Every finding on record at Westminster Oaks

Based upon observations, interviews, and record review, the facility failed to implement care plan interventions for safe transfer with a mechanical lift for 1 out of 24 residents reviewed. (Resident #27)The findings include:On 8/13/25 at 08:25 AM, an observation of Resident #27 was conducted. Resident #27 was observed in a mechanical lift sling, suspended midair over the bed. Staff Member B (a Certified Nursing Assistant (CNA)) present in the room, retrieving Resident #27's wheelchair, removing the leg rest that was sitting on wheelchair seat. Staff Member B was interviewed at this time and stated, I'm getting her up now. When asked about the protocol for transferring Resident #27, Staff B stated, we always use two person assist when using a mechanical lift, but the other CNA and nurse were busy down the hall, so I did it myself. An interview was conducted with the Administrator and Director of Nursing on 8/13/25 at 09:00 AM. They acknowledged that transfers with a mechanical lift require a two person assist at all times. Resident #27's plan of care revealed a self-care performance deficit due to dementia, confusion, activity intolerance, and impaired balance, with a goal to continue to participate with self care throughout the review period. Interventions include transfer using a full body mechanical lift for all transfers with 2 staff person assist.The facility policy for safe resident handling and transfers states, .it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe secure and comfortable experience for the resident while keeping employees safe in accordance with current standards and guidelines. The facility-wide education on use of mechanical lifts dated 2/28/25 (which included a signature by Staff Member B) states, Two staff members must be utilized when transferring residents with a mechanical lift. (photographic evidence obtained)

Based on observations, interviews and records review, the facility failed to review and revised the care plan to address the needs of 1 of 1 residents reviewed. (Resident #120)The findings include: On 08/12/25 at approximately 10:35 AM, Resident #120 was observed resting in her room with an external heart monitor taped to her upper chest, displaying a red blinking light.On 08/12/25 at approximately 3:00 PM, an interview was conducted with Resident #120. She reported that on 08/11/25, she attended a follow up appointment with her cardiologist, during which an external heart monitor was placed to evaluate her for possible atrial fibrillation. Upon returning to the facility, she provided the related paperwork to a staff member.On 08/13/25 at approximately 8:30 AM, the receptionist confirmed that Resident #120 had a follow-up appointment outside the facility on 08/11/25.On 08/13/25 at approximately 12:33 PM, an interview was conducted with Staff A, Registered Nurse. She explained that, when a resident returns to the facility from a physician's appointment with new orders, the nurse on duty will verify the orders and document a progress note in the resident's record.On 08/13/25 at approximately 12:40 PM, an interview was conducted with the Director of Nursing. She acknowledged that the resident had a physician's appointment on 08/11/25. She stated that she did not become aware until today that the resident had a heart monitor, and this is the first time the staff has knowledge of it. She explained that it is the facility's expectation to have the resident assessed and a progress note entered into the resident's record upon return. She further confirmed that, for approximately 48 hours, the facility was not aware of the heart monitor and therefore did not implement monitoring of the device or update the care plan.A shower and skin monitoring sheet, dated 08/12/25 for Resident #120, was reviewed. There is no acknowledgment of the heart monitor (Photographic evidence obtained).Progress notes for Resident #120 from 08/11/25 and 08/12/25 were reviewed. There are no entry notes from the nursing staff regarding the new heart monitor.On 08/13/25 the care plan for Resident #120 was reviewed. The care plan was not updated to reflect the heart monitor device (Photographic evidence obtained).

Based on record review and interview, the facility failed to submit the Payroll-Based Journal (PBJ) report correctly for 1 of 4 quarters reviewed. The findings include: A review of the PBJ data report submitted into the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024, which reports on the period of October 1 to December 31, 2023, revealed excessively low weekend staffing. On 5/19/24 at 12:39 pm, the facility's Administrator was interviewed. He stated the facility had not been low staffed on weekends. He stated that the corporate office did not fill the form correctly.

Based on record review, review of immunization records, and facility policy the facility failed to provide education and offer COVID 19 vaccines in a timely manner for 4 of 5 sampled residents. (Residents #15, #28, #39, #64) The findings included: On 5/20/24, a review of the immunization record of Resident #15 was conducted. The record had an influenza vaccine dated 10/5/2023. There was no COVID vaccine in the record at the time. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing (DON) provided proof of COVID vaccines given on 1/4/21, 2/4/21, 3/8/21, and 6/22/22. The facility did not provide proof of approval or refusal of COVID vaccines after 6/22/22. On 5/20/24, a review of the immunization record of Resident #28 was conducted. The record had documentation of the administration of the COVID vaccine dated 1/14/21, 2/14/21, 11/5/21, and 8/1/22. On 5/21/24, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and/or declination forms. The facility did not provide proof of any of these forms after 8/1/22. On 5/20/24, a review of the immunization record of Resident #39 was conducted. The record had documentation of the COVID vaccine on 1/14/21, 2/4/21, and 11/14/21. The facility did not provide proof of approval or refusal of the COVID vaccine after 11/14/2021. On 5/20/24, a review of the immunization record of Resident #64 was conducted. The record had documentation of an influenza vaccine dated 10/5/2023. There was no proof of offering the COVID vaccine in the record at the time. On 5/21/23, the Infection Control nurse was asked to provide proof any additional COVID vaccines not included in the electronic immunization record along with COVID vaccine consent forms and or declination forms. On 5/22/24, the Director of Nursing provided proof of a COVID vaccine given on 11/1/21. The facility did not provide proof of any acceptance or refusal of a COVID vaccine after 11/12/21. On 5/22/24 at approximately 1:00 PM, the DON provided COVID 2023 Booser Immunization Consent Forms dated 5/22/24 for Residents #15, #28, #39, #64. Resident #15's family had been contacted verbally and the resident and his family refused the vaccine. Resident #28's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster but refused the Moderna vaccine. Resident #39's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster. Resident #64's guardian had been contacted verbally. The guardian wished for the resident to continue the Pfizer booster but refuses the Moderna vaccine. On 5/22/24 at approximately 2:30 PM an interview was conducted with the DON. She was asked when the COVID 2023 Boosters Immunization Consent forms for the residents were completed. The DON acknowledged that they contacted the residents and their families earlier in the day. She mentioned that several residents preferred to receive the covid vaccine from Pfizer. She explained that the facility had a binder for tracking the immunizations. The binder had been lost the past November when all of the medical records were being uploaded into the electronic record. The DON was asked who was responsible for tracking, ordering, providing vaccinations at the facility. She explained that there are three Assistant Directors of Nursing (ADON) and each ADON is responsible for tracking, ordering providing and following up on immunizations for residents in their area. The Facility Administrator indicated that a performance improvement plan (PIP) was initiated that am to track and update immunizations. A copy of the PIP was provided indicating that the facility had started an audit of all in house residents covid vaccines and consent forms had been initiated on 5/22/24. On 5/22/24 a review of the infection prevention and control policy, dated July 2023, was conducted. Page 2 of the policy indicated that residents would be offered the vaccine. Residents and resident representatives will have the opportunity to accept of refuse a COVID-19 vaccine and changed their decision based on current guidance.

