Health inspection·September 19, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a grievance was investigated and tracked through to a conclusion for one resident (#1) out of five sampled residents. Findings included: On 9/18/2023 at 8:55 a.m. an interview was conducted with Resident #1's family member via telephone. Resident #1's family member stated she was not Resident #1's responsible party, and the responsibility was with another family member. Resident #1's family member stated she visited Resident #1 regularly and when she visits, she routinely finds care concerns. Resident #1's family member stated she had been in contact with many staff members to include floor nurses, the Social Service Director, the Director of Nursing, and the Nursing Home Administrator related to the care concerns. She stated staffing at the facility changes often. She stated she has voiced her concerns with care to the facility. She stated her concerns with care have been related to staff not assisting Resident #1 with checking and changing, not providing sufficient hydration, and lying in bed nude with only wearing an adult brief. She stated she has mentioned these concerns on more than one occasion to management and feels the concerns have not been investigated. She stated there has been no communication from the facility about the concerns or any type of resolution. Resident #1's family member stated she had verbalized these complaints to the Administrator, the Social Service Director, and the Director of Nursing. On 9/18/2023 at 10:00 a.m. the Nursing Home Administrator (NHA) and the Social Service Director (SSD) provided the last nine months of the facility's Complaint/Grievance log for review. A review of the log for the months of 1/2023, 2/2023, 3/2023, 4/2023, 5/2023, 6/2023, 7/2023, 8/2023, and 9/2023 revealed the following complaints related to Resident #1: 1. The Grievance log dated 1/7/2023 revealed Resident #1's family member lodged a complaint related to care and services, which was investigated and confirmed with resolution on the same date. The Grievance log revealed Resident #1's family member was communicated back with investigation results. 2. The Grievance log dated 6/12/2023 revealed Resident #1's family member lodged a complaint related to a missing phone, which was investigated and confirmed with resolution on the same date. The Grievance log revealed Resident #1's family member was communicated back with investigation results. On 9/19/2023 an interview with the SSD was conducted. She stated Resident #1's family member's complaints were investigated, and timely resolution and communication to the family member was completed. Page 1 of 12 105551 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0585 Level of Harm - Minimal harm or potential for actual harm A review of the medical record for Resident #1 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. The Advance Directives revealed the resident had a Power of Attorney in place to make his medical and financial decisions. The diagnosis sheet revealed diagnoses to include but not limited to, Parkinson's Disease, abnormal posture, depression, anxiety, and a history of falls. Residents Affected - Few A review of the Progress Notes revealed the following: 7/16/2023 10:59 p.m. Nurse writer entered the room same time as resident's [family member] found resident naked on bed. Resident denied taking off his clothes. [Family member] got upset about resident left without clothes. Nurse writer started to get resident dressed up, and his [family member] began to take picture of resident and nurse. Writer asked [family member] nicely to stop taking her picture without authorization. [Family member] told nurse to stop putting clothes on resident if she continued to take picture. Writer reminds [family member] this is a HIPAA [Health Insurance Portability and Accountability Act] violation, so she has to stop. A review of the current Minimum Data Set (MDS) Annual assessment dated [DATE] revealed the following: Brief Interview Mental Score (BIMS) score of 5, indicating severe cognitive impairment. Activities of Daily Living (ADL) functional capacity listed as, Extensive assist with two person assist to include Bed Mobility, Transfers, Dressing, Toileting, Bathing. Supervision with Eating with one person. On 9/18/2023 at 12:03 p.m. an interview with the SSD revealed she was aware of Resident #1 and also aware of his Power of Attorney (POA). She revealed the POA was another family member. She stated a family member visits routinely but is not the POA. She stated the resident was a pleasant man and needed assistance with most of his ADL's and sometimes goes out to activities. She stated the resident has lower cognitive function but was able to speak with relation to his day. The SSD stated if a complaint is brought up to a staff member, the staff member must follow through with getting the complaint either on the written complaint form, or passing it along to the Unit Manager, and then the complaint is brought to her department's (Social Services) attention. The Social Service Director stated once she receives the complaint, she logs it and starts the