Every finding on record at The Lilac at Silver Palms

Based on observations, record review, and interviews, the facility failed to ensure medications and biologics were properly stored in two out of two medication rooms (First floor and Second floor medication rooms). As evidenced by: Expired saline and sterile water on the second-floor treatment cart, eye drops observed at Resident # 5's bedside; ointment and medications observed in residents' rooms at bedside (Resident #7, Resident # 15, Resident #31, Resident #60, Resident #76 and Resident #108). Expired Intravenous (IV) start kits and alcohol pads found in the first-floor medication room, expired liquid Lansoprazole for Resident#4 in the second-floor medication room and expired insulin for Resident # 68 found in the first-floor medication cart. There were 94 residents residing in the facility at the time of the survey. The findings include. Resident # 31 Observation on 02/17/2026 at 10:08 AM in Resident # 31's room revealed lanolin-petrolatum ointment (A&D ointment) on top of the resident's dresser. (Photo evidence) Review of the medical records for Resident #31 revealed the resident was admitted to the facility on [DATE]. Clinical diagnosis includes Xerosis Cutis. Resident # 108 On 02/17/2026 at 10:10 AM Zinc Oxide ointment was observed on Resident # 108's bedside dresser. (Photo evidence) Review of the medical records for Resident #108 revealed the resident was admitted to the facility on [DATE]. Clinical diagnosis includes Xerosis Cutis Resident #15 On 02/18/2026 at 9:47 AM Zinc Oxide and A&D ointments were observed on Resident #15's bedside table. (Photo evidence} Review of the medical records for Resident #15 revealed the resident was admitted to the facility on [DATE]. Clinical diagnosis included Xerosis Cutis. Review of Residents #15, #31 and #108's Physician's Orders Sheet revealed the residents did not have any orders for zinc oxide or A&D ointment. Interview on 02/20/2025 at 03:00 PM the Director of Nursing (DON) stated Ointments such as A&D and zinc oxide should only be kept in a resident's room with a physician's order. Residents must have a valid order before these topical treatments can be used or stored at the bedside. Even when an order is present, the ointments should be stored safely in a drawer or designated secure area to prevent accidents and maintain resident safety. Medications should not be left at the resident's bedside or on the bedside table at any time. Resident # 60 Observation on 02/17/2026 at 8:39 AM in Resident #60's room revealed a tube of Mupirocin ointment on the nightstand. (Photo evidence). On 02/17/2026 at 9:13 AM Staff B, Licensed Practical Nurse (LPN) was made aware of the identified concern and removed ointment. Staff B, LPN revealed nurses and Certified Nursing Assistants (CNA)s are responsible for checking residents' belongings and removing any medications and educating the residents. All medications or ointments are to be kept in a locked cart and not in residents' rooms. Record review of Resident # 60's clinical records indicated the resident was admitted on [DATE] with diagnosis that included but not limited to: Other Acute Osteomyelitis. Record review of the February 2026 physician orders sheet revealed: no orders for Mupirocin. Resident # 5 Observation on 02/17/2026 at 9:40 AM in Resident # 5's room a bottle of eye drops was at the bedside. (Photo evidence). Record review of Resident #5's clinical records indicated the resident was admitted on [DATE] with diagnosis that included but not limited to: Heart Failure. Record review of the February 2026 physician orders sheet revealed: no orders for eye drops. Resident #76 On 02/17/2026 at 10:10 AM an observation was made of an open drawer next to Resident #76 with a box of medication visible. (Photo evidence). On 02/17/2026 at 10:15 AM, the second-floor south charge nurse LPN was made aware of the finding in Resident # 76's open drawer and removed the medication. Record review of a demographic sheet revealed Resident #76 was admitted on [DATE] with diagnosis that included but not limited to: Gastro-Esophageal Reflux. Record review of February 2026 physician order sheet revealed Resident #76 had an order dated 2/17/2026 for Gas Relief Oral Tablet Chewable (Simethicone). Give 1 tablet by mouth every 8 hours as needed for Gas. Resident #7 Observation in Resident #7's room on 02/17/2026 at 9:49 AM revealed Ciclopirox topical solution on the shelf in the resident's room. (Photo evidence) On 02/18/2026 at 10:58 AM, observation revealed Resident #7 lying in bed the Ciclopirox topical solution was on shelf in the resident's room. (Photo evidence) On 02/19/2026 at 11:25 AM, Resident #7 was in therapy during observation. Ciclopirox topical solution remained on the shelf in the resident's room. Photo evidence. Record review revealed Resident #7 was admitted on [DATE] with a diagnosis of Acute on Chronic Systolic (Congestive) Heart Failure. On 02/19/2026 at 11:15 AM, the Social Services Director stated residents are not allowed to keep medications in their rooms and that prescribed medications remain on the medication cart. On 02/19/2026 at 11:29 AM, the Administrator revealed Resident #7's wife brought the item into the facility and residents are not allowed to have medications in their rooms. On 02/19/2026 at 2:13 PM, Staff F, Licensed Practical Nurse (LPN), stated: Medications are not supposed to be kept in resident rooms. First-Floor Medication Room On 02/17/2026 at 11:10 AM, during a medication storage inspection of the first-floor medication room with the Assistant Director of Nursing (ADON) revealed six Intravenous (IV) start kits with an expiration date of 02/19/2024 and five alcohol pads with an expiration date of 10/09/2025. Second-Floor Medication Room/ Resident #4 Observation on 02/17/2026 at 11:28 AM of the second-floor medication room with the Infection Preventionist revealed a bottle of liquid Lansoprazole for Resident #4 with a label that read discard after 02/07/2026. Record review of a demographic sheet revealed Resident #4 was admitted on [DATE] with diagnosis that included but not limited to: Gastrostomy and Gastro-Esophageal Reflux (GERD). Record review of February 2026 physician order sheet revealed Resident#4 had an order dated 12/25/25 for Lansoprazole Oral Suspension (Lansoprazole) Give 30 milligrams via Percutaneous Endoscopic Gastrostomy (PEG) Tube two times a day related to GERD. Second-Floor Treatment Cart While checking the second-floor treatment cart on 02/17/2026 at 12:35 PM with Staff A, LPN a bottle of sterile water with an expiration date of 10/27/25 and a tube of normal saline expiration date of 10/2025 (photo evidence) was observed. First-Floor Medication Cart/ Resident # 68 A medication storage check completed on the first-floor medication cart with Staff E, Licensed Practical Nurse (LPN) on 02/18/2026 at 12:30 PM revealed an Admelog solo injection insulin pen labeled with Resident # 68's name, open date 1/15/26 and expiration date 2/13/26 stored in medication cart (photo). Staff E, LPN stated: According to the date on the pen it is expired. Record review of the electronic medication administration record revealed Resident #68 was administered Admelog solo injection on 2/17/2026 at 5:36 PM by Staff E, LPN who then stated, I check for the correct resident and the expiration date before I administer the medication.expired insulin should not be stored in cart or administered. On 02/19/2026 at 9:36 AM the Director of Nursing (DON) stated: We have a pharmacy staff come in and check the med carts every two weeks and remove any expired medications or discontinued medications and educate the nursing staff of how to organize the med cart. Staff are required to check expiration dates prior to each use. No expired materials are to be kept in the medication rooms. The unit managers complete a weekly check on Fridays to ensure no expired medications are on the cart. Residents are only allowed to keep ointments and medications at bedside with a physician's order, otherwise Staff are required to remove. No expired materials are to be kept in the medication rooms or carts. No expired medications are to be administered to residents. During an interview on 02/20/2026 at 7:51 AM the Pharmacist consultant stated: Opened insulins expire after 28 days and some after 45 days review of the pharmacy listing of insulin with expiration dates that revealed Admelog Solostar insulin pen expired 28 days after opening. Record review of facility's policy and procedure titled, Medication Storage dated Free of Accident dated: 11/2020 revised 5/4/2022 revealed: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observations, interviews, and record review, the facility failed to protect residents' personal information on one out of four medication carts as evidenced by: 1) facility's staff left paperwork with residents' personal medical information unattended on top of medication cart. 2) Facility's staff failed to close a computer screen before walking away and resident information visible on the second-floor nursing unit. There were three nursing units in the facility at the time of survey. The findings included:Observation on 02/19/2026 at 10:32 AM on the facility's second-floor south unit revealed an unattended medication cart with paperwork that contained residents' personal information visible (photo). On 02/19/2026 at 10:34 AM Staff J, Registered Nurse (RN) exited a room and approached the medication cart and was made aware of the identified concern. Staff J, RN stated: We keep resident's information private by closing our computer screens and shredding documents. This paperwork shouldn't be on top of cart and should have been shredded.On 02/19/2026 at 2:45 PM the Director of Nursing revealed staff are to close computer screens and turn paperwork over to keep resident information private.Observation on 02/19/2026 at 10:40 AM revealed Staff J, RN leaving the 2nd floor medication cart in the hallway with the computer screen open and residents' information visible on screen. Staff B, Licensed Practical Nurse (LPN) was observed walking down the hallway and the closed computer screen. Staff B, LPN was interviewed and stated, I asked [Staff J, RN] to help a resident and she forgot to close the screen, so I closed the computer screen.Record review of facility's policy dated 1/2026 revealed. POLICY: It is the policy of the facility to maintain Medical Records in accordance with State and Federal regulations.6.The facility will safely guard clinical record information against loss, destruction or unauthorized use.

Based on observations, interviews, and record review, the facility failed to follow infection control protocol when storing medical equipment for two (#38, #46) out of two sampled residents as evidenced by: 1) Observation of an incentive spirometer not stored in a dated plastic bag. 2) Observation of an enteral syringe dated 2/16/26 stored at the bedside of Resident#46 for two days. There were 94 residents residing in the facility at the time of survey. The findings included: Resident #38Observation on 02/17/2026 at 8:25 AM revealed an uncovered incentive spirometer stored at Resident #38's bedside.Record review Resident#38's clinical records indicated the resident was admitted on [DATE] with diagnosis that included but not limited to: Cerebral Ischemia.Record review of a Modification of interim payment minimum data set (MDS) reference dated 12/22/25 revealed Resident #38 had no cognitive impairment and received respiratory therapy for seven days.Record review of a care plan initiated: 12/13/2025 revised: 12/15/2025 revealed Resident #38 was at risk for respiratory complications secondary to history of Pulmonary Embolism with interventions that included but not limited to: Observe for signs and symptoms of respiratory complication. Notify Medical Doctor if abnormal findings. On 02/18/2026 at 8:23 AM Resident #38 revealed the incentive spirometer is used daily.On 02/18/2026 at 10:34 AM the Second-Floor Charge Licensed Practical Nurse (LPN) revealed the respiratory care supplies are to be stored in a plastic bag and the bags are dated for infection control purposes.On 02/18/2026 at 10:35 AM Staff B, LPN was made aware of the identified concern and stated, The order for an incentive spirometer was discontinued.An interview on 02/19/2026 at 10:00 AM with the Director of Nursing (DON) revealed Respiratory care items are kept in a plastic bag, dated and changed every seven days for infection control.Record review of the facility's Policies and Procedures: titled, Respiratory/Tracheostomy Care and Suctioning Date Issued:1/2026 revealed POLICY: The intent of this policy is that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and resident's choice. PROCEDURE: The facility will ensure that a resident, who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' c goals and preferences Resident#46 Observation on 02/17/2026 at 10:08 AM revealed Resident#46 was in bed eyes closed and an enteral syringe dated 2/16/26 was on the nightstand.On 02/18/2026 at 8:24 AM Resident#46 was in bed eyes closed and an enteral syringe dated 2/16/26 was observed on the nightstand. Review of Resident#46's clinical records revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Clinical diagnoses include Encounter for attention to Gastronomy.Review of the Quarterly Minimum Data Set, dated [DATE] indicated the resident is severely impaired cognitively, dependent on Activities of Daily Living and has a feeding tube. Record review of a care plan initiated: 02/03/2026 revised: 02/17/2026 revealed Resident #46 required an enteral feeding tube only for hydration needs with interventions that included but not limited to: Administration of flushes as ordered and check patency and placement of tube daily and before administrating feedings and or meds.Record review of a physician's order sheet revealed Resident #46 had orders dated: 2/2/2026 for water flush 120 milliliters (mL) every shift via PEG for tube patency every shift related to Hemiplegia and hemiparesis following cerebral infarction affection left non dominant side and 2/13/26 for Valproic Acid Oral Solution 500 milligrams per 10 mL one time a day for Mood disorder via PEG. Record review of the February 2026 Medication Administration Record revealed signatures indicating flushes and Valproic Acid Oral Solution were administered daily via PEG to Resident #46.On 02/18/2026 at 8:54 AM Staff B, LPN revealed Resident #46 receives medications and water flushes via Percutaneous Endoscopic Gastrostomy (PEG) and stated, The overnight shift is responsible to change the syringe, and I check it before I administer medications.An interview on 02/19/2026 at 9:47 AM with the DON revealed enteral syringes are not to be used more than 24 hours for infection control and the night shift nurses are expected to change the syringes each night shift.Record review of the facility's Policies and Procedures: titled, Policies and Procedures: Enteral Feeding Medication Administration Date Issued:1/2026 revealed POLICY: It is the policy of the facility to provide appropriate medication administration to residents who receive their medications via an enteral feeding tube to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance to State and Federal regulation.Record review of the facility's Policies and Procedures: titled, Policies and Procedures: Infection Prevention and Control and Surveillance Program Date Issued: 1/2026 revealed POLICY: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines.

