Every finding on record at Biscayne Health and Rehabilitation Center

Based on observations, record reviews and interviews, the facility did not maintain an environment free of accident hazards on one (second floor) of two floors. As evidenced by shaving razors observed in Resident #29's room. Staff disposed of lancets in the regular trash and left a housekeeping cart with germicidal wipes unattended and easily accessible. There were 94 residents residing in the facility at the time of the survey. The findings included. 1) An observation on 05/11/2026 at 10:47 AM revealed a shaving razor on the sink in resident #29's. Staff E, Licensed Practical Nurse (LPN) was made aware and entered the room and removed the razor from the sink. At that time, Resident # 29 entered the room and Staff E, LPN asked the resident if the razor belonged to him and Resident # 29 stated: That is not my razor. I keep my razors in the nightstand. At that time, the resident showed the surveyor and Staff E, LPN the shaving razors he kept in the nightstand (Photographic evidence). Staff E, LPN then exited the room.On 05/11/2026 at 10:50 AM, the surveyor asked Staff E, Licensed Practical Nurse if residents were allowed to keep shaving razors in the room unattended. Staff E, LPN responded, No, and went back to Resident # 29's room and retrieved the razors.Review of Resident # 29's clinical records revealed the resident was admitted on [DATE] with diagnosis that included Malignant Neoplasm of overlapping sites of bladder.Record review of Resident # 29's Quarterly Minimum Data Set reference dated 02/18/2026 revealed Resident # 29 had a Brief Interview of Mental status score of 15 out of 15 which indicated the resident had no cognitive impairment.Review of Resident # 29's care plans, initiated on 09/16/2024 and revised on 06/13/2025 for Activities of Daily Living (ADL), indicated the resident had self-care deficits associated with activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria. The interventions included encouraging and assisting the resident with all ADL tasks as appropriate and tolerated, such as bathing, personal hygiene, and oral care. On 05/11/2026 at 1:47 PM, the Assistant Director of Nursing (ADON) was asked about the facility's policy related to shaving razors and the ADON stated, We do not allow residents to keep shaving razors in their rooms for safety purposes.On 05/14/2026 at 11:54 AM the Administrator/Risk Manager stated, I review safety protocols and interventions. Residents are not allowed to keep the shaving razors in the rooms and staff are to keep the razor in the supply room.On 05/14/2026 at 3:48 PM, the Director of Nursing stated: Residents cannot keep shaving razors in rooms. 2) On 05/11/2026 at 11:09 AM, a blood glucose check was conducted by Staff E, LPN, for Resident #4. Upon completion of the procedure, Staff E, LPN discarded the unused lancets in the medication cart trash (Photographic evidence).On 05/11/2026 at 11:40 AM Staff E, LPN was asked about the facility's policy and procedure regarding the proper disposal of unused lancets; Staff E stated: Lancets are to be disposed of into the sharp resistant container for safety purposes. Staff E did not respond when asked why the lancets were disposed of into regular trash.On 05/11/2026 at 5:42 PM the Director of Nursing (DON) stated, Nurses are expected to dispose of used and unused sharps into the sharps container for safety purposes. 3) During an observation conducted on 05/11/2026 at 11:39 AM on the facility's second floor, it was noted that the unattended housekeeping cart located on the west side had a container of germicidal wipes placed atop the cart, with easy access (Photo evidence).On 05/13/ 2026, at 9:45 AM, a follow-up observation on the facility's second floor revealed a container of germicidal wipes was left unattended on top of the housekeeping cart on the west side hallway. (Photo evidence)On 05/11/2026 at 3:47 PM the Corporate Housekeeping staff and the facility's Housekeeping Director revealed the facility has four housekeeping carts and everything related to chemicals that could harm the resident should be locked in the compartment on the cart and the housekeeping and the housekeeping staff have the key. On 05/13/2026 at 9:50 AM, the Housekeeping Director and the Assistant Director of Nursing were made aware of the identified concerns and acknowledged the wipes should not be kept unattended on top of the cart.On 5/13/26 at 1:09 PM Staff G, housekeeping staff stated, I keep disinfectant wipes and cleaning supplies locked in the cart for the safety of residents. Record review of the facility's policy titled, Nursing Home Accident Prevention and Safety Policy Effective Date: August 1, 2021, Review Date: January 3, 2026, revealed: PurposeThe purpose of this policy is to establish procedures that promote a safe environment for residents, staff, visitors, and contractors within the nursing home. This policy aims to prevent accidents, reduce injuries, ensure prompt response to emergencies, and maintain compliance with federal, state, and local safety regulations.Policy Statement:The nursing facility is committed to: Maintaining a safe and hazard-free environment.Preventing accidents and injuries. Identifying and correcting safety risks promptly.Providing staff education and training on safety practices. Ensuring timely reporting and investigation of incidents. Promoting resident rights, dignity, and well-being. All staff members are responsible for complying with safety procedures and reporting on unsafe conditions immediately.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F0761; failed to properly store medications. There were 94 residents residing in the facility at the time of survey. The findings included:Record reviews of the facility's survey history revealed the facility was cited F 0761 during the recertification and Re-licensure survey with an exit date of October 31, 2024. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/10/2026, 03/10/2026 and 04/14/2026 revealed the facility had a QAA Committee meeting monthly and attendees included: Administrator, Director of Nursing (DON), Medical Director, and other department heads. Record review of the facility's Policy and Procedure titled, Quality Assurance and Performance Improvement Date Implemented: 9/1/2022 Date Reviewed/ Revised: 1/1/2026 revealed: Policy:It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.Policy Explanation and Compliance Guidelines: 2. The QA Committee shall be interdisciplinary and shall:Develop and implement appropriate plans of action to correct identified quality deficiencies. During an interview on 05/14/2026 at 4:50 PM the Administrator stated, The members include Medical Director, Nursing home administrator, other department heads and we invite direct care staff members. We meet monthly and as needed to assess ways to make improvements.The Administrator was informed of identified concerns related to repeated deficiencies and the Quality Assurance and Performance Improvement activities.

Based on observations, records reviewed and interviews the facility failed to document adequate information in the medical records for one (Resident # 62) out of two sampled residents with a pressure ulcer. Staff did not sign the Medication Administration Record for pain medication ordered before wound care on several dates in May 2026 for Resident # 62, even though wound care was provided on those days. Five residents with pressure ulcers lived in the facility at the time of the survey. The findings included. During observation on 05/13/2026 at 10:02 AM of Resident # 62's wound care being performed by the facility's Wound Care Nurse and Resident # 62 denied pain at that time.Record review of Resident # 62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to Peripheral Vascular Disease. Review of Resident # 62's care plans that started on 04/13/2026 and revised on 05/05/2026 for a pressure ulcer with interventions that included: Administer medications and treatments as ordered by the medical doctor.Record review of Resident #62's significant change Minimum Data Set reference dated 04/20/2026 revealed Resident # 62 had no cognitive impairment, required setup, clean up assistance for eating and oral hygiene, had a Stage 4 Pressure Ulcer, received scheduled pain medication regimen and had moderate occasional pain or hurting at any time in the last 5 days. Record review of Resident # 62's Physician's order sheet revealed orders dated 04/23/2026 for Tramadol HCl oral tablet 50 milligrams *Controlled Drug* give 1 tablet by mouth every day shift for pain 30 minutes before wound care. Review of the May 2026 Medication Administration Record revealed the Tramadol HCI oral tablet 50 mg 30 minutes before wound care order omitted signatures on: 05/02/2026, 05/03/2026, 05/09/2026, and 05/10/2026.Signatures with code 4 on the dates: 05/04/2026 to 05/06/2026 and 05/11/2026 indicated out of parameters signed by Staff E, Registered Nurse and no progress note was associated with these entries.Record review of the May 2026 Treatment Record revealed daily signatures for wound care on the day shift.During an interview on 05/13/2026 at 3:34 PM the Wound Care Nurse stated that Resident # 62 had an order for Tramadol pain medication prior to wound care and she checks the Medication Administration Record to ensure the medication was given. I do wound care for her daily Monday to Friday, and the floor nurse does it on the weekend.Staff E, Registered Nurse, was not present in facility nor available on 05/14/2026 for an interview.On 05/14/2026 at 3:45 PM, the Director of Nursing stated, The nursing staff are present during the care plan meeting to hear interventions. Nurses are to follow physician orders. If a resident refuses medication the nurse is to document that. Record review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol Revised April 2018, Reviewed January 2026 indicated: Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: b. Pain assessment .

Based on observations, record reviews, and interviews, the facility did not adhere to proper medication storage protocols on the second floor, as evidenced by medicated ointments observed in the rooms of Resident #58, Resident #20, and Resident #29. The findings include:1) Observation on 05/11/2026 at 9:07 AM revealed a container of Diclofenac ointment on top of the sink in Resident # 58's room (Photographic evidence).Review of Resident #58's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Heart Failure and had no cognitive impairment.2) Observation on 05/11/2026 at 9:39 AM and on 05/12/2026 at 11:06 AM a tube of Hydrophilic wound dressing was noted in a basket on Resident # 20's nightstand. (Photo evidence).Review of Resident # 20's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Cerebral infarction due to embolism of right middle cerebral artery and was severely cognitively impaired.3) Observation on 05/11/2026 at 10:54 AM revealed a container of Ciclopirox Topical solution on Resident # 29's nightstand. (Photo evidence).Review of Resident #29's clinical record revealed the resident was admitted on [DATE] with diagnosis that included: Malignant neoplasm of overlapping sites of bladder and had no cognitive impairment. Record review of the facility's policy titled, Storage of Medications revised January 2026 revealed Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.On 05/11/2026 at 11:18 AM Staff E, Licensed Practical Nurse (LPN) was made aware of the identified concerns. Staff E LPN stated: Medications and ointments are kept on the locked cart and not allowed at the bedside. Sometimes family brings them in. We do rounds and remove any ointment at the bedside. On 05/11/2026 at 12:16 PM, the Wound care nurse stated: I put all the creams, ointments, and medicated nail polish back into the treatment cart after providing treatment.On 05/11/2026 at 1:07 PM, Staff D, Certified Nursing Assistant stated: When I do rounds, I look to make sure the resident is safe. If I see any objects that can harm the residents like razors or a knife I remove them. If I see medications in the room, I tell the nurse. On 05/11/2026 at 1:25 PM the Assistant Director of Nursing was made aware of the identified concerns and stated: Residents are not allowed to keep any medications in the room. We keep all medications in the cart for the safety of residents.

Based on observations, interviews and record review the facility failed to provide pharmaceutical services to ensure the accurate administration and documenting of medications for 4 of 5 sampled residents reviewed for controlled medications (Resident #43, Resident # 51, Resident # 83 and Resident #35) and failed to ensure a discontinued controlled medication was removed from the med cart for 1 of 5 residents reviewed for controlled medications (Resident #51). The findings included: Review of the facility's policy titled, Administering Medications with a reviewed date of January 2024 included in part the following: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. As required or indicated for a medication, the individual administering the medication records in the resident's medial record: a. The date and time the medication was administered b. The dosage c. The route of administration Review of the facility's policy titled, Storage of Medications with a revised date of January 2024 included in part the following: 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the facility's policy titled, Preparation and General Guidelines- Controlled Substances: with a date of August 2019 included in part the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedures: A. The Director of Nursing and the consultant pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record). 1 Record review for Resident #51 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission to the facility on [DATE]. The diagnoses included in part the following: Type 2 Diabetes mellitus Without Complications and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #51 dated 08/15/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #51 revealed an order dated 07/23/24 for Alprazolam Tablet 0.25 MG give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 Days and was discontinued on 08/06/24. Review of the Medication Monitoring/Control Record for Alprazolam 0.25 mg Resident #51 from 08/26/24 to 10/09/24 documented the following: On 08/26/24 a dose of Alprazolam was documented as removed from the med cart On 10/09/24 a dose of Alprazolam was documented as removed from the med cart Review of the Medication Administration Record (MAR) for Resident #51 from 08/26/24 to 10/09/24 documented the following: There was no documentation of the medication Alprazolam 0.25 mg being administered. 2) Record review for Resident #43 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission to the facility on [DATE]. The diagnoses included in part the following: Chronic Obstructive Pulmonary Disease, Anxiety Disorder, and Dementia. Review of the MDS for Resident # 43 dated 10/10/24 documented in Section C for cognitive status indicated BIMS (Brief Interview for Mental Status) could not be conducted due to the resident is rare/never understood. Review of the Physician's Orders for Resident #43 revealed an order dated 09/02/24 for Clonazepam Oral Tablet 0.5 MG give 1 tablet by mouth two times a day related to Anxiety Disorder. Review of the Medication Monitoring/Control Record for Clonazepam 0.5 mg Resident #43 from 10/18/24 to 10/30/24 documented the following: On 10/18/24 the 5:00 PM dose had no documentation On 10/25/24 the 5:00 PM dose had no documentation On 10/27/24 the 5:00 PM dose was documented as removed from the med cart Review of the Medication Administration Record (MAR) for Resident #43 from 10/18/24 to 10/30/24 documented the following: On 10/18/24 the 5:00 PM dose of Clonazepam 0.5 mg was administered On 10/25/24 the 5:00 PM dose of Clonazepam 0.5 mg was administered On 10/27/24 the 5:00 PM dose of Clonazepam 0.5 mg was left blank 3 Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cervical Disk Disorder with Myopathy High Cervical Region and Spinal Stenosis Lumbar Region without Neurogenic Claudication. Review of the MDS for Resident #83 dated 10/11/24 documented in Section C with a BIMS score of 14 indicating a cognitive response. Review of the Physician's Orders for Resident #83 revealed an order dated 07/24/24 for Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) give 1 tablet by mouth every 8 hours as needed for pain. Review of the Medication Monitoring/Control Record for Oxycodone/Apap (Percocet) 5-325 mg Resident #83 from 08/13/24 to 10/30/24 documented the following: On 08/03/24 at 9:30 PM documented the medication was removed from the med cart On 08/04/24 at 9:00 PM documented the medication was removed from the med cart On 08/11/24 at 10:30 PM documented the medication was removed from the med cart On 08/17/24 at 10:15 PM documented the medication was removed from the med cart On 08/25/24 at 10:00 PM documented the medication was removed from the med cart On 09/08/24 at 10:00 (did not indicate AM or PM) documented the medication was removed from the med cart On 09/22/24 at 10:00 (did not indicate AM or PM) documented the medication was removed from the med cart Review of the Medication Administration Record (MAR) for Resident #83 from 08/13/24 to 10/30/24 documented the following: On 08/03/24 no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 08/04/24 had no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 08/11/24 no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 08/17/24 had no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 08/25/24 had no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 09/08/24 no documentation for Oxycodone/Apap (Percocet) 5-325 mg On 09/22/24 had no documentation for Oxycodone/Apap (Percocet) 5-325 mg 4. Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Primary Generalized (Osteo)Arthritis, Chronic Pain Syndrome, and Muscle Spasm of Back. Review of the MDS for Resident #35 dated 08/22/24 documented in Section C a BIMS score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #35 revealed an order dated 06/05/24 for Oxycodone-Acetaminophen Oral Tablet 10-325 MG (Oxycodone w/ Acetaminophen) give 1 tablet by mouth every 4 hours as needed for moderate-severe pain. Review of the Medication Monitoring/Control Record for Oxycodone/Apap 5-325 mg Resident #35 from 10/27/24 to 10/30/24 documented the following: On 10/27/24 at 9:00 PM documented the medication was removed from the med cart On 10/28/24 at 12:00 PM documented the medication was removed from the med cart On 10/29/24 at 5:00 PM documented the medication was removed from the med cart On 10/29/24 at 9:00 PM documented the medication was removed from the med cart Review of the Medication Administration Record (MAR) for Oxycodone/Apap 5-325 mg Resident #35 from 10/27/24 to 10/30/24 documented the following: On 10/27/24 at 9:00 PM no documentation of the medication was administered On 10/28/24 at 12:00 PM no documentation of the medication was administered On 10/29/24 at 5:00 PM no documentation of the medication was administered On 10/29/24 at 9:00 PM no documentation of the medication was administered During an interview conducted on 10/30/24 at 12:00 PM with Staff D Licensed Practical Nurse (LPN) who stated she has worked at the facility for 3 years. When asked about controlled medications removed to be administered to a resident, she said we document the medication being removed on the Control sheet (Medication Monitoring/Control Record) and then we document on the MAR for the resident. During an interview conducted on 10/30/24 at 1:00 PM with the Director of Nursing (DON) who stated she has worked at the facility since the middle of August 2024. When asked about the controlled medications she stated the nurse will sign the medication off on the paper log Medication Monitoring/Control Record) and the e-mar (Electronic Medication Administration Record) as well. When asked if a controlled medication is discontinued what happens to the controlled medication in the med cart, she stated the medication is removed from the cart by the nurse who took the order for the med to be discontinued. When asked if they audit the controlled medications on the med carts, she said they are audited every few days but do not keep any record of the audits being performed. When asked who is responsible for the audits, she said the DON (herself) is responsible and either she does the audits, or the pharmacists does. When asked if a discontinued medication was left in the med cart would be administered, she said no because there is no active order, the nurse would not be able to sign the medication off as administered in the e-mar. When asked about Resident #51 and the controlled medication Alprazolam 0.25 mg, she acknowledged she had signed the medication as removed from the cart on 10/09/24. She then acknowledged the medication was not documented as being administered on the MAR on 10/09/24. When asked why the medication was not documented as being administered, she stated sometimes the order is only for 14 days and then it is no longer on the MAR after that so she cannot document the medication as administered on the MAR. During an interview conducted on 10/30/24 at 1:50 PM with Staff F, Registered Nurse (RN) who was asked about controlled medications, she stated they document on the paper Medication Monitoring/Control Record) and on the computer (Medication Administration Record). When asked if a controlled medication is discontinued what happens to the medication, she stated they remove it from the med cart and give it to the DON to be returned to the pharmacy. When asked about the Alprazolam 0.25 mg for Resident #51 she acknowledged the medication was not documented as administered on 10/09/24 even though it was documented as being removed from the med cart on 10/09/24 on the Medication Monitoring/Control Record. The DON also acknowledged the medication Alprazolam 0.25 mg for Resident #51 was discontinued on 08/06/24.

Based on observations, interviews, and record review, the facility failed to properly secure dispensed medications left at the bedside for 1 of 1 resident (Resident #39). The facility also failed to ensure that 1 of 4 medications carts was locked and inaccessible to unauthorized staff and residents. The findings included: Review of the facility's policy titled, Administering Medications, dated January 2024, included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 21. The individual administering the medication initials the resident's Medical Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Review of the facility's policy titled, Storage of Medications, dated January 2024, included the following: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 9. Unlocked medication carts are not left unattended. 1)Record review for Resident #39 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Metabolic Encephalopathy, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #39 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. Review of the Physician's Orders showed that Resident #39 had an order dated 10/19/24 and the following medications were scheduled to be administered at 9:00 AM on 10/28/24: Aspirin 81 mg oral tablet chewable for Deep Vein Thrombosis (DVT) prophylaxis. Ascorbic Acid 500 mg oral tablet, give 1 tablet for supplement. Folic Acid 1 mg oral tablet for supplement. Carbamazepine Extended Release (ER) 300 mg oral capsule for Status Epilepticus. Metoprolol Tartrate 50 mg oral tablet for Hypertension (HTN). Ferrous Sulfate 325 mg oral tablet, Give 1 tablet for anemia. [NAME]-Vite (B-Complex w/ C & Folic Acid) oral tablet for supplement. Review of the October Medication Administration Record (MAR) documented that all the above medications were administered on 10/28/24 at 9:00 AM as scheduled. In addition, the nurse signed for all the medications indicating that Resident #39 did not refuse any medications. Review of the Care Plan dated 10/10/24 documented that Resident #39 does not have behaviors of refusing her medications nor is Resident #39 able to self-administer her medications. Record Review of the nursing progress notes revealed no documentation noting Resident #39 refusing medications. During an observation conducted on 10/28/24 at 9:51 AM noted Resident #39 in bed with the over-bed table in front of her. Further observation revealed on the over-bed table, 2 medication cups with pills, photographic evidence obtained. At this time, an interview was conducted with Resident #39 who stated those were her medications and the nurse had placed them there. During an interview conducted on 10/30/24 at 4:18 PM with the Assistant Director of Nursing (ADON), she stated she has been the ADON at the facility for 5 months. The ADON stated Resident #39 does take her time to take her medications, and the nurse was probably called away for something else. She stated she has educated the nursing staff to dispose of the medications if the resident is not ready to take their medications. The ADON acknowledged that the medications were left there by the nurse and not brought in by the resident's family. 41837 2 On 10/31/24 from 11:43 AM to 11:53 AM an observation was made of a med cart next to room [ROOM NUMBER] left unlocked and unattended with multiple residents, visitors and staff passing by the med cart. During an interview conducted on 10/30/24 at 11:54 AM with Staff D Licensed Practical Nurse (LPN) who stated she has worked at the facility for 3 years. She acknowledged she had left the med cart unlocked and unattended and stated she did not know how that happened.

Based on observations, interviews, and record review, the facility failed to follow fluid restriction orders for 1 of 1 resident on dialysis (Resident #16). The findings included: A chart review revealed that Resident #16 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Muscle Weakness, and Type 2 Diabetes. The Medicare 5-day Minimum Data Set, dated dated dated [DATE] showed that Resident #16 had a Brief Interview of Mental Status score of 15, which was cognitively intact. A review of the physician ' s orders showed the following: No added salt diet with 1,500 milliliters (ml) fluid restriction with 1080 ml allocated for dietary. Dietary 240 ml every Dinner meal, dietary 240 ml every Lunch, and 600 ml every Breakfast meal, which was dated 10/22/24. In an observation conducted on 10/28/24 at 11:00 AM, Resident #16 was noted in her room with 16 ounces of water in a Styrofoam cup near her bed on the side table. In an observation conducted on 10/28/24 at 12:20 PM, Resident #16 was observed eating her lunch meal with the following noted on the meal tray: 8 ounces of water and 4 ounces of juice. Closer observation showed 16 ounces of water in a Styrofoam cup near the lunch tray. This showed that 28 ounces of fluids (828 millimeters) were provided to Resident #16 and not the needed 240 ml of fluids for the lunch meal. The meal ticket showed Resident #16 was on 1500 ml fluid restriction with 8 ounces of water and no juice. In this observation, Resident #16 stated that she was on fluid restrictions but did not know how much per day or per meal and stated, I think I am allowed one cup of water. The Registered Dietitian Progress note dated 09/23/24 revealed that Resident #16 is non-compliant with the renal diet and fluid restriction. She remains resistant to education related to diet/fluid restriction compliance. The note further showed that the therapeutic diet with fluid restriction remains appropriate. The Care plan dated 09/11/24 revealed that Resident #16 was on fluid restrictions and is at risk for complications of hemodialysis and is receiving hemodialysis treatment within the house. An interview conducted on 10/30/24 at 10:20 AM with Staff E, Certified Nursing Assistants, stated that the facility ' s Dietitian would tell her which residents are on a fluid restriction. When asked if she has any residents on fluid restrictions that are assigned to her, she said yes and named Resident #16 ' s roommate but not Resident #16. When asked by this Surveyor if she was the one who gave Resident #16 the 16 ounces of the Styrofoam cup at the bedside, she said no and that it must have been the other nursing staff. An interview conducted on 10/30/24 at 2:00 PM with the Clinical Dietitian stated that the fluid restriction is listed on the diet orders in the electronic system. She further said it is also listed on the meal ticket when the trays arrive.

Based on observations, interviews, and record review, the facility failed to properly post signage for Enhanced Barrier Precautions (EBP) for a resident with a central line, failed to wear appropriate Personal Protection Equipment (PPE) during care of a central line, and failed to maintain the IV catheter tubing in a manner to prevent infection for 1 of 1 resident reviewed for central line receiving IV therapy (Resident #90). The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 04/01/24, included the following: Policy: It is the policy of this facility that Enhanced Barrier Precautions (EBP), . will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Procedures: EBP consists of the use of gowns and gloves for high-contact care activities which include but may not be limited to: Device care or use: central line . CDC recommends the use of EBP for the following residents: 1. All residents with an indwelling medical device such as a urinary catheter, central line, feeding tube, etc. regardless of colonization or infection status. Review of the facility's policy titled, Intravenous Administration of Fluids and Electrolytes, revised 2024, included the following: Purpose: The purpose of this procedure is to provide guidelines for the safe and aseptic administration of IV fluids and electrolytes for hydration. Steps in the Procedure 10. When infusion is complete: a. For intermittent therapy: (2) if tubing will be reused, replace sterile cap Record review for Resident #90 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Osteomyelitis with Draining Sinus, Right Ankle and Foot and Type 2 Diabetes Mellitus with other specified complications. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. Review of Section N of the same MDS revealed Resident #90 was on antibiotic. Review of the Physician's Orders showed that Resident #90 had an order dated 10/28/24 for Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl), use 166 ml/HR Chronic Osteomyelitis with Draining Sinus, Right Ankle and Foot for 16 days with end date: 11/13/24 (This is a re-order, Resident #39 has been on Vancomycin since admission to facility). Maintain Enhanced Barrier Precautions every shift for Midline, every shift, Active 10/29/24 (no order for EBP found prior to 10/29/24). Review of the Care Plan dated 10/22/24 documented that Resident #90 had IV access and is receiving IV antibiotic related to Chronic Osteomyelitis. The goals were for Resident #90 to complete IV Therapy without discomfort through the next review. The interventions included: Administer IV medication as ordered: Vancomycin HCl Intravenous Solution Reconstituted 750 mg. Review of the Care Plan dated 10/22/24 documented that Resident #90 requires Enhanced Barrier Precaution related to surgical wound, and IV. The goals were: Enhanced Barrier Precaution (EBP) will be maintained through the next review date. The interventions included: Educate resident, responsible party or caregivers regarding EBP. Follow infection control guidelines as indicated. Maintain EBP as indicated during dressing, bathing/showering, transferring. providing hygiene, changing linens, changing briefs or assisting with toileting, IV site care, during wound care. Record review of the admissions note dated 10/06/24 revealed Resident #90 had a central line for Vancomycin IV in her right inner arm. During the initial tour conducted on 10/28/24 10:57 AM noted there was no EBP sign outside of Resident #90's room, photographic evidence obtained. Further observation revealed that Resident #90 was receiving IV therapy. During an observation on 10/28/24 at 3:14 PM of Resident #90's room conducted by 2 surveyors and observed the IV medication tubing wrapped around the IV pole without any sterile cap at end of IV tubing, photographic evidence obtained. While surveyors were still in the room, Staff D, Licensed Practical Nurse (LPN) came into Resident #90's room to flush the central line catheter and attach the IV medication tubing to continue medication administration. She entered the room with normal saline syringe and alcohol wipes, performed hand hygiene, and donned gloves, however she did not don a gown. Staff D cleaned the central line catheter with the alcohol wipe in a circle-like motion (not the tip of the catheter) and flushed the line, then attached the uncapped IV tubing to the central line catheter and started the medication. During an interview conducted on 10/29/24 at 3:41 PM with Staff A, Certified Nursing Assistant (CNA), who stated she has worked at the facility since 2020. She stated she usually works on the 2nd floor. Staff A noted that if there is an EBP sign on the outside of the resident's room, the resident has either a tube feeding, under dialysis, or has a wound. She acknowledged that with these residents she will need to don on PPE if she is providing care. During an interview conducted on 10/29/24 at 4:13 PM with Staff B, CNA stated she has been working at the facility for [AGE] years. She acknowledged when the EBP sign is at a resident's door, she must don on PPE while providing care. During an interview conducted on 10/29/24 at 3:56 PM with Staff C, LPN, she noted working at the facility for 4 years. She stated that for residents under EBP, she will need to don on gown and gloves. During an interview conducted on 10/30/24 at 4:18 PM with the Assistant Director of Nursing (ADON), who has worked at the facility as the ADON for 5 months. She stated that she is the facility's infection Preventionist and responsible for posting signage for residents under any precaution or isolation. She acknowledged not having a sign for Resident #90 since she has a central line and donning of PPE should be done prior to care to resident with an IV port. During an interview conducted on 10/30/24 at 3:41 PM with the Director of Nursing (DON), who has worked at the facility for over 2 months. She acknowledged that the nurse should have worn a gown while providing IV care for Resident #90.

