Every finding on record at The Terrace of Delray Beach Nursing and Rehabilita

Based on interview and record review, the facility failed to obtain informed consent for residents prescribed psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication review affecting Residents #4, #14, #87, #129. The findings included: Review of the facility's policy, titled, Use of Psychotropic Medication(s), with a reviewed/revised date of 02/05/25 included in part the following: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 1. Record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses that included in part the following: Encephalopathy, Acute Osteomyelitis Right Ankle and Foot, Major Depressive Disorder Recurrent Moderate, and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Review of the Physician's orders for Resident #129 revealed an order dated 01/18/26 for Duloxetine HCl (an antidepressant) oral capsule delayed release particles 30mg, give 1 capsule by mouth two times a day for Neuropathy. Review of the Informed Consent for Psychoactive Medication dated 01/18/26 signed by Resident #129 revealed no documentation of any drug, dose or frequency or an indication under Statement of Consent. During an interview conducted on 01/28/26 at 11:30 PM with Staff A, Licensed Practical Nurse (LPN), who was asked about residents who are prescribed psychotropic medications, she stated they need to have informed consent, and we monitor behaviors and side effects every shift. When asked about Resident #129, she acknowledged the resident was on an antidepressant and the informed consent had no medication listed. 2. Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease on Dialysis, Anxiety, and Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS assessment End of Prospective Payment System (PPS) Part A stay dated 01/06/26 revealed Resident #87 had a BIMS score of 15, indicating intact cognition. Review of the Physician's orders for Resident #87 revealed an order dated 12/31/25 for Mirtazapine (an antidepressant) 15 milligrams, give 1 tablet by mouth at bedtime for Depression. An additional Physician's order for Temazepam (a benzodiazepine) oral capsule 30 milligrams, give one capsule at bedtime for Insomnia was prescribed on 12/17/25. Review of the Informed Consent for Psychoactive Medication dated 12/09/25 signed by Resident #87 revealed no documentation of these drugs, dose or frequency or an indication under Statement of Consent. During an interview conducted with the Director of Nursing (DON) on 01/29/26 at 9:15 AM, she agreed that Mirtazapine and Temazepam should have been on the informed consent document but were not. 3. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Atherosclerotic Heart Disease of Native Coronary Artery Without Complications, Type 2 Diabetes Mellitus, and Unspecified Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 15, indicating intact cognition. Review of the Physician's orders for Resident #4 revealed an order dated 11/05/25 for Escitalopram (an antidepressant) 5 milligrams, give 1 tablet by mouth one time a day for Depression. Review of the Informed Consent for Psychoactive Medication, dated 09/30/25 signed by the resident, revealed no documentation of this drug, dose, or frequency. During an interview conducted with the DON on 01/29/26 at 9:15 AM, she agreed that Escitalopram should have been on the informed consent document but was not. 4. Record review revealed Resident #14 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included: Atherosclerosis of Coronary Artery Bypass Graft(S) without Angina Pectoris, Dementia, Cognitive Communication Deficit; Mood [Affective] Disorder and Anxiety Disorder. Review of Section C of the MDS assessment dated [DATE] revealed Resident #14 had a BIMS of 11, indicating moderate cognitive impairment. Review of the Physician's orders documented Resident #14 had orders dated 12/02/25 for two psychotropic / psychoactive medications: Divalproex Sodium Oral Tablet Delayed Release 125 mg to give 1 tablet three times a day for Mood disorder and Mirtazapine Oral Tablet 15 mg to give 1 tablet at bedtime for Depression. On 01/15/26, Resident #14 had a physician's order to monitor side effects for psychotropics medication every shift. Review of Resident #14's Informed Consent for Psychoactive Medication revealed it was missing information including the name of the medications, dosage, frequency and the targeted behaviors. The consent form did not confirm whether or not the resident or representative agreed with the psychoactive therapy and was not signed or dated by the person completing the form.

Based on interviews, observations, and record review, the facility failed to allow residents to have consistent access to a functional telephone for communication with family members or an accessible television remote control to support personal choice and self-directed activities, for 1of 2 sampled residents, Resident #12.The findings included:Review of Resident #12's medical record documented the following diagnoses: Dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Major Depressive Disorder, Anxiety Disorder, Poly-osteoarthritis; Waldenstrom Macroglobulinemia, Drug-induced pancytopenia; Muscle wasting and atrophy, and abnormal posture.Review of Resident #12's comprehensive care plan indicated the resident was assessed as able to communicate leisure needs and preferences, preferred a balance of social and independent activities, and was expected to remain engaged in leisure activities of choice. The plan directed staff to encourage in-room leisure activities, including television viewing and telephone or video communication with family and friends, and to support resident feedback regarding leisure preferences.Review of the Social Services care plan identified Resident #12 as a long-term care resident at risk for mood disturbances related to diagnoses of major depressive disorder and anxiety disorder. The plan included interventions directing staff to listen attentively to resident concerns, assess underlying causes of frequent complaints, collaborate with the resident to resolve issues, and communicate actions taken to improve resident satisfaction.On 01/27/26 at 10:02 AM, Resident #12 was observed lying in bed in her private room, dressed in a standard hospital gown. Resident #12 stated she did not have access to a working telephone to contact her relative. She stated that her personal cellular phone had been taken by another relative and that the telephone provided by the facility had not been functioning for nearly one week. The resident stated she did not have access to a television remote control and was therefore unable to change channels independently.Visual observation of the resident's room revealed no visible landline telephone or television remote control. Upon opening the resident's nightstand drawer at her request, a telephone was observed wrapped with its cord but there was no television remote control found.On 01/27/26 at 12:05 PM, Staff G, the Licensed Practical Nurse assigned to Resident #12, stated she was unaware of any issues related to the resident's telephone. She indicated that after speaking with the resident, she learned that the Certified Nursing Assistant (CNA) and housekeeping staff were reportedly aware of the issue but had not communicated it to her.On 01/27/26 at approximately 12:20 PM, the Maintenance Director stated he had been employed at the facility for nearly two years. He stated he was notified on or about 01/22/26 that the resident's telephone was not functioning. He indicated the phone line was operational earlier that week but subsequently stopped working for unknown reasons and attempts to resolve the issue were unsuccessful. He stated that upon contacting the telephone service provider, he was informed the signal for the resident's room could not be identified. When asked whether a cordless telephone had been considered as an interim solution, he stated that it had not been considered. He stated two cordless phones had been ordered for the kitchen and received on 01/27/26, and that one would be provided to Resident #12. The Maintenance Director also stated that due to the facility being at full census, relocating the resident to another room was not possible. He denied placing the telephone inside the resident's nightstand drawer.On 01/27/26 at approximately 3:34PM, Staff H, Certified Nursing Assistant (CNA), stated she was familiar with Resident #12 and believed the resident had access to a telephone. She stated she was unaware that the phone was not functioning and that Resident #12 typically used the facility phone to contact her relative. Staff H acknowledged that it is the responsibility of CNAs to ensure residents have necessary items. She further stated the resident had a television remote control the previous day and was unaware that it was missing on 01/27/26.On 01/27/26 at approximately 3:45 PM, the Activity Director stated that an activity plan had been developed for Resident #12, but no documentation was maintained reflecting when activities were offered or provided. Review of activity progress notes confirmed the absence of recent documentation related to activity participation. The most recent social services documentation prior to the surveyor's interview was dated November 2025.On 01/28/26 at approximately 11:50 AM, Staff I, Registered Nurse, reported that staff had attempted on multiple occasions to encourage Resident #12 to get out of bed to attend activities, but the resident declined. Staff I stated they were unaware that the resident did not have a functioning telephone and believed the resident previously had a television remote control, though it was uncertain of its current location. Staff I stated the facility would ensure the identified issues were addressed.No additional information was provided up to the end of the exit conference on 01/29/26.

Based on observation, interviews and record review, the facility failed to provide showers per resident request for 1of 5 sampled residents reviewed for choices, Resident #87. The findings included:Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease on Dialysis, Anxiety, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) End of Prospective Payment System (PPS) Part A stay dated 01/06/26 revealed Resident #87 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. On 01/26/26 at 11:29 AM, an interview was conducted with Resident #87, who was asked about bathing preferences. The resident stated he thought he had one shower since he had been in the facility and he would like more, but they won't give him showers.Record review revealed physician orders for a shower on Monday, Wednesday, and Fridays on 3-11 (3PM - 11 PM shifts).An interview was conducted with Staff B, Certified Nursing Assistant (CNA), on 01/28/26 at 4:20 PM. Staff B stated she has been assigned to Resident #87 often and stated she is aware that he has showers scheduled but she was told he can't get showers because he has a port. (A dialysis port is a medical device used to provide access to the bloodstream for patients undergoing dialysis treatment, allowing for efficient blood filtration and treatment.) She was then asked who told her that and she responded that the wound care nurse told her that he can't have a shower because his port can't get wet.An interview was conducted with Staff C, Wound Care Registered Nurse (RN), on 01/28/26 at 4:27 PM, who was asked if residents on dialysis can have a shower. She asked if this was about Resident #87 because she was aware that he wanted to take showers. She stated she did tell Staff B that Resident #87 could not have a shower due to having a port for dialysis. She stated that this is her protocol. She was asked if this is the policy of the facility and she stated it was not. She was asked if she discussed this with the Director of Nursing (DON) and she stated she did not. She stated she does not have equipment (dressings) to cover the port to keep the area dry during showers, so he has to have a bed bath.An interview was conducted with the DON on 01/28/26 at 5:00 PM. She stated that residents on dialysis are allowed to take showers and she was unaware that Staff C was telling Staff B not to give Resident #87 a shower. She stated she would be ordering dressings to cover the port so he can have a shower as soon as the dressing comes in.

