Every finding on record at Whispering Oaks

Based on observations, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to control the spread on infection related to: 1. failing to ensure the proper isolation signage was posted for one (Resident #246) of five residents sampled; 2. failing to ensure personal protective equipment (PPE) was available and hand hygiene was performed in room [ROOM NUMBER]; 3. failing to ensure proper placement of medical equipment to prevent infection; and 4: failing to ensure 3 (Staff U, Staff V, and the DON) of 3 staff fingernails did not create a safety or infection control issue.Findings include: 1. Resident #246 was observed in her room resting in bed. An observation was made of a Contact Precautions sign posted on the door. There was no PPE (Personal Protective Equipment) observed on the door or nearby. The sign revealed a STOP sign with the following information:Everyone must: Clean their hands, including before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gone before room exit. Use dedicated or disposable equipment clean and disinfect reusable equipment before you use on another person. On 02/09/2026 at 12:43 p.m. an interview was conducted with Staff V, Registered Nurse (RN). She stated Resident #246 was newly admitted and was on contact precautions for ESBL (Extended-Spectrum Beta-Lactamase). Staff V, RN stated the resident arrived the previous day at 4:30 PM. She confirmed there was no PPE available for staff to use throughout the night and earlier that morning. She stated the staff should wear full PPE for direct care contact. On 02/10/2026 at 1:35 p.m. an observation was made of Staff W, Certified Nursing Assistant (CNA) walking into Resident #246's room. An observation was made of an over-the door PPE shelf storage with gloves and gowns. Staff W proceeded to assist the resident with meal. The Staff member did not wash hands, don gloves or gown. Staff W was observed moving a chair and using a paper towel to grab it, placing in it in the middle of the shared room after assisting Resident #246 with her meal. On 02/10/2026 at 1:41 p.m. an interview was conducted with Staff W, CNA. She confirmed she did not wear gown a gown or gloves when feeding Resident #246. Staff W stated as she read the sign on the door, I should have worn gloves and gown. On 02/10/2026 at 1:45 p.m. an interview was conducted with Staff M, Licensed Practical Nurse (LPN)/Unit Manager (UM). She stated prior to entering the room, staff should wash hands and pay attention to what is on the door. Staff M LPN/UM stated for contact precautions the staff should wear gown and gloves when working directly with patient to include assisting the resident with meal. 2. On 2/9/2026 at 7:42 a.m., an observation of room [ROOM NUMBER]'s door revealed a sign that showed contact precautions with a caddy hanging that contained gowns. An observation of Staff A, Certified Nursing Assistant (CNA) revealed she entered room [ROOM NUMBER] without performing hand hygiene or putting on personal protective equipment (PPE). Staff A, CNA was observed walking to bed B and touched the bedside table, eyeglasses, and telephone. She then walked to bed C and touched the resident's blanket. Further observations of Staff A, CNA revealed she walked to bed A and touched the Styrofoam cup with water on the resident's bedside table. Staff A, CNA was observed exiting the room and did not perform hand hygiene. On 2/9/2026 at 7:46 a.m., an interview was conducted with Staff A, CNA. She said the residents in bed B and bed C are on contact precautions. She said she wore gloves and PPE when she performed direct patient care. Staff A, CNA said she was adjusting the resident's items, which did not require her to wear gloves. On 2/9/2026 at 9:25 a.m., a second observation of Staff A, CNA was conducted. She went into room [ROOM NUMBER] with no PPE on, which had a contact precaution sign on the door. Further observations revealed she went to bed A, then exited the room. Staff A, CNA entered room [ROOM NUMBER] again with no PPE on. She was observed leaving the room with a resident's meal tray. 3. On 2/9/2026 at 1:04 p.m., Resident #16 was observed lying down in bed. Further observations of the area around the resident's bed revealed the connected humidifier reservoir for Resident #16's tracheostomy was in the garbage can. Photographic evidence obtained. On 2/9/26 at 1:05 p.m., an observation of room [ROOM NUMBER] revealed the resident in bed B was requesting to be assisted into bed. Staff B, Registered Nurse (RN) entered the room to assist the resident and was observed putting gloves on, however no other PPE was put on. On 2/9/26 at 1:15 p.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She said the bag in the middle of the humidifier is to collect fluid from the condensation. Staff C, LPN said it is not a closed system because once the bag is full, she can exchange out the bag and keep the tubing connected to the resident and the humidifier. Staff C, LPN said proper placement for the bag should not be on the ground. Staff C, LPN confirmed the humidifier bag should not be in a garbage can. A review of Resident #16's admission record revealed an initial admission of 1/15/25 and a re-admission date of 7/26/25. Further review of the admission record revealed diagnoses to include chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease, unspecified, other diseases of larynx, bronchitis, not specified as acute or chronic and malignant neoplasm of larynx, unspecified. A review of Resident #16's physician orders included the following: - Transmission Based Precautions Contact Precautions: trach [tracheostomy] infection every shift until 02/14/2026, with an order date of 2/10/26. - Cefdinir Oral Suspension Reconstituted 250 MG [milligrams]/5ML [milliliters] (Cefdinir) Give 6 ml via G-Tube [gastrostomy tube] two times a day for Trach infection for 10 Days, with an order date of 1/31/26. A review of Resident #16's care plan included the following: - The resident had a surgical infection, to trach and requires Contact Precaution, with an initiated date of 2/6/26. Further review showed goals to include, To minimize the Spread of Infection, and interventions to include, Contact Precautions. - Behavioral: [Resident #16] is noted with the following behaviors: noncompliant with NPO [nothing by mouth] status, refuses to be suctioned, noncompliant with using walker, refuses to sleep with dehumidifier at times Res: [resident] Is noncompliant with removing his oxygen and trach and NPO status, with an initiated date of 1/27/26. On 2/11/2026 at 10:05 a.m., an interview was conducted with Staff B, RN. She said enhanced barrier precautions is an intervention as they protect staff from carrying something on their clothes. Staff B, RN said she would wear PPE if a resident had a wound, foley, tracheostomy, or G-tube. She said she wore a gown and gloves when residents are on precautions such as enhanced barrier and contact. On 2/11/2026 at 10:30 a.m., an interview was conducted with Staff D, RN/Unit Manager (UM). She said she expected staff to follow the recommendations on the signage for contact precaution. Staff D, RN/UM said staff should wear a gown, mask, glove or face shield. 4. An observation on 2/9/2026 at 9:15 a.m. of the DON revealed long-tan colored nails with rhinestones. Her nails appear to be around ¾ beyond the fingertip. An observation and interview on 2/12/2026 at 12:55 p.m. with Staff U, Licensed Practical Nurse (LPN) was conducted. Staff U, LPN was observed with not natural, painted white French-tip style, and contained rhinestones. Staff U, LPN said the facility educated that staff should have natural nails and only 1/4 long, but it is not enforced. An observation and interview on 2/12/2026 at 1:08 p.m. with Staff V, Registered Nurse (RN), was conducted. Staff V, RN was observed with not natural, painted red French-tip style, and extended beyond 1/4 long. Staff V, RN said her nails are too long, but the policy is not enforced. An interview on 2/12/2026 at 10:36 a.m. with the DON regarding her fingernails. The DON said she does not do direct care. The DON said the direct care staff should not have long nails. The DON stated, I said I got the point, they are long. A review of the facility provided Employee Handbook revealed on page 30 a section titled, Personal Hygiene & Dress Code. The personal hygiene and dress code revealed: The facility requires that all employees present a professional image. Accordingly, each employee is expected to wear appropriate business attire for his or his position while representing the facility. The following are general guidelines to be adhered to by all employees: Personal Hygiene 5: Fingernails should be kept neat, clean, and nails short so not to create safety or infection control issues. No artificial nails, appliqués, or studs on nails may be worn at any time. A review of a facility provided policy effective October 2021 titled, Isolation Precautions – Categories of Transmission-Based Infections revealed the policy is In addition to Standard Precautions, implement Contact Precautions for resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. C: Gloves and Handwashing; 1: While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). 2: Removed gloves before leaving the room and wash hand with an antimicrobial agent or a waterless antiseptic agent. 3: After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. D: Gown; 1: In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. 2: After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces.

Based on observations, interview and facility policy review, the facility did not ensure the kitchen was maintained in a safe and sanitary manner related to food storage, cross contamination of food prep surfaces, general cleanliness and maintaining appropriate dishwashing sanitization levels in one kitchen (main) of one observed.Findings included: On 02/09/2026 at 8:39 AM to 9:15 AM a kitchen tour was conducted with the facility's Registered Dietician (RD) with the following observations made: An observation was made of brown-grease stains and built-up grime above the stove. The Kitchen Manager /Cook (KM) stated this was just from this morning. The RD stated, I see it. It should be clean. An observation was made of a personal water bottle on the Cook's prep station, noted half empty. The RD stated it should not be there and proceeded to remove it. An observation was made of a ceiling vent with dirt, debris and brown matter. The ceiling vent was located above the cooking area. The RD stated he would put in a work order to get it cleaned. An observation was made of the filter in the juice machine with dust, grime and debris. The RD stated he did not know who should be cleaning it. The floor area between the juice machine and the service table was observed with black substances of food particles, dust and debris. An observation was made of two employee jackets hanging on the clean dish rack, touching clean dishes. The RD stated they should not be hanging there and proceeded to remove them. An observation was made of deserts on a cart in a hallway outside the cooler. The RD stated the desert was pears to be served for lunch and they should be stored in the cooler. A tour of the kitchen walk in cooler revealed a box with bags of lettuce, observed wilted, discolored with white bio growth. The RD stated they would discard these items. In the walk-in cooler an observation was made of food boxes with brown- sticky residue on the box. The RD stated he was not sure what it was but would remove it. An observation was made of a log of meat labeled, Ham, dated 2/3/26. The meat was in the middle shelf and not on a tray. The RD stated the ham should be thrown out adding, it is no longer good. He stated cooked foods should not be served after three days. He confirmed the ham was cooked on 2/3/26. An observation was made of numerous plated salads dated 2/2/26 - 2/5/26. The RD stated the salad should have been thrown out on 2/5/26. An observation was made of an undated tray with served portions of ice-cream and brown cake. The RD stated the desserts were to be served later on this day. The RD could not confirm when the desserts were prepared. He stated there should be a date and time. An observation was made of raw chicken stored on the top shelf dated 2/6. The meat was not set on a tray and was directly above food boxes. He stated it would not be at risk of contamination because it was still frozen. On 02/11/2026 at 11:54 AM a second tour of the kitchen was conducted with the RD with the following observations made: Observations were made of the previously observed ceiling vents noted with built in dust, grime and debris, The RD stated, They are not cleaned yet. A temperature check of the milk being served was conducted the milk temperature reading showing 42.4 degrees. The RD stated cold foods should be served at 41 degrees. The RD instructed the aide to add ice on top. An observation was made of an employee's jacket hanging on a chair near the stove with boiled eggs set on top of it and a muffin pan touching the surface. The RD stated that it was unsanitary. He stated employee's personal items should not be in food service/prep areas. He proceeded to remove the eggs. An observation was made of unsanitary dishwashing rags and used cleaning sponges, observed discolored and with brown surfaces. The RD stated, Yes, we should remove those. They would cause cross contamination. An observation was made of a food service utility cart with pieces of napkins and food pieces on the surface. The cart was observed with debris. The RD stated this was a cart for holding dirty dishes cart. He stated nonetheless, the carts should be wiped down daily. On 02/11/2026 at 12:05 PM, an interview and observation was conducted with Staff X, Dietary Aide. Staff X was observed at the dishwashing compartment prepping the sink. He stated prior to washing dishes, he tests the water temp. He did not identify the need to test the sanitization. He stated he never tested the water before. Staff X did not know what the required level was. On 02/11/2026 at12:08 PM, The RD was observed running the dish machine, he stated this was a low temp dish machine. He stated they monitor the sanitization levels. He ran the dishes and tested the sanitizer levels, and the test strip came out with no color. He primed the machine and ran it again. He repeated the process 7 times and each time the color was white, meaning there was not enough sanitizer in the washing solution. He stated he was looking for a purple color. On 02/11/2026 at 12:14 PM, The Regional RD proceeded to assist the RD with testing. He stated the buckets should be primed and the levels tested each time. He proceeded to change the sanitization bucket and primed the dish machine at which the machine levels tested between 50 -100 PPM (parts per million). He stated if the test strip showed no color or white, it meant the concentration was too low, which would be considered unsafe. An interview with the Kitchen Manager on 02/11/2026 at 12:18 PM revealed they would re-wash the dishes that were ran previously. He stated the residents should be served in clean, sanitary dishes. On 02/12/2026 at 1:14 PM, an interview was conducted with the RD. He stated their plan was to avoid food borne contamination. He stated employee clothing coats/jackets and personal items should not be in food prep or storage areas. The RD stated the staff were in serviced, and they should test the water for acceptable PPM every time they change it. he stated they should make sure it is not too high or too low.Review of a facility policy titled, Policy and Procedure - Storage, dated June 2024, revealed 3. Label products with delivery date indicating month and year the product was received.7. Discard leftovers per use by date.8. Cover all prepared items with plastic wrap or foil to prevent off-flavors, drying, and/or cross-contamination.9.Label all prepared items with the product name, preparation date and use by date.Refrigerator Storage1.Store perishable foods in refrigerator and/or foods marked Keep Refrigerated by the manufacturer.2. Maintain refrigerator at a temperature of34-38 degrees F to maintain the food temperature at 41 degrees For less.The facility provided a daily cleaning checklist but not a policy regarding maintaining a clan safe and sanitary kitchen.Photographic Evidence Obtained.

Based on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were completed accurately for 5 residents (#7, #84, #11, #208, and #241) of 11 residents sampled.Findings included: 1. Review of the admission record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnosis to include Bipolar disorder, major depressive disorder, seizures, and personal history of traumatic brain injury (TBI).Review of a Level I PASARR for Resident #7 dated 10/30/24 reveled in section B the seizure and TBI diagnoses were not checked. The level I PASARR showed question 6 was marked No to indicate the individual did not have a related neurocognitive disorder, a serious mental illness or intellectual disability. The review showed the level I PASARR was incomplete and level II PASARR was not submitted for consideration. 2. A record review for Resident #84's admission record revealed the resident was admitted with a primary diagnosis of Schizophrenia. Other diagnoses included generalized anxiety disorder, unspecified convulsions, cognitive communicative disorder, vascular dementia, epilepsy, and major depressive disorder.A review of resident #84's care plan revealed that resident #84 has or is suspected to have a serious mental illness, intellectual disability or other related conditions that require a PASARR level II. The care plan further asserts a goal that PASARR level II recommendations are established and carried out to attain or maintain the highest functional and emotional level. Interventions included psychiatric and psychological services as needed. A review of the PASARR level I screen for resident #84 revealed that the resident has confirmed or suspected mental illnesses with diagnoses of anxiety disorder, depressive disorder and schizophrenia checked. The diagnoses of epilepsy and dementia were not checked. The review showed a level II screen was not submitted for consideration. An interview with staff the social services director (SSD), revealed that they found issues with resident #84's PASARR screening. The SSD said schizophrenia was a serious mental health condition, and a PASARR level II screening should have been conducted. The SSD said that they were under the assumption the PASARR level II screening was completed but was unable to present the documentation to confirm the assumption. 3. A review of Resident #11's admission record revealed an original admission date of 6/27/25 and a re-entry date of 12/5/25. Further review of the admission record revealed diagnoses to include unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other seizures, and depression, unspecified. A review of Resident #11's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 6/26/25, showed no qualifying diagnoses were marked under mental illness (MI) or suspected MI. 4. A review of Resident #208's admission record revealed an admission date of 7/24/2025. Further review of the admission record revealed diagnoses to include other psychoactive substance dependence, in readmission, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder unspecified, and adjustment disorder with depressed mood. A review of Resident #208's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 7/22/2025, showed anxiety as the only qualifying diagnoses marked under mental illness (MI) or suspected MI. 5. A review of Resident #241's admission record revealed an admission date of 01/26/2026. Further review of the admission record revealed diagnoses to include traumatic subdural hemorrhage with loss of consciousness status unknown sequela, bipolar disorder unspecified, alcohol abuse uncomplicated, schizophrenia unspecified, other seizures and insomnia unspecified. A review of Resident #241's admission record revealed an admission date of 01/26/2026. Further review of the admission record revealed diagnoses to include traumatic subdural hemorrhage with loss of consciousness status unknown sequela, bipolar disorder unspecified, alcohol abuse uncomplicated, schizophrenia unspecified, other seizures and insomnia unspecified. A review of Resident #241's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 01/23/26, showed qualifying diagnoses were not marked under mental illness (MI) or suspected MI, and a level II was not submitted for consideration. On 02/12/26 2:17 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated during the morning meetings, the team will look at the PASSAR(s) that are sent, review medical diagnoses and/or H&P (history and physical) to see if there's anything that needed to be changed. The SSD stated, if a change were needed, he would adjust/change, the PASSAR level I. The SSD stated, if there was an issue or something that would flag he would update the Level I, and he would submit for a Level II review. He clarified he would flag diagnoses such as schizophrenia, bipolar, and schizoaffective. He said if sometimes they don't flag to submit a level II PASSAR, he would still send it for review. The SSD stated the Director of Nursing DON or Assistant DON (ADON) would also review the PASSAR(s) to see if they needed to be updated or if they need a level II. The SSD stated SMI included schizophrenia and schizoaffective diagnoses. A review of the facility's policy titled, PASRR- Requirements for Completion, effective August 2025 showed the following policy statement: Pre-admission Screening & Resident Review (PASRR) - Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program (see 42 CFR 483.100) required to be performed on all individuals prior to admission to a Nursing Home. The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. Procedure: This screening is typically done by discharge planners & hospital staff as a step in the discharge process. It is separate from a medical needs assessment, which most often occurs after a person applies for Medicaid, and is a required step to qualify for Medicaid long-term care assistance. 1. During the admissions process, Admissions will communicate with the facility regarding prospective admissions. A Level I PASRR will be provided prior to admission to the Skilled Nursing Facility. The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. 2. Determine if a serious mental illness and / or intellectual disability or a related condition exists while reviewing the PASRR form completed by the Acute Care Facility. (Trigger for Level II Completion) 3. If Serious Mental Illness or ID is indicated, determine if the resident will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30-days of Nursing Facility services. Assure that the certification is signed and dated. 4. If the Physician indicates the stay will likely be less than 30-days SNF services, the resident can be admitted to an SNF. If anticipated stay becomes longer than 30 days a Level II must be completed prior to day 40. Florida Specific Guidelines Florida Facilities (Form 004 Part A effective November 2014) Assure that sections 1-5 are completed prior to admission. If section TV (Provisional Admission) is applicable, the form is only valid if the MD has signed and dated the form. If the admission is a provisional admission, the Social Service Director must start a tickler file and assure the level II is completed within the state-specified time frame. Delirium - within seven (7) days of admission Caregiver respite within 14 days of admission Emergency placement within seven (7) days of admission 30-day hospital exemption within 30-40 days of admission If the preadmission screening requires a Level II evaluation submit all required documents to [contracted state review company] timely, so that a Level II can be completed within the required time frames.

Based on record review and staff interview the facility failed to complete and submit for review the Pre-admission Screening and Resident Review (PASARR) Level II upon acquiring new or qualifying mental health diagnoses for 6 residents (#24, #7, #84, #6, #4 and #241) out of 11 residents sampled for PASARRs.Findings included: 1.) Review of the admission record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses to include a primary diagnosis of schizophrenia, anxiety disorder, bipolar, major depressive disorder, and schizoaffective disorder. Review of the resident's record revealed a level I PASARR (Preadmission Screening and Resident Review) dated 12/5/23. The level I PASARR showed question 6 was marked No to indicate the individual did not have a serious mental illness. The review showed a level II PASARR was not submitted for consideration. 2.) Review of the admission record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnosis to include Bipolar disorder, major depressive disorder, seizures, and personal history of traumatic brain injury (TBI). Review of a Level I PASARR for Resident #7 dated 10/30/24 reveled the seizure and TBI diagnosis were not checked. The level I PASARR showed question 6 was marked No to indicate the individual did not have a related neurocognitive disorder, a serious mental illness or intellectual disability. The review showed the level I PASARR was incomplete and level II PASARR was not submitted for consideration. Review of the resident's record revealed a level I PASARR (Preadmission Screening and Resident Review) dated 12/5/2023. The level I PASARR showed question 6 was marked No to indicate the individual did not have a serious mental illness. The review showed a level II PASARR was not submitted for consideration. 3. A record review for Resident #84's admission record revealed the resident was admitted with a primary diagnosis of Schizophrenia. Other diagnoses included generalized anxiety disorder, unspecified convulsions, cognitive communicative disorder, vascular dementia, epilepsy, and major depressive disorder. A review of resident #84's care plan revealed that resident #84 has or is suspected to have a serious mental illness, intellectual disability or other related conditions that require a PASARR level II. The care plan further asserts a goal that PASARR level II recommendations are established and carried out to attain or maintain the highest functional and emotional level. Interventions included psychiatric and psychological services as needed. A review of the PASARR level I screen for resident #84 revealed that the resident has confirmed or suspected mental illnesses with diagnoses of anxiety disorder, depressive disorder and schizophrenia checked. The diagnoses of epilepsy and dementia were not checked. The review showed a level II screen was not submitted for consideration. An interview was conducted with the social services director (SSD) on 02/12/26 at 2:19 p.m., revealed that they found issues with resident #84's PASARR screening. The SSD said schizophrenia was a serious mental health condition, and a PASARR level II screening should have been conducted. The SSD said that they were under the assumption the PASARR level II screening was completed but was unable to present the documentation to confirm the assumption. 4.) A review of Resident #6's admission record revealed an original admission date of 8/18/18 and a re-entry date of 7/17/24. Further review of the admission record revealed diagnoses to include bipolar disorder, current episode mixed, unspecified, major depressive disorder, recurrent, unspecified, other bipolar disorders and schizophrenia, unspecified. A review of Resident #6's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 7/16/24, showed anxiety disorder, bipolar disorder, depressive disorder, and schizophrenia were marked. A level II evaluation/determination was not found in Resident #6's medical record or provided by the facility. 5.) A review of Resident #4s admission record revealed an initial admission date of 02/06/2018 with a readmission date of 5/25/2020. Further review of the admission record revealed diagnoses to include unspecified mood [affective] disorder, anxiety disorder unspecified, other seizures, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder recurrent unspecified and impulse disorder unspecified.A review of Resident #4's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 02/27/2025, did not have unspecified psychosis and epilepsy checked under mental illness (MI) or suspected MI. The review showed a Level II PASSAR was not submitted for consideration.6.) A review of Resident #241's admission record revealed an admission date of 01/26/2026. Further review of the admission record revealed diagnoses to include traumatic subdural hemorrhage with loss of consciousness status unknown sequela, bipolar disorder unspecified, alcohol abuse uncomplicated, schizophrenia unspecified, other seizures and insomnia unspecified. A review of Resident #241's Preadmission Screening and Resident Review (PASSAR) level I screen, dated 01/23/26, showed qualifying diagnoses were not marked under mental illness (MI) or suspected MI, and a level II was not submitted for consideration. On 0202/12/26 2:17 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated during the morning meetings, the team will look at the PASSAR(s) that are sent, review medical diagnoses and/or H&P (history and physical) to see if there's anything that needed to be changed. The SSD stated, if a change were needed, he would adjust/change, the PASSAR level I. The SSD stated, if there was an issue or something that would flag he would update the Level I, and he would submit for a Level II review. He clarified he would flag diagnoses such as schizophrenia, bipolar, and schizoaffective. He said if sometimes they don't flag to submit a level II PASSAR, he would still send it for review. The SSD stated the Director of Nursing DON or Assistant DON (ADON) would also review the PASSAR(s) to see if they needed to be updated or if they need a level II. The SSD stated SMI included schizophrenia and schizoaffective diagnoses. A review of the facility's policy titled, PASRR- Requirements for Completion, effective August 2025 showed the following policy statement: Pre-admission Screening & Resident Review (PASRR) - Preadmission screening will be conducted prior to admission as the PASRR process is a federally mandated pre-admission screening program (see 42 CFR 483.100) required to be performed on all individuals prior to admission to a Nursing Home. The screening is reviewed by Admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. Procedure: This screening is typically done by discharge planners & hospital staff as a step in the discharge process. It is separate from a medical needs assessment, which most often occurs after a person applies for Medicaid, and is a required step to qualify for Medicaid long-term care assistance. 1. During the admissions process, Admissions will communicate with the facility regarding prospective admissions. A Level I PASRR will be provided prior to admission to the Skilled Nursing Facility. The facility administration will confirm that a Level I review has been completed prior to transfer to the SNF setting. 2. Determine if a serious mental illness and / or intellectual disability or a related condition exists while reviewing the PASRR form completed by the Acute Care Facility. (Trigger for Level II Completion) 3. If Serious Mental Illness or ID is indicated, determine if the resident will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30-days of Nursing Facility services. Assure that the certification is signed and dated. 4. If the Physician indicates the stay will likely be less than 30-days SNF services, the resident can be admitted to an SNF. If anticipated stay becomes longer than 30 days a Level II must be completed prior to day 40. Florida Specific Guidelines Florida Facilities (Form 004 Part A effective November 2014) Assure that sections 1-5 are completed prior to admission. If section TV (Provisional Admission) is applicable, the form is only valid if the MD has signed and dated the form. If the admission is a provisional admission, the Social Service Director must start a tickler file and assure the level II is completed within the state-specified time frame. Delirium - within seven (7) days of admission Caregiver respite within 14 days of admission Emergency placement within seven (7) days of admission 30-day hospital exemption within 30-40 days of admission If the preadmission screening requires a Level II evaluation submit all required documents to [contracted state review company] timely, so that a Level II can be completed within the required time frames.

