicated a phone call from Registered Nurse (RN) K at approximately 10:30 PM in May, where he said, Your father got out again. She recounted the most recent phone call she received in June that her father had left the facility again. She reported the facility did not tell her that he was found a half mile away from the facility, alone, near a convenience store. She tearfully reflected, It was scary, that her father had left the facility and staff did not know where he was for 30 minutes or more. Review of the medical record revealed no documentation by nursing staff of resident #1 cutting off his electronic wander monitoring bracelet, specific incidents of resident #1 attempting to tailgate visitors or staff out the door, or his actual elopement from the facility in the evening in May 2022. Review of the facility incident reports from March of 2022 to July 2022 revealed only the elopement of resident #1 on 6/18/22 recorded. Review of the facility's Reportable Event Tracking log from March 2022 to July 2022 revealed the only elopement incident reported was on 6/18/22. On 7/10/22 at 3:10 PM, CNA I said, I was part of the one that happened one night in May. He recalled he had worked the evening shift that night on the South unit when he was told by emergency transportation personnel that a man, possibly a resident went out the front door. CNA I recalled he ran outside and found resident #1 was about a half block away. He said the resident was In the street, headed north. He stated he was in the dark, close to the ditch that ran along the road and explained if resident #1 had fallen into the ditch no one would have known he was there. He recalled Licensed Practical Nurse (LPN) M ran outside shortly afterwards and attempted to help him coax resident #1 back inside the building. He noted the resident did not want to come back inside, was resistant, and he had to actually guide him back into the safety of the building. He stated he thought Registered Nurse (RN) K notified the Director of Nursing (DON), the physician and the family and he recalled resident #1 was placed on 15- minute checks. On 7/10/22 at 5:00 PM, resident #1's likely May 2022 elopement route was retraced with CNA I. The resident would have walked from the front of the building, down the driveway to the moderately trafficked two-lane road. CNA I demonstrated the spot in the middle of the road where he reached resident #1 that night. The two lane road had no sidewalks and a large ditch approximately 6-8 feet deep which ran the length of the road towards the northwest side. To the right of the facility was a busy intersection with a traffic light. In interviews on 7/10/22 at 2:42 PM and 7/11/22 at 11:05 AM, RN K stated resident #1 was frequently confused and obviously did not want to be here. RN K stated, Everyone knew he wanted to get out. He described resident #1 lingering near the front door, wanting to walk in the back hallway, and standing near his medication cart asking questions like, Are we on the ship now?, How long do we have to be here? and, What room am I in? RN K recalled resident #1 would sometimes have 15-minute safety checks for his exit-seeking behaviors. RN K recalled one night in May, he was notified by a CNA that resident #1 had, gotten out. He explained when he reached the lobby, resident #1 was back inside the building with LPN M. RN K recalled resident #1 had on an electronic wander monitoring bracelet but it did not alarm when he exited the building. He stated when he notified the Director of Nursing (DON) she directed him and LPN E to cut a wander alarm device off another resident and used it to test the door alarm. He described LPN E taking the monitoring bracelet and walking out the front door, but it did not alarm. RN K recalled someone was at the facility the next day to repair the system. He stated the DON also directed him to call resident #1's family and the physician to notify them of the incident. Review of resident #1's medical record revealed a, Resident Safety Check Sheet dated 5/09/22-5/11/22 for 15-minute safety checks starting at 10:00 PM on 5/09/22. On 7/11/22 at 10:30 AM, LPN M stated she had worked on the south unit one night in May when the emergency transport personnel entered the facility and asked if, That guy was supposed to be out there? She stated she was calm at first, but then rushed outside and called out for help. She stated she asked resident #1 to come back inside and he told her no, he was leaving. She noted he had dementia and was a resident, Who tried to get out. She stated the alarm did not activate and the next day a vendor came to repair the system. She remembered doing elopement drills and education after this elopement incident and said, Everybody was talking about the incident the next day, so I am surprised that management did not know. On 7/10/22 at 1:18 PM, in an interview with the DON and Administrator, the DON stated she did not know resident #1 had eloped from the facility in May and was only aware he had tried to tailgate someone through the front door, which she, Heard through the grapevine. The DON acknowledged if incidents were not documented, she could not be sure when the incident happened. The DON confirmed the interventions were put in place when resident #1 was first admitted but not again until 6/18/22 after his elopement. She explained on 6/23/22 the care plan was updated for use of plastic utensils to prevent him from cutting off his electronic wander monitor. The DON confirmed that elopement attempts should trigger a care plan revision and explained the physician should be notified of any incidents and the care plan updated with appropriate interventions. She verified there was no documentation in resident #1's record for an elopement during the month of May. She confirmed the Interdisciplinary Team (IDT) did not discuss resident #1's elopement and no care plan revisions were made to prevent him from leaving the building unescorted again. The DON stated the procedure was for nurses to notify the physician, do a head-to-toe assessment of the resident, and perform a head count of residents in the building. She confirmed she was not aware resident #1 had cut off his electronic wander monitoring bracelet at some point in March until after the June elopement and acknowledged there was no documentation by staff of that incident, or any new interventions put into place until his most recent elopement on 6/18/22. She noted resident #1 was put on 15-minute safety checks in May but stated she did not know why they were done. The DON and Administrator stated they were surprised and stated they were not aware that resident #1 had exited the building at night, before the most recent elopement on 6/18/22. On 7/11/22 at 1:13 PM, the Maintenance Director stated he checked the doors daily on weekdays to ensure they shut properly, alarmed properly and the code was functioning. He stated the front door of the building was the only door that had the electronic wander monitoring system alarm and it was supposed to sound if the door was open and the device passed through the door. He stated if there was a problem with the door that he could not fix, he would call the door repair company. He stated to his knowledge there were no problems this year with the electronic wander monitoring system for the front door, and no other staff had notified him of any problems with the monitoring system, the doors or the alarms. In a telephone interview on 7/11/22 at 2:40 PM, the Chief Operating Officer for the door repair company stated the company came to the facility on [DATE] for a service call in which repairs were made to the front door and the electronic monitoring system was repaired. He stated the company came out for another service call on 6/20/22 and he provided invoices for the visits. On 7/11/22 at 1:40 PM, the DON again stated she did not recall the staff calling her about resident #1 leaving the building at night in May, nor did she recall asking staff to cut a monitoring device off another resident to check the electronic wander monitoring system at the front door. On 7/11/22 at 3:40 PM, the Maintenance Director again confirmed the only repairs or service done on the doors, locks or electronic wander monitoring system was on 6/03/22 to repair hinges that needed to be replaced on the front door and again on 6/20/22 after resident #1's 6/18/22 elopement to ensure the proper function of the doors and alarms. He stated the only reason he would call a door repair vendor to come out was if he identified a problem he couldn't fix or if a resident eloped it was procedure to have them come out and check on the door and alarm function. He denied any vendors came out to the facility to work on the doors or alarms in May of 2022. The Maintenance Director was shown the invoice dated 5/10/22 as work done that day on the facility's front door, electronic wander monitoring system and alarms. He stated he did not recall the vendor coming to the facility or any of the work that had been done. A few minutes later, he recalled receptionist N had told him to call the door company for the repairs. At approximately 4:15 PM on 7/11/22, receptionist N stated she did not tell the Maintenance Director there was a problem with the door, nor did she tell him to call the vendor to come for the repairs on 5/10/22. The Maintenance Director then recalled he had called the vendor to work on the door on 5/10/22, and stated an, Unknown person told him to make the call. On 7/11/22 at 4:45 PM, the DON along with the Regional Nurse and Administrator stated she was not aware why resident #1 had been placed on 15-minute safety checks the night of 5/09/22. They denied knowledge of resident #1 having eloped from the facility on the night of 5/09/22 or any other time beyond the reported elopement on 6/18/22. On 7/12/22 at approximately 10:25 AM, the Regional Nurse stated she had performed an investigation overnight and had determined resident #1 had in fact eloped from the facility on 5/09/22. A few minutes later at approximately 10:35 AM, the DON stated she now remembered she received a phone call on the evening of 5/09/22 from RN K about the incident and stated she felt it was a, Near miss. The DON stated she instructed RN K to initiate 15-minute safety checks on resident #1, and to check the electronic wander monitoring system by cutting a device from another resident to see if the alarm worked that night. She stated she called the Administrator, and she confirmed the vendor was called to inspect and repair the door the next day. The DON confirmed she did not initiate an investigation, nor did she get statements from the staff involved. She also acknowledged the incident was not discussed at morning meetings, nor were any new interventions put into place to prevent future elopements. Review of the medical record revealed an e-Interact Change in Condition Evaluation dated 6/18/22 at 7:30 PM. The document indicated resident #1 left the facility at night Without a leave of absence order. The evaluation showed, Resident had diagnoses of dementia and has exit seeking behaviors. The question, Treatment for last episode indicated he was placed on 15-minute safety checks previously. The summary revealed resident #1 was an elopement risk and was Observed outside of the facility. It continued that staff redirected resident #1 back in to the facility where he was assessed, and the physician and the family were notified. The recommendation of the physician was for Increased supervision, and resident #1 was placed on 1:1 supervision. In an interview on 7/09/22 at 4:01 PM, and review of her witness statement dated 6/18/22, CNA B stated she was assigned to resident #1 on 6/18/22, the evening he eloped from the facility. She stated she was on her break between 6:00 and 6:30 PM when she left in her car from the back parking lot of the facility. She explained she drove to a convenience store approximately half mile away from the facility. She stated she was on her way back from the store when she saw a man wearing jeans, a shirt and a blue hat walking on the sidewalk near the store and thought he looked familiar. She explained she called CNA N at 6:51 PM and asked her to check on resident #7. CNA N told her resident #7 was in his room so CNA B hung up and continued on her way back to the facility. She recalled as she approached the intersection closest to the facility, she saw LPN E and CNAs H and G on the corner then realized the man that looked familiar was resident #1. She stated she stopped and told the other staff she had seen resident #1 near the store and turned her car around to find him. When she reached resident #1 walking on the sidewalk, she pulled into the parking and asked him, Hey do you need a ride? She stated resident #1 did not recognize her, but said yes and walked towards her car. She asked him where he was going and he said, Cocoa, Florida. She explained he got into the back seat and on the way back to the facility he told her she was going the wrong way. She recalled she told him there was a roadblock so she had to use a different route so he wouldn't be upset. She pulled into the facility driveway and waited for the other staff to arrive. Resident #1's likely elopement route was retraced with CNA B on 7/09/22 at approximately 4:15 PM. From the back door of the facility, resident #1 would have walked down the sidewalk leading from the door to the back parking lot. Beyond the back parking lot was a heavily wooded field, which was partially bordered by a broken chain link fence. Resident #1 most likely proceeded toward the front of the building and turned right when he reached the end of the facility's driveway. The moderately busy two-lane road in front of the facility did not have sidewalks so resident #1 would have headed south toward the intersection through the uneven grassy area on the side. The 5-lane intersection had no pedestrian crosswalk or pedestrian light on the north-west side where resident #1 crossed alone. On his route, he would have encountered hazards such as uneven sidewalks, a large, unfenced retention pond, and crossed 6 driveways including the entrance to a large apartment complex. He walked approximately 0.5 miles until he was stopped by CNA B close to the convenience store on the corner of a major thoroughfare. Review of resident #6's witness statement dated 6/18/22 revealed, It was after dinner around 5:30 PM, when he was on the side of the building and encountered resident #1 outside. He told resident #1 he had to have a doctor's permit to leave the facility, then resident #1 quickly walked away. Resident #6 stated he went to the back door of the building and notified LPN E that resident #1 had walked away from the facility. On 7/09/22 at 7:35 PM, agency CNA A stated she usually worked the evening shift on the south unit but was familiar with resident #1. She recalled he was an elopement risk and often wandered the hallways, checking the doors, telling staff he wanted to leave or go outside. She then recalled on the evening of 6/18/22 she was picking up dinner trays on the south hall when she heard the door pad alarm alerting. She stated she checked the nearest door by the activities room, then walked around the corner and saw CNA C. She stated they saw the door by the dining room was alarming and the door was not shut all the way. She recalled CNA C looked outside and did not see anyone, so he turned off the alarm and she went back to picking up the trays. She stated she knew the procedure for a door alarming was to go outside and look around, then close the door, turn off the alarm, and notify a nurse or supervisor so they could initiate a search or head count to determine if a resident was missing. She did not explain why she did not follow procedure for a door alarming that evening. On 7/09/22 at 6:54 PM, agency CNA C stated resident #1 was known to wander around the doors and the courtyard, and the staff would have to re-direct him, sometimes by offering him coffee. He stated the evening shift was often busy with confused residents and recalled the evening of 6/18/22 he had a heavy assignment on the south unit. He stated after dinner he was coming out of a resident's room on the back hallway when he saw CNA A. He stated they went to check the door by the dining room as it was alarming and the door slightly ajar. He stated he looked outside and didn't see anyone so he asked CNA A for the code and turned the alarm off. He recalled after that he went back to his rounds with his residents and about a half hour later he heard from another staff that resident #1 had eloped from the building. In a telephone interview on 7/09/22 at 7:17 PM, and review of her witness statement dated 6/18/22, agency LPN F stated resident #1 was assigned to her the evening of 6/18/22. She recalled resident #1 was calm but was exit seeking at times. She stated he had memory problems and was not safe to walk around outside by himself. She recalled she had seen resident #1 in his room that night eating dinner, but then she was busy with other residents, so she did not know he had eloped from the facility, or the door had alarmed until the DON called her later. She stated if the door alarmed, the CNA was supposed to notify the nurse right away. Resident #1's 6/18/22 elopement investigation was reviewed with the DON and the Administrator on 7/09/22 at 5:20 PM. The DON stated she was notified just before 7:00 PM on 6/18/22 that resident #1 had left the building and a few minutes later they called back to notify her they had found him. The Administrator stated she arrived at the facility first and started the investigation, by interviewing staff and checking the doors to the facility. She stated she had found no problems with the doors. The DON stated she had staff place resident #1 on 1:1 supervision. The staff's statements were reviewed, and the DON confirmed the protocol for staff if door alarm sounded, or if the door was found open was for staff to go outside to check if a resident had exited. Next they would close the door, turn off the alarm and notify an nurse or supervisor so that a head count could be done to determine if a resident was missing. The DON confirmed neither CNA A nor CNA C notified a nurse or supervisor of the open door or the alarm on 6/18/22 per facility protocol. The DON stated their investigation found the root cause of the elopement was due to the facility not being a secure facility. She confirmed resident #1 was at risk for wandering, known to tailgate and wore an electronic wander monitor bracelet. On 7/11/22 at 9:05 AM, resident #1 was in his room with his 1:1 staff sitter. He did not recall leaving the facility at any time, but was able to recall the names of his daughters and was alert and oriented to self. On 7/10/22 at 6:55 PM, the Administrator and DON stated they had started an investigation of resident #1's May elopement. The DON confirmed that appropriate, personalized interventions should have been put into place after the previous incidents. She confirmed that not having interventions such as increased safety monitoring or 1:1 monitoring after resident #1's increased exit-seeking behaviors directly contributed to the most recent elopement in June. The undated document, Facility Assessment revealed diseases, conditions or cognitive disabilities the facility provided care for included impaired cognition and dementia with behaviors. The document further indicated staff were trained on facility responsibilities, abuse and neglect, dementia management, caring for the cognitively impaired, and policies and procedures, consistent with their roles. Review of the policy, Elopements and Wandering Residents revised on 4/09/21 revealed the policy that the facility ensured residents who exhibit wandering behavior or are at risk for elopement receive adequate supervision and care in accordance with their person-centered care plan to address the unique factors that contribute to their wandering or elopement risk. The document revealed, Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The document further indicated person-centered care plans that recognized individual risks should be developed and the effectiveness of interventions should be evaluated, and changes made as needed. The policy also described the guideline that adequate supervision would be provided to help minimize the risk of elopement. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 6/18/22, resident #1 was returned to the facility, RN completed assessment- no injuries. Wanderguard function and placement checked-ok. Resident placed on one to one (1:1) supervision. Head count of all residents in facility performed and all residents present. * On 6/18/22 resident #1 re-evaluated for elopement risk. Resident demographics confirmed in elopement risk binders. Care plan reviewed and updated. * On 6/18/22 all resident with Wanderguards function verified. * On 6/18/22 facility egress doors checked for alarm/functioning with no issues identified. Screeched checked and verified as functioning. * On 6/18/22 staff education on Abuse/Neglect/Exploitation (A/N/E) policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering and exiting facility through designated doors. Post-test given to [NAME][TRUNCATED]