Based on observations, interviews, and record review, the facility failed to follow resident's preferences for incontinence care for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #73. The findings included: Record review for Resident #73 revealed the resident was admitted to the facility with diagnoses that included: Chronic Obstructive Pulmonary Disease, Encounter for Palliative Care, Anxiety Disorder, Hemorrhoids, Constipation, Crohn's Disease of Large Intestine without Complications, Restlessness and Agitation. Review of Resident #73's Physician's orders revealed apply barrier cream to sacrum area and to Turn and Position every 2-3 hours as indicated, every shift AND as needed. Review of Section C of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. Review of Section GG documented Resident #73 required substantial assistance for toileting hygiene and Section H revealed Resident #73 was always incontinent for urine and bowel. Section O revealed Resident #73 receives Hospice Care services. Review of Resident #73's care plan revealed a care focus of at risk for skin breakdown due to Immobility, Bowel/Bladder incontinence and included the following interventions: Encourage/assist resident to change position as often as possible and keep skin clean and dry. Another care focus documented Resident #73 has bowel and bladder incontinence and included the following interventions: Check resident every two hours and assist with toileting as needed and provide peritoneal care after each incontinent episode. Review of the Certified Nursing Assistant (CNA) Tasks for Resident #73 provide no information or task documenting when the resident was receiving peritoneal care or change of incontinence brief. An initial observation conducted on 01/26/26 at 10:09 AM noted Resident #73 was in bed and wearing a hospital gown. She stated that she was waiting for someone to come over and change her, but it wouldn't be until 11:00 AM and then the next scheduled change for the incontinence brief would be around 7:00 PM and then again at 5:00 AM. She then stated she would like someone to change her brief more often, but it is their [facility] policy. At 12:30 PM, Resident #73 was observed in bed, wearing a shirt, and she confirmed she was washed and changed around 11:00 AM. On 01/27/26 at 3:45 PM, Resident #73 was observed in bed wearing a different shirt. She stated that she was changed around 11:00 AM and no other time after that. On 01/28/26 at 4:30 PM, Resident #73 was observed in bed and was wearing a shirt. She stated that they have not changed her brief recently, but now it's almost dinner time and she will not be changed until dinner is finished. She stated she was changed around 11:00 [AM] this morning. She stated she has mentioned it [that she would like to be changed more often] to one of the staff but doesn't know what happened. An interview was conducted on 01/28/26 at 4:51 PM with Staff D, CNA, who stated she has worked at the facility for 3 years and is assigned to care for Resident #73. She stated she checks and provides incontinence care to the residents every 2 hours. She then stated the dinner trays were on the unit and she needed to start passing the trays. An interview was conducted on 01/28/26 at 4:57 PM with the Director of Nursing (DON) who stated she has worked 2 years at facility. She stated the Hospice CNA comes to the facility daily, however the facility staff would always provide care to the resident because she's part of the facility.On 01/29/26 at 9:44 AM, Resident #73 was observed in bed with a hospital gown on and there was no CNA or Hospice CNA in the room to provide care. At 10:35 AM, Resident #73 was again observed, and she stated no one has come to change her yet. At 11:23 AM, the resident had not been changed, and she had pressed the call light. A CNA was observed to then enter Resident #73's room and the surveyor overheard the resident asking the CNA are you here to change me? An interview was conducted on 01/29/26 at 10:22 AM with Staff F, CNA, who stated she has worked at the facility for 5 years. She stated she checks on the residents every 2 hours and provides care, changes the incontinence brief and repositions the resident. She stated she is assigned to Resident #73, and the resident is under Hospice services. Staff F acknowledged that Resident #73 gets baths and is changed every 2 hours.On 01/29/26 at 11:30 AM, Resident #73 was observed in bed and Staff F was in the room and the DON was present. Resident #73 stated she would like to be changed prior to 11:00 AM but not too early because then she would get changed at 7:00 PM or later and that's too long of a gap. Resident #73 also stated they (facility staff) used to change her prior to dinner because sometimes she would have a bowel movement and they would bring in her dinner tray; she would make a fuss and refuse to eat until they changed her. She stated she was not sure what happened that they went back to just changing her later, but she guessed that's their policy. Resident #73 again confirmed she would like to get changed more often during the day. The DON and Staff F were present.

Based on observation, record review, and interviews, the facility failed to coordinate and implement structured activities for 1 of 2 sampled residents reviewed for activities, Resident #13.The findings included:Review of the clinical record documented Resident #13 was admitted to the facility on [DATE]. Review of the Brief Interview for Mental Status (BIMS) score was 5, indicating cognition was severely impaired. The resident's diagnoses included Dementia and Major Depressive Disorder. On 01/26/26 at 11:10 AM, Resident #13 was observed alone in her room with a stuffed animal and two pillows positioned on either side of her body. The television was turned off. Upon interview, as the surveyor prepared to exit the room, Resident #13 made a prayer request to the surveyor. On 01/26/26 at 2:51 PM, Resident #13 was again observed alone in her room with no stimulation other than a doll. She was noted to express herself fluently in a foreign language. The bedroom door was closed, and although the resident had a roommate, she was seen alone. At the same time, music activities were occurring in the activity room. On 01/27/26 at 3:07 PM, the Activity Director stated Resident #13 had a one-to-one (1:1) activity plan intended to be implemented by the Certified Nursing Assistants (CNAs) assigned to her care. The Activity Director stated she did not maintain progress notes or records of ongoing activities and although the activity plan was provided, it lacked specific details regarding scheduled or implemented activities. Review of completed task documentation related to activities for Resident #13 revealed only two entries in the activity log, dated 12/30/25 at 10:19 PM and 01/13/26 at 10:52 PM. There were no checkmarks or indicator present to identify the types of activities offered or completed. Review of the Care Plan (CP) dated 01/08/26 documented Resident #13 is a foreign-speaking woman who initially had difficulty adjusting to the facility but reportedly became accustomed to attending daily activities. The CP stated she prefers spending time with peers but experiences episodes of confusion and attempts to return to her room. Due to adjustment to a new environment and separation from family, she was identified as being at increased risk for anxiety and depression. The CP further documented that Resident #13 would participate in at least one morning activity and one afternoon activity daily and would receive 1:1 programming at least twice weekly for a minimum of 15 minutes per session.No evidence was provided to demonstrate that these activities occurred, and no supporting documentation was available. On 01/29/26 at 1:42 PM, Resident #13 was observed in her room lying in the same position as previously noted, not engaged in any activities. The television was on, but the volume was inaudible. The resident was observed in bed with a doll beside her.The findings were reviewed with the Administrator on 01/29/26. No additional information was provided.

Based on observation and interview, the facility failed to provide privacy curtains for residents in 14 resident rooms (Rooms 121-133) for Bed A, which is closest to the door, and affecting 2 of 2 sampled Residents #40 and #77. The findings included: During an initial tour on 07/28/24 at 9:39 AM, the surveyor observed that Residents #77, residing nearest the door (Bed A), did have no privacy curtains. On 07/29/24 at 11:28 AM, the surveyor observed that Resident #40, residing by the door, did not have privacy curtains. On 07/30/24 at 12:07 PM, the surveyor observed Staff K, RN (Registered Nurse), providing tube feeding to Resident #40. The nurse stated, I'd pull the privacy curtain, but there is no privacy curtain. During an interview on 07/30/24 at 2:45 PM, the spouse of Resident #40 stated the privacy curtain has been missing for many months. The spouse explained, 'the curtain was there for about two years and then all of a sudden one day it was gone.' Another tour was completed on 07/31/24 at 11:00 AM with the Maintenance Director and Regional Maintenance Director. It was observed that none of the rooms on one hallway, for rooms 121 to 133, have privacy curtains by bed A (nearest the door). It was observed that the middle curtain, between the two beds, had widths which were short and did not give complete privacy between Bed A and Bed B (nearest window). The Maintenance Director did not know why the curtains were missing. They both acknowledged that there should be curtains at the beds nearest the doors (Bed As), and longer curtains, width-wise, between the two beds in each room.

Based on interview and record review, the facility failed to ensure the provision of showers as per facility schedule for 1 of 4 sampled residents, Resident #48. The findings included: Review of the record revealed Resident #48 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating he had minimal cognitive impairment. Review of the record lacked any evidence of the provision of showers. A progress note dated 04/04/24 at 9:21 AM documented to please have the resident sit in his wheelchair after his shower one time a day every Tuesday, Thursday, and Saturday. This note also documented if the resident refused to get a shower to phone the resident's significant other / power of attorney (POA), and the phone number was provided. A care plan initiated 01/11/23 documented Resident #48 did reject care, including showers, but lacked the newer intervention to phone the significant other should he refuse. Review of the progress notes subsequent to the 04/04/24 note, lacked any documented refusal of showers or attempts to phone the significant other for assistance, except for a generic statement of refusals during the care plan meeting on 07/18/24. During an interview on 07/28/24 at 11:54 AM, when asked if he was receiving care and assistance from the staff, Resident #48 stated no. When asked what the staff were not providing, the resident stated they didn't take care of him, and asked the surveyor to call his girlfriend. During a phone interview on 07/28/24 at 12:17 PM, the resident's girlfriend, who was also his emergency contact and POA voiced concerns that included the lack of showers. The significant other stated she has gone to every meeting (referring to the quarterly care plan meetings) and complained the resident was not getting his showers. The significant other stated staff will then give him one shower the day after the meeting, and then no more for weeks and weeks. When asked if the resident refuses or resists showers, the significant other stated when he was first admitted to the facility he would refuse, but if staff would offer a shower now he would take one. The significant other stated she had told them a hundred times, if he did refuse, to call her, and she would call him and would be able to encourage or convince him to take a shower. During an interview on 07/28/24 at approximately 1:15 PM, when asked if he would take a shower if offered, Resident #48 stated, Yes, every time. During a subsequent interview on 07/30/24 at 12:33 PM, when asked if he had had a shower this week, the Resident #48 stated, No. During an interview on 07/31/24 at 10:30 AM, when asked about showers for Resident #48, Staff A, Registered Nurse (RN), stated, sometimes the resident is non-compliant, but if we call the significant other, he will comply. When asked about the shower timing, Staff A explained there was a written schedule, and if a resident refused, the Certified Nursing Assistants (CNAs) were to report to the nurse, who would try to encourage the resident to shower. Staff A stated the refusal should be documented by the nurse in the progress notes. During an interview on 07/31/24 at 10:54 AM, when asked who was on the shower schedule for her assignment for the day, Staff B, the CNA assigned to Resident #48 and seven other residents, stated that none of her residents get a shower that day (Wednesday), and that she knows her residents and when they get showers. When asked specifically when Resident #48 would get a shower, Staff B went over to a bulletin board behind the nurses' station but was unable to find the shower schedule. Multiple staff in the area then began to look for the written shower schedule but could not find one. When asked further about the showers, Staff B then stated she floated to that unit today and does not know the shower schedule for that day's assignment. Staff C, Licensed Practical Nurse (LPN), who was standing nearby and also searching for the shower schedule stated, So she should look in the book and know who gets showers. Staff C found a shower schedule in a binder for the 7 AM to 3 PM staff but was unable to locate a schedule for the 3 PM to 11 PM shift. Review of the 7 AM to 3 PM shower schedule revealed Staff B had one shower to provide during her shift. On 07/31/24 at 12:11 PM, the Assistant Director of Nursing (ADON) provided the surveyor with a copy of the shower schedule for both shifts. The ADON stated she had a copy in her office, but agreed there should be one available at the nurses' station. The ADON was informed of the concern related to the lack of showers for Resident #48. Review of the shower schedule provided by the ADON revealed Resident #48 was scheduled for a shower during the 3 PM to 11 PM shift on Monday, Wednesdays, and Fridays. During a side-by-side review of the CNA documentation, the ADON agreed there was no place to enter the provision of a shower. The ADON stated they had been working on the documentation for the CNAs since the company change in May 2023, but had not gotten to each resident.

