Every finding on record at Viera del Mar Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from verbal abuse for 1 of 3 residents sampled for abuse, out of total sample of 7 residents, (#1).Findings:Resident #1 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes, chronic pain syndrome, epilepsy and congestive heart failure.Review of resident #1's Minimum Data Set (MDS) 5-day assessment with Assessment Reference Date of 6/011/26 revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition.Review of the resident's care plan revealed a focus for Activities of Daily Living (ADL) self-care deficit. Interventions included the resident's need for extensive assistance to help move and reposition in bed. The care plan indicated the resident may need one-or-two-person assistance to change position or scoot up in the bed which was initiated on 9/13/24.On 7/27/26 at 12:37 PM, resident #1 shared he had only one issue with a staff member during his time at the facility. He went on to explain that the incident involved Certified Nursing Assistant (CNA) A improperly repositioning him in the bed. Resident #1 recalled he had asked the CNA to pull him up in bed and she had done this by grabbing his shirt by the shoulders and pulling him up. He stated he sustained a skin tear and in response he swung at the CNA to release his shirt. He stated the CNA then cursed and threatened him. He went on to say that he had asked facility management if they trained CNAs on how to properly reposition residents because what happened was 'not okay'.Review of a witness statement from Human Resources (HR) staff on 7/21/26, the date of the incident, revealed CNA A had reported that she had pulled the resident up in bed by the shoulder of his t-shirt and the resident sustained a skin tear to the side of his neck. The statement indicated the resident then punched the CNA in the chest. The CNA reported she had responded to the resident, 'If you do that again, I will (expletive) you up.' The witness statement detailed CNA A reported the incident to a nurse on shift, then clocked out early on her own, and left the facility.Review of a witness statement from CNA A dated 7/24/26 revealed the CNA attempted to pull the resident up in bed by his shirt. She reported he had replied that it hurt and then struck the CNA.Review of an interview of CNA A by the Nursing Home Administrator (NHA) dated 7/24/26 revealed when she went to pull the resident up in bed, the resident struck her. Documentation from the interview indicated the CNA threatened the resident if he hit her again, she would hit him.On 7/27/26 at 2:39 PM, the HR staff verified her previous statement from 7/21/26 which discussed the events of the incident and her interactions with the CNA. She verified CNA A told her she threatened resident #1 that she would hit him back.On 7/28/26 at 11:45 AM, in a phone interview the Advance Practice Registered Nurse confirmed the use of expletives and/or threatening residents was not appropriate behavior. She said she would consider using expletives while threatening a resident as verbally abusive language.In interviews on 7/28/26, two nurses, three CNAs and one Patient Care Aid all identified the language used by CNA A as being inappropriate and abusive language for use with a resident.CNA A did not answer phone interview requests, and voice mails were not returned. Review of the Resident Rights policy, revised January 2024 revealed the facility must treat each resident with respect and dignity; and care for each resident in a manner that promoted maintenance and enhancement of their quality of life. These rights included to be treated with respect, kindness, and dignity and to be free from abuse and neglect.Review of the Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury policy last revised March 2025 revealed residents had a right to be free from abuse and neglect. Abuse included verbal abuse, physical abuse and mental abuse. Neglect was defined as the failure of the facility and its employees to provide goods and services to a resident that were necessary to avoid physical harm or pain.

Based on interview and record review, the facility failed to honor a resident's expressed wishes for Do Not Resuscitate (DNR) by not verifying those wishes were accurately documented to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed for 1 of 1 resident reviewed for advance directives, out of a total sample of 57 residents, (#111). This failure contributed to resident #111 receiving cardiopulmonary resuscitation (CPR) and other invasive procedures in violation of an explicit wish for a natural and dignified death. There was likelihood resident #111 experienced severe pain, and could have suffered broken bones, organ damage, and a prolonged dying process. On [DATE], resident #111 was admitted to the facility with a physician order for DNR on the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008 Transfer Form). The facility's admitting nurse noted she verified the DNR wishes with the resident and family upon admission. The next day, on [DATE], a physician order was placed for full code status without family/resident consent. On [DATE] at 3:35 PM, the resident was found unresponsive, CPR was initiated and emergency medical services (EMS) were called. The staff initiated 3 rounds of CPR which was continued by EMS upon arrival at 3:41 PM. EMS continued CPR while transporting the resident to the hospital. While enroute to the hospital, resident #111 was intubated and EMS staff placed an intraosseous access to her right lower extremity. EMS reported they obtained a return of spontaneous circulation. Resuscitation efforts continued in the hospital where she expired. There were 48 residents in the facility with active DNR orders. An Intraosseous (IO) access is a rapid, lifesaving medical procedure that involves drilling a specialized needle into the bone marrow to deliver fluids and medication. The facility's failure to ensure accurate documentation of the resident's DNR wishes placed all residents with a do not resuscitate order at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitative efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The census at the start of the survey was 116 with 48 residents identified as Do Not Resuscitate.Findings: Resident #111, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute myocardial infarction, Alzheimer's disease, acquired absence of left leg above knee and adult failure to thrive. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of [DATE] revealed resident #111 had a Brief Interview for Mental Status score of 03/15 which indicated she had severe cognitive impairment. The document indicated she was 65 inches tall and weighed 72 pounds and had medically complex conditions which included cancer, atrial fibrillation, coronary artery disease, Alzheimer's Disease, and adult failure to thrive. Review of resident #111's electronic medical record (EMR) revealed a Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form from the hospital which indicated her advanced care planning included DNR. The record also contained an Admission/readmission Nursing Evaluation dated [DATE] completed by Licensed Practical Nurse (LPN) C which indicated resident #111 was DNR which was current and verified by the resident and the resident's family. This assessment was locked by the 200/400 LPN Unit Manager on [DATE]. Review of the physician orders showed an order for Full Code was entered into the EMR by the Director of Nursing (DON) on [DATE]. A care plan was initiated on [DATE] which read, Resident/Representative has requested DNR (Do Not Resuscitate) status indicating CPR measures ARE NOT performed. This care plan was cancelled on [DATE] and a new advance directive care plan was initiated. The new care plan read, Resident/Representative has requested FULL CODE STATUS indicating CPR measures ARE performed. The care plan remained in effect until it was cancelled after resident #111's death. In a phone interview on [DATE] at 4:28 PM, LPN B confirmed she worked the day of [DATE]. She explained she was the nurse on an adjacent unit when she heard the overhead page for an emergency. LPN B stated she went to resident #111's room and observed resident was unresponsive. She recalled the DON verified the resident's code status as full code and CPR was initiated. LPN B was unable to recall who initiated CPR but confirmed she assisted in resuscitative measures until emergency medical services staff arrived and took over. She stated resident #111 left facility with EMS personnel and she called the resident's son to inform him of the events and transfer to the hospital. LPN B acknowledged resident #111's son asked her why CPR was performed and she told him the record showed she was a full code. The facility's Code Blue Response Worksheet showed facility staff initiated 3 rounds of CPR which was continued by EMS upon arrival at 3:41 PM. EMS personnel left the facility with resident #111 at 3:48 PM. Review of emergency room records dated [DATE] showed EMS personnel continued CPR during transport to the hospital. The records documented that while enroute to the hospital, resident #111 was intubated and EMS staff placed an intraosseous access. EMS reported they obtained a return of spontaneous circulation. The document showed that resuscitation efforts continued in the hospital until she expired. In a phone interview on [DATE] at 12:12 PM, resident #111's son reported his mother was in the hospital previously where she had her leg amputated and started going downhill. He stated she was admitted to the facility from her most recent hospital stay. The son confirmed he was notified by the facility of the events on [DATE]. He explained a nurse called him and informed him that his mother was found unresponsive, CPR was performed and she had been transferred to the hospital. He recalled asking her why CPR was done and she told him she was a full code and there was no information in the chart for DNR. He expressed to the surveyor that his mother was a DNR in the hospital and was supposed to be at the facility as well. He recalled she was admitted in the evening on [DATE]. He explained he visited her the next day and saw she still had the DNR bracelet from the hospital on her right wrist. He did not understand why they would do CPR on his mother. He explained she was very frail and doing chest compressions would have cracked her ribs. He recalled the facility did CPR, then EMS did CPR and to his understanding, the hospital did CPR as well. He stated he could not fathom that taking place. Resident #111's son reported he was told by hospital staff that she had come back for a few moments but then passed away. He again stated he did not understand why she would be put through that. He explained his mother had expressed she wanted to be a DNR. He stated she had already suffered enough and was diagnosed with failure to thrive. Resident #111's son stated he never gave anyone permission to change his mother's DNR status. On [DATE] at 4:34 PM, the 200/400 LPN Unit Manager stated she spoke to resident #111's son the night she was admitted to obtain verbal consents to treat but did not discuss advanced directives with him. She verified she locked the Admission/readmission Nursing Evaluation completed by LPN C. The 200/400 LPN Unit Manager stated she was not aware LPN C had documented resident #111's code status as DNR. She acknowledged she only verified the form was filled out, not that the information was accurate. She confirmed she was part of the interdisciplinary/clinical team. She stated they reviewed admission information for all new admissions each morning. She explained the 3008 Transfer Form from the hospital did identify the resident as a DNR, but the hospital did not send a goldenrod Do Not Resuscitate Order (DNRO) form with the resident, so they considered resident #111 to be a full code. On [DATE] at 2:17 PM, the Social Services Director (SSD) stated she was responsible for Advanced Directives along with the clinical team. She explained they reviewed new admissions daily and reviewed the hospital records as well as the 3008 Transfer Form from the hospital. She recalled resident #111's admission paperwork did not contain a goldenrod DNRO so she was considered a full code until that form could be completed. The SSD stated the admitting nurse usually completed an Advance Directive Discussion form with resident or resident representative upon admission but was unable to locate one. She stated she attempted to contact the resident's son but was unable to reach him. The SSD stated the physician, or his nurse practitioner, may have spoken to the family. She reviewed the chart and could not identify any documentation from her, the physician, his nurse practitioner, or any other facility person regarding a discussion with resident #111 or her son regarding advanced directives. The SSD was not aware that the goldenrod DNRO form was not required for a resident to have an expressed wish to be a DNR status. She was also unaware resident #111's son was in the facility the day after her admission. On [DATE] at 2:41 PM, the Registered Nurse (RN) MDS Coordinator verified she signed the baseline care plan but did not complete it. She stated she signed it as the RN but was unable to explain why both DNR and Full Code were checked. The RN MDS Coordinator reviewed the care plans and confirmed a DNR care plan was initiated and cancelled on [DATE] and a Full Code care plan was created in its place. She explained the DNR care plan was developed initially by the SSD who replaced it with the Full Code care plan when they realized a goldenrod DNRO form had not been included in the admission packet from the hospital. The RN MDS Coordinator stated as far she knew, whether a resident was considered a DNR was based on the presence of a goldenrod DNRO form. In a meeting with the nursing home administrator (NHA), DON, Assistant Director of Nursing (ADON) and Compliance Officer on [DATE] at 10:40 AM, the Compliance Officer stated when resident #111's admission paperwork was reviewed on [DATE], there were inconsistencies noted. He explained that staff realized there was whiteout on the transfer form as well as different [NAME] and no goldenrod DNRO form was included in the packet. He stated the admission packet did not contain a goldenrod DNRO form or any paperwork regarding the son's ability to make healthcare decisions for resident #111. He reported staff tried to contact the son to validate DNR but were unable to reach him. The DON acknowledged the ADON and 200/400 LPN Unit Manager signed consent forms indicating they spoke with the son on the evening of [DATE] and obtained consents to treat but did not complete an Advance Directive Discussion form. She could not explain why the son was able to make these healthcare decisions without paperwork but could not validate an advance directive. The DON stated the son only came once and was in and out so fast no one was aware he was there. The facility team was unable to provide any documentation of attempts to contact resident #111's son. The NHA reviewed the visitor log and verified resident #111's son had visited on [DATE] and [DATE]. On [DATE] at 9:34 AM, resident #111's attending physician at the facility confirmed he was also her attending physician in the hospital just prior to her admission to the facility. He stated the son initially wanted his mother to be sent to in-patent hospice, but she did not qualify. He recalled the son agreed to send her to the facility for therapy. The attending physician acknowledged he had spoken with resident #111 and her son regarding code status and was aware her wishes were DNR. He also acknowledged he signed the 3008 Transfer Form which indicated she was DNR. The attending physician explained that a goldenrod DNRO form was not included in the admission packet when resident #111 arrived so he gave order for Full Code until they could talk to the son. He confirmed the goldenrod DNRO form was only for EMS personnel. The attending physician acknowledged he had personal knowledge of the resident's and son's wishes to be DNR and that neither the son nor the resident ever told him to change from DNR to Full Code status. He could not explain why resident #111's wishes were not honored. Review of admission hospital records showed the attending physician documented resident #111's status as DNR/Do Not Intubate on [DATE], [DATE] and [DATE]. Review of the facility's policy and procedure for Advanced Directives Code Status revised 9/2025 revealed it was the policy of the facility to honor Advanced Directives, Code Status and Do Not Resuscitate Orders in accordance with State and Federal regulations. The document provided guidelines that the admitting nurse would verify a resident's code status upon admission with the resident/representative and would confirm the decision with the attending physician. Under the DNR rescinded section, the document instructed social services and nursing to document in a progress note that the code status was changed as per resident/representative request. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], the NHA and DON reviewed the Code Status binders for accuracy. *On [DATE], the NHA and DON confirmed the physician order for code status of all residents *On [DATE], the NHA and DON confirmed each resident's care plan matched the resident's physician order for code status. *On [DATE], the NHA and DON confirmed that residents who were unable to make their own decisions had a designated legally authorized decision maker with supporting documentation. *On [DATE], the NHA and DON ensured each resident with DNR order had a goldenrod Do Not Resuscitate Order form uploaded into the EMR. *On [DATE], the DON and Clinical Team confirmed each resident's desired code status with resident/responsible party and documented their decision in the resident's EMR. Any requested changes were communicated to the resident's physician. *On [DATE], education was initiated for all staff present in facility including contracted staff on preventing, reporting, and stopping resident abuse; Advanced Directives Code Status Policy; updated CPR policy & Competency; and required documentation specific to code status and responsible party. Staff competencies were completed at time of education. *From [DATE] through [DATE], 111 of 184 staff members were educated (60%). Remaining staff will complete education prior to working next shift. *All new hires will be educated on the revised CPR policy during orientation. *On [DATE], Ad-HOC Quality Assurance and Performance Improvement (QAPI) meeting was held, and the committee reviewed the event, discussed the details of the event including lack of hospital documentation and no document supporting the family member as the legally authorized decision maker. The committee determined the root cause was the facility was unable to confirm the resident's legally responsible party which led to the facility being unable to validate her code status. Education was initiated and immediate interventions were implemented to ensure residents' wishes are honored. The facility's Advanced Directives Code Status policy was updated to address actions to take when staff were unable to verify a legally authorized decision maker and approved education and immediate corrective actions, policy change, and review of Facility Assessment through Ad-Hoc. Adopted facility Quality Review plan. *On [DATE], Ad-HOC QAPI meeting was held, and the committee reviewed the plan and the Immediate Jeopardy citation as it related to the event. Facility Assessment reviewed. Facility audits were continued for all immediate corrective actions. Policy changes were added to facility New Hire Orientation. Facility audits of Resident Code Status were reviewed and verified completion of audits for accuracy.Interviews conducted on [DATE] with 20 facility staff (1 RN, 3 LPNs, 10 CNAs, 1 housekeeper, 1 therapy staff, 2 MDS staff, 1 ADON, 1 social services staff) across all shifts indicated they were knowledgeable of advanced directives and facility procedures to verify the resident's code status.The survey team validated the education through interviews for staff knowledge; reviewed code binders for accuracy; and sampled new admissions for accuracy of code status and documentation.

Based on observation, interview and record review, the facility failed to maintain separation between contaminated and clean laundry processes with potential cross-contamination of clean linen and soiled linen. Findings: On 4/29/26 at 12:42 PM, a tour of the laundry room was done with the Housekeeping Manager, Infection Preventionist and Regional Housekeeping Director. It was observed that in the dirty area where linen were sorted, there were three washing machines. The bins containing the soiled linen were very close to the washers and there was no defined separation of the area thereby creating the risk of cross contamination. The housekeeping Manager and the Regional Director of Housekeeping stated they were not aware that clean and soiled linen needed to be separated. They acknowledged that after completing the wash cycle the linen were clean and therefore having the bins with dirty linen so close to the washers, when emptied could cause possible cross contamination of linen. The facility's Infection Prevention and Control Plan 2026 stated the program is designed to prevent, identify, report, investigate and control the spread of infections and communicable disease in the facility.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for 2 of 3 residents reviewed for pain management of a total sample of 57 residents, (#26, #133).Findings1.Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right patella, fracture of the nasal bones, rheumatoid arthritis, unspecified injury of the head and muscle weakness.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #26 had a a brief interview for mental status score (BIMS) of 11 out of 15 which indicated she had moderate cognitive impairment. The MDS assessment also revealed the resident had pain occasionally.Review of the physician orders dated 4/23/36, read resident #26 was to receive 5-325 milligrams (mg) Hydrocodone -Acetaminophen tablet every 6 hours as needed for non-acute pain.Resident #26's plan of care revealed interventions which instructed nurses to administer analgesia medication per orders because of the resident had pain, and /or is at risk for pain because of arthritis, fracture, impaired mobility, multiple co-morbidities and Postoperative discomfort.On 4/27/26 at 9:34 AM, resident #26 was observed in bed and stated she had her call light on because she requested pain medication. She explained she could not go to physical therapy because she was in pain. Resident #26 said that she had been requesting pain medication since 4 AM and had not received any yet. Resident #26 continued to explain the pain medication was recently changed from being scheduled to as needed and stated it might not be a good thing because now she has to ask for it and usually had to wait before they brought it to her. The facility Administrator answered the call light and told the resident the nurse would be in with her medication.Review of the Medication Administration Record (MAR) revealed resident #26 received hydrocodone-acetaminophen 5-325 mg 25 minutes later, at 9:59 AM, and the last time she received it was on 4/26/26 at 1AM.Further review of the MAR revealed that resident #26's order for Hydrocodone-Acetaminophen 5-325 mg was scheduled for every 6 hours from 4/9/26 to 4/23/26. The medication administration audit report revealed the scheduled times of administration were 6 AM, 12 PM, 6 PM and midnight. The report revealed for three days the 12 PM doses were administered almost two and a half hours later than the scheduled time.On 4/20/26 12 PM dose was administered at 2:42 PMOn 4/22/26 12 PM dose was administered at 2:50 PMOn 4/23/25 12 PM dose was administered at 2:40 PMThere were no corresponding progress notes indicating the reason for the late medication administration.On 4/29/26 at 1:54 PM the Director of Nursing (DON) and a Regional Nurse consultant could not provide an explanation nor progress notes to explain why the medication was given almost two and a half hours late. They acknowledged this not was not their process.On 4/29/26 at 2:58 PM, Registered Nurse (RN) H stated that if a medication was given late, she would document the reason and would also call the doctor and the family and document in the medical record. RN H said that she could give the medication one hour before or one hour after the scheduled administration time.On 4/29/26 at 3:05 PM, RN I said that if a medication was scheduled, she had one hour before or one hour after to administer the medication. RN I explained that she rarely gave medications late but sometimes on the Marvista Unit it takes longer to administer medications when there are 37 residents. RN I said if she gave medication later than the scheduled time she would write a note and call the doctor.2. Resident #133 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, unilateral primary osteoarthritis right knee and pain in unspecified joint. Review of the admission MDS assessment dated [DATE] revealed resident #133 was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. The MDS also revealed the resident had frequent pain.Review of the medical record revealed physician's orders for the resident to receive 5-325 mg of Oxycodone -Acetaminophen tablet every 6 hours for non-acute pain.The plan of care initiated on 4/20/26 read that resident #133 had pain and/or is at risk for pain because of chronic physical disability, impaired mobility, migraine, multiple co-morbidities, postoperative discomfort, chronic back pain and neuropathy. The interventions instructed nurses to administer analgesia medication per physician orders.On 4/27/26 at 9:03 AM, resident #133 was sitting up in bed and explained that she was planning to leave the facility because they were not giving her pain medications on time. She said that on Saturday she did not receive her pain medication until 12:30 PM and the nurse told her the next dose would be at 5 PM, but at 6:15 PM, the resident said she was told that she received the last pill at 12:30 PM. The resident stated I got mad because if the nurse knew that was the last one, they should have called the pharmacy. I did not receive anything until 11 PM from the night nurse who got an emergency order. I want to leave this place today, I am leaving at 11 AM. The resident said she was vocal about all her concerns and staff were aware.Review of the MAR read on Saturday 4/25/26, the scheduled times for oxycodone were 12 AM, 6 AM, 12 PM and 6 PM. At midnight the resident received her medication and at 6 AM, she did not receive it because it was marked with the number 12. The corresponding chart code for 12 was Medication on order from Pharmacy, MD aware. At 12 PM the medication was administered and the audit report showed it was documented as given at 2:04 PM. The 6 PM dose was not administered as evidenced by the number 9, chart code read Other, See nurses notes. There were no notes seen. The medication audit report also revealed the next time the medication was administered was on 4/25/26 at 11:09 PM. A progress note written on 4/27/26 at 11:54 AM revealed resident #133 was discharged home.On 4/29/26 at 2:38 PM the UM for the Montecito Unit said that she was aware of resident #133's concerns and that the resident wanted to leave because she did not get her medication on time. She explained that the nurse could have obtained the medication on 4/25/26 on their emergency medication dispensing system. On 4/29/26 at 2:15 PM, the DON was made aware of the findings and said that she did not know this had happened. She said that it was not acceptable for residents to wait for pain medications and that this resident had a script on 4/18/26. The DON explained that Pain Management group came to the facility on Tuesdays and Thursdays and would ask if anyone needed new scripts. She noted the order was changed on 4/23/26 from every 4 hours as needed to every six hours and acknowledged the medication was in their emergency dispensing system. The DON said it should not have been difficult for nurses to get the script from the doctors and reorder the medication if it was not available.The facility's Standards and Guidelines for Medication Administration revised January 2024 stated, Medications are ordered and administered safely and as prescribed and that Medications are administered within 1 hour before or after the prescribed time, unless otherwise specified. If a drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party if indicated.

Based on observation, interview and record review, the facility failed to prevent medication errors greater than 5 per cent for 1 of 5 residents sampled for medication administration, (#101). There were 2 errors in 32 opportunities on 1 of 5 units by 1 of 5 nurses observed, for a medication error rate of 6.25%.Findings:On 04/27/2026 at 9:00 AM, during a medication administration observation, Licensed Practical Nurse (LPN) B removed the following medications for resident # 101 and placed them in a cup, Folic Acid 1 milligram (mg), Apixaban 5 mg, Midodrine 5 mg, Midodrine 10 mg, Sodium Chloride 1 mg, Miralax 1 capful, and Advair inhaler.During the reconciliation process it was noted on the Medication Administration Record (MAR) that Potassium Chloride 20 milliequivalent (meq) was marked as given and Sertraline 50 mg was also marked as given. These medications were not given during the medication administration observation.On 4/28/26 at 11:48 AM, Unit Manager (UM) for 200 and 400 Halls was informed of the medication error. The UM stated her expectation during medication administration is for the nurses to administer the medications to the residents according to physician orders to include administration of medications at the frequency and the time ordered. Review of the Standards and Guidelines: Medication Administration issued 10/2020 and revised 01/2024, read: Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meals, and at bedtime).As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.