Based on observations, interviews, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Resident #68) out of one sampled resident receiving insulin injections as evidenced by documentation indicating expired insulin found on the first-floor medication cart was administered to Resident # 68. The findings included: Observation and interview on 02/18/2026 at 12:30 PM during a medication cart inspection conducted on the facility's first floor with Staff E, Licensed Practical Nurse (LPN) revealed an insulin pen (Admelog solo injection) labeled with Resident #68's name with open date 01/15/26 and expiration date 2/13/26 stored in the medication cart (photo). Staff E, LPN stated: According to the date on the pen it is expired. Review of Resident # 68's electronic medication administration record revealed the Admelog solo injection was last administered on 02/17/2026 at 5:36 PM by Staff E, LPN (photo). Staff E, LPN was asked about the facility's medication storage and administration protocols and stated: I check for the correct resident and the expiration date before I administer the medication. Expired insulin should not be stored in cart or administered.Record review of a demographic sheet revealed Resident # 68 was admitted on [DATE] with diagnosis that included but not limited to: Diabetes Mellitus (DM).Record review of a Quarterly minimum data set reference dated 12/5/25 revealed Resident#68 had a Brief Interview of Mental Status score of 3, indicated severe cognitive impairment and injections and was taking Hypoglycemic medications (including insulin).Record review of a care plan initiated: 03/23/2023 and revised: 03/23/2023 revealed Resident#68 had interventions that included: Accu Checks and sliding scale insulin as ordered.Record review of a physician orders sheet revealed: Resident #68 had an order dated 11/12/25 for Admelog Solostar 100 Units per milliliter (unit/mL) Solution pen-injector directions: inject subcutaneously two times a day related to Type 2 DM.On 02/19/2026 at 9:36 AM, the Director of Nursing was made aware of the identified concern and revealed pharmacy staff comes in and check the med carts every two weeks and remove any expired medications. No expired materials are to be kept in the medication rooms or carts. No expired medications are to be administered to residents. During an interview on 02/20/2026 at 7:51 AM the Pharmacist Consultant stated: Opened insulins expire after 28 days and some after 45 days.Review of a listing of insulin with expiration dates provided for review with the Pharmacist Consultant revealed Admelog Solostar insulin pen expired 28 days after opening.Record review of facility's policy and procedure titled, Quality of Care dated 1/2026 reveled Policy: It is the policy of the facility to ensure that each resident receive, and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations.Definitions:Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Based on interview and record review, the facility failed to demonstrate effective plans of action were implemented to correctly identify repeated deficient practices in the problem areas of F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761Medication Storage. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's Quality Assurance and Performance Improvement policy and procedure dated 1/2026 indicated: These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.Policy: The facility, will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Review of the facility's survey history revealed, during a recertification survey with exit dated January 30, 2025, F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761Medication Storage were cited.Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets revealed: The facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads.Interview with the Administrator on 02/20/2026 at 3:15 PM revealed the QAPI (Quality Assurance and Performance Improvement) meetings are held each month or as needed. The members include: The Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing/ Infection Preventionist, Maintenance Director, Housekeeping/Laundry Supervisor, Social Services Director, Activity Director, Food Service Manager, Business Office Manager, Admissions Coordinator, Medical Records, Registered Dietitian, Pharmacist consultant, Unit Managers and Certified Nursing Assistants. The purpose of the QAPI is to identify and review interventions to meet all the need of residents and ensure regulations are being followed; evaluate and revise interventions as needed. We monitor the progress of our goals by receiving input from staff, family, residents and vendors as well as doing rounds daily. All issues are considered a priority. We have some plans of improvement that remain ongoing.'

Based on observations, interviews, and record review, the facility failed to collaborate and coordinate with hospice representative for one (#5) out of one sampled resident receiving hospice services as evidenced by: facility staff failed to obtain and keep nursing notes in the hospice folder for Resident#5 since December 2025 when Resident started with hospice. There were seven residents receiving hospice care residing in the facility at the time of survey. The findings included:On 02/19/26 at 1:00 PM Resident#5 was in bed with eyes closed and call light in reach. Oxygen was in progress at 2 Liters per minute, no apparent distress.Record review of Resident #5's clinical records revealed Resident #5 was admitted on [DATE] with diagnosis that included but not limited to: Encounter for Palliative Care and Heart Failure.Record review of a significant change in status minimum data set reference dated 12/12/25 indicated Resident #5 has moderate cognitive impairment and receiving hospice care.Record review of a care plan initiated on11/06/25 and revised 11/07/25 revealed Resident #5 received hospice care with interventions that included: Hospice nurse to visit as per hospice schedule, days/times subject to change.Record review of a physician orders sheet revealed Resident #5 had orders dated 12/1/25 for hospice for evaluation and 12/3/25 to Admit to Hospice with diagnosis: Heart Failure. A record review of the Hospice Folder revealed a sign in sheet indicated nursing visited Resident#5 on 12/11/25, 1/15/26, 1/22/26, and 1/28/26 (photo), a Do Not Resuscitate form was dated and signed 11/12/25, admission Doctor's Orders form dated 12/2/25. No plan of care and no nursing notes were found in the folder. On 02/19/26 at 1:00 PM, the second floor Charge Licensed Practical Nurse (LPN) was asked about hospice visits and notes and stated, Resident #5 started with hospice December 2025. I verify that hospice staff comes by checking the book. I don't know how many times a week the hospice nurse visits or the last time. The surveyor asked why there were no hospice nursing notes readily available for review in Resident #5's medical records. The second floor Charge LPN replied, I have been calling asking for notes, but none have been sent. During an interview on 02/19/26 at 1:50 PM, the Director of Nursing (DON) stated: The hospice nurse visits once a week. Hospice staff are to sign, send notes and give report to the floor nurses.On 02/19/26 at 2:15 PM, the second floor Charge LPN entered the conference room and revealed to the surveyors that the hospice notes had just been emailed. The DON was also present and revealed this was not efficient.Record review of the Hospice Nursing Facility Agreement effective 07/23/2024 signed between facility and hospice company revealed Coordination of Care.(i) General. Facility shall participate in any meetings, when requested by Hospice, for the coordination of services provided to Hospice Patients. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day.Record review of the facility's policy and procedures titled, Hospice dated 1/2026 revealed Policy: It is the policy of the facility to provide collaborative care with Hospice providers to ensure that our resident's end of life preferences and choices are honored. Procedures:5. The designated interdisciplinary team member is responsible for the following:Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.Communicating with hospice representatives and other healthcare providers participating in the provision of care for terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family

Based on observations, interviews and record review the facility failed to store food under sanitary condition and to ensure resident's food items were dated and labeled in the nourishment refrigerator on the Second Floor North Wing. This has the potential to affect 31 out of 35 residents who eat orally residing on the Second Floor North Wing out of 94 residents in the facility at the time of the survey.The findings included: Record review of the Use and Storage of Food Brought by Family or Visitors Policy and Procedure (revision date March 20223); Policy Statement-It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident; Policy Explanation and Compliance Guidelines: 2) All food items that are already prepared by the family or visitor brought in must be labeled with content and dated and a) The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.Observation of the nourishment refrigerator on the Second Floor North Wing used to store resident's foods on 2/17/26 at 8:41 AM revealed a lunch bag in the refrigerator without a name or date on it. Photographic evidence submitted.Interview and Observation with Staff A, Licensed Practical Nurse on 2/17/26 at 8:44 AM. She opened the lunch bag and it contained several food items. She stated, This belongs to a resident. The lunch bag should have a label on it and a date.Interview with the Director of Nursing on 2/17/26 at 9:49 AM. She confirmed that food items in the refrigerator and freezer for residents should be labeled and dated.

Based on observations, interviews, and record review, the facility failed to properly position indwelling urinary catheter's tubing in a manner to promote free flow of urine for two ( Resident #29 and Resident #76) of two sampled residents with an indwelling urinary catheter as evidenced by: 1)Resident # 29's indwelling urinary tubing observed extending down and up through pants with urine in the tubing. 2) Resident # 76's indwelling urinary catheter tubing observed coiled with urine in the tubing. This deficient practice prevented urine from freely flowing, increasing the risk for catheter-associated urinary tract infections and other serious medical issues.The findings included: Resident #76Observation on 02/17/2026 at 10:09 AM revealed Resident # 76 in bed, the indwelling urinary catheter tubing was looped and contained urine; there was less than 5 milliliters (mL) of urine in the drainage bag.On 02/17/2026 at 10:11 AM, the second-floor charge LPN was made aware and repositioned catheter tubing to allow the free flow of urine.Resident #76's clinical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to retention of Urine and Neuromuscular Dysfunction of Bladder. Record review of Resident #76's physician's order sheets revealed an order dated: 12/20/2025 to observe indwelling urinary catheter for placement, leakage, or dislodgement every shift.Record review of a care plan initiated 12/31/2025, revised on 01/12/26 revealed Resident#76 was at risk for infections related to urinary catheter indicated for Neurogenic bladder / Urinary Retention. The interventions included: Keep catheter below level of bladder but off the floor Keep catheter tubing free of kinks.Review of the Five-day Minimum Data Set reference dated 01/22/2026 revealed Resident #76 had no cognitive impairment, was dependent on toileting hygiene, had Septicemia, and an indwelling catheter.Record review of the facility's Infection Control Surveillance report for January 2026 revealed Resident #76 was receiving Cefuroxime Axetil 500 milligrams (mg) and Levofloxacin 500 mg antibiotics ordered on 1/18/26 for urinary infection. Resident #29Observation on 02/18/2026 at 11:28 AM revealed Resident #29 in room seated in wheelchair the indwelling urinary catheter tubing extended downward through the resident's pants and then secured upward on wheelchair, preventing urine from flowing freely (photo evidence). On 02/18/2026 at 11:30 AM, the second floor Charge Licensed Practical Nurse (LPN) was made aware and stated: The tubing will be adjusted to allow the free flow of urine.Record review of Resident #29's clinical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included Benign Prostatic Hyperplasia (BPH).Record review of a February 2026 physician orders sheet revealed: Resident #29 had orders dated: 2/5/26 for Suprapubic Catheter. Diagnosis: BPH and 2/10/26: Monitor Suprapubic catheter for placement, leakage, or dislodgement every shift. Record review of a care plan initiated 11/26/2025 and revised 12/08/2025 revealed Resident #29 at risk for infections related to suprapubic catheter indicated for Obstructive Uropathy with interventions including: Keep catheter below level of bladder but off the floor; keep catheter tubing free of kinks.Record review a Five-day Minimum Data Set reference dated 01/22/2026 indicated Resident #29 had no cognitive impairment, required substantial/ maximal assistance for shower/bathe, partial/moderate assistance for dressing, and had an Indwelling catheter. During an interview on 02/19/2026 9:43 AM, the Director of Nursing (DON) revealed the catheter tubing should be straight to prevent back flow of urine to prevent urinary tract infection (UTI). On 02/20/2026 at 7:56 AM, the Infection Preventionist stated, Staff are to ensure tubing is not kinked or coiled to prevent back flow of urine which could cause a UTI. Record review of the facility's Policies and Procedures: titled, Policies and Procedures Infection Control- Indwelling Catheter Care Date Issued: 1/2026 revealed POLICY: It is the policy of the facility to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, in accordance with standards of practice.

