Every finding on record at North Beach Healthcare and Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are properly stored, accurately accounted and dispensed in accordance with professional standards as evidenced by: Packages with medications for return to pharmacy left unattended at the Nurses stations; medication and treatments carts left unattended and unlocked. Discrepancies identified on the Controlled Drugs Disposition Records for South Wing Cart two. Discontinued medication observed on North Wing Medication Cart One. Date discrepancies for Ophthalmic treatments on Medication Carts. Medications left unattended during medication administration observation for Resident # 15 and sharing medications between residents intercepted by surveyor. There were 94 residents residing in the facility at the time of the survey. The findings included.Observation on 02/08/26 at 6:02 AM revealed three bags of medication on top of the counter at South Unit nursing station unattended. On 02/08/26 at 6:12 AM Staff B, Registered Nurse (RN) stated, I placed the medication in bags and left them on top of the nursing station for the pharmacy to pick up. Staff B, RN Further stated: it's ok to leave the medication unattended since it was in a bag. Tour of the South Unit on 02/08/26 at 6:03 AM revealed the South Wing Medication Cart Two with medical equipment on top unlocked and unattended. On 02/08/26 at 6:13 AM Staff C, Licensed Practical Nurse (LPN) approached the South wing Medication Cart Two and was asked about facility's protocol for medication storage Staff C, LPN stated: The medication carts should be locked when not attended. Observation on 02/08/26 at 6:05 AM revealed two unattended unlocked Treatment carts (one on the South Wing and one on the North Wing). On 02/08/26 at 6:15 AM Staff C, LPN was made aware of identified concern and revealed the Treatment carts are to be locked. During an interview on 02/08/26 at 7:04 AM Staff A, RN Weekend supervisor stated The medication and treatment carts should be locked at all times for the safety of the residents because some residents can open the cart and take medicine out. When returning medication to pharmacy we are to scan medication then placed in bag close it and keep it in the medication room. On 02/08/2026 at 6:43 AM a cart check and narcotic count was conducted for South Cart Two with Staff C, Licensed Practical Nurse (LPN) who worked the overnight shift. Several open undated over-the-counter medications found on the medication cart and the following narcotic accounting discrepancies were identified: President #47 Morphine Sulfate Extended Release15 milligram oral tablet one tablet every 12 hours related to pain. Bingo Card Medication Count had 4 tablets remaining. Controlled Drug Disposition Log documented amount on hand: 5 Oxycodone-Acetaminophen Tablet 10-325 milligrams give one tablet every six hours as needed for severe pain. Bingo Card Medication Count had 11 tablets remaining. Controlled Drug Disposition Log documented amount on hand:13 Resident # 54 Oxycodone HCI Oral tablet 30 milligrams by mouth every 4 hours for non-acute pain. Bingo Card Medication Count: 23 tablets remaining. Controlled Drug Disposition Log documentation amount on hand 23. The last date and time documented on the log indicated 2-7-26 time 1625. There were three single doses of tablets dispensed with no corresponding date and time administered signed by Staff C, LPN. Pregabalin capsule 75 milligrams. One capsule by mouth two times a day for Neuropathy. Bingo Card Medication Count: 26 capsules remaining. Controlled Drug Disposition Log documented amount on hand:27 Interview on 02/08/2026 at 6:50 AM, when asked about the facility's protocol for narcotic disposition; Staff C, Licensed Practical Nurse (LPN) stated: I should sign off for the medication when I take it out. When asked why she had not signed out the medication, she stated: I don't have an answer for that On 02/08/2026 at 7:01 AM inspection of the South Wing Medication Cart One conducted with Staff B, RN revealed: Resident #27's Latanoprost 0.005% Ophthalmic Solution instill 1 drop in both eyes at bedtime for Glaucoma did not have an open date and Dorzolamide HCI 2% Ophthalmic Solution instill 1 drop in both eyes two times a day related to Glaucoma -opened November 30, 2025. Resident #90's Latanoprost 0.005% Ophthalmic Solution open date 11/28/2026. Interview on 02/08/202 at 7:10 AM Staff B, RN stated: Opened eye drops should be discarded after 30 days. On 02/08/2026 at 7:48 AM during inspection of the North Wing Medication Cart One with Staff E, LPN and Staff K, RN revealed Resident # 59's discontinued medication Azithromycin 250 mg ordered 1/1/26 for ten days had one tablet remaining in the packet found in the top drawer of the medication cart. Several over the counter medications were noted with no open dates. Staff K, RN revealed the Azithromycin 250 mg medication was discontinued and the remaining one tablet should have been removed from the cart for disposal. Staff E, LPN revealed over-the-counter medication noted with no open date eye drops should be dated and eyedrops discarded 28 days after they are opened. On 02/08/2026 at 8:10 AM an observation of the North Wing Nurses Station an unattended grey plastic package labelled Pharmacy Returns was observed on the counter at the nurses' station. (Photographic evidence). Interview on 02/08/2026 at 8:16 AM Staff A, RN, Weekend Supervisor revealed the package should not be left at the desk. It should be in the med room. On 02/08/2026 at 8:20 AM, with Staff N, RN the following concerns were identified during a medication administration and cart review of North Wing Medication Cart Two revealed Over the Counter (OTC) Ophthalmic Solution for Resident #97 had two open dates (12/29/2025 and opened on 1/1/26) and OTC Ophthalmic Solution for Resident #79 had no open date. Photographic evidence. On 02/08/2026 at 8:56 AM, during medication administration observation conducted by Staff N, RN for Resident # 15 the following medications were prepared to be administered via Gastronomy Tube (G-tube) Losartan potassium 50 milligram (mg) one tablet, Sertraline 50 mg one tablet, Bactrim 800-160 mg one tablet, Baclofen 10 mg one tablet; Staff N, RN entered Resident # 15's room and placed the prepared medication on the overbed table and walked away leaving the medications unattended while she went to put on a disposable gown. Photographic evidence. On 02/08/2026 at 10:08 AM Staff N, RN was observed preparing to withdraw insulin to be administered for Resident #55. The surveyor requested to review the insulin and upon review it was noted the Novolog insulin belonged to another resident and the surveyor intervened. When asked why she was about to share residents' medication. Staff N, RN explained Resident # 55's Novolog insulin was not available. Staff N, RN was asked about the facility's policy when a resident's medication is not available on the cart, Staff N, RN was unable to provide an answer. The Assistant Director of Nursing was notified and assisted Staff N, RN with retrieving the insulin from the Emergency Kit. On 02/10/26 at 3:20 PM the Director of Nursing revealed medications are to be in a sealed bag in the medication room before return to pharmacy and the medications and treatments carts are to remain locked while unattended. Review of the facility's Pharmacy Services Policies: Administering Medications. Updated 04/28/2025 Policy Statement indicated: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 24.Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. Medication Storage Policy Interpretation and Implementation. Revised February 2023 1.Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Controlled Substances. Dispensing and Reconciling Controlled Substances Revised November 2022. 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. On 02/08/2026 at 6:43 AM a cart check and narcotic count and was conducted for South Cart Two with Staff C, Licensed Practical Nurse (LPN) who worked the overnight shift. Several open undated over-the-counter medications found on the medication cart and the following narcotic accounting discrepancies were identified: President #47 Morphine Sulfate Extended Release15 milligram oral tablet one tablet every 12 hours related to pain. Bingo Card Medication Count = 4 tablets remaining Controlled Drug Disposition Log documented amount on hand: 5 Resident # 47 Oxycodone-Acetaminophen Tablet 10-325 milligrams give one tablet every six hours as needed for severe pain. Bingo Card Medication Count=11 tablets remaining. Controlled Drug Disposition Log documented amount on hand:13 Resident # 54 Oxycodone HCI Oral tablet 30 milligrams by mouth every 4 hours for non-acute pain. Bingo Card Medication Count: 23 tablets remaining. Controlled Drug Disposition Log documentation amount on hand 23. The last date and time documented on the log indicated 2-7-26 time 1625. There were three single doses of tablets dispensed with no corresponding date and time administered signed by Staff C, LPN. Resident #54 Pregabalin capsule 75 milligrams. One capsule by mouth two times a day for Neuropathy. Bingo Card Medication Count: 26 capsules remaining Controlled Drug Disposition Log documented amount on hand:27 Interview on 02/08/2026 at 6:50 AM, when asked about the facility's protocol for narcotic disposition; Staff C, Licensed Practical Nurse (LPN) stated: I should sign off for the medication when I take it out. When asked why she had not signed out the medication, she stated: I don't have an answer for that 2) On 02/08/2026 at 7:01 AM inspection of the South Wing Medication Cart One conducted with Staff B, Licensed Practical Nurse (LPN) revealed: Resident #27 Latanoprost 0.005% Ophthalmic Solution instill 1 drop in both eyes at bedtime for Glaucoma did not have an open date. Dorzolamide HCI 2% Ophthalmic Solution instill 1 drop in both eyes two times a day related to Glaucoma -opened November 30, 2025. Resident #90 Latanoprost 0.005% Ophthalmic Solution open date 11/28/2026. Interview on 02/08/202 at 7:10 PM Staff B, LPN stated: Opened eye drops should be discarded after 30 days. On 02/08/2026 at 7:48 AM during inspection of the North Wing Medication Cart One with Staff E, LPN and Staff K, RN one remaining tablet in packet for discontinued medication Azithromycin 250 mg tablet (ZPAK) for Resident #59 ordered 1/1/26 for ten days in the top drawer of the medication cart. Several over the counter medications were noted with no open dates. Staff K, RN revealed the Azithromycin 250 mg medication was discontinued and the remaining one tablet should have been removed from the cart for disposal. Staff E, LPN revealed over-the-counter medication noted with no open date eye drops should be dated and eyedrops discarded 28 days after they are opened. On 02/08/2026 at 8:10 AM an observation of the North Wing Nurses Station an unattended grey plastic package labelled Pharmacy Returns was observed on the counter at the nurses' station. (Photographic evidence). Interview on 02/08/2026 at 8:16 AM Staff A, RN, Weekend Supervisor revealed the package should not be left at the desk. It should be in the med room. On 02/08/2026 at 8:20 AM, with Staff N, RN the following concerns were identified during a medication administration and cart review of North Wing Medication Cart Two revealed Over the Counter (OTC) Ophthalmic Solution for Resident #97 had two open dates (12/29/2025 and opened on 1/1/26) and OTC Ophthalmic Solution for Resident #79 had no open date. Photographic evidence. On 02/08/2026 at 8:56 AM, during medication administration observation conducted by Staff N, RN for Resident # 15 the following medications were prepared to be administered via Gastronomy Tube (G-tube) Losartan potassium 50 milligram (mg) one tablet, Sertraline 50 mg one tablet, Bactrim 800-160 mg one tablet, Baclofen 10 mg one tablet; Staff N, RN entered Resident # 15's room and placed the prepared medication on the overbed table and walked away leaving the medications unattended while she went to put on a disposable gown. Photographic evidence. On 02/08/2026 at 10:08 AM Staff N, RN was observed preparing to withdraw insulin to be administered for Resident #55. The surveyor requested to review the insulin and upon review it was noted the Novolog insulin belonged to another resident and the surveyor intervened. When asked why she was about to share residents' medication. Staff N, RN explained Resident # 55's Novolog insulin was not available. Staff N, RN was asked about the facility's policy when a resident's medication is not available on the cart, Staff N, RN was unable to provide an answer. The Assistant Director of Nursing was notified and assisted Staff N, RN with retrieving the insulin from the Emergency Kit. During an interview on 02/11/2026 at 2:45 PM the identified concerns were discussed with the Director of Nursing. Review of the facility's Pharmacy Services Policies: Administering Medications. Updated 04/28/2025 Policy Statement indicated: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 24.Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. Medication Storage Policy Interpretation and Implementation. Revised February 2023 1.Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Controlled Substances. Dispensing and Reconciling Controlled Substances Revised November 2022. 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.

Based on observations, interviews and record review the facility 1) failed to have available disposable towels at the hand washing sink in the kitchen for the dietary staff, 2) failed to ensure food is being stored under sanitary condition and resident's food items were dated and labeled in the freezer and outdated food was discarded in a timely manner and 3) failed to ensure the hydration cart containing an ice cooler and ice scoop were handled in a sanitary manner to prevent contamination. This has the potential to affect 88 out of 94 residents who eat orally residing in the facility at the time of the survey.The findings included: Record review of the Foods Brought by Family/Visitors Policy and Procedure (revision date March 2022); Policy Statement-Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents; Policy Interpretation and Implementation: 5) Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food; b) Containers are labeled with the resident's name, the item and the use by date and 6) The nursing staff will discard perishable foods on or before the use by date.Review of the Infection Control Policy and Procedure (revision date October 2018); Policy Statement-This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections; Policy Interpretation and Implementation: 1) This facility's infection control policies and practices apply equally to all personnel, residents and the general public and 2) The objectives of our infection control policies and practices are to: b) Maintain a safe, sanitary and comfortable environment for residents.1) Observation during the initial kitchen tour on 2/08/2026 at 6:27 AM revealed at the hand-washing sink, no available disposable towels for the dietary staff to dry their hands.Interview and observation with Staff L, Dietary Aide on 2/08/26 at 6:28 AM revealed they did not place more disposable towels in the dispenser and would need to put more in.Interview with the Certified Dietary Manager on 2/10/26 at 9:33 AM. She stated: The dietary staff is supposed to wash their hands upon entering the kitchen. The hand-washing soap, hand towels and warm water should be available for them. 2) Observation of the freezer used to store resident's foods located in the closed dining room with the Director of Nursing (DON) on 02/08/26 at 09:11 AM revealed the freezer contained outdated resident's food and the food was not labeled. The food item was a pasta dish dated 1/18/26 and had ice particles on it. A frozen pizza was noted with a room number that was not visible and was not labeled with a name. Photographic evidence submitted.Interview with the DON on 02/08/26 at 09:13 AM. She revealed the foods in the refrigerator and freezer for residents should be labeled and dated, she would be throwing away both items in the freezer and would be educating the staff on proper food storage.3) During an observation on the North nursing unit on 2/10/2025 at 11:54 AM revealed Resident # 64 in a wheelchair go over to the Hydration cart, that was located across from the nursing station getting a paper cup off the nourishment cart and attempting to open the ice cooler and picking up the ice scooper.Second observation on the North nursing unit on 2/10/2026 at 12:18 PM revealed Resident # 55 using a rolling walker go over to the Hydration cart, that was located across from the nursing station with a paper cup, picked up the ice scoop from its holder and opened the ice cooler to put ice in her paper cup. The residents were not observed to sanitize their hands before or after obtaining the ice and were not wearing gloves.Interview with the Regional Educator on 2/10/26 at 12:21 PM revealed the residents are not supposed to get their own ice but the staff are to assist the residents by giving them ice when they request it. She stated: We are going to put a lock on the ice coolers.Review of the Demographic Face Sheet for Resident # 64 documented the resident was admitted on [DATE] with a diagnosis of hemiplegia and dementia.Review of the Demographic Face Sheet for Resident # 55 documented the resident was admitted on [DATE] with a diagnosis of dementia and diabetes mellitus.Interview with the DON on 2/11/26 at 12:18 PM. She stated, We immediately pulled the ice chests off the floor. We removed the ice, sanitized the ice chests and did not put them back out until locks were installed and put them behind the nursing station. There is a code to get in the ice chest now and the staff have the code. The expectation is for the resident to ask the staff to give them a cup and put ice in it. Not for them to open the ice chest and place ice in a cup themselves.

Based on observation, interview, and record review, the facility failed to demonstrate effective plans of action were implemented to identify and correct quality deficiencies related to repeated deficient practices under F761-Labeling/Storage of Drugs and Biologicals. As evidenced by the facility failed to ensure medications and medication carts were properly secured and stored to prevent unauthorized access. There were 94 residents residing in the facility at the time of the survey.Findings include:Review of the facility's survey history revealed that during the previous survey dated February 13, 2025, the facility was cited under F761 for Labeling/Storage of Drugs and Biologicals.On 02/04/2026 at 3:33 PM, an interview with the Administrator revealed that the facility has a Quality Assurance and Performance Improvement (QAPI) program and a Quality Assessment and Assurance (QAA) Committee that meets monthly on the third Tuesday and as needed, with the last meeting held on January 27, 2026. He explained that the committee includes all required members, including the Medical Director, Administrator, DON, ADON, department heads, and regional directors. The committee monitors and tracks quality issues through daily staff reports, audits, rounds, and data trending, prioritizing high-risk concerns to ensure resident safety. They use root cause analysis and the 5 Whys method to revise interventions when necessary. The committee tracks corrective actions through monthly meetings, PIP data, audits, and follow-up, and communicates updates to staff through education, town halls, and daily discussions. The Administrator noted that the QAA Committee actively monitors medication storage, infection control, environmental safety, nutrition, and other key areas to ensure improvements are occurring and resident outcomes are protected.Review of the policy and procedure titled Quality Assurance /Quality Assurance Performance Improvement QAPI/QAA Goals/Purpose Statement: revealed that Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost- effectively while maintaining good resident/patient outcomes and perceptions of patient care. NBRC has a Performance Improvement Program which systematically monitors, analyses and improves its performance to improve resident/ patient outcomes. It recognizes that the value in healthcare is the appropriate balance between good measures, excellent care and services and cost. We will monitor our operations for compliance with federal and state regulations.

Based on observations, interviews and record reviews, the facility's staff failed to position an indwelling urinary catheter tubing in accordance with professional standards of care for two (Resident#1 and Resident#62) out of two sampled residents, who had an indwelling urinary catheter as evidenced by: 1.The facility's staff positioned Resident#1's indwelling urinary catheter tubing in a manner causing back flow of urine and 2. The facility's staff positioned Resident#62's suprapubic urinary catheter tubing in a manner causing back flow of urine. This increased the risk of catheter-associated urinary tract infections and other serious medical issues. There were four residents with indwelling catheters and one resident with a suprapubic catheter residing in the facility at the time of survey. On 2/08/2026 at 6:18 AM an observation revealed Resident #62 was in bed, the indwelling urinary catheter tubing was kinked preventing the free flowing of the urine noted in the tubing. Furthermore, no urine was observed in the collection bag (photo evidence). On 02/08/2026 at 6:22 AM Staff D, Certified Nursing Assistant, was notified about identified concern. During an interview on 02/08/2026 at 6:30 AM Staff B, Registered Nurse revealed, Catheter tubing should be straightened out to allow urine to flow. On 02/08/26 at 7:04 AM The RN, Weekend supervisor was asked about facility protocol for catheter tubing positioning and stated, The urinary catheter tubing are to be changed positioned straight for the free flow of urine and to prevent back flow to prevent infection. Observation on 02/10/26 at 10:01 AM revealed Resident #62 was in bed; the indwelling catheter tubing was noted coiled and contained urine. Review of Resident #62's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Other Mechanical complication of other urinary catheter and Urinary Tract Infection. Record review of an admission Minimum Data Set (MDS) reference dated 1/23/26 revealed Resident # 62 is cognitively intact and was dependent for toileting, had an indwelling catheter (including suprapubic catheter and nephrostomy tube) and Urinary tract infection (UTI) in the last 30 days. Record review of a care plan initiated on 01/22/26 revealed Resident #62 had a suprapubic catheter related to: Neurogenic bladder and had history of recurrent UTI with a goal to be free from signs and symptoms of UTI with interventions that included: Monitor urinary catheter for impairment of drainage flow (kinks). Observation on 02/08/26 at 8:21 AM revealed Resident #1 in bed the indwelling urinary catheter tubing was coiled and preventing the flow of urine contained in the tubing. There was no urine in the collection bag (photo evidence). On 02/08/26 at 8:25 AM Staff Z, Licensed Practical Nurse (LPN) was informed of the identified concern and revealed the tubing is to allow the free flow of urine to prevent back flow that can cause an infection. Record review of Resident #1's demographic sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included sequelae of cerebral infarction.Record review of physician orders revealed Resident#1 had orders dated 2/4/26 and 2/7/26 for urinary catheter insertion for 24-hour urine collection one time only for 24-hour urine collection for one day. Record review of admission Minimum Data Set (MDS) reference dated 01/20/26 revealed Resident #1 had severe cognitive impairment and was dependent for toileting and hygiene. Record review of the Electronic Health Record revealed Resident #1 had no care plans pertaining to an indwelling urinary catheter. Further review revealed Resident #1 was care planned for self-care deficit with dressing, grooming, bathing related to: needs assistance with personal care tasks and mobility skills. An interview on 02/10/2026 at 3:23 PM, the Director of Nursing (DON) revealed, indwelling catheter tubing should not be kinked to allow free flow of urine to prevent any retention of urine that could lead to a urinary tract infection. Interview on 02/11/2026 at 2:37 PM the Infection Preventionist revealed indwelling catheter tubing should not be kinked to allow free flowing of urine and prevent UTIs. Record review of facility's policy titled Catheter Care, Urinary dated 2001 revised August 2022 revealed:Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Preparation: Review the resident's care plan to assess any special needs of the resident.Assemble the equipment and supplies as needed. Maintaining Unobstructed Urine Flow. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks unless specifically ordered, do not apply a clamp to the catheter. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observations, interviews, and record review, the facility failed to secure confidential information for residents on two (South and North) out of two units as evidenced by: 1) Residents' medical information left visible and unattended at the front desk. 2) Residents' personal information visible and unattended on the North unit. 3) Residents' medical information posted on the wall of the South unit. 4) Paperwork with residents' information visible and unattended at the North unit nursing station. 4) An open computer screen with residents' medical information visible and unattended on the South unit medication cart #2. 5) An open computer screen and 2 binders with residents' medical information were left visible and unattended on the South unit nursing station. There were 94 residents residing in the facility at the time of survey. The findings included. 1) Observation on 02/08/26 at 6:57 AM revealed paperwork left unattended with residents' medical information on top of the copy machine at the front desk (photo evidence). Interview on 02/08/26 at 7:04 AM, Staff A, Registered Nurse (RN) weekend supervisor was apprised of the identified concern and stated: This information is not supposed to be visible. Residents' information is to be filed away for residents' privacy. 2) Observation on 02/08/25 at 8:19 AM a copy of the Midnight Census for 02/07/2026 was left on North Nurse's station counter. (Photo evidence) 3) On 02/08/26 at 8:36 AM an observation was made of a posting in a highly visible area at the South Wing nursing station, that contained residents' medical information (photo evidence). On 02/10/26 at 9:02 AM the Director of Nursing (DON) was made aware of identified concern and removed the posting. The DON stated: To protect health information staff are to place any medical information in a private area that is not visible to any outside person. 4) A tour of the North unit on 02/08/26 at 11:22 AM revealed paperwork with a resident's confidential information visible and unattended at the North unit nursing station. (photo evidence). The Administrator was made aware and he removed the paperwork. 5) On 02/09/26 at 12:05 PM an observation was made of an open computer screen with residents' medical information visible and unattended on the South Wing Medication Cart #2 (photo evidence). 6) On 02/09/2026 at 01:45 PM a staff member left the computer and two binders with patients' information visible and unattended at the South wing nursing station. (Photo evidence) Interview on 02/11/2026 at 2:20 PM the Director of Nursing (DON) stated Health Insurance Portability and Accountability Act (HIPAA) protect the privacy and security of individuals' health information while they are under our care. This includes ensuring that any resident information is kept confidential and not visible to unauthorized individuals. Examples of maintaining HIPAA compliance include not leaving resident information visible on computer screens, locking computer screens and medication carts before stepping away, and only discussing resident information with appropriate staff involved in the resident's care. Interview on 02/11/2026 at 2:35 PM, Staff A, Registered Nurse/Weekend Supervisor stated: HIPAA is used to protect resident privacy and keep their health information confidential. Staff should not leave any documents with resident names or personal information visible on counters or in public areas. When giving report or discussing resident care, conversations should be kept private so others who are not involved in the resident's care cannot hear protected information. Review of the facility policy titled Protected Health Information (PHI) Management and Protection of 04/2024 indicated: 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on observations, interviews and record reviews, the facility failed provide needed care and services for one (Resident #89) out of two sampled residents, who had diabetic ulcer as evidenced by observations of Resident #89 in bed with heels lying flat on the bed. There were two residents with diabetic ulcers residing in the facility at the time of survey.The findings included.On 02/08/26 at 6:14 AM an observation was made of Resident # 89 in bed with a dressing on the left foot that did not cover the heel, and both heels were resting directly on the mattress (photo evidence). No pillow or offloading/floating devices present. An additional observation on 02/10/26 at 8:30 AM revealed Resident #89 in bed with both heels resting directly on the bed. No pillow or offloading/floating devices present. Record review of Resident # 89's clinical records revealed the resident was admitted on [DATE] with diagnosis that included but not limited to Type 2 Diabetes Mellitus with peripheral angiopathy with gangrene and Peripheral Vascular Disease. Record review of a Quarterly Minimum Data Set (MDS) reference dated 12/30/25 revealed Resident # 89 had moderate cognitive impairment, dependent for putting on/taking off footwear and transfers, required partial moderate assistance for rolling left, and had a diabetic foot ulcer. Record review of a Care Plan initiated on 12/30/25 revealed Resident # 89 had the potential for skin impairment, pressure ulcers related to impaired mobility, requires staff assist to turn and reposition, incontinence of bowel, incontinence of bladder, diagnosis of Diabetes Mellitus, Peripheral Vascular Disease, Peripheral Artery Disease and receives anticoagulants; goal included resident will remain free from pressure ulcer development thru the next review date and interventions that included: Float heels while in bed. During an interview on 02/10/26 at 1:06 PM, the Wound Care Registered Nurse (RN) stated, [Resident # 89] is at risk for pressure ulcer due to impaired mobility and heels are to be floated.On 02/10/26 at 1:17 PM Staff J, Licensed Practical Nurse (LPN) was interviewed about interventions to prevent pressure ulcers and stated, [Resident # 89] has a skin impairment on the heel, and the heels are to be floated with a pillow. I overlooked it.On 02/10/26 at 3:24 PM during an interview with the Director of Nursing it was revealed that staff are to either use soft boots or a pillow to float residents' heels to prevent pressure injuries. Record review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries dated 2001 revised July 2017 revealed Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Based on observations, interviews, and record review, the facility failed to ensure residents' environment remained free of accident hazards on one (North unit) out of two units as evidenced by: 1) The facility's staff failed to lock a housekeeping cart containing hazardous chemicals. 2) The facility's staff failed to keep a closet door that locks on the inside and contained wound care supplies remained locked. There were 3 housekeeping carts in the facility at the time of survey and 94 residents residing in the facility at the time of survey. The findings include.1) An observation on 02/08/26 at10:08 AM revealed an unlocked, unattended housekeeping cart on the North Unit (photo evidence).On 02/08/26 at10:10 AM Staff H, Housekeeping staff was made aware of identified concern and stated, ''The housekeeping cart it supposed to locked for the safety of the residents because chemicals are kept in the housekeeping cart.During the laundry tour on 02/11/26 at 1:13 PM, the Housekeeping Director revealed housekeeping carts should be kept locked to protect residents because there are chemicals in the housekeeping carts. 2) An observation on 02/08/26 at 7:36 AM revealed a room marked Laundry Closet was unlocked and contained wound care supplies and including hydrocortisone cream (photo evidence).On 02/08/26 at 7:45 AM, the Director of Nursing (DON) was made aware of identified concern and revealed the door locked from inside and should remain locked. Record review of the facility's Policy and Procedure titled, Safety and Supervision of Residents revised July 2017 indicated:Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety Our facility-oriented approach to safety addresses risks for groups of residents.

Based on observations, record review and interviews the facility failed to ensure staffing information on the North Wing and South Wing were readily available in a readable format to residents and visitors at any given time. The findings included:Record review of the Posting Direct Care Daily Staffing Numbers Policy and Procedure (no written date available) documented: Policy Statement: Our facility will post on a daily basis for each shit nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; Policy Interpretation and Implementation: 1) Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses-RN, Licensed Practical Nurses-LPN) and the number of unlicensed nursing personnel (Certified Nursing Assistants-CNA, Nursing Assistants-NA) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format and 2) Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: b) The current date (the date for which the information is posted); c) The resident census at the beginning of the shift for which the information is posted; e) The shift for which the information is posted; f) Type (RN, LPN or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g) The actual time worked during that shift for each category and type of nursing staff and h) Total number of licensed and non-licensed nursing staff working for the posted shift. 1) Observation on 02/08/26 at 6:02 AM of the South Wing Nurses' Assignment board revealed the assignment board was dated 02/7/26 and indicated current shift was 3-11 PM. 2) Observation of the North Wing Nurses' board on 2/08/26 at 6:05 AM revealed the board blank and Staff L, Registered Nurse (RN) was writing in the date, census, 11 pm-7am shift, the names of the nurses on duty and the Certified Nursing Assistants (CNAs) on duty. Photographic evidence submitted. Interview with Staff A, Registered Nurse (RN) on 2/08/26 at 6:06 AM. She stated, I had it up there on the board, but I wiped it off for the next shift. Staff A, RN confirmed the information should have stayed there and not been taken off. Interview with the Director of Nursing on 2/11/26 at 12:14 PM. She stated, The expectation concerning the staffing board is that it should be updated every shift and be accurate.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were consistently implemented for 1 out of 2 residents. Resident #1's toothbrush was stored on top of the towel dispenser in the resident's room. The findings include. Observation on 02/08/2026 at 6:25 AM revealed a toothbrush on top of the towel dispenser in Resident # 1's room. (photo evidence). On 02/08/2026 at 9:49 AM Staff F, Certified Nursing Assistant was made aware of identified concern and stated, Toothbrushes are kept in the small basins. An interview with the Director of Nursing on 02/10/2026 at 3:19 PM revealed residents' toothbrushes should be kept inside a plastic bag and placed in a basin. During an interview on 02/11/2026 at 2:37 PM, the Infection Preventionist stated: Toothbrushes are to be kept in a plastic bag and placed inside a basin for infection control. Record review of the facility's policy and procedure titled, Infection Prevention and Control Program indicated Policy StatementAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Policy Interpretation and ImplementationThe IPCP is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.The program is based on accepted national infection prevention and control standards.The IPCP is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.

