Viera Health And Rehabilitation Center

F-F600

On [DATE REDACTED] at approximately 6:05 PM, the facility's Weekend Supervisor unlocked the door for a visitor to leave and neglected to ensure no residents followed out behind the visitor. Resident #1, a vulnerable, severely, cognitively impaired male, followed behind the visitor and exited the safety of the facility unnoticed and unsupervised. Resident #1 was allowed to exit the building and walked outside on the hot, sunny 90 degree Fahrenheit evening for approximately 45 minutes, traveling approximately 1.1 miles away from the facility, (retrieved on [DATE REDACTED] from www.wunderground.com). Along the route it was noted to have uneven, sloped terrain/pavement, curbs and multiple open retention ponds. He would have crossed a heavily trafficked, six lane highway with speed limit of 40 miles per hour to reach the location where an off-duty staff member spotted him. The facility was unaware of resident #1's whereabouts until 6:35 PM when an off-duty staff member happened to see the resident walking down the street with a wander prevention bracelet and called the supervisor.

Resident #1 was admitted to the facility on [DATE REDACTED], with diagnoses to include right femur fracture, difficulty walking, dementia anxiety, major depressive disorder, psychotic disorder with delusions.

The Minimum Data Set (MDS) Admission assessment with assessment reference date of [DATE REDACTED] revealed resident #1 had a Brief Interview for Mental Status score of ,d+[DATE REDACTED] which indicated he had severe cognitive impairment. The assessment indicated he received antipsychotic, antianxiety, antidepressant, and antibiotic medications.

Review of the medical record revealed resident #1 had a physician order for an electronic wander monitoring bracelet to be applied beginning [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 Review of resident #1's medical record revealed he had a care plan for potential for elopement related to his behaviors such as wandering, ambulatory, has confusion, and exit seeking initiated on [DATE REDACTED]. The goal Level of Harm - Immediate described the resident would remain safe and would refrain from leaving the facility unsupervised was jeopardy to resident health or initiated on [DATE REDACTED] and revised on [DATE REDACTED]. Interventions included enhanced supervision, initiated on [DATE REDACTED], safety provide redirection when observed going towards exit doors, also initiated on [DATE REDACTED]. A revision was added to the care plan on [DATE REDACTED] which indicated resident #1 had eloped from building. Residents Affected - Few

On [DATE REDACTED] at 1:05 PM, the Administrator shared a video from his cell phone recorded on [DATE REDACTED] from the facility's video monitoring system. The video which started at approximately 6:05 PM, showed a visitor paused at the door, while the weekend supervisor used a remote control to open the front door to exit the facility. The visitor pushed the door handle and opened the front door exiting the facility lobby. Six seconds later resident #1 went out the door after the resident. The weekend supervisor was seen seated at the receptionist desk with her head down, on the computer, totally unaware of resident #1 tailgating behind the visitor she had let out moments before. The video then showed resident #1 returning to the facility at 6:49 PM. The Administrator stated the video camera was positioned above the receptionist desk, and ran on a loop, so he had recorded the video portion of resident #1 leaving the facility on his phone but had no other

record of his actions from that day.

On [DATE REDACTED] at 11:48 AM, the Weekend Supervisor stated the receptionist hours were Monday- Friday 8 AM-8 PM and Saturday and Sunday from 8 AM-5 PM. The Weekend Supervisor stated she worked most weekends and confirmed she was the supervisor in charge [DATE REDACTED], the day resident #1 eloped. She stated

she had been sitting at the receptionist desk charting assessments after the receptionist left the facility. She said she saw the visitor approach and pushed the button on the remote to unlock the door to let her out. She stated she did not see resident #1 follow behind the visitor. The supervisor explained how she had opened

the door from where she was seated at the desk using the remote without having to actually get up from her position. She explained no one at the facility knew resident #1 was missing until she received a phone call from off duty Licensed Practical Nurse (LPN) G at 6:35 PM, who asked if [name of resident #1] was a resident at the facility.