Based on observations, record review, and interviews, the facility failed to ensure an environment free of accident hazards as evidenced by razor observed in Resident #7's room, 2) Resident #107 observed with heating pad; 3) Overfilled sharps container in Resident #29's room and 4) Unsecured door with interior lock on second floor south hallway. There were 94 residents residing in the facility at the time of the survey.The findings included. 1) On 02/17/2026 at 9:49 AM, observation revealed Resident # 7 in bed alert there was a shaving razor on the shelf. Photo evidence was obtained. On 02/18/2026 at 10:58 AM, observation revealed a razor on the shelf in Resident #7'ss room. On 02/19/2026 at 11:25 AM, Resident # 7 was in therapy and the razor remained on the shelf in the resident's room. Photo evidence was obtained. Record review revealed the resident was admitted on [DATE] with diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure. Review of Resident #7's admission Minimum Data Set, dated [DATE] indicated the resident is cognitively intact and required assistance with oral and personal hygiene. Review of Resident #7's Care Plan dated 01/22/2026 with next review date 04/22/2026 focused on arranging the resident's environment to facilitate activities of daily living performance and keeping frequently used items within reach. Interviews on 02/19/2026 at 11:15 AM, the Social Services Director, revealed residents are not allowed to keep razors in their rooms. Alert residents may use razors under supervision, and the razor is removed afterward. If residents are not alert, Certified Nursing Assistants assist with shaving and remove the razor afterward. Interview on 02/19/2026 at 11:29 AM, the Administrator reported the razor was brought in by Resident #7's wife and residents are not allowed to keep the item. On 02/19/2026 at 2:13 PM, Staff F, Licensed Practical Nurse, LPN, stated: Razors are not supposed to be kept in resident rooms. On 02/20/2026 at 3:13 PM, Staff G, Certified Nursing Assistant, CNA, revealed if a potentially harmful item is identified in a resident's room, the item is removed immediately and secured in a safe place. 2) Observation on 02/17/2026 at 9:19 AM revealed Resident #107 in the bathroom performing morning care and a heating pad was observed on the bed (photo). A private aide was at the bedside and revealed Resident#107 uses the heating pad daily. On 02/17/2026 at 9:30 AM Staff C, Certified Nursing Assistant revealed Resident#107 normally uses the heating pad throughout the day. Record review of Resident #107's clinical records revealed the resident was admitted on [DATE] with diagnosis that included but not limited to depression. Record review of an admission Minimum Data Set reference dated 11/15/25 revealed Resident #107 had no cognitive impairment, required supervision or touching assistance for eating/ oral hygiene, partial/moderate assistance for toileting, substantial/maximal for shower/bathe/dressing, partial/moderate assistance for toilet transfer. Record review of a care plan initiated: 11/13/2025 and revised: 11/18/25 revealed Resident #107 had an ADL (Activities of Daily Living) self-care performance deficit with interventions that included but not limited to: Provide cueing for safety and sequencing to maximize current level of function During an interview on 02/18/2026 at 11:06 AM, the second-floor south unit charge Licensed Practical Nurse (LPN) and Staff B, LPN revealed they had no knowledge of Resident#107 using a heating pad. On 02/18/2026 at 12:08 PM Resident #107 revealed the heating pad was used daily due to the cold weather. On 02/18/2026 at 2:45 PM, the Director Nursing was informed of the identified concern and stated, We don't allow residents to have heating pads because of the risk of getting burned or any skin damage. The nurses were not aware of [Resident #107] uses a heating pad. 3) Observation on 02/17/2026 at 10:44 AM in Resident #29's room revealed a red puncture resistant container secured to the wall filled to capacity. (photo). On 02/17/2026 at 10:45 AM, the second-floor charge LPN was made aware and stated, It will be changed. During an interview on 02/19/2026 at 9:45 AM, the Director of Nursing stated: Staff are to change the sharps container when it is 3/4 full for safety of residents and staff. 4) Observation on 02/17/2026 at 9:58 AM revealed an unlocked door that locked from the inside in the second-floor south unit hallway that contained enteral and medical materials. On 02/17/2026 at 10:00 AM, The second-floor south unit charge LPN was notified and stated, This door is to be kept locked with a key for residents' safety.a resident could wander inside and get locked in. Record review of facility's policy and procedure titled, Free of Accident Hazards/Supervision/Devices dated: 1/2026 indicated: POLICY: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. PROCEDURE: 1. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observations, interviews, and record review, the facility failed to honor residents right to a dignified experience for one (Resident #29) out of one sampled resident with an indwelling cholecystostomy drainage device as evidenced by observation of Resident # 29 receiving physical therapy and the cholecystostomy drainage collection bag was not inside a privacy bag and visible. There was one resident with a cholecystostomy drainage device residing in the facility at the time of survey. The findings included: Observation on 02/18/2026 at 10:27 AM, revealed Resident #29 self-propelling in wheelchair on the 2nd floor hallway towards the therapy room. A cholecystostomy drainage bag was visible (photo). On 02/18/2026 at 10:30 AM Resident # 29 was observed being assisted with ambulation using a walker by the Physical Therapist and Staff D, Occupational therapy assistant. Resident # 29's cholecystostomy drainage bag was visible. On 02/18/2026 at 10:35 AM, Staff B, Licensed Practical Nurse (LPN) was made aware and stated: The drainage bag is to be kept in a privacy bag to provide dignity.During an additional observation on 02/18/2026 at 10:37 AM, Resident # 29 was seated in the therapy room amongst other residents speaking with the Physical Therapist and the cholecystostomy drainage bag visible. Record review of a demographic sheet revealed Resident # 29 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included but not limited to: Fusion of spine, lumbar region.Record review of a Medicare 5- day Minimum Data Set reference dated 01/22/2026 revealed Resident # 29 had a Brief Interview of Mental Status score of 14, indicated no cognitive impairment, was dependent for toileting hygiene, required substantial/ maximal assistance for shower/bathe, partial/moderate assistance for dressing, and had an indwelling catheter. Record review of a care plan initiated 11/26/2025 and revised 02/17/26 revealed Resident # 29 had Activities of Daily Living self-care performance deficit with interventions that included but not limited to: Cholecystostomy care-observe for flush/drainage, signs/symptoms of infection report to Medical Doctor if noted.Record review of a February 2026 physician orders sheet revealed order dated 2/10/26- Observe Cholecystostomy Drainage Catheter Underneath Right Breast for signs and symptoms of infection. During an interview on 02/18/2026 at 10:38 AM, Staff D, Occupational Therapy Assistant and the Physical Therapist revealed they were aware Resident # 29 had a Cholecystostomy drainage catheter but did not realize it was visible today and they would inform nurse if they had noticed it was visible. During an interview with the Director of Nursing on 02/19/2026 at 9:41 AM it was revealed that staff are to place the Cholecystostomy drainage bag in a privacy covering to provide dignity. Record review of facility's policy and procedure titled, Resident Rights-Exercise of Rights date issued: 1/2026 revealed Policy: All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's, goals, preferences, and choices. When providing care and services, staff will respect each resident's individuality, as well as honor and value their input.

Based on observation, record reviews and interviews the facility failed to develop a comprehensive care plan for one (Resident #2) and failed to implement care plan for two (Resident # 6 and Resident # 7) out of seven sampled residents. As evidenced by a fall care plan was not developed for Resident #2 who is at high risk for falls; and staff failed to implement Care Plan interventions to prevent worsening of wounds for Resident # 6 and Resident #7. The findings included: Resident #2 On 02/24/2025 at 11:10 AM Resident #2 was observed sitting in his wheelchair watching television, no distress noted. Review of Resident #2's the clinical revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but were not limited to, History of Falling and Osteoarthritis. Record review of Nurses Notes dated 12/09/2024 revealed during rounds, the resident was noted lying on the floor on his left side beside the bed. Resident remained alert and verbally responsive, no acute distress observed, active range of motion completed, resident was able to move upper extremities, resident reports pain to left shoulder, rated 4/10, pain management measures in place, Nurse Practitioner (NP) made aware, no new orders at this time, call placed to resident's Power of Attorney (POA). Record review of Nurses Notes dated 12/10/2024 revealed the X-ray results received with the following conclusion: Modest osteoarthritis, but no pelvic or hip fracture. Results relayed to NP no new orders received. care ongoing. Record review of Nurses Notes dated 01/05/2025: During rounds, the resident was found on the floor lying on his left side beside the bed. The resident remained alert and verbally responsive. The call light was noted on the bed. Reddened area noted to top of scalp and skin tear to left knee. Vital signs obtained .active range of motion done. The resident was transferred to bed via mechanical lift. Neurological assessment completed. Resident's skin tears to his left knee cleanse with normal saline, pat dry and standard techniques applied. Safety measures maintained, bed at lowest position with call light within reached. The physician made it aware. New orders received for skull X-ray. On 01/07/2025 the resident's daughter was made aware of the [NAME] X-ray result that there was no fracture. Record review of Quarterly Minimum Data Set (MDS) Section C Cognitive Patterns dated 01/23/2025 revealed the resident Brief Interview for Mental Status (BIMS) summary score was 06 out of 15 indicating severe cognitive impairment. Review of the Quarterly MDS Section J for Health Conditions dated 01/23/2025 revealed the resident had two or more fall since admission. Review of a Care Plan initiated on 8/12/2024 with the next review dated 5/1/2025, revealed there was no Fall Care Plan developed for Resident # 2. Interview on 02/24/2025 at 1:19 PM the MDS Coordinator revealed Resident # 2 had a baseline care plan for fall, but she did not realize a fall care plan was not developed. Review of the facility's Policy and Procedures for Comprehensive Care Plans implemented 11/2020 and review dated 07/27/2022 and noted Reviewed by Clinical Services revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that include measurable objectives and timeframes to meet a resident's medical nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 2- the comprehensive care plan will be developed within seven (7) days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs)triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the care plan. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 48906 Resident #6 On 2/24/2025 at 11:57 AM during observation of Resident #6's wound care performed by the wound care nurse assisted by Staff A, Licensed Practical Nurse (LPN), it was noted that both nurses were not wearing gowns as is part of the required Enhanced Barrier Precautions (EBP). Record review of Resident # 6's demographic sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that include: Venous Insufficiency and Peripheral Vascular Disease and chronic non-pressure ulcer of the right heel and midfoot. Record review of a Minimum Data Set (MDS) with reference dated 2/5/2025 for end of Stay revealed Resident #6's a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident has no cognitive impairment; was incontinent of bowel and bladder and had one arterial ulcer present. Record review of a Care Plan initiated on 12/31/2024, revised on 01/28/2025 revealed Resident #6 had actual skin breakdown related to Vascular wound on the right heel; goal included: current skin impairment will be minimized through next review date with interventions that included: Enhanced Barrier Precautions . During an interview on 2/24/2025 at 3:21 PM Staff A, LPN was asked about the required Personal Protective Equipment (PPE) for Resident under Enhanced Barrier Precaution; Staff A, LPN stated: For residents under Enhanced Barrier Precautions, staff are supposed to wear masks, gown, and gloves. I didn't do it because I forgot. On 2/24/2025 at 2:44 PM the wound care nurse was asked if residents with wounds are under Enhanced Barrier Precautions. The wound care nurse revealed; all residents with wounds are under Enhanced Barrier Precautions to prevent the spread of infection. Staff are to wear gloves, gown and masks before providing wound care. The wound care was asked why no gown was being worn during the wound care for Resident # 6. The wound care nurse replied, I didn't wear a gown or mask with [Resident # 6], and I didn't wear a mask with [Resident#7], that was mistake. I was supposed to wear it. Resident #7 Review of the facility's Pressure Ulcer List indicated Resident #7 has a stage 3 (full-thickness skin loss, extending into the subcutaneous tissue /fat layer) on the right heel. On 2/24/2025 at 1:56 PM, Resident #7 was in bed, Staff B, Certified Nursing Assistant (C N A) was providing hygiene care and was not wearing a gown as a required part of Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). Review of Resident #7's demographic sheet revealed the resident was admitted on [DATE] with diagnosis that included: Stage 3 Pressure Ulcer of the right heel. Record review of a physician's order sheet dated 1/27/2025 revealed Resident #7 was under Enhanced Barrier Precaution for wound. Record review of a Significant change MDS reference dated 12/30/2024 revealed Resident #7 had a BIMS score of 2, which indicated severe cognitive impairment, had one stage 3 pressure ulcer/injury and was always incontinent of bowel and bladder. Review of a Care Plan initiated on 04/15/2023 and revised on 04/15/2023 revealed Resident #7 is at risk for skin breakdown, with goal to minimize risk for further skin breakdown and complications with current skin impairment; interventions included: Enhanced Barrier Precautions. During an interview on 2/24/2025 at 2:04 PM Staff B, CNA was asked about the required PPE for a resident under Enhance Barrier Precaution Staff B stated: I should wear a gown. I forgot to put it on. On 2/24/25 at 3:54 PM The Infection Preventionist stated, Staff should wear a gown and gloves when providing care for residents under Enhanced Barrier Precaution. The purpose of Enhanced Barrier Precaution is to help prevent infection. All residents with wounds are under Enhanced Barrier Precaution. We keep the PPE in one caddy for the entire hallway. I ensure that there are enough PPE in the caddy each morning and the supervisor's double check. On 2/24/25 at 3:58 PM, the Director of Nursing stated: Nurses are required to wear gloves and gowns when providing care for residents under enhanced barrier precautions. Resident who have wounds are under Enhanced Barrier Precautions.