Based on observations, record review and interviews, the facility failed to accommodate one (Resident #51) out of one resident's choice for food preferences reviewed. There were a total of 94 residents residing in the facility at the time of this survey. The findings included:Record review of the Resident Rights Policy and Procedure (Revised October 2025) documented: Policy Statement-Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation-1) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a) a dignified existence; b) be treated with respect, kindness and dignity and e) self-determination. Review of the Resident Food Preferences Policy and Procedure (Revised July 2017) documented: Policy Statement-Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation-2) Staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes and 3) Dietitian/Designee will document the resident's food and eating preferences in the care plan. Initial observation and interview with Resident # 51 on 2/08/26 at 8:46 AM revealed the resident sitting on the side of the bed, eating breakfast, The resident did not eat the scrambled eggs. She stated, I have told them I don't eat eggs and they keep giving it to me. Review of the meal ticket on 2/08/26 listed liked foods are fortified foods, shakes and eggs were not listed as a dislike. Photographic evidence submitted Second observation and interview with Resident #51 on 2/09/26 at 8:11 AM revealed the resident sitting up in bed, eating breakfast. The resident's breakfast food tray consisted of Oatmeal, Scrambled Eggs, 1 slice of Toast, Orange Juice and Coffee. She stated, They gave me eggs again. I will not eat it because I had a bad experience with them. Photographic evidence submitted Third observation and interview with Resident #51 on 2/10/26 at 8:33 AM revealed the resident sitting up in bed, eating breakfast. The resident's breakfast food tray consisted of Oatmeal, Egg Omelet, Chopped Sausage Link, 1 slice of Toast, Orange Juice and Coffee. She stated, I got eggs again. Photographic evidence submitted Record review of the Demographic Face Sheet for Resident #51 documented the resident was admitted on [DATE] with a diagnosis of chronic kidney disease, atrial fibrillation and severe protein-calorie malnutrition. anemia, diabetes mellitus, neuropathy, chronic obstructive pulmonary disease, osteoarthritis, depression, insomnia, anxiety disorder and major depressive disorder. Review of Resident # 51's Minimum Data Set (MDS) Significant Change assessment dated [DATE] documented the resident was able to make her needs known, required independent assistance for Activities of Daily Living (ADL), setup assistance for eating and was prescribed a Therapeutic Diet. Review of Resident # 51's Physician's Order Sheets (POS) for December 2025, January 2026 and February 2026 documented the resident was on a Regular Diet, Mechanical Soft texture, thin consistency with Fortified Foods for Nutrition. Review of Resident # 55's Nutrition care plan (written 3/06/2025) indicated the resident has potential for nutritional problem related to nutrition related comorbidities conditions associated with chronic kidney disease, hypertension and malnutrition. At risk for and history of significant weight loss; Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within +/- 10% of current body weight, no signs or symptoms of malnutrition, and consuming at least 50% of most meals daily through review date; Interventions: Diet: Provide diet as ordered; Offer and provide alternate as needed; Honor food preferences; Encourage adequate intake at meals. Interview with the Certified Dietary Manager on 2/10/26 at 12:14 PM. She stated, I take food preferences upon the resident's admission and as needed. Fourth observation and interview with Resident #51 on 2/11/26 at 8:26 AM revealed the resident sitting up in bed, eating breakfast. The resident's food tray consisted of Oatmeal, Chopped Meat, 1 slice of Toast, Orange Juice and Coffee. No eggs were served today. She stated, They didn't give me eggs today. I guess because something was said to them. I like oatmeal they should give me two bowls of it. Review of the meal ticket revealed it was updated on 2/10/26 and the listed liked foods were fortified foods, shakes; Dislikes: Eggs. Review of the 4 cycle menus dated February 8-12, 2026, documented eggs were on the menu to be served for breakfast every day of the week except for Thursday, February 12, 2026. Interview with the Director of Nursing on 2/11/26 at 11:48 AM. She stated: The expectation is that residents should be able to choose their food options. Interview with the Certified Dietary Manager on 2/11/26 at 12:41 PM. She stated: I went to see the resident on yesterday and she basically said there are certain foods she doesn't like. Like eggs, salty foods and no salt on the tray. There are alternatives for resident who don't eat eggs, like waffles, pancakes, French toast, turkey sausage patty, sausage links, corn beef hash, fortified oatmeal, grits and cold cereal. She does have the right to change her mind and to have her choices.

Based on observations, record review, and interviews the facility failed to provide a safe environment for all residents, as evidenced by one out of three dryer lint traps in the laundry room observed full of lint. There were 94 residents residing in the facility at the time of survey. The findings included: On 01/09/25 at 8:51 AM a laundry tour was conducted with the Director of Housekeeping. Observation in the clean room revealed three dryers and one was not in progress. The dryer that was not in progress was noted with a large amount of lint. Review of a log posted on the wall revealed the lint traps are scheduled to be signed bi hourly after dryer lint traps are cleaned. There were two signatures missing and it was last signed at 9:00 PM on 1/8/24 (photographic evidence). Staff D, Housekeeping/laundry personnel revealed the lint trap had not been cleaned yet and explained the protocol and purpose for cleaning the dryers' lint traps I am responsible to clean lint trap hourly and then sign the lint log. I forgot to sign the log and didn't get a chance to clean the trap because I got busy. I am aware that it is a potential fire hazard. The facility does not have a policy for cleaning of the lint traps per the Director of Nursing.

Based on record review and interviews facility failed to notify the Office of the Ombudsman about the transfer of five residents (#17, #16 #10, #24, #73) out of 23 residents sampled, as evidenced by reports of unsuccessful fax transmittals for The Notice of Transfer/Discharge Letter to The Office of The Ombudsman for December and November 2024. There were 94 residents residing in the facility at the time of survey. The findings included: 1) Record review of a demographic sheet revealed Resident#17 was admitted on [DATE], hospitalized on [DATE] and readmitted on [DATE] with diagnosis that include: Chronic Obstructive Pulmonary Disease (COPD) and Acute Respiratory Failure with Hypoxia and Cough Record review of a narrative nurses note dated 11/21/2024 revealed Resident #17 was transferred from the facility via emergency services and admitted to a local hospital for Acute respiratory failure. Record review of the electronic health record revealed a signed Bed Hold policy dated 11/21/24. The fax notification sent to The Office of the Ombudsman for Resident #17's transfer to the hospital dated 11/26/24 revealed the line was busy. 2) Record review of a demographic sheet revealed Resident #16 was admitted on [DATE] and had a hospital leave on 10/9/24. Record review of a Discharge return anticipated MDS with reference date of 10/9/24 Sections: A (identification) revealed Discharge was unplanned to a short-term general hospital. Record review of Resident #16's physician's order sheet revealed an order dated 10/10/24 to transfer the resident to nearby hospital for PEG (percutaneous endoscopic gastrostomy) tube placement. Record review of a Narrative Nurses note dated 10/9/2024 revealed Resident #16 was transferred to a nearby hospital for PEG placement. The fax confirmation of notification sent to the Office of the Ombudsman for Resident #16's transfer to the hospital dated 11/01/24 revealed the line was busy. Interview on 01/08/25 at 09:22 AM, the medical records personal stated: I am responsible for sending the Nursing Home Transfer and Discharge Notice to the office of the Ombudsman. I send it via fax. I send notices every other week. The fax confirmation does say busy, and I will get back to you with the answer. On 01/09/25 at 10:26 AM, the medical records staff revealed all transfer notices for November and December 2024 were not confirmed as received by the Ombudsman. 31581 3) Record review of the Demographic Face Sheet for Resident #10 documented the resident was admitted on [DATE] with a diagnosis of Hemiplegia, emphysema and hypertension. The resident was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet (POS) dated 10/08/2024 for Resident #10 documented to send the resident to the local hospital. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #10 documented the notice was sent with the resident to the hospital on 10/08/2024 with an effective date of 10/08/2024. The location to which the resident is to be transferred or discharged was a local hospital. Further review revealed the form was faxed with no response and the Ombudsman line was busy. The facility did not follow up with the Ombudsman. 4) Record review of the Demographic Face Sheet for Resident #24 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertensive heart disease and chronic obstructive pulmonary disease. The resident was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet (POS) dated 10/19/2024 for Resident #24 documented to send the resident to the local hospital. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #24 documented the notice was sent with the resident to the hospital on 10/19/2024 with an effective date of 10/19/2024. The location to which the resident is to be transferred or discharged was a local hospital. Further review revealed the form was faxed with no response and the Ombudsman line was busy. The facility did not follow up with the Ombudsman. 5) Record review of the Demographic Face Sheet for Resident #73 documented the resident was admitted on [DATE] with diagnosis that include parkinsonism. The resident was discharged on [DATE] to the hospital. Review of the Physician's Orders Sheet (POS) dated 11/02/2024 for Resident #73 documented to send the resident to the local hospital. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #73 documented the notice was sent with the resident to the hospital on 11/02/2024 with an effective date of 11/02/2024. The location to which the resident is to be transferred or discharged was a local hospital. Further review revealed the form was faxed with no response and the Ombudsman line was busy. The facility did not follow up with the Ombudsman. Interview with the Director of Nursing (DON) on 1/09/25 at 9:33 AM. She stated, On 11/02/2024, the resident did not respond to the attention we give her. Assistance was given to the food but she did not respond with the swallowing. Food had to be unpack from her mouth. Nothing eaten from breakfast and lunch. MD was called made him aware and order to send resident to Aventura hospital for evaluation. Family and supervisor made aware. We have been calling the Ombudsman asking for an alternative number to send the faxes. We keep getting a busy signal. They told us we can't email it in. This has been going on for months. Interview with Medical Records Staff on 1/09/25 at 11:11 AM. She stated, I emailed the Ombudsman forms on yesterday for November 2024 and December 2024 for patients discharged . Before that I would fax them monthly and would receive a busy signal. She confirmed that she did not follow up with the Ombudsman concerning an alternative way to send the transfer forms. Interview with the Ombudsman on 1/09/25 at 1:25 PM. She revealed that she had not been receiving the Ombudsman forms weekly nor monthly. She has given the contact information on where to send the Ombudsman forms and has informed the facility that they can email them. On yesterday, 1/08/25 she received the Ombudsman forms for the months of November 2024 and December 2024 via email. Review of a policy titled, Transfer or Discharge Notice (undated) revealed Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation 1. the name, address, email and telephone number of the entity which receives appeal hearing requests;1. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are stored properly; as evidenced by observation revealed discontinued medication observed on Medication Cart, medications left unattended, staff placed insulin in pocket, undated open sterile water for inhalation in medication room, staff's personal items noted on counter in Medication Room and medications observed at bedside. Observation on 01/06/25 at 08:59 AM of South Medication Cart #1 with Staff I, Licensed Practical Nurse (LPN), discontinued medication Dificid (fidaxomicin) 200 mg (milligrams) for Resident #92 was noted in the top drawer of the cart. Review of order written on 12/13/24 documented: Give 200 mg by mouth two times a day for C-Diff until 12/24/24. Review of the Medication Administration Record (MAR) revealed the medication was administered from 12/14/24 to 12/24/24. Interview on 01/06/2025 at 08:59 AM Staff I, LPN (Licensed Practical Nurse revealed the resident started receiving the medication on 12/14/24 and of the South Cart on 01/06/25 at 08:59 AM with Staff I, LPN (Licensed Practical Nurse) Interview on 01/06/25 at 9:16 AM Staff I, LPN acknowledged the Dificid (fidaxomicin) 200 mg (milligrams) for Resident#92 was discontinued and should not have been on the cart. Staff I, LPN revealed all nurses are responsible for checking their cart for discontinued and expired medications. The night supervisor collects the expired and discontinued medications for them to be returned to the pharmacy. During an interview on 01/09/25 at 03:25 PM, the Director Of Nursing (DON) stated: The nurses should be checking the cart before and after the shift; the last nurse that gave the medication should have removed the medication. On 01/06/2024 at 10:00 AM, during medication administration observation with Staff J, Registered Nurse (RN) on the North Wing's Cart 2. Staff J, RN prepared medications that included 30 ml (milliliters) liquid supplement for Resident #64. Staff J, RN proceeded to administer the liquid supplement that was in a medication cup but the refused it; Staff J, RN placed the cup containing the supplement on the tray with the medication cup with pills and the liquid supplement spilled in the medication cup that had the pills. Before exiting the room, Staff J, RN explained to the resident that she needed to discard the pills and return with new pills. Upon returning to the medication cart Staff J revealed there was no drug disposal system in the cart, and she will check in the med room. On 01/06/25 at 10:14 AM, Staff J went to find a drug disposal system in the room located on the north wing behind the nurses station but did not find the drug disposal system. Staff J, RN revealed they will need to get the drug disposal container in the DON's office. Staff J went to get it; Staff J and RN exited the medication room leaving the door open and the unattended on the counter. Staff J returned three minutes later with a large drug disposal system container and dispose of the medications. Interview on 01/06/25 at 10:18 AM, Staff J, RN revealed she is aware the medications should not be left unattended and stated: I thought it was ok because you (surveyor) were there. Upon further observation, Staff J, RN was asked about the items on the counter that included lunch bags/container and the two refrigerators. Staff J, RN revealed the lunch boxes belonged to staff, and the lower locked refrigerator is for insulins and the top refrigerator is for residents' food from family. Both refrigerators were inspected and the upper refrigerator that stored residents' food temperature was noted at 50 degrees Fahrenheit; there were undated labeled grocery store type plastic bags that had resident's names. On 01/06/25 at 11:05AM during an observation of the South Med Room with Staff H, LPN, an undated open bottle with Sterile water for inhalation in plastic bag and an Oxygen Humidifier bottle with water in a plastic bag was noted on the top shelf in the Med Room. On 01/06/25 at 11: 25 AM Staff H, LPN revealed the bottles should have been dated when they opened and needed to be removed; all nurses are responsible for checking the medication rooms. Observation on 01/06/25 at 11:46 AM, Staff J, RN completed Resident #51's blood glucose check and revealed resident needed insulin was not available on the cart. On 01/06/25 at 12:05 PM, Staff J, RN went to the medication room and retrieved the insulin from the refrigerator. Staff J explained the insulin is cold so she will need to wait for the medication to get warm. Staff J placed the insulin in her pocket and went to assist with passing meal trays. On 01/06/25 at 12:15 PM, Staff J, RN removed the insulin from her pocket and placed it in the top drawer of the cart. During an interview on 01/06/24 at 12/24/2024 Staff J, RN revealed she was not aware the insulin should not be placed in her pocket. Interview on 01/09/24 at 3:18 PM the DON revealed the nurse reported the concerns medications should never be left unattended, and the nurse should not have placed the insulin in her pocket for infection control reasons. Regarding the lunch boxes in the room, the DON indicated staff should not leave lunch boxes/personal items in that room because there is a break room for staff. 48906 Observation on 01/06/25 at 09:32 AM Resident #9 was in bed with eyes closed, a medicine cup with a small pink pill was noted on the bed next to Resident #9 (photo evidence). Resident #9's nightstand drawer was open, and a bottle labeled Vitamin C was observed inside (see photo evidence). On 01/06/25 at approximately 9:38 AM, Staff A, Licensed Practical Nurse (LPN) stated: I did not give [Resident#9] any medication. No medications can be kept in the residents' rooms without staff present. Staff A, LPN entered the resident's room with the surveyor and removed cup with the pink pill and disposed of it in the puncture resistant container in the medication cart. Staff A, LPN returned with the Director of Nursing (DON) and the DON removed the bottle labeled Vitamin C and educated Resident #9. Observation and interviews on 01/06/25 at 11:23 AM Resident #17 was awake, alert, oriented, two inhalers were observed inside a tissue box on Resident #17's side table (photo taken). Staff A, Licensed Practical Nurse (LPN) was made aware and removed the item and reeducated resident. Resident# 17 revealed a family member brought in the inhalers. Record review of a Policy titled, Medication Labeling and Storage (undated) revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage: 1. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, record review, and interviews the facility failed to follow infection prevention and control practices with one out of two vital signs machines in the facility and one out of three dryer lint traps in the laundry room, as evidenced by staff member not disinfecting the vital signs machine after measuring a resident's blood pressure and Clean laundry (curtains) stored in washing area. The findings included: 1) On 01/06/25 at 8:03 AM Staff A, Licensed Practical Nurse (LPN) was observed measuring a resident's blood pressure using a vital sign machine. Afterwards, Staff A, LPN placed the used vital sign machine in the hallway near the nursing station. Staff A, LPN then returned to administering medications. Staff A, LPN did not disinfect machine or cuff and no sanitizing wipes were observed in the vital signs machine's basket. On 01/06/25 at 9:32 AM Staff A, LPN was asked about the protocol after using the blood pressure machine on a resident, Staff A, LPN stated: The protocol is to disinfectant with the Sanitizing cloths. I was supposed to clean the machine but forgot. Record review of a Policy titled, Infection Control Guidelines for All Nursing 2005 MED-PASS, Inc. (Revised August 2012) Purpose: To provide guidelines for general infection control while caring for residents. 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and/or mucous membranes. On 01/09/25 at 12:09 PM, interview with the Infection Preventionist revealed there are two vital signs machines in the facility. Staff are responsible to disinfect the vital signs machines with disinfectant wipes after usage to prevent any cross contamination or break outs throughout the facility. Also revealed there are two vital signs machines. On 01/09/25 at 8:51 AM a Laundry Tour was conducted with The Director of Housekeeping. Upon entrance to the wash area there was a cart partially covered with linens in a plastic bag (photo submitted) The Director of Housekeeping revealed the plastic bag contained clean curtains that were being stored in the wash area for purposes of space. Record review of a Policy titled, Departmental (Environmental Services) Infection Control Departmental (Environmental Services) Laundry and Linen revealed Level I: Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General Guidelines: Standard Precautions 1. Separate soiled and clean linen always.

Based on observation, interview and record review, the facility failed to store food under sanitary condition by ensuring 1) the resident's foods were dated, the refrigerator was working properly and 2) there was no thermometer in the refrigerator in the snack/nourishment refrigerator on the resident's unit. This has the potential to affect 89 out of 94 residents who eat orally residing in the facility at the time of the survey and the potential to affect 55 out of 57 residents who eat orally residing on the North Wing and affect 34 out of 36 residents who eat orally residing on the South Wing. The findings included: Record review of the Foods Brought by Family/Visitors Policy and Procedure (revision date March 2022); Policy Statement-Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents; Policy Interpretation and Implementation-5b) Containers are labeled with the resident's name, the item and the use by date. Review of the Refrigerators and Freezers Policy and Procedure (revision date December 2014); Policy Statement-This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation and will observe food expiration guidelines; Policy Interpretation and Implementation-1) Acceptable temperature ranges are 35 degrees Fahrenheit (F) to 40 degrees F and less than 0 degrees F; 2) Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures; 3) Monthly tracking sheets will include time, temperature, initials and action taken and 4) All food shall be appropriately dated to ensure proper rotation by expiration dates. Observation of the North Wing Nourishment Pantry with the Long Term Care Supervisor on 1/06/25 at 10:19 AM revealed the refrigerator was 50 degrees F (Fahrenheit). The refrigerator had three plastic bags which contained resident's foods that were labeled but not dated. Photographic evidence submitted. Observation of the South Wing Nourishment Pantry on 01/06/25 10:23 AM revealed the refrigerator did not contain a thermometer. The refrigerator contained resident's foods dated and labeled. Photographic evidence submitted. Observation and interview with Staff A, Licensed Practical Nurse (LPN) South Wing Nurse on 1/06/25 at 10:24 AM of the South Wing Nourishment Pantry Refrigerator. She stated, Everything should be dated and there is no thermometer in the refrigerator. Interview with the Director of Nursing (DON) on 1/09/25 at 9:43 AM. She confirmed there should be a thermometer in the pantry refrigerator, the temperature in the refrigerator should be 40 degrees F and below and resident's food in the pantry refrigerators should be dated. Record review of the North Wing Daily Freezer/Refrigerator/Cooler/Reach In/Nourishment Temperature Log for January 2025 documented on 1/06/25 at 1:00 AM, the refrigerator temperature was 40 degrees F and on the South Wing Daily Freezer/Refrigerator/Cooler/Reach In/Nourishment Temperature Log for January 2025 documented on 1/06/25 at 6:00 AM, the refrigerator temperature was 38 degrees F.

Based on observation, interview and record review, the facility failed to ensure one (Resident # 398) out of three sampled residents devices was in place to alert staff in the event of an emergency as evidence by Resident 398's call light and phone were observed out of the resident's reach. The findings include: During observation on 01/06/25 at 08:30 AM Resident #398 was observed slouched over in bed eating breakfast. The resident's call light was noted hanging behind the bed and her telephone was observed on top of the overhead light. On 01/07/25 at 09:30 AM; Resident #398 was observed resting in bed and the call light was observed hanging behind the bed. Review of Resident # 398's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include Epilepsy, Unspecified, not intractable, and without status epilepticus. Review of the Physician's Orders Sheet for 11/04/2024 revealed Resident #398 orders include: Bedrails for positioning and or enabling, bedrail x 2 quarters. Review of Resident #398 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident is cognitively appropriate and require maximal assistance for care is required. Review of Resident # 398's Care Plans revealed the Resident has a self-care deficit with dressing, grooming, bathing, needs assistance with personal care tasks, mobility skills, impaired mobility and generalized weakness. Interventions include: Encourage/remind the resident to ask for assistance as needed and staff to anticipate resident's needs with activities of daily living (ADLs). During an interview on 01/09/25 at 12:42 PM Staff G, Licensed Practical Nurse (LPN) revealed the call light should be within reach of residents at all times and rounds should be done every two hours. Review of the facility's policies regarding call light indicates: to ensure that the call light is accessible to the resident when in bed, from the shower or bathing facility and from the floor.

Based on interviews and record review facility failed to implement a nutritional care plan for one resident out of seven residents sampled (Resident #297) as evidenced by staff failed to notify the physician about an incident of aspiration reported by an alert and oriented resident. There were 94 residents residing in the facility at the time of survey. The findings included: Observation and interview on 01/06/25 at 10:03 AM. Resident#297 was in bed awake and alert in bed and a breakfast tray was noted at the bedside. Resident #297 was asked about the choking incident; Resident#297 stated: A chunk of food went too deep in my throat because I need to blend my food, but I cannot have a blender in the room because it's a fire hazard. When it happened, I was screaming and my roommate helped me by wrapping his arms around my belly and squeezing until the food popped out of my mouth. The nurse was present while my roommate was helping me but did not intervene. During an interview on 01/09/25 at 10:01 AM. Staff A, Licensed Practical Nurse (LPN) stated, I did not witness [Resident#297] choking. During the evening medication administration and while I was in the room, [Resident#297] told me, 'If it weren't for my roommate, I wouldn't be here because something got caught in my throat while I was eating.' At that time, I assessed [Resident#297], and [Resident # 297] reported being okay. I also offered to call [Resident#297's] daughter, but the Resident declined. I even asked [Roommate] if he knew the maneuver to help expel food if caught in someone's throat. [Roommate] told me he helped [Resident #297], and everything is fine. There was no documentation, and I did not call the physician. I should have documented and reported the incident to the physician. I continued to monitor [Resident #297] that day and over the weekend and no eating problems arose. Record review of Resident #297's demographic face sheet revealed an admitted [DATE] with diagnosis that included Abdominal Hernia without obstruction or gangrene. Review of a Care Plan initiated on 12/20/2024 revealed Resident #297 had the potential for nutritional problem related to comorbidities that included: abdominal hernia and diverticulum of bladder with a goal to maintain adequate nutritional status as by 03/17/2025. The interventions included: Observe for signs and symptoms of chewing/swallowing difficulties and aspiration; notify physician if noted. Record review of a December 2024 physician's orders sheet revealed Resident #297 was receiving a Gluten Free diet, regular texture and thin liquids. Record review of an Admission Minimum Data Set (MDS) referenced dated 12/22/24 indicated Resident # 297 is cognitively intact and needed set up and clean up assistance for eating and oral hygiene. On 01/09/25 at 3:24 PM, the Director of Nursing revealed she had no knowledge of any choking incident involving Resident #297 and stated: If a nurse is made aware of an incident it should be documented and reported to the physician. Record review of a policy titled, Care Plans, Comprehensive Person-Centered dated 2001 MED-PASS, Inc. (Revised March 2022) revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: 1. provided by qualified persons.

Based on observations, interviews and record reviews facility failed to provide adequate supervision to ensure an environment free of safety hazards for two residents (#9, #17) out of 23 sampled residents as evidenced by boxes of cigarettes and electrical cigarette at Resident #9's bedside and a shaving razor at Resident #17's bedside. There were 94 residents residing in the facility at the time of survey. The findings included: On 01/06/25 at 9:32 AM Resident #9 was observed in bed, the open nightstand drawer had two boxes of cigarettes inside. (photo submitted). On 01/06/25 at 9:35 AM, Staff A, Licensed Practical Nurse (LPN) was asked if residents are allowed to keep cigarettes in room. Staff A, LPN replied, No. During a side-by-side observation of the open drawer in Resident #9's room Staff A, LPN stated, I will check about the cigarettes. Staff A left the room and returned with the Director of Nursing (DON). The DON removed the two packs of cigarettes and educated Resident #9 that these items were not allowed. Record review of a demographic sheet for Resident#9 revealed an admitted [DATE] with diagnosis that included: Encounter for Surgical aftercare following surgery of the digestive system and Quadriplegia. On 01/08/25 at 11:08 AM while observing the smoking area, Staff F, Activities Aide revealed: All the smoking supplies are kept in a locked compartment which is kept at the front desk and only the receptionist and maintenance have a key. Staff F showed a compartment with boxes of smoking supplies, each box was labeled with residents' names. Staff F, Activities Aide further stated: I hand out the smoking supplies to the residents. The residents are not allowed to take any smoking supplies into their room. I ensure the residents return the lighter to me. During another observation on 01/08/25 at 1:27 PM, in Resident # 9's room, a box of cigarette and an electric cigarette were noted in an open drawer in Resident #9's room (photographic evidence). Resident #9 was asked about the understanding of the smoking policy, Resident #9 stated: I smoke in the patio, and I get my supplies from my friend and the staff keep it. The staff transported me to the patio to smoke. I am aware that I should not keep cigarettes in my drawer. The DON was informed of the cigarettes observed in the resident's room. The DON entered Resident #9's room and removed the electric cigarette and a box of cigarettes and reeducated Resident #9. On 01/08/25 at 1:45 PM Staff E, Certified Nursing Assistant (CNA) stated, I check [Resident#9's] drawers daily and inform the nurse if there are any smoking items inside. Every time the staff remove items, Resident#9 gets more. I always see the electric cigarette in the drawer and sometime in the bed and I have informed the nurse. Once I witnessed Resident #9 smoking the electric cigarette in his room and I informed the nurse. Record review of Resident#9's Quarterly Minimum Data Set (MDS) with a reference date of 12/20/24 indicate Resident # 9 is cognitively intact, required set up/clean up assistance for eating, supervision/ touching assistance for oral hygiene and dependent for transfer. Review of an Admission MDS reference dated 09/19/24 documented Yes for current tobacco use. Review of a Care Plan initiated on 09/16/2024 and revised on 11/13/2024 revealed Resident #9 desired to smoke, has been assessed as able to smoke with supervision. Resident or responsible party have been informed of the facility smoking policy and had a history of not being compliant with smoking policy with a goal to demonstrate safe smoking practices thru 12/25/2024. The interventions included: Maintain smoking materials in designated area. Review of the electronic health record of Resident #9 revealed a Smoking assessment dated [DATE] which indicated Resident #9 had the cognitive and physical ability to smoke safely and must request smoking materials from staff. Review of a policy titled, SMOKING POLICY-RESIDENTS effective date: 9/15/2022 revealed Policy: The Center will establish and maintain a safe designated smoking area and safe smoking practices for the residents. Smoking is only allowed in the designated outdoor areas of the facility and during designated times. Procedures: 4. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. 7. The Center will retain and store all smoking materials, including matches, lighters, cigarettes, cigars, and any other smoking implement for all residents who wish to smoke. 11. Electronic cigarettes and vaping are permitted, but only in the facility designated smoking areas. 1. The same rules that apply to regular tobacco cigarettes also apply to electronic smoking and vaping materials. 2. Electronic cigarettes and vaping materials, including the liquids, will be retained and stored by nursing staff On 01/06/25 at 11:23 AM Resident #17 was observed in bed with oxygen in progress via nasal cannula. A shaving razor was observed inside a napkin box on the side table (photographic evidence). Staff A, LPN was notified and removed the shaving razor. Staff A, LPN revealed the Resident # 17's son brought the shaving razor. On 01/06/25 at 11:35 AM Staff C, CNA revealed Resident#17 was not given a shaving razor by the CNA and the shaving razor was not noticed during rounds or during hygiene care. Record review of a demographic sheet for Resident#17 revealed an admitted [DATE] readmission: 9/8/23 with diagnosis that included: Major Depressive Disorder. Review of a Discharge Return Anticipated MDS for Resident#17 reference dated 11/21/24 indicated Resident # 17's cognitive status is undetermined; required supervision/touching assistance for eating/oral hygiene and dependent for toileting/shower/bathe/transfer. Review of a Care Plan initiated on 06/28/2024 and revised on 09/27/2024 revealed Resident#17 had a self-care deficit and decreased mobility and requires set-up to supervision with eating and extensive to total assistance with the rest of Activities of Daily Living (ADL). Goal: Resident #17 will allow staff to assist with ADLs as deemed necessary for proper hygiene and safety thru 12/03/2024. Interventions included: Provide hands-on assistance with dressing, grooming, bathing as needed and staff to anticipate resident's needs with ADLs. Review of a Policy titled, Safety and Supervision of Residents 2001 MED-PASS, Inc. (Revised July 2017) revealed Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: Facility-Oriented Approach to Safety: 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Individualized, Resident-Centered Approach to Safety. Implementing interventions to reduce accident risks and hazards shall include the following: 2. Resident supervision is a core component of the systems approach to safety.

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 F558 Reasonable Accommodations Needs/Preferences, F761 Label/Store Drugs and Biologicals, F880 Infection Prevention & Control, These deficient practices have the potential to affect 94 residents residing in the facility at the time of the survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with exit dated August 31, 2023, F558 Reasonable Accommodations Needs/Preferences was cited related to the facility failure to ensure reasonable accommodations related call lights. F761 Label/Store Drugs and Biologicals, F880 Infection Prevention & Control. Interview with Administrator on 01/09/2025 at 4:00 PM. He revealed the QAPI (Quality Assurance and Performance Improvement) meetings are held on the second Tuesday of each month or as needed. He stated that QAPI committee members are Administrator, Director of Nursing, Assistant Director of Nursing, Medical Records, MDS Coordinator, Staff Coordinator, Activities Director, Social Services Director, Rehabilitation Director, Admission Director, Maintenance Director, Housekeeping Director, Dietary Manager, Medical Director. Human Resources Director, Corporate Officer. During the morning meetings and clinical meetings, they reviewed the last meeting and focused on the deficiencies the facility had for the last survey. Quality Assurance is continuously monitored and communicated with the department heads and tracked to ensure the correct actions implemented. Record review of Quality Assurance/Quality Assurance Performance Improvement QAPI/QAA Goals/Purpose Statement: Our purpose is to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost-effectively while maintaining good resident/patient outcomes and perceptions of patient care. NBRC has a Performance Improvement Program which systematically monitors, analyses and improves its performance to improve resident/ patient outcomes. It recognizes that the value in healthcare is the appropriate balance between good measures, excellent care and services and cost. We will monitor our operations for compliance with federal and state regulations.