On [DATE REDACTED] at 2:26 PM, LPN G said she worked the day shift at the facility on [DATE REDACTED] then later that evening

she went to pick up food at a restaurant not far from the facility with her husband. She explained as they left

the parking lot, she noticed an older gentleman walking down the street who kept looking behind him as if he needed a ride or was looking for someone to pick him up. She stated the man was headed east on the sidewalk along the highway, across the intersection from where she had been parked. LPN G recounted it looked like the man had an electronic wander monitor bracelet on his leg and she asked her husband to make a U-turn so she could get a closer look. She explained they caught up with him further down the road

in front of another store, so they pulled to the side of the road, and she got out of the car. She asked the gentleman if he needed a ride and where he was going. To which he replied, yes and he was going to the base. LPN G stated she did not know him, so she asked him his name, which sounded familiar. She instructed him to sit in the shade and she called her supervisor at the facility to check to see if the man was ours. Around that time a sheriff's officer pulled up and asked resident #1 where he lived, and she told him he was from the facility and a supervisor was on the way to get him. LPN G said she stayed with him until the Weekend Supervisor and another staff arrived at her location. She explained resident #1 did not recognize her but when the supervisor came, it appeared he recognized her. The supervisor got out of her car and talked to him, then he walked to the car with her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 On [DATE REDACTED] at approximately 7:25 PM and on [DATE REDACTED] at 9:18 AM, the likely route was toured by car and by foot (see photo evidence). Per interview the resident left his room on the 200 hall and walked toward the Level of Harm - Immediate front of the building to the lobby approximately 267 feet away. From there he exited the building through the jeopardy to resident health or front door and likely walked approximately 298 feet through the parking lot down a short drive to the sidewalk safety adjacent to a minimally busy two-lane road. On the short road adjacent the parking lot there were two open retention ponds directly across from the facility. At the sidewalk he would have turned right and walked .3 Residents Affected - Few miles over uneven pavement passing multiple business entrances to where that road intersected a moderately trafficked four lane road and turned left. He continued another 0.4 miles on the moderately trafficked road passing five business entrances, the driveway for a fire station and four unsecured retention ponds. At this point there was a large intersection with busy restaurants/convenience store on three of the four corners of the intersection. Resident #1 then turned left onto the highway which was 6 lanes across at that point with traffic coming from the nearby interstate and busy shopping area a short distance away. He walked another 0.1 miles before he was stopped by LPN G and her husband at the jewelry store.

On [DATE REDACTED] at 3:20 PM, LPN B stated she was familiar with resident #1. She said she went with the Weekend Supervisor to pick him up the day he eloped. The LPN stated she went along with the supervisor to retrieve resident #1 from where LPN G found him in case she needed assistance with him due to possible behavior. LPN B said, He was sitting on the sidewalk on the curb with a police officer talking to him near the jewelry store. She stated when she got out of the car resident #1 was apologetic and said he knew he did something

he should not have. The LPN said resident #1 could not recall when or why he left. She said he told her he drove himself from the facility in a car.

On [DATE REDACTED] at 3:53 PM, via telephone, Certified Nursing Assistant (CNA) C stated she worked a double shift from 3 PM to 7 AM on the day resident #1 eloped. She recalled he had wandered around that day, asking questions about every 10 minutes like, when he was going to leave? and could he go home? She said resident #1 packed his bags about an hour and a half into her shift and asked her why his wife had left him there. She recounted all the staff knew of his behaviors that day, and they needed to frequently redirect him.

She expressed that everyone knew he had increased behaviors and had been hard to redirect that day. CNA C said she let the other staff, and his nurse know what he was doing so they could redirect him. She said he asked her where [the name of the city where he used to live] was. CNA C explained the Weekend Supervisor called her around 5:00 PM and asked her to come get resident #1 from the front. CNA C explained that resident #1 was sitting next to the supervisor at the front desk, with his bag and a picture of his wife in his hand when she arrived. The CNA said the supervisor asked her to take him back to his unit and keep him distracted until dinner. CNA C said she took resident #1 back to the nurse's station but shortly after the dinner trays arrived and the CNAs had to deliver them to the residents. CNA C stated she left resident #1 and went to deliver the trays and did not see him again until he was returned to the facility with the Weekend Supervisor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 On [DATE REDACTED] at 4:35 PM, LPN D stated she was assigned to care for resident #1 frequently. She recalled he was very forgetful, and staff had to remind him over and over where he was. The LPN stated she would call Level of Harm - Immediate his wife for him; he would talk to her and only a few minutes later he would already forget that he had just jeopardy to resident health or talked to her. She said, He was physically independent but very forgetful, only oriented to himself. LPN D safety stated resident #1 was eating in his room when she went to give him his medications around 5:30 PM. She said resident #1 had come to the nurse's station earlier and asked her to call his wife, but she told him she Residents Affected - Few would call her later. He came back asking for her to call his wife again. LPN D said when she gave him his medications, she promised him she would call his wife before he went to bed, and he said okay. She explained resident #1 usually walked around the building, but she did not see him that night after she gave him his medications. LPN D stated another staff told her resident #1 had left the building, but they were not sure how he got out. She said when resident #1 returned to the facility, she asked him how he got out of the building and he said, I was very careful. The LPN said he then asked her if he was going to get in trouble.

