Health inspection·November 9, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood she could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 10/15/23 at 4:25 AM, the facility failed to prevent a moderate cognitively impaired resident from exiting the facility unsupervised. Resident #1 exited the facility through the front door by holding the emergency push bar for 15 seconds which activated the door alarm but the red screamer alarm did not sound. Certified Nursing Assistant (CNA) B disengaged the door alarm at 4:37 AM without initiating a search and did not alert other staff of the alarm. Resident #1 walked approximately 707 feet to the sidewalk adjacent to a 6-lane, moderately trafficked road. She proceeded down the side walk and walked approximately 2.2 miles in the dark, crossing two major intersections and a drainage ditch. The resident crossed the 6-lane road and was found by law enforcement in front of a closed fast-food restaurant. The facility was unaware of resident #1's whereabouts until she was located at approximately 6:15 AM in front of the fast-food restaurant. The facility failed to ensure resident #1 was adequately supervised, failed to initiate appropriate interventions for a door alarm and failed to monitor the front lobby door to ensure vulnerable residents did not exit the facility without supervision. The weather at 5:01 AM on 10/15/23 was 71 degrees Fahrenheit (F) and sunrise occurred at 7:26 AM. (Retrieved from www.timeanddate.com on 11/08/23). There were a total of 9 residents who were identified at risk for elopement at the time of the survey. The facility's failure to implement appropriate interventions and to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/15/23 and was removed on 10/18/23. The scope and severity of the deficiency was decreased to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was a [AGE] year-old, admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included metabolic encephalopathy, presence of cardiac pacemaker, atrial fibrillation, psychosis, major depressive disorder and cognitive communication deficit. Page 1 of 7 105471 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the hospital records revealed resident #1 was hospitalized on [DATE] for chest pain. A psychiatric assessment conducted at the hospital indicated resident #1 did not have the capacity to participate in the informed consent process for medical decisions. Review of the Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) of 8/17/23 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated moderate cognitive impairment. The document showed she required supervision and assistance of one staff member for mobility and did not use any mobility devices. The assessment noted resident #1 did not wander and did not use a wander/elopement alarm. Review of the medical record revealed an Elopement Risk Evaluation dated 8/13/23 that indicated resident #1 was alert and oriented, happy with placement and did not have a history of elopement attempts. Review of resident #1's care plan for impaired cognitive function or impaired thought processes related to encephalopathy initiated 8/16/23 included interventions to cue, reorient and supervise as needed. A falls risk care plan initiated 8/14/23 included interventions to keep room well lit, provide verbal reminders not to transfer or ambulate without assistance and to provide assistance as appropriate to meet resident's needs. A progress note dated 9/01/23 read, Resident was exit seeking and removed her [electronic wandering device]. Review of the medical record revealed no evidence of a change in condition evaluation, an Elopement Risk Evaluation, a wandering/at risk for elopement care plan or any further progress notes to address the change in behavior. Review of nursing progress notes revealed resident #1 was transferred to the hospital on 9/06/23 due to complaints of chest pain. She was readmitted to the facility on [DATE]. Review of the hospital record from resident #1's admission on [DATE] revealed a psychiatric assessment dated [DATE] which read, Patient is expressing a choice over where she wants to live, but her decision-making seems impaired in regards to understanding this decision, appreciation of the risks and benefits of the decision and rationale for her choice. Treatment team also reports patient may have been wandering the streets alone in the middle of the night when she lived independently in New York. Another psychiatric assessment conducted 9/10/23 indicated the resident informed the provider, They wanted to put a bracelet on my leg and I was not allowing that. Resident was noted to be restless, fidgety, mildly agitated, uncooperative and confused with poor attention span and easily distracted. Throughout the hospital stay, resident #1 stated several times she did not want to return to the rehabilitation center. She wanted to go home to New York. An Elopement Risk Evaluation dated 9/13/23 indicated resident #1 was fully