Based on observations, interviews, and record reviews, the facility failed to provide quality of care for two residents (Resident #297 and Resident #398) out of twenty-three sampled residents, as evidenced by a Licensed Practical Nurse (LPN) failed to notify the physician and document an incident of food aspiration reported by Resident #297 and failure to position Resident# 398 appropriately during meals to prevent aspiration. There were 94 residents residing in the facility at the time of survey. The findings included: Resident #297 Observation and interview on 01/06/25 at 10:03 AM. Resident#297 was in bed awake alert and oriented bed; a breakfast tray was noted at the bedside. When asked about the choking incident; Resident#297 stated: A chunk of food went too deep in my throat because I need to blend my food, but I cannot have a blender in the room because it's a fire hazard. When it happened, I was screaming and my roommate helped me by wrapping his arms around my belly and squeezing until the food popped out of my mouth. The nurse was present while my roommate was helping me but did not intervene. Resident#297 uncovered tray and an uneaten meat patty was noted on the plate. During an interview on 01/09/25 at 10:01 AM. Staff A, Licensed Practical Nurse (LPN) stated, I did not witness [Resident#297] choking. During the evening medication administration and while I was in the room, [Resident#297] told me, 'If it weren't for my roommate, I wouldn't be here because something got caught in my throat while I was eating.' At that time, I assessed [Resident#297], and [Resident # 297] reported being okay. I also offered to call [Resident#297's] daughter, but the Resident declined. I even asked [Roommate] if he knew the maneuver to help expel food if caught in someone's throat. [Roommate] told me he helped [Resident #297], and everything is fine. There was no documentation, and I did not call the physician. I should have documented and reported the incident to the physician. I continued to monitor [Resident #297] that day and over the weekend and no eating problems arose. Record review of Resident #297's demographic face sheet revealed an admitted [DATE] with diagnosis that included Abdominal Hernia without obstruction or gangrene. Review of a Care Plan initiated on 12/20/2024 revealed Resident #297 had the potential for nutritional problem related to comorbidities that included: abdominal hernia and diverticulum of bladder with a goal to maintain adequate nutritional status as by 03/17/2025. The interventions included: Observe for signs and symptoms of chewing/swallowing difficulties and aspiration; notify physician if noted. Record review of a December 2024 physician's orders sheet revealed Resident #297 was receiving a Gluten Free diet, regular texture and thin liquids. Record review of an Admission Minimum Data Set (MDS) referenced dated 12/22/24 indicated Resident # 297 is cognitively intact and needed set up and clean up assistance for eating and oral hygiene. On 01/09/25 at 3:24 PM, the Director of Nursing revealed she had no knowledge of any choking incident involving Resident #297 and stated: If a nurse is made aware of an incident it should be documented and reported to the physician. 51356 Resident# 398 During observation on 01/06/2025 at 08:30 AM Resident #398 was observed slouched over in bed eating breakfast. During observation on 01/06/25 at 12:30 PM Resident #398 was observed in a reclined position while eating and drinking during lunch. Review of the medical records for Resident #398 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Epilepsy, Unspecified, not intractable, without status epilepticus. Review of the Physician's Orders Sheet for 11/04/2024 revealed Resident #398 had orders that included but not limited to: Bedrails for positioning and/or enabling, bedrail x 2 quarters Review of Resident #398 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed Resident # 398 is cognitively intact and maximal assistance for care is required. Review of Resident # 398's Care Plans revealed the Resident has a self-care deficit with dressing, grooming, bathing related to (r/t): as evidenced by needs assistance with personal care tasks, mobility skills, impaired mobility and generalized weakness. Interventions include- Bedrails for positioning and/or enabling bedrail x 2 quarters and staff to anticipate resident's needs with activities of daily living (ADLs). Interview on 01/09/2025 at 12:34 PM; with Staff G, Licensed Practical Nurse (LPN) stated: If a resident is eating they should be sitting at least at a 45-to-90-degree angle; [Resident #398] normally eats in dining room or her room, she is an independent eater but needs help with setting up her tray and the CNAs (Certified Nursing Assistants) helps to position her in bed. Staff makes frequent rounds in room to prevent choking.

Based on record reviews,observations and interviews the facility's administration failed to implement, provide, and ensure 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 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 implement assigned level of supervision for resident #1 who had exit seeking behaviors, wandered the unit and wandered near exit doors and had the potential for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 1:34 AM through a north egress (emergency exit) back door in the back of the facility on foot on 1/19/2024 placing the resident at risk for harm and or injury. The findings included: Record review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure revision date was on 04/2021, the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation of any type by anyone. 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. A prompt thorough investigation will be conducted by the facility immediately. Review of the facility's policy titled, Wandering and Elopements Policy and Procedure revised March 2019 documented: Policy Heading: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1) If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety and 3) If a resident is missing, initiate the elopement/missing resident emergency procedure. 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 Assistant Director of Nursing documented: The Assistant Director of Nursing 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. In the absence of the Director of Nursing Services, he/she is charged with carrying out the resident care policies. 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. He/she is also responsible for providing a positive, caring, and homelike environment for the residents. 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. Review of the Job Description for the Certified Nursing Assistant documented: The Certified Nursing Assistant is responsible for providing professional care in accordance with established certified nursing assistant policies and procedures. He/she is also responsible for providing a positive, caring, and homelike environment for the residents. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that is congested with heavy traffic, with 40 miles per hour 2 lane traffic each way. Review of Resident's #1 Elopement care plan dated 4/21/2021 documented the resident has a potential for elopement risk related to cognitive impairment, who was exit seeking, wandered the unit and wandered near exit doors; Goal: Resident will safe and will refrain from leaving facility unsupervised thru the next review date; Interventions: Perform frequent observations of residents whereabouts every shift; Provide redirection when observed going towards exit door; Apply alarm bracelet as ordered on right wrist; Verify placement every shift and Check for proper functioning weekly. Review of the progress notes documented the following: Dated 1/19/2024 time stamped 06:25-Narrative Nurses Note: 1900 during initial round, resident was seen walking around the hallway and was redirected to her room. 2130 resident was found walking in the hallway again and said, I want to go home. Due meds given and was putting back to her bed. All safety measures were in place. 2300 while passing by the laundry area, noticed the resident was getting her hair groomed by a CNA. 0000 observed resident putting to bed by her CNA and stayed in the room with her to make sure she stays in bed. 0030 resident was observed walking out of her room towards the nursing station. Initiated and placed resident in a chair to sit in the nurse's station. 1:19 AM observed resident standing in front of nurses station counter and was redirected to her room. 1:22 AM observed resident walking in hallway while doing routine check and redirected back to her room. 2:40 AM while making routine round alarm heard, resident was found missing from assigned room. Initiated elopement protocol, code green initiated. 3:25 AM police were notified about resident's missing. ADON (Assistant Director of Nursing) was notified. Message left for family member. Medical doctor was notified. The progress notes were written by Staff C, Licensed Practical Nurse (LPN). Dated 1/19/24 time stamped 10:30-Narrative Nurses Note: Administrator spoke to the family when she returned the call. Administrator informed the family about patient elopement and gave the family the report of the actual situation. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for December 2023 and January 2024 documented the resident's medications and an or to apply [wander management alarm bracelet] to right wrist, check for placement each shift and functioning Q (every) week. Report any issues immediately to supervisor. The order start date was 8/24/2022. The [wander management alarm bracelet] was checked every day for the month of December 2023 and January 2024 and indicated the resident was wearing it. Review of the Elopement Risk Assessment/Evaluation dated 3/23/2023 and 6/29/23 documented: The resident is at low risk for elopement, does not wander and has never eloped. On 1/30/24 at 9:54 AM, the Administrator/Risk Manager/QAA (Quality Assessment and Assurance) stated: I received a call at approximately 3:30 AM and received a report of a missing person and they didn't retrieve the person. I immediately got in my car and was on my way to the facility for coming to assist with the search. I called [ local state agency] and they accepted the case. The [local law enforcement] was in contact with the facility. On 1/19/2024, the incident occurred. I submitted the one-day report to the [local state agency] with the information given. When I arrived, to the facility the corporate team and other administration personnel were at the facility investigating the elopement. The investigation was ongoing with the corporate team. I participated in QA (quality assurance) with the department heads. I reached out to the resident's family member. I let her know her great aunt was missing, and we are actively looking for her and would provide updates. The resident's niece let us know that she missed out on the calls from the facility earlier. The resident's niece stated the resident's responsible party on file was currently in a nursing home and is hard to reach. The resident remains missing at this time. The [local state agency] five (5) day report indicated the elopement was attributed to the lack of supervision by the two (2) nurses- one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA), they were all placed on suspension on 1/19/2024. We immediately got to work on the response plan. The findings were as stated in the [local state agency] 5-day report, the allegation of neglect was substantiated. The [wander management alarm], red light never came on but the door with the egress alarm did go off. On 1/30/2024 at 10:06 AM, the Registered Nurse (RN), Regional Clinical Director stated, Based on the footage from the camera, it appears that the resident did not have a [wander management alarm] bracelet on, the red light did not go off as it should when a resident with a [wander management alarm] gets near the exit door. She did not have a [wander management alarm] bracelet. The egress door alarm did go off. We educated the licensed nurses to review the elopement assessment. Clinical and non-clinical staff and agency staff were educated on elopement and abuse and neglect, and this would include ongoing education with new hires. The nurses and CNA involved in the resident's elopement were terminated and reported to the board of nursing. On 1/30/2024 at 10:36 AM, Staff A, Licensed Practical Nurse (LPN) via telephone stated: I was working on the 11-7 AM shift on 1/19/2024, I was sitting at the desk and doing daily assessments and the resident was sitting with me, she got up and walked to the side. At 1900 I prepared to make rounds, upon making rounds all 30 residents were accounted for awake and alert. I accepted Medication Cart #2 keys, counted narcotics, and started with med pass. Around 11:30 PM, I stopped to eat. At around 12:00 AM, I started charting sitting at the desk. At that time the resident was at the nursing station with me. The resident got up and walked around the South side of the nursing station. Between 1:45 AM, the call light went off in room [ROOM NUMBER], bed C, I went to assess the resident. When I returned to the nurse's station I saw the light at the back door blinking. I realized that someone had opened or touched the door. I went to the door to check it. I never heard an alarm on the door go off. I just saw the red-light blinking. I was facing the door and went to check the resident's (Resident #1) room and she was not in the room. I went to the resident's room because she was the only resident that was up at that time by the nurses' station. I was not the nurse assigned to the resident. I alerted everyone and a code green was called, and we started the search. I took my truck and drove around the facility looking for the resident. Sometimes the resident would be up at night at the nurse's station. This was common for her to be up at night. I don't recall her having on an [wander management alarm] bracelet. I then ran into the [law enforcement officer] and brought the [law enforcement officer back] to the facility to take a profile of the resident we were looking for. I was suspended from the facility on 1/19/2024. They didn't tell me how long I would be suspended and then I resigned on 1/23/2024. On 1/30/2024 at 10:59 AM, Staff B, RN (Registered Nurse) via telephone stated: The staff realized that the resident was missing, and we started a search. I called the ADON (Assistant Director of Nursing) to let administration know what was going on. I was the RN in the building that night. I was assigned to the South wing [ Staff C, LPN] was assigned to the resident. On 1/30/2024 at 11:04 AM, Staff C, LPN via telephone stated: I am busy at the moment and doing something. Call me back in five hours. Attempted a second contact at the designated time and did not receive any response. On 1/30/2024 at 11:08 AM, Staff D, Certified Nursing Assistant (CNA) via telephone stated: After 11:00 PM, I signed into work. I made rounds and I didn't see the patient in the room. I told the nurse [Staff C, LPN] and she said the patient is here with me. The resident liked to walk around. I go to the laundry room and pick up my cart. The patient was in the hallway. I talked to her and told her to come with me. I took her to her room and had her sit on the bed. Every day she walked around. [Staff A, LPN] and [Staff C, LPN] were at the nursing station. I noticed the patient was missing at 2:30 AM. I made rounds; I didn't see the patient in her room. I called the nurse and told her I could not find the resident. I opened the bathroom door, and I didn't see her. I went outside and I didn't see her. On 1/30/2024 at 11:35 AM observation of the video of the resident exiting the building and interview with the Regional Director of Operations stated: The resident walked out of the door and the alarm for the door went off and the nurse [Staff A, LPN] was sitting at the North wing nurses station and did not get up. The resident was wearing an alarm bracelet and the alarm on the [wander management alarm] did not sound off. According to our investigation and interviews with the nurses, the resident was not wearing a [wander management alarm] bracelet. I have been checking the ME's (Medical Examiner's) office every day since the resident left. She has not been found yet. During observational review of the facility's video footage via the computer approximately 3-4 minutes in duration with the Regional Director of Operations on 1/30/2024 at 11:35 AM. The video footage revealed that on 1/19/2024 at 1:33 AM, Resident #1 was dressed in a black dress with pink socks and a white blanket wrapped around her shoulders was pacing back and forth in the North wing hallway, during this time Staff A, LPN was sitting at the North wing nurses station with her head down. On 1/19/2024 at 1:34 AM Resident #1 pushed the door without any difficulty at 1:34 AM on 1/19/2024 and exited the facility undetected by staff. The resident walked out of the facility with no assistive device and proceeded through the north egress (emergency exit) double door that lead to the facility's courtyard on the north wing. The alarm on the exit door was not audible for staff to hear throughout the facility within the care areas beyond the double doors. On 1/31/2024 at 7:35 AM, the Administrator stated: Around 1:33 AM the resident left out of the door of the facility. The search was started about an hour later at 2:30 AM. The Elopement book is kept at the front desk, at each nursing station and in the therapy room. The Elopement book contains the resident's picture, search grids, what to do in case of an elopement and a check list. On 1/31/2024 at 7:38 AM, RN, Regional Clinical Director stated: We interviewed everyone on the shift. At first, she was helpful [Staff A, LPN] She said she was in the resident's room. I was busy doing resident care . and no mention of what resident she was taking care of. We let the nurses know [Staff A, LPN and Staff C, LPN] we had reviewed the camera footage and showed Staff A] the camera footage. [Staff A] acknowledged, she was sitting at the North nurses' station. She stated she did hear an alarm .thought it was a call light or a resident who .really does not need anything. We asked her if she heard the alarm, [Staff A, LPN] replied, yes I heard the alarm. The video showed that [Staff A] did not get up from the nurse's station when the alarm went off. The alarm is audible for up to 110 ft. It was a typo in the report done by the Administrator. It should be the North egress door, not the South egress door. Her [wander management alarm] bracelet was checked on 12/20/2023. She did have a [wander management alarm] bracelet. The maintenance person checks the [wander management alarm] monthly and nursing checks every shift. The resident was not placed on one to one because the resident was being closely monitored at the nurses' station that night, her room is next to the nurses' station, and she is checked on frequently. [Staff A, LPN] stated she heard the alarm go off, thought it was a call light. Staff in the facility responded to the alarm at 2:30 AM. According to the orders, the Maintenance Director checks the [wander management alarm] monthly, the last audit for the resident's [wander management alarm] was completed on 12/20/2023. According to the video the alarm started going off at 1:33 AM, staff responded at 2:30 AM. Three staff members got into their cars and went in opposite directions searching for the resident for approximately 30 minutes. The alarm was turned off by the Maintenance Director at approximately 4:00 AM on 1/19/2024. No one on staff on the morning of 1/19/2024 had a code to turn off the alarm. The resident was being closely monitored at the nurse's station from the night of 1/18/2024 into the morning of 1/19/2024. The resident's room is right next to the nursing station, and she was monitored frequently. On 1/31/2024 at 7:57 AM, the Maintenance Director stated, I checked the [wander management alarm] weekly before the incident and now it is checked every day. I have a [wander management alarm] bracelet and I set off the alarm on each door. For the residents, I have a device if the [wander management alarm] bracelet is active or if the battery is low. For the resident, she was last checked on 12/20/2023 and it was functioning. For the alarm bracelets tag, it is placed on the resident, I take it to the door to make sure it is activated. The area outside the North egress door is an outside parking area/street. Since the incident, there is a 6 feet fence enclosing the area. On 1/31/2024 at 9:41 AM, Assistant Director of Nursing (ADON) stated: It was 3:30 in the morning, Thursday going into Friday in the morning, my phone rings. [Staff B, RN] said I have some bad news. She started to tell me [ Resident #1] was missing. They searched all over the building, staff went looking for her outside of the building and they have not found her. She then went on to say, they called the [local law enforcement] at 3:20 AM or 3:25 AM, the police told them there was a lady hit by a train, near here. I don't remember if the alarm was ringing while we were on the phone. [Staff B, RN] was on the South wing when she called me. She tried to contact the Administrator and was not able to. I tried to contact the Administrator, but he didn't answer. I tried to contact the DON (Director of Nursing) and she didn't answer. I contacted [RN, Regional Clinical Director] about the incident. When I got here to the facility after 6:00 AM, two [local law enforcement officers] were here and they wanted to see all of the exit doors. The Maintenance Director showed them all of the exit doors. The DON and myself drove around the facility to look for the resident. The road was blocked by [local law enforcement officers] and they told us that a lady was hit by a train, and she didn't have any ID (identification) on her. They said the person passed away and was sent to the Medical Examiner's office and they were waiting for confirmation for identification of the person. We still have not received confirmation as to who that was. On 2/01/2024 at 8:07 AM, the Maintenance Director stated: The exit/egress door alarms are monitored weekly by activating the door-pushing up against the door, waiting for the 15 second door opening delay, making sure the alarm sounds once the door is opened, the maglock ensures the 15 second delay before the door opens, once someone tries to open the door. I then open the door, close the door, then reset the alarm, and make sure that the door is locked. The screamers, which are the red boxes located on the inside on the top of the door were installed on 1/19/2024, they are battery operated. A key is needed to turn the screamers off once the door is opened after the 15 second delay. The wander guard monitors are all installed close to the exit doors and are checked for proper functioning. All exit doors are checked weekly, even before the incident. The scope and severity of F835 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 2/01/2024. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 2/01/2024. These corrective actions were verified by the survey team through observation, record review and interview on 1/30/2024 to 2/01/2024. The facility's immediate jeopardy removal plan included: The staff (128 persons) at 100% were in-serviced/trained on 1/19/2024 to 1/29/2024, regarding: how to respond to call lights promptly, elopement drills, codes, and emergencies responses, how to respond to door alarms, competency for elopement training, how to deal with patients that have behaviors, behavior management for exit seeking resident, abuse, neglect and exploitation training, accidents, and hazards and the QAPI (Quality Assurance Performance Improvement) process with the administrative team. The facility conducted a thorough inspection of all eight (8) exit doors and their existing alarm systems to make sure they are in working order in the facility, each exit door has a [wander management alarm], a screamer alarm (Installed 1/19/2024) and an egress maglock alarm with a 15 second opening delay. The alarm systems are audible and can be heard at their loudest in the area where it goes off and is reasonably audible throughout the facility. Nurses are assigned to check residents with wander guards at least once per shift for placement and functionality. The Elopement Risk Book was revised on 01/28/2024, contains-List of Residents, guidelines for elopement /Unsafe Wandering Prevention, Facility Floor Plan, Pictures of Residents for elopement, Face sheets, Elopement Drill Schedule, and Elopement Mock Drills protocol. A 6-foot fence was installed to the north courtyard to ensure that residents are not able to exit to the neighborhood and busy streets from the facility's courtyard on the north wing. Maintenance staff or their qualified designees, conduct weekly door audits to ensure all doors are in proper working order, including checking that the alarm is audible at the nursing station and care areas. An audit of all residents who reside in the facility was conducted to evaluate at risk for leaving the facility without informing staff and/or if they may desire to leave the facility. Additional Audits-Dated 1/19/2024 to 1/27/2024; Elopement Drill Audit, Dated 1/20/2024 to 1/28/2024; [wander management alarm bracelet] Audit, Dated 1/21/2024 to 1/26/2024; Daily Door Audits (All shifts), Dated 1/21/2024 to 1/27/2024; Elopement Drill/Actual Event Evaluation, Dated 1/28/2024; Facility Search Grid.

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 10 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 . The facility had surveys with IJ levels citations in the previous three years during surveys. The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment. 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 1:34 AM, through an egress (emergency exit) back door in the back of the facility on foot undetected. These repeated deficient practices have the potential to affect any of the residents residing in the facility. Refer to F 600, F 607, F 689 and F835. The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (revised February 2020) documented the following: Policy-This facility shall develop, implement and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents; QAPI purpose is a type of quality management program which takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality. Policy Explanation and Compliance Guidelines: 1) The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; 2) The QAA Committee shall be interdisciplinary and shall: b) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; 3) b) Policies and procedures for feedback, data collection systems and monitoring, c) Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i.) Tracking and measuring performance, iii.) Identifying and prioritizing quality deficiencies, iv.) Systematically analyzing underlying causes of systemic quality deficiencies and v.) Developing and implementing corrective action or performance improvement activities. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated [DATE], [DATE] and [DATE] documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator/Risk Manager, Medical Director, Director of Nursing (DON), Infection Control and Prevention Officer, Admissions Coordinator, Rehab Director, Social Services Director, Dietitian, Business Office Manager, Activities Director, Food Service Director, MDS (Minimum Data Set) Coordinator, Maintenance Director, Housekeeping Director, Human Resources Manager and Licensed Nurses. On [DATE] at 3:33 PM, the Administrator/Risk Manager/QAA stated, The QAA Committee meets every month on the second Thursday of the month. The committee consist of the Medical Director, Administrator, DON, and all interdisciplinary team members. The purpose of QAA is to use evidence-based data, reports and feedback to identify trends and capitalize on systems that are working and if any negative trends to put measures in place to remedy those. The facility's removal plan also indicates: The Administrator and the department heads were educated on the QAPI/QAA Processes with emphasis on identifying quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice to include failure to supervise residents in previous incidents resulting in an immediate jeopardy. The facility held an Adhoc QAPI on [DATE] regarding the following below to check for compliance: [DATE], last IJ deficiencies Last Annual survey cited deficiencies. On [DATE], as part of the continuation of the Adhoc QAPI initiated on [DATE], the administrator conducted a meeting with the interdisciplinary team on the following Immediate jeopardy deficient practice received from the Agency for Health Care Administration (AHCA) office on the following areas as stated above, (F600, F607, F689, F835, F867). - Included in the discussion is the plan of correction initiated and some completed prior to this meeting. The following education and/or corrective actions were completed on [DATE] as follows: F 600 Abuse and Neglect, F 607, F 689, F 835,F 867 Education Plan: The staff, newly hired staff, and agency staff will be educated on the following below: F 600 Abuse/Neglect, F 607, F 689 with emphasis on Resident with an exit seeking behavior, F 835 administration ,867 QAPI/QAA Process Elopement drill with emphasis on prompt and timely response to door alarms Behavior Management on Resident with Exit Seeking behavior. The physician's order for [wander management] includes checking for placement q shift and function daily for licensed nurses. Upon receipt of physician order for [wander management], the licensed nurse will transcribe this to the Medical record (ETAR/EMAR). The licensed nurse who received the order will apply the [wander management] when available, however in the event that it is not, the resident will be placed on a one-on-one supervision until the [wander management system] becomes available. The succeeding shift will check for placement and location of the [wander management] as observed. In order to monitor the accuracy of the medical record documentation, the 7P-7A licensed nurses will perform an audit of physician orders with emphasis on the [wander management] placement and physically check the placement and location of the The Administrator and the department heads were educated on the QAPI/QAA Processes with emphasis on identifying quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice to include failure to supervise residents in previous incidents resulting in an immediate jeopardy. The facility held an Adhoc QAPI on [DATE] regarding the following below to check for compliance: [DATE], last IJ deficiencies Last Annual survey cited deficiencies. On [DATE], as part of the continuation of the Adhoc QAPI initiated on [DATE], the administrator conducted a meeting with the interdisciplinary team on the following Immediate jeopardy deficient practice received from the Agency for Health Care Administration (AHCA) office on the following areas as stated above, (F600, F607, F689, F835, F867). - Included in the discussion is the plan of correction initiated and some completed prior to this meeting. The following education and/or corrective actions were completed on [DATE] as follows: F 600 Abuse and Neglect, F 607, F 689,F 835,F 867 Education Plan The staff, newly hired staff, and agency staff will be educated on the following below: F 600 Abuse/Neglect, F 607 F 689 with emphasis on Resident with an exit seeking behavior. F 835 Administration F 867 QAPI/QAA Process Elopement drill with emphasis on prompt and timely response to door alarms. Behavior Management on Resident with Exit Seeking behavior. The physician's order for [wander management] includes checking for placement q shift and function daily for licensed nurses. Upon receipt of physician order for [wander management], the licensed nurse will transcribe this to the Medical record (ETAR/EMAR). The licensed nurse who received the order will apply the [wander management] when available, however in the event that it is not, the resident will be placed on a one-on-one supervision until the [wander management] becomes available. The succeeding shift will check for placement and location of the [wander management] as observed. In order to monitor the accuracy of the medical record documentation, the 7P-7A licensed nurses will perform an audit of physician orders with emphasis on the [wander management] placement and physically check the placement and location of the equipment on the resident. DON/ADON/Nurse Supervisor and/or designee will evaluate the [wander management] order process daily to ensure implementation and accuracy. Admission Process on reviewing newly admitted and readmitted resident's medical record with emphasis on Elopement assessment and order for [wander management] as needed. The staff will be educated on the DOOR ALARM SYSTEMS: Types of Alarms in Building Mag Lock Alarm (15 seconds to respond)- Sound: Audible continuous alarming sound. Exit Alarm Screamer- Sound: Audible- High Pitch continuous sound activated when door is opened. [Wander management] alarm: Sound: Audible High Pitch continuous sound activated when a [wander management] crosses the threshold. [Wander management] Annunciator is located at each Nursing Station and Front Desk and identifies the specific exit door that is open and activated by Wander Guard. If necessary, education will be provided via telephone and/or mail to ensure compliance is attained by the DON/Staff Developer/designee. Elopement education/competency will be changed from once a year to twice a year. Elopement drill will be done by the regional/consultant team on a quarterly basis x 1 year. The education set forth above will continue for the newly hired employees and staff agency. Monitoring will be ongoing. The DON and/or designee will conduct an elopement drill every shift starting on [DATE] x 14 days then daily x 7 days then weekly for 4 weeks and monthly thereafter. Elopement book audits will be completed by the DON and/or designee daily x 14 days then weekly x 4 weeks then monthly thereafter. Residents with [wander management] will be audited for placement q shift and functioning daily. The maintenance director will check the [wander management] system functioning daily. Nursing will monitor the [wander management] order process daily. Results of audits will be reported to the QAPI committee monthly to sustain compliance. Exit doors will be monitored q shift for alarm functioning x 14 days then daily x 4 weeks then weekly thereafter. Random Door alarm staff response observation. Education and competency will be monitored by the Regional Clinical Educator and/or designee for 100% completion and will continue to newly hired employees and agency staff. The revised elopement packet will be shared with existing contracted staffing agencies. Elopement education and competency will be done twice a year. Discussed audits/findings in the monthly QAA/QAPI meeting to sustain compliance; may revise POC as needed. The findings will be shared with the [consultant company] for additional oversight. DON/ADON/Nurse Supervisor and/or designee will evaluate the [wander management] order process daily to ensure implementation and accuracy. Admission Process on reviewing newly admitted and readmitted resident's medical record with emphasis on Elopement assessment and order for [wander management] as needed. The staff will be educated on the DOOR ALARM SYSTEMS: Types of Alarms in Building Mag Lock Alarm (15 seconds to respond)- Sound: Audible continuous alarming sound. Exit Alarm Screamer- Sound: Audible- High Pitch continuous sound activated when door is opened. Wander Guard Alarm: Sound: Audible High Pitch continuous sound activated when a [wander management] crosses the threshold. [Wander management] Annunciator is located at each Nursing Station and Front Desk and identifies the specific exit door that is open and activated by [wander management system]. If necessary, education will be provided via telephone and/or mail to ensure compliance is attained by the DON/Staff Developer/designee. Elopement education/competency will be changed from once a year to twice a year. Elopement drill will be done by the regional/consultant team on a quarterly basis x 1 year. The education set forth above will continue for the newly hired employees and staff agency. Monitoring will be ongoing. The DON and/or designee will conduct an elopement drill every shift to start on [DATE] x 14 days then daily x 7 days then weekly for 4 weeks and monthly thereafter. Elopement book audits will be completed by the DON and/or designee daily x 14 days then weekly x 4 weeks then monthly thereafter. Residents with [wander management] will be audited for placement q shift and functioning daily. The maintenance director will check the [wander management] system functioning daily. Nursing will monitor the: The Administrator and the department heads were educated on the QAPI/QAA Processes with emphasis on identifying quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice to include failure to supervise residents in previous incidents resulting in an immediate jeopardy. The facility held an Adhoc QAPI on [DATE] regarding the following below to check for compliance: [DATE], last IJ deficiencies. Last Annual survey cited deficiencies. On [DATE], as part of the continuation of the Adhoc QAPI initiated on [DATE], the administrator conducted a meeting with the interdisciplinary team on the following Immediate jeopardy deficient practice received from the Agency for Health Care Administration (AHCA) office on the following areas as stated above, (F600, F607, F689, F835, F867). Included in the discussion is the plan of correction initiated and some completed prior to this meeting. The following education and/or corrective actions were completed on [DATE] as follows: F 600 Abuse and Neglect, F 607, F 689, F 835, F 867 Education Plan: The staff, newly hired staff, and agency staff will be educated on the following below: F 600 Abuse/Neglect 607, F 689 with emphasis on Resident with an exit seeking behavior., F 835 Administration 867 QAPI/QAA Process. Elopement drill with emphasis on prompt and timely response to door alarms. Behavior Management on Resident with Exit Seeking behavior. The physician's order for [wander management] includes checking for placement q shift and function daily for licensed nurses. Upon receipt of physician order for [wander management] the licensed nurse will transcribe this to the Medical record (ETAR/EMAR). The licensed nurse who received the order will apply the [wander management] when available, however in the event that it is not, the resident will be placed on a one-on-one supervision until the [wander management system] becomes available. The succeeding shift will check for placement and location of the [wander management]] as observed. In order to monitor the accuracy of the medical record documentation, the 7P-7A licensed nurses will perform an audit of physician orders with emphasis on the [wander management] placement and physically check the placement and location of the equipment on the resident. DON/ADON/Nurse Supervisor and/or designee will evaluate the [wander management] order process daily to ensure implementation and accuracy. Admission Process on reviewing newly admitted and readmitted resident's medical record with emphasis on Elopement assessment and order for [wander management] as needed. The staff will be educated on the DOOR ALARM SYSTEMS: Types of Alarms in Building. Mag Lock Alarm (15 seconds to respond)- Sound: Audible continuous alarming sound .Exit Alarm Screamer- Sound: Audible- High Pitch continuous sound activated when door is opened. [Wander management Alarm]: Sound: Audible High Pitch continuous sound activated. The Administrator and the department heads were educated on the QAPI/QAA Processes with emphasis on identifying quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice to include failure to supervise residents in previous incidents resulting in an immediate jeopardy. The facility held an Adhoc QAPI on [DATE] regarding the following below to check for compliance: [DATE], last IJ deficiencies. Last Annual survey cited deficiencies. On [DATE], as part of the continuation of the Adhoc QAPI initiated on [DATE], the administrator conducted a meeting with the interdisciplinary team on the following Immediate jeopardy deficient practice received from the Agency for Health Care Administration (AHCA) office on the following areas as stated above, (F600, F607, F689, F835, F867). Included in the discussion is the plan of correction initiated and some completed prior to this meeting. The following education and/or corrective actions were completed on [DATE] as follows: F 600 Abuse and Neglect, F 607, F 689, F 835, F 867 .The staff, newly hired staff, and agency staff will be educated on the following below: F 600 Abuse/Neglect 607, F 689 with emphasis on Resident with an exit seeking behavior. F 835 Administration 867 QAPI/QAA Process, Elopement drill with emphasis on prompt and timely response to door alarms, Behavior Management on Resident with Exit Seeking behavior. The physician's order for [wander management] includes checking for placement q shift and function daily for licensed nurses. Upon receipt of physician order for wander management], the licensed nurse will transcribe this to the Medical record (ETAR/EMAR). The licensed nurse who received the order will apply for the [wander management] when available, however in the event that it is not, the resident will be placed on a one-on-one supervision until the [wander management] becomes available. The succeeding shift will check for placement and location of the [wander management] as observed. In order to monitor the accuracy of the medical record documentation, the 7P-7A licensed nurses will perform an audit of physician orders with emphasis on the [wander management] placement and physically check the placement and location of the equipment on the resident. DON/ADON/Nurse Supervisor and/or designee will evaluate the [wander management] order process daily to ensure implementation and accuracy Admission Process on reviewing newly admitted and readmitted resident's medical record with emphasis on Elopement assessment and order for [wander management] as needed. The staff will be educated on the DOOR ALARM SYSTEMS: Types of Alarms in Building. Mag Lock Alarm (15 seconds to respond)- Sound: Audible continuous alarming sound . Exit Alarm Screamer- Sound: Audible- High Pitch continuous sound activated when door is opened. [Wander management] alarm: Sound: Audible High Pitch continuous sound activated when a [wander management] crosses the threshold. [Wander management] Annunciator is located at each Nursing Station and Front Desk and identifies the specific exit door that is open and activated by [Wander management] If necessary, education will be provided via telephone and/or mail to ensure compliance is attained by the DON/Staff Developer/designee. Elopement education/competency will be changed from once a year to twice a year. Elopement drill will be done by the regional/consultant team on a quarterly basis x 1 year. The education set forth above will continue for the newly hired employees and staff agency. Monitoring will be ongoing. The DON and/or designee will conduct an elopement drill every shift starting on [DATE] x 14 days then daily x 7 days then weekly for 4 weeks and monthly thereafter. Elopement book audits will be completed by the DON and/or designee daily x 14 days then weekly x 4 weeks then monthly thereafter. Residents with [wander management] will be audited for placement q shift and functioning daily. The maintenance director will check the [wander management] system functioning daily. Nursing will monitor the [wander management] order process daily. Results of audits will be reported to the QAPI committee monthly to sustain compliance. Exit doors will be monitored q shift for alarm functioning x 14 days then daily x 4 weeks then weekly thereafter. Random Door alarm staff response observation. Education and competency will be monitored by the Regional Clinical Educator and/or designee for 100% completion and will continue to newly hired employees and agency staff. The revised elopement packet will be shared with existing contracted staffing agencies. Elopement education and competency will be done twice a year. Discussed audits/findings in the monthly QAA/QAPI meeting to sustain compliance; may revise POC (Plan Of Correction) as needed. The findings will be shared with the [consulting company] for additional oversight. [Wander management] Annunciator is located at each Nursing Station and Front Desk and identifies the specific exit door that is open and activated by [Wander management]. If necessary, education will be provided via telephone and/or mail to ensure compliance is attained by the DON/Staff Developer/designee. Elopement education/competency will be changed from once a year to twice a year. Elopement drill will be done by the regional/consultant team on a quarterly basis x 1 year. The education set forth above will continue for the newly hired employees and staff agency. Monitoring will be ongoing. The DON and/or designee will conduct an elopement drill every shift starting on [DATE] x 14 days then daily x 7 days then weekly for 4 weeks and monthly thereafter. Elopement book audits will be completed by the DON and/or designee daily x 14 days then weekly x 4 weeks then monthly thereafter. Residents with [wander management] will be audited for placement q shift and functioning daily. The maintenance director will check the [wander management] system functioning daily. Nursing will monitor the [wander management] order process daily. Results of audits will be reported to the QAPI committee monthly to sustain compliance. Exit doors will be monitored q shift for alarm functioning x 14 days then daily x 4 weeks then weekly thereafter. Random Door alarm staff response observation. Education and competency will be monitored by the Regional Clinical Educator and/or designee for 100% completion and will continue to newly hired employees and agency staff. The revised elopement packet will be shared with existing contracted staffing agencies. Elopement education and competency will be done twice a year. Discussed audits/findings in the monthly QAA/QAPI meeting to sustain compliance; may revise POC as needed. The findings will be shared with the [consultants] for additional oversight. Results of audits will be reported to the QAPI committee monthly to sustain compliance. Exit doors will be monitored q shift for alarm functioning x 14 days then daily x 4 weeks then weekly thereafter. Random Door alarm staff response observation. Education and competency will be monitored by the Regional Clinical Educator and/or designee for 100% completion and will continue to newly hired employees and agency staff. The revised elopement packet will be shared with existing contracted staffing agencies. Elopement education and competency will be done twice a year. Discussed audits/findings in the monthly QAA/QAPI meeting to sustain compliance; may revise POC as needed. 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 (128 persons) at 100% were in-serviced/trained on [DATE]-[DATE], regarding: how to respond to call lights promptly, elopement drills, codes, and emergencies responses, how to respond to door alarms, competency for elopement training, how to deal with patients that have behaviors, behavior management for exit seeking resident, abuse, neglect and exploitation training, accidents, and hazards and the QAPI process with the administrative team. The facility conducted a thorough inspection of all eight (8) exit doors and their existing alarm systems to make sure they are in working order in the facility, each exit door has a wander guard alarm, a screamer alarm (Installed [DATE]) and an egress maglock alarm with a 15 second opening delay. The alarm systems are audible and can be heard at their loudest in the area where it goes off and is reasonably audible throughout the facility. Nurses are assigned to check residents with wander guards at least once per shift for placement and functionality. The Elopement Risk Book was revised on [DATE], contains-List of Residents, Guidelines for elopement /Unsafe Wandering Prevention, Facility Floor Plan, Pictures of Residents for elopement, Face sheets, Elopement Drill Schedule, and Elopement Mock Drills protocol. A 6-foot fence was installed to the north courtyard to ensure that residents are not able to exit to the neighborhood and busy streets from the facility's courtyard on the north wing. Maintenance staff or their qualified designees, conduct weekly door audits to ensure all doors are in proper working order, including checking that the alarm is audible at the nursing station and care areas. An audit of all residents who reside in the facility was conducted to evaluate at risk for leaving the facility without informing staff and/or if they may desire to leave the facility. Additional Audits-Dated ,d+[DATE]-,d+[DATE]; Elopement Drill Audit, Dated ,d+[DATE]-,d+[DATE]; [ wander management alarm] bracelet Audit, Dated [DATE] to [DATE]; Daily Door Audits (All shifts), Dated [DATE] to [DATE]; Elopement Drill/Actual Event Evaluation, Dated [DATE]; Facility Search Grid.