Based on record review, interviews, and policy review, the facility failed to ensure residents were monitored for antipsychotic medication behaviors and side effects, for two out of six residents, (#15 and #17), sampled.Findings included: 1. On 02/12/2026 at 1:53 p.m., Resident #15 was observed fully covering her head with her shirt. During an interview on 02/12/2026 at 1:45 p.m., Staff HH Certified Nursing Assistant (CNA), stated Resident #15 had behaviors such as yelling and refusing care. Staff HH stated the resident had often requested staff to leave me alone. Staff HH stated this happened two to three times a week. During an interview on 02/12/2026 at 1:55 p.m., Staff II CNA, stated Resident #15 sometimes yelled at staff and other residents. Staff II stated Resident #15 refused to comply with being dressed and changed. During an interview on 02/12/2026 at 2:02 p.m., Staff JJ Registered Nurse (RN), stated Resident #15 sometimes has her days. Staff JJ stated the week of 02/02/2026, Resident #15 refused to get out of bed and voided [urinated] on herself. Staff JJ stated, because Resident #15's actions weren't extreme or aggressive, they weren't documented. Staff JJ stated the refusals should've been documented. Staff JJ stated having no expectations for CNAs to perform monitoring for behaviors and side effects of antipsychotics as ordered by the physician. Staff JJ stated regardless if a resident presented with behaviors or not, it should have been documented. Review of Resident # 15's medical record revealed the resident was admitted into the facility on [DATE]. The medical diagnoses of the resident included: unspecified psychosis not due to a known physiological condition, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, schizophrenia, unspecified, schizoaffective disorder, unspecified, bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified generalized anxiety disorder. Review of Resident #15's Minimum Data Set (MDS), dated [DATE], section C revealed the resident had a Brief Interview Minimum Status of 00, which indicated severe cognitive impairment. Section I revealed active diagnoses, for resident #15 including: non-alzheimer's dementia anxiety disorder, depression bipolar disorder psychotic disorder schizophrenia. Section N revealed the resident was taking antipsychotic medication. Review of Resident #15's orders, revealed an order for aripiprazole oral tablet 20 MG, to be given enterally [by mouth] at bedtime, dated 01/27/2025, with no end date. There was an order to record behavior monitoring seen and any side effects with use of psychotic medications given. If side effects are seen physician should be notified. Please record behavior even if dose of medication is not given, every shift, dated 02/17/2025. Review of Resident #15's Medication Administration Record (MAR), revealed the resident had received aripiprazole oral tablet 20 MG, daily, from 11/01/2025 through 02/11/2026. Review of Resident #15's Behavior Monitoring (BH), revealed for the order to record behavior monitoring seen and any side effects with use of psychotic medications given. If side effects are seen physician should be notified. Please record behavior even if dose of medication is not given, every shift, had not been completed. There was no data from 11/01/2025 through 02/11/2026, in Resident #15's record for behavior monitoring of medications given. Review of Resident #15's care plan, revealed a focus: Resident #15 was noted to have the following behaviors: placed blankets over head. Chose to not to have vital signs taken, chose not to take medication. Threw suitcase towards staff, threw bed linen and milk that was on a tray to the floor. Refused activities of daily living care, refused to wear shoes; wandered to other resident rooms, opened lockers, took other resident clothing and put them on, slammed doors, took meal trays to different locations, cursed at staff, took clothes off naked in room. Removed resident name labels from walls. Refused ADL care when soiled/wet, revised 10/30/2025. The goal was to control or minimize outburst, revised 09/25/2025. The interventions included: observe/document for side effects and effectiveness, document episodes of behaviors & review to determine the effectiveness of intervention, initiated 09/02/2021. There was an intervention to observed for changes in behavior and report to physician, insomnia, nervousness, loss of interest, decreased ability to concentrate, repetitive movements, initiated 09/02/2021. A focus of Resident #15's care plan was of the resident using psychotropic medications related to dementia and schizophrenia, revised 12/17/2024. The goal was to have minimum side effects, revised 09/25/2025. The interventions included: administer medications as ordered and to observe or document for side effects and effectiveness. The anti-psychotropic side effect monitoring was for agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, trunk or extremities, pacing, seizure activity, stiffness of neck, sore throat, tremors, and rashes. 2. A review of Resident #17's admission record showed an original admit date of 02/28/2025 with a readmission date of 10/05/2025, with diagnoses to include but not limited to: mixed receptive-expressive language disorder bipolar disorder, current episode manic severe with psychotic features generalized anxiety disorder schizophrenia dementia in other diseases classified elsewhere , mild A record review of Resident #17's physician orders showed the following: Haloperidol oral tablet 1 (one) MG (milligram), give one tablet by mouth one time a day related to other schizophrenia, ordered 12/19/2025. Haloperidol oral tablet 2 (two) mg, give two tablets by mouth in the evening related to other schizophrenia, ordered 12/19/2025. Trazadone HCL (hydrochloride) oral tablet 50 mg, give one tablet by mouth at bedtime for depression, ordered 10/27/2025. Trihexyphenidyl HCL oral tablet two mg, give two tablets by mouth three times a day for dystonia give with meals, ordered 10/27/2025 No orders were found for behavior monitoring or monitoring for side effects. A review of Resident #17's care plan showed the following focus, goals and interventions (to include but not limited to) and position: PASRR (Pre-admission Screening and Record Review) Level II: [Resident #17] has or is suspected to have a serious mental illness (SMI), Intellectual disability (ID) or other related conditions that require a PASRR Level II, date initiated 10/14/2025. Goal: Recommendations are established and carried out to attain or maintain the resident highest functional and emotional level. Interventions: behavior modification plan as follows: no plan entered. medication management as follows: no entries. psychiatric/psychological service follow up. Behavioral: [Resident #17] is noted with the following behaviors: pulls out foley catheter, poor safety awareness, date initiated 4/03/2025 Goal: Control/minimize outburst Interventions: Document episodes of behavior and review to determine the effectiveness of interventions. Psychotropic Med (medication): [Resident #17] uses psychotropic medications related to antipsychotic to manage : schizophrenia, date initiated 3/03/2025 Goals: Will have minimal side effects, date initiated 03/03/2025, revision date 6/20/2025 and target date 3/07/2026 Interventions: Psychotropic side effect monitoring: agitation, blurred vision, cardiac or blood abnormalities, confusion, constipation, dry mouth, difficulty urinating, disturbed gait, drooling, drowsiness, headache, hypotension, involuntary movement of mouth, tongue, or extremities, nausea or vomiting, pacing, seizure activity, stiffness of neck sore throat, tremors, rashes, date initiated 3/03/2025 Administer medications as ordered. Observe/document for side effects and effectiveness, date initiated 3/03/2025 A review of Resident #17's psychiatry progress note date 11/21/2025 showed the following in review of systems: Depression -depressed mood, insomnia Psychosis- auditory hallucinations, delusions (of persecution, grandeur, jealousy, erotogenic), diminished emotional expression, disorganized behaviors, disorganized speech, visual hallucinations Mania- abnormally and persistently elevated, expansive or irritable mood Dementia- executive functions, impairment of complex attention, language, learning and memory, perceptual motor, social cognition. Assessment/Plan: Schizoaffective disorder, bipolar type Plan: -Continue haloperidol (antipsychotic). Consider [Brand name medication] if able to obtain it for the patient. -Continue Trazodone -Monitor for adverse effects of haloperidol, particularly dyskinesia and extrapyramidal symptoms EPS. A review of Resident #17's psychiatry progress note date 12/19/2025 showed the following in review of systems: Cognition summary impaired related to dementia. Under review of systems the following: Depression -depressed mood, insomnia Psychosis- auditory hallucinations, delusions (of persecution, grandeur, jealousy, erotogenic), diminished emotional expression, disorganized behaviors, disorganized speech, visual hallucinations Mania- abnormally and persistently elevated, expansive or irritable mood Dementia- executive functions, impairment of complex attention, language, learning and memory, perceptual motor, social cognition. Plan: -Reduce Haldol to one mg po (oral) q (every) am (morning) and 2 mg po qhs (every night) in GDR attempt -Continue Trazodone -Monitor for adverse effects of haloperidol, particularly dyskinesia and extrapyramidal symptoms EPS. A review of Resident #17's psychiatry progress note date 01/16/2026 showed the following in review of systems: Depression -depressed mood, insomnia Psychosis- auditory hallucinations, delusions (of persecution, grandeur, jealousy, erotogenic), diminished emotional expression, disorganized behaviors, disorganized speech, visual hallucinations Mania- abnormally and persistently elevated, expansive or irritable mood Dementia- executive functions, impairment of complex attention, language, learning and memory, perceptual motor, social cognition. Plan: -Continue Haldol -Continue Trazodone -Monitor for adverse effects of haloperidol, particularly dyskinesia and extrapyramidal symptoms EPS. On 02/12/2026 at 9:47 a.m. an interview was conducted with Staff R, Licensed Practical Nurse (LPN). Staff R, LPN stated the resident should be monitored for behavior and side effects. Staff R, LPN stated normally when she documents a medication such as Haldol, she would see it in the MAR to then document any side effects. On 02/12/2026 at 12:35 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the facility has a psych provider who comes in multiple times during the week and does the monitoring of residents. The DON stated the providers know their residents and monitor every day all day. The DON stated monitoring is something that happens daily. The DON stated she needed to confirm something before explaining how monitoring behavior and side effects happens. The DON stated we monitor our residents, we all do. On 02/12/2026 at 1:37 p.m. the DON stated monitoring is done by the team and provided a copy of the Certified Nursing Assistant (CNA) TASK titled Behavior Monitoring and Interventions Report, but stated it is the nurse's responsibility to report if the CNA documents to a behavior. On 02/12/202 at 1:52 p.m., an interview was conducted with Staff J, Registered Nurse/Unit Manager (RN/UM). Staff J, RN/UM stated the resident psychotropic medications and behavior should be monitored by the nurses. If the resident had behaviors, then the nurse would refer them to psych. Staff J, RN/UM stated, It's nursing 101 and each nurse should know what behaviors to look for related to psych diagnosis and medication side effects. For example, a resident with tardive dyskinesia (tremors), the nurse should be able to know what to assess the resident for. The facility does Gradual Dose Reduction (GDR) meetings, and stated, he believes they are done weekly and psych is here all the time. If the resident had behaviors, typically that would be documented in the progress notes and then the nurse would call the doctor. Staff J, RN/UM stated, if you do not see it in the MAR/TAR (medication administration record/treatment administration record), you should see this in a progress note. If the CNA notices behaviors, the CNA should notify the nurse, because the CNA does not know what the signs and symptoms of psychotropic medications are. Staff J, RN/UM stated he did not expect CNAs to know what behaviors are for specific psych diagnosis or medications. On 02/12/2026 at 1:45 p.m., an interview was conducted with Staff S, CNA. Staff S, CNA stated, for behavior monitoring, she would look in the chart to see how the resident is to be transferred either with one or two person assist, look to see how they are to be showered, check for bowel and/or bladder incontinence every two hours, make sure they have water and/or coffee. On 02/12/2026 at 1:48 p.m., an interview was conducted with Staff T, CNA. Staff T, CNA stated for behavior monitoring she would check on her rooms, check for water, change residents for incontinence care, check to see if residents are fighting, make sure bed for fall risk residents, help residents to the bathroom and how a resident transfers either with one or two persons assist. A review of the policy titled, Behavior Management Program Overview, effective October 2021 showed the following policy statement: The facility promotes the utilization of a behavior management program based on individual resident needs. The facility Behavior Management Program is provided by the interdisciplinary team and recognizes that behaviors exhibited by residents require appropriate identification, data collection, intervention, management, and evaluation to assist the resident in obtaining their highest practicable level of functioning. The interdisciplinary team works in partnership with the resident/resident representative to establish effective interventions and goals. Non- pharmacological interventions are the first choice in management of behavioral symptoms. PROCEDURE Psychoactive medications are used after non-pharmacological interventions have been attempted without success. The lowest possible effective dose of psychoactive medication will be prescribed for documented clinical symptoms. Dose management is reviewed by the Interdisciplinary Team (IDT) and in conjunction with physician and pharmacist recommendations. Clinical contraindications to dose reduction are documented. Side effects of the psychoactive medications are monitored by observation and documented on the eMAR (electronic medication administration record) The facility does not use chemical restraints, which are drugs used for discipline or convenience and are not required to treat medical symptoms. 1. Complete the Admission/re-admission Data Collection 2. Complete the Psychosocial History and Assessment 3. Review potential causes of behavioral symptoms with the IDT. Potential causes include, but are not limited to: Illness/conditions (i.e., pain, constipation, Alzheimer's disease) Cognitive status problems (i.e., confused) Mood and/or relationship problems (i.e., grief. placement adjustment) Environmental conditions (i.e., noise, crowding) Current treatment/management procedures (i.e. how are behaviors currently being addressed) Medication side effects Behavior Management Program Overview 4. Identify and implement interventions based on identified triggers and possible causes of behaviors. 9. Monitor the frequency of the behavior(s) and the effectiveness of the interventions 10. Review side effects from medication, notify practitioner if needed 12. Review the Resident at the next clinical meeting if a crisis occurs

Based on observation, record review, and interview, the facility failed to provide residents who are unable to carry out activities of daily living (ADLs) the necessary services to maintain good grooming and personal hygiene for two (#84 and #151) out of three sampled residents. Findings included: On 02/09/2026 at 8:19 AM an observation of Resident #84 having long and overgrown nails. Resident #84's nails were about half an inch past the fingertips. Review of Resident #84's medical record revealed medical diagnoses of schizophrenia, other drug induced secondary parkinsonism, muscle wasting and atrophy, weakness, cognitive communications deficit, muscle weakness (generalized), and vascular dementia with unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. Review of Resident #84's medical record revealed a Brief Interview for Mental status (BIMS) score of 00. A BIMS score of 00 indicates severe cognitive impairment. Resident #84 required partial/moderate assistance for personal hygiene. Partial/moderate assistance is described as the helper does less than half of the effort. The helper lifts, holds, or supports, trunk or limbs, but provides less than half the effort. Personal hygiene is defined as the ability to maintain personal hygiene including combing hair, shaving, applying makeup, washing/drying face and hands (excludes, baths, showers, and oral hygiene). Resident #84 would require a helper in order to have trimmed nails. Nail care records for Resident #84 revealed no nail care was provided on01/22/2026 at 8:40 PM and nail care provided on 02/10/2026 at 1:46 PM. Personal hygiene records for Resident #84 revealed personal hygiene care was completed from 01/14/2026- 02/12/2026. There were no documented refusals of care found. Review of Resident #84's care plan revealed a focus area for, ADL self-care performance deficit as evidenced by: impaired cognition, impaired balance, and impaired vision. The interventions that were implemented to mediate this deficit were as follows: observe for pain during activity and report to nursing if noted, physical, speech, and occupational therapies to evaluate and treat per orders, call bell within reach while in room/bathroom/shower room, and remind Resident #84 to use the call bell light, supervision for locomotion, one staff assist for personal hygiene, provide cues, and segment tasks as needed, provide/encourage Resident #84 to accept assistance as necessary to ensure task successfully completed. Additional interventions included: discuss resident preferences for time or routine changes in daily activities and honor the resident within reasonableness if Resident #84 refused care, report changes in ADL performance to nursing, and observe/report changes in ADL ability, any potential for improvement, and/or reasons for inability to perform ADLs to licensed nursing staff as needed. An interview and observation occurred on 02/09/2026 at 12:05 PM Resident #151 with facial hair on the upper lip and chin/neck area, approximately a quarter of an inch long. Resident #151 stated having ear pain due to needing to be cleaned. Review of Resident #151's medical records revealed medical diagnoses of other lack of coordination, weakness (generalized), peripheral vascular disease, atherosclerotic heart disease of native coronary artery without angina pectoris, dizziness and giddiness, syncope and collapse, type 2 diabetes mellitus without complications, legal blindness, as defined in USA, and age related physical debility. Review of Resident #151 medical record revealed a BIMS score of 14, indicating Resident #151 was cognitively intact with little to no memory or thinking impairment. Resident #151 required substantial/maximal assistance for personal hygiene care. Substantial/maximal assistance is described as the helper does more than half of the effort, additionally, the helper lifts or holds the trunk or limbs and provides more than half of the effort. Resident #151 would require a helper in order to have clean ears and a shaved face. Personal hygiene records for Resident #151 revealed that they were provided with personal hygiene care from 01/30/2026- 02/12/2026. There was no documented refusals of care. Review of Resident #151's personal hygiene task revealed documented completion of the task at 1:48 PM on 02/10/2026. Review of Resident #151's care plan revealed a focus area for ADL self-care performance deficit. The interventions implemented to mediate this deficit include the following: the call bell should be within reach in room/bathroom/shower and remind the resident to use the call bell light, assistance from one staff for personal hygiene tasks, limitations to range of motion in the resident's upper extremity, encourage/provide passive/active assistance with routine care withing their physical capacity, and report changes in ADL performance to nursing. During an interview on 02/10/2026 at 1:39 PM Staff H, Certified Nursing Assistant (CNA), stated when providing personal hygiene care to residents, they are expected to shave the resident's face, wash their face, brush their teeth, and wash their hair. Staff H, stated Resident #84 and Resident #151 have not refused care when she has been assigned to the residents. Staff H stated Resident #84, is able to use verbal communication to express likes and dislikes. Staff H said that when Resident #84 wants something, they are able to make it known. Staff H said that Resident #84's shower days are Tuesday, Thursday, and Saturday. Staff H said she is unaware if Resident #151 normally gets her face shaved. Staff H said that most residents are dependent on staff for assistance with shaving, and few are able to shave themselves independently. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 02/10/2026 at 12:52 PM. Staff G, LPN said the expectation for ADL care is each resident receive a baths/showers on their assigned days. Each resident should receive oral care, everyday along with their faces washed, proper feeding, and their hair combed/brushed. An observation was made with Staff G of Resident #84. Staff G said that Resident #84's nails were long and that it was time for a trim. Staff G said there were no shower sheets in any residents' electronic medical record. Staff G said that Resident #84 should receive nail care as needed. Staff G, LPN said that CNAs are responsible for nail care. Staff G said that she is not aware of Resident #84 refusing any care and Resident #84 verbally communicates his wants and needs. Staff G said that Resident #84's ADLs are steady. Staff G, LPN, said that residents should have their ears cleaned during ADL care and/or their shower days, and did not know of Resident #151 reporting any pain. Staff G said Resident #151 is not known to refuse care. During the interview Staff G, LPN observed Resident #151's facial hair and asked Resident #151 about her ear pain. Staff G, LPN said she would look into ear cleaning and facial hair removal. Staff G, LPN said there were no shower sheets in any residents' electronic medical record. Staff G said that staff does not document ear cleaning or shaving as specific tasks in a resident's electronic record. The visible check mark in a resident's personal hygiene task is indicative that all personal hygiene was provided. During an interview on 02/10/2026 at 4:07 PM Staff I, CNA stated the personal hygiene responsibilities of a CNA include ensuring the resident is clean. Personal hygiene care includes ensuring residents receive showers, and their hair and nails are clean. Staff I said that they respect a resident's refusal, but if their hygiene is poor and the resident refuses care three times, they will report the refusal to their supervisor. Staff I said that they will trim fingernails as needed. An interview was conducted with Staff M, LPN/Unit Manager (UM) on 02/10/2026 at 4:47 PM. Staff M, LPN/UM stated the staff should follow orders of the task listing provided in the electronic medical record when they are providing personal hygiene care to residents. Staff M said ADL care should include toileting, brushing teeth, washing the face, combing the hair, and ensuring residents look presentable. Fingernails are cared for depending on medical diagnoses. Staff M said CNA's responsibility includes shaving residents and checking their hygiene every day, every shift. Each resident's hygiene should be how you would want to be presented. Personal hygiene tasks should be documented inside each resident's electronic medical record. Staff M, LPN/UM said they assume if a resident's personal hygiene task has a check mark, all personal hygiene care has been completed. Staff M said that CNAs document what residents consume, baths, level of independence or dependence, range of motion, how many times they provide residents with cups of water, and teeth brushing. Staff M, LPN/UM said if a resident refuses care, a CNA should document the refusal and let the nurse know, Staff M said nail care should be documented in the resident's electronic medical record, and sometimes, activities provide nail care- polish nails etc. Staff M, LPN/UM reviewed Resident #84's electronic medical record and noted that Resident #84 received nail care one time during his residency at the facility, on 02/10/2026 at 1:46 PM, there was no prior history. Staff M said they observed Resident #151 earlier today and has a lot of contact with Resident #151. Staff M said during the interaction, she did not notice hair on Resident #151's upper lip and chin/neck area. Staff M said shower days for Resident #151 are Monday, Wednesday, and Friday, but staff are still expected to provide residents with baths and check resident hygiene every day. Staff M said that Resident #151 never refuses care. During this observation, Staff M observed Resident #151 had facial hair. An interview was conducted with the Director of Nursing (DON) on 02/11/2026 at 3:46 PM. The DON stated a lot of residents refuse care. If resident refuses care another staff member should make another attempt to provide care. If a resident refuses on multiple occasions, staff should try to contact the resident's family. The family may be able to speak with the resident or support the facility in personal hygiene/ ADL care. The DON said some residents are extremely resistant to change and will continue to refuse care. The DON said every resident should be clean to ensure there are no foul odors. Nail care should occur once per week, on shower days, or every two weeks. The DON said ear care should be completed during a resident's shower; staff should wash the resident's outer ear; however, staff cannot use cotton swabs, a resident can do so if they choose to. If there are ear cleanliness concerns, the facility would consult with the physician for further directions. The DON stated follow standards of care related to resident hygiene. No policy and procedure was received for ADL care by the end of the survey.