Based on observation, interview, and record review, it was determined that the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety that include; ensure the department is free of pest, ensure that hot and cold foods are held at regulatory temperatures, ensure that equipment is cleaned and maintained on a regular basis, and ensure that dietary staff facial hair is properly covered as per regulation. The findings included: 1) During the initial kitchen/food service observation tour conducted on 07/24/23 at 9:00 AM and accompanied with the facility's Food Service (FSD), the following were noted: (a) Flying insects were noted to be observed in the food preparation/tray line serving area, the food storage room, and the main dining room. Flying insects were noted to be landing directly on clean food preparation surfaces, and containers of prepared foods. Dietary staff were observed to be swatting at the flying insects. Four flying insects were observed in the food preparation/serving area. The FSD stated, that there has been fly issues lately in the kitchen, but the issue had not been reported to administration. The FSD reported, she did not know were the flies were entering, but possibly from the kitchen delivery entrance. An observation of the delivery entrance was completed and there was an installed air-curtain to stop the entrance of insects however, the unit was noted to be old and a very small air stream was being forced from the unit and did not cover the entire entrance for the prevention of insect entrance. (b) Observation of the Convection Ovens (#1 and #2) revealed, both to be heavily soiled and with a heavy build-up of black carbon matter. The FSD confirmed, the surveyors observation and stated that the ovens were not being cleaned weekly according to the equipment cleaning schedule. It was also discussed that potential carbon ingestion by resident's could result in a food borne illness. (c) Observation conducted of the Reach -in Refrigerator #1 noted that the exteriors of the 8 food storage shelves located within the unit were peeling plastic and paint. The FSD confirmed, the surveyors findings and stated that new shelves would be ordered. It was discussed with the FSD that small pieces of plastic and rust could potentially fall into foods being stored within the unit and result in a resident food borne illness. 2) During a second kitchen/food service tour conducted on 07/25/23 at 7:20 AM the following was observed: (d) Flying insects (3) were again noted to be observed in the food production/serving area. The insects were noted to be landing on the clean food preparation and serving surfaces and prepared foods. The FSD reported, the pest control company was contacted concerning the kitchen pest issues on 07/24/23. (e) Temperatures of the hot and cold foods located on the tray line with the use of the facility's calibrated food bayonet thermometer. The temperatures test noted that hot foods were not being held at a minimum of 135 degrees Fahreinheit (F) and cold foods were not being held at the regulatory requirement of a minimum 41 degrees F. The food temperatures were recorded as follows: Individual Sausage Patties = 120 degrees F Pancakes = 90 degrees F Whole Milk (8 once cartons) = 59 degrees F Fruit Juice (4 ounce portions) = 51 degrees F (f) During the observation it was noted that a dietary [NAME] with facial hair was without a proper covering. The [NAME] was observed to be working in the food preparation/serving areas and dish machine areas without a covering. The FSD stated, that the kitchen did not have beard coverings in supply. It was discussed that Staff B, the Diet Aide, that facial hair could potentially fall into foods while working in the food preparation/serving areas. 3) During the observation of the first and second floor pantry rooms conducted on 07/26/24 at 1:30 PM, and accompanied with the Director of Nursing the following was observed: (g) First Floor Pantry Room: The refrigerator gaskets were noted to have a heavy build-up of black mold type matter, the rooms floor was heavily soiled and stained and appeared it was not cleaned on a regular basis, and the cupboard drawers (2) were heavily soiled and full of soiled disposable plates, cups, and lids. (h) Second Floor Pantry Room: The refrigerator gaskets were soiled and there was a buildup of black mold type matter, and the rooms floor was heavily soiled and stained. * Photographic evidence obtained

Based on observation, interview, and record review, it was determined that foods were not prepared by methods that conserve nutritive value, flavor, and appearance for 4 (#53, #56, #64, and #391) out of 19 residents with physician ordered Pureed diets. The findings included: 1) During the initial kitchen/food service observational tour on 7/24/2023 at 9:00AM, a 1/3 pan of pureed vegetables dated 07/23/23 was located in the walk-in refrigerator. During the initial tour the breakfast/lunch cook, (Staff A) was interviewed and it was reported, the pan was pureed green beans that had been fully cooked and pureed on 07/23/23 and were intended to be served for the lunch meal of 07/24/23. Observation of the green beans revealed them to be thoroughly cooked, pureed and lacked a bright green color. Staff A further stated, all pureed vegetables are regularly cooked and pureed over 24 hours ahead of the intended meal. The surveyor discussed with Staff and the Food Service Director (FSD) that the vegetables were fully cooked and would be heated and held at high temperature prior to serving on 07/24/23. It was also discussed that prolonged cooking and heating results in a loss of nutrient content as well as appearance and palpability. It was also discussed that resident's with physician ordered Pureed diet are often at nutritional risk. Staff A reported, she is a recent hire and has not been trained and didn't have knowledge of the preparation of pureed foods. Review of the facility's Diet Census for 07/24/23 revealed, there were currently 19 resident's with a physician ordered Pureed Diet. Resident's #53, #56, #64, and #391 were included in the sample of the 19 residents. 2) During the review of the approved menu for the breakfast meal of 07/25/23 , it was noted that 4 ounces (#8 Scoop) of Pureed Pancakes was to be served to residents with a physician ordered Pureed Diet. Observation of the breakfast meal in the main kitchen on 07/25/23 at 7:15 AM revealed, that a 3 ounce (#10) scoop was being utilized as a standard serving of the pureed pancake. The FSD confirmed the surveyors observation and stated that the cook (Staff A ) was using the incorrect serving utensil. Review of the facility's Diet Census for 07/24/23 noted that there were currently 19 resident's with physician ordered Pureed Diet. Resident's #53, #56, #64, and #391 were included in the sample of the 19 residents. 3) A review of the clinical rerecords of sampled Resident's #53, 56, #64, and #391 revealed, all resident were at nutritional risk , underweight, or malnourished as evidenced by the following: Resident #53 Date Of Admission: 6/30/23 Diagnoses: Protein/Calorie Malnutrition Physician's Orders: Pureed Diet with Nectar Thick Liquids Weight History: 7/25/23 = 57 # 7/14/23 = 60# 7/1/23 = 64 # Body Mass Index (BMI) = 9.2 (Severely Malnurished) Ht = 66 Resident #56 Date Of Admission: 6/23/23 Diagnoses: Protein/Calorie Malnutrition/ Diabetes Type 2 Physicians Order: Pureed /NAS/CCHO (No added Salt/Consistent Controlled Carbohydrate Diet) Weight History: 7/20/23 = 145 # (Risk For Malnutrition) BMI= 26.5 Resident #64 Date Of Admission: 3/21/23 Diagnoses: Protein/Calorie Malnutrition Physician's Orders: Pureed Diet Weight History: 7/25/23 = 108# 6/9/23 = 109 3/23/23 = 110 BMI = 18 (Underweight/Malnutrition) Ht = 65 Resident #391 Date Of Admission: 1/19/23 Diagnoses: Protein/Calorie Malnutrition, Diabetes Type 2 Physician's Orders Pureed Diet with Nectar Thick Liquids Weight History: 7/24/23 = 137 6/9/23 = 153 3/1/23 = 156 1/20/23 = 172 BMI = 21.5 - Risk For Malnutrition Ht = 67

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the first and second floor resident rooms, dialysis treatment room, and nursing storage closets and affected one out of 28 sampled residents (Resident #141). The findings included: Review of the facility's policy's and procedures noted the following: Policy and Procedure on Environmental Services dated 09/01/2021 revealed: INTENT: It is the policy of the facility to provide Environmental Services accordance to State and Federal regulations. PROCEDURE: 1. The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 2. The facility will provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or or her personal belongings to the extent possible. 3. The facility will provide: a. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; c. Furniture, such as a bed-side cabinet, drawer space; During the Environmental Tour conducted on 07/26/23 at 1:15 PM and 07/28/23 at 1:15 PM, accompanied with the [NAME] President of Environmental Services, the Maintenance Directors and Director of Nursing (DON) the following findings were revealed: 1) First Floor: Room#101- The exterior of the nightstand had sharp edges (X2), a very strong urine odor coming out from the bathroom, and wires on the floor around Bed A. Room#102- The exterior of the resident room chair was noted to be heavily worn, and the bathroom floor was heavily stained throughout. Room#103- There was a small hole on the floor between the closet doors, the exterior of the nightstand had exposed sharp edges (X2), and the bathroom ceiling appeared to have water damage. Room#104- The exterior of the nightstand had exposed sharp edges (X2). Room#105 -The exterior of the nightstand had exposed sharp edges (X2), the window blinds did not work and there were 3 slats missing. The exterior of the overbed tables were is disrepair and had exposed sharp edges. Room#106- The exteriors of the nightstand had sharp edges (X2), and tiles at the entrance of the room were broken and were a trip hazard. Room#107 -The exterior of the nightstand had sharp edges (X2), the light cover located over the room sink was missing, and the doorstop needed to be removed due to it being a trip hazard. Room#109 -The exterior of the nightstand had exposed sharp edges (X2). Room#110 -The exterior of the nightstands had exposed sharp edges (X2), and bathroom light was missing one light bulb out of two. Room#111- The exterior of the nightstand had sharp edges (X2), the bathroom door handle was loose, and the bathroom ceiling appeared to have water damage. Room#115 -The exterior of the nightstands had exposed sharp edges (X2), and the bathroom floor was heavily soiled and stained. Room#116 -The exterior of the nightstands had exposed sharp edges (X2), the bathroom entry/exterior door had areas of peeling paint, and bathroom floor was in disrepair with heavy areas of peeling paint. Room#118 The floor in the room was dirty, the sink had stains, the exterior of the nightstand had sharp edges (X2), and the paint on the walls was peeling. Room#120 -The exterior of the nightstands had exposed sharp edges (X2), the toilet seat was falling off the commode, the blinds were missing from the window, the bathroom floor was in disrepair and there were numerous areas of peeling paint. Room#121- The exterior of the nightstands had exposed sharp edges (X2), the bathroom floor was in disrepair with numerous areas of peeling paint , and the ceiling air conditioner vent was in need of re-painting. The First Floor Nurses Station had numerous hazardous chemicals stored without being secured that included: 1070-ml sterile water, Floor Care/maintenance of finished floor, Chemtron-Hand cleanser and sanitizer, Glass cleaner, Cleaner and Disinfectant, Glove-Free no boil-Fryer cleaner. The First Floor Nursing Storage Closet- The room was noted to be unlocked and not secured with supplies that included: Vitamin A&D Ointment, disposable razor packs, Nebulizer mask and kit, hair brushes, tooth paste, and oral care swabs. 2) Second Floor: Room#201- The bathroom floor was in disrepair with numerous areas of peeling paint. Room#202- The bathroom walls were heavily soiled, there was peeling paint, the bathroom toilet required re-caulking to the floor, and the exterior of the room chair was heavily worn. Room#203- The room base boards required re-painting, and te shower room floor was in disrepair with numerous areas of peeling paint. Room#205- The bathroom floor was in disrepair with numerous areas of peeling paint, the room base boards required re-painting, and the room floor was noted to have large black stains. Room#206- The bathroom floor had areas of peeling paint, the shower room floor was heavily soiled and stained, and exteriors of overbed table had exposed sharp edges (X2). Room#207- The night stands (X2) had exposed sharp edges, the bathroom walls and floor was in disrepair and soiled, and the bathroom ceiling had a stain and was black in color. Room#208- The exterior room chair was heavily worn, and the bathroom floor was heavily soiled and stained. Room#209- The bathroom floor was heavily soiled and in disrepair, and the exterior of the nightstand had exposed sharp edges (Bed A). Room#210 - The exterior of the room chair was heavily worn, and bathroom floor heavily soiled, stained and in disrepair. Room#211- The bathroom floor was heavily soiled and in disrepair with numerous large areas of peeling paint, and room walls were in disrepair and required repainting. Room#212- The exterior of the room chair was heavily worn, and the bathroom floor was heavily soiled, in disrepair with numerous areas of peeling paint. Room#213- The exterior of the nightstands (X2) had exposed sharp edges. The bathroom floor was in disrepair with numerous areas of peeling paint. Room#216 - The toilet seat was not secured and was heavily worn, and shower floor was heavily soiled and stained. Room#218- The bathroom floor was heavily soiled and in disrepair with numerous areas of peeling paint. Room#219 -The bathroom floor was heavily soiled and stained. Room#220- The bathroom floor and walls were in disrepair with numerous areas of peeling paint, and the shower room floor was soiled, stained and in disrepair. Room#221- The resident's privacy curtain was soiled, the bathroom floor was heavily soiled and in disrepair. Room#222- The bathroom floor was soiled, stained and in disrepair with areas of peeling paint, and wall rail molding was coming off the wall (B Bed). Room#223- The bathroom floor was heavily soiled, stained and in disrepair with numerous areas of peeling paint, and the exterior of over-bed tables (X2) had exposed sharp edges. Room#224- The bathroom and shower room were heavily soiled, stained and in disrepair with numerous areas of peeling paint. Room#225- The bathroom floor was in disrepair with numerous areas of peeling paint, and the exterior over bed tables (X2) had exposed sharp edges. Room#226 -The bathroom floor was in disrepair with numerous areas of peeling paint. Room#227-The exterior of the room chairs were heavily worn (2X). The bathroom and shower room floor were heavily soiled, stained and in disrepair with numerous areas of peeling paint. Room#228- The bathroom and shower floor were in disrepair with numerous areas of peeling paint, the room walls required re-painting and the room base boards required re-painting. Room#229- The bathroom and shower floors were in disrepair with numerous areas of peeling paint, and the window blinds were missing and not working. The second floor nursing storage closet was unlocked and there were disposable razor packs, Nebulizer mask and kit, tooth paste, tooth brushes, Oral Care Swabs and other items in the room. The second floor Dining/Activities Room - Windows were dirty inside and out and a green algae build-up was observed, the floor had large stains, and the therapy equipment was stored in a corner and was rusty. Observation of the Dialysis Treatment Room on 07/26/2023 at 10:17AM: (a) The 2 garbage containers were noted to be without a lid and was overflowing with garbage, food wrappers, dirty gloves and Personal Protective Equipment (PPE). (b) A Red Bag for Biohazardous Waste was noted to be stored on the room floor near the dialysis machines. The dialysis nurse, a Licensed Practical Nurse (LPN) (Staff D) reported, it is the policy that red bags should be stored in a Biohazardous Box. (c) The wall around the room handwash sink was noted to have areas of peeling paint and there was a black mold like substance around and under the sink. (d) The door to the dialysis treatment chemicals room did not have a lock and there was open staff food observed and food lunches stored directly on the chemical shelves. Staff D reported, the the lunch bag was brought from his home and is stored in the room on a daily basis. (e) The 4 walls and room floor were heavily soiled and stained. There were large areas of peeling paint. Interview conducted with Staff D during the tour revealed, dialysis staff did not know who or how often the room was cleaned and sanitized. (f) There was soiled cleaning equipment, a (a broom and dustpan stored in the clean dialysis chemical room. Interview with Staff C, a Registered Nurse & Staff D revealed, this is where the soiled equipment is stored and they were not aware of the location were the soiled equipment was to be stored when not in use. (g) The room blinds were observed to be broken and slats were noted to be missing and was not providing resident privacy during the dialysis treatment. (h) The room window (inside and outside) was heavily soiled with dirt, dust, rust, and dead insects. Following the tours the environment issues were again confirmed with the administrative staff. * Photographic evidence obtained for all issues with the environment tours. 32090 3) Observation completed on 07/24/23 at 11:15 AM revealed Resident #141 lying in his bed, the resident was alert and oriented. Resident #141 stated he lives with his daughter, and he came here temporarily and was admitted recently. The resident reported, he had a stroke in 2019 and is not able to move his left arm, and he needs assistance. Resident #141 stated the bed makes his body painful, but he can't be sit in his wheelchair for long periods because it hurts too. Resident #141 stated he talked to the Maintenance staff who said he is looking for another mattress for him and will also see if the bed needs to be replaced. Observation on 07/26/23 at 09:40 AM revealed, Resident #141 was lying in his bed, he was sleeping but woke up and stated he was willing to be interviewed. Resident #141 stated he was not good because they had not changed his mattress. The resident reported he had already spoke to Maintenance Staff (Staff G). The resident reported, they were going to change his mattress, but they never did it and he is leaving the facility tomorrow. Resident #141 was asked did Staff G provide an explanation why they did not change his mattress, he reported, they did not. Observation on 07/26/2023 at 12:40pm revealed, Resident #141 was in his room, sitting in his chair, and he reported he wanted to go to in the dining room for lunch. Resident #141 reported, he was told they will change his mattress today and he was very thankful to the surveyor and reported, at least today I will sleep good in the bed. While completing observations and interview, the Maintenance Director and Staff G were observed bringing a new mattress in a box into Resident #141's room. They removed the old mattress and replaced it with the new one. Observation on 07/27/23 at 11:45 AM revealed, Resident #141 was lying in his bed, he was very happy with the new mattress and he was able to sleep the night before. Resident #141 reported, he is leaving today and was waiting to bef picked up to go home. The resident had no concerns with anything else. Interview with Staff G, a Maintenance Staff member on 07/26/23 10:41 AM revealed, when a resident told him he/she is not comfortable with the bed or mattress he will check and report it immediately to the head of the Maintenance Department. Staff G added, if they have mattresses in storage, they will replace the mattress, but if there is none, they will replace the mattress with another mattress they would take from an empty bed. Staff G stated, this facility does not have a system to report work orders, or to report problems and the need for repairs, instead they work with what they need to do every day. Staff G reported, the facility had 2 staff members. One person covered the first floor, and he was assigned the second floor, but now he covers both floors. Staff G stated, there is only one maintenance staff member beside the head of the Department. Staff G reported, the facility is looking to hire for the maintenance position. Staff G stated, At this moment the facility does not have any bed mattress (regular or air mattress) in storage. They received about 10 units, and they had pending request and they replaced the ones who needed the mattresses to be replaced. Staff G stated, he was aware Resident #141 had been uncomfortable with the mattress he had in his bed; he checked the bed, and he found no problems. The problem is the mattress pad in the middle is gone. Staff G added, the mattress assigned to Resident #141is thinner than others, the regular ones. Staff G reported, Resident #141 told him about his mattress a couple of days ago. Staff G stated, Resident #141 is very pleasant person and very alert. Staff G stated, he told his boss, the head of his department and he said that he was going to change it, but he did not say anything else. Staff G stated, on those cases he usually does change the mattress himself, but it is a process because he has to talk to the nurse, to tell Certified Nursing Assistant(CNA) to take resident out of the bed. Staff G reported, he will bring another mattress from an empty bed and will replace the bad one, but Staff G reported, he has been overwhelmed too and he did not do it yet. Staff G stated, that mattress that is in the resident's bed is not good at all, it should be thrown in the garbage. Interview with the Maintenance Director on 07/26/23 at 11:10 AM revealed, when residents have problems with their mattress, they put on a new mattress or swap them from an empty bed and sanitize them. The Maintenance Director stated, the facility does not have any mattresses in storage now, but they ordered 10 a while ago. The Maintenance Director stated the last time the facility received new mattress was about two months ago, but when they do not have new mattress in storage, they replace the one the resident is complaining about with one taken from an empty room. The Maintenance Director stated his department has a system in place to make sure the residents' request for a new mattress or bed or any situation that is being handled by his department is resolved. The Maintenance Director stated, they have books on both floors in the nurse stations. The Maintenance Director explained he and his staff will look at the book daily, and he assigns work to his staff or himself to be resolved. When asked about Resident #141, the Maintenance Director stated he fixed his TV in the room the other day, and Resident #141 told him a few days ago, he does not speak English, but he made signs indicating a problem in his back. The Maintenance Director stated, he was assisted with translation by Staff G who speaks the same language of Resident #141 and told him they must change his mattress. The Maintenance Director acknowledged he did not change the mattress. The Maintenance Director stated, Staff G is working right now on changing Resident #141's mattress, after he was interviewed. When asked why it was not changed before, the Maintenance Director stated, I was waiting for the new mattresses they ordered. Asked why he did not replace with a mattress from an empty bed, he stated I wanted to give him a new mattress. Asked if he observed the condition of Resident#141's mattress, the Maintenance Director stated he did not see it because the resident was in bed most of the time. The Maintenance Director stated, Resident #141's work order was not in the book, and when asked why his request was not logged in the book for work orders, the Maintenance Director stated, I don't know, but I know he needs a mattress and I was waiting for the new mattresses to come. The Maintenance Director provided the surveyor with the work order book from the second floor, and he verified there was no order to change the mattress for Resident #141. A ftew minutes later he provided a copy of the purchase order created on 07/26/2023 at 11:09 am, minutes after this surveyor interviewed Staff G and the facility was made aware about the Resident #141's concern. It was noted, the purchase order was created after the first interview with Staff G. The Maintenance Director admitted they completed the order a few minutes ago to purchase new mattresses. During a further interview with the Maintenance Director on 07/26/2023 at 12:45 pm, while he was taking the new mattress out of the box and replacing Resident #141's old mattress revealed, he did not have any new mattress in storage, but his boss bought this one and gave to him to replace the old one. Record review of Resident #141's Face sheet revealed Resident #141's date of admission was on 07/18/2023. Diagnoses included but were not limited to Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, Other specified arthritis, unspecified side, Depression, and Hypertensive heart disease with heart failure. Record review of the Work Order Book for the month of the month of July revealed, no work order listed under resident #141's name. Record review of the Purchase Order dated 07/26/2023 created at 11:09am revealed, the order was placed for Mattress Pressure relief 80 (10 units). Record review of the Minimum Data Set (MDS) revealed it was in progress to be completed. Record review of Resident #141's Care Plan dated 07/19/2023 revealed: Resident has an Activity of Daily Living (ADL) self-care deficit related to (r/t) chronic medical condition. Goal: Resident will not have a decline in ADL functioning through the next review date. Interventions included but were not limited to: Assistive devices as ordered/indicated, Encourage and assist with all Activities for Daily Living (ADLs) tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. The resident is Independent for meeting emotional, intellectual, physical, and social needs. Prefers a balance of social and independent leisure activities. Physical Limitations Resident prefers to spend some time in his room, states he enjoys watching television (tv), updated with the cable line up. Interventions: The resident will be encouraged to (3) groups of choice weekly for social and cognitive stimuli by next review date, Assist/escort to activity functions of potential interest as needed. Interview with the Director of Social Services (DSS) on 07/26/23 at 12:25 PM revealed, she did not receive any complaint or concern voiced by Resident #141. The DSS provided the grievance log for this month and only three grievances had been filed. None of them belonged to resident #141. Record review of Grievance Log revealed no grievances filed on behalf of resident #141. Record review of the Policy and Procedures on Maintenance Services revised 2009, reviewed January 2023 revealed: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner always. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 8. The Maintenance Director is responsible for maintaining the following records/reports. k. Inspection of buildings; l. Work order requests; m. Maintenance schedules; 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F812 Food Procurement, Store/Prepare/Serve-Sanitary. This practice has the potential to increase the risk of negative resident outcomes and to affect all 91 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with the exit date 08/14/2022 Food Procurement, Store/Prepare/Serve-Sanitary was cited related to the facility failed to ensure foods were prepared and distributed at safe temperatures, as evidenced by a failure to provide food holding temperatures were consistently monitored and recorded for all menu items. During an interview on 07/27/2023 at 01:34 PM, the Nursing Home Administrator and Director of Nursing (DON) revealed, the Quality Assessment and Assurance Committee (QAA) meets the second Thursday of every month. The administrator stated that the QAA Committee is comprised of the following members: the Administrator, Medical Director, DON, Assistant Director of Nursing (ADON)/Infection Preventionist, Social Worker, Environmental Director, Rehabilitation Director, Dietitian, Human Resources Director, Medical Records Activities Director, Admissions Director, Food Service Director. The Nursing Home Administrator (NHA) stated, We have Performance Improvement Plans (PIPs) for, Return to Hospital rates, as we have had a higher percent. The DON stated, we have been monitoring the reason why the residents have been going to the hospital. The NHA continued and stated, we worked on one PIP for Customer Service, we are trying to improve out star rating for customer service, to get our google rating up, the system in the front, whenever you check in, gets your phone number in order to ask for your opinion or feedback, we can use that to figure out what was going on. We also have our Guardian Angel rounds with questions to the residents, the services and for grievance processes, we are working on a program moving forward for the employee of the month. The DON stated, we are not where we want to be, and we are trying to improve, I feel that it has gotten better but not where I want it to be, we do not have A high turnover, it has gotten better, more nurses that stay here, it is more stable and that improves our customer service. The NHA stated, for Environmental, basically we had this maintenance assistance who resigned recently and he has not been replaced yet, we have an open position, we have another employee who is part time and he was asked to work full time for now to help around, we have different projects, we replaced 20 LED (Light Emitting Diode) lightbulbs on hallways, we are re-doing bathroom floors on the second floor, up to now on some of them, we repainted the second floor day room, we repair the kitchen's roof, we are painting rooms including bathroom walls, we are going from room to room and we want to do a room every day, the hallways and the room doors have been painted, we are placing chiller pipes in the ceiling and a new compressor to help with the air conditioning (AC), also two weeks ago we did a water hyperchlorination and disinfection project, we flushed the entire building with clorine, we replaced the call light's chain on the overhead lights, we have done re-caulking of the sinks in every room, we are doing deep cleanings and replacing the room tiles; after the survey, we have plans to replace furniture. Review of Policies and Procedures, document titled 2023 QAPI (Quality Assurance and Performance Improvement) Plan revealed: QAPI Goals At Biscayne Health and Rehabilitation, we are committed to focusing on clinical care, quality of life and resident choice. We expect all of our facilities to reflect this in their annual regulatory survey outcomes with deficiencies less than the state average, achieving compliance upon the first revisit and not having substandard quality of care deficiencies. On behalf of those we serve, we are committed to using QAPI to improve our performance and practices and to ensure we meet and exceed regulatory requirements and standards. In conducting a root cause analysis for the center's regulatory outcomes, Biscayne Health and Rehabilitation identified the following goals: Goal #1: Decrease/Eliminate complaint surveys by improving customer service. Goal #2: Ensure that the facility is survey ready 365 days a year by embracing company's policies and following them daily.

Based on observations, interviews, and record review, the facility failed to follow infection control standards of practice as evidenced by dialysate (a fluid used during dialysis) jugs on the counter next to a disinfectant spray and sink; personal bags found in storage rooms; a broom/dustpan found in dialysate storage rooms; a biohazard bag on floor; and an overflowing trash bin. These actions have the potential to affect the seven residents who are receiving dialysis including sampled Resident #17. The findings included: On 07/26/23 at 10:17 AM. During an observation of the dialysis treatment room. By the sink area, there were five dialysate jugs and one spray bottle that was labeled disinfection spray, and napkins in a clear bin on the counter. (See photographic evidence) An open trash bin was empty and by the sink. One step-on closable red biohazard bin is at the back of the room. Personal bags were located on the floor shelf of the television stand. (See photographic evidence) In the front storage room, there was a resident scale mechanical lift, there was a chair with rusted legs, and an unknown object underneath a plastic blanket, with plastic bags above it. A broom and dustpan were stored between the chair and the wall. (See photographic evidence) When asked, Do you have a clean and dirty sink? Staff C, a RN (Registered Nurse) stated, We only have one sink. When asked How do you use this sink and where can you store your dialysate that you're using? Staff D, an LPN (Licensed Practical Nurse) stated, We wash our hands and use hand sanitizer. We hold our dialysate on the sink. We don't want it on the floor. The disinfecting spray is to clean the dialysis machine and dialysis chair between residents. On 07/26/23 at 12:33 PM, during an interview with the Infection Preventionist, the observations were discussed, and the photographic evidence was shown. The Infection Preventionist stated, Those employees work with our contracted dialysis company, and they are covering for the dialysis nurses that usually come to the facility. Another Surveyor addressed the findings with me, and we did a walkthrough together earlier. We contacted our dialysis company to address the situation in the dialysis room. A representative will come out to visit the facility. We did an in-service with the dialysis technicians. We are having a team of maintenance, housekeeping, administration, nursing, and me to come to address the concerns today. On 07/27/23 at 09:30 AM, during an interview of staff from the dialysis contract company, Staff E, a RN (Registered Nurse) and Staff F, a CCHT (Certified Clinical Hemodialysis Technician). Staff E, RN stated, I am a dialysis nurse for the company. I float between facilities, and we are assigned here today. When asked, Is it allowed to have dialysis jugs next to a disinfectant spray bottle at the sink? Staff E RN stated, At dialysis facilities, we would have two sinks. If one sink is available, it would be shared. No, we are not allowed to have dialysate next to a disinfectant bottle. Staff F, CCHT, agreed to the statement. When the dialysis staff were asked, Can you have an open trash can, a Broom with a dustpan be stored in the dialysate room? Staff F stated, We usually do not have brooms and dustpans in the room. Staff E, RN stated, For trash, open trash cans can be used but not overflowing. We have regular trash cans that can close. We ask for housekeeping to come in. The broom and dustpan can harbor germs, microbes, and infections. We can't disinfect it. It shouldn't be in the room. It's not like you can wipe down the surface like trash cans, tables, chairs, and dialysis machines. Staff F, CCHT, agreed to the statement. Review of the in-service and training titled, Dialysis Management: Infection control practices for dialysis facilities. Dated 7/26/23 at 10:00 AM. Instructed by Infection Preventionist and Staff C, RN and Staff D, Licensed Practical Nurse (LPN) signatures are present. (See photographic evidence) Review of facility's policy titled, Infection Prevention and Control Plan for Nursing Homes 2022-2023. It is noted on page 5, under Infection Prevention Control program goals and objectives. 2) To provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection and communicable diseases. Review of contract dialysis company policy titled Infection Control Practices for Dialysis Facilities dated revised 04/02/2020 and 07/11/2022. It is noted under section 2. Policy: The infection control practices recommended for dialysis units will reduce opportunities for patient-to-patient transmission of infectious agents, directly or indirectly via contaminated devices, equipment and supplies, environmental surfaces, or hands of personnel. It is noted, under Section 4: Procedure: A sufficient number of sinks with warm water and soap have been available to facilitate hand washing. (TX: Hands-free washing sinks are required in the treatment room.) In D-2: Not handling or storing contaminated (i.e., used) supplies, equipment, blood samples, or biohazard containers in areas where medication and clean (i.e., unused) equipment and supplies are handled. It is noted, in section 5: Environmental Practices, A. Physical environment: 1) Environmental cleaning of the dialysis unit will be accomplished as outlined by the housekeeping policies and procedures. Housekeeping service will have a written schedule that determines the frequency of cleaning and maintaining the cleanliness of all equipment, structures, areas, and systems within its scope of responsibility. E) Clean supplies stored in the treatment area will be segregated to clean carts or cabinets. Review of facility's policy titled Environmental Services, dated September 1, 2021. It is noted, Intent: It is the policy of the facility to provide Environmental services in accordance with State and Federal regulations. 1) The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 3) housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation, interview and record review, the facility failed to ensure foods were prepared and distributed at safe temperatures, as evidenced by failure to provide evidence that food holding temperatures were consistently monitored and recorded for all menu items. This deficient practice places residents at risk for potential foodborne illness and has the potential to affect 84 residents in the facility who eat orally out of 92 resident residing in the facility at the time of the survey. The findings included: Observation in the kitchen on 7/12/22 at 11:30 AM, revealed staff placing hot food on to the steam table in preparation for lunch service scheduled to begin at 12:00 PM. The Cook (Staff A) was observed using a calibrated dial stem thermometer to check food holding temperature for all hot food items on the steam table. This task was completed under the supervision of the Food Service Director (FSD). All temperatures were taken by 11:54 AM, but the staff was not observed recording the temperature results. The tray line service began at 12:05 PM. Interview with the FSD on 7/12/22 at 12:15 PM revealed he maintains a log which is used to record all of the food holding temperatures. The temperatures of all food items are checked and recorded for each meal. The temperatures are usually recorded by the cook on the menu and then transcribed to the temperature log. Review of the the Food Temperature Record for the weeks 6/19/22 to 6/25/22, 6/26/22 to 7/2/22, and 7/3/22 to 7/9/22 revealed all logs were blank. Review of the food temperature log binder revealed no Food Temperature Record on file for the current week 7/10/22 to 7/16/22. Interview with the Cook (Staff A) on 07/12/22 at 12:20 PM revealed she writes the temperatures on the menu which is on the clipboard. Review of the documents on the clipboard for Week 4 of the menu cycle revealed temperatures for regular menu items were recorded on the week at a glance menu for the breakfast, lunch and dinner meals on 7/11/22 and for the breakfast meal on 7/12/22. There were no temperatures recorded for the therapeutic and or texture modified hot or cold menu items. There were no therapeutic diet extension sheets on the clipboard for the current week. Interview with the FSD on 7/12/22 at 12:25 PM revealed he sometimes writes the food holding temperatures on another piece of paper and then transfers the temperatures to the log. The FSD was not able to provided any evidence that the temperatures had been taken or recorded for the past three weeks or the first three day of the current week. The FSD revealed the temperatures are usually recorded on the menu and then transferred to the log. The FSD revealed the paper copies of the menu are not maintained after use because any menu substitutions are recorded electronically and approved by the Dietitian. The FSD was not able to locate copies of the menu with the food holding temperatures. Interview with the FSD 07/12/22 at 12:28 PM revealed he removed the therapeutic diet extension sheets from the clipboard on 7/11/22 to make copies for the survey team and he did not put them back on the clipboard. Review of copies provided revealed no temperatures recorded for 7/1022 or 7/11/22 on the therapeutic extension sheets. The FSD stated he had not transferred the temperature to the log for the last 3 weeks and he was unable to locate the menu and or extension sheets for these weeks. There was no evidence that the temperatures had be checked or recorded. Interview with the Regional Food Service Consultant on 7/12/22 at 2:45 PM revealed the facility policy and procedure regarding food holding temperatures was revised on 7/12/22 and all dietary staff had been in-serviced on use of the temperature log for recoding the temperatures. Review of the facility policy and procedure titled Monitoring of Holding Temperatures dated July 2017 revealed: The temperatures of foods held in the steam table will be monitored by food service staff. 1. An accurate thermometer is maintained in the food service department. 2. The maximum length of time the food will be held on the steam table is 4 hours total. 3. The food service staff will take temperatures prior to meal service to ensure temperatures are in compliance with regulatory standards 4. Temperatures are recorded on the menu. 5. Any food item that is not in compliance with the above standards: hot items will be reheated to 165 degrees Fé (Fahrenheit) for at least 15 seconds before serving. Cold items will be placed back in refrigeration of 41 degrees F or then and rechecked after 2 hours for compliance Review of the facility policy and procedure titled Daily Temperature Log dated 7/12/22 revealed: The Dietary Cook or Supervisor will take all hot and cold food and beverage item temperatures three times per day. The temperature will be monitored for acceptable safe temperature zone for each item. Written records of temperatures are stored in the office.