Based on observation, interviews and record review, the facility failed to protect one (Resident #1) out of three residents sampled during the time of this survey. The facility's staff (Staff A Licensed Practical Nurse (LPN), Staff C LPN and Staff D, Certified Nursing Assistant) failed to supervise and implement adequate measure to prevent the elopement of Resident #1 who was exit seeking, wandered the unit, and wandered near exit doors. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. 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 1/19/2024 at 1:34 AM on foot and the facility's staff did not begin the search until 2:50 AM and did not find the resident. The facility is located in an area where there is heavy 40 miles per hour 2 lane traffic. The resident still has not been located at the time of the survey. Refer to F 607, F 689, F 835, and F 867. The findings included: Record review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure revision date was on 04/2021, the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation of any type by anyone. 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. A prompt thorough investigation will be conducted by the facility immediately. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with a diagnosis that include but not limited to Alzheimer's disease, seizures, and glaucoma. Review of Resident's #1's Elopement care plan dated 4/21/2021 documented the resident has a potential for elopement risk related to cognitive impairment, who was exit seeking, wandered the unit and wandered near exit doors; Goal: Resident will be safe and will refrain from leaving facility unsupervised thru the next review date; Interventions: Perform frequent observations of residents whereabouts every shift; Provide redirection when observed going towards exit door; Apply alarm bracelet as ordered on right wrist; Verify placement every shift and check for proper functioning weekly. Review of the progress notes documented the following: Dated 1/19/2024 time stamped 06:25-Narrative Nurses Note: 1900 during initial round, resident was seen walking around the hallway and was redirected to her room. 2130 resident was found walking in the hallway again and said, I want to go home. Due meds given and was putting back to her bed. All safety measures were in place. 2300 while passing by the laundry area, noticed the resident was getting her hair groomed by a CNA( Certified Nursing Assistant). 0000 observed resident putting to bed by her CNA and stayed in the room with her to make sure she stays in bed. 0030 resident was observed walking out of her room towards the nursing station. Initiated and placed resident in a chair to sit in the nurse's station. 1:19 am observed resident standing in front of nurses station counter and was redirected to her room. 1:22 AM observed resident walking in hallway while doing routine check and redirected back to her room. 2:40 AM while making routine round alarm heard, resident was . missing from assigned room. Initiated elopement protocol, code green initiated. 3:25 AM police . notified about resident missing. ADON (Assistant Director of Nursing) was notified. Message left for family member. Medical doctor was notified. The progress notes written by Staff C, Licensed Practical Nurse (LPN). Dated 1/19/2024 time stamped 10:30 AM Narrative Nurses Note: Administrator spoke to the family when she returned the call. Administrator informed the family about patient elopement and gave the family the report of the actual situation. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for December 2023 and January 2024 documented the resident was receiving the following medications: Namenda 10mg (milligrams) tab (tablet) 1 tab PO (by mouth) BID (twice a day) for mood; Donepezil HCL (hydrochloric acid) 10mg tab 1 tab PO HS (at night) for dementia and apply [wander management] alarm bracelet to right wrist. Check for placement shift and functioning Q (every) week. Report any issues immediately to supervisor. The order start date was 8/24/2022. The [wander management] alarm bracelet was checked every day for December 2023 and January 2024 and indicated the resident was wearing it. Review of the Elopement Risk Assessment/Evaluation dated 3/23/2023 and 6/29/2023 documented: The resident is at low risk for elopement, does not wander and has never eloped. On 1/30/2024 at 9:54 AM, the Administrator/Risk Manager/QAA (Quality Assessment and Assurance) stated: I received a call at approximately 3:30 AM and received a report of a missing person and they didn't retrieve the person. I immediately got in my car and was on my way to the facility for coming to assist with the search. I called [local state agency] and they accepted the case. The [local law enforcement] was in contact with the facility. On 1/19/2024, the incident occurred. I submitted the one-day report to the [local state agency] with the information given. When I arrived, to the facility the corporate team and other Administration personnel were at the facility investigating the elopement. The investigation was ongoing with the corporate team. I participated in QA (quality assurance) with the department heads. I reached out to the resident's family member. I let her know her great aunt was missing, and we are actively looking for her and would provide updates. The resident's niece let us know that she missed out on the calls from the facility earlier. The resident's niece stated the resident's responsible party on file was currently in a nursing home and is hard to reach. The resident remains missing at this time. The [ local state agency] five (5) day report indicated the elopement was attributed to the lack of supervision by the two (2) nurses- one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA), they were all placed on suspension on 1/19/2024. We immediately got to work on the response plan. The findings were as stated in the [local state agency] 5-day report, the allegation of neglect was substantiated. The [wander management] alarm bracelet red light never came on but the door with the egress alarm did go off. On 1/30/2024 at 10:06 AM, the Registered Nurse (RN), Regional Clinical Director stated: Based on the footage from the camera, it appears that the resident did not have an [wander management] alarm bracelet on, the red light did not go off as it should when a resident with a [wander management] bracelet gets near the exit door. She did not have a [wander management] alarm bracelet. The egress door alarm did go off. We educated the licensed nurses to review the elopement assessment. Clinical and non-clinical staff and agency staff were educated on elopement and abuse and neglect, and this would include ongoing education with new hires. The nurses and CNA involved in the resident's elopement were terminated and reported to the board of nursing. On 1/30/2024 at 10:36 AM, Staff A, Licensed Practical Nurse (LPN) via telephone stated, I was working on the 11-7 AM shift on 1/19/2024, I was sitting at the desk and doing daily assessments and the resident was sitting with me, she got up and walked to the side. At 1900 I prepared to make rounds, upon making rounds all 30 residents were accounted for awake and alert. I accepted Medication Cart #2 keys, counted narcotics, and started with med pass. Around 11:30 PM, I stopped to eat. At around 12:00 AM, I started charting sitting at the desk. At that time the resident was at the nursing station with me. The resident got up and walked around the South side of the nursing station. Between 1:45 AM, the call light went off in room [ROOM NUMBER], bed C, I went to assess the resident. When I returned to the nurse's station I saw the light at the back door blinking. I realized that someone had opened or touched the door. I went to the door to check it. I never heard an alarm on the door go off. I just saw the red-light blinking. I was facing the door and went to check the resident's (Resident #1) room and she was not in the room. I went to the resident's room because she was the only resident that was up at that time by the nurses' station. I was not the nurse assigned to the resident. I alerted everyone and a code green was called, and we started the search. I took my truck and drove around the facility looking for the resident. Sometimes the resident would be up at night at the nurse's station. This was common for her to be up at night. I don't recall her having on an [wander management] alarm bracelet. I then ran into the [law enforcement officer] and brought the [law enforcement officer] back to the facility to take a profile of the resident we were looking for. I was suspended from the facility on 1/19/2024. They didn't tell me how long I would be suspended and then I resigned on 1/23/2024. On 1/30/2024 at 10:59 AM, Staff B, RN (Registered Nurse) via telephone stated: The staff realized that the resident was missing, and we started a search. I called the ADON (Assistant Director of Nursing) to let administration know what was going on. I was the RN in the building that night. I was assigned to the South wing. [ Staff C, LPN] was assigned to the resident. On 1/30/2024 at 11:04 AM, Staff C, LPN via telephone stated, I am busy at the moment and doing something. Call me back in five hours. Attempted a second contact at the designated time and did not receive any response. On 1/30/2024 at 11:08 AM, Staff D, Certified Nursing Assistant (CNA) via telephone stated: After 11:00 PM, I signed into work. I made rounds and I didn't see the patient in the room. I told the nurse [Staff C, LPN] and she said the patient is here with me. The resident liked to walk around. I go to the laundry room and pick up my cart. The patient was in the hallway. I talked to her and told her to come with me. I took her to her room and had her sit on the bed. Every day she walked around. [Staff A, LPN and Staff C, LPN] were at the nursing station. I noticed the patient was missing at 2:30 AM. I made rounds; I didn't see the patient in her room. I called the nurse and told her I could not find the resident. I opened the bathroom door, and I didn't see her. I went outside and I didn't see her. On 1/30/2024 at 11:35 AM observation of the video of the resident exiting the building and interview with the Regional Director of Operations stated, The resident walked out of the door and the alarm for the door went off and the nurse [Staff A, LPN] was sitting at the North wing nurses station and did not get up. The resident was wearing an alarm bracelet and the alarm on the [wander management] alarm bracelet did not sound off. According to our investigation and interviews with the nurses, the resident was not wearing a [wander management] alarm bracelet. I have been checking the ME's (Medical Examiner's) office every day since the resident left. She has not been found yet. During observational review of the facility's video footage via the computer that was approximately 3 to 4 minutes in duration with the Regional Director of Operations on 1/30/2024 at 11:35 AM. The video footage revealed that on 1/19/2024 at 1:33 AM, Resident #1 was dressed in a black dress with pink socks and a white blanket wrapped around her shoulders was pacing back and forth in the North wing hallway, during this time Staff A, LPN was sitting at the North wing nurses station with her head down. On 1/19/2024 at 1:34 AM Resident #1 pushed the door without any difficulty at 1:34 AM on 1/19/2024 and exited the facility undetected by staff. The resident walked out of the facility with no assistive device and proceeded through the north egress (emergency exit) double door that lead to the facility's courtyard on the north wing. The alarm on the exit door was not audible for staff to hear throughout the facility within the care areas beyond the double doors. The scope and severity of F600, was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 2/01/2024. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 2/01/2024. These corrective actions were verified by the survey team through observation, record review and interview from 1/30/2024 to 2/01/2024. The facility's immediate jeopardy removal plan included: The staff (128 persons) at 100% were in-serviced/trained on 1/19/2024 to 1/29/2024, regarding: how to respond to call lights promptly, elopement drills, codes, and emergencies responses, how to respond to door alarms, competency for elopement training, how to deal with patients that have behaviors, behavior management for exit seeking resident, abuse, neglect and exploitation training, accidents, and hazards and the QAPI process with the administrative team. The facility conducted a thorough inspection of all eight (8) exit doors and their existing alarm systems to make sure they are in working order in the facility, each exit door has a wander guard alarm, a screamer alarm (installed 1/19/2024) and an egress maglock (magnetic lock) alarm with a 15 second opening delay. The alarm systems are audible and can be heard at their loudest in the area where it goes off and is reasonably audible throughout the facility. Nurses are assigned to check residents with wander guards at least once per shift for placement and functionality. The Elopement Risk Book was revised on 01/28/2024, contains-List of Residents, Guidelines for elopement /Unsafe Wandering Prevention, Facility Floor Plan, Pictures of Residents for elopement, Face sheets, Elopement Drill Schedule, and Elopement Mock Drills protocol. A 6-foot fence was installed to the north courtyard to ensure that residents are not able to exit to the neighborhood and busy streets from the facility's courtyard on the north wing. Maintenance staff or their qualified designee will conduct weekly door audits to ensure all doors are in proper working order, including checking that the alarm is audible at the nursing station and care areas. An audit of all residents who reside in the facility was conducted to evaluate the risk of leaving the facility without informing staff and/or if they may desire to leave the facility. Additional Audits-Dated 1/19/2024 to 1/27/24; Elopement Drill Audit, Dated 1/20/2024 to 1/28/2024; [Wander management alarm] bracelet Audit, Dated 1/21/2024 to 1/26/2024; Daily Door Audits (All shifts), Dated 1/21/2024 to 1/27/2024; Elopement Drill/Actual Event Evaluation, Dated 1/28/2024; Facility Search Grid.

Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staffs' failure implement the facility's policy related to wandering and elopement and failed to provide care and services including adequate supervision for one (Resident #1) out of three residents sampled. This deficient practice enabled Resident #1 to exit the facility at 1:34 AM on 01/19/2024, 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. The resident has not been located as of 02/01/2024. The findings included: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 documented: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint nit required to treat the resident's symptoms. Policy Interpretation and Implementation The resident abuse, neglect and exploitation or misappropriation of property by anyone including, but not necessarily limited to: 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents b. neglect of residents; and/or c. theft, exploitation, or misappropriation of resident property 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 7. implement measures to address factors that may lead to abusive situations, for example: a. Adequately prepare staff for caregiving responsibilities. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 11. Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property. Record review of the facility's policy titled Wandering and Elopements revision date March 2019 documented: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1 If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2 If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3 If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. emergency management, rescue squads, etc.) 4 When the resident returns to the facility, the director of nursing services or charge nurse shall: a. Examine the resident for injuries. b. contacts the attending physician and report findings and conditions of the resident. c. notifies the resident's legal representative (sponsor) d. notify search teams that the resident has been located. e. complete and file an incident report; and f. document relevant information in the resident's medical record Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Alzheimer's disease, Dementia, anxiety, and Seizures. Review of the Physician's Orders Sheet for January 2024 revealed Resident #1 had orders that included but not limited to: order dated 8/24/2022- Apply/maintain [wander management] alarm bracelet to right wrist. Check for placement and functioning every shift. Report any issues immediately to the supervisor. Medications Include: Namenda Tablet 10 MG (Memantine HCl)-Give 1 tablet by mouth two times a day for mood. Donepezil HCl Tablet 10 MG-Give 1 tablet by mouth at bedtime for dementia. Record review of the Electronic Medication Administration Record (EMAR) for 1/1/2024 to1/18/2024 revealed Resident #1 was checked off on the EMAR as having an [wander management] alarm bracelet on by assigned nurses. Record review of Resident #1 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Pattern documented Brief Interview for Mental Status score (BIMS) 5 on a 0-15 scale indicating the resident is cognitively impaired. Section E for behaviors documented Resident experiences Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident wandered 1to 3 days. Section GG for Functional abilities documented no impairment of upper and lower extremity, no mobility devices used, supervision for sitting to standing position, chair to bed transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Partial assistance for walking 50 feet and substantial assistance for walking 150 feet.and Section P for restraints documented wander elopement alarm used daily. Review of the Elopement Risk Assessment/Evaluation dated 3/23/2023 and 06/29/2023 documented: Score of 0-9. LOW RISK for elopement. No interventions at this time. Record review of Resident #1's most recent Psychological consult dated 2/2021 documented: Resident appears calm, cooperative, in no apparent distress at this time. Record review of Resident #1 's Elopement Care Plans Reference Date 04/12/2021 revealed: Resident has a potential for elopement due to: cognitive impairment, has periods of increased confusion, is exit seeking, is (I) ambulatory, wanders the unit & wanders near exit doors, has a history of elopement. 01/19/2024 elopement. Interventions Include: Educate resident/responsible party regarding sign out procedures as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; provide 1:1s as needed. Apply [wander management] alarm bracelet as ordered (R) wrist. Verify placement every shift. Check for proper functioning weekly. Include resident in Elopement Book and Update physician and responsible party if resident elopes. Review of the Narrative Nurses notes for Resident #1 dated 01/19/2024 timestamped 06:25 documented: Administrator spoke to the family member when she returned the call, Administrator informed the family about patient elopement and give the family the report of actual situation. 1900 During initial rounds, resident was seen walking around the hallway and was redirected to her room. Resident was found walking in the hallway again and said, I want to go home. Medications due were given to the resident and resident was placed in bed. All safety measures were in place. At 2300 while passing by the laundry area, nurse noticed the resident was getting her hair groomed by a Certified Nursing Assistant (CNAs). At 0000 observed resident being put to bed by her CNAs and stayed in the room with her to make sure she stayed in bed. At 0030 Resident was observed walking out of her room towards the nursing station. Initiated and placed resident in a chair to sit in the nurse's station. At 1:19 AM observed the resident standing in front of nurses' station counter and redirected to her to her room. At 1:22 AM observed resident walking in the hallway while doing routine check and redirected back to her room. At 2:40 AM while making routine rounds, alarm heard, resident was found missing from assigned room. Initiated elopement protocol, code green initiated. At 3:25 AM police .notified about the resident missing. Assistant Director of Nursing (ADON) was notified, message left for family member, medical doctor was notified. The National Weather Service (www.weather.gov) Climate Data for the Miami area on January 19, 2024, ranged from temperatures of 69 degrees Fahrenheit (F) to 77 degrees F. Interview on 01/30/2024 at 10:00 AM Administrator (NHA), Risk Manager, Quality Assurance (QA), stated: I received a call at approximately 3:00 AM to 3:30 AM on 1/19/2024, I was out of town, I got report that there was a missing person at the facility, immediately I got in the car and was on my way to facility, When I got to the facility the corporate response team were already there. I called the police, [Local State Agency] and made the report on my way to the facility. [Local State Agency] accepted the case, I submitted the immediate report to Agency for Health Care Administration (AHCA), when I arrived at the facility the corporate team and other Administration personnel were at the facility investigating the elopement. The investigation was ongoing with the corporate team. I participated in QA with the department heads, I reached out to the resident's family members, the resident's niece let us know that she missed out on the calls from the facility earlier, the resident's niece stated the resident's responsible party on file was currently in a nursing home and is hard to reach. I was placed on leave/suspension on 1/19/2024 by the corporate team while the investigation continued. I was reinstated on Friday afternoon 1/26/2024. The AHCA five (5) day report indicated the elopement was attributed to the lack of supervision by the two (2) nurses- one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA), they were all placed on suspension on 1/19/2024. The resident is still missing at this time, we immediately got to work on the response plan. The findings were as stated in the AHCA 5-day report, it was substantiated. The [wander management] alarm bracelet red light never came on but the door with the egress alarm did go off. Interview on 1/30/2024 at 10:15 AM The Regional Clinical Director (RCD) stated: Based on the footage from the camera, it appears that the resident did not have a [wander management] alarm bracelet on, the red light did not go off as it should when a resident with a [wander management] alarm bracelet gets near the exit door. The egress door alarm did go off. Clinical and non-clinical staff and agency staff were educated on elopement, and abuse and neglect and this would include ongoing education with new hires. The nurses and CNA involved in the resident's elopement were terminated and reported to the board of nursing. Interview on 1/30/2024 at 10:36 AM Licensed Practical Nurse (LPN) (Staff A) via telephone stated: I was working on the 11 to 7 AM shift on 1/19/2024, all I remember is that I was sitting at the desk doing skin assessments checks, the resident was sitting with me, she got up and walked to the side. At 1900 I clocked in and made rounds, the 30 residents were accounted for, awake and alert, I accepted Medication Cart #2 keys, counted narcotics and started with med pass, around 11:30 PM ,I stopped to eat, at 12:00 AM I started charting sitting at the desk, at this time resident was at nursing station with me, resident got up and walked around the south side of the nurses station, between 1:45 AM the call light went off in room [ROOM NUMBER] bed C, I went to assess the resident, when I returned to the nurse's station I saw the light at the back door blinking, I realized that someone had opened or touched the door, I went to the door. I never heard an alarm go off, I just saw the red-light blinking, I went to check the resident's room, the resident was not in the room, I alerted everyone, and a code green was called, I went to the resident's room because she was the only resident that was up at that time by the nurses' station. I took my truck and went around the facility looking for the resident. Sometimes the resident would be up at night at the nurse's station, I do not recall if the resident had on an [wander management] Alarm bracelet. I then ran into the police officer and brought the officer back to the facility to take a profile of the resident we were looking for. I was not the nurse assigned to the resident. I was suspended from the facility on 1/19/2024 and I ended up resigning on 1/23/2024. Interview on 1/30/24 at 11:03 AM Registered Nurse (RN) (Staff B) via telephone stated: On 1/19/2024, the staff realized that the resident was missing, we started a search, I called the ADON (Assistant Director of Nursing to let administration know what was going on. I was the RN in the building that night, I was assigned to the South Wing. [Staff C, LPN] was assigned to the resident. Interview on 1/30/2024 at 11:07 AM Staff C, LPN via telephone stated: I am busy at the moment, call back in 5 hours.Another surveyor on the team called Staff C back at the designated time and did not receive any response. Interview on 1/30/2024 at 11:09 AM CNA (Staff D) via telephone stated: I started to work at 11:00 PM on 1/18/2024, I did my rounds, I did not see the resident in her room, I called Staff C and told her, the resident was not in her room, the nurse said the resident was at the nurses' station. I went to get linen to start doing my job, I saw the resident in the hallway, I took her by the hand and led her into her room and had her sit on the bed. Everyday this resident walks around. The nurses [Staff A and Staff C] were at the nursing station. Around 2:30 AM I made my rounds, I did not see the resident in her room, I called the nurse and told her I could not find the resident, I checked all the rooms and the shower rooms, I checked outside and did not find the resident. Staff D ended the interview and hung up the phone. Interview on 1/30/2024 at 11:40 AM Regional Director of Operations (RDO) showed surveyors a video dated 1/19/2024 via the computer that lasted approximately 3 to 4 minutes (time stamped 1:31 AM to 1:34 AM) in duration, depicting Resident #1 walking back and forth in the hallway on the north wing/unit and eventually exiting through the door leading to the unfenced/open courtyard. The video also shows a nurse sitting at the nurse's station on the north wing/unit. The RDO stated: According to our investigation and interviews with the nurses, the resident was not wearing an [wander management] alarm bracelet. Interview on 1/31/2024 at 7:36 AM the NHA stated: According to the footage the resident left the facility around 1:33 AM, based on the staff account the search for the resident started at 2:30 AM. Interview on 1/31/2024 at 7:39 AM the Regional Clinical Director (RCD) stated: I interviewed all the staff before the shift was over, I interviewed [Staff A], she stated she was in the resident's room, I was busy doing resident care, no mention of what resident she was taking care of, we let the nurses know (Staff A and Staff C) we reviewed the camera footage and showed [Staff A] the camera footage. [Staff A] acknowledged she was sitting at the desk, stated she did hear an alarm .thought it was a call light or a resident who I know that really does not need anything. We asked her if she heard the alarm, [Staff A] replied, yes I heard the alarm. The video showed that [Staff A] did not get up from the nurses' station when the alarm went off. The RCD stated: In the immediate report the information about [Staff A] responding to the South Egress note is a typo by the NHA, he was driving from [NAME] in his car and doing the report at the time. On 12/20/2023 the [wander management] alarm bracelet was checked specifically for this resident. [Staff As stated] she heard the alarm go off, thought it was a call light. Staff in the facility responded to the alarm at 2:30AM. According to the orders the maintenance Director checks the [wander management] Alarm bracelet monthly, the last audit for the resident's [wander management] Alarm bracelet was completed on 12/20/2023. According to the video the alarm started going off at 1:33 AM and staff responded at 2:30 AM. Three staff members got into their cars and went in opposite directions searching for the resident for approximately 30 minutes. The alarm was turned off by the Maintenance Director at approximately 4:00 AM on 1/19/2024. No one on the staff on the morning of 1/19/2024 had a code to turn off the alarm. The resident was being closely monitored at the nurse's station from the night of 1/18/2024 into the morning of 1/19/2024. The resident's room is right next to the nursing station, and she was monitored frequently. Interview on 1/31/2023 at 7:57AM, the Maintenance Director stated: I was checking the [wander management] Alarm bracelet weekly before the incident and currently they are checked daily every shift. I check the alarm using the [wander management] alarm bracelet tag remote hand-held device by setting off the alarms at each exit door. I test the [wander management] alarm bracelet to see if the [wander management] alarm bracelet is active and if the battery is low and I check the resident's [wander management] alarm bracelets against the exit doors. On 12/20/2023 the resident's [wander management] alarm bracelet was checked, and it was functioning according to the audit received from the facility. Interview on 1/31/2024 at 9:41AM; the Assistant Director of Nursing (ADON) stated: I was contacted at 3:30AM on 1/19/2024, by Registered Nurse [Staff B] who stated that [Resident #1] is missing, and the staff have searched all over the building and outside of the facility and they did not find the resident. She then stated that they called the police around 3:20 AM and the police told them that there was a lady that was hit by a train near the facility .I cannot remember hearing the alarm going off when I was on the phone with [Staff B]. I know the nurse was on the south wing when she was speaking to me on the phone [Staff B] attempted to contact other administrative personnel, I was the first person to answer, after speaking with the nurse, I called the NHA and corporate personnel who answered. When I came to the facility around 6:00 AM, there were two police officers at the facility and they wanted to see all the exit doors, I had the maintenance director show the police officers all the exit doors, The Director of Nursing (DON) and myself drove around the facility looking for the resident. The road was blocked off by the railroad tracks close to the facility, we saw the cops there, they told us that an older female was hit by the train, and she did not have any identifiable information on her. I believe the cops said the person passed away and was sent to Medical Examiner's office and they were awaiting confirmation on the identification of the person who was killed. We have not received any information as to who was hit by the train and killed on 1/19/2024. Interview on 2/1/2024 at 8:07AM Maintenance Director stated: The exit/egress door alarms are monitored weekly by activating the door-pushing up against the door, waiting for the 15 second door opening delay, making sure the alarm sounds once the door is opened, the maglock ensures the 15 second delay before the door opens, once someone tries to open the door. I then open the door, close the door, then reset the alarm, and make sure that the door is locked. The screamers, which are the red boxes located on the inside on the top of the door were installed on 1/19/2024, they are battery operated. A key is needed to turn the screamers off once the door is opened after the 15 second delay. The [wander management] alarm bracelet monitors are all installed close to the exit doors and are checked for proper functioning. Interview on 2/1/2024 at 1:16 PM the Director of Nursing (DON) stated: As of 1/27/2024 we have two residents on elopement risk, we had an additional resident on elopement risk that went to the hospital on 1/27/2024. The two residents currently on elopement risk have orders for [wander management] alarm bracelets, the residents' names and pictures are in the elopement book, their rooms are located close to the North Wing nurses' station. We have 1 elopement book at each nursing station (North and South), one at the reception desk at the entrance of the building and one in the therapy room. The nursing staff are instructed to check placement every shift and functionality daily. For functionality nurses have to physically take the resident close to an exit door and make sure that the [wander management] alarm bracelet is active, this new order was placed into practice starting 1/19/2024. The two residents that are currently on elopement risk are confused residents, they may have periods of clear cognition, [Resident #2] ambulates with a slow gate sometimes, [Resident #3] is always in her wheelchair. [Resident #1] had a [wander management] in place, the 7:00 AM to 7:00 PM north wing nurse on 1/18/2024 was interviewed and stated the resident had a [wander management] alarm bracelet on during her shift, the 7:00 PM to 7:00 AM nurse (Staff C) stated that the resident did not have a [wander management] alarm bracelet, but she signed at the beginning of the shift that the resident did have a [wander management] alarm bracelet on. In the interview later on 1/19/2024 [Staff C] stated that the resident did not have an [wander management] Alarm bracelet. The DON stated we always had the elopement risk book in the 4 locations mentioned. When I started working here in March 2023 the elopement books were in place already. [Resident #1] was on the elopement risk list in the book. We have a facility educator (ADON) who conducts education and training and in addition a corporate educator, NHA, DON, ADON, and supervisors are the master drill persons in charge during the elopement drills at the facility that is done every shift (3 shifts) starting 1/19/2024. The scope and severity of F607 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 02/01/2024. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 02/01/2024. These corrective actions were verified by the survey team through observation, record review and interview on 01/30/2024 to 02/01/2024. The facility's immediate jeopardy removal plan included: The staff (128 persons) at 100% were in-serviced/trained on 1/19/2024 to1/29/24, regarding: how to respond to call lights promptly, elopement drills, codes, and emergencies responses, how to respond to door alarms, competency for elopement training, how to deal with patients that have behaviors, behavior management for exit seeking resident, abuse, neglect and exploitation training, accidents, and hazards and the QAPI process with the administrative team. The facility conducted a thorough inspection of all eight (8) exit doors and their existing alarm systems to make sure they are in working order in the facility, each exit door has an [wander management] alarm, a screamer alarm (Installed 1/19/2024) and an egress maglock (magnetic lock) alarm with a 15 second opening delay. The alarm systems are audible and can be heard at their loudest in the area where it goes off and is reasonably audible throughout the facility. Nurses are assigned to check residents with [wander management] alarm bracelets at least once per shift for placement and functionality. The Elopement Risk Book was revised on 01/28/2024, contains-List of Residents, Guidelines for elopement /Unsafe Wandering Prevention, Facility Floor Plan, Pictures of Residents for elopement, Face sheets, Elopement Drill Schedule, and Elopement Mock Drills protocol. A 6-foot fence was installed to the north courtyard to ensure that residents are not able to exit to the neighborhood and busy streets from the facility's courtyard on the north wing. Maintenance staff or their qualified designees, conduct weekly door audits to ensure all doors are in proper working order, including checking that the alarm is audible at the nursing station and care areas. An audit of all residents who reside in the facility was conducted to evaluate the risk for leaving the facility without informing staff and/or if they may desire to leave the facility. Additional Audits-Dated 1/19/2024 to 1/27/2024; Elopement Drill Audit, Dated 1/20/2024 to/128/2024; [wander management] alarm bracelet Audit, Dated 1/21/2024 to1/26/2024; Daily Door Audits (all shifts), Dated 1/21/2024 to 1/27/2024; Elopement Drill/Actual Event Evaluation, Dated 1/28/2024; Facility Search Grid. On 02/01/2024 at 8:18 AM during an observation, inspection and walk through with the facility's Maintenance Director, the eight (8) exit doors in the facility were inspected and opened to make sure the [wander management] alarm bracelet, screamers and door alarms were in working order. When pushed open all 8 exit door alarms went off (alarmed) before and after the 15 second door opening delay, the alarms were loud/audible in the immediate area and could be heard throughout the facility. All 8 exit doors were equipped with screamer alarms, egress maglock door alarms and [wander management] alarm bracelet monitors that were tested and were all in working order. A 6-foot fence was installed around the courtyard in the north wing unit. These corrective actions were verified by the survey team through observation, record review and interview on 01/30/2024 to 02/01/2024.