Based on observation, interview and record review, the facility neglected to investigate and address the resident's exit seeking behaviors and failed to implement preventative measures after an actual elopement to prevent further elopements for 1 of 5 residents reviewed for elopement of a total sample of 6 residents at risk for elopement, (#1). On 6/18/22 at approximately 5:30 PM, resident #1 pushed the facility's back fire exit door open and left the facility unsupervised. A few minutes later, Certified Nursing Assistants (CNAs) A and C heard the alarm, found the back door ajar, but failed to notify nurses or other staff of the alarm or check whether a resident may have exited the building. Once outside, resident #1 crossed the facility's back parking lot and walked half mile along a moderately busy street and crossed a major 5 lane intersection. He was found by facility staff approximately 30 minutes later near a convenience store located on a major thoroughfare. During interviews with staff and family, it was discovered the resident had also eloped from the facility a month before, on 5/09/22 at 10:00 PM. He had exited the unlocked front door of the facility, unsupervised while it was open for emergency services and proceeded onto the street in front of the facility. He was found a few minutes later in the middle of the road in the dark after emergency services personnel alerted facility staff. The Director of Nursing and the Administrator denied knowledge of resident #1's elopement from the facility on the night of 5/09/22. The facility's failure to recognize the extent of the resident's wandering behaviors and address escalating incidents of exit seeking placed all residents who wandered at risk for serious injury /impairment/death. This failure resulted in Immediate Jeopardy, which began on 5/09/22 and was removed on 7/12/22. Findings: Cross Reference F607 and F689 Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 2/07/22 revealed resident #1 was hospitalized for dementia, was alert, but disoriented and could follow simple instructions. The form indicated resident #1 was able to ambulate independently without assistance from a device and was an elopement risk. The Minimum Data Set Quarterly assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. The assessment indicated resident #1 had delusions and wandering behaviors daily. Section G of the assessment indicated resident #1 was able to transfer, walk, and move on and off the unit with supervision only. Review of the elopement assessment at admitted d 2/09/22 inaccurately indicated resident #1 was dependent for activities of daily living or could not move without assistance. The remaining questions of the evaluation were left incomplete and there was no score given for his elopement risk. No revision or further assessment was documented for elopement risk until 5/03/22. On 7/10/22 at 2:00 PM, the Director of Nursing (DON) acknowledged resident #1's admission elopement assessment was incorrect and incomplete. She said it, was an issue, the nurse didn't use the information from the hospital discharge paperwork to fill out the admission elopement assessment. She indicated the elopement assessment accuracy was identified as an issue after resident #1's elopement on 6/18/22. Review of the medical record revealed a Social Service Admission assessment dated [DATE] which indicated the resident was alert, had short and long-term memory loss, moderately impaired decision making and usually understood others. The document revealed resident #1 had behavior problems of wandering, was unhappy with nursing home placement and an electronic wander monitoring bracelet was placed on him for safety. Although documentation by Social Service Staff on the admission assessment indicated resident #1 had an electronic wander monitoring bracelet placed on him, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan for risk for elopement, active exit seeking and aimless wandering dated 2/10/22 noted potential to approach exit doors. The goal included resident would not leave the facility unattended. Interventions included staff to check placement of electronic wander monitoring system bracelet every shift, monitor resident for tailgating when visitors were in the building, and use audible monitoring system to alert staff of exit seeking behaviors. Additional interventions included staff to use diversional activities when exit seeking behaviors occurred. Review of the medical record showed the resident was seen by psychiatry 2 days post admission for increased confusion in the evenings and exit seeking behaviors. The psychiatry evaluation dated 2/11/22 noted the resident had poor disorganized thought processes, poor insight and judgement, and impaired knowledge. The evaluation read, He is adamant he wants to go home. Quite paranoid that something bad is going to happen to him at the facility. Symptoms occurring almost daily and causing severe distress. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated resident #1 was confused why he was at the facility, and had cut off his electronic wander monitoring bracelet. There was no documentation by nursing staff of resident #1 cutting off his electronic wander monitoring bracelet, nor any documentation of notification to the physician or the family about the incident. The care plan did not include any interventions for this incident until after resident #1's second elopement on 6/23/22. In a telephone interview on 7/10/22 at 12:00 PM, resident #1's daughter stated he was at the facility due to dementia and wandering behaviors. She recalled the facility applied electronic wander monitoring bracelet on her father shortly after he arrived but was later told by staff, he had cut it off. The daughter remembered some time ago, staff had telephoned to inform he had tried to leave the facility but was caught at the door by staff. She recalled another instance when Registered Nurse (RN) K called her at approximately 10:30 PM in May and said, Your father got out again. She then recounted the most recent phone call she received in June that her father had eloped from the facility again. Resident #1's daughter stated the facility did not tell her he was found a half mile away. She tearfully said, It was scary, that her father had left the facility and the staff did not know where he was for 30 minutes or more. In an interview on 7/10/22 at 1:18 PM, the Director of Nursing (DON) said, I was not aware that he cut the [electronic wander monitoring bracelet] off in March. I was made aware or found out in June, and that's when we updated the care plan. The DON was unable to explain why cutting off the device was not reported to her or listed on the incident log. She stated she could not recall how she found out about the removal of the wander monitoring device. Review of psychiatry notes dated 5/4/22, 5/18/22, and 5/25/22 revealed resident #1 had continued increased agitation and exit seeking behaviors per staff that were worse in the afternoons and evenings. Review of the facility incident reports from March of 2022 to July 2022 revealed no documentation of incidents involving resident #1 except the elopement reported on 6/18/22. Review of the facility's Reportable Event Tracking log from March 2022 to July 2022 revealed no documentation of an event involving resident #1 other than the elopement incident reported on 6/18/22. On 7/10/22 at 3:10 PM, CNA I described the night in May when he found resident #1 walking in the middle of the road at night by a deep drainage ditch near the facility. He stated he was told by emergency personnel who were entering the facility that a resident may have exited the building. He said he thought RN K notified the DON, the physician and family of the resident's exit from the facility. He recalled resident #1 was placed on 15- minute safety checks when he was brought back. In interviews on 7/10/22 at 2:42 PM and on 7/11/22 at 11:05 PM, RN K stated, Everyone knew the resident wanted to get out. He described resident #1's exit seeking behaviors that included wandering the back hallway and lingering near the front door. RN K recalled he was the assigned nurse on the night in May when resident #1 got outside unsupervised and was found in the middle of the road. He said once resident #1 was back inside the facility, he performed a head-to-toe assessment and placed a call to notify the DON. He noted the DON instructed him to call the physician and the family to inform them of the incident. He remembered the DON also instructed him and Licensed Practical Nurse (LPN) E to test the electronic wander monitoring system at the front door as it did not alarm when resident #1 went out that night. He said he was instructed by the DON to take a wander alert device off another resident and take it out the door to test the alarm. He conveyed when they tested the door with the wander monitoring device, the alarm did not sound. On 7/11/22 at 10:30 AM, LPN M recalled the night in May she helped bring resident #1 back inside after he eloped from the facility. She remembered resident #1's electronic wander monitoring device did not activate the alarm at the front door when he left the building. She also recalled the next day a vendor came to the facility to repair the alarm and check the doors. She stated, Everybody was talking about the incident the next day, and she was surprised to hear management did not know about it. On 7/10/22 at 1:18 PM, the DON denied knowledge of the resident's elopement in May. The DON acknowledged if incidents were not documented by staff and only reported verbally, she could not be sure when the incident happened. She stated elopement attempts made by a resident should be documented and would warrant care plan revisions. She stated the protocol was for staff to complete a risk report, notify the physician and update the care plan to provide the best individualized care for the resident. She acknowledged the resident's elopement incident in May was not documented nor was the care plan revised until after the second elopement on 6/18/22. On 7/11/22 at 3:40 PM, the Maintenance Director was shown a service invoice dated 5/10/22 which was retrieved from the door repair/electronic wander system repair company. He acknowledged the invoice showed work was done on 5/10/22 to the facility's front door, electronic wander monitoring system and alarms. He stated he did not remember the vendor coming to the facility for any repair work to the door but a few minutes later he recalled he was instructed to call the repair company to service the door on 5/10/22. On 7/11/22 at 4:45 PM, the DON and the Administrator denied knowledge of resident #1's elopement from the facility on the night of 5/09/22. The DON stated she was not aware resident #1 had eloped from the facility in May 2022 and was only aware he was stopped by staff when he tried to tailgate someone through the front door. The DON stated she might have heard something about resident #1's attempt to leave the building through the grapevine. On 7/12/22 at approximately 10:25 AM, the Regional Nurse stated she investigated and determined resident #1 had eloped from the facility on 5/09/22. A few minutes later at approximately 10:35 AM, the DON said she now remembered she received a phone call on the evening of 5/09/22 from RN K about the incident. She stated she felt it was a near miss. The DON explained she did not initiate an investigation, nor did she get statements from the staff involved. She also acknowledged the incident was not discussed at daily meetings, nor were any interventions put into place to prevent future elopements. Review of the elopement incident of 6/18/22 revealed an e-Interact Change in Condition Evaluation dated 6/18/22 at 7:30 PM. The document indicated resident #1 left the facility at night unsupervised and was redirected back to the facility by staff. The document noted resident #1 had dementia and exit seeking behaviors. The Evaluation listed intervention for the was the resident was placed on 15 minute checks. The document indicated the physician and family were notified and the physician recommendation was for increased supervision. On 7/09/22 at 4:01 PM, CNA B recounted she saw resident #1 walking near the convenience store about a half mile away from the facility on 6/18/22 on her way back from the store on her break. She stated when she came back to the facility, she saw staff outside searching for the resident. She described turning her car around and driving back to the store. She said she pulled over and when she asked resident #1 if he needed a ride, he got in the back seat of the car. On 7/09/22 at 6:54 PM, agency CNA C stated resident #1 was known to be a wanderer and elopement risk to the staff. He stated resident #1 had to be frequently re-directed away from the doors and exits. He recalled on 6/18/22 as he came out of a resident's room, he saw CNA A checking the doors as she had heard an alarm. He stated they went to the door by the dining room which was not completely closed and the keypad was blinking and alarming. He recalled he looked outside and did not see anyone so he closed the door and turned off the alarm. He stated at that point, both he and CNA A went back to the unit. On 7/09/22 at 7:35 PM, agency CNA A recounted resident #1 was an elopement risk and often wandered the hallways, attempted to open doors and told staff he wanted to leave. She stated on 6/18/22 she was picking up trays on the south unit and heard an alarm. She checked the nearest door then proceeded around the corner to the back hallway where she encountered CNA C. They found the door by the dining room slightly ajar and alarming. She stated CNA C looked out the door, didn't see anyone so he closed the door, turned off the alarm and they went back to their duties. CNA A indicated the procedure if a door alarmed was to go outside, look around, then close the door, turn off the alarm and notify a nurse or supervisor so a head count could be done. She did not explain why she did not follow procedure that night and notify the nurse or supervisor. On 7/09/22 at 5:20 PM, the facility's elopement investigation was reviewed with the DON and Administrator. The DON reviewed the staff's statements and acknowledged the protocol was not followed by staff on 6/18/22 when they heard the door alarm. She stated staff should have checked outside, then closed the door, turn off the alarm and notify a nurse or supervisor so that a head count could be done to determine if a resident was missing. The DON stated their investigation concluded the root cause of the elopement was due to the facility not being a secure facility. She did not include staff not following the elopement protocol by searching outside and notifying supervisory staff as a contributing factor to the elopement. On 7/10/22 at 6:55 PM, the DON stated if they had known about the first elopement they could have added interventions to resident #1's care plan and placed him on one to one (1:1) supervision. She confirmed that not reviewing and revising interventions after the first elopement contributed to the second elopement. Review of the policy Abuse, Neglect and Exploitation dated November 2021, the document defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The document detailed the facility would establish policies and procedures to investigate any such allegations and would provide ongoing oversight and supervision of staff in order to assure policies were implemented as written. The document went on to describe the steps of the immediate investigation including written procedures, investigating different types of alleged violations, and identifying and interviewing all involved persons and others who might have knowledge of the allegations. The document instructed the investigation should focus on determining if abuse, neglect, exploitation and or mistreatment had occurred, the extent and cause, while providing complete and thorough documentation of the investigation. Review of immediate actions implemented by the facility revealed the following, which were verified by the survey team: o On 6/18/22 staff education on Abuse/Neglect/Exploitation (A/N/E) policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering/exiting facility through designated doors. Post-test given to validate education. o On 6/19/22 staff education on A/N/E policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering/exiting facility through designated doors. Post-test given to validate education. Licensed staff education conducted on completing Stop and Watch if change in condition is identified and staff breaks to ensure coverage when taking breaks. o On 6/20/22 staff education on A/N/E policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering/exiting facility through designated doors. Post-test given to validate education. o On 6/20/22 staff education on A/N/E policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering/exiting facility through designated doors. Post-test given to validate education. o On 6/21/22 staff education staff education completed on A/N/E policy with emphasis on neglect to include reporting requirements, elopement standards, and guidelines, 4-point action plan, 1:1 supervision, responding to door alarms and proper actions to take upon responding, and entering/exiting facility through designated doors. Post-test given to validate education. Completed 100% staff (54/54). o On 6/22/22 Interdisciplinary Team (IDT) reviewed/revised elopement risk care plans for residents currently identified at risk for elopement. Interventions revised based on resident's individualized needs. o Monthly Quality Assurance and Performance Improvement (QAPI) meeting-reported quality review findings. No changes recommended based on reviews. o On 7/11/22 incident report filed regarding: 5/09/22 elopement of resident #1. o On 7/11/22 ad hoc QAPI committee meeting to review/revise Performance Improvement Plan (PIP) related to elopement based on new findings. IDT care plan reviews for residents currently at risk for elopement with focus on level of supervision and behavior monitoring r/t active exit seeking behaviors each shift. o On 7/11/22 Director of Clinical Services educated Department Managers to include Administrator and DON on facility Incidents and Accidents policy. Post-test completed to validate education. Licensed nurse education initiated and completed 100% (22/22) on Incidents and Accidents policy to include reporting. Posttests completed to validate education. Agency nurses will be educated prior to beginning each shift. Review of in-service with post-tests and reconciliation with staff roster validated education was completed according to the facility's plan. o From 7/09/22 to 7/12/22 interviews conducted with staff representing all shifts including 3 RNs, 5 LPNs, 15 CNAs, 1 Occupational Therapist and 2 housekeeping staff revealed staff participated in elopement drills, A/N/E education, 1:1 observation, door alarm procedures, stop and watch tool, coverage for breaks, where to enter and exit the facility, change in condition monitoring, and incident and accident reporting, as well as the facility's elopement standards and guidelines. All staff were able to verbalize knowledge and understanding of the education provided after the IJ. The sample was expanded to include 5 additional residents at risk for wandering, and elopement. Observations, interviews and record reviews revealed residents #2, #3, #4, and #5 residents had elopement risk assessments, appropriate care plans, and demographic information placed in the elopement binders.

Based on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to implement elopement prevention and neglect prohibition procedures, and meet individualized care needs to maintain the highest practicable level of wellbeing for 1 of 5 residents reviewed for elopement risk, of a total sample of six residents, (#1). Findings: Cross Reference F600 and F689 Review of resident #1's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 2/08/22 revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the resident ambulated independently and had a risk alert for elopement. Review of a facility incident investigation revealed on 6/18/22, resident #1 exited the building unnoticed by staff and was found approximately 0.5 miles away before staff realized he was missing. Review of the facility's policy and procedure for Elopements and Wandering Residents revised 4/09/21 read, Procedure for Locating Missing Resident: A. Any staff member becoming aware of a missing resident will alert supervisor using approved protocol. B. Facility designated and approved Internal Alert Code will be announced 3 times over the facility intercom. C. The designated facility staff will look for the resident. On 7/09/22 at 4:39 PM, Licensed Practical Nurse (LPN) E recalled on 6/18/22 she was at her medication cart when she heard someone yell her name and bang on the door. She stated resident #6 was outside the door and yelled, He got out! The pastor got out and he is up the street. LPN E stated she did not hear an alarm to indicate an exit door had been breached and she did not use the facility's intercom system to announce Code Green to alert all staff about the missing resident. LPN E said, I did not call a Code Green because he was already out, and I knew who he was. On 7/09/22 at 7:17 PM, LPN F stated she was the nurse assigned to resident #1 on 6/18/22. She said, I had no idea the resident was out of the building. LPN F explained if an exit door alarm sounded, staff were to go outside and check the surrounding area. She stated if no one was observed, staff should conduct a head count to verify no residents were missing. LPN F said, If [staff] hears an alarm and does not see anyone then they should tell the nurse right away. On 7/09/22 at 7:35 PM, Certified Nursing Assistant (CNA) A stated on 6/18/22 between approximately 6:00 PM and 6:30 PM, she heard an exit door alarm while she was picking up dinner trays. She stated she walked towards the door that was alarming and met up with CNA C who came from the opposite direction. CNA A stated they both looked through the glass door and did not see anyone in the vicinity. She recalled the door was ajar and CNA C pulled it closed and then turned off the alarm. CNA A stated she went back to her assigned hallway to finish picking up the dinner trays. CNA A confirmed neither she nor CNA C informed anyone that the door had been alarming. She stated they did not know anyone was missing and only told the nurse about the open door after she was informed a resident went missing and had been returned. CNA A stated the nurse did not call a Code Green because they were in a hurry to retrieve the resident. On 7/09/22 at 6:54 PM, CNA C stated on 6/18/22 he heard an exit door alarm. He recalled as he walked towards the door where CNA A stood, he saw a blinking light on the keypad which indicated the door was not closed. He stated he looked outside and did not see anyone. CNA C said, I did not go outside. He explained he pulled the door shut and entered the code on the keypad to silence the alarm. CNA C acknowledged he and CNA A left the area and continued their duties without informing anyone of the unlocked door and alarm. He stated about 30 minutes later he overheard someone say one of the residents left the building. On 7/10/22 at 2:42 PM, in a telephone interview, Registered Nurse (RN) K recalled an incident in May 2022 when resident #1 managed to exit the facility at about 10:00 PM. RN K recalled a staff member informed him one of his assigned residents was found outside in the street, but by the time he got to the front lobby the resident had been returned to the facility and no one called a Code Green. RN K stated he informed either the Director of Nursing (DON) or the Unit Manager and the resident's family about the incident. He said, Being a new nurse, I am not aware of everything to be done by the book. I am sure I asked the other nurses what to do. I did not know what specific document was needed. I did not write a nursing note about the incident. I do not know all the protocols. I feel like I was not properly trained. I am leaving the company because I don't feel it is safe to work this way. RN K stated since the resident's most recent elopement in June 2022, he participated in elopement drills but still had not received education on how to properly document elopement incidents. On 7/11/22 at 11:06 AM, RN K explained he was a new nurse, and the facility hired him in February 2022 as his first job. RN K said, Orientation was one day of handbook stuff and then shadowing a nurse for five days while doing medication administration and other things like treatments. I did not observe any administrative stuff. RN K explained he was never trained on how to check if a resident's electronic monitoring device worked and still did not know how to do it. He said, There were times when admissions were coming in and I did not know what to do. Nobody taught me. I thought it would happen before I got to the floor. RN K added he usually worked alongside nurses from staffing agencies and relied on their guidance although they were not fully knowledgeable of all the facility's policies and procedures. On 7/11/22 at 3:15 PM, LPN P stated she had been on staff for about four weeks. She explained her orientation consisted of a little over an hour of classroom training and then she followed a nurse on the floor for three shifts. She explained she had to mostly teach herself how to document on the computer. LPN P said, If a resident would elope, the important thing is to get him back in the building and assess him. On 7/11/22 at 12:06 PM, the DON stated the previous Staff Development Coordinator (SDC) was responsible for RN K's education. She acknowledged newly hired staff received 30 minutes of general education including the topics Abuse/Neglect/Misappropriation, Elopement and Smoking. The DON stated there was a binder with information that agency nurses were expected to review before they started work. She explained agency staff signed a document to confirm they reviewed the binder but she could not confirm if the SDC validated agency staff comprehension of the material or made herself available to offer support or address questions and problems. The DON acknowledged RN K had a standard orientation although he was a new graduate with no experience. She said, There is no specific program or additional orientation for new graduate nurses. There is no special monitoring due to lack of clinical experience. On 7/12/22 at 3:12 PM, the DON reviewed the facility's Orientation Agenda and confirmed nurses should participate in two days of classroom orientation. The agenda indicated the first classroom day was from 9:00 AM to 4:00 PM and the second was from 9:00 AM to 3:00 PM. However, review of RN K's timecards revealed on 2/18/22 he received only 2.02 hours of classroom orientation. On 2/21/22, he received 2.3 hours of floor orientation, and from 2/22/22 to 2/25/22 he received four shifts of floor orientation. Review of LPN P 's timecard revealed she received only 1.8 hours of classroom orientation and three shifts of floor orientation. The DON confirmed timecards were accurate and said, Yes. That is the time they spent in orientation.