Based on observation, interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for Severe Mental Disorder (SMI) or intellectual disability (ID) was completed correctly at the time of admission for two residents (Resident #84 and Resident #2) out of three residents investigated for PASRR by admitting both residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency has the potential to affect 92 residents residing in the facility at the time of the survey. The findings included: Resident #84 On 07/11/22 at 10:20 AM, Resident # 84 was observed lying in bed, he was alert times one (person) but not interviewable. Record review of Resident #84's medical record revealed the resident was originally admitted on [DATE]. According to the face sheet, the resident had diagnoses to include but not limited to Unspecified [CONDITION(S)] not due to substance or known physiological condition, Major Depressive disorder, [CONDITION(S)], and Disorganized [CONDITION(S)]. Record review of Resident # 84's Quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 06/22/2022 revealed in Section A Identification Information PASRR Level II coded as No. In Section C for Cognitive Patterns coded score 04 out of 15 for the Brief Interview for Mental Status (BIMS). In Section I Active Diagnoses coded Psychiatric/ Mood disorders, Depression and Psychotic disorder (other than [CONDITION(S)]) and additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented coding for [CONDITION(S)]. In Section N Medications coded antipsychotic and antidepressant medication. Review of Resident #84's PASRR Level I completed at the hospital and dated on 10/27/2021 revealed the hospital did not check any mental illness in Section I PASARR Screen Decision-Making, in Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASRR evaluation not required. Review of Resident #84's care plan dated 11/11/2021 and last revised on 06/22/2022 revealed use of [CONDITION(S)] medications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #84's primary physician consult dated 11/13/2021 revealed a psychiatry consult evaluation and revision for comorbid [CONDITION(S)]. Record review of Resident # 84's Psychiatry Intake Note dated 02/07/2022 revealed a referral for psych evaluation and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation completed and treatment ordered included [MEDICATION(S)] 100 mg in the morning and 300 mg at bedtime, and [MEDICATION(S)] 100 mg at bedtime. Record review of Resident # 84's Psychiatry Intake Note dated 04/27/2022 revealed [CONDITION(S)], [CONDITION(S)] Disorder and Probable Major Neurocognitive Disorder due to Alzheimer's Disease, with behavioral disturbance, orders to continue [MEDICATION(S)] 100 mg daily and 300 mg at bedtime, and [MEDICATION(S)] 100 mg at bedtime. Resident #2 On 07/13/2022 at 10:15 AM, Resident # 2 was observed lying in bed and watching television. the resident was not no alert and oriented. Record review of Resident # 2's medical record revealed the resident was admitted on [DATE]. According to the face sheet, the resident diagnoses include but not limited to [CONDITION(S)], unspecified, Primary [CONDITION(S)], Depression unspecified, unspecified [CONDITION(S)] not due to a substance or known physiological condition, Anxiety Disorder, unspecified, other specified depressive episodes, Major Depressive Disorder, recurrent, moderate. Record review of Resident # 2's Admission Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 04/05/2022 in Section A for Identification Information indicated PASRR Level II coded as No. In Section C Cognitive Patterns coded a score of 01 out of 15 in the Brief Interview for Mental Status (BIMS). In Section I Active Disease diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In Section N for Medications was coded for use of antipsychotic and antidepressant medications. Record review of Resident # 2's PASRR Level I, completed on 08/03/2021 by a Registered Nurse (RN) at the previous facility where resident lived revealed no mental illness checked in Section I: PASRR Screen-Decision Making, In Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASRR evaluation not required. Record review of Resident #2's Care plan dated 04/11/2022 revealed use of [CONDITION(S)] medications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident # 2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Psychiatry Intake Note dated 03/31/2022 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: 1. Discontinue [MEDICATION(S)], start [MEDICATION(S)] 7.5 mg at bedtime. Start [MEDICATION(S)] 125 mg twice a day for mood stabilization, [MEDICATION(S)] level in one week. Continue [MEDICATION(S)] 0.5 mg at bedtime for [CONDITION(S)]. Record review of Resident #2's Psychiatry Intake Note dated 06/28/2022 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan Case and plan discussed with doctor who aggressive with the following orders: - Continue [MEDICATION(S)] 250 mg 3 times a day. - Continue [MEDICATION(S)] 5 mg at bedtime - Continue [MEDICATION(S)] 7.5 mg at bedtime - Continue [MEDICATION(S)] 5 mg at bedtime - Continue [MEDICATION(S)] 15 mg at bedtime - Continue [MEDICATION(S)] 0.5 mg 2 times a day. On 07/14/2022 at 12:29 PM the Director of Social Services (DSS) revealed she is not in charge of the PASRRs and that it is done by the admissions department. During an interview on 07/14/2022 at 12:52 PM, the Admissions Coordinator revealed that for the admissions she makes sure that the residents came with the PASRR Level I and residents with PASRR Level II are not admitted to the facility on ce they know resident needs Level II PASRR. The Admissions Coordinator explained she only checks the Level I PASRR the name, date of birth, and date signed are correct, makes sure the 5 pages are in the package and signed by the RN (Registered Nurse) in the hospital. If a resident is being admitted from home, the facility will complete a Level I and the Director of Nursing (DON) or a designated RN will sign it. The Admissions Coordinator stated that after she reviews the package for Level I PASRR, it is checked by the medical records staff. The medical records staff will take the PASRR Level I; if it is completed and upload it in the electronic record. The Admissions Coordinator stated that the facility never admitted a resident with a PASRR Level II; and added that Level II is for example is if a person has multiple psych issues, conditions like Down Syndrome, etc. and noted that for those cases they would do a Level II PASRR. The Admissions Coordinator stated that all residents should be screened for PASRR Level I because without it the facility does not get paid and that will tell if the resident meets the criteria to receive rehabilitation. In case a resident has [CONDITION(S)] or behavior and if the form said yes and if she finds it in the documents, she will go to DON. Before going to the DON, she will contact the Case Manager from the hospital to verify that the information for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admissions Coordinator explained that in the past she admitted residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . but the answer to all questions in Section II were No. and she never had a resident who required a Level II PASRR. When asked why Resident # 84 did not have a Level II PASRR, the Admissions Coordinator stated it was not done because the hospital stated that the patient did not require a Level II PASRR. The Admission Coordinator stated that she was not aware Resident # 84 and Resident #2 had a mental condition such as [CONDITION(S)] when they were admitted in the facility. The Admissions Coordinator stated when she checked the residents' PASRR Level I she only checked the name, dates, and number of pages, but not the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/14/2022 at 1:50 PM, the medical records staff revealed she only uploaded the PASRR Level I in the electronic system when the residents came from hospital, and reported to the Admissions Coordinator if the resident does not have a PASRR Level I. The medical records staff stated that she only looked at the name and date on the last page to make sure it is signed and completed but she does not check for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what she would do if she does not see a checked mark in Section I for diagnosis, the medical records staff stated that she is not too familiar with what she should be looking for in the PASRR because the facility did not train her on PASRR. The medical records staff re-stated that she only looked for names, signature, and dates. The medical record staff added that she will report anything missing on the Level I PASRR during the morning meetings but sometimes the Level I PASRRs are already uploaded by the Admissions Coordinator, so therefore she does not check those documents because they are already uploaded. Interview with the DON on 07/14/2022 at 06:15 PM revealed, when the hospital sends referrals for new admissions, the facility makes sure the Level I PASRR is completed in the documentation they receive. The DON stated that it is usually the Admissions Coordinator who receives all the paperwork, and she emails it to her or print out the documents and they will look at it. The DON stated she looks at the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated in cases where there is no mental diagnosis listed on the Level I PASRR, but the patient is taking psych meds she will check the history and check if the patient has an actual mental diagnosis. The DON stated if there is no mental diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained the PASRR document is done on preadmission, so it is supposed to be corrected before admission. The DON reported that she cannot state for sure that she is checking 100% of all admissions, but the new admissions are discussed in the morning meetings and added that the facility does not do PASRR Level I if the document was not completed correctly and unless the resident has a new condition, a change, or a new mental diagnosis. The DON stated, I know when they have certain diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she started as a DON here in September and she does not remember to have reviewed any Level I PASRR that required a Level II evaluation. The DON stated she is the one in charge of reviewing the PASRR Level I because the facility does not have any staff with a master's degree in social work; and is aware that another RN can also do the review, but she is the one doing it. The DON was showed Resident #84 and Resident#2's PASRR Level I which did not have any checked diagnosis, the DON acknowledged it was not completed properly because both residents have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she knew the Level I PASRR is completed to let the facility know if a resident can be admitted in the facility. The DON was asked what she would have done if noticed both residents' PASRR Level I were not completed properly, the DON stated that she would have the doctor evaluate Resident # 84 and Resident # 2 to decide if the residents were able to stay in the facility. The DON was asked if she knew about the state mental health designated authority that can do the screening and decide if PASRR Level II is required, and DON stated she did not know. Record review of Policy and Procedures on PASRR effective 04/2015 and revised on 10/2021 revealed: I. PURPOSE: Pre-Admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . IV. POLICY: The facility ensures that all residents admitted to the facility has PASRR Level I done prior to admission to facility or Level II as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V. PROCEDURE: 1. Prior to admission, the admission department including nursing navigator must ensure that hospital or another nursing home facility has completed PASRR Level I for new residents prior to admittance to facility 2. Upon receipt of PASRR I from hospital or another nursing home, facility will review PASRR Level I by DON or designee. If PASRR Level I indicated that resident exhibited actions or behaviors that may make resident a danger to self or others, facility must request from hospital or nursing home a Level II PASRR. If PASRR Level I indicates that a resident has serious mental illness and PASRR Level I indicates that a PASRR Level II is needed, facility must request from hospital or another nursing home, a PASRR Level II priors to admission to facility.

Based on observations, interview, and record review, the facility failed to accurately code a Minimum Data Set (MDS) for one (Resident #84) out three residents sampled for Pre-Admission Screening and Resident Review (PASRR) as evidenced by; the facility's staff did not code diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This has the potential to affect 92 residents living in the facility at the time of the survey. The findings included: Observation on 07/11/22 at 10:20 AM, revealed Resident # 84 in bed, he was alert times one (person) but not interviewable. Interview with the pharmacy consultant on 07/13/2022 at 12:01 PM revealed, Resident #84 is receiving [MEDICATION(S)] 100 mg (milligrams) twice a day, and 300 mg at bedtime which was increased on 06/28/2022 from 100 mg once a day to twice a day, and 300 mg at bedtime for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 84's Face Sheet revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 84's Quarterly Minimum Date Set (MDS) with assessment reference date (ARD) of 06/22/2022 revealed in Section A Identification Information PASRR Level II coded as No. In Section C for Cognitive Patterns coded score 04 out of 15 in the Brief Interview for Mental Status (BIMS) indicating the resident has severely impaired cognition. In Section I Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented coding for [CONDITION(S)]. In Section N Medications coded antipsychotic and antidepressant medication. Record review of Resident #84's care plan dated 11/11/2021 and last revised on 06/22/2022 revealed use of [CONDITION(S)] medications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 84's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #84's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #84's Primary Physician consult dated 11/13/2021 revealed a psychiatric consult evaluation and revision of comorbid [CONDITION(S)]. Record review of Resident #84's Psychiatric consult dated 02/07/2022 revealed a referral for psych evaluation and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation completed and treatment ordered included [MEDICATION(S)] 100 mg in the morning and 300 mg at bedtime. Record review of Resident # 84's Psychiatric consult dated 04/27/2022 revealed [CONDITION(S)] among other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the MDS Coordinator on 07/14/2022 at 03:02 PM revealed that after reviewing Resident #84's chart (diagnosis, medication, and psychiatric consult) the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator stated that she did not complete the Quarterly assessment on 06/22/2022. Record review of Resident # 84's MDS Quarterly (2) Modifying existing record dated 06/22/2022 and Center for Medicare Services (CMS) Submission Report MDS 3.0 NH (Nursing Home) Final Validation report revealed a corrected and coded diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Policy and Procedures on MDS revised on 09/2021 revealed: Policy Statement The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established process for completing, submitting, and making corrections to the MDS. Policy Interpretation and Implementation Completion of MDS. 1. Interdisciplinary Team will complete sections of MDS for a resident in the facility. Correction of Error 5. If an error is discovered after the encoding period and the record in error is an OBRA Assessment, determine if the error is major or minor. MDS Coordinator may modify assessment within 2 years of ARD and modification can be completed 14 days after error is discovered. a. A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to the QIES ASAP system. During an interview on 07/14/2022 at 06:30 PM the Director of Nursing (DON) revealed when asked about Resident # 84's Quarterly MDS in which the facility did not code the resident for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations,record review and interview, the facility failed to ensure two residents (Resident # 84 and Resident #2) out of three residents sampled for Preadmission Screening and Resident Review (PASRR) were referred for evaluation to ensure and complete Level II PASRR. There were 92 residents residing in the facility at the time of the survey. the findings included: On 07/11/22 at 10:20 AM, Resident # 84 was observed lying in bed, he was alert times one (person) but not interviewable. Record review of Resident # 84's medical records revealed the resident was originally admitted to the facility on [DATE]. According to the face sheet, the resident had diagnoses to include but not limited to Unspecified [CONDITION(S)] not due to substance or known physiological condition, Major Depressive disorder, [CONDITION(S)], and Disorganized [CONDITION(S)]. Record review of Resident # 84's Quarterly Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 06/22/2022 revealed in Section A Identification Information documented PASRR Level II coded as No. In Section C for Cognitive Patterns coded a score of 04 out of 15 in the Brief Interview for Mental Status (BIMS) meaning severely impaired cognition. Section I for Active Diagnoses coded under Psychiatric/ Mood disorders diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section N for medications coded antipsychotic and antidepressant medication. Record review of Resident # 84's Quarterly MDS (2) Modifying existing record dated 06/22/2022 and Center for Medicare Services (CMS) Submission Report MDS 3.0 NH Final Validation report revealed it was corrected and coded diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #84's PASRR Level I completed at the hospital and dated on 10/27/2021 revealed the hospital's nurse did not check any mental illness in Section I on the PASRR Screen Decision-Making, in Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASRR evaluation not required. Record review of Resident #84's care plan dated 11/11/2021 and last revised on 06/22/2022 revealed use of [CONDITION(S)] medications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #84's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #84's current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #84's Primary Physician consult dated 11/13/2021 revealed a psychiatry consult evaluation and revision of comorbid [CONDITION(S)]. Record review of Resident #84's Psychiatry Intake Note dated 02/07/2022 revealed referral for psych evaluation and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation completed and treatment ordered included [MEDICATION(S)] 100 mg in the morning and 300 mg at bedtime, and [MEDICATION(S)] 100 mg at bedtime. Record review of Resident #84's Psychiatry Intake Note dated 04/27/2022 revealed [CONDITION(S)], [CONDITION(S)] Disorder, and Probable Major Neurocognitive Disorder due to Alzheimer's Disease, with behavioral disturbance, and ordered to continue [MEDICATION(S)] 100 mg daily and 300 mg at bedtime, and [MEDICATION(S)] 100 mg at bedtime. Resident #2 On 07/13/2022 at 10:15 AM, Resident # 2 was observed lying in bed and watching television. the resident was not no alert and oriented. Record review of Resident # 2's medical record revealed the resident was admitted to the facility on [DATE]. According to the face sheet, clinical diagnoses include but not limited to [CONDITION(S)], unspecified, Primary [CONDITION(S)], Depression Unspecified, Unspecified [CONDITION(S)] not due to a substance or known physiological condition, anxiety disorder, unspecified, other specified depressive episodes, major depressive disorder, recurrent, moderate. Record review of Resident # 2's Admission Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 04/05/2022 in Section A for Identification Information indicated PASRR Level II coded as No. In Section C Cognitive Patterns coded a score of 01 out of 15 in the Brief Interview for Mental Status (BIMS). In Section I Active Disease diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In Section N for Medications was coded for use of antipsychotic and antidepressant medications. Record review of Resident # 2's PASRR Level I, completed on 08/03/2021 by a Registered Nurse (RN) at the previous facility where resident lived revealed no mental illness checked in Section I: PASRR Screen-Decision Making, In Section II Other Indications for PASRR Screen-Decision Making checked all boxes indicating No when answering all questions on the form, in Section IV PASRR Screen Completion checked option No diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASRR evaluation not required. Record review of Resident # 2's Care plan dated 04/11/2022 documented the use of [CONDITION(S)] medications related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident # 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Psychiatry Intake Note dated 03/31/2022 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: 1. Discontinue [MEDICATION(S)], start [MEDICATION(S)] 7.5 mg at bedtime, start [MEDICATION(S)] 125 mg twice a day for mood stabilization, [MEDICATION(S)] level in one week, and Continue [MEDICATION(S)] 0.5 mg at bedtime for [CONDITION(S)]. Record review of Resident # 2's Psychiatry Intake Note dated 06/28/2022 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan case and plan discussed with doctor . with the following ordered medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Continue [MEDICATION(S)] 250 mg 3 times a day. - Continue [MEDICATION(S)] 5 mg at bedtime - Continue [MEDICATION(S)] 7.5 mg at bedtime - Continue [MEDICATION(S)] 5 mg at bedtime - Continue [MEDICATION(S)] 15 mg at bedtime - Continue [MEDICATION(S)] 0.5 mg 2 times a day. On 07/14/2022 at 12:29 PM the Director of Social Services (DSS) revealed she is not in charge of the PASRRs and that it is done by the admissions department. On 07/14/2022 at 12:52 PM, the Admissions Coordinator revealed that during admissions she makes sure that the residents came with the PASRR Level I and residents with PASRR Level II are not admitted to the facility on ce they know resident needs Level II PASRR. The Admissions Coordinator explained she only checks the Level I PASRR the name, date of birth, and date signed are correct, makes sure the 5 pages are in the package and signed by the RN (Registered Nurse) in the hospital. If a resident is being admitted from home, the facility will complete a Level I and the Director of Nursing (DON) or a designated RN will sign it. The Admissions Coordinator stated that after she reviews the package for Level I PASRR, it is checked by the medical records staff. The medical records staff will take the PASRR Level I; if it is completed and upload it in the electronic record. The Admissions Coordinator stated that the facility never admitted a resident with a PASRR Level II; and added that Level II is for example is if a person has multiple psych issues, conditions like Down Syndrome, etc. and noted that for those cases they would do a Level II PASRR. The Admissions Coordinator stated that all residents should be screened for PASRR Level I because without it the facility does not get paid and that will tell if the resident meets the criteria to receive rehabilitation. In case a resident has [CONDITION(S)] or behavior and if the form said yes and if she finds it in the documents, she will go to DON. Before going to the DON, she will contact the Case Manager from the hospital to verify that the information for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admissions Coordinator explained that in the past she admitted residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . but the answer to all questions in Section II were No. and she never had a resident who required a Level II PASRR. When asked why Resident # 84 did not have a Level II PASRR, the Admissions Coordinator stated it was not done because the hospital stated that the patient did not require a Level II PASRR. The Admission Coordinator stated that she was not aware Resident # 84 and Resident #2 had a mental condition such as [CONDITION(S)] when they were admitted in the facility. The Admissions Coordinator stated when she checked the residents' PASRR Level I she only checked the name, dates, and number of pages, but not the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/14/2022 at 1:50 PM, the medical records staff was asked about her involvement with the newly admitted residents' PASRR Level I, the medical records staff stated that she only uploaded the PASRR Level I in the electronic system when the residents came from hospital, and reports to Admissions Coordinator if they do not have PASRR Level I. The medical records staff stated that she only looked at the name and date on the last page to make sure it is signed and completed but she does not check for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what she would do if she does not see a checked mark in Section I for diagnosis, the medical records staff stated that she is not too familiar with what she should be looking for in the PASRR because the facility did not train her on PASRR. The medical records staff re-stated that she only looked for names, signature, and dates. The medical record staff added that she will report anything missing on the Level I PASRR during the morning meetings but sometimes the Level I PASRRs are already uploaded by the Admissions Coordinator, so therefore she does not check those documents because they are already uploaded. Interview with the DON on 07/14/2022 at 06:15 PM revealed, when the hospital sends referrals for new admissions, the facility makes sure the Level I PASRR is completed in the documentation they receive. The DON stated that it is usually the Admissions Coordinator who receives all the paperwork, and she emails it to her or print out the documents and they will look at it. The DON stated she looks at the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated in cases where there is no mental diagnosis listed on the Level I PASRR, but the patient is taking psych meds she will check the history and check if the patient has an actual mental diagnosis. The DON stated if there is no mental diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained the PASRR document is done on preadmission, so it is supposed to be corrected before admission. The DON reported that she cannot state for sure that she is checking 100% of all admissions, but the new admissions are discussed in the morning meetings and added that the facility does not do PASRR Level I if the document was not completed correctly and unless the resident has a new condition, a change, or a new mental diagnosis. The DON stated, I know when they have certain diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she started as a DON here in September and she does not remember to have reviewed any Level I PASRR that required a Level II evaluation. The DON stated she is the one in charge of reviewing the PASRR Level I because the facility does not have any staff with a master's degree in social work; and is aware that another RN can also do the review, but she is the one doing it. The DON was showed Resident #84 and Resident#2's PASRR Level I which did not have any checked diagnosis, the DON acknowledged it was not completed properly because both residents have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she knew the Level I PASRR is completed to let the facility know if a resident can be admitted in the facility. The DON was asked what she would have done if noticed both residents' PASRR Level I were not completed properly, the DON stated that she would have the doctor evaluate Resident # 84 and Resident # 2 to decide if the residents were able to stay in the facility. The DON was asked if she knew about the state mental health designated authority that can do the screening and decide if PASRR Level II is required, and DON stated she did not know. Record review of Policy and Procedures on PASRR effective 04/2015 and revised on 10/2021 revealed: I. PURPOSE: Pre-Admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Social Security Act. It is intended to ensure that Medicaid-certified nursing facility applicants and residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . IV. POLICY: The facility ensures that all residents admitted to the facility has PASRR Level I done prior to admission to facility or Level II as indicated by resident's condition and behavior. The facility ensures that PASRR Level I must reflect current condition and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V. PROCEDURE: 1. Prior to admission, the admission department including nursing navigator must ensure that hospital or another nursing home facility has completed PASRR Level I for new residents prior to admittance to facility 2. Upon receipt of PASRR I from hospital or another nursing home, facility will review PASRR Level I by DON or designee. If PASRR Level I indicated that resident exhibited actions or behaviors that may make resident a danger to self or others, facility must request from hospital or nursing home a Level II PASRR. If PASRR Level I indicates that a resident has serious mental illness and PASRR Level I indicates that a PASRR Level II is needed, facility must request from hospital or another nursing home, a PASRR Level II priors to admission to facility.

Based on observations, interviews and records reviewed the facility failed to address grievances for one resident (Resident #2) out of seven residents sampled, as evidenced by Resident # 2's family complained to the facility regarding food, activities of daily living, room cleanliness and communication between Resident #2's family and the facility. There was no documentation to indicate reported concerns were addressed by the facility. There were 88 residents residing in the facility at the time of the survey. The findings included: Observation on 08/24/2021 at 12:11 PM revealed, Resident #2 in his room eating lunch which consisted of a pureed diet with assistance from a Certified Nursing Assistant. Review of the facility's grievance policy and procedure, revised April 2017, revealed The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. item 8 showed: Upon received of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and /or complaint. Review of a letter sent to the facility along with pictures by Resident# 2's family member on 6/10/2021 revealed concerns regarding Resident #2's mouth care, food that was brought in by family was left out and rotted and the uncleanliness of the room. On 6/17/2021 the family sent an email addressed to the previous Administrator regarding the poor communication between the facility and the family and Resident #2 being unable to communicate with family members. Review of the facility grievance log from March 2021 to August 2021 revealed no documentation to indicate a grievance investigation was initiated for Resident #2. Review of the face sheet for Resident #2 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed Brief Interview of Mental Status (BIMS) indicated that Resident #2 is rarely understood. For Functional status, Resident #2 is coded as totally dependent for transfer, eating, and personal hygiene and requires extensive assistance for bed mobility. On 08/24/2021 at 5:06 PM, during an interview the Director of Nursing (DON) revealed that if they received a grievance, they investigated it. The grievances are discussed in the morning meetings. Regarding Resident #2, the DON stated that Resident #2's family made a complaint and part of the complaint was about food but she did not know exactly and was not involved in that concern. The DON stated that she think it was the previous Administrator that investigated it and does not know how the previous administrator communicated with the family. The DON revealed she was aware of the concerns and was not part of the follow up. The DON stated that the concerns related to Resident #2 was discussed in the morning meeting but she did not recall the results, because it the Administrator and Social Services were taking care of the case and a grievance should have been opened. The DON checked the morning meetings for June 2021 and July 2021 for the information related to Resident # 2's concerns and revealed no information was found. The DON revealed that she remembered that the family had sent a letter but she did not recall the concerns and a grievance should have been opened. The DON explained that when the family came to the facility they brought food and did not tell anybody and the facility had not given Resident #2 the food anyway because it was not his food. The DON acknowledged she could not find any grievances filed for Resident # 2 in the grievance logs. On 08/25/2021 at 11:52 AM, the DON presented documentation regarding a complaint from the family of Resident #2 in August. The family had called admissions to discuss concerns related to a requested window bed. The DON revealed this concern was also not documented in the grievance log. The DON added that the facility did not have a Social Worker before and the previous Administrator had taken over the grievances The DON was asked if the family's concern in August should have been addressed and documented in the grievance log. The DON stated that she could not answer for the previous Administrator but based on conversations, the family was satisfied and the concerns were addressed. On 08/24/2021 at 5:22 PM, during an interview the Social Worker revealed she started working in the facility July 2021. The Social Worker reported that she ensured all investigations are completed within 48 hours. The Social Worker reported that during morning meetings all complaints are discussed with all departments and how complaints will be addressed. The Social Worker reported that she had not received any complaints regarding Resident #2. On 08/25/2021 at 12:29 PM the Social Worker reported that she did not find any documentation regarding Resident #2 complaint investigation for June 2021 or July 2021.

Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of five residents sampled during the time of this survey. The facility's staff failed to supervise and implement adequate measures to prevent the delayed transfer of Resident #1 to the hospital for medical treatment. The resident's roommate Resident #5 was transferred instead of Resident #1. The error was not discovered until the next day. There were 87 residents residing in the facility at the time of the survey. On [DATE], it was determined that the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The Immediate Jeopardy was determined to be Past Non-Compliance. The facility's Administrator, Director of Nursing, and Corporate Nurse were notified of the immediate jeopardy on [DATE] at 3:35 PM. It was determined, the Immediate jeopardy began on [DATE] and the Immediate jeopardy was removed [DATE]. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol written by the Administrator and the revision date was on ,d+[DATE], the policy documented: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Face Sheet for Resident #1 documented, the resident was originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) dated [DATE] documented Resident #1 had a BIMS Summary Score of 04 indicating cognitive impairment and required total dependence with one person physical assist for ADLs (Activities of Daily Living). Review of the nursing progress notes documented the following: Dated [DATE] at 06:42 PM-Resident noted with moderate amount of blood in her anal area. Called medical doctor, ordered for fecal occult blood for tomorrow daughter visited to bring her clothes and made aware of the order of MD (Medical Doctor) stated that resident had history of anal bleeding due to polyps; Dated [DATE] at 02:51 AM-Monitoring in progress for rectal bleeding. Dependent assist in progress with all care provided frequent rounds in progress; Dated [DATE] at 05:37 PM-New lab results relayed to medical doctor, new order to send resident to local hospital due to rectal bleeding, family member notified. Call placed to ambulance company, stating that they will come in three hours; Dated [DATE] at 08:20 PM-Daughter made aware of her mother picked up by ambulance; Dated [DATE] at 08:47 AM-Received resident #1 resting in bed, awake, alert. Rectal bleeding noted, nurse aware and Dated [DATE] at 09:21 AM-Resident transferred to local hospital via stretcher due to rectal bleeding, via ambulance. Review of the Physician Telephone Order (PTO) for Resident #1 dated [DATE] documented, test order for Fecal/Occult Blood, Complete Blood Count (CBC), Basic Metabolic Panel (BMP) for bacteria/infection. Review of the laboratory results for Resident #1 dated [DATE] documented, abnormal results. The Hemoglobin (Hgb) was 7.1 and the Hematocrit (Hct) was 23.9. The medical doctor was called. Review of Physician Telephone Order for Resident #1 dated [DATE] documented, per medical doctor patient will be transferred to local hospital due to rectal bleeding. Family notified. Diagnosis-Rectal Bleeding. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Certified Nurse Assistant (CNA) Flow Sheet documented the following: Dated [DATE] at 6:11 AM, Staff H, CNA (11 PM-7 AM) provided care to the resident and dated [DATE] at 10:53 PM, Staff J, CNA (3 PM-11 PM) provided care to Resident #1. Review of the Risk Manager's investigation dated [DATE] documented: On February 28, 2021, she was discharged to the hospital via 911 for respiratory distress. She was readmitted to us on [DATE], and baseline labs confirmed a decrease with Hemoglobin of 8.1 and Hematocrit of 26.4. Labs were redrawn on [DATE], and there was a further decrease to her Hemoglobin to 7.1 and Hematocrit to 23.9. The physician was immediately notified on [DATE], and an order was obtained at approximately 2:30 PM to transfer the resident to the local hospital for further evaluation and treatment. The ambulance company was notified by the Clinical Manager/Unit Manager at approximately 3:30 PM regarding the transfer of Resident #1 to the hospital. The ambulance company informed us that they will arrive between ,d+[DATE] hours of the notification of request for transfer. At approximately, 9:10 PM, the ambulance showed up for the transport of Resident #1 to the hospital. Her roommate (Resident #5) was inadvertently transferred instead. When Resident #5 (the roommate) arrived at the hospital she was admitted as Resident #1 based on the transferring documentation. On the morning of [DATE], when the Unit Manager arrived in the facility and conducting morning rounds she realized that the wrong resident was transferred. She immediately notified the NHA (Nursing Home Administrator) and DON (Director of Nursing) and instructions were given to transfer the resident immediately via 911 (emergency services). The hospital was immediately notified and resident information was updated. In addition, the family was made aware. The nurse responsible for the resident was immediately suspended and Abuse and Neglect reeducation started and is ongoing. Review of the Face Sheet for Resident #5 documented, the resident was originally admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Brief Interview for Mental Status (BIMS) dated [DATE] documented, resident #5 had a BIMS Summary Score of 03 indicating cognitive impairment and required total dependence with one, two+ persons physical assist for ADLs (Activities of Daily Living). Review of the Physician Telephone Order (PTO) for Resident #5 dated [DATE] documented, per medical doctor resident will be sent to local hospital due to significant abnormal lab. Family notified. A clarification order dated [DATE] documented, per medical doctor resident will be sent to a local hospital due to altered mental status. Family notified. Review of the nursing progress notes documented the following: Dated [DATE] at 9:15 AM-MD aware about resident's confusion and agitation; Dated [DATE] 11:30 AM-Due to past history of CVA ([CONDITION(S)] Accident) resident will be transferred to hospital as per doctor order. Family notified. Review of the Patient Transfer Form for Resident #5 dated [DATE] documented send to local hospital; Reason for Transfer: Altered Mental Status. Review of the hospital records for Resident #5 dated [DATE] documented the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital's physician documentation for Resident #5 documented on [DATE] at 15:31 and on [DATE] at 18:18 Addendum: Patients medical record has been updated to reflect the patients correct demographic information [Resident #5]. Patient was originally registered as [Resident #1] as erroneous demographic information, which was sent with the patient from the facility. The patient is now showing correctly in the system for the medical admission with the same patient number. During interview on [DATE] at 9:22 AM, the Administrator/Risk Management/Quality Assurance stated, The nurse involved was Staff A, Registered Nurse (RN) and Staff C, RN/ Nurse Supervisor Evening shift. The day before, the Unit Manager came to me and told me they were sending Resident #1 out because she was bleeding from the rectum. I asked about the lab results and they said her blood was low and she may need a transfusion. They got an order from the physician to transfer her to a local Hospital. It was not a 911 transfer and they used the other ambulance service. The roommate of Resident #1 was transferred instead. The next morning, Staff B, RN/Nurse Supervisor for the morning shift came in and she called me at 9:00 AM. I was not here at the facility at that time. She told me Resident #1 did not go out and they sent her roommate instead. The roommate went with the paperwork as Resident #1. I said to her where is Resident #1, she said here and I said to call 911 and get her out of the building stat and that is what happened. When I came in I started to dig in and change some systems. I sent an email to the Chief IT (Information Technology) to change the beds from A and B to Door and Window, because there would be no more confusion. I made sure every resident had an arm band on. We do an audit daily to make sure they are wearing the arm band and admissions they are now doing the arm bands and the door tags and the alert for the new admissions. I suspended Staff A, RN for three days. During the suspension, I had the Nurse Supervisor Staff C, RN come in and she said the resident was prepared for transfer. The right paperwork was sent with the wrong resident. I did not report this to the nursing board. Nurse RN (Staff A) was terminated. I conducted Abuse and Neglect training with all staff. Resident #1 was supposed to go to a local hospital and 911 took her to the closest hospital. Resident #1 did not come back to our facility. During interview on [DATE] at 9:46 AM, the Director of Nursing (DON) stated: On [DATE] we had to send the patient to the hospital for a low hemoglobin. On the 18th she was still here. Her Hemoglobin (Hgb) was 8.1 and her Hematocrit (Hct) was 26.4 on [DATE]. On [DATE], we had another lab drawn and the Hgb was 7.1 and 23.9 for the Hct. We had an order to send the resident to the hospital. On [DATE] we found out the resident was still in the building. We sent her out 911 to a local hospital. [CONDITION(S)] and rectal bleeding were some of her admission diagnoses. When we send a resident to the hospital the procedure is we arrange the transportation, notify the family, we do the paperwork, the nurse in charge puts the paperwork in an envelope or a clip, when the ambulance comes we take the vital signs, the nurse is in the room with the resident and gives the paperwork to the ambulance workers. She (Nurse A, RN) did not identify the right person to send to the hospital. She had the right paperwork but the wrong patient went. That was her regular assignment and she had taken care of the resident before. The nurse was suspended, but not the supervisor in charge. The assigned nurse was the one responsible and should have identified the patient properly. In-services were conducted on abuse and neglect to the staff. In-services started on [DATE]. Interview on [DATE] at 10:17 AM, Staff B, RN, Nurse Supervisor for the morning shift stated: We reported to the daughter that she had rectal bleeding. She had rectal bleeding before she came to the facility. She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When the test results came back the doctor was called and gave the order to send the resident to the hospital. All the paper for the transfer was given to the supervisor in the afternoon Staff C, RN, Nurse Supervisor for evening shift and she delegated to the nurse assigned to the patient. That nurse is supposed to make sure the right patient goes with the right paperwork to the hospital. The nurse is supposed to be in the room when the resident is being transferred anywhere to make sure the right person is leaving the facility. The nurse have to be in the room to make sure transportation pick up the right person. I came in the next morning and I made the rounds to make sure everything was all right. When I went into the room resident #1 was still there and I said how could that be. I called the Administrator to let her know immediately. She told me to call 911 to transfer her to the hospital, call the family and the doctor. She said that was not possible because the patient was already transferred to the hospital. Her vital signs were stable, it was the rectal bleeding and the labs that were low. 911 was going to take her to the closest hospital. When 911 came, I was in the room with her and gave them the paperwork. She did not have any rectal bleeding the next morning. During an interview on [DATE] at 10:29 AM via telephone with Staff C, RN, the Nurse Supervisor for the evening shift stated, On that day she was transferred, she had an order to be transferred. When I came in, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a charge nurse, Staff A, RN assigned to the patient (Resident #1). When the order from the doctor came in, the paperwork was originated by the first shift. I made sure the paperwork was prepared. I told her the patient is to be transferred to the hospital. She was informed the patient was to be transferred to the hospital per the doctor orders. The first shift had called the ambulance and we were waiting for the ambulance to come for the transfer. When the ambulance comes to pick up the resident, you have to go to the patient and take the vital signs. She took the vital signs with the ambulance staff there. I do not know who she took the vital signs on. When the patient was picked up and the patient left the building, I presumed everything was okay. I never went into the room to make sure the resident left the building. I was on the phone with a local hospital for an admission that had come into the facility to clarify medications for the new admission. The facility called me and said to me they were going to suspend me. They did not suspend me during the investigation. I was not there when the transfer happened. I told my side of the story because there was a nurse there when it occurred. I do not understand how she sent the wrong patient to the hospital, she worked with the patient before. She even disconnected the PEG tube. The nurse or the CNA (Certified Nursing Assistant) is usually in the room when the ambulance staff comes. During an interview on [DATE] at 12:16 PM via telephone regarding Resident #1, the Admissions Director stated, When the resident was transferred, the daughter was called. She said a local agency called her about the facility. She wanted to know what we had to do with it. The mother was going to go home with hospice. She told me she was at the hospital for five days. Interview on [DATE] at 9:11 AM, Staff D, Licensed Practical Nurse (LPN) stated, The nurses work 12 hour shifts from 7 AM-7 PM and 7 PM-7 AM. The CNAs work the 8 hour shifts. When a resident is being transferred to the hospital, we get an order from the doctor depending on what is happening to the resident. There is paperwork to be filled out, the responsible party called and the ambulance called. Once the ambulance arrives the assigned nurse for that patient is supposed to have all the paperwork ready. The nurse will be already in the room or accompany the ambulance workers to the room so they can identify who is supposed to be going out to the hospital. After the resident left, the nurse is to make sure their documentation left with them. After a couple of hours, after the resident has left, the nurse will call the hospital to see if the resident was admitted . Sometimes it is turned over to the next shift if the shift is ending. The CNA maybe in the room when the ambulance workers come but it is the nurse's responsibility to make sure the right resident goes out. The CNA will make sure the resident is clean and ready to go when the ambulance comes. Interview on [DATE] at 11:00 AM Staff E, LPN (7 AM-7 PM) stated, When a resident is transferred to the hospital, the doctor gives the order to send to the hospital. The family of the resident is notified about the transfer. The Administrator and the DON are notified about the transfer. We call the ambulance company. When they arrive, we give them the papers. We accompany them to the resident and show them that the resident is the resident and check the name bracelet. Interview on [DATE] at 11:18 AM Staff G, RN (7 AM-7 PM) stated, When the resident is going out to the hospital, the doctor will give me orders. I call the family to let them know the condition of the family. Call the ambulance and prepare the papers for the hospital. When the ambulance arrives, I take the ambulance workers to the resident's room. I have the CNA prepare the resident to go to the hospital. I give the paperwork. I check the ID (identification) wrist band. I ask the resident their name, check their computer picture and the chart picture (face sheet). I make sure the resident leaves the building with the ambulance worker. I walk outside with the patient to the ambulance because it is my responsibility. Interview on [DATE] at 2:46 PM via telephone Staff H, CNA (11 PM-7 AM) stated, I work on the ,d+[DATE] shift. I was not there when they sent the wrong patient to the hospital. I heard about it. When I got in she had already gone out. Interview on [DATE] at 3:02 PM via telephone Staff I, LPN (7 PM-7 AM) stated, I am new to the facility. I have only been working ,d+[DATE] months. I have never sent anyone out to the hospital but I have seen the other nurses take vitals, get paperwork together, get the med list for when the ambulance comes, when they come check their wristbands. Interview on [DATE] at 3:10 PM via telephone Staff J, CNA (3 PM-11 PM) stated, I don't remember working with her. Interview on [DATE] at 5:22 PM via telephone, Resident #1's Daughter stated, My mother passed away on Saturday. They called and told me my mother was at a local hospital and when I called there, they gave me vital signs for someone else. That means my mother never left the facility. They called me the next day to say they were sending my mother to another local Hospital. My mother was in the hospital for three weeks. She went on hospice, came home and died . During an interview on [DATE] at 2:43 PM with the Administrator it was stated, The clarification PTO (Physician Telephone Order) was done because the doctor made a mistake. The two roommates were going out to the hospital and he got them mixed up. There was no lab work done for Resident #5 on [DATE]. She was sent out for altered mental status. During an interview on [DATE] at 4:12 PM via telephone, Resident's #5 daughter's stated, The next day they contacted me that mother was at the hospital at night. I do not remember the exact time but it was at night. They told us she had too much sodium in her system, that is why she was sent to the hospital. They sent her to the hospital and we questioned it. They said it was a doctor's order. During an interview on [DATE] at 9:24 AM the DON stated, The patient transfer form was sent with the ambulance workers dated [DATE] with the reason for the transfer was altered mental status. Initially the doctor ordered via telephone for the resident to be transferred to the hospital for significant abnormal labs on [DATE]. Later a clarification order was done via telephone on [DATE] to send to the hospital due to altered mental status. The doctor came in on [DATE] to sign off on the telephone order. There is a written progress note written on [DATE]. The note: Dated [DATE] at 8:00 AM-Resident exhibit s/s of confusion. Dated [DATE] at 9:15 AM-MD aware about resident's confusion and agitation. Dated [DATE] at 11:30 AM-Due to past history of CVA ([CONDITION(S)] accident) resident will be transferred to hospital as per doctor order. She was sent out because on the MAR (Medication Administration Records) her blood sugar was elevated. For a couple of days her blood sugar was elevated at 399, 391, 393 and on [DATE], 293. (American Diabetic Association (ADA) recommendation for someone with diabetes is: ,d+[DATE]. Blood sugar 2 hours after meals. A normal for person without diabetes: Less than 140). The DON added that, Both residents who were roommates were ordered to go to the hospital on the same day on [DATE]. The ambulance was supposed to pick up Resident #1, but instead picked up Resident #5. Resident #5 was sent with Resident #1's information instead of her own. During an interview on [DATE] at 9:50 AM via telephone with Resident's #5 Attending Physician it was stated, This patient had uncontrolled glucose. I received a call about the patient. The nurse told me she had altered mental status and with [CONDITION(S)]. I ordered labs to be done at the hospital because of the altered mental status. The first telephone order was an error. During an interview on [DATE] at 10:25 AM with Staff B, RN, Nurse Supervisor for the morning shift it was stated, I called the ambulance for both residents Resident #1 and Resident #5. The discharge papers for both residents were prepared by me. I was not here when the ambulance was coming because my shift was changing. There was a delay in the ambulance. Resident #5 went out with Resident #1's paperwork. The next morning when I made the rounds, I noticed the mistake. I checked the computer for her picture and looked at her name band. Resident #5 paperwork was still here. I called the hospital to let them know that was the wrong patient. I spoke with the admissions department. I called 911 for Resident #1 to go out. They checked the records and it was a mistake, they had Resident #1's paperwork instead of Resident #5. I was here when emergency rescue came to take Resident #1. I called a local agency to let them know a mistake was made. I called the local hospital to make sure Resident #1 was admitted . I faxed the correct paperwork to the hospital on Resident #5. Interview on [DATE] 10:06 AM via telephone, the Medical Director who is also Resident #1's Attending Physician stated, When the nurse called me from the facility about Resident #1, I gave the order to send her to the hospital on [DATE]. I found out later, another patient was sent to the hospital, her roommate Resident #5. When the ER (emergency room ) doctor called me about her admission, the labs were abnormal. I was at the hospital at the time and noticed she was not my patient because it was a mistake. I clarified the situation. I then called the facility and spoke to the nurse and they told me there was a mistake. The ER doctor explained to me about her condition and advised that we admit her. I wrote the PTO order for Resident #1 due to her rectal bleeding. She could be sent by regular ambulance. I do not think there would have been any complications due to her delay. When I found out that she was not sent to the hospital, I told them to send her out by 911. When I write a telephone order or a physician writes a telephone for the resident to go to the hospital, the expectation is for them to send the patient out to the hospital when an order is given. I have been the Medical director for one year. I am supposed to be notified or the attending physician immediately when there is an error in resident transfer and delay of treatment. Record review of the hospital records for Resident #1 revealed, the resident was admitted to local hospital's emergency roiagnom on [DATE] at 9:35 AM and discharged on [DATE] under hospice care. The hospital's triage note indicated the resident was brought by rescue for rectal bleeding for 2 days. Emergency care documentation revealed, Resident # 1 for Respiratory- with notation of scattered Rhonchi ( low-pitched wheezes). Gastrointestinal documentation included but were not limited to Brown Stool which is Hemoccult Positive. Neurological note indicated, Moving arms, bedridden with chronic appearing leg weakness, following minimal commands, moans and yells. Psychiatric: anxious and yelling out a lot, obviously confused/demented. Medical decision making differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Inpatient Orders included: Oxygen therapy by nursing, Transfuse Red Blood Cells Active Bleed-Adult. Review of the hospital's laboratory records revealed, Resident #1's Hgb 6.4 g/dl (critical), Hct 21.2 %-Low, Lactic Acid 3.8 mmol/L(millimoles/liter) (critical) and Sodium level 160 mmol/L-high. Review of the History of present illness documentation revealed, Resident #1 was transferred from the emergency department to the Intensive Care Unit. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient separately transferred to hospice care for palliation. Interview on [DATE] at 1:15 PM, the Administrator revealed, that after the incident, the facility changed the beds from A and B to door and window. The facility has implemented a 2 person identifier process. Whenever an order is received from the physician for a resident's transfer and the ambulance company is called. The ambulance company, the nurse and the CNA must go to the room with them to make sure the right resident is being transferred by checking the arm bands. If the resident is alert and oriented they will speak to the resident and verify the resident's name. If the resident is not alert and oriented they will look at the picture in the computer on the face sheet and match it to the name band on the wrist to ensure it is the right resident. When the resident is on the gurney, they should check the name band and make sure the documents going out matches the arm band of the resident. So that when the resident arrives at the receiving facility, everything goes with that resident. The Administrator revealed, that audits are conducted every morning and the admissions department goes into the rooms and check the arm bands of every resident. Record review of the documentation provided by the facility related to corrective actions implemented, revealed in-service sign in sheets for trainings provided to licensed nurses and CNAs [DATE] to [DATE], for abuse and neglect, and transfer and discharge. The Nurse and the CNA are to verify and document on the facility document (undated) titled 2 person identifier for transfers to the hospital/discharges to the community that documents staff should document the following information: Resident Name, Room #, Date, Time of transfer, transferring location, reason/diagnosis, nurse initials and CNA initials; with instructions to place in the residents medical records. Review of the audit logs revealed, the audits for the arm band/door tag checks were implemented on [DATE] and were ongoing.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to neglect and abuse resulting in repeated deficient practice. The facility's history includes repeated deficient practice for substandard quality of care related to abuse and neglect in the year 2019, 2020 and 2021. The findings included: Record view of the facility's policy titled, Quality Assessment and Assurance Committee protocol written by the Administrator and the revision date was on 08/2006, the policy documented: This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. The committee will meet monthly to review quality of care. The following individuals will serve on the committee: Committee Chairperson, Administrator, Director of Nursing Services, Medical Director, Dietary Representative, Pharmacy Representative, Social Services Representative, Activities Representative, Environmental Services Representative, Infection Control Representative, Rehabilitative/Restorative Services Representative, Staff Development Representative, Safety Representative and Medical Records Representative. The primary goals of the Quality Assessment and Assurance Committee are: 1) To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan; 2) To oversee facility systems and processes related to improving quality of care and services and 3) To help identify negative outcomes relative to resident care and resolve them appropriately. Review of the Quality Assurance and Performance Improvement (QAA) Committee Meeting Sign-in Sheets dated 2/09/21 (January meeting), 3/09/21 (February meeting) & 4/13/21 (March meeting) and 5/11/21 (April meeting): documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 4/28/21 at 12:03 PM, the Administrator/Risk Management/QAA stated; QAA meets monthly on Tuesdays. The committee consist of the Administrator, DON, Medical Director, and other members of the team. QAA meeting has an agenda every month. Each department reports what is going on in their department. Month to month is different on how to improve on the situation that is going on in the building. The QAPI (Quality Assurance Performance Improvement) meeting in April will be for March 2021 and we will be discussing about abuse and neglect. We changed the beds from A and B to Door and Window. Every resident has an arm band on. Every morning Admissions make sure new admissions have a wrist band moving forward. We also conduct a visual audit daily making sure the wristbands are on the right resident and that they are wearing them. On 6/04/21 at 1:15 PM, the Administrator/Risk Management/QAA stated; QAA meets monthly on Tuesdays. Committee consist of the Administrator, DON, Medical Director, and other members of the team. QAA meeting has an agenda every month. Each department reports what is going on in their department. We changed the beds from A and B to Door and Window. We now have a 2 Person identifier process. When they receive an order from the physician they are going to carry out the transfers. They will call the ambulance company, the ambulance company the nurse and the Certified Nursing Assistant (CNA) must go to the room with them to make sure the right resident is being transferred. By checking the arm bands. If the resident is alert and oriented they will speak to the resident and they will answer their name. If not, alert and oriented they will look at the picture in the computer on the face sheet and match it up with the name band on the wrist to ensure the right resident. When the resident is on the gurney, they should check the name band and make sure the documents going out matches the arm band of the resident. So, when the resident gets to the receiving facility, everything goes with that resident. Audits are conducted every morning. Admissions go into the rooms and check the arm bands of every resident. We have twelve residents who are alert and oriented who refuse to wear arm bands and they are care planned for it.

Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by the facility's staff failure to provide care and services including adequate supervision for one (resident #1) out of three residents sampled during the time of this survey. Due to the deficient practices, Resident #1 who displayed exit seeking behaviors, was documented as a high risk for elopement and on 8/14/20 at 11:40 PM eloped from the facility undetected through an emergency exit door in the lobby area of the facility. The resident was not located until 2:00 PM on 8/15/20 at his home 5.9 miles from the facility by a family member who reported resident #1's location to the facility. Refer to F 600, F 689, F 835 and F 867. The findings included: Review of the facility's policy titled, Abuse, Neglect and Exploitation protocol written by the Administrator and the revision date was on 11/2019, the policy documented: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse, corporal punishment or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. A prompt thorough investigation will be conducted by the facility immediately. The facility's Policies and Procedures did not directly address neglect. Review of the Face Sheet for Resident #1 documented, the resident was admitted to the facility on [DATE] after being discharged from a local hospital following an incident where he was found unresponsive outside a local grocery store. Clinical [DIAGNOSES REDACTED]. Record review, observation of the facility's video footage and interviews revealed, the facility's staff had opportunities to prevent the elopement of resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address resident #1's displayed exit seeking behaviors and intent of elopement. The resident wore an alarm bracelet on his left arm that was not triggered when the resident eloped. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on 8/14/20 at 11:40 PM. Review of Resident's #1 Behavioral Symptoms care plan dated 8/14/20 documented the resident exhibits the following behavior: elopement, observed trying to leave the facility with no apparent reason; Goal: Episodes of problem behavior will decrease to one a (week/month) thru next review date; Approaches: Keep resident safe with close supervision, Keep wander guard in place at all times; Make staff aware of resident's high risk for elopement; Monitor resident's whereabouts at frequent intervals. Review of the nursing progress notes documented the following: Dated 8/12/20 time stamped 2:19 PM- Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/13/20 time stamped 2:51 PM-Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/14/20 time stamped 7:15 AM (Recorded as Late Entry on 8/15/20 time stamped 1:40 AM)-Patient is able to ambulate with a walker. While giving patient medication at 6:00 AM, patient stated that he wanted to go out to pay some bills. Patient was redirected by the nurse and the nurse told him that he is not allowed to go out of the facility. Patient was able to understand and was placed inside of his room under close monitoring. Report were giving to the next shift nurse about the patient statement. Patient is placed in his room and under close monitoring; Dated 8/14/20 time stamped 7:27 PM-Resident walks frequently in and out bed, became anxious and is consistently asking to go home. Resident proceeds to open the door on several attempts. Resident was redirected, placed on close monitoring for elopement precaution; wander guard placed on resident's left arm. Sister was notified of the resident's behavior and elopement; Nursing progress note dated 8/14/20 time stamped 8:00 PM (Recorded as Late Entry on 8/15/20 time stamped 9:54 AM)-Resident received out of bed (OOB) at side door of facility ambulating with walker very agitated and trying to leave the facility. Awake Alert Oriented times two (AAOX2) with confusion. Resident was redirected on numerous occasions but insisted on leaving and wound not stay in room. One to one care implemented with Certified Nursing Assistants (CNAs) on duty. Wander guard in place and working; Dated 8/14/20 time stamped 11:00 PM-Resident noted in hallway in wheelchair (w/c). One to one monitoring continues with CNA on duty. Wander guard still in place for precaution. Nursing progress note dated 8/14/20 time stamped 11:40 PM-After the change on shift, the CNA on duty reported to assigned nurse that she brought the patient to his room and left him unattended. When she returned she noticed that the patient was missing. An extensive search of the facility and surrounding communities ensued. However, resident was unable to be located. Review of the physician's orders [REDACTED]. Medications were: [MEDICATION NAME] 10 milligrams (mg) 1 tablet oral once a day at 9:00 AM for hypertension, he missed the 9:00 AM dose on 8/15/20; [MEDICATION NAME] 25 mg( indicated for the treatment of [REDACTED].)1 cap every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, he missed the doses on 8/15/20; [MEDICATION NAME] ER 24 hour. 25 mg ( indicated for the treatment of [REDACTED]. Review of the Physical Therapy Evaluation and Plan of Treatment dated 8/13/20, documented resident #1 was certified to received physical therapy on 8/12/20 and was referred due to new onset of decrease in strength, decrease in functional mobility and decrease in transfers. The resident was at risk for falls. He was scheduled to receive physical therapy 6 times a week, daily. Review of the Physical Therapy Treatment Encounter Notes documented the following: Dated 8/13/20: Patient was observed ambulating in the hallway using a walker (not provided by rehab), he was standing at the nursing station, he was redirected back to his room and advised that he must remain in room as precaution; Dated 8/14/20: Resident observed standing at the nursing station. He was redirected and taken back to his room. Nursing made aware. Demonstrates impaired foot placements and walker management. He is not safe to ambulate alone, patient refused to release walker to therapist in an effort to prevent self-ambulation and falls. Review of the Physical Therapy Discharge Summary dated 8/17/20, documented the patient was advised on not ambulating alone. During observational review of the facility's video footage with the Administrator and Corporate staff on 8/18/20 at 12:23 PM. The video footage revealed that on 8/14/20 at 11:23 PM, resident #1, dressed in a black colored pants and green shirt was standing at the doorway to his room, during this time staff were observed in the hallway. On 8/14/20 at 11:37 PM, resident #1 ambulated from his room with no assistive device and proceeded through the double door that lead to the lobby area of the facility. Resident #1 attempted to open the front doors of the facility and was unsuccessful. Resident #1 then walked to the emergency fire exit door located at the side near the administration office, Resident #1 then pushed the door open without any difficulty at 11:40 PM on 8/14/20 and exited the facility undetected by staff. There was a nurse seated at the nurses' station and a Certified Nursing Assistant (CNA) had just walked past the resident's room down the hallway where the double doors leading to the lobby were located. Resident # 1 had a Wander Guard Bracelet on the wrist of his left arm and an identification band on his right wrist. The alarm on the exit door was not audible for staff to hear on any of floors in the facility within the care areas beyond the double doors. The wander guard alert system did not trigger to alert staff. (Video footage obtained) On 08/18/2020 at approximately 1:00 PM after review of the above mention video footage, the Senior Administrator and the Chief Nursing Officer conducted a demonstration with the state surveyor of the alarm door's audibility. During this demonstration it was revealed that the alarm for the emergency exit door was still not audible beyond the double doors in the lobby and could not be heard in the care areas, at the 1st floor front nurses' desk nor on the 2nd floor. the Senior Administrator and the Chief Nursing Officer at this time determined and acknowledged that the audible alarm for the fire emergency door was not loud enough and could not be heard at the 1st floor front nurses' desk nor on the 2nd floor and beyond the double doors in the lobby. During interview on 8/18/20 at 11:08 AM the Administrator/Risk Manager reported that, Resident #1 was put to bed by the 11:00 PM to 7:00 AM CNA (Staff B) and the CNA (Staff B) left the room and went to take care of another resident. When Staff B was done and went back to check on Resident #1 he was missing. Staff B notified the Licensed Practical Nurse (LPN) (Staff D) and Registered Nurse (RN) (Staff A), the Supervisor. They activated Code Pink (the facility's elopement code), they searched the whole facility and the outside grounds. They notified the Police Department and the sister. The police officer came and did a report. The police was given a description and a picture of Resident #1. The Administrator/Risk Manager reported that the police officer stated he was going to go look for the resident. The DON (Director of Nursing) came in to help with the facility search as soon as she was notified. The DON called the sister and started doing the reporting to all the local agency and the 1-day report. Immediate in-servicing was done to staff that were in the building. The Administrator/Risk Manager stated, We called the nearby hospitals the next day. A little bit before 2:00 PM the next day, the sister called and she said he was found at his house. She said that he preferred to stay at home with her and we notified the doctor and he was okay with it. We did an AMA (Against Medical Advice) form over the phone and we notified the police department that he was found. The resident had a Wander Guard. He took the Wander Guard off before leaving the facility. The sister said that he told her that he took the Wander Guard off. We believe he got out through the side door by my office. The sound on the alarm was not loud enough for the 1st floor nurses' station to hear it. Since then, maintenance made the alarm louder and placed a baby monitor at the 1st floor nurses' station. During interview on 8/18/20 at 11:20 AM, the DON stated, The supervisor notified me. I immediately got to the facility, we continued searching the facility code pink. I got in contact with the sister several times, back and forth. I immediately in-serviced the staff about elopement, one on one and reporting. We called maintenance so they can come in and look at the door. We did the reporting. Stayed in contact with the sister throughout the morning. The DON stated that Resident #1's sister told her at around 12:00 PM on 8/15/2020 that she was on her way to his address to see if he was there. The DON stated, once she got there she called me and said he was in good condition and did not want to return to the facility. The AMA form was signed verbally. The police department was notified and turned it over to another police department who were going to do wellness check. The doctor was notified. During interview on 8/18/20 at 1:00 PM, the Director of Environmental Services stated, He tried to get out when I was with him on that day (8/14/20). I told them he was an elopement risk. They chose to put a Wander Guard on him and I checked it. The Wander Guard went off at all the doors (front, side door by nurses' station and back door used for delivery) and was able to be heard all over the building. During interview on 8/18/20 at 3:16 PM Staff A, a Registered Nurse Supervisor for the 7:00 PM to 7:00 AM shift stated, on that Friday night, my shift was 3:00 PM to 11:00 PM, he (resident #1) was having issues on getting out. It was told to me that he was having a problem getting out, he wanted to go home. I was told by the DON, that they had put a Wander Guard on him. At that point, I initiate one CNA in his room. I told the CNA; I was going to put her in that room. He was fine, walking around, going to the nurses' station. He was sitting in front of the nurses' station. He still wanted to go home. I contacted the sister, so he could talk to his sister. He wanted to go home before coming to the facility. I told the sister that her brother wanted to go home that he had a wander guard which was a device that alarms when he is close to the door. He was sitting down talking to his sister, he put down the phone. I told all the CNAs working on that shift to watch him. The CNA was following him, where ever he went. After dinner, I went upstairs. I was supervising the whole building. When I came back down, he was quiet and moving around. He was trying to get out of the double doors, and the Wander Guard alarm went off and he was taken back to the nurses' station early in the evening. Around 11:20 PM to 11:40 PM, I heard the nurse say check the rooms. I asked what is going on, they say he is not in his room. They noticed during the changing of shift that the CNA on 3:00 PM to 11:00 PM shift told (Staff B) to watch him on the 11:00 PM to 7:00 PM shift. (Staff B) took the patient to the room and left him lying down to sleep. (Staff B) went to another room to change a patient but when Staff B returned the resident (resident #1) was no longer in the bed. She said she was gone for 5 to 7 minutes. I called the DON immediately. Most of the CNAs went outside on the streets, searching for the patient. Staff in the facility were searching room to room, bathroom to bathroom. The DON came here. I called the police to report the resident missing. He was wearing a lime green shirt with black pants. The Police Officer came and took the report and gave a case number. I called doctor (Attending Physician) to tell him the resident is missing. He wore the Wander Guard on his left arm. When he got out, I did not hear the alarm because I was on the second floor. (Staff B) said she didn't hear the alarm go off. During interview on 8/18/20 at 4:30 PM via telephone interview Staff B, a Certified Nursing Assistant (CNA) 11:00 PM to 7:00 PM shift stated, I came to work at 11:00 PM. I put him (resident #1) in the room at 11:20 PM. I go take care of another patient and when I finished, I went back to his room. When I go to the room, I don't see him. They called the Administrator, the DON. Everyone was looking for him. They saw on the video he left at 11:40 PM. I had eleven patients that night. He was not on one to one. The CNA before told me to watch him. The nurse never told me to watch him. I don't remember no Wander Guard bracelet on him. I didn't hear an alarm. During interview on 8/18/20 at 6:28 PM via telephone, Resident's #1 sister stated, I don't know about an AMA (Against Medical Advice). We didn't try to get him to go back to the facility. He didn't want to go back to the facility. He doesn't have a court order to be there, so we can't force him. He is living on his own. I called them to let them know the police was here at his place. He doesn't use a walker or a cane. Since he has been out, he has not seen a doctor. During interview on 8/19/20 at 11:35 AM via telephone interview, Staff C, a Registered Nurse Supervisor for the 7:00 AM to 7:00 PM shift stated, the resident (resident #1) left Friday night. I got the report on Saturday morning. I called the sister and she said that the brother was with her. The family agreed to keep him. They felt he would go right back home. She gave permission for the AMA and I explained to her what the AMA was. During interview on 8/19/20 at 2:33 PM with Staff D, a Licensed Practical Nurse that worked 7:00 PM to 7:00 AM shift stated, When I got in (resident #1) he seemed agitated and he was trying to leave the building. They had him on one to one monitoring. I spoke to him briefly to see where his mindset was. He seemed to be alert and oriented times two. He was confused. They continued him on one to one monitoring. I checked his vitals at 11:00 PM, I wrote it down. No meds were to be given at that time. The 3:00 PM to 11:00 PM shift still had him on monitoring and on the 11:00 PM to 7:00 AM shift. I was on the side where (resident #1) was from 11:00 PM to 11:15 PM and he was in his room. At 11:15 PM, I went to the south side, which was my side. Around 11:25 PM, the CNA(Staff B) came to me and said we can't find (resident #1). Staff D reported that the CNA stated that resident #1 was placed in his room, and when the CNA, Staff B returned to the room resident #1 was not there. Staff D, LPN stated, I started searching every room. I searched rooms, bathrooms, patios. I didn't find anything. I started searching around the facility and the community. A code pink was started and everyone was searching. The police was notified, his sister was notified. All of the notifications were done by the supervisor on duty at that time. He had a Wander Guard bracelet on. I can't remember which arm it was on. During interview on 8/19/20 at 3:16 PM Staff E, a Registered Physical Therapist reported, Resident #1 was not safe to ambulate alone, determined on 8/12/20 evaluation date. Nursing was made aware; he is not safe to ambulate alone. During interview on 8/20/20 at 12:20 PM the Administrator/Risk Manager stated, We don't have a policy on one to one supervision. We would need a doctor's order for one to one supervision. If they are at risk for elopement we will call the doctor to obtain the order. You need a doctor's order for a true one to one. Once the resident is exhibiting the behaviors, we call the doctor to obtain an order. If he doesn't order, we put them on close supervision, which is technically a one to one. We notified the doctor that he had eloped. We called the family member and were informed that the resident did not want to come back and did a verbal AMA on the phone with family member. We called the doctor a second time to notify him of an AMA. They had told me in the afternoon that he was exit seeking, the Wander Guard was put on him and working and on close supervision. When we came to figure out, how he got out, we became aware of him using the fire exit door. At night when there is no noise, you should be able to hear the alarm. A baby monitor was added on Tuesday, 8/18/20 at the nurses' station to monitor if and when the fire exit door is opened. We felt we had fixed it by putting the key card at the doors. We could not put a key card at the fire exit door. On 8/20/20 to 8/21/20, the corrective actions verified by the survey team related to the facility's failure to implement their abuse and neglect policy included: The staff were in-serviced/trained on 8/15/20 for 7:00 AM-7:00 PM shift, 7:00 PM-7:00 AM shift for nurses, 7:00 AM-3:00 PM shift, 3:00 PM-11:00 PM shift and 11:00 PM-7:00 AM shift for certified nursing assistants (CNA) regarding: Wandering precautions and wander guard device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on 8/15/2020 and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code pink, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 8/15/20 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on 8/15/2020 and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. Prompt re-training was initiated on 8/15/20 for all shifts regarding Abuse Reporting, Need for 1 to 1, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1 and Code Pink.

Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of three residents sampled during the time of this survey. The facility's staff failed to supervise and implement adequate measure to prevent the elopement of Resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. The resident wore an alarm bracelet on his left arm that was not triggered when the resident eloped. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on 8/14/20 at 11:40 PM. The resident was not located until 2:00 PM on 8/15/20 at his home 5.9 miles from the facility by a family member who reported Resident #1's location to the facility. There were 83 residents residing in the facility at the time of the survey. Refer to F 607, F 689, F 835 and F 867. The findings included: Review of the facility's policy titled, Abuse, Neglect and Exploitation protocol written by the Administrator with a revision date of 11/2019, indicated: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse, corporal punishment or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. A prompt thorough investigation will be conducted by the facility immediately. The facility's Policies and Procedures did not directly address neglect. Review of the Face Sheet for Resident #1 documented, the resident was admitted to the facility on [DATE] after being discharged from a local hospital following an incident where he was found unresponsive outside a local grocery store. Clinical [DIAGNOSES REDACTED]. Review of Resident #1's Behavioral Symptoms care plan dated 8/14/20 documented the resident exhibits the following behavior: elopement, observed trying to leave the facility with no apparent reason; Goal: Episodes of problem behavior will decrease to one a week/month thru next review date; Approaches: Keep resident safe with close supervision, Keep wander guard in place at all times, make staff aware of resident's high risk for elopement and monitor resident's whereabouts at frequent intervals. Review of the nursing progress notes documented the following: Dated 8/12/20 time stamped 2:19 PM- Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/13/20 time stamped 2:51 PM-Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/14/20 time stamped 7:15 AM (Recorded as Late Entry on 8/15/20 time stamped 1:40 AM)-Patient is able to ambulate with a walker. While giving patient medication at 6:00 AM, patient stated that he wanted to go out to pay some bills. Patient was redirected by the nurse and the nurse told him that he is not allowed to go out of the facility. Patient was able to understand and was placed inside of his room under close monitoring. Report was given to the next shift nurse about the patient statement. Patient is placed in his room and under close monitoring; Dated 8/14/20 time stamped 7:27 PM-Resident walks frequently in and out of bed, became anxious and is consistently asking to go home. Resident proceeds to open the door on several attempts. Resident was redirected, placed on close monitoring for elopement precaution; wander guard placed on resident's left arm. Sister was notified of the resident's behavior and elopement. Nursing progress note dated 8/14/20 time stamped 8:00 PM (Recorded as Late Entry on 8/15/20 time stamped 9:54 AM)-Resident received out of bed (OOB) at side door of facility ambulating with walker very agitated and trying to leave the facility; Awake Alert Oriented times two (AAOX2) with confusion. Resident was redirected on numerous occasions but insisted on leaving and wound not stay in room. One to one care implemented with Certified Nursing Assistants (CNAs) on duty. Wander guard in place and working; Dated 8/14/20 time stamped 11:00 PM-Resident noted in hallway in wheelchair (w/c). One to one monitoring continues with CNA on duty. Wander guard still in place for precaution. Nursing progress note dated 8/14/20 time stamped 11:40 PM-After the change on shift, the CNA on duty reported to assigned nurse that she brought the patient to his room and left him unattended. When she returned she noticed that the patient was missing. An extensive search of the facility and surrounding communities ensued. However, resident was unable to be located. Progress notes dated 08/15/2020 time stamped at 12:38 AM indicated, incident was reported to officer {name of police officer} via phone. Progress notes dated 08/15/2020 time stamped 1:10 AM indicated, officer on duty came to the facility and opened a report with {case #}. Search for resident continues. Review of the physician's orders [REDACTED]. Medications included: [MEDICATION NAME] 10 milligrams (mg) 1 tablet oral once a day at 9:00 AM for hypertension, Resident #1 missed the 9:00 AM dose on 8/15/20; [MEDICATION NAME] 25 mg( indicated for the treatment of [REDACTED].#1 missed the dose on 8/15/20; [MEDICATION NAME] HCL 25 mg (used chiefly to treat anxiety and alcoholism.)1 cap every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, Resident #1 missed all the doses on 8/15/20; [MEDICATION NAME] ER 24 hour. 25 mg ( indicated for the treatment of [REDACTED].#1 missed the dose on 8/15/20 and Potassium Chloride 25 mg 2 tabs daily at 9:00 AM, missed dose on 8/15/20. Review of the Physical Therapy Evaluation and Plan of Treatment dated 8/13/20, documented resident #1 was certified to receive physical therapy on 8/12/20 and was referred due to new onset of decreased strength, decrease in functional mobility and decrease in transfers. Resident #1 was at risk for falls and was scheduled to receive physical therapy 6 times a week, daily. Review of the Physical Therapy Treatment Encounter Notes documented the following: Dated 8/13/20: Patient was observed ambulating in the hallway using a walker (not provided by rehab), he was standing at the nursing station, he was redirected back to his room and advised that he must remain in room as precaution; Dated 8/14/20: Resident observed standing at the nursing station. He was redirected and taken back to his room. Nursing made aware. Demonstrates impaired foot placements and walker management. He is not safe to ambulate alone, patient refused to release walker to therapist in an effort to prevent self-ambulation and falls. Review of the Physical Therapy Discharge Summary dated 8/17/20, documented the patient was advised on not ambulating alone. During observational review of the facility's video footage with the Administrator and Corporate staff on 8/18/20 at 12:23 PM. The video footage revealed that on 8/14/20 at 11:23 PM, resident #1, was wearing a baseball type hat, dressed in a black colored short, bright green shirt and sneakers was standing at the doorway to his room, during this time staff were observed in the hallway. On 8/14/20 at 11:37 PM, resident #1 ambulated from his room with no assistive device and proceeded through the double door that lead to the lobby area of the facility. Resident #1 attempted to open the front doors of the facility and was unsuccessful. Resident #1 then walked to the emergency fire exit door located at the side near the administration office, Resident #1 then pushed the door open without any difficulty at 11:40 PM on 8/14/20 and exited the facility undetected by staff. There was a nurse seated at the nurses' station and a Certified Nursing Assistant (CNA) had just walked past the resident's room down the hallway where the double doors leading to the lobby were located. Resident # 1 had a Wander Guard Bracelet on the wrist of his left arm and an identification band on his right wrist. The alarm on the exit door was not audible for staff to hear on any of floors in the facility within the care areas beyond the double doors. The wander guard alert system did not trigger to alert staff.(video footage evidence obtained) On 08/18/2020 at approximately 1:00 PM after review of the above mention video footage, the Senior Administrator and the Chief Nursing Officer conducted a demonstration with the state surveyor of the alarm door's audibility. During this demonstration it was revealed that the alarm for the emergency exit door was still not audible beyond the double doors in the lobby and could not be heard in the care areas, at the 1st floor front nurses' desk nor on the 2nd floor. The Senior Administrator and the Chief Nursing Officer at this time determined and acknowledged that the audible alarm for the fire emergency door was not loud enough and could not be heard at the 1st floor front nurses' desk nor on the 2nd floor and beyond the double doors in the lobby. During interview on 8/18/20 at 11:08 AM the Administrator/Risk Manager reported that, Resident #1 was put to bed by the 11:00 PM to 7:00 AM CNA (Staff B) and the CNA (Staff B) left the room and went to take care of another resident. When Staff B was done and went back to check on Resident #1 he was missing. Staff B notified the Licensed Practical Nurse (LPN) (Staff D) and Registered Nurse (RN) (Staff A), the Supervisor. They activated Code Pink (the facility's elopement code), they searched the whole facility and the outside grounds. They notified the Police Department and the sister. The police officer came and did a report. The police was given a description and a picture of Resident #1. The Administrator/Risk Manager reported that the police officer stated he was going to go look for the resident. The DON (Director of Nursing) came in to help with the facility search as soon as she was notified. The DON called the sister and started doing the reporting to all the local agency and the 1-day report. Immediate in-servicing was done to staff that were in the building. The Administrator/Risk Manager stated, We called the nearby hospitals the next day. A little bit before 2:00 PM the next day, the sister called and she said he was found at his house. She said that he preferred to stay at home with her and we notified the doctor and he was okay with it. We did an AMA (Against Medical Advice) form over the phone and we notified the police department that he was found. The resident had a Wander Guard. He took the Wander Guard off before leaving the facility. The sister said that he told her that he took the Wander Guard off. We believe he got out through the side door by my office. The sound on the alarm was not loud enough for the 1st floor nurses' station to hear it. Since then, maintenance made the alarm louder and placed a baby monitor at the 1st floor nurses' station. During interview on 8/18/20 at 11:20 AM, the DON reported that she was notified at approximately 12:00 AM by the supervisor. The DON state,I immediately got to the facility,we continued searching. I got in contact with the sister several times, back and forth. I immediately in-serviced the staff about elopement, one on one and reporting. We called for maintenance to come in and look at the door. We did the reporting. Stayed in contact with the sister throughout the morning. The DON stated that Resident #1's sister told her at around 12:00 PM on 8/15/2020 that she was on her way to his address to see if he was there .The DON stated, Once she got there she called me and said he was in good condition and did not want to return to the facility. The Against Medical Advice ( AMA) form was signed verbally. The police department was notified and turned it over to another police department who were going to do a wellness check. The doctor was notified. During interview on 8/18/20 at 1:00 PM, the Director of Environmental Services stated, He tried to get out when I was with him on that day (8/14/20). I told them he was an elopement risk. They chose to put a Wander Guard on him and I checked it. The Wander Guard went off at all the doors (front, side door by nurses' station and back door used for delivery) and was able to be heard all over the building. During interview on 8/18/20 at 3:16 PM Registered Nurse Supervisor (Staff A) for the 7:00 PM to 7:00 AM shift stated, On that Friday night, my shift was 3:00 PM to 11:00 PM, he (resident #1) was having issues on getting out. It was told to me that he was having a problem getting out, he wanted to go home. I was told by the DON, that they had put a Wander Guard on him. At that point, I initiate one CNA in his room. I told the CNA; I was going to put her in that room. He was fine, walking around, going to the nurses' station. He was sitting in front of the nurses' station. He still wanted to go home. I contacted the sister, so he could talk to his sister. He wanted to go home before coming to the facility. I told the sister that her brother wanted to go home that he had a wander guard which was a device that alarms when he is close to the door. He was sitting down talking to his sister, he put down the phone. I told all the CNAs working on that shift to watch him. The CNA was following him, where ever he went. After dinner, I went upstairs. I was supervising the whole building. When I came back down, he was quiet and moving around. He was trying to get out of the double doors and the Wander Guard alarm went off and he was taken back to the nurses' station early in the evening. Around 11:20 PM to 11:40 PM, I heard the nurse say check the rooms. I asked what is going on, they say he is not in his room. They noticed during the changing of shift that the CNA on 3:00 PM to 11:00 PM shift told (Staff B) to watch him on the 11:00 PM to 7:00 PM shift. (Staff B) took the patient to the room and left him lying down to sleep. (Staff B) went to another room to change a patient but when Staff B returned the resident (resident #1) was no longer in the bed. She said she was gone for 5 to 7 minutes. I called the DON immediately. Most of the CNAs went outside on the streets, searching for the patient. Staff in the facility were searching room to room, bathroom to bathroom. The DON came here. I called the police to report the resident missing. He was wearing a lime green shirt with black pants. The Police Officer came and took the report and gave a case number. I called the doctor (Attending Physician) to tell him the resident is missing. He wore the Wander Guard on his left arm. When he got out, I did not hear the alarm because I was on the second floor. (Staff B) said she didn't hear the alarm go off. During interview on 8/18/20 at 4:30 PM via telephone Staff B, a Certified Nursing Assistant (CNA) 11:00 PM to 7:00 PM shift stated, I came to work at 11:00 PM. I put him (resident #1) in the room at 11:20 PM. I go take care of another patient and when I finished, I went back to his room. When I go to the room, I don't see him. They called the Administrator, the DON. Everyone was looking for him. They saw on the video he left at 11:40 PM. I had eleven patients that night. He was not on one to one. The CNA before told me to watch him. The nurse never told me to watch him. I don't remember no Wander Guard bracelet on him. I didn't hear an alarm. During interview on 8/18/20 at 6:28 PM via telephone, Resident's #1 sister stated, I have no idea what happened. They told me it was impossible for him to get out because he was wearing some type of bracelet. I spoke with the facility. I don't know about an AMA (Against Medical Advice). We didn't try to get him to go back to the facility. He didn't want to go back to the facility. He doesn't have a court order to be there, so we can't force him.They told me he must have taken off the bracelet but when I saw him it was still on. When I ask him, he won't tell me anything. His memory goes in and out. The police officer came by, they called me and I told them he was home. He is living on his own. I called them to let them know the police was here at his place. Since he has been out, he has not seen a doctor. During interview on 8/19/20 at 11:35 AM via telephone interview, Staff C, a Registered Nurse Supervisor for the 7:00 AM to 7:00 PM shift stated, I work on Friday, Saturday and Sunday. The resident (resident #1) left Friday night. I got the report on Saturday morning. I called the sister and she said that the brother was with her. The family agreed to keep him. They felt he would go right back home. She gave permission for the AMA and I explained to her what the AMA was. During interview on 8/19/20 at 2:33 PM with Staff D, a Licensed Practical Nurse that worked 7:00 PM to 7:00 AM shift stated, When I got in (resident #1) he seemed agitated and he was trying to leave the building. They had him on one to one monitoring. I spoke to him briefly to see where his mindset was. He seemed to be alert and oriented times two. He was confused. They continued him on one to one monitoring. I checked his vitals at 11:00 PM, I wrote it down. No meds were to be given at that time. The 3:00 PM to 11:00 PM shift still had him on monitoring and on the 11:00 PM to 7:00 AM shift. I was on the side where (resident #1) was from 11:00 PM to 11:15 PM and he was in his room. At 11:15 PM, I went to the south side, which was my side. Around 11:25 PM, the CNA(Staff B) came to me and said we can't find (resident #1). Staff D reported that the CNA stated that resident #1 was placed in his room, and when the CNA, Staff B returned to the room resident #1 was not there. Staff D, LPN stated, I started searching every room. I searched rooms, bathrooms, patios. I didn't find anything. I started searching around the facility and the community. A code pink was started and everyone was searching. The police was notified, his sister was notified. All of the notifications were done by the supervisor on duty at that time. He had a Wander Guard bracelet on. I can't remember which arm it was on. During interview on 8/19/20 at 3:16 PM Staff E, a Registered Physical Therapist stated, Resident #1 was scheduled to receive Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (SLP). He received an evaluation on 8/12/20 for PT, OT and SLP evaluation on 8/13/20. He was not safe to ambulate alone, determined on the evaluation dated 8/12/20. Nursing was made aware; he is not safe to ambulate alone. During interview the Administrator/Risk Manager on 8/20/20 at 12:20 PM stated, We don't have a policy on one to one supervision. We would need a doctor's order for one to one supervision. If they are at risk for elopement we will call the doctor to obtain the order. You need a doctor's order for a true one to one. Once the resident is exhibiting the behaviors, we call the doctor to obtain an order. If he doesn't order, we put them on close supervision, which is technically a one to one. We notified the doctor that he had eloped. We called the family member and were informed that the resident did not want to come back and did a verbal AMA on the phone with family member. We called the doctor a second time to notify him of an AMA. They had told me in the afternoon that he was exit seeking, the Wander Guard was put on him and working and on close supervision. When we came to figure out, how he got out, we became aware of him using the fire exit door. At night when there is no noise, you should be able to hear the alarm. A baby monitor was added on Tuesday, 8/18/20 at the nurses' station to monitor if and when the fire exit door is opened. We felt we had fixed it by putting the key card at the doors. We could not put a key card at the fire exit door. On 8/20/20 to 8/21/20, the corrective actions related to the facility's failure to prevent the neglect verified by the survey team through observations, record review and interviews included: The staff were in-serviced/trained on 8/15/20 for 7:00 AM-7:00 PM shift, 7:00 PM-7:00 AM shift for nurses, 7:00 AM-3:00 PM shift, 3:00 PM-11:00 PM shift and 11:00 PM-7:00 AM shift for certified nursing assistants (CNA) regarding: Wandering precautions and wander guard device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on 8/15/2020 and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code pink, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 8/15/20 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on 8/15/2020 and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. Prompt re-training was initiated on 8/15/20 for all shifts regarding Abuse Reporting, Need for 1 to 1, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1 and Code Pink.

Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (resident #1) out of three sampled residents with exit seeking behaviors. This deficient practice enabled resident #1 to exit the facility at 11:40 PM on 8/14/20, undetected. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place allowed the resident to elope undetected by staff on 8/14/20 at 11:40 PM. The resident was not located until 2:00 PM on 8/15/20 at his home 5.9 miles from the facility by a family member who reported resident #1's location to the facility. There were 83 residents residing in the facility at the time of the survey. Refer to F 600, F 607, F 835 and F 867. The findings included: Review of the facility's policy titled, Elopement revised February 2019 indicated: Policy Statement: Staff shall investigate and report all cases of missing residents. Elopement is defined as a resident leaving an area of supervision to an area of non-supervision. Review of the Face Sheet for Resident #1 documented, the resident was admitted to the facility on [DATE] after being discharged from a local hospital following an incident where he was found unresponsive outside a local grocery store. Clinical [DIAGNOSES REDACTED]. Review of the Wandering Observation Guide dated 8/14/20 documented resident #1 was ambulatory and had a history of [REDACTED]. Review of the Brief Interview for Mental Status (BIMS) dated 8/12/20 documented resident #1 had a BIMS Summary Score of 9 out of 15 indicating moderate impairment and noted that the resident was confused but is able to make needs known and can follow simple commands. Review of Resident's #1 Behavioral Symptoms care plan dated 8/14/20 documented the resident exhibits the following behavior: elopement, observed trying to leave the facility with no apparent reason; Goal: Episodes of problem behavior will decrease to one a (week/month) thru next review date. Approaches: Keep resident safe with close supervision, keep wander guard in place at all times, make staff aware of resident's high risk for elopement and monitor resident's whereabouts at frequent intervals. Review of the physician's orders [REDACTED]. Medications were: [MEDICATION NAME] 10 milligrams (mg) 1 tablet oral once a day at 9:00 AM for hypertension, he missed the 9:00 AM dose on 8/15/20; [MEDICATION NAME] 25 mg ( indicated for the treatment of [REDACTED].)1 cap every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, he missed the doses on 8/15/20; [MEDICATION NAME] ER 24 hour. 25 mg ( indicated for the treatment of [REDACTED]. Review of the nursing progress notes documented the following: Dated 8/12/20 time stamped 2:19 PM- Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/13/20 time stamped 2:51 PM-Resident observed in bed in lowest position, resident observed anxious getting out of the bed and room, voicing he has to go home; Dated 8/14/20 time stamped 7:15 AM (Recorded as Late Entry on 8/15/20 time stamped 1:40 AM)-Patient is able to ambulate with a walker. While giving patient medication at 6:00 AM, patient stated that he wanted to go out to pay some bills. Patient was redirected by the nurse and the nurse told him that he is not allowed to go out of the facility. Patient was able to understand and was placed inside of his room under close monitoring. Report were giving to the next shift nurse about the patient statement. Patient is placed in his room and under close monitoring; Dated 8/14/20 time stamped 7:27 PM-Resident walks frequently in and out bed, became anxious and is consistently asking to go home. Resident proceeds to open the door on several attempts. Resident was redirected, placed on close monitoring for elopement precaution; wander guard placed on resident's left arm. Sister was notified of the resident's behavior and elopement. Nursing progress note dated 8/14/20 time stamped 8:00 PM (recorded as late entry on 8/15/20 time stamped 9:54 AM)-Resident received out of bed (OOB) at side door of facility ambulating with walker very agitated and trying to leave the facility, Awake Alert Oriented times two (AAOX2) with confusion. Resident was redirected on numerous occasions but insisted on leaving and wound not stay in room. One to one care implemented with Certified Nursing Assistants (CNAs) on duty. Wander guard in place and working; Dated 8/14/20 time stamped 11:00 PM -Resident noted in hallway in wheelchair (w/c). One to one monitoring continues with CNA on duty. Wander guard still in place for precaution. Nursing progress note dated 8/14/20 time stamped 11:40 PM- After the change on shift, the CNA on duty reported to assigned nurse that she brought the patient to his room and left him unattended. Upon return she noticed that the patient was missing. An extensive search of the facility and surrounding communities ensued. However, resident was unable to be located. Review of the Physical Therapy Evaluation and Plan of Treatment dated 8/13/20, documented resident #1 was certified to received physical therapy on 8/12/20 and was referred due to new onset of decrease in strength, decrease in functional mobility and decrease in transfers. The resident was at risk for falls. He was scheduled to receive physical therapy 6 times a week, daily. Review of the Physical Therapy Treatment Encounter Notes documented the following: Dated 8/13/20: Patient was observed ambulating in the hallway using a walker (not provided by rehab), he was standing at the nursing station, he was redirected back to his room and advised that he must remain in room as precaution; Dated 8/14/20: Resident observed standing at the nursing station. He was redirected and taken back to his room. Nursing made aware. Demonstrates impaired foot placements and walker management. He is not safe to ambulate alone, patient refused to release walker to therapist in an effort to prevent self-ambulation and falls. Review of the Physical Therapy Discharge Summary dated 8/17/20, documented the patient was advised on not ambulating alone. During observational review of the facility's video footage with the Administrator and Corporate staff on 8/18/20 at 12:23 PM. The video footage revealed that on 8/14/20 at 11:23 PM, resident #1 dressed in a black colored pants and green shirt was standing at the doorway to his room, during this time staff were observed on the hallway. On 8/14/20 at 11:37 PM resident #1 ambulated from his room with no assistive device and proceeded through the double door that lead to the lobby area of the facility. Resident #1 attempted to open the front doors of the facility and was unsuccessful. The resident then walked to the emergency fire exit door located at the side near the administration office, the resident pushed the door without any difficulty at 11:40 PM on 8/14/20 and exited the facility undetected by staff. There was a nurse seated at the nurses' station and a Certified Nursing Assistant (CNA) had just walked past the resident's room down the hall where the double doors leading to the lobby were located. The resident had a Wander guard Bracelet on the wrist of his left arm and an identification band on the right wrist. The alarm on the exit door was not audible for staff to hear on any of the floors in the facility within the care areas beyond the double doors. The wander guard alert system did not trigger to alert staff. Based on the reviewed facility's video footage, the facility's staff had opportunities to prevent the elopement of resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address resident #1's displayed exit seeking behaviors and intent of elopement. Resident #1 had an alarm bracelet on his left arm that was not triggered when he eloped. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place allowed the resident to elope undetected by staff on 8/14/20 at 11:40 PM. Based on observational tour of the facility's parameter increased risk factors included the fact that, the facility is located in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Both locations where the facility is located and the location where the resident was found the next day, are high traffic areas with busy two lane roads and four lane cross streets. A review of the National Weather Service climate Data for the Miami area on August 14, 2020 to August 15, 2020 ranged at record breaking temperatures of 82 degrees Fahrenheit (F) to 92 degrees F. During interview on 8/18/20 at 11:08 AM the Administrator/Risk Manager reported that, Resident #1 was put to bed by the 11:00 PM to 7:00 AM CNA (Staff B) and the CNA (Staff B) went to take care of her next resident. When Staff B was done and went back to check on him and he was missing. Staff B notified the Licensed Practical Nurse (LPN) (Staff D) and Registered Nurse (RN) (Staff A), the Supervisor. They activated Code Pink which is our elopement code, they searched the whole facility and the outside grounds. They notified the Police Department and the sister. The police officer came and did a report. The police was given a description and a picture of Resident #1 and the police officer stated that he was going to go look for the resident. The DON (Director of Nursing) came in to help with the facility search as soon as she was notified. The DON called the sister and started doing the reporting to all the local agency and our 1-day report. Immediate in-servicing was done to staff that were in the building. The administrator stated , We called the nearby hospitals the next day. A little bit before 2:00 PM the next day, the sister called and she said he was found at his house. She said that he preferred to stay at home with her and we notified the doctor and he was okay with it. We did an AMA (Against Medical Advice) form over the phone and we notified the police department that he was found. The resident had a Wander Guard. He took the Wander Guard off before leaving the facility. The sister said that he told her that he took the Wander Guard off. We believe he got out through the side door by my office. The sound on the alarm was not loud enough for the 1st floor nurses' station to hear it. Since then, maintenance made the alarm louder and placed a baby monitor at the 1st floor nurses' station. On 8/18/20 at 11:20 AM, the DON stated, The supervisor notified me. I immediately got to the facility, we continued searching the facility code pink. I got in contact with the sister several times, back and forth. I immediately in-serviced the staff about elopement, one on one and reporting. We called maintenance so they can come in and look at the door. We did the reporting. Stayed in contact with the sister throughout the morning. The DON stated that Resident #1's sister told her at around 12:00 PM on 8/15/2020 that she was on her way to his address to see if he was there. The DON stated, once she got there she called me and said he was in good condition and did not want to return to the facility. The AMA form was signed verbally. The police department was notified and turned it over to another police department who were going to do wellness check. The doctor was notified. During interview on 8/18/20 at 1:00 PM, the Director of Environmental Services stated, He tried to get out when I was with him on that day(8/14/20). I told them he was an elopement risk. They chose to put a Wander Guard on him and I checked it. The Wander Guard went off at all the doors (front, side door by nurses' station and back door used for delivery) and was able to be heard all over the building. During interview on 8/18/20 at 3:16 PM Staff A, a Registered Nurse Supervisor for the 7:00 PM to 7:00 AM shift stated, on that Friday night, my shift was 3:00 PM to 11:00 PM, he (resident #1) was having issues on getting out. It was told to me that he was having a problem getting out, he wanted to go home. I was told by the DON, that they had put a Wander Guard on him. At that point, I initiate one CNA in his room. I told the CNA; I was going to put her in that room. He was fine, walking around, going to the nurses' station. He was sitting in front of the nurses' station. He still wanted to go home. I contacted the sister, so he could talk to his sister. He wanted to go home before coming to the facility. I told the sister that her brother wanted to go home that he had a wander guard which was a device that alarms when he is close to the door. He was sitting down talking to his sister, he put down the phone. I told all the CNAs working on that shift to watch him. The CNA was following him, where ever he went. After dinner, I went upstairs. I was supervising the whole building. When I came back down, he was quiet and moving around. He was trying to get out of the double doors and the Wander Guard alarm went off and he was taken back to the nurses' station early in the evening. Around 11:20 PM to 11:40 PM, I heard the nurse say check the rooms. I asked what is going on, they say he is not in his room. They noticed during the changing of shift that the CNA on 3:00 PM to 11:00 PM shift told (Staff B) to watch him on the 11:00 PM to 7:00 PM shift. (Staff B) took the patient to the room and left him lying down to sleep. (Staff B) went to another room to change a patient but when Staff B returned the resident (resident #1) was no longer in the bed. She said she was gone for 5 to 7 minutes. I called the DON immediately. Most of the CNAs went outside on the streets, searching for the patient. Staff in the facility were searching room to room, bathroom to bathroom. The DON came here. I called the police to report the resident missing. He was wearing a lime green shirt with black pants. The Police Officer came and took the report and gave a case number. I called doctor (Attending Physician) to tell him the resident is missing. He wore the Wander Guard on his left arm. When he got out, I did not hear the alarm because I was on the second floor. (Staff B) said she didn't hear the alarm go off. During interview with Staff B, a Certified Nursing Assistant (CNA) (11:00 PM to 7:00 PM shift) on 8/18/20 at 4:30 PM via telephone stated, I came to work at 11:00 PM. I put him (resident #1) in the room at 11:20 PM. I go take care of another patient and when I finished, I went back to his room. When I go to the room, I don't see him. They called the Administrator, the DON. Everyone was looking for him. They saw on the video he left at 11:40 PM. I had eleven patients that night. He was not on one to one. The CNA before told me to watch him. The nurse never told me to watch him. I don't remember no Wander Guard bracelet on him. I didn't hear an alarm. During a telephone interview with Resident's #1 sister on 8/18/20 at 6:28 PM via telephone. She stated, I have no idea what happened. They told me it was impossible for him to get out because he was wearing some type of bracelet. They were in touch with me constantly. They continued reaching out to me to see if I heard from him. I would have hoped he would stay there for a while. I spoke with the facility. I don't know about an AMA (Against Medical Advice). We didn't try to get him to go back to the facility. He didn't want to go back to the facility. He doesn't have a court order to be there, so we can't force him They told me he must have taken off the bracelet but when I saw him it was still on. He has not told me what happened and how he got out of the facility. Some family members have told me, they saw him get out of a car. When I ask him, he won't tell me anything. His memory goes in and out. The police officer came by, they called me and I told them he was home. He is living on his own. I called them to let them know the police was here at his place. He doesn't use a walker or a cane. They were trying to help him walk there. The sister revealed that since he has been out, he has not seen a doctor. During an interview with Staff C, a Registered Nurse Supervisor (7:00 AM to 7:00 PM shift) on 8/19/20 at 11:35 AM via telephone. She stated, I work on Friday, Saturday and Sunday. The resident (resident #1) left Friday night. I got the report on Saturday morning. I called the sister and she said that the brother was with her. The family agreed to keep him. They felt he would go right back home. She gave permission for the AMA and I explained to her what the AMA was. During an interview with Staff D, a Licensed Practical Nurse (7:00 PM to 7:00 AM shift) on 8/19/20 at 2:33 PM stated, When I got in (resident #1) he seemed agitated and he was trying to leave the building. They had him on one to one monitoring. I spoke to him briefly to see where his mindset was. He seemed to be alert and oriented times two. He started saying things that he was confused. They continued him on one to one monitoring. I checked his vitals at 11:00 PM, I wrote it down. No meds were to be given at that time. The 3:00 PM to 11:00 PM shift still had him on monitoring and on the 11:00 PM to 7:00 AM shift. I was on the side where (resident #1) was from 11:00 PM to 11:15 PM and he was in his room. At 11:15 PM, I went to the south side, which was my side. Around 11:25 PM, the CNA(Staff B) came to me and said we can't find (resident #1). Staff D reported that the CNA stated that resident #1 was placed in his room, and when the CNA, Staff B returned to the room resident #1 was not there. Staff D, LPN stated, I started searching every room. I searched rooms, bathrooms, patios. I didn't find anything. I started searching around the facility and the community. A code pink was started and everyone was searching. The police was notified, his sister was notified. All of the notifications were done by the supervisor on duty at that time. He had a Wander Guard bracelet on. I can't remember which arm it was on. During interview on 8/19/20 at 3:16 PM Staff E, a Registered Physical Therapist stated, He (resident #1) was scheduled to receive Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (SLP). He received an evaluation on 8/12/20 for PT, OT and SLP evaluation on 8/13/20. He was not safe to ambulate alone, determined on the date of evaluation 8/12/20 .Nursing was made aware; he is not safe to ambulate alone. During an interview with the Administrator/Risk Management on 8/20/20 at 12:20 PM stated, We don't have a policy on one to one supervision. We would need a doctor's order for one to one supervision. If they are at risk for elopement we will call the doctor to obtain the order. You need a doctor's order for a true one to one. Once the resident is exhibiting the behaviors, we call the doctor to obtain an order. If he doesn't order, we put them on close supervision, which is technically a one to one. We notified the doctor that he had eloped. We called the family member and were informed that the resident did not want to come back and did a verbal AMA on the phone with family member. We called the doctor a second time to notify him of an AMA. They had told me in the afternoon that he was exit seeking, the Wander Guard was put on him and working and on close supervision. When we came to figure out, how he got out, we became aware of him using the fire exit door. At night when there is no noise, you should be able to hear the alarm. A baby monitor was added on Tuesday, 8/18/20 at the nurses' station to monitor if and when the fire exit door is opened. We felt we had fixed it by putting the key card at the doors. We could not put a key card at the fire exit door. On 8/20/20 to 8/21/20, the corrective actions verified by the survey team related to the facility's failure provide adequate supervision and a secured environment included: The staff were In-serviced/trained on 8/15/20 for 7:00 AM-7:00 PM shift, 7:00 PM-7:00 AM shift for nurses, 7:00 AM-3:00 PM shift, 3:00 PM-11:00 PM shift and 11:00 PM-7:00 AM shift for certified nursing assistants (CNA) regarding: Wandering precautions and wander guard device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on 8/15/2020 and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing staff, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code pink, ensuring that the wandering observation tool is used effectively per facility's protocol. Prompt re-training was initiated on 8/15/20 for all shifts regarding Abuse Reporting, Need for 1 to 1, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1 and Code Pink.

Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and ensure that effective and efficient preventative measures were in place to prevent the, neglect and elopement of one resident (Resident #1) out of three sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included an ineffective wander alert system, failure to ensure exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to provide and implement specific instructions to care staff for assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 11:40 PM through an emergency exit door on 8/14/20 placing the resident at risk for harm and or injury. There were 83 residents residing in the facility at the time of the survey. Refer to F 600, F 607, F 689 and F 867. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol written by the Administrator and the revision date was on 11/2019, the policy documented: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical and mental abuse, corporal punishment or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. A prompt thorough investigation will be conducted by the facility immediately. The facility's Policies and Procedures did not directly address neglect. Review of the facility's policy titled, Elopement revised February 2019 indicated: Policy Statement: Staff shall investigate and report all cases of missing residents. Elopement is defined as a resident leaving an area of supervision to an area of non-supervision. Review of the Job Description for the Nursing Home Administrator documented: The Administrator is responsible for developing, managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Nursing Supervisor documented: The Nursing Supervisor is responsible for supervising the day to day nursing activities in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Registered Nurse documented: The primary purpose of your job description is to provide direct nursing care the residents and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility and as may be required by the Director of Nursing services to ensure that the highest degree of quality care is maintained at all times. Review of the Job Description for the Licensed Practical Nurse documented: The Licensed Practical Nurse is responsible for providing professional care in accordance with established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. During observational review of the facility's video footage with the Administrator and Corporate staff on 8/18/20 at 12:23 PM. The video footage revealed that on 8/14/20 at 11:23 PM, resident #1 dressed in a black colored pants and green shirt was standing at the doorway to his room, during this time staff were observed on the hallway. On 8/14/20 at 11:37 PM resident #1 ambulated from his room with no assistive device and proceeded through the double door that lead to the lobby area of the facility. Resident #1 attempted to open the front doors of the facility and was unsuccessful. The resident then walked to the emergency fire exit door located at the side near the administration office, the resident pushed the door without any difficulty at 11:40 PM on 8/14/20 and exited the facility undetected by staff. There was a nurse seated at the nurses' station and a Certified Nursing Assistant (CNA) had just walked past the resident's room down the hall where the double doors leading to the lobby were located. The resident was observed wearing a Wander Guard Bracelet on the wrist of his left arm and an identification band on the right wrist. The alarm on the exit door was not audible for staff to hear on any of floors in the facility within the care areas beyond the double doors. The wander guard alert system did not trigger to alert staff.(Video footage evidence obtained) On 08/18/2020 at approximately 1:00 PM after review of the above mention video footage, the Senior Administrator and the Chief Nursing Officer conducted a demonstration with the state surveyor of the alarm door's audibility. During this demonstration it was revealed that the alarm for the emergency exit door was still not audible in the care areas, at the 1st floor front nurses' desk nor on the 2nd floor and could not be heard at the beyond the double doors in the lobby. the Senior Administrator and the Chief Nursing Officer at this time determined and acknowledged that the audible alarm for the fire emergency door was not loud enough and could not be heard beyond the double front doors from the lobby. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Review of the Face Sheet for Resident #1 documented, the resident was admitted to the facility on [DATE] after being discharged from a local hospital following an incident where he was found unresponsive outside a local grocery store. Clinical [DIAGNOSES REDACTED]. Review of Resident's #1 Behavioral Symptoms care plan dated 8/14/20 documented the resident exhibits the following behavior: elopement, observed trying to leave the facility with no apparent reason; Goal: Episodes of problem behavior will decrease to one a (week/month) thru next review date; Approaches: Keep resident safe with close supervision, Keep wander guard in place at all times; Make staff aware of resident's high risk for elopement; Monitor resident's whereabouts at frequent intervals. Review of the physician's orders [REDACTED]. Medications were: [MEDICATION NAME] 10 milligrams (mg) 1 tablet oral once a day at 9:00 AM for hypertension, he missed the 9:00 AM dose on 8/15/20; [MEDICATION NAME] 25 mg( indicated for the treatment of [REDACTED].)1 cap every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, he missed the doses on 8/15/20; [MEDICATION NAME] ER 24 hour. 25 mg ( indicated for the treatment of [REDACTED]. During interview on 8/18/20 at 11:08 AM the Administrator/Risk Manager reported that, Resident #1 was put to bed by the 11-7 CNA (Staff B) and the CNA (Staff B) went to take care of her next resident. When Staff B was done and went back to check on him and he was missing. Staff B notified the Licensed Practical Nurse (LPN) (Staff D) and Registered Nurse (RN) (Staff A), the Supervisor. They activated Code Pink which is our elopement code, they searched the whole facility and the outside grounds. They notified the Police Department and the sister. The police officer came and did a report. The police was given a description and a picture of Resident #1 and the police officer stated that he was going to go look for the resident. The DON (Director of Nursing) came in to help with the facility search as soon as she was notified. The DON called the sister and started doing the reporting to all the local agency and our 1-day report. Immediate in-servicing was done to staff that were in the building. The administrator stated , We called the nearby hospitals the next day. A little bit before 2:00 PM the next day, the sister called and she said he was found at his house. She said that he preferred to stay at home with her and we notified the doctor and he was okay with it. We did an AMA (Against Medical Advice) form over the phone and we notified the police department that he was found. The resident had a Wander Guard. He took the Wander Guard off before leaving the facility. The sister said that he told her that he took the Wander Guard off. We believe he got out through the side door by my office. The sound on the alarm was not loud enough for the 1st floor nurses' station to hear it. Since then, maintenance made the alarm louder and placed a baby monitor at the 1st floor nurses' station. During interview on 8/18/20 at 11:20 AM, the DON stated, The supervisor notified me. I immediately got to the facility, we continued searching the facility code pink. I got in contact with the sister several times, back and forth. I immediately in-serviced the staff about elopement, one on one and reporting. We called maintenance so they can come in and look at the door. We did the reporting. Stayed in contact with the sister throughout the morning. The DON stated that Resident #1's sister told her at around 12:00 PM on 8/15/2020 that she was on her way to his address to see if he was there. The DON stated, once she got there she called me and said he was in good condition and did not want to return to the facility. The AMA form was signed verbally. The police department was notified and turned it over to another police department who were going to do wellness check. The doctor was notified. The DON reported that the CNA (Staff B) was given verbal instructions by LPN (Staff D) to closely monitor Resident #1. During interview on 8/18/20 at 3:16 PM Staff A, a Registered Nurse Supervisor for the 7:00 PM to 7:00 AM shift stated, On that Friday night, my shift was 3:00 PM to 11:00 PM, he (resident #1) was having issues on getting out. It was told to me that he was having a problem getting out, he wanted to go home. I was told by the DON, that they had put a Wander Guard on him. At that point, I initiate one CNA in his room. I told the CNA; I was going to put her in that room. He was fine, walking around, going to the nurses' station. He was sitting in front of the nurses' station. He still wanted to go home. I contacted the sister, so he could talk to his sister. He wanted to go home before coming to the facility. I told the sister that her brother wanted to go home that he had a wander guard which was a device that alarms when he is close to the door. He was sitting down talking to his sister, he put down the phone. I told all the CNAs working on that shift to watch him. The CNA was following him, where ever he went. After dinner, I went upstairs. I was supervising the whole building. When I came back down, he was quiet and moving around. He was trying to get out of the double doors and the Wander Guard alarm went off and he was taken back to the nurses' station early in the evening. Around 11:20 PM to 11:40 PM, I heard the nurse say check the rooms. I asked what is going on, they say he is not in his room. They noticed during the changing of shift that the CNA on 3:00 PM to 11:00 PM shift told (Staff B) to watch him on the 11:00 PM to 7:00 PM shift. (Staff B) took the patient to the room and left him lying down to sleep. (Staff B) went to another room to change a patient but when Staff B returned the resident (resident #1) was no longer in the bed. She said she was gone for 5 to 7 minutes. I called the DON immediately. Most of the CNAs went outside on the streets, searching for the patient. Staff in the facility were searching room to room, bathroom to bathroom. The DON came here. I called the police to report the resident missing. He was wearing a lime green shirt with black pants. The Police Officer came and took the report and gave a case number. I called doctor (Attending Physician) to tell him the resident is missing. He wore the Wander Guard on his left arm. When he got out, I did not hear the alarm because I was on the second floor. (Staff B) said she didn't hear the alarm go off. During interview on 8/18/20 at 4:30 PM, via telephone Staff B, a Certified Nursing Assistant (CNA) for the 11:00 PM to 7:00 PM shift revealed, she was assigned Resident #1 on 8/14/20. Staff B reported that she left Resident #1 in his room and went to care for another resident, upon return, Resident #1 was not in his room. Staff B stated , they saw on the video he left at 11:40 PM. I had eleven patients that night. He was not on one to one. The CNA before told me to watch him. The nurse never told me to watch him. I don't remember no Wander Guard bracelet on him. I didn't hear an alarm. During interview on 8/18/20 at 6:28 PM via telephone, Resident's #1 sister stated, I spoke with the facility. I don't know about an AMA (Against Medical Advice). We didn't try to get him to go back to the facility. He didn't want to go back to the facility. They told me he must have taken off the bracelet but when I saw him it was still on. Some family members have told me, they saw him get out of a car. When I ask him, he won't tell me anything. His memory goes in and out. The police officer came by, they called me and I told them he was home. He is living on his own. I called them to let them know the police was here at his place .They were trying to help him walk there. Since he has been out, he has not seen a doctor. During interview on 8/19/20 at 11:35 AM via telephone interview, Staff C, a Registered Nurse Supervisor for the 7:00 AM to 7:00 PM shift stated, I called the sister and she said that the brother was with her. The family agreed to keep him. They felt he would go right back home. She gave permission for the AMA and I explained to her what the AMA was. During interview on 8/19/20 at 2:33 PM with Staff D, a Licensed Practical Nurse that worked 7:00 PM to 7:00 AM shift stated, When I got in (resident #1) he seemed agitated and he was trying to leave the building. They had him on one to one monitoring. I spoke to him briefly to see where his mindset was. He seemed to be alert and oriented times two. He was confused. They continued him on one to one monitoring. I checked his vitals at 11:00 PM, I wrote it down. No meds were to be given at that time. The 3:00 PM to 11:00 PM shift still had him on monitoring and on the 11:00 PM to 7:00 AM shift. I was on the side where (resident #1) was from 11:00 PM to 11:15 PM and he was in his room. At 11:15 PM, I went to the south side, which was my side. Around 11:25 PM, the CNA (Staff B) came to me and said we can't find (resident #1). Staff D reported that the CNA stated that resident #1 was placed in his room, and when the CNA, Staff B returned to the room resident #1 was not there. Staff D, LPN stated, I started searching every room. I searched rooms, bathrooms, patios. I didn't find anything. I started searching around the facility and the community. A code pink was started and everyone was searching. The police was notified, his sister was notified. All of the notifications were done by the supervisor on duty at that time. He had a Wander Guard bracelet on. I can't remember which arm it was on. During interview on 8/19/20 at 3:16 PM Staff E, a Registered Physical Therapist stated, He (resident #1) received an evaluation on 8/12/20 for PT, OT and SLP evaluation on 8/13/20. Long term goal for PT was safely able to ambulate level surface 100 feet using the roller walker and stand by assist. Short term goal safely ambulate on level surfaces 20 feet using rolling walker with with continuous steps, with use of ankle strategy and with use of stepping strategy 60% of the time with decreased assist from caregivers to increase independence and safety in room. He was only supposed to use the rolling walker when he was receiving PT therapy in his room. He was not safe to ambulate alone, determined on the date of evaluation 8/12/20. Nursing was made aware; he is not safe to ambulate alone. During an interview with the Administrator/Risk Management on 8/20/20 at 12:20 PM stated, We don't have a policy on one to one supervision. We would need a doctor's order for one to one supervision. If they are at risk for elopement we will call the doctor to obtain the order. You need a doctor's order for a true one to one. Once the resident is exhibiting the behaviors, we call the doctor to obtain an order. If he doesn't order, we put them on close supervision, which is technically a one to one. We notified the doctor that he had eloped. We called the family member and were informed that the resident did not want to come back and did a verbal AMA on the phone with family member. We called the doctor a second time to notify him of an AMA. They had told me in the afternoon that he was exit seeking, the Wander Guard was put on him and working and on close supervision. When we came to figure out, how he got out, we became aware of him using the fire exit door. At night when there is no noise, you should be able to hear the alarm. A baby monitor was added on Tuesday, 8/18/20 at the nurses' station to monitor if and when the fire exit door is opened. We felt we had fixed it by putting the key card at the doors. We could not put a key card at the fire exit door. On 8/20/20 to 08/21/20 the survey team verified the facility's immediate jeopardy removal plan that included: All residents were screened and determined we had no further residents that have exit seeking behaviors. Maintenance Director and or designee has completed a facility screen of all fire exit doors. Wander Guard representative did a facility visit and inspection of Wander Guard sensor device. As a result replacing exiting sensors. Facility conducted a facility wide elopement screening to identify any residents displaying exit seeking behavior. The facility added a non-recording live monitor that will sound with any door openings. The facility will systematically incorporate a monthly mock elopement drill to ensure that staff remain vigilant of residents that have exit seeking behaviors and/or wandering. When an actual resident is identified as an elopement risk, the following will occur: Facility will initiate a nurse to nurse verification upon shift change of all/any resident displaying exit seeking behaviors and/or on elopement precautions. This will be tracked on a communication log. Wander guard log of visible placement on resident to be initiated and checked by nurse every shift .This will be an immediate implemented system and permanent: The facility added an Elopement book to front desk and both nurse's station and it will be there to place those residents at risk as an identifier and quick reference. All Fire alarm doors will be checked every shift by Maintenance Supervisor and/or designee and documented on a log. During morning meeting, new admissions will be reviewed for exit seeking behaviors to identify and discuss by interdisciplinary team and place prompt interventions. Any residents that require a 1:1 monitoring will be initialized by nurse supervisor until physician's orders [REDACTED]. Education will be completed by DON and/or designee. Any residents displaying exit seeking behaviors, will be immediately placed on 1:1 monitoring which will be done by assigning a C.N.A. to care solely for that resident and keep him/her on his/her visual field at all times. C.N.A. would not be leaving resident without 1:1 monitoring without relief of another staff member. MD will be notified to obtain 1:1 monitoring orders and any other new orders resident might require. Education will be completed by DON and/or designee. 100% of staff will be in-serviced on: 1) New audible and visual alarm on Exit doors by administration area with visual and audible sound in nursing station on first floor: education will be continued to be provided by Maintenance Director and/or designee. 2) Awareness of all residents with wander guard and the audible sound it makes: education will be provided by DON and/or designee. Nursing Staff will receive education on endorsing and monitoring of any resident displaying exit seeking behaviors and or on Elopement Precautions/ One to One monitoring.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents resulting in elopement within the past 12 months. The previous incident resulted in the identification of immediate jeopardy that occurred when another resident eloped from the facility undetected on [DATE] and was found deceased on [DATE] eleven miles from the facility. The facility was cited for Freedom from Abuse and Neglect, Develop/Implement, Abuse/Neglect Policies, Free of Accident Hazards, Supervision, Devices and Administration. On [DATE], the facility was negligent and failed to provide adequate supervision and effective services to prevent the elopement of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 eloping from the facility at 11:40 PM, through an emergency exit door located in the facility's lobby area undetected. These repeated deficient practices has the potential to affect any of the 83 residents residing in the facility. Refer to F 600, F 607, F 689 and F 835. The findings included: Record review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated [DATE], [DATE] and [DATE] documented the facility had a QAPI Committee meeting monthly. Attendees included: the Administrator, Director of Nursing (DON), Medical Director, Social Services, Activities, Nutrition, MDS, Therapy, Environmental/Maintenance, Business Office, Business Development, Licensed Nurse, Human Resources, Medical Records. The documentation provided did not indicate previous elopement issue and concerns related to the immediate jeopardy/substandard quality of care that occurred on [DATE]. During interview with the Administrator/Risk Manager on [DATE] at 12:20 PM revealed, the QAPI meetings are conducted monthly. The QAPI committee consists of all department heads and the Medical Director. The Administrator/Risk Manager stated, We review the policies in QAPI (Quality Assurance Performance Improvement). Usually in December and as needed during the year. We don't have a policy on one to one supervision. We would need a doctors' order for one to one supervision. If they are at risk for elopement will call the doctor to obtain the order. You need a doctors' order for a true one to one. Once the resident is exhibiting the behaviors, call the doctor to obtain an order. If he doesn't order, we put them on close supervision, which is technically a one to one. We notified the doctor had eloped. We called the family member and were informed that the resident did not want to come back. Verbal AMA on the phone with family member. We called the doctor a second time to notify him of an AMA. They had told me in the afternoon that he was exit seeking, the Wander Guard was put on him and working and on close supervision. When we came to figure out, how he got out, we became aware of him using the fire exit door. At night when there is no noise, you should be able to hear the alarm. Baby monitor was added on Tuesday, [DATE] at the nurses' station to monitor if and when the fire exit door is opened. We felt we had fixed it by putting the key card at the doors. We could not put a key card at the fire exit door. During interview on [DATE] at 2:33 PM the Senior Administrator revealed, an evaluation of the Elopement Drills will be incorporated into our QAPI. We will be conducting these drills monthly on alternating shift. The first drill conducted [DATE] was conducted at the change of shift with 7:00 AM to 3:00 PM shift and 11:00 PM to 7:00 AM staff that were present. On [DATE] to [DATE], the corrective actions that were verified by the survey team related the facility's Quality Assurance and Performance Improvement (QAPI) Committee failure to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice included: The staff were in-serviced/trained on [DATE] for 7:00 AM to 7:00 PM shift, 7:00 PM to 7:00 AM shift for nurses, 7:00 AM to 3:00 PM shift, 3:00 PM to 11:00 PM shift and 11:00 PM to 7:00 AM shift for certified nursing assistants (CNA) regarding: Wandering precautions and wander guard device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on [DATE] and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code pink, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on [DATE] for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor exits. The facility contracted an electrical company on [DATE] and they will be adding a flashing light and audible notification to the main nurse's station on the 1st floor. Prompt re-training was initiated on [DATE] for all shifts regarding Abuse Reporting, Need for 1 to 1, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1 and Code Pink. The Quality Assurance team will monitor compliance and will provide feedback to the management company as to results of monthly meeting regarding Abuse and Neglect and Resident safety. Administrator and/or designee will gather information from the interdisciplinary team and report to Quality Assurance committee monthly and adjust better ensure the safety of our residents as needed.