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 1:34 AM on 01/19/2024, undetected. The facility's system failure, lack of adequate supervision and failure in ensuring an adequate and effective alert monitoring system was in place, allowed the resident to elope undetected. The resident has not been located as of 02/01/2024. The findings included: Record review of the facility's policy titled Wandering and Elopements revision date March 2019 documented: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1 If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2 If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the resident from leaving in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. 3 If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e. emergency management, rescue squads, etc.) 4 When the resident returns to the facility, the director of nursing services or charge nurse shall: a. Examine the resident for injuries. b. contacts the attending physician and report findings and conditions of the resident. c. notifies the resident's legal representative (sponsor) d. notify search teams that the resident has been located. e. complete and file an incident report; and f. document relevant information in the resident's medical record Review of the facility's policy titled Accidents and Incidents-Investigating and Reporting revision date July 2017 documented: All accidents or incidents involving residents, employees, visitors, vendors etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1 The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of the facility's policy titled Safety and Supervision of Residents revision date July 2017 states: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Alzheimer disease, Dementia, and seizures. Review of the Physician's Orders Sheet for January 2024 revealed Resident #1 had orders that included but not limited to: 8/24/2022- Apply/maintain [wander management] Alarm bracelet to right wrist. Check for placement and functioning every shift. Report any issues immediately to the supervisor. Record review of the Electronic Medication Administration Record (EMAR) for 1/1/2024 to 1/18/2024 revealed Resident #1 was checked off on the EMAR that the resident had the [wander management alarm bracelet] on by assigned nurses. Record review of Resident #1 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Pattern documented Brief Interview for Mental Status (BIMS) score of 5 on a 0-15 scale indicating the resident is cognitively impaired. Section E for behaviors documented Resident experiences Delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident wandered 1 to 3 days. Section GG for Functional abilities documented no impairment of upper and lower extremity, no mobility devices used, supervision for sitting to standing position, chair to bed transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Partial assistance for walking 50 feet and substantial assistance for walking 150 feet. Section P for restraints documented wander elopement alarm used daily. Review of the Elopement Risk Assessment/Evaluation dated 3/23/2023 and 06/29/2023 documented: Score of 0-9. LOW RISK for elopement. No interventions at this time. Record review of Resident #1's most recent Psychological consult dated 2/2021 documented: Resident appears calm, cooperative, in no apparent distress at this time. Record review of Resident #1's Elopement Care Plans Reference Dated 04/12/2021 revealed: Resident has a potential for elopement due to: has cognitive impairment, has periods of increased confusion, is exit seeking, is (I) ambulatory, wanders the unit & wanders near exit doors, has a history of elopement. 01/19/2024 elopement. Interventions Include: Educate resident/responsible party regarding sign out procedures as needed. Perform frequent observations of resident's whereabouts every shift. Provide redirection when observed going towards exit doors. Encourage resident to participate in activities of choice; provide 1:1s as needed. Apply [wander management alarm bracelet] as ordered (R) wrist. Verify placement every shift. Check for proper functioning weekly. Include resident in Elopement Book and Update physician and responsible party if resident elopes. Review of the Narrative Nurses notes for Resident #1 dated 01/19/2024 timestamped 06:25 documented: Administrator spoke to the family member when she returned the call, Administrator informed the family about patient elopement and give the family the report of actual situation. 1900 During initial rounds, resident was seen walking around the hallway and was redirected to her room. Resident was found walking in the hallway again and said, I want to go home. Medications due were given to the resident and resident was placed in bed. All safety measures were in place. At 2300 while passing by the laundry area, nurse noticed the resident was getting her hair groomed by a Certified Nursing Assistant (CNA). At 0000 observed resident being put to bed by her CNA and stayed in the room with her to make sure she stayed in bed. At 0030 Resident was observed walking out of her room towards the nursing station. Initiated and placed resident in a chair to sit in the nurses' station. At 1:19 AM observed the resident standing in front of nurses' station counter and redirected to her to her room. At 1:22 AM observed resident walking in the hallway while doing routine check and redirected back to her room. At 2:40 AM while making routine rounds, alarm heard, resident was found missing from assigned room. Initiated elopement protocol, code green initiated. At 3:25 AM police .notified about the resident missing. Assistant Director of Nursing (ADON) was notified, message left for family member, medical doctor was notified. The National Weather Service Climate Data for the Miami area January 19, 2024, ranged from temperatures of 69 degrees Fahrenheit (F) to 77 degrees F (http://www.weather.gov/). During an interview on 01/30/2024 at 10:00 AM, the Administrator (NHA), Risk Manager, Quality Assurance (QA), stated: I received a call at approximately 3:00 to 3:30 AM on 1/19/2024, I was out of town, I got report that there was a missing person at the facility, immediately I got in the car and was on my way to facility, When I got to the facility the corporate response team were already there. I called the police, [State Agency] and made the report on my way to the facility. [State Agency] accepted the case, I submitted the immediate report to AHCA (Agency for Healthcare Administration), when I arrived at the facility the corporate team and other administration personnel were at the facility investigating the elopement. The investigation was ongoing with the corporate team. I participated in QA with the department heads. I reached out to the resident's family members, the resident's niece let us know that she missed out on the calls from the facility earlier, the resident's niece stated the resident's responsible party on file was currently in a nursing home and is hard to reach. I was placed on leave/suspension on 1/19/2024 by the corporate team while the investigation continued. I was reinstated on Friday afternoon 1/26/2024. The AHCA five (5) day report indicated the elopement was attributed to the lack of supervision by the two (2) nurses- one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA), they were all places on suspension on 1/19/2024. The resident is still missing at this time, we immediately got to work on the response plan. The findings were as stated in the AHCA 5-day report, it was substantiated. The [wander management] alarm bracelet red light never came on but the door with the egress alarm did go off. Interview on 1/30/2024 at 10:15 AM, the Regional Clinical Director (RCD) stated: Based on the footage from the camera, it appears that the resident did not have an [wander management] alarm bracelet on, the red light did not go off as it should when a resident with a [wander management alarm bracelet] gets near the exit door. The egress door alarm did go off. Clinical and non-clinical staff and agency staff were educated on elopement, and abuse and neglect and this would include ongoing education with new hires. The nurses and CNA involved in the resident's elopement were terminated and reported to the board of nursing. Interview on 1/30/24 at 10:36 AM LPN, Staff A via telephone stated: I was working on the 11:00 to 7:00 AM shift on 1/19/2024, all I remember is that I was sitting at the desk doing skin assessments checks, the resident was sitting with me, she got up and walked to the side. At 1900 I clocked in and made rounds, the 30 residents were accounted for, awake and alert. I accepted Medication Cart #2 keys, counted narcotics, and started with med pass, around 11:30 PM, I stopped to eat, at 12:00 AM I started charting sitting at the desk, at this time the resident was at nursing station with me. The resident got up and walked around the south side of the nurses station, between 1:45 AM the call light went off in room [ROOM NUMBER] bed C, I went to assess the resident, when I returned to the nurses' station I saw the light at the back door blinking, I realized that someone had opened or touched the door, I went to the door. I never heard an alarm go off, I just saw the red-light blinking, I went to check the resident's room, the resident was not in the room, I alerted everyone, and a code green was called, I went to the resident's room because she was the only resident that was up at that time by the nurses' station. I took my truck and went around the facility looking for the resident. Sometimes the resident would be up at night at the nurse's station, I do not recall if the resident had on a [ wander management] alarm bracelet. I then ran into the police officer and brought the officer back to the facility to take a profile of the resident we were looking for. I was not the nurse assigned to the resident. I was suspended from the facility on 1/19/2024 and I ended up resigning on 1/23/2024. Interview on 1/30/2024 at 11:03 AM, Registered Nurse (RN) (Staff B) via telephone stated: On 1/19/2024, the staff realized that the resident was missing, we started a search, I called the Assistant Director of Nursing (ADON) to let administration know what was going on. I was the RN in the building that night, I was assigned to the South Wing. [Staff C, LPN] was assigned to the resident. Interview on 1/30/2024 at 11:07 AM Licensed Practical Nurse (LPN) (Staff C) via telephone stated: I am busy at the moment, call back in 5 hours. Another surveyor on the team called Staff C back at the designated time and did not receive any response. Interview on 1/30/2024 at 11:09 AM Staff D, via telephone stated: I started to work at 11:00 PM on 1/18/2024, I did my rounds, I did not see the resident in her room, I called [Staff C] and told her, the resident was not in her room, the nurse said the resident was at the nurses' station. I went to get linen to start doing my job, I saw the resident in the hallway, I took her by the hand and led her into her room and had her sit on the bed. Everyday this resident walks around. The nurses [Staff A and Staff C] were at the nursing station. Around 2:30 AM I made my rounds, I did not see the resident in her room, I called the nurse and told her I could not find the resident, I checked all the rooms and the shower rooms, I checked outside and did not find the resident. Staff D then ended the interview and hung up the phone. Interview on 1/30/2024 at 11:40 AM, the Regional Director of Operations (RDO) showed surveyors a video dated 01/19/2024 time stamped from 1:31 AM to 1:34 AM via the computer, depicting the resident walking back and forth in the hallway for approximately 3 to 4 minutes in duration on the north wing/unit and eventually exiting through the door leading to the unfenced/open courtyard. The video also shows a nurse sitting at the nurse's station on the north wing/unit. RDO stated according to our investigation and interviews with the nurses, the resident was not wearing an [wander management] alarm bracelet. Interview on 1/31/2024 at 7:36 AM the NHA stated: According to the footage the resident left the facility around 1:33 AM, based on the staff account the search for the resident started at 2:30 AM. Interview on 1/31/2024 at 7:39 AM the Regional Clinical Director (RCD) stated: I interviewed all the staff before the shift was over, I interviewed [Staff A], she stated she was in the resident's room, I was busy doing resident care, no mention of what resident she was taking care of, we let the nurses know (Staff A and Staff C) we reviewed the camera footage and showed [Staff A] the camera footage. [Staff A] acknowledged she was sitting at the desk, stated she did hear an alarm, I thought it was a call light or a resident who I know that really does not need anything. We asked her if she heard the alarm, [Staff A] replied, yes I heard the alarm. The video showed that [Staff A] did not get up from the nurse's station when the alarm went off. The RCD stated in the immediate report the information about Staff A responding to the South Egress note is a typo by the NHA, he was driving from [NAME] in his car and doing the report at the time .When I interview the day shift nurse stated the [wander management alarm bracelet] was off. [Staff A] stated she heard the alarm go off, thought it was a call light. Staff in the facility responded to the alarm at 2:30 AM. According to the orders the maintenance Director checks the [wander management alarm] monthly, the last audit for the resident's [wander management alarm] was completed on 12/20/2023. According to the video the alarm started going off at 1:33 AM but staff responded at 2:30 AM. Three staff members got into their cars and went in opposite directions searching for the resident for approximately 30 minutes. The alarm was turned off by the Maintenance Director at approximately 4:00 AM on 1/19/2024. None on the staff on the morning of 1/19/2024 had a code to turn off the alarm. The resident was being closely monitored at the nurse's station from the night of 1/18/23 into the morning of 1/19/2023. The resident's room is right next to the nursing station, and she was monitored frequently. Interview on 1/31/2023 at 7:57 AM, the Maintenance Director stated: I was checking the [wander management alarm] weekly before the incident and currently they are checked daily every shift. I check the alarm using the [wander management alarm bracelet] .by setting off the alarms at each exit door. I test the [wander management alarm] to see if the [ wander management alarm bracelet]is active and if the battery is low and I check the resident's [wander management] Alarm bracelets against the exit doors. On 12/20/23 the resident's [wander management] alarm bracelet, and it was functioning according to the audit received from the facility. Interview on 1/31/2024 at 9:41 AM, the Assistant Director of Nursing (ADON) stated: I was contacted at 3:30 AM on 1/19/2024, by Registered Nurse (Staff B) who stated that [Resident #1] is missing, and the staff have searched all over the building and outside of the facility and they did not find the resident. She then stated that they called the police around 3:20 AM and the police told them that there was a lady that was hit by a train near the facility. I cannot remember hearing the alarm going off when I was on the phone with Staff B. I know the nurse was on the south wing when she was speaking to me on the phone. Staff B attempted to contact other administrative personnel, I was the first person to answer, after speaking with the nurse, I called the NHA and corporate personnel who answered. When I came to the facility around 6:00 AM, there were two police officers at the facility and they wanted to see all the exit doors, I had the maintenance director show the police officers all the exit doors. The Director of Nursing (DON) and myself drove around the facility looking for the resident. The road was blocked off by the railroad tracks close to the facility, we saw the cops there, they told us that an older female was hit by the train, and she did not have any identifiable information on her. I believe the cops said the person passed away and was sent to Medical Examiner's office and they were awaiting confirmation on the identification of the person who was killed. We have not received any information as to who was hit by the train and killed on 1/19/2024. Interview on 2/1/2024 at 8:07 AM, the Maintenance Director stated: The exit/egress door alarms are monitored weekly by activating the door-pushing up against the door, waiting for the 15 second door opening delay, making sure the alarm sounds once the door is opened, the maglock ensures the 15 second delay before the door opens, once someone tries to open the door. I then open the door, close the door, then reset the alarm, and make sure that the door is locked. The screamers, which are the red boxes located on the inside on the top of the door were installed on 1/19/2024, they are battery operated. A key is needed to turn the screamers off once the door is opened after the 15 second delay. The [wander management alarm] monitors are all installed close to the exit doors and are checked for proper functioning. During an interview on 2/1/2024, at 1:16 PM the Director of Nursing (DON) stated: As of 1/27/2024 we have two residents on elopement risk, we had an additional resident on elopement risk that went to the hospital on 1/27/2024. The two residents currently on elopement risk have orders for [wander management bracelets], the residents' names and pictures are in the elopement book, their rooms are located close to the North Wing nurses' station. We have 1 elopement book at each nursing station (North and South), one at the reception desk at the entrance of the building and one in the therapy room. The nursing staff are instructed to check placement every shift and functionality daily. For functionality nurses have to physically take the resident close to an exit door and make sure that the [wander management bracelet] is active, this new order was placed into practice starting 1/19/2024. The two residents that are currently on elopement risk are confused residents, they may have periods of clear cognition, [Resident #2] ambulates with a slow gate sometimes, [Resident #3] is always in her wheelchair. [Resident #1] had [wander management bracelet] in place, the 7:00 AM to 7:00 PM north wing nurse on 1/18/2024 were interviewed and stated the resident had a [wander management bracelet] on during her shift, the 7:00 PM to 7:00 AM nurse [Staff C] stated that the resident did not have a [wander management alarm bracelet], but she signed at the beginning of the shift that the resident did have a [wander management bracelet] on. In the interview later on 1/19/2024 [Staff C] stated that the resident did not have a [wander management bracelet]. We always had the elopement risk book in the 4 locations mentioned. When I started working here in March 2023 the elopement books were in place already. [Resident #1] was on the elopement risk list in the book. We have a facility educator [ADON] who conducts education and training and in addition a corporate educator. NHA, DON, ADON, and supervisors are the master drill persons in charge during the elopement drills at the facility that is done every shift (3 shifts) starting 1/19/2024. The scope and severity of F689 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 02/01/2024. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 02/01/2024. These corrective actions were verified by the survey team through observation, record review and interview on 01/30/2024 to 02/01/2024. The facility's immediate jeopardy removal plan included: The staff (128 persons) at 100% were in-serviced/trained from 1/19/2024 to 1/29/2024, regarding: how to respond to call lights promptly, elopement drills, codes, and emergencies responses, how to respond to door alarms, competency for elopement training, how to deal with patients that have behaviors, behavior management for exit seeking resident, abuse, neglect and exploitation training, accidents, and hazards and the QAPI process with the administrative team. The facility conducted a thorough inspection of all eight (8) exit doors and their existing alarm systems to make sure they are in working order in the facility, each exit door has a [ wander management alarm], a screamer alarm installed 1/19/2024 and an egress maglock (magnetic lock) alarm with a 15 second opening delay. The alarm systems are audible and can be heard at their loudest in the area where it goes off and is reasonably audible throughout the facility. Nurses are assigned to check residents with [wander management alarm bracelets] at least once per shift for placement and functionality. The Elopement Risk Book was revised on 01/28/2024, contains-List of Residents, Guidelines for elopement /Unsafe Wandering Prevention, Facility Floor Plan, Pictures of Residents for elopement, Face sheets, Elopement Drill Schedule, and Elopement Mock Drills protocol. A 6-foot fence was installed to the north courtyard to ensure that residents are not able to exit to the neighborhood and busy streets from the facility's courtyard on the north wing. Maintenance staff or their qualified designees will conduct weekly door audits to ensure all doors are in proper working order, including checking that the alarm is audible at the nursing station and care areas. An audit of all residents who reside in the facility was conducted to evaluate residents at risk for leaving the facility without informing staff and/or if they may desire to leave the facility. Additional Audits-Dated 1/19-27/2024; Elopement Drill Audit, Dated 1/20-28/2024; [wander management alarm] Audit, Dated 1/21-26/2024; Daily Door Audits (All shifts), Dated 1/212024 to 1/27/2024; Elopement Drill/Actual Event Evaluation, Dated 1/28/2024; Facility Search Grid. On 02/01/2024 at 8:18 AM during an observation, inspection and walk through with the facility's Maintenance Director, the eight (8) exit doors in the facility were inspected and opened to make sure the [wander management alarm], screamers and door alarms were in working order. When pushed open all 8 exit door alarms went off (alarmed) before and after the 15 second door opening delay, the alarms were loud/audible in the immediate area and could be heard throughout the facility. All 8 exit doors were equipped with screamer alarms, egress maglock door alarms and [wander management] alarm bracelet monitors that were tested and were all in working order. A 6-foot fence was observed to have been installed around the courtyard in the north wing unit.