Based on Observation and interview, the facility failed to implement infection control standards and procedures related to Soiled Utility Rooms. As evidenced by during focused observations the three Soiled Utility rooms in the facility were found to be unlocked. There were 98 residents residing in the facility at the time of the survey. The findings included: On 01/28/25 at 10:09 AM Focus tour with the surveyor and Registered Nurse Infection Control Preventionist -The two soiled utility rooms on the second floor and the soiled utility room on the first floor were observed to be unlocked. Infection preventionist stated the soiled utility rooms are unlocked during the day. Interview on 01/28/25 at 10:24 AM Licensed Practical Nurse Supervisor, first floor (Staff B), stated herself and the nurses on the first floor have the keys to the soiled utility room, the door is supposed to always remain locked and if staff needs to enter the soiled utility room, they have to ask the nurses or her to unlock the soiled utility room. Interview on 01/30/25 at 07:45 AM Director of Nursing (DON) stated keyed entry locks have been installed on the 3 soiled utility room doors by the maintenance director as of 1/29/24. Staff have been educated and given the code for entry to the soiled utility rooms. Review of the facility policy titled Infection Prevention and Control Program revision date 01/15/2025 states: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, record review and interviews, the facility failed to provide an environment free from accidents for Resident #24, as evidenced by, observations of electric and hand razors on the Resident # 24's nightstand. There were 98 residents residing in the facility at the time of the survey. The findings included: During an observation on 01/29/25 at 09:08 AM Resident #24 was observed watching television. An electric and a disposable razor was noted on the resident's nightstand (Photo evidence). During an observation on 01/30/25 at 08:56 AM, Resident #24 was observed eating breakfast. The razors were still on the nightstand at the resident's bedside. Review of Resident #24's medical records revealed the resident was admitted on [DATE]. Clinical diagnoses include but not limited to: Parkinson's disease with dyskinesia, without mention of fluctuations and Type two Diabetes. Review of the Physician's Orders Sheet (POS) revealed Resident #24 has no orders associated with the use of razors for activities of daily living. Record review of Resident #24 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 15, on a 0-15 scale indicating the resident is cognitively intact Section GG for Functional Abilities documented moderate assistance for care is required. Record review of Resident #24's Care Plans revealed the Resident's activities of daily living (ADL) is self-care performance deficit and impaired mobility. Interventions include- Requires assistance as required by one staff with eating. Requires assistance as required by one staff with dressing. Requires assistance as required by one staff with oral hygiene. Interview on 01/30/25 at 12:42 PM, the Director of Nursing (DON) stated the razors should be kept by the staff at all times. The resident prefer to shave himself. The Resident's son brought him his own personal electronic razor because he is on anticoagulants and at risk for bleeding and had education about shaving safety and where the razor should be stored. Interview on 01/30/25 at 01:13 PM, Staff C, Certified Nursing Assistant (CNA) revealed the razors are kept in the supply room. Resident #24 shaves independently and she does rounds to check on him to make sure he is finished; if she sees razors on the nightstand or in an open dresser she would take it and put it away and the resident will ask for it when he needs it. The resident has never had a shaving incident since she has worked with him. Review of the facility policy and procedure regarding safe and homelike environment 04/2023, states the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Review of the facility policy and procedure regarding Incidents and Accidents 03/2023, states it is the policy in this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident and to ensure residents receive adequate supervision to prevent accidents.

Based on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (Resident #27) out of 25 sampled residents. As evidenced by, during several observations, Resident #27's oxygen was being administered via nasal cannula at the incorrect rate. There were 98 residents residing at the facility at the time of the survey. The findings included: On 01/27/25 at 07:44 AM Resident # 27 was asleep in bed; Oxygen (02) via Nasal cannula (NC) noted running at 2 liters per minute (LPM). On 01/28/25 at 07:35 AM Resident #27 was in bed asleep, 02 running at 2 LPM via NC. On 01/29/25 at 07:54 AM resident in bed awake, 02 running at 2 LPM via NC, no distress noted. Review of Resident # 27's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Respiratory disorders in diseases classified elsewhere, Respiratory failure, unspecified with hypoxia. Review of the Physician's Orders Sheet for January 2025 revealed Resident #27 had orders that included but not limited to: O2 at 3 liters a minute via nasal cannula continuously every shift for Respiratory Failure. Review of Resident #27 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 10, on a 0-15 scale indicating the resident is moderately impaired cognitively. Section GG for Functional status indicated the resident is dependent for activity of daily living (ADLs). Section O for Special Treatments revealed Resident #27 is receiving oxygen therapy. Review of Resident #27 's Care Plans Reference Date 11/27/24 revealed: resident is at risk for respiratory complications related to: obstructive sleep apnea, respiratory failure. Date Initiated: 03/09/2023 Revision on: 12/01/2024. Resident will be free of signs/symptoms of respiratory distress and maintain optimal functioning within limitations imposed by disease process through review date. Interventions Included-Educate resident and or health care decision maker on respiratory health. Educate resident in energy conservation techniques and pursed lip breathing. Encourage resident to express feelings of fear and anxiety and provide verbal and nonverbal support. Medicate as ordered and monitor for effectiveness and observe for signs and symptoms of side effects. Observe for increased wheezing and or lower activity tolerance and report to Physician (MD) as indicated. Observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress and report to MD as indicated. Obtain labs as ordered and report to MD as indicated. Provide respiratory treatment as ordered and monitor effectiveness. Interview and observation on 01/29/25 at 09:40 AM; Registered Nurse (Staff A) stated: I check the resident's oxygen orders in the computer system and then during my rounds, I check to make sure the orders match what the resident is receiving. The surveyor and Staff A checked the resident's oxygen concentrator together in the resident's room. The oxygen level on the concentrator was infusing at 2 LPM and acknowledged_ the orders for the resident's oxygen is 3 LPM via NC. Interview on 01/30/25 at 10:17 AM; the Director of Nursing (DON) revealed the nurses have been in-serviced regarding checking their assigned resident's oxygen orders during their shifts, also at the beginning and the end of their shift. Review of the facility's policy and procedure titled Oxygen Administration revision date 05/04/2022 states: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under the orders of a physician, except in the case of an emergency.

Based on observation and interview, the facility failed to ensure the proper rotation of Dietary Medication supplements. As evidenced by, during observation of first floor's Medication Storage Room, two nutritional supplements were found to be expired. There were 98 residents residing in the facility at the time of the survey. The findings included: On [DATE] at 11:13 AM, During Medication Storage Room observation with Registered Nurse (Staff A), two Vanilla Nutritional Drinks were found in the 1st floor medication storage room with an expiration date of [DATE]. Interview on [DATE] at 12:13 PM, Registered Nurse (Staff A) stated: these supplements are used for residents during medication administration as prescribed, particularly residents who do not want their medications with water. The nurses and the nursing supervisors check the medication storage rooms daily and on each shift. Interview on [DATE] at 10:27 AM, the Director of nursing (DON) stated: Nurses are responsible for checking the medication storage room daily on their shifts. In addition, the central supply clerk and the nursing supervisors will be checking the medication storage rooms on Mondays and Fridays. Review of the facility policy titled Medication Storage revision date [DATE] states: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, interview and record review, the facility failed to ensure one (Resident #13) out of 16 sampled residents was not verbally abused by facility staff. The findings included: Record review of the facility's Abuse, Neglect and Exploitation Policy and Procedure dated 10/1/2022 included, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse - means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. III. Prevention of Abuse, Neglect and Exploitation - The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of residents property and exploitation that achieves: D. The identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect; VII. Reporting/Response - The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protective services and other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of the Activities of Daily Living (ADLs) Policy and Procedure, revised 1/2023 documented: Policy-The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate. Care and services will be provided for the following activities of daily living: 1) Bathing, dressing, grooming and oral care; 3) Toileting. Policy Explanation and Compliance Guidelines: 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Observation and interview of Resident #13 on 9/11/23 at 8:02 AM revealed, the resident sitting in a wheelchair in her room. She stated, The nurse [ ], Staff C, Licensed Practical Nurse (LPN) and the CNA (Certified Nursing Assistant) [ ], Staff D, are very disrespectful to me. I had surgery and came back to the facility on [DATE] and I had a messy diaper. The CNA [ ], Staff D was very rough with me and I told her so. She told me that she would leave me alone and not change me. I told the nurse [ ], Staff C, LPN and she didn't say anything. I reported it to the DON (Director of Nursing) and they called both of them down. The nurse [ ], Staff C LPN said to me, they are going to be wondering where you are and I am going to make sure that you are gone. Every Monday and Tuesday I have to endure this. They still provide care to me. I am the resident council president. I told the previous DON and I don't know if anything was done. The resident started to cry as she started talking about the encounter. A team meeting with the Administrator and DON on 9/11/23 at 8:48 AM was conducted to discuss the abuse and dignity allegation from Resident #13. The current Administrator and the current DON were not aware of Resident #13's allegations. Review of the Demographic Face Sheet for Resident #13 documented, the resident was admitted on [DATE] with a diagnosis of idiopathic progressive neuropathy, hypertension, anxiety disorder, major depressive disorder, schizoaffective disorder bipolar and insomnia. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #13 documented, the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and she was able to make her needs known and she required limited assistance with one person physical assist for ADLs (activities daily living). Review of the ADL (Activities of Daily Living) care plan for Resident #13 (written 10/09/22) documented, the following: Focus-Resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to chronic disease process; Goal: Resident will maintain highest capable level of ADL ability throughout the next review period as evidenced by his/her ability to perform ADLs and Interventions: Assist resident with ADL's as needed, encourage residents participation. Review of the State Immediate Abuse Report concerning the allegation from Resident #13, the report documented the following: On September 11, 2023 at approximately 10:00am, resident reported to AHCA surveyor that on August 3, 2023, while CNA [ ], Staff D was cleaning her up, she stated that she told [ ], Staff D that she was being rough and hurting her. The resident stated, She yelled and said that she was going to leave and left the room. The resident stated that after making that statement [ ], Staff D left her alone. The resident stated that she called for assistance and [ ], Staff D was the one who returned to her room. The resident stated that [ ], Staff D came in and said to her, You're going to fight me and if I lose my job, I don't really care. The resident also stated the at the nurse [ ], Staff C LPN was standing at the door watching and did nothing or said anything. Both staff were suspended, pending full investigation. In-service on Abuse and Neglect initiated and ongoing. Investigation initiated and statement obtained from resident. Statement and ongoing investigation was reviewed with resident. Observation and interview with Resident #13 on 9/13/23 at 10:20 AM revealed, the resident sitting in a wheelchair in her room, watching tv. She stated, Thank you. I am so happy now that the nurse and cna are no longer taking care of me. On 9/14/23 at 7:50 AM, interview with Staff E, Registered Nurse (RN). She stated, She is alert and oriented times three. She requires limited assistance for ADLs. She receives medication every four hours for pain related to hip surgery. The resident is very pleasant and not difficult to work with. I work with her on Wednesdays, Thursdays and Fridays. When she presses the call light, we answer immediately. When she presses the call light, she needs assistance. She doesn't just press it, to press it. On 9/14/23 at 8:54 AM, interview with the DON. She stated, I went to speak to the nurse [ ], Staff C LPN and the cna [ ], Staff D on the unit. I sent them home pending investigation. I spoke to the resident and she wrote a statement. She was getting care from the cna [ ], Staff D and the cna [ ], Staff D left her. She didn't finish she put on the light and the same cna [ ], Staff D came to finish her. While the cna [ ], Staff D was speaking to her, the nurse [ ], staff C was standing in the hallway. She said the cna [ ], Staff D said to her you want to fight me so you can get me fired, I don't care if I get fired. The nurse [ ], Staff C was in the doorway with an attitude and didn't say anything because she doesn't like me. On 9/14/23 at 8:56, interview with the Administrator. She stated, We filed an abuse and neglect report with [ ] state agency once the allegation of abuse was brought to our attention. The nurse [ ], Staff C and can [ ], Staff D were sent home and the investigation is still ongoing. On 9/14/23 at 12:16 PM, interview with Staff F, CNA. She stated, She helps me when I give her care, she is not total. She puts on her own clothes, goes to the bathroom by herself. I make up her bed. When she came back from the hospital she was total care, but she is better now. When she puts the light on, when I see it, I go to her and give her help. She is very alert. I don't have any problems with her.