Based on observations, interviews, and record reviews, the facility failed to update and implement an individualized person-centered care plan related to an indwelling urinary catheter device for one resident (#12) of one resident reviewed.Findings included:An observation on 2/9/2026 at 9:00 A.M. revealed Resident #12 sleeping in bed with street clothes on. The resident was observed with a urinary catheter hanging and draining at the side of the bed.A review of Resident #12's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to obstructive and reflux uropathy, specified disorders of urethra, and benign prostatic hyperplasia.A review of Resident #12's minimum data set (MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15 indicating Resident #12 is cognitively intact. Section H revealed under Bladder and Bowel the resident had an indwelling catheter.A review of Resident #12's progress notes related to urinary catheter revealed the following:On 1/9/2026 at 10:48 p.m. the nurse wrote- Received new orders from NP (Nurse Practitioner) to straight cath (Catheterize)and if greater than 500mL (milliliters), leave foley (indwelling urinary catheter) in. Care continued.On 1/9/2026 at 11:25 p.m. the nurse wrote - Straight cath'ed (catheterized) the resident. Over 700mL of yellow urine. Notified NP. Left foley in as ordered. Orders in [documentation software]. Care ongoing.A review of Resident #12's care plan revealed there was no care plan area related to an indwelling urinary catheter. An interview was conducted on 2/11/2026 at 2:08 P.M. with Staff K, Licensed Practical Nurse (LPN). Staff K, LPN said care plans are updated with every quarterly MDS assessment and if a significant change occurs. Staff K, LPN said Resident #12 had a significant change on 1/9/2026 and his care plan should have been updated during that time.An interview was conducted on 2/11/2026 at 2:55 P.M. with Staff L, Clinical Reimbursement Director (CRD). Staff L, CRD said the interdisciplinary team (IDT) meets every morning and reviews the order listing report for the past 24 hours or 72 hours. Staff L, CDR said based on that information, care plans are updated. Staff L, CDR said Resident #12's indwelling urinary catheter orders were overlooked during the IDT meeting, and his care plan had not been updated.A review of a care plan audit report for Resident #12 revealed a care area related to indwelling urinary catheter had been created on 1/9/2021 and resolved on 12/20/2022.Review of a facility policy effective February 2024, titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting revealed a policy - The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care.The policy's procedure was, 2: Update to care plans: a: ongoing updates to care plans are added by a member of the IDT (interdisciplinary team), as needed.

Based on observations interviews and record review, the facility failed to ensure a safe environment was provided related to the use of a fan for one resident (#34) out of one resident observed.Findings included: An observation and interview on 2/9/2026 at 8:35 A.M. revealed Resident #34 lying in bed. A box fan approximately 21-23 inches in height was observed in between the resident's headboard and pillow. The pillow was observed resting on the box fan, next to the resident's head. The box fan was not running at the time. Resident #34 said he liked the fan there because he gets hot and cold quickly, so it's easy for him to reach it and turn it on or off.An observation on 2/10/2026 at 10:05 A.M. and on 2/11/2026 at 10:40 A.M. of Resident #34's bed revealed the box fan in between his headboard and his pillow as previously observed.A review of Resident #34's admission record revealed the resident was admitted on [DATE] and included diagnoses not limited to muscle weakness (generalized) and need for assistance with personal care. A review of Resident #34's brief interview for mental status (BIMS) score conducted on 12/21/2025 revealed a score of 15 indicating Resident #34 is cognitively intact.An interview on 2/11/2026 at 10:42 A.M. with Staff J, Registered Nurse (RN)/ Unit Manager (UM) was conducted. He observed the fan and stated the placement of the fan is, Not good, it's a risk. Staff J, UM said the placement of the fan is a problem as it was too close to the resident and the rotating blades could cause injury if touched accidentally. Staff J, stated, it's not safe.An interview on 2/11/2026 at 10:50 A.M. with [NAME] President of Operations (VPO) and Assistant Nursing Home Administrator (ANHA) was conducted. The VPO and ANHA said they observed the fan and they did not like the placement of the fan and it should be moved. The VPO said the fan placement was a safety concern because of the distance, how close it was to the resident's body. The ANHA said the fan should not be placed on Resident #34's bed.Review of a facility policy titled, Free of Accident Hazards/Supervision/Devices, effective September 2025, revealed: The facility shall ensure that patient-centered care and services are provided to residents in accordance with each resident's preferences and goals, and in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs. The procedure included: 1.The facility shall ensure that: a. The resident environment remains free of accident hazards to the extent possible. b. Each resident receives supervision and assistance to prevent accidents to the extent possible.

Based on observations, interviews and record review, the facility did not ensure an assessment for self-administration related to enteral feedings was completed for one resident (#16) out of one resident reviewed.Findings included: On 02/10/2026 at 4:15 p.m., a medication administration was observed for Resident #16 by assigned nurse, Staff Q, Registered Nurse (RN). On 02/10/2026 at 5:10 p.m., an observation and interview was conducted with Resident #16 in his room. Resident #16 stated he had not received his 4:00 p.m. scheduled dose of Jevity. The resident stated he would take care of it. Resident #16 was observed walking to the sink, filling a cup with tap water, returned to his bed, sat on the edge and opened a small commercial eight-ounce container of Jevity 1.5, and poured into another cup. An observation was made of Resident#16's bedside table with three unopened boxes of Jevity 1.5 eight-ounce containers. Resident #16 was observed administering his Jevity along with flushes of water. Resident #16 stated he normally gives himself his enteral feedings and water. Resident #16 stated sometimes the nurse would check in to see if he took his Jevity and the other half do not check in with him. Resident #16 could not state how often he would take the Jevity but stated he usually takes his feedings when he was due for medication. A review of Resident #16's admission record showed an original admit date of 01/15/2025 with a readmission date of 7/2/2025 with diagnoses to include but not limited to: dysphagia, oropharyngeal phase, gastrostomy status, other disease of the larynx, and adult failure to thrive.A record review of Resident #16's physician orders include but not limited to:- Enteral feed order six times a day enteral feed: Jevity 1.5 cal. (calorie) 8oz (ounces) ARC(reference to commercial enteral feeding) bolus PEG (percutaneous endoscopic gastrostomy) tube. Administer 237 ml (milliliters) bolus 6 times per 24 hours during waking hours. Total volume to infuse 1422 ml/24 hours, ordered 7/28/2025-Delegate to dietitian the responsibility to alter, change, or modify dietary orders including oral supplements, measured of height and weight, modification to or addition of diet restrictions/therapeutics, downgrade of diet consistency in consultation with SLP (Speech-Language Pathology) when needed, enteral feeding and water flushes, ordered 7/28/2025.- NPO (nothing by mouth) diet, ordered 7/26/2025.- Evaluate for displacement of tube (PEG) by observing for abdominal distress, nausea/vomiting, pain, distention. If displacement is suspected, clamp tube and call MD every shift, ordered 7/26/2025.- Flush enteral tube (PEG) with 250 ml of water every 4 hours for patency and hydration, ordered 8/01/2025.A record review of Resident #16's Self-Administration of Mediation Resident assessment dated [DATE] and a locked date of 9/26/2025, showed in Section A (mental assessment). Question 6- Can state what time or how often is to be taken? The assessment was checked no . Question 7- Remembers to take medication- the assessment was checked no. Section B (physical assessment): Question 5- Can correctly measure the appropriate amount of medication from the container- the assessment was checked no. Question 15- The resident is deemed able to safely self-administer medications and that it is clinically appropriate- the assessment was checked no. On 02/11/2026 at 10:36 a.m., an interview was conducted with the Registered Dietician (RD). The RD stated he was not aware of Resident #16 self-administering his bolus feedings nor had the resident told the RD he was taking his own bolus feedings. The RD stated if a physician order for bolus feedings was given, then the nurse would be the one to administer. A record review of Resident #16's care plan showed the following focus area: Tube feeding: [Resident #16] is receiving enteral nutrition because of dysphagia, initiated 01/16/2025 with the following interventions to include but not limited to: Administration of enteral nutrition as ordered (refer to MD (physician) orders for current orders). Administration of flushes as ordered (refer to MD orders for current orders). Observe/document /report to MD PRN (as needed) aspiration-fever, SOB (shortness of breath) tube dislodged, infection at tube site, tube dysfunction or malfunction, abnormal breath/lung sounds.On 02/11/2026 at 1:28 p.m., an interview was conducted with the primary Advanced Registered Nurse Practitioner (ARNP) for Resident #16. The ARNP stated, when an order is placed for enteral feeding boluses, the order would be for the nurses to implement. On 02/11/2026 at 11:49 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was unaware of Resident #16 self-administering his enteral feedings/boluses. The DON stated residents should be assessed for appropriate self-administering medication, the IDT (interdisciplinary team) input, and a physician order would be required. A review of the facility's policy titled, Medication Administration Self-Administration by Resident initiated on 11/17 showed the following policy statement:Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures to include but not limited to:1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process.

Based on observation, interviews and record reviews, the facility failed to prevent the right to be free from verbal abuse for one of three sampled residents (#3) related to verbal abuse during activities of daily living care. Findings included: Resident #3 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to spinal compression, functional quadriplegia, dysarthria and anarthria, spinal stenosis cervical region, muscle weakness, cognitive communication deficit, diabetes, joint contracture, chronic obstructive pulmonary disease, spondylosis with myelopathy of cervical region, pulmonary hypertension, generalized anxiety disorder, hypertension, and recurrent major depressive disorder. Review of the quarterly Minimum Data Set, dated [DATE] showed Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section GG Functional Abilities showed the resident was dependent for eating, toileting hygiene, bathing, and rolling on the bed.Review of the physician orders showed:Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG daily for depression as of 05/24/25Duloxetine HCl Oral Capsule Delayed Release Particles 30 MG at bedtime for depression as of 08/08/25buspirone HCl Oral Tablet 7.5 MG BID for anxiety as of 08/08/25 to 11/07/25buspirone HCl Oral Tablet 10 MG bid for anxiety as of 11/07/25Vistaril Oral Capsule 50 MG every 8 hours as needed for anxiety for 14 days as of 11/12/25 Alprazolam Oral Tablet 1 MG every 24 hours as needed for anxiety for 14 days as of 11/12/25 Review of the progress notes showed:On 11/07/25, psychiatrist note, Patient seen at staff request following a reportable incident in which a staff member was reportedly rude and verbally inappropriate toward the patient. Patient is alert with speech impairment but able to speak very slowly. States he is still feeling upset with anxiety symptoms? Denies trauma-related symptoms. No suicidal or homicidal ideation reported.O: Objective: Patient alert, cooperative, and calm throughout visit. Communicates appropriately with slow speech and nodding head yes or no. No behavioral agitation, tearfulness, or withdrawal observed. Affect stable, mood appears euthymic. Patient is NOT in need of additional referral or follow up servicesIncrease Buspar 10mg BIDContinue Duloxetine 60 mg PO QD and 30 mg PO QHS for depression.Schedule regular follow-up appointments to reassess mood and treatment efficacy.Major Depressive Disorder and Generalized Anxiety Disorder? on Cymbalta 60 mg AM + 30 mg PM and Buspar 7.5 mg BID. No evidence of psychiatric decompensation related to the incident. Emotional response appropriate to situational stressor, he would like Buspar increased to 10mg bid for increased anxietyOn 11/12/25, psychiatrist note showed Resident is being seen for a follow-up psychiatric appointment and is noted to be a poor historian due to his expressive aphasia. During today's visit, he appeared drowsy and was not fully participating in the interview, having difficulty making his needs known. Despite these communication challenges, he reports himself to be doing fine and denies any mistreatment.He appears to be well cared for by facility staff with no signs or symptoms of caregiver neglect or concerning issues noted at this time. Generalized Anxiety disorder: - Start Alprazolam 1 mg PO every 24 hours PRN for 14 days (End date: 11/27/2025)- Start Vistaril 50 mg PO every 8 hours PRN for 14 days (End date: 11/27/2025)- Continue Buspirone 10 mg PO BID for anxiety.11/17/25, Resident denies any pain or discomfort. Resident is resting in bed with eyes closed. Safety measures in place. Call light and bed control within reach of the left hand. I will continue to monitor. Review of the Trauma Informed Care on 11/11/25 showed --Has the resident ever been diagnosed with PTSD (Post Traumatic Stress Disorder) had a life altering event or life changing event? Yes. --If yes, what type of event? Had a life altering event. --Is there a smell, sound, touch, taste, sight or other sensation that causes a flashback or trigger? No.--Is the resident being seen by any of the following: psychologist and psychiatrist--Does he attend support groups? No. --Care Plan Update:Trauma Informed CareGoal: staff will assist in managing the resident's response to the trigger; staff will make efforts to avoid the flashback or trigger; the frequency or severity of my trauma related signs and symptoms will not increase.Interventions: coordinate psychology or psychiatric services on admission and as needed; coordinate support groups as requested; encourage to express feeling, concerns and thoughts; know what triggers are and minimize expose if possible; observe for reported symptoms of a trigger; provide with meaningful activities. Review of the PHQ-9 dated 1/11/15 showed minimal depression Little interest or pleasure in doing things-symptoms presence: Yes.Little interest our pleasure in doing things- symptom frequency. two to six days Feeling down, depressed, or hopeless - symptom present. Yes Feeling down, depressed or hopeless - symptom frequency. 2 to 6 days. Trouble falling or staying asleep, or sleeping too much- symptom present. Yes Trouble falling or staying asleep, or sleeping too much - symptom frequency. 7 to 11 days Review of the care plans showed:Trauma Informed Care-Had a life altering event. Interventions included but not limited to: coordinate psychology or psychiatric services on admission and as needed, encourage to express feeling, concerns and thoughts, observe for reported symptoms of a trigger. Resident #3 uses psychotropic medications related to anxiety. Interventions included but not limited to psychological services per order and prn, psychiatry services per order / prn/ protocol, use of psychotropic medications will be reviewed at least quarterly with the IDT/MD to review continued need for the medication and ensure lowest dose. Resident #3 uses psychotropic medications related to depression. Interventions included but not limited to monitor for psychotropic side effects, administer medications as ordered and observe/document for side effects and effectiveness. Activities of Daily Living (ADL): The Resident has an ADL Self Care Performance Deficit. Interventions included but not limited to: BED MOBILITY: Assist of x 2 to turn and/or reposition. During an interview on 11/19/25 at 11:00 a.m. Resident #3 was lying in bed with a brief in place and blankets. Resident #3 was able to put his bed up and down. Resident #3 had difficulty speaking. He nodded his head yes to the following questions: does the staff answers your call light; do you feel safe at the facility; does the staff treat you well; do they keep you dry? When asked if anyone else had verbally or physically abused him, he nodded no. He typed on his phone the following: Staff C, Certified Nursing Assistant (CNA) when told her to get my phone and call light she didn't and told me to get it myself and she closed the door, when I was yelling for the nurse she said see if you get any food, get it yourself and she knew I could not lift my right arm and then I was very scared because I didn't know what she was capable of because when she was trying to turn me she was yelling at me, you're not gonna break my fckn back and she rolled me with no assistance and I have pads underneath my bum because I have a bone spur on my tailbone and she never put that back I felt helpless and humiliated because I'm here for therapy and she knows that. Resident #3 stated the Nursing Home Administrator (NHA) and Director of Nursing (DON) spoke with him. He stated he feels safe here. He stated all the other staff was great. He stated he just started sleeping all night after the incident. He was sleeping before the incident. He stated he was just getting back to his normal self. During an interview on 11/19/25 at 12:45 p.m. Staff C, CNA via phone conversation stated she was assigned to Resident #3. She stated she fed him breakfast and lunch. She stated he said he did not want any more food that he was full. She stated no incident happened when turning him. She stated she talked about the resident with the NHA, and the Risk Manager and my union representative. She stated she knew Resident #3 was a little upset because he was staying in bed too long and the nurse and therapist talked to him about getting out of bed. Staff D, Licensed Practical Nurse (LPN), the nurse, and the resident were having a conversation about that. Staff C stated the resident used a urinal, so she checked on him and he was fine. Staff C stated she could not recall if she turned him or not. Staff C hung up during the interview phone call. During an interview on 11/19/25 at 1:08 p.m. Staff D, LPN stated she had worked at the facility for about a year. She was made aware of the incident (with Resident #3) after it happened. Staff D stated she was not aware of it on the day of the incident. She stated the resident told a staff member in therapy about the incident the next day. Staff D stated Resident #3 had not told her he was not sleeping at night. She stated she talks to the resident all the time. She stated the resident was a very soft-spoken person. She stated the resident had not shown any signs of increased anxiety or depression that she had seen. Staff D stated she did not hear any hollering on the day of the incident. She stated the only time she remembers the resident's door being closed was around 2 p.m. Which would have been the time the aides were doing their final rounds before shift change to provide care. She stated she has not seen any changes in the resident since the incident. Staff D stated the resident was buying more food but had no mood changes. She stated she was not involved (in the incident) and administration spoke with her only briefly. During an interview on 11/19/25 at 1:18 p.m. Staff E, CNA stated he provides care for the resident. He changes the resident, assists the resident with eating, cleans the resident up. He used to shower the resident but now he gets his showers in the afternoons. It takes 2 persons to turn the resident and two person for Hoyer into wheelchair. He stated the resident gets up in a wheelchair 3 x week. Staff E stated the resident has not had any mood changes that he was aware of. The resident had not expressed any concerns or complaints to him. During an interview on 11/19/25 at 1:32 p.m. with Staff F, Social Service (SS) which was over the 300 and 400 hallways. She stated she makes rounds and sees the resident daily or every other day. She stated she did a Trauma Informed Care evaluation on the resident on 11/11/25. Staff F stated the resident did not want any further counseling for the incident. Staff F stated the resident had not reported increased anxiety, depression or sleeplessness to her. She stated she asks the resident those exact questions. The resident stated he had no concerns. She stated she tries to encourage him. She stated she does not provide him any counseling. During an interview on 11/19/25 at 2:08 p.m. NHA, DON, and Risk Manager (RM) stated they were notified on 11/06/25 at 13:13 p.m. that Resident #3 had something he possibly wanted to report. Staff G, CNA came into her office, activities office, and reported the conversation to Staff H the Activity Director. Staff H reported it to the NHA. They stated the NHA, RM, and the DON went down to Resident 3's. The resident was not there, he was out and about. The DON stated she first approached him and he gave her permission to discuss the incident. She stated they went to a private area. The DON stated she asked Resident #3 how he was doing? He stated, okay. The DON asked him if he felt bad? Having any pain? The DON asked him if he was afraid? He stated, no. The DON stated she asked the resident did he have anything he wanted to share? The DON told the resident he could stop the interview at any time. The DON state the resident was a functional quad, and not able to verbal totally audible. The DON stated the resident can communicate with his phone. The DON stated the resident expressed to me, that he was mistreated. The DON stated the resident described what happened, both verbally and on the phone. He told me that someone, Staff C, CNA, used vulgar language. The DON stated Resident #3 stated, they literally threatened him, he said if you don't do this then I am going to do XYZ. The resident stated Staff C stated she was not going to give him his call bell or phone. The resident showed where he keeps his phone tucked on his side. The resident told the DON, they did it deliberately, she (Staff C) verbalized, if you don't turn then I am not going to give it back because I am not going to break my fing back. The DON stated Resident #3 asked her if they were they allowed to do that? The DON stated the resident informed them how it made him feel. The DON stated Resident #3 stated, he felt humiliated. The DON stated the resident did not want his family to know. His POA had recently changed from one family member to another. The DON stated the resident finally gave permission to tell his family. The DON stated that Law Enforcement was called and came to the facility and opened an investigation. The DON stated the resident stated Staff C did not touch him in anyway, she just made threats. The DON stated she informed the resident of the investigation process. The DON stated she informed the resident Staff C would not be caring for him anymore. The DON stated they performed a skin assessment on the resident. The RM stated they interviewed residents on the 200 hallway because she was prior assigned to that area. The RM stated only 2 residents on the 200 hall knew Staff C, CNA and said her tone could be poor at times, occasionally. The NHA stated Staff C, CNA came into the facility on [DATE] (Saturday) and wrote a statement. The statement showed Staff D, LPN stated the resident needed to get up and get out of bed and go to therapy. The RM stated she called Staff C, CNA on 11/10/25 with specific questions. The RM stated she asked Staff C, What care did you provide the resident? Staff C stated, ADL and feeding assistance.The RM asked, Was there any conversations? Staff C stated, None other than to help turn.The RM asked, How did you ask him? Staff C, stated, Can you please come toward me.The RM asked, Did you use any explanative? Staff C, denied. The RM asked, Did you remove his cell phone while providing care? Staff C, stated, It was on the tray table, did not move the tray table. The RM asked, Did you replace the call bell? Staff C stated, It was on the left side of his head. The RM asked, Did you at any point did you say, there was nothing you could do about it regarding cell phone and call light. Staff C stated, Why would I do that. That would be a dignity issue. Abuse. The RM aske, Did you shut the door while in room? Staff C stated, Pulled the curtain while providing care. The RM asked, While providing care did he try to alert you anything was wrong? Staff C, stated, Not that I remember. The RM asked, Did he cry out for help? She stated, No. The DON stated SS did a new PhQ-9, psychosocial evaluation on the resident to see how he was doing since the incident. The DON stated the resident was having some tearfulness due to this incident initially. The DON stated the resident was affected by the incident They stated he stated he was humiliated. The DON stated since the incident the resident has not expressed any symptoms. Review of the facility's policy, Abuse Prevention Program, revised August 2022 showed the facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the Identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing their risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. Verbal abuse: oral, written, or gestured language that includes despairingly and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age and / or ability to comprehend or disability. Mental emotional abuse: includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Whether mental abuse has occurred is determined by a reasonable person standard and does not require a specific response from the resident. Prevention: Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation may be more likely to occur, such as: residents with needs / behaviors which might lead to conflict or abuse / neglect staff burnoutanalyze the occurrences to determine what changes are needed, if any, to policies and procedures and education to prevent further occurrences.