Based on record reviews, observations and interviews, the facility failed to provide appropriate supervision to prevent an elopement of one (resident#1) out of five sampled residents with wandering and exit seeking behaviors. Resident #1 eloped from the facility on 03/19/23 between 10:30 to 11:30 AM undetected. Resident #1 was found at 11:30 am four blocks away from the facility by the law enforcement. This situation resulted in immediate jeopardy. On 03/30/2023 the facility's Immediate Jeopardy Removal Plan was verified by the survey team through record review and interviews. It was determined the IJ was removed on 3/29/2023. The scope and severity was reduced to a (D), no actual harm that is not immediate jeopardy. The findings included: Record review of the facility's Elopement policy and procedures dated March 2023, the Policy Statement documents: Staff shall investigate and report all cases of missing residents. The Policy and Interpretation documents: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 4. If an employee discovers that a resident is missing from the facility, he/she shall a. Determine if the resident is out on out on an authorized leave of pass; b. If the resident was notauthorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursng Services, the residents legal representative (sponsor), the attending physician, law enforcement officials and (as necessary) volunteer agencies (i.e. Emergency Management, Rescue squads, etc.) d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. Review of the clinical records face sheet revealed, Resident #1 had an initial admitted [DATE] and discharged on [DATE] to another nursing home. The clinical diagnoses included: Hemiplegia following Cerebral Infarction affecting Right Dominant Side, Infection, and Inflammatory reaction due to other urinary stents, Other Cerebral Infarction due to Occlusion or Stenosis of Small Artery, Hematuria Unspecified, Type 2 Diabetes Mellitus with Hyperglycemia, Other Reduced Mobility, Other Lack of Coordination, Dysarthria and Anarthria following Cerebral Infarction, Difficulty in Walking, Unsteady on feet, Cognitive Communication Deficit. Review of Resident #1's Comprehensive Nursing Evaluation dated 01/09/23 revelaed: Elopement Risk Assessment - Alert and Oriented x2, History of elopement/wandering - Do not wander/has never eloped. Mobility - Total or mostly dependent in locomotion, Adjustment to facility placement - Content with placement, Elopement Risk Score - 2 - Score of 0-9. NOT AT RISK for elopement. No interventions at this time. Review of Resident #1's Minimum Data Set (MDS 3.0) Summary dated 01/16/23 revealed: Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score 10 - indicating Moderate cognitive impairment, Behavior- Not exhibited. Review of Staff B, Licensed Practicial Nurse (LPN) nurse progress note for Resident #1, dated 03/19/23 at 12:12 PM revealed, that Resident #1 is in bed, Vital Signs stable, Alert and Oriented. Denies any discomfort or distress at this time. Breakfast served and resident consumed 80% without difficulty. Resident transfers self from bed to wheelchair and propels self around the facility. AM medications given to resident, and he swallowed with no distress. At approximately 10:30 AM resident wheeled himself to the patio around the vending machine. At 11:51 AM, Facility received an outside call-in reference to resident #1 and was informed that resident was out of the facility down the street with the police. I immediately called the administrator and went to retrieve the resident. Resident returned to facility at 12:07PM, head to toe assessment performed. No injuries or distress noted. Resident voiced no problems or distress, placed on one to one and Staff B, LPN was assigned to resident. Will continue to monitor resident for changes. Review of the Baseline Care Plan of Resident #1 dated on 01/10/23 revealed, Focus: Resident does not display any sliding scale of cognitive impairment. Goal: Resident will maintain with current level of cognitive function. Intervention: Encourage resident to make decisions; assist as needed. Focus: Resident #1 has a potential for elopement due to he is able to wheel self in wheelchair and was noted to be out of the facility without notifying the facility prior. Goal: Resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Intervention: Social worker to initiate discharge planning to a more appropriate setting for the resident. Record review of Resident #1's Psychological Evaluation dated 03/20/23 reveals, Reason for referral: confused thinking, Inappropriate behavior, Anxiety, Anxious/irritable mood, Elopement. Patient [ .] reports to have 2 children with whom he has regular contact. Patient is cognitively intact oriented X3, and able to participate in and provide useful information for this initial diagnostic evaluation. Patient does have a cognitive communication deficit and/or other underlying cognitive issues at the moment. Patient was administered the screening test SLUMS (St. Louis University Mental Status Exam); he scored a 10 of 24 points. I do believe this is true representation of his abilities. His motivation was low, and his speech was slow. Patient reports difficulty adjusting to long-term stay at this facility and wants to return home. Patient reports loss of interest, feeling down, depressed, or hopeless and trouble falling asleep. Patient reports some passive death wishes. Patient reports poor communication with ex-wife. Patient would like to begin therapy while at the facility. Record review of Resident #1's Psychiatric evaluation dated 03/20/23 revealed; [AGE] years old client with multiple comorbid medical conditions and no reported history of mental illness seen for initial evaluation-capacity, continuity of care and supportive therapy. Reported, increasingly confused, leaving facility without pass over the last 24 hours. Without any resulting major incident or injuries, Patient is Alert and Oriented times 2 (AAOX2) with slurred speech and periods of confusion, experiencing challenges with self-care, and activities of daily living (ADLs). Interview on 03/28/23 at 10:45 AM with the Administrator revealed, the day of the incident happened, Resident #1 was seen at about 10:30 AM by the Staff B, Licensed Practical Nurse (LPN). Resident #1 was sitting in his wheelchair. Then Resident #1 went to the patio. Staff B/LPN received a call by 11:50 AM on 03/19/2023 from the police stating that the resident was found about 4 blocks away at 11:30 AM, across the street at another Nursing Home. Staff B/LPN went to bring the resident back to the facillity. Staff C, Certified Nursing Assistant (C N A) dropped off Staff B/LPN to bring resident #1 back to the facility. A head to toe assessment was done, and there were no apparent issues. Resident #1 was placed on one-to-one supervision and a wander guard was placed on resident #1. While checking the resident they did an immediate recount of the residents. The Administrator came to the facility at 12:03 PM on 03/19/2023, he was notified at 11:53 AM. By 12:05PM, all residents were counted, and all the exit doors were checked. The first encounter with the resident was completed, the Administrator spoke to the resident and he stated, he went to look for his wife because his television was not working. Resident #1 stated that he left the facility threw the front door. Resident #1 stated that the reason why he could go threw the front door was because nobody was in reception area. The front door was programmed to go off the timer and unlock from 9:30 AM to 7:00 PM on Sundays, when the front desk receptionist was there. When administrator interviewed the receptionist, it was reported, she came late to work because she had a flat tire. Based on the Receptionist punch card, she arrived at 10:37 AM on 03/19/2023, and she was asked whether she notified anybody about being late, she replied, No. Interview on 03/28/23 at 12:06 PM with Staff B/LPN revealed, she was working at the time of the incident on 03/19/23. Before the incident happened, she did not notice any signs of Resident #1 wanted to leave the facility, or wandering. Resident #1 was alert and oriented. She was the regular nurse attending the resident and he never showed a desire of wanting to leave. That Sunday her schedule was 7:00 AM to 7:30 PM. That day she gave the medication to Resident #1 who was in his room. Normally the was resident is in his room and on the patio. The last time that she saw Resident #1 that day was around 10:30ish. Because he came to ask her for some ice at the nurses station, because he wanted to go to the patio to have a soda. The patio is an area enclosed inside the facility. There are no doors from the patio that lead to the outside. All doors in the facility are locked with a keypad. In the case of the front door, the receptionist has a clicker to let people in and out. She stated, the day of the incident; to my knowledge the door was locked. Later that day she heard that door was not locked because the door was on a timer. The facility has a weekend receptionist sitting in the front desk during the day, supervising the ins and outs. She observed staff was there, but was not aware of the time of her arrival. She received the phone call from the receptionist who transferred the call stating that there was a nurse from the other facility asking if the facility has a resident under the name of [Resident #1's], she stated, yes, and she continued saying that she was a nurse from another nursing home, close by and that the police was in that facility with the resident. I then called the administrator, gave the residents location and I went to the location where the resident was with another Certified Nursing Assistant (CNA) , Staff C, who drove me. At the time, we did not have a supervisor onsite. The Nurse who has been working in the facility the longest would be the in-charge nurse. When I arrived at the location, I provided the police my information and I pushed the resident in the wheelchair back to the facility. The Resident was normal, and not agitated. When I asked the resident why he was on the street, he said, I just wanted to go out. When she came back the Administrator was in the facility already. A full assessment was conducted, there were no injuries, everything was normal. After that we got together, and a CNA was placed on one-to one supervision and her assignments were split with other staff. The resident did not say how he got out. The nurse stated that the receptionist did not call stating that she was going to be late arriving to the facility. She did not know who the direct supervisor of the receptionist was. Interview on 03/28/23 at 12:48 PM with Staff C/CNA revealed, she was very familiar with the resident who eloped, she was in charge of taking care of the resident. Resident #1 never indicated about wanting to leave. He just talked about wanting to go back to his house. He was a very nice quiet man. Resident #1 never wandered or looked for an exit while he was in the facility. The day of the incident, Staff C/CNA provided care to the resident, she had two residents to take care of in the room where the Resident #1 was, and she left their room at around 10:20 AM. Resident #1 sometimes managed to go to the bathroom by himself, but he needed assistance because he used to lose his balance. Resident #1 used to go outside to buy soda in the vending machine located in the patio. When she went to his room at around 11:30ish Staff C/CNA, did not see him there, and at the same time, Staff B/LPN received a call about Resident#1 being at another facility. Staff C/CNA and Staff B/LPN went to the facility in a car and Staff B/LPN stayed with the resident and brought him back from the other facility. Resident #1 could not talk too much and when asked why he was there, he stated that he just wanted to go home. On 03/30/2023 the facility's Immediate Jeopardy Removal Plan was verified by the survey team through record review and interviews. The following was verified: 1. Reviewed Resident #1's records, a head-to-toe assessment completed on 03/19/2023 after the resident came back to the facility. There was notification to the residents physician and family. 2. Reviewed the Elopement risk binder with residents' pictures and demographics in place. All residents assessed for at risk of elopement have an updated care plan in place which reflects the residents' condition. 3. Reviewed Resident #1's Elopement Risk Evaluation conducted on 03/20/2023. 4. Reviewed the head count conducted on 03/19/2023 as stated in the removal plan where it was identified the resident was not in the facility, and statement signed by NHA on 03/19/2023 where it confirmed all residents were accounted for. 5. Reviewed Egress door audits conducted on 03/19/2023 by Maintenance staff which revealed all doors were working properly. 6. Reviewed binder with pictures and demographics of residents (5) assessed at risk of elopement. 7. Reviewed the assessments, care plan and validated with interview with the charge nurse/unit manager in the Removal Plan as stated by the NHA. 8. Reviewed the Ad-Hoc Quality Assurance Performance Improvement Meeting held on 03/20/2023, resident leaving the facility, Root Cause Analysis, Interventions based on Root Cause Analysis, Charter Performance Improvement Plan. 9. Psychologist evaluation reviewed for resident #1. 10. Reviewed Resident Council meeting attendance sheet and minutes of discussion of policy on Signing Out (Out on pass) dated 03/20/2023. 11. Reviewed discharge documentation and notification to Ombudsman which revealed a safe discharge. 12. Review of photocopy of Proof of the facility sending a copy of policy and procedure of the Residents' Leave of Absence (LOA) to family and residents' representative. 13. Reviewed Education provided by the NHA and Director of Nurses (DON) to all staff from facility on 03/19/2023, 03/20/2023, 03/21/2023, 03/23/2023, 03/28/2023 and 03/29/2023. Education topics reviewed and verified staff showed understanding and knowledge of all of them. (Verified by interview) 14. Reviewed documentation completed on drills conducted by administration from 03/19/2023 to 03/23/2023. As stated during the interview conducted with the NHA those drills will be conducted weekly for all shifts and for 4 weeks, then monthly thereafter. (Newly hired employee list provided and verified attendance at the training). 15. Observation conducted during this survey visit revealed all egress doors are locked and armed. As stated in the removal plan, the facility installed a new enhanced security system at the front door which switched from automatic to always closed to ensure continuous supervision of in and out of the facility. 16. Reviewed audits conducted daily from 03/19/2023 to 03/30/2023 of all doors (lobby door and all egress doors and wander guard monitoring system). 17. Reviewed the Risk Management/Quality Assurance Process Improvement Committee AD-Hoc Meeting Minutes' attendance sheet dated 03/20/2023 and 03/29/2023. 18. Reviewed audits and attendance sheet for AD-Hoc meetings done on 03/20/2023 and 03/29/2023. 19. Reviewed Ad-Hoc meeting signings sheet with the topic discussed as stated in the plan of removal. 20. Reviewed Ad-Hoc meeting dated 03/29/2023 sign-in sheets with the topic discussed about actions to remove IJ F 689. 21. Administrator stated today they have scheduled an Ad Hoc QAPI meeting after survey exit and the plan is to continue doing until IJ removal. The scope and severity was reduced to a D.

Based on record review and interview, the facility's administration failed to use its resources effectively to ensure resident's rights were honored related to advanced directives and failed to ensure residents were free from neglect by ensuring that the facility's policy addressing advance directives was followed. These actions affected the care for one (Resident #1) out of 3 sampled residents with Do Not Resuscitate (DNR) orders. On [DATE], the supervisor Registered Nurse (RN), Staff A found Resident #1 unresponsive with no vital signs. Resident #1 had a Do Not Resuscitate (DNR) order. Staff A, RN failed to check the resident's code status and initiated Cardiopulmonary Resuscitation (CPR). The failure to honor the resident's advance directive by initiating CPR resulted in medical neglect. This situation resulted in immediate jeopardy. There were ten (10) residents residing in the facility with Do Not Resuscitate (DNR) orders. There were seventy-seven (77) residents residing in the facility at the time of the survey. Cross reference: F 578 and F 600 The findings included: Review of the job description for the job titled, Administrator revised [DATE] revealed: Purpose of Your Job Position: The primary purpose of your position is to direct the day-today functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations the govern nursing facilities to ensure that the highest degree of quality can be provided to our residents at all times. Duties and Responsibilities: Administrative Functions: -Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. -Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. -Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility. Personnel Functions: -Consult with department directors concerning the operation of their departments to assist in eliminating and correcting problem areas, and/or improvement of services. -Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards of practice. Resident Rights: -Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights are well established and maintained at all times. Review of the job description for the job titled, Director of Nursing Services revised [DATE] revealed: Purpose of Your Job Position: The primary purpose pf your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Administrative Functions: -Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. -Develop, maintain and periodically update written policies and procedures that govern the day-to-day functions of the nursing services department. Personnel Functions: -Ensure that CNA's, department personnel, and visitors follow the department's established policies and procedures at all times. -Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the resident. Staff Development -Assist in developing advance directive in-service training programs for the staff and community. Review of the facility's policy and procedure titled, Resident Rights, Dignity and Visitation Rights revised [DATE] revealed: Standard: The facility promotes the exercise of rights for each resident, including those who face barriers (communication and hearing problems and cognitive limits) in the exercise of these rights. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Guidelines include: 8. The right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Record review of the facility's policy and procedure titled, Advance Directives revised [DATE] revealed: Standard: It will be the standard of this facility that the resident has the right to request, refuse and/or discontinue treatment and to formulate an advance directive and participate in advance care planning. Advance Directives/Advance Care Planning designations will be respected in accordance with state law and facility policy. Review of the facility's policy and procedure titled, Code Blue and CPR-Florida revised [DATE] revealed: Standard: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of Cardiopulmonary Resuscitation (CPR). To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility protocol (i.e. Code Blue to room [ROOM NUMBER] times) and direct staff to bring emergency equipment cart and AED (automated external defibrillator) machine to the scene. 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the E H R (electronic health record), e-MAR or point of care kiosk. At that point provision or withholding of resuscitation efforts may begin. Review of the facility's policy and procedure titled, ANE (Abuse, Neglect and Exploitation) and Investigations revised [DATE] revealed: Neglect is the 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 Resident #1's demographic face sheet revealed he was admitted to the facility on [DATE] and he expired in the facility on [DATE]. Review of the clinical record revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Do Not Resuscitate Form revealed the DNR form was signed by Resident #1's son on [DATE] and two physicians on [DATE]. Record review of the interdisciplinary progress notes revealed a nursing entry in the Electronic Health Record (EHR) dated [DATE] that indicated the progress note was created by a Registered Nurse (Staff A) on [DATE] at 19:39:12 and was effective [DATE] at 12:15:00 revealed: Resident's family member at bedside visiting, also speaking to resident's son [name] on face time resident's son sounded very concerned and discussed my reasons for calling [hospice company name] resident appeared very sleepy and BG [Blood Glucose] checked =75 also, CNA [Certified Nursing Assistant] reports poor intake of breakfast. Nurse offered 4 ounces of med pass shake and 25% taken. Call placed to (name) Hospice to inform them of resident's decreased alertness and change in condition and waited on hold ,d+[DATE] minutes and unable to speak to a nurse, requested that they call me back ASAP (As soon as possible). Back to resident's room [room number] and family member still speaking to the resident's son on the telephone informed him that I was advised that the vital rep/nurse will call me back shortly. Assessment ongoing and vital sign BP [Blood Pressure] being assessed. Cuff placed on left upper-arm and BP did not register, found resident to be pulseless and unresponsive, call to 911 by the Front desk receptionist call code blue and north wing nurses responded, code cart to room, backboard and CPR and AED [Automated External Defibrillator] started due to unsure of DNR status. Verified DNR status as Fire-Rescue arrived on the scene and provided them with documents DNR form, face sheets with contact info, and family member [names] remains at facility she was offered comfort for her loss and emotional support by staff, she was receptive and was crying. Fire Rescue captain remained at the resident bedside as the other crew departed. Awaiting the arrival of the Police. Nurse called [Hospice company name] back to inform them that the patient had expired time stated by charge nurse is 13:30 pm informed that they will dispatch a representative to assist the family. Police officer arrived on scene and rescue captain provided him with information for the call and description of the events. Police officer provided nurse with the case number [CASE #] for the record. He contacted he doctor [name] and representative to ascertain that he would sign Death Certificate. Interview with Registered Nurse Supervisor (Staff A) via telephone on [DATE] at 2:04 PM revealed: When I came in to work on [DATE] I found out I was assigned to a unit. This resident was one of 28 residents I was assigned to care for in addition to being the supervisor on duty. He decompensated during the shift and he expired. 911 was called and hospice was also called. At the time, I was not sure what his code status was because we have patients who are on hospice who do not have DNR ordered. I was not sure of his status. It was a crazy, hectic morning with 28 patients. I initiated CPR and later found out he had a DNR. The typical protocol when a resident is found unresponsive is to assess the patient, call for rapid response, and establish the code status. In the meantime, you do what a prudent nurse would do which would include initiating CPR as necessary while calling for help. It is difficult when you are alone. I called for help and the other nurses responded. A few minutes after the other nurses arrived, someone checked his code status. Once we established he was a DNR, the CPR was discontinued. I would say the CPR continued for about five minutes. It was discontinued before 911 arrived. This resident's DNR was located behind another resident's form in the yellow DNR binder. The DNRs are in alphabetical order and we were unable to locate the DNR form initially. Once it was located the CPR was discontinued. Interview with the Director of Nursing (DON) on [DATE] at 11:57 AM revealed the incident involving Resident #1 was discovered during a routine clinical record review on [DATE]. The clinical team met on [DATE] to review the clinical records for residents who were discharged . The DON reported that while reading the chart for Resident #1 the reviewed progress note was not clear how the event happened. There was no timeline in the nurse's documentation, so we immediately called the nurse (Staff A) [DATE]. The progress note did not tell me when or if she started CPR. When I contacted her, she said she did not start CPR. I asked her to give me a statement, but she never sent the statement. I called her again that night to request the written statement with a timeline of events and she said I am not going to lie to you, I did start CPR. She refused to provide a written statement, but she reported that she did do CPR. The DON stated that Staff A was contacted on [DATE] again, I asked her for a statement with a timeline of how the event occurred. She never sent a statement, and she has not picked up the phone since [DATE]. We started an investigation and determined this incident needed to be reported as an adverse incident. The Primary Care Physician and the Medical Director were notified of the incident. We checked the record for Resident #1 and found that everything was in place. The DNR was in the binder and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This is the reason we requested that the nurse give a written timeline of the event. She refused to provide a written timeline. There was no code log completed. We do not have an exact timeline for the event, we can only go by what is in the chart. From the chart review, the event was about 12:15 PM on [DATE]. Some of the nurses will call me right away if there is a code. It is preferred that they call me. This event occurred over a weekend. I did receive a call from the nurse (Staff A) that day about three hours after the event. She reported to me that the resident had expired, and hospice and the family were here. During the call of course she reported the death. She did not report to me that she administered CPR. This was not discovered until the chart review was being conducted on [DATE]. We notified the Primary Care Physician and the Medical Director of the event on [DATE]. Interview with the Nursing Home Administrator (NHA)/Risk Manager on [DATE] at 2:23 PM revealed she serves as the Administrator and the Risk Manager. The DON is the Abuse Prevention Coordinator. The NHA stated that the incident that occurred on [DATE] should have been reported immediately to her or the DON, likely to the DON first. The NHA stated that she did not have any knowledge of the events related to CPR being initiated on Resident #1 who was a resident with a DNR order. The NHA revealed she found out on [DATE] when it was reported to her by the DON after the clinical record review was done during a daily clinical meeting where all discharges are reviewed. The clinical team includes at a minimum the DON, ADON (Assistant Director of Nursing), and MDS (Minimum Data Set) Coordinator and she does not attend the meetings. The NHA explained that the DON reported on [DATE] following the meeting that after review of the clinical record for Resident #1 it was unclear if CPR was initiated for the resident. The DON reached out to the RN (Staff A) for clarification. Once reported to me the investigation continued. We determined this to be an adverse incident because the resident's advance directive was not followed. The adverse was submitted on [DATE]. The reason this was not considered potential neglect would be because the patient was deceased , and no harm was done to the patient. At the time, the thought process was this was an adverse event, and the patient was deceased , and no further harm was done to the patient, so it was not considered neglect.

Based on record review and interview, the facility failed to honor residents' rights to Request/refuse/discontinue treatment related to advance directives for 1 (Resident #1) out of 3 residents sampled. The facility's staff initiated Cardiopulmonary Resuscitation (CPR) on Resident #1 who had a Do Not Resuscitate (DNR) order and was receiving Hospice services. On [DATE], a Registered Nurse (RN) found Resident #1 unresponsive with no vital signs and did not verify the resident's code status of DNR and initiated CPR. This situation resulted in immediate jeopardy. There were ten (10) out of the seventy-seven (77) residents residing in the facility with DNR orders at the time of the survey. Cross reference: F 600 and F 835 The findings included: Record review of the facility's policy and procedure titled, Resident Rights, Dignity and Visitation Rights revised [DATE] revealed: Standard: The facility promotes the exercise of rights for each resident, including those who face barriers (communication and hearing problems and cognitive limits) in the exercise of these rights. The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Guidelines include: 8. The right to request, refuse, and or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Review of the facility's policy and procedure titled, Advance Directives revised [DATE] revealed: Standard: It will be the standard of this facility that the resident has the right to request, refuse and/or discontinue treatment and to formulate an advance directive and participate in advance care planning. Advance Directives/Advance Care Planning designations will be respected in accordance with state law and facility policy. Review of the facility's policy and procedure titled, Code Blue and CPR-Florida revised [DATE] revealed: Standard: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of Cardiopulmonary Resuscitation (CPR). To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility protocol (i.e., Code Blue to room [ROOM NUMBER] times) and direct staff to bring emergency equipment cart and AED (automated external defibrillator) machine to the scene. 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the EHR (Electronic Health Record), E-MAR (Electronic Medication Administration Record) or point of care kiosk. At that point provision or withholding of resuscitation efforts may begin. Review of Resident #1's demographic face sheet revealed an admitted to the facility of [DATE] and he expired in the facility on [DATE]. Review of the clinical record revealed multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Do Not Resuscitate Form revealed the DNR form was signed by Resident #1's son on [DATE] and two physicians on [DATE]. Record review revealed a significant change Minimum Data Set (MDS) was completed for Resident #1 dated [DATE]. The assessment revealed, Resident #1 had a BIMS (Brief Interview for Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Section J for Prognosis indicated Resident #1 had a condition or chronic disease that may result in life expectancy of less the 6 months. Section O for Special Treatments included [CONDITION(S)] and hospice. Record review of Resident #1's care plan dated [DATE] revealed resident/resident representative has chosen to be a DNR status. Goal: Resident/resident representative wishes regarding Do Not Resuscitate status will be honored in the event of a [CONDITION(S)]. Interventions included: An advance directive can be revoked or changed if the resident/resident representative changes their mind about the medical care they want delivered. Resident has a DNR status ([DATE]). Staff to honor resident's wishes regarding advance directives/CPR status. Record review of the interdisciplinary progress notes revealed a nursing entry in the Electronic Health Record (EHR) dated [DATE] that indicated the progress note was created by a Registered Nurse (Staff A) on [DATE] at 19:39:12 and was effective [DATE] at 12:15:00 revealed: Resident's family member at bedside visiting, also speaking to resident's son [name] on face time resident's son sounded very concerned and discussed my reasons for calling [hospice company name] resident appeared very sleepy and BG [Blood Glucose] checked =75 also, CNA [Certified Nursing Assistant] reports poor intake of breakfast. Nurse offered 4 ounces of med pass shake and 25% taken. Call placed to [ company name] Hospice to inform them of resident's decreased alertness and change in condition and waited on hold ,d+[DATE] minutes and unable to speak to a nurse, requested that they call me back ASAP [As soon as possible]. Back to resident's room [room number] and family member still speaking to the resident's son on the telephone informed him that I was advised that the vital rep/nurse will call me back shortly. Assessment ongoing and vital sign BP [Blood Pressure] being assessed. Cuff placed on left upper-arm and BP did not register, found resident to be pulseless and unresponsive, call to 911 by the Front desk receptionist, call code blue and north wing nurses responded, code cart to room, backboard and CPR and AED [Automated External Defibrillator] started due to unsure of DNR status. Verified DNR status as Fire-Rescue arrived on the scene and provided them with documents DNR form, face sheets with contact info, and family member [ names] remains at facility she was offered comfort for her loss and emotional support by staff, she was receptive and was crying. Fire Rescue captain remained at the resident bedside as the other crew departed. Awaiting the arrival of the Police. Nurse called [Hospice company name] back to inform them that the patient had expired time stated by charge nurse is 13:30 pm informed that they will dispatch a representative to assist the family. Police officer arrived on scene and rescue captain provided him with information for the call and description of the events. Police officer provided nurse with the case number [CASE #] for the record. He contacted the doctor [name] and representative to ascertain that he would sign Death Certificate. Interview with Licensed Practical Nurse (Staff B) on [DATE] at 10:43 AM revealed that in the event of an emergency staff should go into the computer in the patient profile to determine the residents code status. Staff can also look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . If the system is down, we also have a binder at the nurse's station which has the DNR forms for any resident with a DNR. I was here the day (Resident #1) expired. I was assigned to work on the North Wing with another nurse (Staff D); a CNA came to the North Station to inform us of a code blue on the South Unit. I do not know if they called the code, but I did not hear it, typically they call Code Blue over the intercom. Me and the other nurse went to the resident's room. When I arrived, the Supervisor (Staff A) was doing chest compressions. She asked me take over while she was trying to place the AED. While I was taking over I asked the other nurse (Staff D) to go and check the code status. She came back right away and told me the resident had a DNR. I would say this was less than a minute because the resident's room was close to the nursing station. The code stopped and I left the room. I think they had already called 911 but they had not arrived yet. It is not standard of practice to start CPR before the code status is checked. We have had in-service training and the procedure is to always check the code status of the resident before initiating CPR. When a resident's code status changes, Social Services updates nursing and places the yellow DNR form in the binder at the station. There is a binder at both North and South stations which has all of the DNRs on file for the whole building. Interview with Licensed Practical Nurse (Staff C) on [DATE] at 12:57 PM revealed: I was in a resident's room doing wound care when I heard they had called a code blue. I grabbed a crash cart and went to the room. When I arrived they already had a crash cart in the room and had already started CPR. I am not sure which nurse was doing CPR. I went towards the South Station and I heard the Nursing Supervisor [Staff A] say she could not find the DNR papers so I told her they were right in the binder. I took the DNR binder and showed her the DNR for the resident. This occurred after CPR was initiated. The protocol here if a resident is found unresponsive, you check for breathing and pulse, then you call for help and check to see if there is a DNR available. A code blue is called over the intercom and all of the nurses respond. If I am in the room and I find a resident unresponsive I call for help to the room. I have someone check for the DNR and someone to call 911. CPR is not started until the code status is verified. Interview with Registered Nurse Supervisor (Staff A) via telephone on [DATE] at 2:04 PM revealed: When I came in to work on [DATE] I found out I was assigned to a unit. This resident was one of 28 residents I was assigned to care for in addition to being the supervisor on duty. He decompensated during the shift and he expired. 911 was called and hospice was also called. At the time, I was not sure what his code status was because we have patients who are on hospice who do not have DNR ordered. I was not sure of his status. It was a crazy, hectic morning with 28 patients. I initiated CPR and later found out he had a DNR. The typical protocol when a resident is found unresponsive is to assess the patient, call for rapid response, and establish the code status. In the meantime, you do what a prudent nurse would do which would include initiating CPR as necessary while calling for help. It is difficult when you are alone. I called for help and the other nurses responded. A few minutes after the other nurses arrived, someone checked his code status. Once we established he was a DNR, the CPR was discontinued. I would say the CPR continued for about five minutes. It was discontinued before 911 arrived. This resident's DNR was located behind another resident's form in the yellow DNR binder. The DNRs are in alphabetical order and we were unable to locate the DNR form initially. Once it was located the CPR was discontinued. Interview with Registered Nurse (Staff D) on [DATE] at 10:56 AM revealed: On [DATE] I was assigned to work on the North Wing. One of the CNAs (name unknown) came to North Wing and told me that there was a code in South Wing. Maybe they called the code, but I did not hear it. I was working on North Wing with another Nurse (Staff B). When the CNA reported the code we both went to the South Wing. We went to the resident's room and his nurse [Staff A] was doing chest compressions. She asked the other nurse [Staff B] to help and asked me to go and check the patients code status. I saw that the patient had a DNR. I do not know if the nurse checked the code status before she started the chest compressions. Once I checked the code status I informed the nurse and she stopped the CPR. I came right back to the room once I checked the computer. The CPR was stopped before rescue arrived. When a code is called we are supposed to complete a code log which is on top of the crash cart. We document the vital signs, the resident status, and a timeline of the event. Usually when there is a code called, the patients nurse will check the patient's status and then instruct the other nurses what to do. I did not see anyone fill out the code log that day. Once I told the nurse the resident had a DNR the code stopped and I went back to my unit. The crash cart was in the room, but I did not see anyone filling out the code log. Interview with the Director of Nursing (DON) on [DATE] at 11:57 AM revealed the incident involving Resident #1 was discovered during a routine clinical record review on [DATE]. The clinical team met on [DATE] to review the clinical records for residents who were discharged . The DON reported that while reading the chart for Resident #1 the reviewed progress note was not clear how the event happened. There was no timeline in the nurse's documentation, so we immediately called the nurse [Staff A] on [DATE]. The progress note did not tell me when or if she started CPR. When I contacted her, she said she did not start CPR. I asked her to give me a statement, but she never sent the statement. I called her again that night to request the written statement with a timeline of events and she said I am not going to lie to you, I did start CPR. She refused to provide a written statement, but she reported that she did do CPR. The DON stated that Staff A was contacted on [DATE] again, I asked her for a statement with a timeline of how the event occurred. She never sent a statement, and she has not picked up the phone since [DATE]. We started an investigation and determined this incident needed to be reported as an adverse incident. The Primary Care Physician and the Medical Director were notified of the incident. We checked the record for Resident #1 and found that everything was in place. The DNR was in the binder and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 11:25 AM the DON revealed: When we did the record review for this incident, we did not find a code log anywhere for this incident. This is the reason we requested that the nurse give a written timeline of the event. She refused to provide a written timeline. There was no code log completed. We do not have an exact timeline for the event, we can only go by what is in the chart. From the chart review, the event was about 12:15 PM on [DATE]. Some of the nurses will call me right away if there is a code. It is preferred that they call me. This event occurred over a weekend. I did receive a call from the nurse [Staff A] that day about three hours after the event. She reported to me that the resident had expired, and hospice and the family were here. During the call of course she reported the death. She did not report to me that she administered CPR. This was not discovered until the chart review was being conducted on [DATE]. We notified the Primary Care Physician and the Medical Director of the event on [DATE]. Interview with the Nursing Home Administrator (NHA)/Risk Manager on [DATE] at 2:23 PM revealed she serves as the Administrator and the Risk Manager. The DON is the Abuse Prevention Coordinator. The incident that occurred on [DATE] should have been reported immediately to me or the DON, likely to the DON first. I did not have any knowledge of the events when this resident with a DNR order and had CPR initiated. I found out on [DATE] after the clinical record review was done during a daily clinical meeting. All discharges are reviewed in this meeting. The clinical team includes at a minimum the DON, ADON (Assistant Director of Nursing), and MDS Coordinator. Other clinical team members are involved as indicated. I do not attend the meetings. It was reported to me by the DON on [DATE] following the meeting that after review of the clinical record for Resident #1 it was unclear if CPR was initiated for the resident. The DON reached out to the RN (Staff A) for clarification. Once reported to me the investigation continued. We determined this to be and adverse incident because the resident's advance directive was not followed. The adverse was submitted on [DATE]. The reason this was not considered potential neglect would be because the patient was deceased , and no harm was done to the patient. At the time, the thought process was this was an adverse event, and the patient was deceased , and no further harm was done to the patient, so it was not considered neglect. As the NHA my role is to oversee the facility and ensure the facility policies and procedures including Resident Right, Advanced Directive are honored, and protocols are followed. After the event we did conduct an audit to verify the code status for all residents residing in the facility and to ensure the DNR forms were on file in the DNR binders.