Based on interview and record review, the facility failed to ensure accuracy and completeness of the medical record related to an elopement incident for 1 of 5 residents reviewed for elopement risk, of a total sample of six residents, (#1). Findings: Cross Reference F600 and F689 Review of resident #1's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 2/08/22 revealed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document indicated the resident ambulated independently and had a risk alert for elopement. On 7/10/22 at 12:53 PM, in a telephone interview, resident #1's daughter stated her father managed to get out of the facility three times. She recalled the first time was when her father attempted to go through the front door, but staff were present and stopped him before he left. The daughter stated the second incident occurred at night and her father got to the road in front of the facility. She stated in the third and most recent incident, her father left the facility and was found by staff quite a distance away. Review of resident #1's electronic and paper medical records revealed no documentation of any attempts to exit through the front door that were prevented by staff. In addition, there was no documentation of an actual elopement that involved resident #1 exiting the facility at night and being retrieved from the middle of the street by staff. The resident's care plans were not updated to reflect revised approaches, and neither frontline nor administrative nursing staff initiated change of condition forms to record the incidents. Resident #1's admission Elopement Evaluation dated 2/09/22 did not reflect the risk alert for elopement as noted on the hospital transfer form. The document indicated the resident was not comatose but was dependent for activities of daily living or could not move without assistance. The remaining questions of the evaluation were left incomplete and there was no score given for his elopement risk. On 7/10/22 at 1:18 PM, the Director of Nursing (DON) reviewed resident #1's medical record and confirmed there was no documentation regarding attempted or actual elopements prior to an actual elopement in June 2022. She stated to her knowledge, resident #1 eloped from the facility once. She recalled she heard about an attempted elopement through the grapevine but staff were able to prevent the resident from exiting the facility. The DON explained resident #1 attempted to tailgate someone through the front doors. She stated her expectation was that the assigned nurse would document at least a progress note regarding that incident even if the resident did not get outside. She acknowledged the medical record should include documentation of notifications to the physician and family, and care plan revisions to reflect exit-seeking behaviors and elopement attempts. On 7/11/22 at 11:06 AM, Registered Nurse (RN) K recalled a night in May 2022 when resident #1 eloped from the facility and got out to the road. RN K confirmed he was the resident's assigned nurse, but he did not write document the elopement or complete change in condition documentation regarding the incident. On 7/11/22 at 10:30 AM, Licensed Practical Nurse (LPN) L recalled she responded to resident #1's elopement one night in May 2022 and assisted with returning him to the facility. LPN L acknowledged she would normally document an incident like that in the medical record and also provide management with a written statement but did not do so in this situation. She stated it was important for nurses to regularly document on residents' behaviors such as wandering, and also record incidents like elopements. On 7/11/22 at 3:15 PM, LPN Q stated resident #1 was confused but able to converse reasonably well and often verbalized the desire and intent to go home. LPN Q said, I did not document it when he said that, but sometimes it was so bad I remember having to call the family to calm him. Review of the facility's policy and procedure Documentation in Medical Record (undated) read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Review of the facility's policy titled, Incidents and Accidents dated 1/2022 included the requirements for documentation of elopement incidents. The policy read, Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions.

Based on observation, interview and record review, the facility failed to initiate and complete a thorough investigation of an elopement incident to rule out neglect and ensure the safety of 1 of 5 residents reviewed for elopement risk, of a total sample of 6 residents, (#1). Findings: Cross Referene F600 and F689 Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 2/07/22 revealed resident #1 was hospitalized for dementia. He was alert but disoriented and could follow simple instructions. The form indicated resident #1 was able to ambulate independently and noted a risk alert for elopement. Resident #1 had a care plan initiated on 2/10/22 for a risk for elopement/active exit seeking, aimless wandering due to cognition, and potential to approach exit doors. The goal was resident #1 would not leave the facility unattended. Interventions included check placement of electronic wander monitoring system bracelet every shift, monitor resident for tailgating when visitors were in the building, and use audible monitoring system to alert staff of exit seeking behaviors. Additional interventions directed staff to use diversional activities when exit seeking behaviors occurred. On 7/10/22 at 12:00 PM, in a telephone interview, resident #1's daughter confirmed the facility notified her on 6/18/22 that her father had eloped from the facility. She explained she had received calls from the facility in the past regarding other incidents including her father cutting off his electronic wander bracelet and attempting to follow someone out of the facility. She recounted a phone call she received in May 2022 from Registered Nurse (RN) K who informed her, Your father got out again. Resident #1's daughter was unable to remember the exact date of the call but recalled it was about 10:30 PM. Review of the facility's incident and Reportable Event Tracking logs from March to July 2022 revealed no entries related to resident #1 in May 2022. Only the elopement incident on 6/18/22 was recorded and reported on the logs. On 7/10/22 at 1:18 PM, in an interview with the Director of Nursing (DON) and Administrator, the DON stated she was not aware resident #1 had eloped from the facility in May 2022 and was only aware he was stopped by staff when he tried to tailgate someone through the front door. The DON stated she might have heard something about resident #1's attempt to leave the building through the grapevine. Review of resident #1's medical record with the DON revealed Resident Safety Check Sheet forms were initiated on 5/09/22 at 10:00 PM and continued through 5/11/22 for 15-minute safety checks. She acknowledged the resident had 15-minute safety checks initiated but she could not explain why this intervention was necessary. The DON and Administrator expressed surprise when informed the resident's daughter had been notified of a nighttime elopement incident in May 2022 by RN K. On 7/10/22 at 3:10 PM, Certified Nursing Assistant (CNA) I recalled he worked the evening shift on the South Unit when transportation company personnel who were in the facility to drop off a resident told him that someone, possibly a resident, just went out the front door. CNA I stated he ran outside immediately to find resident #1 in the street, headed north, about half block away from the facility. CNA I stated there was a deep ditch that ran parallel to the road, and it was so dark that no one would have known if the resident had stumbled into the ditch. He recalled Licensed Practical Nurse (LPN) M ran outside shortly afterwards and helped coax resident #1 back inside the building as he was resistant to return. CNA I stated to his knowledge, nurses made notification telephone calls to the DON, the physician, and the family. In interviews on 7/10/22 at 2:42 PM by telephone, and on 7/11/22 at 11:05 AM in person, RN K recalled the night in May when a CNA told him resident #1 had gotten out. He stated when LPN M and CNA I brought resident #1 back inside the building the resident still wore an electronic wander monitoring bracelet on his ankle, but the monitoring system alarm did not seem to work. RN K stated he notified the DON who directed LPN E to cut a wander alarm device off another resident and use it to test the door alarm. He stated LPN E took the monitoring bracelet, walked out the front door, and the alarm did not sound. RN K recalled seeing technicians working on the front lobby doors the next day. On 7/10/22 at 6:54 PM, the Administrator and DON were informed multiple staff described either being witnesses to an elopement incident in May or hearing about it afterwards. They reiterated they were not aware of any such incident. The Administrator stated based on the new information, the facility initiated an investigation. On 7/11/22 at 10:30 AM, LPN M confirmed she rushed outside when alerted by transportation personnel that a resident exited the facility. She stated the electronic wander monitor alarm did not sound during the incident even though resident #1 wore the monitoring device. She recalled the next day a vendor came to the facility and worked on the system. LPN M acknowledged she found it strange that she was never asked to write a statement or participate in an incident investigation. She said, Everybody was talking about the incident the next day, so I am surprised that management did not know. On 7/11/22 at 1:40 PM, the DON re-stated she did not recall any staff notification in May 2022 regarding resident #1 leaving the building. She denied directing a nurse to cut a monitoring bracelet off another resident to check the function of the electronic wander monitoring system. On 7/11/22 at 2:40 PM, in a telephone interview, the Chief Operating Officer for the facility's door repair company stated they responded to a service call from the facility on 5/10/22 and repaired the electronic monitoring system at the front lobby doors. However, in interviews on 7/11/22 at 1:13 PM and 3:40 PM, the Maintenance Director denied any repairs to the electronic wander monitoring system or to any door at the facility other than a repair to the hinges on the front doors on 6/03/22 and a service check on 6/20/22. The Maintenance Director was shown the door company's service invoice dated 5/10/22 for repair work to the front doors and the electronic monitoring system. He acknowledged the invoice was valid and the work listed on the document was done. The Maintenance Director then recalled he had contacted the vendor and requested service for doors and alarm system but was unable to recall who informed him about the malfunction of the doors or if a member of the administrative team directed him to make the service call. On 7/12/22 at approximately 10:25 AM, during a meeting with the Administrator, Regional Nurse and DON, the Regional Nurse stated she initiated an incident investigation the previous evening and determined resident #1 did in fact elope from the facility on 5/09/22 at approximately 10:00 PM. The DON stated as a result of the previous evening's discussions with the Regional Nurse, she recalled receiving a phone call on the evening of 5/09/22 from RN K regarding an incident she described as a near miss. The DON confirmed she was the person who instructed RN K to initiate 15-minute safety checks for resident #1 and check the function of electronic wander monitoring system at the front doors. The DON stated she notified the Administrator of the incident that night and confirmed the vendor was called to inspect and repair the front door alarm system the next day. The Administrator stated she was the facility's Risk Manager with responsibility for leading investigations and reporting findings as indicated. The Administrator validated she received notification of the incident from the DON, but also did not recall it until the previous evening's discussions with the Regional Nurse. The DON and Administrator acknowledged they did not initiate an incident investigation, nor obtain statements from the any staff involved to determine exactly what happened. The DON confirmed the incident was not discussed at interdisciplinary team meetings, and no new, appropriate interventions were put in place to prevent future elopements. The Regional Nurse confirmed the facility should have investigated the incident to determine the root cause, determine necessary actions, and adhere to reporting requirements. Review of the facility's policy, Incidents and Accidents dated January 2022, revealed staff would report, investigate, and review any accidents or incidents that occurred or allegedly occurred on facility property or if it may have involved a resident. An incident was defined as any situation that was not consistent with routine care or routine operation. The document indicated the purpose of the investigation and reporting was to ensure appropriate and immediate interventions were implemented to prevent recurrences and improve management of resident care. The guidelines indicated if an incident was witnessed by other people, the supervisor or designee would obtain statements of the event by those that witnessed it and submit that documentation. The facility's policy Abuse, Neglect and Exploitation dated November 2021, the document defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The document indicated the facility would establish and implement procedures to investigate any such allegations including identifying and interviewing all involved persons and others who might have knowledge of the allegations. The document revealed the investigation should focus on determining if neglect had occurred, the extent and cause, while providing complete and thorough documentation of the investigation.

Based on observation, interview and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 1 of 3 residents reviewed for pressure ulcers, of a total sample of 35 residents, (#48). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #48 was identified with 2 new facility acquired unstageable pressure ulcer/injury by the surveyor from 4/6-4/7/21. The resident had 1 unstageable pressure ulcer/injury to his left heel and 1 on left inner ankle. The facility failed to identify wounds at an early stage and failed to initiate timely treatment and preventive measures. Findings: The National Pressure Injury Advisory Panel (NPIAP) redefined the definition of a pressure injury (formerly pressure ulcer) in 2016. The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence . The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin . which may appear differently in darkly pigmented skin.Stage 2 Pressure Injury: Partial-thickness skin loss with .Stage 3 Pressure Injury: Full-thickness skin loss .Stage 4 Pressure Injury: Full-thickness skin and tissue loss . If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar .Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration intact or non-intact skin .Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure . (The National Pressure Injury Advisory Panel website at www.npiap.com accessed on 4/9/21). Resident # 48 was a [AGE] year-old African American male admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents' significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted he required limited to extensive assistance of 1 person with bed mobility, dressing, and personal hygiene. He was bed/chair bound, had indwelling urinary catheter and was always incontinent of bowel. He was at risk for developing pressure ulcers/injuries. He was admitted to facility with 1 stage 4 pressure ulcer, 1 stage 3 facility acquired pressure ulcer and 1 unstageable-deep tissue injury that was also not present upon admission/entry or re-entry. He had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The MDS assessment showed resident #48 did not .reject evaluation or care necessary to achieve the resident's goals for health and wellbeing . Review of resident #48's medical record revealed a care plan initiated on 12/3/20 and revised on 4/5/21 for actual skin breakdown related to stage 4 pressure ulcers to both hips. Interventions included pressure reducing mattress and wound care as ordered. The resident's Activities of Daily Living (ADL) self-care performance deficit plan was initiated on 12/4/20. Interventions were for 1 staff to provide extensive assistance with bathing/showering, turning and repositioning in bed. The care plan initiated on 11/24/20 for skin breakdown related to impaired mobility secondary to [CONDITION(S)] included interventions for nurses to complete weekly skin assessment, Certified Nursing Assistants (CNA) to monitor skin during bathing, especially over bony prominences, and report abnormalities to nurse, nursing staff to monitor skin for signs and symptoms of skin breakdown, related to cracking, blistering and offload heels while in bed as resident allows. The goal of the skin care plan was the resident will remain free of skin breakdown throughout next review date 6/2/21. On 4/5/21 at 8:45 AM, resident #48 was in bed on a specialty mattress eating breakfast. He was alert and oriented to person, place, and time. He had a visible wound dressing on his right hip dated 4/4/21, which was soiled with dark brown/tan drainage. The resident said he got the wound on his hip while he was in quarantine on the other side of the facility. The resident had a urinary drainage bag present and said that he needed this because he was paralyzed from his waist down and had no feeling. His lower extremities were contracted, bent upward and covered with blanket. On 4/6/21 at 5:07 PM, the facility Wound Nurse was prepared to enter the resident's room and said the resident was on enhanced precautions as he had an infection in his wound. The resident was lying in bed wearing bilateral foam type boots that covered his feet and ankles. The resident was asked if he had any sores on his heels. He reached down and took off his left boot. There was a darkened area approximately the size of a small orange on his left heel. On 4/7/21 at 10:48 AM, an observation of wound care was conducted with the Wound Nurse and CNA A. The nurse gathered her supplies and performed wound care to resident #48's bilateral hip wounds and sacral area. The left lateral hip pressure wound measured 5.6 centimeters (cm.) by 6.4 cm. by 1.4 cm deep, 80% granulation (pink) tissue, 5% necrotic tissue. The wound to right lateral hip measured 7.25 cm by 6.6 cm. by 0.8 cm deep, 90% granulation tissue. The pressure wound to medial coccyx was resolved. The CNA held the resident's legs up off the bed so the Wound Nurse could remove the residents' foam boots and socks. He had no breakdown seen on the right heel or ankle area. The Wound Nurse looked at his left lower extremity and said, the left heel has 1/2-dollar size, dark necrotic eschar (dead tissue) and dime size dark necrotic area on the left medial (inner) ankle. She said the areas look like they have been there for awhile and should have been reported by the CNAs to the nurses. She added, the nurse doing the weekly skin sweeps missed it. CNA A said she was the Restorative CNA and applied his boots daily. She said she had not reported any changes in his left heel to the nurse because she thought the darkened necrotic areas to the left heel and left inner ankle were not new. CNA A said she helped his regular CNA with care, and the left heel and ankle looked worse than last week. The Wound Nurse acknowledged there was a dramatic difference in the appearance of the right foot which had no breakdown as compared to the left. On 4/7/21 at 12:51 PM, the Director of Nursing (DON) said, she looked at resident #48's pressure wounds to his left heel and inner ankle. She added, this did not happen overnight. The CNAs or the nurses doing the weekly skin sweeps should have caught this sooner, notified the doctor, obtained new treatment orders and notified the family. On 4/7/21 at 1:13 PM, Licensed Practical Nurse (LPN) B verified, she was assigned to resident #48 on day shift 3 days last week and from 4/5 to 4/7 this week. LPN B said, she did the wound care to his hips and bottom and the restorative CNAs applied his boots. She said none of the CNAs mentioned he had skin breakdown on his left heel and inner ankle. The CNAs should be washing his feet and report any breakdown to the nurse, because the resident is paralyzed and would not be able to feel it. She added if the CNAs brought concerns to her attention she would have assessed the resident's skin, report any new breakdown to the Unit Manager (UM), do a change in condition note, notify the physician, get treatment orders, and notify the family. LPN B said she was not the nurse that did the resident's weekly skin checks. She said the standard of practice would be to look under his heels since this is a vulnerable area and he stays in bed, and does not move his lower extremities. On 4/7/21 at 1:26 PM, the resident's assigned CNA C said she was agency staff and had worked at the facility less than 1 month. She added that today was the first time she had cared for resident #48. CNA C said that part of giving a bath would be to check the resident from head to toe and notify the nurse of any concerns. On 4/7/21 at 2:38 PM, CNA F said she was assigned to resident #48 on the 3-11 shift last Friday 4/2/21. She knew the resident well and had been assigned to his care for approximately 6 months. She said he usually had his boots on when she arrived on duty and she removed them after dinner and applied lotion to his feet. She added she changed his brief, and informed the nurse when his hip dressings were soiled. CNA F recalled last Friday, 4/2/21, I think it was his left heel which had red spot brewing, and I reported this to the nurse, probably nurse (LPN) I. She did not know if the nurse checked his left heel. She acknowledged she was assigned to resident #48 last week on 3/29, 3/31 and 4/2/21. She noted the only day she had concerns with his foot/heel was on Friday 4/2/21. She said, I turn the resident side to side every 2 hours and because he is African American it's hard to tell with skin changes. Review of resident #48's medical record revealed the Wound Doctor documented on 3/15/21 that pressure wound on the right lateral buttock was resolved. Review of Registered Nurse (RN) G's documentation on the Weekly Skin Evaluations dated 3/20, 3/27 and 4/contradicted the doctor's assessment as she documented right lateral buttock area was still open. RN G had completed the 10 most recent Weekly Skin Evaluations on Saturdays. There wasn't any documentation by RN G regarding any skin breakdown to the left heel or ankle. On 4/7/21 at 4:17 PM, a telephone interview was conducted with RN G. She acknowledged she completed resident #48's skin evaluations the past 10 weeks with the most recent one done on Saturday 4/3/21. RN G said, she looked at everything including the resident's heels/ankles when doing the skin checks. She then stated, the left heel has always been softer than the right and she did not document the difference. I assumed they already documented the difference on his admit assessment and it is my fault for not looking at his admission assessment to see if they already documented it. Review of the Skin Assessment policy and procedure revealed, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .Begin head to toe, thoroughly examining the skin for conditions. Pay close attention to pressure points, bony prominence and underneath medical devices .Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers and [CONDITION(S)] .Consideration for resident with darkly pigmented skin: It is not always possible to identify redness on darkly pigmented skin. Indicators of early pressure damage: localized heat, [CONDITION(S)], bogginess, induration, temperature differences of surrounding tissue, skin discoloration . On 4/7/21 at 4:25 PM, the Advanced Practice Registered Nurse (APRN) H assessed resident #48's feet/ankles with the North Wing Unit Manager (UM). The resident was in bed, alert and talkative. The APRN said the left heel and inner ankle had discolored areas approximately the size of a [NAME]. The APRN said, both wounds were unstageable DTIs (Deep Tissue Injuries) and instructed the UM to obtain an x-ray of the left lower extremity to rule out [CONDITION(S)] (bone infection). The APRN said, this has been here for at least a week. The UM said the CNA should have reported changes sooner to the nurse and the nurse doing the weekly skin evaluations missed this. On 4/7/21 at 5:30 PM, LPN K who worked Monday to Friday on the 3-11 PM shift said that he did the initial skin assessment when resident #48 came back to the North Wing from the Coronavirus Disease 2019 (Covid) Unit. The resident was in the Covid unit from 1/19 to 1/29/21. LPN K said the resident did not have any discolorations on his heels when he returned. He added he had not looked at the residents' heels in over a month. LPN K stated, we have a lot of agency staff working here who don't know the residents and many of them no longer work at the facility. More than likely the breakdown on his left heel/ankle could have been due to agency nurses who would not have known better. On 4/8/21 at 9:32 AM, the Occupational Therapist (OT) said she obtained orders from the physician for foam boots for resident #48 on 3/2/21 because resident #48 had wounds on the outer ankles. The order was for foam boots to be applied for 6-8 hours daily in bed for pressure relief. She did not remember seeing any breakdown on the resident's heels or inner ankles at that time. She trained the CNAs on the application of the boots and he was taken off therapy caseload as of 3/2/21. The OT added the resident was completely numb from his waist down as he was paraplegic. The OT said that staff who donned and doffed the boots daily should have identified any new breakdown on the heels or inner ankles. She stated the resident's muscles were very atrophied and bony prominences were protruded which made his skin vulnerable to breakdown. On 4/8/21 at 10:47 AM, the DON said, the CNAs were responsible to inform the nurse immediately when there was a change in skin integrity so the nurse could assess the resident. The DON verbalized they did not have a process in place for CNAs to document any identified alterations in skin integrity. She stated the CNAs would verbally inform the nurse. The DON acknowledged that since the CNAs applied and removed resident #48's foam boots daily they should have identified and reported alterations in his left heel and ankle sooner. The Administrator said resident #48's regularly assigned day CNA was not available for interview by surveyor as she was on leave. On 4/8/21 at 11:58 AM, the Wound Nurse said he Wound Doctor would not have looked at resident's heels/ankles unless concerns were brought to her attention. The Wound Nurse acknowledged that RN G failed to complete a thorough skin assessment as RN G continually documented for 3 weeks that the resident had an open area on the right buttock after the Wound Doctor had resolved the area on 3/15/21. On 4/8/21 at 12:29 PM a telephone interview was conducted with LPN I. She said she worked on the North Wing 3-11 shift on Friday 4/2/21. She said she was not aware that resident #48 had any new skin concerns. She said CNA F did not report any skin issues with the resident's heel or ankle. She stated if she was made aware of any new skin issues, she would have assessed the skin, then notified the physician to obtain treatment orders. On 4/8/21 at 4:08 PM, the DON reviewed the resident's weekly Braden Scale for Prediction Pressure Ulcer Risk forms from 3/2/21 to present. She noted the resident was erroneously scored at a lower risk than he should have. The DON reviewed form dated 4/7/21 which had a score of 16 that indicated he was at risk for pressure injury. The DON said he should have scored 12 to 13, which would have put the resident at moderate to high risk. The areas that were not scored properly were weight loss, sensory perception, moisture, mobility and friction/shear. On 4/8/21 at 4:29 PM, a telephone interview was conducted with the Wound Care Doctor. She said she had just observed resident #48's wounds via telemedicine. She stated, the left heel looks like a pressure ulcer with non-infected eschar and same with the inner ankle. They are both unstageable pressure ulcers and I do not know how long they have been present. The wound doctor was made aware that the surveyor identified discoloration left heel and inner ankle from 4/6 to 4/7/21 during survey. She was also made aware that RN G who did the last 10 weekly skin sweeps documented erroneous information and CNA F had reported to LPN I on 4/2/21 of red spots brewing on the resident's left heel. The Wound Doctor acknowledged the facility staff should have identified these pressure injuries when they noticed the redness. She verbalized the staff should have intervened, reported to the physician and repositioned the resident frequently. The Wound Doctor added, If we are aware that he has a stage 1 that would be the time to put in preventive measures to keep if from progressing. Review of the facility's Pressure Injury Prevention and Management policy and procedure, with no date revealed, To minimize the risk of formation of pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions .Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over bony prominence .Licensed nurses will conduct a full skin assessment on all residents upon admission/re-admission, weekly .Certified Nursing Assistant will inspect skin during the resident bath/shower and will report any concerns to the residents nurse .

Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for 1 of 4 dependent residents of a total sample of 35 residents, (#28). Findings: Resident #28 was readmitted to the facility from an acute care hospital on 10/15/20. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date 2/4/21 revealed no history of rejection of care. Her Brief Interview for Mental Status (BIMS) score was 15/15 which indicated she was cognitively intact. The resident required extensive assistance of 1- 2 staff with her personal hygiene and was totally dependent on staff for bathing. The resident's care plan for ADL self-care performance deficit revised on 7/6/20 noted interventions that included, Bathing/showering: The resident is totally dependent on 1 staff for personal hygiene . On 4/5/21 at 9:15 AM, resident #28 was lying in bed. Her fingernails were approximately 1/2 to 3/4 inches long with brownish colored debris under the nails. The resident was oriented to person, place, and time. She was able to speak when she placed her finger over the [CONDITION(S)] tube. She said she wanted her fingernails trimmed shorter and cleaned. Registered Nurse (RN) E was present in the resident's room and acknowledged the resident's nails were long and dirty. On 4/5/21 at 12:06 PM, the resident was lying in bed. She was awake and alert. She showed her nails and they remained the same, long and dirty. On 4/5/21 at 1:59 PM, the resident's assigned Certified Nursing Assistant (CNA) D said, when I am not busy, I do the nail care and I have no free time. On 4/6/21 at 10:15 AM, the resident was lying in bed and showed her fingernails. Her fingernails were cut sideways, jagged with brownish residue under the nails. The resident nodded yes that staff had only trimmed her fingernails but not cleaned nor filed them. On 4/7/21 at 12 PM, the resident was lying in bed. She again showed her fingernails that were jagged and dirty. The nails had brownish/orange residue under the nails. The resident indicated staff had not cleaned or filed them. On 4/7/21 at 12:02 PM, RN E acknowledged the resident's nails were cut jagged, approximately 1/4 inch long and dirty. RN E said, I told the CNA yesterday about 3:00 PM to do the nail care. She said she could not remember the name of the CNA. The facility's policy for Providing Nail Care dated 2020 read, The purpose of this procedure is to provide guidelines for provision of care to resident's nails for good grooming and health .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing. Nail care will be provided as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury .

Based on observation, interview and record and record review, the facility failed to provide adequate supervision for a resident with severe cognitive impairment, known history of elopement and assessed at high risk for wandering/elopement for 1 of 3 residents reviewed at risk for elopement out of a total sample of 12 residents, (#10). These failures contributed to the elopement of resident #10 and placed him at risk for serious injury, impairment or death. While resident #10 was out of the facility unsupervised, there was high likelihood he could have fallen, become lost, or been hit by a car. On 08/03/20 at approximately 10 AM, while being monitored by staff every 30 minutes, resident #10 exited the facility through his room window. He opened one of the 2 side by side windows in his room, pushed out the screen, and exited through the window opening. Resident #10 walked 2 miles past multiple businesses, stores, gas stations and areas with deep culverts for water drainage until he was located by law enforcement standing at a bus stop in front of a local chain restaurant. The bus stop was close to an entrance and exit to Interstate 95 The temperature on August 3, 2020 was 94 degrees Fahrenheit with humidity of 51 percent which placed the resident at risk for dehydration and/or sun exposure (Timeanddate.com website at www.timeanddate.com accessed on 8/24, 2020). The resident was found by law enforcement who observed him standing at the bus stop with a white band on his ankle. The resident was out of the facility unsupervised for 3 hours when the facility received a call from law enforcement that the resident had been found at the bus stop near Interstate 95. The facility's failure to provide adequate supervision for a resident with severe cognitive impairment and history of wandering behavior resulted in Immediate Jeopardy starting on 08/03/20. The Immediate Jeopardy was removed on 08/04/20. Findings: Review of the facility Elopements and Wandering Resident Policy, not dated, read, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . 2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or any necessary supervision to do so . 6. Monitoring and Managing Residents at Risk for Elopement . d. Adequate supervision will be provided to help prevent accidents and elopements . Review of the Facility Assessment Tool, dated 04/06/20, revealed that the facility was competent to provide care and services for residents with [DIAGNOSES REDACTED]. Resident #10 was a [AGE] year-old male with severe cognitive impairment and history of elopement. He was admitted to the facility on [DATE] from an acute care hospital. The resident's [DIAGNOSES REDACTED]. He was admitted to the acute care hospital on [DATE] for confusion and his neurological assessment revealed that his memory was poor with a [DIAGNOSES REDACTED]. He had previously been placed in an Assisted Living Facility (ALF) where he eloped and was found walking in a river. The Admission/Re-Admission Screening form dated 07/18/20 noted he was alert and oriented to person and time only and independent with mobility. The admission Minimum Data Set (MDS) assessment dated [DATE] noted that the resident's Brief Interview for Mental Status (BIMS) score was 3 indicating severely impaired cognition and behaviors included delusions. The admission Wandering assessment dated [DATE] documented he was ambulatory; had a history of [REDACTED]. A second Wandering Assessment was completed on 07/21/20 (72 hours after admission) and documented he continued to be at high risk to wander. The resident's plan of care initiated on 07/21/20 included elopement risk/exit seeking, history of exit seeking related to dementia, cognitive deficits and paranoia related to [MEDICAL CONDITION] and placement of Wander Guard device to his left ankle. The goal included the resident will not leave the facility unattended and remain safe in facility. Interventions were to monitor for tailgating,reassure resident when distressed over placement, divisional activities when exit-seeking behavior occurring (i.e: offer food, activities, and one-on-one company). A second plan of care included resident is at risk for complications related to [MEDICAL CONDITION] drug use: [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Social Service assessment dated [DATE] documented the assessment was completed with the resident who had short-term and long-term memory problems and since he is unable to make his own decisions, he has a Durable Power of Attorney. The sections for mood state, behavior problems and other history were left blank. The summary section documented the resident was very confused. The assessment did not include obtaining resident's past history from the resident's Power of Attorney. Review of a Behavior Note dated 07/27/20 revealed the resident was observed with superficial cuts on his right thumb and index finger caused by a disposable razor. The resident had stated, those were to protect, there are people out to get me. After this incident interventions put in place included every 30-minute safety checks, room door to be left open, room to be checked for unsafe items every shift, kitchen to supply paper plates and plastic utensils and psychological services pending. On 08/20/20 at 9:32 AM, the Administrator stated that resident #10 was admitted to the facility for short-term rehabilitation. He had previously lived in an Assisted Living Facility (ALF) and he left the facility and was found in a river. She said that on 8/03/20 at 10 AM, resident #10 opened the window in his room, pushed out the window screen and exited through the open window. At 10:10 AM the Occupational Therapist (OT) entered resident #10's room to provide therapy services and the resident was not there. The OT notified the Certified Nursing Assistant (CNA) assigned to resident #10. When they both could not locate the resident, an Elopement announcement was called over the intercom system. An immediate search was conducted in the interior, and exterior of the facility. The search was expanded to include the surrounding property and surrounding streets without success in locating resident #10. A CNA went into the resident's room and pulled up the window blinds. The window had been opened and the screen had been pushed out. At this time resident #10's physician, responsible party and Law Enforcement were notified. According to the Administrator 14 Law Enforcement officers responded to the facility. A bloodhound with handler were called to search for the resident and a drone was used. The bloodhound picked up resident #10's scent which lead out of the facility parking lot to the gas station/convenience store across the street. It was not until 3 hours later at 1 PM that resident #10 was found by Law Enforcement in front of a major home improvement store on the heavily trafficked highway close to Interstate 95. The resident was then transferred to the hospital for evaluation and he returned to the facility the same day at 5 PM (7 hours after the elopement). The administrator stated that she completed an investigation, but she never attempted to interview the resident or conduct and interview with the resident's responsible party to help establish why he left the facility. The administrator said the root cause for the elopement was the facility could not have predicted that the resident would elope through his window. She said upon return to the facility, resident #10's room was changed for closer supervision and he was placed on 1:1 supervision. On 08/04/20 at 11:45 AM (18 hours later) while on 1:1 supervision, resident #10 jumped off his bed and used both his arms to smash the glass out of his room window. He attempted to climb out but retreated. He then ran out of his room, through the lobby, past the receptionist desk and ran directly into the double glass fire/exit door causing him to fall backwards. He sustained lacerations to both arms that were bleeding. The Administrator stated that in February 2019 the facility had a similar incident where a resident eloped through his room window. As a result, 2 screws were placed in all room windows and audits of all room windows were being conducted monthly by the Maintenance Director. On 08/03/20 immediately after resident #10's elopement, the Maintenance Director identified 6 room windows that did not have 2 screws in place. On 08/20/20 at 11:12 AM, the Maintenance Director stated that he was responsible for checking all the facility windows every month. All resident room windows should have 1 hex head screw in each window frame which allows the window to open only 6 inches. Every month I was checking that the screws were in place and that the window would open and close properly. On 08/03/20 the Administrator asked me to check all resident room windows to make sure that the screws were in place. He stated that his audit conducted on 08/03/20 revealed that out of a total of 120 resident room windows, 6 windows were found to be missing 1 screw in the window frame. The missing screws were replaced. Review of the monthly window audits conducted by the Maintenance Director on 07/03/20 and 08/03/20 documented all room window nails (screws) were in place. The audit conducted on 08/03/20, after the elopement revealed that rooms 105, 108, 121, 134, 136, 158 and 160 did not have the required screws in place. This placed 8 other residents at potential risk for elopement since the windows were not secured and were able to be fully opened. The monthly audits only identified that the screws were in place. The security of the screws into the window frame was not part of the auditing process. On 08/20/20 at 12:53 PM, the Director of Nursing (DON) stated that that all residents were checked at least every 2 hours. She said that residents with Wander Guard devices had been assessed at risk for wandering/elopement and supervision was the same unless the resident was talking about leaving or showing behaviors of wandering. She said that resident #10 was placed on every 30 minute checks following his incident with the razor. The facility has no policy for supervision for a resident who is at high risk for wandering/elopement. His intention was to leave regardless of interventions that were in place. On 08/20/20 at 12:15 PM, CNA A revealed she was assigned to resident #10 on 08/03/20. She stated that the resident was on every 30-minute and she last observed the resident at 10 AM resting in bed. On 08/20/20 at 12:57 PM, the Administrator revealed that resident #10 was placed on every 30-minute checks on 07/26/20 because of behaviors. He was found dismantling a disposable razor which was in his personal belongings and was not found during his admission process. He had only small cuts on his fingers. She explained that the Interdisciplinary Team had made the decision for every 30-minute checks because it was a standard to start with every 30-minute checks. We felt the 30-minute checks were appropriate for his behavior issues. On 08/21/20 at 11:35 AM, Licensed Practical Nurse (LPN) B stated that she was the nurse assigned to resident #10 on 08/03/20 when he eloped from the facility. She said she checked his room and then notified the receptionist. I then went outside and discovered that the resident's window was opened. I did not notice if anything was on the ground. I ran to my car to check the roads near the facility but was not able to find him, so I returned to the facility to take care of my residents. She stated that she was present when resident #10 returned to the facility at 5 PM but she never asked the resident why he left the facility. On 08/20/20 at 1:05 PM, an observation of resident #10's room was conducted with the Administrator. The room was located on the South Wing at the very end of the hallway and was adjacent to an exit door. The room had 2 side by side windows that faced the back-parking lot. Observations out of the room window revealed several parked cars, 2 trash dumpster's and thick woods at the back and side of the property. On 08/20/20 at 3:30 PM, a phone interview was conducted with resident #10's responsible party. She revealed that she was the Power of Attorney and had been involved in his care for a long time. She said that resident #10 had [MEDICAL CONDITION] that had radiated to his brain which required [MEDICAL CONDITION] treatments, [MEDICAL CONDITION], placement of a gastrostomy tube (GT) with frequent feedings and placement of a port for his [MEDICAL CONDITION]. He then developed memory problems and also had a family history dementia. He was previously at an Assisted Living Facility (ALF) and he was doing well until he eloped and was found walking in a river behind the facility. He was a professional fisherman and then worked in maintenance. This is probably why he navigates to water. She said she received a phone call on 08/03/20 from the facility informing that he had eloped from the facility through his room window and that Law Enforcement was looking for him. She stated that when she placed him at the facility, I expected that he would not get out by himself because I was told it was a secure facility. I thought it was a locked facility. My concern was getting him back and I was very worried about him being near any water because that is where he ended up when he left the ALF. He is still in the hospital and I am having problems with finding a place that will take him due to his elopement behaviors. On 08/20/20 at 3:35 PM, a phone interview was conducted with the Brevard Law Enforcement Officer who located resident #10 on 08/03/20. He stated that he responded to the facility at 10:05 AM and there were 13 officers that were dispatched to the facility. A bloodhound with handler and a drone was set up to assist with locating the resident. The bloodhound was able to pick up resident #10's scent from the facility to the gas station/convenience store across the street. Then his scent was lost. The officer said he drove around for 3 hours looking for the resident. While driving north bound on a highly trafficked 5-lane highway, I observed a male staggering around at the bus stop in front a local chain restaurant which was near Interstate 95. I noticed a white bracelet on his ankle, and he was wearing flip flops, a navy colored shirt and shorts and his feet were dirty. The officer said the resident was in the sun and he was not sweating. Since the temperature was in the 90's I knew he might be dehydrated so I provided him with some water. He was stumbling around and confused. The resident stated he had left the facility through the bedroom window, I just opened it up and crawled out. When he was asked why he left the facility he responded that he needed to get out of the building before the nurse with the medications got to his room. According to the resident, The meds were killing people and he did not feel safe at the facility. Review of the Brevard Law Enforcement Incident Report narrative dated 08/03/20 revealed at 10:05 AM, Law Enforcement responded to a report of a missing and endangered adult. The resident is a disabled elderly adult who suffers from several medical conditions, Dementia and other psychological conditions as well as physical conditions. A search was conducted in the immediate areas surrounding the facility and a bloodhound was used to track the resident. The track led south from the facility to the wood line on the south side of the parking lot. The track then led east and then south and ended. The resident was found by Law Enforcement walking south bound on a highly trafficked 5-lane highway. The resident stated that he did not feel safe at the facility because a staff member was going to beat him and kill him. The resident was then transferred to the hospital to be evaluated for possible injuries. While at the hospital the resident did not speak much and what he would say did not make any sense. On 08/21/20 at 6:15 PM, a phone interview with resident #10's physician who was also the facility's Medical Director. He stated that the resident had significant advanced Dementia and he was rapidly declining. He said the resident was unpredictable and needed close supervision. The physician added that since the resident had attempted to elope from the facility on 2 occasions, he will require a secure room with alarms on the windows. I have had 2 conversations by phone with the facility about purchasing window alarms. The first discussion was on 08/03/20 and the second was today (08/21/20). Review of the corrective measures implemented on 08/04/20 by the facility to remove Immediate Jeopardy revealed the following: The Maintenance Director checked and secured all 60 resident room windows and validated the function of the facility exit doors and ensured that all resident windows were locked and secured. The maintenance management system was updated to reflect ongoing monthly checks of window safety. All 92 residents were re-evaluated for elopement risk. 8 residents were identified with wander guard placement: the placement and function were validated, the presence of resident information in the elopement books and care plan review was completed. Education on elopement policy and procedures was completed with 87 of 87 active employees by the Director of Nursing and/or designee. The validation was completed with elopement drills on 8/03/20, 8/05/20. 8/06/20, 8/07/20 on all shifts. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was held on 08/03/20 with the Administrator, Director of Nursing, Medical Director and 6 other management staff. All members reviewed the elopement policy and procedure, educational plan and auditing plan. Audits of resident room windows were conducted on 08/03/20, 08/04/20, 08/05/20, 08/06/20/ 08/10/20, 08/10/20, 08/13/20, 08/14/20, 08/17/20, and 08/21/20 twice a day and all resident room windows were locked and secure. An educational plan was developed and 87/88 employees were educated on 08/03/20. One staff member who is on leave of absence will be educated prior to returning to work. Contracted staff were to be educated upon their initial assignment to the facility and the facility orientation will include in depth education on the elopement policy and procedure. Anyone unable to demonstrate understanding will receive additional education with immediate competency testing. The failure to demonstrate continued competency will result in further disciplinary action up to and including termination. An additional Ad Hoc QAPI meeting was held on 08/21/20 with the Administrator, Director of Nursing, Medical Director and 7 of 18 managerial staff members including members of the facility's Governing Body in which this plan was accepted. The effectiveness of this plan will be evaluated on a weekly basis via QAPI meeting for 4 weeks and then monthly for 5 months. Education and elopement drill sign in sheets were reviewed and revealed that staff attended in person or were called at home and education was completed. 70% of the staff had participated in the elopement drills. Window audit forms were reviewed and completed by the Administrator, Administrator in Training (AIT) and/or designated person. No issues were identified. A purchase order date 08/21/20 for window alarms had been completed and reviewed. The Administrator stated that window alarms will be placed on room windows of the resident with wander guard devices. The resident sample was expanded to include 2 additional residents (#11, #12) who were assessed as being wander/elopement risk, having a wander guard device in place and independent with ambulation. Record reviews, observations and interviews with staff revealed no issues. Interviews with 11 staff members on 7/21/20 revealed they were knowledgeable regarding the facility's elopement policy and procedure, wander guard placement, supervision and missing resident process.