Based on observation, staff interview, and record review, the facility failed to ensure 1. One of one walk in freezer unit was maintained in a manner to prevent frosting and heavy ice build up on shelving and packaged food items and 2. Failed to ensure one of one dish washing machine was operating within wash and rinse water temperature specification requirements. Findings included: 1. On 8/21/2023 at 9:15 a.m., an interview was conducted with Staff B, Dietary Manager and Staff C, Registered Dietician. Staff B said he had only been working at the facility for a couple of weeks. Staff C said she too was new to the facility and was only a Traveling Dietician. Staff B and Staff C confirmed there was a full time Dietician for the facility that was currently in the hiring process. An initial kitchen tour was conducted with Staff B and Staff C. During the tour, they said the dish machine did not normally operate until 10:00 a.m. as the facility is very large and each meal service took some time to complete. On 8/21/2023 at 10:18 a.m., a second kitchen tour was conducted with Staff B. Staff R, Dietary Aide was operating the dish washing machine. Staff B and Staff R both said the dish washing machine was a Low Temperature machine and that it had been operating properly with no issues. Both said the Wash and Rinse temperatures had been optimal and reached the machine specifications requirement. Staff B and Staff R pointed out on the machine a specifications plate that showed the machine's requirements, and showed the machine operated at low temperature with a chemical sanitizer. Staff R revealed the Wash cycle temperatures should reach about 120 degrees F (Fahrenheit) and the Rinse cycle should reach at least 130 - 135 degrees F. Staff B. confirmed this as well. A review of the specifications plate on the machine showed Wash cycle should reach at least 120 degrees F. and the Rinse cycle should reach at least 120 degrees F. Staff R and Staff B were asked what the chemical sanitizer range should reach and how they identified that. Staff B said he utilized the litmus paper test strips to test the sanitizer during each meal service, and on a daily basis to test the sanitizer output. He was then asked what the Parts Per Million (PPM) range should read. He said the range should be 150 - 400 PPM. A review of the machine specifications plate with Staff R and Staff B revealed the PPM should be in range between 50 and 100 PPM. There was signage hanging on the wall that indicated PPM range between 50 and 150 PPM. Staff B confirmed the machine should be operating with PPM between 50 and 150 PPM. Staff R was not sure what the PPM range should be with the sanitizer component of the machine. Prior to demonstrating the machine use and temperature requirements, both Staff B and Staff R said there had not been any concerns with the machine and the maintenance company had been out to check the machine and provided routine maintenance on it with no concerns. Staff B provided the Dish Machine Log for months 8/2023, 7/2023, and 6/2023 for review. It was determined through review of all three months logs, and for each day and each meal service, that the Wash temperatures were documented at 125 degrees F and above, the Rinse temperatures were documented at 125 degrees F. and above, and the PPM sanitizer was documented at 100 PPM. At 10:22 a.m. Staff R along with Staff B, demonstrated the use of the dish washing machine. The first demonstration of the machine at 10:22 a.m. revealed; The Wash gauge reached around 100 - 105 degrees F. The Rinse gauge when the rinse cycle started and finished, only reached 105 degrees F. The gauge face was observed fogged up and almost unreadable. However, after using a bright light, the gauge could then be read more clearly. At 10:24 a.m. a second crate of dishes was run through and again the Wash temperature reached 100 - 105 degrees F. and the Rinse temperatures reached 108 degrees F. Both the Wash and Rinse cycle were confirmed by Staff B, Staff C and the Dietician. At 10:30 a.m. Staff B said the dish washing machine was working appropriately when first started this morning and had been working fine prior to that. He confirmed the temperature gauge was very hard to read and he would need to call the maintenance department and ask how the water heater boosters were and if they needed to be adjusted. Staff B revealed he would call the dish machine maintenance company to have them come out and look at the machine and see about getting a new temperature gauge. He said would use paper and plastic until the machine was fixed. On 8/23/2023 12:00 p.m., during an interview with the Dietary Manager and the Maintenance Director, both had indicated the facility's water heater booster had to be adjusted to a higher temperature, so the required heating temperatures reached the dish machine. It was confirmed that the kitchen and laundry room shared the same water heater booster. The Nursing Home Administrator also provided the Dish Machine Temperature Log policy and procedure with an effective date of 1/2021 for review. The Policy revealed; To monitor dish machine temperatures and chemical saturation (parts per million PPM), for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. The Procedure section revealed; #1 Record month and year at the top of the form #2 Send an empty dish rack through the dish machine prior to recording temperature. a. This allows the water to reach appropriate temperatures. b. May take 3-4 times. 2. During the initial kitchen tour on 8/21/2023 at 9:15 a.m., both the walk in refrigerator and walk in freezer were observed. Upon walking in the refrigerator, there was a door in the back of the unit that lead to the inside of the walk in freezer. The analog thermometer in the walk in refrigerator that was hanging on one of the shelves in the unit read 40 degrees F. Staff B said they had just had the door open while bringing in packages of food items. After the temperature for the walk in refrigerator was read, the door to the walk in freezer unit was observed closed, but the above the door hinge and arm was not clicked in to indicate the door was completely shut. The door pulled open easily. Upon walking into the freezer unit, the back wall appeared with a double fan motor unit and with a shelving system below the motor unit. The back wall of the unit had a three tiered shelving unit with the top shelf approximately one foot below the motor unit housing. Further observations revealed packages of food items to include packaged spinach x 3 with heavy built up ice. There were clumps of ice built up on these packs of food items measuring from five inches across and six to eight inches high. The packaged food items were positioned on the top shelf, and directly below the motor unit housing. There was also very heavy ice built up on the top shelf measuring approximately six to ten inches across to five to eight inches high. There was was heavy ice built up on the floor of the unit, behind the bottom shelf. Staff B confirmed the observations. He was not sure why so much heavy ice was built up but confirmed that none of the packaged food items should have ice build up. Photographic evidence was obtained On 8/24/2023 the Nursing Home Administrator confirmed they did not have a specific Dish Machine operations policy and procedure. She provided the Safety Policy and Procedure, with and effective date of 1/2021, for review. The Policy revealed; The facility promotes an optimal safe work environment in daily work routines and equipment operations. The procedure section revealed; #2 Follow manufacturer directions for each piece of equipment for property safety procedures. #4 Maintain equipment in proper working order. Report malfunctions immediately to the Maintenance Department. The Nursing Home Administrator revealed that the above policy and procedure is an interpretation of the facility's Dish Washing Machine and it's use.

Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #26 and #215) of 59 residents received treatment and care in accordance with professional standards of practice related to not obtaining orders for the use of a skin cream and accurately completing skin assessments for Resident #26 and not following hospital discharge orders related to a catheter and wound vac for Resident #215. Findings included: On 08/22/23 at 11:07 a.m., Resident #26 was observed in bed. A red rash was observed around her nose and on her forehead. Resident #26 stated the rash itched and staff was putting cream on it. On 08/23/23 at 9:25 a.m., Resident #26 was observed in the hallway, dressed for the day, and wearing shoes. A red rash was observed around her nose and on her forehead. Staff U, Registered Nurse (RN), was observed at the medication cart. She stated Resident #26 had dermatitis and she had a cream for it. A review of the Admission Record showed Resident #26 was initially admitted into the facility on [DATE] with a primary diagnosis of multiple sclerosis. A review of Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. A review of the Order Summary Report with an order date range of 08/01/23 to 08/31/23 revealed no orders for a skin cream. A review of the Skin Check Weekly & PRN (as needed) forms revealed the following: 08/23/23- No new areas of skin impairment. 08/16/23- No new areas of skin impairment. 08/09/23- No new areas of skin impairment. 08/02/23- No new areas of skin impairment. The red areas were not noted on the Skin Check Weekly & PRN forms. A review of the Skin Observation task showed Resident #26 did not have any scratches, red areas, discoloration, skin tears, or open areas within the last 30 days. The red areas were not noted on the Skin Observation task. There were no progress notes related to the skin condition. The care plan revealed a focus area of impairment to skin integrity related to dermatitis to the face. Interventions included administering medications as ordered, treatment as ordered, report changes in discoloration area, pain location, type frequency, and intensity. On 08/23/23 at 2:15 p.m., Staff U, RN, stated the resident had a cream for 14 days and she was done with it. Staff U, RN, stated Resident #26 finished the cream about a week ago. The nurse reviewed the electronic medical record for Resident #26 and could not find the completed order for the cream. Staff U, RN, stated the resident had an order for Ketoconazole. She then stated it was probably hydrocortisone. Staff U, RN, could not find a completed or discontinued order for the creams in the month of August. On 08/24/23 at 1:07 p.m., the Director of Nursing (DON) stated nurses should not be administering a cream without an order. On 08/24/23 at 11:00 a.m., Staff P, Regional Nursing Consultant, stated Resident #26 had a cream for the rash in January and February. She confirmed that she did not have a recent order for a cream. ` The policy and procedure provided by the facility Weekly and PRN Skin Check effective October 2021 revealed the following: The nurse will conduct weekly skin check and /or a PRN check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. If a new area of impairment is identified during or between scheduled checks, it should be documented on the weekly and PRN Skin Check and the appropriate skin grid initiated depending on the cause. A review of the Admission Record for Resident #215 revealed he was admitted into the facility on [DATE] with diagnoses that included anoxic brain damage, persistent vegetative state, encephalopathy, pressure ulcer of sacral region stage 4, chronic kidney disease, altered mental status, unspecified injury of unspecified kidney, tracheostomy status, and gastrostomy status. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form from a local hospital showed Resident #215 had a wound vac and he was incontinent. The comments section indicated the resident had a wound vac with black foam and to change the dressing on Monday, Wednesday, and Friday. A review of the Admission/Readmit: Data Collection and Baseline Care Plan with an effective date of 07/18/23 showed the resident had a condom catheter. The care plan related to the catheter revealed a focus area of the resident uses a urinary catheter with risk for infection and/or complications. Interventions included review with physician for possible removal of catheter. The resident was admitted with a coccyx pressure wound. Interventions included treatment as ordered. A review of the Order Summary Report for completed and discontinued orders did not show any orders for a catheter, catheter care, or a wound vac. A review of the Advance Wound Care form did not reveal an order to discontinue the wound vac. On 08/24/23 at 1:10 p.m., the DON stated Resident #215 was admitted with a condom catheter from the hospital but did not have a catheter during his stay in the facility. His family was adamant about him having a catheter. The DON stated you must have a specific diagnosis to have a condom catheter. The DON stated she would check to see if Resident #215 needed a wound vac, but did not follow up.

Based on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of allegations of abuse, neglect, exploitation, or mistreatment for one (Resident #113) of three sampled residents. Findings included: On 08/21/2023 at 9:00 a.m., Resident #113 was observed laying in bed holding his arm, with his covers halfway on his body. Resident # 113's arm was observed with a laceration. On 08/22/2023 at 11:00 a.m., Resident #113 was observed laying in bed with his covers on top of him. Resident # 113 arm was observed with an dirty bandage on his arm, next to the open laceration. A review of the admission record showed Resident # 113 was admitted to the facility on [DATE], with diagnoses to include but not limited to Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Metabolic Encephalopathy, Other Toxic Encephalopathy, Malignant Neoplasm of Peritoneum, and Uncomplicated, Chronic Kidney Disease, Stage 3A. A review of the order summary report dated 08/22/2023 showed treatment as follows: cleanse left arm areas with normal Saline, apply skin prep to periwound skin and adhesive contact areas. Further review of the order summary showed treatment as follows: cleanse left forearm with Normal Saline apply skin prep to periwound skin and adhesive contact areas, order date 08/23/2023. A review of the progress note dated 08/15/2023, signed by Staff M, Registered Nurse, Unit Manager, showed Staff M received a call from [local hospital] saying when they received Resident #113, he had skin tears on his knee. They offered to take him to the emergency room but Resident #113 said he was not in pain. Staff M noted that per [local hospital] they reported the transportation people to their supervisor. A review of the Weekly Skin Check dated 08/12/2023, showed No New Areas of Skin Impairment. A review of the electronic medical record showed a skin check was not conducted on 08/15/2023 when Resident #113 arrived back to the facility. A review the Weekly Skin Check dated 08/19/2023, showed No New Areas of Skin Impairment. During an interview on 08/ 23/2023 at 10:08 a.m., the Director of Nursing said she was not notified of any incident that occurred on 8/15/2023 with Resident # 113, it was just brought to her attention 8/22/2023. The DON said after she was notified about the incident, she conducted her investigation and found out Resident # 113 had an incident outside of the facility with his transport service. She said a nurse at [local hospital] reported to Staff M, the unit manager, that when Resident #113 arrived at his appointment with transportation service, she pulled the resident's covers off of him and noticed blood on his covers and skin tears on his legs and knees. During an interview on 8/23/2023 at 2:00 p.m., Staff M said she received a call from the nurse at [local hospital] on 8/15/2023 to inform the facility that Resident #113 was left in the front lobby by someone from the transportation service. She said the nurse reported she noticed blood on the resident's sheet when he arrived so she conducted an assessment on the resident and found big abrasions on his legs and arms. She said the nurse told her she immediately reported Resident #113's condition to her supervisor and was informed by her supervisor to notify the nursing facility. Staff M said the nurse reported to her that they offered to send Resident #113 to the emergency room (ER) but he refused to go. Staff M said, when the resident arrived back to the facility, they did not conduct an skin assessment on him. She was not aware of the skin tears on the resident's arms until later on. She said she did not report the information that was given to her by the nurse at [local hospital] to the Director of Nurses (DON) and the Risk Manager (RM), she only reported the information to the floor nurse who took care of the resident when he came back to the facility. Staff M said she knew she should have made sure that an skin assessment was done and that she should have reported the information to her supervisor/ DON. During an interview on 8/23/2023 at 1:30. p.m., the Nursing Home Administrator (NHA)/RM said she was not notified that Resident #113 had an incident on 8/15/2023 until [this writer] brought it to her attention. She said after she was notified, she conducted an investigation and found out by another resident that Resident #113 was dropped on the floor on 8/15/2023 by the transport service. The NHA/ RM said the resident across the hall reported to her he watched the transport service drop Resident #113 on the floor while trying to transfer him onto their stretcher. He also reported he watched them clean up the blood from the resident off the floor, then left the room with Resident #113 on their stretcher. The NHA/ RM said she reached out to the transportation services to further investigate the situation. The transportation service reported Resident #113 was sitting on the edge of his bed and fell off the bed and scraped his knee according to their driver. They reported when they asked the resident if he was okay, the resident replied, Yes, so they picked him up off the floor, placed him on their stretcher and left the facility to take the resident to his appointment without telling anyone at the facility what happened. The NHA/ RM said a nurse from [local hospital] called the unit manager to report to her the condition Resident #113 was in when he arrived at their facility. The unit manager followed up by notifying Resident #113's doctor to obtain an order for his left knee, but she did not notify the RM and the DON about Resident #113's condition. The NHA/ RM said the nurse did everything she was supposed to do. She felt like the only thing the nurse did not do was an event report, but all other protocols were followed. A review of the facility Risk Management Manual titled, Abuse Prevention Program, Change date, August 2022. Policy: The facility has designated and implemented processes, which strive to reduce that risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education if staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Definition: Alleged Violations A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not been investigated and if verified, could be noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown, and misappropriation of resident property. Procedure: The facility has implemented the following procedures in an effort to provide residents, visitors, and staff with a safe and comfortable environment. The Administrator, DON, and/ or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, exploitation and misappropriation. Identification: Events of injuries of unknown origin/ source, such as suspicious bruising occurrences, patterns, & trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified ad thoroughly investigated, with appropriate reporting as indicated. Event report is initiated upon identification of actual, suspected, and/ or abuse. Investigation: An event report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. Reporting: The facility will follow Federal regulations and State specific reporting requirements. DCF will be notified promptly. The administrator of the facility and/ or designee will be notified immediately. Photographic evidence obtained.

Based on observations, record review, and interview, the facility failed to confirm the accuracy of a Pre-Admission Screening and Resident Review (PASRR) and to correct the document for seven (Residents #172, #205, #28, #81, #82, #110 and #130) of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. Review of Resident #172's Admission Record identified an original admitted [DATE] and a recent admitted [DATE]. The review of Resident #172's Pre-Admission Screening and Resident Review (PASRR), dated 8/25/21, showed the diagnoses of bipolar disorder, psychotic disorder, and substance abuse. The PASRR revealed the resident had had the following characteristics of difficulty of interpersonal functioning, concentration, persistence, and pace, and adaptation to change, recent treatment for mental illness, and exhibited actions or behaviors that may make them a danger to themselves or others. The PASRR showed the resident may not be admitted to an [sic] Nursing Facility and that a Level II PASRR evaluation would have to be requested due to the diagnosis or a suspicion of a Serious Mental Illness. The Admission Record for Resident #172 showed diagnoses not included on the residents PASRR: dementia in other disease classified elsewhere unspecified severity with other behavioral disturbance, unspecified schizophrenia, unspecified recurrent major depressive disorder, and unspecified mood (affective) disorder. A review of Resident #172's clinical record did not include a Level II PASRR determination. The facility did not provide the resident's Level II PASRR determination. On 8/24/23 at 2:13 p.m., Staff Q, Assistant Director of Nursing (ADON), reviewed the PASRR and confirmed Resident #172's PASRR should have been redone due to the addition of diagnoses. 2. Review of Resident #205's Admission Record showed an admitted [DATE] and included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. A review of Resident #205's Pre-Admission Screening and Resident Review (PASRR) did not show the resident had any diagnosis of mental illness (MI) or suspected MI. On 8/24/23 at 2:09 p.m., an interview was conducted with the Admissions Coordinator and Staff Q. The Coordinator stated that Admissions department ensured the PASRR obtained prior to admission and was reviewed for accuracy, if inaccurate the Nursing Home Administrator (NHA) and Social Services (SS) review if the Level II was necessary then gets back in contact with the case manager (hospital). Staff Q stated that the SS and NHA have been auditing PASRR's for the last two weeks. 3. Review of Resident #81's face sheet showed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The Face sheet indicated a list of secondary diagnoses that included the following: -Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with onset date of 7/19/19 -Major depressive disorder, Recurrent, with onset date of 6/5/18 -Schizophrenia, unspecified, with onset date of 5/16/14. Review of the PASRR Level I Screen completed, signed and dated by a facility nurse on 2/11/2020 showed the resident had mental illness identified as Depressive Disorder and Schizophrenia. Review of the resident record showed there was no level II PASRR available for review. In an interview on 08/24/23 at 02:00 p.m. with Staff Q, she stated the social worker reviewed the PASRR for accuracy and if it was warranted a request for a Level II screen would be made. She indicated for Resident #81 once new diagnoses of dementia and mental illnesses were identified a request for a level II PASRR should have been made. 4. Review of Resident #82's Level I PASRR dated 2/11/20, showed a mental illness diagnosis of Anxiety Disorder, Depressive Disorder, and Schizophrenia and indicated the resident did not have a primary or secondary diagnosis of dementia or related neurocognitive disorder. A review of Resident #82's diagnosis list in the electronic record showed a diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 4/1/20 as a secondary diagnosis. A review of the residents care plan related to PASRR Level II Resident has or is suspected to have a Serious Mental Illness (SMI), Intellectual Disability (D) or other related conditions that require a a PASRR Level II, This plan was initiated on 5/11/21. A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had non-Alzheimer's Dementia, Seizure disorder, Anxiety Disorder, Depression other than Bipolar. A review of the Psychiatric note dated 6/16/23 indicated the reason for the visit was to address Major depressive disorder, anxiety disorder, pseudobulbar affect, Vascular dementia. An interview on 08/24/23 at 2:00 p.m. with Staff Q revealed she, along with the social worker, reviewed the PASRR when the resident was admitted and if there were errors, the PASARR would be re-done and if a level II was needed all required documents would be sent for the review. 5. A review of the Admission Record for Resident #110 showed he was admitted on [DATE], with diagnoses included but not limited to Schizophrenia, Unspecified, Psychotic Disorder with Delusions Due to known Physiological Condition, Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, Post - Traumatic Stress Disorder, Chronic, Abuse of Other Non- Psychoactive Substance. A review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status, (BIMS) score of 02, which indicated severe cognitive impairment. A review of the Preadmission Screening and Resident Review (PASRR), Level I Screen, showed Section 1, PASRR Screen Decision Making, not completed. During an interview on 8/24/2023 at 3:00 p.m., Staff Q stated she was responsible for ensuring Level II PASRR's were obtained for residents at the facility who were eligible for a Level II. Staff Q, ADON, confirmed she did not follow up to obtain a Level II PASRR for Resident # 110. 6. On 08/21/23 at 10:00 a.m., Resident #28 was observed in bed repeatedly hitting her head with her fist. The Admission Record for Resident #28 showed she was initially admitted on [DATE] with diagnoses of major depressive disorder and generalized anxiety disorder. The Admission Record revealed new diagnoses of vascular dementia, unspecified severity, with other behavioral disturbance documented on 10/01/22, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, schizophrenia documented on 05/18/22, anxiety disorder documented on 04/15/21, and unspecified psychosis not due to a substance or known physiological condition documented on 04/03/20 and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #28 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia and the resident was not assessed for PASSAR Level II. A review of Resident #28's PASRR Level I Assessment, dated 08/27/19 showed diagnoses of anxiety disorder and depressive disorder and no PASRR Level II was required. Review of the medical record showed the resident was not assessed for PASRR Level II. 7. The Admission Record for Resident #130 showed he was initially admitted on [DATE] with a diagnosis of schizophrenia. The Admission Record revealed new diagnoses of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety documented on 04/04/22, depression documented on 04/04/22, and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the MDS dated [DATE] showed Resident #130 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder and depression and the resident was not assessed for PASRR Level II. Review of Resident #130's PASRR Level I Assessment, dated 02/01/21 revealed no qualifying mental health diagnosis and that no PASRR Level II was required. Review of the medical record revealed the resident was not assessed for PASRR Level II. On 08/24/23 at 1:50 p.m., Staff Q said she completed and submitted the PASRRs. The Social Services Director and Administrator reviewed the PASRRs for accuracy. She looked at medications and diagnoses to determine what should be checked on the PASRR. Staff Q confirmed diagnoses were not indicated on the Level I PASARR for Resident #28 and #130. She stated the forms should have been corrected and resubmitted to Kepro for a Level II PASRR. Review of the facility's policy titled PASRR Requirements Level I and Level II- Florida effective February 2021 revealed A resident review must be completed when there has been a significant change in a resident mental or physical condition resident review is also required if a resident is transferred to a hospital for care and the stay last longer than 90 consecutive days prior to readmission. 2. Written notification requirement for Level II referral: upon completion of the Level I PASRR screen, if the resident has a diagnosis of or suspicion of having a Serious Mental Illness (SMI), Intellectual Disability (ID) or both the screener must send the resident or legal representative written notice stating the individual has a diagnosis of, or is suspected of having an SMI, ID, or both and is being referred for a Level II evaluation. 37999 46498 39438