Based on record review, and interview, the facility failed to ensure that a newly admitted resident received timely, consistent, and properly documented dermatologic treatment in accordance with professional standards of practice and the comprehensive, person-centered care plan for two of three residents reviewed for wound care, of a total sample of six residents, (#6, and #2). 2. Resident #2 was admitted to the facility on [DATE] for nerve pain. The Minimum Data Set Quarterly assessment dated [DATE] noted resident #2 was cognitively intact, required partial to moderate assistance with activities of daily living, and was occasionally incontinent. Review of resident #2's care plan dated 8/18/25 revealed a focus for a pressure ulcer to open area, buttocks. Interventions included to complete weekly skin checks and measure length, width, and depth, if possible. Resident #2 had a care plan dated 8/18/25 for risk for skin impairment. Care plan interventions included monitor/observe skin while providing routine care, nutritional supplements/diet as ordered, preventative skin treatments as ordered, skin checks weekly and provide incontinence care promptly. Review of physician orders dated 8/16/25, with no stop date, included cleanse bilateral lower legs with normal saline, pat dry, and wrap with dry dressing for wound care-abrasion. The order specified staff to monitor site for signs of infections until healed, every evening shift for wound care. Review of the Treatment Administration Record (TAR) for the physician order dated 8/18/25 to 8/31/25 revealed a missing treatment on 8/20/25. Review of physician orders dated 8/18/25 for wound care in between buttocks. The order specified to cleanse the area with 1/4 Dakins and apply zinc oxide every shift. The TAR for the wound care in between buttocks order from 8/18/25 to 8/31/25 revealed missing treatments for 8/24/25 nightshift, 8/30/25 dayshift, and 8/31/25 dayshift. A physician orders dated 8/21/25 with no stop date– for wound Care-Abrasion: Cleanse (bilateral lower legs) with NS, pat dry, and wrap with dry dressing. Monitor site for signs/of infections until healed. Every dayshift for wound care. The TAR for the physician order 8/18/25 to 8/31/25 revealed missing treatments on 8/23/25 and 8/30/25. On 1/22/25 at 3:15 PM, the Wound Care Nurse (WC), stated her responsibilities were for residents who needed treatment for stage three or greater pressure wounds (deeper, open wounds). She stated the 'cart nurses' (staff nurses) provided regular treatment for wounds stage two and less (less serious wounds). On 1/22/25 at 12:40 PM, LPN revealed her responsibilities as the 'cart nurse'. She stated she completed wound assessments weekly and provided wound treatments when ordered. She further stated that if there were any issues she would let the wound care nurse know or her nurse manager. LPN1 confirmed she cared for resident #2 and provided wound care. She stated she always got her treatments completed by the end of her shift and would let the next shift know or manager if unable to complete. Findings: Review of resident #6's medical record revealed she was admitted to the facility from an acute care hospital on [DATE]. The record showed she had limited communication ability, and she required limited assistance for mobility. Review of the admission assessment showed the resident was admitted with a rash on both feet that had been present for several weeks. A dermatology consultation on 01/13/2026 noted diagnosis of tinea pedis (fungal infection). On 01/13/2026, the dermatologist, prescribed Ketoconazole cream two percent to be applied daily to both feet until resolved. On 01/22/2026 at approximately 1:16 PM, the dermatologist, confirmed she prescribed the Ketoconazole cream to be applied daily to both feet. She stated that failure to apply the cream as ordered could result in worsening fungal infection and secondary complications. On 01/21/2026 at approximately 1:45 PM, Licensed Practical Nurse (LPN) B initially stated she applied the cream to the resident's belly button and documented the application. Upon further interview, LPN B clarified the cream was intended for the resident's feet and acknowledged that she misspoke. During the interview, LPN B showed the tube of Ketoconazole cream in the treatment cart labeled with the resident's name and dated 01/13/2026. The Ketoconazole tube was unopened. When asked how she had been applying the cream when the tube was not opened, LPN B stated that she had thrown a tube away earlier that morning and that the tube observed was a new tube. She verified that medications were not shared between residents and that refills were only obtained from the pharmacy. On 01/21/2026 at approximately 12:17 PM, LPN A stated the tube should last approximately three weeks if applied daily to both feet. She stated only one tube of Ketoconazole cream had been obtained from the pharmacy and it had not been reordered or refilled as it was only ordered one week ago, on 1/13/26. On 01/22/2026 at approximately 12:39 PM, LPN C confirmed she applied Ketoconazole cream to the top of the resident's feet that day. LPN C stated the tube had not been refilled and would last approximately two and a half to three weeks. LPN C confirmed that medications were not shared between residents. On 01/22/2026 at approximately 2:00 PM, LPN D confirmed the Ketoconazole cream had never been refilled since the order was placed on 01/13/2026. LPN D reiterated that medications were not shared between residents, and a new pharmacy order was required if the medication ran out. Family interviews on 01/21/2026 at 4:00 PM and 01/22/2026 at 10:51 AM confirmed the resident had not received the prescribed cream for several days after her admission. The resident's daughters expressed concern regarding the resident not receiving her treatment, emphasizing the dermatologist had ordered daily application. They stated they felt the missed treatments placed their mother at risk for worsening infection and skin breakdown. Attempts to contact the Pharmacy Consultant on 01/22/2026 at approximately 12:59 PM and 1:21 PM were unsuccessful.

Based on observation, interview, and record review, the facility failed to maintain sufficient nursing staff to provide the necessary care and services and ensure resident needs and preferences were addressed timely for 4 of 9 residents reviewed for call light response, of a total sample of 12 residents, (#7, #10, #11 and #12).Findings: On 10/22/25 at 1:17 PM, observation of the Montecito South's nurses station computer screen showed three rooms with active call lights and the following wait times: room [ROOM NUMBER] - 25 minutes, room [ROOM NUMBER] - 20 minutes, and room [ROOM NUMBER] -8 minutes. On 10/22/25 at 1:22 PM, call lights were illuminated outside rooms #301, #302 and #303. Resident #12, in room [ROOM NUMBER], was heard calling out, Hello, I need assistance, please. 1.On 10/22/25 at 1:24 PM, resident #12 was lying in bed, holding his left thigh approximately 45 degrees upward. Staples were present on his left stump, with redness noted around the incision site. Resident #12 stated he had returned from the hospital the previous evening for wound care and therapy. He reported pressing his call light to request pain medication, as his last dose was received at 9:00 AM and he was now due for more. He rated his pain as 9 out of 10 on his left stump. The surveyor exited the room at 1:28 PM; no staff were seen in the hallway, and the call lights for rooms #301 and #303 remained on. Review of resident #12's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including orthopedic aftercare following a surgical amputation, infection of the amputation stump, type 2 diabetes, and repeated falls. Review of the 5-day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/08/25 showed resident #12 Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of resident #12's Medication Administration Record (MAR) revealed resident #12 last received Oxycodone 10 milligrams (mg) on 10/22/25 at 11:46 AM, with the effect noted as effective. The physician's order specified Oxycodone 10 mg every 8 hours as needed (PRN) for moderate pain. Prior to his readmission, the resident had received 2 tablets of Oxycodone 10 mg every 4 hours PRN for non-acute pain from 10/03/24 to 10/10/25. Review of resident #12's comprehensive care plan dated 10/22/25 revealed a focus on pain related to neuropathy, postoperative discomfort, wound, and disease process. Interventions directed nurses to evaluate the effectiveness of pain interventions and to notify the physician if interventions were unsuccessful. 2. On 10/22/25 at 1:29 PM, resident #10 was sitting in a wheelchair in her room, #301. She stated she wanted to be transferred back to bed because she had been sitting for over two hours. She explained she required assistance from a Certified Nursing Assistant (CNA) to stand and could not do so without help. She reported her call light had been on for approximately 30 minutes, adding, We are having a big staffing issue around here. She mentioned another resident down the hall had been yelling for help and said, I normally wait 30 minutes for the call light to be answered. On 10/22/25 at 1:32 PM, CNA B entered resident #10's room, stating she was not the resident's assigned CNA but was responding to the call light. On 10/22/25 at 1:33 PM, while exiting room [ROOM NUMBER], the surveyor heard resident #12 moaning and cursing, with his call light still illuminated. Review of resident #10's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, migraine, difficulty in walking, and osteoarthritis. Review of the MDS quarterly assessment with an ARD of 7/22/25 showed resident #10's BIMS score was 15 out of 15, indicating intact cognition. Review of resident #10's comprehensive care plan with a focus on Activities of Daily Living (ADL) selfcare deficit related to chronic medical conditions, fatigue, and impaired balance was revised on 4/22/25. Interventions indicated resident #10 may require dependent assistance from one or two staff for ADL care, with needs fluctuating based on weakness, fatigue, and weight bearing status. On 10/23/25 at 12:40 PM, resident #10 stated she had waited over an hour for assistance the previous day due to staffing shortages. She expressed frustration, saying, Why do I have to wait until they are done with everybody else? She added she felt sidelined. She described CNAs as overworked, managing dressing, toileting, meal services, and transfers, and concluded, The wait times tell me they are understaffed and overworked. 3. On 10/22/25 at 1:33 PM, resident #11 was sitting in her wheelchair in her room and stated she activated her call light over 15 minutes ago. She reported suffering from breathing problem and needed her inhaler before physical therapy, scheduled for 1:15 PM. She added, her main concern was waiting at times for call lights to be answered. Resident #11, who had been in the facility less than a week, noted long call light wait times regardless of shift or day. She said, The fellow across in room [ROOM NUMBER] kept hollering hello, hello multiple times earlier and also had to wait a long time for whatever he needed. Resident #11 mentioned she became anxious when waiting, displaying pursed-lip breathing and a productive cough. The surveyor exited her room at approximately 1:43 PM and no staff were visible. Review of resident #11's medical record revealed she was admitted to the facility on [DATE] with diagnoses including wedge compression fractures (T7-T8 and T5-T6), chronic obstructive pulmonary disease (COPD), generalized anxiety disorder, and acute and chronic respiratory failure with hypercapnia (high blood levels of carbon dioxide) and hypoxia (low levels of oxygen in the body tissues). Review of resident #11's comprehensive care plan identified risk for altered respiratory status related to COPD and episodes of shortness of breath. Review of a Summary of Skilled Services note dated 10/20/25 which indicated resident #11 was alert, required extensive assistance with mobility and transfers, and had experienced several anxiety episodes displaying pursed lip breathing and treated effectively with pain medication. 4. On 10/24/25 at 9:35 AM, resident #7 shared she had served as Resident Council President for over two years. She reported a great shortage of staff, especially on weekends, which made it very hard on staff and residents. Resident #7 described an incident where in the dining room a resident waited more than 20 minutes for service, prompting her to ask the receptionist to page the staff. She indicated the kitchen staff subsequently collected meal trays and instructed residents to return to their rooms, stating meals would be delivered to their rooms due to staffing shortages. Resident #7 noted short staffing had been discussed in previous Resident Council meetings and offered to provide meeting notes emphasizing, If they don't know what we talked about, how is anything going to be corrected? Review of resident #7's medical record revealed she was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, difficulty in walking, osteoarthritis, and myalgia (muscle pain). Review of the MDS quarterly assessment with ARD of 9/25/25 revealed resident #7's BIMS score of 15 out of 15, indicating intact cognition. Review of Resident Council meeting minutes dated 10/06/25, 9/29/25, and 9/08/25 reflected repeated concerns noted as shortages - staff & supplies and very short staffed. On 10/22/25 at 2:03 PM, CNA B stated she noticed call lights were active in rooms #302 and #303 when she exited room [ROOM NUMBER] but was redirected to assist another resident in room [ROOM NUMBER] who required immediate care. She shared some of her assigned residents had complained about long waits and stated she apologized when this occurred, adding all staff were expected to answer call lights. On 10/22/25 at 3:23 PM, CNA A stated she was assigned to residents #10, #11, and #12 and was assisting another resident when the call lights were activated. She described the workload as heavy, saying That hall is kind of difficult. She reported some residents expected assistance on fixed schedules, which was not always possible. CNA A acknowledged, An hour wait would not be acceptable, and admitted she had planned to transfer resident #10 at 1:00 PM but was delayed assisting in room [ROOM NUMBER]. She confirmed resident #12 frequently requested pain medication and that nurses occasionally became frustrated with repeated requests. She concluded, Not answering call lights in a timely manner could be considered neglect. On 10/24/25 at 5:19 PM, during a telephone interview, CNA F reported at times only one CNA was assigned to a unit during the 11:00 PM - 7:00 AM shift. She noted delays occurred due to having to locate supplies and the need for two staff to assist residents with transfers. When asked if she had mentioned her concerns to management, she responded she had not because management must be aware of staffing shortages. CNA F stated assisting with dining room service was difficult as it would leave only one CNA on the unit for up to two hours. On 10/24/25 at 2:18 PM, during an interview with the Administrator (NHA) and the Director of Nursing (DON), the NHA stated resident #12 frequently activated his call light immediately after staff left his room. The DON described the resident as drug seeking and clarified that while scheduled pain medications could be given one hour early or late, PRN medication could not be administered sooner than prescribed. Both the NHA and DON acknowledged expectations for timely call light response. The NHA confirmed residents had voiced staffing concerns during Resident Council meetings but stated she and the DON had made rounds on evening and weekends without noting issues. Review of the facility's Call lights policy and procedure, revised January 2024, read, Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. The Procedure required staff to Answer call light promptly. All facility personnel are expected to respond to call light. Listen to resident's request. DO NOT make residents feel that you are too busy. Respond to resident's request, if unable to assist, notify the nurse. Return to the resident promptly with a reply. Review of the Facility Assessment, approved by the Quality Assurance and Performance Improvement committee on 10/14/25, revealed its purpose was to determine the resources necessary to provide competent resident care using a competency-based approach. The assessment identified staffing levels based on resident population, acuity, and care needs, and read, Staffing is adjusted to meet the needs of current population and resident needs. Data showed the following number of residents required staff assistance with ADLs:Dressing 1-2 staff: 93 residents dependent: 26 residentsBathing 1-2 staff: 93 residents dependent: 29 residentsTransfer 1-2 staff: 74 residents dependent: 36 residentsEating 1-2 staff: 97 residents dependent: 4 residentsToileting 1-2 staff: 75 residents dependent: 41 residents The assessment emphasized timely response to ADL and toileting needs to maintain continence, dignity, and person-centered care.

Based on interview, and record review the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected prescribed medications for 1 of 2 residents reviewed for behaviors, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was readmitted to the facility from an acute care hospital on 8/20/25. Her diagnoses included multiple sclerosis, major depressive disorder, anxiety and seizures. Additional diagnoses of bipolar disorder, brief psychotic disorder, and psychosis were added after resident #2's readmission on [DATE]. Review of resident #2's significant change in status MDS assessment with an Assessment Reference Date (ARD) of 9/11/25 revealed she received high-risk medications classified as anticonvulsants and antibiotics during the 7-day look back period. Review of resident #2's medical record revealed physician's orders for Venlafaxine 150 milligrams (mg) daily for depression, Cephalexin 500 mg twice daily for urinary tract infection, Divalproex 250 mg every 12 hours for bipolar disorder, Haloperidol 5 mg twice daily for behavioral disorder, Lacosamide 200 mg twice daily for seizures, Lamotrigine 200 mg twice daily for seizures, Quetiapine 50 mg three times daily for psychosis, Seroquel 75 mg every eight hours for brief psychosis, and Oxycodone-Acetaminophen 5-325 mg every eight hours as needed (PRN) for non-acute pain. Review of the Medication Administration Report (MAR) for September 2025 revealed resident #2 received Venlafaxine, Cephalexin, Divalproex, and Lamotrigine from 9/07/25 to 9/11/25. She also received Haloperidol from 9/07/25 to 9/09/25, Lacosamide from 9/08/25 to 9/11/25, Quetiapine from 9/08/25 to 9/10/25, Seroquel on 9/10/25 and 9/11/25, and Oxycodone-Acetaminophen on 9/08/25. Review of Section N - Medications of the MDS assessment indicated the form required documentation of 11 drug classes by use and indication. The instructions directed staff to mark the box if the resident received medications within the pharmacological classification during the last seven days, or since admission or reentry if less than seven days. On 10/23/25 at 2:42 PM, the MDS Lead reviewed resident #2's significant change in status MDS assessment with an ARD of 9/11/25 alongside the September MAR. She confirmed section N should have included antipsychotic, antidepressant, and opioid medications. She explained MDS staff reviewed the MAR to determine which medications a residents received during the lookback period, using the Resident Assessment Instrument (RAI) as a guide. The MDS Lead stated the assessment was completed by a new MDS Coordinator and corporate audits were performed but only on a random basis. She acknowledged the expectation was for all MDS assessments to be accurate. Review of the facility's Comprehensive MDS Assessment and Care Plan policy, revised February 2024, revealed the facility would complete the comprehensive assessment using the RAI specified by the Centers for Medicare & Medicaid Services. The policy read, The facility will conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity initially and periodically.

Based on interview, and record review, the facility failed to ensure completion and accuracy of a Level I Preadmission Screening and Resident Review (PASARR) after a readmission for a resident diagnosed with a Serious Mental Illness (SMI), following a significant change in the resident's mental condition for 1 of 1 residents reviewed for PASARR from a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 8/20/25. Her diagnoses included multiple sclerosis, major depressive disorder, anxiety and seizures. Additional diagnoses of bipolar disorder, brief psychotic disorder, and psychosis were added after resident #2's readmission on [DATE]. Review of resident #2's significant change in status Minimum Data Set (MDS) assessment with an Assessment Reference Date of 9/11/25 revealed a Brief Interview for Mental Status score of 15 out of 15 which, indicating intact cognition. The assessment documented a Mood Interview was conducted and no symptoms were identified. It also noted no rejection of care necessary to achieve health and well-being goals and no behavioral symptoms. The MDS assessment listed active diagnoses of anxiety, depression, bipolar, and psychotic disorder. Review of resident #2's Comprehensive Care Plan revealed a focus area initiated on 8/21/25 for a history of exhibiting behaviors. These included recent hallucinations/delusions, impulsivity, physical and verbal aggression, resisting care, crawling on the floor and in hallways, throwing objects when anxious or upset, chronic noncompliance with safety and medical interventions, refusal to wear clothing or briefs, socially inappropriate behaviors such as spitting and yelling. Another focus area showed mood instability, anxiety, bipolar disorder, depression, psychosis, and prior [NAME] Act (52-hour involuntary hold) with suicidal ideations. Review of the progress notes in the medical record revealed the following entries:*8/24/25 - Nurse documented resident #2 called 911 reporting seizures. Upon evaluation, no seizure activity was observed. Emergency Medical Services (EMS) responded, and despite the absence of seizure activity, the resident insisted on being transferred to the hospital and was transferred to the Emergency Room. *9/01/25 - Nurse documented the resident refused medications, food and drink. The Psychiatric Advanced Practice Registered Nurse (APRN) was notified and ordered Lorazepam and Haldol, along with one-on-one observation for safety. The resident continued exhibiting behaviors throughout the night, including removing clothes, and urinating and defecating in the room. The Psychiatric APRN was notified the medications were ineffective and issued an order for a [NAME] Act resident. The nurse notified the Director of Nursing (DON), the resident's husband, and called 911. The [NAME] Act is a Florida law that enables families and loved ones to provide emergency mental health services and temporary detention for people who are impaired because of their mental illness, and who are unable to determine their needs for treatment. (Retrieved from www.ufhealth.org on 11/01/25). Review of resident #2's Certificate of Professional Initiating Involuntary Examination dated 9/01/25 and signed by Psychiatric APRN K listed diagnoses of psychosis, refusal of care, and suicidal ideation. It stated due to her mental illness, the resident was unable to determine whether an examination was necessary, and there was a substantial likelihood she would cause serious bodily harm to herself without treatment. The supportive evidence read, Pt (patient) with history of psychosis and refusing care. Pt has been experiencing the exacerbation. No specific triggers. The patient has been naked, throwing herself on the floor with death wishes. The patient is refusing all kind of care. The patient is not redirectable and refusing to eat or drink. Giving IM medicine has been ineffective. [NAME] Act is the least restrictive alternative to ensure the safety of the other frail residents and staff. If not [NAME] Acted and received appropriate treatment in a psychiatric hospital, the patient will likely continue to escalate and hurt others. As the behaviors occur periodically and not consistently, [NAME] Act should not be rescinded based on a lack of behavior for a few consecutive hours. Review of the hospital's Attending admission Note dated 9/01/25 revealed an Assessment and Plan including complicated Urinary Tract Infection (UTI), aggression, violent behavior requiring restraints, suicidal ideation, history of psychosis, acute metabolic encephalopathy and one-on-one sitter under continued [NAME] Act status. Review of hospital's psychiatrist note dated 9/01/25 indicated the patient was admitted under a [NAME] Act after being violent and confused. The patient's husband described the situation as going out of whack, correlating with her refusal to eat and discontinuation of prescribed medications. Her symptoms included confusion and behavioral disturbances. The psychiatrist noted a possible exacerbation of bipolar disorder and anxiety, worsened by the UTI. Review of additional progress notes in resident #2's medical record following hospital discharge revealed the following entries:*9/06/25 - The DON documented upon resident #2's return from the hospital, staff were instructed to increase monitoring and report any changes in condition promptly to their immediate supervisor or directly to the DON.*9/11/25 - Resident appeared confused; husband expressed concern regarding mental status. Nurse attributed confusion to UTI. *9/14/25 - Resident was agitated, spat out medications, punched staff, refused care, yelled profanities, and threw food trays. *9/16/25 - Resident called 911 multiple times, tore items in her room, and hid her phone. *9/19/25 - Resident was transferred to the hospital for altered mental status (AMS). Review of APRN I's progress note dated 9/12/25 read, Prior to last visit, [NAME] Act was initiated. Patient had increased anxiety and agitation. Patient was throwing self on the floor with no clothes and her symptoms were out of control. Started Haldol 5 mg (milligrams) PO (by mouth) or IM (intramuscularly) bid (twice a day) for 14 days and Ativan 1 mg IM q 8hrs (every 8 hours) as needed for 14 days. During last visit, patient had increased somatic delusions and had psychosis . Increased Seroquel to 75 mg TID (three times a day) for psychosis. Review of APRN I's progress note dated 9/15/25 documented medication adjustments including Haldol, Ativan, Seroquel, and Depakote to address psychosis, agitation, and mood instability. The Mental Status Examination described the resident as poorly groomed, disheveled, with impair insight and judgement. Diagnoses were updated to schizoaffective disorder (bipolar type) and unspecified dementia with behavioral disturbance. Review of APRN J's progress notes dated 9/15/25 through 9/19/25 described resident #2 as continuing to exhibit psychotic episodes, agitation, elevated ammonia levels, and combative behavior. Review of a Change in Condition progress note dated 9/19/25 revealed resident #2 was transferred to the hospital due to AMS. Review of resident #2's medical record revealed a State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) Level I Screen form dated 9/04/25. Section I. A, MI (mental illness) or suspected MI, (check all that apply) was left blank. Section IV indicated No diagnosis or suspicion of SMI or ID (intellectual disability) indicated. Level II PASRR evaluation not required. There was no evidence in the medical record a new Level I PASARR was completed after readmission or following the onset of new psychiatric diagnoses and behavioral changes. On 10/23/25 at 1:44 PM, Licensed Practical Nurse (LPN) H stated resident #2 had a lot of psych behaviors, including throwing herself on the floor, yelling, refusing medications and care, throwing food and medications, and spitting. LPN H reported resident #2's behaviors worsened before the [NAME] Act, and the hospital later identified a UTI. She stated psychiatric services saw resident #2 at least twice weekly and the behaviors continued daily after her return on 9/06/25. On 10/23/25 at 4:01 PM, Social Services Assistant L stated he did not know whether Social Services was involved in reviewing or resubmitting the PASARR. He indicated he was unaware of any mention of it by the former Social Services Director (SSD). On 10/23/25 at 8:53 PM, during a telephone interview, Registered Nurse (RN) C reported caring for resident #2 the night she was [NAME] Acted. She described the resident as out of control, screaming, crying, throwing objects, removing clothes, defecating, urinating on the floor, and refusing food and fluids. She confirmed APRN K ordered the hospital transfer under a [NAME] Act. On 10/23/25 at 4:20 PM, the DON explained new admissions were reviewed by the interdisciplinary team the next business day, including PASARR documentation received from the hospital. She stated the SSD or DON was responsible for reviewing the PASARR and one should be completed when a new SMI diagnosis or behavioral changes occurred. The DON acknowledged a new PASARR was not completed despite significant behavioral changes during resident #2's stay. On 10/24/25 at 1:30 PM, the Administrator (NHA) stated resident #2 had an extensive psychiatric history and was followed closely by psychiatric providers. The NHA confirmed documentation showed resident #2 exhibited delusions, including claims of giving birth in the facility. The NHA validated the PASARR was not resubmitted, calling it an oversight. On 10/24/25 at 2:18 PM, the Regional Nurse Consultant (RNC) stated residents receiving psychotropic medications were followed by psychiatric providers. The RNC acknowledged the PASARR should have been reviewed but opined that a Level II may not have been issued even if resubmitted. On 10/24/25 at approximately 2:45 PM, the NHA stated the facility did not have a policy defining which staff member was responsible for updating PASARRs. A copy of the facility's policy regarding Behavioral Health or Behavior Management was requested but not provided.

Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices in accordance with infection control standards when assisting a resident with an intravenous (IV) infusion for 1 of 1 residents observed during the facility tour, from a total sample of 12 residents, (#5).Findings: Review of resident #5's medical record revealed she was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction), type 2 diabetes, stroke, anemia, and weakness. Review of resident #5's comprehensive care plan identified a focus area related to a midline catheter in the right upper extremity for treatment of anemia. The goal of the care plan was for the resident to experience no complications associated with the IV access or its use through the next review date. On 10/23/25 at 12:09 PM, Licensed Practical Nurse (LPN) G exited resident #5's room wearing gloves on both hands. While outside the resident's room, LPN G used scissors from the medication cart to open an IV-line package, then reentered the room. Inside the room, LPN G connected the IV line to a medication pouch on the IV pole, pulled a garbage can closer to her and the IV pole and continued setting up the IV tubing to begin an iron infusion. After several minutes working with the IV machine, LPN G informed resident #5 she needed to step out to obtain assistance. On 10/23/25 at 12:15 PM, LPN G confirmed she had exited resident #5's room without removing her gloves or performing hand hygiene and then returned to the room wearing the same gloves. She validated she moved the trash can wearing the same gloves and resumed working with the IV line. LPN G stated she was in a rush because the resident was waiting on her to finish setting up the infusion to eat her lunch. She acknowledged her actions violated infection control protocol and placed resident #5 at risk for infection. On 10/24/25 at approximately 2:20 PM, the Director of Nursing (DON) stated staff were expected to remove gloves before exiting a resident's room and perform hand hygiene immediately afterward. The DON added, Obviously, the nurse knew it was incorrect. Review of the Facility Assessment, updated on 10/06/25, revealed all staff received infection control and hand hygiene education upon hire and annually thereafter.