Based on record review and interview, the facility failed to ensure staff awareness and implementation of DNR (Do Not Resuscitate) status for 1 of 1 sampled resident, Resident #70. The findings included: Review of the Policy, titled, Communication of Code Status, Implemented 05/01/24, documented, in part, it is the policy of this facility to adhere to residents rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 1. The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. 2. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code b. Do Not Resuscitate c. Do Not Intubate d. Do not Hospitalize 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record. 4. The designated sections of the medical record are: Physician Orders, Care plan and Documents. 5. In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code. 6. The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services. 7. The Social Services Director shall maintain a list of residents who have an Advance Directive on file. 8. The resident ' s code status will be reviewed at least quarterly during care plan meeting and documented in the medical record. Review of the electronic medical record (EMR) documented the code status as a Full Code. Review of the Physician's orders dated 02/28/24 revealed an order for Full Code. Further review, under the document tab, revealed a DNR [Do Not Resusitate] document that was dated 03/26/24. The physician signed the DNR document on 05/08/24 and showed effective 06/21/24 in the document tab. A review of the Care Plan documented a full code. During an interview on 07/29/24 at 1:57 PM with Staff C, Licensed Practical Nurse (LPN), she was asked to pull up Resident #70 electronic record and was asked what Resident #70 code status was. She stated she is a full code. The surveyor asked what the physician's order showed. Staff C stated the order is a full code status and was ordered on 02/28/24. When the surveyor asked her to review there area Under the document tab, she stated their is a DNR signed by the physician on 05/08/24 and date of document is 03/26/24 when the document was filled out. When asked, Staff C stated the process for knowing what the code status is, I would look at the order and code status. We have a DNR book. When asked to get the book and show the surveyor Resident #70 DNR status in it, she did not see a DNR document in the book. Staff C didn't understand the concern until surveyor pointed it out. She then stated the order needed to be updated. She stated the process after the DNR is signed, is that the Social Worker or the nurse would put the order in the computer. An interview conducted on 07/30/24 at 12:35 PM with the son and POA (Power of Attorney) of Resident #70, revealed he had requested a DNR order and thought it was in March 2024 but they were going back and forth and a lot was going on. When the surveyor stated the physician had signed the form in May 2024, he stated it should have been effective when first signed and shouldn't have been delayed that long.

Based on observation and interview, the facility failed to maintain a clean, safe and comfortable environment for the residents as evidenced by the environment not being homelike, carts broken and wheelchairs in disrepair, on the 100 and 200 units. The finding included: 1. During an initial tour on 07/28/24 of the resident's rooms, observations revealed the following: a. room [ROOM NUMBER] - The bathroom has paint peeling on the wall underneath the soap dispenser. The grout around the toilet was brown and not white. b. room [ROOM NUMBER]A - the sitting chair in the room had a large stain in the middle of the seat as well as a couple of tears on the seat. c. the Linen Cart on hallway 100 was observed to be broken. 2. The following wheelchairs were observed to have torn arm rests: room [ROOM NUMBER] bed A room [ROOM NUMBER] bed B room [ROOM NUMBER]-A room [ROOM NUMBER]-B room [ROOM NUMBER]-B room [ROOM NUMBER]-A. Photographic Evidence Obtained. 3. A secondary tour was completed on 07/31/24 at 11:30 AM with the Maintenance Director and the Regional Maintenance Director. They both acknowledged the findings. The Maintenance Director stated that he relies on the residents and rehab to tell him if the wheelchair arms need to be replaced. He stated he would be going around and auditing all the wheelchairs and would keep a log. He stated he has only been here a couple of months.

Based on record review and interview, the facility failed to have adequate discharge documenation to ensure the facility followed physician orders to provide Home Health Services set up and that services were provided to residents on discharge home for 1 of 3 sampled residents reviewed for discharge, Resident #92. The findings included: Review of Resident #92 electronic medical record (EMR) revealed Resident #92 was admitted to the facility on [DATE] and discharged on [DATE]. The resident had diagnoses to include Unspecified Fracture of Left Patella, Pain, Difficulty Walking, Hypertension, Type II Diabetes Mellitus, Depression and Anxiety. Review of the physician's orders dated 04/18/24 documented to discharge the resident home with RN (Registered Nurse) evaluation, Physical Therapy (PT), Occupational Thereapy (OT), and Home Health Aide (HHA) and to follow up with Primary Care Physician (PCP) in 1 week. Review of the Progress Notes dated 04/18/24 at 7:30 PM documented, Resident discharged home accompanied by friend, family in stable condition. All due care rendered. All the discharged instructions along with the remaining meds given to Resident. Resident verbalized understanding. Left with all the personal belongings. Resident instructed to visit PCP [Primary Care Physician] in 3-5 days of discharge. On 07/26/24 at 10:17 AM, an interview was conducted with Resident #92. The resident confirmed the facility did not arrange for Home Health services, so they were not provided at the time she was discharged home. During an interview on 07/29/24 at 1:40 PM with Social Worker Director (SWD), she stated, she [SSW] sets up discharges, if there is an order for home health, I would reach out to the company; Her insurance was [name provided], I sent out her documents to [Name provided] Home Health Care. I don't make the appt because the company needs to get approval and schedule with client. If person needs DME (Durable Medical Equipment) I send for wheelchair then I request it but she didn't have DME orders. The SWD could not provide evidence that the Home Health Agency was provided with documents for the required service to Resident #92. An interview was conducted on 07/30/24 at 12:21 PM with [name provided] Home Health Care (HHC) and spoke with the HHC Coordinator. He stated when he tried to pull the resident's name up in his computer, [the resident's] name does not come up in system. If we would have received documentation from the nursing home we would have made a file. They usually fax it and call to follow up to see if we received it but I don't see any of it. There was no evidence in the record that Home Health Services were set up or provided for Resident #92 as per the physician orders. Review of the discharge plan of care provided did not address or document the specific needs of the resident as outlined in the physician orders.

Based on policy review, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 1 sampled resident, Resident #54. The findings included: Review of the policy, titled, Restorative Nursing Programs, implemented on 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 10. A resident's Restorative Nursing Plan will include: . c. Frequency of activities d. Duration of activities . 12. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. Record review revealed Resident #54 was admitted to the facility 05/23/23. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #54 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS also documented the resident received 1 day of restorative therapy services during the 7 day look back period. Review of the Rehab to Restorative Program Recommendations dated 06/06/23 included the services of Bed Mobility and Active Range of Motion (AROM) with the frequency of services to be determined (TBD). Review of the current physician order dated 06/13/23 specified the RNP (Restorative Nurse Program) was to provide AROM and bed mobility services. This order lacked any frequency and or duration. Review of Restorative Aide documentation in the electronic medical record (EMR) revealed services for AROM were provided for Resident #54 only twice in the month of July 2024. An interview was conducted on 07/31/24 at 1:08 PM with Staff E, Restorative Certified Nursing Assistant (CNA), who when asked how often restorative services were being provided and where it was documented, Staff E stated sometimes the resident refused. Staff F, Restorative CNA stated the program was 3 times a week as a standard of the restorative program. Neither of the Restorative Aides were able to locate documentation for the provision of services 3 days weekly or of the resident's refusal of services. During an interview on 07/31/24 at 3:16 PM, when asked what the frequency and duration of activities of residents on restorative therapy were and where it was documented, the Administrator stated the frequency and duration should be documented in the order.

Based on policy review, observation, interview, and record review, the facility failed to ensure timely and ongoing nail care for 1 of 2 sampled residents reviewed for Activities of Daily Living (ADLs), Resident #22. The findings included: Review of the policy, titled, Nail Care, implemented 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. C. The persons responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 7. Procedure: . i. Document completion of task, any complications, or if resident refuses. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident needed substantial to maximum assistance from staff for all Activities of daily Living (ADLs). Review of the care plan initiated 12/08/22 documented Resident #22 had an ADL self-care performance deficit, but lacked any information related to nail care. Review of the Certified Nursing Assistant (CNA) tasks section of the electronic medical record revealed a checkmark daily for the nail care task, indicating it was performed each day. During an interview and observation on 07/28/24 at 10:00 AM, Resident #22's fingernails were long and dirty, with a dark substance under each nail. When asked about his fingernails, Resident #22 stated, They need to be cut. When asked about the cleaning of his fingernails, the resident explained when the nails are cut, they are cleaned. An observation on 07/30/24 at 8:29 AM revealed the fingernails for Resident #22 remained long and dirty. When asked about his fingernails, the resident again stated they need to be trimmed and cleaned, and asked the surveyor if she could do it. On 07/30/24 at 11:30 AM, Resident #22 was in bed with different clothing noted. When asked if the CNA provided a bed bath, the resident stated she did. When asked if she cleaned or trimmed his nails, the resident stated no and that he had asked for them to be trimmed last week and they never got done. The resident's fingernails remained long and dirty. Upon entering the room on 07/31/24 at 11:43 AM, Resident #22 stated, Thank you, as he held up his fingernails to show the surveyor. Resident #22 explained a girl had just came into the room about an hour earlier and trimmed his nails. Staff A, Registered Nurse (RN), who was nearby, stated his nails were trimmed by the Activity Assistant. Staff A was informed the resident's fingernails were long and needed to be cleaned since an observation on 07/28/24, and that the resident stated he had requested his nails be trimmed the previous week. Staff A was also informed the CNAs were documenting the completion of nail care daily. During an interview on 07/31/24 at 1:12 PM, when asked how she was involved in resident nail care, the Activity Assistant stated she has a beauty hour weekly where residents come into the Activity room to get their nails done. The Activity Assistant explained she also goes into the rooms of those residents who prefer to stay in their rooms to help with nail care. When asked about Resident #22, the Activity Assistant stated he was on her list for the previous week, but she did not get to him. The Activity Assistant confirmed she had trimmed and cleaned his nails earlier today.