Based on observation, interview and record review, the facility failed to ensure 1) Hand hygiene was conducted between residents during dining and 2) The food service staff were wearing hair restraints properly. The certified nursing aide (CNA) was observed passing breakfast trays to residents without practicing hand hygiene and a Food Service Worker was serving on the lunch tray line without the hair net covering the entire head. This has the potential to affect fifty three residents out of fifty eight residents who eat orally residing in the facility. The findings included: 1) Record review of the Infection Prevention and Control Program Policy and Procedure, revised 8/15/2022 documented: Policy-This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 4) Standard Precautions: b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of the Hand Hygiene Policy and Procedure, revised 1/17/2022 documented: Policy-Staff shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1) Associates must perform hand hygiene using proper technique consistent with accepted standards of practice; 2) Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands. Observation of the second floor breakfast food trays on 9/11/23 at 8:22 AM. Two food carts arrived on the second floor with breakfast trays. At 8:31 AM, nursing staff went to the food carts to serve breakfast food trays to the residents in their rooms. At 8:33 AM, observed Staff G, CNA (Certified Nursing Assistant) go into the nourishment room, come out and go to the food cart without sanitizing her hands. Staff G, was observed to deliver the trays to the residents and came back to the food cart and got another food tray without sanitizing her hands. Multiple observations were made with Staff G, not sanitizing her hands in between serving the residents. A second observation of the second floor breakfast food trays on 9/12/23 at 7:45 AM revealed, Staff G, CNA, was observed going into the food cart without sanitizing her hands. She proceeded to take the food tray into a resident's room and left out of the room to retrieve a bedside table for the resident and did not sanitize her hands before going back into the resident's room with the bedside table. On 9/12/23 at 8:34 AM, interview with Staff G, revealed, she stated, You are supposed to sanitize your hands before getting the food tray. Open the cart, take the tray and look in the tray to make sure you have everything. If you need something you find it. Then knock on the patients door and ask may I come in and set up the tray. If the patient is a feeder, you put the tray there and come back later to feed the patient. You have to wash your hands with sanitizer and set up the food. I know on yesterday I didn't sanitize my hands. I forgot too. 2) Record review of the Staff Attire Policy and Procedure, revised 10/2019 documented: Policy Statement-It is the centers policy that all Dining Services employees wear approved attire for the performance of their duties. Action Steps-1) The Dining Services Director insures that all staff members have their hair off the shoulder, confined in a hair net or cap and facial hair properly restrained. Observation of the food service worker, Staff H on 9/12/23 at 11:13 AM revealed, Staff H was wearing a hair net that did not completely cover his hair while working on the lunch tray line. He was also, wearing a beard net. The dietary worker had the front part of his hair out of the hair net and the rest of his hair was covered. On 9/12/23 at 11:14 AM, interview with Staff H, Food Service Worker. He revealed he knew the hair net was supposed to cover his head completely. On 9/12/23 at 11:15 AM, interview with the Food Service Director. She stated, Hair nets are supposed to completely cover the hair.

Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewe. The binding arbitration agreements did not provide for the selection of a neutral arbitrator agreed upon by both parties. The findings included: Record review for the Arbitration Agreements on the facility's letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility Optional Dispute Resolution Agreements/Binding Arbitration Agreements documented the following: Resident #34 signed and dated the Arbitration Agreement on 12/29/2022, Resident #6 signed and dated the Arbitration Agreement on 1/16/2022 and Resident #46 signed and dated the Arbitration Agreement on 7/10/2023 and the Arbitration Agreements failed to show the arbitration agreements provided for the selection of a neutral arbitrator agreed upon by both parties. On 9/14/23 at 10:41 AM, interview and record review with the Admissions Director and the Administrator confirmed that the Dispute Resolution agreement/Binding Arbitration Agreement forms did not document the following: The binding arbitration agreement provide for the selection of a neutral arbitrator agreed upon by both parties. Review of the Binding Arbitration Agreements Policy and Procedure, revised 3/2023 documented: Policy-This facility asks all residents to enter into an agreement for binding arbitration. Policy Explanation and Compliance Guidelines: 2) The agreement must: a) Provide for the selection of a neutral arbitrator agreed upon by both parties. This policy and procedure was received from the Administrator on 9/14/23 at 11:34 AM.

Based on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident #34, Resident #6 and Resident #46) out of three residents reviewed, informed the residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. The findings included: Record review for the Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility's Optional Dispute Resolution Agreements/Binding Arbitration Agreement form documented the following: Resident #34 signed and dated the agreement on 12/29/2022, Resident # 6 signed and dated the agreement on 1/16/2022 and Resident #46 signed and dated the agreement on 7/10/2023 and the form failed to show the arbitration agreements provided to the residents included 1) Neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and 2) The binding arbitration agreement allows the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 9/14/23 at 10:41 AM, interview and record review with the Admissions Director and the Administrator confirmed that the Dispute Resolution agreement/Binding Arbitration Agreement forms did not document the following: 1) Neither the resident or his/her representative is required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and 2) The binding arbitration agreement allows the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. Review of the Binding Arbitration Agreements Policy and Procedure, revised 3/2023 documented: Policy-This facility asks all residents to enter into an agreement for binding arbitration. Policy Explanation and Compliance Guidelines: 2) The agreement must: d) Explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility and 3) The agreement must not contain any language that prohibits or discourages the resident or anyone else from communication with federal, state or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees and representatives of the Office of the State Long-Term Care Ombudsman. This policy and procedure was received from the Administrator on 9/14/23 at 11:34 AM.

Based on record review and interview, the facility failed to provide bed hold policies upon discharge to the hospital for three Residents (Residents #4, #13 & #25) out of 16 sampled residents. The findings included: 1) Review of the medical records for Resident #25 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to. Adult failure to thrive, Anorexia, Gastrostomy status. Resident #25 was discharged to the hospital on 08/11/2023. The resident was readmitted on [DATE]. Further Review of Resident #25's medical records revealed: Resident #25's Bed hold policy form for Discharge Return Anticipated on 08/11/2023 was not completed. Review of the discharge summary progress note for Resident 25 dated 08/11/2023 timestamped 14:30 documented: Upon rounds, Resident observed with blood coming out of his mouth. Assessment done, Resident profusely with blood and clotting coming from mouth. Unable to find the cause of bleeding with resident keeping mouth shut. Vital signs as follows: Blood Pressure 120/79 Temperature: 98.1 Pulse: 124 Heart Rate: 20. Physician made aware, new order given to send resident to emergency room for further evaluation. Paramedics arrived to facility and transferred resident to the local hospital. Responsible party made aware. Interview on 09/13/23 01:17 PM with the Social Services Director (SSD) revealed, when residents are discharged to the hospital, we are not doing the bed hold policy form because we have the capacity to readmit all of our residents. Every resident that wanted to be readmitted to this facility has been able to return. The resident transfer forms are sent to the ombudsman by e-fax or physical fax every week or two weeks depending on how many discharges we have. We do have a bed hold policy form and I will have to follow up with corporate for specific directions moving forward. Review of the facility's policy and procedure titled, Bed Hold Notice Upon Transfer with a revision date of 3/2023 states: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and address information explaining the return of the resident to the next available bed. 48906 2) Review of the medical records for Resident (#4) revealed, it was a closed record with an initial admitted [DATE], a readmitted [DATE], and a discharge date of [DATE]. Review of resident's medical record revealed, diagnoses including Gastrointestinal (GI) hemorrhage and hemorrhage of anus and rectum. Review of the resident's medical record revealed, there is no signed document of the facility's Bed Hold Policy. Review of nurse's note written on September 6, 2023, at 5:47 AM revealed, Certified Nursing Assistant notified nurse that she saw blood in resident's stool, nurse assessed resident, a call was placed to Medical Doctor(MD), waiting for return call and oncoming shift will be updated on resident's condition. Review of Nurse note written on September 6, 2023, at 3:25 PM revealed, a large amount of loose stool with blood, MD notified, and new orders to send resident to local Hospital via ambulance. Interview on 09/13/2023 at 1:15pm with the Social Services Director(SSD) revealed, the facility does have a Bed Hold Policy in place and does not have a form for the Bed Hold policy. The SSD stated, each resident is accepted back due to the facility's current capacity to receive residents. The SSD reported, she will follow up with producing a form for the Bed hold policy. The SSD stated, she sends a Transfer form to the ombudsman via fax, either monthly or weekly and the forms with a confirmation receipts are kept in the office. The SSD, provided a copy of a completed fax sent to the Ombudman regarding the transfer of Resident # 4 to the hospital. The form was dated 09/13/23, and sent at 11:43am. 31581 3) Record review of the Demographic Face Sheet for Resident #13 documented, the resident was admitted on [DATE] with a diagnoses of idiopathic progressive neuropathy, hypertension, anxiety disorder, major depressive disorder, schizoaffective disorder bipolar and insomnia. The resident was discharged to the hospital on 7/31/2023 for surgery. The resident was readmitted to the facility on [DATE]. Review of the Admit/Readmit Screener Form for Resident #13 documented the following: Dated 7/31/2023-Resident transferred to [ ] local hospital for left hip replacement. Review of the Bed Hold Policy Form for Resident #13 revealed there was no bed hold policy form documented in the resident's electronic chart for the hospital transfer dated 7/31/2023. On 9/11/23 at 8:16 AM, interview with Resident #13 revealed, she stated, I went to the hospital on August 1 for surgery. On 9/14/23 at 9:11 AM, interview with the Social Services Director revelaed, she stated, the Bed hold policy was not given because she didn't sign for it. The resident went to the hospital on 7/31/2023 and came back on 8/01/2023 for an outpatient procedure. On 9/13/23 at 9:13 AM, interview with the Director of Nursing (DON). She stated, The resident was transferred out to the hospital for left hip replacement surgery on 7/31/23. She returned on 8/01/23.

Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and to ensure effective and efficient preventative measures were in place to prevent the elopement of one resident (Resident #1) out of three residents sampled who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure an emergency exit door was able to be opened by staff promptly, ensure the exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement the assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices led to Resident #1 exiting the facility undetected through an emergency exit door at approximately 5:45 AM on 5/22/23, placing the resident at risk for injury/harm. There were 50 residents residing in the facility at the time of the survey. The Administrator was informed of the possible existence of the immediate jeopardy (IJ) on 06/05/2023 at approximately 12:45PM. The IJ Template was provided to the administrator on 06/05/2023 at 5:49PM. On 06/06/2023, it was determined the Immediate Jeopardy was Past Non-Compliance due to the corrective actions implemented and quality assurance implemented prior to the start of the survey. Refer to F 689. The Findings Included: Review of the facility's Policy and procedures titled, Incidents and Accidents revision date 03/03/23 states: It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident and to ensure residents receive adequate supervision to prevent accidents. Review of the facility's policy and procedures titled, Elopement and Wandering Residents revision date 03/16/2023 states: The facility ensures that residents who 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 their elopement risk. The procedure for locating missing resident: a. Any staff member becoming aware of a missing resident will alert personnel using the facility approved protocol (e.g., internal alert code). b. The designated facility staff will look for the resident in the building or on the grounds. c. If the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the Regional Director of Operations and/or Regional Nurse Consultant. d. Director of Nursing (DON) or designee shall notify the physician and family member or legal representative. e. Facility will conduct a head count to ensure all other residents have been accounted for. f. All parties will be notified of the outcome once the resident is located. g. Reporting to the State Survey agency shall be conducted if applicable. Review of the facility's policy and procedure titled, Administration of the Facility revision date 1/12/2022 states: This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident. Review of the job description for job titled, Administrator dated 12/2018 revealed: Summary: Lead and direct the overall operation of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Review of the Job Description for job titled, Director of Nursing dated 12/2021 revealed: Summary-Manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. Review of the Job Description for job titled, Registered Nurse dated 04/2020 revealed: Summary- Provide direct nursing care to the residents and provide clinical oversight of the day-to-day nursing activities performed by Licensed Practical Nurses and or Certified Nursing Assistants and/or Patient Care Assistants. Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern the facility. Review of the Job Description for job titled, Licensed Registered Nurse dated 07/2021 revealed: Summary-Provide direct nursing care to the residents and provide oversight of the day-to-day nursing activities performed by Certified Nursing Assistants and/or Patient Care Assistants. Clinical oversight must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern facility. Review of the Job Description for job titled, Certified Nursing Assistant dated 04/2020 revealed: Summary-Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for the residents. On 6/5/23 at 9:05 AM during an observational tour of the facility with the Director of Maintenance (DOM), surveyors retraced the path Resident #1 took to exit the facility. Resident #1 exited the north station second floor exit door, down two flights of stairs to the first floor, exited the north station first floor exit door that led to the facility's parking lot, where there was an open gate leading out to a residential street. The facility is in an area that has a high traffic volume and is located on the corner of a busy intersection near a major roadway. At the time of the tour the alarms on all three of the emergency doors surveyors exited through alarmed. On the second floor of the facility, there were four emergency exits. On the first floor, there are three emergency exits and the main entrance to the facility. At the time of the tour, all the emergency exit doors in the facility were in working order and had a functional alarm system. Residents #2 and #3, who exhibited exit seeking behavior were observed wearing wander guards with a continuous flashing light displaying they were in working order. Review of the Demographic Face Sheet for Resident #1 revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Alzheimer's Disease, Dementia, unspecified, severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Type II Diabetes Mellitus without complications, Hypertension, Seizures and Acute Kidney Failure. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #1 had orders that included but were not limited to: 04/19/23 Wander guard to Right Ankle due to: Increased Wandering. Record review of Resident #1 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score was unable to be determined. Section D for Mood documented no response for mood interview. Section E for Behavior documented no physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)-behaviors of this type occurred 1-3 days, Section E 900 documented no wandering behavior exhibited. Section G for Functional Status documented extensive assistance with two-persons physical assistance required for Activities of daily living. Section J for Health Conditions documented no falls and no shortness of breath. Section N for Medications documented resident received antianxiety and antidepressants in the last 7 days. Section P for physical restraints documented no physical restraints used, no wander/elopement alarm used. Record review of Resident # 1's Care Plans Reference Date 03/18/23 revealed: Resident is an elopement risk/wanderer related to Impaired safety awareness, actively exit seeking. Goal: The resident's safety will be maintained through the review date. Interventions: supervision for safety, 30-minute frequent monitoring for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Wander alert Guard, and Increased observations for safety Record review of the Elopement Risk Assessment/Evaluation dated 3/18/23 and 5/22/23 documented: History of elopement/wandering - Resident has history of wandering in past 3 months (post hospitalization or history from resident/family and/or observed wandering behaviors). Cannot follow instructions, cannot communicate. Mobility - Is ambulatory, Adjustment to facility placement - Content with placement, Elopement Risk Score - H, at Risk to Elopement Record review of the progress notes documented the following: Dated 05/22/23 timestamped 05:45 Upon providing wound care to resident in room [ROOM NUMBER] with the assistance of one Certified Nursing Assistant (CNAs) staff, the alarm located close to room [ROOM NUMBER] went on. Search made to look for every single resident. Resident in room [ROOM NUMBER] could not be found. All staff kept searching in every single room, then in the parking lot. DON made aware. Dated 05/22/23 Timestamped 08:15 Physician (MD) and resident's family made aware. Resident returned to facility in stable condition. Assessment done, respiration even and unlabored, no complaint of pain voiced. Skin intact, dry and warm to touch; old bruises noted at bilateral arms. Vitals checked: BP 117/68, P 81, R 20, T 97.6, O2 97% room air. Safety and comfort measures maintained, call light within reach. Will continue to monitor. Dated 05/22/23 time stamped 09:18 Resident placed on 1:1 supervision. Family made aware. Per family they will be coming in to stay with resident to provide supervision. Physician Progress note Dated 5/22/2023 time stamped 20:57- Situation: The Change In Conditions (CIC) reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis). At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 113/63 - 5/22/2023 07:40 Position: Sitting r/arm (Right arm). Pulse: P 63 - 5/22/2023 07:40 Pulse Type: Regular. RR: R 16 - 5/22/2023 07:40. Temperature: T 97.8 - 5/22/2023 07:40 Route: Forehead (non-contact). Weight: W 134.5 lbs. - 5/8/2023 12:13 Scale: Standing. Pulse Oximetry: O2 97.0 % - 5/21/2023 08:27 Method: Room Air. Blood Glucose: BS 100.0 - 3/26/2023 18:14. Resident/Patient is in the facility for: Long Term Care, Relevant medical history is: Dementia. Resident/Patient had the following medications changes in the past week: n/a. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed. Functional Status Evaluation: No changes observed. Behavioral Status Evaluation: No changes observed- Respiratory Status Evaluation. Nursing observations, evaluation, and recommendations are: Resident has exit seeking behaviors. Family with resident. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Continue to monitor closely and seek alternative placement within a secured unit. Maintain aspiration precautions. Assistance with ADLs. Interview on 06/05/2023 at 8:55 AM with Director of Maintenance stated that the company that conducts maintenance to all the doors of the facility is a [Local Company] for the door systems. All the doors have a system, if the door is pushed a low sounding alarm goes off and for 15 seconds the door will not open, after 15 seconds the door will open, and a louder alarm will go off. All the nursing stations received the alert, and it tells the location of the alarm going off. Magnetic cards are used by staff to go in and out of the facility through all doors. For residents with wander Guards, the sound is louder for the entrance door, and it will go off as the resident approaches the door. For emergency doors, residents with wander guards will have to push the doors, the doors will make a sound and will not open for 15 seconds, after 15 seconds the door will open, and a very loud alarm goes off. All the emergency doors operate the same way. Interview on 6/5/23 at 9:30AM with Licensed Practical Nurse (Staff A) for the 2nd floor north station stated she has been working here for 15 days, and stated she was not on shift but she heard about the resident eloping from the facility, stated when the alarm goes off from the exit door it is very loud and you cannot help but to hear it, when the alarm goes off, usually a silver code alert is announced and then all staff know what they need to do and go to the area and receive instructions on what to do from the staff at the location. Interview on 6/5/23 at 10:10AM with the Interim Nursing Home Administrator (NHA) it was stated, on 5/22/23 in the morning the Registered Nurse (Staff B) went immediately to the door when the alarm sounded, all staff have magnetic key cards in the facility. Staff B magnetic key card did not work, the alarm kept going off, the nurse panicked and instead of pressing the emergency exit door to open it, she went around to the front of the second floor and took the elevator to the 1st floor, exited out of the side/ambulance entrance, went around the building to where the door was alarming to look for the resident, she did not see the resident. We do not have surveillance cameras at the facility. The resident exited the emergency exit door on the first-floor north station that leads out to the parking lot of the facility. The search was expanded, a head count was completed in the facility to figure out who was the missing resident. On 5/22/23 the staff called the Director of Nursing (DON) to notify her about the missing resident, the DON called me, in the meanwhile the staff was searching the building and the neighborhood for the resident. As I was calling the police station to report the incident, I received a call from the DON. The DON stated she received a call from the local Police station stating that they have the resident. The DON went to pick the resident up and brought him back to the facility. The resident was found at the local high school 1.7 miles away from the facility. A staff member was dropping her child off to school and noticed the resident with the police, the staff member gave the police the contact number for the DON. When the NHA was asked what plans were in place and what plans are currently in place to prevent resident elopements from occurring it was stated, all emergency exit doors have a regular door alarm and a screamer alarm, the staff is notified by hearing the very loud sound. The training we provided is when the alarm goes off, 1-2 persons go through the door to see who went out the door, the remaining staff do a head count to identify which resident is missing, once the staff determine which resident is missing, we do a code silver alert-it is an elopement code for a person we cannot find. Everyone goes to the floor where the resident's room is located and receives an assignment from the designated staff at the location. When the resident returned to the facility, we completed a head-to-toe assessment of the resident, and placed the resident on 1 to1 supervision. All the residents in the facility were reassessed for wandering and elopement. Currently we have two residents at risk for elopement, they have wander guards, their pictures and face sheets are in an elopement binder at every nursing station and at the front desk. Staff were retrained on the Egress door system-going out through the emergency exit doors with the 15 second push. We activated key cards for all doors for every staff member. Previously some staff members had limited access with their assigned cards and there was an all-access key card on every medication cart that opened all the facility's doors. We educated all the staff on abuse and neglect training, including all contracted staff in the rehabilitation department, environmental and dietary. All the trainings were completed on 6/1/23. Interview on 06/06/23 at 11:07 AM with Registered Nurse (Staff B) via telephone it was stated, that she has been working in the facility since December of last year, her shift is usually 7:00 PM to 7:00 AM three days a week. When the alarm went off on 05/22/23 at 5:45 AM I ran to the door where the alarm was going, but my key did not work thus the CNAs went running to take the elevator to see if a resident had gone out. We looked everywhere and we could not find anybody. We went to the street to look, and we did not see anything, so we went back to the facility and kept looking and called the DON. Interview on 06/06/23 at 11:25 AM with Certified Nursing Assistant (Staff C) via telephone it was stated, that she has been working in the facility since November of last year, her schedule is 7:00 PM to 7:00 AM three days a week. She was working the night shift when the resident eloped on 05/22/23. She looked for the resident in the facility and the surroundings and she went in her car with the nurse to look for the resident in the neighborhood, but they could not find him, and they both came back to the facility. Since then, she has been taking more in-service trainings on elopements, elopement drills, abuse and neglect, and resident rights. Interview on 6/6/23 at 1:57PM with the Director of Nursing (DON) it was stated, I have been working here as the interim DON since 4/17/23. She reported around 6:15AM on 5/22/23 I got a phone call alerting me that the facility had a code silver alert (Elopement), Resident #1 was missing, I arrived to the facility approximately at 6:30 AM, retraced the resident's path through the facility, (from the second floor north station, down the stairs out to the parking lot) at this time staff was already searching the neighborhood on foot, I jumped in my car and began searching in the neighborhood. At 7:23am, I received a call from the local Police department stating that they had the resident at the local high School, and we could come and pick him up. I picked up the resident, gave the police the information they requested about the resident, returned to the facility with the resident, did a head-to-toe assessment, the resident was okay, vital signs were within normal limits, the resident ate his breakfast, received his morning medications, notified family, and let them know the resident was doing well. The family stated they will be coming to the facility right away. The resident's wife usually stays with the resident all day, at the time the resident eloped the wife was not here, and the resident gets very agitated when his wife is not around, the resident's wife stayed with the resident all the time from 5/22/23 until 5/24/23 until he was discharged . Since this incident happened as the DON, and prior to the incident I had identified that the residents at risk for elopement were all on the first floor, I moved all the elopement residents to the first floor, and it appears that the residents got a little confused with the change of location. I moved 7 residents at risk for elopement from the first floor to the second floor, they seemed to become a little more active after the move, not all at the same time, each resident at different times, this was all a part of my audit as a new DON coming to a new building. I instructed the receptionist to keep their eye on the elevators, educated the nursing staff on the increased anxiety among residents and what to look for. On 4/19/23 I conducted an in-service on elopement, wander guard, care-plans, orders all relating to elopement risk for the nursing staff. Including the Certified Nursing Assistants to check for the functioning of the wander-guards, when in working order, the wander guards should show a continuous flash of red light. Prior to the elopement incident, we identified that we could not meet the needs of the residents at risk of elopement with the increase exit seeking behavior, the whole administrative team and regional office decided that we would start to discharge the residents to locked unit facilities because we could not meet their needs because of the increased activity the residents were displaying. The facility's immediate jeopardy removal plan included: On 5/22/23 - Manager on Duty checklist and schedule developed. On 5/22/23 - 6/30/23; Active Manager on Duty schedule in place. On 5/22/23 - Elopement risk re-evaluations were completed for 100% of residents currently residing in the facility. No new residents identified at risk for elopement based on re-evaluations. On 05/22/23 to 05/31/23 - Elopement drills or door activation drills followed by a full elopement drill were conducted each shift. Elopement risk alert binders were reviewed by the DON/designee for accuracy and were confirmed to have demographics present for all residents at risk for elopement. On 6/6/23 - Observation of the first and second floor north nursing and entrance reception area-risk alert binders in each station and entrance with the demographic sheet of the residents and picture confirming that the resident is at risk for elopement. On 5/22/23-Orders were reviewed by the DON/designee for presence of wander guard placement and function for residents at risk for elopement. Wander guards were verified to be functioning. Observation on 6/6/23 revealed currently there are only two residents in the facility at risk for elopement. The two residents observed wearing wander guards on their wrists, and the wander guards were working correctly. On 5/22/23 - Care plans were reviewed for residents at risk for elopement, 6/6/23 care plans confirmed to be present and revised as indicated. On 5/23/23 - Facility egress doors checked for alarm/functioning by maintenance director. Outside door vendor, [A .], evaluated all doors for proper function. Egress doors are determined to be alarming/functioning properly. Screamers verified to be functioning appropriately. On 5/23/23 - Administrator (NHA) Job description reviewed with NHA by President of Clinical services. NHA educated on how to access support services from regional team. On 5/23/23 - Director of Nursing (DON) Job description reviewed with DON by President of Clinical services. The DON initiated staff education on Accidents/Incidents, Abuse & Neglect, and Elopements with Post-tests, including possible elopement risk factors and providing adequate supervision to help prevent accidents and elopements. On 05/23/23-06/01/23; Abuse and Neglect Training, elopement training/drills, Egress Door, and Door Activation training, and accidents and incidents training completed for all staff, including pre and post test. Attendees-Eighty-four (84) staff to include Registered Nurses, licensed Practical Nurses, Certified Nursing Assistants, Housekeeping staff, Dietary Staff, Speech therapists, Occupational therapists, Physical therapists, Activities Supervisor, Activities staff, Receptionists, Social Services Director, Central Supply Staff, Maintenance Director, Administrator, Marketing staff, Minimum data Set Coordinator, and Admissions Staff. On 5/23/23-6/01/23 - Staffing reviewed by NHA and DON daily. On 5/31/23 Elopement risk status added to the Gray Bar in electronic medical record for all residents at risk for elopement. Record review revealed that a field was added; Special Instruction reads: Elopement Risk. Record review revealed on 05/23/23 Maintenance Director installed additional screamers. On 05/24/23 the Maintenance Director changed the internal mechanism inside the screamers to provide a continuous alarm until manually reset by the key. On 5/23/2023 - DON continued staff education on Accidents/Incidents, Abuse & Neglect, and Elopement with post tests including door egress process. Elopement drills or door activation drills followed by a full elopement drill continued each shift. On 5/24/2023 - Staff education continues relating to Accidents/Incidents, Abuse and Neglect, and Elopements with post-tests including door egress procedures. A root cause analysis was completed on the event and review of action plan. A Quality Assurance and Quality Improvement meeting was conducted to discuss the event, the root cause analysis, and the performance improvement plan. Door screamers were changed to alarm continuously until manually reset by key. Magnetic cards to unlock the stairwell doors were activated to allow staff immediate access. Elopement drills and door activation drills continue. On 5/24/23 further record review of root cause analysis revealed: Problem Statement, one sentence description of event or problem: Resident was able to exit unit via stairwell without being detected. Why - 15 sec egress upon pushing on door. Why -Staff was unable to open the door. Why-Door locks and appropriate magnetic card were not utilized, and staff did not use 15 second egress. Why- Lack of education. Root Cause(s)- Failure to provide appropriate education. On 5/25/2023 and 5/26/2023 - The Orientation packet was reviewed to ensure current elopement procedures were included, education was given to licensed nurses about notification of changes related to increased anxiety and exit seeking behaviors. Nurses were educated on adding additional interventions and oversight to exit seeking residents. Elopement drills and door activation drills continue. From 5/26/2023 to 6/1/2023, staff education continued until 100% compliance was obtained on elopement drills. On 6/1/2023 - Elopement drills and door activation drills continue. The DON or designee will conduct quality reviews on new admissions/readmissions for elopement risk status to ensure care plan was in place and interventions in place for residents identified at risk for elopement weekly x 4 weeks. Quality reviews to be continued monthly x 3 months. Reviews were ongoing. The DON or designee will conduct elopement competency reviews with 10 staff weekly x 4 weeks to ensure staff remain competent on elopement process. Competency reviews to be continued monthly x 3 months. Reviews ongoing. The immediate jeopardy removal plan was verified as completed from June 5 - 6, 2023 by reviewing the above documentation; observing inside and outside surroundings of the facility; observing all the coded, audible alarm exit doors in the facility in working order; interviewing thirty (30) staff members to verify they received elopement, incidents and accidents, abuse and neglect in-services, participated in elopement drills, and egress door and door activation training. The verification included RN's, LPN's, and CNA's from all shifts, support staff and contracted staff in housekeeping, dietary and rehabilitation. Reviewed in-services and sign in sheets for: Dates-05/23/23-06/01/23; Abuse and Neglect Training, elopement training/drills, Egress Door, and Door Activation training, and accidents and incidents training completed for all staff, including pre and post test. Attendees-Eighty-four (84) staff -Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping staff, Dietary Staff, Speech Therapists, Occupational Therapists, Physical Therapists, Activities Supervisor, Activities staff, Receptionists, Social Services Director, Central Supply Staff, Maintenance Director, Administrator, Marketing staff, Minimum Data Set Coordinator, and Admissions Staff. Dates-5/23/23 - 6/2/23; Ongoing elopement drills training for all staff on every shift. Date-5/31/23 - Quality Improvement and Performance process, performance improvement process and data analysis for audits reviewed, and education provided to the DON and NHA by the [NAME] President of Clinical Services. Dates-6/2/23-6/6/23 - Ongoing random elopement drills for all staff present in the facility.