Based on interview, and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, undated revealed objectives which included to Establish systems through which to monitor and evaluate corrective actions. The Implementation section described the process in which the QAPI plan identified and corrected deficiencies. The key components included developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of the corrective action, revising when necessary. The facility had deficiencies at F842 in complaint surveys conducted on 12/14/23 and 10/16/24 for non-compliance with the medical record and accuracy of documentation. Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 12/14/23 revealed a Plan of Correction was completed on 1/19/24. The facility documented education to the nursing staff on the components of F842, resident records, and accuracy of documentation was performed. Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 10/16/24 revealed a Plan of Correction was completed on 11/22/24. The facility again documented education was provided to the current nursing staff and newly hired nurses on the components of F842. The Plan of Correction indicated audits were to be performed until compliance was reached. During this survey, deficiencies were again identified at F842, for resident records and accuracy of documentation. As a result of the repeated citation, it was identified there was insufficient auditing and oversight by the QAPI team to prevent repeated deficiencies. On 9/09/24 at 5:15 PM, the Administrator (NHA) stated she had attended two QAPI meetings since starting to work in the facility in mid-July 2025. She explained during the QAPI meeting, they reviewed processes relevant to each department to ensure no deficiencies or concerns with deviations from their policy were identified. She indicated when issues were identified, they worked with their corporate team to develop and implement a Performance Improvement Plan. The NHA stated she was not aware of the previous deficiencies regarding medical records documentation.

Based on record review, and interview, the facility failed to provide a written discharge summary and list of medications for 1 of 2 residents reviewed for discharge status, of a total sample of 7 residents, (#2).Findings: Cross Reference F842 Review of resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including nontraumatic subacute subdural hemorrhage (brain bleed), chronic obstructive pulmonary disease, type 2 diabetes, repeated falls, speech and language deficits, abnormalities of gait and mobility, and difficulty walking. Review of resident #2's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/11/25 revealed a Brief Interview for Mental Status score of 15/15 indicating intact cognition. The MDS assessment showed the resident participated in the assessment, and there was an active discharge plan for return to the community. The assessment also reflected a referral to a Local Contact Agency had not been made because the discharge date was three or fewer months away. Review of the Discharge MDS assessment with ARD of 7/06/25 revealed a planned discharge home, return not anticipated. Review of resident #2's comprehensive care plan showed a focus for discharge to the community, initiated on 11/15/24 and resolved on 3/08/25. A new plan was initiated on 3/08/25 and read, The resident chooses to remain in this facility for long term care services. The care plan was closed on 7/15/25 after his discharge. Review of resident #2's medical record revealed a Discharge Summary form with an effective date of 7/06/25 at 11:06 (time of day was not specified). The Summary of Stay section indicated the resident was discharged home with his spouse and mother-in-law. The resident status was listed as long term care. Several sections of the discharge form were left blank or unanswered, including Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs (Activities of Daily Living)/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed. The Medications and Treatments questions were unanswered. The form instructed staff to **ATTACH COPY OF MEDICATION LIST**, enter pharmacy details, and document whether scripts were provided. These were not addressed and were left unanswered. There was no evidence in the record that a copy of the Discharge Summary was given to resident #2, nor was it signed by the resident or staff. There was also no evidence of a medication reconciliation or confirmation that medications were provided upon discharge. Review of resident #2's physician orders revealed an order dated 7/07/25, which read, Discharge patient home with home health PT/OT (Physical Therapy/Occupational Therapy) and Nursing. Review of June 2025 and July 2025 Progress Notes did not reveal any entries regarding discharge planning. No documentation was found regarding education provided, disposition of medications, or scripts issued when the resident left. Review of the July 2025 Medication Administration Record (MAR) revealed medications scheduled for 9:00 PM were not given, with code 3 (out of pass) listed as the reason. Review of resident #2's Release of Responsibility for Leave of Absence Resident Sign Out Sheet revealed no entries in July 2025. Attempts to contact resident #2 by telephone on 9/08/25 and 9/09/25 by the survey team were unsuccessful. On 9/08/25 at 1:38 PM, in a telephone interview, resident #2's sister, listed in the medical record as the Health Care Surrogate, Power of Attorney (POA), and emergency contact for resident #1, confirmed her brother was discharged home on 7/06/25 but said she was not notified in advance. She shared she received a call from the facility afterward informing her the resident was no longer at the facility. On 9/08/25 at 8:15 PM, in a telephone interview, Certified Nursing Assistant (CNA) A shared she previously worked for the facility from March 2024 to August 2025. She recalled resident #2 was mostly independent. She acknowledged working some weekends and shared she did not see any visitors with resident #2 when she was assigned to his care. CNA A stated she did not assist, nor did she observe resident #2 packing his belongings or him leaving the facility during her 7 AM to 3 PM shift on Sunday, 7/06/25. On 9/09/25 at 1:48 PM, in a telephone interview, Licensed Practical Nurse (LPN) B stated she resigned mid-August 2025 and was assigned to resident #2's unit once or twice. She indicated she did not discharge anyone during her shift on Sunday 7/06/25. She explained she would have entered a progress note in the medical record if she discharged a resident. She did not recall any residents leaving for any reason that day. She stated no one from the facility had inquired about the care of resident #2 on Sunday 7/06/25 or afterwards. On 9/08/25 at 3:43 PM, 9/08/25 at 8:36 PM, and 9/09/25 at 10:39 AM, attempts were made to contact LPN C, who was assigned to resident #2 from 7 AM to 7 PM on Sunday 7/06/25, unsuccessfully. No reply from LPN C was received. On 9/09/25 at 12:26 PM, the Social Services Assistant indicated the Social Services Director (SSD) was out of the facility currently. He confirmed responsibility for discharge planning. He explained a perfect discharge process would include discussion during weekly Utilization Review (UR) meeting to learn about the resident's progress and set a discharge date . He shared once they established a discharge date , home care services and durable medical equipment was set up as needed. He mentioned it did not always happen this way and at times, when a resident wanted to leave the same day, it was not a smooth process, but they tried to follow the same process. He indicated a Discharge Summary form was opened in the system and each discipline responsible for their section of the form would complete it. The Discharge Summary should be placed in the folder and given to the resident at discharge. He recalled talking to resident #2 regarding his desire to go home but there were barriers with placement regarding his mobility and a big dog in the house. The Social Services Assistant indicated he spoke with resident #2 about his concerns, because his spouse worked so much. He stated there would be the staff to provide documentation about the discharge plan in the medical record. Later at 1:01 PM, the Social Services Assistant showed a copy of an email sent by the SSD to the Home Health Agency (HHA) on Monday 7/07/25 at 12:22 PM. He shared based on the email, he inferred this was not a planned discharge, otherwise, the HHA set up would have been done before resident #2 left. The assistant explained the HHA responded they received the message and there was no other messages from them. He shared the HHA would have communicated with the facility if the resident had declined services. He stated he did not assist the SSD with resident #2's discharge. The Social Services Assistant indicated he did not find any progress notes regarding the discharge planning or the SSD's conversations with resident #2 before his discharge. On 9/09/25 at 2:00 PM, the Director of Nursing (DON) explained code 3 in the MAR was used when a resident was out of the facility on a pass. She reviewed resident #2's Discharge Summary form and acknowledged it was incomplete and not signed. The DON was shown the email provided by the Social Services Director which indicated the resident was discharged on 7/06/25 but the physician order for discharge and referral sent to the HHA were not done until the next day, 7/07/25. The DON did not make any comments to explain. On 9/09/25 at 2:13 PM, in a telephone interview, the HHA's Administrator confirmed they received resident #2's referral on 7/07/25. She explained they attempted to set up a Start of Care visit multiple times but resident #2 declined the home health services on 7/16/25. On 9/09/25 at 3:05 PM, the DON stated she reached out to the nurses working on 7/06/25, both did not work here any longer, but was unsuccessful contacting LPN C. The DON indicated she spoke with LPN B who did not recall anything from that Sunday. The DON shared she also reached out to the DON at the time and was told resident #2 was discharged without a physician's order but did not recall anything else besides that. The DON stated the CNAs who worked with resident #2 that weekend were no longer employed by the facility. She explained they could not exactly determine when resident #2 left the facility, and that he probably left overnight or early that morning based on a census report updated at 4:00 AM on 7/07/25. At 3:10 PM, the Administrator (NHA) joined the interview. The NHA stated that weekend, two disgruntled employees who were no longer employed by the facility, were the Managers on Duty. She shared they were terminated because of findings from that weekend but did not provide details of their findings. The NHA stated she inferred while talking to staff about resident #2, there had been discussions about him going home but there were family disagreements on how to proceed. The NHA validated the medical record should have included notes regarding the discharge plan. She confirmed resident #2 was a long-term resident. On 9/09/25 at 4:30 PM, in a telephone interview, the former Social Services Assistant explained resident #2 was admitted to the facility with his sister being his POA. She recalled resident #2's discharge was mentioned by the resident when he got married in April 2025. She explained at that time he was not ready for discharge. Review of the facility's Transfers and Discharges policy and procedure, revised February 2024, read, The facility will develop and implement an effective discharge process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care.

Based on interview, and record review, the facility failed to accurately document the discharge plan and disposition in the medical record; and the Activities of Daily Living (ADLs) for 1 of 2 residents reviewed for discharge status and ADLs, of a total sample of 7 residents, (#2). Findings:Cross Reference F628 Review of resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including nontraumatic subacute subdural hemorrhage (brain bleed), chronic obstructive pulmonary disease, type 2 diabetes, repeated falls, speech and language deficits, abnormalities of gait and mobility, and difficulty walking. Review of resident #2's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/11/25 revealed the resident participated in the assessment, and there was an active discharge plan for return to the community. Review of the Discharge MDS assessment with ARD of 7/06/25 revealed a planned discharge home, return not anticipated. Review of resident #2's medical record revealed a Discharge Summary form with an effective date of 7/06/25 at 11:06 (time of day was not specified). The Summary of Stay section indicated the resident was discharged home with his spouse and mother-in-law. The resident status was listed as long term care. Several sections of the discharge form were left blank or unanswered, including Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs (Activities of Daily Living)/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed. The Medications and Treatments questions were unanswered. The form instructed staff to **ATTACH COPY OF MEDICATION LIST**, enter pharmacy details, and document whether scripts were provided. These were not addressed and not documented. There was no evidence in the record that a copy of the Discharge Summary was given to resident #2, nor was it signed by the resident or staff. There was also no evidence of a medication reconciliation or confirmation that medications were provided upon discharge. Review of resident #2's physician orders revealed an order dated 7/07/25 and read, Discharge patient home with home health PT/OT (Physical Therapy/Occupational Therapy) and Nursing. Review of June and July 2025 Progress Notes did not reveal any entries regarding discharge planning. No documentation was found regarding education provided, disposition of medications, or scripts issued when the resident left. Review of resident #2's Documentation Survey Report for June 2025 and July 2025, which showed ADL tasks such as dressing, personal hygiene, bladder and bowel, eating and fluids documented by the Certified Nursing Assistant (CNAs) were left blank on the following shifts: 7 AM to 3 PM - 6/5, 6/7, 6/8, 6/9, 6/11, 6/12, 6/13, 6/17, 6/21, 6/22, 6/23, 6/25, 6/27, 6/28, 6/29, 7/3, 7/4, 7/5, 7/6 3 PM - 11 PM - 6/7, 6/12, 6/14, 6/15, 6/19, 6/20. 6/21, 6/23, 6/25, 6/28, 6/29, 6/30, 7/2, 7/5, 7/6 11 PM - 7 AM - 6/5, 6/7, 6/9, 6/13, 6/14, 6/20, 6/21, 6/22, 6/26, 6/29, 6/30, 7/3, 7/4, 7/5, 7/6 On 9/09/25 at 12:44 PM, the Director of Nursing (DON) shared her expectation was that CNAs documented the care they provided to the residents prior to leaving the facility and as close as possible to the time the care was performed. She explained nurses were to document their assessments and progress notes before a resident left the facility. Later at 2:00 PM, the DON stated she was not working in the facility at the time but responded, I understand what you mean, in regard to the blanks in staff's documentation for resident #2. She acknowledged the Discharge Summary was incomplete and unsigned. Review of the facility's Medical Records policy and procedure revised in January 2024 read, Medical Records will be maintained within the facility per federal requirements.

Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent fall with major injury for 1 of 3 residents reviewed for falls, of a total sample of 4 residents, (#1). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #1. Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), dementia with behavioral disturbance, need for assistance with personal care, and difficulty walking. Review of the most recent Minimum Data Set (MDS) Admission 5-day assessment with assessment reference date of 7/16/24 revealed during the look-back period, resident #1 scored 4 out of 15 on the Brief Interview for Mental Status which indicated she was severely cognitively impaired. No behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The Preferences for Customary Routine and Activities interview completed with the resident noted it was somewhat important for her to go outside for fresh air. The Functional Abilities and Goals assessment showed the resident required a wheelchair and walker, substantial/maximum staff assistance to complete Activities of Daily Living (ADL), mobility functions, and to wheel a wheelchair. Walking was not assessed due to her medical condition/safety concerns. The resident was incontinent of bladder and bowel functions, short of breath with exertion or lying flat, did not have a history of falls within the previous 6 months of admission, nor since admission or during the assessment period. The assessment indicated a Care Area was triggered for an identified problem of Falls. Review of the Lifestyle & Activity Preferences Evaluation dated 7/24/24 noted resident #1 had impaired hearing, required glasses, needed reminders for activity participation, and needed assistance to/from activity settings with wheelchair mobility. On 10/13/24 at 12:10 AM, resident #1 was observed sitting in a wheelchair at the end of the nursing unit hallway looking out the windows into the parking lot. Licensed Practical Nurse (LPN) U was nearby and explained the resident had poor cognition; was confused and enjoyed the sun. Review of Unscored Fall Risk Evaluations completed on 9/05/24 and 9/14/24 noted nurses assessed resident #1's Safety Awareness/Behavior with a lack of understanding of cognitive functions and altered awareness of physical environment. The evaluation completed 9/15/24 noted additional risks had developed related to Safety Awareness/Behaviors with lack of understanding of physical limitations, including anxiety and restlessness. On 10/15/24 at 11:05 AM, resident #1 was observed lying awake in bed in her room. The resident's right lower leg was hanging off the side of the bed. Faded, healing bruises were observed under her eyes and a half inch partially healed laceration was visible near the bridge of her nose. Resident #1 was not able to answer basic questions appropriately. Review of the facility's September and October 2024 Fall Logs revealed before resident #1 fell on [DATE], she had 4 previous falls on 9/05/24, twice on 9/13/24, and again on 9/15/24. In an interview on 10/14/24 at 3:26 PM, the Director of Nursing (DON) confirmed none of the falls before the fall incident on 10/05/24 were witnessed by staff. A nurse's Progress Note completed by the Unit Manager (UM) showed that on 9/05/24, a Certified Nursing Assistant (CNA) observed resident #1 on the floor of her room, bleeding from the back of her head. A Physical Medicine And Rehabilitation Progress Note dated 9/05/24 read, . (resident #1) reports falling but does not remember how. She states she does have some pain to her head. Nurse reports patient attempted to transfer herself this morning and subsequently fell in the process. Nurse reports patient is at baseline with confusion and neurochecks and vital signs had been normal. Patient had a head laceration that was bleeding. I asked patient if she would like Tylenol, she initially stated no that she has a high pain tolerance but when asked again she said yes. Psych: Alert oriented to person only.Falls: Risk of complication: HIGH . PT (Physical Therapy)/OT (Occupational Therapy) to assess balance/gait and recommended to improve balance/coordination, and strength. Fall precautions optimized per facility. On 10/15/24 at 10:50 AM, CNA J explained she knew resident #1 well and sometimes had her on assignment. The CNA said resident #1 often attempted to get out the wheelchair to stand up on her own, she enjoyed being near the windows with sunlight, and CNAs monitored the resident in common areas or the television viewing area. She described frequent checks as, whenever I'm done and making sure they're okay. The CNA said she was not ever directed to check on resident #1 within specific timeframes. She described the resident as impulsive and could get up from her wheelchair very quickly and it was difficult to monitor her all the time. She explained they could be attending to another resident for more than 20 minutes at one time and staff needed to watch the resident closely to make sure she was not trying to go outside alone. Review of a SBAR (Situation-Background-Assessment-Recommendation) form completed by LPN A documented resident #1 fell on [DATE] and had a facial laceration with altered level of consciousness that required emergency 911 transport to the hospital. The Hospital Transfer Form noted the resident was combative and confused, and was high fall risk. On 10/14/24 at 11:17 AM, CNA F recalled on 10/05/24 at approximately 1:00 PM, he returned lunch trays to the dining room and as he looked outside, he saw resident #1 alone across the courtyard on the patio getting out of her wheelchair. He explained he ran outside and across the courtyard to help, but by the time he reached her, she was lying on the ground face first. He said resident #1 had blood on her face and swelling on her head. On 10/14/24 at 10:44 AM, CNA G said she frequently had resident #1 on her assignment. The CNA recalled she was working on 10/05/24, the day the resident fell outside. She said staff knew the resident was a high fall risk and they had to keep a very close eye on her because she liked to go outside for sunshine and frequently tried to go out the door unsupervised. She said she intercepted the resident multiple times over the past few months and prevented her from going out alone. The CNA explained resident #1 was not safe to be outside on her own. She described resident #1 used her feet to scoot in the wheelchair and could not go very far but she could open the door. She said on 10/05/24 after lunch, the resident was sitting in her wheelchair in the common area near the courtyard exit door when she told the CNA she wanted to go outside. The CNA said she told the resident she would return to go out with her as soon as she could, after she assisted other residents. The CNA explained, she assisted another resident in a room with lunch and was later alerted by another CNA that resident #1 was outside on the ground. She said CNAs were unable to monitor the resident closely while they assisted other residents with meals and incontinence care because she was very quick. The CNA explained frequent checks were supposed to be every 15 minutes or as often as possible. She said CNAs did not have written documentation for residents who were at high risk for falls and that it was communicated to each other verbally, we all just know. In a telephone interview with LPN A on 10/13/24 at 3:53 PM, she explained resident #1 was frequently included in her assignments and knew her well. She recalled on 10/05/24 at approximately 1:00 PM, she was alerted by CNAs the resident had fallen outside on the patio, face down on the ground. She said she assessed the resident and found her to be more disoriented than normal. She was bleeding from her nose and face with a large bump on her forehead. The LPN said she was very concerned the resident may have a serious head injury and she contacted Advanced Practice Registered Nurse (APRN) L for orders to send her out to the hospital. She said the APRN was hesitant to send the resident out because she wasn't on blood thinner medication and the Health Care Surrogate (HCS) didn't want her to go out to the hospital. The LPN said she was unable to reach the HCS and then successfully reached another Emergency Contact who consented to the transfer. She said the resident was transported to the hospital by emergency personnel. On 10/14/24 at 1:04 PM, Personal Care Assistant (PCA) B said she knew resident #1 well. The PCA said the resident enjoyed being outside and often wandered. The PCA explained the resident previously had someone with her at all times doing one to one supervision but that had stopped a few weeks ago. She said after the one to one supervision stopped, resident #1 had many falls. She recalled on 10/05/24, the day the resident fell , she was assigned to resident #1 during the day shift. She explained that from 11:30 AM to 1:00 PM, she was assigned to be in the dining room to assist with lunch and was unable to monitor the resident. The PCA explained staff were often occupied in a room for extended periods with other residents for meal assistance, incontinence care, and showers and could not always monitor resident #1 closely. She recalled when she returned to the unit after dining room duties, the resident was outside on the concrete, flat on her face. The PCA stated, I don't know what we can do for her if she doesn't have that one on one supervision. On 10/14/24 at 1:15 PM, the long term care UM stated nurses delegated to CNAs and let them know verbally when residents were on frequent checks. She explained, frequent checks normally meant about every 15 minutes. The Unit Manager stated, she (resident #1) likes to sit outside, she is very confused, and she will try to open the door and go out when she's on the unit; she doesn't remember she can't walk; no, she is not safe to sit outside by herself. Review of the Comprehensive Care Plan documented undated Special Instructions that read, Staff to escort resident for safety to the courtyard. A focus initiated on 7/15/24 read, The resident has impaired cognitive function/impaired thought processes r/t [related to] diagnosis of dementia. Interventions initiated on 7/15/24 noted nurses were expected to notify the physician of any changes in the resident's condition, and communicate concerns with family/caregivers about confusion, and the resident's capabilities or needs. A focus initiated 9/19/24 read, The resident has a history of exhibiting the following behaviors: Chronic/frequent refusals of care and/or services, Impulsivity, Resists care, Verbal aggression. In an interview on 10/14/24 at 2:23 PM, the Regional Nurse Consultant checked resident #1's records and acknowledged the care plan Special Instructions for staff to escort the resident to the courtyard were undated. She confirmed the entry was added to the care plan after the resident fell on [DATE], but she could not locate any date/time stamp entry history for it in the Electronic Health Record (EHR). Review of a Care Plan focus initiated 7/17/24 and revised 9/16/24 read, The resident is at risk for falls R/T Unsteady Gait/Poor Balance, Use of antihypertensive medications, Use of psychotropic medications, Hx [history] of falls. The care plan goal was for the resident's potential for sustaining a fall-related injury would be minimized by utilizing fall precautions/interventions through next review date. On 9/06/24, an intervention was initiated to offer the resident assistance with toileting before and after meals. On 9/16/24 interventions initiated included a non-slip mat applied to the wheelchair, floor mats, offer and assist to common areas while awake and as tolerated, and a scoop mattress. There were no interventions in place before resident #1's fall on 10/05/24 that specified increased supervision or the frequency of any supervision by staff. A Progress Note entered by LPN I on 10/05/24 at 10:04 PM, documented after resident #1 was treated at the hospital emergency room (ER), she returned to the facility on a stretcher with two attendants. The nurse noted facial bruising and swelling, and orders for antibiotic medications for a urinary tract infection (UTI). A Progress Note entered by LPN I on 10/06/24 at 8:14 AM, noted the physician was notified the resident had returned from the hospital the previous day with findings of a UTI with antibiotic medication orders. A Progress Note entered by the Assistant DON on 10/07/24 indicated the interdisciplinary Team reviewed resident #1's fall incident that occurred at approximately 4:45 PM the resident was observed lying on the ground with a laceration to the facial area an swelling of the forehead. The note revealed first aid was performed, and the family and physician were notified. Treatment to the skin alterations were in place, neurological checks and the care plan was reviewed and updated. Review of the Electronic Health Record (EHR) revealed no neurological evaluations/assessments were completed by nurses after the resident returned from the hospital on 10/05/24. On 10/16/24 at 12:51 PM, the DON checked resident #1's medical record and acknowledged nurses did not complete neurological (neuro) checks after the fall on 10/05/24. The DON stated, there wouldn't be a reason for them not to do neuro checks after the fall; they should do them. Review of the hospital's Emergency physician's discharge note dated 10/05/24 revealed the resident sustained a closed nondisplaced nasal fracture. The CT scan showed possible nasal fracture. On 10/14/24 at 12:09 PM, the DON said the Assistant DON was not available for interview. Review of the Safety Interventions Record reports from July through October 2024 revealed no record of any entries for instructions or interventions for fall prevention. The CNA Kardex with print date 10/14/24 indicated resident #1 required two staff for transfers with a mechanical lift as she was dependent and unable to assist. Under the section for Behavior/Mood it was noted if the resident had behavior issues, CNAs were expected to remove her from the situation and take her to an alternate location. The form read, Special Instructions: Staff to escort resident for safety to the courtyard . SAFETY . Encourage and remind resident to use CALL BELL and to wait for staff assistance with transfers, ambulation, toileting, etc. Encourage resident to only go out with staff family supervision. Offer and assist to common areas while awake as tolerated. The Physical Therapy (PT) Evaluation & Plan of Treatment report dated 7/14/24 indicated the reason for referral was due to new onset of decrease in functional mobility, decrease in strength, reduced dynamic balance and increased need for assistance from others. The Evaluation indicated resident #1 had precautions due to falls and Confusion. The document revealed patient behaviors required consistent supervision, and had worsening of cognitive impairment and changes. On 9/18/24 at 8:49 AM, additional precautions section was changed from one to one supervision required for falls and confusion to only falls and confusion, modified by the Therapy Director. The Occupational Therapy Progress Report dated 9/21/24 read, . Remaining impairments: Patient continues with deficits in standing balance/tolerance, general strength and cognition . The PT Treatment Encounter Note dated 10/04/24 was similar and read, . Precautions: (falls) and Confusion . with no mention of the previous required supervision from 7/14/24. On 10/15/24 at 10:43 AM, the Therapy Director said he participated in daily clinical meetings where fall management and interventions were discussed. He said resident #1 received ongoing PT and OT services since she was admitted [DATE]. He recalled the resident had multiple falls and therapy implemented wheelchair interventions and continued services for fall risk prevention to improve ADL self-care functions, balance, strength, and gait (walking). He did not recall clinical discussions to increase supervision for the resident. He stated therapy services included treatments and adaptive equipment, and did not include or provide increased supervision interventions outside of therapy sessions. On 10/15/24 at 10:39 AM, LPN H said when the resident was admitted to the facility, her family paid for one on one supervision, and she did well. She explained the private aide took her outside as resident #1 enjoyed it and it seemed to make her calmer. She said after the private supervision stopped, facility nurses and CNAs were expected to do frequent checks on resident #1 which meant every 15 minutes. The LPN said nurses were concerned the resident had multiple falls, after the one to one supervision was removed. She said several nurses informed management who responded that nurses' concerns were discussed in clinical meetings, but resident #1's supervision was never increased. The LPN recalled the resident was never safe to go outside to the courtyard patio alone before or after she fell outside. She said it was difficult for nurses to monitor up to 33 residents at a time and also constantly watch resident #1. She said in the past, the facility placed other residents on one to one when needed, but not resident #1. She stated, after she came off the private one to one, we could see why she needed it; she was restless; I would take her outside when I could, but I couldn't even chart. On 10/16/24 at 2:25 PM, LPN E said frequent checks meant every 15 to 30 minutes. She said residents who were not safe to be outside alone needed staff present to make sure they didn't fall. She explained nurses voiced their opinions about residents' needs for increased supervision and/or fall risks to the Unit Managers, and they relayed the concerns to management. She conveyed it was unrealistic for nurses to frequently check and watch residents with dementia, poor safety awareness, and impulsivity who tried to walk or get up on their own as well as being responsible for other multiple residents at the same time. The LPN stated, it's difficult for us to keep them safe and it's hard to get them management) to put them on one to one. On 10/15/24 at 2:36 PM, LPN I explained, resident #1 was a super high fall risk and when the resident was admitted , she needed to be watched constantly and had a 24-hour sitter that helped to keep her calmer. The LPN said she tried to check on resident #1 every 15 minutes, but she was really fast and didn't understand even when staff tried to reorient her. The LPN stated, she tried to self-transfer, get up and walk. The LPN conveyed, that many nurses inquired with management about the resident's high fall risk because they struggled to keep her redirected and busy to avoid falling. The LPN stated, when the sitter went away, we saw why she needed one to one; the CNAs cannot constantly watch her. On 10/15/24 at 2:08 PM, CNA F explained resident #1 was very impulsive, sometimes combative, and tried to move around all the time. The CNA expressed staff often were not able to closely observe resident #1 and take care of other residents at the same time. The CNA stated, it was known not to put her outside by herself; she's pretty quick. On 10/15/24 at 3:16 PM, LPN A said she struggled to keep a close eye on resident #1 because she had poor safety awareness and was impulsive. The LPN explained she tried to be creative and redirect the resident while she passed medications to other residents by keeping her busy and distracted at the medication cart. She recalled on 10/05/24, CNA G took the resident outside before lunch time until the CNA was occupied and assigned to assist other residents in their rooms with meals. The LPN recalled at about 1:00 PM, CNAs alerted her the resident was outside on the ground. She said the resident was at the hospital for the remainder of her shift that ended at 7:00 PM. She said she returned the next day for the day shift and received report from LPN I who said resident #1 had a UTI with prescriptions. The LPN said all the nurses thought the resident should go back on 1:1 and stated, even if you take your eyes off her for 5 minutes it can be a disaster; she is confused and can get up again. Review of Progress Notes documented by the Psychiatric Nurse Practitioner on 9/11/24 read, . Mood is labile. She is agitated. Nursing staff report she's had increased behaviors since her private duty nurse was discontinued by the patient's POA (power of attorney). She had a recent fall due to impulsive behaviors and trying to self-transfer. She is confused and reports not knowing what is going on. She enjoys sitting outside in the sun and eating in the dining room. Appearance/Behaviors: Sitting in the common area restless . Thought process: Somewhat disorganized . Thought association: Somewhat loose . Insight and Judgement: Impaired . Recall/Short-term memory: Impaired . Attention span/Concentration: Impaired . Fund of knowledge: Impaired . The Psychiatry Subsequent Note dated 9/20/24 read, . Mood is, trapped. Nursing staff report the patient remains anxious and restless. She is impulsive and gets up without asking for help . She reports feeling trapped in the facility . As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying anxiety disorder. They symptoms are occurring almost daily and causing severe distress . In a telephone interview on 10/13/24 at 4:05 PM, resident #1's POA explained she was responsible for the resident's financial affairs. The POA recalled when resident #1 was admitted to the facility in July 2024, she had 24-hour 1:1 supervision paid for by the resident because the Healthcare Surrogate (HCS) was concerned she would fall and be seriously injured, she was very impulsive and had very bad dementia. She stated the resident paid 1:1 service was discontinued after a couple of months because it was very expensive, and the resident could no longer afford it. On 10/16/24 at 10:05 AM in a telephone interview, resident #1's Emergency Contact Representative explained the resident was never safe to be outside in the courtyard alone. She said the resident was placed on private duty supervision at her own expense because the HCS feared she would fall and be seriously hurt. She said the resident was very impulsive and she stood up on her own while in the wheelchair. She said the private supervision stopped for financial reasons and she worried after that because the resident started to have falls and stated, they (facility) don't provide 1:1 service. On 10/16/24 at 10:54 AM in a telephone interview, resident #1's HCS recalled she was worried the resident would fall and get seriously hurt at the facility without 1:1 supervision, so she requested the POA pay for the services on behalf of the resident. She explained she was especially worried and concerned when the resident started having multiple falls in September 2024, after the individual supervision stopped. She said after the resident fell on [DATE], the facility did not provide her with any updates and she found out from the hospital later that the resident had a nasal fracture. She said the facility told her they didn't have staff to provide 1:1 supervision and stated, she started falling when the one on one went away. Review of APRN L's Nursing Home Visit Encounter dated 10/07/24 read, . weakness, had a fall out of her wheelchair over the WE (weekend). Sent to ER, no sutures required and sent back to the facility . bruises to both eyes, forehead and abrasion to her nose and forehead. The note did not mention resident #1 sustained a nondisplaced nasal fracture. On 10/16/24, two unsuccessful attempts were made to contact APRN L by telephone. On 10/15/24 at 2:36 PM in a telephone interview, LPN I said she frequently had resident #1 on her assignment. She recalled on 10/05/24 during the 7:00 PM to 7:00 AM shift, the resident returned to the facility by stretcher from the hospital. She recalled 2 transportation attendants accompanied the resident with the hospital discharge packet. She said the discharge packet included new prescriptions for UTI, and she contacted the on call APRN for orders. The LPN explained the records contained lab results, a chest X-ray, and CT of the head and stated, she had a lot of stuff; I didn't read the scans in-depth; when they dropped her off, they said she had no fractures. On 10/16/24 at 9:20 AM, the Long Term Care Unit Manager explained all resident falls and interventions/revisions of care were discussed in morning clinical meetings where she participated. She said resident #1 was on frequent checks and the 1:1 status was removed by the family for financial reasons. She said on 10/07/24, a Monday, she discussed what happened with APRN L who saw and assessed her. She said CNAs were expected to check on residents with frequent checks in between patient care and stated, we know she's a fall risk so everybody on the unit that works frequently check on her. On 10/16/24 at 2:17 PM, the DON explained the facility had a Falling Leaf Program to alert staff of residents who were high fall risk. She said the program consisted of a green magnet placed on the residents door to alert staff and it was intended to bring increased awareness. The DON said the facility did not have written standards and guidelines for the program and stated, we didn't consider putting her on the 1:1; she's (resident #1) on the Falling Leaf Program; it's to keep eyes on them; we review her in the clinical meetings. On 10/16/24 at 12:51 PM, the DON explained the facility reviewed all resident emergency visits for orders and test results every weekday morning during clinical meetings. She recalled the resident's fall and ER visit was discussed, on 10/07/24, and the Unit Manager reported the resident had a UTI and was prescribed antibiotic medications. She checked the hospital ER discharge records and said she was not aware resident #1 had sustained a nasal fracture. The DON stated, I didn't know we had this; I would say that the hospital didn't send it; she should be monitored for the fracture. On 10/16/24 at 1:00 PM, the DON explained when staff had concerns about any resident's behavior or safety, they reported it to the Unit Manager who communicated the information to the Interdisciplinary Team (IDT) in morning meetings. She said the team was aware resident #1 was a high fall risk and she was placed on the Falling Leaf Program with a magnet on her door after she started falling in September. Review of resident #1's Comprehensive Care Plan, Kardex for CNAs, and Safety Interventions Records revealed no Falling Leaf Program nor Frequent Checks were added to the plan of care since the resident was admitted to the facility on [DATE], for three months. On 10/16/24 at 2:17 PM, the NHA conveyed resident #1 was not considered for facility provided 1:1 supervision and stated, she's on the Falling Leaf Program; it's to keep eyes on them; we review her and any resident in the clinical meetings. On 10/16/24 at 2:30 PM, LPN E referred to the Falling Leaf Program and stated, it's something about guardian angel or something like that. The LPN could not accurately explain what the facility's high risk fall program was. On 10/16/24 at 2:34 PM, CNA P explained the magnet on the door to designate a leaf was to check the room when it's cleared for a fire. PCA Q stated, I think you're right; I've seen them. We check the room then we put it there. The CNA nor the PCA had knowledge of the facility's Falling Leaf Program for residents with high fall risk. In a telephone interview on 10/16/24 at 9:53 AM, MD M said he was aware resident #1 fell on [DATE], he previously reviewed the hospital records, and recalled she had a UTI. The MD explained he expected APRN L to review hospital ER records and test results as part of the assessment. At 1:42 PM, MD M said he was unaware resident #1 had sustained a nasal fracture. He explained he expected nurses to monitor residents for complications of fractures and stated, any head injury we always want to keep an eye on it after they come back from the ER and if they complain of pain we jump on it. A written statement provided by MD M dated 10/15/24 read, . I completed a case study on resident (#1) related to her fall on 10/05/24. After review of chart including but not limited to: hospital records, BIMS assessment, care plan, activity preferences, psych notes, prior falls, etc. The facility followed residents plan of care and resident preferences and resident was adequately supervised based on the investigation review including statements. On 10/16/24 at 12:36 PM in a telephone interview the Medical Director said he expected nurses to notify the physician of ER findings and test results. He said he expected nurses to monitor residents with fractures and stated, they must do neuro checks if it's a head injury. Review of the Facility assessment dated [DATE] read, . Mobility and fall/fall risk with injury prevention Transfers, ambulation, restorative nursing, falling leaf program for high fall risk residents, supporting resident independence in doing as much of these activities by himself/herself. With consistent assignments in person-centered care, staff and management place value on a stable team of individuals committed to knowing the resident and building care on a foundation of relationships. Staff, as well as residents and families benefit, as they get to know and depend on one another to work fluidly and flexibly support the unique strengths of each elder: .Routine tasks are assigned by the appropriate manager based upon demonstrated knowledge, skills and abilities per shift and needs of the facility/resident. When requirements are identified that overlap departments, the manager that identifies a shortfall will address the concern with the interdisciplinary team toward establishing a process. Managers are expected to closely monitor any changes in processes or procedures to maintain a positive culture for our staff and residents. A nasal fracture is a break in the bone or cartilage over the bridge, or in the sidewall or septum (structure that divides the nostrils) of the nose. Serious nose injuries cause problems that need a health care provider's attention right away. For example, damage to the cartilage can cause a collection of blood to form inside the nose. If this blood is not drained right away, it can cause an abscess or a permanent deformity that blocks the nose. It may lead to tissue death and cause the nose to collapse. Sometimes, surgery may be needed to correct a nose or septum that has been bent out of shape by an injury. A doctor may be able to return nasal bones that have moved out of place back to their normal position within the first 2 weeks after the break. (retrieved on 10/17/24 from www.medlineplus.gov). Review of the facility's standards and guidelines dated February 2024 and titled Falls-Managing, Preventing, and Documentation read. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. <[TRUNCATED]

Based on interview and record review, the facility failed to report possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, major depressive disorder, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. Hospital medical records dated 10/05/24, indicated resident #1 sustained a fall with a head injury that required emergency transport to the hospital. While at the hospital, the resident received emergency physician assessments, monitoring, treatment, diagnostic laboratory blood work, prescription medication orders, and Computed Tomography (CT) imaging. The CT imaging found the resident sustained a possible nondisplaced nasal bone fracture. Review of the most recent Minimum Data Set (MDS) Admission 5-day assessment with Assessment Reference Date (ARD) 7/16/24 revealed during the look-back period, resident #1 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam that indicated she was severely cognitively impaired. The assessment showed she had no behavioral symptoms or rejection of care necessary to achieve goals for health and well-being noted. The Preferences for Customary Routine and Activities interview completed with the resident noted it was somewhat important for her to go outside for fresh air. The Functional Abilities and Goals assessment showed the resident required a wheelchair and walker, substantial/maximum staff assistance to complete Activities of Daily Living (ADL), mobility functions, and to wheel a wheelchair. Walking was not assessed due to her medical condition/safety concerns. The resident was incontinent of bladder and bowel functions, short of breath with exertion or lying flat, did not have a history of falls within the previous 6 months of admission, nor since admission or during the assessment period. The resident received high-risk antidepressant, antibiotic, and diuretic (fluid removing) medications, and supplemental oxygen therapy. The assessment indicated a Care Area was triggered for an identified problem of Falls. Review of the Comprehensive Care Plan documented undated Special Instructions that read, Staff to escort resident for safety to the courtyard A focus initiated on 7/15/24 read, The resident has impaired cognitive function/impaired thought processes r/t [related to] diagnosis of dementia. Interventions initiated on 7/15/24 noted nurses were expected to notify the physician of any changes in the resident's condition, and communicate concerns with family/caregivers about confusion, and the resident's capabilities or needs. Another focus initiated 9/19/24 described resident #1 as having impulsive behaviors. A Care Plan Focus initiated 7/17/24 and revised 9/16/24 described resident #1 was at risk for falls related to an unsteady gait, poor balance, use of antihypertensive medications, use of psychotropic medications, and history of falls. The care plan goal read, The resident potential for sustaining a fall-related injury will be minimized by utilizing fall precautions/interventions through next review date. On 9/06/24, an intervention to offer the resident assistance with toileting before and after meals was initiated. Interventions initiated on 9/16/24 included staff to offer and assist resident #1 to common areas while awake and as tolerated. On 10/07/24, after her fall, the facility implemented an intervention to encourage resident to only go out with staff/family supervision. The care plan did not contain an intervention for frequent checks or a fall program. Review of the facility's September and October 2024 Fall Logs showed before resident #1 fell on [DATE], she had four other falls: on 9/05/24, twice on 9/13/24, and on 9/15/24. In an interview on 10/14/24 at 3:26 PM, the Director of Nursing (DON) confirmed none of the falls before the fall on 10/05/24 were witnessed by staff. Review of a SBAR (Situation-Background-Assessment-Recommendation) Change In Condition note completed by Licensed Practical Nurse (LPN) A dated 10/05/24, revealed resident #1 fell and had a facial laceration with an altered level of consciousness which required emergency transport to the hospital. The Hospital Transfer Form noted the resident was combative and confused, and described her as a, high fall risk. On 10/14/24 at 11:17 AM, Certified Nursing Assistant (CNA) F recalled on 10/05/24 at approximately 1:00 PM, as he returned lunch trays to the dining room and looked outside, he saw resident #1 alone across the courtyard on the patio getting out of her wheelchair. He explained he ran outside and across the courtyard to help her, but by the time he reached her, she was already lying on the ground face first. He said resident #1 had blood on her face and swelling on her head. In a telephone interview with Licensed Practical Nurse (LPN) A on 10/13/24 at 3:53 PM, she explained she knew resident #1 well. She recalled on 10/05/24 at approximately 1:00 PM, she was alerted by CNAs resident #1 was on the patio outside face down on the ground. She said she assessed the resident and found her to be more disoriented than normal, and was bleeding from her nose and face with a large bump on her forehead. The LPN said she was very concerned the resident may have a serious head injury and she contacted Advanced Practice Registered Nurse (APRN) L for orders to send her out to the hospital. The LPN said the Emergency Contact consented to the transfer and resident #1 was emergently transported to the hospital. Review of APRN L's Nursing Home Visit Encounter dated 10/07/24 read, . weakness, had a fall out of her wheelchair over the WE (weekend). Sent to ER (emergency room ), no sutures required and sent back to the facility . bruises to both eyes, forehead and abrasion to her nose and forehead. The note did not mention the possible nondisplaced nasal fracture from the hospital paperwork. On 10/16/24 at 10:54 AM, in a telephone interview, resident #1's Healthcare Surrogate recalled she was worried the resident would fall and get seriously hurt at the facility without one to one supervision, so she requested the Power of Attorney (POA) pay for the services on behalf of the resident. She explained she was especially worried and concerned when the resident started having multiple falls in September 2024, after the individual supervision stopped. She said after the resident fell on [DATE], the facility did not provide her with any updates, and she found out from the hospital later that the resident had a nasal fracture. She said the facility told her they didn't have the staff to provide one to one supervision and stated, she started falling when the one on one went away. In interviews on 10/16/24 at 1:00 and 2:00 PM, the DON explained when staff had concerns about any resident's behavior or safety, they reported it to the Unit Manager who communicated the information to the Interdisciplinary Team (IDT) in morning meetings. She said the team was aware resident #1 was a high fall risk so she was placed on the Falling Leaf Program with a magnet on her door after she started falling in September. On 10/16/24 at 2:15 PM, the Nursing Home Administrator conveyed the facility had not considered providing one to one supervision as a fall intervention for resident #1 and stated, she's on the Falling Leaf Program; it's to keep eyes on them; we review her and any resident in the clinical meetings. Review of resident #1's Comprehensive Care Plan, Kardex for CNAs, and Safety Interventions Records revealed no Falling Leaf Program nor were frequent checks added to the plan of care since the resident was admitted to the facility on [DATE], for three months. Review of the facility's form titled, Potential Adverse Report Incident Investigation Worksheet dated 10/08/24 noted a description of the event circumstances and read, This worksheet is designed to assist in determining if the incident/event is reportable on the AHCA 15 day report in compliance with Florida Statute 400.147 . resident had returned from the patio with [CNA G] less than 5 minutes prior, when the resident was observed by [CNA F] self propel thru patio door when she stood and lost her balance. The form noted three staff were involved, CNA F, CNA G, and LPN A. The facility's Conclusion/Analysis of Investigation read, Resident is independent with propulsion in the wheelchair. The resident had just left the patio less than 5 minutes prior with the assigned CNA (CNA G). (CNA F) witnessed the resident self propel from the doors on (unit name) to the patio (thru) door and stood and lose her balance falling forward. He immediately went to the resident and alerted the nurse. The form showed no State Agency reports were submitted. In a joint interview with the DON and Nursing Home Administrator on 10/14/24 at 11:45 AM, the DON said the facility did not report resident #1's incident on 10/05/24 because the resident was supervised, in an enclosed area, and staff didn't want to annoy her. The DON stated, it was just an accident; she stood from the wheelchair; it wasn't adverse. The Nursing Home Administrator acknowledged the resident required a higher level of care as a result of the incident and stated, neglect is considered to be someone who isn't taken care of. On 10/16/24 at 2:17 PM, the Nursing Home Administrator confirmed she was the Risk Manager and responsible for the facility's adverse incident reporting. She said the facility did not consider resident #1's incident to be reportable to the State Agency because her plan of care was followed and the facility was not aware at that time of resident #1's possible fracture. On 10/16/24 at 12:36 PM, in a telephone interview the Medical Director said he was not resident #1's attending physician, and the facility had not notified him of the fall or a possible adverse incident. Review of the facility's standards and guidelines dated January 2024 and titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin indicated neglect was defined as the failure to the facility, or it's employees to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress to a resident. The document described neglect included cases where the facility's indifference or disregard for resident care, comfort or safety resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Further, the document indicated the facility must ensure all alleged violations were reported immediately and in accordance with laws through established procedures. The facility's Risk Manager job description, dated and signed by the Nursing Home Administrator and DON on 3/22/24 described the Risk Manager would investigate allegations of abuse or neglect in coordination with the Abuse Coordinator, would ensure an event reporting system was implemented in the facility to ensure staff reported adverse events to the Risk Manager timely to develop appropriate measure to minimize the risk of adverse events to residents. The document included direction that the Risk Manager would ensure the mandatory immediate and completed 5-day reports were submitted per regulation.