Based on interview and record review, it was determined the facility failed to follow physician's orders and provide routine medication to 1 of 4 sampled residents (Resident #1). The findings include: On 7/2/22 a review of the Order Summary Report for Resident #1 was conducted. Page 1 of the summary revealed that Resident #1 had a diagnosis of enterocolitis due to a [CONDITION(S)] (C-Diff) infection (a bacterium that causes an infection of the large intestine). Page 4 of the Order Summary Report contained a verbal order written on 4/20/22 for Resident #1 to be given [MEDICATION(S)] HCL 125 milligrams (mg) capsules 1 tablet by mouth every 6 hours to treat a [CONDITION(S)] (C-Diff) infection. The start date of the order was 4/20/22. A review of the Medication Administration Record (MAR) for the month of April for Resident #1 revealed that a number 9 was entered on 4/20/22 at 6:00 PM (1800), and 4/21/22 at 12:00 AM (0000). On 4/21/22 at 6:00 AM (0600) the field was left blank. On 4/21/22 at 12:00 PM, 4/21/22 at 6:00 PM, and 4/22/22 at 12:00 AM 9's were entered on the MAR. The key on the MAR form revealed that an entry of 9 indicated other and directed the reader to review the progress notes. A review of the progress notes was completed. An admission note was written on 4/20/22 at 9:12 PM (21:12). The note indicated that Resident #1 was receiving antibiotic treatment (ABT) and contact isolation for a C-Diff infection. The note also stated that several medications ordered by the physician were unavailable on the medication cart. On 4/20/22 at 11:17 PM, (2317) progress note entry again indicated that medication was unavailable for administration. On 4/21/22 at 1:17 AM, a note was written that [MEDICATION(S)] HCL Capsules 125 mg had been ordered; but the medication was unavailable on the medication cart. On 4/21/22 at 4:12 AM, a note indicated that the resident was awake in bed and experiencing skin irritation due to the enterocolitis. In the same note an entry was made that the resident's order for antibiotics did not arrive with the nightly pharmacy delivery. The note indicated that a follow up call would be made to the pharmacy in the morning during business hours. On 4/21/22 at 11:53 AM, a note was written stating: awaiting the arrival of medications. There was no documentation that a call had been made to the pharmacy. There was also no documentation that the physician had been notified. On 4/22/22 at 12:19 AM, a note was written that medication was unavailable the writer spoke with the pharmacist and the medication would be available in the morning. A review of the care plan for Resident #1 revealed that Resident #1 had dehydration and potential for fluid deficit due to frequent stooling caused by the [CONDITION(S)] infection. The first intervention listed on the care plan was to administer medications as ordered. On 7/7/2022 a review of the Medication Errors Policy dated 4/22 was conducted. The policy stated that the facility shall ensure medications will be administered according to physician orders. Page 2 of the policy stated that the facility will consider medication administered not in accordance with prescriber's orders including medication omissions. On 7/7/22 at approximately 1:21 PM, an interview was conducted with Nurse A, Licensed Practical Nurse (LPN), she was asked to explain the process for obtaining newly ordered medications. We go to the (automated medication dispensing system) to get them. If the medication is not in there, we can call the pharmacy to see when it will come in. Nurse A, LPN was asked what happens if the medication is unavailable, if a secondary pharmacy was utilized or if the physician was notified, Nurse A answered, We just don't give the medicine. On 7/7/22 at approximately 2:30 PM, an interview was conducted with the Assistant Director of Nursing. (ADON). She was asked to explain the 6 fields containing an entry of 9 on the MAR from 4/20/22 at 6:00 PM through 4/22/22 at 12:00 AM, where the [MEDICATION(S)] HCL Capsule 1 tablet was to be administered every 6 hours to treat Resident#1's [CONDITION(S)] Infection. She explained that a 9 entered on the MAR meant other and to check the nurse's notes for further information. The surveyor explained that a review of the nurse's notes indicated that the [MEDICATION(S)] was unavailable for administration from Resident #1's time of admission on 4/20/22 through 4/22/22 at 6:00 AM. The APON explained that 7:00 PM is the cut off time for the pharmacy. If a medication is not ordered beforehand, it will not arrive until the following day. If the resident has an infection, then the pharmacy will call the backup pharmacy to obtain the medication. She also explained that if the medication does not arrive in time the nurse would call the physician to notify them that the medication is unavailable. The ADON was asked if there was documentation that the physician was notified that the medication was unavailable. She was unable to provide documentation that the physician had been notified. The ADON was then asked if the physician should have been notified that the [MEDICATION(S)] was unavailable for administration. The ADON replied: Yes.

Based on interview and record review, the facility failed to ensure all staff were fully vaccinated and failed to implement the additional precautions to test unvaccinated staff as outlined in their COVID-19 staff vaccination policy for one of five sampled staff. The COVID-19 staff vaccination rate was 99% which had an isolated impact on the four residents who were confirmed COVID-19 positive with mild symptoms that did not result in hospitalization or death. Findings include: On 6/13/22 at 3:53 PM, review of the facility's COVID-19 staff vaccination information identified there were a total of 170 staff: 165 were fully vaccinated, four staff had a granted non-medical exemption, and one staff was partially vaccinated. Therefore, the staff vaccination rate was 99%. According to the resident COVID-19 antigen test results, three residents tested positive for COVID-19 on 6/6/22 and one additional resident tested positive for COVID-19 on 6/11/22. Two of the residents did not have any symptoms and the other two residents had mild symptoms. According to the facility's Vaccination, Testing, and Face Covering policy updated on 11/2021 indicated, in pertinent part, .All team members are required to be vaccinated against COVID-19 must be fully vaccinated no later than December 31, 2021. Any team member not fully vaccinated by this date will be subject to the regular testing .Team members who report to the workplace at least once every seven days; a) must be tested for COVID-19 at least once every seven days . Review of Certified Nurse Aide (CNA) A's information revealed the staff was hired on 11/8/21. CNA A received the first dose of a multi-dose COVID-19 vaccine on 10/20/21 but had not received a second dose in the primary vaccination series for COVID-19 as of 6/13/22 which was about 8 months after the first dose. According to the CDC, the second dose of a multi-dose COVID-19 vaccine should be no more than eight weeks after the first dose for people who are not moderately or severely immunocompromised. On 6/13/22 at 4:22 PM, the administrator stated that no one had followed up with CNA A's second dose. The administrator indicated human resources (HR) was responsible for following up, but they hired a new HR director in December 2021, and this staff just fell through the cracks. During a follow-up interview at 4:38 PM, the administrator stated that they conduct COVID-19 testing twice a week for unvaccinated staff. When asked to provide two-weeks' worth of testing for CNA A, the administrator stated that they hadn't conducted any testing in the last two weeks for CNA A since they weren't aware that the CNA had missed the second dose, so the CNA wasn't added to the list of unvaccinated staff who should receive routine testing.

Based on record review and staff interview the facility failed to refer a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #8) The findings include: Review of Resident #8's medical record revealed the resident was prescribed [MEDICATION(S)] (an antipsychotic) with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record failed to contain evidence of a level II PASARR resident review. An interview was conducted with the Administrator on 1/13/22 at 11:58 AM. She stated the facility does not have a policy regarding PASARR. A follow up interview was conducted with the Administrator on 1/13/22 at 12:58 PM. She reviewed resident #8's record and confirmed a level II PASARR was not completed.

Based on record review, staff interviews, and policy review the facility failed to implement a process to ensure [CONDITION(S)] medications are only initiated after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed in accordance with the facility policy for 1 of 5 residents reviewed for unnecessary medications. (Resident #8) The findings include: Review of Resident #8's medical record revealed the resident was prescribed [MEDICATION(S)] 50 mg (milligrams) by mouth three times a day on 8/29/21 for agitation. The nursing notes dated 8/29/21 6:48 PM, revealed the resident has had increased agitation this weekend, going in other resident rooms, hitting staff, cursing at staff, accusing staff of things they have not done, yelling , frequent on and off crying spells, and hard to redirect. APRN (Advanced Practice Registered Nurse) notified and new orders for [MEDICATION(S)] 50 mg by mouth three times a day and [MEDICATION(S)] 0.5 mg tablet by mouth every eight hours as needed. The record revealed the resident began taking [MEDICATION(S)] 50 mg by mouth three times a day on 8/29/21. The record revealed no attempts other than redirection to determine possible underlying causes of the resident's behavior prior to the initiation of the antipsychotic medication. An interview was conducted with the Director of Nursing (DON) on 1/12/22 at 4:15 PM. The DON stated she has no evidence the facility attempted to rule out medical causes of the resident's behaviors prior to the initiation of the [MEDICATION(S)] (antipsychotic medication) in August 2021. An interview was conducted with the APRN on 1/13/22 at 12:32 PM. The APRN reviewed the resident's physician orders and confirmed no blood work or urinalysis was attempted prior to starting the [MEDICATION(S)]. The facility policy for Use of [CONDITION(S)] Drugs (7/20) stated number 4: The indications for use of any [CONDITION(S)] drug will be documented in the medical record. a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility, documentation shall include the specific condition as diagnosed by the physician. b. For [CONDITION(S)] drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. [CONDITION(S)] medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed.