45019 Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of three residents sampled with exit seeking behaviors. This deficient practice led to Resident #1 exiting the facility undetected at approximately 5:45AM on 5/22/23. The facility's lack of adequate supervision and failure to ensure an adequate and effective alert monitoring system was in place enabled the resident to elope undetected by staff on 5/22/23 at approximately 5:45 AM. The resident was located at approximately 7:23 AM on 5/22/23 by law enforcement at a local high school 1.7 miles away from the facility. Law enforcement reported the resident's location to the facility's Director of Nursing (DON) after the resident was identified by a staff member dropping her child off at the local high school. There were 50 residents residing in the facility at the time of the survey. The Administrator was informed of the possible existence of the immediate jeopardy (IJ) on 06/05/2023 at approximately 12:45PM. The IJ Template was provided to the administrator on 06/05/2023 at 5:49PM. On 06/06/2023, it was determined the Immediate Jeopardy was Past Non-Compliance due to the corrective actions implemented and quality assurance implemented prior to the start of the survey. Refer to F835. The Findings Included: On 6/5/23 at 9:05 AM during an observational tour of the facility with the Director of Maintenance (DOM), surveyors retraced the path Resident #1 took to exit the facility. Resident #1 exited the north station second floor exit door, down two flights of stairs to the first floor, exited the north station first floor exit door that led to the facility's parking lot, where there was an open gate leading out to a residential street. The facility is in an area that has a high traffic volume and is located on the corner of a busy intersection near a major roadway. At the time of the tour the alarms on all three of the emergency doors surveyors exited through alarmed. On the second floor of the facility, there were four emergency exits. On the first floor, there are three emergency exits and the main entrance to the facility. At the time of the tour, all the emergency exit doors in the facility were in working order and had a functional alarm system. Residents #2 and #3, who exhibited exit seeking behavior were observed wearing wander guards with a continuous flashing light displaying they were in working order. Review of the facility's Policy and procedures titled, Incidents and Accidents revision date 03/03/23 states: It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident and to ensure residents receive adequate supervision to prevent accidents. Review of the facility's policy and procedures titled, Elopement and Wandering Residents revision date 03/16/2023 states: The facility ensures that residents who 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 their elopement risk. The procedure for locating missing resident: a. Any staff member becoming aware of a missing resident will alert personnel using the facility approved protocol (e.g., internal alert code). b. The designated facility staff will look for the resident in the building or on the grounds. c. If the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the Regional Director of Operations and/or Regional Nurse Consultant. d. Director of Nursing (DON) or designee shall notify the physician and family member or legal representative. e. Facility will conduct a head count to ensure all other residents have been accounted for. f. All parties will be notified of the outcome once the resident is located. g. Reporting to the State Survey agency shall be conducted if applicable. Interview on 06/05/2023 at 8:55 AM with Director of Maintenance stated that the company that conducts maintenance to all the doors of the facility is a [Local Company] for the door systems. All the doors have a system, if the door is pushed a low sounding alarm goes off and for 15 seconds the door will not open, after 15 seconds the door will open, and a louder alarm will go off. All the nursing stations received the alert, and it tells the location of the alarm going off. Magnetic cards are used by staff to go in and out of the facility through all doors. For residents with wander Guards, the sound is louder for the entrance door, and it will go off as the resident approaches the door. For emergency doors, residents with wander guards will have to push the doors, the doors will make a sound and will not open for 15 seconds, after 15 seconds the door will open, and a very loud alarm goes off. All the emergency doors operate the same way. Interview on 6/5/23 at 9:30AM with Licensed Practical Nurse (Staff A) for the 2nd floor north station stated she has been working here for 15 days, and stated she was not on shift but she heard about the resident eloping from the facility, stated when the alarm goes off from the exit door it is very loud and you cannot help but to hear it, when the alarm goes off, usually a silver code alert is announced and then all staff know what they need to do and go to the area and receive instructions on what to do from the staff at the location. Interview on 6/5/23 at 10:10AM with the Interim Nursing Home Administrator (NHA) it was stated, on 5/22/23 in the morning the Registered Nurse (Staff B) went immediately to the door when the alarm sounded, all staff have magnetic key cards in the facility. Staff B magnetic key card did not work, the alarm kept going off, the nurse panicked and instead of pressing the emergency exit door to open it, she went around to the front of the second floor and took the elevator to the 1st floor, exited out of the side/ambulance entrance, went around the building to where the door was alarming to look for the resident, she did not see the resident. We do not have surveillance cameras at the facility. The resident exited the emergency exit door on the first-floor north station that leads out to the parking lot of the facility. The search was expanded, a head count was completed in the facility to figure out who was the missing resident. On 5/22/23 the staff called the Director of Nursing (DON) to notify her about the missing resident, the DON called me, in the meanwhile the staff was searching the building and the neighborhood for the resident. As I was calling the police station to report the incident, I received a call from the DON. The DON stated she received a call from the local Police station stating that they have the resident. The DON went to pick the resident up and brought him back to the facility. The resident was found at the local high school 1.7 miles away from the facility. A staff member was dropping her child off to school and noticed the resident with the police, the staff member gave the police the contact number for the DON. When the NHA was asked what plans were in place and what plans are currently in place to prevent resident elopements from occurring it was stated, all emergency exit doors have a regular door alarm and a screamer alarm, the staff is notified by hearing the very loud sound. The training we provided is when the alarm goes off, 1-2 persons go through the door to see who went out the door, the remaining staff do a head count to identify which resident is missing, once the staff determine which resident is missing, we do a code silver alert-it is an elopement code for a person we cannot find. Everyone goes to the floor where the resident's room is located and receives an assignment from the designated staff at the location. When the resident returned to the facility, we completed a head-to-toe assessment of the resident, and placed the resident on 1 to1 supervision. All the residents in the facility were reassessed for wandering and elopement. Currently we have two residents at risk for elopement, they have wander guards, their pictures and face sheets are in an elopement binder at every nursing station and at the front desk. Staff were retrained on the Egress door system-going out through the emergency exit doors with the 15 second push. We activated key cards for all doors for every staff member. Previously some staff members had limited access with their assigned cards and there was an all-access key card on every medication cart that opened all the facility's doors. We educated all the staff on abuse and neglect training, including all contracted staff in the rehabilitation department, environmental and dietary. All the trainings were completed on 6/1/23. Interview on 06/06/23 at 11:07 AM with Registered Nurse (Staff B) via telephone it was stated, that she has been working in the facility since December of last year, her shift is usually 7:00 PM to 7:00 AM three days a week. When the alarm went off on 05/22/23 at 5:45 AM I ran to the door where the alarm was going, but my key did not work thus the CNAs went running to take the elevator to see if a resident had gone out. We looked everywhere and we could not find anybody. We went to the street to look, and we did not see anything, so we went back to the facility and kept looking and called the DON. Interview on 06/06/23 at 11:25 AM with Certified Nursing Assistant (Staff C) via telephone it was stated, that she has been working in the facility since November of last year, her schedule is 7:00 PM to 7:00 AM three days a week. She was working the night shift when the resident eloped on 05/22/23. She looked for the resident in the facility and the surroundings and she went in her car with the nurse to look for the resident in the neighborhood, but they could not find him, and they both came back to the facility. Since then, she has been taking more in-service trainings on elopements, elopement drills, abuse and neglect, and resident rights. Interview on 6/6/23 at 1:57PM with the Director of Nursing (DON) it was stated, I have been working here as the interim DON since 4/17/23. She reported around 6:15AM on 5/22/23 I got a phone call alerting me that the facility had a code silver alert (Elopement), Resident #1 was missing, I arrived to the facility approximately at 6:30 AM, retraced the resident's path through the facility, (from the second floor north station, down the stairs out to the parking lot) at this time staff was already searching the neighborhood on foot, I jumped in my car and began searching in the neighborhood. At 7:23am, I received a call from the local Police department stating that they had the resident at the local high School, and we could come and pick him up. I picked up the resident, gave the police the information they requested about the resident, returned to the facility with the resident, did a head-to-toe assessment, the resident was okay, vital signs were within normal limits, the resident ate his breakfast, received his morning medications, notified family, and let them know the resident was doing well. The family stated they will be coming to the facility right away. The resident's wife usually stays with the resident all day, at the time the resident eloped the wife was not here, and the resident gets very agitated when his wife is not around, the resident's wife stayed with the resident all the time from 5/22/23 until 5/24/23 until he was discharged . Since this incident happened as the DON, and prior to the incident I had identified that the residents at risk for elopement were all on the first floor, I moved all the elopement residents to the first floor, and it appears that the residents got a little confused with the change of location. I moved 7 residents at risk for elopement from the first floor to the second floor, they seemed to become a little more active after the move, not all at the same time, each resident at different times, this was all a part of my audit as a new DON coming to a new building. I instructed the receptionist to keep their eye on the elevators, educated the nursing staff on the increased anxiety among residents and what to look for. On 4/19/23 I conducted an in-service on elopement, wander guard, care-plans, orders all relating to elopement risk for the nursing staff. Including the Certified Nursing Assistants to check for the functioning of the wander-guards, when in working order, the wander guards should show a continuous flash of red light. Prior to the elopement incident, we identified that we could not meet the needs of the residents at risk of elopement with the increase exit seeking behavior, the whole administrative team and regional office decided that we would start to discharge the residents to locked unit facilities because we could not meet their needs because of the increased activity the residents were displaying. Review of the Demographic Face Sheet for Resident #1 revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but were not limited to: Alzheimer's Disease, Dementia, unspecified, severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, Anxiety, Type II Diabetes Mellitus without complications, Hypertension, Seizures and Acute Kidney Failure. Resident #1 was discharged from the facility on 05/24/23. Review of the Physician's Orders Sheet for May 2023 revealed, Resident #1 had orders that included but were not limited to: 04/19/23 Wander guard to Right Ankle due to: Increased Wandering. Medications included: Divalproex Sodium Tablet Delayed Release 500 Milligram (MG)- Give 1 tablet by mouth three times a day for seizure, Carbamazepine Suspension 100 MG/5ML(milligrams/milliliter) - Give 2.5 ml by mouth every 6 hours for seizure, Mirtazapine Tablet 7.5 MG- Give 1 tablet by mouth at bedtime for depression, Donepezil HCl (Hydrochloride) 5 MG Tablet- Give 1 tablet by mouth at bedtime for Dementia, Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) - Give 5 ml by mouth three times a day for Mood stabilization, Lorazepam Tablet 0.5 MG- Give 5 ml by mouth three times a day for Mood stabilization, Olanzapine Tablet 5 MG- Give 5 ml by mouth three times a day for Mood stabilization, Risperidone Tablet 0.5 MG- Give 1 tablet by