Based on record review and interview, the facility failed to provide timely and appropriate post-fall nursing and medical care for 1 of 3 residents reviewed for accidents, (#1). The facility's failure to perform post-fall evaluations and neurological assessments resulted in actual harm. During a 5-week stay in the facility, resident #1 had unwitnessed falls, suffered a right heel fracture and sustained bruises of unknown origin on her arms and head. She was hospitalized for [REDACTED]. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed resident #1 was able to express her ideas and wants but she required an interpreter to communicate with physicians and healthcare staff in her preferred language, Spanish. She had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment, with disorganized thinking or altered level of consciousness. Resident #1 had unsteady balance and required supervision for walking but was able to stabilize herself without staff assistance. She had no impairment of her lower extremities and direct care staff believed she was capable of increased independence. The MDS assessment indicated resident #1 had 1 fall with no apparent injury within the first week of admission. Section Q of the assessment revealed resident #1's overall goal was to be discharged to another facility. During telephone interviews on [DATE] at 8:23 AM and [DATE] at 9:13 AM, resident #1's daughter and son-in-law verbalized concerns regarding injuries suffered by resident #1 during her time in the facility. They described resident #1 as doing well with therapy and walking independently around the facility within 2 to 3 days after she was admitted . The daughter recalled receiving several calls during her mother's month-long stay regarding falls and other incidents. She explained she visited her mother almost every day and said, One day I was visiting . I immediately noticed a bruise to the side of her forehead. The daughter could not recall the date, but stated the social worker and the unit's head nurse were present when she discovered the area. She said, Nobody knew how it happened. They kept talking about different ways it could have happened. The family explained after the incident with the bruise they continued daily visits and noted resident #1 was usually seated in a wheelchair rather than walking in the hallways. Resident #1's son-in-law stated he felt something was wrong in her last few days in the facility because her walking was slower and she was mostly in a wheelchair. The daughter said, I asked why she wasn't walking anymore, and they said it was better for her to sit. In the end she could barely walk and talk. Resident #1's daughter stated she was notified her mother fell on the morning of [DATE], and later that day the facility informed her that her mother had a heel fracture. The daughter explained she arrived at the facility with her brother the following day to accompany her mother to an appointment with the foot doctor. The family described resident #1 as not acting normal . looked strange . very agitated, crying and scared . as they sat in the lobby waiting for transportation. They said, Her eyes looked different, really big . her breathing was really fast and she had a little bit of a tremor. The daughter stated her mother was mumbling words and could not put a sentence together. She explained her mother's status worsened on the way to the podiatrist and during the appointment she was agitated, screaming and blurting out nonsensical words and sentences. The daughter said, Although she had dementia usually we could communicate with her. But her words just did not make any sense. She stated when they returned to the facility her mother still exhibited the abnormal behaviors of extreme agitation and anxiety, and she was left in care of the nursing staff. The daughter recalled a few hours later, at about 6:00 PM, the facility notified her that her mother became even more irrational and was sent to the hospital. The son-in-law stated when the family arrived at the hospital a doctor informed them resident #1 had bleeding in her brain. He explained after a few days in the intensive care unit (ICU), a neurologist informed them their mother was not a surgical candidate and nothing could be done to fix the bleeding in her brain. The family stated resident #1 remained in the hospital until she was transferred to a hospice unit on [DATE]. Resident #1's daughter explained her mother was in a coma, no longer eating or drinking, and lay in bed with her eyes closed. She said, She does not know anybody or anything. The nurses turn her every 2 hours so she doesn't get bedsores or have pain. We are just waiting for her to die. I cannot understand how she went from doing good in the rehab, walking like she did before, to dying like this. She only had a fracture on her heel. I don't understand. Review of resident #1's medical record revealed a 3008 hospital transfer form dated [DATE]. The form indicated at the time of transfer from the hospital to the facility, resident #1 walked with assistance, had full weight-bearing status on both legs and was a fall risk. The document revealed she was alert, disoriented, but can follow simple instructions. On admission to the facility, a nursing evaluation dated [DATE] revealed resident #1 had no foot pain and her heels were free of redness. Nurses' notes for the period [DATE] to [DATE] indicated resident #1 continuously wandered in the hallways for most of the day and night with only brief rest periods. Nurses' documentation revealed resident #1 occasionally had signs and symptoms of anxiety and attempts to re-direct her or encourage rest periods were not always effective. Change in condition forms dated [DATE] and [DATE] revealed resident #1 fell twice during that period. Review of the Physical Therapy (PT) Discharge Summary revealed resident #1 was on caseload from [DATE] to [DATE]. The document indicated she met her short-term and long-term goals related to pain, increased lower extremity strength and safe ambulation. Resident #1 was then referred to the Restorative Nursing Program (RNP) to increase distance with ambulation up to 300 feet using no assistive device, to include outdoor ambulation. On [DATE] at 10:49 AM, the Director of Rehab (DoR) confirmed resident #1 successfully achieved some PT goals and surpassed others before the end of her certification period. She said, Resident was physically high level with ambulation. The DoR explained resident #1 was referred to the RNP to maintain the gains she made in PT. The DoR stated after resident #1 was discharged from PT, the therapy department never received a referral from nursing regarding a decline in ambulation. A change in condition note dated [DATE] at 3:07 AM, revealed resident #1 fell during the night shift, and licensed practical nurse (LPN) D left a voicemail to notify the physician of the fall a few minutes later at 3:30 AM. On [DATE] at 6:01 AM, LPN D wrote, Resident noted to have slight limp to her right leg She still denies pain but limp was noted when she got up to try to wander around at 5:30 AM. (Physician) notified, pain med administered based on non-verbal cues including grimacing while walking. Awaiting (physician) order for xray. The SBAR Communication Form dated [DATE] revealed a required mental status evaluation was not conducted at the time of the fall, and although resident #1's behavioral evaluation indicated changes, there was no description of those signs and symptoms. On [DATE] at 3:38 PM, LPN D stated she was assigned to resident #1 for the night shift on [DATE] when she fell . LPN D confirmed she left a voicemail to notify the physician at the time of the fall, at about 3:30 AM on [DATE]. She recalled later that morning she noticed resident #1 had a limp and showed signs of pain when she walked. LPN D clarified resident #1 appeared to be limping with weight bearing rather just an altered gait as she appeared to have before the fall. LPN D said, I was concerned enough to call the (physician) again at about 6 AM. I left a second voicemail. LPN D stated she requested an x-ray and wrote a progress note regarding the second notification to the physician. LPN D explained she did not receive a call from the physician prior to the end of her shift at 7 AM but she informed the on-coming nurse, LPN A, about resident #1's fall and limp, and that she was waiting for an order for [REDACTED].>On [DATE] at 3:51 PM, LPN A confirmed she received report from LPN D on [DATE], but she did not recall receiving any information about resident #1 having a fall with possible injuries or a pending x-ray order. She validated after a fall, nurses were expected to do regular neurological assessments and complete change in condition follow-up evaluations every shift for 72 hours. Resident #1's next nursing evaluation was documented by LPN B in a Daily Skilled Note dated [DATE] at 10:53 PM, approximately 20 hours after the fall. The form indicated resident #1's pain level was 0, although the attached narrative note indicated resident #1 complained of foot pain. The medical record revealed the first follow-up nursing evaluation for resident #1's change in condition related to her fall was done by LPN A the following day, on [DATE] during the 7 AM to 3 PM shift. The form indicated a change in condition follow-up evaluation was to be done once every 8 hours for 72 hours after an incident. The evaluation did not include documentation of resident #1's neurological status regarding pupil size and reaction to light or review of her mental status and orientation. There was no response noted in the evaluation's Section 2 m. Is resident experiencing foot pain? Review of an MD (physician) Communication form revealed a request from the Director of Nursing (DON) for the physician to evaluate resident #1's medication. The DON's note described resident #1's continuous walking during the day and night and suggested possibly something to help (with) sleep? The request was addressed on [DATE] by the physician, who ordered [MEDICATION NAME] 50 milligrams (mg) at bedtime. [MEDICATION NAME] is an antidepressant medication that is sometimes used to treat [MEDICAL CONDITION]. (www.drugs.com) The communication form did not include any reference to resident #1's fall or possible foot/leg injury. Review of the incident log revealed documentation of resident #1's fall on [DATE] at 3 AM. The facility's investigation revealed the assigned certified nursing assistant (CNA) found resident #1 lying on her back on the floor in her room. The risk management summary form indicated resident #1 stated she did not fall or hit her head, rather she chose to lie on the floor. The document showed neurological evaluation or neurochecks at the time of the fall were normal and there was no apparent injury. Neurological checks (neurochecks) are usually done after an unwitnessed fall to identify signs of a head injury. The evaluation includes checking level or consciousness, vital signs, pupil size and reactivity to light, and hand grip strength. Standard clinical nursing practice suggests this evaluation should be done immediately after the fall, then at regular intervals such as every 15, 30 or 60 minutes, gradually decreasing in frequency over a specified time. (www.hcpro.com) Review of the Falls Management policy revised on [DATE] read, Patients experiencing a fall will receive appropriate care and investigation of the cause. The document included direction to perform neurological assessment for all unwitnessed falls. The policy for Assessment: Neurological, reviewed [DATE], revealed the purpose was To monitor patient for neurological compromise. The policy indicated after an unwitnessed fall, neurological assessments should be performed every 30 minutes for 2 hours, then every hour for 4 hours, then every 4 hours for 24 hours. Neurological assessments would therefore be conducted at least 14 times over a total of 30 hours. Review of the Neurological Assessment Flow Sheet revealed instructions to document the date and time of every neurological assessment. The flow sheet indicated nurses were to assess a resident's level of consciousness, pupil response, motor functions such as hand grasps and ability to move extremities, and response to painful stimulus at the required intervals for 30 hours. The form revealed columns for documentation of the resident's vital signs including blood pressure, temperature, pulse and respiration at the time of each neurological assessment. The facility's Fall Response Protocol, revised in (MONTH) 2013, indicated that after a fall, nurses would notify the physician, charge nurse and family, perform neurological assessments and monitor the resident for 72 hours. The protocol read, After ,[DATE] hours, call family/responsible party to provide status report and document. Review of resident #1's medical record revealed only 1 neurological assessment flow sheet. The incomplete document was dated [DATE]. There was no flow sheet to document neurological assessments after resident #1's fall on [DATE], and only 1 of the 9 required fall follow-up evaluations was completed during the 72-hour period after that fall. The nursing progress notes did not include documentation of provision of a status report to resident #1's family per facility protocol. On [DATE] at 11:25 AM, the Director of Social Services (DSS) confirmed one day she observed resident #1's daughter and LPN A examining resident #1's face and head while she was seated in her wheelchair in the hallway. The DSS said, It was probably the left side of her face and head. The DSS described a discolored area on resident #1's forehead near to the temple area. She said, I think I asked them if she possibly hit her head on the rail. The DSS stated she left LPN A and the daughter discussing what could have happened but did not report the issue to anyone since nursing staff were aware. On [DATE] at 11:42 AM, LPN A confirmed she was the acting unit manager (UM) on the day resident #1's assigned nurse, LPN H, informed her there was an area of concern on resident #1's forehead. LPN A stated she evaluated the area and described it as barely noticeable discoloration. It looked like a healing bruise. I had not known her to have a discoloration or bruise there before. LPN A stated when the DON was notified she also assessed resident #1. LPN A confirmed she did not contact the physician or suggest neurological assessments. She said, Since it was something new, I would have expected (LPN H) to do a change in condition assessment. Review of the incident log and resident #1's medical record revealed no documentation of the discolored area, possibly a bruise, to resident #1's head. The incident log showed on [DATE] at 9 AM, staff observed resident #1 with bruises of unknown origin on both arms. The facility's investigation determined no definite cause and suggested the bruises did not appear to be fall-related. Resident #1's next comprehensive nursing evaluation was documented 5 days later, on [DATE] at 7:51 AM. A Change in Condition note revealed resident #1 fell again during the night shift. Registered Nurse (RN) [NAME] assessed resident #1 at the time of the fall and noted her mental status was increased confusion or disorientation but she had no neurological changes. The incident log revealed on [DATE] at 6:00 AM, resident #1's roommate notified staff that she was on the floor. The investigation indicated resident #1 denied pain and had no apparent injuries. During a telephone interview on [DATE] at 8:07 AM, RN [NAME] stated resident #1 was usually fairly steady on her feet, but for her last few days in the facility she was mostly in a wheelchair. He confirmed on [DATE] during the night shift, resident #1's roommate alerted staff that resident #1 was on the floor. RN [NAME] stated he assessed resident #1 although she spoke no English and he spoke only a little Spanish. He said, I did a basic neurological test. She could squeeze my hands, move all extremities, and responded to my touch on her feet and legs. RN [NAME] confirmed the facility had a policy for the frequency and duration of neurochecks but he could not recall the specifics. He said, I know I did it when I found her on the floor and there were no negative findings. RN [NAME] was not able to recall or confirm that he performed neurochecks again before the end of the shift. He said, I remember charting the neurocheck I did, but I have not been able to find the paper since. On [DATE] at 1:13 PM, LPN A stated on [DATE] she noticed resident #1's right ankle was red and swollen. She explained resident #1 usually had some swelling in both ankles but on that day the left ankle was normal. LPN A said, It was pretty significant swelling and redness It was the outer ankle and the side of her foot that were swollen. It was painful to touch. She grimaced when I touched it. The North Court UM confirmed she evaluated resident #1's right foot at LPN A's request and notified the physician immediately. She showed a text message on her cell phone dated [DATE] at 5:49 PM that revealed the physician was also informed resident #1 was still limping. She acknowledged a nurse's progress note indicated resident #1 was observed limping 6 days before, after the fall on [DATE]. On [DATE] at 5:37 PM, CNA C stated she was regularly assigned to resident #1. She confirmed resident #1 usually walked throughout the hallways continuously. However, CNA C said, She used a wheelchair towards the end, maybe ,[DATE] days before she left .She was still trying to stand up and you could tell she couldn't make it. CNA C explained that resident #1 had a limp that worsened and said, I reported her foot hurting and swelling to the nurse more than once. On [DATE] at 5:46 PM, LPN B recalled resident #1 had problems walking for about 1 to 2 days before she was hospitalized . LPN B said, She would still try to walk away, but when she stood up, she would not be able to bear full weight on her right foot. We would ask her to sit back down. I do not recall anyone mentioning x-rays I figured it was just the [MEDICAL CONDITION] in her legs causing the pain. She could not wear shoes comfortably any longer. LPN B confirmed prior to discharge, resident #1 showed pain by grimacing when she put her weight on the right leg. LPN B was asked if she notified anyone including the physician of resident #1's difficulty walking and foot pain. She said, Not really. I also figured it could be the shoes being too tight from the [MEDICAL CONDITION]. On [DATE] at 5:50 PM, CNA F explained resident #1 stopped walking towards the end of her time in the facility and was usually seated in a wheelchair whenever she saw her. CNA F said, There was definitely something about her leg, because I didn't really see her walking anymore. On [DATE] at 11:33 AM, RN G recalled during her last week in the facility, resident #1 complained of foot pain and had facial grimacing. RN G confirmed prior to that week, resident #1 was independently ambulatory. Review of the medical record revealed no documentation of a post-fall change in condition follow-up evaluations on the day and evening shifts on [DATE], and no record of any neurological assessments after that fall. On [DATE] at 5:41 PM, a nurse's note revealed resident #1 was noted to have right lower extremity swelling and warmth. The physician was notified and ordered a right ankle x-ray to rule out a fracture, and a Doppler ultrasound of the right leg to check for a blood clot. A review of the care plan for falls dated [DATE] and last revised on [DATE] did not include intervention to conduct neurological checks after the unwitnessed falls on [DATE] and [DATE]. The Radiology Results Report revealed resident #1's right ankle x-ray was done on [DATE] at 7:30 PM and the result was reported an hour later at 8:26 PM. The report indicated resident #1 had a right heel avulsion fracture, which occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. (www.mayoclinic.org). The injury was deemed to be Acute to subacute or of indeterminate age, from hours to weeks old. On [DATE] at 12:02 PM, LPN A completed a change in condition follow-up note related to the fall on [DATE]. The evaluation indicated resident #1 was alert with confusion. However, LPN A did not obtain current vital signs nor assess resident #1's pupils prior to departure for a 1:30 PM podiatry appointment. A skin check conducted an hour later at 1:02 PM revealed she had previously identified bruises on her right and left hands and forearms and her right ankle. A Podiatry progress note, dated [DATE], revealed resident #1 presented with a right heel fracture, The duration, as stated by the patient, is several days. The podiatrist noted resident #1 had constant throbbing pain with a severity of 8 on a 0 to 10 scale. From conversation with the family, the podiatrist discerned resident #1 was a rather active [AGE] year old but over the past several days she was no longer walking and was using a wheelchair. The progress note described resident #1's general appearance as, distressed. A progress note dated [DATE] at 6:06 PM, written by the Director of Nursing (DON), revealed resident #1 returned to the facility with a right leg boot and directions for non-weight bearing status to the right leg. The note indicated resident #1 was unwilling to listen to direction, refused care and stated medication offered was poison. The facility contacted the attending physician who gave an order to send resident #1 to the hospital for evaluation of her altered mental status (AMS). On [DATE] at 1:13 PM, LPN A stated she was again assigned to resident #1 on [DATE], the day after she discovered the right foot injury. She described resident #1 as usually pleasant, not combative but before she left for a podiatry appointment that afternoon she was very restless. LPN A explained resident #1 was very agitated when she returned from the appointment, so she notified the physician of the behavior change by text message at 2:42 PM. LPN A stated the physician did not respond before the end of her shift at 3 PM, but she passed the information on to either the on-coming afternoon shift nurse or the UM. On [DATE] at 1:26 PM, the North Court UM stated after LPN A left, she attempted to call the physician again to report resident #1's agitation but was not able to contact him. The UM explained due to resident #1's agitation she had