Based on interviews and record reviews, the facility failed to investigate incidents of elopement for 2 of 2 residents sampled for elopement (Residents #1 and #2) and failed to ensure corrective actions were carried out for 1 of 2 residents reviewed (Resident #1). The facility's failure to investigate incidents of elopement to determine root cause lead to additional occurrences of elopement and placed 11 other residents identified as risk for elopement at a likelihood of serious injury and death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/2/2021. The facility Administrator was notified of the Immediate Jeopardy on 4/7/2021 at 5:15 PM, prior to survey exit on 4/8/2021. The Immediate Jeopardy was determined to have begun on 2/2/2021, the day Resident #2 exited the building unsupervised. Immediate Jeopardy was removed on 4/8/2021. The surveyors verified implementation of the removal plan. The deficient practice was reduced to a scope and severity level of an D. The findings include: Resident #2 1. On 4/6/2021, a review was conducted of the facility generated document provided by the Administrator titled, AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). The contents of this document were not electronically transmitted to the Agency as required. Review of the report revealed an incident had occurred on 2/4/2021 at 9:00 AM, in which Resident #2, a cognitively impaired resident, was discovered at the Pool House. The report did not note if the resident was found inside or outside the Pool House. The Pool House sits on the edge of Commencement Cove (road) across from the [NAME] Center for Lifelong Learning and is approximately 250 yards from the facility's Admission-Transition Unit where the resident was housed. Further review of the report indicated the resident was at risk for injury or harm as the box next to the section for Resident elopement, if the elopement places the resident at risk of harm or injury was selected. The form identified that the Administrator had completed the form and that the family and physician had been notified. However, the section instructing to List name and license numbers of personnel and the capacity in which they were directly involved with this incident, i.e. register nurse, certified nursing assistance, etc. was left blank. Review of the section Circumstance of the incident - (Narrative of Facts) revealed that Resident #2 had exited the side door of the Unit, walked over to the Pool House trying to go home, was found by the Director of Nursing (DON) who drove him around the community, was returned to the health center (facility) by the DON, Resident #2 thanked the DON for the ride, and no apparent injuries were noted. Review of the section Analysis of incident (Apparent cause (s)) revealed Resident #2 exited the side door while staff were providing morning care to other residents, he did not have his wander alarm in place, and he was found within a few minutes. Review of the Corrective Action Summary revealed the resident was put on 1:1 staff supervision and added to the elopement book. On 4/6/2021 at 12:20 PM, an interview was conducted with the DON. The surveyor asked for clarification of the date the incident described in the facility produced document AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only) actually occurred. She stated that she was unaware of an elopement event occurring for Resident #2 on 2/4/2021, but she couldn't say for sure because she didn't work that day. On 4/6/2021 at 12:25 PM, an interview was conducted with the Administrator. The surveyor asked for clarification regarding who had completed the facility produced and provided document titled AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). She replied that it was either her or Registered Nurse (RN) H. The surveyor asked for clarification regarding the date the incident described on the document actually occurred and she confirmed 2/4/2021 was an error and the actual event occurred on 2/2/2021. The surveyor asked what the purpose of the document was and the Administrator replied that she was directed by Corporate to complete it and it was intended for internal use only. Review of Resident #2's closed clinical record revealed the elopement event was not documented as there was no nursing assessment dated [DATE], no time the resident was last seen by staff, no time alarm sounded (as all exterior doors off the units are equipped with emergency alarms), no time the resident was returned to the Unit, no time of implementation of safety procedures to ensure no repeated elopements, no notification to the physician or family, no witness statements from staff working the Unit or from the DON who discovered the resident, no facility incident report filed, no nurse's notes from 2/2/2021 about the event, and no evidence of 1:1 staff supervision could be found. Review of Nurse's Notes revealed that Resident #2 had also exited out of the building unattended by staff on 2/15/2021, 2/23/2021 and 2/28/2021. Review of the facility's Abuse, Neglect and Exploitation policy and procedure revised July 2020 revealed in Section V. Investigation of Alleged Abuse, Neglect and Exploitation revealed the following: - An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. - Written procedures for investigations include: - Identifying staff responsible for the investigation; - Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; - Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause; and - Providing complete and thorough documentation of the investigation Resident #1 2. A review was conducted of the facility reported event that was submitted electronically to the Agency on 2/19/2021 involving Resident #1. The form identified that Resident #1 eloped from the facility following a beauty shop appointment on 2/4/2021 (the time was not noted) due to not being picked up at the end of her appointment. Resident #1 was able to leave the beauty shop (located in the nursing home) unaccompanied and was found in the Assisted Living Facility (ALF) next door to the nursing home at an unknown time. According to the report, Resident #1 asked the receptionist in the ALF next door to call her a cab to take her to Temple Terrace, FL. On 4/7/2021 at approximately 12:00 PM, an interview was conducted with the Beautician, who had provided hair care to Resident #1 on the day of the elopement. During the interview the Beautician reviewed his appointment book and stated that Resident #1 had an appointment scheduled at 12:45 PM on 2/4/2021. The Beautician could not remember if the resident was on time or what time he finished the appointment, but appointments are generally 15 minutes long. He stated that he was not told to call for the resident to be picked up, the resident acted like she knew what she was doing and just left the salon after the appointment was finished, he did not know what direction the resident went. On 4/8/2021 at approximately 9:15 AM, an interview was conducted with the receptionist of the neighboring ALF, who was working on the day the resident eloped. During this interview the receptionist stated that Resident #1 walked up to her desk and requested that a cab be called to take her home. She stated she does not recollect the time, but her work schedule is from 4:00 PM to 7:30 PM Monday through Friday and the event would have taken place after she arrived to work that day. A review was conducted of Resident #1's Elopement assessment dated [DATE] which revealed that the resident was identified as being at risk for elopement. A review was conducted for Resident #1 Comprehensive Care Plan dated 2/2/2021 which revealed the resident had cognitive impairment secondary to dementia, poor safety awareness and short-term memory loss. It further noted that the resident had a recent history of attempting to leave the unit unassisted and required a WanderGuard (a bracelet type device that alarms if a resident breaches the predetermined perimeter) for safety. The goal was to remain safe on the unit and not leave the unit unattended/unassisted without staff or visitors. Approaches listed for Resident #1 included documenting all incidents of wandering from the Unit and/or outside the facility when or if they should occur and keep resident's picture and elopement profile at the front desk. A record review of the elopement book housed at the reception desk revealed Resident #1 was not listed or identified within the book. An interview was conducted with the Director of Nursing (DON) on 4/6/2021 at approximately 2:00 PM, in which she verified that Resident #1's picture and elopement profile were not in the front desk elopement book. A record review was conducted of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review was conducted of Resident #1's January to April 2021 Treatment Administration Records (TARs) which revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The checks indicated that the resident's WanderGuard was in place and functioning. A review was conducted of facility nursing notes and elopement assessments from January to April 2021. Nursing notes did not reveal any documented events of wandering that would have caused the resident to receive a WanderGuard and to be upgraded from a non-wander risk to a wander risk. 3. An interview was conducted with the Administrator on 4/5/2021 at approximately 4:00 PM in which she confirmed that the facility had not done an investigation following the elopement of Resident #2 or Resident #1. No explanation could be provided as to why the events were not investigated. The surveyor informed the Administrator that the facility had not completed the corrective actions listed on the mandatory state report filed on 2/19/2021 for Resident #1. The Administrator replied, Okay, I've already added that to my plan. Review of the facility's Elopements and Wandering Residents policy and procedure revised June 2019 revealed in Section 7(g), Procedure for Locating Missing Resident, Appropriate reporting requirements to the State Survey agency shall be conducted. Review of the facility's Elopement Checklist located at the front of the elopement book revealed it is to be completed after the resident has been located and returned to the Unit. The checklist included: - Nurse to complete immediate assessment for harm, including vital signs, ROM (range of motion) and neuro-checks x 1. Also need to test WanderGuard for placement and functionality and document in nurses note. - Make note of and document timelines for the following: a. Time resident last seen by staff b. Time alarm sounded (if applicable) c. Time resident located and where d. Time of return to Unit e. Time of implementation of safety procedures to insure no repeated elopements - As soon as possible after resident determined to be stable, notify family/POA (Power of Attorney) and attending physician, making note of the times. - Begin investigative process: a. Collect witness statements from each staff member who may have information about the elopement. Prior to end of shift have a shift huddle to discuss event and write down any pertinent details, i.e., resident behaviors, cognition, was alarm going off, etc. b. Open and complete an Incident Report in AHT (cloud-based electronic health record system). The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions. Re-educated leadership to include: The Director of Nursing (DON), Assistant Directors of Nursing (ADONs), Social Services Director (SSD), Certified Dietary Manager (CDM), Admissions, Minimum Data Set (MDS) Coordinator and Therapy Director, among others, on components of a thorough investigation for reportable events and incidents to include: specific type of allegation, details of incident (5 W's: Who, What, When, Where and Why), victim and potential perpetrator, list of witnesses and statements, cognitive status of any resident witnesses, interviews and statements on 4/8/2021. This was verified by record review of in-service sign in sheet and content discussed (5 W's). Audited incident reports for last 3 months for investigation and if reportable of which 2 were deemed reportable. Immediate Federal Reports were filed on 4/8/2021 for Residents #1 and #2. This was verified by record review of incident report audit tool and the Immediate Report filed on 4/8/2021. Administrator taking on risk management tasks. This was verified by record review of a signed statement by the Administrator regarding acknowledgment of responsibility for risk management and reporting.