Based on interview and record review, the facility failed to thoroughly investigate and identify possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. Hospital records dated 10/05/24, revealed resident #1 sustained a fall with a head injury that required emergency transport to the hospital. While at the hospital, the resident received emergency physician assessments, monitoring, treatment, diagnostic laboratory blood work, prescription medication orders, and imaging. Review of the most recent Minimum Data Set Admission 5-day assessment with reference date 7/16/24 revealed during the look-back period, resident #1 scored 4 out of 15 on the Brief Interview for Mental Status exam which indicated she was severely cognitively impaired. No behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The Preferences for Customary Routine and Activities interview completed with the resident noted it was somewhat important for her to go outside for fresh air. The Functional Abilities and Goals assessment showed the resident required a wheelchair and walker, substantial/maximum staff assistance to complete Activities of Daily Living (ADL), mobility functions, and to wheel a wheelchair. Walking was not assessed due to her medical condition/safety concerns. The resident did not have a history of falls within the previous 6 months of admission, nor since admission or during the assessment period. The assessment indicated a Care Area was triggered for an identified problem of Falls, to include a positive Care Plan Decision. Review of the Comprehensive Care Plan documented undated Special Instructions that read, Staff to escort resident for safety to the courtyard A focus initiated on 7/15/24 read, The resident has impaired cognitive function/impaired thought processes r/t [related to] diagnosis of dementia. Interventions initiated on 7/15/24 noted nurses were expected to notify the physician of any changes in the resident's condition, and communicate concerns with family/caregivers about confusion, and the resident's capabilities or needs. A focus initiated 9/19/24 indicated resident #1 had a history of impulsivity. Review of a Change In Condition progress note completed by Licensed Practical Nurse (LPN) A and dated 10/05/24, revealed resident #1 fell and had a facial laceration with an altered level of consciousness that required emergency transport to the hospital. The Hospital Transfer Form noted the resident was totally dependent on human assistance for mobility and ADLs, was combative and confused, and indicated she was a high fall risk. On 10/14/24 at 11:17 AM, Certified Nursing Assistant (CNA) F recalled that on 10/05/24 at approximately 1:00 PM, while he was returning lunch trays to the dining room he looked outside, and saw resident #1 outside, alone across the courtyard on the patio getting out of her wheelchair. He explained he ran out the door and across the courtyard to help her, but by the time he reached her, she was lying on the ground, face first. He stated resident #1 had blood on her face and swelling on her head. On 10/14/24 at 10:44 AM, CNA G recalled on 10/05/24 at approximately 1:00 PM, resident #1 fell from her wheelchair outside on the nursing unit courtyard. The CNA explained staff were expected to conduct 15 minute checks on the resident because she had severe dementia and was a fall risk. She said the resident frequently wanted to go outside to sit in the courtyard but could not go out alone safely. The CNA recalled she assisted the resident for lunch on the nursing unit near the courtyard and then she had to assist other dependent residents with their meals. She said at approximately 1:15 PM, she was informed resident #1 was outside alone and fell . She said she provided a handwritten statement about the event on 10/05/24 and placed it in the Unit Manager's box. The CNA explained she actually provided two handwritten statements to facility management; one on 10/05/24, the day of the incident, and another earlier that morning, 10/14/24, with the Nursing Home Administrator. On 10/15/24 at 3:16 PM, LPN A said she struggled to keep a close eye on resident #1 because she had poor safety awareness and was impulsive. The LPN explained she tried to be creative and redirect the resident while she passed medications to other residents. She said she would try to keep her busy and distracted at the medication cart. She recalled on 10/05/24, CNA G took the resident outside until lunch time when the CNA was busy assisting other residents in their rooms with their meals. The LPN recalled at about 1:00 PM, other CNAs alerted her the resident was outside on the ground. She said the resident was at the hospital for the remainder of her shift that ended at 7:00 PM. She said she returned the next day on the day shift and she received report from LPN I who told her resident #1 had a UTI with prescriptions. The LPN said all the nurses thought the resident should be on one to one supervision and stated, even if you take your eyes off her for 5 minutes it can be a disaster; she is confused and can get up again. A Progress Note entered by the Assistant Director of Nursing (ADON) on 10/07/24 read, IDT [Interdisciplinary Team]- On 10/05/24 at approximately 1645 [4:45 PM] the resident was observed lying on the ground. Laceration to the facial area and swelling on the forehead. First aid performed, MD [Medical Doctor] and family was notified, resident transferred to ER[emergency room ] for evaluation and returned with negative FX [fracture] results and [NAME] [antibiotics] for UTI, MD and family notified, treatment to skin alterations in place, neurological checks and CP [care plan] reviewed and updated. Staff to encourage resident to go outside with staff supervision. On 10/14/24 at 12:09 PM, the DON said the ADON was not available for interview, as she was out of the country on leave. On 10/14/24 at 1:04 PM, Patient Care Assistant (PCA) B recalled on the day of resident #1's fall, 10/05/24, she was assigned to resident #1. The PCA explained, she was assigned dining room duty from 11:00 AM to 1:00 PM and the resident remained on the nursing unit. She said when she returned to the unit, she saw the nurse going outside, and resident #1 was face down on the concrete. The PCA stated, nobody saw her fall. The person that found her was walking from that side to our side going to the courtyard and saw her on the ground; They didn't ask me to write a statement. On 10/14/24 at 1:15 PM, the Long Term Care Unit Manager recalled on 10/07/24, two days after resident #1's fall incident, she collected some written staff statements from her box, and some of them were placed under the DON's door. She explained on 10/07/24, she assisted in the facility's investigation and called some staff later for additional statements that she transcribed to a form. Review of CNA G's Interview Record form provided by the facility dated 10/07/24, indicated the Nursing Home Administrator was the interviewer. No other statements from CNA G for the day of the incident (10/05/24), or for that day (10/14/24) were provided to the surveyor. On 10/14/24 at 11:32 AM, in an joint interview with the DON, the Nursing Home Administrator reviewed the facility's investigation and staff statements collected from resident #1's incident and said the facility had one statement from CNA G dated 10/07/24. The Nursing Home Administrator explained she met with CNA G that morning to review the timeline. The Nursing Home Administrator and the DON were informed surveyor interviews with staff conflicted with the facility's investigation evidence provided. On 10/14/24 at 12:09 PM, the DON and Nursing Home Administrator said they were concerned information attained in staff interviews conflicted with their investigation of the incident. The DON stated, all the statements are in the folder. Review of the facility's investigation documents revealed no statement from assigned PCA B. On 10/16/24 at 9:20 AM, the Long Term Care Unit Manager explained all resident falls and interventions/revisions of care were discussed in the morning clinical meetings in which she participated. She said on 10/07/24, a Monday, she discussed what happened with APRN L who assessed her. She said CNAs were expected to check on residents with frequent checks in between patient care and stated, we know she's a fall risk so everybody on the unit that works frequently check on her. Review of the hospital ER treatment and discharge notes on 10/05/24 revealed resident #1's Computed Tomography (CT) scan findings showed a possible nondisplaced nasal fracture and the ER physician summary noted the need for antibiotics per resident #1's nondisplaced nasal fracture. Review of APRN L's Nursing Home Visit Encounter dated 10/07/24 read, . weakness, had a fall out of her wheelchair over the WE (weekend). Sent to ER, no sutures required and sent back to the facility . bruises to both eyes, forehead and abrasion to her nose and forehead. The note did not mention resident #1 sustained a nondisplaced nasal fracture. On 10/16/24, two unsuccessful attempts were made to contact APRN L by telephone. On 10/16/24 at 12:51 PM, the DON explained the facility reviewed all resident emergency visits for orders and test results every weekday morning during clinical meetings. She recalled the resident's fall and ER visit was discussed on 10/07/24, and the Unit Manager reported the resident had a UTI and was prescribed antibiotic medications. She said she checked the hospital ER discharge records and was not aware resident #1 had sustained a nasal fracture. The DON stated, I didn't know we had this; I would say that the hospital didn't send it; she should be monitored for the fracture. On 10/14/24 at 2:29 PM, the Regional Nurse Consultant stated, she (resident #1) doesn't need supervision; she goes outside; she goes out there, they take her outside and they don't watch her because she gets mad when they go out there. In a telephone interview on 10/16/24 at 9:53 AM, attending physician M said he was aware resident #1 fell on [DATE], he previously reviewed the hospital records, and recalled she had a UTI. The physician explained he expected APRN L to review the hospital ER records and test results as part of the assessment. The physician acknowledged he reviewed and signed APRN L's note on 10/15/24 and recalled the resident complained of a headache. At 1:42 PM, physician M said he was unaware resident #1 had sustained a nasal fracture. The physician explained he expected nurses to monitor residents for complications of fractures and stated, any head injury we always want to keep an eye on it after they come back from the ER and if they complain of pain we jump on it. A written statement from physician M dated 10/15/24 provided by the facility indicated he had completed a review of resident #1's chart related to her fall on 10/05/24 including hospital records, care plan, prior falls, etc. Review of the facility's form titled, Potential Adverse Report Incident Investigation Worksheet dated 10/08/24 noted a description of the event circumstances and read, This worksheet is designed to assist in determining if the incident/event is reportable on the AHCA 15 day report in compliance with Florida Statute 400.147 . resident had returned from the patio with [CNA G] less than 5 minutes prior, when the resident was observed by [CNA F] self propel thru patio door when she stood and lost her balance. The form noted three staff were involved, CNA F, CNA G, and LPN A. The facility's Conclusion/Analysis of Investigation read, Resident is independent with propulsion in the wheelchair. The resident had just left the patio less than 5 minutes prior with the assigned CNA (CNA G). (CNA F) witnessed the resident self propel from the doors on (unit name) to the patio (thru) door and stood and lose her balance falling forward. He immediately went to the resident and alerted the nurse. The form showed no State Agency reports were submitted. Review of the facility's standards and guidelines dated January 2024 and titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin indicated neglect was defined as the failure to the facility, or it's employees to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress to a resident. The document described the facility should take action as soon as practicable once notified to initiate an investigation and any corrective actions depended on the result of the investigation. It detailed that a coordinated effort would allow the Quality Assessment and Assurance Committee to determine a thorough investigation was conducted, the resident was protected and analysis was conducted as to why the situation occurred. Review of the Facility assessment dated [DATE] revealed the facility would provide person-centered/directed care, record and discuss treatment and care preferences and would identify hazards and risks for residents. The facility's Risk Manager job description dated and signed by the Nursing Home Administrator and DON on 3/22/24 indicated the Risk Manager/Designee would investigate allegations of abuse, neglect, and exploitation of a resident in coordination with the Abuse Coordinator and develop appropriate measure to minimize the risk of adverse events to residents.

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had a complete and readily accessible medical record, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. On 10/15/24 at 10:39 AM, Licensed Practical Nurse (LPN) H said nurses reviewed residents' (emergency room ) ER and hospital records to implement follow up needs, alert physicians, and obtain orders. The LPN explained hospital records were placed in an upload bin at the nurse's station for Medical Records personnel to scan to the electronic health record (EHR). On 10/15/24 at 2:36 PM, in a telephone interview, LPN I recalled on 10/05/24 during the 7:00 PM to 7:00 AM shift, resident #1 returned to the facility by stretcher from the hospital. She said two transportation attendants accompanied the resident with the hospital discharge packet/documents. The LPN explained, she placed the packet in a drawer at the nurse's station. LPN I said the hospital ER discharge packet included two prescriptions for UTI, laboratory blood results, chest X-ray results, and CT of the head results. The LPN stated, she had a lot of stuff and a plethora of labs; I didn't read the scans in-depth; when they dropped her off, they said she had no fractures. On 10/16/24 at 9:20 AM, the Long Term Care Unit Manager explained all resident ER findings were discussed in morning meetings so care needs/revisions could be implemented. The Unit Manager said she could not recall if she brought the resident's hospital discharge packet to the meeting however she did remember the resident had a UTI with prescriptions. The Unit Manager did not mention any hospital results for a nasal fracture. On 10/16/24 at 10:54 AM, in a telephone interview, resident #1's Health Care Surrogate (HCS) recalled after resident #1 fell on [DATE], the facility did not provide her with any updates and after the resident returned to the facility, she found out from the hospital physician the resident had a nasal fracture. She said she worked at the hospital and the ER discharge records were always faxed to the facility's Admissions office. On 10/14/24 at 10:30 AM, the Medical Records Clerk said she was responsible for retrieving ER and hospital records from the nursing units to scan to the EHR. She said there were no unscanned records in her office and confirmed resident #1's ER/hospital records from 10/05/24 were not scanned into the EHR and said she would try and locate it. On 10/14/24 at 1:15 PM, the Long Term Care Unit Manager explained, nurses needed ER records to review resident follow up needs and provide physician notifications. She said after processing, nurses placed the documents in a bin at the nurse's station for Medical Records, who picked them up daily to scan to EHRs. By the end of the day on 10/14/24 (the second day of the survey), the facility had still not provided the requested hospital records from resident #1's visit on 10/05/24. On 10/15/24 at 12:13 PM, the Director of Nursing (DON) confirmed the facility was unable to locate resident #1's hospital ER discharge records from 10/05/24. She presented some of the records was unable to provide the complete discharge record. She could not explain why the original records were missing. Review of resident #1's hospital ER treatment and discharge notes revealed on 10/05/24, resident #1 sustained a fall with a head injury and required emergency transport to the hospital. While at the hospital, the resident received emergency physician assessments, monitoring, treatment, diagnostic laboratory blood work, prescription medication orders, and Computed Tomography (CT) imaging. The paperwork revealed the CT scan found a possible nondisplaced nasal fracture, and the ER physician noted the closed nasal fracture. Review of Advanced Practice Registered Nurse (APRN) L's Nursing Home Visit Encounter dated 10/07/24 revealed resident #1 had a fall out of her wheelchair, was sent to the ER, and sent back to the facility. Her documentation described the resident had bruises to both eyes, and her forehead, and an abrasion to her nose and forehead. The note contained no mention resident #1 sustained a possible nondisplaced nasal fracture. On 10/16/24, two attempts were made to contact APRN L by telephone. On 10/16/24 at 8:36 AM, the DON explained residents' hospital discharge records and instructions were reviewed every morning in clinical meetings. The DON referred to resident #1's 10/05/24 records and stated, now the records are missing. On 10/16/24 at 9:20 AM, the Long Term Unit Manager explained the Interdisciplinary Team (IDT) discussed resident ER visits and new admissions in morning clinical meetings. She acknowledged hospital records were reviewed to ensure follow up and coordinate any changes to plans of care. She recalled she returned to work on Monday, 10/07/24 and attended the morning meeting where resident #1's fall and ER visit was discussed. She recalled the resident had a UTI with prescriptions and the weekend nurse had entered the medication orders. She confirmed the hospital discharge notes couldn't be located and stated, we didn't have the packet; I believe MDS [Minimum Data Set Coordinator] requested the records. On 10/16/24 at 9:39 AM, the MDS Coordinator explained she completed MDS assessments which required a complete medical record including hospital/ER notes and reports in order ensure accuracy. She stated, if any additional or missing information was needed, I do have e-fax or I can fax a request. The MDS Coordinator said no one had asked her to request resident #1's 10/05/24 ER notes. On 10/16/24 at 11:15 AM, the Director of Marketing said the hospital normally sent resident ER hospital records to the Admissions Department. She confirmed no one from the facility requested resident #1's 10/05/24 ER records from her. On 10/16/24 at 10:00 AM, the Medical Records Clerk said she cleared the nursing unit baskets every day and collected records to scan to the EHR. She said she knew the clinical providers needed all the records to accurately assess the resident. A short time later at 10:30 AM, the Medical Records Clerk said resident #1's medical record was incomplete and confirmed no one asked her to follow up and locate the missing records before the surveyor requested them on 10/14/24. On 10/16/24 at 12:51 PM, the DON said Unit Managers brought ER records and results to morning meetings and the records were reviewed by the clinical team. She recalled resident #1's ER visit was discussed and there were two prescriptions for UTI. The DON said it was important to have all the ER records in a timely manner for clinical review. The DON reviewed the hospital documents provided by the facility on 10/15/24 and acknowledged the CT showed a possible nasal fracture. She confirmed she had not been aware of the fracture and stated, she (resident #1) should be monitored for the fracture; I don't know that we had this; I would say the hospital didn't send it. A written statement provided by attending physician M dated 10/15/24 revealed he had completed a case study on resident #1 related to her fall on 10/05/24. He indicated he reviewed her chart including but not limited to the hospital records, care plan, activity preferences, prior falls, etc. In a telephone interview on 10/16/24 at 9:53 AM, attending physician M confirmed he was aware resident #1 fell on [DATE], and recalled she had a UTI. The physician explained he expected providers to review hospital ER records and test results as part of the assessment. The physician said he thought the resident had a headache and acknowledged he reviewed and signed APRN L's progress note on 10/15/24. In a second interview later that day at 1:42 PM, attending physician M said he had been unaware resident #1 had sustained a nasal fracture. The physician explained he expected nurses to monitor residents for complications of fractures and stated, any head injury we always want to keep an eye on it after they come back from the ER and if they complain of pain we jump on it. On 10/16/24 at 12:36 PM, in a telephone interview, the Medical Director said he expected nurses to notify the physician of ER findings and test results. He said he had hospital record electronic access but MD M did not have direct access to the hospital's EHR system as he did not see patients in the hospital. The Medical Director conveyed all clinical records were needed to properly assess a resident and he expected nurses to notify the doctor and monitor residents with fractures. Review of the undated Facility Assessment revealed the Medical Records Clerk was responsible for the organization and completeness of patient medical records.

Based on interview and record review, the facility failed to provide care and services, according to professional standards of practice, to avoid complications of a known medical condition and prevent rehospitalization for 1 of 2 residents reviewed for hospitalization , out of a total sample of 43 residents, (#574). The facility's failure to promptly identify and treat a change in condition and failure to obtain and implement physician orders in a timely manner resulted in actual harm for resident #574. The resident suffered altered mental status and debilitating symptoms which necessitated transfer to an acute care hospital for evaluation and treatment. Findings: Review of the medical record revealed resident #574, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder) and liver cirrhosis. The resident was discharged to the hospital on 6/20/24. Cirrhosis is scarring of the liver that results from injury or long-term disease. The scar tissue impacts the function of the liver and affects its ability to clean the blood (retrieved on 8/05/24 from www.medlineplus.gov/cirrhosis.html). Hepatic encephalopathy develops when toxins or poisons such as ammonia, build up in the brain because the liver cannot break them down. It can cause nausea, vomiting, confusion, loss of consciousness, and coma (retrieved on 8/05/24 from www.medlineplus.gov/lab-tests/ammonia-levels). The General Admission Data assessment dated [DATE] revealed resident #574 was alert, easily arousable, cooperative, and oriented to person, place, time, and situation. The document indicated the admission nurse(s) contacted the resident's medical provider to reconcile her medications, and all orders were confirmed and verified. Review of the Order Summary Report revealed resident #574 had physician orders dated 6/09/24 for Lactulose 10 grams/15 milliliter (gm/ml), give 30 ml four times daily for hyperammonia, and Rifaximin 550 milligrams (mg), give one tablet every 12 hours for hyperammonia. Lactulose causes a decrease in blood ammonia concentration and reduces the degree of encephalopathy by drawing ammonia from the blood into the colon where it is excreted in an increased number of bowel movements (retrieved on 8/05/24 from www.liverfoundation.org/liver-diseases/complications-of-liver-disease/hepatic-encephalopathy/treating-hepatic-encephalopathy). Rifaximin 550 mg is an antibiotic medication that is usually administered twice daily. If you are taking Rifaximin to prevent hepatic encephalopathy, do not stop taking it without talking to your doctor as you may experience symptoms of encephalopathy (retrieved on 8/05/24 from www.medlineplus.gov/druginfo/meds/a604027.html). Review of resident #574's medical record revealed she had a care plan for antibiotic therapy related to liver disease, initiated on 6/11/24. The goal was the resident would receive the drug. The interventions instructed nurses to administer antibiotic medication as ordered, obtain pertinent labs and report to the physician. Review of a care plan for risk for alteration in neurological status related to a diagnosis of encephalopathy, initiated on 6/11/24, had a goal that resident #574 would be free from signs and symptoms of complications of neurological deficit and would maintain optimal status and quality of life. The interventions instructed nurses to administer medications as ordered and report signs and symptoms of neurological complications such as constipation, difficulty swallowing, decline in range of motion, decline in cognitive function, change in level of consciousness, and slurred speech. A care plan for liver disease related to cirrhosis, initiated on 6/17/24, had a goal that the resident would be free from signs and symptoms of liver complications including cognitive decline or mental status changes. The interventions included administer medications as ordered by the physician. The document indicated nursing staff would monitor, document, and report malaise, fatigue, constipation, altered level of consciousness, confusion, or disorientation, and notify the physician as indicated. The care plan read, Obtain and monitor lab/diagnostic work as ordered by [physician]. Report results and follow up as indicated. Review of a Psychiatry Evaluation Note dated 6/10/24 revealed resident #574 was newly admitted to the facility and was alert and oriented with appropriate affect and mood. The psychiatrist noted the resident had an organized thought process, intact thought associations, good insight and judgement, and was at her baseline status. A Physician/Practitioner Note dated 6/11/24 revealed Advanced Practice Registered Nurse (APRN) G reviewed resident #574's medical chart which included hospital records. APRN G noted the resident had a past medical history of nonalcoholic cirrhosis. His assessment findings showed the resident was alert, awake, able to follow simple commands, and able to communicate. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 6/12/24 revealed resident #574 was admitted from a short-term general hospital. The document indicated she had adequate hearing and vision, clear speech, clear comprehension, and was able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which showed she was cognitively intact. The document revealed resident #574 did not exhibit inattention, disorganized thinking, or an altered level of consciousness. The MDS assessment indicated she displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Resident #574 participated in and provided information for the assessment, and her overall goal was to discharge to the community. Review of the medical record revealed a Late Entry Physician/Practitioner Progress Note dated 6/13/24 at 4:56 PM. The document was created four days later, on 6/17/24 at 4:56 PM, by APRN G who noted resident #574 denied any specific problems and remained alert and able to follow simple commands. The assessment showed the resident was comfortable, alert and oriented, and able to communicate. However, an Occupational Therapy Treatment Encounter Note dated 6/13/24 revealed resident #574 refused to get out of bed for her therapy session and complained of nausea. The therapy note read, Provided patient with bucket and reported to nursing. A Physical Therapy Treatment Encounter Note dated 6/13/24 indicated the resident refused to get out of bed for therapy. There were no associated nursing or provider progress notes regarding the resident's complaint of nausea or refusal to get out of bed on 6/13/24. Review of another Late Entry Physician/Practitioner Progress Note dated 6/15/24 at 2:00 PM, revealed APRN G wrote resident #574 denied any specific problems and remained alert and able to follow simple commands. The assessment showed the resident was comfortable, alert and oriented, and able to communicate. The note read, Nursing reports patient at baseline with no recent acute events.reviewed patient plan of care with assigned nurse, Nurse added no new patient concerns.Nursing to notify provider of any change in mentation or behavior. The document indicated resident #574's ammonia level was being monitored and the resident continued to receive Rifaximin 550 mg and Lactulose 45 ml. The ordered dosage of Lactulose on 6/15/24 was 30 ml and it was not increased to 45 ml until 6/17/24; therefore, the note did not accurately reflect the resident's active plan of care. A Laboratory progress note dated 6/16/24 at 2:52 AM, revealed Licensed Practical Nurse (LPN) B notified APRN G of resident #574's lab result. Review of the lab report showed the resident's ammonia level was elevated to 97 micromoles/Liter (mcmol/L). However, review of the Order Summary Report revealed no physician order for the stat or immediate lab, and review of nursing progress notes and APRN G's progress note on 6/15/24 showed no evidence of identification of a change in status or signs and symptoms of hyperammonia that required an urgent lab test. The medical record did not show a response from APRN G or any new orders to treat the resident's elevated ammonia level. According to the Merck Manual Professional Version (reviewed/revised December 2021), a normal Ammonia level is 23-47 mcmol/L (retrieved on 8/05/24 from www.merckmanuals.com/professional/resources/normal-laboratory-values/blood-tests-normal-values). Review of a Psychiatry Subsequent note dated 6/17/24 revealed the provider assessed resident #574 and noted, Mood is unwell. She reports nausea which is affecting her appetite. A Physical Therapy Treatment Encounter Note dated 6/17/24 revealed resident #574 refused four separate attempts to participate in therapy sessions. An Occupational Therapy Treatment Encounter Note dated 6/17/24 read, .patient reporting not feeling well and too tired to get out of bed. Review of a Progress note dated 6/17/24 at 7:30 PM, revealed resident #574's family members voiced concerns that their mother had a history of high ammonia levels, complained of constipation with no bowel movement for at least two days, and was exhibiting increased confusion. LPN E notified the provider and received orders for an abdominal x-ray and a routine ammonia lab test. The provider increased the resident's Lactulose from 30 ml to 45 ml, almost 18 hours after the facility received and reported the stat ammonia lab result of 97 mcmol/L to APRN G. An Occupational Therapy Treatment Encounter Note dated 6/18/24 revealed resident #574, demonstrated increased fatigue on this day. A Progress Note dated 6/18/24 at 2:33 PM, revealed resident #574's son repeated his concerns about his mother. The document indicated he notified the Casabella UM that she, .did not have a [bowel movement] in 3 days and that his mother's ammonia level was high. Son wanted mother transfer to [Emergency Department]. The note revealed the UM informed the son his mother's needs could be met in the facility. She contacted the provider and obtained orders for another type of laxative drug and a stat ammonia lab test. Review of a Progress Note dated 6/18/24 at 7:01 PM, revealed resident #574 was alert with confusion, complained of continued constipation despite a small, hard bowel movement. The progress note indicated the resident's ammonia level had decreased. Review of the laboratory result dated 6/18/24 revealed the resident's ammonia level was 66 mcmol/L, still above the normal range. A Physical Therapy Treatment Encounter Note dated 6/19/24 revealed resident #574 remained in bed and, .had poor responsiveness to therapist throughout session and nursing was notified. Review of an Occupational Therapy Treatment Encounter Note dated 6/19/24 revealed resident #574 was, .lethargic this date and difficulty with arousal, nursing aware of [patient] status. Review of the medical record revealed the Casabella UM completed a Change in Condition note on 6/20/24 at 2:40 PM. The document indicated resident #574 had altered mental status and the provider recommended sending her to the hospital. There was no associated nursing progress note with details of the resident's status. A Late Entry Physician/Practitioner Progress Note dated 6/20/24 at 3:33 PM was created by APRN G on 6/21/24 at 3:33 PM. The document indicated he assessed resident #574 in her room, and as in all previous notes, described her as alert, awake, able to communicate and follow simple commands. APRN G noted the resident's ammonia level and mentation were improved, but her son was insistent that his mother required hospitalization . A progress note dated 6/20/24 at 3:50 PM, revealed resident #574 was transferred to the hospital by ambulance personnel, accompanied by a family member. In a telephone interview on 8/05/24 at 7:07 PM, resident #574's daughter stated she received a text message from her mother on Monday 6/17/24 at 11:32 AM, that indicated she had abdominal pain, could not eat anything for breakfast, and had not had a bowel movement for a week. The daughter recalled her response to her mother was that the facility needed to check her ammonia level as it was probably increasing. She stated her mother stopped texting and she became worried, so she visited later that evening. The resident's daughter said, Her lunch was untouched, and the dinner tray was there as well. Her eyes were closed, and I touched her to wake her up. She did not seem like her normal self. She was not alert and not talking. Usually, she is excited to see me and asks about my kids. The daughter stated she expressed her concerns to the assigned night shift nurse who contacted APRN G and received orders for an abdominal x-ray and bloodwork. The daughter stated the nurse explained the results would likely not be available until the following morning, so she asked her to contact the physician again regarding sending her mother to the hospital. The resident's daughter stated the nurse returned and informed her she got push-back from the practitioner, who felt there was nothing the hospital could do that could not be done in the facility. The daughter recalled the following morning, on Tuesday 6/18/24, she returned to the facility at about 9:40 AM and her mother's uneaten breakfast was on the tray table. She stated there were two medication cups on the table beside the meal tray, one with pills and the other with 10 ml of liquid medication that appeared to be Lactulose, and no nurse in the room or nearby. The resident's daughter recalled the Casabella Unit Manager (UM) reassured her she would fix the situation, and she returned with an additional 30 ml cup of Lactulose. Resident #574's daughter stated no family members visited the facility on Wednesday 6/19/24, and by Thursday 6/20/24, her mother's condition had declined even more. On 8/01/24 at 2:29 PM, in a telephone interview with resident #574's son, he explained after about a week in the facility, his mother began exhibiting symptoms of high ammonia levels and she was barely responsive during the final three days. He stated the change in his mother's condition was significant as she was usually very alert, oriented, and talkative. The son recalled the facility denied several requests made by him and his sister to send his mother to the hospital as they noticed her symptoms worsening. He explained on Thursday, 6/20/24 at about 2:00 PM, he unexpectedly received a phone call from his mother's phone. He stated he was happy when he saw her number, as a call from her would suggest she felt better and was finally able to converse with him. Resident #574's son said, I was surprised because it was a [Certified Nursing Assistant] on my mom's phone, and she said my mom was not really responding so she thought it would help to hear my voice. I told her to get a nurse immediately. The son stated he waited for 25 minutes but did not hear back from a nurse, so he called the Casabella UM on her direct line and demanded she send his mother to the hospital. The resident's son emphasized that his mother's ammonia levels would not have escalated to that extent if she had been receiving her medication as prescribed. He stated he felt a significant factor was staff did not want to give the Lactulose at times because it caused frequent and/or loose bowel movements which they did not want to clean up. The resident's son explained as his mother became less responsive, it would have been difficult or almost impossible for her to take her medication orally, so he was not sure the medical record accurately reflected medications given. He explained when he arrived at the facility at approximately 3:30 PM, Emergency Medical Services (EMS) personnel were there, and his mother was unresponsive except for occasional slight moans. Review of a written statement by resident #574's son dated 8/05/24 revealed when he arrived at the hospital his mother was unresponsive, and the Emergency Department (ED) nurse informed him the facility reported to EMS that was her baseline status. The son indicated he immediately called the Casabella UM and while on speakerphone, he asked her who informed EMS that his mother's current condition was her baseline. The document revealed the Casabella UM replied, Well she's been like that for a few days. Resident #574's son noted that the facility's delay in care did not make his mother's unresponsive state a new baseline. The statement indicated resident #574 was unable to swallow any medication and she required two courses of rectally administered Lactulose before her mental status improved. Review of resident #574's hospital record revealed an Emergency Department Clinical Report dated 6/20/24. The document indicated on arrival at the ED, EMS personnel gave the history of the resident's illness as decreased responsiveness for about a week. The physician assessment revealed resident #574 responded only to painful stimulus and bloodwork collected in the ED revealed her ammonia level was 141 mcmol/L. The hospital record showed the resident required Lactulose enemas to treat her elevated ammonia level that was, .likely secondary to her not receiving her Lactulose. The ED Primary Assessment Document showed the resident's Glasgow Coma Scale score on arrival was 7 based on best motor response as withdrawal from pain, best verbal response as incomprehensible words, and no eye opening. The Glasgow Coma Scale (GCS) is used to measure a patient's level of consciousness by assessing eye, motor, and verbal responses. A GCS score of 8 or less indicates the possibility of a severe traumatic brain injury (retrieved on 8/07/24 from www.webmd.com/brain/what-is-the-glasgow-coma-scale). On 8/01/24 at 5:37 PM, in a telephone interview with a Pharmacy Customer Service Technician, she validated pharmacy records showed only six tablets Rifaximin 550 mg were dispensed for the resident, which was enough to last for three days. She stated the pharmacy sent an authorization form to the facility, according to the protocol for any high-cost medication, but it was never returned. The Pharmacy Customer Service Technician verified no additional Rifaximin 550 mg tablets were dispensed for resident #574. On 8/01/24 at 2:43 PM, APRN G was informed the facility's pharmacy Packing Slip Details showed the pharmacy dispensed only a 3-day supply of Rifaximin 550 mg for resident #574. After review of the Medication Administration Record (MAR), he was told the resident did not receive three doses of Lactulose between 6/17/24 and 6/19/24, and despite documentation to the contrary, the resident's lethargy and nausea during that period made it highly unlikely that she received all doses of Lactulose as ordered. APRN G stated he was never made aware the resident's Rifaximin was not available, and nurses did not mention the drug required authorization due to the cost. APRN G verified medications should be administered as ordered, and if that was not possible, nurses should have contacted him. He said, My expectation is I will be notified about all refusals or medications not available. I could have made an adjustment, probably increased Lactulose since that was already shown to be effective. When asked about the delayed response to the stat Ammonia lab result of 97 mcmol/L reported on 6/16/24, APRN G acknowledged he received the result from LPN B via text message. He reviewed his communication records and confirmed there was no evidence he responded to the message. When informed the order to increase resident #574's Lactulose from 30 ml to 45 ml to treat her elevated ammonia level was not received until after 7:00 PM on 6/17/24, APRN G said, Eighteen hours is too long to respond to a lab. In a follow up telephone interview with APRN G on 8/02/24 at 1:22 PM, he stated he reviewed his communication records again and discovered he was notified of resident #574's refusal to take her medication only once, on 6/18/24. APRN G added that he had no recollection or documentation of ordering the initial stat ammonia lab on 6/15/24. On 8/01/24 at 3:08 PM, Certified Nursing Assistant (CNA) D joined the interview with APRN G and confirmed she spoke to resident #574's son on the phone on the afternoon of 6/20/24, the resident's last day in the facility. CNA D recalled from the beginning of the day shift, the resident's eyes remained closed, even when she informed her that breakfast was there. She stated it almost seemed as if resident #574 was ignoring her, and she reported to the nurse that the resident seemed different. CNA D explained during change of shift report that morning, the off going night shift CNA told her resident #574 had not responded to her during the night shift either. CNA D said, She was conscious but not responding. Even therapy had that same concern. APRN G confirmed he was not notified of the significant decrease in resident #574's level of consciousness. He validated CNA D's description of resident #574 depicted classic symptoms of a high ammonia level. On 8/01/24 at 1:23 PM and 8/05/24 at 4:52 PM, in telephone interviews, LPN B stated she assumed care of resident #574 on the night shift of 6/15/24, after she received change of shift report from LPN A. She explained LPN A never mentioned any concerns regarding the resident's clinical status, so she was surprised when another night shift nurse approached her with a note from LPN A that indicated resident #574 required a stat ammonia lab test. LPN B explained she called LPN A, who told her that as she left the facility, she ran into APRN G in the parking lot, and he gave her that order. LPN A wrote it on a piece of paper, handed it to another nurse who was on her way into the building, and told her to give it to LPN B. LPN B expressed disbelief and said, Really! We're doing things like this now? She stated she arranged for the stat lab after she texted APRN G and received confirmation he needed the test to be done. LPN B verified she did not receive a response from APRN G after she texted him the lab result and she texted him again on 6/16/24 at 6:37 AM, regarding contacting the day shift nurse if he had any new orders for the resident. LPN B stated LPN A returned the next morning for the day shift and she relayed the lab result to her. When asked about her notes on the electronic MAR dated 6/14/24 and 6/15/24 regarding the resident's Rifaximin that was not available, LPN B stated she wrote the notes after she thoroughly searched the medication room and the medication cart and realized it was not there. LPN B said, When I gave report to [LPN A] the next morning, I mentioned that the medicine was not there, and she was like a deer in the headlights.I told [LPN A] that when [APRN G] calls they need to get an alternative. I told her it's funny that some people are saying they give it, but it isn't here. LPN B expressed frustration that some nurses habitually documented they administered medications that were not given and said, No wonder her numbers are going high. On 8/02/24 at 12:26 PM, the Casabella UM described resident #574's baseline mentation as alert, oriented and chatty. The UM stated she was never made aware the resident's Rifaximin was not dispensed by the pharmacy beyond the initial 3-day supply. She acknowledged the resident's daughter informed her that her mother's ammonia level was high, she was not doing well, and she probably did not receive the correct dose of Lactulose. The UM verified resident #574's stat ammonia lab result on 6/16/24 was not addressed timely, and her expectation was nurses would have contacted her or the Director of Nursing if APRN G did not respond. The UM validated on 6/20/24, resident #574's son called her as he became concerned after his conversation with CNA D. The UM said, I went to check on her and she was drowsy, slurring, not sitting. I was concerned. I called [APRN G] on the phone and he said go ahead and send her out. The UM stated she could not explain why nurses' documentation did not show the decline in the resident's condition reported by CNAs and therapy staff, and she was unsure if medications were given as ordered. In an undated, written Case Study document, the facility's co-Medical Director wrote, It is critical for patients to adhere to their prescribed medication regimen. The Case Study validated the consistent failure to administer essential medications like Lactulose posed a significant risk to patients' health. The co-Medical Director noted the importance of adherence to both Rifaximin and Lactulose as a comprehensive treatment plan for liver disease. Review of the facility's policy and procedure Change in Resident Condition or Status - Resident Rights revised in June 2023, revealed the facility would notify the resident, the attending physician, and his/her representative of changes in the resident's medical or mental condition that included significant changes and the need to alter treatment. The document indicated a significant change of condition included a major decline that would not resolve itself without intervention, impacted more than one area of the resident's health status, and required interdisciplinary review and/or revision of the care plan. The policy read, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Facility Assessment, dated 3/22/24, revealed the facility would accept residents with common diseases and conditions that included digestive system disorders such as cirrhosis. The document indicated the facility would offer care and services to manage medical conditions by providing assessment, early identification of problems/deterioration, and management of medical symptoms. The Facility Assessment revealed nurses would administer medications needed by residents.