investigation by way of communicating with the complainant, and passing the concern to the DON, the Administrator, and respective department related to the complaint. She stated the grievance should be identified and then addressed in a timely manner with investigation and communication back to the person who made the complaint. She stated the facility addressed a complaint from a family member of Resident #1 on 6/12/2023 and 1/7/2023. She stated the complaints were related to a missing phone and nursing care and both were investigated and resolved within the same day they were lodged. The Social Service Director stated there were no other voiced or written grievances for Resident #1 6/12/2023. The Social Service Director reviewed the resident's medical record to include a nurse progress note, dated 7/16/2023. She confirmed the note revealed the resident's family member had concerns with him lying naked on the bed and this concern was not addressed. The SSD stated the information was never forwarded to her in order for her to investigate it. She stated she was not sure of the nurse who wrote the note, but the staff member should have forwarded the concern to the Social Service Department. On 9/19/2023 at 1:00 p.m. an interview was conducted with the NHA and the DON. They stated Resident #1's family member routinely speaks with them regarding her concerns with care and services. They stated they felt all areas of concern had been sufficiently identified and investigated. They stated they were not aware of the concern that occurred on 7/16/2023. They confirmed the nurse note dated 7/16/2023 did explain Resident #1's family member voiced concerns, but stated the concern was not 105551 Page 2 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forwarded to them or the Social Service Director to investigate. The DON stated management is responsible for reading daily progress notes and are to report any concerns during daily meetings. On 9/18/2023 the Nursing Home Administrator provided the Resident and Family Concerns and Grievances policy and procedure with an implementation date of 11/28/2017 for review. The policy revealed the following: Policy: To comply with federal regulation, the facility has implemented the policy to support and facilitate each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Definitions section of the policy revealed; Prompt efforts resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. The Policy Explanation and Compliance Guideline section revealed; 1. The Administrator has appointed the facility Grievance Official to be the Social Service Director and his/her designee. Revised 9/7/2022. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. 4. Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to: a. The contact information of the grievance official with whom a grievance can be filed, including his or her name, and phone number. 5. Grievances may be voiced in the follow forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings. e. Via the company toll free Customer Service Line (if applicable). 6. Procedure: 105551 Page 3 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. The staff member recording the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. (i) Take any immediate actions needed to prevent further potential violations of any resident right. (ii) Report any allegations involving neglect, abuse, injuries of unknown source, and/or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. b. Forward the grievance form to the Grievance Official as soon as practicable. c. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. (i) Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. (ii) All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance. (iii) All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to concerns/grievances and will share them only with those who have a need to know. d. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. e. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum. (i) The date the grievance was received. (ii) The steps taken to investigate the grievance. (iii) A summary of pertinent findings or conclusions regarding the resident's concern(s). (iv) A statement as to whether the grievance was confirmed or not confirmed. (v) Any corrective actions taken or to be taken by the facility as a result of the grievance. (vi) The date the written decision was issued. f. For investigations regarding allegations of neglect, abuse, injuries of unknown source, and or misappropriation of resident property, a report of the investigative results will be submitted to the 105551 Page 4 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0585 Level of Harm - Minimal harm or potential for actual harm State Survey Agency, and other officials in accordance with State law, within five business days of the incident. 7. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. Residents Affected - Few 8. The facility will make prompt efforts to resolve grievances. 9. The concern/grievance will be logged after it's resolved by the resident and/or responsible party. 