Based on observation, staff interview and record review, the facility failed to ensure 2 of 2 vulnerable residents at risk for elopement (Resident #1 and #2) were not able to exit the building unsupervised (Resident #1 on 2/4/21 and Resident #2 on 2/2/21, 2/15/21, 2/23/21 and 2/28/21). Additionally, on 4/5/21/21, the facility failed to ensure all entry/exit doors were secured to prevent subsequent elopements and that staff were educated on how to respond to elopement alarms which has the potential to effect 11 current residents identified as at risk for elopement. The facility's failure to prevent multiple elopements and eliminate potential hazards placed Residents #1 and #2 and 11 other residents at a likelihood of serious injury and death. The facility is located off a [NAME] two-lane road with a 20 mile per hour speed limit within a wooded, gated 90-acre campus. There is an active construction site located directly across from the facility's main entrance and front parking lot which was observed with open gates on the first three days of survey (4/5/2021 - 4/7/2021). Residents are at risk of being injured or killed by passing cars and hazards associated with an unsecured, active construction site (i.e. unattended power tools and machinery, open trenches, uncovered electrical, etc.). The area immediately surrounding the facility is sloped, creating some areas where there are steep drops or stairs. There are exposed tree roots on the lawn in the rear of the building which pose an additional tripping hazard. (Photographic evidence obtained) The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/2/2021. The facility Administrator was notified on of the Immediate Jeopardy on 4/7/2021 at 5:15 PM, prior to survey exit on 4/8/2021. The Immediate Jeopardy was determined to have begun on 2/2/2021, the day Resident #2 exited the building unsupervised. The Immediate Jeopardy was removed on 4/8/2021, based on verification of implementation of removal plan. The deficient practice was reduced to a scope and severity level of an D. The findings include: On 4/5/2021 from approximately 10:15 AM to 11:15 AM, the survey team conducted an initial tour of the facility with the Director of Nursing (DON). During the tour the survey team tested first floor door alarms for functionality and staff response. On 4/5/2021 at 10:13 AM, the exit door leading to the front parking lot was activated and the alarm sounded for approximately 20 minutes. No staff responded during this time. At 10:34 AM, the exit door on the 160-170's hall was activated. After no staff responded to the alarm for 10 minutes, the surveyor and DON re-entered the facility and dismissed the alarm. At 10:46 AM, the exit door alarm was sounded on the 120-130's hall. Staff were observed walking on the unit and disregarding the alarm. At approximately 10:51 AM, the exit door on the 140-150's hall was sounded. No staff were observed to respond. On 4/5/2021 at 10:25 AM, an interview was conducted with Registered Nurse (RN) A, charge nurse, at the main nurses' station, which is located approximately 45 feet from the exit door next to the beauty shop. While the alarm was still audible in the background, the surveyor asked if she could hear an alarm sounding and she replied, No. On 4/5/2021 at 10:27 AM, an interview was conducted with RN B, at a medication cart in front of the nurses' station and approximately 50 feet from the exit door next to the beauty shop. While the alarm was still audible in the background, the surveyor asked if she could hear an alarm sounding and she shook her head no. On 4/5/2021 at 10:44 AM, observations were made of Certified Nursing Assistant (CNA) C, and CNA D, after the alarm was sounded on the 160's hall. CNA C was observed to be walking on the unit going from one room to another and did not acknowledge the alarm. CNA D was observed pushing a scale into a resident's room and did not acknowledge the alarm. When CNA C was asked why she didn't respond to the alarm, she could provide no explanation and continued on with her work. When CNA D was asked why she didn't respond to the alarm, she stopped pushing the scale, went to the door and stated, I don't know how to turn it off. I don't have the code. No concern was evident from either staff in regard to a possible eloped resident. Resident #2 1. On 4/6/2021, a review was conducted of the facility generated document provided by the Administrator titled, AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). The contents of this document were not electronically transmitted to the Agency as required. Review of the report revealed an incident had occurred on 2/4/2021 at 9:00 AM, in which Resident #2, a cognitively impaired resident, was discovered at the Pool House. The report did not note if the resident was found inside or outside the building. The Pool House sits on the edge of Commencement Cove (road) across from the [NAME] Center for Lifelong Learning and is approximately 200 yards from the facility. Further review of the report indicated the resident was at risk for injury or harm as the box next to the section for Resident elopement, if the elopement places the resident at risk of harm or injury was selected. The form identified that the Administrator had completed the form and that the family and physician had been notified; however, the section instructing to List name and license numbers of personnel and the capacity in which they were directly involved with this incident, i.e. register nurse, certified nursing assistance, etc. was left blank. Review of the section circumstance of the incident/narrative of facts revealed that resident #2 had exited the side door of the Unit, walked over to the Pool House trying to go home, was found by the DON who drove him around the community, was returned to the health center by the DON, Resident #2 thanked the DON for the ride, and no apparent injuries were noted. Review of the section analysis of incident/apparent cause revealed Resident #2 exited the side door while staff were providing morning care to other residents, he did not have his wander alarm in place, and he was found within a few minutes. Review of the corrective action summary revealed the resident was put on 1:1 staff supervision and added to the elopement book. Review of the 2021 Adverse Incidents and Federal Reports provided by the facility revealed no reports had been filed for Resident #2. On 4/6/2021 at 12:20 PM, an interview was conducted with the DON. The surveyor asked for clarification of the date the incident described in AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only) actually occurred. She stated that she was unaware of an elopement event occurring for Resident #2 on 2/4/2021, but she couldn't say for sure because she didn't work that day. On 4/6/2021 at 12:25 PM, an interview was conducted with the Administrator. The surveyor asked for clarification regarding who completed AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). She replied that it was either her or RN H. The surveyor asked for clarification regarding the date the incident described on the document actually occurred and she confirmed 2/4/2021 was an error and the actual event occurred on 2/2/2021. The surveyor inquired about the purpose of the document and the Administrator replied that she was directed by Corporate to complete it and it was intended for internal use only. Review of Resident #2's Face Sheet revealed the resident was admitted from home on 1/26/2021 with a diagnosis of dementia with behavioral disturbances. Review of Physician Orders revealed an order dated 1/27/2021 for WanderGuard (a bracelet type device that alarms if a resident breaches the predetermined perimeter) check Q (every) shift for placement and Q night for function for safety. Review of the resident's admission Minimum Data assessment dated [DATE] revealed under Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 03, indicating severe cognitive impairment. Section G - Functional Status revealed Resident #2's balance was not steady, but able to stabilize with assistance and required supervision and a one-person physical assist for locomotion on the unit (movement between locations on the same floor). Section J - Health Conditions revealed Resident #2 had 1 fall since admission. Section P - Restraints revealed a wander/elopement alarm was used less than daily. Review of Resident #2's elopement risk assessments revealed no assessment had been completed upon admission, however an assessment was completed on 2/2/2021 at 3:50 PM which indicated the resident was at risk of elopement. Further review revealed Resident #2 received a score of 12 and residents who score 8 and above are deemed to be at risk to elope and should be placed on the Elopement Risk Protocol. Review of the comprehensive care plan revealed a risk area of cognitive deficits related to dementia, poor safety awareness, requires WanderGuard for safety, and has a recent history of leaving the unit unassisted with a problem onset date of 2/2/2021. Care plan interventions included Document all incidents of wandering from the unit and/or outside the facility when or if they should occur. Review of Resident Safety Checks revealed the resident was placed on 15-minute checks from 2/2/2021 to 2/3/2021. There was no indication in the record that increased supervision was provided at any other time. Review of Nurse's Notes revealed the following events and patterns of displayed behavior: - 1/27/2021 Wandering into other residents rooms and very difficult to redirect. - 1/28/2021 resident was found sitting on floor (fall) and Resident stated he was trying to 'get up and leave'. - 2/2/2021 Resident stated about 1AM that he wanted someone to come here and take him home and Report received that the resident was reaching down to pick up a piece a paper off the floor and lost his balance. (fall) - 2/4/2021 Resident stating 'I'm leaving to go home to my wife and kids' - 2/5/2021 trying to go into other residents' rooms and Stated he had to leave and 'go get his mother' and that 'she was expecting him'. - 2/10/2021 wandering throughout hallways of second floor, most of shift looking for exit doors to leave facility, proceeded to open a window, and stated 'I am going home one way or the other' - 2/15/2021 Resident eloped through back door. and chased throughout the community - 2/16/2021 attempting to get out of 149A window with blinds and window up and screen partially out - 2/17/2021 attempting to exit the building through window - 2/21/2021 Resident came out of his room at 5 am with 3 bags packed and was exit seeking. - 2/23/2021 resident continued to push screen completely out and get out of window and Resident proceeded down sidewalk, down stairs, and started to ambulate down sidewalk towards [NAME] Center. - 2/25/2021 started to walk and tripped over his bag that he had placed next to his chair (fall) - 2/28/2021 Resident at 3:30pm went out back door Further review revealed no nurse's notes were entered on 1/29/2021, 1/30/2021, 1/31/2021, 2/3/2021, 2/7/2021, 2/8/2021, 2/12/2021, 2/13/2021, 2/22/2021, 2/27/2021, or 3/2/2021. Resident #2 was discharged on [DATE]. Review of Resident #2's February Treatment Administration Record (TAR) revealed an order to check Wanderguard for placement every shift. N was entered on 2/1/2021 at 2:00 PM, 2/2/2021 at 6:00 AM and 2:00 PM, 2/3/2021 at 6:00 AM and 2:00 PM, 2/4/2021 at 6:00 AM, 2/7/2021 at 10:00 PM, 2/8/2021 at 6:00 AM, 2/14/2021 at 6:00 AM, and 2/18/2021 at 10:00 PM. Review of the TAR notes revealed that N meant these treatments were not administered due to Staff on duty forgot to sign on those dates except for on 2/14/2021 which was due to Resident asleep and 2/18/2021 which was due to Unable to check. Resident on 40's hall. The TAR was left blank on 2/10/2021 at 6:00 AM, 2/11/2021 at 6:00 AM, 2/14/2021 at 2:00 PM, 2/22/2021 at 10:00 PM, 2/23/2021 at 2:00 PM, 2/24/2021 at 2:00 PM and 10:00 PM, 2/26/2021 at 10:00 PM, and 2/27/2021 at 6:00 AM. Further review of the TAR revealed an order to check WanderGuard for function on 11-7 shift (daily). N was entered on 2/2/2021, 2/3/2021, 2/4/2021, 2/5/2021, 2/8/2021, 2/14/2021, and 2/16/2021. Review of the TAR notes revealed N meant that these treatments were not administered due to Staff on duty forgot to sign on those dates except for 2/14/2021 and 2/16/2021 due to resident asleep. The TAR was left blank on 2/10/2021, 2/11/2021, 2/13/2021, and 2/28/2021. On 4/8/2021 at 10:17 AM, an interview was conducted with CNA L who works the hall that Resident #2 was housed on. When asked if Resident #2 would be safe if out alone in the community unsupervised and she shook her head and stated, I would be concerned that he would get lost. On 4/8/2021 at 1:12 PM, an interview was conducted with RN K. When asked if Resident #2 would be safe if out alone in the community unsupervised and she replied, No. When asked why she replied, Because he's impulsive and combative. Resident #1 2. A review was conducted of the facility reported event that was dated 2/19/2021 involving Resident #1. The form identified that Resident #1 eloped from the facility following a beauty shop appointment on 2/4/2021 (the time was not noted) due to not being picked up at the end of her appointment. Resident #1 was able to leave the beauty shop (located in the nursing home) unaccompanied and was found in the Assisted Living Facility (ALF) next door to the nursing home at an unknown time. According to the report, Resident #1 asked the receptionist in the ALF next door to call her a cab to take her to Temple Terrace, FL. The document revealed the following corrective actions were completed after the elopement of Resident #1: - Beautician was educated on how to call staff who will escort residents to and from appointments at the salon. - Elopement book prepared and placed in salon. - Beautician educated on how to use elopement book. - Continuing education provided to staff regarding the elopement policy and procedure. On 4/5/2021 at approximately 4:00 PM, an interview was conducted with the Director of Nursing (DON) and Administrator. When asked if the corrective actions for Resident #1's elopement were carried out, they both verified that they had not been. On 4/7/2021 at approximately 12:00 PM, an interview was conducted with the Beautician, who had provided hair care to Resident #1 on the day of the elopement. During the interview the Beautician reviewed his appointment book and stated that Resident #1 had an appointment scheduled at 12:45 PM on 2/4/2021. The Beautician could not remember if the resident was on time or what time he finished the appointment. He stated that he was not told to call for the resident to be picked up, the resident acted like she knew what she was doing and just left the salon after the appointment was finished, he did not know what direction the resident went. On 4/8/2021 at approximately 9:15 AM, an interview was conducted with the receptionist of the neighboring ALF, who was working on the day the resident eloped. During this interview the receptionist stated that Resident #1 walked up to her desk and requested that a cab be called to take her home. She stated she does not recollect the time, but her work schedule is from 4:00 PM to 7:30 PM Monday through Friday and the event would have taken place after she arrived to work that day. These interviews revealed that up to a 3-hour window potentially elapsed between the resident's beauty appointment at 12:45 PM and when the ALF receptionist reported to work at 4:00 PM. A record review was conducted of the facility state report filed 2/19/2021 for Resident #1. No internal investigation or supporting documentation for this incident was provided by the facility. A record review was completed for Resident #1's Comprehensive Care Plan dated 2/2/2021. The resident was identified to have cognitive deficits secondary to dementia and poor safety awareness. Resident #1 was identified as having a recent history of leaving the Unit unassisted and requiring a WanderGuard for her safety. Goals on the care plan included for the resident to be safe on the unit and not leave the Unit unattended/unassisted without staff/visitors. On 4/5/2021 at approximately 12:25 PM, an interview was conducted with CNA G who she was not made aware of Resident #1's elopement, but was aware that when her family would come to the facility that she wanted to leave after them. On 4/5/2021 at approximately 12:45 PM, an interview was conducted with CNA C who stated she was not aware of Resident #1's elopement from the facility. On 4/5/2021 at approximately 1:00 PM, an interview was conducted with RN B who stated she was not made aware that Resident #1 had eloped from the facility and was not aware of any increased supervision for this resident. 3. Review of the facility's Elopements and Wandering Residents policy and procedure revised June 2019 revealed in Section 4, Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. (b.) The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. (c.) Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. (e.) Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. (f.) The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Review of an addendum, Tips for Prevention of Future Elopements, revealed Consider use of a 'Chain of Custody' for High Risk Residents; develop a schedule for periodic checks on the resident and Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff and whoever is involved in the resident's care even for a short period of time. Review of the facility's Elopement Checklist located at the front of the elopement book revealed it is to be completed after the resident has been located and returned to the Unit. The checklist included: - Nurse to complete immediate assessment for harm, including vital signs, ROM (range of motion) and neuro-checks x 1. Also need to test WanderGuard for placement and functionality and document in nurses note. - Make note of and document timelines for the following: a. Time resident last seen by staff b. Time alarm sounded (if applicable) c. Time resident located and where d. Time of return to Unit e. Time of implementation of safety procedures to insure no repeated elopements - As soon as possible after resident determined to be stable, notify family/POA (Power of Attorney) and attending physician, making note of the times. - Begin investigative process: a. Collect witness statements from each staff member who may have information about the elopement. Prior to end of shift have a shift huddle to discuss event and write down any pertinent details, i.e., resident behaviors, cognition, was alarm going off, etc. b. Open and complete an Incident Report in AHT (cloud-based electronic health record system). 4. The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective action. Elopement assessments completed for all residents by 4/8/2021. This was verified by record review of 107 resident elopement assessment audits. Re-educated staff from all shifts who worked between 4/5/2021 and 4/7/2021, approximately 66% of staff, on elopement standards and guidelines. This was verified through interviews with 4 staff and record review of training for elopement drills. Elopement drills initiated and completed on 4/6/2021, 4/7/2021 and 4/8/2021 with 78% of staff participating. This was verified by record review of drill logs and observation of staff responding to elopement drills on first shift on 4/6/2021 and on 2nd shift on 4/7/2021. Alarm response time audits completed 3 times for each alarmed exit door on 4/6/2021, 4/7/2021 and 4/8/2021. This was verified by record review of audit sheets that indicated a response time of less than 60 seconds or re-education was provided. Residents have photos in elopement in electronic medical record and placed in elopement book as risk assessments direct. This was verified by review of elopement books and risk assessments completed for all residents. Construction gates locked and new signage placed to keep gates closed. This was verified by observations of gates closed on 4/7/2021 at approximately 9:15 AM and 5:45 PM and 4/8/2021 at 9:00 AM and 5:45 PM.