Based on observation, record review, and interview, the facility failed to provide enteral nutrition for one (Resident #150) out of six residents sampled for tube feeding as evidence by staff stopping the nutrition prior to the prescribed amount being infused. Findings included: On 8/21/23 at 12:50 p.m., Resident #150 was observed lying in bed with a enteral pump on an infusion pole next to the bed. The observation showed that no nutrition bottle was hanging on the pole and the pump was not running. On 8/22/23 at 11:04 a.m., Resident #150 was observed without a bottle of nutrition hanging from the infusion pole and the nutrition pump was not running. (Photographic Evidence Obtained) Review of Resident #150's Admission Record revealed the resident had been admitted on [DATE] with diagnoses that included but not limited to oropharyngeal phase dysphagia, unspecified protein-calorie malnutrition, and gastrostomy status. Review of Resident #150's physician orders, completed on 8/22/23 at 1:48 p.m., revealed an order started on 6/19/23 for Enteral Feed - every shift Enteral Feed: Glucerna 1.2 Cal Continuous via tube to infuse at a rate of 50 mL/hour (hr). Total volume of 1200 mL infused in 24 H (hour). May turn off for care/services. Start at 2 p.m. Verify infusing every (Q) shift. Clear pump when total volume has infused. The above order identified that Resident #150's enteral nutrition would have to run for 24 hours or more depending on care times to infuse 1200 mL's at 50 mL/hr (24 hours x 50 mL/hr = 1200 mL). During an interview on 8/22/23 at 11:12 a.m. Staff K, Licensed Practical Nurse (LPN) stated the Resident #150's nutrition had been taken down at 10-ish (10:00 a.m.) and goes back up at 2:00 p.m., I believe. The staff member reviewed the enteral feed order and confirmed that the resident was to have 1200 milliliter (mL's) of Glucerna infused. Staff K calculated the time that it would take to infuse 1200 mL at 50 mL/hour (as ordered) and confirmed it would be 24 hours or longer due to the stopping of nutrition during care. The staff member confirmed the order did not allow for taking the nutrition down at 10:00 a.m., then stated the bottle was empty. On 8/22/23 at 11:26 a.m., an observation of Resident #150 showed that no nutrition was infusing. On 8/22/23 at 11:40 p.m., an observation was conducted of Resident #150's nutrition delivery system delivering 50 mL/hr and 936 mL had been infused. A full bottle that contained 1000 mL's of Glucerna 1.2 was hanging from the pole. Staff K confirmed that 935 mL's had been infused not the ordered 1200 mL's. The Nutritional Risk Evaluation Monthly, effective 8/14/23 at 2:04 p.m. for Resident #150 showed Glucerna 1.2 @ 50 mLs/hr until 1200 mLs, 100 mLs q4hrs. The evaluation showed the resident's current weight was 96.4 pounds with no weight change and a nothing by mouth (NPO) diet. A review of Resident #150's Medication Administration Record, printed on 8/22/23 at 5:53 p.m., did not show that staff were to stop the infusion of the resident's nutrition at 10:00 a.m., per Staff K's interview. It did identify that staff verified the infusion every shift (Q shift). The care plan for Resident #150 showed the resident was receiving enteral nutrition through tube feeding and the goals were to Will obtain adequate nutrition and (&) hydration and interventions included Administration of enteral nutrition as ordered (Refer to MD orders for current orders). Review of the policy: Nutrition - Enteral/Parental Nutrition & Hydration, effective October 2021, included Optimizing nutritional status to delay decline will be an appropriate goal only if in accordance with resident/patient or legal guardian's wish. An interview was conducted with the Director of Nursing on 8/24/23 at 2:31 p.m. The DON reviewed the order for Resident #150's enteral feeding and said the expectation would be that the order for nutrition be followed and that continuous (infusion) would be continuous except for care periods.

Based on record review and interview, the facility failed to follow physician orders related to side effect monitoring for psychotropic medications for one (Resident #161) out of five sampled residents. Findings included: The Admission Record showed Resident #161 was initially admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, generalized anxiety disorder, and altered mental status. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #161 was rarely/never understood. Section N Medications indicated the resident took antianxiety and antidepressants for 7 days. The Order Summary Report with active orders as of 08/24/23 revealed the following orders: side effect monitoring; Ativan oral tablet 0.5 MG- Give 1 tablet by mouth (po) at bedtime for anxiety; buspirone HCL oral tablet 10 MG- Give 1 tablet po three times a day related to generalized anxiety disorder; divalproex sodium oral capsule delayed release sprinkle 125 MG- Give 2 capsule po three times a day for mood disorder; mirtazapine oral tablet 7.5 MG- Give 1 tablet po at bedtime for depression; and sertraline HCL oral tablet 25 MG- Give 1 tablet po at bedtime for depression. A review of the Medication Administration Record (MAR) and Treatment Medication Record (TAR) for June 2023, July 2023, and August 2023 revealed side effects were not monitored as ordered. The care plan initiated 04/17/23 showed a focus area of the use of psychotropic medications related to antidepressants to manage depression and anxiety. Interventions included antidepressant side effect monitoring and psychotropic side effect monitoring. On 08/24/23 at 1:20 p.m., the Director of Nursing (DON) stated she would have to check on the order related to side effect monitoring but did not follow up.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and two errors were identified for two (#87 and #106) of six residents observed. These errors constituted a 8% medication error rate. Findings included: 1. On 8/22/23 at 8:55 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #87. The staff member dispensed the following medications: - Acidophilus Probiotic 1 billion over-the-counter (OTC) capsule - Retrieved from medication refrigerator. - Amlodipine Besylate 2.5 milligram (mg) tablet - Baclofen 20 mg tablet - Vitamin D 25 microgram (mcg) - 2 tablets OTC - Loratadine 10 mg tablet OTC - Vitamin B-12 1000 mcg - 2 tablets OTC - Praxada 150 mg capsule - Potassium chloride Extended Release 20 milliequivalent (meq) - Furosemide 20 mg tablet - Gabapentin 100 mg - 2 capsules - Tamsulosin 0.4 mg capsule - Lubiprostone 24 mcg capsule - Metformin 500 mg tablet Review of Resident #87's Order Summary Report revealed an order for Acidophilus Oral Capsule (Lactobacillus) - Give 2 capsule by mouth two times a day for GI Probiotic. The review of Resident #87's August Medication Administration Record (MAR) showed Staff H had documented 2 capsules of Acidophilus had been administered. The observation of Staff H dispensing Resident #87's oral medications and the confirmation from Staff H that 16 tablets/capsules had been dispensed verified the resident did not receive 2 capsules of the probiotic. 2. On 8/22/23 at 9:19 a.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #106. Staff I dispensed the following medications: - Docusate Sodium 100 milligram (mg) capsule over-the-counter (OTC) - Folic acid 400 microgram (mcg) - 2 tablets OTC - Lactulose 10 gram/15 milliliter (mL) - 15 mL's - Tamsulosin 0.4 mg capsule - Vitamin D3 50 mcg (2000 international unit (iu)) OTC Staff I confirmed 5 tablets/capsules and one liquid medication had been dispensed. Staff I administered the medications to Resident #106. Review of Resident #106's August Medication Administration Record (MAR) showed the resident was scheduled at 9:00 a.m. to receive 17 grams of Polyethylene Glycol powder mixed with 8 ounces of water one time a day for constipation along with the above dispensed medications. The MAR showed Staff I had administered the Polyethylene Glycol. The observation did not show the resident had received Polyethylene Glycol. On 8/24/23 at 9:08 a.m., the Director of Nursing (DON) and Staff P, Regional Nurse Consultant (RNC) were notified of the medication errors observed. Review of Medication Administration, dated 09/18, revealed that Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The procedure instructed that Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record.

Based on observations, record reviews, and interviews the facility failed to ensure 1. one (secured 400-hall) out of five treatment carts were locked while unattended by authorized personnel on two separate occasions, 2. a tube of medicated topical ointment prescribed for a resident was not left on the dresser in a room that the resident did not reside, and 3. one (2-High) out of eight medication carts did not contain an unopened vial of Insulin Lispro. Findings included: 1. On 8/21/23 at 9:28 a.m., an observation was conducted on the secured behavioral 400-hall of a treatment cart parked behind the nursing desk next to a dining/common area. The area did not have a latched gate or door and was accessible to residents, unauthorized personnel, and visitors. The observation revealed the first drawer of the treatment cart held 2 bottles of Thick Hand Sanitizer, a box that indicated it contained a tube of Hydrocortisone cream, multiple packages of denture cleanser, and a bottle of a reddish-brown liquid. The second drawer held multiple tubes of prescribed medicated ointments, the third drawer held sterile packages of wound care supplies, a spray bottle of a liquid, and a bottle of body cleanser, the fourth drawer contained sterile packages and two bottles that contained unknown substances, and the bottom drawer contained multiple items including unpackaged cigarettes and a bottle of hair cleanser. (Photographic evidence obtained) An interview was conducted on 8/21/23 at 9:32 a.m., with Staff L, Licensed Practical Nurse (LPN). Staff L arrived to the nursing desk area from assisting with the passing of breakfast trays to residents in their rooms and confirmed the treatment cart was unlocked. Staff L stated the residents of the secured behavioral unit couldn't go through the cart then stated residents shouldn't (go through the cart). 2. On 8/22/23 at 11:12 a.m., an observation was conducted with Staff K, LPN, of a tube of medicated ointment on a dresser of a 4-bed room (room [ROOM NUMBER]) that was currently under Enhanced Barrier Precautions and where 4 residents did reside. The staff member confirmed the observation and said the medication was prescribed to a resident that did not reside in the room and stated she must have grabbed the wrong tube. Staff K confirmed the medicated topical ointment should not have been left in the room. (Photographic evidence was obtained) 3. On 8/24/23 at 10:54 a.m., a review of the 2-High medication cart was conducted with Staff M, Registered Nurse (RN)/Unit Manager (UM). The observation identified an unopened vial of Humalog (Insulin Lispro). The pharmacy label instructed Refrigerate until opened then store at room temperature. Staff M confirmed the resident had an opened vial of the same insulin that was almost full and that the unopened vial should be refrigerated. Review of the policy - Medication Storage, dated 09/18, revealed that Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. The procedure revealed that Insulin products should be stored in the refrigerator until opened.

Based on observation, interview, and record review, the facility failed to ensure that one (Resident #37) of one resident reviewed for dental services was provided with dental follow-up for missing dentures. Findings included: An interview with Resident #37 on 08/21/23 at 10:17 a.m. revealed he had broken upper and lower teeth. The resident said he had dentures and lost them. He said he thought someone was working on getting new ones, but he was not sure who was working on it. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated the following: -No broken or loose fitting dentures -No cavity or broken natural teeth Review of the Nutrition Evaluation dated 6/28/23 indicated the following: -chewing problems -dysphagia A review of Resident #37's care plan showed has potential oral/dental problem dated 9/26/18. The care plan, including the interventions, had no mention of the use of dentures. A review of the dental vendor Patient Progress report dated 4/19/23 showed that Patient presents for evaluation. Top denture and lower partial fit ok. No follow up needed Observations of Resident #37 on 08/24/23 at 8:44 a.m. revealed the resident lying in bed and noted to have no missing upper teeth. During an interview with the resident at this time, he reported that he had his top dentures but his bottom dentures were lost. The resident showed his mouth which reflected his upper dentures present and his lower dentures not present. During an interview on 08/24/23 at 8:46 a.m. with Staff S, Certified Nursing Assistant (CNA), she located the resident's denture cup from his nightstand which was empty and voiced his upper dentures was present at the end of her shift last evening. The resident took his upper denture from his mouth and then placed it in the cup, Staff S reported the resident was transferred from another unit with only the top dentures which he used daily. She said she was not aware of the resident having bottom dentures while on this unit. An interview on 08/24/23 at 8:52 a.m. with Staff I, Licensed Practical Nurse (LPN), revealed the resident transferred from the 300 unit and only had upper dentures since being on the 400 unit. She said Social Services was responsible for dental follow-up. An interview on 08/24/23 at 8:55 a.m. with Staff T, Social Service Director, revealed she was not aware of the resident having missing dentures. She said nursing would usually tell Social Services if there was a dental problem, and would then schedule an appointment for the resident to be seen by the dental vendor. She said she was not sure when then resident was last seen by the dental vendor. Review of the facility policy titled Dental Services Policy indicated the following: The facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent further decrease in range of motion for one (Resident #3) of three sampled residents. Findings included: On 8/21/2023 at 10:12 a.m., 11:45 a.m., 12:50 p.m., and 1:55 p.m., Resident #3 was observed in her room, lying flat in bed and with her head on a pillow. One quarter bed rails on both sides of the bed were up. Resident #3 had eyes closed and with the bed linen over her and covering the lower part of her body. She was not presenting with any behaviors, pain or discomfort during all observed times. Further observations revealed both of her upper extremities (hands) were contracted. Her hands were positioned and leaning on bed rails in a manner that appeared uncomfortable. Resident #3 was not interviewable. The resident was observed not wearing any splints or braces on either of her hands. On 8/22/2023 at 7:06 a.m. and 8:20 a.m., the resident was observed in bed in a flat position with both bed rails up. Both of her hands were positioned and leaning on the metal bars of the bed rails and appeared to look uncomfortable. She was not observed wearing any splints or braces on either of her hands during all observed times. On 8/22/2023 at 12:15 p.m., the Resident #3 was observed out of bed and in a reclining chair, positioned next to her bed. She had covers and a blanket over her with her eyes closed and resting comfortably. She was not observed presenting with any behaviors, pain or discomfort. Resident #3's hands could not be observed as they were placed beneath the blanket/linen. The side of the blanket/linen was lifted slightly to observe her hands. Both hands were observed without any splints or hand devices. On 8/23/2023 at 7:10 a.m., Resident #3 was noted in bed, lying flat and under the covers. Both bed rails were up. Both of the resident's arms and hands were out from the bed linen/covers and positioned on her sides. Both of the resident's hands were noted without any splints or braces on. She was also observed at 8:01 a.m., 8:30, and 9:45 a.m. lying in bed with no splints or braces on either of her hands. On 8/23/2023 at 10:10 a.m. an interview with Staff F, Certified Nursing Assistant (CNA) was conducted. She said she had the resident on her normal working assignment and had her on a regular basis. Staff F said she was knowledgeable of the resident and her care. Staff F revealed the resident had been at the facility for a very long time and she needed total care with all of her Activities of Daily Living (ADL). Staff F confirmed Resident #3 had contractures on both of her hands. Staff F was asked if the resident utilized splints or guards. Staff F said the resident did but she had not placed them on her yet. She was asked if there were special tasks regarding palm guard/splints and she confirmed there was and it was noted in the CNA Kardex [daily task plan]. She confirmed the palm guard/splints were to be positioned and placed during the day at the start of the 7:00 a.m.-3:00 p.m. shift. Staff F confirmed she had not gotten to it yet and was going to place them on the resident shortly. She confirmed the resident did not refuse to wear the palm guards/splints. When asked how Staff F documented the palm guards/splints were placed on each day, she revealed there was no check list for that but if there were any problems with the palm guards/splints and if the resident were to refuse, she would tell either the unit nurse or the unit manager. Staff F confirmed she worked on 8/22/2023 as well and believed she put the palm guard/splints on but was not sure. She had no documentation to support the palm guard/splints were on that day. A review of the medical record showed Resident #3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the diagnosis sheet revealed diagnosis sheet revealed current diagnoses to include but not limited to: Dysphagia, Contracture, unspecified joint, Contracture, unspecified hand, Epilepsy, and Intellectual Disability. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed: (Cognition/Brief Interview Mental Score or BIMS score - Not score, but indicated resident had short term/long term memory problem and with severely impaired decision making skills); (ADL - BED MOBILITY = Total Dependence, TRANSFER = Total Dependence, DRESSING = Total Dependence, TOILET USE = Total Dependence, PERSONAL HYGIENE = Total Dependence); (Upper Extremity - Impairment both sides, Lower extremity - Impairment on both sides, Mobility device - None). A review of the current Physician's Order Sheet (POS) dated for the month of 8/2023 showed: - Monitor pain every shift and record pain number on a 0-10 scale x shift. - Resident to wear bilateral palm guards on in a.m. , and off in p.m., as tolerated. May remove for care and inspection of skin integrity x day shift (order date 4/6/2023). A review of the Care Plan Interdisciplinary Team (IDT) note dated 5/30/2023 showed - Care plan meeting held today with resident/[family member] in facility. IDT members information given [by] UM [unit manager], CNA, Activities Director and MDS. Discussed Kardex, medication and treatment. She uses Bilateral palm guards and is on pain meds. [Family member] says she is happy when everything is good. Plan of care will continue. A review of the all nursing notes dated from 11/25/2022 through to current 8/23/2023 did not show documentation to support Resident #3 had ever refused the use of the palm guards or hand splints. A review of the Certified Nursing Assistant (CNA) tasks/Kardex document, showed a section for : Splint task splint type - Bilateral palm guard apply to: Splint bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated. This task was noted assigned to CNA and RNA (Restorative Nursing Assistant). The task history for this device noted the same direction on 4/5/2021, 10/29/2021, and 1/16/2021. There were no device notes since 1/16/2023. A review of the care plans with next review date 11/15/2023, showed the following problem areas: a. Cognition - Has impaired cognitive function/dementia or impaired thought process r/t Severely impaired BIMS score of 0-7, Disease process, with interventions in place as reviewed and observed. b. Resident has a problem with communication: Rarely or never understood - unable to express ideas or want, Rarely/never understands, with interventions in place as reviewed and observed. c. Has an ADL Self Care Performance Deficit as evidence by: Cannot complete ADL tasks independently and requires individualized interventions to maintain because; Weakness, Impaired cognition, with interventions to include but not limited to: Range Of Motion - Limitations to Lower and Upper extremities encourage/provide passive/active with routine care and within physical capacity; Side Rails - Left and Right 1/4 rails up as mobility aid and/or for safety during care provision and is medically appropriate for use because of weakness. d. Range of Motion: Resident has a risk or actual limitations in Range of Motion as evidenced by: Impairment on both side hands bilateral palm guards, with interventions to include but not limited to: Splint task, Splint type: Bilateral palm guard apply to: blank no information; Splint to bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated; Observe and Report decline in ROM. e. Skin Integrity risk - Resident has potential/actual impairment to skin integrity r/t keloids all over her back, with interventions to include but not limited to: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. On 8/24/2023 at 8:40 a.m., an interview with Staff A, Licensed Practical Nurse (LPN) showed during her shift she would make rounds and ensure her staff were implementing care plan interventions per the Kardex and care plan problem areas. She confirmed Resident #3 had contractures on both of her hands and she was to wear splints/palm guard devices on both hands during the day to include all of the 7:00 a.m. - 3:00 p.m. shift. Staff A said the assigned aide for the day was responsible for applying the splint/palm guard daily but there was no documentation to support if the splints/palm guards were placed on or not. Staff A also said the aides did not put the splint/palm guards on, then she would do it. She confirmed as far as the donning and doffing of the splints/palm guard, the restorative staff were not responsible to do that. On 8/24/2023 at 12:30 p.m., an interview with the 100 Unit Manger Staff E confirmed the resident had a long standing of contractures on both her right and left hands. Staff E said Resident #3 had resided at the facility for many years and she required and used palm guards on both of her hands on a daily basis to reduce further contracture. Staff E was not aware Resident #3's palm guards were not applied on 8/21/2023, 8/22/2023, and the morning of 8/23/2023. She said all staff were aware to look at their Kardex daily care plans and were to follow each intervention. She said the floor nurse as well as herself made rounds to ensure all interventions were in place, per each assignment. Staff E could not provide any documentation to support palm guards were placed and positioned each day, or if the palm guards were ever refused. Staff E said, to her knowledge, Resident #3 had never refused the use of the palm guards. During an interview on 8/24/2023 at 2:00 p.m. with the Nursing Home Administrator, she said the facility did not have a specific Contracture Management policy and procedure for review.