Based on interview and record review, the facility failed to provide pharmaceutical services, consistent with professional standards of practice, to ensure proper acquisition and administration of routine medication; and failed to appropriately dispose of discontinued medication to promote medication safety, for 1 of 2 residents reviewed for hospitalization , out of a total sample of 43 residents, (#547). Findings: Review of the medical record revealed resident #574, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder) and liver cirrhosis. The resident was discharged to the hospital on 6/20/24. According to the American College of Gastroenterology, Cirrhosis of the liver refers to scarring of the liver which results in abnormal liver function. One of the symptoms associated with cirrhosis is hepatic encephalopathy caused by decreased filtration of toxins from the blood. The resulting buildup of poisons such as ammonia in the brain can lead to confusion, excess drowsiness, slurred speech, and coma. Medications prescribed to treat hepatic encephalopathy include Lactulose and/or certain types of oral antibiotics (retrieved on 8/08/24 from www.gi.org/topics/liver-cirrhosis/). Review of the Order Summary Report revealed resident #574 had physician orders dated 6/09/24 for Lactulose 10 grams/15 milliliter (gm/ml), give 30 ml four times daily for hyperammonia, and Rifaximin 550 milligrams (mg), give one tablet every 12 hours for hyperammonia. Review of resident #574's medical record revealed she had a care plan for antibiotic therapy related to liver disease, initiated on 6/11/24. The goal included the resident would receive the antibiotic (Rifaximin) as ordered. The interventions instructed nurses to administer antibiotic medications as ordered by the physician. Review of resident #574's Medication Administration Record (MAR) for June 2024 revealed Rifaximin 500 mg was scheduled for administration at 9:00 AM and 9:00 PM every day. The medication start date was noted as 6/10/24 at 9:00 AM. The MAR showed the drug was administered as ordered except for doses on 9:00 PM on 6/14/24, 6/15/24, 6/16/24; 9:00 AM on 6/17/24; and 9:00 PM on 6/18/24. Review of electronic Medication Administration Record (eMAR) notes revealed the following: On 6/14/24 at 10:25 PM, Licensed Practical Nurse (LPN) B did not administer resident #574's scheduled dose of Rifaximin 550 mg. She noted the medication was on order. On 6/15/24 at 10:25 PM, resident #574's Rifaximin was still not available. LPN B wrote that the drug remained on order, and the facility received a high-cost medication notice from the pharmacy. On 6/16/24 at 8:16 PM, LPN F noted resident #574's Rifaximin was still on order. On 6/17/24 at 8:23 AM, LPN E indicated she did not administer resident #574's Rifaximin. The note read, Medication on order, awaiting pharmacy arrival. On 6/18/24 at 10:15 PM, LPN H noted resident #574 refused all her scheduled medications, including Rifaximin 550 mg. On 8/01/24 at 1:23 PM and 8/05/24 at 4:52 PM, in telephone interviews, LPN B verified she was unable to administer resident #574's Rifaximin 550 mg doses on 6/14/24 and 6/15/24 as the medication was not available in the facility. LPN B confirmed she thoroughly searched the medication cart and the medication room and did not find it. She stated on the morning of 6/16/24 she reported off to LPN A at the end of her shift and informed her she needed to contact the prescriber to request an alternative drug. LPN B recalled LPN A appeared surprised when she told her it was strange that some nurses documented they gave a medication the facility did not have. On 8/01/24 at 5:37 PM, in a telephone interview with a Pharmacy Customer Service Technician, she validated pharmacy records showed a total of six tablets of Rifaximin 550 mg were dispensed for the resident, which was enough to last for three days. The Pharmacy Customer Service Technician explained the drug was categorized as a high-cost medication that required special authorization because a 14-day supply cost $1499.00. She stated the pharmacy sent an authorization form to the facility, but it had not been returned, so no additional Rifaximin 550 mg tablets were dispensed for resident #574. On 8/01/24 at 5:42 PM, in a telephone interview, a facility Pharmacist confirmed the pharmacy dispensed six Rifaximin tablets, a 3-day supply, to ensure the resident's immediate admission medication needs were met. He explained Rifaximin was an expensive drug that required authorization prior to routine dispensing and refilling. The Pharmacist stated the process was the pharmacy would send an authorization form, and the Director of Nursing would sign and return it. He reviewed the pharmacy records and stated the authorization request was sent multiple times in attempts to avoid a delay in sending resident #574's medication. An email from the facility's pharmacy, dated 8/01/24 at 9:12 PM, provided confirmation that on 6/10/24, the pharmacy sent a 3-day supply of Rifaximin 550 mg for resident #574, according to protocol for the first dispensing of a high-cost drug. The document indicated on that date, a high-cost form was printed and put in the tote, faxed to the facility, and also sent electronically. The timeline revealed the pharmacy repeated the procedures to obtain authorization for the drug on 6/14/24, when the 3-day supply was used up, and again on 6/17/24. The pharmacy's final attempt to obtain authorization was on 6/19/24, when a representative called the facility but did not get a response. Review of the MAR revealed after the initial 3-day supply of Rifaximin was completed, six nurses, LPNs A, E, F, I, J, and K, signed the document over an 8-day period to validate they had administered the drug. On 8/02/24 at 9:58 AM, the Montecito Unit Manager (UM) stated the facility initiated an investigation within the last 24 hours, after State Survey Agency staff identified the concern related to the availability of resident #574's Rifaximin. The Montecito UM said, During our investigation, some of the nurses informed us that they were using the medication that was supposed to be sent back [to the pharmacy] that belonged to another resident. She explained the medication was discontinued on 6/03/24 for other resident. The Montecito UM validated nurses borrowing medication from other residents' supplies was just as concerning as nurses documenting they gave a medication that was never dispensed by the pharmacy. She explained the facility's clinical management team reviewed the facility's 24-hour report in daily meetings and concerns related to resident #574's missed doses of Rifaximin and unavailability of the drug were never identified or addressed by nurse management. On 8/02/24 at 11:12 AM, LPN A was informed the MAR showed she administered resident #547's Rifaximin 550 mg four times, although the drug was not available for the resident. She stated she administered the medication from another resident's card. LPN A explained the medication had been discontinued and the card was in the medication room in a bin designated for discontinued medications that were to be returned to the pharmacy. LPN A said, I took medication from the patient who did not need it anymore. I know I should not be borrowing. She explained she retrieved the card of Rifaximin from the medication room and returned it to the other resident's section of the medication cart. LPN A stated discontinued medications were usually returned to the pharmacy within 24 hours and she could not explain why the card of Rifaximin would have been in the bin in the medication room from 6/03/24 to 6/14/24. In addition, LPN A could not explain how other nurses would have known to retrieve Rifaximin for resident #547 from another resident's section of the medication cart. On 8/02/24 at 11:40 AM, the Assistant Director of Nursing stated during an audit of all medication carts last night, the facility discovered a card of Rifaximin 550 mg with 17 pills. She confirmed the drug had been discontinued approximately two months ago, and the card should have been removed from the cart promptly and returned to the pharmacy in a timely fashion to prevent errors. Review of the facility's policy and procedure for Medication Storage and Labeling, revised in January 2024, read, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The document revealed discontinued drugs should be returned to the dispensing pharmacy or destroyed. On 8/02/24 at 12:16 PM, in a telephone interview, LPN I stated resident #574's Rifaximin 550 mg was not available, .so to do a good [medication] pass I borrowed the medication. I don't remember on how many occasions. She acknowledged the accepted standard of practice was to note the medication was not administered and notify the physician and pharmacy. On 8/02/24 at 12:26 PM, the Casabella UM stated she was nurses never informed her of any concerns related to obtaining resident #574's Rifaximin from the pharmacy. She confirmed nurses should not be borrowing medications from other residents. The Casabella UM said, I cannot speak to what the nurses were doing. I am not sure if the [medication] was given. On 8/02/24 at 1:08 PM, LPN E stated she typically would not document that she gave a medication if she did not do so, and she definitely would not borrow medications from one resident for another. She was not able to explain how or if she administered resident #547's Rifaximin 550 mg on 6/13/24 at 9:00 AM, although it had not been dispensed by the pharmacy after the initial supply had run out. Review of the facility's policy and procedure for Medication Administration, revised in January 2024, described medications would be ordered and administered safely and as prescribed. The document read, Medications ordered for a particular resident may not be administered to another resident.

Based on observation, interview and a palatability test, the facility failed to serve palatable food at the appropriate temperature to residents in two of five halls, (300 and 600), in the facility. Findings: On the Recertification survey from 7/29/24 to 8/01/24 several residents on the 300 and 600 halls complained about cold food to the surveyors: On 7/29/24 at 11:06 AM, resident #105 stated the food was often cold, especially the eggs. On 7/29/24 at 12:38 PM, resident #104 stated the meals were sometimes late, which could cause food to be cold. On 7/30/24 at 11:00 AM, resident #79 described he often had cold food during his meals. On 7/30/24 at 11:44 AM, resident #37 complained breakfast was consistently cold and said other residents complained about the cold food too. Per the meal times posted at each nurse's station, the dining room and contained in the admission packet, the first lunch tray was scheduled to be sent out of the kitchen at 11:45 AM to the first hall to be served. The 600 hall was the last hall in the facility to be served meal trays out of the five dining areas. The document indicated lunch trays would be delivered at 12:45 PM for those residents residing on the 600 hall. During observation of the steam table and tray service plating in the kitchen on 8/01/24 at 12:46 PM, the hot meal items on the lunch trays for the 600 hall were covered with a clear plastic cover, instead of an insulated dome lid as other previous trays had. The hot meal items posted for lunch per the menu handout provided to residents were listed as beef tacos, refried beans, and yellow rice. On 8/01/24 at 12:58 PM, lunch trays arrived to the 600 hall via a non-insulated, non-heated, metal cart. At 1:12 PM, the last tray was delivered from the 600 hall cart. A previously requested test tray from the same cart was then sampled by two surveyors. The plate was covered by a clear acrylic lid and revealed yellow rice, refried beans and two soft tacos with ground meat, lettuce and cheese. The ground meat in the soft taco and the refried beans were lukewarm and not palatable to the two surveyors. In conversations with the Chef and Certified Dietary Manager (CDM) on 8/01/24 at 1:20 PM, and 1:28 PM, the Chef explained the steam table temperatures were taken 30 minutes before they plated the first meal at 11:15 AM. The Chef shared the documented temperature log for the day's lunch which showed the taco meat was 170 degrees Fahrenheit (F), and the refried beans were 168 degrees F before plating started. The Chef confirmed he was aware of several grievances about hot food being served cold at the facility. The CDM confirmed the food temperatures were measured 30 minutes before the first tray was even served and said the temperature of the hot food met food temperature standards at the time the temperatures were taken. The Chef then validated the facility was missing 25-30 insulated plate lids to cover the hot food delivered to the 600 hall, and confirmed the facility did not utilize a thermal food transport system with insulated transport carts to maintain the hot food temperatures throughout the facility meal service.

