Inspection·June 20, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to thoroughly investigate a possible elopement for 1 of 2 resident reviewed for elopement, of a total sample of 32 residents, (#22). Residents Affected - Few Findings: Resident #22 was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, psychotic disorder with delusions and cognitive communication deficit. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date 5/12/24 noted resident #22 had long-term and short-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment showed resident #22 wandered 4 to 6 days out of 7 and used a wander/elopement alarming device daily. The medical record contained a care plan revised 11/16/23 which indicated resident #22 was at risk for elopement as evidenced by impaired safety awareness. Interventions included the use of an alerting bracelet and picture of resident to be kept in elopement binders. The most recent revision to interventions was 1/19/23. Review of the facility Elopement Drills revealed a drill with sign-in sheet dated 6/05/24. The drill sheet indicated a resident with a wander alert bracelet tripped the alarm at the front door. The alarm sounded and the nurse checked the alarm panel without delay. The nurse immediately directed a Certified Nursing Assistant (CNA) to go to the front door where she then observed resident #22 directly outside the front door and she returned him to the unit. On 6/19/24 at 3:36 PM, CNA A stated she worked the night resident #22 set off the front alarm. She recalled Registered Nurse (RN) C sent CNA F to the front door. CNA A stated she remained on the unit. She recalled the Administrator came to the facility that night because the resident had gotten out the front door and staff completed an in-service on elopement. On 6/19/24 at 3:41 PM, Licensed Practical Nurse (LPN) B stated she was working the night resident #22 pushed the front door and got outside the door. She stated she heard the alarm at the nurses' station, and she then checked each resident on the unit as per policy. She recalled she heard resident #22 got out the front door but not very far. She stated the Administrator came in and held an in-service and a mock drill that same day. On 6/19/24 at 3:47 PM, RN C confirmed she worked the night resident #22 set off the front door alarm. She recalled she gave him his medication at approximately 8:00 PM. RN C said she was at the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105872 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskawilla Nursing and Rehab Center 1024 Willa Springs Dr Winter Springs, FL 32708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)