ambulatory and wandered aimlessly. The elopement assessment score was 14 which indicated she was an elopement risk. The document indicated safety measures implemented included a wander bracelet/roam alert. Review of the medical record revealed no order for use of a wander/elopement alarm, a wandering/at risk for elopement care plan or any further progress notes to address resident #1's wandering behavior. The medical record did not contain any evidence the wander bracelet was ever implemented. Review of the MDS 5-Day Medicare assessment with ARD of 9/17/23 revealed resident #1 had a BIMS score of 9 out of 15 which indicated she had moderate cognitive impairment. The document indicated she now required limited assistance of one staff member for mobility and used a walker. The document 105471 Page 2 of 7 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 indicated resident #1 did not wander but did not indicate if she used a wander/elopement alarm. Level of Harm - Immediate jeopardy to resident health or safety A nursing progress note dated 10/15/23 read, the Director of Nursing (DON) was notified resident #1 left the building unsupervised at approximately 5:30 AM on 10/15/23. Resident was agitated and aggressive after she returned to the facility. Her physician ordered her to be sent to the hospital for evaluation due to altered mental status. Residents Affected - Few On 11/06/23 at 10:08 AM, during a telephone interview, Licensed Practical Nurse (LPN) D verified resident #1 eloped from the facility on 10/15/23. She said she was assigned to resident #1 on 10/15/23 and the resident was confused and wandered around the unit. LPN D recalled seeing resident #1 in the front lobby between 10:00-11:00 PM and instructed the resident to go back to her room and she did. LPN D recalled she went to the resident's room around midnight and did her vital signs. She remembered seeing resident #1 in bed at about 3:00 AM. She explained that when she went to the resident's room to administer medications at 5:30 AM, the resident was not there. LPN D stated she began looking for her and asked staff if anyone had seen her. She reported a staff member told her to look in the front lobby. LPN D reported when she got to the front lobby, she noted the front door had a blinking light which indicated someone had gone out the front door. She recalled there were no alarms sounding at the time. She verified the door also had a red screamer alarm box which was not making any noise. LPN D stated she alerted everyone and a search began as well as notification to the DON. She explained she had only worked with the resident for about a month and was sure she did not wear an electronic wandering device. She could not recall exactly where the resident was located but remembered it was down the street away from the facility. LPN D stated when resident #1 returned to the facility, she was very agitated and tried to get out again. On 11/05/23 at 11:29 AM, the Maintenance Assistant verified the facility had security cameras and captured some of the events of 10/15/23 when resident #1 left the building. He explained the camera in the front lobby detected motion and recorded, but stopped recording when there was no motion. He stated the front door had an electronic alarm system which would automatically lock if a resident with an electronic wandering device came near. He did not know if resident #1 had a wander device. The Maintenance Assistant showed the surveillance video dated 10/15/23 that showed resident #1 entered the front lobby at 3:30 AM. The resident then sat on the sofa just outside of the camera range. At 3:37 AM, CNA B entered the front lobby and proceeded to the doorway that led to the back maintenance hallway. She returned back into the font lobby at 3:40 AM and proceeded back down the hallway to the left into the facility. At 3:52 AM, resident #1 stood up and proceeded down the hallway into the facility while pushing her wheelchair. At 3:57 AM, the resident entered the front lobby and sat on the sofa just out of sight of the camera. At 3:59 AM, CNA B again entered the lobby from the hallway carrying a food tray and entered the door to the maintenance hallway. She returned at 4:01 AM and spoke to resident #1 which could not be heard due to the camera not having audio. At 4:24 AM, resident #1 stood up and walked toward the front exit door without her wheelchair. She approached the door and attempted to enter a code on the keypad. At 4:25 AM, she pushed on the release bar to open the door. The camera skipped to 4:26 AM when a pharmacy delivery person entered through the front door. At 4:37 AM, CNA B disengaged the door alarm at 4:37 AM without initiating a search. At 5:57 AM, facility staff were seen looking in the office and out the front door for resident #1. At 6:31 AM, Registered Nurse (RN) C exited the back door of the maintenance hallway that led to the back parking lot. At 6:55 AM, RN C returned through the back door with the