Based on observation, interviews, and record review, the facility failed to thoroughly investigate potential allegation of neglect related to elopement for 1 of 8 sampled residents, (#1). The facility's failure to investigate and determine the root cause of the elopement, prevented them from implementing interventions and safeguards to prevent further elopements. On 4/8/23 at 11 AM, resident #1 walked past the facility's receptionist and exited through the facility's front doors. The staff were unaware the resident had exited the facility, unsupervised until another resident observed the resident outside through his bedroom window and alerted staff. Licensed Practical Nurse (LPN) A and LPN B ran outside and caught up with the resident after he had ambulated a total of 600 feet with his rolling walker off the facility grounds and onto a sidewalk, parallel to a moderately traveled road and brought him back. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, drowned in a retention pond or been hit by a car. The facility's failure to ensure a thorough investigation was completed resulted in Immediate Jeopardy starting on 4/8/22. The Immediate Jeopardy was removed on 7/18/23, after verification of the facility's Immediate Jeopardy removal plan. The scope and severity of the deficiency was decreased to a D, no actual harm, with penitential for more than minimal harm, that is not Immediate Jeopardy. Findings: Cross Reference F689, F835 Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing Admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. Review of monthly Nursing Summaries from June 2022 to November 2022, noted resident #1 was not an elopement risk. Review of a progress note dated 12/9/22 by the Director of Nursing, (DON) indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, and books. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed toward the resident. LPN A said when she caught up to the resident, he was near the end of the sidewalk. He was appropriately dressed, wore shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. LPN A stated she wrote a statement and gave it to LPN B. She said she spoke to either the DON or Assistant DON (ADON) by telephone, not in person. She indicated she documented the incident in Risk form which she thought was part of the clinical record. On 7/16/23 at 12:55 PM, the facility's Receptionist recalled a resident had left the building and stood by the post of the facility's entrance. She said she did not see him until he was out by the door as there was a stretcher going through the door at the same time. She indicated the nurse went outside to bring the resident back. On 7/16/23 at 1:33 PM, the Receptionist clarified her earlier interview and said she saw resident #1 outside the sliding glass door near a pillar. She explained she did not go outside to bring the resident back but it took her a few minutes to ask the Concierge to go get him because she could not leave the reception desk. She noted, I guess I prioritized the reception desk. She indicated the Concierge came back and told her LPN A had seen resident #1 outside and went to get him. On 7/17/23 at 11:33 AM, the Receptionist again clarified her previous statements. She said she saw a resident in a red shirt with a rolling walker but did not realize it was resident #1. She said she was very busy and there were many visitors near the reception desk. She reported she did not see the resident leave or see him outside near the pillar. As long as he was ok, I don't know where they found him. On 4/16/23 at 3:45 PM, during an interview, the DON said resident #1 exited the facility on 4/8/23 between 11 AM and 11:15 AM. She stated the facility did not consider this event as an elopement because the staff had eyes on him the entire time. Contrary to the Receptionist's statement, the DON explained resident #1 was in the lobby and the receptionist saw him. She noted there was a transport company that was taking a large resident on a stretcher and resident #1 walked beside the stretcher undetected by the Receptionist. She stated at the same time, the Concierge was going outside to retrieve a clipboard from her car and saw resident #1 walk through the exit doors. On her way back from her car, the Concierge saw the resident near the first handicap parking spot. She explained LPN A saw resident #1 near the stop sign and the first handicap spot in the parking lot. The DON looked through the conference room window and pointed to the first handicap spot and stop sign at the end of a circular driveway underneath the portico. The DON repeated that was the area where LPN A and LPN B found resident #1. The DON stated she was out of town during the incident, but she received a phone call between 12 PM and 1 PM. She noted the ADON started the investigation, obtained witness statements and created a timeline of events. She explained the the incident did not get documented in either the Incident Log or the Reportable Log as they did not classify the incident as an elopement because we had eyes on him the whole time. The DON acknowledged hazards off of the facility grounds such as the street and retention ponds but she said the resident remained in or near the facility parking lot, no hazards there. She indicated a re-enactment of the events was not done. On 7/17/23 at 1 PM, the DON provided a witness statement from the Concierge that noted she arrived for her shift at 11 AM and realized she left her clipboard in her car. She went out to her her car and observed a gentleman with a walker headed to the parking lot. I said excuse me, he didn't respond and I continued to my car. I came back up the sidewalk, passing the same gentleman, at that time he made it to the handicap parking spot. I approached the receptionist. I could hear her on the phone, and she stated a gentleman outside so I exited the building immediately to find there were two nurses and the gentleman assisting to bring him back inside. The DON did not provide an explanation as to why the Concierge did not intervene when she saw resident #1 exit the facility. At 1:14 PM, the ADON joined the meeting and noted they did not go to resident #3's room during their investigation to see out the window. The ADON said they did not interview resident #3 but added we probably should have. The ADON stated the information they gathered showed resident #1 was found by the first handicap parking spot, although the nurses' interviews reflected differently. The DON did not provide an answer when asked how staff had eyes on the resident at all times when he was outside and both the Concierge and the Receptionist were inside. The DON and ADON verified the witness statements did not reflect a timeline with locations and sequence of events. On 7/17/23 at 1:25 PM, the DON and ADON were accompanied to resident #3's room. When they looked out his window, they verified they could not see the stop sign or the first handicap parking spot. Shortly thereafter they were accompanied outside to the front of the facility near the Stop sign and the first handicap parking spot. They validated they could not see resident #3's bedroom windows and it would not have been possible for LPN A to have seen resident #1 at the stop sign near the first handicap parking spot. They were informed the resident was found off facility property. The DON stated she was not aware. The DON and ADON were shown the spot where LPN A and LPN B found the resident, near the end of the paved sidewalk. The DON acknowledge the hazards such as the retention ponds across the street, the wooded area, and the vehicular traffic. The DON confirmed the investigation was not thorough or effective. On 7/17/23 at 2:38 PM, the Regional Nurse Consultant, (RNC) stated she was told resident #1 was in the line of sight of staff at all times after he exited the facility. She indicated she reviewed the witness statement yesterday. She said the facility policy did not define elopement but added that if a resident was somewhere he or she should not be, it could be an unsafe situation. She was informed the facility had not submitted either an Immediate or 5 Day report to the Agency for Health Care Administration. The RNC indicated it was up to the Administrator and DON's discretion to submit an Immediate and 5 Day report. She conveyed, In light of new findings we have to continue the investigation. On 7/17/23 at 6:47 PM, during a telephone interview, LPN B recalled on Saturday, of the Easter Weekend, 4/8/23, resident #1 eloped from the facility prior to 12 PM. She remembered resident #3 informed LPN A that resident #1 was outside of the facility when he looked out his window. LPN B said she followed LPN A and they both exited the facility through the emergency fire exit door. She stated they caught up with the resident and he was near the end of the sidewalk, close to a wooded area. She noted the resident was tired because he was not used to walking that far in the heat. She recalled the Concierge was in the lobby when they returned with the resident, not outside. LPN B remembered the Concierge and the Receptionist suggested the resident may have exited along side the transport company that was taking another resident out. LPN B said she wrote a witness statement and spoke to the DON or ADON on the phone 2 or 3 times. She also spoke with the facility Administrator who was now the Regional [NAME] President of Operations and the RNC by 3 way call. She stated the Regional [NAME] President and the RNC did not want her to document the elopement incident in the clinical record. She explained they wanted her to include in her witness statement that staff had eyes on the resident the entire time and that he was alert and oriented. She noted the resident was confused and told them she was not comfortable with this. She added the facility management never wanted staff to put a note in the medical record of any incidents including falls. LPN B provided a screen shot of a text she received from the ADON. The image reflected it was sent by the ADON on 4/8/23, instructing LPN B, Don't document anything in PCC (the facility electronic medical record) regarding [resident #1] until I get it cleared. On 7/18/23 at 1:20 PM, during an interview with the DON and ADON, the ADON stated she had instructed the Weekend Supervisor to obtain witness statements from the staff involved in the elopement incident. She said she spoke with LPN B on her personal phone and took a verbal statement from the Receptionist. The ADON stated she did not communicate with the staff involved by email or texts. The DON and ADON were informed the elopement incident was not documented in the clinical record. The ADON responded and said she should have instructed the staff to make sure it was documented. She added that education was provided during orientation, to ensure incidents are documented in the progress notes. The ADON was shown the screen shot of the text she sent to LPN B that instructed her not to document the elopement in the progress notes. The ADON acknowledged she sent the text to LPN B and instructed LPN B not to make a nurse/incident note in the medical record. The ADON explained she had communicated with the Regional [NAME] President and the RNC at the time and was directed not to document the elopement in the medical record unless it was cleared. Neither the DON or ADON explained how a nurse obtained clearance to document an incident in the clinical record. Review of the facility's immediate actions to remove Immediate Jeopardy were verified by the survey team. 1. The facility conducted an ad hoc QA&A meeting on 7/17/23 which included the facility Administrator, DON, Medical Director via telephone, and additional staff members. No additional recommendations were made at that time. 2. Root Cause Analysis completed 3. Incident reports reviewed from the last 30 days to ensure proper investigations were completed. No further concerns noted. 4. Education on 7/17/23 through 7/18/23 related to the facility elopement policy and timely completion of a comprehensive investigation by the Regional Nurse Consultant, DON and Administrator. Education sign in sheets noted 187 staff received education. 5. Facility Administrator and Director of Nursing educated on 7/18/23 related to position duties- including risk management, facility elopement policy, timely completion of a comprehensive investigation, QAPI/QAA implementation process and reporting of incidents/accidents process by the Regional [NAME] President of Operations and Regional Nurse Consultant. On 7/18/23 the facility's ad hoc QA&A meeting attendance sign in sheet was reviewed which included the Administrative Staff and the Medical Director who attended by phone. The facility provide an Accident Investigation Report which will be used as guide to include steps for interviews, investigation and reporting. There were forms for staff witness statements and an elopement decision tree. The facility provided sign in sheets for staff education on Abuse, Neglect, Exploitation and Elopement. The sign in sheets reflected all 187 facility staff received education including the Administrator, DON. The Administrator and DON received further education on Risk Management and the completion of a comprehensive investigation. Fifteen staff were interviewed from various disciplines that included Therapy, CNAs, Nursing, Activities and Dietary. The staff spoke about their recent education on elopement, abuse, neglect and exploitation and that they were mandatory reporters. The staff spoke about and indicated understanding and competency with elopement drills.

Based on record review, and interviews, the facility failed to prevent a vulnerable, cognitively impaired resident from exiting the facility, unsupervised and failed to provide adequate supervision and secure environment for 1 of 8 sampled residents reviewed for elopement, (#1). On 4/8/23 at 11 AM, resident #1 walked past the facility's receptionist and exited through the facility's front doors. The staff were unaware the resident had exited the facility, unsupervised until another resident observed the resident outside through his bedroom window and alerted staff. Licensed Practical Nurse (LPN) A and LPN B ran outside and caught up with the resident after he had ambulated a total of 600 feet with his rolling walker off the facility grounds and onto a sidewalk, parallel to a moderately traveled road and brought him back. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, drowned in a retention pond or been hit by a car. The facility's failure to provide a secure environment and adequate level of supervision, resulted in Immediate Jeopardy starting on 4/8/23. The Immediate Jeopardy was removed on 7/18/23 and scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Finding: Cross Reference F610, F835 Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing Admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of monthly Nursing Summaries from June 2022 to November 2022, noted resident #1 was not an elopement risk. Review of the nurse's progress note dated 12/6/23 indicated the resident was observed smoking a cigarette in his room. The nurse noted the resident was instructed to extinguish the cigarette and was informed the facility was a non-smoking facility. The nurse informed the Hospice provider and received new orders for nicotine patches. Three days later on 12/9/22, the Director of Nursing, (DON) documented a progress note that indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, book, etc. A nursing progress note dated 12/10/22 indicated the County Sheriff was at the facility for a 911 telephone call made by the resident claiming he was abducted. The resident told a Certified Nursing Assistant, (CNA), he had called his girlfriend. He later clarified his girlfriend was abducted, and he wanted 911 to find her. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors until he eloped from the facility on 4/8/23. On 12/20/22, resident #1 was seen by a Psychiatric Mental Health Nurse Practitioner, who noted the resident was taking antidepressant medication, Trazadone, 100 mg at bedtime, antianxiety medication, Lorazepam, 1 mg every 8 hours for anxiety and another antidepressant, Duloxetine 60 mg daily for depression and anxiety related to depression. The Practitioner asked the resident if he had any plans to elope from the facility and the resident responded, I tried to leave once but they caught up with me. I am not, can I do that again. I just want to wait and see what happens. The resident was seen again on 12/23/22 for reports of being unstable, requiring psychiatric assessment. The Practitioner reported the resident had paranoid delusions, he reports that people want to harm him and/or trying to kill him. He reported seeing a person standing in the doorway of his room, holding a gun and seeing a helicopter land on the roof of the building. Review of the monthly Nursing Summary dated 12/30/22 noted the resident 's cognition as clinically stable and noted he was not an elopement risk despite him voicing exit seeking statements and paranoid delusions. On 1/14/23, a nursing progress note documented the resident telephoned 911 and a Law Enforcement Officer came to the facility and spoke to the resident. The resident told the Officer he wanted to get out of here and go home to the place by the Walmart. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 10 out of 15 that indicated his cognition was moderately impaired. The assessment noted he did not exhibit any wandering behaviors and he required limited assistance of 1 staff person for transfers, walking and locomotion. On 7/16/23 at 1:50 PM, resident #3 explained a few months ago, he was in his room and when he looked out his window, he saw resident #1 outside, walking away from the facility. He said he had seen resident #1 in the facility and thought, what in the world is he (resident #1) doing out there? Resident #3 said. He said he quickly found a nurse and reported it to her. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 1:21 PM, resident #1's exit route from the facility was retraced with LPN A. The resident would have walked past the receptionist's desk and walked through the inner glass sliding doors. The inner sliding doors were controlled by the receptionist, who was responsible for allowing visitors in and out of the facility. The resident then exited by the outer doors which opened and closed automatically. The resident would have stayed to the right of the facility and followed the sidewalk adjacent to the curved driveway that ran under the portico. The resident walked on the sidewalk that ran parallel to both the parking lot and the facility and then turned left, through the parking lot to reach the sidewalk that ran parallel to the road, a total of 600 feet. LPN A pointed to the spot she found the resident and noted he faced the ponds across the street, and looked confused. There were two retention ponds noted across the street full of water and to the right, was a hospital's emergency entrance. On 7/16/23 at 12:55 PM, the facility's receptionist recalled a resident had left the building and stood by the post of the facility's entrance. She said she did not see him until he was out by the door as there was a stretcher going through the door at the same time. She indicated the nurse went outside to bring the resident back. On 7/16/23 at 1:33 PM, the receptionist clarified her earlier interview and said she saw resident #1 outside the sliding glass door near a pillar. She explained she did not go outside to bring the resident back but it took her a few minutes to ask the Concierge to go get him because she could not leave the reception desk. She noted, I guess I prioritized the reception desk rather than the resident. She indicated the Concierge came back and told her LPN A had seen resident #1 outside and went to get him. On 7/17/23 at 11:33 AM, along with the Director of Nursing, (DON) the receptionist again clarified her previous statements. She said she saw a resident in a red shirt with a rolling walker but did not realize it was resident #1. She said she was very busy and there were many visitors near the reception desk. She explained she was responsible for controlling the front door, allowing people in and out of the building. She reported she did not see the resident outside near the pillar. As long as he was ok, I don't know where they found him. The DON stated it would be expected the receptionist go outside to investigate and/or retrieve the resident. On 7/16/23 at 3:45 PM, the DON spoke about the incident and the facility's investigation. She said at the time the receptionist observed resident #1, a larger male resident was being transported on a stretcher, out of the facility. She indicated resident #1 walked beside the stretcher and the receptionist did not see him exit the doors. She said at the same time, the Concierge was going to her car to retrieve something.The resident was walking with his walker as the Concierge exited the facility. She explained the Concierge tried to get the resident #1's attention but the resident did not answer. The DON did not explain why the Concierge did not intervene as the resident walked out of the facility. When the Concierge walked back towards the facility entrance, she saw resident #1 on the sidewalk near the stop sign by the first handicap parking spot. She stated this was at the same time LPN A, came outside with another nurse and escorted the resident back into the facility. The DON noted the incident occurred on Saturday, 4/8/23, 1 day before Easter Sunday, between 11 AM and 11:15 AM. She said she was out of town, but the Assistant Director of Nursing made sure all the witness statement were taken and the facility created a timeline based on the statements. When informed that resident #1's elopement was not documented in his medical record, the DON explained they did not consider it as an incident that needed to be reported, so it was not recorded on either the Incident Log or Reportable Log. The DON added, we felt like we had eyes him the entire time. She acknowledged there were hazards such as the retention ponds and street traffic, but noted the resident was near the facility's parking lot. She indicated she was responsible for the investigation, but the ADON handled this investigation. The DON said that a re-enactment of the elopement incident was not done. On 7/17/23 at 6:47 PM, LPN B stated she was familiar with resident #1 and frequently saw him in the hallways. She said she tried to engage him in conversation but his cognition varied from day to day. Some days you could talk to him and have a conversation, on other days he would be confused, looking for his parents or children. She remembered on Saturday of Easter Weekend, 4/8/23, resident #3 alerted LPN A to look out his bedroom window. She said LPN A saw resident #1 outside the facility on the sidewalk, near the road. LPN B explained she saw LPN A running toward the nursing station, saying something like he was outside. LPN B stated she followed LPN A and both nurses exited the emergency fire exit door at the end of the hallway. She noted resident #1 was past the parking lot, and they caught up with him on the sidewalk. She reported he was across from the hospital's emergency entrance. She indicated he was tired, and not used to walking that far in the heat. LPN B recalled it was hot because she was still sweating when she got back inside. She said they had the resident sit on the seat of the rolling walker and they wheeled him back to the front entrance of the facility. LPN B recalled the Concierge was in the lobby area when they brought the resident back. She remembered the receptionist and the Concierge suggested resident #1 may have exited when the transport company took another resident out of the facility. She explained she assessed the resident, found no injures and his vital signs were in range. He was put back to bed because he was tired, and he slept. She said resident #1 mentioned he was going to a gas station and joked that he had not had a cigarette in a long time and that he really needed one. Review of the facility's immediate actions included the following that were verified by the survey team. 1. Review of Resident #1's clinical record revealed no further incidents up until discharge from the facility on 5/17/23. 2. On 7/17/23 current facility residents had elopement risk screens completed. No residents were newly identified to be at risk for elopement. 3. Elopement Drills conducted on 7/17/23 and 7/18/23 with an established schedule to continue weekly drills until substantial compliance was determined by the QA committee. 4. Education on 7/17/23 through 7/18/23 related to the facility's elopement policy. Education provided by Regional Nurse Consultant, DON and Administrator. The staff educated comprised of 187 total facility employees 5. Education on 7/18/23 related to allowing visitors entrance and exit by facility staff members only via manual access button located behind the receptionist's desk. Three of 3 front desk staff received the education. On 7/18/18, the staff sign in sheets for elopement, abuse, neglect, exploitation and the required immediate reporting of incidents training revealed all 187 facility employees had received the education. The front desk staff education was reviewed that included ensuring visitors entry/exit to the facilty. The facility provided audits of elopement drills that had been conducted. Fifteen staff interviews were conducted from 7/17/23 to 7/18/23 that included CNAs, Dietary, Activity, Nursing and Therapy staff. The staff spoke about the recent education on elopement, abuse, neglect and exportation. The staff demonstrated their understanding of the education and their role in the prevention of elopement. The staff noted they had participated in elopement drills. The facility provide copies of the quiz/test that demonstrated the staff's understanding of the education.

Based on observation, record review, and interviews, the facility failed to effectively provide supervision and secure environment to prevent elopement and failed to conduct thorough investigation to prevent further elopement for 1 of 8 sampled residents, (#1). On 4/8/23 at 11 AM, resident #1 walked past the facility's receptionist and exited through the facility's front doors. The staff were unaware the resident had exited the facility, unsupervised until another resident observed the resident outside through his bedroom window and alerted staff. Licensed Practical Nurse (LPN) A and LPN B ran outside and caught up with the resident after he had ambulated a total of 600 feet with his rolling walker off the facility grounds and onto a sidewalk, parallel to a moderately traveled road and brought him back. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, drowned in a retention pond or been hit by a car. The facility's Administration failed to ensure resident #1 received adequate supervision to prevent elopement and failed to collect factual evidence to ensure a complete and thorough elopement investigation was performed. These failures impeded the Administration's implementation of safeguards to prevent further elopements and resulted in Immediate Jeopardy that started on 4/8/23. The Immediate Jeopardy was removed on 7/18/23, after verification of the facility's Immediate Jeopardy removal plan. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. Findings: Cross Reference F610, F689 Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing Admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of a progress note dated 12/9/22 by the Director of Nursing, (DON) indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, and books. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors. On 7/16/23 at 1:50 PM, resident #3 explained a few months ago, he was in his room and when he looked out his window, he saw resident #1 outside, walking away from the facility. He said he had seen resident #1 in the facility and thought, what in the world is he (resident #1) doing out there? Resident #3 said. He said he quickly found a nurse and reported it to her. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 1:33 PM, the facility's receptionist recalled a resident had left the building. She said she did not see him as there was a stretcher going through the door at the same time. She explained she did not go outside to bring the resident back because she could not leave the reception desk. She noted, I guess I prioritized the reception desk rather than the resident. She said she was very busy and there were many visitors near the reception desk. She explained she was responsible for controlling the front door, allowing people in and out of the building. As long as he was ok, I don't know where they found him. On 7/16/23 at 3:45 PM, the DON spoke about the incident and the facility's investigation. She said at the time the receptionist observed resident #1, a larger male resident was being transported on a stretcher, out of the facility. She indicated resident #1 walked beside the stretcher and the receptionist did not see him exit the doors. She said at the same time, the Concierge was going to her car to retrieve something.The resident was walking with his walker as the Concierge exited the facility. She explained the Concierge tried to get resident #1's attention but the resident did not answer. When the Concierge was walking back towards the facility entrance, she saw resident #1 on the sidewalk near the stop sign and the first handicap parking spot. The DON did not explain why the Concierge did not intervene as the resident walked out of the facility. The DON noted the incident occurred on Saturday, 4/8/23, of the Easter weekend between 11 AM and 11:15 AM. She said she was out of town, but the Assistant Director of Nursing made sure all the witness statement were taken and the facility created a timeline based on the statements. When informed that resident #1's elopement was not documented in his clinical record, the DON explained they did not consider it as an incident that needed to be reported, so it was not recorded on either the Incident Log or Reportable Log. The DON added, we felt like we had eyes on him the entire time. The DON did not provide an answer when asked how staff had eyes on the resident at all times when he was outside and both the Concierge and the Receptionist were inside. She acknowledged the resident would have encountered hazards such as retention ponds and street traffic while he was outside but he was only in the parking lot. She indicated a re-enactment of the elopement was not done. On 7/17/23 at 1:14 PM, during an interview with the DON, the Assistant DON, (ADON) joined the meeting and stated they did not go to resident #3's room during their investigation to see out the window. The ADON said they did not interview resident #3 but added we probably should have. Contrary to LPN A's statement that the resident was located at the end of the sidewalk close to a wooded area, the ADON stated from the information they gathered, resident #1 was found by the first handicap parking spot. The DON and ADON verified the witness statements did not reflect a timeline with locations and sequence of events. On 7/17/23 at 1:25 PM, the DON and ADON were accompanied to resident #3's room. When they looked out his window, they verified they could not see the stop sign or the first handicap parking spot. Shortly thereafter they were accompanied outside to the front of the facility near the Stop sign and the first handicap parking spot. They validated they could not see resident #3's bedroom windows and it would not have been possible for LPN A to have seen resident #1 at the stop sign near the first handicap parking spot to have eyes on him at all times. They were informed the resident was found off facility property. The DON stated she was not aware. The DON and ADON were shown the spot where LPN A and LPN B found the resident, near the end of the paved sidewalk. The DON acknowledge the hazards such as the retention ponds across the street, the wooded area, and the vehicular traffic. The DON confirmed the investigation was not thorough or effective. On 7/17/23 at 2:38 PM, the Regional Nurse Consultant, (RNC) stated she was told resident #1 was in the line of sight of staff at all times after he exited the facility. She indicated she reviewed the witness statement yesterday. She said the facility policy did not define elopement but added that if a resident was somewhere he or she should not be, it could be an unsafe situation. She was informed the facility had not submitted either an Immediate or 5 Day report to the Agency for Health Care Administration. The RNC indicated it was up to the Administrator and DON's discretion to submit an Immediate and 5 Day report. She conveyed, In light of new findings we have to continue the investigation. On 7/17/23 at 6:47 PM, during a telephone interview, LPN B recalled on Saturday, of the Easter Weekend, 4/8/23, resident #1 eloped from the facility prior to 12 PM. She remembered resident #3 informed LPN A that resident #1 was outside of the facility when he looked out his window. LPN B said she followed LPN A and they both exited the facility through the emergency fire exit door. She stated they caught up with the resident and he was near the end of the sidewalk, close to a wooded area. She noted the resident was tired because he was not used to walking that far in the heat. She recalled the Concierge was in the lobby when they returned with the resident, not outside. LPN B remembered the Concierge and the Receptionist suggested the resident may have exited along side the transport company that was taking another resident out. LPN B said she wrote a witness statement and spoke to the DON or ADON on the phone 2 or 3 times. She also spoke with the facility Administrator who was now the Regional [NAME] President of Operations and the RNC by 3 way call. She stated the Regional [NAME] President and the RNC did not want her to document the elopement incident in the clinical record. She explained they wanted her to include in her witness statement that staff had eyes on the resident the entire time and that he was alert and oriented. She noted the resident was confused and told them she was not comfortable with this. She added the facility management never wanted staff to put a note in the medical record of any incidents including falls. LPN B provided a screen shot of a text she received from the ADON. The image reflected it was sent by the ADON on 4/8/23, instructing LPN B, Don't document anything in PCC (the facility electronic medical record) regarding [resident #1] until I get it cleared. On 7/18/23 at 1:20 PM, during an interview with the DON and ADON, the ADON stated she had instructed the Weekend Supervisor to obtain witness statements from the staff involved in the elopement incident. She said she spoke with LPN B on her personal phone and took a verbal statement from the Receptionist. The ADON stated she did not communicate with the staff involved by email or texts. The DON and ADON were informed the elopement incident was not documented in the clinical record. The ADON responded and said she should have instructed the staff to make sure it was documented. She added that was education provided during orientation, to ensure incidents are documented in the progress notes. The ADON was shown the screen shot of the text she sent to LPN B that instructed her not to document the elopement in the progress notes. The ADON acknowledged she sent the text to LPN B and instructed LPN B not to make a nurse/incident note in the medical record. The ADON explained she had communicated with the Regional [NAME] President and the RNC at the time and was directed not to document the elopement in the medical record unless it was cleared. Neither the DON or ADON explained how a nurse obtained clearance to document an incident in the clinical record. Review of the facility's Immediate Jeopardy removal plan included the following that was verified by the survey team. 1. The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/17/23 which included the facility Administrator, DON, Medical Director via telephone, and additional staff members. No additional recommendations were made at that time. 2. Root Cause Analysis completed 3. Elopement Drills conducted on 7/17/23 and 7/18/23 with an established schedule to continue weekly until substantial compliance is determined by the QA committee. 4. Education on 7/17/23 through 7/18/23 related to the facility elopement policy and timely completion of a comprehensive investigation. Education provided by the Regional Nurse Consultant, DON and Administrator. Those educated comprised 187 total facility employees. 5. Facility Administrator and Director of Nursing educated on 7/18/23 related to position duties- including risk management, facility elopement policy, timely completion of a comprehensive investigation, QAPI/QAA implementation process and reporting of incidents/accidents process by the Regional [NAME] President of Operations and Regional Nurse Consultant. On 7/18/23 15 staff, including Certified Nursing Assistants (CNA)s, Therapy staff, Nurses, Dietary and Activies staff, were interviewed. They indicated they received recent education on elopement and incident reporting to their direct supervisors and/or the facility's Administrative staff. The staff discussed their involvement and participation in elopement drills. The staff spoke about their role in providing supervision to prevent elopement. Education sign in sheets were reviewed and it was determined the Administrator, DON, ADON, RNC and [NAME] President of Operations attended in-service on Abuse, Neglect Adverse Reporting, Elopement, Wandering and Supervision. The facility provided their Elopement decision tree, routine resident checks, potential adverse report sheet and resident interview forms with prompts for Abuse, Neglect and Exploitation.