Based on observation, interviews, record and policy review, the facility failed to provide timely care and treatment for a skin tear for 1 of 1 sampled resident reviewed for skin conditions, Resident #1. The findings included: The facility's policy, titled, Skin Integrity-Skin Tear, implemented on 05/01/24, documented, in part, the following: When a skin tear is discovered, the nurse shall complete an incident report. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. Interventions will be modified in a resident's plan of care as needed. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection, Heart Failure, and Unspecified Peripheral Vascular Disease. Resident #1 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 on her admission minimum data set. On 07/28/24 at 9:27 AM, an observation was made of a white bandage on the resident's right forearm with no date on the bandage. Photographic evidence obtained. At this time, the resident was asked if she knew why she had the bandage on and she stated she thought she scraped her arm on the bed rail. On 07/29/24 at 10:12 AM, another observation of Resident #1's right forearm revealed no bandage on the arm but an observation of a skin tear on the arm. On 07/29/24 at 3:55 PM, an interview was conducted with Staff H, Registered Nurse (RN), who stated she had been taking care of Resident #1 yesterday and today and does not know anything about the Band-Aid on the resident's arm. An interview with the Infection Control Preventionist on 07/29/24 at 4:05 PM revealed she put the dressing on the arm yesterday because she saw a hematoma on the right arm. She stated, today she saw the skin tear and put a Band-Aid on it. Photographic Evidence Obtained. The surveyor asked if she called the physician for an order for the skin tear dressing and she stated she did not. She then took the Band-Aid off that was on the skin tear. Review of the Electronic Health Record (EHR) revealed no note about the skin tear, no incident report and no care plan for the skin tear. 32078

Based on policy review, observation, interview, and record review, the facility failed to ensure appropriate indwelling urinary catheter care and maintenance for 2 of 2 sampled residents, as evidenced by staff failed to provide appropriate urinary catheter care for Resident #22 and failed to ensure an anchoring device for the urinary catheter of Resident #77. Both residents had a history of urinary tract infections (UTIs). The findings included: Review of the policy, titled, Catheter Care, implemented 05/01/24 documented, in part, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . This policy further instructed care for the male was for staff to first cleanse the penis in the area closest to meatus (insertion site), followed by the shaft of the penis moving down or away from the insertion site, and lastly cleaning the urinary tube cleansing outward away from the body, holding the tubing to ensure the catheter remains in place and is not pulled. Review of the policy, titled, Catheterization of a Male, implemented 05/01/24, documented, in part, Policy: Urinary catheterizations will be performed in accordance with current standards of practice to minimize risk for bacterial contamination . 9. s. ii. Secure the catheter to the resident's upper thigh or lower abdomen . 1. Review of the record revealed Resident #22 was admitted to the facility on [DATE], was transferred to the hospital related to complications with his indwelling urinary catheter on 06/17/24 and readmitted to the facility on [DATE]. Resident #22 returned to the facility with the urinary catheter. Further review of the record revealed Resident #22 had Urinary Tract Infections (UTIs) on 02/09/24 and 02/25/24, both times with the cultures indicating E. Coli (Escherichia Coli), a bacteria found in the stool, but not in urine, which was indicative of poor personal or catheter care. These UTIs also indicated the bacteria as MDROs (multidrug-resistant organisms), which are bacteria that have become resistant to certain antibiotics. Resident #22 was also diagnosed during the hospitalization of 06/17/24 with another UTI with MDROs. An observation of care for the indwelling urinary catheter for Resident #22 was made on 07/30/24 at 9:41 AM with Staff D, Certified Nursing Assistant (CNA). The CNA cleaned the catheter tubing first, with a back and forth (outward and inward) motion using one cloth. Then the CNA cleaned the resident's inner thighs, followed by the shaft of the penis, and then the end of the penis at the insertion site. During an interview on 07/31/24 at 11:55 AM, when asked in what direction she was supposed to cleanse the urinary catheter tubing, Staff D appropriately explained from close to the body outward. When asked why she went back and forth on the catheter tubing, the CNA stated, I did? I'm sorry. The Assistant Director of Nursing (ADON) was asked to provide the above-mentioned policies on 07/31/24 during the afternoon and was informed there were concerns with the urinary catheter care and maintenance. 2. Review of the record revealed Resident #77 was admitted to the facility on [DATE], was transferred to the hospital related to urinary catheter issues and an elevated white blood count on 02/24/24, with readmission to the facility on [DATE]. The resident returned to the facility with an indwelling urinary catheter. Further review of the record revealed orders as of 10/05/23 for the use of the indwelling urinary catheter along with the order to secure the tubing using an anchoring device to prevent movement and urethral traction. Review of a urinalysis with the culture and sensitivity dated 01/12/24 documented the resident had a UTI with the organism E. Coli. During an interview and observation on 07/28/24 at 9:40 AM, Resident #77 confirmed he had an indwelling urinary catheter, and the drainage bag was noted hooked to the bed frame. When asked if he had a leg strap or anchor on his thigh, Resident #77 pulled down the covers and an adult brief was noted, with no anchor or thigh strap observed. A second observation on 07/30/24 at 4:09 PM also lacked any type of anchor or thigh strap to secure the catheter tubing for Resident #77. The ADON was made aware of the concern on 07/31/24 during the afternoon but was unable to confirm as the resident had been transferred to the hospital earlier that day, related to urinary catheter issues. The lack of the anchoring device was observed by two surveyors on both occasions.

Based on observation, interviews, record and policy review; the facility failed to provide pain management for 1 of 1 resident reviewed for pain management (Resident #294); and and failed to provide medications as per physician order for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #4 and #28. The findings included: The policy of the facility, titled, Pain Management implemented 05/01/24, revealed an assessment or evaluation of pain may necessitate gathering the following information, as applicable to the resident The resident's goals for pain management and his/her satisfaction with the current level of pain control. 1. Record review documented Resident #294 was admitted to the facility on [DATE] with diagnoses that included Syncope and Collapse, Other symptoms, and signs involving the musculoskeletal system and Presence of cardiac pacemaker. Her Brief Interview for Mental Status (BIMS) score was 14 on the admission minimum data set with an assessment reference date of 07/27/24, indicating the resident was cognitively intact. On 07/28/24 at 1:43 PM, an initial interview with the resident was conducted. She stated she had pain on her right chest wall since she fell and they only will give her Tylenol but that does not help. She stated she told the nurses that she needed something stronger but she was always getting Tylenol when she asked for pain medication. On 07/29/24 at 10:14 AM, the resident stated she did not get Tylenol all night last night and stated she had pain. An interview was conducted with Staff H, Registered Nurse (RN), on 07/29/24 at 3:45 PM. Staff H stated that the resident has not told her that she had pain. She told her that she had a headache or generalized discomfort. She stated if she knew she had pain and was not relieved by Tylenol she would have had her seen by pain management. At that time, the primary physician was in the building and the nurse asked him if he could see the resident today. An interview was conducted with Staff I, Licensed Practical Nurse Supervisor, on 07/30/24 at 12:15 PM. She stated she had a conversation with the physician yesterday who told her that he ordered pain medication for the resident and will send the prescription to the pharmacy. Staff I stated that she forgot to put the conversation with the physician in the progress note, and forgot to put the verbal order into the Electronic Health Record (EHR). The medication card for the Tramadol was put in to the medication cart when it was delivered at 6:30 AM today but the order was not in the EHR yet. An interview was conducted with Resident #294 on 07/30/24 at 12:45 PM. She stated she did not have pain today. The physician came to see her yesterday and she told him that she had pain and he said he was giving her more medication. Review of the physician note dated 07/29/24 revealed the resident had right chest wall pain 6 out of 10 since her fall. She is complaining of right chest wall pain not relieved by licocaine patch or Tylenol. I have added some Aleve and also tramadol for now (we are going to get pain management involved). 32078 2. Record review documented Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pain. The 5-day Minimum Data Set (MDS) Assessment completed on 07/18/24 documented Resident #4 received an as needed medications for pain, and her Care Plan, initiated on 06/25/24, documented Resident #4 is at risk for Pain. Review of physician orders for Resident #4 showed this resident is to receive a Lidocaine Patch, applied to bilateral shoulders topically one time a day for pain. Apply to intact skin and remove patch after a maximum of 12 hours of application (12 hours on and 12 hours off) and remove per schedule. Review of the electronic Medication Administration Record (eMAR) showed that nursing staff had documented that Resident #4's Lidocaine patch was NA (not available) from 07/24/24 AM to 07/28/24 AM, the Patch was documented as provided on 07/29/24 AM, but NA (not available) on 07/30/24. there was no monitoring of pain completed on the days the patch was not available or provided. No further documentation was found on the eMAR or in the Progress notes regarding a reason for the Lidocaine Patch being unavailable, or what steps were taken to get the medication for the resident. 3. Record review documented Resident #28 was admitted to the facility on [DATE] with diagnoses that included Chronic Pain Syndrome. The MDS for Significant Change completed on 06/02/24 documented Resident #28 received a scheduled pain medication regimen, and the Care Plan initiated on 06/06/24 documented the resident is at risk for pain. Review of physician orders for Resident #28 showed this resident is to receive a Lidoderm Patch 5%, and it is to be applied to affected site topically one time a day for pain. Apply to intact skin and remove patch after a maximum of 12 hours of application (12 hours on and 12 hours off) and remove per schedule (05/15/24 - 07/29/24). There was also a physician order for Lotrisone Cream 1-0.05% to be applied to chest, arms, back topically every shift for rash until 07/10/24. Review of the eMAR showed that nursing staff had documented that Resident #28's Lotrisone Cream was not available on 07/02/24 for the day and evening shift application times. Also, for the Lidoderm (Lidocaine) Patch 5%, there was no documentation on 07/04/24, and nursing staff documented the Lidoderm Patch 5% as NA (not available) on 07/09/24, 07/10/24, 07/12/24, 07/27/24 and 07/28/24. There was no monitoring of pain documented as done on the days the patch was not available / provided, except for 07/09/24 for which the pain level recorded was 0 (zero). No further documentation was found on the eMAR or in the Progress notes regarding a reason for the Lotrisone Cream or Lidoderm Patch 5% being unavailable, or what steps were taken to get the medication for the resident. The Director of Nursing was interviewed on 07/31/24 at approximately 12:30 PM. She was unable to provide any further information or documentation as to why the Lidoderm/Lidocaine patches and the Lotrisone cream were marked unavailable, and as to why pain monitoring was not documented On 07/31/24 at 1:30 PM, the Pharmacist Consultant was asked to enquire of the Pharmacy if the unavailable medications were provided to the facility. The Pharmacist Consultant stated that the information received from the Pharmacy indicated the medications marked not available were delivered to the facility and should have been available. No further information was provided by the facility.