Based on observations, review of medical records, facility policies, and interviews with facility staff and a family member, the facility failed to provide supervision to one (Resident #1) of three residents sampled for high-risk of elopement. Resident #1 was severely cognitively impaired, ambulatory, repeatedly expressed a wish to leave the facility and had attempted to leave the facility before January 25, 2023. Resident #1 was assessed to be an elopement risk and was care planned to have 1 to 1 supervision when smoking. On January 25, 2023, Resident #1 was able to exit the facility unbeknownst to staff and was found 2.9 walking miles from the facility 44 hours later. The resident whose diagnoses included dementia suffered the likelihood of harm, due to the potential for wandering into on-coming traffic along busy streets, being hit by a vehicle causing injury or death. Resident #1 had history of falling and could have fallen on uneven sidewalks. The resident had no means to obtain food, water or shelter for the time he was absent from the facility creating the likelihood for dehydration, and/or harm from exposure to the elements. This resulted in the findings of Immediate Jeopardy starting on 1/25/2023. The immediacy was removed on 2/01/2023 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings included: Review of Resident #1's admission record revealed an initial admitted [DATE] and a returned date of 1/27/23. Resident #1 was admitted to the facility with diagnoses that included Dementia unspecified severity without behavioral disturbance, psychotic disturbance and anxiety, muscle wasting and atrophy, weakness, unsteadiness of the feet, [NAME]'s encephalopathy, seizures, chronic obstructive pulmonary disease (COPD) Dementia, alcohol abuse, bipolar disorder, acute and chronic respiratory failure, and a history of repeated falls. Review of a quarterly Minimum Data Set (MDS) dated [DATE], section C, cognitive patterns showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section G, functional status, under F. Locomotion off unit - how resident moves to and returns from off-unit locations, showed the resident required supervision with one person assist. G0300 Balance during transitions and walking showed the resident was coded 1, not steady, but able to stabilize without staff assistance. Section N, medications showed the resident received antipsychotic, antianxiety and antidepressant medication 7 days a week. Review of a care plan for Resident #1 dated 8/24/22, revealed an elopement risk focus, indicating Resident #1 is at risk for elopement. The goal section showed the resident will not exit the facility without staff knowledge, or appropriate supervision. Interventions included: 1:1 supervision indefinite at all times, complete required information on elopement risk identification information sheet, if the resident is wandering offer frequent rests and snacks if indicated, secured unit, refer to psychological services as needed, diversional activities. Further review of the care plan revealed Resident #1 was a current smoker, with a goal to remain safe while smoking. Interventions included to observe for smoking safety through observation and interview and supervised smoking at all times. Review of a document titled, order summary report, date range: 11/01/22 to 01/31/23, showed Resident #1 did not have physician orders in place related to supervision prior to the elopement occurring on 01/25/23. Review of a document titled, elopement-v 2, dated 8/24/22, showed the following: 1. Is this resident confused? Yes 2. Resident is ambulatory or mobile (walker, wheelchair/chair) Yes. 3. Is question 1 and question 2 both Yes? Activate elopement interventions as follows: Educate staff that the resident is now an elopement risk, place picture in elopement book, update the orders care plan and Kardex and notify supervisor-document in the medical record. Review of a document titled, Elopement Risk, dated 9/1/22, showed Resident #1 had a diagnosis of dementia, was cognitively impaired, confused and was independently mobile. The document showed, resident has history of elopement, desires to leave facility, verbalizes desire to leave facility such as, I don't want to stay here, how do I get out of here, I'm looking for my sister, exit seeking, wandering, looking out of/trying to open windows, loitering by exit doors/or attempting to open exit doors. The resident is assessed as an elopement risk. On 2/1/23 at 12:17 p.m., a telephone interview was conducted with Resident #1's family member. She stated she was notified Resident #1 left the faciity on [DATE]. She stated they said he walked out the door, climbed up a fence and left the facility. She stated no one saw him leave and they did not know where he was for a couple of days. The family member stated she received a phone call from a stranger at the bus station who was trying to buy him (Resident #1) a bus ticket to get to Maryland. The phone call was received on 1/27/23 in the morning. The family member stated the resident was a severe alcoholic with a wet brain ([NAME]-Korsakoff syndrome (WKS), is a brain disorder related to the acute and chronic phases of a vitamin B1 deficiency, a common complication of long-term heavy drinking) due to falling and hitting his head many times. She stated he always runs away from facilities wanting to get back to Maryland. The family member said, they [facility] knew he was at risk for elopement. I have discussed his history with the Social Services Director (SSD). They should have known he is flight risk. The family member stated she was not anticipating moving the resident to Maryland because the family is not able to take care of him. On 1/30/23 at 10:30 a.m., an interview was conducted with Resident #1. The resident was observed in the fenced courtyard outside the 400 secured hall, smoking a cigarette. The resident was with his 1:1 aide, Staff E, Certified Nursing Assistant (CNA). Resident #1 expressed frustration with his placement and his desire to leave the facility. The resident said, I want out of here. I am mad the police brought me back here. I do not want to be here. This is not my destination. I was trying to get to Baltimore, Maryland. Resident #1 stated on the day he eloped (1/25/23), I walked out of that gate, no, I did not jump. I don't remember jumping a fence like everyone is telling me. There was no staff here. Everyone had just walked outside to smoke their cigarettes. I got to that gate [pointing to a six-foot gate in the middle of the courtyard] and walked out. I proceeded to the other one over there [pointing to another six-foot gate] I hopped that thing. The next thing you know I was on the other side, I walked to the bus station, not too far from here, probably a mile or two. I got up the road and the police brought me back. The resident stated he did not take any belongings when he left. He stated he was gone for about a whole day. The resident could not confirm where he went or where he spent the night. Resident #1 said, I want out of here. I am wasting space, someone else could use the bed. My family won't come and get me. I want to leave. I just don't want the cops getting me again. Resident #1 stated he would try and leave the facility again. He stated he just needed a bus ticket to get to Maryland. The resident stated if he was to leave again, he would jump the fence. Resident #1 said, I am a tall guy, that small fence is nothing. The resident stated he wanted to go to Maryland because there is a job waiting for him. On 1/30/23 at 1:57 p.m., a telephone interview was conducted with Staff F, CNA. Staff F stated she was working the day Resident #1 eloped. She said, I was working that day. I was passing the cigarettes as the residents were going out to smoke, I was standing by the nurse's station. One of my residents asked me to help him. When my resident asked for help, I turned to grab gloves and continued to help my resident. We were by the exit door. I later viewed the camera and from the camera you can see [Resident #1] walk past me. I did not see him. He walked out and turned the corner right away behind the building. I did not see him. My back was turned. From the camera you can see him sneak behind me. Staff F stated that Staff G, CNA, was supposed to be 1:1 with him, but he was providing resident care. The other CNA (Staff H, CNA) said she would step in to do the 1:1. She was also standing by the door as the residents were leaving to go outside. Staff F stated Staff G had been assigned because they said we needed a man that day in case he jumped over again. Staff F stated the resident had been exit-seeking. Staff F said, I saw him attempting to leave the day before. I was in room [ROOM NUMBER] and as I looked outside the window, I saw him pulling on the gate, he was banging on the gate as he was climbing. I yelled at [Staff G, CNA] assigned to him. He pulled him back and brought him inside. Staff F stated Resident #1 had tried to leave three times before, the 4th time he left. She stated the incidents were reported to the unit manager. Staff F said, They all knew it. He was trying to jump on the fence. The first time he got out is when they should have fixed the fence. It was sometime in September. They should have made the middle fence area higher. Everyone knew he wanted to leave. The CNA stated on the day he eloped; she could tell earlier in the day he was anxious because he was pacing. Staff F said, you can see it on the camera. You can see him looking around the room. She stated she participated in the search. They looked everywhere in the facility and outside. Staff F stated she gave a statement and told them she did not see him because she was busy with her resident. On 01/30/23 at 10:29 a.m., an interview was conducted with the SSD. She stated she worked with the residents in the 400 unit, a behavioral unit where Resident #1 resided. She stated there was a code on the door to get in and out of the unit. Residents do not have these codes. The SSD confirmed Resident #1 was admitted to the facility because he had potential to wander. She said, He is not safe without supervision. He was placed on the secured unit from day one, because of wandering. The SSD stated she spoke to the family member and was alerted to his history. She stated the family member reported that he kept escaping from other facilities and there were not enough staff to keep him safe there. The SSD said, He has wandered while here. He has tried to go out through the back of the facility. He tried to climb the fence to get away. Every once in a while, he attempts a move, he is an alcoholic, he wants to drink, and he said he was seeking alcohol. She stated nursing staff assess residents for risk of wandering. She stated Resident #1 had not had any previous elopements attempts that she knew of, besides trying to jump the fence. She said, He did not go far. He was brought back before he could go off premises sometime in Review of a document titled psychosocial history and assessment, dated 8/31/22, showed Resident #1 had a psychiatric diagnosis and was being treated with psychotropic medications for bipolar disorder. The resident was unable to state his goals and will remain a long-term care resident of the facility. His memory and cognition were noted not intact and are severely impaired. Review of a progress note dated, 9/1/22 showed, during the smoke break time resident went to the back of the building and climbed over the fence. The resident could not be located on 09/01/22 at 1:27 p.m. The missing person action plan was initiated. The following took part in the search of the resident inside and outside the property. Nursing staff reviewed the LOA (leave of absence) book to determine whether or not the resident signed out. It is noted when last seen, the resident was wearing the following T-shirt and grey pants. The resident was last seen in the smoking area on 9/1/22 at 1:20 p.m. Review of a document titled, Psych Note, dated 9/8/22, showed Resident #1 was seen for psychiatric follow-up and medication management at the request of staff. The document showed reportedly last week patient left the facility and eloped via scaling over fences. He was found and returned to the facility without conflict or combativeness. Family reports he has a history of climbing fences, he was uninjured in the events. He is seen today on the memory care unit, states that he would like to go home, but he is a poor historian unable to provide many details of the event). A progress note, dated 9/13/22, showed, IDT (interdisciplinary) meeting in regard to resident needing a 1:1. Resident will remain on 1:1 at smoking times. Review of a document titled, Psych Note, dated, 9/15/22, showed, he is now only on 1:1 supervision when out for smoking due to history of elopement attempts. Review of an ARNP nursing home progress note, dated 9/22/22, showed the resident was seen in his room in secured unit. He remains on 1:1 during smoke breaks due to elopement risk. The assessment plan showed, he requires 1:1 when out on smoke breaks . locked unit, continue current medications. Review of a social services note for Resident #1 dated 10/5/22 showed the SSD spoke to Resident #1's family member who stated the resident was in an assisted living facility previously and he had too much freedom to wander out and she feared he would get hurt by traffic. Review of a social services note dated 10/18/22, the SSD spoke to Resident #1's family member. The family member wanted him placed in a nursing facility; she had declined assisted living placement. Family member stated, He has too much freedom in an assisted living and can leave the facility and get hurt. Review of a nursing home progress note for Resident #1, by the Advanced Registered Nurse Practitioner (ARNP), dated 11/17/22, showed, resident was seen for vascular dementia with agitation, resident was outside in smoking area, he began pacing and looking at the road yelling, I want to leave this place. he became verbally abusive towards staff. A progress note dated,11/17/22, showed: writer was notified by CNA [smoke aide] that while out smoking, resident was pacing close to the fence and looking at the road. When CNA tried to get closer to the resident just in case, he tried to jump the fence, resident became nervous and verbally aggressive and telling everyone .I want to leave this place now and I want to go to Baltimore where my daughter is. Review of a psych note for Resident #1 dated 12/20/22 showed, the resident felt more agitated more than usual with the holidays. He continues to have persistent insomnia. A progress note dated 1/8/23 showed Resident #1 was confused, and to activate elopement interventions. Review of a social services progress notes dated 01/25/23 at 3:02 p.m., showed the SSD called the resident's family member at 3.p.m. this afternoon to see if she has seen or heard from [the resident], but she did not pick up. Message left in her voicemail informing her the facility is currently looking for him . Review of a progress note dated 1/27/23, showed the resident returned to the facility, admitting diagnosis listed, Risk for elopement. Review of Resident #1's psychiatry note dated,1/27/23 showed the resident has a history of depression, dementia with behavioral disturbance seen for psych evaluation. Patient was reported missing from the facility on 1/25/23. Authorities found the patient at the bus stop on 1/27/23. He was assessed and cleared at the hospital and returned to the facility. He stated I just walked out the gate when questioned about how he left the facility. He stated that he went to another facility to visit a friend. He is oriented to person . He continues to have persistent insomnia. Patient is a flight risk. Continue 1:1 surveillance until further notice. On 1/31/23 at 10:59 a.m., an interview was conducted with Staff H, CNA. She confirmed she was working the 400 secured unit when Resident #1 eloped. She stated at 2 p.m., the nurse went to give him medications or something and she could not find him. She said, I last saw him at the previous smoke break at 10:30 a.m. That was the last time. He was with Staff G. Around 12.30 p.m., Staff F put in the code on the door so we can take the residents out to smoke. She stated she thought Staff F was assigned 1:1 to Resident #1. Staff H said, I do not know. I did not see the resident go out the door. I was there as the residents were going out to smoke. Sometimes he doesn't have cigarettes and that makes him anxious. He did not have cigarettes that day, he just walked around the outside, he was pacing. All the time he says he wants to leave the facility. I try to encourage him, I check to see what he needs, I get him a snack. Staff H stated when the resident paces during smoke breaks, she notifies the Unit Manager. She stated the Unit Manager comes out to stop him from getting upset and calms him down. Staff H stated the resident has tried to leave before. She stated he jumped the fence and was brought back. Staff H stated the resident is always pacing looking for an opportunity to get out. Staff H said, he wants to leave all the time. Even at the 10:30 a.m. break on 1/25/23, he was pacing. He was waiting for the moment to escape. She said, I didn't say anything to the Unit Manager because it is his normal behavior. Everyone knows he is pacing because he wants to leave. Staff H stated after the code silver was called, she stayed at the facility looking for the resident. We looked everywhere for him. We did not find him. Staff H said, what went wrong was we did not know who was taking the 1:1 assignment. She stated they do not conduct rounds every two hours in the secured unit, because someone is always in the common areas and the residents are independent. On 1/31/23 at 10:38 a.m., an interview was conducted with Staff G, CNA. He stated he was working the day Resident #1 eloped from 400. He stated he had been assigned to the resident as his 1:1 during the 10:30 a.m. smoke break. Staff G said, He did not say we wanted to leave. He was walking around the courtyard, like he always does. Staff G stated he was not sure who was supposed to be assigned to him during the 12:30 p.m. smoke break. Staff G stated he was giving another resident a shower when Resident #1 eloped. He stated two CNAs take the smoke task and one of them is supposed to supervise the resident 1:1. On 1/31/23 at 12:00 p.m., an interview was conducted with Staff I, Registered Nurse (RN). Staff I confirmed she was the Nurse assigned to Resident #1 the day he eloped on 1/25/23. Staff I said, I was doing blood pressure checks for the afternoon blood pressure medications between 1p.m. and 2 p.m. I noticed he was not in the room. The bathroom door was closed. I left the room, gave him a couple minutes. I knocked on the door again, there was no answer. When I did not find him in the room, I asked the CNAs to help locate him. We started looking inside the unit. We verified he was not there. I got the Unit Manager. He started looking everywhere. He couldn't find him, so he called code silver. Staff I stated prior to the elopement she was aware Resident #1 was supposed to have 1:1 supervision when he was outside smoking. She stated that day she saw two CNAs go outside smoking. She said, I did not know who was assigned his 1:1. It is usually written on the board so the CNA would know who is assigned. That day it was not listed, so they did not know. Staff I stated she thought the CNAs should check on him at least every 2 hours. Staff I stated, Someone should have looked for him. She stated she thought he went outside with everyone else during smoke break, even though he did not have cigarettes. Staff I stated the resident gets anxious when he is cigarette seeking. She stated she was aware he was at risk of elopement. She was told he needs to be eyes on when outside. The problem was that no one watched him specifically. On 1/31/23 at 10:06 a.m., an interview was conducted with Staff S, RN Unit Manager. He stated Resident #1 liked to stay in his room, He doesn't like crowds and when he is outside, he keeps to himself. He stated on 1/25/23 he was working because he manages both units on 400 hall. He stated around 2 p.m., the nurse (Staff I) reported she could not find the resident. Staff S said, I told her to check everywhere. I went and verified he was nowhere to be found. I called code silver. We couldn't find him anywhere. We notified the administration and started neighborhood search. Staff S stated prior to this elopement, Resident #1 attempted to leave the facility. It was sometime in September. Staff S said, He was outside smoking, I guess staff did not notice right away. We saw him on the camera at the back of the building on the inside of our fenced area. He jumped one gate. He said he jumped the fence. A maintenance person saw him and brought him inside. We assessed him he had no injuries. Staff S stated after the incident, their correction plan was for him to be put on 1:1 supervision when outside smoking. He stated they notified psych. He stated since then, when he goes outside, he is supposed to be eyes on. On 1/25/23, he was supposed to be on a 1:1. Staff S stated he reviewed the camera footage after he left on 1/25/23 and saw on the video one CNA opened the door and the other was assisting the other residents. Staff S said, I don't know how, but he snuck behind her. Every day he is assigned a 1:1. The nurse or unit manager selects a CNA to be with him. Typically, we have 3 CNAs and 1 nurse assigned on the unit. Two CNAs take the smoke task, one of them would be the 1:1 with him. Staff S stated 1:1 means be with the resident everywhere they go. Staff S stated the breakdown was with the one who opened the door. They did not keep an eye on the resident. They knew the resident likes to smoke. They should have missed him when they did not see him out there smoking. I guess no one checked his room until the nurse went to get his blood pressure taken around 2 p.m. On 1/31/23 at 12:25 p.m., an interview was conducted with Resident #1's Physician Assistant- Psychiatry (PA) The PA stated she sees Resident #1 at least monthly. She stated she met with the resident when he returned from the elopement incident. The PA stated the resident reported during the visit he wanted to leave and did not want to be at the facility. The PA said, He stated he went to another facility to meet with a friend. He said he walked out there, he did not say where specifically or what he did overnight. He was oriented. She stated during previous sessions, he had not stated he wanted to leave, at least not anything out of the norm. Everyone in a secured unit would want to leave. The PA said, If anybody is going to leave, it will be him. He is oriented to person and place. She stated his PCP (primary care physician) thinks he has delusions and is under some psychosis and is recommending a medication change. She stated staff had not notified her that the resident wanders or that he is continually stating he wants to leave. The PA said, I think [Resident #1] is smart. He will find a way to leave if he wants to. On 1/30/23 at 1:52 p.m., review of the facility's camera system was conducted. (A copy of the footage was obtained). Camera #1 showed on 1/25/23 at 12:53 p.m. Resident # 1 was walking behind other residents as they ambulated/propelled themselves towards the glass door. The resident was wearing a pair of blue jeans and a black jacket. A staff member is noted holding the door open. The resident walked past this staff member (later identified as Staff H) and proceeded to the right of the building. The other residents are observed proceeded to the smoking patio as Staff H holds the door. As he turns to the right of the building, Resident #1 disappears from the camera's view. Staff F could be seen at the edge of the footage as numerous residents went out to smoke. She is observed bending towards a resident in a wheelchair. Camera #2 showed the resident at 12:54 p.m. at the back of the facility's building walking towards 15th street. The resident was no longer on the property. The resident is observed walking in the middle of the road, to the right of a white car parked off the street. The resident is observed removing his jacket, turned, and looked back at the building, and then proceeded to his right. The Nursing Home Administrator (NHA) stated he turned right on 15th street, which connects MLK (Martin [NAME] King, Highway 574) and Hillsborough (Highway 92). It was unclear where the resident went after that. The vicinity was noted with multiple side streets that interconnect to both highways. On 1/31/22 at 2:03 p.m., an observation was made of the area between the facility and the bus station. The resident turned right on 15th street. The sidewalks along 15th street were uneven, with cracked cement terrain on both sidewalks, and the road itself was rough with broken and cracked surfaces. A speed limit of 30 miles per hour was posted on 15th street, which proceeded to two highways, MLK (Highway 574) and Hillsborough (Highway 92). The two multiple lane highways had speed limits between 40 and 45 miles/hour. The roads were observed to have a constant flow of traffic. The facility reported in their investigation timeline, the resident was last seen on 1/25/23 at 3 p.m. by a store clerk at a local liquor store. Review of the travel route from the facility to (name of store) liquors on 1/25/23 revealed the resident traveled for about one hour, a walking distance of 2.7 miles via 15th street. The store is located on North Nebraska Avenue, also known as Highway 45, which has a speed limit between 40-45 miles/hour. The resident had to cross MLK/Highway 92 to get from the facility to the store. Highway 92 was observed with a heavy traffic flow at the 3 p.m. hour. https://www.[NAME].gov/document/speed-limit-map-26286 On 1/27/23 at 8:56 a.m., Resident #1 was located by a bystander at a Greyhound bus station in [NAME], located approximately 2.9 walking miles from the facility. Resident #1's whereabouts remains unknown from the last camera footage observation on 1/25/23 at 12:54 p.m., or the 3 p.m. citing at the liquor store, to the date he was located on 1/27/23 at 8:56 a.m. Review of weather history in [NAME] area during the 3-day elopement period, 1/25/23 to 1/27/23 revealed large temperature changes from day time and night time hours as follows: January 25, 2023, Max temp: 80 degrees Fahrenheit. Minimum temp: 64 degrees January 26, 2023, Max temp: 63 degrees Fahrenheit. Minimum temp: 55 degrees January 27, 2023, Max temp: 64 degrees Fahrenheit. Minimum temp: 48 degrees [NAME], FL Weather History | Weather Underground (wunderground.com) On 1/30/23 at 10:45 a.m., an interview was conducted with Staff K, CNA, observed providing 1:1 supervision to Resident #1. She stated the resident had been plotting the escape. She said, I saw this coming; I work with him a lot. He was studying the fence area and the staff's movement. He did not say he was going to leave, but he had been pacing the courtyard. She stated earlier today, he threatened to leave again. Staff K stated the resident stated if the family does not come and get him, he will leave. Staff K said, he said he will jump the fence. That is why we are watching him 24 hours. The CNA stated there is supposed to be two CNAs when the residents go out to smoke. She stated there were two of them that day and they were both suspended. She stated on that day, she was not working, but she heard the resident distracted the CNAs, and as they were pushing the dependent residents outside, he snuck to the side of the building and left. Staff K stated the resident was gone overnight, but he could not remember where he was. She stated the resident has dementia and is confused. On 1/30/23 at 10:54 a.m., an interview was conducted with Staff M, CNA. He stated he normally worked in the secured unit, but he did not work the day the resident eloped. He stated the unit is secure and only way a resident can get to the fenced courtyard was if they were buzzed out by a staff member. He showed a control box at the desk in the nurse's area and said, Someone has to enter the key code here to allow access in and out of the unit. He stated they take the residents out to smoke every two hours and there is supposed to be two staff. He said, The expectation is to make sure all the residents get back inside. You have to look and make sure no one is left behind. I don't know that they looked. Staff M stated since the elopement Resident #1 was on a 1:1 supervision 24 hours. On 1/30/23 at 11:01 a.m., an interview was conducted with Staff R, Assistant Director of Maintenance. He conducted a tour of the presumed route Resident #1 may have taken. He stated he was not at the facility that day, but staff said the resident climbed the fence. He stated the only way he could have left the facility was through the back door of the secured unit. He stated all other exits have cameras pointing to the exterior doors. The exterior doors are alarmed; they also have a wander guard alarm system. He stated, Resident #1 is a tall guy, and he could easily jump the gate. He stated the gate is always locked, and the only time it is opened is when they have to let in the yard people to cut the grass. He stated on those days, they make sure there is a spotter watching the gate area when the gate is unlocked. During the tour the gate was observed secured with a chain link with two padlocks. Staff R stated there was a small gate behind the enclosed picnic area where he could have snuck behind to avoid the view of the camera by the East exit. Staff R stated that gate is short, about 6 feet tall, and he could easily jump that. The area was observed with overgrown bushes. The courtyard was also observed with another 6-foot gate which the resident may have jumped over. On 1/30/23 at 11:15 a.m., an interview was conducted with the Director of Maintenance (DOM). He stated he was in charge of the facility's security. He stated they conduct rounds to make sure the facility's entrances are secure on both exterior doors and gates. The DOM stated the only way the resident may have left the facility would have been to climb over the gate. He stated the staff should have been supervising him. He stated they have added a second padlock to the gate, and they would be flipping the gate around so the bar that he stepped on will be on the outside. He stated they are obtaining quotes for a fence to better secure the courtyard. On 01/31/23 at 3:19 p.m., an interview was conducted with the NHA and the Director of Nursing (DON). The DON said, For the incident on 9/1/22, the resident went to the smoking area. He was not on a 1:1 at the time and he climbed the fence. A maintenance staff saw him and stopped him. Our response to the incident was to put him on a 1:1; mirrors went up in the back courtyard to assist with the monitoring. We updated the care plan to include 1:1 supervision during smoking time, and updated Kardex. The DON stated she could not recall retraining the staff. She stated upon hire the CNAs are taught how to read the Kardex and if there are any concerns the nurse is to be notified. The NHA said, Every staff member knew he was on a 1:1. They should have watched him. The DON and NHA stated they were not aware there had been an incident on 11/17/22. They reviewed the progress note dated 11/17/22 showing the resident attempted to jump the fence. They stated they were not notified. The NHA stated they should have been notified. She stated they review progress notes in their morning meeting, We read the 24-hour report daily. She stated she would not know how they could have missed such a significant incident. For the incident on 1/25/23, the DON stated they did not know the resident was anxious and had been pacing prior to the elopement. The DON stated she found out later he was ou [TRUNCATED]