stayed with her and assisted the assigned CNA to ensure resident #1's safety. The UM explained the administrator was eventually able to contact the physician. She said, We explained to (the physician) about resident's altered mental status and the significant change in behaviors and cognition. It was a big change. The UM stated when ambulance personnel arrived, resident #1 was so agitated, it took them about 30 minutes in the parking lot to calm her before they could safely transport her. The UM confirmed resident #1 left the facility after 6 PM, more than 3 hours after LPN A's initial call to the physician. On [DATE] at 4:05 PM, the Admissions Director (AD) stated she conducted a follow-up visit in the hospital approximately 1 week after resident #1 was discharged . She stated the purpose of the visit was to find out when resident #1 was returning to the facility. The AD explained the family informed her resident #1 was either going to a hospice house or staying in the hospital's inpatient hospice unit. The AD said, I asked what happened for the dramatic decline. Review of the hospital progress notes revealed resident #1 was triaged in the emergency department on [DATE] at 6:48 PM with a chief complaint of AMS combative. A computerized tomography (CT) scan of resident #1's head showed a left side subdural hematoma that measured 12 centimeters long and 9 millimeters deep. A subdural hematoma is a collection of blood between the layers of tissue that surround the brain. Subdural hematomas are usually caused by severe head injuries. The bleeding and increased pressure on the brain from this injury can cause confusion and lead to unconsciousness and death. (www.webmd.com). The hospital record revealed resident #1 was admitted to the ICU after a consultation with a brain surgeon. A progress note read, Clinical impression: Medium sized, subacute, traumatic left subdural hematoma. Unknown whether a loss of consciousness occurred. On [DATE] at 4:35 PM, the assistant DON (ADON)/clinical educator stated her expectation was nurses would notify the physician of any change in a resident's condition. The ADON explained if a physician did not respond to a voicemail regarding an emergent situation, nurses were expected to continue efforts to contact him/her and escalate the concern to nursing management including the DON. She stated nurses were expected to complete all tasks and documentation at the time of an incident. The ADON validated documentation accuracy and completeness included thorough follow-up evaluations every 8 hours, for 72 hours after a fall. During review of resident #1's medical record with the ADON, she confirmed after the fall on [DATE], there was only 1 follow-up evaluation completed in 72 hours. She validated neurochecks should be done for all unwitnessed falls to assess for and identify any signs and symptoms of a head injury. The ADON explained neurochecks were scheduled over time as symptoms not present at the time of the fall might develop within minutes to days afterward. During interviews on [DATE] at 12:28 PM and 12:57 PM, the DON validated neurochecks were to be performed after all unwitnessed falls. She acknowledged there was no evidence in resident #1's electronic and paper medical records that the required neurochecks were conducted after falls on [DATE] and [DATE]. She stated her expectation was nurses would evaluate and monitor residents regularly for 72 hours after a fall. However, on review of the medical record, she confirmed resident #1 did not receive post-fall monitoring after both falls, according to the facility's policy. The DON confirmed her written communication with the physician was focused on resident #1's continuous wandering and pacing rather than her fall on [DATE] with a possible injury. She acknowledged the physician's medication order corresponded with her request to address the specific behavior. The DON acknowledged she was made aware of an area of concern on the left side of resident's forehead. She described it as almost under her hairline, that did not really look like a bruise but more like a difference in pigmentation. The DON confirmed the area was not reported or investigated as a bruise of unknown origin. Regarding resident #1's last day in the facility, the DON recalled the podiatrist informed her resident #1 was very confused and combative during her appointment. The DON explained the behaviors escalated when resident #1 returned to the facility and she personally reported the change in condition to the medical director. On [DATE] at 2 PM, the facility's medical director validated nurses were expected to notify physicians of any changes in residents' condition, including falls. He explained physicians relied on nurses' evaluations and assessment findings to guide appropriate treatment plans. The medical director confirmed neurochecks should be done at regular intervals after a fall and the physician should be notified of any changes noted during post-fall assessments. He was provided with resident #1's CT scan report with findings of a traumatic subdural hematoma and informed of her current terminal prognosis. The medical director acknowledged it was a significantly negative outcome for resident #1. During interviews on [DATE] at 2:24 PM and 2:58 PM, the administrator stated she was the facility's risk manager and was responsible for conducting and overseeing investigations into injuries of unknown origin and allegations of abuse and neglect. She described resident #1's fracture as an injury of unknown origin. When asked to provide statements obtained during the investigation of resident #1's falls on [DATE] and [DATE], the administrator explained the DON was responsible for fall investigations and it was not protocol to obtain statements for falls. The administrator was informed the facility's Clinical Processes used to educate nursing staff clearly indicated statements should be obtained from at least a CNA and a nurse in the event of a resident's fall. The administrator stated she was neither aware of the severity of resident #1's condition nor that post-fall evaluations and neurochecks were not conducted per policy and procedure to ensure resident received necessary care and services. She confirmed facility staff searched other residents' charts but were unable to find any documentation of neurochecks for resident #1. The administrator provided a witness statement obtained 3 days after resident #1's right heel fracture was discovered. The statement from CNA I, dated [DATE], revealed on [DATE] she informed LPN H that resident #1's foot got caught under her wheelchair. CNA I wrote, I told (LPN H) the nurse but I'm not sure what she did about it. Review of the Abuse Prohibition policy, revised on [DATE], defined neglect as a threat to a resident's health or welfare by deprivation of essential needs The document indicated events including suspicious bruising would be recorded, thoroughly investigated and clinical examinations and recommended follow-up should be completed. Review of the LPN and RN job descriptions, revised [DATE], revealed responsibilities included collaborating with nursing leadership to exchange information regarding patient care, responding to emergencies throughout the shift, notifying physicians regarding changes in condition and obtaining orders.

Based on interview and record review, the facility failed to effectively administer its resources to provide appropriate levels of supervision for 8 of 13 residents who smoked (#1, 2, 4, 6, 8, 10, 11 & 12). This failure contributed to resident #1 sustaining a burn on her abdomen while smoking without supervision and placed her and other residents at risk for serious injury/impairment/death from thermal burns, and fires. The facility's failure to provide adequate supervision for unsafe smokers, and failure to monitor all smokers for dangerous practices resulted in non-compliance at the Immediate Jeopardy level as of 9/10/18, which was determined to be ongoing as of the exit date. Cross Reference to F656, F689 & F865 Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].medlineplus.gov) with left side weakness, [MEDICAL CONDITION], generalized muscle weakness, lack of coordination, abnormal posture and nicotine dependence. The Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 9/13/18 revealed resident #1 had a Brief Interview of Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Review of the medical record revealed resident #1 was admitted to the facility with a known history of smoking. On 4/09/18 she was discovered smoking cigarettes in her room on 2 occasions. Resident #1 was evaluated and found to require supervision with smoking. However, nursing progress notes revealed resident #1 was found smoking inside the facility again on 6/13/18. Although the facility assessed resident #1 and developed care plan interventions designed to ensure her safety while smoking, she repeatedly smoked without supervision, and was known to ask other residents for cigarettes. A nursing progress note dated 9/10/18 revealed when staff discovered a wound on resident #1's abdomen, she admitted to sustaining a burn while smoking without supervision. The resident suffered a burn approximately 1.5 centimeters (cm) X 2 cm on her abdomen. The medical record indicated resident #1 continued to smoke without staff supervision after the incident. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed documentation of resident #2 smoking regularly without staff supervision. He was observed smoking in his room on 2 occasions between (MONTH) and (MONTH) (YEAR), and repeatedly obtained cigarettes and smoked in the courtyard without supervision. 3. Residents #4 and #6 were evaluated to need supervision with smoking. However, on 11/20/18 they were observed in the designated smoking area smoking without staff supervision. Residents #4 and #6 had boxes of cigarettes and lighters in their possession. 4. Residents #8, 10, 11 and 12 were evaluated and deemed to be independent smokers, and their care plan interventions directed staff to monitor for adherence to the facility's smoking policy and procedure regarding smoking. However, observations and interviews revealed these residents had unsafe smoking practices. On 11/20/18 at 5:45 PM, resident #8 stated he obtained cigarettes and lighters from other smokers and on 11/20/18 at 4:47 PM, resident #11 stated he usually kept his cigarettes and lighter in his room. Resident #10 was observed dropping ashes on the ground in the courtyard. On 11/20/18 at 11:46 AM, she confirmed she also kept her smoking materials although she was supposed to return them to the nurse. Resident #10 explained she sometimes shared her cigarettes with other residents. On 11/20/18 at 4:44 PM, resident #12 stated he also kept his smoking materials in his room and shared his cigarettes with other residents. In addition, resident #12 explained he sometimes hid a lighter outside in the courtyard. Review of job descriptions for members of the facility's management team revealed their assigned responsibilities and accountabilities for residents' safety and well-being. Although interviews with the facility's administration revealed awareness of safety concerns related to residents' smoking habits, administration failed to assume responsibility for supervision of smokers and intervene to ensure residents' safety. The job description for the Center Executive Director or administrator, effective 1/01/16, revealed he/she was responsible for directing and coordinating the activities of all departments .to ensure proper health care services to residents. The administrator was expected to collaborate with all departments regarding known problem areas and participate in monitoring and auditing to Create an environment that is focused on patient and staff safety. On 11/20/18 at 12:58 PM, the administrator and director of nursing acknowledged resident #1 had a known history of smoking and always tried to obtain cigarettes from other residents. The DON said, At the time, all the smokers were borrowing cigarettes from each other. On 11/21/18 at 9:09 AM, the DON explained that after resident #1 sustained the abdominal burn, administration conducted a superficial investigation and did not interview other smokers at the time to identify other potential injuries. She said, I feel like it was not a thorough investigation and acknowledged they did not even list the incident on the facility's incident/accident log or adhere to mandatory State and Federal reporting requirements. The DON said, I don't think we put any new interventions in place to protect the resident and other smokers after the day of the incident. She admitted that during the 5-week period after the incident, the management team developed no interventions to increase supervision for resident #1 or any other smokers. The DON stated the facility provided only some smokers with education on the smoking policy and procedure (P&P), but did not implement a system to retrieve cigarettes and lighters from residents or assign staff members to monitor and supervise the smoking area. The administrator explained the facility used to have scheduled smoking times in the past. She stated independent smokers who kept their cigarettes would obtain lighters from staff, and supervised smokers would be accompanied to the smoking area by assigned staff. The DON explained CNAs and nurses were busy and after a while there was no adherence to the smoking schedule or organized supervision of residents. She said, Nobody implemented those times and CNAs often refused. I'm not sure about what happened. She stated the facility tried to give smokers a sense of independence but confirmed, That method didn't work because they were bumming cigarettes off each other. The DON stated she recognized the dangers posed by inappropriate access to smoking materials and lack of staff supervision and said, I should have said more. She confirmed there were staff members available to supervise and monitor all smokers but, We did not take it from the discussion stage to planning and implementing. We didn't provide supervision to the smokers who required supervision to smoke safely. On 11/20/18 at 10:00 AM to 11/21/18 at 1:28 PM the administrator explained smokers were not allowed to keep lighters with them, however, independent smokers were allowed to keep cigarettes in a locked compartment in their rooms. The administrator stated prior to working at this facility she never heard of independent smokers. She said, I didn't know how the CNAs were supervising residents outside when there was no designated CNA. It was haphazard and do-whatever-you-want. The administrator explained smokers who required assistance were taken outside at their request and she described the process as hit and miss. The administrator acknowledged the current process placed the responsibility for safety on cognitively and physically impaired smokers rather than on facility staff. She said, There are more than enough staff in the building to supervise residents who smoke . but they were not utilized efficiently to supervise residents in the smoking area. The administrator validated the facility did not implement new or effective interventions or processes after resident #1 was found smoking in her room on 2 occasions, or again after she suffered a burn injury. She said, I reviewed all the documentation but I could find no evidence that anything was done. She explained the facility continued to have issues with monitoring and supervision of smokers and their access to smoking materials. The administrator stated she discussed the potential for accident with her management team and said, I don't think the team realized the seriousness of the situation.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Performance Improvement (QAPI) program for safe smoking to ensure adequate supervision was provided for 4 of 6 smokers, (#1, 2, 4 & 6). Resident #1 had a known history of unsafe smoking practices, and although she was identified as requiring supervision when smoking, she sustained a burn on her abdomen on 9/10/18 while smoking without supervision. Residents #2, 4 & 6, also required supervision due to unsafe smoking behaviors that put them and other residents at risk for serious injury/impairment/death from [MEDICAL CONDITION] fires. Cross reference: F656, F689, F835. The facility's QAPI committee failed to identify quality deficiencies by not investigating resident #1's abdominal burn to determine the root cause of the incident. The facility failed to evaluate and analyze the risk to all smokers once the incident was reported. Furthermore, the facility failed to educate staff and monitor for compliance with supervision as per the smoking policy and procedure (P&P). These failures resulted in substandard quality of care at the Immediate Jeopardy level as of 9/10/18, which was determined to be ongoing. Findings: Review of the P&P for Smoking effective 6/01/96 and revised 7/24/18 revealed residents were permitted to smoke in designated areas only. The P&P defined supervised smoking as occurring with, The observer being in direct area of the smoker, within eye contact and able to respond in emergencies. The purpose was to ensure safety for residents who chose to smoke. The P&P indicated the designated smoking area would have metal containers with self-closing covers for emptying of ashtrays. The document revealed that if assessed to be safe, independent smokers could keep cigarettes in locked compartment in their rooms. However, no resident would be allowed to keep a lighter. The P&P for the Center Quality Assurance Performance Improvement (QAPI) Process effective 1/30/17 and revised 2/13/17 revealed the facility's QAPI program would be comprehensive, data-driven and evidence-based. The administrator was tasked with leading the QAPI processes. The P&P indicated .identified problem areas are addressed with data analysis, process improvements, and ongoing monitoring . The responsibilities of the QAPI committee included identification of potential issues through routine activities. In an interview on 11/20/18 at 1:33 PM, the administrator stated the previous administrator did not hold an emergency ad hoc QAPI meeting after resident #1's cigarette burn was reported. She explained that as a new administrator to the facility, she was made aware of the incident on 10/03/18 but did not meet with the QAPI committee until the regularly scheduled monthly meeting on 10/18/18. The administrator explained the committee discussed the failure of staff to implement the smoking P&P and reviewed a 17-point plan of action to ensure compliance with the smoking P&P. She stated that the next scheduled QAPI meeting was held on 11/13/18. At this meeting, discussions included the failure of the 17-point plan as resident #2 was discovered smoking in his room on 11/11/18, and other smokers were not returning their lighters. The QAA committee decided to put a hold on admitting residents who smoked until the facility could ensure a safe smoking process. Review of the QAPI committee's 17-point Educational Plan of Action revealed the document restated the facility's existing P&P for smoking, but did not provide updated appropriate interventions, monitoring requirements or data collection tools to address the lack of supervision for smokers. In addition, the facility admitted a new smoker to the facility, resident #13, on 11/14/18, 3 days after the QAA committee decided not to admit any more smokers. On 11/20/18 at 2:58 PM, the administrator stated daily audits of the smoking area were conducted by herself and other staff. However, she was not able to provide information on frequency of the audits, specific staff involved or any documentation of audit results. The administrator acknowledged the facility did not identify the absence of supervision for smokers, improperly discarded ashes and cigarette butts and unauthorized possession of lighters. On 11/21/18 at 9:33 AM, the director of nursing (DON) validated there was no emergency QAPI committee meeting after resident #1's burn incident was reported. She recalled, It was a superficial investigation. The DON said, I don't think we put any new interventions in place to protect the resident (#1) and other smokers after the day of the incident. She admitted the issue was discussed by the QAPI committee, and they identified the facility's smoking procedure was not adequate. The DON said, We did not take it from the discussion stage to planning and implementing. On 11/21/18 at 1:28 PM, the administrator acknowledged the QAPI committee did not do a root cause analysis, implement an action plan or evaluate the potential for harm to smokers after resident #1 was discovered smoking inside the facility on 4/9/18 and 6/13/18, or after she suffered a burn on 9/10/18. In addition, nursing documentation from (MONTH) to (MONTH) (YEAR) revealed resident #1 was repeatedly discovered smoking without supervision. The administrator said, I reviewed all the documentation but I could find no evidence that anything was done . I don't think the team realized the seriousness of the situation. Resident #2 was discovered smoking in his room on 8/24/18, and staff found burn holes and ashes on his pillow on 9/05/18. Nursing documentation revealed repeated observations of resident #2 smoking in the courtyard without staff supervision, and he again lit a cigarette in his room on 11/11/18. Residents #4 & 6 were permitted to smoke without supervision and to retain their cigarettes and lighters contrary to the facility's smoking P&P. On 11/21/18 at 9:28 AM, the DON confirmed there were no designated staff members who supervised the smokers. The QAA committee failed to recognize the root cause of resident #1's burn injury. The committee did not conclude the incident was a result of a system failure that originated in the lack of supervision by staff. Instead, the facility focused on residents #1 & 2 being non-compliant although they were cognitively impaired, and provided only verbal education regarding safety concerns for residents #4 & 6. Despite documentation of multiple incidents of unsafe smokers being observed smoking without supervision and being discovered with smoking materials in their possession, the facility did not implement any measures for increased supervision or a system for monitoring access to lighters.