Based on record review and interview, the facility failed to ensure residents were free from neglect by not honoring advance directives for one (Resident #1) out of three residents sampled with a Do Not Resuscitate (DNR) order and initiated Cardiopulmonary Resuscitation (CPR) on Resident #1. Because of this deficient practice the resident likely suffered unwarranted pain during this procedure and was not afforded the right to die with dignity as his advanced directives were not honored. The failure to honor the resident's advance directive by initiating CPR resulted in medical neglect. The facility neglected to follow the procedure to verify code status prior to initiating CPR.This situation resulted in immediate jeopardy. There were ten (10) residents with DNR orders out of the seventy-seven (77) residents residing in the facility at the time of the survey. Cross reference: F 578 and F 835. The findings included: Record review revealed, on [DATE], Registered Nurse (RN) Staff A found Resident #1 unresponsive with no vital signs. Resident #1 had a Do Not Resuscitate ( DNR) order. Staff A, RN failed to check the resident's code status and initiated CPR. Review of the facility's policy and procedure titled, Code Blue and CPR-Florida revised [DATE] revealed: Standard: This facility will honor the resident/resident representative wishes regarding either the provision or withholding of Cardiopulmonary Resuscitation (CPR). To ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Guidelines: If a resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. Remain with the resident. 2. Call out for help. 3. Licensed Nurse will assume command of the scene and will direct other personnel in the effort. 4. Direct a staff member to announce the emergency per facility protocol (i.e. Code Blue to room [ROOM NUMBER] times) and direct staff to bring emergency equipment cart and AED machine to the scene. 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the E H R (electronic health record), e-MAR or point of care kiosk. At that point provision or withholding of resuscitation efforts may begin. Record review of the facility's policy and procedure titled, ANE [Abuse, Neglect and Exploitation] and Investigations revised [DATE] revealed: Neglect is the 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. Record review of the facility's abuse/neglect log revealed the incident was not reported to the state agency as neglect. An AHCA (Agency for Healthcare Administration) Federal Immediate and Five-Day Reports were not submitted by the facility. Record review of Resident #1's demographic face sheet revealed he was admitted to the facility on [DATE], hospitalized from [DATE] through [DATE], and he expired in the facility on [DATE]. Review of the clinical record revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Do Not Resuscitate Form revealed the DNR form was signed by Resident #1's son on [DATE] and two physicians on [DATE]. Record review of the interdisciplinary progress notes revealed a nursing entry in the Electronic Health Record (EHR) dated [DATE] that indicated the progress note was created by a Registered Nurse (Staff A) on [DATE] at 19:39:12 and a late entry for [DATE] at 12:15:00 revealed: Resident's family member at bedside visiting, also speaking to resident's son [name] on face time resident's son sounded very concerned and discussed my reasons for calling [hospice company name] resident appeared very sleepy and BG [Blood Glucose] checked =75 also, CNA [Certified Nursing Assistant] reports poor intake of breakfast. Nurse offered 4 ounces of med pass shake and 25% taken. Call placed to [name] Hospice to inform them of resident's decreased alertness and change in condition and waited on hold ,d+[DATE] minutes and unable to speak to a nurse, requested that they call me back ASAP [As soon as possible]. Back to resident's room [room number] and family member still speaking to the resident's son on the telephone informed him that I was advised that rep/nurse will call me back shortly. Assessment ongoing and vital sign BP [Blood Pressure] being assessed. Cuff placed on left upper-arm and BP did not register, found resident to be pulseless and unresponsive, call to 911 by the front desk receptionist, call code blue and north wing nurses responded, code cart to room, backboard and CPR and AED [Automated External Defibrillator] started due to unsure of DNR status. Verified DNR status as Fire-Rescue arrived on the scene and provided them with documents DNR form, face sheets with contact info. Fire Rescue captain remained at the resident bedside as the other crew departed. Awaiting the arrival of the Police. Nurse called [Hospice company name] back to inform them that the patient had expired time stated by charge nurse is 13:30 pm informed that they will dispatch a representative to assist the family. Police officer arrived on scene and rescue captain provided him with information for the call and description of the events. Police officer provided nurse with the case number [CASE #] for the record. He contacted the doctor [name] and representative to ascertain that he would sign Death Certificate. Interview with Licensed Practical Nurse (Staff B) on [DATE] at 10:43 AM revealed that in the event of an emergency staff should go into the computer in the patient profile to determine the residents code status. Staff can also look at the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . If the system is down, we also have a binder at the nurse's station which has the DNR forms for any resident with a DNR. I was here the day [Resident #1] expired. I was assigned to work on the North Wing with another nurse (Staff D); a CNA came to the North Station to inform us of a code blue on the South Unit. I do not know if they called the code, but I did not hear it, typically they call Code Blue over the intercom. Me and the other nurse went to the resident's room. When I arrived, the Supervisor [Staff A] was doing chest compressions. She asked me take over while she was trying to place the AED. While I was taking over I asked the other nurse [Staff D] to go and check the code status. She came back right away and told me the resident had a DNR. I would say this was less than a minute because the resident's room was close to the nursing station. The code stopped and I left the room. I think they had already called 911 but they had not arrived yet. It is not standard of practice to start CPR before the code status is checked. We have had in-service training and the procedure is to always check the code status of the resident before initiating CPR. When a resident's code status changes, Social Services updates nursing and places the yellow DNR form in the binder at the station. There is a binder at both North and South stations which has all of the DNR's on file for the whole building. Interview with a Licensed Practical Nurse (Staff C) on [DATE] at 12:57 PM revealed, I was in a resident's room doing wound care when I heard they had called a code blue. I grabbed a crash cart and went to the room. When I arrived they already had a crash cart in the room and had already started CPR. I am not sure which nurse was doing CPR. I went towards the South Station and I heard the Nursing Supervisor (Staff A) say she could not find the DNR papers so I told her they were right in the binder. I took the DNR binder and showed her the DNR for the resident. This occurred after CPR was initiated. The protocol here is if a resident is found unresponsive, you check for breathing and pulse, then you call for help and check to see if there is a DNR available. A code blue is called over the intercom and all of the nurses respond. If I am in the room and I find a resident unresponsive I call for help to the room. I have someone check for the DNR and someone to call 911. CPR is not started until the code status is verified. Interview with Registered Nurse Supervisor (Staff A) via telephone on [DATE] at 2:04 PM revealed: He decompensated during the shift and he expired. 911 was called and hospice was also called. At the time, I was not sure what his code status was because we have patients who are on hospice who do not have DNR ordered. I was not sure of his status. I initiated CPR and later found out he had a DNR. The typical protocol when a resident is found unresponsive is to assess the patient, call for rapid response, and establish the code status. In the meantime, you do what a prudent nurse would do which would include initiating CPR as necessary while calling for help. It is difficult when you are alone. I called for help and the other nurses responded. A few minutes after the other nurses arrived, someone checked his code status. Once we established he was a DNR, the CPR was discontinued. I would say the CPR continued for about five minutes. It was discontinued before 911 arrived. This resident's DNR was located behind another resident's form in the yellow DNR binder. The DNRs are in alphabetical order and we were unable to locate the DNR form initially. Once it was located the CPR was discontinued. Interview with Registered Nurse (Staff D) on [DATE] at 10:56 AM revealed: On [DATE] I was assigned to work on the North Wing. One of the CNAs (name unknown) came to North Wing and told me that there was a code in South Wing. I was working on North Wing with another Nurse [Staff B]. When the CNA reported the code we both went to the South Wing. We went to the resident's room and his nurse [Staff A] was doing chest compressions. She asked the other nurse [Staff B] to help and asked me to go and check the patients code status. I saw that the patient had a DNR. I do not know if the nurse checked the code status before she started the chest compressions. Once I checked the code status I informed the nurse and she stopped the CPR. I came right back to the room once I checked the computer. The CPR was stopped before rescue arrived. When a code is called we are supposed to complete a code log which is on top of the crash cart. We document the vital signs, the resident status, and a timeline of the event. Usually when there is a code called, the patients nurse will check the patient's status and then instruct the other nurses what to do. I did not see anyone fill out the code log that day. Once I told the nurse the resident had a DNR the code stopped. The crash cart was in the room, but I did not see anyone filling out the code log. On [DATE] at 11:25 AM the DON revealed: When we did the record review for this incident, we did not find a code log anywhere for this incident. This is the reason we requested that the nurse give a written timeline of the event. She refused to provide a written timeline. There was no code log completed. We do not have an exact timeline for the event, we can only go by what is in the chart. From the chart review, the event was about 12:15 PM on [DATE]. This event occurred over a weekend. I did receive a call from the nurse [Staff A] that day about three hours after the event. She reported to me that the resident had expired, and hospice and the family were here. During the call of course she reported the death. She did not report to me that she administered CPR. This was not discovered until the chart review was being conducted on [DATE]. We notified the Primary Care Physician and the Medical Director of the event on [DATE]. Interview with the Nursing Home Administrator/Risk Manager on [DATE] at 2:23 PM revealed the DON is the Abuse Prevention Coordinator. The incident that occurred on [DATE] should have been reported immediately to me or the DON, likely to the DON first. I did not have any knowledge of the events when this resident with a DNR order and had CPR initiated. I found out on [DATE] after the clinical record review was done during a daily clinical meeting. The clinical team includes at a minimum the DON, ADON (Assistant Director of Nursing), and MDS (Minimum Data Set) Coordinator. I do not attend the meetings. It was reported to me by the DON on [DATE] following the meeting that after review of the clinical record for Resident #1 it was unclear if CPR was initiated for the resident. The DON reached out to the RN [Staff A] for clarification. Once reported to me the investigation continued. We determined this to be an adverse incident because the resident's advance directive was not followed. The adverse was submitted on [DATE]. The reason this was not considered potential neglect would be because the patient was deceased , and no harm was done to the patient. At the time, the thought process was this was an adverse event, and the patient was deceased , and no further harm was done to the patient, so it was not considered neglect.

Based on observations, record reviews, and interviews the facility failed to provide adequate supervision and a secured environment for one (resident #1) out of four residents sampled for elopement. This facility's deficient practice enabled resident #1 to exit the facility undetected by staff on [DATE] at 1:48 p.m. Resident # 1 was found deceased by law enforcement in an alley near the facility. Refer F 600 & F 609 The findings included: Observation on ,[DATE]/ 2020 at 9:05 a.m. revealed there was an exit door inside the rehab gym. Upon entering the rehab gym there were two staff members, the rehab director and the corporate nurse. On ,[DATE]/ 2020 at 9:16 a.m. a tour of the rehab unit was conducted with the Administrator, Director of Nursing (DON), Vice President of Clinical Operations and Occupational Therapist (Staff A) revealed, the rehab gym's main entrance door had a keypad with a lock to enter. There was another exit door that lead to the street with a camera on both the inside and outside of the exit door that lead to the street. The door did not have an alarm and it was unlocked. The administrator stated once the staff leaves the rehab gym's area the door is locked. Before there was a lock, but during working hours the door remained unlocked and could be opened from the outside, but if there was no staff inside the rehab gym room or once staff left for the day, the door was locked. The Administrator explained that now the main door to enter the rehab gym has a keypad with a code is locked at all times. The Administrator reported that the other door inside the rehab gym that resident #1 exited through is an exit door that leads to the street (Northeast 171 street). The door had a camera inside and on the outside, it did not have an alarm, and it was unlocked. Further observation of the exit door revealed that upon exiting though this door to the outside there was a sidewalk that led to the street. On [DATE] at approximately 11:00 a.m. review of the surveillance video recorded on [DATE]th, 2020 with Administrator revealed : Staff B Occupational Therapist was observed walking inside the rehab gym towards the chart area. On [DATE] at 1:41 p.m. resident #1 was observed walking inside the rehab gym towards the exit door. On [DATE] at 1:48pm. Resident #1 was observed opening the exit door of the rehab gym, the door did not have an alarm, resident #1 was observed exiting the facility and walking towards the street closest to the exit door of the rehab gym. The administrator stated resident #1 was found deceased by law enforcement at approximately 5:00 p.m. Review of clinical records face sheet revealed, resident #1 had an initial admission date of [DATE] and was readmitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of resident #1's quarterly Minimum Data Set ((MDS) dated [DATE], revealed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7 out 15 indicating severe cognitive impairment. Section E - Behavior item for Wandering-Presence & Frequency: Has the resident wandered ? coded 1= Behavior of this type occurred 1 to 3 days. Review of care plan for resident #1 dated [DATE] with revision date of [DATE] revealed the resident was an elopement risk/wanderer history of attempts to leave facility unattended, impaired safety awareness, wanders aimlessly. Goals: resident will not leave facility unattended through the next review date . Interventions: Check for proper functioning of the audible alarm system regularly . On [DATE] at 11:41 a.m. the Administrator revealed that, at the time resident#1 went inside the rehab gym area, there was only one staff member in the rehab gym. The staff that was inside the rehab gym stated that she did not hear the door, or if someone entered the room and that she was documenting in the chart. The Administrator reported that at approximately 5:30 p.m. the police came to the facility to ask if someone was missing and to let the facility know that the resident had been found and the body was still in the alley in front of the facility. The administrator revealed that rounds were supposed to be done every two hours to check on the residents and make sure everything was fine before this incident happened. The administrator was unable to provide information that confirmed staff completed rounds. The administrator stated that she needed to check if staff did the rounds, because the rounds were supposed to be done by the nurse or the Certified Nursing Assistant. Interview with Staff E Certified Nursing Assistant (CNA) on [DATE] at 2:14 p.m. revealed Staff E worked from 3:00 p.m. to 11:00 p.m. on day of the incident. Staff E reported that at 4:30 p.m. she was assigned and extra room the assigned room was resident #1's room. Staff E stated they gave me the room at 4:30 p.m. I checked the room and did not see the patient, I went immediately to tell the nurse, the nurse told me go look for him, I went to the north wing to get him by the time I finished I saw the nurse talking to the police outside. Staff E explained that when the DON came she reported what happened. Staff E explained that resident #1 was a little confused and usually walked around the facility getting snacks and going into other residents' rooms and staff would redirect the resident by telling him to go back to his room. Staff E stated conducted rounds every 30 minutes and sometimes the residents called. Interview with staff F Licensed Practical Nurse (LPN) on [DATE] at 2:53 p.m. revealed she was familiar with resident #1. On the day resident #1 eloped she worked 7:00 a.m. to 3:00 p.m. and resident #1 was assigned to her for care. Staff F reported that she saw resident #1 in the facility walking around and eating during her shift. Staff E stated that resident # 1 was in the building when she left and that she gave the resident his morning medications. Staff E stated that she was not sure if resident #1 was due afternoon medications because she did not have the Medication Administration Record [REDACTED]. Staff F reported that resident #1 walked around inside the building and used to watch TV in the activity room and she was not sure if resident #1 he would walk to the rehab gym. Staff F reported, that she was called by the Social Worker after she went home asking when the last time was she saw resident #1 . She found out that resident #1 was missing the next morning when it was mentioned that the patient had eloped and that resident #1 went missing during her shift after one o'clock. Staff E explained that resident was in his room eating. Telephone Interview with Staff B, Occupational Therapist on [DATE] at 3:37 p.m. revealed, she remembered at around lunch time resident #1 came into the rehab gym, she noticed that resident #1 was there and told him he needed to exit the rehab gym because he couldn't be there. Staff E stated she went with resident #1 and he exited the gym. Staff E stated that there were two maintenance staff at the front of the rehab gym outside fixing something. Staff B reported that she did not hear resident #1 come back inside the rehab gym or go towards the door. She stated, I don't know at what time he came back to the gym and didn't hear anything of anyone coming in or out of the gym. She reported that she found out that resident # 1 had eloped after she got home around 6:30 p.m. and received a call from the Director of Rehabilitation informed her that resident#1 had eloped. During an Interview with Administrator, Regional Clinical Director, Vice President of Clinical, Regional Vice President for Operations and Director Of Nursing on [DATE] at 12:12 p.m. it was revealed that the Registered Nurse (RN), staff H was the person that went and identified the body. Staff H did not notice any apparent injuries. They explained that prior to the incident the staff were doing rounds to monitor the resident's wandering. The rounds were to be made every two hours, beginning of shift, when given medication and throughout the day. The DON stated, we do rounds to know the whereabouts of the residents and give care. The administrator confirmed the Certified Nursing Assistants (CNAs) and nurses from report the information given from nurse to the other nurse and the CNA to the other CNA at the start of every shift. The DON confirmed and stated that related to the incident that occurred Both the nurse and the CNA were supposed to conduct the rounds to check. The administrator revealed that according to the statements that they reviewed related to the incident; the CNA did not see the resident when she got to the facility at 3:00 p.m She stated that the CNA did tell the nurse (staff H) that she did not see the resident at about 4:30 p.m. When they started the search at 4:30 p.m. Staff H, was told by one of the employees that resident #1 was in the TV lounge but doesn't remember the name of the staff who told staff H that resident #1 was in the TV lounge. The administrator stated that she would have to look at the statement from the nurse to check at what time was the resident at the TV. The administrator stated that at 4:30 p.m. they started to search for the resident in the facility. The DON- stated she wasn't in the facility that day but they called her to let her know the resident was not in the facility and she did not remember the time they called to let her know. The administrator stated that the resident never eloped from the facility before, he was coded for elopement because he has history of dementia and used to always walk around. The rehab gym would be open and the residents could go inside if there was someone inside the gym. If no staff was there the gym was always locked. He knew the rehab gym, but he was not receiving therapy. In general, he used to walk around the facility. The Administrator stated that staff H did not come to let her know that the resident was missing. The first time she found out the resident was missing was at 5:30 p.m. The administrator stated that the nurse did not tell anyone. The DON -stated the Nurse Manager was the one that called her after the police came to identify the resident and let them know. Vice President of Clinical Operations stated that rounds should be done every two hours and is a standard measure procedure to provide care for the residents and the information is not specified in the facility's policy. She reported that the nurses, the Occupational Therapist and the CNA were removed from the schedule. Telephone Interview with Staff H a Registered Nurse (RN) on [DATE] at 12:30 p.m. revealed he worked the 3:00 p.m. to 11:00 p.m. shift on the day of the incident and that resident # 1 was on his assignment for care. Staff H reported he was familiar with resident #1, he was short stature guy, he was confused, and he wasn't aware of situations around, he was alert and oriented x 2 and he used to wander into other residents' rooms, walk to the nurse's station, to the front lobby and never really wanted to stay inside his room. I am not aware of him trying to leave the facility before. I was in the facility; I came in late that day. I became a part of it when they were doing code green when they were looking. I came in walked in with my headphones, I clocked in I put on my PPE, my mask on, I went to house stock medication room to put my personal things there. I am not too sure because it happened last Friday, I remember doing my rounds, we counted the medication and I went and started writing my documentation and went about doing my nursing routine until the code green was called. Staff H recalled the Certified Nursing Assistant mentioning something about resident #1 being missing but did not remember if it was before or after the code green, since he was doing his nursing routine. Staff H stated I don't know if it was before or after the code green. I recalled two staff members started searching and I had stopped what I was doing, I checked his room first, I went to the waiting area, I looked inside the rooms. Staff H stated that staff members found out the resident was missing at the same general time. I stepped outside and I saw an investigation was going on and he was already dead at that point. It was all during code green, all staff members were on board and looking . me being part of this, I went outside the facility and I saw they were doing an investigation. A police officer followed me to the facility, from there the secretary notified administration. The time I went outside was approximately between 5:00 p.m. and 5:30 p.m. Staff H reported he recognized resident #1 laying down, his clothes were clean, his top and pants were clean, they were not dirty, there were no injuries from the back and since he was lying down facing down, he could not see. He stated the resident was found in the community. I did spot him across the street over where you had to make a right turn .leaning on a fence. At that point pretty much everyone was aware, everyone was looking during code green, I forgot who it was, but I spoke to someone in the front area, at that point we had more resources at hand. Staff H stated that he did not mention anything about seeing the body because he was so caught up in the moment and the resident actually being dead was a surprise Staff H stated, The police never came to the facility, I don't know if the police answered the facility, they were having a yellow fence, it looked to me that the resident was dead for a while, I saw one police officer looking at the back of the building two or three officers and a van surrounding. At that point they were trying to figure out what was going on to see how this guy ended up being dead, they came after I spotted it, they asked me if I recognized the man, I said yes that is one of my residents then I quickly walked back to the facility. That's how the police became involved. It's a small facility they may not know what happened the one small thing I heard was that Resident #1 left the facility at around 1:52 p.m. Staff H stated I did not mention that the resident was outside dead to administration because I was still caught up and we were focused on the nursing, I'm assuming they had already started the investigation. At that time the police was already there, the same officers I had met outside they walked me back to the facility. Someone within the building notified administration. When they came it was an open can, the police was already collecting statements, I'm assuming administration was making an investigation but I'm not sure what was going all around. I can't speak at what point administration found out the resident went missing, I can only tell you my point of view. While the code green was going on I went outside, I assumed he went outside the facility, when I walked outside that's when I found police officers already doing an investigation. Interview with Assistant Director of Nursing (ADON) and Regional Clinical Director on [DATE] at 1:24 p.m. revealed that, during a code green for elopement a staff is chosen at random to run the elopement drill and mostly the nurses and nursing assistants would do it. The Regional Clinical Director stated they call code green and the staff would come to the designated area which is the main dining room. At that designated point the assignments are given to check rooms and the outside area. Everybody responds but the person who is most senior in the building would be given the directions. The Regional Clinical Director stated I wasn't here that day, but yes, they called the code green and did the room search on that day. The code green was called after the police came. In conclusion the police came to the facility and asked if there was a missing a person and code green for elopement was called after. Review of the facility policy revealed : Standards and Guidelines (SG) Resident Elopement policy revised [DATE] revealed in the guidelines : it is the responsibility of all associates, upon identification to immediately report their supervisor any member suspected to be missing/elopement. Procedure: A coordinated search of the unit will be conducted and other units will also be notified and properly searched. Search teams will cover entire units (bathrooms, closets, etc.), as well as all other areas of the facility (lobby, dining rooms, offices). Time and location where the member was last seen will be established, to include whom they were with, as well as appearance. (i.e. clothing) Record review of facility's policy titled SG Abuse Neglect and Exploitation (ANE) and Investigations Section: Risk Management revision date [DATE] revealed: It will be the standard of this facility honor resident's rights and to address with employees the seven components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the administrator/DNS/designee. Neglect .is the 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. Identification .When any allegation or confirmed abuse, neglect, mistreatment or exploitation of a resident occurs including suspicion, the appropriate state agencies will be notified immediately including Adult Protective Services ,[DATE]-ABUSE, federal reporting using the Immediate and 5 day Federal Reports and the local police or Ombudsman if indicated. Protection .The facility will protect residents from harm during an investigation up to and including removing the suspected employee(s) from the work . Reporting .All allegations of abuse, neglect, mistreatment, exploitation of residents' funds or property are to be reported immediately to the Administrator and according to Federal and State Regulations. Any theft, resident to resident altercations where significant injury has occurred, or allegations/suspicions/ or witnessed abuse or neglect has occurred with significant injury or reasonable suspicion of a crime need reported to the local law enforcement.

Based on record review and interviews, the facility failed to immediately report an incident of abuse and neglect that lead to a negative outcome for one (resident #1) out of 4 sampled residents. This deficient practice enabled resident #1 to elope from the facility undetected on [DATE] at 1:48 p.m The resident was not discovered as missing until 5:30p.m. on [DATE] .Subsequently, the resident was found deceased by law enforcement on [DATE], approximately 0.2 miles in an alley near the facility. The facility did not report the incident to the required agencies until 4 hours after the incident occurred on [DATE]. Refer to F 600 & F 689 The findings included: Record review of the facility Policy and Procedures titled: Standard and Guidelines: SG ANE investigations, revised [DATE] revealed that all allegations of abuse, neglect, mistreatment, exploitation of resident's funds or property are to be reported immediately to the Administrator and according to Federal and State Regulations. Any theft, resident to resident altercations where significant injury has occurred, or allegations/suspicions/ or witnesses abuse and neglect has occurred with significant injury or reasonable suspicion of a crime need reported to the local law enforcement. The facility will notify the Department of Children and Families as practically possible and the file the Federal Immediate Report to the State Agency (if applicable). Review of the Federal Immediate Reports for AHCA (Agency for Health Care Administration), provided by facility, revealed that the incident involving resident #1 was reported to AHCA on [DATE] at 11:31 p.m. The time of the incident was 5:30 p.m. The report indicated that resident #1 with [DIAGNOSES REDACTED]. No apparent injury noted or reported. Review of face sheet revealed that resident #1 initial admission was [DATE] and last admitted was [DATE]. The [DIAGNOSES REDACTED]. Record review of Admission/Readmission Nursing Notes for resident #1, dated [DATE] revealed that resident was assessed as high risk for wandering and elopement. Record review of the Minimum Data Set (MDS), for the previous admission for resident #1, dated [DATE] for Section C- Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 7 out 15 indicating severe cognitive impairment. Interview on [DATE] at 11:34 a.m. with Administrator/ Risk Manager at 11:40 a.m. revealed that the facility staff was notified by the police at 5:30 p.m. that they found the resident's #1 in the street and the body was still there. The police came to ask if the resident #1 was living in the facility. On [DATE] at 1:55 p.m. the Administrator revealed AHCA was notified on [DATE] at 11:31 p.m. and the Department of Children and Families (DCF) was prior to AHCA report. Interview on [DATE] at 2:56 p.m. with Administrator, Director of Nursing, Vice President of Clinical, Regional Clinical Director and Regional Director of Operations revealed that the Administrator was the Risk Manager and was responsible for the reporting of the incident to AHCA. The Administrator stated that she was aware that the incident should have been reported to within two (2 ) hours to the State Agencies.

Based on record reviews, observations and interviews, the facility failed to prevent neglect of one (resident #1 ) out of four sampled residents with known wandering and exit seeking behaviors as evidenced by, resident #1 eloped on [DATE] at 1:48 p.m undetected, due to the facility's staff failure to implement the two (2) hour check system. This facility's deficient practice resulted in the death of resident's #1 whose body was found by law enforcement in an alley near the facility on [DATE] approximately 5:30 p.m. Cross reference F 689 & F 609 The findings include: Review of the facility policy and procedures Standards and Guidelines for Abuse Neglect and Exploitation (SG ANE) titled: Standard and Guidelines: SG ANE Investigations, revised [DATE] revealed, neglect is the 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. Item 3. PREVENTION : Staff , residents .The facility environment will be monitored to prevent any potential ANE through : Routine monitoring of the physical layout for unsafe or unsupervised areas to minimize occurrence. Review of the facility's policy titled, Standards and Guidelines: SG Resident Elopement revised [DATE] revealed: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or any necessary supervision to do so. Resident/ patient (s) who are not cognitively impaired and are legally able to make their own choices and have been informed of facility guidelines regarding leaving facility grounds, who choose not to follow these guidelines will not be considered in this definition as an elopement. Review of AHCA (Agency for Health care Administration) Immediate Report, dated [DATE] revealed that resident #1, with [DIAGNOSES REDACTED]. No apparent injury noted or reported. Review of clinical records face sheet revealed, resident #1 had an initial admission date of [DATE] and was readmitted to the facility on [DATE]. Clinical [DIAGNOSES REDACTED]. Review of resident #1's Minimum Data Set ((MDS) dated [DATE], for the previous admission revealed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7 out 15 indicating severe cognitive impairment. Section E - Behavior item for Wandering-Presence & Frequency : Has the resident wandered ? coded 1= Behavior of this type occurred 1 to 3 days. Review of the Admission/Readmission Nursing Notes for resident #1, dated [DATE] revealed that resident #1 was assessed as high risk for wandering and elopement. Review of the Nursing Progress Notes dated [DATE] for resident #1 revealed the last nursing notes entry was on [DATE] at 9:28 a.m. Review of Baseline Care Plan last revision on [DATE] revealed that resident #1 had a history of [REDACTED]. The interventions included keep resident safe by watching for tailgating at the exit doors. Reviewing the previously admission, initiated on [DATE] revealed that resident had a Care Plan for elopement risk/ wandering with history of attempts to leave facility unattended. Review of the Baseline Care Plan dated [DATE] revealed mobility care plan indicating Focus: resident needs help walking. Intervention : Walking: the resident can walk independently but will need someone to walk with .for safety due to either confusion or fall risk. Review of the weather in Miami on [DATE] revealed a variation between 82 F to 86 F in the afternoon with humidity between 81 to 84%. (Past weather in Miami .5 June .2020. www.timeanddate.com/weather/usa/miami/historic month=6&year=2020). Resident #1 being an elderly individual is especially vulnerable to the effects of heat, and are at risk of heat-related illnesses like heat stroke that could lead to death, according to the Center for Disease Control (CDC). On [DATE] at 9:08 a.m. during observations and interview with the Director of Nursing (DON), Administrator/Risk Manager, and Vice-President of Clinical Services the facility's exit door in the rehabilitation gym did not have a lock nor an alarm. They revealed during the observation that on [DATE], the day of the incident the exit door of the rehabilitation gym did not have a lock and no alarm. They explained that the door gives access straight to Northeast 171 street. They explained that law enforcement found resident #1 deceased leaning over in the alley across the street at the front of rehabilitation gym. Resident # 1 left facility at 1:48 p.m. through the unlocked door in the gym. During the time of the elopement Staff B, Occupation Therapist (OT) was inside the rehabilitation gym. Resident #1 was not scheduled for therapy at the time of elopement. During review with the Administrator/Risk Manager on [DATE] at 11:15 a.m. of the video footage dated [DATE] showed, staff B entered the rehabilitation gym area on [DATE] at 1:41 pm. At 1:48 p.m. the video showed resident #1 walking directly without hesitation to the exit door of the rehabilitation gym that was unlocked and exited the facility unnoticed by Staff B. Further review revealed footage from the outside camera, showed resident #1 on the street waiting for cars to pass before crossing the street. On [DATE] at 11:28 a.m. during interview and observation the Director of Nursing (DON) revealed that the Rehab gym had a chatting area that was opened and had visibility of the entire room. The DON stated that the gym equipment shelves were obstructing the OT view on the day of the incident and they have moved the equipment shelves closer to the wall to enable visibility. Interview on [DATE] at 11:34 a.m. with Administrator revealed that at the time of resident #1's elopement, Staff B, OT was in the rehabilitation gym and did not hear the rehab gym exit door opening and closing at the time resident #1 eloped. The administrator explained that the facility never had an alarm for the exit door of the rehab gym. After resident #1 eloped, they were notified by the police at approximately 5:30 p.m. that a body was found in the street. The police wanted to verify if the body belonged to a resident that lived in the facility and that the body was still there. The Administrator stated that the staff are supposed to make rounds every two hours to check on the resident whereabouts and to make sure that everything was fine, and she would need to check if the nurse or Certified Nursing Assistant (CNA) completed rounds on the day of the incident. The Administrator reported that dinner time was at 5:00 p.m. and did not know if the nurse checked if resident #1 was there. Interview on [DATE] at 11:53 a.m. with Director of Nursing, Administrator, Vice-President of Clinical and Regional Director of Operations revealed that the Registered Nurse (RN) unit supervisor, staff H went with the police and recognized the body to be that of resident #1 and at that time staff H did not notice any injuries. They reported that the staff are required to do rounds every 2 hour and at the beginning of each shift, to check if residents were okay, and to provide care. The nurses provide information at change of shift to the oncoming nurse and the CNAs should provide information to the oncoming CNAs from one shift to the next. During the change of shift the nurses and the CNAs are supposed to make rounds to check on residents and make sure residents are in the facility. On the day resident #1 eloped, staff E, a CNA who started her shift at 3:00 p.m. noticed that resident #1 was not in the facility. At about 4:30 p.m. CNA, Staff E, told Staff H, RN that she had not seen resident #1 and RN stated that he was told that resident #1 was in the TV lounge, but he did not remember the name of the person that told him resident #1 was in the TV lounge. At 4:30 p.m. they started to search the entire facility. The DON stated that she was not working on the day the incident occurred and that the Health Information Manager called her by phone at around 5:00 p.m. and told her resident #1 was missing. The Administrator stated that she first heard that the resident was missing when the police officer came to the building and Staff H, RN never reported to her that resident #1 was missing and that they were searching for resident #1. The Administrator reported that resident #1 had no history of elopement. He was coded for elopement risk because he had dementia and he was walking around. Interview on [DATE] at 12:43 p.m. with Staff D, CNA revealed resident #1 was a little confused. She provided lunch to resident #1 on the day of the elopement at around 1:00 p.m. After lunch resident #1 he was walking around and that he usually walk around. Staff D,CNA reported that the last time she saw resident #1 was around 1:40 p.m. Staff D explained that she usually did rounds when she had the chance but did not because she was busy with other residents and did not notice that he was missing. Interview on [DATE] at 2:56 p.m. with Administrator, Director of Nursing, Vice President of Clinical, Regional Clinical Director and Regional Director of Operations revealed that on the day of the incident the Maintenance Director checked if all doors were working. The doors that the resident #1 used to leave the facility was the only door that did not have an alarm. On [DATE] at 4:07 p.m. the Maintenance director reported that on [DATE] the alarmed lock that was ordered for the rehabilitation gym's exit door was installed and working. The wander management systems for resident #1 was activated, but the exit door for the rehabilitation gym did not have the wander management systems on the day resident #1 eloped. Interview on [DATE] at 2:09 p.m. with Administrator /Risk Manager revealed that on the day of the elopement nobody came to tell her that resident #1 was missing. She was not in the facility because she had left for the day. She received a phone call around by 5:30 p.m. from Medical Records regarding the elopement. The elopement code green was triggered after the police officer came to the building. The administrator explained that she was driving back to the facility when Staff H went with the police to identify the body and recognized it was resident #1's body. The Administrator stated that the CNAs were supposed to report to the nurse as a first chain of command, but they could also report directly to her. The nurse could report to DON or to herself. The DON was off on the day of the incident, but the nurse had her phone number as well. Telephone Interview with Staff B Occupational Therapist on [DATE] at 3:37 p.m. revealed, around lunch time resident #1 came into the rehab gym, she noticed that he was there and told him he needed to exit the rehab gym because he couldn't be there. Staff B reported that she escorted resident #1 out of the gym. Staff B reported that time there were two maintenance staff in front of the rehab gym outside fixing something. Staff B reported, I don't know at what time he came back to the gym and didn't hear anything or anyone coming in or out of the gym. Staff B stated that after she got home around 6:30 p.m. the rehabilitation director called and told her that the resident had eloped. Telephone interview with Staff E, CNA on [DATE] at 2:14 p.m. revealed on the day of the incident she worked 3:00 pm to 11:00 p.m. Staff E,CNA reported being assigned to resident #1's room. Staff B stated that when she went to do rounds and did not see resident #1 she reported it to the nurse and the nurse told her to look for the resident at 4:30 pm. Staff E stated, by the time I went to look for him I saw the nurse already talking to the police. They gave me the room at 4:30 p.m. I checked the room and did not see the patient; I went immediately to tell the nurse. The nurse told me go look for him. By the time I finished I saw the nurse talking to the police outside. Staff E stated, my DON came and told me to come in and told me what happened. When I didn't see him, I reported it immediately. Staff E explained that resident # 1 usually walked around and go inside other patients' rooms, and staff would tell him not to go inside other rooms , he would go to therapy and then he would go back to his room. Staff E explained that resident #1 was a little confused. On [DATE] at 2:53 p.m. during a telephone interview, Licensed Practical Nurse (LPN), staff F revealed she worked the 7:00 a.m to 3:00 p.m. shift and resident #1 was on her assignment. Staff F reported that she saw resident walking around and eating. I was called by the Social Worker when I went home . I found out he was missing the following day because he was here on my shift. He was missing during my shift after one o'clock he was in his room eating and doing his thing. I was told that he was missing during my shift I didn't see him missing. When I was home the same evening, I got a call from the social worker asking me when the last time I had seen him and the next morning they mentioned that the patient had eloped. The patient was in the building when I left. I know I gave him his morning medications but I don't have the MARS in front of me, I'm not too sure if he was due for his evening medication but I know I gave him his morning medication. He was a pleasant man always a pleasant gentleman. He would walk around inside the building he used to watch TV in the activity room. The staff was there watching. I'm not sure if he would walk to the rehab gym, I worked with him only on that Thursday after he came back from the hospital. Telephone Interview with Staff G Unit/Supervisor on [DATE] at 4:20 p.m., revealed she was in the building for about four hours the day resident #1 eloped. She was about to start her shift but at about 12:10 p.m. she left the facility. Staff G stated, I am aware that a patient eloped from the building, but I was not in the building when it happened. I am familiar with resident #1 he was noted for wandering around the unit, and he would wander to get his meals, but he would never elope. Staff G reported that when the incident occurred she was called back to help and she returned to the facility at around 6:30 p.m. Telephone Interview with Staff H Registered Nurse on [DATE] at 12:30 p.m. revealed he worked the 3:00 p.m. to 11:00 p.m. shift on the day of the incident and that resident # 1 was on his assignment for care. Staff H reported he was familiar with resident #1, he was short stature guy, he was confused, and he wasn't aware of situations around, was alert and oriented x 2. He used to wander into other residents' rooms, walk to the nurse's station, to the front lobby and never really wanted to stay inside his room. I am not aware of him trying to leave the facility before. I was in the facility ; I came in late that day. I became a part of it when they were doing code green when they were looking. I came in walked in with my headphones, I clocked in I put on my PPE, my mask on, I went to house stock medication room to put my personal things there. I am not too sure because it happened last Friday, I remember doing my rounds, we counted the medication and I went and started writing my documentation and went about doing my nursing routine until the code green was called. Staff H recalled the Certified Nursing Assistant mentioning something about resident #1 being missing but did not remember if it was before or after the code green, since he was doing his nursing routine. Staff H stated I don't know if it was before or after the code green. I recalled two staff members started searching and I had stopped what I was doing, I checked his room first, I went to the waiting area, I looked inside the rooms. Staff H stated that staff members found out the resident was missing at the same general time. I stepped outside and I saw an investigation was going on and he was already dead at that point. It was all during code green, all staff members were on board and looking . me being part of this, I went outside the facility and I saw they were doing an investigation. A police officer followed me to the facility, from there the secretary notified administration. The time I went outside was approximately between 5:00 p.m. and 5:30 pm. Staff H reported he recognized resident #1 laying down, his clothes were clean, his top and pants were clean, they were not dirty, there were no injuries from the back and since he was lying down facing down, he could not see. He stated the resident was found in the community. I did spot him across the street over where you had to make a right turn .leaning on a fence. At that point pretty much everyone was aware, everyone was looking during code green, I forgot who it was, but I spoke to someone in the front area, at that point we had more resources at hand. Staff H stated that he did not mention anything about seeing the body because he was so caught up in the moment and the resident actually being dead was a surprise Staff H stated, The police never came to the facility, I don't know if the police answered the facility, they were having a yellow fence, it looked to me that the resident was dead for a while, I saw one police officer looking at the back of the building two or three officers and a van surrounding. At that point they were trying to figure out what was going on to see how this guy ended up being dead, they came after I spotted it, they asked me if I recognized the man, I said yes that is one of my residents then I quickly walked back to the facility. That's how the police became involved. It's a small facility they may not know what happened the one small thing I heard was that Resident #1 left the facility at around 1:52 p.m. Staff H stated I did not mention that the resident was outside dead to administration because I was still caught up and we were focused on the nursing, I'm assuming they had already started the investigation. At that time the police was already there, the same officers I had met outside they walked me back to the facility. Someone within the building notified administration. When they came it was an open can, the police was already collecting statements, I'm assuming administration was making an investigation but I'm not sure what was going all around. I can't speak at what point administration found out the resident went missing, I can only tell you my point of view. While the code green was going on I went outside, I assumed he went outside the facility, when I walked outside that's when I found police officers already doing an investigation.