Based on observation, interview and record review, the facility failed to document pain levels for 2 of 6 sampled residents reviewed for medications (Resident #4 and Resident #28); failed to document Blood Glucose levels before each meal, as ordered 1 of 5 sampled residents reviewed for unnecessary medications (Resident #81); failed to document the percentage of meals eaten for 1 of 4 sampled residents reviewed for nutrition (Resident #70); failed to clarify the type of dialysis received for 1 of 1 sampled resident reviewed for Dialysis (Resident #292); and failed to accurately document the provision of nail care for 1 of 2 sampled residents reviewed for Activities of Daily Living [ADLs] (Resident #22). The findings included: 1a) Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included Pain. The 5 day Minimum Data Set (MDS) Assessment completed on 07/18/24 documented Resident #4 received as needed medications for pain, and her Care Plan initiated on 06/25/24 documented Resident #4 is at risk for Pain. The physician orders for Resident #4 contained an order for pain monitoring which documented: Monitor and record pain level every shift for pain management. Pain Scale: Mild pain 1-3 Moderate pain 4-6 Severe 7-10. Review of the electronic Medication Administration Record (eMAR) and Progress Notes revealed no documentation showing the monitoring of pain levels were completed within Resident #4's record. 1b. Record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that included Chronic Pain Syndrome. The MDS for Significant Change completed on 06/02/24 documented Resident #28 received a scheduled pain medication regimen, and the Care Plan initiated on 06/06/24 documented the resident is at risk for pain. The physician orders for Resident #28 contained an order for pain monitoring which documented: Monitor and record pain level every shift for pain management. Pain Scale: Mild pain 1-3 Moderate pain 4-6 Severe 7-10. Review of the eMAR and Progress Notes revealed no documentation showing the monitoring of pain levels were completed within Resident #28's record. On 07/31/24 at approximately 12:30 PM, the Director of Nursing (DON) was asked to assist in locating any documentation showing staff were recording Resident #4's pain levels during each shift. The DON acknowledged that no documentation of pain levels for each shift could be found. 2. Record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2. The MDS assessment completed on 05/03/24 documented the resident diagnosis of Diabetes Mellitus 2 and the receiving of hypoglycemic medication. Resident #81's Care Plan initiated on 04/30/24 documented this resident is at risk for adverse effects of hyper/hypoglycemia and alteration in nutrition / hydration related to diagnosis of Diabetes Mellitus 2. Resident #81's physician's orders contained an order for Blood Glucose monitoring before meals. Call MD if Blood Sugar is above 250 or below 60. Review of the eMAR showed that nursing staff are initialing that the monitoring is being done, but the actual blood glucose numbers are not being recorded on the eMAR, within the Vitals section of the electronic record, or anywhere within the Progress Notes. The only documented blood glucose reading of 177 g/dl was recorded on 07/22/24. On 07/31/24 at approximately 12:30 PM, the Director of Nursing (DON) was asked to assist in locating any documentation showing that nursing staff were recording Resident #81's blood glucose levels before each meal. The DON acknowledged that no documentation of blood glucose levels, except for the one recording on 07/22/24, could be found for Resident #81. 33103 3. Review of Resident #70 electronic medical record (EMR) revealed a physician's order that included an order of 06/13/24 for three snacks daily; Report % [percent] consumed. Review of the Medication Administration Record (MAR) revealed the order began on 06/13/24. There were nurse's initials and a check mark documented this was completed but does not document the % of the snack consumed. Review on the July 2024 Task sheet from 07/02/24-07/31/24 (could only pull 30 days) named monitor eating did not document which meal or snacks were provided but only documented the time and % consumed. During an interview on 07/31/24 at 1:23 PM with the Dietician, she stated she has only been in this facility for two months, but has been monitoring her weight loss and added snacks in the last intervention. She pulled up % consumed for each which was 50-75%. She acknowledged that there should be documentation for all three meals plus 3 snacks per day documented. She acknowledged that she did not see snack documentation being completed as this was not being done. 25404 4. Review of the policy, titled, Nail Care, implemented 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. C. The persons responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 7. Procedure: . i. Document completion of task, any complications, or if resident refuses. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented the resident needed substantial to maximum assistance from staff for all Activities of Daily Living (ADLs). During an interview and observation on 07/28/24 at 10:00 AM, Resident #22's fingernails were long and dirty, with a dark substance under each nail. When asked about his fingernails, Resident #22 stated, They need to be cut. When asked about the cleaning of his fingernails, the resident explained when the nails are cut, they are cleaned. An observation on 07/30/24 at 8:29 AM revealed the fingernails for Resident #22 remained long and dirty. When asked about his fingernails, the resident again stated they need to be trimmed and cleaned, and asked the surveyor if she could do it. On 07/30/24 at 11:30 AM, Resident #22 was in bed with different clothing noted. When asked if the CNA provided a bed bath, the resident stated she did. When asked if she cleaned or trimmed his nails, the resident stated no and that he had asked for them to be trimmed last week and they never got done. The resident's fingernails remained long and dirty. Resident #22's fingernails were trimmed and cleaned on 07/31/24 at about 10:45 AM. Review of the care plan initiated 12/08/22 documented Resident #22 had an ADL self-care performance deficit, but lacked any information related to nail care. Review of the Certified Nursing Assistant (CNA) tasks section of the electronic medical record revealed a checkmark daily for the nail care task, indicating it was performed each day. 39026 5. Record review revealed Resident #292 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD), Depression and Anemia. Review of the care plan for Resident #292 revealed a care plan for hemodialysis and peritoneal dialysis. An interview was conducted with Staff G, Minimum Data Set (MDS) Coordinator, on 07/31/24 at 9:30 AM. She stated she should not have a care plan for peritoneal dialysis, only hemodialysis and cancelled the care plan for peritoneal dialysis.

Based on observation, interview, record and policy review, the facility failed to have an effective infection control program related to care and services provided to residents on Enhanced Barrier Precautions which affected 5 of 20 sampled residents on Enhanced Barrier Precautions (EBP), Residents #292, #194, #1, #22, and #77. The findings included: The facility's policy, titled, Enhanced Barrier Precautions, implemented on 05/01/24 and revised on 05/28/24, revealed, in part: 2b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. 1. Record review documented Resident #1 was admitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection (UTI), Heart Failure, and Unspecified Peripheral Vascular Disease. Review of the Admission Minimum Data Set MDS) asssessment documented Resident #1 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15. Review of the physician orders for Resident #1 revealed an order for Enhanced Barrier Precautions for sacral wound dated 06/19/24. Observation of her resident's room on 07/28/24 at 10:38 AM and 07/29/24 at 11:07 AM revealed no sign for Enhanced Barrier Precautions and no Personal Protective Equipment (PPE) cart available at or near the door. 2. Record review documented Resident #194 was admitted to the facility on [DATE] with diagnoses that included Pneumonia, Nontraumatic Intracranial Hemorrhage, and Dysphagia. On 07/29/24 at 9:13 AM, an observation of medication administration via Percutaneous Endoscopic Gastrostomy (PEG) tube was made. An Enhanced Barrier Precaution sign was in the resident's room on top of a Personal Protective Equipment (PPE) cart. Staff J, Registered Nurse (RN), was observed administering medication into the PEG tube with no gown on. An interview was conducted Staff J on 07/29/24 at 2:30 PM. He stated that he was in-serviced that they put a gown on and gloves for catheter care, IV (intravenous) care, and wound care. When asked if he had to wear a gown to administer medication via PEG tube, he stated he was not sure about that. 3. Record review documented Resident #292 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Depression and Anemia. Resident #292 attends in-house hemodialysis on Tuesday, Thursday and Saturday. Observation of the resident's room on 07/28/24 at 10:38 AM and 07/29/24 at 11:07 AM revealed no sign for Enhanced Barrier Precautions and no Personal Protective Equipment (PPE) cart available in the room or at or near the door. A physician order was placed in her Electronic Health Record (EHR) on 07/29/24 for Enhanced Barrier Precaution due to 'dialysis catheter'. There was no care plan for Enhanced Barrier Precautions placed in the EHR. An interview with the Infection Control Preventionist was conducted on 07/29/24 at 3:13 PM. She initially stated the rooms with residents with dialysis do not need the Enhanced Barrier Sign with available PPE. The Enhanced Barrier Precautions policy was reviewed with the Infection Control Preventionist who then stated the nurse should have worn a gown during medication administration via PEG tube and she also stated that residents with dialysis should be on EBP. She stated she gave in-services on EBP on 05/24/24. 25404 4. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the record revealed Resident #22 had a Urinary Tract Infection (UTI) as per the laboratory results reported on 02/09/24. This urinalysis and culture reported the organism was ESBL (extended-spectrum beta-lactamase), classified as an organism resistant to antibiotic, necessitating the use of contact precautions with PPE (personal protective equipment). This infection was treated with an antibiotic for seven days. Further review of the orders and corresponding Medication Administration Record (MAR) revealed contact precautions for just three days as of the evening shift on 02/09/24. During a side-by-side record review and interview on 07/31/24 at 9:54 AM, the Infection Control Preventionist confirmed she would expect the contact precautions for a resident with an active MDRO to be maintained through the entire dose of antibiotics. Review of the current orders revealed Resident #22 had an indwelling urinary catheter, with care to be provided every shift, and maintaining and implementing enhanced barrier precautions. During an observation on 07/28/24 at 9:57 AM, Resident #22 was in bed and was noted to have a urinary catheter. A small rolling plastic three drawer container was noted near the roommate's dresser with PPE, but no sign indicating EBP use was observed. A second observation on 07/29/24 at 11:50 AM revealed the same small container with still no EBP sign. An observation of direct personal care for Resident #22 was made on 07/30/24 at 9:41 AM with Staff D, Certified Nursing Assistant (CNA). The small rolling plastic drawer had been removed and a larger three drawer plastic container was noted between the two beds, as both residents had indwelling urinary catheters, and an EBP sign was noted on top of the PPE storage bin. Staff D provided personal care to Resident #22, but at no time donned a gown. During an interview on 07/31/24 at 11:55 AM, when asked about the use of a gown during direct care of a resident with an indwelling urinary catheter, Staff D stated she was not aware she needed to wear a gown, or she would have done so. 5. Review of the record revealed Resident #77 was admitted to the facility on [DATE] and was admitted with an indwelling urinary catheter. Review of the orders revealed Enhanced Barrier Precautions (EBPs) were initiated as of 05/20/24. An observation on 07/28/24 at 9:40 AM revealed Resident #77 in bed and an urinary drainage device noted hooked to the bed frame. A small storage bin was noted near the resident's dresser that contained PPE. No sign for EBP was noted on the door or in the room. A subsequent observation on 07/29/24 at 11:46 AM still revealed a lack of an EBP sign. 51137 6. Review of the record revealed Resident #40 was admitted to the facility on [DATE] with the need to be fed via PEG tube (percutaneous endoscopic gastrostomy, a surgically placed feeding tube directly into the stomach), secondary to Parkinson's Disease and the inability to swallow. An order dated 11/15/24 included the resident was to be fed continuously via the PEG tube. An additional order dated 05/20/24 documented to maintain Enhanced Barrier Precautions (EBP) every shift due to the indwelling device. Observations on 07/28/24 at 11:15 AM and 07/29/24 at 11:50 AM revealed Resident #40 in bed with the feeding pump at bedside and tube feeding noted. There was a small three drawer container with PPE (personal protective equipment) inside the room. There was no sign indicating the resident was on Enhanced Barrier Precautions, to instruct staff on when and how to use the PPE. Photographic Evidence Obtained. During an interview on 07/29/24 at 3:40 PM, the spouse confirmed Resident #40 was fed only via the PEG tube. When asked if staff were using the gowns during direct care for the resident, the wife stated, No. The spouse explained she visits daily and often arrived at the facility when staff were providing care to her husband, and staff had not been wearing the gowns. The spouse further volunteered the small three drawer container just showed up one day with no explanation. When explained the use EBP, the wife stated she had not been told about the precautions.