Based on observation, interviews and record reviews, the facility failed to identify and act upon known elopement events for 2 of 2 residents sampled for elopement (Resident #1 and #2) and failed to provide training for staff in response to door alarms and resident elopements. The facility's failure to identify elopement risk as an area of improvement placed Residents #1 and #2 as well as 11 other residents identified at risk for elopement at a likelihood of serious injury and death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/2/2021. The facility Administrator was notified on of the Immediate Jeopardy on 4/7/2021 at 5:15 PM, prior to survey exit on 4/8/2021. The Immediate Jeopardy was determined to have begun on 2/2/2021, the day Resident #2 exited the building unsupervised. The Immediate Jeopardy was removed on 4/8/2021, based on verification of implementation of removal plan. The deficient practice was reduced to a scope and severity level of an D. The findings include: Record reviews conducted for Resident #2 revealed the resident had eloped from the facility on 2/4/2021 (per the facility generated document provided by the Administrator titled AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day); 2/15/21, 2/23/21 and 2/28/2021 (Per nursing note documentation). An electronic report was never filed with the Agency as required for this event. Review of a 15-Day Report submitted to the Agency electronically revealed Resident #1 had eloped from the facility on 2/4/2021. No Immediate Report had been submitted to the Agency electronically and as required for this event. Review of the 2021 Adverse Incidents and Federal Reports provided by the facility confirmed that no reports had been filed for Resident #2 and no Immediate Report had been filed for Resident #1. A review of QAPI Meeting Minutes was conducted for the meetings held on 2/3/2021 and 3/2/2021. No information, reports, or investigations were found for the 5 elopement events that had occurred during the month of February for Residents #1 and #2. A review of the 15-Day Report filed by the facility included the corrective actions reported to have been implemented after the elopement of Resident #1. These corrective actions included education provided to the Beautician on how to call staff who will escort residents to and from appointments at the salon; elopement book prepared and placed in salon, with education on how to use the elopement book; and continuing education provided to staff regarding the elopement policy and procedure. On 4/5/2021 at approximately 10:15 AM, no elopement book was observed in the salon. On 4/5/2021, the facility was asked to produce documentation of continuing education provided to staff regarding the elopement policy and procedure. The facility was unable to produce this documentation. On 4/7/2021 at approximately 12:00 PM, an interview was conducted with the Beautician, who had provided hair care to Resident #1 on the day of the elopement. He pointed to the elopement book on the table in the salon and stated that he didn't know what it was, it was just sitting on the table when he arrived earlier that day. He further stated that no one from the facility had spoken to him regarding Resident #1's elopement. On 4/5/2021 at approximately 4:00 PM, an interview was conducted with the Director of Nursing (DON) and Administrator. When asked if the corrective actions for Resident #1's elopement were carried out, they both verified that they had not been. Neither the DON nor Administrator could provide an explanation as to why the elopements were not discussed at QAPI, why Resident #1's corrective actions were not carried out, or why there was no follow-up. On 4/5/2021 during the initial tour with the DON, observations were made of staff members failing to respond to sounding door alarms. At 10:13 AM, the exit door leading to the front parking lot was activated and the alarm sounded for approximately 20 minutes. No staff responded during this time. At 10:34 AM, the exit door on the 160-170's hall was activated. After no staff responded to the alarm for 10 minutes, the surveyor and DON re-entered the facility and dismissed the alarm. At 10:46 AM, the exit door alarm was sounded on the 120-130's hall. Staff were observed walking on the unit and disregarding the alarm. At approximately 10:51 AM, the exit door on the 140-150's hall was sounded. No staff were observed to respond. On 4/5/2021 at 10:25 AM, an interview was conducted with Registered Nurse (RN) A, charge nurse, at the main nurses' station, which is located approximately 45 feet from the exit door next to the beauty shop. While the alarm was still audible in the background, the surveyor asked if she could hear an alarm sounding and she replied, No. On 4/5/2021 at 10:27 AM, an interview was conducted with RN B at a medication cart in front of the nurses' station and approximately 50 feet from the exit door next to the beauty shop. While the alarm was still audible in the background, the surveyor asked if she could hear an alarm sounding and she shook her head no. She stated if she hears an alarm, she tells her supervisor then goes to check the doors and calls a code pink. On 4/5/2021 at 10:44 AM, observations were made of Certified Nursing Assistant (CNA) C and CNA D after the alarm was sounded on the 160's hall. CNA C was observed to be walking on the unit going from one room to another and did not acknowledge the alarm. CNA D was observed pushing a scale into a resident's room and did not acknowledge the alarm. When CNA C was asked why she didn't respond to the alarm, she could provide no explanation and continued on with her work. When CNA D was asked why she didn't respond to the alarm, she stopped pushing the scale, went to the door and stated, I don't know how to turn it off. I don't have the code. No concern was evident from either staff in regards to a possible eloped resident. On 4/5/2021 at 10:50 AM, an interview was conducted with CNA I (second floor) who has worked at the facility for [AGE] years. Stated that she was unsure of the facility's internal alert code for elopement and referred the surveyor to CNA J who would be able to answer the surveyor's questions. On 4/5/2021 at 10:58 AM, an interview was conducted with CNA J (second floor) who has worked at the facility for [AGE] years. She stated she was also unsure of the facility's internal alert code for elopement as she hasn't been at work when an actual elopement has occurred. She further stated that she received elopement training at some point but doesn't recall having any in the last year. On 4/5/2021 at approximately 11:00 AM, an interview was conducted with CNA F in which she stated she has not received any training on elopement from the facility. On 4/7/2021 at approximately 2:46 PM, an interview was conducted with RN E (hired 12/14/2020). When asked if she had received any elopement training prior to today she replied, No. On 4/6/2021 at approximately 2:00 PM, an interview was conducted with the DON. She confirmed that no elopement training was provided to staff after the elopements of Residents #2 and #1. On 4/6/2021 at approximately 10:00 AM, documentation was requested regarding door alarm audits. No records were provided. On 4/8/2021 at approximately 9:00 AM, the facility was observed conducting an audit of all windows to ensure that safety clips were in place to prevent future window elopements from occurring. On 4/8/2021 at approximately 10:00 AM, the survey team conducted a quality assurance check of the facility's window safety audit. An observation was made of the window in room [ROOM NUMBER], which is the window Resident #2 exited from on 2/23/2021. The window clip was observed to be positioned in the upper corner allowing for the window to be opened approximately 2 feet wide which was wide enough for a person to fit through. (Photographic evidence obtained) On 4/8/2021 at approximately 3:00 PM, the Administrator was notified of the survey team's window audit finding. The facility responded by conducting another window audit. The Immediate Jeopardy was removed onsite after the receipt of an acceptable IJ removal plan. The survey team verified the facility's immediate corrective actions. Alarm audits conducted for response time. This was verified by record review of elopement drills held on 4/6/2021, 4/7/2021 and 4/8/2021 and interviews with 4 staff including nurses and CNAs. Audited elopement assessments for all residents and identified those at risk were added to elopement books. This was verified by record review of 107 resident elopement assessment audits and review of updated elopement books. Drill assessment audited for improvements. This was verified by record review of elopement drills containing audits. Window audit completed on 4/8/2021 of all facility windows. This was verified by observing all windows of residents at risk for elopement and any windows previously exited. Initiated QAPI to include ad hoc QAPI conducted on 4/5/2021 and special focus QAPI on 4/8/2021. This was verified by record review of meetings held on 4/5/2021 and 4/8/2021.