Based on record review and interview, the facility failed ensure that adequate interventions were in place to prevent a fall for a resident who was non-ambulatory for one resident (resident # 2) out three residents reviewed for falls. The findings included: Record review of the face sheet revealed, resident # 2 was admitted on [DATE] and discharged on [DATE]. The [DIAGNOSES REDACTED]. Record review of the inventory for personal effects dated 2/6/2017 for resident # 2 revealed that one black walker was listed. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed, section C for Brief Interview for Mental Status (BIMS) was noted as 3 out of a summary score of 15 indicating cognitive impairment. Section G for transfers was coded as total dependence with two persons physical assistance. Locomotion on the unit was total dependence and two-person physical assistance. Toilet use was total dependence with two-person physical assistance. Moving from sitting to standing position activity did not occur. Walking activity did not occur. Moving on and off toilet activity did not occur. Surface to surface transfer: Not steady only able to stabilize with staff assistance. Upper extremity no impairment. Lower extremity had impairment on both sides. Mobility devices cane, crutch and walker was noted as, no. Wheel chair use was coded as, yes. Record review of the facility's fall log revealed that resident # 2 had a fall on 5/12/2019. Record review of the discharge summary for resident # 2 dated 5/12/2019 at 1:30 PM revealed, resident was alert to person and place. Assigned Certified Nursing Assistant (CNA) reported, while helping resident coming out from the bathroom with a walker, resident was unable to push anymore, and slid her on the floor at the edge of the bed. Resident stated: Two ladies were helping me, and I slid on the floor. I was unable to push myself up in the bed anymore . As needed [MEDICATION NAME] was administered with relief. Skin tear noted to right 4th toe. First aid care given by wound care nurse. Resident # 2 was able to move all extremities within normal limits. Daughter of resident # 2 in for a visit, was made aware and requested to send resident # 2 to the hospital. Call was placed to doctor of resident # 2 with an order to send resident # 2 to the hospital. Record review of the fall care plan for resident # 2 initiated on 2/4/2017 and revised in (MONTH) 2019 revealed, resident was at risk for falls. Gait and balance problems. Goal: Resident will not sustain a fall related to an injury by utilizing fall precautions through next review date. There was no mention of any interventions for the use of a walker. Record review of the Activities of Daily Living (ADL) care plan for resident # 2 initiated on 2/22/2017 and revised in (MONTH) 2019 revealed, resident had an ADL self-care performance deficit related weakness. Poor endurance secondary to shortness of breath. Goal: Resident will be free of complications related to ADL deficit through the next review date. Interventions: Resident required assistance with ADLs. Transfer: Extensive to total assistance. Walking: non-ambulatory. Toilet use: Extensive to total assistance. There was no mention of any interventions for use of a walker. Interview on 06/19/2019 at 1:38 PM with the Regional Therapy Director in the presence of the Rehabilitation Director revealed, resident # 2 had a wheel chair and not a walker. Interview on 6/19/2019 at 2:36 PM with staff A, a Certified Nursing Assistant (CNA) regarding resident # 2 revealed, resident # 2 could not walk and could only stand. Resident # 2 had a wheel chair and a walker. Resident # 2 did not use the walker and did not get out of bed and only did when the daughter of resident # 2 was there. Saff A noted, when resident # 2 was wet she would clean her in the bed and never took her to the restroom. Staff A stated, resident # 2 fell when she was off from work. Interview on 6/19/2019 at 2:50 PM with staff B, a Licensed Practical Nurse (LPN) regarding resident # 2 revealed, Resident #2 was incontinent of bowel and bladder and would go to the restroom with the daughter. Resident # 2 needed assistance for toileting. Resident # 2 needed two staff to take her to the restroom. Resident # 2 could walk with a rolling walker. Record review of the nurse's notes for resident # 2 dated 5/12/2019 at 1:30 PM with review from staff B revealed, she was on break and Registered Nurse (RN) staff C, supervisor noted that two CNAs were helping resident # 2 and tried to place resident #2 on the bed, but resident # 2 could not stand. Resident # 2 slid down to the floor. Resident # 2 had gone to the restroom and was on her way back and she had slid down. Resident # 2 would sometimes ask to go to the restroom. Resident # 2 was walking with a rolling walker with two CNAs. Staff C, a RN Supervisor assessed resident # 2. They called the daughter of resident # 2 and the doctor. Resident # 2 had a skin tear to the right 4th toe and the wound care nurse was aware. The family requested for resident # 2 to go to the hospital. The doctor ordered for resident # 2 to go to the hospital. Interview on 6/19/2019 at 3:34 PM with staff C, a Registered Nurse (RN)/weekend supervisor for resident # 2 revealed, she had worked on 5/12/2019 which was a Sunday. Staff C reviewed the discharge summary for resident # 2 dated 5/12/2019 at 5:44 PM and noted that resident # 2 was alert to person and place. Resident # 2 was coming out from bathroom with a walker and two CNAs. Resident # 2 stated, two CNAS were helping her and she slid to the floor. As needed [MEDICATION NAME] was given to resident # 2 with relief. There was a skin tear to the right 4th toe. The family of resident # 2 requested for resident # 2 to be sent to the hospital and the doctor of resident # 2 gave the order. Staff C explained, she had not seen resident # 2 with a walker and noted that was what staff told her. Interview on 6/19/2019 at 3:55 PM with staff D, RN MDS nurse regarding the quarterly MDS for resident # 2 dated 3/19/2019 revealed, resident # 2 had a BIMS score of 3 out of 15. Review of the MDS, section G for function revealed, resident # 2 was coded as total and 2-person assistance for transfers. Review of the MDS for resident # 2 revealed she had a wheel chair and no walker. Staff D noted, resident # 2 refused to walk. Resident # 2 was capable of walking, but was afraid of falling. Resident # 2 only wanted to walk when her daughter was present. Resident # 2 chose to stay in bed most of the time. Resident # 2 was not using the walker and she did not remember if the walker was in the room or not. Interview on 6/19/2019 at 4:15 PM with staff E, a Restorative CNA, in the presence of staff D, regarding resident # 2 revealed, resident # 2 never walked with restorative and only walked with her daughter with a rolling walker. Staff [NAME] did not know where resident # 2 received the rolling walker. Staff [NAME] noted, they had their own walker and when a resident was done she would take the walker with her. Staff [NAME] mentioned, resident # 2 was discharged from Physical Therapy on 11/7/2018 and discharged from restorative on 1/11/2019 due to resident refusal. Staff [NAME] noted, she never saw resident # 2 walking with a walker by herself and did not know if resident # 2 had a walker in the room. Interview on 6/19/2019 at 4:28 PM with Regional Therapy Director in the presence of Staff D, MDS nurse and Staff E, Restorative CNA regarding resident # 2 revealed, Therapy did not issue a walker and there was no potential for gait. She was not willing to walk. Staff E, a Restorative CNA had noted, restorative had not given resident # 2 a walker. Staff D, RN MDS nurse reviewed the personal inventory sheet of resident # 2 dated 2/6/2017 that revealed that a walker was listed. Phone interview on 6/19/2019 at approximately 4:45 PM with staff F, CNA regarding resident # 2 revealed, resident # 2 had to go to the toilet. Staff F, told the nurse for resident # 2 that she and another CNA had put resident # 2 on the toilet and when she finished. Resident # 2 had tried to go back to bed. While resident # 2 tried to go to bed, she asked staff for help. Resident # 2 was walking with a rolling walker. Resident # 2 went to the edge of the bed and she could not push herself on the bed. Resident # 2 was sliding to the floor. Staff F explained, resident # 2 wanted to use the walker and stated she could walk. The walker was in the room. Staff F noted, she asked the nurse and the nurse for resident # 2 stated that resident # 2 could walk. Resident # 2 mentioned that she could go to the toilet with a walker. Staff F noted, she never saw resident # 2 walk before and this was the second time she had worked with her. Interview on 6/19/2019 at 4:55 PM with Staff E, MDS nurse revealed that resident # 2 was non-ambulatory according to therapy and was not on the restorative program. Resident # 2 had no care plan to use a rolling walker. Staff [NAME] nurse concluded, The CNAs should know who is safe to use a walker and who is not safe to use a walker. Interview on 6/19/2019 at approximately 5:15 PM with Director of Nursing (DON) regarding resident # 2 revealed, on 5/12/2019 at 1:20 PM the assigned CNA and another aide both reported that while they got close to the bed of resident # 2, resident # 2 was not able to go to the bed and was sliding down. The assigned CNA reported that resident # 2 was with a walker and she slide to the floor at the edge of the bed. Resident # 2 had noted that two ladies were helping her, and she was not able to push up on to the bed. The DON mentioned that resident # 2 received the walker from the family. The DON noted that a family member of resident # 2 had refused the mechanical lift. The DON mentioned that staff helped resident # 2 from the restroom with a walker, since resident # 2 had refused the mechanical lift. The DON explained, If the resident was in the bathroom two staff would help her if she had a walker. It is not written how the resident got to the restroom. The 5/12/19 hospital record for resident #2 was reviewed and revealed, the resident had a left ankle xray while in the emergency room due to the residents complaint of pain and the final result was a Left Non-Displaced Distal Fibular Fracture.

Based on interview and record review the facility failed to ensure adequate monitoring related to insulin medication for 1 (Resident #3) out of 3 residents reviewed for medication administration. The physician order for [REDACTED]. The findings include: Resident #3 was originally admitted to the facility on [DATE], with a current admission date of [DATE]. She was eventually discharged from the facility, emergently on 4/30/2014. Her [DIAGNOSES REDACTED]. Her last recorded weight was on 4/7/2014, which was 163 pounds and her heights was 64 inches. Record review of the Minimum Data Set (MDS) for Resident #3, dated 9/10/2013, the 14-day Comprehensive Assessment revealed Section C. Cognitive Patterns, the Brief Instrument Mental Score (BIMS)=5; the highest possible score is 15; on another " Significant Change " MDS, dated , 12/11/2013 revealed Section C. Cognitive Patterns, BIMS=05; the latest MDS, dated , 3/11/2014 a Quarterly Comprehensive Assessment, reflected in Section C. Cognitive Patterns, BIMS=05 Review of the Care Plan(s) for Resident #3, dated 1/29/2014: problem: resident is at risk for complications associated with hyper or [DIAGNOSES REDACTED] related to [DIAGNOSES REDACTED]. sugar levels, administer insulin as ordered, perform Accu-checks (a test for blood glucose levels) as ordered, monitor intake of meals, offer substitutes, supplements, or alternatives as needed. Review of the April 2014 physician ordered insulin medication(s) for Resident #3 for [DIAGNOSES REDACTED]. The Sliding Scale (SS) order was the following: Accu-Check/Fingerstick twice daily at 7:30am and 5:30pm; Humalog (rapid acting insulin) 100 units/ml inject subcutaneously per SS: 151-200=2 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; BS<70=12 units and call physician. In addition to the above insulin dosages and SS dosages, there was an additional physician order dated 4/21/2014 which (appeared) to read the following: Humalog 100 units/ml give 80 units prior to every meal. According to the facility records, this physician order was taken over the telephone and written in the medical record by one of the facility ' s staff nurses. The same staff nurse transcribed this physician " telephone order " onto the Medication Administration Record [REDACTED]. According to the MAR, Resident #3 would receive these additional dosages of Humalog 80 units at 6:30am, 11:30am, and 4:30pm. However there was no physician order or nurse documentation that the amount of Accu-checks, the monitoring of blood glucose levels was increased. In this scenario, the insulin dosages for Humalog (Rapid-acting insulin) increased by up to 3 administrations per day, but the monitoring for blood glucose levels did not. Review of the medical record revealed that Resident #3 she started to receive the physician ordered additional 3 doses of Humalog prior to every meal on 4/26/2014. A mere 4 days later, on 4/30/2014, the resident was found unresponsive due to [DIAGNOSES REDACTED] (blood glucose level=0, per nurses notes) and was sent out by emergency medical service (EMS) to an acute care hospital. On 4/30/14, the following information was found in the records for Resident #3: 6:30 am - 80 units of Humalog (fast acting insulin) was documented as given; at 7:30 am - Accu-check testing revealed her blood glucose level=115; no sliding scale insulin coverage was given; at 9:00 am - 30 units of [MEDICATION NAME]-N (short acting insulin); at 11:30 am - 80 units of Humalog (fast acting insulin) was given; at 1:45 PM - Resident #3 was found unresponsive and the Accu-check couldn ' t read the glucose level, the machine reflected blood glucose level= " LO. " , per the nurses notes. The resident was given a [MEDICATION NAME] 1 mg intramuscular injection by the nursing staff, and IM. 1:50 pm EMS was called and the resident was sent out to an acute care hospital. Interview on 5/9/2014 at 3:02pm with the staff nurse who worked with Resident #3 the day she was found unresponsive revealed she received and wrote the telephone order from the assigned Advanced Registered Nurse Practitioner (ARNP) on 4/21/2014 which increased the resident ' s insulin to Humalog (rapid-acting insulin) prior to each meal (at 6:30am, 11:30am, and 4:30pm). She reported that the physician order is for Humalog 8 units not Humalog 80 units as it appears to be written. She reports her hand writing is such that a " U " closely resembles an " O. " She revealed she worked with Resident #3 often and confirmed she was the staff member who found the resident unresponsive on 4/30/2014. She revealed the following was the sequence of events that day: at the start of her shift, the MAR indicated [REDACTED]=115, and per the sliding scale the resident was not due any insulin coverage; at 9:00am, she administered [MEDICATION NAME]-N (fast-acting insulin) 30 units which is a physician ordered daily dose. She confirmed that she saw Resident #3 with a breakfast tray but did not know if the resident had eaten all of her meal. She reported that at 11:30am she administered Humalog 8 units (however, the record reflects Humalog 80 units were administered). She confirmed that the lunch trays were not on the unit at this time therefore she gave the resident a cup of applesauce along with this insulin dose. She confirmed she did not perform an Accu-check at this time, because the physician orders for checking/monitoring blood glucose levels are for 7:30am and 5:30pm. She reported that at approximately 12:00 noon, lunch had arrived on the unit for the residents and she went to check on Resident #3. She reported she called her name and there was not response; only a grunt-like sound and the resident ' s eyes were closed. She then performed an Accu-check and the unit read, " Lo. " She reported additional staff came in to the room to assist; she then administered an emergent intramuscular dose of [MEDICATION NAME] 1mg. She revealed she witnessed Resident #3 with jerky-like movement(s); EMS was called and eventually transferred the resident out to an acute care facility. Record review of labs for Resident #3 reveal the following: 4/25/2014; Hemoglobin A1C=9.6 (reference range: 4.0-6.0); 1/10/2014 Hemoglobin A1C=6.6. Interview (telephone) on 5/9/2014 at 5:10pm with the ARNP assigned to Resident #3; she confirmed she was familiar with the resident and that she had been taking care of her since her admission to the facility. She confirmed that the resident had blood sugars that have been up and down and hard to control. She reported that on 4/25/2014 the resident had a lab result for the Hemoglobin A1C (a test that determines how well diabetes is being controlled) and her level=9.5; and she gave medication orders to assist with controlling the resident ' s blood sugar levels. She confirmed that she did not have an Endocrinologist consulted for Resident #3 because what she had done regarding the insulin regimen for this resident is exactly what an Endocrinologist would have done. She reports that she has seen this resident once per month. The surveyor read to the ARNP the list of insulin medications Resident #3 was being administered from the April 2014 physician order sheet, and the April 2014 MAR indicated [REDACTED]. She reported that all of the above were her orders with the exception of: Humalog order was for 8 units (not 80 units) and the 9:00am [MEDICATION NAME]-N (short-acting insulin) dose. She reported that she had not ordered this type of insulin in years because there are more effective doses in the market. The surveyor reported to the ARNP that Resident #3 had been receiving that 9:00am dose of [MEDICATION NAME]-N (short-acting insulin) 30 units since 2/24/2014 per the MARs and physician orders according to the medical record. She reported that she is in a lot of facilities and review a lot of order sheets which contain a lot of medications, she reported that she does not read all of them, prior to signing them. Interview (telephone) on 5/9/2014 at 5:30pm with the Attending Physician for Resident #3, and the provider following the (above) ARNP; he reported that he could not answer all of the surveyor questions at this moment without the resident ' s medical record physically in front of him. The surveyor read the list of insulin medications to the physician from the medical record, and he reported he was not able to tell the surveyor if the list of insulin medications types, times, and dosages were appropriate for Resident #3 until he had the medical record physically in front of him. He reported he was aware Resident #3 was transferred out to and acute care setting, and was currently admitted in an Intensive Care Unit (ICU). Review of the medical record for Resident #3 from the acute care hospital, revealed the following: the principal admitting [DIAGNOSES REDACTED].=225 en route to hospital. Primary Impression: Hypoglycemic [MEDICAL CONDITION]; Secondary Impression: Persistent [DIAGNOSES REDACTED]. Lab work in emergency room : 4/30/14 at 3:15pm: BS=53; 4/30/14 at 4:06pm: BS=60. A history and physical noted, dated: 4/30/2013: Patient was admitted to the ICU. Review of Humalog manufacturer (website) warnings and precautions revealed: dose adjustment, monitoring, and considerations: closely monitor blood glucose in all patients treated with insulin, change insulin regimens cautiously. Review of the facility ' s insulin syringes in use revealed the following: VanishPoint 1ml Insulin syringe; 1ml=100 units of insulin; the markings on the syringe reveal they are capable of holding up to 100 units of insulin.

Based on observation, interview and record review, the facility failed to prevent the worsening of a pressure ulcer for 1 (Resident #3) out of 3 Residents sampled for pressure ulcer care. The residents wound went from a Stage II to Unstageable, and increased in size by up to 7 centimeters. This practice has the potential to place residents at risk for additional negative outcomes as well as preventing the attainment of their highest practicable physical well-being. The findings include: Record review revealed that Resident #3 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The resident was admitted to the facility with a Stage 2 pressure ulcer to his sacral area. Review of the Minimum Data Set (MDS) reflects that a comprehensive assessment was done on 11/4/2013 with the following entry regarding skin: Section M: (Skin): Stage 2 present on admission; no measurements entered; Section M0700: Most severe tissue type for any pressure ulcer: select the best description of the most severe type of tissue present in any pressure ulcer bed: 2) Granulation tissue: pink or red tissue with shiny, moist, granular appearance. Review of the skin care plan for Resident #3 revealed: Pressure Ulcer; Resident has pressure ulcers; Sacrum Stage 4; dated 11/7/13; document reflects Stage 2 was written then crossed out, Stage 3 was written then crossed out, Stage 4 was written then crossed out; finally Unstageable remained on the form dated 11/14/2013. Related to Decreased mobility, immobility, incontinence, nutritional status, disease process [MEDICAL CONDITIONS]. Goal: pressure ulcer will exhibit signs of healing as evidenced by a decrease in size, improved appearance, and be free from signs and symptoms of infection by next review date. Approaches: Report changes in skin status to physician, discuss non-compliance issues with resident/responsible party, educate resident about pressure ulcer etiology, primary risk factors, treatment, prevention, monitor labs, monitor effectiveness of/response to treatment(s), consult and make referrals for physical therapy, occupational therapy, wound nurse: complete weekly skin check, complete Braden Scale Risk Assessment quarterly and as needed (PRN) and skin risk analysis the 1st time Braden Score less than 18; notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care, provide diet as ordered and monitor nutritional status and dietary needs, assist PRN to reposition/shift weight to relieve pressure, provide pressure relieving or reductions device, pressure reduction mattress, specialty mattress (low air loss); chair cushion was not annotated on this care plan; position with pillows to maintain proper body alignment PRN. Observation of the wound care treatment for [REDACTED]. The resident was alert and oriented times three and able to answer surveyor questions appropriately. He was observed to be on an air mattress. Once placed left lateral, the old dressing was removed revealing an open, large, wide, and deep wound bed. The center of the wound bed appeared to have whitish and yellowish tissue throughout its center. The surrounding skin was intact. The wound was cleaned with normal saline; a physician prescribed ointment was applied to a 4x4 gauze; packed into the wound bed; which was then covered with a dry 4x4 gauze, and secured with tape. The nurse proceeded to place today's date and her initials on the wound dressing. Once the treatment was finished the resident was observed to be placed in a supine position, again. Observation on 12/4/2013 at 11:20am revealed, Resident #3 was in his bed watching television, and lying supine, on his back. Observation on 12/4/2013 at 2:26pm revealed, Resident #3 was in his bed, watching television, and lying supine, on his back. Interview on 12/4/2013 at 2:27pm, with the Certified Nurse ' s Aide (C.N.A) assigned to care for Resident #3 today; she confirmed the resident is alert and oriented and able to make his needs known. She reports, the resident cannot turn himself in bed and is not really able to help staff move and position him. She reports, the resident was not turned because he has a pillow to sort of turn himself. Interview on 12/4/2013 at 2:40pm with Resident #3 revealed he is not being turned as often as he used to be. He reported, he was sometimes resistant to them turning him because the staff used a draw sheet to move him and it was painful at times. He reported, he felt his wound may have gotten worse because he did not get an air mattress when he initially arrived to the facility. He reports, he feels bad his wound is getting worse and confirmed he knows he must be turned and repositioned, but he is unclear on why it is not happening in this facility. Interview on 12/4/2013 at 2:48pm with the nurse assigned to care for Resident #3 today, she confirms the resident is alert and oriented and able to make his needs known. She confirmed, the resident has a sacral ulcer but she was not sure of the stage or dimensions. She reports the resident should be turned and repositioned every 2 hours and that she believes he has been turned and repositioned every 2 hours today. Record review reflects the following dates, dimensions, and characteristics of Resident #3's sacral wound while he has been in this facility (the measurements are in centimeters): 10/25/2013: (admitted ), Stage 2: Measurements: Length=1.0; Width=0.4; Depth=0.2; Characteristics: Exudate, light clear color, granulation, defined wound edges, normal surrounding tissue. 10/31/2013: Stage 2: Measurements: Length=1.0; Width=0.4; Depth=0.2; Characteristics: Exudate, light clear color, granulation, defined wound edges, normal surrounding tissue. 11/7/2013: Stage 3; Measurements: Length=2.2; Width=1.5; Depth=0.3 Characteristics: Exudate, light serous, no odor, granulation, defined wound edges, normal surrounding tissue. 11/14/2013: Stage: Unstageable; Measurements: Length=9.0; Width=7.0; Depth=0.4 Characteristics: Exudate: moderate: odor: no; Tissue type: granulation, slough, eschar; Wound edges: defined; Surrounding tissue: normal/intact. 11/21/2013; Stage: Unstageable; Measurements: Length=9.0; Width=7.0; Depth=0.6 Characteristics: Exudate: moderate serous: odor: no; Tissue type: granulation, slough; Wound edges: defined; Surrounding tissue: normal/intact Record review reflects that consent for Debridement of this wound was on the medical record and was dated 11/21/2013. Record review reflects another outside company that specializes in wounds was consulted on the case for Resident #3. Their documentation reflects the following (all measurements are in centimeters): 11/7/2013; Measurements: Length=3.3; Width=2.2; Depth=0.3 Notes: Granulation tissue: unhealthy; Necrotic Tissue: Excessive; Necrotic Tissue color: Black; Drainage: Serous; Clinical Stage: III; Status: New; 11/14/2013: Length=9; Width=7; Depth=0.4 Notes: Necrotic tissue: Excessive; Necrotic Tissue Color: Yellow/Black; Drainage: Serous; Clinical Stage: Unstageable; Status: Deteriorating; Note: wound noted with increased wound volume, increased necrotic tissue noted as well, awaiting consent to debride wound, unit manager made aware of increase in wound volume and deterioration of the wound; 11/21/2013: Length=9; Width=7; Depth=0.6 Notes: Necrotic Tissue: Excessive; Necrotic Tissue Type: Yellow; Drainage Serous; Clinical Stage: Unstageable; Status: Unchanged. Interview on 12/4/2013 at 3:13pm with the Director of Nursing (DON) reveals, Resident #3 was admitted with a stage 2 pressure ulcer to his sacrum. She confirms an air mattress was not ordered until 11/11/2013, at least 17 days after his admission. Upon review of the medical record, the DON confirms Resident #3 had an increase in the wound dimensions and this increase was not reported to her. Record review revealed that Resident #3 did not have an air loss mattress ordered until 11/11/2013, up to 17 days after admission, and up to 4 days after the facility noted the resident wound had gone from Stage 2 to a Stage 3. Review of facility's policy titled, Wound Care reveals the following: Standard: It will be the standard of the facility to provide skin/wound care to residents to assist in maintaining or achieving optimal skin integrity. 7) document any findings of any skin abnormalities that require treatment on the 24-hour report; 17) The facility wound care nurse or designee will record information regarding each resident with a wound on the weekly wound Quality Assurance (QA) log for internal communication and quality assurance/risk management purposes.