Health inspection·April 14, 2022

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 observation, interview, and record review, the facility failed to ensure supervision for 1 of 4 sampled residents (Resident #67) related to wandering, which also affected Resident #117 and Resident #15. The findings included: Resident #67 was admitted on [DATE] with diagnosis that included Alzheimer's and anxiety disorder Review of the Minimum Data Set (MDS) assessment, dated 02/24/22, documented Resident #67 as being severely cognitively impaired. Resident #67's Care Plan for Wandering Risk, effective date 10/15/21, documented interventions of offering snacks in between meals, provide reassurance and comfort when anxious, assist with calling son, check wander guard for proper placement and function, and update Code Purple folder (wanderers identification book) with resident's picture and important information. On 04/11/22 at 10:44 AM during an interview, Resident #117 wrote that Resident #67 comes in his room uninvited, sometimes uses his restroom and they (the staff) must physically remove her. He communicated that it upsets him, and that he has complained to the nurses. Review of the MDS assessment dated [DATE] documented Resident #117 as being cognitively intact with diagnosis that include inability to speak due to surgical removal of his voice box, altered breathing due to breathing through a hole in his neck and requiring limited to extensive assistance for all activities except eating. On 04/11/22 at 11:29 AM during an interview, Resident #15 stated a confused woman in a wheelchair who speaks Spanish, a foreign language, comes in her room and fiddles with her bedding. She also said that sometimes it unnerves her because she is sleeping and feels someone messing with her bed. Review of the MDS assessment dated [DATE] documented Resident #15 as being cognitively intact with diagnosis that included Heart Disease and requiring extensive assistance for all activities except eating. On 04/13/22 at 8:20 AM, Resident #117 communicated that Resident #67 came in his room again yesterday and had to be escorted out. He also communicated that he complained again to the staff about it. On 04/13/22 at 2:00 PM, Staff A CNA (Certified Nursing Assistant) stated he is aware of Resident #67 wandering in other people's rooms and about her going into Resident #117's room. He stated he goes and gets her out. Staff A said they try to redirect her but sometimes he is busy giving care to someone else and does not know she has gone into another resident's room. Page 1 of 3 105801 105801 04/14/2022 Joseph L Morse Health Center Inc The 4847 Fred Gladstone Drive West Palm Beach, FL 33417

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/13/22 at 2:15 PM, Staff B, Registered Nurse (RN) stated that she is aware of Resident #67's wandering and going uninvited into other residents' rooms. She said they put a wander guard on her chair to keep her from leaving the floor. She also stated they try to have her sit by the nurse's station so they can watch her. On 04/13/22 at 4:22 PM, Resident #117 communicated in the presence of another surveyor that Resident #67 came in his room again and had to be removed yesterday. He said that it bothers him, he does not like it, it has been going on for months and he has complained about it to the staff. On 04/13/22 at 4:25 PM, Resident #15 stated in the presence of another surveyor that Resident #67 comes in her room uninvited and messes with her bedding. She stated that it bothers her, actually it bothers everyone. Review of the Progress Note, titled, Nursing on 12/23/21 at 5:57 AM, stated, resident woke up around 5:15 AM and started making a lot of noise roaming around calling in Spanish [her native language] she pulled the alarm of the emergency door, security was called to reset the alarm. Redirected several times, she got aggressive. Review of the Progress Note, titled, Nursing on 01/16/22 at 1:45 AM, stated, received resident awake out of bed roaming around in her wheelchair, going door to door waking up other residents; she went to a resident's room broke a picture frame then threw stuff on the floor. Review of the Interdisciplinary Behavior Observation Form dated 01/18/22, documented Resident #67 with behaviors of yelling, screaming, being verbally abusive and entering other residents' rooms. Review of the Interdisciplinary Behavior Observation Form dated 03/02/22, documented Resident #67 with behaviors of being verbally abusive, threatening, screaming at others, cursing, and being physically abusive. Interventions used for the behaviors listed separating Resident #67 from the other resident, redirect, and return her to her room. Review of the Interdisciplinary Behavior Observation Form dated 03/10/22, documented Resident #67 in other resident's room with behaviors of being verbally abusive, threatening, screaming at others, cursing, and being physically abusive, kicking, attempts to hit, and very combative. Review of the Progress Note, titled, Nursing on 03/10/22 at 4:11 PM, stated Resident was very aggressive today. Went to other resident's room used the toilet and attempts to kicks the Resident (#117) . when Writer trying to take (Resident#67) out, she started, yelling, shouting, and kicking. (Resident #67) went to another resident's room trying to kick another resident. ANRP (nurse practitioner) notified, received new order Ativan 0.5 milligram intramuscular (sedation shot). Ativan given in the left arm. Review of the Progress Note, titled, Medical on 03/16/22 at 2:41 PM, documented under Behaviors: yelling, screaming, biting, delusions, verbally and physically abusive, going into other rooms and hoarding. Review of the Progress Note, titled, Geri-Psychiatry Follow-up Evaluation on 03/17/22 at 2:35 PM, documented under Assessment: Worsening anxious moods, sundowning (state of confusion spanning into the night), wandering and agitation. 105801 Page 2 of 3 105801 04/14/2022 Joseph L Morse Health Center Inc The 4847 Fred Gladstone Drive West Palm Beach, FL 33417

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Progress Note, titled, Activities on 03/27/22 at 5:11 PM, stated Resident #67 can self-propel her wheelchair around the unit and is noted to wander into other resident's rooms. Review of the Progress Note, titled, Medical on 03/31/22 stated Resident # 67 has been exhibiting the following behavior of yelling, biting, resisting care, delusions, verbally and physically abusive, going into other rooms, hoarding and states the behaviors occur randomly throughout day and night hours. Resident #67 was observed during the survey to self-propel her wheelchair in the hallways and dining room on her unit. 105801 Page 3 of 3