105551 Page 5 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure the care plan interventions were implemented according to orders for two residents at risk for elopement (#3 and #4) related to use of a Roam Alert bracelets out of five sampled residents. Findings included: On 9/18/2023 at 1:35 p.m. Resident #4 was observed in her room lying in bed. Her arms were exposed, and a yellow Roam Alert bracelet was observed on her right wrist. An interview was unable to be conducted. On 9/19/2023 at 7:27 a.m. Resident #4 was observed in her bed and lying flat with head on the pillow. Resident #4 had a Roam Alert bracelet on her right wrist. An interview was conducted on 9/18/2023 at 2:00 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E confirmed Resident #4 was an elopement risk and should wear a Roam Alert bracelet on her arm. Staff E stated the Roam Alert bracelet would sound off a door alarm should the resident get near the alarm system at any of the exit doors. The LPN stated Resident #4 had not had any exit seeking behaviors but utilized the Roam Alert bracelet due to her cognition and diagnosis of dementia. The LPN stated she and the other Unit Managers update the Roam Alert books to reflect who is an elopement risk throughout the facility and will keep the books at the nurse stations as well as the front lobby desk. She stated she and the other unit managers ensure all staff are knowledgeable of where the book is and how to identify if a resident is an elopement risk. Review of the North Wing Roam Alert book revealed a blank floor plan with room numbers, an elopement policy and procedure, and photos with names of residents who were elopement risks. Further review of the book revealed a sheet of paper that indicated; Roam Alert Log North Unit. Resident #4 was identified as an elopement risk and revealed she is to wear a Roam Alert bracelet on her right wrist. The book also revealed a face sheet with Resident #4's photograph. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Review of the Advance Directives revealed the resident had a Power of Attorney who made her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to dementia, altered mental status, and history of falls. Review of the current Physician's Order Sheet dated for the month 9/2023 revealed the following: Roam Alert for Safety. Check placement and function every shift. Place on Right Wrist and check skin for integrity; original order date 8/17/2023. Review of the most current Minimum Data Set (MDS) assessment Medicare 5 day dated 8/13/2023 revealed: Cognition/Brief Interview Mental Status Score (BIMS) of 8, indicating severe cognitive impairment. Activities of Daily Living (ADL) revealed Supervision as one person assistance with most ADLs. However, requires limited assistance with dressing; Behaviors revealed no behaviors exhibited with relation to wandering. Review of the most recent Elopement Risk assessment dated [DATE], revealed; Not wandering/seeking 105551 Page 6 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0656 to find spouse and/family, and checked as not at risk for elopement. Level of Harm - Minimal harm or potential for actual harm Review of the current care plans with a next review date 11/19/2023, revealed the following: Residents Affected - Few 1. ADL self-care performance deficit related to metabolic encephalopathy, Hypertension, Dementia, Syncope, Altered Mental Status, History of falling, with interventions in place as reviewed and observed. 2. High risk for fall and related injury related to: Disease process/condition, Functional problem, Hypertension Dementia, Syncope, Altered Mental Status, History of falling, Medication usage and unavoidable decline. Use of assistive device to include wheelchair, fall risk factors present as determined by fall risk screen, with interventions in place as reviewed and observed. 3. Tend to wander aimlessly due to impaired cognitive function. However, is not actively seeking an exit at this time, and with interventions in place to include but not limited to: Check for proper functioning of the audible alarm system every shift and as need. On 9/19/2023 at 9:36 a.m. both MDS/Care Plan Coordinators Staff Band C revealed they were aware of Resident #4 and her being an Elopement risk. They stated the resident utilized a Roam Alert bracelet per the order and care plan. They reviewed the current care plans, and confirmed there was not any specific direction related to the use and maintenance of this Roam Alert band. Staff B and C both confirmed the intervention was not as descriptive with use and maintenance of this device, and confirmed other residents who have the same device are care planned specifically with the maintenance and us. On 9/202023 at 1:00 p.m. the Nursing Home Administrator provided the Comprehensive Care Plans, with an implementation date of 11/28/2017, for review. The Policy revealed the following; It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet at resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Definitions section of the policy revealed; Person-centered-care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The Policy Explanation and Compliance Guideline section of the policy revealed; 1. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. The resident's goals for admission, desired outcomes, and preferences for future discharge. 105551 Page 7 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 3. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His medical diagnoses include but are not limited to; fracture of the left acetabulum, history of falling, muscle weakness, Alzheimer's disease, adjustment disorder with anxiety, and cognitive communication deficit. Review of Resident #3's Minimum Data Set (MDS) dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of Resident #3's Elopement Risk evaluations dated 8/8/23 and 9/6/23 revealed the resident was at risk for elopement. An interview was conducted on 9/18/23 at 12:50 p.m. with Resident #3. The resident was observed to be sitting in his wheelchair, in the therapy gym. The resident was observed to be pleasantly confused and unable to describe past events with accuracy. An observation was made on 9/18/23 at 12:52 p.m. there was no wandering device observed on the resident or his wheelchair. An interview was conducted on 9/19/23 at 12:52 p.m. with Staff F, Occupational Therapy Assistant (OTA) she felt the residents' wrists and observed his ankles and observed his entire wheelchair and she confirmed there was no wandering device on the resident or his wheelchair. An interview was conducted on 9/18/23 at 12:54 p.m. with Staff D, Licensed Practical Nurse (LPN), she stated she was Resident #3's nurse. She stated the resident was supposed to have a wandering device on. She stated she had not checked for it yet. She reviewed the Physician orders and confirmed the resident was ordered to have a wandering device attached to the back of his wheelchair on the left side. An interview was conducted on 9/18/23 at 12:55 p.m. with Staff E, LPN, Unit Coordinator she confirmed the resident only had one wheelchair. An interview was conducted on 9/18/23 at 1:10 p.m. with the Director of Nursing (DON) he stated the location of the resident's wandering device is located in the elopement books and wouldn't necessarily be on the Physician orders. He located an elopement book and confirmed Resident #3's wandering device should be on the left side of his wheelchair. Resident #3 was observed being propelled down the hall by Staff F, OTA and the DON observed the resident's wheelchair and confirmed there was no wandering device on the resident or the wheelchair. Staff F, OTA stated Resident #3 received a new wheelchair last week sometime. She stated she was not the one who changed the wheelchair, but he got a new one because it was too low for him. She stated his old wheelchair would be in the therapy storage area in the therapy room. 105551 Page 8 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/18/23 at 1:14 p.m. Staff G, Occupational Therapist (OT) stated she did not change his wheelchair Staff F, OTA did. The DON said Staff F, OTA said she didn't change it. Staff G, OT went to the computer to see what therapist changed the wheelchair and confirmed there was no documentation related to changing his wheelchair. Staff H, Physical Therapist Assistant (PTA) was in the therapy room, and she said she changed the chair on Wednesday of last week (9/13/23). She said his other chair was way too small for him. She said she does not remember there being a wandering device on his old chair because she would have seen it. She entered the therapy storage area, and she said, I believe this was his wheelchair and there was no wandering device on it. She stated she did not remember ever seeing it on the wheelchair. The wheelchair was observed not to have a wandering device on it. On 9/18/23 at 1:18 p.m. the DON said when the wheelchairs get changed the wandering device stays with the resident no matter what. Review of Resident #3's Physician orders revealed an order with a start date of 9/12/23 and no end date as; Roam alert for safety. Check placement and function every shift. Review of Resident #3's Treatment Administration Record (TAR) revealed a physician's order to start on 9/12/23 and was discontinued on 9/18/23 as; Ensure [wandering device] is in place every shift back of w/c (wheelchair) left side. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift on 9/12/23 through the night shift on 9/17/23. Further physician orders review on the TAR revealed; Roam alert for safety. Check for placement and function every shift with a start date of 9/12/23 and no end date. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift of 9/12/23 through the night shift on 9/18/23. 