Based on observations, review of medical records, facility policies, and interviews with facility staff and a family member, the facility neglected to provide services and supervision to one (Resident #1) of three sampled for high-risk elopement. Resident #1 was an ambulatory, vulnerable resident, who previously expressed wishes to leave the facility, and previously made elopement attempts. Documented concerns by nursing staff showed they feared Resident #1 would be able to exit the facility by jumping the fence. Resident #1 had been assessed to be an elopement risk, requiring 1 to 1 supervision when smoking. Resident #1 was able to exit the facility unbeknownst to staff and was not found until a bystander located him at a bus station located 2.9 walking miles from the facility and notified a family member, 44 hours after he left the facility. The local authorities responded to the site and transported the resident to the hospital by Emergency Medical Services (EMS). Resident #1 was unaccounted for from 1/25/23 at 12:53 p.m. to 1/27/23 8.49 a.m., a period of 44 hours. The resident who had a dementia diagnosis suffered the likelihood of harm, due to the possibility of wandering into on-coming traffic, being hit by a vehicle causing injury or death. Resident #1 had a history of falling and could have fallen on uneven sidewalks. The resident has a history of seizure and bipolar disorders and his absence from the facility put him at risk due to going without medications for 44 hours creating the likelihood of return of symptoms and/or withdrawal from the medication. The resident had no means to obtain food, water, or shelter for the time he was absent from the facility creating the likelihood for dehydration, and/or harm from exposure to the elements. The facility neglected to provide supervision for Resident #1 whose history of elopement and high risk for elopement was documented, and care planned. Additionally, based on resident interview, staff interview, physician interview, record review, and hospital record review, the facility failed to prevent staff-to-resident physical abuse for 1 resident (Resident #2) out of 3 residents reviewed for abuse. The staff-to-resident abuse resulted in Resident #2 sustaining a pinpoint red area to the face, a left broken rib, and a left pleural effusion. This resulted in the findings of Immediate Jeopardy starting on 1/25/2023. The immediacy was removed on 2/01/2023 after verification of the implementation of removal action(s). The scope and severity was reduced to a G (no actual harm with potential for more than minimal harm). Findings included: Review of a facility policy titled, Abuse Prevention Program, Revised August 2022, showed the facility has designated and implemented processes, which we strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident's behavior which may increase the likelihood of such events. DEFINITIONS: Abuse-Includes Verbal, Physical, and Mental/Emotional Abuse Abuse Willful infliction of injury upon a resident by a staff member, another resident, a vendor, a visitor, or other individual. .Instances of abuse of residents, irrespective of any mental or physical condition, that causes physical harm, pain or mental anguish to include verbal, sexual, physical, and mental abuse. .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Procedure: The facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. The Administrator is responsible for designating an Abuse Coordinator. The designated shift supervisor is identified as responsible for immediate initiation of the reporting process The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. The Administrator, DON and/or designated induvial are also ultimately responsible for the following: Implementation Ongoing monitoring Investigation Reporting Tracking and Trending Implementation and Ongoing Monitoring .Training Facility orientation program and ongoing training programs will include, but may not be limited to: 483.95(c)Freedom from abuse, neglect, & exploitation requirements in 483.13. 483.95(c) Activities that constitute abuse, neglect, exploitation, & misappropriation of resident property as set forth in 483.12. .Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques. Refer to HR Manual for identifying and managing staff burnout, and [NAME] availability . Prevention: .Facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation may be more likely to occur, such as: Residents with needs/behaviors which might lead to conflict or abuse/neglect. Staff burnout . Identification Events of injury of unknown origin/source, such as suspicious bruising occurrences, patterns, and trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified and thoroughly investigated, with appropriate reporting as indicated . Neglect: failure of the facility, it's employees our service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under prevention, facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, misappropriation may be more likely to occur, such as residents with needs/behaviors which might lead to conflict or abuse/neglect. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures and education to prevent further occurrences. Protection: Upon identification of actual, suspected . neglect . systems are in place to provide for the protection of the resident. These systems may include, but may not be limited to: Suspension for accused, suspected employee(s), pending the outcome of the investigation to protect the alleged victim . Initiation of discharge process if the resident is a danger to him/herself or others. provision of 1:1 monitoring, or enhanced supervision as indicated. 1. Review of Resident #1's admission record revealed an initial admitted [DATE] and a returned date on 1/27/23. Resident #1 was admitted to the facility with diagnoses that included Dementia unspecified severity without behavioral disturbance, psychotic disturbance and anxiety, muscle wasting and atrophy, weakness, unsteadiness of the feet, [NAME]'s encephalopathy, seizures, chronic obstructive pulmonary disease (COPD) Dementia, alcohol abuse, bipolar disorder, acute and chronic respiratory failure, and a history of repeated falls. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], section C, cognitive patterns showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section G, functional status, under F. Locomotion off unit - how resident moves to and returns from off-unit locations, showed the resident required supervision with one person assist. G0300 Balance during transitions and walking showed the resident was coded 1, not steady, but able to stabilize without staff assistance. Section N, medications showed the resident received antipsychotic, antianxiety and antidepressant medication 7 days a week. Review of a care plan for Resident #1 dated 8/24/22, revealed an elopement risk focus, indicating Resident #1 is at risk for elopement. The goal section showed the resident will not exit the facility without staff knowledge, or appropriate supervision. Interventions included: 1:1 supervision indefinite at all times, complete required information on elopement risk identification information sheet, if the resident is wandering offer frequent rests and snacks if indicated, secured unit, refer to psychological services as needed, diversional activities. Further review of the care plan revealed Resident #1 was a current smoker, with a goal to remain safe while smoking. Interventions included to observe for smoking safety through observation and interview and supervised smoking at all times. Review of a document titled, order summary report, date range: 11/01/22 to 01/31/23, showed Resident #1 did not have physician orders in place related to supervision prior to the elopement. Review of a document titled, elopement-v 2, dated 8/24/22, showed the following: 1. Is this resident confused? Yes 2. Resident is ambulatory or mobile (walker, wheelchair/chair) Yes. 3. Is question 1 and question 2 both Yes? Activate elopement interventions as follows: Educate staff that the resident is now an elopement risk, place picture in elopement book, update the orders care plan and Kardex and notify supervisor-document in the medical record. Review of a document titled, Elopement Risk, dated 9/1/22, showed Resident #1 had a diagnosis of dementia, was cognitively impaired, confused and was independently mobile. The document showed, resident has history of elopement, desires to leave facility, verbalizes desire to leave facility such as, I don't want to stay here, how do I get out of here, I'm looking for my sister, exit seeking, wandering, looking out of/trying to open windows, loitering by exit doors/or attempting to open exit doors. The resident is assessed as an elopement risk. On 2/1/23 at 12:17 p.m., a telephone interview was conducted with Resident #1's family member. She stated she was notified Resident #1 left the faciity on [DATE]. She stated they said he walked out the door, climbed up a fence and left the facility. She stated no one saw him leave and they did not know where he was for a couple of days. The family member stated she received a phone call from a stranger at the bus station who was trying to buy him (Resident #1) a bus ticket to get to Maryland. The phone call was received on 1/27/23 in the morning. The family member stated the resident was a severe alcoholic with a wet brain ([NAME]-Korsakoff syndrome (WKS), is a brain disorder related to the acute and chronic phases of a vitamin B1 deficiency, a common complication of long-term heavy drinking) due to falling and hitting his head many times. She stated he always runs away from facilities wanting to get back to Maryland. The family member said, they [facility] knew he was at risk for elopement. I have discussed his history with the Social Services Director (SSD). They should have known he is flight risk. The family member stated she was not anticipating moving the resident to Maryland because the family is not able to take care of him. On 1/30/23 at 10:30 a.m., an interview was conducted with Resident #1. The resident was observed in the fenced courtyard outside the 400 secured hall, smoking a cigarette. The resident was with his 1:1 Aide, Staff E, Certified Nursing Assistant (CNA). Resident #1 expressed frustration with his placement and his desire to leave the facility. The resident said, I want out of here. I am mad the police brought me back here. I do not want to be here. This is not my destination. I was trying to get to Baltimore, Maryland. Resident #1 stated on the day he eloped (1/25/23), I walked out of that gate, no, I did not jump. I don't remember jumping a fence like everyone is telling me. There was no staff here. Everyone had just walked outside to smoke their cigarettes. I got to that gate [pointing to a six-foot gate in the middle of the courtyard] and walked out. I proceeded to the other one over there [pointing to another six-foot gate] I hopped that thing. The next thing you know I was on the other side, I walked to the bus station, not too far from here, probably a mile or two. I got up the road and the police brought me back. The resident stated he did not take any belongings when he left. He stated he was gone for about a whole day. The resident could not confirm where he went or where he spent the night. Resident #1 said, I want out of here. I am wasting space, someone else could use the bed. My family won't come and get me. I want to leave. I just don't want the cops getting me again. Resident #1 stated he would try and leave the facility again. He stated he just needed a bus ticket to get to Maryland. The resident stated if he was to leave again, he would jump the fence. Resident #1 said, I am a tall guy, that small fence is nothing. The resident stated he wanted to go to Maryland because there is a job waiting for him. On 1/30/23 at 1:57 p.m., a telephone interview was conducted with Staff F, CNA. Staff F stated she was working the day Resident #1 eloped. She said, I was working that day. I was passing the cigarettes as the residents were going out to smoke, I was standing by the nurse's station. One of my residents asked me to help him. When my resident asked for help, I turned to grab gloves and continued to help my resident. We were by the exit door. I later viewed the camera and from the camera you can see [Resident #1] walk past me. I did not see him. He walked out and turned the corner right away behind the building. I did not see him. My back was turned. From the camera you can see him sneak behind me. Staff F stated that Staff G, CNA, was supposed to be 1:1 with him, but he was providing patient care. The other CNA (Staff H, CNA) said she would step in to do the 1:1. She was also standing by the door as the residents were leaving to go outside. Staff F stated Staff G had been assigned because they said we needed a man that day in case he jumped over again. Staff F stated the resident had been exit-seeking. Staff F said, I saw him attempting to leave the day before. I was in room [ROOM NUMBER] and as I looked outside the window, I saw him pulling on the gate, he was banging on the gate as he was climbing. I yelled at [Staff G, CNA] assigned to him. He pulled him back and brought him inside. Staff F stated Resident #1 had tried to leave three times before, the 4th time he left. She stated the incidents were reported to the unit manager. Staff F said, They all knew it. He was trying to jump on the fence. The first time he got out is when they should have fixed the fence. It was sometime in September. They should have made the middle fence area higher. Everyone knew he wanted to leave. The CNA stated on the day he eloped; she could tell earlier in the day he was anxious because he was pacing. Staff F said, you can see it on the camera. You can see him looking around the room. She stated she participated in the search. They looked everywhere in the facility and outside. Staff F stated she gave a statement and told them she did not see him because she was busy with her resident. On 01/30/23 at 10:29 a.m., an interview was conducted with the SSD. She stated she worked with the residents in the 400 unit, a behavioral unit where Resident #1 resided. She stated there was a code on the door to get in and out of the unit. Residents do not have these codes. The SSD confirmed Resident #1 was admitted to the facility because he had potential to wander. She said, He is not safe without supervision. He was placed on the secured unit from day one, because of wandering. The SSD stated she spoke to the family member and was alerted to his history. She stated the family member reported that he kept escaping from other facilities and there were not enough staff to keep him safe there. The SSD said, He has wandered while here. He has tried to go out through the back of the facility. He tried to climb the fence to get away. Every once in a while, he attempts a move, he is an alcoholic, he wants to drink, and he said he was seeking alcohol. She stated nursing staff assess residents for risk of wandering. She stated Resident #1 had not had any previous elopements attempts that she knew of, besides trying to jump the fence. She said, He did not go far. He was brought back before he could go off premises sometime in September. Review of a document titled psychosocial history and assessment, dated 8/31/22, showed Resident #1 had a psychiatric diagnosis and was being treated with psychotropic medications for bipolar disorder. The resident was unable to state his goals and will remain a long-term care resident of the facility. His memory and cognition were noted not intact and are severely impaired. Review of a progress note dated, 9/1/22 showed, during the smoke break time resident went to the back of the building and climbed over the fence. The resident could not be located on 09/01/22 at 1:27 p.m. The missing person action plan was initiated. The following took part in the search of the resident inside and outside the property. Nursing staff reviewed the LOA (leave of absence) book to determine whether or not the resident signed out. It is noted when last seen, the resident was wearing the following T-shirt and grey pants. The resident was last seen in the smoking area on 9/1/22 at 1:20 p.m. Review of a document titled, Psych Note, dated 9/8/22, showed Resident #1 was seen for psychiatric follow-up and medication management at the request of staff. The document showed reportedly last week patient left the facility and eloped via scaling over fences. He was found and returned to the facility without conflict or combativeness. Family reports he has a history of climbing fences, he was uninjured in the events. He is seen today on the memory care unit, states that he would like to go home, but he is a poor historian unable to provide many details of the event). A progress note, dated 9/13/22, showed, IDT (interdisciplinary) meeting in regard to resident needing a 1:1. Resident will remain on 1:1 at smoking times. Review of a document titled, Psych Note, dated, 9/15/22, showed, he is now only on 1:1 supervision when out for smoking due to history of elopement attempts. Review of an ARNP nursing home progress note, dated 9/22/22, showed the resident was seen in his room in secured unit. He remains on 1:1 during smoke breaks due to elopement risk. The assessment plan showed, he requires 1:1 when out on smoke breaks . locked unit, continue current medications. Review of a social services note for Resident #1 dated 10/5/22 showed the SSD spoke to Resident #1's family member who stated the resident was in an assisted living facility previously and he had too much freedom to wander out and she feared he would get hurt by traffic. Review of a social services note dated 10/18/22, the SSD spoke to Resident #1's family member. The family member wanted him placed in a nursing facility; she had declined assisted living placement. Family member stated, He has too much freedom in an assisted living and can leave the facility and get hurt. Review of a nursing home progress note for Resident #1, by the Advanced Registered Nurse Practitioner (ARNP), dated 11/17/22, showed, resident was seen for vascular dementia with agitation, resident was outside in smoking area, he began pacing and looking at the road yelling, I want to leave this place. he became verbally abusive towards staff. A progress note dated,11/17/22, showed: writer was notified by CNA [smoke aide] that while out smoking, resident was pacing close to the fence and looking at the road. When CNA tried to get closer to the resident just in case, he tried to jump the fence, resident became nervous and verbally aggressive and telling everyone .I want to leave this place now and I want to go to Baltimore where my daughter is. A progress note dated 1/8/23 showed Resident #1 was confused, and to activate elopement interventions. Review of a social services progress notes dated 01/25/23 at 3:02 p.m., showed the SSD called the resident's family member at 3.p.m. this afternoon to see if she has seen or heard from [the resident], but she did not pick up. Message left in her voicemail informing her the facility is currently looking for him . Review of a progress note dated 1/27/23, showed the resident returned to the facility, admitting diagnosis listed, Risk for elopement. Review of Resident #1's psychiatry note dated,1/27/23 showed the resident has a history of depression, dementia with behavioral disturbance seen for psych evaluation. Patient was reported missing from the facility on 1/25/23. Authorities found the patient at the bus stop on 1/27/23. He was assessed and cleared at the hospital and returned to the facility. He stated I just walked out the gate when questioned about how he left the facility. He stated that he went to another facility to visit a friend. He is oriented to person . He continues to have persistent insomnia. Patient is a flight risk. Continue 1:1 surveillance until further notice. Review of a psych note for Resident #1 dated 12/20/22 showed, the resident felt more agitated more than usual with the holidays. He continues to have persistent insomnia. Review of the Medication Administration Record (MAR) for Resident #1, for the period 1/1/23 - 1/31/23, showed the resident was scheduled to receive the following medications: Trazodone HCI oral tablet 50 MG (micrograms). Give 1 tablet by mouth at bedtime for insomnia, anxiety, order date 11/1/22. Flomax oral capsule 0.4 MG, give 1 capsule by mouth one time a day to improve voiding, order date 8/25/22. Lorazepam oral tablet 1 MG, give 1 tablet by mouth two times a day for anxiety, order date 11/18/22. Seroquel oral tablet 50 MG, give 1 tablet by mouth two times a day for bipolar disorder, order date 1/13/23. Midodrine HCI Oral tablet 10 MG, give 1 tablet by mouth three times a day for low blood pressure. Hold medication if SBP (Systolic Blood Pressure) is ? 110, order date 10/18/22. The review showed staff initials entered with a code 3 meaning, Absent from facility, confirming Resident #1 did not receive his medications for a period of 44 hours. On 1/31/23 at 10:59 a.m., an interview was conducted with Staff H, CNA. She confirmed she was working the 400 secured unit when Resident #1 eloped. She stated at 2 p.m., the nurse went to give him medications or something and she could not find him. She said, I last saw him at the previous smoke break at 10:30 a.m. That was the last time. He was with Staff G. Around 12.30 p.m., Staff F put in the code on the door so we can take the residents out to smoke. She stated she thought Staff F was assigned 1:1 to Resident #1. Staff H said, I do not know. I did not see the resident go out the door. I was there as the residents were going out to smoke. Sometimes he doesn't have cigarettes and that makes him anxious. He did not have cigarettes that day, he just walked around the outside, he was pacing. All the time he says he wants to leave the facility. I try to encourage him, I check to see what he needs, I get him a snack. Staff H stated when the resident paces during smoke breaks, she notifies the Unit Manager. She stated the Unit Manager comes out to stop him from getting upset and calms him down. Staff H stated the resident has tried to leave before. She stated he jumped the fence and was brought back. Staff H stated the resident is always pacing looking for an opportunity to get out. Staff H said, he wants to leave all the time. Even at the 10:30 a.m. break on 1/25/23, he was pacing. He was waiting for the moment to escape. She said, I didn't say anything to the Unit Manager because it is his normal behavior. Everyone knows he is pacing because he wants to leave. Staff H stated after the code silver was called, she stayed at the facility looking for the resident. We looked everywhere for him. We did not find him. Staff H said, what went wrong was we did not know who was taking the 1:1 assignment. She stated they do not conduct rounds every two hours in the secured unit, because someone is always in the common areas and the residents are independent. On 1/31/23 at 10:38 a.m., an interview was conducted with Staff G, CNA. He stated he was working the day Resident #1 eloped from 400. He stated he had been assigned to the resident as his 1:1 during the 10:30 a.m. smoke break. Staff G said, He did not say we wanted to leave. He was walking around the courtyard, like he always does. Staff G stated he was not sure who was supposed to be assigned to him during the 12:30 p.m. smoke break. Staff G stated he was giving another resident a shower when Resident #1 eloped. He stated two CNAs take the smoke task and one of them is supposed to supervise the resident 1:1. On 1/31/23 at 12:00 p.m., an interview was conducted with Staff I, Registered Nurse (RN). Staff I confirmed she was the Nurse assigned to Resident #1 the day he eloped on 1/25/23. Staff I said, I was doing blood pressure checks for the afternoon blood pressure medications between 1p.m. and 2 p.m. I noticed he was not in the room. The bathroom door was closed. I left the room, gave him a couple minutes. I knocked on the door again, there was no answer. When I did not find him in the room, I asked the CNAs to help locate him. We started looking inside the unit. We verified he was not there. I got the Unit Manager. He started looking everywhere. He couldn't find him, so he called code silver. Staff I stated prior to the elopement she was aware Resident #1 was supposed to have 1:1 supervision when he was outside smoking. She stated that day she saw two CNAs go outside smoking. She said, I did not know who was assigned his 1:1. It is usually written on the board so the CNA would know who is assigned. That day it was not listed, so they did not know. Staff I stated she thought the CNAs should check on him at least every 2 hours. Staff I stated, Someone should have looked for him. She stated she thought he went outside with everyone else during smoke break, even though he did not have cigarettes. Staff I stated the resident gets anxious when he is cigarette seeking. She stated she was aware he was at risk of elopement. She was told he needs to be eyes on when outside. The problem was that no one watched him specifically. On 1/31/23 at 10:06 a.m., an interview was conducted with Staff S, RN Unit Manager. He stated Resident #1 liked to stay in his room, He doesn't like crowds and when he is outside, he keeps to himself. He stated on 1/25/23 he was working because he manages both units on 400 hall. He stated around 2 p.m., the nurse (Staff I) reported she could not find the resident. Staff S said, I told her to check everywhere. I went and verified he was nowhere to be found. I called code silver. We couldn't find him anywhere. We notified the administration and started neighborhood search. Staff S stated prior to this elopement, Resident #1 attempted to leave the facility. It was sometime in September. Staff S said, He was outside smoking, I guess staff did not notice right away. We saw him on the camera at the back of the building on the inside of our fenced area. He jumped one gate. He said he jumped the fence. A maintenance person saw him and brought him inside. We assessed him he had no injuries. Staff S stated after the incident, their correction plan was for him to be put on 1:1 supervision when outside smoking. He stated they notified psych. He stated since then, when he goes outside, he is supposed to be eyes on. On 1/25/23, he was supposed to be on a 1:1. Staff S stated he reviewed the camera footage after he left on 1/25/23 and saw on the video one CNA opened the door and the other was assisting the other residents. Staff S said, I don't know how, but he snuck behind her. Every day he is assigned a 1:1. The nurse or unit manager selects a CNA to be with him. Typically, we have 3 CNAs and 1 nurse assigned on the unit. Two CNAs take the smoke task, one of them would be the 1:1 with him. Staff S stated 1:1 means be with the resident everywhere they go. Staff S stated the breakdown was with the one who opened the door. They did not keep an eye on the resident. They knew the resident likes to smoke. They should have missed him when they did not see him out there smoking. I guess no one checked his room until the nurse went to get his blood pressure taken around 2 p.m. On 1/31/23 at 12:25 p.m., an interview was conducted with Resident #1's Physician Assistant- Psychiatry (PA) The PA stated she sees Resident #1 at least monthly. She stated she met with the resident when he returned from the elopement incident. The PA stated the resident reported during the visit he wanted to leave and did not want to be at the facility. The PA said, He stated he went to another facility to meet with a friend. He said he walked out there, he did not say where specifically or what he did overnight. He was oriented. She stated during previous sessions, he had not stated he wanted to leave, at least not anything out of the norm. Everyone in a secured unit would want to leave. The PA said, If anybody is going to leave, it will be him. He is oriented to person and place. She stated his PCP (primary care physician) thinks he has delusions and is under some psychosis and is recommending a medication change. She stated staff had not notified her that the resident wanders or if he is continually stating he wants to leave. The PA said, I think [Resident #1] is smart. He will find a way to leave if he wants to. On 1/30/23 at 1:52 p.m., review of the facility's camera system was conducted. (A copy of the footage was obtained). Camera #1 showed on 1/25/23 at 12:53 p.m. Resident # 1 was walking behind other residents as they ambulated/propelled themselves towards the glass door. The resident was wearing a pair of blue jeans and a black jacket. A staff member is noted holding the door open. The resident walked past this staff member (later identified as Staff H) and proceeded to the right of the building. The other residents are observed proceeded to the smoking patio as Staff H holds the door. As he turns to the right of the building, Resident #1 disappears from the camera's view. Staff F could be seen at the edge of the footage as numerous residents went out to smoke. She is observed bending towards a resident in a wheelchair. Camera #2 showed the resident at 12:54 p.m. at the back of the facility's building walking towards 15th street. The resident was no longer on the property. The resident is observed walking in the middle of the road, to the right of a white car parked off the street. The resident is observed removing his jacket, turned, and looked back at the building, and then proceeded to his right. The Nursing Home Administrator (NHA) stated he turned right on 15th street, which connects MLK (Highway 574) and Hillsborough (Highway 92). It was unclear where the resident went after that. The vicinity was noted with multiple side streets that interconnect to both highways. On 1/31/22 at 2:03 p.m., an observation was made of the area between the facility and the bus station. The resident turned right on 15th street. The sidewalks along 15th street were uneven, with cracked cement terrain on both sidewalks, and the road itself was rough with broken and cracked surfaces. A speed limit of 30 miles per hour was posted on 15th street, which proceeded to two highways Interstate Martin [NAME] King (Highway 574) and Hillsborough (Highway 92) The two multiple lane highways had speed limits between 40 and 45 miles/hour. The roads were observed to have a constant flow of traffic. The facility reported in their investigation timeline, the resident was last seen on 1/25/23 at 3 p.m. by a store clerk at a local liquor store. Review of the travel route from the