resident and Director of Nursing. The Maintenance Assistant explained the resident had pushed on the exit door's release bar for 15 seconds which then released the door as it was a fire exit door. He explained a breach alarm would have sounded and the door would remain unsecured until a code was entered to reset the door. 105471 Page 3 of 7 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 11/06/23 at 1:48 PM, [NAME] A verified she worked on 10/15/23. She recalled as she drove to work, she saw a woman standing close to the street. [NAME] A explained the woman was on the same side of the street facing oncoming traffic and was very close to the traffic. She stated she moved over into the far-left lane because she was afraid she would hit the woman if she walked into the street. [NAME] A recalled she arrived at work a few minutes after 5:30 AM and began to prepare breakfast. She stated she was approached by a staff member who said a resident was missing. [NAME] A told the person she saw a woman down the street but did not know if she was the missing resident. [NAME] A confirmed she traveled that way regularly for work. She stated it was fortunate the resident was found as it was not safe to walk around on the street after dark. She remarked, There are a lot of crazy people on the street. On 11/05/23 at 11:17 AM, Receptionist E stated she was not working at the time resident #1 eloped from the facility. She verified there was a red screamer alarm on the front door and recalled that alarm being installed several months ago. Receptionist E explained the front door also had an electronic alarm system that would lock the door if a resident with an electronic wandering device approached. She stated the evening receptionist was responsible for engaging the red screamer alarm at night at the end of the shift. On 11/06/23 at 5:37 PM, Receptionist F acknowledged she worked evenings and weekends. She stated she was responsible for watching who came in and went out of the facility. She explained she had to make sure everyone signed in and out including residents. Receptionist F validated the front door had an electronic alarm system that would sound if a resident wearing an electronic wandering device got close to the door. She explained the door locked and would not open. She stated the alarm could be silenced once the resident moved away from the door. Receptionist F reported her shift ended at 9:00 PM. She stated her normal routine was to announce the lobby would close at 9:00 PM to alert visitors. She stated at 9:00 PM, it was her responsibility to engage the red screamer alarm, pull down the metal door that closed the reception desk off from the lobby, and forward incoming telephone calls. Receptionist F insisted she had a set routine and was certain she turned on the red screamer alarm before she left. On 11/06/23 at 11:56 AM, the Social Services Director (SSD) stated she spoke with resident #1's son and was told the resident lived alone in New York. She was hospitalized in New York and told she would be placed in a nursing home. The son said he brought her to live at his home but she became aggressive with him. The SSD recalled resident #1 told her son she wanted to go back to New York. The SSD acknowledged she was aware of resident's hospitalization on 9/06/23. She explained she advised the admission department not to re-admit resident #1 because she did not want to be here. The SSD reviewed the psychiatric evaluation done in the hospital on 9/07/23 and noted she had not seen that evaluation before. She acknowledged resident #1 should have been listed as an elopement risk and interventions implemented. The SSD could not say if staff discussed resident #1 being an elopement risk in daily morning meeting or in clinical meetings. The SSD recalled she received a call from the DON the morning resident #1 got out of the building. She said she spoke with the resident after she returned to the facility and the resident told her she just wanted to get out and left through the front door. The SSD explained the police were with resident #1 by the time the facility staff got there. She obtained a report number from the police but had not requested a copy of the report. On 11/06/23 at 4:04 PM, the Rehabilitation Director stated resident #1 was on caseload from 9/13/23 through 10/12/23. The Director reported resident #1 was able to ambulate with moderate assistance meaning she either needed an assistive device or just needed more time to ambulate. She stated resident #1 was cognitively impaired and disoriented to situation. She recalled she was fixated on going 105471 Page 4 of 7 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 back to New York. Level of Harm - Immediate jeopardy to resident health or safety On 11/07/23 at 10:23 AM, the MDS Coordinator verified a care plan for wandering and at risk for elopement was not initiated until 10/15/23, the date resident #1 eloped. She reviewed the care plan history and acknowledged