Based on record review, observation and interview, the facility failed to implement care plan interventions for smoking to ensure safety and compliance with smoking policy and procedures for 4 of 6 smokers who required supervision (#1, 2, 4 & 6) and 4 of 7 independent smokers (#8, 10, 11 & 12) of a total of 13 sampled residents who smoked. This failure contributed to resident #1 sustaining a burn on her abdomen while smoking without supervision and placed her and other residents at risk for serious injury/impairment/death from [MEDICAL CONDITION] fires. The facility's failure to implement care plan interventions to ensure safety and prevent accidents resulted in non-compliance at the Immediate Jeopardy level as of 9/10/18, which was determined to be ongoing as of the exit date. Cross reference to F689 Findings: Review of the facility's policy and procedure (P&P) for Smoking effective 6/01/96 and revised 7/24/18, revealed the facility permitted smoking in designated areas only. The document defined supervised smoking as, The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. The purpose was To ensure that patients who choose to smoke will do so safely. The P&P revealed a patient's smoking status and level of supervision required should be documented in the care plan, and updated as necessary. The P&P for Person-Centered Care Plan effective 11/28/16 and revised 3/01/18, revealed the facility would develop and implement an individualized care plan to meet each resident's needs. The care plan should include services to be provided, and interventions would be communicated to appropriate staff. 1. A review of the medical record revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].medlineplus.gov) with left side weakness, [MEDICAL CONDITION], generalized muscle weakness, lack of coordination, abnormal posture and nicotine dependence. The Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 9/13/18 revealed resident #1 had a Brief Interview of Mental Status (BIMS) score of 4, that indicated severe cognitive impairment. She required extensive assistance for bed mobility and transfers and was totally dependent on staff for personal hygiene tasks. Resident #1 had unsteady balance and was only able to stabilize without assistance from staff. She had functional limitation in range of motion of her arm and leg on one side. A Smoking Evaluation completed in (MONTH) and (MONTH) (YEAR) revealed resident #1 required supervision when smoking due to poor memory, inability to demonstrate the location of the designated smoking area and unsafe smoking habits including smoking inside the facility. The care plan for smoking with supervision, initiated on 7/06/18, had a goal that resident #1 would smoke safely. The interventions were based on the results of smoking evaluations and included, Supervise resident in accordance with assessed needs (and) maintain patient's (resident's) smoking materials at nurses' station. The care plan indicated resident #1 should wear a fire retardant smoking apron to prevent hot ashes from burning her clothing or skin. Resident #1 also had a care plan for behavior problems related to non-compliance with the facility's smoking policy, initiated on 4/26/18. The care plan goals included resident #1 would smoke in the designated area and follow the smoking policy. The interventions included supervised smoking, nurse to keep cigarettes and lighter and staff to provide assistance to the designated smoking area. Despite the development of care plans with interventions to ensure resident #1's safety, nursing progress notes indicated facility staff did not provide adequate supervision with smoking. Nursing documentation from (MONTH) to (MONTH) (YEAR) revealed repeated incidents of resident #1 smoking inside and outside the facility with neither staff supervision nor a smoking apron. The progress notes indicated resident #1 was discovered smoking in her room twice on 4/09/18 and in the facility's hallway on 6/13/18. She was able to obtain cigarettes from other residents, and progress notes indicated she regularly smoked in the courtyard without supervision. Resident #1 suffered a burn approximately 1.5 centimeters (cm) X 2 cm on her abdomen on 9/10/18 and was still able to access cigarettes and lighters in the facility after the incident. Nursing progress notes on 9/15/18 and 9/16/18 revealed resident #1 continued to go to the courtyard without staff, and on 9/18/18 she was observed smoking without supervision. Later that day resident #1 smelled of smoke and admitted she got cigarettes from other residents. On 9/26/18, resident #1 was again observed smoking without supervision. On 11/20/18 at 11:10 AM, resident #1 explained she sometimes obtained cigarettes from other residents in the smoking area where they smoked without staff supervision. Resident #1 confirmed she got a burn on her abdomen while smoking unsupervised and stated she did not use a safety apron. On 11/20/18 at 12:06 PM, licensed practical nurse (LPN) A, who was regularly assigned to resident #1, stated she was not aware resident #1 required supervision when smoking until after the incident when she sustained a burn to her abdomen. LPN A acknowledged she did not monitor or supervise resident #1 as indicated in the care plan because she thought she was a safe smoker at that time. In an interview conducted on 11/20/18 at 12:41 PM, LPN B and the wound nurse confirmed resident #1 informed them that she dropped ashes and burned her abdomen while smoking without supervision. The wound nurse stated resident #1 required supervision with smoking, and explained, She begs and borrows from her peers. LPN B stated a search of resident #1's room on that day produced a lighter from her bedside table drawer. On 11/20/18 at 12:58 PM, the director of nursing (DON) stated she was aware resident #1 was always attempting to get cigarettes. She said, All the smokers were borrowing cigarettes from each other. The DON acknowledged the facility initiated a care plan for resident #1 for non-compliance with the smoking policy, rather than implementing the existing interventions to provide supervision and prevent sharing of smoking materials. On 11/21/18 at 10:41 AM, certified nursing assistant (CNA) C stated resident #1 obtained cigarettes from other residents, smoked without supervision and was not able to apply the smoking apron without assistance. CNA C confirmed she observed resident #1 smoking outside without staff supervision about 3 weeks after she got burned. She explained the facility used to have scheduled supervised smoking times, but the system no longer existed. CNA C stated she did not intervene or report the situation. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD 10/31/18, revealed resident #2 had a BIMS score of 8 that indicated moderate cognitive impairment. He required supervision for transfers, and personal hygiene and had unsteady balance during transfers and walking. Review of the medical record revealed resident #2 had a care plan for smoking with supervision initiated on 8/24/18. The interventions in the care plan noted that the resident preferred to be outside daily to smoke and staff were to provide opportunities for supervised smoking. A review of the nursing progress notes revealed resident #2 smoked regularly without staff supervision. On 8/24/18, staff noted a strong smell of cigarette smoke and found cigarettes and a lighter in his room. On 8/28/18, staff again found cigarettes in his room, and other residents reported resident #2 attempted to barter his clothes for cigarettes. On 8/30/18, resident #2 smoked without supervision in the courtyard and other residents reported he kept a lighter in his sock. Resident #2 turned in a box with 3 previously smoked cigarettes, and later that day he was again observed smoking in the courtyard smoking without supervision. That night, resident #2's daughter visited and found a lighter hidden in his room. On 9/05/18, staff discovered ashes in resident #2's bed and burn holes in his pillow, but resident #2 continued to request cigarettes from other residents and refused to relinquish lighters in his possession. On 10/17/18, resident #2 was discovered smoking without supervision while wearing a nicotine patch and on 11/11/18, he was again smoking in the courtyard without supervision. Later that day, resident #2 lit a cigarette in his room. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a neurological disorder that affects the control of sleep and wakefulness. People with [DIAGNOSES REDACTED] experience intermittent episodes of falling asleep during the daytime. These sudden sleep attacks could occur during any type of activity, at any time of the day. (www.webmd.com) The MDS 14-day Medicare assessment with ARD of 11/8/18 revealed resident #4 had a BIMS score of 13 that indicated little to no cognitive impairment. He required supervision for transfers and personal hygiene, and had unsteady balance during transfers and walking. Resident #4 had a care plan for smoking, initiated on 1/01/18. The goal was for the resident to smoke safely. The care plan interventions included supervision when smoking, monitor for compliance with smoking policy and maintain smoking materials at the nurses' station. Review of nursing progress notes from (MONTH) to (MONTH) (YEAR) revealed staff were aware resident #4 propelled himself to the courtyard to smoke unsupervised throughout the day, according to his preference. On 11/06/18, a note described resident #4 .self-propelling throughout the facility and outside to the courtyard to the smoking area. Another note dated 11/10/18 read, Propels self in (wheelchair) goes out to smoke frequently independently. An activities note dated 11/16/18 revealed resident #4 .continues to be outside daily to smoke. During a tour of the designated smoking area with the North Wing Unit Manager (UM) on 11/20/18 at 10:36 AM, resident #4 was observed smoking without staff supervision. He held a pack of cigarettes and a white lighter, and his clothing, shoes and wheelchair were covered with ashes. Resident #4 explained he kept his cigarettes and lighter in his room and smoked in the courtyard whenever he wanted. The UM acknowledged resident #4's care plan indicated he required supervision when smoking and he should not be in possession of smoking material. However, she made no immediate attempt to retrieve the cigarettes and lighter from resident #4. In interviews conducted on 11/20/18 from 11:18 AM to 4:44 PM with CNAs E, G & H, I, LPN B, and the North Wing UM, they validated resident #4 smoked unsupervised at his leisure and kept his smoking materials with him. This contradicted the interventions noted in the care plan that directed staff to supervise resident #4 while smoking, monitor for compliance with the smoking policy and secure his smoking materials at the nurses' station. CNAs E, G & H and LPN B verbalized awareness of care plan interventions and acknowledged they were not implementing the approaches. On 11/20/18 at 11:18 AM, CNA G confirmed she was regularly assigned to resident #4 but said, I have never supervised him in all the time he has been here. He goes out to the courtyard when he wants to. CNA G stated she had seen cigarette boxes in resident #4's pockets when she assisted him with dressing, and saw him throw empty cigarette boxes in the trashcan in his room. On 11/20/18 at 11:20 AM, resident #4's assigned nurse LPN B stated he was supposed to be supervised when smoking. She acknowledged she was aware resident #4 kept his cigarettes in his room although he did not have a locked compartment to secure them. On 11/20/18 at 11:25 AM, the North Wing UM stated resident #4 should not have cigarettes and a lighter without supervision. She explained it was possible that he obtained a lighter from another resident. On 11/21/18 at 3:39 PM, CNA I confirmed resident #4's care plan interventions were not enforced. CNA I explained the facility's smoking procedures changed over the years, and the facility staff no longer accompanied residents who required supervision to the smoking area at designated times. She said she was regularly assigned to resident 4, but, I have never taken him out. She added, I've seen a box of cigarettes on his bedside table and acknowledged resident #4 should not have cigarettes in his room. On 11/20/18 at 3:53 PM, CNA E explained resident #4 . always goes out to smoke by himself. She confirmed she knew he required supervision when smoking and acknowledged she was told he was found smoking in his room. However, although regularly assigned to care for resident #4, CNA E said, I have never taken him out. He goes out on his own. On 11/20 /18 at 4:39 PM, CNA H stated she was aware resident #4 should have supervision when smoking, but admitted , I've seen him out there smoking with the other residents, no staff. On 11/20/18 at 4:44 PM, Resident #4's roommate confirmed resident #4 often kept his cigarettes on his bedside in plain view, and staff did not secure them. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's Smoking Evaluation dated 11/11/18, revealed resident #6 required supervision with smoking due to not being able to locate the designated smoking area and sharing smoking material. Review of resident #6's medical record revealed a care plan for smoking with supervision, initiated on 11/11/18. The interventions included to supervise resident in accordance with assessed needs, monitor for compliance with smoking policy and maintain smoking materials at the nurses' station. However, a nursing progress note indicated on 11/18/18 resident #6 kept cigarettes in his room. On 11/20/18 at 10:36 AM, resident #6 was observed in the designated smoking area. There were no staff members in the courtyard area to supervise him as he smoked, and he was in possession of a pack of cigarettes and a lighter. Later that morning at 11:46 AM, resident #6 remained in the smoking area and continued to smoke without supervision. He was observed dropping ashes on the ground instead of using an ashtray. The administrator and the North Wing UM acknowledged resident #6's care plan interventions were not implemented to meet the goal of safety with smoking. Later that day at 4:50 PM, resident #6 confirmed he usually kept his cigarettes and lighter in his bedside table drawer despite being caught providing other residents with cigarettes. Resident #6 stated he had not observed any staff supervision of smokers in the smoking area since his admission 2 weeks ago. During interviews conducted on 11/20/18 from 5:25 PM to 5:40 PM, CNA F and LPN A stated they were regularly assigned to resident #6. Both staff members verbalized resident #6 was a smoker, but neither was aware his care plan directed staff to provide supervision with smoking. CNA F and LPN A confirmed they had never supervised resident #6 or monitored his smoking materials as directed by his care plan. On 11/20/18 at 5:25 PM, CNA F stated resident #6 was a smoker and explained he smoked independently. She did not know where to find information on the level of supervision smokers needed. CNA F stated resident #6 kept cigarettes in his bedside table drawer. She confirmed she had never supervised resident #6 or any other smoker. On 11/20/18 at 5:40 PM, LPN A said, I was under the impression he was an independent smoker. He has been going in and out at will. LPN A was not aware resident #6 was re-assessed and changed to smoking supervision status. 5. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His MDS quarterly assessment with ARD of 8/14/18, revealed resident #8's BIMS score was 10, which indicated moderate cognitive impairment. He required limited assistance from staff for transfers, and extensive assistance for personal hygiene. Review of the Smoking Evaluation forms dated 7/08/18, 7/24/18 and 10/15/18 revealed the resident was deemed an independent smoker. Resident #8's care plan for smoking included an intervention of monitoring for compliance with the facility's smoking policy & procedure (P&P). However, interviews with resident #12 and LPN A revealed resident #8's non-compliance with the smoking policy was not addressed by the facility. On 11/20/18 at 4:44 PM, resident #12 stated he regularly gave cigarettes to resident #8 because he was .too scared to ask the nurses. Resident #12 explained resident #8 did not always need him to light his cigarettes because he had access to a lighter. On 11/20/18 at 5:40 PM, LPN A said, He asks other residents for cigarettes all the time. 6. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#10 had a Smoking Evaluation form dated 10/15/18 that indicated she was able to smoke independently. Her care plan for smoking included interventions to monitor for compliance with facility smoking P&P and maintain smoking materials at the nurses' station. On 11/20/18 at 11:46 AM, during a tour of the smoking area with the administrator, resident #10 was smoking about 6 feet away from the cigarette butt container. There was no ashtray in the immediate area and she flicked ashes on the ground. She explained she was an independent smoker and kept her cigarettes. The administrator validated resident #10 was not disposing of the ashes properly. On 11/20/18 at 5:42 PM, CNA L stated resident #10 was an independent smoker so he had never observed her to check if she followed smoking policies. CNA L was not aware resident #10's cigarettes should be kept at the nurses' station. On 11/21/18 at 3:45 PM, registered nurse (RN) K stated resident #10 was giving out cigarettes in the recent past. She confirmed nursing management was informed but did not enforce the care plan approach for cigarettes to be kept at the nurses' station. 7. Resident #11 was admitted to the facility on [DATE]. Review of the medical record revealed a care plan for independent smoking, initiated on 9/16/14. The care plan interventions were updated on 8/15/18 to include, Monitor (resident's) compliance to smoking policy. The interventions reflected direction in the P&P for Smoking, revised 7/24/18, that no (resident) would be able to maintain their own lighter or matches. On 11/20/18 at 4:47 PM, resident #11 stated he kept his cigarettes and lighter most of the times because it was sometimes difficult to get a lighter from the nurses' station. 8. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had a care plan for smoking independently initiated on 9/16/14. The care plan interventions were updated on 8/15/18 to include Monitor patients compliance to smoking policy. The intervention reflected direction in the P&P for Smoking revised 7/24/18, that no patient would be able to maintain their own lighter or matches. On 11/20/18 at 10:33 AM, resident #12 was in the designated smoking area seated in a wheelchair. He had an unlit cigarette and a green lighter. Resident #12 explained he kept his cigarettes and lighter in his room because sometimes he never got a full lighter back. He was aware the smoking P&P did not permit residents to have lighters in their rooms. He stated, But that doesn't mean I can't keep one outside. It isn't going to burn anyone out here. Resident #12 explained he kept a lighter hidden in the courtyard garden area. Later that afternoon at 4:44 PM, resident #12 admitted he provided cigarettes for other residents, including residents #2, 4 and 8. Resident #12 stated that the facility staff had not provided any supervision of smokers in the smoking area. He said, There are never any staff out there watching us. They don't know what anyone is doing unless somebody tells them. On 11/21/18 at 9:09 AM, the DON confirmed if residents' care plans recommended supervision or monitoring, the facility's goal was to ensure this occurred. She acknowledged this was not being done for the smokers according to their care plans, and said, We did not assign a staff member to monitor the smoking area. On 11/21/18 at 9:28 AM, the administrator stated during investigation of the incident with resident #1's burn, she discovered the facility used to have scheduled smoking times for the supervised smokers. The DON stated there was currently no smoking schedule or designated staff member to supervise residents who smoked. She said, I'm not sure about what happened. On 11/21/18 at 11:43 AM, the MDS Coordinator stated residents' smoking evaluations were completed by UMs or assigned nurses. She explained the staff member who took a smoker out to the courtyard to supervise him or her was responsible for reporting any changes that affected safety. The MDS Coordinator acknowledged there needed to be oversight of independent smokers as well to ensure they were compliant with the smoking policy. She validated supervision and monitoring of all smokers was inconsistent and said, We have had a problem in the building that needed to be addressed in the past. The MDS Coordinator suggested in order to effectively implement care plan interventions related to monitoring and supervising smokers, a staff member needed to be assigned to the smoking area.