Based on interviews, and record review, the facility failed to allow a resident to remain in the facility, failed to provide rationale as to why the resident's care needs could not be met at the facility and failed to document attempts at meeting those needs before transfer for 1 of 3 residents reviewed for transfers of a total sample of 8 residents, (#1). Findings. Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing Admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. Resident #1's comprehensive Hospice Care plan was initiated on 7/1/22 with plan for the resident to remain at the facility long term hospice care due to chronic diastolic heart failure. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of monthly nursing summaries from June 2022 to November 2022, all noted resident #1's cognition was clinically stable and he was not an elopement risk. Review of the nurse's progress note dated 12/6/23 indicated the resident was observed smoking a cigarette in his room. The nurse noted the resident was instructed to extinguish the cigarette and was informed the facility was a non-smoking facility. Resident #1 expressed understanding that he was in a non-smoking facility. The nurse informed the Hospice provider and received new orders for nicotine patches. Three days later on 12/9/22, the Director of Nursing, (DON) documented a progress note that indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, book, etc. The medical record progress notes from 11/22/22 to 5/17/23 indicated the resident received regular visits from a Psychiatric Mental Health Nurse Practitioner (PMHNP). On 12/23/223 the resident had a follow up visit with the PHMNP. She noted, .Alert and orientated x3. Affectively blunted. Mood is irritable . The PHMNP noted the resident had paranoid delusions that people were out to harm him. He reported someone is trying to kill him. He saw a person standing in the doorway of his room, holding a gun. He reports there was a helicopter landing on the roof of the building. The PHMNP noted the resident was unstable and added the antipsychotic medication Seroquel, 25 mg twice a day for brief psychotic disorder. There was no indication she had diagnosed resident #1 with dementia. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 3:45 resident #1's elopement was discussed with the Director of Nursing, DON. She indicated the resident had eloped from the facility on 4/8/23 between 11 AM and 11:15 AM. She said when the resident returned to the facility, on 4/8/23, he was immediately placed on 1:1 supervision which was subsequently decreased to 15-minute checks on 4/10/23. The 15 minute checks were discontinued on 4/18/23. The DON stated resident #1 made no further elopement attempts while he was on the 1:1 supervision or 15-minute checks. She added resident #1 was transferred to a sister facility that had a locked unit. She did not respond when asked why the resident was discharged from the facility when the resident did not make any further attempts to leave. On 4/10/23 the PHMNP had a follow up visit with resident #1. The resident reported people were chasing him around and he had paranoid thoughts that a man is out to harm him. He cut the interview short and said he was too tired to answer any more questions. The PHNP noted, Dementia persisting with behavioral disturbance. She also noted that the resident was unstable but did not require any medication changes. Ongoing medical stabilization and emotional support would be good enough. The PHMNP did not indicate the resident needed be transferred to another facility with a locked unit. A review of the progress note by the Advance Practice Registered Nurse dated 5/11/23 showed the resident was placed on 1:1 supervision for wandering. There was no documentation the resident was exit seeking. On 5/15/23 the PHMNP saw resident #1 and noted in her progress note the resident was managed effectively in the nursing home and all ADLs (Activities of Daily Living) are provided. Her recommendations included, Patient is getting adequate level of care giver support in the facility. No significant changes are needed. At the same time, she noted, The patient requires to go to higher level of care (locked memory care unit). The PHMNP did not provide any evidence of why the resident would benefit from a locked unit, only that he needed one. Review of the medical record noted a transfer form that indicated the resident was transferred to another nursing home on 5/17/23. The form indicated the facility could not meet resident #1's needs. The explanation on the transfer form read, Resident is confused and wanders building IDT (Interdisciplinary Team) felt [name of another nursing home] would be better for him-brother agreed. Further review of the form revealed that neither the physician nor the resident signed the transfer form. There was no documentation of the which resident needs the facility could not meet or why another nursing home would be better for him when he had been at this facility for almost one year. On 7/18/23 at 1:47 PM, resident #'1's discharge was discussed with the DON and ADON. The DON said resident #1 had increased exit seeking behavior which contradicted her previous statement made on 7/16/23 at 3:45 PM where she noted the resident had made no further attempts to exit. She was informed there was no documentation of exit seeking behavior in the clinical record after the resident's elopement on 4/8/23. She explained the facility had wanted to transfer the resident to a facility with a secure unit, but he did not have a diagnosis of dementia. She indicated she had spoken with the PHMNP and diagnosis of dementia was added to resident #1's diagnoses list. The DON stated they had spoken to resident #1's brother and he agreed with the transfer. When asked if resident #1 had been deemed incapacitated to make medical decisions, the DON said he was his own person and was not deemed incapacitated. On 7/18/23 at 2:14 PM, during a telephone interview, the resident's brother explained the resident told people he was the emergency contact. The brother stated he lived in another state and did not make any decisions for resident #1.

Based on interview and record review, the facility failed to provide pain management services in accordance with the comprehensive care plan, and the resident's goals for care and preferences for 1 of 2 residents reviewed for pain management, of a total sample of 40 residents, (#164). The facility's failure to provide pain medications as requested by the resident, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Clinical record review revealed resident #164 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's History and Physical, dated 6/26/22, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A laminectomy is a type of back surgery used to relieve compression on the spinal cord . performed when less invasive treatments have failed. (Retrieved on 7/21/22 from www.healthline.com). Anarthria is a severe form of dysarthria. Dysarthria is a motor speech disorder that occurs when someone can't coordinate or control the muscles used for speaking. (Retrieved on 7/28/22 from www.healthline.com). [CONDITION(S)] is an injury to the spinal cord due to severe compression. (Retrieved on 7/28/22 from www.hopkinsmedicine.org). The resident's Admission Readmission Nursing Packet, dated 6/25/22, revealed on admission, resident #164 had pain to her sacrum, a vertical spinal surgical site, and complained of a burning sensation to her right lower leg. The assessment noted the resident described her pain as severe, sharp, radiating at level 10 on a pain scale of 1 to 10. The assessment identified the most likely cause of the resident's pain was her post-operative incision, and pain relief was achieved with pain medications. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] belongs to a class of drugs known as opioid analgesics. It works in the brain to change how your body feels and responds to pain. [MEDICATION(S)] is a combination medication used to help relieve moderate to severe pain. (Retrieved on 7/21/22 from www.webmd.com). The resident's admission Minimum Data Set (MDS) assessment with assessment reference date of 7/02/22 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8/15. The assessment indicated the resident received scheduled and as needed pain medications for frequent pain of moderate intensity. A physician's note, dated 7/09/22, read, Pain under control on great amount of narcotics around clock . acute on chronic back pain . [history of Thoracic-Sagittal spine] fusion. On 7/11/22 at 4:38 PM, resident #164 stated she was sutured from T3 to L5-6, the Thoracic to Lumbar spine region, and had issues with her spine that caused both chronic and acute pain. She recalled on the day she was admitted to the facility, transportation from the hospital took over one hour. The resident stated by the time she arrived at the facility, her pain level was 10/10 and she had to wait for one hour to get pain medication. Resident #164 stated nursing staff explained there was a pharmacy problem as a nurse had not entered her prescribed medications into the computer system. She recounted another incident on 7/09/22 when she went without pain medications for eight hours. The resident said, It was not pretty. She described vomiting as she suffered high levels of pain. The resident's husband said, It was really bad! He explained that while his wife was vomiting, she was unable to get any medication. The resident and her husband stated the facility needed to be more consistent with administration of pain medications. Resident #164 stated she had informed a couple of Licensed Practical Nurses (LPNs) of her concerns, and she was told they would get caught up on her pain medication and/or pass her concerns to the next shift. The resident explained she usually tried to get pain medication prior to therapy but these requests were not always honored. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The document revealed a period of approximately 9 hours elapsed before the next dose was administered on 7/10/22 at 3:22 AM, as reported by the resident. On 7/12/22 at 3:42 PM, LPN J stated resident #164 was a post-surgical patient who received pain medication as scheduled and as needed. LPN J explained the resident's care needs included medication administration and pain management. On 7/13/22 at 11:41 AM, the resident stated last night, 7/12/22, was a bad night with pain as there was some problem with narcotic medications. She explained at 10:00 PM, a nurse told her the pharmacy would deliver her [MEDICATION(S)] tablets no later than midnight. The resident stated she told her assigned nurse that the nurse on the 7:00 AM to 7:00 PM shift had promised her the [MEDICATION(S)] tablets would arrive by 10:00 PM. Resident #164 stated the 7:00 PM to 7:00 AM nurse responded, I am not the pharmacy. The resident reported the nurse, whose name she could not recall, told her to lay off the call light as she had reached her limit for pain medication. The resident stated the nurse informed her she would not call the physician or the pharmacy to obtain the code to access the facility's emergency medication supply. Resident #164 stated at about 5:00 AM this morning, 7/13/22, the night nurse entered her room, placed a cup with a tablet on the tray table, and walked away. On 7/13/22 at 5:58 PM, in a telephone interview, LPN H stated she was regularly assigned to resident #164 on the 7:00 PM to 7:00 AM shift and was aware of the resident's condition. She verbalized the resident normally requested [MEDICATION(S)] every 4 hours. She recalled during the change of shift report, the previous nurse, LPN J, informed her she had to retrieve [MEDICATION(S)] for the resident from the facility's Emergency Drug Kit (EDK). She stated LPN J told her the pharmacy would deliver narcotics for the resident on the next scheduled pharmacy run. LPN H stated the resident received her last dose of [MEDICATION(S)] on 7/12/22 at approximately 5:00 PM. She verbalized the resident asked for pain medication between 9:30 PM to 10:00 PM on 7/12/22 and reported her pain level at that time as 7 on a pain scale of 1 to 10. LPN H stated she told the resident she would get her medication when the pharmacy delivered it. LPN H explained that when a medication was not available, the facility's process included either checking if it could be obtained from the EDK or calling the pharmacy for a stat or rush delivery. LPN H stated she could not obtain a code from the pharmacy to access the EDK because the previous nurse had already used a code, retrieved and administered one tablet to the resident. LPN H further explained if the pharmacy delivery was in transit, she could not obtain a code for emergency medication. She acknowledged she did not notify the physician or request any additional medication to address the resident's report of level 7 pain and lack of access to as needed medications for breakthrough pain. LPN H stated she rounded on the resident at 3:00 AM and she was asleep. However, LPN H verbalized she did not actually enter the resident's room to assess her pain level, but observed the resident from the hallway. She confirmed resident #164 requested pain medication at 9:30 PM but did not receive [MEDICATION(S)] for pain until 8 hours later at 5:30 AM on 7/13/22. Review of the facility's job description for Licensed Practical Nurse revealed the LPN was responsible for the optimal quality of care for residents, and his/her responsibilities included administration of medication and treatments according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/22 at 9:43 AM, the Montecito Unit Manager (UM) stated the goal of pain management was for pain to be treated and managed appropriately. She stated the facility had an Automated Dispensing System (ADS) and all LPN H had to do was submit another request to the pharmacy to obtain [MEDICATION(S)] from the ADS. The UM stated the physician should have been notified that the medication was not available, and an order obtained for breakthrough pain medication. She said, Ultimately, the nurse should have obtained medication from the ADS. The UM stated it was not acceptable for the resident to be in pain and not receive medication as ordered. She validated the resident's pain was not managed adequately. On 7/14/22 at 10:12 AM, the Director of Nursing (DON) stated the facility had an ADS, and the process was for the physician to contact the pharmacy to authorize dispensing of medication. The nurse would then contact the pharmacy to obtain a code to access the ADS, and two nurses would retrieve the medication from the ADS using the code. The DON stated he was not aware the nurses could not obtain a code if a pharmacy delivery was in transit as described by LPN H. He verbalized the physician should have been informed the medication was not available, and LPN H should have then repeated the process used by the previous nurse to obtain the medication from the ADS. The DON stated the expectation was for the nurse to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated if a resident requested pain medication, it should be administered within a reasonable timeframe. He confirmed LPN H should have contacted the physician and obtained orders to address resident #164's pain in a timely manner. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Policies and Procedures for Management of the [name of Automated Dispensing Systems] read, Nursing and Pharmacy will use the ADS Station as an inventory, charging and information system for the control and distribution of medications for Emergency, First-Dose use and other situations where medications are not available from the pharmacy . The facility must contact the pharmacy and obtain an authorization code for removal of any controlled substance . If there is no script on file, the pharmacist will page the prescriber for an electronic prescription or an emergency supply . If the medication is not available, call the pharmacy using the after- hours emergency number(s) if necessary. On 7/14/22 at 11:05 AM, resident #164 stated she would be comfortable with a pain level of 3/10. She explained that after her post-operative acute pain was resolved, she would be able to cope better with her chronic pain. Interventions on the resident's care plan At increased risk for alteration in comfort [related to] generalized discomfort and recent laminectomy initiated on 7/11/22 included administer pain medication as ordered, and notify physician of unrelieved or worsening pain. The facility's policy Pain Assessment and Management, revised in March 2020, read, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy Administering Pain Medications revised in October 2010 revealed steps in the procedure included, Administer pain medications as ordered. The Facility Assessment, updated/reviewed on 6/29/22, indicated services and care offered by the facility would be based on the residents' needs and included assessment of pain and pharmacologic and non-pharmacological pain management.

Based on observation, interview, and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility; failed to conduct assessments to identify risk for elopement and implement appropriate interventions to mitigate elopement risk; and failed to ensure staff responded to an exit door alarm to promote safety for 1 of 5 total residents reviewed for elopement, (#1). On 11/15/21 at approximately 1:00 PM, the facility failed to prevent resident #1, a physically and cognitively impaired resident from exiting the facility unsupervised. The resident walked away from her room, through an unoccupied unit and exited through fire egress doors at the end of a hallway. No staff member responded to the door alarm and resident #1 continued walking for approximately 220 feet until she fell on the concrete sidewalk near the parking lot on the east side of the facility. The resident sustained a laceration above her left eye, a black eye, an abrasion on her left cheek and a skin tear on her left lower leg. The facility was unaware of resident #1's whereabouts until approximately 1:10 PM when a visitor notified the receptionist there was someone on the ground outside. While resident #1 was out of the facility unsupervised, she fell and sustained facial/head injuries and there was reasonable likelihood she could have been hit by a car, drowned, or become lost. These failures contributed to the elopement of resident #1 and placed all residents who wandered at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on 11/15/21. Findings: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder, major depressive disorder, lung cancer, adrenal gland cancer, [CONDITION(S)], and peripheral vascular disease. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 3/02/21 revealed resident #1 was not ambulatory and used a wheelchair. The document indicated the resident was alert, disoriented but could follow simple instructions. The Admission Nursing Data Collection evaluation dated 3/30/21 revealed resident #1 was oriented to person only, used a wheelchair for mobility, and was unable to walk. Review of an admission Wandering Risk Observation dated 3/30/21, revealed resident #1 was not ambulatory and did not exhibit wandering behaviors in the previous 90 days. The document directed staff to obtain wandering history from multiple sources including family, the medical record, and all caregivers. The evaluation form indicated a wandering risk score was not applicable or NA as the resident was not at risk for wandering behaviors. A Wandering Risk Observation dated 6/30/21 showed resident #1 was re-evaluated and found to be independently ambulatory and still did not exhibit wandering behaviors. The document read Score: NA and indicated the resident was not at risk for wandering behaviors. A Psychiatry Follow Up Note dated 8/02/21 read, Nursing staff report intermittent irritability with redirection . May consider initiation of [MEDICATION(S)]. Review of Progress Notes revealed a behavior note dated 8/17/21 regarding resident #1's new exit seeking behavior on 8/16/21 and the initiation of 1:1 supervision. Resident #1's Wandering Risk Observation dated 8/17/21 revealed she remained independently ambulatory and currently exhibited wandering behaviors. The document indicated the resident was at risk for wandering behaviors, but her risk score remained NA. Review of the medical record revealed resident #1 had a care plan for wandering behaviors and elopement, initiated on 8/17/21. The goal was the resident would not harm herself. The interventions directed staff to anticipate the resident's care needs, report changes in behavioral status to the physician, and provide 1:1 supervision. A Psychiatry Follow Up Note dated 8/24/21 revealed resident #1 required 1:1 supervision for an increase in exit seeking behaviors. The note described resident #1 as oriented to person with poor impulse control, insight, judgement, and memory. The document read, Worsening dementia can cause wandering and pacing behaviors. The psychiatry recommendations included continue the plan of care and add medication, [MEDICATION(S)] 5 milligrams at bedtime for dementia and confusion. A Psychiatry Follow Up Note dated 9/08/21 revealed resident #1 was seen at the request of staff to address increased anxiety and crying. The psychiatrist noted resident #1 no longer had 1:1 supervision although the resident's care plan still included this active intervention. Resident #1 had a care plan for falls due to impaired mobility and weakness, initiated on 3/31/21. An intervention dated 9/23/21 directed staff to conduct frequent rounds to observe patient's safety. The Minimum Data Set (MDS) assessment with reference date of 10/07/21 revealed resident #1 had a Brief Interview for Mental Status score of 3 which indicated severe cognitive impairment. The MDS assessment indicated resident #1 did not exhibit wandering behaviors in the lookback period. She required limited assistance with transfers and walking in her room, and supervision for walking in the corridor and locomotion. The resident had unsteady balance during transfers and walking but was able to stabilize herself without assistance. She used a walker and wheelchair for mobility and had one fall with injury since the previous MDS assessment. Resident #1 was on hospice services and had a life expectancy of less than six months. Review of resident #1's medical record revealed an Exception Report dated 11/15/21 at 1:10 PM that read, Patient found lying on outside sidewalk. The document indicated the resident suffered injuries including a 4 centimeter (cm) by 0.5 cm laceration above her left eye, a 3 cm by 0.5 cm laceration on her left leg, and an abrasion on her left cheek. She complained of right wrist and arm pain. When assessed, the resident was noted to be alert and oriented to person and situation. The report indicated resident #1's backless shoes were an environmental hazard. The document read, Resident stated she was trying to get to bingo and got turned around and then tripped on her shoe. The facility's immediate actions were to remove the resident's backless shoes, initiate monitoring every 15 minutes and arrange for an escort to bingo. A Wandering Risk Observation dated 11/15/21 at 4:25 PM, was completed approximately three hours after resident #1 eloped from the facility and wandered outside the building. The evaluation showed the resident was independently ambulatory, had a history of wandering in the previous 90 days but did not currently exhibit wandering behaviors. The document did not provide a wandering risk score and the question, Is the resident at risk for wandering behaviors? was not answered. On 12/20/21 at 1:45 PM, Certified Nursing Assistant (CNA) C stated resident #1 was confused and sometimes stated she wanted to go home to her mother and father. CNA C confirmed the facility did not have a secure unit, and the resident got outside one day after lunch and fell . She said, She had a black left eye, pretty dark. On 12/20/21 at 2:00 PM, CNA B stated resident #1 was forgetful, wandered, walked independently, and used a walker. She stated in the past she redirected the resident when she wandered to the dining room or pushed on doors between units. CNA B said, She would get caught. [We] found her in places she shouldn't be. CNA B stated resident #1 was confused and she thought she was waiting for her mother to arrive. CNA B confirmed she was assigned to care for resident #1 on the day she eloped. She stated she checked on the resident's whereabouts approximately every hour during the shift as she was aware the resident wandered. CNA B recalled she assisted the resident to the bathroom after lunch that day and then left her in the Mar Vista unit's common area at some time between 12:30 PM and 1:00 PM. CNA B stated she then went to assist the resident whose room was across the hallway from resident #1's room. She stated while she was with the other resident, resident #1 left the common area and she last saw her going in and out of her room. CNA B stated someone informed her resident #1 got outside through the Via [NAME] exit door. She explained although the door alarm was sounding, she did not hear it because she was inside a room. CNA B stated when the resident was returned to her room, she had a cut above her eye and a significant amount of blood on her hands because she touched the wound. On 12/20/21 at 3:32 PM, in a telephone interview, resident #1's daughter confirmed the facility informed her that her mother walked through an empty unit, got outside, and suffered a fall with facial injuries. She stated her mother attempted to exit the building again after that incident. The daughter stated her mother previously lived with her and was on hospice services. She explained her mother was at risk for falls, had dementia, and while at home she regularly attempted to leave the house to return to her mother's house. The daughter explained her mother had not walked for months before admission to the facility but improved soon after admission. On 12/20/21 at 4:18 PM, the Mar Vista Unit Manager (UM) stated resident #1 was at risk for falls due to unsteady balance and shuffling gait. The UM explained the resident was confused, wandered, and sometimes pushed on exit doors. She confirmed prior to this incident, resident #1 had attempted to leave the facility through an exterior exit door. She stated on the day resident #1 got outside the facility, no staff noted when she left the unit, and they did not hear the alarm when the door was breached. The UM acknowledged resident #1 would not be safe outside the facility by herself. She was unsure how far the resident could have traveled but noted she could have gotten lost or injured since the road in front of facility was moderately trafficked. On 12/20/21 at 4:41 PM, in a telephone interview, Licensed Practical Nurse (LPN) A stated she was regularly assigned to care for resident #1 and was aware the resident wandered and sometimes pushed exit doors and set off alarms. She explained staff would reset the door alarm, but if not done, the alarm would reset itself. LPN A said, She would be walking and wanting to go to bingo. She didn't know where she was going. She could walk but she would leave [her] walker behind. LPN A stated she was shocked when she discovered resident #1 left the facility as staff were assigned to check on her every 15 minutes. She confirmed resident #1 fell while outside, hit her head and bruised her face. On 12/20/21 at 5:00 PM, CNA E stated he was assigned to work at the facility's reception desk on the day resident #1 was found outside the facility. CNA E stated a visiting family member called the front desk and informed him there was a resident outside on the ground. He stated he ran outside and encountered resident #1, who was bleeding from a head injury and complained of pain. He recalled she was seated on the curb by the side parking lot, facing the nearby construction site, and her walker was in an upright position behind her, but out of reach. CNA E stated resident #1 told him she was trying to get to bingo. He explained he did not hear any door alarms prior to the incident, and there was no visual indicators to show the fire door had been opened. On 12/20/21 at 5:50 PM, the Maintenance Director explained resident #1 exited the facility through an emergency exit door on the Via [NAME] unit. He explained the door was a fire egress door with a magnetic lock which released automatically if the panic bar was pushed for 15 seconds. The Maintenance Director stated an alarm sounded at the door, but the volume was low, and no staff heard it. He stated the alarm volume could not be adjusted and he was surprised there was no associated light indicator panel in the facility. He explained the facility did not have security cameras nor an electronic wandering monitor system. On 12/21/21 at 11:50 AM, resident #1's elopement route was retraced by the state survey agency staff. She left her room, passed through the Mar Vista unit's common area and arrived at the closed double doors that separated the Mar Vista and Via [NAME] units. The resident opened the doors and walked along the hallway of the empty Via [NAME] unit until she arrived at an exterior exit door, approximately 260 feet away from her room. She pressed and held the panic bar on the exit door until the magnetic lock released, maneuvered her walker through the door and stepped out onto the sidewalk. Resident #1 walked an additional 220 feet as she traveled along the sidewalk, around the side of the building. Hazards outside the facility included four retention ponds, all containing water, and a construction site approximately 60 feet from the location where the resident fell . The moderately trafficked road in front of the facility was approximately 100 feet away. On 12/21/21 at 2:14 PM, the UM confirmed all questions on the Wandering Risk Observation form should be answered by nurses. She explained the evaluation form did not provide a score that assisted in the determination of elopement risk. She stated the interdisciplinary team reviewed the form and decided if residents were at risk for wandering. The UM acknowledged the form was standardized, but lack of a score left the determination of wandering risk open to each nurse's individual interpretation. The UM said, They use their assessment skills, not an exact science. She recalled the facility initiated 1:1 supervision for resident #1 in August 2021 when she tried to open an exterior exit door on the Casa [NAME] unit. She stated 1:1 supervision was usually done for a 72-hour period to establish behavior patterns. The UM said, The resident was safe with the 1:1. On 12/21/21 at 3:05 PM, the Director of Nursing (DON) explained resident #1 required 1:1 supervision after pushing on an exit door in August 2021. She stated the intervention was discontinued as the resident ceased to exhibit exit seeking behavior. She confirmed the medical record did not include any nursing documentation regarding discontinuation of this level of supervision. The DON acknowledged the care plan showed 1:1 supervision was a current intervention at the time of her elopement incident in November 2021. She stated the care plan was not correct. The DON explained after resident #1's elopement on 11/15/21, the resident was placed on frequent checks, every 15 minutes, not 1:1 supervision. She confirmed after the resident eloped, she once again attempted to breach an exit door on 12/01/21 and the facility initiated 1:1 supervision at that time. On 12/21/21 at 3:54 PM, resident #1's elopement incident was discussed with the facility's leadership team. The Regional Nurse Consultant (RNC) said, She didn't have an elopement. She was not attempting to exit the facility. Not elopement per se. The RNC explained the resident was simply confused, became disoriented and exited the facility while trying to get to bingo. The RNC acknowledged the resident was able to exit the facility, and she was not allowed to leave without supervision. The RNC confirmed nearby hazards included lakes. The DON said, It is not possible to assess every single risk until unfortunately something happens. She acknowledged the facility had not considered approaches to include supervision such as a hall monitor or to have administrative staff assist with monitoring residents when nursing staff were busy at mealtimes. Review of the policy and procedure Resident Elopement (undated) revealed the facility would .take appropriate steps to identify the risk of, prevent, detect, and respond promptly to resident elopement. The policy's definition of elopement was. that situation where a cognitively impaired resident with impaired safety judgement leaves the center without staff knowledge. The Facility Assessment Tool updated on 5/05/21 revealed the facility could care for residents who had behavioral issues and cognitive impairment. The document indicated the facility would identify hazards and risks and involve residents and their representatives in creating appropriate person-centered plans of care.