mouth every 12 hours related to unspecified psychosis not due to a substance or known physiological. Further review of the Electronic Medical Records (EMAR) for Resident #1 revealed the resident received all his prescribed medications as ordered on the 5/21/23 at night and on 5/22/23 at 9AM in the morning. Record review of Resident #1 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score was unable to be determined. Section D for Mood documented no response for mood interview. Section E for Behavior documented no physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)-behaviors of this type occurred 1-3 days, Section E 900 documented no wandering behavior exhibited. Section G for Functional Status documented extensive assistance with two-persons physical assistance required for Activities of daily living. Section J for Health Conditions documented no falls and no shortness of breath. Section N for Medications documented resident received antianxiety and antidepressants in the last 7 days. Section P for physical restraints documented no physical restraints used, no wander/elopement alarm used. Record review of Resident # 1's Care Plans Reference Date 03/18/23 revealed: Resident is an elopement risk/wanderer related to Impaired safety awareness, actively exit seeking. Goal: The resident's safety will be maintained through the review date. Interventions: supervision for safety, 30-minute frequent monitoring for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Wander alert Guard, and Increased observations for safety Record review of the Elopement Risk Assessment/Evaluation dated 3/18/23 and 5/22/23 documented: History of elopement/wandering - Resident has history of wandering in past 3 months (post hospitalization or history from resident/family and/or observed wandering behaviors). Cannot follow instructions, cannot communicate. Mobility - Is ambulatory, Adjustment to facility placement - Content with placement, Elopement Risk Score - H, at Risk to Elopement Record review of the progress notes documented the following: Dated 05/22/23 timestamped 05:45 Upon providing wound care to resident in room [ROOM NUMBER] with the assistance of one Certified Nursing Assistant (CNAs) staff, the alarm located close to room [ROOM NUMBER] went on. Search made to look for every single resident. Resident in room [ROOM NUMBER] could not be found. All staff kept searching in every single room, then in the parking lot. DON made aware. Dated 05/22/23 timestamped 08:15 Physician (MD) and resident's family made aware. Resident returned to facility in stable condition. Assessment done, respiration even and unlabored, no complaint of pain voiced. Skin intact, dry and warm to touch; old bruises noted at bilateral arms. Vitals checked: BP 117/68, P 81, R 20, T 97.6, O2 97% room air. Safety and comfort measures maintained, call light within reach. Will continue to monitor. Dated 05/22/23 time stamped 09:18 Resident placed on 1:1 supervision. Family made aware. Per family they will be coming in to stay with resident to provide supervision. Physician Progress note Dated 5/22/2023 time stamped 20:57- Situation: The Change In Conditions (CIC) reported on this CIC Evaluation are/were: Behavioral symptoms (e.g. agitation, psychosis). At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 113/63 - 5/22/2023 07:40 Position: Sitting r/arm (Right arm). Pulse: P 63 - 5/22/2023 07:40 Pulse Type: Regular. RR: R 16 - 5/22/2023 07:40. Temperature: T 97.8 - 5/22/2023 07:40 Route: Forehead (non-contact). Weight: W 134.5 lbs. - 5/8/2023 12:13 Scale: Standing. Pulse Oximetry: O2 97.0 % - 5/21/2023 08:27 Method: Room Air. Blood Glucose: BS 100.0 - 3/26/2023 18:14. Resident/Patient is in the facility for: Long Term Care, Relevant medical history is: Dementia. Resident/Patient had the following medications changes in the past week: n/a. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed. Functional Status Evaluation: No changes observed. Behavioral Status Evaluation: No changes observed- Respiratory Status Evaluation. Nursing observations, evaluation, and recommendations are: Resident has exit seeking behaviors. Family with resident. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Continue to monitor closely and seek alternative placement within a secured unit. Maintain aspiration precautions. Assistance with ADLs. Dated 05/24/23 time stamped 11:31 SW met with resident today. The resident's wife continues to remain at bedside, daughter will be here tonight to provide 1:1 assistance. Resident's mood is calm, no anxious or sad mood observed. Wife voiced resident has remained calm as she remains at beside with resident. Resident's cognition remains impaired, diagnosis of Alzheimer's Disease. Resident has been accepted into locked skilled nursing home and will be transported to facility tonight. Wife and daughter informed and in agreement. The resident's wife translated such to resident. Dated 05/24/23 time stamped 17:01 Social Worker (SW) contacted resident's daughter to discuss alternate placement options as resident has eloped from facility and continues to be at risk for elopement. Staff and social workers previously discussed that all exit doors in facility can be pushed open after 15 seconds. SW informed daughter that resident requires a locked unit, daughter and resident's wife in agreement. SW contacted locked skilled nursing home and spoke to admissions representative. Clinicals sent to facility via email, Clinicals reviewed by Director of Nursing (DON), resident not accepted at facility. SW contacted admissions representative, at another locked skilled nursing home, clinicals emailed, resident accepted into facility. SW informed daughter and wife, both in agreement with transfer. Facility information provided to daughter. Resident will be transported today to Locked skilled nursing home. Resident will be transported to facility via Transit, pickup time - 8:00 p.m. Resident's wife will accompany resident to facility. Resident provided assistance with packing belongings. Family voiced satisfaction with care rendered while a resident in the facility. Dated 05/24/23 time stamped 21:00 Resident left facility via stretcher in stable condition accompanied by spouse and two attendants. No complaint of pain or discomfort voiced; no sign of apparent distress noted. Skin intact, dry and warm to touch. Vitals checked: BP 119/71, P 70, R 18, O2 97% room air, T 97.5. Resident left facility with all of his belongings. The facility's immediate jeopardy removal plan included: On 5/22/23 - Manager on Duty checklist and schedule developed. On 5/22/23 - 6/30/23; Active Manager on Duty schedule in place. On 5/22/23 - Elopement risk re-evaluations were completed for 100% of residents currently residing in the facility. No new residents identified at risk for elopement based on re-evaluations. On 05/22/23 to 05/31/23 - Elopement drills or door activation drills followed by a full elopement drill were conducted each shift. Elopement risk alert binders were reviewed by the DON/designee for accuracy and were confirmed to have demographics present for all residents at risk for elopement. On 6/6/23 - Observation of the first and second floor north nursing and entrance reception area-risk alert binders in each station and entrance with the demographic sheet of the residents and picture confirming that the resident is at risk for elopement. On 5/22/23-Orders were reviewed by the DON/designee for presence of wander guard placement and function for residents at risk for elopement. Wander guards were verified to be functioning. Observation on 6/6/23 revealed currently there are only two residents in the facility at risk for elopement. The two residents observed wearing wander guards on their wrists, and the wander guards were working correctly. On 5/22/23 - Care plans were reviewed for residents at risk for elopement, 6/6/23 care plans confirmed to be present and revised as indicated. On 5/23/23 - Facility egress doors checked for alarm/functioning by maintenance director. Outside door vendor, [A .], evaluated all doors for proper function. Egress doors are determined to be alarming/functioning properly. Screamers verified to be functioning appropriately. On 5/23/23 - Administrator (NHA) Job description reviewed with NHA by President of Clinical services. NHA educated on how to access support services from regional team. On 5/23/23 - Director of Nursing (DON) Job description reviewed with DON by President of Clinical services. The DON initiated staff education on Accidents/Incidents, Abuse & Neglect, and Elopements with Post-tests, including possible elopement risk factors and providing adequate supervision to help prevent accidents and elopements. On 05/23/23-06/01/23; Abuse and Neglect Training, elopement training/drills, Egress Door, and Door Activation training, and accidents and incidents training completed for all staff, including pre and post test. Attendees-Eighty-four (84) staff to include Registered Nurses, licensed Practical Nurses, Certified Nursing Assistants, Housekeeping staff, Dietary Staff, Speech therapists, Occupational therapists, Physical therapists, Activities Supervisor, Activities staff, Receptionists, Social Services Director, Central Supply Staff, Maintenance Director, Administrator, Marketing staff, Minimum data Set Coordinator, and Admissions Staff. On 5/23/23-6/01/23 - Staffing reviewed by NHA and DON daily. On 5/31/23 Elopement risk status added to the Gray Bar in electronic medical record for all residents at risk for elopement. Record review revealed that a field was added; Special Instruction reads: Elopement Risk. Record review revealed on 05/23/23 Maintenance Director installed additional screamers. On 05/24/23 the Maintenance Director changed the internal mechanism inside the screamers to provide a continuous alarm until manually reset by the key. On 5/23/2023 - DON continued staff education on Accidents/Incidents, Abuse & Neglect, and Elopement with post tests including door egress process. Elopement drills or door activation drills followed by a full elopement drill continued each shift. On 5/24/2023 - Staff education continues relating to Accidents/Incidents, Abuse and Neglect, and Elopements with post-tests including door egress procedures. A root cause analysis was completed on the event and review of action plan. A Quality Assurance and Quality Improvement meeting was conducted to discuss the event, the root cause analysis, and the performance improvement plan. Door screamers were changed to alarm continuously until manually reset by key. Magnetic cards to unlock the stairwell doors were activated to allow staff immediate access. Elopement drills and door activation drills continue. On 5/24/23 further record review of root cause analysis revealed: Problem Statement, one sentence description of event or problem: Resident was able to exit unit via stairwell without being detected. Why - 15 sec egress upon pushing on door. Why -Staff was unable to open the door. Why-Door locks and appropriate magnetic card were not utilized, and staff did not use 15 second egress. Why- Lack of education. Root Cause(s)- Failure to provide appropriate education. On 5/25/2023 and 5/26/2023 - The Orientation packet was reviewed to ensure current elopement procedures were included, education was given to licensed nurses about notification of changes related to increased anxiety and exit seeking behaviors. Nurses were educated on adding additional interventions and oversight to exit seeking residents. Elopement drills and door activation drills continue. From 5/26/2023 to 6/1/2023, staff education continued until 100% compliance was obtained on elopement drills. On 6/1/2023 - Elopement drills and door activation drills continue. The DON or designee will conduct quality reviews on new admissions/readmissions for elopement risk status to ensure care plan was in place and interventions in place for residents identified at risk for elopement weekly x 4 weeks. Quality reviews to be continued monthly x 3 months. Reviews were ongoing. The DON or designee will conduct elopement competency reviews with 10 staff weekly x 4 weeks to ensure staff remain competent on elopement process. Competency reviews to be continued monthly x 3 months. Reviews ongoing. The immediate jeopardy removal plan was verified as completed from June 5 - 6, 2023 by reviewing the above documentation; observing inside and outside surroundings of the facility; observing all the coded, audible alarm exit doors in the facility in working order; interviewing thirty (30) staff members to verify they received elopement, incidents and accidents, abuse and neglect in-services, participated in elopement drills, and egress door and door activation training. The verification included RN's, LPN's, and CNA's from all shifts, support staff and contracted staff in housekeeping, dietary and rehabilitation. Reviewed in-services and sign in sheets for: Dates-05/23/23-06/01/23; Abuse and Neglect Training, elopement training/drills, Egress Door, and Door Activation training, and accidents and incidents training completed for all staff, including pre and post test. Attendees-Eighty-four (84) staff -Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping staff, Dietary Staff, Speech Therapists, Occupational Therapists, Physical Therapists, Activities Supervisor, Activities staff, Receptionists, Social Services Director, Central Supply Staff, Maintenance Director, Administrator, Marketing staff, Minimum Data Set Coordinator, and Admissions Staff. Dates-5/23/23 - 6/2/23; Ongoing elopement drills training for all staff on every shift. Date-5/31/23 - Quality Improvement and Performance process, performance improvement process and data analysis for audits reviewed, and education provided to the DON and NHA by the [NAME] President of Clinical Services. Dates-6/2/23-6/6/23 - Ongoing random elopement drills for all staff present in the facility.