Based on interviews and record reviews, the facility failed to immediately report an alleged violation of neglect for resident elopement for 1 of 2 residents sampled for elopement (Resident #2). The findings include: Review of the facility's 2021 Adverse Incidents and Federal Reports revealed no reports had been filed electronically as required for Resident #2. Resident #2 1. On 4/6/2021 at approximately 12:00 PM, the surveyor asked the Administrator why Resident #2's elopement was not reported to the Agency. She replied that it was, and handed the surveyor a document titled, AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). The surveyor informed the Administrator that Immediate Reports are to be filed electronically with the Agency. The Administrator verified she was aware of this procedure and provided no explanation as to why an Immediate Report was not filed electronically. On 4/6/2021, a review was conducted of the facility generated document provided by the Administrator titled, AHCA Confidential Nursing Home Complete Adverse Incident Report - 15 Day (Internal Use Only). Review of the report revealed an incident had occurred on 2/4/2021 at 9:00 AM, in which Resident #2 was discovered at the Pool House. The Pool House sits on the edge of Commencement Cove (road) across from the [NAME] Center for Lifelong Learning and is approximately 250 yards from the facility. Review of the section circumstance of the incident/narrative of facts revealed that Resident #2 had exited the side door of the Unit, walked over to the Pool House trying to go home, was found by the Director of Nursing (DON) (who drove him around the community), and was returned to the health center (facility) by the DON. This section also revealed that Resident #2 thanked the DON for the ride and no apparent injuries were noted. Review of the section analysis of incident/apparent cause revealed Resident #2 exited the side door while staff were providing morning care to other residents, he did not have his wander alarm in place, and he was found within a few minutes. Review of the facility's Elopements and Wandering Residents policy and procedure revised June 2019 revealed in Section 7(g), Procedure for Locating Missing Resident, Appropriate reporting requirements to the State Survey agency shall be conducted. Review of the facility's Abuse, Neglect and Exploitation policy and procedure revised July 2020 revealed in Section VII. Reporting/Response revealed the following: - Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: - Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or - Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury Review of the facility's 2021 Adverse Incidents and Federal Reports revealed no Immediate Report had been filed electronically as required for Resident #1. Resident #1 2. A review was conducted of the facility reported event that was submitted electronically to the Agency on 2/19/2021 involving Resident #1. The form identified that Resident #1 eloped from the facility following a beauty shop appointment on 2/4/2021 (the time was not noted) due to not being picked up at the end of her appointment. Resident #1 was able to leave the beauty shop (located in the nursing home) unaccompanied and was found in the Assisted Living Facility (ALF) next door to the nursing home at an unknown time. According to the report, Resident #1 asked the receptionist in the ALF next door to call her a cab to take her to Temple Terrace, FL. On 4/6/2021 at approximately 10:00 AM, an interview was conducted with the Administrator. When asked why the facility failed to file an Immediate Report electronically with the Agency due to possible neglect, the Administrator replied that she did not feel that the facility was culpable in the resident's elopement. The surveyor asked the Administrator if the facility was culpable in the resident's elopement as evidenced by: A review was conducted of Resident #1's Elopement assessment dated [DATE] which revealed that the resident was identified as being at risk for elopement. A review was conducted for Resident #1 Comprehensive Care Plan dated 2/2/2021 which revealed the resident had cognitive impairment secondary to dementia, poor safety awareness and short-term memory loss. It further noted that the resident had a recent history of attempting to leave the Unit unassisted and required a WanderGuard (a bracelet type device that alarms if a resident breaches the predetermined perimeter) for safety. The goal was to remain safe on the Unit and not leave the unit unattended/unassisted without staff or visitors. Approaches listed for Resident #1 included documenting all incidents of wandering from the Unit and/or outside the facility when or if they should occur and keep resident's picture and elopement profile at the front desk. On 4/5/2021, a record review of the elopement book housed at the reception desk revealed Resident #1 was not listed or identified within the book. A record review was conducted of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/6/2021 at approximately 10:00 AM, at the conclusion of the interview with the Administrator, she agreed that an Immediate Report should have been filed.