Based on interview and record review, the facility failed to implement abuse and neglect policies and procedures, and failed to ensure staff supervised and provided care and services to 1 out of 3 sampled residents (Resident #1). Refer to F 600, F 607, F 609, F 689. The findings included: Record review of the facility's policy titled, Abuse/Neglect prevention protocol and reporting written by the Administrator and the revision dates were: 06/2019, revealed: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility will immediately report all allegations or information that creates reasonable cause to believe that a resident was abused to the appropriate jurisdictional authorities and the resident's responsible relative A prompt thorough investigation will be conducted by the facility immediately . The Facility's policy did not directly address neglect. Record review of the facility's Elopement Policy revised (MONTH) 2019 indicated: Policy Statement: Staff shall investigate and report all cases of missing residents. Elopement is defined as a resident leaving an area of supervision to an area of non-supervision . Record review of Job Description for the Nursing Home Administrator revealed : The Administrator is responsible for developing , managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and home like environment for the residents. Record review revealed the Director of Nursing is responsible for planning , organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal state and local standards and established nursing policies and procedures. He /she is also responsible for providing a positive , caring and homelike environment for the residents. Record of job descriptions revealed the Charge Nurse is responsible for supervising the day to day nursing activities in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive , caring and homelike environment for the residents. Record review of the Job Description for the Registered Nurse revealed: The primary purpose of your job position is to provide direct nursing care the residents and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal , state, and local standards guidelines and regulations that govern our facility and as may be required by the director of nursing services to ensure that the highest degree of quality care is always maintained . Record of job descriptions revealed the director of Social Service is responsible for planning organizing, developing and directing the day to day operation of the Social Services Department in accordance with current Federal, State and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive , caring and homelike environment for the residents. Essential functions of the job item # 30 Ensures that a clean orderly , sanitary and safe environment for residents is maintained at all times. During a review of the facility's video footage for 09/05/2019 revealed, a housekeeping staff person was in the elevator with Resident #1, the staff person exited the elevator on the first floor of the facility and went to the right, shortly afterwards Resident #1 was observed sitting and wheeling himself in a non-motorized wheelchair, the resident exited the elevator and went to the left, pushed open the facility's glass type door without any difficulty and exited the facility. There was no staff person posted at the door. There appeared to be ramp outside the door used by Resident #1. While the resident was exiting the facility, a medication cart was seen in the video footage located next to the elevator and a facility nurse was observed to walk to the medication cart, but the nurse did not acknowledge Resident #1 as the resident exited the facility. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. The National Weather Service climate Data for the Miami area (MONTH) 05, 2019 to (MONTH) 8th, 2019 ranged at record breaking temperatures of 93 degrees Fahrenheit (F) to 94 degrees F. Record review of the Face Sheet for resident #1 revealed, the resident was admitted to the facility on [DATE] from a local hospital for Long Term Care residency under the Guardianship program. The clinical [DIAGNOSES REDACTED]. The resident was receiving nutrition by a Percutaneous Endoscopic Gastrostomy (PEG/feeding tube). Record review of Resident #1's last care plan conference dated 06/27/2019 included problem areas: Risk for [MEDICAL CONDITION] related to Diabetes. Risk for respiratory complications Shortness of breath. Risk for fall/injury related to impaired balance, impaired cognition/safety awareness, risk for complications of tube feeding as evidenced by aspiration . Record review revealed Physician orders [REDACTED]. The Medication Administration Records (MAR) for 09/05/19 revealed, resident #1 did not get his blood glucose checked at 12:00 noon as ordered. Record review of Physician order [REDACTED]. Record review of POS and MAR indicated [REDACTED]. The physician ordered {Formula} one container 250 milliliters (ml) via PEG bolus 6 times per day, check tube placement by aspirating stomach contents before meals: at 6:30 am, 11:30 am, 4:30 pm. Water Flush 75 ml (milliliters) before and after each bolus feeding 6 times per day. The resident did not receive the Enteral feeding as ordered for one container (250 ml) via PEG bolus 6 times per day and the 75 ml water flush before and after each bolus. The MAR indicated [REDACTED]. Review of the nursing notes revealed, documentation by staff A, an RN dated 09/05/2019 at 7:03 am, edited /created at 6:04 PM, the documentation included, Resident received on stable condition, no complain of pain or discomfort during this shift, no shortness of breath (SOB) or respiratory distress at this moment. Activities of daily living (ADL's) provided by staff, call light at easy reach bed in lowest position, head of bed (HOB) elevated, therapy in progress, well tolerated . Review of the nursing notes created by Staff B, a RN Manager on 09/05/2019 at 7:10 am, revealed documentation for, Resident awake, and alert seen seated in wheelchair in his room, no sign of acute distress noted. The nursing progress note narrative dated 09/05/2019 at 3:15 PM by Staff A, RN documented: After several attempts to administer resident's medications, I could not find him in room or in the designated areas. I looked for him everywhere with the help of my Certified Nursing Assistants (CNAs) but did not find him. I reported to my supervisors, notified Doctor {name} , and continued to look for him. Record review of the nursing assistant's documentation revealed, the nursing assistant providing care to resident #1 signed for care and services being provided in the electronic records at 8:21 am on 09/05/2019. This was determined to be inaccurate since the resident left the facility at 7:44 am on 09/05/19. During an interview with Staff B, RN and Charge Nurse, on 10/01/2019 at 2:45 PM revealed, he worked the day of the incident from 7:00 am to 7:30 PM. Staff B reported, Resident # 1 was alert and oriented and had a usual routine. Staff B stated that Resident #1 would get up in the morning, ask for his medications and bolus feeding. Resident # 1 liked reading and spent a lot of time downstairs on the front patio and on the patio in the back. Staff B revealed, the routine for the nurses when they came on duty in the morning, included doing rounds and to check on the residents. Between 8:00 am to 10:00 am, the nurses would do med pass. At 11:30 am to 12:00 noon blood sugars checks, and Insulin administration would be done. The residents are prepared for lunch and bolus feedings are also done between 11:30 am to 12:00 noon. The nurse's complete documentation and assessments in between those duties. Staff B reported, afternoon med pass for some residents are completed between 1:00 PM to 2:00 PM. Staff B stated, they must do rounds after med pass and Activities of Daily Living (ADL) care, between nurses and CNAs the residents should be constantly monitored. Staff B revealed, the nurse assigned that day notified him around 3:00 PM on 09/05/2019 that resident #1 resident was missing, and all staff started looking for the resident. During an interview on 10/02/19 at 11:01 am, the Administrator revealed, I was in the facility. I was told immediately at around 3:45 PM by the Social Worker, from there I went up to the floor, they said he was not in his room, they searched the grounds and I called 911, the doctor and the guardian. I sent out a van with the Social Worker to search the area. Law enforcement came, and we did a missing person's report with the police department. I looked at the cameras with the officer and the last time he was seen on camera was at 7:48 am. He came down the elevator. I saw him on the camera hanging out, then you don't see him anymore. We kept searching for him for next couple of days and we called local hospitals. Then on Sunday, (MONTH) 8th, the police called for the guardian's information because they had a body that fits his description. So, I gave the guardian's information to the police because they needed the guardian to come and see if it was him. On 09/9/19, we got confirmation from the guardian that it was him. He was found Downtown Miami next to a building in the government center area. The administrator stated, the nursing station does not always have a staff nurse, but we have a unit secretary, but she is not always there. The administrator explained it was not reported because it was an adverse incident. During interview on 10/03/2019 at 12:14 PM, the DON revealed, the nurse that was working with Resident #1 gave a statement that he administered the medications to Resident #1 early on 09/05/19 because the resident asked for it early. The DON reported, the nurse was terminated, because he did not follow the doctor orders, he did not check on the resident and follow up. The DON revealed, the nursing assistant that was assigned to Resident #1 for the day shift was already home when they realized the resident was missing by the oncoming 3:00 PM to 11:00 PM nursing assistant. On 10/03/19 at 1:50 PM the DON stated, We were working with a resident that had this planned, in my opinion he knew the time staff would not miss him and during the endorsement (terminology used by facility for change of shift) he choose the time we were most busy, and he had his routine we got out smarted by this resident . there was no indication that the resident wanted to go . The DON acknowledged, the nurse had opportunities to realize the resident was missing. The DON stated, If the blood sugar check was done at 12 o'clock the nurse would have noticed the resident was missing at that time and looked for the resident, we could have noticed the resident was missing at that time. The door resident #1 went through did not require a code to exit. The DON revealed, it was a concern that the door alarm only worked for residents with a wander alarm and anyone that does not have a wander alarm system could go through the doors at any time. The DON stated, We did not report it because we did not realize until after we did a consult, and we were told that it should have been reported. The reporting is under the Social Worker and he informed the administrator that a resident was missing. I know that is a concern and a lesson learned for me about reporting those things. During an interview with the Social Worker on 10/03/19 at 2:40 PM, the Social Worker reported, he did not report this incident because he was told by the administrator that it is an adverse incident. The Social worker stated, he knew that he may have needed to report it as abuse/neglect but did not because they did not tell him to and under normal circumstances he would have reported all abuse and neglect issues. The Social Worker reported, he did ask if he should report this event. The Social Worker reported that on 09/09/2019, a Monday, upon return to work from the weekend he was informed of the residents' death. In a follow up interview on 10/04/19 at 5:37 PM with the Social Worker it was explained, because the administrator told him from the beginning it was an adverse incident and there was no need to report it. The Social Worker stated, The requirement for reporting is soon as I get it, I will do an immediate, then when I get everything then the 5 day and then the adverse.

Based on interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of three sampled residents. This deficient practice enabled resident #1 to exit the facility at 7:44 am on [DATE]. The staff assigned to care for Resident #1 did not report resident #1 as missing to the supervisor until the second shift at 3:15 PM on [DATE]. Subsequently, the resident was found by law enforcement on [DATE], approximately 11 miles from the facility and was deceased . Refer to F 600, F 607, F 609, F 835. The findings included: Record review of the facility's Elopement Policy revised (MONTH) 2019 indicated: Policy Statement: Staff shall investigate and report all cases of missing residents. Elopement is defined as a resident leaving an area of supervision to an area of non-supervision . Record review of the Face Sheet for Resident #1 revealed, the resident was admitted to the facility on [DATE] from a local hospital as a long term care resident under the Guardianship program. The clinical [DIAGNOSES REDACTED]. The resident was receiving nutrition by a Percutaneous Endoscopic Gastrostomy (PEG/feeding tube). Record review of the initial admission observation evaluation completed [DATE] revealed, resident #1 was assessed for the risk of elopement at the time of admission indicating that he was not at risk for elopement. Record review of the last quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact based on Brief Interview of Mental Status score of ,[DATE]. Section G for functional status indicated for bed mobility, the resident required supervision for self-performance and set up only. For locomotion on and off the unit, resident #1 required supervision and set up only. For dressing Resident #1 required extensive assistance with one person for physical assist. For Eating: Extensive assistance with one person physical assist. For toilet use and personal hygiene, the resident required assistance with one person for physical assist. Record review of Resident #1's last care plan conference dated [DATE] included problem areas: Risk for [MEDICAL CONDITION] related to Diabetes. Risk for respiratory complications Shortness of breath. Risk for fall/injury related to impaired balance, impaired cognition/safety awareness, risk for complications of tube feeding as evidenced by aspiration . Record review revealed Physician orders [REDACTED]. The medication administration records (MAR) for [DATE] revealed, resident #1 did not get his blood glucose checked at 12:00 noon as ordered. Record review of Physician order [REDACTED]. Record review of POS and MAR indicated [REDACTED]. The physician ordered {Formula} one container 250 milliliters (ml) via PEG bolus 6 times per day, check tube placement by aspirating stomach contents before meals: at 6:30 am, 11:30 am, 4:30 pm. Water Flush 75 ml (milliliters) before and after each bolus feeding 6 times per day. The resident did not receive the Enteral feeding as ordered for one container (250 ml) via PEG bolus 6 times per day and the 75 ml water flush before and after each bolus. The MAR indicated [REDACTED]. Review of the nursing notes revealed, documentation by staff A, an RN dated [DATE] at 7:03 am, edited /created at 6:04 PM, the documentation included, Resident received on stable condition, no complain of pain or discomfort during this shift, no shortness of breath (SOB) or respiratory distress at this moment. Activities of daily living (ADL's) provided by staff, call light at easy reach bed in lowest position, head of bed (HOB) elevated, therapy in progress, well tolerated . Review of the nursing notes created by Staff B, a RN Manager on [DATE] at 7:10 am, revealed documentation for, Resident awake, and alert seen seated in wheelchair in his room, no sign of acute distress noted. The nursing progress note narrative dated [DATE] at 3:15 PM by Staff A, RN documented: After several attempts to administer resident's medications, I could not find him in room or in the designated areas. I looked for him everywhere with the help of my Certified Nursing Assistants (CNAs) but did not find him. I reported to my supervisors, notified Dr , and continued to look for him. Record review of the nursing assistant's documentation revealed, the nursing assistant providing care to Resident #1 signed for care and services being provided in the electronic records at 8:21 am on [DATE]. This was determined to be inaccurate since the resident left the facility at 7:44 am on [DATE]. During a review of the facility's video footage for [DATE] revealed, a housekeeping staff person was in the elevator with resident #1, the staff person exited the elevator on the first floor of the facility and went to the right, shortly afterwards resident #1 was observed sitting and wheeling himself in a non-motorized wheelchair, the resident exited the elevator and went to the left, pushed open the facility's glass type door without any difficulty and exited the facility. There was no staff person posted at the door. There appeared to be ramp outside the door used by resident #1. While the resident was exiting the facility, a medication cart was seen in the video footage located next to the elevator and a facility nurse was observed to walk to the medication cart, but the nurse did not acknowledge Resident #1 as the resident exited the facility. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. The National Weather Service climate Data for the Miami area (MONTH) 05, 2019 to (MONTH) 8th, 2019 ranged at record breaking temperatures of 93 degrees Fahrenheit (F) to 94 degrees F. During an interview with Staff B, RN and Charge Nurse, on [DATE] at 2:45 PM revealed, he worked the day of the incident from 7:00 am to 7:30 pm. Staff B reported, resident # 1 was alert and oriented and had a usual routine. Staff B stated that resident #1 would get up in the morning, ask for his medications and bolus feeding. Resident # 1 liked reading and spent a lot of time downstairs on the front patio and on the patio in the back. Staff B revealed, the routine for the nurses when they came on duty in the mornings included doing rounds and to check on the residents. Between 8:00 am to 10:00 am, the nurses would do med pass. At 11:30 am to 12:00 noon blood sugars checks, and Insulin administration would be done. The residents are prepared for lunch and bolus feedings are also done between 11:30 am to 12:00 noon. The nurse's complete documentation and assessments in between those duties. Staff B reported, afternoon med pass for some residents are completed between 1:00 PM to 2:00 PM. Staff B stated, they must do rounds after med pass and ADL care, between nurses and CNAs the residents should be constantly monitored. Staff B revealed, the nurse assigned that day notified him around 3:00pm on [DATE] that resident #1 resident was missing, and all staff started looking for the resident. On [DATE] at 4:07 PM, the receptionist, Staff K revealed, he worked the reception desk on [DATE]. Staff K reported, he worked 8:30 am to 5:00pm. When he came in, he turned the screen for the cameras on, and he would check the screen periodically and make sure residents do not go out through the front door. Staff K reported, I can see what is happening on the cameras from the front and the cameras by the elevator, I did not see when the resident exited even though I can see the cameras, I screen everyone that come in the front door and we have visitors sign in when they come in to see where they are going and who they are here to see. I glimpse at the camera in between. During interview on [DATE] at 4:13 PM, Staff C, a Licensed Practical Nurse (LPN) reported, I was on the on the second floor, I did not see him that day. I found out at approximately 3:15 PM when the nurse manager, (Staff B) called me, I got report from him, I reported to the department heads, Staff B told me they did room check. We then went out and did a parameter check and from there we called the police, the doctor, and the guardian. When the police arrived, we gave the report in the administrators' office and provided the police with a picture of the patient. The cameras were reviewed by the administrator with the police. The Social Services Director, charge nurses, staff B, Staff G, an LPN and Staff A, an RN that was resident #1's assigned nurse were present. The time on the cameras indicated resident #1 exited at 7:44 am on [DATE]. Staff C reported, the only behavior resident #1 exhibited was taking food from trays and the resident refused to participate in the restorative dining program for snacks. Staff C reported, Resident #1 did not want to be supervised and he wanted to eat on his own. Staff C reported, we explained to him, it was for his safety and he signed a refusal of treatment form on [DATE]. On [DATE] at 9:39am Staff D, a Certified Nursing Assistant (CN A) revealed, she worked the night shift on [DATE] to [DATE] on the 11:00pm to 7:00 am shift. Staff D stated that she was familiar with Resident #1. Staff D explained, that Resident #1 would use the call light for assistance if he needed to use the bathroom or toilet. Staff B stated, The night before he was okay, I asked him if wanted to go to toilet and I asked him if he needed help with anything he said, no. Early in the morning, he said the only thing he wanted was for me to make the bed. I helped him to the chair, made the bed and then he went back into the bed. At the end of my shift, he was in bed and in his night clothes. Staff D reported, he did not show any signs or say he was leaving or planned to leave. He never gave any problem. He sleeps ok during the night and would only get up to use the restroom. I do round at least every 2 hours and for PEG tube and residents with breathing problems, I check on them more often. The day they were looking for him they called me, and I told them, I left him in the bed. When we changed shift the CN A that comes in on the oncoming shift and I did room to room with the morning C N [NAME] I left the patient in the bed. The Nursing assistant that worked 7:00am to 3;00PM shift on [DATE] with Resident #1 was terminated and not available for an interview. During an interview on [DATE] at 9:45 am Staff E, the C N A that worked the 3:00 PM to 11:00 PM shift on [DATE] stated, she worked with Resident #1 and he was an alert patient. Staff [NAME] reported, I would help him get undressed, dressed and ready for bed. When I came in to work, I did not see him, I looked for him, but he was missing. The last time I saw him was at the end of my shift the night before and he was in bed watching TV (Television). He did not say he was leaving, he had a feeding tube and he was okay. We searched for him and did not find him. During an interview on [DATE] at 11:01 am, the Administrator revealed, I was in the facility, I was told immediately at around 3:45 PM by the Social Worker, from there I went up to the floor, they said he was not in his room, they searched the grounds and I called 911, the doctor and the guardian. I sent out a van with the Social Worker to search the area. Law enforcement came, and we did a missing person's report with the police department. I looked at the cameras with the officer and the last time he was seen on camera was at 7:48 am. He came down the elevator. I saw him on the camera hanging out, then you don't see him anymore. We kept searching for him for next couple of days and we called local hospitals. Then on Sunday, (MONTH) 8th, the police called for the guardian's information because they had a body that fits his description. So, I gave the guardian's information to the police because they needed the guardian to come and see if it was him. On [DATE], we got confirmation from the guardian that it was him. He was found Downtown Miami next to a building in the government center area. The administrator stated, the nursing station does not always have a staff nurse, but we have a unit secretary, but she is not always there. Now we have the security guard. During an interview on [DATE] at 11:42 am with the Social Worker it was reported, Resident #1 was very quiet, he liked to go outside. The Social Worker revealed, he did not see resident #1 that day . and had no inclination that he would leave. The Social Worker reported, regular visits and reviews were done and Resident #1 never complained of any issues and met every month with the guardian. The Social Worker stated, I found out around 3:40 PM from the Assistant Director of Nursing (ADON) that we have a resident missing, we searched, I went out to the street, and the parameters of the area store. To see if I saw him at the gas station, {grocery stores} .nothing here they called the guardian and the police. Our drivers went and looked in the area to if we saw him. I found out that following Monday about his death from the administrator. Interview on [DATE] at 2:29 PM with Staff G, an LPN and nurse manager revealed, she normally works on the first floor. Staff G revealed, she worked on Thursday, [DATE], the day resident #1 went missing. Staff G stated, I came in at 7:50 am that morning because I was running late, and I worked until about 4:00 pm. When asked if any staff was at the nurse's station upon her arrival, staff G stated, No, when I came in no one was at the desk and I did not see the resident that day. The nurses were in the hallway and no one was at the nurse's station. During an interview on [DATE] at 11:05 am with the Activities Director, Staff J, it was reported, she did not see Resident #1 on [DATE]. She explained, he would come downstairs to the patio or be upstairs in his room or activities. He participated in small groups and he liked to come to the activities area on the patio. He liked sports and she would give him magazines to read, that was his Forte. He showed no signs or inclination that he wanted to leave. He would go up to activities in the afternoon and watched TV with his friend after dinner. The Activities Director explained, activities are based on assessments of residents likes and dislikes related to activities including in room activities. Resident #1 had a routine and he would be on the patio or in his room. I did not see him that day and that was nothing unusual. During interview on [DATE] at 11:25 am with Staff K, an Activity staff person, the activities attendance log presented, and it revealed, resident #1 did not attend activities on [DATE]. Staff K primarily oversaw the activities on the second floor, and reported resident #1would go downstairs to the patio to read and listen to the radio. Staff K revealed, she did not check for him that day because he had his routine. During interview on [DATE] at 12:14 PM, the DON revealed, the nurse that was working with Resident #1 gave a statement that he administered the medications to resident #1 early on [DATE] because the resident asked for it early. The DON reported, the nurse was terminated, because he did not follow the doctor orders, he did not check on the resident and follow up. The DON revealed, the nursing assistant that was assigned to resident #1 for the day shift was already home when they realized the resident was missing by the oncoming 3:00 PM to 11:00 PM nursing assistant. During an interview on [DATE] at 1:50 PM the DON stated, We were working with a resident that had this planned, in my opinion he knew the time staff would not miss him and during the endorsement (terminology used by facility for change of shift) he choose the time we were most busy, and he had his routine we got out smarted by this resident . there was no indication that the resident wanted to go . The DON acknowledged, the nurse had opportunities to realize the resident was missing. The DON stated, If the blood sugar check was done at 12 o'clock the nurse would have noticed the resident was missing at that time and looked for the resident, we could have noticed the resident was missing at that time. The door Resident #1 went through did not require a code to exit. The DON revealed, it was a concern that the door alarm only worked for residents with a wander alarm and anyone that does not have a wander alarm system could go through the doors at any time. The DON stated, We did not report it because we did not realize until after we did a consult, and we were told that it should have been reported. The reporting is under the Social Worker and he informed the administrator that a resident was missing. I know that is a concern and a lesson learned for me about reporting those things.

Based on record review and interviews, the facility failed to report an incident of abuse and neglect that lead to a negative outcome for one (resident #1) out of 3 sampled residents. This deficient practice enabled resident #1 to elope from the facility undetected on [DATE] at 7:44 am and the resident was not discovered as missing until 3:15 PM on [DATE]. Subsequently, the resident was found by law enforcement on [DATE], approximately 11 miles from the facility and was deceased . The facility did not report the incident to the required agencies until 2 weeks after the incident occurred on [DATE]. Refer to F 600, F 607, F 689, F 835. The findings include: Record review of the facility's policy titled: Abuse/ Neglect prevention protocol and reporting written by the administrator and the revision dates were: ,[DATE], ,[DATE], ,[DATE]: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility will immediately report all allegations or information that creates reasonable cause to believe that a resident was abused to the appropriate jurisdictional authorities and the resident's responsible relative A prompt thorough investigation will be conducted by the facility immediately . A prompt thorough investigation will be conducted by the facility immediately . VII Reporting Report to the Adult Protective Service within 2 hours and complete immediate report followed by a written five (5) days Record review of the Face Sheet for resident #1 revealed, the resident was admitted to the facility on [DATE] from a local hospital as a long term care resident under the Guardianship program. The clinical [DIAGNOSES REDACTED]. The resident was receiving nutrition by a Percutaneous Endoscopic Gastrostomy (PEG/feeding tube). Record review of the last quarterly Minimum Data Set ((MDS) dated [DATE] indicated resident #1 was cognitively intact. Section G for functional status indicated for bed mobility, the resident required supervision for self-performance and set up only. For locomotion on and off the unit, resident #1 required supervision and set up only. For dressing resident #1 required extensive assistance with one person for physical assist. For Eating: Extensive assistance with one person physical assist. For toilet use and personal hygiene, the resident required assistance with one person for physical assist. Record review of Resident #1's last care plan conference dated [DATE] included problem areas: Risk for [MEDICAL CONDITION] related to Diabetes. Risk for respiratory complications Shortness of breath. Risk for fall/injury related to impaired balance, impaired cognition/safety awareness, risk for complications of tube feeding as evidenced by aspiration . Record review revealed Physician order [REDACTED]. The medication administration records (MAR) for [DATE] revealed, resident #1 did not get his blood glucose checked at 12:00 noon as ordered. Record review of Physician orders [REDACTED]. Record review of POS and MAR indicated [REDACTED]. The physician ordered {Formula} one container 250 milliliters (ml) via PEG bolus 6 times per day, check tube placement by aspirating stomach contents before meals: at 6:30 am, 11:30 am, 4:30 pm. Water Flush 75 ml (milliliters) before and after each bolus feeding 6 times per day. The resident did not receive the Enteral feeding as ordered for one container (250 ml) via PEG bolus 6 times per day and the 75 ml water flush before and after each bolus. The MAR indicated [REDACTED]. Review of the nursing notes revealed, documentation by staff A, an RN dated [DATE] at 7:03 am, edited /created at 6:04 PM, the documentation included, Resident received on stable condition, no complain of pain or discomfort during this shift, no shortness of breath (SOB) or respiratory distress at this moment. Activities of daily living (ADL's) provided by staff, call light at easy reach bed in lowest position, head of bed (HOB) elevated, therapy in progress, well tolerated . Review of the nursing notes created by Staff B, a RN Manager on [DATE] at 7:10 am, revealed documentation for, Resident awake, and alert seen seated in wheelchair in his room, no sign of acute distress noted. The nursing progress note narrative dated [DATE] at 3:15 PM by Staff A, RN documented: After several attempts to administer resident's medications, I could not find him in room or in the designated areas. I looked for him everywhere with the help of my Certified Nursing Assistants (CNAs) but did not find him. I reported to my supervisors, notified Doctor {name} , and continued to look for him. Record review of the nursing assistant's documentation revealed, the nursing assistant providing care to Resident #1 signed for care and services being provided in the electronic records at 8:21 am on [DATE]. This was determined to be inaccurate since the resident left the facility at 7:44 am on [DATE]. During a review of the facility's video footage for [DATE] revealed, a housekeeping staff person was in the elevator with resident #1, the staff person exited the elevator on the first floor of the facility and went to the right, shortly afterwards resident #1 was observed sitting and wheeling himself in a non-motorized wheelchair, the resident exited the elevator and went to the left, pushed open the facility's glass type door without any difficulty and exited the facility. There was no staff person posted at the door. There appeared to be a ramp outside the door used by Resident #1. While the resident was exiting the facility, a medication cart was seen in the video footage located next to the elevator and a facility nurse was observed to walk to the medication cart, but the nurse did not acknowledge resident #1 as the resident exited the facility. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway. During an interview with Staff B, RN and Charge Nurse, on [DATE] at 2:45 PM revealed, he worked the day of the incident from 7:00 am to 7:30 pm. Staff B reported, resident # 1 was alert and oriented and had a usual routine. Staff B stated that resident #1 would get up in the morning, ask for his medications and bolus feeding. Resident # 1 liked reading and spent a lot of time downstairs on the front patio and on the patio in the back. Staff B revealed, the routine for the nurses when they came on duty in the mornings included doing rounds and to check on the residents. Between 8:00 am to 10:00 am, the nurses would do med pass. At 11:30 am to 12:00 noon blood sugars checks and Insulin administration would be done. The residents are prepared for lunch and bolus feedings are also done between 11:30 am to 12:00 noon. The nurse's complete documentation and assessments in between those duties. Staff B reported, afternoon med pass for some residents are completed between 1:00 PM to 2:00 PM. Staff B stated, they must do rounds after med pass and ADL care, between nurses and CNAs the residents should be constantly monitored. Staff B revealed, the nurse assigned that day notified him around 3:00 pm on [DATE] that resident #1 resident was missing, and all staff started looking for the resident. During interview on [DATE] at 4:13 PM, Staff C, a Licensed Practical Nurse (LPN) reported, I was on the on the second floor, I did not see him that day. I found out at approximately 3:15 PM when the nurse manager, (Staff B) called me, I got report from him, I reported to the department heads, Staff B told me they did room check. We then went out and did a parameter check and from there we called the police, the doctor, and the guardian. When the police arrived, we gave the report in the administrators' office and provided the police with a picture of the patient. The cameras were reviewed by the administrator with the police. The Social Services Director, charge nurses, staff B, Staff G, an LPN and Staff A, an RN that was resident #1's assigned nurse were present. The time on the cameras indicated resident #1 exited at 7:44 am on [DATE]. Staff C reported, the only behavior resident #1 exhibited was taking food from trays and the resident refused to participate in the restorative dining program for snacks. Staff C reported, resident #1 did not have to be supervised and he wanted to eat on his own. Staff C reported, we explained to him, it was for his safety and he signed a refusal of treatment form on [DATE]. On [DATE] at 9:39 am Staff D, a Certified Nursing Assistant (CNA) revealed, she worked the night shift on [DATE] to [DATE] on the 11:00 pm to 7:00 am shift. Staff D stated that she was familiar with resident #1. Staff D explained, that resident #1 would use the call light for assistance if he needed to use the bathroom or toilet. Staff B stated, The night before he was okay, I asked him if wanted to go to toilet and I asked him if he needed help with anything he said, no. Early in the morning, he said the only thing he wanted was for me to make the bed. I helped him to the chair, made the bed and then he went back into the bed. At the end of my shift, he was in bed and in his night clothes. Staff D reported, he did not show any signs or say he was leaving or planned to leave. He never gave any problem. He sleeps ok during the night and would only get up to use the restroom. I do rounds at least every 2 hours and for PEG tube and residents with breathing problems, I check on them more often. The day they were looking for him they called me, and I told them, I left him in the bed. When we changed shift the CN A that comes in on the oncoming shift and I did room to room with the morning C N [NAME] I left the patient in the bed. During an interview on [DATE] at 9:45 am Staff E, the C N A that worked the 3:00 PM to 11:00 PM shift on [DATE] stated, she worked with Resident #1 and he was an alert patient. Staff [NAME] reported, I would help him get undressed, dressed and ready for bed. When I came in to work, I did not see him, I looked for him, but he was missing. The last time I saw him was at the end of my shift the night before and he was in bed watching TV (Television). He did not say he was leaving, he had a feeding tube and he was okay. We searched for him and did not find him. During an interview on [DATE] at 10:57 am, the Director of Nursing (DON) reported, he was off the day of the event and he came to the facility when he was notified that the resident was missing to help with the search. During an interview on [DATE] at 11:01 am, the Administrator revealed, I was in the facility, I was told immediately at around 3:45 pm by the Social Worker, from there I went up to the floor, they said he was not in his room, they searched the grounds and I called 911, the doctor and the guardian. I sent out a van with the Social Worker to search the area. Law enforcement came, and we did a missing person's report with the police department. I looked at the cameras with the officer and the last time he was seen on camera was at 7:48 am. He came down the elevator. I saw him on the camera hanging out, then you don't see him anymore. We kept searching for him for next couple of days and we called local hospitals. Then on Sunday, (MONTH) 8th, the police called for the guardian's information because they had a body that fits his description. So, I gave the guardian's information to the police because they needed the guardian to come and see if it was him. On [DATE], we got confirmation from the guardian that it was him. He was found Downtown Miami next to a building in the government center area.The administrator stated, the nursing station does not always have a staff nurse, but we have a unit secretary, but she is not always there. During an interview on [DATE] at 11:42 am with the Social Worker it was reported, resident #1 was very quiet, he liked to go outside. The Social Worker revealed, he did not see resident #1 that day . and had no inclination that he would leave. The Social Worker reported, regular visits and reviews were done and resident #1 never complained of any issues and met every month with the guardian. The Social Worker stated, I found out around 3:40 PM from the Assistant Director of Nursing (ADON) that we have a resident missing, we searched, I went out to the street, and the parameters of the area store. To see if I saw him at the gas station, {grocery stores} .nothing here they called the guardian and the police. Our drivers went and looked in the area to if we saw him. I found out that following Monday about his death from the administrator. Interview on [DATE] at 2:29 PM with Staff G, an LPN and nurse manager revealed, she normally works on the first floor. Staff G revealed, she worked on Thursday, [DATE], the day resident #1 went missing. Staff G stated, I came in at 7:50 am that morning because I was running late, and I worked until about 4:00 pm. When asked if any staff was at the nurse's station upon her arrival, staff G stated, No, when I came in no one was at the desk and I did not see the resident that day. The nurses were in the hallway and no one was at the nurse's station. During an interview on [DATE] at 11:05 am with the Activities Director, Staff J, it was reported, she did not see resident #1 on [DATE]. She explained, he would come downstairs to the patio or be upstairs in his room or activities. He participated in small groups and he liked to come to the activities area on the patio. He liked sports and she would give him magazines to read, that was his Forte. He showed no signs or inclination that he wanted to leave. He would go up to activities in the afternoon and watched TV with his friend after dinner. The Activities Director explained, activities are based on assessments of residents likes and dislikes related to activities including in room activities. Resident #1 had a routine and he would be on the patio or in his room. I did not see him that day and that was nothing unusual. During interview on [DATE] at 11:25 am with Staff K, an Activity staff person, the activities attendance log presented and it revealed, resident #1 did not attend activities on [DATE]. Staff K primarily oversaw the activities on the second floor, and reported resident #1 would go downstairs to the patio to read and listen to the radio. Staff K revealed, she did not check for him that day because he had his routine. During interview on [DATE] at 12:14 PM, the DON revealed, the nurse that was working with resident #1 gave a statement that he administered the medications to resident #1 early on [DATE] because the resident asked for it early. The DON reported, the nurse was terminated, because he did not follow the doctor orders, he did not check on the resident and follow up. The DON revealed, the nursing assistant that was assigned to resident #1 for the day shift was already home when they realized the resident was missing by the oncoming 3:00 PM to 11:00 PM nursing assistant. During an interview on [DATE] at 1:50 PM the DON stated, We were working with a resident that had this planned, in my opinion he knew the time staff would not miss him and during the endorsement he chose the time we were most busy, and he had his routine we got out smarted by this resident . there was no indication that the resident wanted to go . The DON acknowledged, the nurse had opportunities to realize the resident was missing. The DON stated, If the blood sugar check was done at 12 o'clock the nurse would have noticed the resident was missing at that time and looked for the resident, we could have noticed the resident was missing at that time. The door resident #1 went through did not require a code to exit. The DON revealed, it was a concern that the door alarm only worked for residents with a wander alarm and anyone that does not have a wander alarm system could go through the doors at any time. The DON stated, We did not report it because we did not realize until after we did a consult, and we were told that it should have been reported. The reporting is under the Social Worker and he informed the administrator that a resident was missing. I know that is a concern and a lesson learned for me about reporting those things. During an interview with the Social Worker on [DATE] at 2:40 PM, the Social Worker reported, he did not report this incident because he was told by the administrator that it is an adverse incident. The Social worker stated, he knew that he may have needed to report it as abuse/neglect but did not because they did not tell him to and under normal circumstances he would have reported all abuse and neglect issues. The Social Worker reported, he did ask if he should report this event. The Social Worker reported that on [DATE], a Monday, upon return to work from the weekend he was informed of the residents' death. In a follow up interview on [DATE] at 5:37 PM with the Social Worker it was explained, because the administrator told him from the beginning it was an adverse incident and there was no need to report it. The Social Worker stated, The requirement for reporting is soon as I get it, I will do an immediate, then when I get everything then the 5 day and then the adverse.