On [DATE REDACTED] at 5:21 PM, in a second interview, the Weekend Supervisor said, When [resident #1] was talking to me before the elopement, he had a picture of his wife, but I do not recall him having a bag. She said she had seen the picture in his room but did not recall seeing him carry it around with him in the past. The supervisor stated she let him sit with her and talk a little bit because she knew he was an elopement risk, and

it would give him a change of scenery. She stated if she knew he was exit seeking she would have put him

on one-to-one supervision. She acknowledged it was not likely he would have eloped if he had more supervision such as one to one. She stated she had not been aware his behavior was different that day.

Review of resident #1's medical record revealed limited nursing progress notes describing resident #1's behaviors until a week before his elopement. These progress notes revealed escalating exit seeking behaviors in the week preceding the elopement. A nursing progress note dated [DATE REDACTED], read, The resident removed the electronic wander monitoring bracelet on his right ankle. The bracelet was located [in] the trash can in his room. New bracelet applied on the left ankle. A nursing progress note the next day, [DATE REDACTED] documented the resident was wandering up and down the unit, packed his belonging and told others he was going home. The nurse charted she notified the charge nurse and the as needed anti-anxiety medication was given. On the day he eloped, [DATE REDACTED], the nurse documented the resident's behavior remained unchanged.

He continued to wandering the unit, and she noted resident #1, constantly needs to be redirected without success. The nurse indicated resident #1 was again medicated for anxiety.

Review of the Medication Administration Record (MAR) dated for [DATE REDACTED] revealed resident #1 had an as needed (prn) order for anti-anxiety medication every 8 hours for restlessness/agitation that was in effect for 14 days starting on [DATE REDACTED]. The resident received the medication one time on [DATE REDACTED], once on [DATE REDACTED] and again once on [DATE REDACTED]. The order was not renewed, and it was discontinued after the 14 days were completed. On [DATE REDACTED], the day after resident #1 cut off his electronic wander monitoring bracelet the nurse noted in the progress notes he was wandering up and down the unit and an anti-anxiety prn medication was given. A renewal order for the same as needed anti-anxiety medication every 8 hours for restlessness/agitation was documented as restarted in the record. Over the course of the week before the elopement resident #1 received one dose of the as needed anti-anxiety medication on [DATE REDACTED], two doses on [DATE REDACTED], a dose on [DATE REDACTED], a dose on [DATE REDACTED] and another dose on [DATE REDACTED] both prior to and after the elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 On [DATE REDACTED] at 1:58 PM, the 200 Unit Manager (UM) acknowledged the prn anti-anxiety medication was restarted on [DATE REDACTED] after resident #1 cut his electronic wander monitoring bracelet off the previous day. She Level of Harm - Immediate was asked why resident #1 did not have additional interventions added to his care plan when this occurred, jeopardy to resident health or and his behaviors escalated the days prior to the elopement. The UM could not answer but acknowledged safety again the resident took his wander monitoring bracelet off on Sunday [DATE REDACTED] and placed it in the garbage.

She continued the bracelet was replaced on the other limb. The UM said she was notified of the incident Residents Affected - Few when she came to work on Monday.

In a telephone interview on [DATE REDACTED] at 3:33 PM, resident #1's wife stated she was notified by staff of her husband's elopement on [DATE REDACTED] around 9:00 PM after he was returned to the facility. She said, I was kind of upset because he had a bracelet on his leg, and he still got out. She said they told her the wander monitoring bracelet was put on her husband so he would not leave the facility. Resident #1's wife stated her husband has Alzheimer's Dementia. She said the day he got out of the nursing home their son who lived in another state came to visit her husband. She stated they brought her husband lunch and were able to eat with him.

She wondered if it triggered her husband when they left the facility after lunch, because he had seen his son earlier that day and had been told he was only visiting for the day. She cried and said, My heart almost fell out of my chest when they said he was on [highway name] when they found him. Resident #1's wife said it was very scary to think about what could have happened since he walked that far away and was on that busy road alone.