Based on resident record review and staff interview, the facility's Minimum Data Set (MDS) Assessment (Resident Assessment Instrument) failed to accurately reflect a resident's behaviors for 1 of 2 residents reviewed for elopement (Resident #2). The findings include: Review of Resident #2's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 2/2/2021 revealed under Section A - Identification Information that the resident was admitted to the facility from the community on 1/26/2021. Review of Section D - Mood revealed a Total Severity Score of 00 based on a scale of 0 - 27 meaning the resident did not exhibit any indicators of depression. Review of Section E - Behaviors revealed the resident did not exhibit any of the following behaviors: [CONDITION(S)] to include hallucinations or delusions, physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, etc.), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms like screaming, etc.), rejection of care, or wandering. Review of Section I - Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Nurse's Notes revealed the following events and patterns of displayed behavior: - 1/27/2021 5:18 PM Resident has been agitated today. Wandering into other residents rooms and very difficult to redirect. - 1/27/2021 2:44 PM has been very agitated and aggressive 7-3pm shift, had to threaten security to get him out of my face on two occasions and had to call the Charge nurse [Registered Nurse M] who came in on two occasions to calm him down, and When I mentioned [resident's doctor] would like him to lie down in his room and rest, he became very angry - 1/27/2021 10:19 AM Call placed to son to discuss recent wandering behaviors and aggression toward staff members. According to son resident has been exhibiting these behaviors for the past 75 days and primarily in the am (morning) hours. Resident is currently stating he wants to leave the facility and is entering other residents rooms and wanting to leave the ATU (Admission-Transition Unit). - 1/28/2021 9:42 PM Resident stated he was trying to 'get up and leave' - 2/2/2021 2:26 AM Resident stated about 1AM that he wanted someone to come here and take him home. Did not want to sleep here. Further review revealed no Nurse's Notes were entered on 1/29/2021, 1/30/2021, or 1/31/2021. On 4/7/2021 at 10:13 AM, an interview was conducted with the MDS Coordinator. The surveyor reviewed the contents of the Nurses' Notes above with the MDS Coordinator and asked if the resident's 2/2/2021 Admission MDS Assessment, which indicated he exhibited no behaviors or behavioral symptoms, accurately reflected his status provided the fact that aggressive and wandering behaviors were noted as being present on the first full day following admission. The MDS Coordinator agreed that the MDS Assessment should have reflected the noted behaviors being exhibited.

Based on observation, record review, policy review and interviews, the facility failed to ensure the Interdisciplinary Team (IDT) determined if self-administration of medication was appropriate prior to resident self-administering medications for 1 or 19 sampled residents (#22). The findings include: On 1/5/21 at approximately 11:30 AM, three medications were observed on resident #22's overbed table. The facility nurse was not in the room. The medication observed was [MEDICATION NAME] 55 mcg nasal spray (a medication used to treat seasonal and year-round allergies [REDACTED]. On 1/5/21 at approximately 11:35 AM, an interview was conducted with Staff E, a Registered Nurse, (RN). Staff E revealed the medications that were found in the room are usually left on the overbed table for resident #22 to self-administer. A review of resident #22 medical record was completed. The record review failed to reveal an assessment of resident #22 capacity to self-administer medications, failed to reveal a care plan for self-administration of medication and failed to reveal a physician order [REDACTED].>On 1/8/21 at approximately 8:10 AM, an interview was conducted with the Director of Nursing (DON) who revealed the facility currently does not have residents who self-administer medications. The DON confirmed any resident who wants to self-administer medications would require the IDT to first review the request and would then require inclusion on the Care Plan prior to the resident self-administering medication. On 1/8/21 at approximately 8:50 AM, a review of the policy, Resident Self-administration of Medication, last revised on 7/20 revealed the resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on interview and record review the facility failed to report allegations of abuse for 1 of 2 residents sampled for abuse, (resident #3). The findings include: A family interview was conducted for resident #3 on 01/05/2020 at 12:41 PM, in which the residents daughter stated that she had a concern with how her mother was treated by a staff member. The daughter stated that on December, 4, 2020 she found a bruise and a skin tear on her mothers left elbow when changing her clothes. During this observation she asked her mother what happened and the resident stated that the staff had been rough during her care. The daughter stated she immediately called the Assistant Director of Nursing (ADON) into the room and voiced her concerns about her mothers care and her complaint of being handled rough. During the interview she stated that she felt that she notified the right person of her mothers allegation, and she felt that this issue was going to be handled. The staff member in question that cared for resident #3 on December 4, 2020 was removed from her mothers care and she never heard back from the facility regarding her mothers allegation. An interview was conducted with the ADON on 1/6/2021 at 2:58 PM. During this interview the ADON stated she did go to resident #3's room on December 4, 2020 at the daughters insistence. It was reported to her by resident #3 and the residents daughter that the resident was handled roughly by the staff that morning resulting in a bruise and skin tear on the residents left arm. During this interview the ADON stated that an immediate abuse report should have been filed and notification should have been made to the administrator and risk manager. An interview with the facility Administrator was conducted on 1/6/2020 at approximately 3:45 PM, in which she stated a grievance was filed for the residents skin tear and bruising however, no immediate reporting was completed at the time of the allegation of abuse. A record review was conducted of the facilities abuse policy dated 07/2020. The policy titled Abuse, Neglect and Exploitation. Section VII, (A)(1)(a) instructs staff to report all alleged violations to the administrator, state agency, adult protective services and all other required agencies immediately but not later that 2 hours after the allegation is made.