105551 Page 9 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 observations, interviews, and record review the facility failed to ensure a wandering device was placed on one resident (#3) out of 5 residents reviewed to be at risk for elopement. Findings included: Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His medical diagnoses include but are not limited to; fracture of the left acetabulum, history of falling, muscle weakness, Alzheimer's disease, adjustment disorder with anxiety, and cognitive communication deficit. Review of Resident #3's Minimum Data Set (MDS) dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of Resident #3's Elopement Risk evaluations dated 8/8/23 and 9/6/23 revealed the resident was at risk for elopement. An interview was conducted on 9/18/23 at 12:50 p.m. with Resident #3. The resident was observed to be sitting in his wheelchair, in the therapy gym. The resident was observed to be pleasantly confused and unable to describe past events with accuracy. An observation was made on 9/18/23 at 12:52 p.m. there was no wandering device observed on the resident or his wheelchair. An interview was conducted on 9/19/23 at 12:52 p.m. with Staff F, Occupational Therapy Assistant (OTA) she felt the residents' wrists and observed his ankles and observed his entire wheelchair and she confirmed there was no wandering device on the resident or his wheelchair. An interview was conducted on 9/18/23 at 12:54 p.m. with Staff D, Licensed Practical Nurse (LPN), she stated she was Resident #3's nurse. She stated the resident was supposed to have a wandering device on. She stated she had not checked for it yet. She reviewed the Physician orders and confirmed the resident was ordered to have a wandering device attached to the back of his wheelchair on the left side. An interview was conducted on 9/18/23 at 12:55 p.m. with Staff E, LPN, Unit Coordinator she confirmed the resident only had one wheelchair. An interview was conducted on 9/18/23 at 1:10 p.m. with the Director of Nursing (DON) he stated the location of the resident's wandering device is located in the elopement books and wouldn't necessarily be on the Physician orders. He located an elopement book and confirmed Resident #3's wandering device should be on the left side of his wheelchair. Resident #3 was observed being propelled down the hall by Staff F, OTA and the DON observed the resident's wheelchair and confirmed there was no wandering device on the resident or the wheelchair. Staff F, OTA stated Resident #3 received a new wheelchair last week sometime. She stated she was not the one who changed the wheelchair, but he got a new one because it was too low for him. She stated his old wheelchair would be in the therapy storage 105551 Page 10 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0689 area in the therapy room. Level of Harm - Minimal harm or potential for actual harm On 9/18/23 at 1:14 p.m. Staff G, Occupational Therapist (OT) stated she did not change his wheelchair Staff F, OTA did. The DON said Staff F, OTA said she didn't change it. Staff G, OT went to the computer to see what therapist changed the wheelchair and confirmed there was no documentation related to changing his wheelchair. Staff H, Physical Therapist Assistant (PTA) was in the therapy room, and she said she changed the chair on Wednesday of last week (9/13/23). She said his other chair was way too small for him. She said she does not remember there being a wandering device on his old chair because she would have seen it. She entered the therapy storage area, and she said, I believe this was his wheelchair and there was no wandering device on it. She stated she did not remember ever seeing it on the wheelchair. The wheelchair was observed not to have a wandering device on it. Residents Affected - Few On 9/18/23 at 1:18 p.m. the DON said when the wheelchairs get changed the wandering device stays with the resident no matter what. Review of Resident #3's Physician orders revealed an order with a start date of 9/12/23 and no end date as; Roam alert for safety. Check placement and function every shift. Review of Resident #3's Treatment Administration Record (TAR) revealed a physician's order to start on 9/12/23 and was discontinued on 9/18/23 as; Ensure [wandering device] is in place every shift back of w/c (wheelchair) left side. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift on 9/12/23 through the night shift on 9/17/23. Further physician orders review on the TAR revealed; Roam alert for safety. Check for placement and function every shift with a start date of 9/12/23 and no end date. Review of the documentation revealed the order was signed off as completed every shift starting from the evening shift of 9/12/23 through the night shift on 9/18/23. Review of Resident #3's care plan with an initiated date of 8/8/23 revealed I am an elopement risk/wanderer r/t [related to] History [sic] of attempts to leave facility unattended the goal included I rely upon staff to monitor my location to decrease my ability to elope from the facility through interventions as provided. The interventions included but are not limited to apply roam alert- Check for working condition, placement and skin integrity as ordered. Review of the facility's Elopements and Wandering Residents policy with an implementation date of 11/28/2017 revealed Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: .3. The facility is equipped with door locks/alarms to help avoid elopements. 4. alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 105551 Page 11 of 12 105551 09/19/2023 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0689 Level of Harm - Minimal harm or potential for actual harm 5. the facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Residents Affected - Few 105551 Page 12 of 12