no care plan was in place prior to that date. The MDS Coordinator reviewed psychiatric note dated 9/07/23 from the hospital and Elopement Risk Evaluation completed by the facility on 9/13/23 which indicated resident was an elopement risk. The MDS Coordinator did not explain why a care plan was not developed at the time resident #1 was identified as a wandering/elopement risk. She clarified the Unit Manager usually reviewed the assessments and evaluations completed by the nurses and added, This one got missed, unfortunately. Residents Affected - Few In a telephone interview on 11/03/23 at 2:14 PM, resident #1's son stated he brought his mother to live with him this past summer. He conveyed she lived independently in New York but one morning, she left her home in South Manhattan and was found in South Bronx at 2:30 AM. He recalled he was contacted by the police and told he either had to come get her or she would be placed in a nursing home in New York. Resident #1's son stated she was always trying to leave to go back to New York. He recalled a time when she got into a car with strangers and asked them to take her to the bus stop. He stated she would get in the car with anyone. He explained he lost his job because he had to stay home with his mom to take care of her and be sure she did not leave and get lost. He reported she had only been with him for 3 weeks when he realized he could not care for her and started a search to to place her in a facility. He confirmed he was contacted about his mother leaving the facility on 10/15/23. He recounted the facility told him she snuck behind a visitor and went out the door when they buzzed the visitor out. He recalled he was told she got down the road less than a mile away. He expressed he did not know how she made it that far down the street. He stated she was constantly falling and had fallen twice while living with him as she was unsteady on her feet. He verbalized she would not be safe outside by herself. He stated the facility should have known about her wandering as it was in all the hospital paperwork. He reported she was transferred to the hospital after she eloped from the facility. He explained she kept trying to get out of the hospital and they had to restrain her. He stated she was sent to a nursing home that had a secure unit. He said he was in agreement and felt it was safer for her to be in a secured unit. On 11/07/23 at 4:56 PM, the Regional Director of Clinical Services stated the facility identified several areas of opportunity for improvement during their investigation. She noted the nurse who documented resident #1's exit seeking behavior failed to complete a change in condition assessment and an elopement risk evaluation, did not notify the physician of a change in behavior and did not initiate any interventions to keep the resident safe. She explained the the nurse who completed the Elopement Risk Evaluation on 9/13/23 failed to implement elopement risk interventions, did not notify the physician or management team and did not document any actions after she identified elopement risk. She noted the Interdisciplinary Team (IDT) failed to review hospital documentation, progress notes and the medical record for newly admitted or re-admitted residents which resulted in failure to implement appropriate care plan and interventions. The Regional Director of Clinical Services stated the facility also determined that staff failed to respond appropriately to the door alarm. She explained they observed on the video that CNA B turned off the door alarm on 10/15/23 at 4:37 AM, without checking if a resident got out and did not alert any staff to the alarm. She explained the Quality Assessment and Performance Improvement committee determined the Root Cause of the elopement were failures to properly assess and identify resident #1 as an elopement risk, and failure to implement appropriate interventions for the risk and failure to follow elopement protocols. Review of the policy and procedure Elopement revised 10/24/22 revealed a purpose to assure the 105471 Page 5 of 7 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 Level of Harm - Immediate jeopardy to resident health or safety safety and security of all residents. The document directed staff to assess the resident status upon admission and quarterly thereafter to determine if the resident should be considered at risk for elopement. Prevention protocols should be followed and documented on the care plan for any resident identified as at risk for elopement. The document identified several multi-faceted interventions for resident at risk which included identifying information being placed in the elopement binder, increased supervision and implement and/or update care plan for the resident. Residents Affected - Few On 10/15/23 at 5:30 AM, resident #1's probable elopement route was re-traced. She exited the facility's front lobby door and turned right, walked through the parking lot, and left the