Based on record review and interview, the facility failured to provide the appropriate Beneficiary Notification Form (CMS Form 10055/SNF ABN) to 2 of 3 sampled residents, Resident #22 and #70. The findings included: On 07/31/24, reviews of the Beneficiary Notices provided by the facility for Resident #22 and Resident #70 revealed they were discharged from Part A Medicare services and the beneficiary notices were completed. The residents were not provided with the required documentation, CMS Form 10055 (SNF ABN), at the time of Medicare Part A discharge, as follows: 1. Record review revealed Resident #22's start date for Medicare Part A services was 07/04/24. His last covered day of Part A Services was 07/09/24. The facility initiated the discharge from Part A services when the benefit days were not exhausted, and Resident #22 chose to remain in the facility. The CMS Form 10123 (NOMNC) was provided to Resident #22 on 07/04/24, but the CMS Form 10055 (SNF ABN) was not provided. The SNF ABN is required if the resident has skilled benefit days remaining and is being discharged from Part A services but will continue living in the facility. 2. Record review revealed Resident #70's start date for Medicare Part A services was 03/22/24. His last covered day of Part A Services was 03/27/24. The facility initiated the discharge from Part A services when benefit days were not exhausted, and Resident #22 chose to remain in the facility. The CMS Form 10123 (NOMNC) was provided to Resident #22 on 03/22/24, but CMS Form 10055 (SNF ABN) was not provided. The SNF ABN is required if the resident has skilled benefit days remaining and is being discharged from Part A services but will continue living in the facility. On 07/31/24 at 2:10 PM, an interview was conducted with the Social Services Director (SSD), who is responsible for providing residents with the Beneficiary Notices. The SSD stated that she had no knowledge of the CMS Form 10055 (SNF ABN), and she didn't have any copies of the SNF ABN to provide to residents who were discharged from Medicare Part A services and who chose to remain in the facility. A copy of the SNF ABN form was provided to the SSD via email on 07/31/24. The SSD enquired as to how the SNF ABN form was to be completed, so a copy of the instructions for the SNF ABN Form was emailed to her on 07/31/24, along with a copy of beneficiary notice scenarios to show which CMS Forms were needed when residents are discharged from Part A services.

Based on record review and interview, the facility failed to state in their Admission Agreement (page15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 88 of 88 residents at the time of survey. The findings included: Review of the facility's 'Arbitration Agreement Program Guide' and 'Arbitration Agreement' was completed on 07/30/24. The separate 'Arbitration Agreement' and 'Arbitration Program Guide' contained all required regulatory language. However, within the Admission Agreement (Agreement between the Facility and Resident / Representative), there is a paragraph on page 15 (Item #26) which stated: WAIVER OF RIGHT TO JURY TRIAL. BY SIGNING THIS AGREEMENT RESIDENT AND RESPONSIBLE PARTY ARE WAIVING (A) THE RIGHT TO A JURY TRIAL FOR ANY CLAIM(S) BROUGHT HEREIN AND (B) INSOFAR AS THE ARBITRATION AGREEMENT IS EFFECTIVE ARE AGREEING TO ARBITRATE CLAIMS PROVIDED FOR THEREIN INCLUDING ANY AND ALL CLAIMS ARISING OUT OF OR RELATED TO THE FACILITY SERVICES PROVIDED HEREUNDER TO RESIDENT, INCLUDING, SPECIFICALLY, RESIDENT'S MEDICAL CARE AND TREATMENT. Even if the resident / representative chose not to sign the separate 'Arbitration Program Guide' and 'Arbitration Agreement,' the above paragraph contained within the Admission Agreement (Resident Contract), each resident / representative seeking admission to the facility was being required to sign an arbitration agreement as a condition of admission and/or as a requirement to receive care and services at the facility. Nowhere in this paragraph did it inform the resident / representative that they are not required to agree to this Arbitration Agreement as a condition for admission or to receive care and services, nor does it give the resident / representative the right to rescind the agreement within 30 days of signing it. On 07/31/24 at 9:56 AM, an interview was conducted with the Admissions Director. She was shown the paragraph #26 on page 15 and informed that this paragraph in the admission agreement was requiring every person that signs the Admission Agreement to waive their right to a jury trial. The wording of paragraph #26 is not in line with Federal regulation regarding Arbitration Agreements. She stated she would inform the new owners that the Admission Agreement must be amended to remove this paragraph in the Agreement. On 07/31/24 at approximately 12:45 PM, the owner of the facility was informed by this surveyor of the concern with the wording contained in paragraph #26 on page 15 of the admission agreement, and the lack of information in the paragraph that informs the resident that they are not required to agree to waive their right to a jury trial. The owner acknowledged understanding of the concern with the wording of paragraph #26.

Based on observation, interview and record review, the facility failed to provide foods that were prepared in a sanitary manner in accordance with professional standards. The findings included: 1. During the initial kitchen tour, on 06/25/23 at 8:53 AM, accompanied by the Food Service Director (FSD) and Staff A, Cook the following were noted: a. The air conditioning unit was not working in the kitchen, and the facility had been using portable units to cool the kitchen. The portable units required water to be plumbed to them. The water that was plumbed to the portable units was the cold water from the hand washing sink, located at the end of the production area where meals are plated from the hot holding unit. Due to the units being plumbed to the hand washing sink, the sink was rendered unusable due to only having hot water. The facility converted a food prep sink at the coffee / beverage station into a designated hand washing sink by installing a soap dispenser and paper towel dispenser on the wall over and next to the sink. The designated hand washing sink that was next to the coffee / beverage station was observed to have a bucket that contained cloudy liquid (sanitizer, according to staff) and towels that were being used to sanitize food and non-food contact surfaces in the basin of the sink. The hand washing sink was the only working hand washing sink due to the air conditioning not working in the kitchen. b. Coffee pots were stored directly under the hand soap dispenser that was mounted to the wall at the hand washing sink. c. Staff A, Cook, dropped a pan of sliced ham on the floor and some of the ham in the pot had spilled over onto the floor. Staff A picked up the pieces of ham from the floor with her gloves hands and placed the pieces of ham in the trash receptacle at the end of the food assembly line area. Staff A then proceeded to wrap a full size 2 inch deep pan of the ham without changing gloves and performing hand hygiene until surveyor intervention. d. There was an accumulation of rust on the vents in the exhaust over the cooking equipment. e. There was an accumulation of residue on the lids and exterior of the ice machines. f. The floor drain under the three compartment sink was overflowing onto the floor. g. The surface on the top of the toaster was peeling. h. There was an accumulation of residues on the wall behind the tables in the food preparation area by the ice machines. i. There was an accumulation of food residues on the blade to the counter mounted manual can opener. j. Accumulation of ice from the cooling units directly over and on a box of commercially processed whip cream in the walk in freezer. k. The floor inside of the entrance to the walk in cooler was damaged to a point that exposed the raw concrete underneath the tiles. At the conclusion of the initial kitchen tour, the FSD acknowledged understanding of the concerns. 2. On 06/26/23 at 6:55 AM, during an observation in the kitchen, accompanied by the FSD, the hand washing sink located at the coffee / beverage station had a bucket of cloudy liquid and there were numerous used cups, utensils and towels in the basin of the sink. At the time of the observation, the FSD was made aware and instructed staff to stop using the sink for food and drink preparation. 3. During the follow up kitchen tour, on 06/27/23 at 11:07 AM, accompanied by the FSD and Staff A, Staff B (Cook), was observed picking up an object from the floor. The cook placed the object in the waste receptacle and continued through the kitchen. The Cook was instructed to wash her hands prior to continuing work. The Cook proceeded to the hand washing sink that was not in use, turned on the water and ran her hands under the water and then turned off the water and dried her hands. The Cook then proceeded again through the kitchen until being prompted by the surveyor to properly wash her hands with soap at the working hand washing sink. The Cook then exited the kitchen to retrieve an empty food trolley so that staff could place meals in it for the residents. At the time of the observation, the FSD acknowledged understanding of the observation.