Based on record review and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to provide care and services including adequate supervision for 1 (resident #1) out of 3 residents sampled at the time of the survey. This deficient practice has the potential to affect all 89 residents residing in the facility. The assigned nurse and certified nursing assistant did not provide scheduled care and services as required based on the resident assessment and plan of care related to resident #1's physician ordered care and treatments. This deficient practice enabled resident #1 to elope from the facility undetected on [DATE] at 7:44 am and the resident was not discovered as missing until 3:15 PM on [DATE]. Subsequently, the resident was found by law enforcement on [DATE], approximately 11 miles from the facility and was deceased . Refer to F 600, F 609, F 689, F 835. The findings included: Record review of the facility's policy titled, Abuse/Neglect prevention protocol and reporting written by the Administrator and the revision dates were: ,[DATE], revealed: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility will immediately report all allegations or information that creates reasonable cause to believe that a resident was abused to the appropriate jurisdictional authorities and the resident's responsible relative A prompt thorough investigation will be conducted by the facility immediately . The facility's Policies and Procedures reviewed did not directly address neglect. Record review of the Face Sheet for Resident #1 revealed, the resident was admitted to the facility on [DATE] from a local hospital as a long term care resident under the Guardianship program. The clinical [DIAGNOSES REDACTED]. The resident was receiving nutrition by a Percutaneous Endoscopic Gastrostomy (PEG/feeding tube). Record review of the last quarterly Minimum Data Set ((MDS) dated [DATE] indicated resident #1 was cognitively intact with a Brief Interview of Mental Status (BIMS ) score of ,[DATE]. Section G for functional status indicated for bed mobility, the resident required supervision for self-performance and set up only. For locomotion on and off the unit, Resident #1 required supervision and set up only. For dressing Resident #1 required extensive assistance with one person for physical assist. For Eating: Extensive assistance with one person physical assist. For toilet use and personal hygiene, the resident required assistance with one person for physical assist. Record review of Resident #1's last care plan conference dated [DATE] included problem areas: Risk for [MEDICAL CONDITION] related to Diabetes. Risk for respiratory complications Shortness of breath. Risk for fall/injury related to impaired balance, impaired cognition/safety awareness, risk for complications of tube feeding as evidenced by aspiration . Record review revealed Physician orders [REDACTED]. The Medication Administration Records (MAR) for [DATE] revealed, resident #1 did not get his blood glucose checked at 12:00 noon as ordered. Record review of Physician order [REDACTED]. Record review of POS and MAR indicated [REDACTED]. The physician ordered {Formula} one container 250 milliliters (ml) via PEG bolus 6 times per day, check tube placement by aspirating stomach contents before meals: at 6:30 am, 11:30 am, 4:30 pm. Water Flush 75 ml (milliliters) before and after each bolus feeding 6 times per day. The resident did not receive the Enteral feeding as ordered for one container (250 ml) via PEG bolus 6 times per day and the 75 ml water flush before and after each bolus. The MAR indicated [REDACTED]. Review of the nursing notes revealed, documentation by staff A, an RN dated [DATE] at 7:03 am, edited /created at 6:04 PM, the documentation included, Resident received on stable condition, no complain of pain or discomfort during this shift, no shortness of breath (SOB) or respiratory distress at this moment. Activities of daily living (ADL's) provided by staff, call light at easy reach bed in lowest position, head of bed (HOB) elevated, therapy in progress, well tolerated . Review of the nursing notes created by Staff B, a RN Manager on [DATE] at 7:10 am, revealed documentation for, Resident awake, and alert seen seated in wheelchair in his room, no sign of acute distress noted. The nursing progress note narrative dated [DATE] at 3:15 PM by Staff A, RN documented: After several attempts to administer resident's medications, I could not find him in room or in the designated areas. I looked for him everywhere with the help of my Certified Nursing Assistants (CNAs) but did not find him. I reported to my supervisors, notified Dr , and continued to look for him. Record review of the nursing assistant's documentation revealed, the documentation that nursing assistant providing care to resident #1 signed for care and services being provided in the electronic records at 8:21 am on [DATE]. This was determined to be inaccurate since the resident left the facility at 7:44 am on [DATE]. During a review of the facility's video footage for [DATE] revealed, a housekeeping staff person was in the elevator with resident #1, the staff person exited the elevator on the first floor of the facility and went to the right, shortly afterwards resident #1 was observed sitting and wheeling himself in a non-motorized wheelchair, the resident exited the elevator and went to the left, pushed open the facility's glass type door without any difficulty and exited the facility. There was no staff person posted at the door. There appeared to be ramp outside the door used by resident #1. While the resident was exiting the facility, a medication cart was seen in the video footage located next to the elevator and a facility nurse was observed to walk to the medication cart, but the nurse did not acknowledge resident #1 as the resident exited the facility. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. During an interview with Staff B, RN and Charge Nurse, on [DATE] at 2:45 PM revealed, he worked the day of the incident from 7:00 am to 7:30 PM. Staff B reported, Resident # 1 was alert and oriented and had a usual routine. Staff B stated that Resident #1 would get up in the morning, ask for his medications and bolus feeding. Resident # 1 liked reading and spent a lot of time downstairs on the front patio and on the patio in the back. Staff B revealed, the routine for the nurses when they came on duty in the mornings included doing rounds and to check on the residents. Between 8:00 am to 10:00 am, the nurses would do med pass. At 11:30 am to 12:00 noon blood sugars checks, and Insulin administration would be done. The residents are prepared for lunch and bolus feedings are also done between 11:30 am to 12:00 noon. The nurse's complete documentation and assessments in between those duties. Staff B reported, afternoon med pass for some residents are completed between 1:00 PM to 2:00 PM. Staff B stated, they must do rounds after med pass and ADL care, between nurses and CNAs the residents should be constantly monitored. Staff B revealed, the nurse assigned that day notified him around 3:00 PM on [DATE] that Resident #1 was missing, and all staff started looking for the resident. During interview on [DATE] at 4:13 PM, Staff C, a Licensed Practical Nurse (LPN) reported, I was on the on the second floor, I did not see him that day. I found out at approximately 3:15 PM when the nurse manager, (Staff B) called me, I got report from him, I reported to the department heads, Staff B told me they did room check. We then went out and did a parameter check and from there we called the police, the doctor, and the guardian. When the police arrived, we gave the report in the administrators' office and provided the police with a picture of the patient. The cameras were reviewed by the administrator with the police. The Social Services Director, charge nurses, staff B, Staff G, an LPN and Staff A, an RN that was resident #1's assigned nurse were present. The time on the cameras indicated resident #1 exited at 7:44 am on [DATE]. Staff C reported, the only behavior Resident #1 exhibited was taking food from trays and the resident refused to participate in the restorative dining program for snacks. Staff C reported, resident #1 did not have to be supervised and he wanted to eat on his own. Staff C reported, we explained to him, it was for his safety and he signed a refusal of treatment form on [DATE]. On [DATE] at 9:39 am Staff D, a Certified Nursing Assistant (CN A) revealed, she worked the night shift on [DATE] to [DATE] on the 11:00 pm to 7:00 am shift. Staff D stated that she was familiar with Resident #1. Staff D explained, that resident #1 would use the call light for assistance if he needed to use the bathroom or toilet. Staff B stated, The night before he was okay, I asked him if wanted to go to toilet and I asked him if he needed help with anything he said, no. Early in the morning, he said the only thing he wanted was for me to make the bed. I helped him to the chair, made the bed and then he went back into the bed. At the end of my shift, he was in bed and in his night clothes. Staff D reported, he did not show any signs or say he was leaving or planned to leave. He never gave any problem. He sleeps ok during the night and would only get up to use the restroom. I do round at least every 2 hours and for PEG tube and residents with breathing problems, I check on them more often. The day they were looking for him they called me, and I told them, I left him in the bed. When we changed shift the CN A that comes in on the oncoming shift and I did room to room with the morning C N [NAME] I left the patient in the bed. During the survey it was revealed by the Director of Nursing that the Certified Nursing Assistant that worked with Resident #1 on the 7:00 am to 3:00 PM shift, on the day of the event was terminated. Attempts to contact the Certified Nursing assistant was unsuccessful. During an interview on [DATE] at 9:45 am Staff E, the C N A that worked the 3:00 PM to 11:00 PM shift on [DATE] stated, she worked with Resident #1 and he was an alert patient. Staff [NAME] reported, I would help him get undressed, dressed and ready for bed. When I came in to work, I did not see him, I looked for him, but he was missing. The last time I saw him was at the end of my shift the night before and he was in bed watching TV (Television). He did not say he was leaving, he had a feeding tube and he was okay. We searched for him and did not find him. During an interview on [DATE] at 10:57 am, the Director of Nursing (DON) reported, he was off the day of the event and he came to the facility when he was notified that the resident was missing to help with the search. During an interview on [DATE] at 11:01 am, the Administrator revealed, I was in the facility, I was told immediately at around 3:45 pm by the Social Worker, from there I went up to the floor, they said he was not in his room, they searched the grounds and I called 911, the doctor and the guardian. I sent out a van with the Social Worker to search the area. Law enforcement came, and we did a missing person's report with the police department. I looked at the cameras with the officer and the last time he was seen on camera was at 7:48 am. He came down the elevator. I saw him on the camera hanging out, then you don't see him anymore. We kept searching for him for next couple of days and we called local hospitals. Then on Sunday, (MONTH) 8th, the police called for the guardian's information because they had a body that fits his description. So, I gave the guardian's information to the police because they needed the guardian to come and see if it was him. On [DATE], we got confirmation from the guardian that it was him. He was found Downtown Miami next to a building in the government center area. The administrator stated, the nursing station does not always have a staff nurse, but we have a unit secretary, but she is not always there. During an interview on [DATE] at 11:42 am with the Social Worker it was reported, Resident #1 was very quiet, he liked to go outside. The Social Worker revealed, he did not see Resident #1 that day . and had no inclination that he would leave. The Social Worker reported, regular visits and reviews were done and Resident #1 never complained of any issues and met every month with the guardian. The Social Worker stated, I found out around 3:40 PM from the Assistant Director of Nursing (ADON) that we have a resident missing, we searched, I went out to the street, and the parameters of the area store. To see if I saw him at the gas station, {grocery stores} .nothing here they called the guardian and the police. Our drivers went and looked in the area to if we saw him. I found out that following Monday about his death from the administrator. Interview on [DATE] at 2:29 PM with Staff G, an LPN and Nurse Manager revealed, she normally works on the first floor. Staff G revealed, she worked on Thursday, [DATE], the day Resident #1 went missing. Staff G stated, I came in at 7:50 am that morning because I was running late, and I worked until about 4:00 PM. When asked if any staff was at the nurse's station upon her arrival, staff G stated, No, when I came in no one was at the desk and I did not see the resident that day. The nurses were in the hallway and no one was at the nurse's station. During an interview on [DATE] at 11:05 am with the Activities Director, Staff J, it was reported that she did not see Resident #1 on [DATE]. She explained, he would come downstairs to the patio or be upstairs in his room or activities. He participated in small groups and he liked to come to the activities area on the patio. He liked sports and she would give him magazines to read, that was his Forte. He showed no signs or inclination that he wanted to leave. He would go up to activities in the afternoon and watched TV with his friend after dinner. The Activities Director explained, activities are based on assessments of residents likes and dislikes related to activities including in room activities. Resident #1 had a routine and he would be on the patio or in his room. I did not see him that day and that was nothing unusual. During interview on [DATE] at 11:25 am with Staff K, an Activity staff person, presented the activities attendance log and it revealed, Resident #1 did not attend activities on [DATE]. Staff K primarily oversaw the activities on the second floor, reported Resident #1 would go downstairs to the patio to read and listen to the radio. Staff K revealed, she did not check for him that day because he had his routine. During interview on [DATE] at 12:14 PM, the DON revealed, the nurse that was working with Resident #1 gave a statement that he administered the medications to Resident #1 early on [DATE] because the resident asked for it early. The DON reported, the nurse was terminated, because he did not follow the doctor orders, he did not check on the resident and follow up. The DON revealed, the nursing assistant that was assigned to Resident #1 for the day shift was already home when they realized the resident was missing by the oncoming 3:00 PM to 11:00 PM nursing assistant. During an interview on [DATE] at 1:50 PM the DON stated, We were working with a resident that had this planned, in my opinion he knew the time staff would not miss him and during the endorsement (terminology used by facility for change of shift) he chose the time we were most busy, and he had his routine we got out smarted by this resident . there was no indication that the resident wanted to go . The DON acknowledged, the nurse had opportunities to realize the resident was missing. The DON stated, If the blood sugar check was done at 12 o'clock the nurse would have noticed the resident was missing at that time and looked for the resident, we could have noticed the resident was missing at that time. The door resident #1 went through did not require a code to exit. The DON revealed, it was a concern that the door alarm only worked for residents with a wander alarm and anyone that does not have a wander alarm system could go through the doors at any time. The DON stated, We did not report it because we did not realize until after we did a consult, and we were told that it should have been reported. The reporting is under the Social Worker and he informed the administrator that a resident was missing. I know that is a concern and a lesson learned for me about reporting those things. During an interview with the Social Worker on [DATE] at 2:40 PM, the Social Worker reported, he did not report this incident because he was told by the administrator that it is an adverse incident. The Social worker stated, he knew that he may have needed to report it as abuse/neglect but did not because they did not tell him to and under normal circumstances he would have reported all abuse and neglect issues. The Social Worker reported, he did ask if he should report this event. The Social Worker reported that on [DATE], a Monday, upon return to work from the weekend he was informed of the residents' death. In a follow up interview on [DATE] at 5:37 PM with the Social Worker it was explained, because the administrator told him from the beginning it was an adverse incident and there was no need to report it. The Social Worker stated, The requirement for reporting is as soon as I get it, I will do an immediate, then when I get everything then the 5 day and then the adverse.

Based on record reviews and interviews, the facility failed to prevent neglect related to one (resident #1) out of three residents sampled during the time of this survey. This deficient practice enabled resident #1 to elope from the facility undetected on 09/05/19 at 7:44 am and the resident was not discovered as missing until 3:15 PM on 09/05/19. Refer to F607, F609, F689, F835. The findings included: Record review of the facility's policy titled, Abuse/Neglect prevention protocol and reporting written by the Administrator and the revision date was on 06/2019, the policy revealed: Our Facility will make all reasonable efforts to ensure that residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, or involuntary seclusion, willful deprivation, of services to maintain the residents' physical and mental health and that their property will not be misappropriated, by the facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility will immediately report all allegations or information that creates reasonable cause to believe that a resident was abused to the appropriate jurisdictional authorities and the resident's responsible relative A prompt thorough investigation will be conducted by the facility immediately . The facility's Policies and Procedures did not directly address neglect. Record review of the Face Sheet for Resident #1 revealed, the resident was admitted to the facility on [DATE] from a local hospital for long term care residency under the Guardianship program. The clinical [DIAGNOSES REDACTED]. The resident was receiving nutrition by a Percutaneous Endoscopic Gastrostomy (PEG/feeding tube). Record review of clinical records, video footage and interviews revealed, the staff had opportunities to prevent the resident from eloping, but due to a failure in supervision, a failure in providing care and services that included providing scheduled medications and treatments this allowed the residents elopement to be undetected by staff when resident #1 left the faciity on [DATE] at 7:44 AM until 3:15 PM, when staff identified the resident was missing. Record review of Resident #1's last care plan conference dated 06/27/2019 included problem areas: Risk for [MEDICAL CONDITION] related to Diabetes. Risk for respiratory complications Shortness of breath. Risk for fall/injury related to impaired balance, impaired cognition/safety awareness, risk for complications of tube feeding as evidenced by aspiration . Record review revealed Physician orders [REDACTED]. The medication administration records (MAR) for 09/05/19 revealed, Resident #1 did not get his blood glucose checked at 12:00 noon as ordered. Record review of Physician order [REDACTED]. Record review of POS and MAR indicated [REDACTED]. The physician ordered {Formula} one container 250 milliliters (ml) via PEG bolus 6 times per day, check tube placement by aspirating stomach contents before meals: at 6:30 am, 11:30 am, 4:30P.M. Water Flush 75 ml (milliliters) before and after each bolus feeding 6 times per day. Resident #1 did not receive the Enteral feeding as ordered for one container (250 ml) via PEG bolus 6 times per day and the 75 ml water flush before and after each bolus. The MAR indicated [REDACTED]. Record review of the nursing assistant's documentation revealed, the nursing assistant providing care to Resident #1 signed for care and services being provided in the electronic records at 8:21 am on 09/05/2019. This was determined to be inaccurate since the resident left the facility at 7:44am on 09/05/19. Review of the nursing notes revealed, documentation by Staff A, an RN dated 09/05/2019 at 7:03 am, edited /created at 6:04 PM, the documentation included, Resident received on stable condition, no complain of pain or discomfort during this shift, no shortness of breath (SOB) or respiratory distress at this moment. Activities of daily living (ADL's) provided by staff, call light at easy reach bed in lowest position, head of bed (HOB) elevated, therapy in progress, well tolerated . Review of the nursing notes created by Staff B, a RN Manager on 09/05/2019 at 7:10 am, revealed documentation for, Resident awake, and alert seen seated in wheelchair in his room, no sign of acute distress noted. The nursing progress note narrative dated 09/05/2019 at 3:15 PM by Staff A, RN documented: After several attempts to administer resident's medications, I could not find him in room or in the designated areas. I looked for him everywhere with the help of my Certified Nursing Assistants (CNAs) but did not find him. I reported to my supervisors, notified Doctor , and continued to look for him. During a review of the facility's video footage for 09/05/2019 revealed, a housekeeping staff person was in the elevator with resident #1, the staff person exited the elevator on the first floor of the facility and went to the right, shortly afterwards resident #1 was observed sitting and wheeling himself in a non-motorized wheelchair, the resident exited the elevator and went to the left, pushed open the facility's glass type door without any difficulty and exited the facility. There was no staff person posted at the door. There appeared to be ramp outside the door used by Resident #1. While the resident was exiting the facility, a medication cart was seen in the video footage located next to the elevator and a facility nurse was observed to walk to the medication cart, but the nurse did not acknowledge Resident #1 as the resident exited the facility. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. During an interview with Staff B, RN and Charge Nurse, on 10/01/2019 at 2:45 PM revealed, he worked the day of the incident from 7:00 am to 7:30 pm. Staff B reported, resident # 1 was alert and oriented and had a usual routine. Staff B stated that resident #1 would get up in the morning, ask for his medications and bolus feeding. Resident # 1 liked reading and spent a lot of time downstairs on the front patio and on the patio in the back. Staff B revealed, the routine for the nurses when they came on duty in the mornings included doing rounds and to check on the residents. Between 8:00 am to 10:00 am, the nurses would do med pass. At 11:30 am to 12:00 noon blood sugars checks, and Insulin administration would be done. The residents are prepared for lunch and bolus feedings are also done between 11:30 am to 12:00 noon. The nurse's complete documentation and assessments in between those duties. Staff B reported, afternoon med pass for some residents are completed between 1:00 PM to 2:00 PM. Staff B stated, they must do rounds after med pass and Activities of Daily Living (ADL) care, between nurses and CNAs the residents should be constantly monitored. Staff B revealed, the nurse assigned that day notified him around 3:00 PM on 09/05/2019 that Resident #1 resident was missing, and all staff started looking for the resident. During interview on 10/01/2019 at 4:13 PM, Staff C, a Licensed Practical Nurse (LPN) reported, I was on the on the second floor, I did not see him that day. I found out at approximately 3:15 PM when the nurse manager, (Staff B) called me, I got report from him, I reported to the department heads, Staff B told me they did room check. We then went out and did a parameter check and from there we called the police, the doctor, and the guardian. When the police arrived, we gave the report in the administrators' office and provided the police with a picture of the patient. The cameras were reviewed by the administrator with the police. The Social Services Director, charge nurses, staff B, Staff G, an LPN and Staff A, an RN that was resident #1's assigned nurse were present. The time on the cameras indicated resident #1 exited at 7:44 am on 09/05/2019. Staff C reported, the only behavior resident #1 exhibited was taking food from trays and the resident refused to participate in the restorative dining program for snacks. Staff C reported, resident #1 did not have to be supervised and he wanted to eat on his own. Staff C reported, we explained to him, it was for his safety and he signed a refusal of treatment form on 09/03/2019. On 10/02/19 at 9:39 am Staff D, a Certified Nursing Assistant (CN A) revealed, she worked the night shift on 09/04/2019 to 09/05/2019 on the 11:00pm to 7:00 am shift. Staff D stated that she was familiar with Resident #1. Staff D explained, that Resident #1 would use the call light for assistance if he needed to use the bathroom or toilet. Staff B stated, The night before he was okay, I asked him if wanted to go to toilet and I asked him if he needed help with anything he said, no. Early in the morning, he said the only thing he wanted was for me to make the bed. I helped him to the chair, made the bed and then he went back into the bed. At the end of my shift, he was in bed and in his night clothes. Staff D reported, he did not show any signs or say he was leaving or planned to leave. He never gave any problem. He sleeps ok during the night and would only get up to use the restroom. I do round at least every 2 hours and for PEG tube and residents with breathing problems, I check on them more often. The day they were looking for him they called me, and I told them, I left him in the bed. When we changed shift the CN A that comes in on the oncoming shift and I did room to room with the morning C N [NAME] I left the patient in the bed. During the survey it was revealed by the Director of Nursing that the Certified Nursing Assistant that worked with Resident #1 on the 7:00 am to 3:00 PM shift, on the day of the event was terminated. Attempts to contact the Certified Nursing assistant was unsuccessful. During an interview on 10/02/19 at 9:45 am Staff E, the C N A that worked the 3:00 PM to 11:00 PM shift on 09/05/2019 stated, she worked with Resident #1 and he was an alert patient. Staff [NAME] reported, I would help him get undressed, dressed and ready for bed. When I came in to work, I did not see him, I looked for him, but he was missing. The last time I saw him was at the end of my shift the night before and he was in bed watching TV (Television). He did not say he was leaving, he had a feeding tube and he was okay. We searched for him and did not find him. During an interview on 10/02/19 at 10:57 am, the Director of Nursing (DON) reported, he was off the day of the event and he came to the facility when he was notified that the resident was missing to help with the search. During an interview on 10/02/19 at 11:01 am, the Administrator revealed, I was in the facility, I was told immediately at around 3:45 P.M. by the Social Worker, from there I went up to the floor, they said he was not in his room, they searched the grounds and I called 911, the doctor and the guardian. I sent out a van with the Social Worker to search the area. Law enforcement came, and we did a missing person's report with the police department. I looked at the cameras with the officer and the last time he was seen on camera was at 7:48 am. He came down the elevator. I saw him on the camera hanging out, then you don't see him anymore. We kept searching for him for next couple of days and we called local hospitals. Then on Sunday, (MONTH) 8th, the police called for the guardian's information because they had a body that fits his description. So, I gave the guardian's information to the police because they needed the guardian to come and see if it was him. On 09/9/19, we got confirmation from the guardian that it was him. He was found Downtown Miami next to a building in the government center area. The administrator stated, the nursing station does not always have a staff nurse, but we have a unit secretary, but she is not always there. During an interview on 10/02/2019 at 11:42 am with the Social Worker it was reported, Resident #1 was very quiet, he liked to go outside. The Social Worker revealed, he did not see Resident #1 that day . and had no inclination that he would leave. The Social Worker reported, regular visits and reviews were done and resident #1 never complained of any issues and met every month with the guardian. The Social Worker stated, I found out around 3:40 PM from the Assistant Director of Nursing (ADON) that we have a resident missing, we searched, I went out to the street, and the parameters of the area store. To see if I saw him at the gas station, {grocery stores} .nothing here they called the guardian and the police. Our drivers went and looked in the area to if we saw him. I found out that following Monday about his death from the administrator. Interview on 10/02/2019 at 2:29 PM with Staff G, an LPN and nurse manager revealed, she normally works on the first floor. Staff G revealed, she worked on Thursday, 09/05/19, the day resident #1 went missing. Staff G stated, I came in at 7:50 am that morning because I was running late, and I worked until about 4:00 pm. When asked if any staff was at the nurse's station upon her arrival, staff G stated, No, when I came in no one was at the desk and I did not see the resident that day. The nurses were in the hallway and no one was at the nurse's station. During an interview on 10/03/2019 at 11:05 am with the Activities Director, Staff J, it was reported that she did not see Resident #1 on 09/05/2019. She explained, he would come downstairs to the patio or be upstairs in his room or activities. He participated in small groups and he liked to come to the activities area on the patio. He liked sports and she would give him magazines to read, that was his Forte. He showed no signs or inclination that he wanted to leave. He would go up to activities in the afternoon and watched TV with his friend after dinner. The Activities Director explained, activities are based on assessments of residents likes and dislikes related to activities including in room activities. Resident #1 had a routine and he would be on the patio or in his room. I did not see him that day and that was nothing unusual. During interview on 10/03/2019 at 11:25 am with Staff K, an Activity staff person, the activities attendance log presented, and it revealed, Resident #1 did not attend activities on 09/05/2019. Staff K primarily oversaw the activities on the second floor, and reported Resident #1would go downstairs to the patio to read and listen to the radio. Staff K revealed, she did not check for him that day because he had his routine. During interview on 10/03/2019 at 12:14 PM, the DON revealed, the nurse that was working with Resident #1 gave a statement that he administered the medications to Resident #1 early on 09/05/19 because the resident asked for it early. The DON reported, the nurse was terminated, because he did not follow the doctor orders, he did not check on the resident and follow up. The DON revealed, the nursing assistant that was assigned to Resident #1 for the day shift was already home when they realized the resident was missing by the oncoming 3:00 PM to 11:00 PM nursing assistant. During an interview on 10/03/19 at 1:50 PM the DON stated, We were working with a resident that had this planned, in my opinion he knew the time staff would not miss him and during the endorsement (facility's terminology used for change of shift) he chose the time we were most busy, and he had his routine we got out smarted by this resident . there was no indication that the resident wanted to go . The DON acknowledged, the nurse had opportunities to realize the resident was missing. The DON stated, If the blood sugar check was done at 12 o'clock the nurse would have noticed the resident was missing at that time and could have looked for the resident, we could have noticed the resident was missing at that time. The door Resident #1 went through did not require a code to exit. The DON revealed, it was a concern that the door alarm only worked for residents with a wander alarm and anyone that does not have a wander alarm system could go through the doors at any time. The DON stated, We did not report it because we did not realize until after we did a consult, and we were told that it should have been reported. The reporting is under the Social Worker and he informed the administrator that a resident was missing. I know that is a concern and a lesson learned for me about reporting those things. During an interview with the Social Worker on 10/03/19 at 2:40 PM, the Social Worker reported, he did not report this incident because he was told by the administrator that it is an adverse incident. The Social worker stated, he knew that he may have needed to report it as abuse/neglect but did not because they did not tell him to and under normal circumstances he would have reported all abuse and neglect issues. The Social Worker reported, he did ask if he should report this event. The Social Worker reported that on 09/09/2019, a Monday, upon return to work from the weekend he was informed of the residents' death. In a follow up interview on 10/04/19 at 5:37 PM with the Social Worker it was explained, because the administrator told him from the beginning it was an adverse incident and there was no need to report it. The Social Worker stated, The requirement for reporting as soon as I get it, I will do an immediate, then when I get everything then the 5 day and then the adverse.