Review of the facility's corrective actions were verified by the survey team and included the following:

* On [DATE REDACTED], Resident #1 was returned to the facility and re-evaluated by licensed nurse. Full body assessment of resident completed. One to one supervision initiated. Physician and resident representative notified on event.

* On [DATE REDACTED], the facility filed an immediate federal report related to allegation of neglect of resident #1 to Agency for Healthcare Administration, notified Department of Children and Families and initiated a full investigation. Physician and resident representative notified.

* On [DATE REDACTED], the Elopement Risk Alert Binder was reviewed to ensure resident's picture and demographics were in place. Plan of care and Kardex reviewed to ensure accuracy of resident's current condition. Increased monitoring related to exit seeking behaviors verified in place.

* On [DATE REDACTED], Risk Evaluation related to elopement was conducted for resident #1.

* On [DATE REDACTED], Facility conducted head count of residents currently residing in the facility; all were accounted for and safe.

* On [DATE REDACTED], Doors were assessed by Administrator and Maintenance Director to ensure proper functioning; no issues or concerns were identified. It was identified through Root Cause Analysis (RCA) process that the electronic wander monitoring alarm is deactivated during the remote door opener activation to allow visitors out. Systemic changes listed below to prevent occurrence.

* By [DATE REDACTED], Residents residing in the facility were re-evaluated/reviewed for elopement risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 * By [DATE REDACTED], Residents identified at risk for elopement were reviewed by Unit Managers/designee for: Elopement Screen, Care plan in place related to wandering risk, CNAs Kardex reflective of resident status Level of Harm - Immediate and Resident(s) present in Elopement Binder. jeopardy to resident health or safety * On [DATE REDACTED], the Director of Nursing (DON) /designee reviewed elopement binders to ensure residents at risk for elopement were present and identified. Residents Affected - Few * On [DATE REDACTED], Resident #1 was evaluated by psychiatry.

* On [DATE REDACTED], DON/designee educated staff on:

a. Components of the regulation:

F-F689

b. Elopement Policy and Procedure

c. 1:1 supervision

d. Door/Egress checks

e. Responding to an alarm

f. Response to a missing resident

g. Elopement Triggers

h. Proactive interventions for residents at risk for wandering/elopement

i. In an abundance of caution, abuse and neglect education completed.

* On [DATE REDACTED], DON/designee carried out elopement drills. Education provided as indicated based on Elopement Drill findings. The facility has completed 35 elopement drills that includes 185 staff members out of 186 (the staff member not included is out of the State).

* By [DATE REDACTED], ,d+[DATE REDACTED] facility staff members were re-educated.

* By [DATE REDACTED], ,d+[DATE REDACTED] facility staff members were re-educated, no staff worked without receiving in-person education. Newly hired employees will receive education on above in orientation.

* On [DATE REDACTED], the facility removed the automatic door opener.

* On [DATE REDACTED], the facility adjusted the alarm delay from 15 seconds to 5 seconds to prevent tailgating.

* Beginning [DATE REDACTED], the facility Administrator/designee/DON/designee will ensure that the safety and well-being as it relates to elopement is maintained by continued participation, evaluation, and intervention through:

a. Clinical standup review of the 24-hour report to identify change in condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 105885 Department of Health & Human Services Printed: 09/16/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105885 B. Wing 08/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Healthcare and Rehabilitation Center 8050 Spyglass Hill Rd Viera, FL 32940

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)

F 0689 b. Monitoring of egress systemic changes

Level of Harm - Immediate c. Maintaining QAPI process. jeopardy to resident health or safety * On [DATE REDACTED], anti-tailgate device was added to the front door along with antennae moved to improve field of frequency. Residents Affected - Few From [DATE REDACTED] to [DATE REDACTED], interviews were conducted with 28 staff members who represented all shifts. Staff included 8 CNAs,8 LPNs, 4 RNs, 2 Housekeepers, 1 Receptionist, 1 MDS Coordinator, 2 Dietary personnel, 1 Maintenance Director, and 1 Physical Therapy Assistant who verbalized their understanding of the education provided.

The resident sample was expanded to include all eight residents identified as at risk for elopement currently

in the facility. Interviews with three alert and oriented residents regarding interviews conducted by facility staff regarding feeling safe and no neglect and chart reviews for the other 8 residents to ensure elopement risk evaluations and skin checks were completed on [DATE REDACTED]. Observations, interviews, and record reviews revealed no concerns related to Elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 105885