Based on observation, interview, record review and review of policies and procedures, the facility failed to provide adequate supervision to 1 of 3 sampled residents, resulting in the elopement of Resident #1. Resident #1, who was reportedly last seen by staff on 03/27/22 at 7:15 PM, exited the facility behind a visitor, out of an emergency exit by the Physical Therapy Gym. The facility's system failure, and lack of adequate supervision, allowed the resident to elope undetected by staff. The facility contacted the police after conducting a facility wide search. Resident #1 was returned to the facility approximately 13 hours later after being found by a facility staff member. This situation resulted in Immediate Jeopardy. While Resident #1 was off facility property there was the potential he could have fallen or got hit by a car and suffered serious injuries or death. The findings included: The facility's policy titled 'Elopement', revised 09/18/13, documented, Definition of Elopement: Elopement applies to a Resident who is not competent. An elopement occurs when a resident leaves the outside perimeter of the facility without following facility policies and procedures for leaving the premises. Facility policies and procedures for leaving the premises are: discharge of transfer orders, leaving AMA or leaving on an authorized leave or pass. Facility perimeter: Area outside the facility: 1. [NAME] Boulevard west to Sims Road, 2 [NAME] Boulevard east to Las Verdes Way, 3. Delray Medical Center and grounds west to Lake View Care Center, 4. Delray Medical Center and grounds north to [NAME] Boulevard, 5. Delray Medical Center and grounds west to Country Lake Circle. * Procedure: Should an employee discover that a resident is missing from the facility, he/she should: 1. Determine the resident is out on an authorized leave or pass 2. If not on leave or pass, Code Green must be called and an extensive search by nursing and security staff shall be initiated immediately. The Administrator, DON and Risk Manager must be notified at this time. 3. All facility staff is to search their immediate areas, making certain to check behind all closed doors, all stairwells as well as the facility grounds. 4. Should the resident be found, the licensed nursing staff will examine the resident for injuries, cancel the Code Green or other facility code, notify the attending physician, the resident's family/responsible party, complete an unusual occurrence report and make appropriate entries in the resident's medical record. 5. In the event the resident is not found after 30 minutes of search, the nurse in charge/supervisor will notify the Administrator, the DON, the Risk Manager, the local police, the family/responsible party and the attending physician. 6. The licensed nurse will document objective information concerning the missing resident in the resident's medical record. 7. The licensed nurse shall complete an Unusual Occurrence Report and document the event, the steps taken to locate the resident, and the individuals notified. 8. The facility risk manager will report the event to AHCA pursuant to FS 400.147, by completing the Adverse 15-Day Report. The facility's policy titled 'Elopement Risk Assessment' (undated) documented: Procedure: 9. In the event the assessment was initiated because of an elopement (where the resident's whereabouts were unknown), the elopement will be reported in accordance with the facility's Accident/Incident Unusual Occurrence Policy. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses to include heart failure, [CONDITION(S)], and anxiety disorder and was under Hospice services for a diagnosis of [CONDITION(S)]. The resident was discharged after the elopement on 03/28/22, at the family's request, to alternate skilled nursing facility with a secured unit. According to the resident's most recent assessment, a discharge MDS (Minimum Data Set) dated 03/28/22, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was 'cognitively intact'. During an interview with the facility's Medical Director on 05/26/2022 at 1:32 PM, it was reported, He was alert and oriented to himself only. He was in a state of delusion and paranoia and he wanted to leave to go home. A Skilled Nursing Evaluation dated 03/27/22 at 01:17, documented, Resident does not wander at night and Resident sleeps intermittently at night and that Resident #1 ambulates independently'. The Baseline Care Plan, dated 03/27/22, documented Resident #1 required 'one-person physical assist' for bed mobility, transfer and locomotion on unit and no setup help or physical help from staff' for walk in room, walk in corridor and that resident did have a wheelchair.' An Admission Evaluation dated 03/27/22 at 1:39 AM, documented Resident #1 was 'alert and oriented x 3' with hearing and vision documented as 'adequate'. Review of an 'Elopement' report in Resident #1's electronic health record documented the following, Nursing Description: This nurse arrived at [name of facility], the Mauve unit nursing station approximately 1910 hours (7:10 PM) on 03/27/22. [Resident #1] was standing at the nurse's station talking to our unit secretary, [Staff H]. I began initial rounds to check on my residents and rooms including new residents. [Resident #1] was new to me and I asked the unit secretary who he was and she introduced me to the man standing at the nurses station as [Resident #1] I continued with my rounds and began my med pass about 1945 (7:45 PM). I gave medications to the residents that want their medications early and then to the rest of the residents. [Resident #1]'s room is [Room #] toward the end of the hall. At about 2200 hours (10:00 PM) I was looking for [Resident #1] and could not find him to give him his medication. The Unit Secretary [Staff H] stated that he was at the nurse's station when she left for her break at 2000 hours (8:00 PM). At this time, I began to ask the other nurse and aides if they had seen [Resident #1]. I went to [200 unit], the other unit at [name of facility] to see if he had walked over there and if anyone had seen him. They had not. Immediate Action Taken: when I had no initial sighting of [Resident #1], I called the Director of Nursing, to report that we could not locate him in the facility. I left a message with a brief description of this incident. The nurse [Staff E], Registered Nurse, working with me mentioned that she may have seen him a little earlier out on the road in front of [name of local medical center] when she had gone out to her car. We both went outside and took her car to look briefly down [NAME] Blvd., then north on Military Trail. We had no sighting. I continued to call the Assistant Director of Nursing (ADON) and then our manager, [Staff B], Registered Nurse/Unit Manager. [Staff B] answered the phone and directed me to call a code [NAME] in the facility for all staff members to search every room in the building for this resident and to call the Administrator. The Administrator stated that he was on his way and that we should notify the family member [Resident #1's son]. His son was called, and a description of the incident was repeated to him. I also called [name of Hospice Agency] as Resident #1 was in their care. [Name of Hospice Nurse] on call informed me that in their notes it states that Resident #1 was known to leave the facility, we were not given that information in our notes. I then called the [name of local police department] and they arrived about the same time as the Administrator. The police department asked us to conduct another search of the facility for [Resident #1]. We looked at our security cameras and did see a man that appeared to be [Resident #1] leave the facility following a [visitor] at 2015 hours (8:15 PM). Further review revealed the report documented Resident #1 as: * Oriented to person, place, situation and time * No injuries observed at time of incident * admitted within last 72 hours * Ambulating without assistance * Wanderer Review of a 'Reporting Officer Narrative' dated 03/28/22, documented, On March 28, 2022, at 0118 hours (1:18 AM), I responded to Lakeview Care Center regarding a patient who eloped from the facility. I made contact with [Staff G], Licensed Practical Nurse upon my arrival and she stated the following: On March 28, 2022, at approximately 2200 hours (10:00 PM), she was tending to her assigned patients to provide nightly medication. When she arrived in [Resident #1's] room to provide [Resident #1] with medication, he was not there. The last time he was seen was at the nursing station near his room at approximately 1915 hours (7:15 PM). After noticing that he wasn't in his room, she and several nurses searched rooms, bathrooms, and perimeter of the facility. Her and a couple of nurses also searched the significant corridors and businesses in the area. After viewing the video footage at the facility, it was discovered that [Resident #1] left the center at 2015 hours (8:15 PM) and walked toward the front of the facility. Due to the main entrance doors (nurse entry and exit doors) not being reset, [Resident #1] could exit without the alert alarm activating. [Resident #1] began to have a conversation with an unknown white female believed to be a Nurse Aide. Shortly after, [Resident #1] is seen walking away eastbound in the parking lot area near the main entrance of [name of local medical center]. As of this writing, the identity and contact information of the nurse aide that was seen on video talking to [Resident #1] before he walked away is still being worked on. A statement by the ADON (Assistant Director of Nursing), dated 03/30/22 documented, Report received that resident was at Nursing Station speaking with staff as observed by primary nurse [Staff G]. Reported resident was speaking with [Staff H]. Reported that on next rounds resident was not observed on unit. Unit was searched and resident was not observed. Facility was searched and resident was not observed. Facility perimeter searched and resident was not observed. Family and [Name of Hospice] contacted. [Name of Police Department] contacted, perimeter searched and resident was not observed. Primary nurse on day of event: [Staff G]. Co-nurse on unit day of event: [Staff E]. [Name of Hospice] nurse on call: [Name of Nurse]. On 03/29 off going nurse reported on her way home she saw a man that fit description of resident walking in her neighborhood. Nurse approached resident, was able to get him in car and escorted him to facility. Resident was assessed by nursing staff and had no noted apparent injuries. Resident voiced he wanted to return home. Meal was provided for resident. Family was contacted and on their way to facility. Record Review: admitted to [name of facility] 03/26/22 after home evaluation completed by [Name of Hospice]. Resident was on [Name of Hospice agency] services due to dyspnea (shortness of breath), pain, terminal agitation, terminal congestion with a prognosis deemed as grim. Prior care regimen was resident was at caregiver home Monday through Friday due to Son working. Ambulated independently. Family reported sleeps most of day and up at night. Medical history included: anxiety, agitation, hallucinations, restlessness and [CONDITION(S)]. Family reported worsening confusion/disorientation at night with no improvement of symptoms. Upon entry to [name of facility] and review of records indicate resident was alert and oriented x 3. Ambulates independently. BIMS 13. Resident had not exhibited wandering episodes, had not exhibited attempts to leave facility, had not exhibited voicing wanting to leave prior and had not exhibited packing belongings prior to 03/28. Event did not result in death, brain/spinal damage, permanent disfigurement, fracture/dislocation of bones/joints or limitation of neurological/physical/sensory function. Resident was transferred to another facility closer to family home. This statement was signed by the ADON on 03/30/22. The ADON confirmed that this statement was documented as the facility's investigation of Resident #1's elopement. An 'Elopement/Unauthorized Departure Risk Assessment, dated 03/28/22 at 13:09 (1:09 PM), after Resident #1 returned to the facility after eloping the previous evening/night completed by the Director of Social Services, documented: Evaluation: * Resident #1 had the physical ability to leave the facility. * Resident #1 did have a history of unauthorized departure from the home or a health care setting. * Resident #1 verbalized anger and/or a serious intent to leave the facility and/or has a history of unauthorized departures. Outcome & Recommendations: * Resident was 'not considered at risk for unauthorized departure/elopement/flight risk. * Resident is alert and oriented x 3, express desire to return home but is not considered risk to elope. Resident does not comply to the facility admission policy. He feels he is able to come and go as he please. SW recommends an ALF environment for resident. In review of the facility floor plan, there are 2 possible routes from Resident #1's room to the exit door at the main entrance: Route #1 - From Resident #1's bedroom, Resident would have walked approximately 112 feet to the 100-unit nurse's station. From the 100 unit nurse's station, Resident would have walked approximately 117 feet to