Based on resident interview, staff interview, physician interview, record review, and hospital record review the facility failed to ensure one resident (#2) out of 3 residents reviewed for trauma informed care received the services to mitigate triggers and prevent re-traumatization related to a facility staff member physically abusing Resident #2 on 4/30/22. Resident #2 was retraumatized on the evening of 12/28/22 when a male caregiver was providing care to Resident #2's roommate and Resident #2 believed the staff member was the same staff member who abused him. This event resulted in Resident #2 being transferred to a hospital under a state Involuntary confinement Act on 12/29/22 due to increased paranoia, fear of being attacked, and suicidal ideations with a plan to hang himself and then returning from the hospital on antipsychotic medication. Findings included: An interview was conducted with Resident #2 on 1/30/23 at 10:30 a.m. The resident was observed to be in the hallway next to the nurse. He was in his wheelchair with a hand splint on his left hand and forearm and his left leg placed on the wheelchair footrest. He self-propelled himself into his room using his right leg. The resident stated these 3 men keep coming through my window and smoking and laughing at me it's hard to see them because it's dark in my room and they wear dark clothes and are black. I think they are going to hurt me, but they haven't hurt me yet they just keep smoking cigarettes and laughing at me. But, about 5 months ago my roommate in B bed, who isn't here anymore put on his call light and it took a long time and he kept pushing and pushing and pushing the button, finally this CNA [Certified Nursing Assistant] came in and he was being really nasty to my roommate and I said to him hey man, come here listen my friend has back problems and is in pain he needs pain medication and the CNA said who the f*** are you and I said I am his friend and I am your friend he just needs help. I was laying in my bed and then he grabbed my bad arm, my left arm, and was pulling me and pulling me and I was trying to reach my call light. When I would get it to call for help, he would take it away from me. He pulled me onto the floor I grabbed the arm of the wheelchair, but he climbed on top of me and punched me 8 times in the chest and once in my eye and once in my head and he was kneeing me in my balls. I was yelling so loud, and I know the nurse was maybe 500 feet away from me. She told the police she didn't hear anything but how could she not of heard me when she was the one who came in and pulled the guy off of me and she said to him I don't want you here no more, get out! Then he grabbed me by my pants and flung me back into the bed I almost hit the wall with my head, and I had a surgery on my head a long time ago and I thought I was going to hit it on the wall. I was getting so mad every time he hit me, and I tried to hit him back but I didn't have the strength because I was just in the hospital for 9 days before that. [Staff B, Registered Nurse [RN]] was the nurse that night. [Staff B] got 2 supervisors to come in. My chest was bruised, and they took x-rays and I went out to the hospital I'm not sure what happened. But I still have pain today in my chest and I was on pain medications for 2 months. It is getting better but it still hurts. I had come back from the hospital the day before because I had lasers done to break up a kidney stone and then I come back here and get beat up. That's not right. I was bleeding from my penis, but I don't know if that was from him kneeing me in the balls or from the lasers I'm not sure. [Staff A, RN] the nurse came and checked me out and she will tell you. I had never seen that CNA before and I think I saw him the next day too, but he did not take care of me. But he should be in jail he should not be here they did terminate him though and I haven't seen him since. Anyone who comes in here I start shaking because I'm afraid he is going to come back he should be in jail for what he did. Review of Resident #2's admission record revealed he was initially admitted to the facility on [DATE] then readmitted on [DATE] from an acute care hospital. His diagnosis included but are limited to Hemiplegia hemiparesis following cerebral infarction affecting left non-dominant side, reduced mobility, Alzheimer's disease, dementia, Major depressive disorder, recurrent, generalized anxiety disorder. Further review of the admission record revealed the resident also diagnosed with schizoaffective disorder with an onset date of 1/6/23, unspecified psychosis not due to a substance or known physiological condition with an onset date of 1/6/23 and Suicidal ideations with an onset date of 1/6/23. Review of Resident #2's Minimal Data Set, Section C, Cognitive Patterns, dated 1/11/23 revealed a brief interview for mental status score of 14 out of 15 indicating the resident is cognitively intact. An interview was conducted with Staff A, RN on 1/30/23 11:10 a.m. she said I have worked here for [AGE] years. I am very familiar with [Resident #2]. The incident that happened with him was interesting because when I first looked at him after he told me what happened I did not see anything on his skin. He told me the CNA hit him in his chest and other places, but I can't exactly remember where else, but he did tell me he hit him in more than one place. At first, I didn't see anything, but he kept rubbing his chest and having pain. I got him some pain medications and had the doctor order a chest Xray and then we sent him out to have a CT scan, that did not show any impact. I think the incident happened on a Saturday and I don't work Saturday and Sundays or if I do, I don't work on my usual unit. But [Staff B, RN] was working that evening and she usually keeps her med [medication] cart right outside of his room when she passes medication. The CNA who worked that evening I had not worked with him because he worked the 3:00p.m.-11:00p.m. shift but when I would see him at change of shift. He was quiet, he is an older man I would say close to 60 and he was African American. He would help me lift residents up in bed or transfer them back into the bed and I did not have any concerns with his care, he was just quiet and would help when I would ask him. He never came back after that incident. I don't think he came back the next day, they followed the protocol. [Resident #2] has had hallucinations about 3 men crawling into his window and smoking and laughing at him. I called psych to come and see him and told them we should get a UA [urinalysis] and labs because you know sometimes if they have a UTI [urinary tract infection] they will have hallucinations or if their hemoglobin is low they aren't getting enough oxygen to their brain so they will hallucinate. But nothing was positive because you have to look at the clinical aspect before putting the resident on medications. Psych did put him on medications and then he became depressed and told me he wanted to kill himself. Immediately I called psych and they came that same day and he admitted to them that he wanted to kill himself and he planned to do it that day. He was Involuntarily Conficned (Baker Acted) and they started him on another medication, and he will still have some hallucinations, but it is much better now. Honestly, these hallucinations started before the incident with the CNA. He used to be on Depakote and risperidone, and he was doing well on them, then he was a candidate to ween off the medications, so he was weaned off and it wasn't till about 8-9 months later did he start to have the hallucinations. A phone interview was conducted with Staff B, RN was conducted on 1/30/23 at 1:16p.m. she said I was familiar with [Resident #2] and the incident with the CNA [Staff J, CNA] .I worked with [Staff J, CNA] on that unit for several months. Before he had worked on other units. He was like any other CNA. If you asked him to do something he would always go do it. He never complained, he was quiet. About 3 weeks ago [Resident #2] said to me that he thought the CNA who was working with his roommate was [Staff J,CNA] and he said to me [Staff J,CNA] is in here working with him (meaning his roommate) and he needs to be in jail, he has been in here for 2 hours smoking and I told him he needs to leave he should be in jail. I explained to [Resident #2] that the CNA was not [Staff J, CNA] it was [Staff D] another CNA. I wrote a behavior note about this and told the supervisors. Review of Resident #2's behavior note dated 12/28/22 at 9:34p.m. revealed resident currently in ABT [antibiotics] due to UTI [urinary tract infection]. Today he began to say: In the room there is a black man similar to [Staff J, CNA] who has been smoking in the room for hours. This writer immediately went to the room and verified that the CNA was in the room working, I told to the resident: the CNA is in the room working, and he is not smoking, them [then] the resident began to yell. Everyone wants to kill me. But they can't with me. The supervisor was notified regarding the complaint and the behavior of the resident. The resident was redirected and now resting in bed, calmer. An interview was conducted on 2/1/23 at 3:12 p.m. with Staff D, CNA he said I have worked here for about a decade. I am part-time and I float to different units. I never had worked with [Resident #2] before this night but he was on the phone when I first did my rounds around 3p.m. he usually goes outside. Then around maybe 5p.m. he was in the hallway and he said I smell cigarettes; I smell cigarettes he thought I was smoking. I told him I don't smoke I have never smoked. He then asked if I was [Staff J] and I told him no. Then I was in the room changing his roommate and he kept saying I smell smoke you are smoking, and I again said no I don't smoke. Then he kept thinking I was [Staff J] and just kept saying you are [Staff J] I tried to tell him I wasn't, but he wouldn't believe me. The nurse must've heard him talking about me being [Staff J] and she came in and told him I wasn't smoking and I wasn't [Staff J] but he wouldn't believe her. He was very upset. So, I ended up trading assignments with another CNA on that unit and the unit manager talked with him. I'm not sure if he calmed down because I did not work with him anymore. An interview was conducted with Staff C, CNA on 1/31/23 at 5:50 p.m. [Resident #2] is good I just gave him a shower. I was not here the night of the incident with [Staff J] but I do know when I would work, [Resident #2] did not like [Staff J]. [Resident #2] would call him names like monkey and stuff like that. This happened before the incident, he did not like [Staff J]. A combined interview was conducted with Staff B, RN and Staff C, CNA on 1/31/23 at 6:00p.m. Staff B said .Then a few days ago when he thought [Staff D] was [Staff J] I tried to explain to him that is [Staff D] that is not [Staff J]. [Staff D] is not smoking and [Resident #2] said to me you are lying that is [Staff J] you are on his side because you told the police you didn't hear me yelling. You are lying. I went out of the room because he was so mad. I told my supervisor and he came and talked with [Resident #2] and I told [Staff D] come you have to switch with the other CNA who was on shift that night because he thinks you are [Staff J] so I switched the two CNA's assignments so [Staff D] wouldn't take care of him anymore that night.He was sleeping when I finished my shift at 11:00p.m . During an interview with the Director of Nursing (DON) on 1/30/23 at 2:44 p.m. she said .I know [Resident #2] has said to me that he is still seeing [Staff J], in his room and outside of his window. He will go long periods of not talking about it then he goes through periods where he gets fixated on it and tell everyone about it. About a month ago, he was really paranoid that day, it was actually the day he was Baker Acted, so I called [Resident #2's Psychiatrist Physician Assistant (PA-C] saying he is in a panic he kept seeing [Staff J] and you could not tell him otherwise I tried to tell him he was safe, he [Staff J] was not here anymore. [Staff A, RN] went in and tried to talk to him but you could not tell him otherwise and [Resident #2's Psychiatrist] came to see him I think that day and she ended Baker Acting him because he was saying he was going to kill himself and you could not bring him back to reality. But he was very cooperative about it though. An interview with Resident #2's Psychiatrist PA-C was conducted on 1/30/23 at 11:50 a.m. she said I treat [Resident #2], he has Dementia with psychosis which I usually treat with Depakote, because he does not have any psychotic diagnoses just the dementia with psychosis. I just sent him out to the hospital because he had thoughts of killing himself and he came back on olanzapine and the plan is to increase his Depakote and wean him of the olanzapine. She was informed of the residents' statements regarding the 3 men crawling through his window and smoking and laughing and she said, oh is he still talking about them, something must have happened to him? she was also informed of the residents encounter with the abuse of the CNA and she said I can't believe this happened to him, I am shocked. No one told me about this. She asked when the event occurred, and she was informed it occurred on 4/30/22. She said she started at the facility at the end of September. She said psychology followed him back then and she reviewed the psychologist note and stated the psychologist wrote in her notes that he got in an altercation with another resident are we sure it wasn't another resident that did this. She was told it was a CNA. Resident #2's Psychiatry PA-C indicated Resident #2 is relatively oriented sometimes to place and definitely not to the time, but he does have the diagnosis of dementia so if you catch him early in the morning or late at night, he will have sundowners. Sometimes these dementia patients get stuck in a traumatic time. Usually, dementia patients with psychosis I just see as needed. then Staff A, RN said please see him he is falling apart, and he was depressed, and nobody ever told me that happened to him. He usually tells me he sees black figures he's never described them as black people just figures in all black or black entities. I am going to go see him now, I was planning on increasing his Depakote. Staff A is very good I trust her with these patients she knows them very well. An interview was conducted with Resident #2's Psychologist on 2/1/23 at 1:16 p.m. she stated I started seeing him [Resident #2] on 5/2/22 for sadness and anxiety and in the moment, he told me the abuse was with another resident then the staff told me it was with another staff member. He has never told me about the 3 black men/figures. He shared his frustration related to his health when the alleged incident happened with the staff member, and he focused a lot during that time related to his pain and anxiety. He likes to go outside, and he doesn't have the energy to do what he wants to do. He perseverates on topics. He will have good days, but he will also have anxious days. He is anxious but he knows when to go and seek the things that calm him down like going outside. He does use the coping skills he likes. He is very pleasant, and he is always open to the session, he is open with me on how is feeling if he is tired he will say I'm tired let's talk next week. I see him bi-weekly. Further interview was conducted with Resident #2's Psychiatry PA-C on 1/31/23 at 12:16 p.m. She said .He said he was still seeing those dark figures, but they were being nice to him. it was still a delusion but not a paranoid delusion. It's mild visual hallucinations nothing auditory. I was not involved with his care prior to the incident so it is hard to say that is the cause of his hallucinations but that is a high possibility that the incident with the staff member triggered for him. I did talk to Staff A, RN about the incident that happened with [Resident #2] and his hallucinations because it could've been a trigger for him plus he has been off his Aricept for who knows how long but Staff A, RN told me he had hallucinations before the event occurred and that he had been off his Aricept for a while. I am not sure if his hallucinations before were regarding these men coming from his window or sticking their tongue out to him, but I know now he does see them. Review of Resident #2's progress note titled encounter dated 5/2/22 written by his psychologist revealed .Chief Complaint: Patient referred for initial mental health assessment due to sadness and anxiety. History Of Present Illness: The patient reported feeling anxiety after a recent altercation with another resident. .Case Conceptualization: The patient reported feeling pain and anxiety from the recent altercation with another resident. Staff reported that the incident was referred to DCF [Florida Department of Children and Families] and police for investigation. The patient reported that another resident physically assaulted him. He reported feeling nervous and scared. The patient will benefit from psycho-therapy follow-up to improve coping skills and manage current mood symptoms. .Short Term Goals: The patient will understand symptoms and triggers of anxiety The patient will also explore and start using daily coping skills to manage anxiety symptoms. Long Term Goals: Patient will report decrease of unwanted emotions (depression/anxiety) by implementing a compassionate and flexible approach and development of awareness and acceptance oriented coping strategies. Target date:08/02/22. .Addendum details: Staff clarified later this day, that the incident reported by the patient was with a CNA, not another resident. Addendum Created Date: 2022-05-18. Review of Resident #2's progress note dated 12/29/22 at 9:26 a.m. revealed Resident OOB [out of bed] in w/c [wheelchair] as usual however voiced he saw a man in the window smoking and then the man enter to his room last night. Psych eval requested immediately. Resident delusional this am [morning]. Review of Resident #2's psychiatry encounter dated 12/29/2022 revealed .Visit Type: Crisis intervention Chief Complaint/Nature of Presenting Problem: Anxiety History of Present Illness: [Resident #2] is a [AGE] year old male with a history of anxiety, depression, and insomnia who presents today for follow up psychiatric evaluation at [Facility]. Staff requested that the patient be seen due to increase of hallucinations and paranoia. Patient continues to state that he thinks people are going to come through the window and attack him. He endorses that there are other people in the room with us. He describes them as 5 all black men, unable to describe their faces or clothing. He states that they are standing around us. He states I will kill them all and then I will kill myself. He endorses having a plan to hang himself from the doorway. He states I have nothing to live for anymore. I just want to go home. Due to concern of suicidal and homicidal ideation, patient to be Baker Acted at this time. Patient agrees to the plan to be transferred to the hospital for mental health evaluation. Will transfer to [Hospital] at this time. Patient to be on 1:1 until EMS [Emergency Medical Service] arrival. Further progress note review dated 12/29/22 at 11:26 a.m. revealed Resident eval by psych and voiced wishes of suicidal indentation [ideation] with a plan, voiced I have nothing to live for. Resident cont [continue] with increasing paranoia. Order received to transfer resident to [Hospital] for eval and tx [treatment]. Progress note dated 12/29/22 at 11:27 a.m. revealed Resident was place on 1:1 immediately for safety and family aware as resident agree to notify family. Review of Resident #2's Certificate of Professional Initiating Involuntary Examination dated 12/29/22 revealed .Supporting Evidence Patient continued to be increasingly paranoid. He reports there are five black men in here he fears being attacked and states I'll kill them all. He admits to suicidal ideation. He has a plan to hang himself and states I have nothing to live for. Review of Resident #2's care plans did not reveal a person-centered care plan that addressed the staff to resident abuse with interventions to decrease triggers for the resident. Review of Resident #2's medication administration record revealed an order date of 1/6/23 and no stop date for Olanzapine 5mg give 1 tablet by mouth at bedtime for psychosis. Review of Resident #2's Psychiatry note dated 1/10/23 revealed .History Of Present Illness: . patient arrives from the hospital on olanzapine 5mg, without psychotic diagnosis. Will re-evaluate in 2 weeks for medications changes . Review of Resident #2's Psychosocial History and assessment dated [DATE] revealed 12. Trauma Informed Care 1.Has the resident ever been diagnosed with PTSD (Post Traumatic Stress Disorder), had a life altering event or life changing event? the answer No was marked. Further review of Resident #2's Psychosocial History and Assessments dated 11/8/22 and 1/16/22 also revealed the resident was assessed not to have had a life altering event or life changing event. An interview was conducted with the facility's Social Services Director on 1/31/23 at 1:36 p.m. she stated I have been here for 9-[AGE] years. I do psychosocial assessments on all the residents. We do them annually, quarterly, and with a significant change. We do a brief one when they come back from the hospital. I talk to the resident, and I talk to the family, and we go over what kind of support system they have i.e. family, friend. We look to see if that is still in place. We also get history on education, how they walk, and stuff like that. And we assess them to make sure they can make their needs known and they can talk to us, and we look at their cognition. We look to see that they are responding and verbally telling us for example does your daughter still come to see you and do you want me to reach out to them. We want to make [NAME] they are comprehending what we are asking. We question about past traumas especially with the initial admission. If they say yes, they've have had a past rape it will trigger our psychosocial questions which are more questions that are generated on the form, meaning the psychosocial assessment form. Then psychology and Psychiatry come on board. Some people will have PTSD and we want to know what triggers they have and again that psychosocial form will list those questions to ask. The form will also bring out intervention options. I will have to figure out if that generates a care plan or not. I am familiar with [Resident #2] I remember the incident between the CNA and [Resident #2] not in detail but I remember it. I was not involved but I was told what happened. I am familiar that he just got Baker Acted. I was told by psych that he was taken to the hospital or maybe it was the DON who told me he was Baker Acted and also, I was told they were trying to rule out UTI. I talked to him when he came back from the hospital, and he told me he was doing fine. I did not talk to him before he went to the hospital. The assessment would capture the abuse and if it affected him if he feels in that moment that it affected him and if he said to me, it affects him. But in that moment, he did not say that to me, so it did not trigger. The psychosocial assessments, I just read the questions to him, and he answers me. He has never triggered to bring me to ask more specific questions. For new admissions I will also talk to the family but for [Resident #2] he is alert and oriented, so I just write down what he tells me. Review of the facility's Trauma Informed Care policy revised October 2022 revealed Policy: The facility will provide services for residents who have experienced mental or psychosocial adjustment difficulty, or who have a history of trauma or have diagnosis of post-traumatic stress disorder (PTSD) Trauma-Informed Care is care provided by staff that understands and considers the trauma and promotes environments of healing and recovery minimizing re-traumatization. Purpose: To ensure that residents who are trauma survivors receive culturally sensitive, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization's of the resident. Process: Admission-Nursing The admitting nurse will review the history and physical for diagnosis of post traumatic stress disorder (PTSD) and assess if the resident has experienced or witnessed life threatening or altering event through the admission data collection process. The admitting nurse will attempt to obtain additional information regarding triggers from family and/or resident representative, resident, and records. The admitting nurse will develop a baseline person centered intervention based on gathered information. The admitting nurse will communicate the identified mental or psychosocial adjustment difficulty and / or post traumatic stress disorder (PTSD) to team using the any of the following communication menthods: -24-hour report -shift to shift report -progress notes -Kardex Establish throughout the assessment and observation process nonpharmacological interventions that assist in decreasing the frequency o severity of the trauma related symptoms The facility will maintain ongoing documentation of any expressions or indication of distress, lack of improvement or decline in resident functioning in he resident's record and steps taken to determine the underlying cause of the negative outcome. Residents will be referred to psychology/psychiatry services. Social Services The Social Services Department will attempt to establish a rapport and conduct further psychosocial assessment of the resident's mental or psychosocial adjustment difficulty and / or post-traumatic stress disorder (PTSD) and develop a comprehensive person-centered care plan that addresses the specific triggers and appropriate interventions. Establish nonpharmacological interventions that assist in decreasing the frequency or severity of the of the trauma related symptoms. Evaluate the effectiveness of the care plan quarterly and as needed Utilize licensed mental health professionals to address any expressions or indications of distress Social Services will provide ongoing onsite support and coordinate support groups if needed Activities Review diagnosis of PTSD or traumatic event Complete the activities assessment and preferences and implement resident centered meaningful activities and nonpharmacological interventions Reevaluate interventions is needed Coordinate support groups, spiritual groups, volunteers of interest etc.