Based on observations, interview and resident record review, the facility failed to ensure a medication error rate of 5% or below, for 2 of 25 medication opportunities observed (Residents #31 and #60). Error rate of 8%. The findings include: 1. On 01/07/2021 beginning at approximately 8:30 AM, medication administration observations were conducted with Staff Member C, a Licensed Practical Nurse (LPN). Resident #31 was given by mouth a multivitamin with iron, along with 13 other medications. A review of Resident #31's Medication Administration Record, [REDACTED]. On 01/07/2021 at approximately 9:30 AM, the medication error was reviewed with Staff Member C. Staff Member C stated that she must have picked up the wrong bottle; that they both looked the same, but one had an orange label and the other label was green. 2. On 01/07/2021 beginning at approximately 08:43 AM, medication administration observations were conducted with Staff Member D, an LPN. Resident #60 was given a total of eight medications, divided into two medication cups. Included in one of the medication cups, was one chewable Simethicon 80mg gas relief tablet. Resident #60 took the entire cup of medication into his mouth and swallowed without water. He did this with both medication cups. At no time, did Staff Member D, instruct the resident that the gas relief medication needed to be chewed. A review of the medication bottle for the generic over-the counter chewable tablets - Gas Relief - Simethicon 80mg instructed on the back of the bottle chew thoroughly. (photo documentation obtained) On 01/07/2021 at approximately 9:25 AM, Staff Member D was informed of the medication error. She stated the resident always takes his medications like that.

Based on resident interview, staff interview, and record review, the facility failed to allow the resident the right to choose the type of bathing she would prefer for 1 of 1 resident sampled for bathing (#81). The findings include: Resident #81 was admitted to the facility on [DATE] post fall in her home. On 1/14/19 the admission minimum data set (MDS) indicates it is very important for her to choose the type of bath she prefers. The quarterly MDS dated [DATE] indicates a brief interview for mental status (BIMS) of 12 which indicates moderately impaired, and she requires a one person physical assist for most activities of daily living. An interview was conducted with the resident on 05/14/19 at 9:40 AM. She was asked about her choices and she said, I am supposed to have baths three times per week. That does not happen. A follow up interview was conducted on 5/17/19 at 2:05 PM she was asked about getting a choice about bathing again. She stated, Those girls do not want to give me a shower. A review of her electronic record indicates she is bathed on Tuesday, Thursday, and Saturdays on 3PM-11PM shift. Review of the bath day roster shows that the resident received a shower twice from 4/6/19 to 5/14/19. Other days it indicates she had complete bed baths. The shower days were 4/6/19 and 5/4/19. An interview was conducted with Registered Nurse Employee E on 5/16/19 at 12:00 PM. She was asked the process for determining preferences for residents. She said residents are asked on admission regarding their preferences about bathing and wake-up times. A follow-up interview was conducted on 5/16/19 at 2:25 PM. She was asked about resident #81's bathing schedule. She said the times for bathing and showers are basically scheduled by room number, resident #81 gets her baths on 3-11 shift. She was asked to tell me the number of showers resident #81 received in the past month. She reviewed the electronic record for bathing and said it looked like she had received 2 showers one on 4/6/19 and another on 5/4/19. The other days indicate bed baths. She was then asked if she felt that was appropriate. She said personally I think she should be showered more. The nurse verified that the report does not show if she was asked what type of bath she wanted to receive.

Based on staff interview, clinical record review, and policy review, the facility failed to notify the resident, resident representative and the ombudsman of the reason for a hospital transfer in writing and for 1 of 2 (#81) residents reviewed for hospitalization . The findings include: Resident #81 was admitted to the facility on [DATE]. She was sent out of the facility and admitted to the hospital on [DATE] with a return to the facility on [DATE]. Review of the electronic record revealed she went to the hospital for suspected cardiovascular accident (stroke). She was sent out of the facility a second time on 4/14/19 with a return on 4/18/19. This admission was in relation to altered mental status with a return [DIAGNOSES REDACTED]. Further review of the electronic record and the written chart failed to reveal notifications to the Ombudsman or a copy of the notification in writing to the family. The administrator was interviewed on 5/17/19 at 10:03 AM. He was asked to provide the documentation that the resident and her representative received a copy of the documentation she was being transferred to the hospital in writing and that the Ombudsman was notified. He said he would check with the records, and social services and return. On 5/17/19 at 10:30 AM he returned to say that he could not find any form in writing for the two transfers to the hospital for Resident #81. At the time of exit no documentation was provided to indicate that the Ombudsman was notified of the two transfers to the hospital for #81 or that the resident and family were notified in writing. A policy was requested for transfer and discharge from the facility. The policy was provided: Transfer and Discharge, reviewed 06.18: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. Page 3 of 4: 7 Emergency Transfer/Discharges - initiated by the facility for medical reasons Page 4 of 4: J. provide transfer notice as soon as practicable to resident and representative. K. social services director or designee shall provide notice of transfer to a representative of the transfer to a representative of the State Long-Term Ombudsman via monthly list.

Based on staff interview, clinical record review, and policy review, the facility failed to provide to the resident and resident representative written notice of the bed hold policy for 1 of 2 residents (#81) reviewed for hospitalization . The findings include: Resident #81 was admitted to the facility on [DATE]. She was sent out of the facility on 2/22/19 and admitted to the hospital on [DATE] with a return to the facility on [DATE]. Review of the electronic record revealed she went to the hospital for suspected cardiovascular accident (stroke). She was sent out of the facility a second time on 4/14/19 with a return on 4/18/19. This admission was in relation to altered mental status with a return [DIAGNOSES REDACTED]. Further review of the electronic record and the written chart failed to reveal notifications in writing of the bed hold policy at the time of the transfers to the hospital. A copy of the policy for bed holds was requested. The policy provided is titled: Policy of Bed Hold Bed Hold Notice and Transfer; Reviewed 06/18. The policy reads at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. Policy Explanation and Compliance Guidelines: 1. before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. the duration of the state bed hold policy , if any during which the resident is permitted to return and resume residence in the nursing facility . b. the reserve bed payment policy in the state plan policy if any, C. the facility policies regarding bed hold periods to include allowing a resident to return to next available bed. 2. in the event of an emergency transfer of a resident , the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated in each State's plan. An interview was conducted with the Administrator on 5/17/19 at 10:03 AM. He was requested to provide documentation that the resident and her representative were notified of the bed hold policy at the time of her transfers to the hospital. He said he would check and return. A follow-up interview was conducted at 10:30 AM. He said he could not find that the bed hold information was provided to Resident #81.

Based on interviews and resident medical record reviews, the facility failed to ensure the baseline care plan included the care needs of the resident and failed to ensure the resident and/or the resident's representative received a summary of their baseline care plan for 1 of 2 resident's newly admitted to the facility. (Residents #171) The findings include: 1. On 05/14/2019 a record review was conducted for Resident #171. Resident #171 was admitted on [DATE] and started on antibiotics for a urinary tract infection [MEDICAL CONDITION] The baseline care plan, in place, indicated Resident #171 was on a regular diet, at risk of falls, at risk for skin integrity issues/concerns and pain management issues/concerns and had low chronic back pain. There were no interventions identified on the care plan related to the UTI. The resident's responsible party signed the care plan, but the facility was not able to demonstrate that a summary of the baseline was provided to either the resident or the representative. Interview conducted with the DON on 05/14/2019 at approximately 4:45pm regarding the development of the admission baseline care plan. She stated the baseline care covers general areas of assessment, the resident's order would be included as part of the resident's plan of care. She did not feel the resident needed a specific care plan for urinary tract infection as standard of care would apply to the care needed for this resident. She also stated that when family signs off on the care plans, the team offers the resident/family a copy, though she stated she is not able to demonstrate this. She stated the baseline care plan form was developed by the(NAME)office to cover falls, skin, and safety issues. A review of the facility's policy and procedure entitled Baseline Care Plan indicates: 1. The baseline care plan will: b. include the minimum healthcare information necessary to properly care for a resident including, but not limited to: 1. Initial goals based on admission orders [REDACTED]. Dietary orders; iv. Therapy services; v. Social Services; vi. PASARR recommendation, if applicable. 2a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living iii. Any special needs such as for IV therapy, [MEDICAL TREATMENT] or wound care. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum the following: a. The initial goals of the resident b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.