reach the 200 unit nurse's station. From the 200-unit nurse's station, Resident would have turned to the left and navigated a corridor, approximately 170 feet to the exit door - passing residents' rooms, the PT, OT and ST and Administrator's office and the reception desk. Route #2 - From Resident #1's bedroom, Resident would have walked approximately 112 feet to the 100-unit nurse's station. From the 100-unit nurse's station, resident would have turned to his left and navigated a corridor approximately 125 feet to the end of the corridor, where the Main Dining room is located. At the end of the corridor, resident would have turned to his right and navigated another corridor approximately 100 feet past public restrooms, Human Resources office, and lobby/reception area. During a driving tour conducted on 05/25/22 at 1:03 PM, it was noted that there is a canal behind the facility with a fence that contains 3 cables on the west side of the facility. There is also a lake to the south of the facility that is fenced in with a chain link fence and to the east of the facility is an open lake. Headed out of the facility (on road shared by facility and hospital) toward [NAME] Blvd., the hospital emergency entrance is across from the facility; the shared road has no sidewalks and where the shared road meets [NAME] Blvd there is no pedestrian crossing signal. [NAME] Blvd. heading east has 2 lanes of traffic heading east and 2 lanes of traffic heading west, there are sidewalks on both sides of [NAME] Blvd. Sitting at the traffic signal on [NAME] Blvd. turning north onto Military Trail, at that intersection, [NAME] Blvd has 2 left turning lanes, 2 through lanes and 1 right turning lane on east bound direction and the same for west bound direction. There were pedestrian crossing signals at [NAME] Blvd and Military Trail. Going north on Military Trail past shopping plaza, at the light at Military Trail and Verde Drive with 3 through lanes in the north bound direction and 3 lanes in the south bound direction. Continuing north bound on Military Trail past a canal that was on both sides of the road, at the next traffic signal at Military Trail and Lake Blvd. there were 2 lanes of traffic going in the north bound direction and the south bound direction with pedestrian crossing signal. Continuing past a second canal on both sides of the road, then a shopping plaza on the east side and another shopping plaza with construction on the west side of the road. The traffic signal at Military Trail and West Atlantic Avenue has left turning lane, 3 through lanes and 1 right turning lane heading in the north bound and south bound directions. There are pedestrian crossing signals on all 4 corners of the intersection. Past the shopping plaza on the left and shopping plaza on the right. Past a third canal on both sides of the road and then past a fourth canal on both sides of the road. The next traffic signal is Military Trail and Lake Front Blvd. 2 through lanes and 1 left turning lane in both the north bound direction and the south bound direction and there are pedestrian crossing signals. The next intersection is Military Trail and Lake [NAME] Road with 2 through lanes and 1 left turning lane in both the north bound direction and the south bound direction and there are pedestrian crossing signals. The next intersection is Military Trail and Via Delray with 2 through lanes and 1 left turning lane in both the north bound direction and the south bound direction and there are pedestrian crossing signals. There are a total of 5 canals, 2 lakes, and 5 intersections. There are no sidewalks from the facility to the road ([NAME] Blvd). During an interview conducted on 05/23/22 at 2:10 PM with Staff B, Registered Nurse/Unit Manager, when asked about Resident #1 eloping from the facility, Staff B replied, He exited the building. I wasn't here when he came in one day and went out the next day. I was here when he returned. He was found in the community, off of north Military Trail and [NAME] Blvd. [Staff E's name], Registered Nurse found him. During an interview conducted with the Administrator on 05/23/22 at approximately 3:00 PM, when requested to review video of Resident #1 exiting the facility, the Administrator stated that the video system deletes the videos every 14 days and that the videos requested would have been deleted prior to entrance. During an interview conducted on 05/24/22 at 9:21 AM with the DON and the ADON (by phone), when asked about Resident #1's elopement, the ADON replied, It was the evening shift and the nurse was [Staff G's name], Licensed Practical Nurse. When he came on, he was at the nurse's station, and she went on to do her med pass and when she did her next set of rounds, she noticed that he was gone. It was the 7P to 7A shift. From there, they looked for the resident throughout the facility and were not able to find him, they called the family, they called the police, they called [Name of Hospice] and they searched the facility and the perimeter. Staff got in their vehicles and searched the area. The following morning, the second night shift nurse, Staff E [name of nurse] had left to go home and she said that she saw Resident #1 in the neighborhood where she resides, which is not far from the facility, I don't know the exact location. She spoke with him and was able to get him in her vehicle and bring him back to the facility . When the ADON was asked when Resident #1 was returned to the facility, the ADON replied, At least between 9:00 AM and 10:00 AM the next morning during our morning meeting. When he got back to the facility, we did an assessment and he said that he was trying to get home. He lived in Lake Worth. During an interview conducted on 05/24/22 at 10:05 AM with Staff E Registered Nurse, when asked about Resident #1 eloping from the facility Staff E replied, I found him on the sidewalk on Military Trail at Oak Hill Rd. at the entrance to my community. I left work and it was between 9:00 AM and 10:00 AM. He was going north. He did not tell me where he was going. It is 5 minutes when I am driving and close to an hour for me to walk (to the facility) It was past 9:00 AM and Military Trail was not crowded at that time. I got him there and he was evaluated, and I sat with him in his room until he got his food and then I left. I don't know him. That was the first day that I talked to him. The night before I found him, he was at the nurse's station, and I remembered what he was wearing when he was at the nurse's station and was able to recognize him. During an interview conducted on 05/25/22 at 9:26 AM with the Social Services Director, when asked about Resident #1 being assessed as an elopement risk, the Social Services Director replied, He came at night over a weekend. I don't know if they did an elopement assessment before I came in, so I did one when I first saw him that Monday morning on 03/28/22. When I spoke to him, he was alert, and he wanted to go back home. The family lives in Lake Worth, that is why he went to a facility in Lake Worth. The daughter says that he went to [sister facility] because she lived right down the road. During an interview conducted on 05/25/22 at 10:04 AM with Resident #1's family member, when asked about the elopement, the family member replied, I got a call from the facility asking me if I had my dad'. I told them 'No, I entrusted him in your care' and I was informed that they could not find him. They told me that they searched the entire facility and searched all of the rooms and he was nowhere to be found. They informed me that they were trying to get security for the person that is responsible for the video recording for the time period that he was missing. I asked if they notified the police and they said yes. I spoke to one of the directors of the facility and he told me that they drove around the area looking for him. I was distraught and wanted to go to the facility to help them. The (former) Administrator told me that it would be counter-intuitive to do so. When asked of any harm as a result of the elopement, Resident #1's family member replied, When I saw him, I didn't see any physical harm, but I know he was distraught because he slept somewhere outside of the facility and was not found until late the following day. I know to this day, he is still a little bit distraught. I'm not medically trained to assess the full impact, but he always talks about not being comfortable. When asked where Resident #1 was going, Resident #1's family member replied, I don't know, he had no one in the area and no place that he was trying to go that I can think of. It could be a situation where he just wanted to leave, he was not used to the place. I am not sure what exactly his frame of mind was. I am not sure that he would be able to respond appropriately if you talk to him. On 05/25/22 at 11:11 AM, an interview was attempted with Resident #1 by phone. However, Resident #1 was not able to give appropriate answers and was determined to not be interviewable. During an interview conducted on 05/25/22 at 1:35 PM with Staff J Licensed Practical Nurse, when asked about Resident #1 not being assessed as an elopement risk, Staff J replied, He was alert and oriented x 2 - he was able to answer questions that I asked him, he wasn't showing any confusion at the time of admission. When asked about the elopement, Staff J replied, I wasn't there when he exited the facility. He was walking all right. I did not know that the resident had exited other facilities. When asked of any education related to elopement since the incident, Staff J replied, I don't remember if there had been any education or Elopement drills since then. I don't work every day. At that time, he didn't show any signs of wandering. He did not express wanting to leave the facility. There was nothing on the transfer from the hospital documentation indicating elopement risk. During an interview conducted with Staff G Licensed Practical Nurse, on 05/25/22 at 2:12 PM, she reported He had walked out another time, I was told, by the back area of the hallway that connects the two units. While they were doing renovations in the hallway, the door was open, and he walked out, and the door was not locked at that time because they were using it to go in and out. An employee that was walking in the door stopped him immediately and walked him back in. When asked for documentation of the incident, the Staff G Licensed Practical Nurse replied, I don't think there was any documentation, it was not reported. I had no reason to believe that he would be out of the building. No one had mentioned to me that he had tried to walk out before. I was told during the course of the evening about him trying to walk out the door. None of which is documented in the resident's record. Staff G Licensed Practical Nurse was not able to recall the name of the staff member that reported to her and the name of the staff member that brought Resident #1 back inside. During an interview conducted on 05/25/22 at 4:59 PM with the Director of Social Services, when asked about Resident #1 not being assessed as an elopement risk, the Director of Social Services replied, I met him for the first time on 03/28/22 and did my elopement assessment forms and the BIMS. I determined that he wasn't an elopement risk because he was alert and oriented and knew where he was going. He told me that he was going back to his home in Lake Worth. I didn't get the full details about him going out of the building and going home, but nobody said that it was an elopement. The daughter came in late in the day he was admitted , she left him here and he wanted to go home. Monday, I came back to work and they told me that he left the facility. His daughter didn't want him home, she wanted him to get rehab here. He was getting therapy. When she wanted him closer, I told her okay and we got him into a facility that was closer to her home. During an interview conducted on 05/26/22 at 6:02 PM with Staff I Certified Nursing Assistant responsible for Resident #1 at the time of the elopement, when asked about Resident #1 eloping from the facility, Staff I replied, I was on duty, if you see the resident he looks like a visitor and not a patient. I never knew that he goes out in the day because I work nights. His family came and left him a fridge and a lady came from the church and then the son left, and I continued to work with my other patients. When I went to check on him at around 8:00 PM, he wasn't there in his room. I began to ask, and I talked to the nurse and then we all began to cooperate to find him. The nurse called the Administrator, I think it was [Staff B] and then the Administrator came and then everybody was looking, and the Administrator took over. We searched the whole facility, and everybody was looking for him. Resident #1 was admitted on [DATE]. Resident #1 eloped from the facility on 03/27/22 at 8:10 PM, according to the facility's review of the video. Resident #1 was returned to the facility approximately 13 hours later by Staff G. During the approximately 13 hours the resident was missing from the facility, there was potential for Resident #1 to sustain an injury, up to and including death, as a result of being possibly struck by traffic, as well as other environmental hazards.