property. Resident #1 walked approximately 707 feet to the sidewalk adjacent to a 6-lane, moderately trafficked road. She turned left and proceeded down the side walk approximately 2 miles crossing two major intersections and a drainage ditch. The resident crossed the 6-lane road where she was stopped by law enforcement in front of a closed fast-food restaurant. Observation of the probable route revealed a dense commercial area with restaurants, offices, gas stations and stores. The 6-lane road had two major intersections where the 6-lane road converged with another 6-lane road with additional turn lanes on each side. Historical weather data revealed on the morning resident #1 eloped, 10/15/23, the temperature at 5:01 AM was 71 degrees Fahrenheit (F) and mostly cloudy. Sunrise occurred at 7:26 AM (retrieved on 11/08/23 from www.timeanddate.com). Review of the Facility Assessment Tool revealed the facility accepted and could care for residents with psychiatric and mood disorders including psychosis, impaired cognition, depression, anxiety, and behaviors that needed intervention. The document indicated the facility provided person-centered care including identification of hazards and risks for residents. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 10/15/23 at 5:30 AM, resident #1 was discovered missing and the facility implemented its elopement policy and procedures. *On 10/15/23 at 6:55 AM, resident #1 returned to the facility with facility staff. She was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on 1:1 supervision. *On 10/15/23, resident #1 was re-evaluated for elopement risk and a comprehensive care plan was initiated due to her increased risk. *On 10/15/23, the facility re-evaluated all residents' elopement risk and there were no newly identified concerns. A quality review audit of the 9 residents who were at risk for elopement revealed no concerns related to their electronic wandering devices, care plans and physicians' orders. The elopement binders were reviewed to ensure identified residents at risk were in the books. *On 10/15/2023, Plant Operations checked all doors and alarms center wide for proper functioning. A new red screamer alarm (keyed alarm) was installed on the double doors between the west wing and the front lobby. All red screamer alarms were labeled with on and off positions identified facility wide. 105471 Page 6 of 7 105471 11/09/2023 Rehabilitation Center of Orlando 9311 S Orange Blossom Trl Orlando, FL 32837

F 0689 *On 10/15/2023, the facility initiated 24-hour front door coverage to monitor the front lobby exit door. Level of Harm - Immediate jeopardy to resident health or safety *On 10/15/23, the facility held an ad hoc QAPI meeting and conducted a Root Cause Analysis and reviewed recommendations to develop a plan for correction to include education, post-tests, drills and audits. The ad hoc QAPI committee including the Medical Director (via telephone) approved the recommendations. Residents Affected - Few *On 10/17/2023, the facility reviewed hospital medical records and resident/family interviews for all new admissions in the last 30 days to ensure identification of potential elopement risks. *On 10/18/23, the facility held an ad hoc QAPI meeting to evaluate the plan put into place on 10/15/2023. Education, actions taken and audits were reviewed. The ad hoc QAPI committee including the Medical Director approved the current plan and recommendations for continued education and audits. *From 10/15/23 to 10/18/23, licensed nurses were re-educated on accuracy of elopement risk evaluations and providing appropriate supervision for residents with wandering or exit seeking behaviors. Education included completion of accurate elopement evaluations, supervisor notification of change in condition with emphasis on new or increased behaviors of wandering or exit seeking. As of 10/18/2023, 22 out of 31 nurses received education, a total of 71%. *From 10/15/23 to 10/18/23, staff were educated on Abuse/Neglect; Missing Residents Policy and Procedures; Elopement and Missing Persons; Response to Door Alarms; and Elopement Post Test were completed. Elopement Drills were conducted on all 3 shifts. As of 10/18/2023, a total of 129 of 138 staff members received elopement education and participated in the elopement drills, a total of 93%. *From 10/15/23 to 10/18/23, the facility completed 9 elopement drills to cover all 3 shifts with satisfactory staff response documented on elopement drill worksheets. *Interviews were conducted from 11/05/23 to 11/08/23 with 22 staff members (8 CNAs representing all shifts, 2 receptionists, 2 RNs, 4 Licensed Practical Nurses, 2 therapists, 2 environmental services, 1 activity staff and 1 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures and supervision of residents at risk for elopement. The resident sample was expanded during the survey to include 4 additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #3, #13, #14, and #15. 105471 Page 7 of 7