Based on observation, record review and interview, the facility failed to provide adequate supervision for 4 of 6 residents identified at risk for unsafe smoking, (#1, #2, #4 & #6). This failure contributed to resident #1 smoking unsupervised and sustaining a burn on her abdomen, and placed other residents at risk for serious injury/impairment/death from [MEDICAL CONDITION] fires. The facility's failure to adequately supervise all smokers to ensure their safety and prevent accidents resulted in substandard quality of care at the Immediate Jeopardy level as of 9/10/18, which was determined to be ongoing. Cross reference to F656, F835, and F865 Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].medlineplus.gov) with left side weakness, [MEDICAL CONDITION], generalized muscle weakness, lack of coordination, abnormal posture and nicotine dependence. The Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 9/13/18 revealed resident #1 had a Brief Interview of Mental Status (BIMS) score of 4, that indicated severe cognitive impairment. She required extensive assistance for bed mobility and transfers and was totally dependent on staff for personal hygiene tasks. Resident #1 had unsteady balance and was only able to stabilize with assistance from staff. She had functional limitation in range of motion of her arm and leg on one side. Review of a care plan dated 7/06/18 revealed resident #1 was to be supervised with smoking. The interventions included, Supervise resident in accordance with assessed needs (and) maintain patients smoking materials at nurses' station. The care plan indicated resident #1 should wear a fire retardant smoking apron to prevent hot ashes from burning her clothing or skin. Resident #1 also had a care plan for behavior problems related to non-compliance with the facility's smoking policy, initiated on 4/26/18. The care plan goals was resident #1 would smoke in the designated area and follow the smoking policy. The interventions included supervised smoking, nurse to keep cigarettes and lighter and provide assistance to the designated smoking area. Review of resident #1's medical record revealed a history and physical admission note dated 3/12/18 that showed resident #1 smoked a half pack of cigarettes per day. A nurse's note on 4/09/18, revealed resident #1 was a smoker who .requires supervision due to patient (resident) smoking in her room. The Smoking Evaluation form dated 4/09/18 indicated resident #1 was assessed by a nurse and deemed to require supervision with smoking as she had poor memory, unsafe smoking habits and was unable to demonstrate the location of the designated smoking area. The form read, Resident lit a cigarette in her room on 2 occasions today. Another nursing progress note dated 6/13/18 revealed staff smelled cigarettes in the hallway and resident #1 was again observed smoking inside the facility. A progress note dated 6/14/18 indicated resident #1 was a smoker and .spends time in the courtyard smoking. At a care plan meeting held on 7/06/18, resident #1's daughter informed the facility the family would supply her mother with smoking materials. A Smoking Evaluation form completed on that day revealed resident #1 continued to require supervision when smoking as, Resident sometimes forgets and smokes in room. The evaluation indicated resident #1 no longer disposed of cigarette ashes and butts properly. The next Smoking Evaluation completed on 8/25/18, revealed resident #1 required supervised smoking due to .a history of lighting and smoking cigarettes in her room. The document showed that in addition to not disposing of ashes and cigarette butts safely, resident #1 now had a history of [REDACTED]. A change in condition note dated 9/10/18 indicated resident #1 had a Skin wound or ulcer. Nursing progress notes dated 9/10/18 and 9/11/18 detailed the wound was a Burned area . to right abdomen and Right abdomen burn spot . An assessment by the North Wing unit manager (UM) on 9/11/18 described a 1.5 centimeter (cm) x 2 cm red area to abdomen and also noted 1 cm x 1.5 cm blister to same area under her navel. A Customer at Risk meeting note regarding discussions by the interdisciplinary team (IDT) on 9/14/18 revealed resident #1 was still considered a supervised smoker and remained non-compliant with smoking policy and procedure. The note read, She has been smoking at times when the staff are not with her. Resident #1 was to remain a supervised smoker, wear a smoking apron, and have no access to cigarettes or lighters. Despite IDT discussion of the requirements for staff supervision and use of an apron when smoking, nursing documentation revealed resident #1 continued to smoke without supervision. Nursing progress notes dated 9/15/18 and 9/16/18 revealed resident #1 continued to wheel herself from inside the facility to the courtyard without assistance. On 9/17/18, a nurse's note indicated resident #1 no longer smoked and her sister stopped providing cigarettes. The attending physician ordered nicotine patches to prevent cravings. However, the medical record showed the following day, on 9/18/18, resident #1 was again observed in the courtyard smoking with another resident, unsupervised by staff. In yet another incident later that day, the North Wing UM noted resident #1 smelled of cigarettes. Her documentation revealed resident #1 admitted to smoking and did not wear a safety apron. She told the North Wing UM she got cigarettes from other residents. Another incident, documented by the South Wing UM on 9/26/18, indicated resident #1 smoked a cigarette provided by another resident, without staff supervision. The Smoking Evaluation dated 10/15/18 revealed resident #1 had a history of [REDACTED]. The assessment revealed, Supervised smoking is required. On 11/20/18 at 11:10 AM, resident #1 stated she got cigarettes from other residents in the smoking area, and they who would light them for her. She was not aware she had to wear a protective apron when smoking. Resident #1 said, The people who work here don't smoke so we (the residents) smoke together. Resident #1 confirmed she suffered a cigarette burn on her abdomen, but could not provide details regarding the incident. On 11/20/18 at 12:06 PM, licensed practical nurse (LPN) A stated she was regularly assigned to resident #1. She explained she found out about resident #1's cigarette burn in report from another nurse in (MONTH) (YEAR). LPN A stated to her knowledge resident #1 was a safe smoker who did not require supervision prior to that incident. LPN A was not aware resident #1 had been deemed an unsafe smoker since (MONTH) (YEAR). On 11/20/18 at 12:41 PM, LPN B stated she was assigned to resident #1 on the day her burn was discovered. LPN B explained the assigned CNA asked her to evaluate an area of redness on resident #1's abdomen. LPN B described a circular red area about the size of a pencil eraser on the right side of her navel. She stated the surrounding area was red. LPN B said, It looked like a burn and I asked if she dropped her cigarette . LPN B informed the wound care nurse who also evaluated the area. LPN B stated resident #1 then admitted to both nurses that she had been smoking, dropped ashes on her abdomen and burned herself. The wound care nurse stated resident #1 should have been a supervised smoker at that time, but explained, She begs and borrows from her peers. Her sister was not supplying cigarettes anymore. LPN B said, When we found the burn we looked in her drawer and found a hidden lighter. It was wrapped up in something. On 11/20/18 at 12:58 PM, the director of nursing (DON) stated resident #1's burn was discussed by the IDT and a nicotine patch was initiated, but it was not successful as resident #1 continued to smoke. The DON said, She was always trying to get cigarettes. At the time, all the smokers were borrowing cigarettes from each other. The DON confirmed resident #1 managed to get cigarettes from the other smokers in the facility. She stated the facility educated resident #1 on the smoking policy and safety issues, and although she verbalized agreement, resident #1 remained non-compliant. She stated resident #1 was then care-planned for non-compliance. When asked how the resident #1 with severe cognitive impairment was able to comprehend education of the smoking policy, the DON did not provide an answer. On 11/21/18 at 10:41 AM, certified nursing assistant (CNA) C explained when resident #1 did not have cigarettes and wanted to smoke, some of the other residents gave her cigarettes. She stated there were aprons hanging outside in the smoking area, but resident #1 would not remember to put an apron on, and probably would not be able to reach it. CNA C stated she did not recall whether resident #1 ever asked staff for cigarettes. CNA C confirmed she observed resident #1 in the courtyard smoking without supervision about a month ago, after she sustained the burn on her abdomen, but did not intervene or report the situation because it was normal. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment with ARD of 10/31/18 revealed resident #2 had a BIMS score of 8, which indicated moderate cognitive impairment. He required supervision with transfers and had unsteady balance. Resident #2 had a care plan for smoking with supervision, impaired cognitive function and behaviors related to non-compliance with the facility's smoking policy. Care plan interventions included a preference to be outside daily to smoke and staff were to provide opportunities for supervised smoking. Review of the medical record revealed documentation of resident #2 smoking regularly without staff supervision, both inside and outside the facility. A nursing progress note dated 7/29/18 revealed resident #2 refused his prescribed nicotine patch and informed the nurse he was going to smoke. On 8/24/18, the North Wing UM wrote, Resident noted in room with strong smell of cigarette smoke. A search of the room produced cigarettes and a lighter that were confiscated by the North Wing UM. She informed resident #2 he would no longer have independent smoking status, instead, he would be supervised by staff. However, later that day resident #2 was noted to smell of smoke and was found with cigarettes in his wheelchair. He explained he got the smoking materials from another resident. A Smoking Evaluation form completed on that day read, Supervised smoking is required due to non-compliance with smoking policy, smoking in his room, and getting cigarettes from other residents. On 8/27/18 and 8/28/18, the North Wing UM again discovered cigarettes in resident #2's room. She documented that resident #2's peers stated he went outside to the smoking area and attempted to barter his clothing for cigarettes. On 8/30/18, a resident informed staff that resident #2 was in the courtyard smoking and had a lighter hidden in his socks. The nursing note read, Staff went out and found him smoking unsupervised. Resident #2 turned in a box to staff with 3 previously smoked cigarettes. Later that day, resident #2 was again observed in the courtyard smoking, and that night his daughter visited and found a lighter hidden in his room. A Customer at Risk meeting note dated 8/31/18 revealed the IDT found resident #2 had .poor safety awareness and poor memory recall and was unwilling to rescind cigarettes and lighters. A nursing note on 9/05/18 revealed facility staff discovered .ashes in resident's bed and burn holes in his pillow. On 9/06/18, he was provided with a nicotine patch and placed on non-smoking status. However, on 10/17/18, a nursing progress note revealed resident #2 continued to smoke without staff supervision. The South Wing UM documented resident #2 wore a nicotine patch and was observed smoking outside with another resident. The note read, .resident continues to puff on his cigarette with an extra cigarette placed at the side of his left ear. Resident #2 refused to identify the resident who provided him with cigarettes, but a female resident admitted to lighting it. Another Smoking Evaluation that day revealed resident #2 still required supervision with smoking. A nursing progress note dated 11/11/18 revealed resident #2 was observed smoking in the courtyard, unsupervised by staff. A nurse brought him into the facility and within 5 minutes resident #2 lit another cigarette and headed towards the courtyard. The nurse retrieved 2 cigarettes from resident #2 at that time. On 11/20/18 at 4:44 PM, resident #12, an independent smoker, stated resident #2 had a history of [REDACTED]. Resident #12 confirmed he sometimes supplied resident #2 with cigarettes. 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a neurological disorder that affects the control of sleep and wakefulness. People with [DIAGNOSES REDACTED] experience intermittent episodes of falling asleep during the daytime. These sudden sleep attacks could occur during any type of activity, at any time of the day. (www.webmd.com) The MDS 14-day Medicare assessment with ARD of 11/8/18 revealed resident #4 had a BIMS score of 13 that indicated little to no cognitive impairment. He required supervision for transfers and personal hygiene, and had unsteady balance during transfers and walking. Resident #4 had a care plan for smoking, initiated on 1/01/18. The goal was for resident #4 to smoke safely, and interventions included supervision when smoking, monitor for compliance with smoking policy and maintain smoking materials at the nurses' station. A care plan for impaired cognitive skills with short-term memory deficits revealed interventions to anticipate and provide daily care, and provide cues and prompting as needed. Review of Smoking Evaluation forms for resident #4 revealed he was deemed to be an independent smoker on 12/29/17, 1/17/18 and 4/17/18. However, on 6/20/18 an evaluation indicated resident #4 required supervision with smoking as he was .suspected of smoking in the bathroom and disposing of cigarette butts in the toilet. Despite the unsafe practices, resident #4's Smoking Evaluation forms dated 7/24/18, 10/15/18 and 10/25/18 read Independent smoking is allowed and did not include his known history of unsafe smoking habits and improper disposal of cigarette butts and ashes. The current evaluation, completed by the DON on 10/29/18, indicated resident #4 required supervised smoking due to a history of unsafe smoking habits. Review of nursing progress notes from (MONTH) to (MONTH) (YEAR) revealed documentation of resident #4 propelling himself to the courtyard to smoke. A nurse's note dated 10/29/18, written less than 4 hours after the smoking evaluation indicated resident #4 required supervision, read, Enjoyed the court yard for smoke breaks. However, there was no documentation of staff supervision. On 11/06/18, a nursing progress note described resident #4 .self-propelling throughout the facility and outside to the courtyard to the smoking area. A note dated 11/10/18 read, Propels self in (wheelchair) goes out to smoke frequently independently. An activities note dated 11/16/18 revealed resident #4 .continues to be outside daily to smoke. During a tour of the designated smoking area with the North Wing UM on 11/20/18 at 10:36 AM, resident #4 was seated in his wheelchair smoking. He held a pack of cigarettes and a lighter in his right hand. Resident #4 wore dark blue pants that had gray and white ashes sprinkled across his lap and down the front of both pant legs. There were also heavy layers of ashes on his boots and the frame of his wheelchair. When asked if he kept his smoking supplies, resident #4 said, Yes. He acknowledged he should not have a lighter in his room, but explained he kept his smoking materials so he could come out to the courtyard to smoke whenever he wanted. The UM stated she did not know how resident #4 got the cigarettes and lighter. The UM acknowledged resident #4 should not be in possession of smoking material, and should not be smoking without a staff member present. The UM confirmed there were no staff members in the courtyard. On 11/20/18 at 11:18 AM, CNA G stated she was regularly assigned to resident #4. She confirmed resident #4 smoked cigarettes, and said, I have never supervised him in all the time he has been here. He goes out to the courtyard when he wants to. She stated sometimes she assisted with undressing resident #4 and saw cigarette packs in the pockets of his pants. CNA G explained she had also seen resident #4 throw away empty cigarette boxes in the trashcan in his room. On 11/20/18 at 11:20 AM, resident #4's assigned nurse LPN B stated resident #4 was supposed to be supervised when smoking. She said, He's supposed to have someone with him. She could not explain how he got a lighter because he did not ask her for one that morning. LPN B explained resident #4 always kept his cigarettes, and said, I don't know why, because he doesn't even have a smoking box in his room. She stated smoking boxes were provided for independent smokers only. She did not provide an answer when asked why he was not supervised when smoking. On 11/20/18 at 11:25 AM, the North Wing UM stated residents were free to go to the courtyard whenever they wanted. She said, We can't stop them from sitting out there. The UM acknowledged resident #4 should not have possession of cigarettes and a lighter without supervision. She stated he probably got them from another smoker in the courtyard. On 11/20/18 at 3:53 PM, CNA E stated resident #4 always went outside to smoke without supervision and recalled hearing resident #4 was found smoking in his room a few months ago. CNA E stated she was regularly assigned to resident #4 and knew he should be supervised but said, I have never taken him out. He goes out on his own. She explained everyone knew resident #4's roommate, resident #12 shared his cigarettes with other residents. CNA E did not answer when asked what was done about resident #4's non-compliance with smoking policy. On 11/20 /18 at 4:39 PM, CNA H confirmed she observed resident #4 smoking in the courtyard without staff supervision on many occasions. She acknowledged she did not intervene although she was aware it was wrong. On 11/20/18 at 4:44 PM, resident #4's roommate confirmed resident #4 kept his cigarettes openly in his room. He said, They were always on his side table. Resident #12 could not recall the cigarettes ever being removed by staff, although they were usually in clear view. On 11/21/18 at 3:39 PM, CNA I acknowledged resident #4 should not have cigarettes in his room. However, she said, I've seen a box of cigarettes on his bedside table. She explained CNAs used to supervise the smokers a few years ago, but it became problematic, as some CNAs did not want to be exposed to the cigarette smoke. CNA I explained the rules changed over the years and facility staff eventually stopped escorting/supervising residents in the smoking area. 4. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a care plan for smoking with supervision, initiated on 11/11/18. The interventions included supervise resident in accordance with assessed needs, monitor for compliance with smoking policy and maintain smoking materials at the nurses' station. A Smoking Evaluation form for resident #6 dated 11/07/18 read, Independent smoking is allowed. However, a re-evaluation 4 days later on 11/11/18 revealed resident #6 required supervision with smoking due to not being able to locate the designated smoking area and sharing smoking material. Review of the medical record revealed a nursing progress note dated 11/18/18 regarding resident #6's refusal to return his cigarettes to the nurses' station, instead he kept them in his room. During a tour of the designated smoking area with the North Wing UM on 11/20/18 at 10:36 AM, resident #6 was seated in his wheelchair smoking. He held the cigarette in his right hand and had a pack of cigarettes and a lighter in his lap. A significant amount of ashes was noted on the ground to the right of his wheelchair. There were 3 other residents smoking nearby, but no facility staff members were observed in the courtyard despite resident #4's status as a supervised smoker. Upon return to the smoking area with the administrator later that morning at 11:46 AM, resident #6 remained seated in his wheelchair smoking. The cigarette butt container was to his left side but he held the cigarette in his right hand. Resident #6 was unable to reach the container due to a severe deformity of his left arm. He repeatedly dropped ashes on the ground beside his wheelchair as he smoked, and the administrator validated resident #6 was improperly disposing of the ashes. Resident #6 stated he was an independent smoker and kept his cigarettes in his room and held on to his lighter during the day. The administrator did not comment or correct resident #6 regarding his status as a supervised smoker. Resident #10, an independent smoker, was seated about 6 feet away from resident #6 and the cigarette butt container. There were no ashtrays within her reach and she repeatedly flicked ashes from her cigarette onto the ground, towards resident #6, while she commented on the wind blowing the ashes off her cigarette. On 11/20/18 at 4:50 PM, resident #6 stated he usually kept his cigarettes and lighter in his bedside table drawer. Resident #6 stated to his knowledge he was an independent smoker until that afternoon when the facility decided all smokers should be supervised. He acknowledged other residents asked for cigarettes sometimes, and said he, gave out a few. Resident #6 stated he had not seen any staff members supervising residents smoking in the courtyard in the 2 weeks he had been a resident of the facility. Resident #6 acknowledged he dropped cigarette ashes on the ground in the smoking area instead of in an ashtray, and described it as a habit. When asked about disposal of cigarette butts, resident #6 explained he carefully put out his cigarette, placed the butts in his pocket and disposed of them when he returned to his room. He explained he did not want to drop the butts on the ground because it would be, untidy. On 11/20/18 at 5:25 PM, CNA F stated she was assigned to resident #6 and was aware he smoked. CNA F explained resident #6 smoked independently and kept cigarettes in his bedside table drawer. She confirmed she had never supervised him or any other resident in over 6 month, since she was hired. CNA F said, I'm not a smoker, so I would have to pass it up. They would have to find someone to go out there with him. She was not aware resident #6 required supervision when smoking. On 11/20/18 at 5:28 PM, the South Wing UM stated resident #6 was an independent smoker until he shared cigarettes with other residents. She said, on 11/11/18, we made him a supervised smoker. He should not have access to his cigarettes. The UM confirmed resident #6's smoking materials should be kept at the nurses' station and staff should accompany him to the courtyard, then return the cigarettes and lighter to the nurses' station. The South Wing UM could not explain why resident #6 had smoking materials and was smoking without supervision. On 11/20/18 at 5:40 PM, resident #6's assigned nurse, LPN A was informed resident #6 was in the courtyard smoking without supervision. She said, I was under the impression he was an independent smoker. He has been going in and out at will. LPN A confirmed she was not aware resident #6 was re-assessed on 11/11/18 and changed to supervision with smoking. During a tour of the courtyard on 11/20/18 at 10:45 AM, the smoking area was noted in the southeast corner. There were 2 standing plastic containers for cigarette butts, and 2 ashtrays. There was no self-closing, metal can with lid and sand for collection of butts and ashes from the ashtrays. Observation of the southwest area of the courtyard, opposite the smoking area, revealed cigarette butts scattered along both sides of the walkway that led to facility's side door. There was a large gray trashcan and a white 5-gallon bucket to the right of the door. There were 2 cigarette butts in white plastic bucket, and a strong odor of cigarettes emanated from the trash can. There was a black circular mark with a smear of ash beside the flap of the trashcan's lid. On removal of the lid, a significant amount of cigarette butts and empty cigarette boxes were observed on top of and mixed with paper and food debris inside the trashcan. On 11/20/18 at 10:48 AM, the administrator and Maintenance Supervisor validated there were cigarette butts in the regular trashcan and on both sides of the walkway. The Maintenance Supervisor confirmed the cigarette butts in the trashcan posed a safety concern and could be a fire hazard. The Resident Council president was gardening nearby between the flowerbeds and stated he was in the courtyard almost every day. He validated the smokers often dropped their cigarette butts and ashes all over the courtyard, not just in the smoking area. He stated resident #12 was the main offender, and would take his cigarette butts all the way to the facility door before dropping them on or beside the walkway just before he entered the building. The resident council president pointed to several butts beside the timbers that bordered the flowerbeds. He stated residents occasionally dropped cigarette butts in the garden amidst the mulch in the flowerbeds. Review of the facility's policy and procedure (P&P) Smoking effective 6/01/96 and revised on 7/24/18, revealed the facility would permit smoking in designated areas only. The document defined supervised smoking as, The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. The purpose was, To ensure that patients (residents) who choose to smoke will do so safely. The P&P revealed designated smoking areas should have ashtrays and metal containers with self-closing covers into which ashtrays could be emptied. The admitting nurse would perform a smoking evaluation on every resident who wished to smoke and the level of supervision required should be documented in the care plan. The document revealed smoking materials should be labeled and secured at the nurses' station, unless the resident was cognitively and physically able to do so. In that case, residents could secure their cigarettes in their rooms in locked compartments. The P&P read, Patients will not be allowed to maintain their own lighter .